Hypergonadotropic hypogonadism and sperm abnormalities in men born with benign sacrococcygeal teratoma

To elucidate the hypothetical role of a primary germ cell defect in the development of a germ cell tumor, with subsequent testicular dysfunction, the authors studied a series of men who had surgery performed for a benign sacrococcygeal teratoma when newborns. The mean levels of serum testosterone and gonadotropins did not differ from the control patients. However, gonadotropin-releasing hormone stimulation caused exaggerated responses of serum luteinizing hormone and follicle-stimulating hormone. Testicular size was small in three of eight patients. Semen analysis showed abnormal semen quality in five of eight patients. Only one patient had no evidence of testicular dysfunction. The results indicate that men born with benign sacrococcygeal teratoma may have Leydig cell dysfunction, abnormal spermatogenesis, or both. It was speculated that the associated abnormalities may have a common etiology: for instance, they might be due to a congenital germ cell defect.

Quantitation of muscles and fat by ultrasonography: a useful method in the assessment of malnutrition in children

We used ultrasonography to measure muscles in the arms and thighs of 16 children with malignant diseases. Thicknesses of transverse sections of the brachial biceps muscle and the femoral quadriceps muscle were measured by ultrasound at the midpoint of the right arm and thigh. These two measures had a linear correlation (r = 0.76). The ultrasound measurements did not differ from those obtained by the CT scan which was used as a reference standard. The reproducibility of the measurements was good; the coefficient of variation was 2.4% for the midarm muscles and 2.8% for the midthigh muscles. We conclude that the ultrasound method combined with simple anthropometric measurements is helpful in the assessment of nutritional status of children with potential malnutrition.

Aggression: the dominant psychological response in children with malignant disease

During the 11-yr. period of 1976 to 1986 leukemia or lymphoma treatment at the Children's Hospital, University of Helsinki was electively discontinued for the children in 90 different families. Of the 53 (59%) patients (mean age 6.4 yr. at diagnosis and 12.8 yr. at completion of questionnaires) who agreed to participate in the present study, 48 had acute lymphoblastic leukemia and five nonHodgkin lymphoma. Patients' and parents' impressions of the patients' psychological reactions during patients' prior chemotherapy were evaluated on parental and self-ratings. Also, knowledge of and presumed causes of the malignancy were studied. Patients' reactions of aggression, depression, eating disorders, hypersensitivity, phobic anxiety, death anxiety, and night terror were examined using factor analysis. Aggression, in the form of irritation and anger, was displayed more often by girls than by boys. Patients of families suffering from stress were prone to exhibit aggression in the form of mood changes, irritation, and anger. Patients with disease-related knowledge, as opposed to those less well informed, were less depressed. Discrepancies between parents' and patients' thoughts about the origin of the malignancy were noted.

Renal growth and function 11-28 years after treatment of Wilms' tumour

In order to obtain more information on the long-term effects of treatment of Wilms' tumour we investigated 30 subjects treated at the Children's Hospital between 1960 and 1976. All had been nephrectomized and in 4 the length of the remaining kidney was subnormal. In the other subjects kidney length was related to follow up time and age at follow up. Blood pressure was elevated in 5 subjects. Urinary albumin excretion deviated only slightly from normal. Tubular functions were well preserved in all subjects. In this small series we were unable to establish any relation between the abnormalities observed and the treatment given. Our results suggest that, despite wide interindividual variation those who survive Wilms' tumours seldom have long-term renal complications.

Biphasic reduction and concanavalin A binding properties of serum alpha-fetoprotein in preterm and term infants

Reference values for postnatal serum alpha-fetoprotein (AFP) and concanavalin A (ConA) binding subfractions of AFP in preterm and term infants are presented. Preterm infants had 10-fold higher serum concentrations of AFP than did term infants at birth. The reduction of serum values of AFP was biphasic in both groups and differed significantly between the two groups. The first declining phase continued for approximately 4 months in preterm and for 2 months in term infants, and was related to the degree of prematurity. The AFP values reached adult levels by 12 months in preterm and by 9 months in term infants. The developmental pattern of the carbohydrate moiety of AFP was determined by ConA fractioning. The proportion of the ConA nonreactive subfraction of AFP in preterm and term infants at birth was 6% and 13%, respectively; it increased more rapidly in term than in preterm infants but reached 85% to 95% by the age of 6 months in both infant groups. Our results indicate that the postnatal maturation of AFP synthesis is dependent on gestational age. Malignant recurrences of neonatal sacrococcygeal teratomas were associated with an increase in serum concentration of AFP and a decrease in the proportion of the ConA nonreactive subfraction of AFP.

