101
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Chae H, Kim M, Choi SH, Kim SK, Lee JW, Chung NG, Cho B, Kim Y. Influence of plasma methotrexate level and MTHFR genotype in Korean paediatric patients with acute lymphoblastic leukaemia. J Chemother 2020; 32:251-259. [PMID: 32431230 DOI: 10.1080/1120009x.2020.1764280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Whether plasma MTX concentrations and MTHFR C677T and A1298C polymorphisms could be used as a predictor of occurrence of MTX-related toxicities in Korean paediatric patients with acute lymphoblastic leukaemia (ALL) were assessed. HD-MTX related toxicities, MTHFR polymorphisms and MTX plasma concentrations following 337 HD-MTX cycles to 117 children with ALL on maintenance therapy were analyzed. A significantly higher frequency of hyperbilirubinemia (P = 0.0443) and renal toxicity (P = 0.0107) were associated with high MTX concentrations by Fisher's exact test. Moreover, high MTX concentrations at 24 h, 48, and 72 h were significantly associated with increased frequency of vomiting (P < 0.05) and hyperbilirubinemia (P < 0.05) by Mann-Whitney U test. There was a significantly higher frequency of mucositis in patients with the MTHFR 677 TT genotype (P = 0.0273) and a significantly higher frequency of MTX dose reduction in patients with the 677 TT genotype (P = 0.0217), compared to the CC/CT genotype. Independently, plasma MTX concentrations and MTHFR C677T genotype could be useful markers for tailoring MTX dosing and monitoring adverse effects in childhood ALL HD-MTX therapy in Korean patients.
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Affiliation(s)
- Hyojin Chae
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun Hee Choi
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seong-Koo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae-Wook Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bin Cho
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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102
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Mateos MK, Tulstrup M, Quinn MC, Tuckuviene R, Marshall GM, Gupta R, Mayoh C, Wolthers BO, Barbaro PM, Ruud E, Sutton R, Huttunen P, Revesz T, Trakymiene SS, Barbaric D, Tedgård U, Giles JE, Alvaro F, Jonsson OG, Mechinaud F, Saks K, Catchpoole D, Kotecha RS, Dalla-Pozza L, Chenevix-Trench G, Trahair TN, MacGregor S, Schmiegelow K. Genome-Wide Association Meta-Analysis of Single-Nucleotide Polymorphisms and Symptomatic Venous Thromboembolism during Therapy for Acute Lymphoblastic Leukemia and Lymphoma in Caucasian Children. Cancers (Basel) 2020; 12:E1285. [PMID: 32438682 PMCID: PMC7280960 DOI: 10.3390/cancers12051285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 12/22/2022] Open
Abstract
Symptomatic venous thromboembolism (VTE) occurs in five percent of children treated for acute lymphoblastic leukemia (ALL), but whether a genetic predisposition exists across different ALL treatment regimens has not been well studied. METHODS We undertook a genome-wide association study (GWAS) meta-analysis for VTE in consecutively treated children in the Nordic/Baltic acute lymphoblastic leukemia 2008 (ALL2008) cohort and the Australian Evaluation of Risk of ALL Treatment-Related Side-Effects (ERASE) cohort. A total of 92 cases and 1481 controls of European ancestry were included. RESULTS No SNPs reached genome-wide significance (p < 5 × 10-8) in either cohort. Among the top 34 single-nucleotide polymorphisms (SNPs) (p < 1 × 10-6), two loci had concordant effects in both cohorts: ALOX15B (rs1804772) (MAF: 1%; p = 3.95 × 10-7) that influences arachidonic acid metabolism and thus platelet aggregation, and KALRN (rs570684) (MAF: 1%; p = 4.34 × 10-7) that has been previously associated with risk of ischemic stroke, atherosclerosis, and early-onset coronary artery disease. CONCLUSION This represents the largest GWAS meta-analysis conducted to date associating SNPs to VTE in children and adolescents treated on childhood ALL protocols. Validation of these findings is needed and may then lead to patient stratification for VTE preventive interventions. As VTE hemostasis involves multiple pathways, a more powerful GWAS is needed to detect combination of variants associated with VTE.
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Affiliation(s)
- Marion K Mateos
- Kids Cancer Centre, Sydney Children's Hospital Randwick, Sydney, NSW 2031, Australia
- School of Women and Children's Health, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
| | - Michael Cj Quinn
- Statistical Genetics Laboratory, QIMR Berghofer Medical Research Institute, Herston, Brisbane, QLD 4006, Australia
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Glenn M Marshall
- Kids Cancer Centre, Sydney Children's Hospital Randwick, Sydney, NSW 2031, Australia
- School of Women and Children's Health, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Ramneek Gupta
- Department of Health Technology, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
| | - Chelsea Mayoh
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Benjamin O Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
| | - Pasquale M Barbaro
- Children's Medical Research Institute, University of Sydney, Westmead, Sydney, NSW 2145, Australia
- Queensland Children's Hospital, Brisbane, QLD 4101, Australia
| | - Ellen Ruud
- Department of Pediatric Hematology and Oncology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
| | - Rosemary Sutton
- School of Women and Children's Health, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Pasi Huttunen
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital, Stenbäckinkatu 9, 00290 Helsinki, Finland
| | - Tamas Revesz
- Women's and Children's Hospital, North Adelaide, SA 5006, Australia
| | - Sonata S Trakymiene
- Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Santariškių Str. 7, LT-08406 Vilnius, Lithuania
| | - Draga Barbaric
- Kids Cancer Centre, Sydney Children's Hospital Randwick, Sydney, NSW 2031, Australia
| | - Ulf Tedgård
- Department of Pediatric Hematology and Oncology, Skåne University Hospital, Lasarettsgatan 48, 221 85 Lund, Sweden
- Department of Clinical Sciences Lund, Pediatrics, Lund University, Sölvegatan 19, BMC F12 Lund, Sweden
| | - Jodie E Giles
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Frank Alvaro
- John Hunter Children's Hospital, Newcastle, NSW 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive Callaghan, Newcastle, NSW 2308, Australia
| | - Olafur G Jonsson
- Children's Hospital, Barnaspitali Hringsins, Landspitali University Hospital, Hringbraut 101, 101 Reykjavik, Iceland
| | - Françoise Mechinaud
- The Royal Children's Hospital, Parkville, Melbourne, VIC 3052, Australia
- Unite Hematologie Immunologie, Hopital universitaire Robert-Debre, 75019 Paris, France
| | - Kadri Saks
- Department of Hematology and Oncology, Tallinn Children's Hospital, 13419 Tallinn, Estonia
| | - Daniel Catchpoole
- Tumour Bank, Children's Cancer Research Unit, The Children's Hospital at Westmead, Westmead Sydney, NSW 2145, Australia
| | - Rishi S Kotecha
- Perth Children's Hospital, Nedlands, Perth, WA 6009, Australia
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Nedlands Perth, WA 6009, Australia
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Perth, WA 6102, Australia
| | - Luciano Dalla-Pozza
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, Sydney, NSW 2145, Australia
- Children's Cancer Research Unit, The Children's Hospital at Westmead, Westmead, Sydney, NSW 2145, Australia
| | - Georgia Chenevix-Trench
- Cancer Genetics Laboratory, QIMR Berghofer Medical Research Institute, Herston, Brisbane, QLD 4006, Australia
| | - Toby N Trahair
- Kids Cancer Centre, Sydney Children's Hospital Randwick, Sydney, NSW 2031, Australia
- School of Women and Children's Health, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Stuart MacGregor
- Statistical Genetics Laboratory, QIMR Berghofer Medical Research Institute, Herston, Brisbane, QLD 4006, Australia
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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103
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Mogensen PR, Grell K, Schmiegelow K, Overgaard UM, Wolthers BO, Mogensen SS, Vaag A, Frandsen TL. Dyslipidemia at diagnosis of childhood acute lymphoblastic leukemia. PLoS One 2020; 15:e0231209. [PMID: 32251440 PMCID: PMC7135240 DOI: 10.1371/journal.pone.0231209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/18/2020] [Indexed: 01/19/2023] Open
Abstract
As survival of acute lymphoblastic leukemia (ALL) exceeds 90%, limiting therapy-related toxicity has become a key challenge. Cardio-metabolic dysfunction is a challenge during and after childhood ALL therapy. In a single center study, we measured triglycerides (TG), total cholesterol (TC), high (HDL) and low density lipoproteins (LDL) levels at diagnosis and assessed the association with BMI, early therapy response, on-therapy hyperlipidemia and the toxicities; thromboembolism, osteonecrosis and pancreatitis. We included 127 children (1.0-17.9 years) all treated according to the NOPHO ALL2008 protocol. Dyslipidemia was identified at ALL-diagnosis in 99% of the patients, dominated by reduced HDL levels (98%) and mild hypertriglyceridemia (61%). Hypertriglyceridemia was not associated with body mass index (P = 0.71). Five percent of patients had mild hypercholesterolemia, 14% had mild hypocholesterolemia, 13% had decreased and 1% elevated LDL-levels. Increased TG and TC levels at ALL-diagnosis were not associated with any on-therapy lipid levels. Lipid levels and BMI were not associated to MRD after induction therapy; However, BMI and hypercholesterolemia were associated with worse risk group stratification (P<0.045 for all). The cumulative incidence of thromboembolism was increased both for patients with hypo- (20.0%) and hypercholesterolemia (16.7%) compared to patients with normal TC levels (2.2%) at diagnosis (P = 0.0074). In conclusion, dyslipidemic changes were present prior to ALL-therapy in children with ALL but did not seem to affect dysmetabolic traits during therapy and were not predictive of on-therapy toxicities apart from an association between dyscholesterolemia at time of ALL-diagnosis and risk of thromboembolism. However, the latter should be interpreted with caution due to low number in the groups.
