Physical function and fitness in long-term survivors of childhood leukaemia

OBJECTIVE

To evaluate the physical function and fitness in survivors of childhood leukaemia 5-6 years after cessation of chemotherapy.

MATERIALS AND METHODS

Thirteen children (six boys and seven girls; mean age 15.5 years) who were treated for leukaemia were studied 5-6 years after cessation of therapy. Physical function and fitness were determined by anthropometry, motor performance, muscle strength, anaerobic and aerobic exercise capacity.

RESULTS

On motor performance, seven of the 13 patients showed significant problems in the hand-eye co-ordination domain. Muscle strength only showed a significantly lower value in the mean strength of the knee extensors. The aerobic and the anaerobic capacity were both significantly reduced compared to reference values.

CONCLUSION

Even 5-6 years after cessation of childhood leukaemia treatment, there are still clear late effects on motor performance and physical fitness. Chemotherapy-induced neuropathy and muscle atrophies are probably the prominent cause for these reduced test results. Physical training might be indicated for patients surviving leukaemia to improve fitness levels and muscle strength.

Perception of effort at low and moderate intensity exercise in survivors of childhood acute lymphoblastic leukaemia

OBJECTIVE

The study examined the degree to which male and female survivors of acute lymphoblastic leukaemia (ALL) perceive effort at low and moderate intensity exercise in association with related physiological variables.

MATERIALS AND METHODS

Participants were 67 children. Thirty-five (14 boys and 21 girls) were long-time survivors of ALL and 32 (18 boys and 14 girls) were control subjects. The Children's Effort Rating Table (CERT) was used to measure whole-body perceived exertion at low and moderate intensity exercise. Peak oxygen uptake was measured using a motorized treadmill. CERT and physiological data were analysed using 2 x 2 mixed analyses of variance, appropriate t-tests and coefficients of correlation.

RESULTS

In absolute terms, boys treated for ALL found perception of effort to be more strenuous at both low (3.9 vs. 3.5 units) and moderate (6.1 vs. 5.3 units) intensity exercise than control subjects, although differences were not significant (p > 0.05); girls treated for ALL found perception of effort to be the same as controls at low intensity exercise (3.1 vs. 3.1 units) but slightly higher than controls at moderate intensity exercise (5.6 vs. 5.2 units); neither of these differences were significant (p > 0.05). When CERT values were adjusted for (.-)VO(2) peak (%) and heart rate (HR) peak (%) differences remained non-significant. There were no significant interactions (Intensity x Group) in males, but the interaction for (.-)VO(2) peak (%) was significant in females (p < 0.05). The main effect for Intensity (low and moderate) was significant for all variables in boys and girls (p < 0.0001). The main effect for Group (ALL and controls) identified significantly greater absolute (b.p.m.) and relative (%) HR values in ALL boys at low and moderate intensity exercise. In female ALL and control subjects the interaction (Intensity x Group) distinguished between (.-)VO(2) peak (%) at moderate intensity exercise and HR peak (%) at low and moderate intensity exercise. Coefficients of correlation between perceived effort and (.-)VO(2) peak (%) in boys and girls were low to high (0.28-0.76), and between absolute and relative HR were also low to high (0.33-0.73). There were low correlations between time 'off therapy' and perceived effort, (.-)VO(2) peak (%) and HR peak (%) (-0.003 to -0.49).

CONCLUSION

It was concluded that perception of effort in survivors of ALL at low and moderate intensity exercise was the same as that of control subjects. Correlations between perceived effort and physiological variables at moderate exercise were low to high, while those between perceived effort and time from treatment were generally weak.

Effect of childhood acute lymphoblastic leukemia therapy on spermatogonia populations and future fertility

CONTEXT

Isolation of spermatogonial stem cells before potentially sterilizing cancer therapy, followed by transplantation of these cells into the testis after such treatment, may be an effective approach to prevent infertility among prepubertal boys suffering from acute lymphoblastic leukemia (ALL). A key clinical consideration in this context is the timing of biopsy, if collection of spermatogonia could be delayed from diagnosis to the later phase of leukemia treatment, better patient selection could be offered.

OBJECTIVE

The objective of the study was to examine the routine testicular biopsy material collected to detect testicular leukemia to evaluate if treatment for leukemia affects numbers and maturation of the spermatogonia during the prepubertal period.