Iron deficiency in coeliac disease is mild and it is detected and corrected by gluten-free diet

In 54 children with coeliac disease, mild iron deficiency anaemia or evidence of iron deficiency without anaemia were common at the time of diagnosis. Treatment with a gluten-free diet without iron medication eliminated all evidence of iron deficiency and completely normalized laboratory values. Subsequent challenge with gluten resulted in the rapid reappearance of suboptimal iron balance as evidenced by a decrease in serum ferritin concentration.

Perceptions of problematic events and quality of care among patients and parents after successful therapy of the child's malignant disease

Fifty-three children (mean age 6.4 at diagnosis, 12.8 years at completion of questionnaires) identified as having acute lymphoblastic leukaemia (48) or non-Hodgkin lymphoma (5) during the 11-year period of 1976-1986 participated in the present study. Patients' and parents' perceptions of malignancy-related changes in significant relationships, of treatment-related problematic events, as well as of the quality of care provided during induction and maintenance-therapy were assessed using questionnaires. The results indicated mainly positive changes in significant relationships during the chemotherapy. However, concurrent stressful life events affected the relationships adversely. Alopecia (hair loss) was the most problematic disease-related event for the patient and the patient's anorexia for the parents. Patients' complaints were most often about the quality of care during induction, namely pain, fear and insufficient information. Parents' complaints were about the lack of continuity in the staff-patient relationship during maintenance-therapy.

Reproduction following treatment for childhood leukemia: a population-based prospective cohort study of fertility and offspring

Of all children diagnosed with leukemia in Denmark, Finland, Iceland, Norway, and Sweden, 981 had discontinued therapy before 1985 and had been followed up annually after cessation of therapy. Progeny was registered and fertility evaluated among survivors who passed age 18 years without a relapse (n = 299). By April 1989, 48 offspring were registered, one of whom had congenital anomalies. This was no more than expected from the incidence of birth defects in the general population. No childhood malignancies or genetic diseases have so far been diagnosed in the progeny. In the study group, none of the 19 female and 8 male survivors of myeloid leukemias had become parents, and only 4 fathers were reported among the 131 male survivors of acute lymphoblastic leukemia (ALL). However, 23 of the 149 females treated for ALL had delivered 41 children. Fertility was measured as cumulative rates of first birth by maternal age. In a Cox regression analysis, cases who had received prophylactic radiation of the central nervous system (CNS) had a lower first birth rate than those without radiation (rate ratio 0.39, 95% CI 0.15-1.00), indicating that doses of 18-24 Gy to the brain may possibly be a risk factor. By using the Norwegian birth cohort of 1966 as a control group, matching the median year of birth for the study subjects, the group of female ALL survivors as a whole was as likely as the general female population to have given birth up to the age of 23. The first generation of females successfully treated for childhood ALL seems to have a nearly normal reproductive pattern during young adulthood, without increased risk of congenital anomalies in the offspring. However, cranial radiation as CNS prophylaxis may possibly impair subsequent reproduction.

Low levels of serum transport proteins indicate catabolic protein status during induction therapy for acute lymphoblastic leukemia

Twelve children with newly diagnosed acute lymphoblastic leukemia (ALL) were followed during the first 24 weeks of induction and consolidation therapy. Twelve additional patients with other types of cancer, receiving no prednisone medication, served as a reference group. The serum total protein, albumin, transferrin, and prealbumin concentrations were measured at 0, 2, 4, 6-10, 16, and 24 weeks and used as biochemical indices of protein nutritional status. In all patients studied, serum albumin and prealbumin concentrations were low at diagnosis. Decreasing serum total protein and transferrin concentrations, stable low serum albumin, and increasing prealbumin levels were observed during the ALL induction therapy. In contrast, these protein levels remained stable in the children with other malignancies. By week 8 the patients with ALL had lower serum total protein, albumin, and transferrin than the children with other types of cancer. We conclude that the low levels of the serum transport proteins indicate catabolic protein status in children with ALL during early weeks of therapy.

Serum tumor necrosis factor does not correlate with changes in muscle volume in children with malignancies

This study examined the connection between serum tumor necrosis factor (TNF) concentration and the development of cachexia in 12 children with acute lymphoblastic leukemia (ALL). The changes in muscle thickness were used as criteria for malnutrition, estimated by an ultrasound method during the 16 weeks of chemotherapy subsequent to diagnosis. Serum TNF concentrations were elevated at diagnosis and gradually decreased toward the reference limits by week 16. There was no correlation between TNF and muscle thickness. The results were also compared to those obtained from 8 children with other malignancies in whom the mean relative weight remained below normal whereas in those with ALL it gradually increased to +15%. Thus, we found no evidence of the association between elevated serum TNF concentrations and cachexia in man.