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Affiliation(s)
- Pernille Rudebeck Mogensen
- Department of Diabetes and Bone-metabolic Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | | | - Benjamin Ole Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Signe Sloth Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Allan Vaag
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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104
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Mondelaers V, Ferster A, Uyttebroeck A, Brichard B, van der Werff Ten Bosch J, Norga K, Francotte N, Piette C, Vandemeulebroecke K, Verbeke C, Schmidt S, Benoit Y, Lammens T, De Moerloose B. Prospective, real-time monitoring of pegylated Escherichia coli and Erwinia asparaginase therapy in childhood acute lymphoblastic leukaemia and non-Hodgkin lymphoma in Belgium. Br J Haematol 2020; 190:105-114. [PMID: 32057100 DOI: 10.1111/bjh.16495] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/24/2019] [Indexed: 11/25/2022]
Abstract
Asparaginase (ASNase) is an important anti-leukaemic drug in the treatment of childhood acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma (NHL). A substantial proportion of patients develop hypersensitivity reactions with anti-ASNase neutralising antibodies, resulting in allergic reactions or silent inactivation (SI), and characterised by inactivation and rapid clearance of ASNase. We report results of a prospective, real-time therapeutic drug monitoring of pegylated Escherichia coli (PEG-)ASNase and Erwinia ASNase in children treated for ALL and NHL in Belgium. Erwinia ASNase was given as second-line after hypersensitivity to PEG-ASNase. In total, 286 children were enrolled in the PEG-ASNase cohort. Allergy was seen in 11·2% and SI in 5·2% of patients. Of the 42 patients treated with Erwinia ASNase, 7·1% experienced allergy and 2·4% SI. The median trough PEG-ASNase activity was high in all patients without hypersensitivity. After Erwinia administration significantly more day 3 samples had activities <100 IU/l (62·5% vs. 10% at day 2 (D2)). The median D2 activity was significantly higher for intramuscular (IM; 347 IU/l) than for intravenous Erwinia administrations (159 IU/l). This prospective, multicentre study shows that monitoring of ASNase activity during treatment of children with ALL and NHL is feasible and informative. Treatment with Erwinia ASNase warrants close monitoring and optimally adherence to a 2-day interval of IM administrations.
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Affiliation(s)
- Veerle Mondelaers
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
| | - Alina Ferster
- Pediatric Hematology-Oncology, Hôpital Universitaire des Enfants Reine Fabiola (HUDERF-UKZKF), Brussels, Belgium
| | - Anne Uyttebroeck
- Pediatric Hematology-Oncology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Bénédicte Brichard
- Pediatric Hematology-Oncology, Cliniques Universitaires Saint-Luc (UCL), Brussels, Belgium
| | | | - Koenraad Norga
- Pediatric Hematology-Oncology, University Hospital Antwerp, Antwerp, Belgium
| | - Nadine Francotte
- Department of Pediatric Oncology, CHC- Hospital of Hope, Montegnée, Belgium
| | - Caroline Piette
- Department of Pediatric Oncology, CHR Citadelle, Liège, Belgium
| | - Katrien Vandemeulebroecke
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verbeke
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Susanne Schmidt
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Yves Benoit
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
| | - Tim Lammens
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
| | - Barbara De Moerloose
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
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105
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Kuhlen M, Kunstreich M, Niinimäki R, Dunstheimer D, Lawitschka A, Bardi E, Willasch A, Bader P, Högler W, Peters C, Balduzzi A. Guidance to Bone Morbidity in Children and Adolescents Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:e27-e37. [DOI: 10.1016/j.bbmt.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/12/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
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106
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Nadeem K, Colantonio D, Kircanski I, Naqvi A, Hitzler J, Whitlock JA, Dupuis LL. Clinical decisions following implementation of asparaginase activity monitoring in pediatric patients with acute lymphoblastic leukemia: Experience from a single-center study. Pediatr Blood Cancer 2020; 67:e28044. [PMID: 31625674 DOI: 10.1002/pbc.28044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 11/08/2022]
Abstract
We undertook this retrospective study to describe decisions made following asparaginase activity monitoring implementation at our center. Clinically apparent reactions (CARs) and asparaginase activity monitoring costs were described. Patients with acute lymphoblastic leukemia, aged <18 years who received asparaginase between April 2016 and September 2017, were included. Decisions made following receipt of asparaginase activity results were categorized as continuation, modification, premedication, or discontinuation. We included 129 patients (median age: 5.33 years) receiving 565 asparaginase doses. CARs were observed following 25 asparaginase doses (19/361 [5.3%] pegaspargase). A total of 224 asparaginase activity levels were ordered in 88 patients. Following receipt of 190 asparaginase activity results, asparaginase therapy was continued, modified, or premedicated in 188 (98.9%), 1 (0.005%), and 1 (0.005%) cases, respectively. Inadequate asparaginase activity was observed in three patients receiving Erwinia asparaginase. Asparaginase activity monitoring allowed patients with pegaspargase-associated CAR and adequate activity to continue therapy unchanged and was cost neutral.