DESIGN AND PARTICIPANTS

The study involved 28 testicular biopsies from 23 prepubertal boys treated for ALL.

OUTCOME MEASURE

Samples were stained immunohistochemically to evaluate the expression of the spermatogonial markers MAGE 4A, OCT4, CD9, and AP2gamma, and of the Sertoli cell marker WT-1. To relate these findings to gonadal function after sexual maturation, the surviving patients were evaluated as adults.

RESULTS

Several MAGE 4A-, CD9-, or OCT4-positive spermatogonia were detected in testicular biopsies after standard risk therapy without cyclophosphamide, whereas their numbers were significantly reduced in six patients receiving high-risk ALL therapy involving cyclophosphamide. No significant alteration in spermatogonial numbers was associated with testicular leukemia. All patients not treated with cyclophosphamide recovered normal testicular function, with normal sperm quality and endocrine function.

CONCLUSION

Treatment for childhood leukemia without high-dose cyclophosphamide seldom depletes the spermatogonial stem cell pool totally.

Impact of healing touch on pediatric oncology outpatients: pilot study

Healing Touch (HT) is a biofield therapy used to enhance well-being. We conducted a pilot study to assess its effects in pediatric oncology patients. We enrolled patients in the continuation or consolidation phase of therapy. Patients or their parent completed simple visual analogue scales (VASs; 0-10) for relaxation, vitality, overall well-being, stress, anxiety, and depression before and after a 20-minute period of rest and a standardized HT treatment. Patients' heart rates were monitored and later analyzed for heart rate variability (HRV) characteristics. Of the nine patients, all completed VASs and six had usable HRV data. The average age was 9 years. VAS scores for stress decreased significantly more for HT treatment than for rest (HT: 4.4-1.7; rest: 2.3-2.3; p = .03). The HRV characteristic of total power was significantly lower during HT than for rest (HT 599 +/- 221; rest: 857 +/- 155; p = .048), and sympathetic activity was somewhat but not significantly lower (HT: 312 +/- 158; rest: 555 +/- 193; p = .06). HT is associated with lowered stress and changes in HRV. Further studies are needed to understand the mechanisms of these effects in larger samples and to explore the impact on additional clinically relevant measures.

Endocrine and metabolic disorders in young adult survivors of childhood acute lymphoblastic leukaemia (ALL) or non-Hodgkin lymphoma (NHL)

BACKGROUND

Treatments of acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma (NHL), involving various combinations of chemotherapy (chemo), cranial irradiation (CI) and/or bone marrow transplantation after total body irradiation (BMT/TBI), are often successful but may have several long-term harmful effects.

OBJECTIVE

To evaluate late endocrine and metabolic complications in adult survivors of childhood ALL and NHL, in relation with the different therapeutic schemes received.

DESIGN

Endocrine and metabolic parameters were determined in 94 patients (48 men, mean age: 24 +/- 5 years) with a former childhood ALL (n = 78) or NHL (n = 16) and subgrouped according to their previous treatment: chemo only (group I; n = 44), chemo + CI (group II; n = 32) and chemo + BMT/TBI (group III; n = 18).

RESULTS

Severe GH deficiency (peak < 3.0 ng/ml after glucagon) was observed in 22% and 50% of patients of groups II and III, respectively, while hypothyroidism was mainly observed in group III (56%). Moreover, 83% of men developed hypogonadism after BMT/TBI, compared to 17% and 8% in groups I and II, respectively (P < 0.05), and all grafted women had ovarian failure, in contrast with other female patients in whom menarche had occurred spontaneously. Patients with BMT/TBI had also an adverse metabolic profile, with insulin resistance in 83% and dyslipidaemia in 61%.

CONCLUSIONS

This study reveals a high prevalence of endocrine and metabolic disorders in young adult survivors of childhood ALL or NHL, this frequency mainly depending on the treatment received. Treatment with BMT/TBI is the most detrimental and many of these patients will develop GHD, hypothyroidism, hypogonadism, insulin resistance and dyslipidaemia.