Psychosexual development of adolescent males after malignancies in childhood

We studied psychosexual development in 28 adolescent males who had survived leukemia and compared it with that in 25 adolescent males who had survived other malignancies in childhood. A clinical semistructured psychiatric interview was used to form 8 criteria of psychosexual development. Sexual identity was also assessed using a psychological test. By every criterion, development was more disturbed in patients who had survived leukemia. Attitudes toward adult-type genital sexuality, contact ability with the opposite sex, and the developmental level of sexuality were most significantly affected.

Growth after treatment of solid tumours in childhood

We examined 90 survivors of childhood solid tumours diagnosed in our hospital between 1960 and 1976. Their ages at the time of this study ranged from 12.2 to 41.5 years. Adult standing height was usually normal. However, final standing height was less than expected in the females, and sitting height was below the normal mean in the males. The males who had received both chemotherapy and radiation therapy to the spine had a greater decrement in sitting height, but we did not find any association between radiation therapy to the spine without chemotherapy and subsequent total growth of the spine as measured by sitting height. We conclude that these children generally do not experience any major growth disturbances.

Skeletal muscle wasting and protein-energy malnutrition in children with a newly diagnosed acute leukemia

The changes in skeletal muscle mass of 14 children with newly diagnosed acute leukemia were studied during the first 24 weeks of antileukemia therapy. A muscle index was calculated from the femoral quadriceps muscle thickness, measured by using an ultrasound method, and from the body surface area. Serum albumin concentration was used as a biochemical indicator of protein status. Some children had muscle wasting before diagnosis. The highest degree of muscle wasting developed by 4 to 6 weeks with an average of 27% decrease of the muscle index. Because of simultaneous increase of adipose tissue (average, 33% at 6 weeks and 37% at 12 weeks), the relative body weight or the limb circumferences did not decrease. Muscle mass recovery occurred within the next 6 months. Our data emphasize that changes in the relative body weight or limb circumferences do not reveal nutritional protein depletion and muscle wasting that occurs in children with newly diagnosed acute leukemia.

Initial blood fetal hemoglobin concentration is elevated and is associated wtih prognosis in children with acute lymphoid or myeloid leukemia

We examined the relationship between initial blood fetal hemoglobin (HbF) concentration and prognosis in 100 children with leukemia. HbF concentration was usually elevated and ranged between 0 and 19.5 g/l. Multivariate analysis showed that, in patients with acute lymphoblastic leukemia (ALL), each increment of 1 g/l in initial HbF concentration resulted in a 1.13-fold rise in the risk of death or relapse (95% confidence limits 1.01-1.25, P less than 0.05). In patients with myeloid leukemias, each increment of 1 g/l in HbF was associated with a 1.20-fold (1.05-1.37, P less than 0.02) rise in the risk of death or relapse. In the patients with myeloid leukemias the mean initial HbF concentration was also higher (3.4 g/l; 0.5-19.5 g/l) than in the patients with ALL (1.1 g/l; 0-18.7 g/l; P = 0.08). Our results indicate that the degree of increase in HbF synthesis is associated with the degree of malignancy: the more aggressive the disease, the more augmented is the synthesis of HbF.

Long-term cardiac sequelae after treatment of malignant tumors with radiotherapy or cytostatics in childhood

A series of 41 individuals were restudied after childhood cancer with a median follow-up time of 17 years after chest irradiation or treatment with cyclophosphamide or Adriamycin (doxorubicin). Radiotherapy of the chest had been used in 21 patients, and in 13 of these irradiation was also directed at the heart. Thirty-five patients received cyclophosphamide and five received Adriamycin therapy. All patients were investigated by a pediatric cardiologist. Investigations included an electrocardiogram (ECG), a chest radiographic film, an echocardiogram, an exercise test, and a 24-hour ECG. Altogether 20 patients (49%) showed some abnormality in cardiac tests. Each additional year of follow-up was associated with a 1.3-fold (95% confidence limits, 1.04-1.66; P less than 0.05) increase in the risk for pathologic cardiac findings. The risk for an abnormal cardiac test result in the 13 patients who had received cardiac irradiation was 12.8-fold (95% confidence limits, 1.8-90.8; P less than 0.02) that of the other patients. However, abnormalities in cardiac function were mild.