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Affiliation(s)
- Komail Nadeem
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - David Colantonio
- Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital/Eastern Ontario Regional Laboratory Association, Ottawa, Canada
| | - Ida Kircanski
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Ahmed Naqvi
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Johann Hitzler
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - James A Whitlock
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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107
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de Rojas T, Neven A, Towbin AJ, Carceller F, Bautista F, Riedl D, Sodergren S, Darlington AS, Fernandez-Teijeiro A, Moreno L. Clinical research tools in pediatric oncology: challenges and opportunities. Cancer Metastasis Rev 2020; 39:149-160. [DOI: 10.1007/s10555-020-09856-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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108
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Kloos RQH, Pieters R, Jumelet FMV, de Groot-Kruseman HA, van den Bos C, van der Sluis IM. Individualized Asparaginase Dosing in Childhood Acute Lymphoblastic Leukemia. J Clin Oncol 2020; 38:715-724. [PMID: 31922920 DOI: 10.1200/jco.19.02292] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE In the DCOG ALL-11 protocol, polyethylene glycol-conjugated Escherichia coli asparaginase (PEGasparaginase) and Erwinia asparaginase treatment of pediatric acute lymphoblastic leukemia are individualized with therapeutic drug monitoring (TDM). The efficacy of TDM and its effect on asparaginase-associated toxicity are reported. PATIENTS AND METHODS After induction with 3 fixed intravenous doses of 1,500 IU/m2 PEGasparaginase, medium-risk patients (n = 243) received 14 individualized doses that targeted trough levels of 100-250 IU/L, standard-risk patients (n = 108) received 1 individualized dose, and high-risk patients (n = 18) received 2-5 fixed administrations (1,500 IU/m2). After a neutralizing hypersensitivity reaction, patients were started with 20,000 IU/m2 Erwinia asparaginase 3 times per week, and l-asparagine was measured to monitor asparaginase efficacy. Several asparaginase-associated toxicities were studied. RESULTS The final median PEGasparaginase dose was lowered to 450 IU/m2. Overall, 97% of all trough levels of nonallergic patients were > 100 IU/L. Asparagine was < 0.5 μM in 96% and 67% of the PEGasparaginase and Erwinia asparaginase levels > 100 IU/L, respectively. Ten percent developed a neutralizing hypersensitivity reaction to PEGasparaginase, of which 40% were silent inactivations. The cumulative incidence of grade 3-4 pancreatitis, central neurotoxicity, and thromboses was 12%, 4%, and 6%, respectively, and not associated with asparaginase activity levels. During medium-risk intensification, 50% had increased ALT and 3% hyperbilirubinemia (both grade 3/4 and correlated with asparaginase activity levels), and 37% had grade 3/4 hypertriglyceridemia. Hypertriglyceridemia occurred less in intensification compared with ALL-10 (37% v 47%), which is similar to ALL-11 but with higher asparaginase levels during intensification. CONCLUSION TDM of asparaginase results in a significant reduction of the PEGasparaginase dose with adequate asparaginase activity levels and sufficient asparagine depletion. In addition, with TDM, silent inactivation and allergic-like reactions were identified. However, the effect of reduced asparaginase activity levels on toxicity is limited.
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Affiliation(s)
- Robin Q H Kloos
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Florine M V Jumelet
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Hester A de Groot-Kruseman
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Pediatric Oncology and Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Inge M van der Sluis
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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109
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Forster VJ, Bell G, Halsey C. Should nitrous oxide ever be used in oncology patients receiving methotrexate therapy? Paediatr Anaesth 2020; 30:9-16. [PMID: 31667903 DOI: 10.1111/pan.13760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/27/2022]
Abstract
Nitrous oxide (N2 O) is frequently used for short anesthesia/analgesia in children undergoing painful or repetitive procedures. Children with acute lymphoblastic leukemia (ALL) require repeated lumbar punctures with direct instillation of intrathecal chemotherapy, usually the anti-folate agent methotrexate, during their treatment. These procedures are frequently performed under anesthesia. Concerns have been intermittently raised about a drug interaction between methotrexate and N2 O that may potentiate the undesirable side effects of methotrexate, including neurotoxicity. However, the clinical evidence consists mainly of isolated case reports leading to a lack of consensus among pediatric anesthetists about the relative risk benefits of using N2 O in children with ALL. In this article, we review the biochemical basis and scientific observations that suggest a significant interaction between N2 O and methotrexate due to their dual inhibition of the key enzyme methionine synthase. The possible role of this interaction in potentiating neurotoxicity in children with cancer is discussed, and arguments and counterarguments about the clinical significance of this largely theoretical relationship are explored. Following comprehensive review of all the available data, we make the case for the circumstantial evidence being sufficiently compelling to prompt a review of practice by pediatric anesthetists and call for a precautionary approach by avoiding the use of N2 O in children receiving concurrent methotrexate.
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Affiliation(s)
- Victoria J Forster
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Graham Bell
- Department of Anaesthetics, Royal Hospital for Children, Glasgow, UK
| | - Christina Halsey
- Institute of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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110
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Finch ER, Smith CA, Yang W, Liu Y, Kornegay NM, Panetta JC, Crews KR, Molinelli AR, Cheng C, Pei D, Ramsey LB, Karol SE, Inaba H, Sandlund JT, Metzger M, Evans WE, Jeha S, Pui CH, Relling MV. Asparaginase formulation impacts hypertriglyceridemia during therapy for acute lymphoblastic leukemia. Pediatr Blood Cancer 2020; 67:e28040. [PMID: 31612640 PMCID: PMC6868303 DOI: 10.1002/pbc.28040] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/20/2019] [Accepted: 09/26/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glucocorticoids and asparaginase, used to treat acute lymphoblastic leukemia (ALL), can cause hypertriglyceridemia. We compared triglyceride levels, risk factors, and associated toxicities in two ALL trials at St. Jude Children's Research Hospital with identical glucocorticoid regimens, but different asparaginase formulations. In Total XV (TXV), native Escherichia coli l-asparaginase was front-line therapy versus the pegylated formulation (PEG-asparaginase) in Total XVI (TXVI). PROCEDURE Patients enrolled on TXV (n = 498) and TXVI (n = 598) were assigned to low-risk (LR) or standard/high-risk (SHR) treatment arms (ClinicalTrials.gov identifiers: NCT00137111 and NCT00549848). Triglycerides were measured four times and were evaluable in 925 patients (TXV: n = 362; TXVI: n = 563). The genetic contribution was assessed using a triglyceride polygenic risk score (triglyceride-PRS). Osteonecrosis, thrombosis, and pancreatitis were prospectively graded. RESULTS The largest increase in triglycerides occurred in TXVI SHR patients treated with dexamethasone and PEG-asparaginase (4.5-fold increase; P <1 × 10-15 ). SHR patients treated with PEG-asparaginase (TXVI) had more severe hypertriglyceridemia (>1000 mg/dL) compared to native l-asparaginase (TXV): 10.5% versus 5.5%, respectively (P = .007). At week 7, triglycerides did not increase with dexamethasone treatment alone (LR patients) but did increase with dexamethasone plus asparaginase (SHR patients). The variability in triglycerides explained by the triglyceride-PRS was highest at baseline and declined with therapy. Hypertriglyceridemia was associated with osteonecrosis (P = .0006) and thrombosis (P = .005), but not pancreatitis (P = .4). CONCLUSION Triglycerides were affected more by PEG-asparaginase than native l-asparaginase, by asparaginase more than dexamethasone, and by drug effects more than genetics. It is not clear whether triglycerides contribute to thrombosis and osteonecrosis or are biomarkers of the toxicities.
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Affiliation(s)
- Emily R. Finch
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Colton A. Smith
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Yiwei Liu
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Nancy M. Kornegay
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - John C. Panetta
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Kristine R. Crews
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Alejandro R. Molinelli
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children’s
Research Hospital, Memphis, TN
| | - Deqing Pei
- Department of Biostatistics, St. Jude Children’s
Research Hospital, Memphis, TN
| | - Laura B. Ramsey
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Seth E. Karol
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN,Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, TN
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, TN
| | - John T. Sandlund
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, TN
| | - Monika Metzger
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, TN,Department of Global Pediatric Medicine, St. Jude
Children’s Research Hospital, Memphis, TN
| | - William E. Evans
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, TN,Department of Global Pediatric Medicine, St. Jude
Children’s Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, TN
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude
Children’s Research Hospital, Memphis, TN
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Anaya-Ruiz M, Bandala C, Landeta G, Martínez-Morales P, Zumaquero-Rios JL, Sarracent-Pérez J, Pérez-Santos M. Nanostructured Systems in Advanced Drug Targeting for the Cancer Treatment: Recent Patents. Recent Pat Anticancer Drug Discov 2019; 14:85-94. [PMID: 30381087 DOI: 10.2174/1574892813666181031154146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/23/2018] [Accepted: 10/30/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cancer is one of the leading causes of death in the world and it is necessary to develop new strategies for its treatment because most therapies have limited access to many types of tumors, as well as low therapeutic efficacy and high toxicity. OBJECTIVE The present research aims to identify recent patents of drug delivery nanostructured systems that may have application in improving cancer treatment. METHODS Recent patents regarding the drug delivery nanostructured systems for cancer treatment were obtained from the patent databases of the six main patent offices of the world: United States Patent and Trademark Office, European Patent Office, World Intellectual Property Organization, Japan Patent Office, State Intellectual Property Office of China and Korean Intellectual Property Office. RESULTS A total of 1710 patent documents from 1998 to 2017 including "drug delivery nanostructured systems for cancer treatment" were retrieved. The top five countries in patent share were USA, China, South Korea, Canada and Germany. The universities and enterprises of USA had the highest amount of patents followed by institutions from China. CONCLUSION There is a strong tendency for the development of new nanostructured systems for the release of drugs; particularly, in recent years, the development of nanoparticles has focused on nanodiscs, gold nanoparticles and immunoliposomes.