Bone-marrow relapse in paediatric acute lymphoblastic leukaemia

Marrow relapse is the major obstacle to cure for 10-15% of young patients with acute lymphoblastic leukaemia (ALL). Recent investigations into the biology of minimal residual disease indicate that many early relapses derive from residual cells present at first diagnosis, but some late relapses might represent new mutations in leukaemic cells not eliminated by conventional therapy. Treatment of marrow relapse involves higher doses and more intensive schedules of the drugs used for initial therapy with or without haemopoietic stem cell transplantation. In most reports, transplantation is better than continuation chemotherapy in early marrow relapse, but its role in later relapse is less clear. Current therapy cures 10% of patients with early marrow relapses and 50% of those with late relapses, but outcomes have changed little in the past two decades. Understanding the molecular biology of ALL underlies development of improved risk stratification and new therapies. Although better drugs are needed, introduction of new agents into clinical trials in paediatric disease has been difficult. Innovative trial designs and use of valid surrogate endpoints may expedite this process.

Acute lymphoblastic leukaemia presenting with acute renal failure: report of two cases

Acute renal failure is a well-recognized complication of acute leukaemias. Howevcr, serious renal failure caused by leukaemic infiltration as a primary manifestation is unusual. Here we report two patients with acute lymphoblastic leukaemia presenting with acute renal failure due to leukaemic infiltration. The first patient died before the administration of specific therapy for leukaemia, whereas the second case recovered after chemotherapy. She was discharged without necessitating dialysis therapy.

Puppets, robots, critics, and actors within a taxonomy of attention for developmental disorders

This review proposes a new taxonomy of automatic and controlled attention. The taxonomy distinguishes among the role of the attendee (puppet and robot, critic and actor), the attention process (stimulus orienting vs. response control), and the attention operation (activation vs. inhibition vs. adjustment), and identifies cognitive phenotypes by which attention is overtly expressed. We apply the taxonomy to four childhood attention disorders: attention deficit hyperactivity disorder, spina bifida meningomyelocele, traumatic brain injury, and acute lymphoblastic leukemia. Variations in attention are related to specific brain regions that support normal attention processes when intact, and produce disordered attention when impaired. The taxonomy explains group differences in behavioral inattention, hyperactivity, and impulsiveness, as well as medication response. We also discuss issues relevant to theories of the cognitive and neural architecture of attention: functional dissociations within and between automatic and controlled attention; the relative importance of type of brain damage and developmental timing to attention profile; cognitive-energetic models of attention and white matter damage; temporal processing deficits, attention deficits and cerebellar damage; and the issue of cognitive phenotypes as candidate endophenotypes.

Serum lactate dehydrogenase as a prognostic marker of childhood acute lymphoblastic leukemia

The estimation of serum lactate dehydrogenase (LDH) is easy, readily available and economic. We can assume the prognosis of childhood acute lymphoblastic leukemia (ALL) through this measurement. This case control prospective study was aimed to evaluate that the level of serum LDH has the prognostic marker of childhood ALL. The study was carried out in the Paediatric Haematology and Oncology unit, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, during the period from January to December 2006 on 69 subjects with age ranging from birth to 15 years irrespective of sex. The study subjects were grouped into case (ALL-44) and control (healthy-25). Serum LDH level were performed in ALL patients on admission, day 14 and day 29 of induction and in healthy control when came for check up and found healthy. Haematological parameters were performed in ALL patients and in healthy control along with the measurement of serum LDH. On admission the level of serum LDH was significantly raised in ALL patients than healthy control (p<0.001). After induction, serum LDH level were significantly decreased at day 14 and day 29 of induction from admission (p<0.001). There was significant rise of platelet count were observed at day 29 of induction from admission (p<0.001). A significant decrease of peripheral and bone marrow blast cell percentages were observed at day 29 of induction from admission (p<0.001). The total WBC count was significantly decreased along with serum LDH at day 14 and day 29 of induction from admission (p<0.001). So, the measurement of serum LDH can be accepted as a good and reliable prognostic marker of childhood acute lymphoblastic leukemia.

Diffusion capacity predicts long-term survival after allogeneic bone marrow transplantation for acute lymphoblastic leukemia

BACKGROUND

The aim of this study was to evaluate changes in pulmonary function measures as predictors of outcome in acute lymphoblastic leukemia (ALL) patients after myeloablative allogeneic bone marrow transplantation (BMT).