Ten years' experience in patients with osteogenic sarcoma in Finland

Ten years' results of 56 patients with high grade osteogenic sarcoma are reported. Fifty-two patients had M0 disease. Immediately after open biopsy the patients were treated with chemotherapy using modified Rosen's protocols T4, T7 and T10. The primary tumor was adequately removed in most patients. Six children were treated with limb saving. The actuarial and disease-free survival was 80% after 1 year, and 73% to 8 years. Two patients died because of toxic side effects of chemotherapy, one of septicemia, the other of late cardiac failure secondary to doxorubicin.

Small testicles with impaired production of sperm in adult male survivors of childhood malignancies

Testicular size has been studied in 66 adult men who survived leukemia (n = 14) or cancer (n = 52) in childhood. Mean follow-up time was 14.5 years. The testicular size was measured as the length and breadth in mm; testicular volume index was calculated. Serum concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and prolactin were measured. A sperm sample was obtained from 46 men. The patients had smaller testicles than healthy medical students; 51 had small testicles. The size was the smallest in patients who survived leukemia. Multivariate analysis showed that the variables with independent effects on testicular size were cranial and testicular irradiation and therapy with cyclophosphamide. Sperm production was dependent on testicular size. We conclude that determination of serum FSH combined with testicular size may offer a practical approach for predicting the subsequent testicular damage in boys with malignancies.

Growth failure and growth hormone deficiency in children after bone marrow transplantation for leukemia

Eleven patients between the ages of 6 and 18 years who had been treated for acute leukemia were investigated for growth and growth hormone (GH) secretion. All had undergone bone marrow transplantation (BMT) between 0.7 and 5.1 (median 2.0) years previously. Preparation of patients for BMT had included high-dose cyclophosphamide and total body irradiation. In the eight patients at risk of growth failure, the relative height decreased 0.5-2.5 SD units (median 1.0) during the follow-up period. Eight patients secreted subnormal amounts of GH as studied by measuring spontaneous pulsatile GH secretion overnight. The maximal nocturnal GH peak varied between 3.3 and 28.3 micrograms/l (median 9.3). The mean nocturnal GH concentration varied from 1.2 to 8.3 micrograms/l (median 2.3) and depended on the length of the follow-up period. We conclude that deficient GH secretion is one reason for poor growth after BMT. A good growth response to GH substitution would support the role of GH deficiency in the observed growth retardation after BMT.

Tumor necrosis factor in children with malignancies

We measured serum tumor necrosis factor alpha (TNF) concentrations by a double-antibody radioimmunoassay method, with a detection level of 10 ng/liter, in 32 children with malignancies. Seventeen had acute lymphoblastic leukemia, 4 had acute nonlymphocytic leukemia, and 11 had solid tumors. At the diagnosis of malignant disease, 30 of the 32 patients had elevated serum TNF levels ranging up to 450 ng/liter. After complete remission status was achieved, 2-6 months from the diagnosis, the TNF levels were within the range of 130 healthy children who served as the reference group. Most of them had TNF levels below the detection limit. We consider the upper limit of normal to be 40 ng/liter. We conclude that elevated serum TNF concentration may be of potential significance in the diagnosis and follow-up of children with malignant diseases.

Effective prophylaxis against platelet refractoriness in multitransfused patients by use of leukocyte-free blood components

Development of permanent platelet refractoriness is a major problem in multitransfused patients with diseases such as leukemia, aplastic anemia, or pediatric solid tumors. We tried to prevent alloimmunization in these patients by systematic use of leukocyte-free blood components with less than one million of contaminating leukocytes per unit of platelets or red cells. Our study group comprised 26 patients with a minimum of 10 platelet transfusions per patient. These patients were compared with a historical reference group of 21 patients who had received standard blood products. In the leukocyte-free group none developed platelet refractoriness, in contrast to the reference group where 11 of the 21 patients became refractory to random platelets. The median corrected platelet increment for random pooled platelets was significantly higher in the leukocyte-free group compared with the reference group. The increasing number of transfusions did not correlate with the development of platelet refractoriness; instead we propose that the lower limit of antigenic exposure is important. We conclude that systematic use of leukocyte-free blood components effectively prevents development of platelet refractoriness and contributes to optimal supportive care of children with cancer.

Four pairs of siblings with acute leukemia during 1966-1985 in the Nordic countries: indication of an elevated familial risk?

Four pairs of siblings with acute leukemia in the Nordic countries during 1966-1985 are reported. The national data indicate that the risk of leukemia is 5.9 times greater in siblings of children with leukemia.