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Affiliation(s)
- Maricruz Anaya-Ruiz
- Cell Biology Laboratory, Biomedical Research Center of the East, Mexican Institute of Social Security, Metepec, Puebla CP 74360, Mexico
| | - Cindy Bandala
- Department of Neuurosciences, National Institute of Rehabilitation, City of Mexico, Mexico
| | - Gerardo Landeta
- Coordination of Applied Research, University Center for Linkage and Transfer of Technology, Benemérita Autonomous University of Puebla, Puebla CP 72570, Mexico
| | - Patricia Martínez-Morales
- Laboratory of Molecular Biology, Center for Biomedical Research of the East, Mexican Institute of Social Security / CONACYT, Metepec, Puebla CP 74360, Mexico
| | - Jose L Zumaquero-Rios
- Laboratory of Parasitology and Vectors, Faculty of Biology, Benemérita Universidad Autonomous University of Puebla, Puebla CP 72570, Mexico
| | - Jorge Sarracent-Pérez
- Laboratory of Parasitology, Institute of Tropical Medicine "Pedro Kouri ", Havana CP 11400, Cuba
| | - Martín Pérez-Santos
- Technology Marketing Office, University Link Center and Technology Transfer, Benemerita Universidad Autonoma de Puebla, Puebla CP 72570, Mexico
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Rank CU, Wolthers BO, Grell K, Albertsen BK, Frandsen TL, Overgaard UM, Toft N, Nielsen OJ, Wehner PS, Harila-Saari A, Heyman MM, Malmros J, Abrahamsson J, Norén-Nyström U, Tomaszewska-Toporska B, Lund B, Jarvis KB, Quist-Paulsen P, Vaitkevičienė GE, Griškevičius L, Taskinen M, Wartiovaara-Kautto U, Lepik K, Punab M, Jónsson ÓG, Schmiegelow K. Asparaginase-Associated Pancreatitis in Acute Lymphoblastic Leukemia: Results From the NOPHO ALL2008 Treatment of Patients 1-45 Years of Age. J Clin Oncol 2019; 38:145-154. [PMID: 31770057 PMCID: PMC6953441 DOI: 10.1200/jco.19.02208] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Asparaginase-associated pancreatitis (AAP) is common in patients with acute lymphoblastic leukemia (ALL), but risk differences across age groups both in relation to first-time AAP and after asparaginase re-exposure have not been explored. PATIENTS AND METHODS We prospectively registered AAP (n = 168) during treatment of 2,448 consecutive ALL patients aged 1.0-45.9 years diagnosed from July 2008 to October 2018 and treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol. RESULTS Compared with patients aged 1.0-9.9 years, adjusted AAP hazard ratios (HRa) were associated with higher age with almost identical HRa (1.6; 95% CI, 1.1 to 2.3; P = .02) for adolescents (10.0-17.9 years) and adults (18.0-45.9 years). The day 280 cumulative incidences of AAP were 7.0% for children (1.0-9.9 years: 95% CI, 5.4 to 8.6), 10.1% for adolescents (10.0 to 17.9 years: 95% CI, 7.0 to 13.3), and 11.0% for adults (18.0-45.9 years: 95% CI, 7.1 to 14.9; P = .03). Adolescents had increased odds of both acute (odds ratio [OR], 5.2; 95% CI, 2.1 to 13.2; P = .0005) and persisting complications (OR, 6.7; 95% CI, 2.4 to 18.4; P = .0002) compared with children (1.0-9.9 years), whereas adults had increased odds of only persisting complications (OR, 4.1; 95% CI, 1.4 to 11.8; P = .01). Fifteen of 34 asparaginase-rechallenged patients developed a second AAP. Asparaginase was truncated in 17/21 patients with AAP who subsequently developed leukemic relapse, but neither AAP nor the asparaginase truncation was associated with increased risk of relapse. CONCLUSION Older children and adults had similar AAP risk, whereas morbidity was most pronounced among adolescents. Asparaginase re-exposure should be considered only for patients with an anticipated high risk of leukemic relapse, because multiple studies strongly indicate that reduction of asparaginase treatment intensity increases the risk of relapse.
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Affiliation(s)
- Cecilie U Rank
- Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | | | - Kathrine Grell
- Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Nina Toft
- Herlev University Hospital, Herlev, Denmark
| | | | | | | | | | | | | | | | | | - Bendik Lund
- Trondheim University Hospital, Trondheim, Norway
| | - Kirsten B Jarvis
- Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | | | - Goda E Vaitkevičienė
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Vilnius University, Vilnius, Lithuania
| | - Laimonas Griškevičius
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Vilnius University, Vilnius, Lithuania
| | | | | | | | - Mari Punab
- Tartu University Hospital, Tartu, Estonia
| | | | - Kjeld Schmiegelow
- Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
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Agarwala S, Banavali SD, Vijayvargiya M. Bisphosphonate Combination Therapy in the Management of Postchemotherapy Avascular Necrosis of the Femoral Head in Adolescents and Young Adults: A Retrospective Study From India. J Glob Oncol 2019; 4:1-11. [PMID: 30241233 PMCID: PMC6223416 DOI: 10.1200/jgo.17.00083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Purpose With improved survival after chemotherapy for acute lymphoblastic leukemia (ALL), it is imperative to maintain good quality of life as part of the management of post-therapy adverse effects. Avascular necrosis of the femoral head (AVNFH) is one such adverse effect. A need exists for a therapy that ameliorates discomfort, provides a productive life, is cost effective, and is joint preservative. We conducted the current study to evaluate the response to bisphosphonate in the nonsurgical management of AVNFH in adolescents and young adults (AYA) who receive treatment for ALL. Materials and Methods This is a retrospective study of 20 AYA patients—34 affected hips—who received zolendronic acid 5 mg intravenously each year along with oral alendronate 70 mg weekly for 3 years. Clinical evaluation was performed by using the Visual Analog Scale and the Harris Hip Score. Radiographs were used to classify the Ficat-Arlet stage, monitor radiologic collapse, and evaluate the rate of progression. Results Pain relief with a drop in the Visual Analog Scale score was observed at a mean duration of 5.2 weeks (range, 3 weeks to 11 weeks) after the start of therapy. Radiologic progression by one grade was observed in 12 hips (35.3%), and only one hip (2.94%) showed progression by two grades. At a mean follow-up of 50.3 months, 31 affected hips (91.1%) had a satisfactory clinical outcome and had not required any surgical intervention. The proportion of hips that required total hip arthroplasty were 0%, 5%, and 22.2% in Ficat-Arlet stage I, II, and III, respectively. Conclusion The combination of intravenous zolendronic acid and oral alendronate provides a pragmatic solution for the management of AVNFH after therapy for ALL in AYA patients. This therapy is safe, effective, and well tolerated.