METHODS

Forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO) were evaluated before and after allogeneic BMT every 3 months in 32 patients who survived for at least 100 days. General case histories were also examined.

RESULTS

Univariate analysis revealed that decreased post-BMT DLCO was associated with increased overall and event-free survival (p < 0.05). While a pre-BMT FEV1 of < 70% was associated with significantly decreased overall survival (p < 0.05), multiple regression analysis indicated that patients without cytomegalovirus (CMV) infection, having limited chronic graft-versus-host disease (GVHD) and with markedly decreased DLCO had better overall survival (p < 0.05). After adjusting for age, gender, chronic GVHD, and CMV infection, patients with decreased DLCO exhibited enhanced overall survival. Two-year survival and event-free survival rates were significantly higher in patients with decreased DLCO.

CONCLUSION

We conclude that DLCO may be a good long-term predictor of outcome in patients with ALL following BMT.

Reduced frontal white matter volume in long-term childhood leukemia survivors: a voxel-based morphometry study

BACKGROUND AND PURPOSE

To our knowledge, no published studies have examined whole-brain regional differences to identify more discrete volumetric changes in the brains of childhood leukemia survivors. We used voxel-based morphometry (VBM) to examine regional gray and white matter differences in a group of long-term survivors of acute lymphoblastic leukemia (ALL) compared with a group of healthy controls. Differences in regional white matter volume were expected, given previous reports of white matter changes during treatment for ALL and reduced brain white matter volumes in long-term survivors. Follow-up analyses examined the relationship of regional brain volumes to cognitive function.

MATERIALS AND METHODS

We compared 9 long-term survivors of ALL with 14 healthy controls. Survivors of ALL were treated with systemic and intrathecal chemotherapy only. T1-weighted axial 3D spoiled gradient high-resolution images collected on a 1.5T MR imaging scanner were used for the VBM analysis. Neuropsychological evaluations were conducted within 2 months of the MR imaging to assess cognitive function.

RESULTS

VBM analysis revealed 2 specific regions of reduced white matter in the right frontal lobes of survivors of ALL compared with healthy controls. Survivors of ALL had lower performances on tests of attention, visual-constructional skills, mental flexibility, and math achievement compared with healthy individuals. Decreased performance on neuropsychological measures was associated with decreased regional white matter volumes. No differences were found between the groups with respect to gray matter regions.

CONCLUSION

These findings are consistent with previous literature describing the long-term cognitive, academic, and imaging findings of survivors of ALL and suggest that right frontal white matter is particularly vulnerable to disruption following intensive chemotherapy for ALL. Future studies should focus on further clarifying the white matter changes observed.

Efficacy of primary hepatitis B immunization in children with acute lymphoblastic leukemia

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) carry a high risk of hepatitis B virus (HIV) infection. The present study was conducted to see if prior routine hepatitis B vaccine received as a part of national immunization program could prevent HBV infection in these children.

METHODOLOGY

Ninety-six children with ALL were screened for HBV. Children were divided into three groups according to their initial HBV serology; previously vaccinated children (Group I) (n=34) previously unvaccinated and seronegative children (Group II) (n=56),and unvaccinated but HBsAg negative and anti-HBs positive children (group III) (n=6). Sixty-seven of 96 (69.7%) children received vaccination. The schedule was initiated during the third month of maintenance therapy and each course consisted of three doses given at one month interval.

RESULTS

Anti-HBs seroconversion following the first course of three doses of hepatitis B vaccination in group I, II and III was 57%, 33% and 100%, respectively. It increased to 97% in Group I, 62.5% in Group II, 100% in Group III. HBsAg positivity was found in 11 children (11.5%) and all of them developed chronic hepatitis B. Ten of them were in Group II whereas only one child was in Group I (P<0.04).

CONCLUSION

This data reveals that routine HBV vaccination within the national immunization program plays an important role in decreasing subsequent hepatitis B infection in children with ALL.

Acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia, a malignant disorder of lymphoid progenitor cells, affects both children and adults, with peak prevalence between the ages of 2 and 5 years. Steady progress in development of effective treatments has led to a cure rate of more than 80% in children, creating opportunities for innovative approaches that would preserve past gains in leukaemia-free survival while reducing the toxic side-effects of current intensive regimens. Advances in our understanding of the pathobiology of acute lymphoblastic leukaemia, fuelled by emerging molecular technologies, suggest that drugs specifically targeting the genetic defects of leukaemic cells could revolutionise management of this disease. Meanwhile, studies are underway to ascertain the precise events that take place in the genesis of acute lymphoblastic leukaemia, to enhance the clinical application of known risk factors and antileukaemic agents, and to identify treatment regimens that might boost the generally low cure rates in adults and subgroups of children with high-risk leukaemia.

Adrenal axis function after high-dose steroid therapy for childhood acute lymphoblastic leukemia

BACKGROUND

A 4-week course of high-dose glucocorticoids may cause prolonged adrenal suppression even after a 9-day tapering phase. In this study, adrenal function and signs and symptoms of adrenal insufficiency were prospectively assessed in children with acute lymphoblastic leukemia (ALL) after induction treatment including high-dose prednisone (PDN) or dexamethasone (DXM).

PROCEDURES

Sixty-four children with ALL, treated according to the AIEOP ALL 2000 Study protocol, underwent low dose ACTH (LD-ACTH) stimulation 24 hr after the last tapered steroid dose. In those with impaired cortisol response, additional LD ACTH tests were performed every 1-2 weeks until cortisol levels normalized. Signs and symptoms of adrenal insufficiency were recorded during the observation period.

RESULTS

All patients had normal basal cortisol values at diagnosis. Twenty-four hours after last glucocorticoid dose, morning cortisol was reduced in 40/64 (62.5%) patients. LD-ACTH testing showed adrenal suppression in 52/64 (81.5%) patients. At the following ACTH test 7-14 days later, morning cortisol values were reduced in 8/52 (15.4%) patients and response to the test was impaired in 12/52 (23%). Adrenal function completely recovered in all patients within 10 weeks. No difference was found between patients treated with PDN or DXM. Almost 35% of children with impaired cortisol values at the first test developed signs or symptoms of adrenal insufficiency. One child developed a severe adrenal crisis during adrenal suppression.

CONCLUSIONS

High-dose glucocorticoid therapy in ALL children may cause prolonged adrenal suppression and related clinical symptoms. Laboratory monitoring of cortisol levels and steroid coverage during stress episodes may be indicated.

Functional Capacity of Children with Leukemia

The purpose of this study was to determine if the functional capacity and quality of life of children receiving treatment against acute lymphoblastic leukemia (ALL) is decreased compared to healthy age and gender-matched children. Functional capacity was assessed with a number of measurements as the peak oxygen uptake (VO2peak) and ventilatory threshold determined during a ramp treadmill test, functional mobility (Timed Up and Down Stairs test [TUDS]) and ankle dorsiflexion passive and active range of motion (passive and active DF-ROM, respectively). Quality of life (QOL) was determined with the Spanish version of the Child Report Form of the Child Health and Illness Profile-Child Edition (CHIP-CE/CRF). Fifteen children (9 boys, 6 girls; mean [SD] age: 6.8 +/- 3.1 years) receiving maintenance therapy against ALL were studied and fifteen, nonathletic healthy children (9 boys, 6 girls; 6.9 +/- 3.3 years) were selected as controls. The mean values of VO2peak and active DF-ROM were significantly (p < 0.05) lower in patients (25.3 +/- 6.5 ml . kg (-1) . min (-1) vs. 31.9 +/- 6.8 ml . kg (-1) . min (-1) in controls and 19.6 +/- 8.0 degrees vs. 24.1 +/- 5.0 degrees , respectively). Children's self report of satisfaction (with self and health) (p < 0.05), comfort (concerning emotional and physical symptoms and limitations) (p < 0.01) and resilience (positive activities that promote health) (p < 0.01) were significantly decreased in patients with ALL. In summary, children receiving treatment against ALL have overall lower functional capacity and QOL than healthy children. However, their physical condition and health status are sufficiently high to allow them to participate in physical activities and supervised exercise programs.