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Affiliation(s)
- Sanjay Agarwala
- Sanjay Agarwala and Mayank Vijayvargiya, P.D. Hinduja Hospital and Medical Research Centre; and Shripad D. Banavali, Tata Memorial Centre, Mumbai, India
| | - Shripad D Banavali
- Sanjay Agarwala and Mayank Vijayvargiya, P.D. Hinduja Hospital and Medical Research Centre; and Shripad D. Banavali, Tata Memorial Centre, Mumbai, India
| | - Mayank Vijayvargiya
- Sanjay Agarwala and Mayank Vijayvargiya, P.D. Hinduja Hospital and Medical Research Centre; and Shripad D. Banavali, Tata Memorial Centre, Mumbai, India
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114
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Levêque D, Becker G. The role of therapeutic drug monitoring in the management of safety of anticancer agents: a focus on 3 cytotoxics. Expert Opin Drug Saf 2019; 18:1009-1015. [PMID: 31478396 DOI: 10.1080/14740338.2019.1662395] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Therapeutic drug monitoring in oncology is used to prevent major toxicities of selected anticancer agents due to overexposure by individualizing the dose based on a pharmacokinetic target. Areas covered: Numerous studies relating a relation between pharmacokinetic variability and toxicity have been reported since the eighties but very few have been implemented in clinical practice due to a lack of validation and harmonization, logistical constraints and reluctance from oncologists. Following recent recommendations, this paper highlights the current-validated applications of pharmacokinetic monitoring in oncology focusing on the safety of anticancer therapies. Expert opinion: Paradoxically given the oldness of the agents, guidelines of dose adjustment have been recently available for intravenous busulfan, 5-fluorouracil, and high-dose methotrexate. Interestingly, besides the enhancement of tolerability, it applies to potential curative clinical situations. In an era of personalized oncology that integrates complex molecular factors in the treatment of cancer, education is needed for oncologists to show the benefits of this valuable (even old) resource for the safety of patients. Therapeutic drug monitoring for busulfan, 5-fluorouracil and methotrexate will still hold in the future unless more active agents are available in the concerned indications.
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115
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Albertsen BK, Grell K, Abrahamsson J, Lund B, Vettenranta K, Jónsson ÓG, Frandsen TL, Wolthers BO, Heyman M, Schmiegelow K. Intermittent Versus Continuous PEG-Asparaginase to Reduce Asparaginase-Associated Toxicities: A NOPHO ALL2008 Randomized Study. J Clin Oncol 2019; 37:1638-1646. [DOI: 10.1200/jco.18.01877] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Asparaginase is an essential drug in childhood acute lymphoblastic leukemia (ALL) therapy and is frequently given for months to obtain continuous asparagine depletion. We randomly assigned patients to continuous versus intermittent pegylated-asparaginase (PEG-asp) treatment, hypothesizing there would be decreased toxicity with unchanged efficacy. METHODS Children (median age, 4.2 years) treated for non–high-risk ALL according to the Nordic Society for Pediatric Hematology and Oncology ALL2008 protocol received five intramuscular PEG-asp injections (1,000 IU/m2) every two weeks and were then randomly assigned to additional three doses (6-week intervals [experimental arm], n = 309) versus 10 doses (2-week intervals [standard arm], n = 316). The primary end point was noninferior (6% margin) disease-free survival. Toxicity reduction was a secondary end point. Occurrence of asparaginase-associated hypersensitivity, pancreatitis, osteonecrosis, and thromboembolism were prospectively registered. RESULTS After a median follow-up of 4.1 years, the 5-year disease-free survival was 92.2% (95% CI, 88.6 to 95.8) and 90.8% (95% CI, 87.0 to 94.6) in the experimental and standard arms, respectively. The 3-year cumulative incidence of any first asparaginase-associated toxicity (hypersensitivity [n = 13]; osteonecrosis [n = 29]; pancreatitis [n = 24]; thromboembolism [n = 17]) was 9.3% in the experimental arm and 18.1% in the standard arm ( P = .001). Asparaginase-associated toxicity reduction was confirmed in sex- and risk-group–adjusted Cox regression analysis stratified by age (≥ 10 and < 10 years; hazard ratio, 0.48; P = .001). The experimental arm had the lowest incidences of all four toxicities, reaching significance for pancreatitis (6-month risk, 5.8% v 1.3%; P = .002). CONCLUSION The excellent cure rates and reduced toxicity risk support the use of intermittent PEG-asp therapy after the first 10 weeks in future childhood ALL trials that apply prolonged PEG-asp therapy.
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Affiliation(s)
| | - Kathrine Grell
- University of Copenhagen, Copenhagen, Denmark,
- Rigshospitalet, Copenhagen, Denmark
| | | | - Bendik Lund
- Trondheim University Hospital, Trondheim, Norway
| | | | | | | | | | - Mats Heyman
- Karolinska University Hospital, Stockholm, Sweden
| | - Kjeld Schmiegelow
- University of Copenhagen, Copenhagen, Denmark,
- Rigshospitalet, Copenhagen, Denmark
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116
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Hunger SP. More Is Not Always Better: The Perils of Treatment Intensification in Pediatric Acute Lymphoblastic Leukemia. J Clin Oncol 2019; 37:1601-1603. [DOI: 10.1200/jco.19.00889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Stephen P. Hunger
- Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
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117
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Mateos M, Trahair T, Mayoh C, Barbaro P, Sutton R, Revesz T, Barbaric D, Giles J, Alvaro F, Mechinaud F, Catchpoole D, Kotecha R, Dalla-Pozza L, Quinn M, MacGregor S, Chenevix-Trench G, Marshall G. Risk factors for symptomatic venous thromboembolism during therapy for childhood acute lymphoblastic leukemia. Thromb Res 2019; 178:132-138. [DOI: 10.1016/j.thromres.2019.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/10/2019] [Accepted: 04/10/2019] [Indexed: 01/19/2023]
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Schmidt D, Kristensen K, Schroeder H, Wehner PS, Rosthøj S, Heldrup J, Damsgaard L, Schmiegelow K, Mikkelsen TS. Plasma creatinine as predictor of delayed elimination of high-dose methotrexate in childhood acute lymphoblastic leukemia: A Danish population-based study. Pediatr Blood Cancer 2019; 66:e27637. [PMID: 30835935 DOI: 10.1002/pbc.27637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Severely delayed elimination of methotrexate (MTX) is difficult to predict in patients treated with high-dose MTX (HD-MTX), but it may cause life-threatening toxicity. It has not been defined how an increase in plasma creatinine can be best used as a predictor for severely delayed MTX elimination, thus providing a guide for therapeutic interventions to minimize renal toxicity. METHODS Pharmacokinetic data were retrospectively collected on 218 Danish children with acute lymphoblastic leukemia treated with HD-MTX 5 or 8 g/m2 on the NOPHO2000 protocol. Moderately delayed MTX elimination was defined as 42-hour plasma MTX ≥ 4.0-9.9 μM, and severely delayed elimination was defined as 42-hour plasma MTX ≥ 10 μM. RESULTS Median 42-hour plasma MTX was 0.61 μM (interquartile range, 0.4-1.06 μM). Of 1295 MTX infusions with 5 g/m2 (n = 140 patients) or 8 g/m2 (n = 78 patients), 5.1% were severely (1.5%) or moderately (3.6%) delayed. The risk of having delayed elimination was highest in the first of eight infusions with MTX 5 g/m² (7.4% vs 0.0 to 4.1% for subsequent MTX infusions) (P < 0.02). A 25 μM increase or a 1.5-fold increase in plasma creatinine within 36 hours from start of the MTX infusion had a sensitivity of 92% (95% CI, 82%-97%) and a specificity of 85% (95% CI, 83%-87%) for predicting 42-hour MTX ≥4.0 μM. CONCLUSIONS A 25 μM increase or a 1.5-fold in plasma creatinine within 36 hours after start of an HD-MTX infusion can predict delayed MTX elimination, thus allowing intensification of hydration and alkalization to avoid further renal toxicity and promote the elimination of MTX.
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Affiliation(s)
- Diana Schmidt
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kim Kristensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Development DMPK, PKPD, Novo Nordisk A/S, Maaløv, Denmark
| | - Henrik Schroeder
- Department of Pediatric Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Peder Skov Wehner
- Department of Pediatric Hematology and Oncology, H.C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Steen Rosthøj
- Department of Pediatric Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Heldrup
- Department of Pediatric Oncology, Lund University Hospital, Lund, Sweden
| | - Linn Damsgaard
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Toksvang LN, Schmidt MS, Arup S, Larsen RH, Frandsen TL, Schmiegelow K, Rank CU. Hepatotoxicity during 6-thioguanine treatment in inflammatory bowel disease and childhood acute lymphoblastic leukaemia: A systematic review. PLoS One 2019; 14:e0212157. [PMID: 31125338 PMCID: PMC6534292 DOI: 10.1371/journal.pone.0212157] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/18/2019] [Indexed: 12/14/2022] Open
Abstract
Background The recently established association between higher levels of DNA-incorporated thioguanine nucleotides and lower relapse risk in childhood acute lymphoblastic leukaemia (ALL) calls for reassessment of prolonged 6-thioguanine (6TG) treatment, while avoiding the risk of hepatotoxicity. Objectives To assess the incidence of hepatotoxicity in patients treated with 6TG, and to explore if a safe dose of continuous 6TG can be established. Data sources Databases, conference proceedings, and reference lists of included studies were systematically searched for 6TG and synonyms from 1998–2018. Methods We included studies of patients with ALL or inflammatory bowel disorder (IBD) treated with 6TG, excluding studies with 6TG as part of an intensive chemotherapy regimen. We uploaded a protocol to PROSPERO (registration number CRD42018089424). Database and manual searches yielded 1823 unique records. Of these, 395 full-texts were screened for eligibility. Finally, 134 reports representing 42 studies were included. Results and conclusions We included data from 42 studies of ALL and IBD patients; four randomised controlled trials (RCTs) including 3,993 patients, 20 observational studies including 796 patients, and 18 case reports including 60 patients. Hepatotoxicity in the form of sinusoidal obstruction syndrome (SOS) occurred in 9–25% of the ALL patients in two of the four included RCTs using 6TG doses of 40–60 mg/m2/day, and long-term hepatotoxicity in the form of nodular regenerative hyperplasia (NRH) was reported in 2.5%. In IBD patients treated with 6TG doses of approximately 23 mg/m2/day, NRH occurred in 14% of patients. At a 6TG dose of approximately 12 mg/m2/day, NRH was reported in 6% of IBD patients, which is similar to the background incidence. According to this review, doses at or below 12 mg/m2/day are rarely associated with notable hepatotoxicity and can probably be considered safe.
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Affiliation(s)
- Linea Natalie Toksvang
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Magnus Strøh Schmidt
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sofie Arup
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Hebo Larsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, The Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
| | - Cecilie Utke Rank
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Paediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Anastasopoulou S, Eriksson MA, Heyman M, Wang C, Niinimäki R, Mikkel S, Vaitkevičienė GE, Johannsdottir IM, Myrberg IH, Jonsson OG, Als-Nielsen B, Schmiegelow K, Banerjee J, Harila-Saari A, Ranta S. Posterior reversible encephalopathy syndrome in children with acute lymphoblastic leukemia: Clinical characteristics, risk factors, course, and outcome of disease. Pediatr Blood Cancer 2019; 66:e27594. [PMID: 30592147 DOI: 10.1002/pbc.27594] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a distinct entity with incompletely known predisposing factors. The aim of this study is to describe the incidence, risk factors, clinical course, and outcome of PRES in childhood acute lymphoblastic leukemia (ALL). PROCEDURE Patients aged 1.0 to 17.9 years diagnosed with ALL from July 2008 to December 2015 and treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol were included. Patients with PRES were identified in the prospective NOPHO leukemia toxicity registry, and clinical data were collected from the medical records. RESULTS The study group included 1378 patients, of whom 52 met the criteria for PRES. The cumulative incidence of PRES at one month was 1.7% (95% CI, 1.1-2.5) and at one year 3.7% (95% CI, 2.9-4.9). Older age (hazard ratios [HR] for each one-year increase in age 1.1; 95% CI, 1.0-1.2, P = 0.001) and T-cell immunophenotype (HR, 2.9; 95% CI, 1.6-5.3, P = 0.0005) were associated with PRES. Central nervous system (CNS) involvement (odds ratios [OR] = 2.8; 95% CI, 1.2-6.5, P = 0.015) was associated with early PRES and high-risk block treatment (HR = 2.63; 95% CI, 1.1-6.4, P = 0.033) with late PRES. At follow-up of the PRES patients, seven patients had epilepsy and seven had neurocognitive difficulties. CONCLUSION PRES is a neurotoxicity in the treatment of childhood ALL with both acute and long-term morbidity. Older age, T-cell leukemia, CNS involvement and high-risk block treatment are risk factors for PRES.
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Affiliation(s)
- Stavroula Anastasopoulou
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Mats A Eriksson
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Chen Wang
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Riitta Niinimäki
- Oulu University Hospital, Department of Children and Adolescents, and University of Oulu, PEDEGO Research Unit, Oulu, Finland
| | - Sirje Mikkel
- Department of Hematology and Oncology, University of Tartu, Tartu, Estonia
| | - Goda E Vaitkevičienė
- Children's Hospital, affiliation of Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | | | - Ida Hed Myrberg
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | | | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Joanna Banerjee
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arja Harila-Saari
- Department of Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
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Affiliation(s)
- Cliona Rooney
- Center for Cell and Gene Therapy, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Tim Sauer
- Center for Cell and Gene Therapy, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Erdmann F, Feychting M, Mogensen H, Schmiegelow K, Zeeb H. Social Inequalities Along the Childhood Cancer Continuum: An Overview of Evidence and a Conceptual Framework to Identify Underlying Mechanisms and Pathways. Front Public Health 2019; 7:84. [PMID: 31106186 PMCID: PMC6492628 DOI: 10.3389/fpubh.2019.00084] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 03/26/2019] [Indexed: 12/13/2022] Open
Abstract
Inequalities in health according to social conditions are regarded as unnecessary and unjust. There is a large body of evidence on inequalities in adult cancer, observable throughout the societies on a national level as well as on a global scale. Socioeconomic influences on health matter at all ages including childhood, for which childhood cancer is the leading cause of disease related death in high-income countries (HICs). Substantial differences in the reported incidence of childhood cancers have been observed globally by socioeconomic development of a population. This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, and for cancer in infants (below 1 year), compared to low- and middle-income countries (LMICs). Considerable inequalities between populations and degree of socioeconomic development are also noted for survival from childhood cancer, with substantially lower survival rates seen in most LMICs compared to HICs. With respect to inequalities by socioeconomic position (SEP) within countries, findings of an association between SEP and childhood cancer risk are diverse and limited to studies from HICs. On the contrary, observations on social inequalities in survival within countries are accumulating and indicate that survival inequalities do not only concern resource-poor countries but also high-income populations including European countries. In turn, a childhood cancer diagnosis in itself may have implications on the parents' socioeconomic situation as well as on the later socioeconomic life after having survived the disease. The underlying mechanisms and causal pathways of these empirically demonstrated social inequalities are poorly understood, although it is of significant public health relevance for any actions or strategies to reduce childhood cancer-related inequity. We propose a conceptual framework on potential underlying mechanism and pathways specifically addressing social inequalities in childhood cancer and after childhood cancer to (i) illustrate potential pathways by which social determinants may create health inequities at different points of the childhood cancer continuum; (ii) illustrate potential pathways by which a childhood cancer diagnosis may impact the socioeconomic situation of the concerned family or the later life of a childhood survivor; and (iii) point out how major determinants may relate to each other.
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Affiliation(s)
- Friederike Erdmann
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), Lyon, France
- Department of Prevention and Evaluation, Leibniz - Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Maria Feychting
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Mogensen
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hajo Zeeb
- Department of Prevention and Evaluation, Leibniz - Institute for Prevention Research and Epidemiology - BIPS GmbH, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
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123
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Klaassen ILM, Lauw MN, Fiocco M, van der Sluis IM, Pieters R, Middeldorp S, van de Wetering MD, de Groot‐Kruseman HA, van Ommen CH. Venous thromboembolism in a large cohort of children with acute lymphoblastic leukemia: Risk factors and effect on prognosis. Res Pract Thromb Haemost 2019; 3:234-241. [PMID: 31011707 PMCID: PMC6462738 DOI: 10.1002/rth2.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 11/15/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is relatively common in children with acute lymphoblastic leukemia (ALL). Thrombotic risk factors in ALL are asparaginase and steroids. However, within the ALL populations treated on the same regimen, it is less clear which other risk factors play a role. Furthermore, few data are available on the effect of VTE on ALL outcomes. METHODS In 778 children (1-18 years) with newly diagnosed precursor-B-lineage or T-lineage ALL, treated in the Dutch Childhood Oncology Group (DCOG) ALL-10 protocol in the Netherlands (October 2004 to April 2013), we conducted a nested case control study with 59 VTE cases and 118 controls to identify risk factors for VTE. RESULTS Fifty-nine of 778 ALL patients developed VTE (7.6%), with cerebral venous sinus thrombosis (CVST) in 26 of 59 patients (44.1%). VTE occurred during induction treatment in 59.3% (n = 35) and in 40.7% (n = 24) during medium risk intensification. Conditional multivariable logistic regression analysis showed that age and ALL subtype were significantly associated with VTE (age ≥7 years: OR 2.72, 95% CI 1.33-5.57; ALL subtype T-ALL: OR 2.95, 95% CI 1.02-8.57). A multivariable Cox model showed no association between the occurrence of VTE and event free survival. In CVST patients, permanent disability was present in 34.6%. CONCLUSION Within this large pediatric ALL cohort, we demonstrated a high morbidity in CVST patients. Age ≥7 years at diagnosis and T-ALL subtype were the main risk factors for VTE, and should be considered in preventive strategies.