Stress lysis in childhood leukemia

Children with acute lymphoblastic leukemia (ALL) can experience a decrease in their white blood count (WBC) prior to chemotherapy, a phenomenon commonly attributed to the administration of allopurinol and hydration. We reviewed the records of 20 children with newly diagnosed ALL prior to the administration of allopurinol and found that 80% of patients experienced a decrease in their WBC (median decrease 14,000/mm(3)) in the less than 24-hr interval between evaluation at the referring center and admission to our hospital (P = 0.002). The basis for this often-observed phenomenon appears to be that leukemic cells rapidly lyse in response to the stress-induced release of endogenous corticosteroids.

Bone marrow necrosis preceding infantile acute lymphoblastic leukaemia

We report a case of bone marrow necrosis preceding infantile acute lymphoblastic leukaemia (ALL). Bone marrow necrosis is a rare antemortem event and has been known to be present in many conditions, notably in haematological malignancies like acute lymphoblastic leukaemia. This case was a 6-month-old Chinese boy who was referred to Hospital Universiti Kebangsaan Malaysia for further investigation of pancytopaenia, high-grade fever, bloody diarrhoea and petechial rashes for one week. His first bone marrow aspirate revealed bone marrow necrosis. His clinical condition improved after ten days. However, his full blood picture then revealed the presence of 5% blast cells. His subsequent marrow 2 weeks later revealed acute lymphoblastic leukaemia (FAB-L1) and immunophenotyping showed precursor B acute lymphoblastic leukaemia-null type. He was started on United Kingdom Acute Lymphoblastic leukaemia (UK ALL) Infantile Leukaemia protocol, however, he defaulted treatment after 3 days. Mode of presentation, mechanism of disease and laboratory investigations and outline of treatment will be discussed.

Recovery kinetics of heart rate and oxygen uptake in long-term survivors of acute leukemia in childhood

Analysis of the recovery period following physical exercise has gained importance in evaluating cardiopulmonary capacity, not only in athletes but also in patients with proven or suspected heart failure. The purpose of this study was to apply these methods to long-term survivors of acute lymphoblastic leukemia (ALL) in childhood, who are at risk of developing anthracycline-induced cardiomyopathy. Nine children (mean age 12 years) and 10 adults (mean age 24 years) were included in the study after treatment for childhood ALL. Recovery of oxygen uptake and heart rate following maximal spiroergometric exercise was compared to that in 29 trained and untrained age-matched controls. The change in oxygen uptake (DeltaVO2) and heart rate (DeltaHR) between maximal effort and 60 s of recovery did not differ significantly, either between children after oncological therapy (DeltaVO2: 14.95 ml/kg, DeltaHR: 35 bpm) and healthy children (DeltaVO2: 15.85 ml/kg, DeltaHR: 37 bpm), or between adult former oncological patients (DeltaVO2: 13.1 ml/kg, DeltaHR: 27 bpm) and untrained adults (DeltaVO2: 15.7 ml/kg, DeltaHR: 31 bpm). There was, however, a significant difference in DeltaVO2 between trained adults (DeltaVO2: 24.5 ml/kg) and both untrained adult controls (DeltaVO2: 15.7 ml/kg, p=0.004) and adult patients (DeltaVO2: 13.1 ml/kg, p=0.0002). This difference was not detected for heart rate. In conclusion, the recovery period did not reveal a discernible difference in cardiopulmonary capacity between former ALL patients and untrained age-matched controls. We did confirm that heart rate and oxygen uptake recovery serve as indicators of physical fitness.

PEG-asparaginase

L-asparaginases have been established components in the treatment of acute leukemias for nearly 40 years. Their antitumor effect results from the depletion of asparagine, an amino acid essential to leukemic cells, and subsequent inhibition of protein synthesis leading to considerable cytotoxicity. The efficacy of L-asparaginases has been limited by a high rate of hypersensitivity reactions and development of anti-asparaginase antibodies, which neutralize their activity. PEG-asparaginase, a form of Escherichia coli L-asparaginase covalently linked to polyethylene glycol, was rationally synthesized to decrease immunogenicity of the enzyme and prolong its half-life. In recent years, clinical trials have established the importance of intramuscular PEG-asparaginase in frontline pediatric and adult acute lymphoblastic leukemia therapy. Present studies are evaluating the feasibility of intravenous PEG-asparaginase administration.