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Affiliation(s)
- Irene L. M. Klaassen
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamthe Netherlands
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Mandy N. Lauw
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
- Department of HematologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Marta Fiocco
- Medical StatisticsDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenthe Netherlands
- Mathematical Institute Leiden UniversityLeidenthe Netherlands
- Dutch Childhood Oncology GroupThe Haguethe Netherlands
| | - Inge M. van der Sluis
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | | | | | - C. Heleen van Ommen
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
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124
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Gong F, Meng Q, Liu C, Zhao Y. Efficacy and association analysis of high-dose methotrexate in the treatment of children with acute lymphoblastic leukemia. Oncol Lett 2019; 17:4423-4428. [PMID: 30988812 PMCID: PMC6447950 DOI: 10.3892/ol.2019.10128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/15/2019] [Indexed: 01/24/2023] Open
Abstract
Effect of high-dose methotrexate (MTX) on children with acute lymphoblastic leukemia (ALL) with different subtypes and disease courses was investigated. A retrospective analysis of 207 children with ALL who were admitted to the People's Hospital of Pingyi County from March 2014 to June 2017 was carried out. According to the subtype of the disease, the children were divided into two groups. B-lineage group: ALL occurred in B-lineage lymphocytes (n=128); T-lineage group: ALL occurred in T-lineage lymphocytes (n=79). According to the disease course, the children were divided into three groups. High-risk group: disease course >15 days (n=67); moderate-risk group: disease course >8 and <15 days (n=58); low-risk group: disease course <8 days (n=82). The plasma concentration, calcium formyltetrahydrofolate (CF) rescue times and adverse reactions were compared at 12 h (T1), 48 h (T2), and 72 h (T3) after MTX infusion. The plasma concentration in B-lineage group was significantly higher than that in the T-lineage group at T2 and T3 (P<0.05). The incidence of adverse reactions in children with ALL in the B-lineage group was significantly higher than that in the T-lineage group (P<0.05). The CF rescue times in high-risk group were more than that in moderate- and low-risk groups (P<0.05). The incidence of adverse reactions in the high-risk group was significantly higher than that in the moderate- and low-risk groups (P<0.05), and in the moderate-risk group was significantly higher than that in the low-risk group (P<0.05). Compared with T-lineage ALL children, high-dose MTX causes more toxic injury to B-lineage ALL children. During clinical application of MTX in the treatment of ALL, close attention should be paid to the changes of the vital signs of patients, and timely CF rescue should be performed.
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Affiliation(s)
- Fangwei Gong
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Qingjun Meng
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Chengjuan Liu
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Yeqi Zhao
- Ward 6, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
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125
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Reduced vs. standard dose native E. coli-asparaginase therapy in childhood acute lymphoblastic leukemia: long-term results of the randomized trial Moscow-Berlin 2002. J Cancer Res Clin Oncol 2019; 145:1001-1012. [PMID: 30840197 PMCID: PMC6435612 DOI: 10.1007/s00432-019-02854-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 02/01/2019] [Indexed: 11/30/2022]
Abstract
Purpose Favorable outcomes were achieved for children with acute lymphoblastic leukemia (ALL) with the first Russian multicenter trial Moscow–Berlin (ALL-MB) 91. One major component of this regimen included a total of 18 doses of weekly intramuscular (IM) native Escherichia coli-derived asparaginase (E. coli-ASP) at 10000 U/m2 during three consolidation courses. ASP was initially available from Latvia, but had to be purchased from abroad at substantial costs after the collapse of Soviet Union. Therefore, the subsequent trial ALL-MB 2002 aimed at limiting costs to a reasonable extent and also at reducing toxicity by lowering the dose for standard risk (SR−) patients to 5000 U/m2 without jeopardizing efficacy. Methods Between April 2002 and November 2006, 774 SR patients were registered in 34 centers across Russia and Belarus, 688 of whom were randomized. In arm ASP-5000 (n = 334), patients received 5000 U/m2 and in arm ASP-10000 (n = 354) 10 000 U/m2 IM. Results Probabilities of disease-free survival, overall survival and cumulative incidence of relapse at 10 years were comparable: 79 ± 2%, 86 ± 2% and 17.4 ± 2.1% (ASP-5000) vs. 75 ± 2% and 82 ± 2%, and 17.9 ± 2.0% (ASP-10000), while death in complete remission was significantly lower in arm ASP-5000 (2.7% vs. 6.5%; p = 0.029). Conclusion Our findings suggest that weekly 5000 U/m2E. coli-ASP IM during consolidation therapy are equally effective, more cost-efficient and less toxic than 10000 U/m2 for SR patients with childhood ALL. Electronic supplementary material The online version of this article (10.1007/s00432-019-02854-x) contains supplementary material, which is available to authorized users.
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126
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Wolthers BO, Frandsen TL, Patel CJ, Abaji R, Attarbaschi A, Barzilai S, Colombini A, Escherich G, Grosjean M, Krajinovic M, Larsen E, Liang DC, Möricke A, Rasmussen KK, Samarasinghe S, Silverman LB, van der Sluis IM, Stanulla M, Tulstrup M, Yadav R, Yang W, Zapotocka E, Gupta R, Schmiegelow K. Trypsin-encoding PRSS1-PRSS2 variations influence the risk of asparaginase-associated pancreatitis in children with acute lymphoblastic leukemia: a Ponte di Legno toxicity working group report. Haematologica 2019; 104:556-563. [PMID: 30467200 PMCID: PMC6395330 DOI: 10.3324/haematol.2018.199356] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Asparaginase-associated pancreatitis is a life-threatening toxicity to childhood acute lymphoblastic leukemia treatment. To elucidate genetic predisposition and asparaginase-associated pancreatitis pathogenesis, ten trial groups contributed remission samples from patients aged 1.0-17.9 years treated for acute lymphoblastic leukemia between 2000 and 2016. Cases (n=244) were defined by the presence of at least two of the following criteria: (i) abdominal pain; (ii) levels of pancreatic enzymes ≥3 × upper normal limit; and (iii) imaging compatible with pancreatitis. Controls (n=1320) completed intended asparaginase therapy, with 78% receiving ≥8 injections of pegylated-asparaginase, without developing asparaginase-associated pancreatitis. rs62228256 on 20q13.2 showed the strongest association with the development of asparaginase-associated pancreatitis (odds ratio=3.75; P=5.2×10-8). Moreover, rs13228878 (OR=0.61; P=7.1×10-6) and rs10273639 (OR=0.62; P=1.1×10-5) on 7q34 showed significant association with the risk of asparaginase-associated pancreatitis. A Dana Farber Cancer Institute ALL Consortium cohort consisting of patients treated on protocols between 1987 and 2004 (controls=285, cases=33), and the Children's Oncology Group AALL0232 cohort (controls=2653, cases=76) were available as replication cohorts for the 20q13.2 and 7q34 variants, respectively. While rs62228256 was not validated as a risk factor (P=0.77), both rs13228878 (P=0.03) and rs10273639 (P=0.04) were. rs13228878 and rs10273639 are in high linkage disequilibrium (r2=0.94) and associated with elevated expression of the PRSS1 gene, which encodes for trypsinogen, and are known risk variants for alcohol-associated and sporadic pancreatitis in adults. Intra-pancreatic trypsinogen cleavage to proteolytic trypsin induces autodigestion and pancreatitis. In conclusion, this study finds a shared genetic predisposition between asparaginase-associated pancreatitis and non-asparaginase-associated pancreatitis, and targeting the trypsinogen activation pathway may enable identification of effective interventions for asparaginase-associated pancreatitis.
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Affiliation(s)
- Benjamin O Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Thomas L Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Chirag J Patel
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Rachid Abaji
- CHU Sainte-Justine Research Center and Department of Pharmacology, University of Montreal, QC, Canada
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St Anna Children's Hospital and Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Austria
| | - Shlomit Barzilai
- Pediatric Hematology and Oncology, Schneider Children's Medical Center of Israel, Petah-Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Antonella Colombini
- Department of Pediatrics, Ospedale San Gerardo, University of Milano-Bicocca, Fondazione MBBM, Monza, Italy
| | - Gabriele Escherich
- University Medical Center Eppendorf, Clinic of Pediatric Hematology and Oncology, Hamburg, Germany
| | - Marie Grosjean
- Center for Biological Sequence Analysis, Technical University of Denmark, Lyngby, Denmark
| | - Maja Krajinovic
- CHU Sainte-Justine Research Center and Department of Pharmacology, University of Montreal, QC, Canada
- Department of Pediatrics, University of Montreal, QC, Canada
| | - Eric Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
| | - Der-Cherng Liang
- Division of Pediatric Hematology-Oncology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Anja Möricke
- Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Department of Pediatrics, Kiel, Germany
| | - Kirsten K Rasmussen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Inge M van der Sluis
- Dutch Childhood Oncology Group, The Hague and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Martin Stanulla
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Rachita Yadav
- Center for Biological Sequence Analysis, Technical University of Denmark, Lyngby, Denmark
- Molecular Neurogenetics Unit, Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Wenjian Yang
- St. Jude Children's Research Hospital, Department of Pharmaceutical Sciences, Memphis, TN, USA
| | - Ester Zapotocka
- University Hospital Motol, Department of Pediatric Hematology/Oncology, Prague, Czech Republic
| | - Ramneek Gupta
- Center for Biological Sequence Analysis, Technical University of Denmark, Lyngby, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Denmark
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Sinusoidal obstruction syndrome in a paediatric patient with acute lymphoblastic leukaemia after completion of reinduction therapy according to ALL Intercontinental Berlin-Frankfurt-Münster 2009. Contemp Oncol (Pozn) 2019; 22:266-269. [PMID: 30783392 PMCID: PMC6377418 DOI: 10.5114/wo.2018.82646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/23/2018] [Indexed: 12/23/2022] Open
Abstract
Sinusoidal obstruction syndrome (SOS), also termed veno-occlusive disease (VOD) of the liver, is a well-known complication of haematopoietic stem cell transplantation (HSCT) both in children and adults. In the medical literature there are occasional reports of SOS in patients receiving conventional chemotherapy. In children with solid tumours this entity occurs during treatment of nephroblastoma, rhabdomyosarcoma, and medulloblastoma. In the late 1990s SOS was quite often observed as the complication of oral 6-thioguanine (6-TG) in patients suffering from acute lymphoblastic leukaemia (ALL), who received 6-TG throughout maintenance. In current protocols, the syndrome has become uncommon because treatment with 6-TG is limited to two weeks of oral therapy. Here, we report a case of a nine-year-old boy with ALL, who developed sinusoidal obstruction syndrome shortly after completing the reinduction block of chemotherapy (cyclophosphamide, cytarabine, thioguanine) according to the ALL Intercontinental Berlin-Frankfurt-Münster 2009 (ALL IC BFM 2009) treatment protocol.
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128
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Barzilai-Birenboim S, Arad-Cohen N, Nirel R, Avrahami G, Harlev D, Gilad G, Elhasid R, Izraeli S, Litichever N, Elitzur S. Thrombophilia screening and thromboprophylaxis may benefit specific ethnic subgroups with paediatric acute lymphoblastic leukaemia. Br J Haematol 2019; 184:994-998. [DOI: 10.1111/bjh.15752] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/11/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Shlomit Barzilai-Birenboim
- Department of Paediatric Haematology and Oncology; Schneider Children's Medical Centre of Israel, Petach Tivka; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Nira Arad-Cohen
- Department of Paediatric Haematology-Oncology; Ruth Rappaport Children's Hospital; Rambam Health Care Campus; Haifa Israel
| | - Ronit Nirel
- Department of Statistics; Hebrew University; Jerusalem Israel
| | - Galia Avrahami
- Department of Paediatric Haematology and Oncology; Schneider Children's Medical Centre of Israel, Petach Tivka; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Dan Harlev
- Department of Paediatric Haematology-Oncology; Ruth Rappaport Children's Hospital; Rambam Health Care Campus; Haifa Israel
| | - Gil Gilad
- Department of Paediatric Haematology and Oncology; Schneider Children's Medical Centre of Israel, Petach Tivka; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Ronit Elhasid
- Department of Paediatric Haemato-Oncology; Tel Aviv Medical Centre; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shai Izraeli
- Department of Paediatric Haematology and Oncology; Schneider Children's Medical Centre of Israel, Petach Tivka; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Naomi Litichever
- Department of Paediatric Haematology and Oncology; Schneider Children's Medical Centre of Israel, Petach Tivka; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Sarah Elitzur
- Department of Paediatric Haematology and Oncology; Schneider Children's Medical Centre of Israel, Petach Tivka; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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A prospective study of a simple algorithm to individually dose high-dose methotrexate for children with leukemia at risk for methotrexate toxicities. Cancer Chemother Pharmacol 2018; 83:349-360. [DOI: 10.1007/s00280-018-3733-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/23/2018] [Indexed: 01/16/2023]
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130
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Mogensen SS, Harila-Saari A, Mäkitie O, Myrberg IH, Niinimäki R, Vestli A, Hafsteinsdottir S, Griškevicius L, Saks K, Hallböök H, Retpen J, Helt LR, Toft N, Schmiegelow K, Frandsen TL. Comparing osteonecrosis clinical phenotype, timing, and risk factors in children and young adults treated for acute lymphoblastic leukemia. Pediatr Blood Cancer 2018; 65:e27300. [PMID: 29943905 DOI: 10.1002/pbc.27300] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/23/2018] [Accepted: 05/30/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Treatment-related osteonecrosis (ON) is a serious complication of treatment of acute lymphoblastic leukemia (ALL). PROCEDURE This study included 1,489 patients with ALL, aged 1-45 years, treated according to the Nordic Society of Paediatric Haematology and Oncology ALL2008 protocol, using alternate-week dexamethasone during delayed intensification, with prospective registration of symptomatic ON. We aimed at comparing risk factors, timing, and clinical characteristics of ON in children and young adults. RESULTS ON was diagnosed in 67 patients, yielding a 5-year cumulative incidence of 6.3%, but 28% in female adolescents. Median age at ALL diagnosis was 12.1 years and 14.9 years for females and males, respectively. At ON diagnosis, 59 patients had bone pain (91%) and 30 (46%) had multiple-joint involvement. The median interval between ALL and ON diagnosis was significantly shorter in children aged 1.0-9.9 years (0.7 years [range: 0.2-2.1]) compared with adolescents (1.8 years [range: 0.3-3.7, P < 0.001]) and adults (2.1 years [range: 0.4-5.3, P = 0.001]). Female sex was a risk factor in adolescent patients (hazard ratio [HR] = 2.1, 95% confidence interval [CI]: 1.1-4.2) but not in children aged 1.1-9.9 years (HR = 2.4, 95% CI: 0.9-6.2, P = 0.08) or adults aged 19-45 years (HR = 1.1, 95% CI: 0.3-4.0). Age above 10 years at ALL diagnosis (odds ratio [OR] = 3.7, P = 0.026) and multiple joints affected at ON diagnosis (OR = 3.4, P = 0.027) were risk factors for developing severe ON. CONCLUSION We provide a detailed phenotype of patients with ALL with symptomatic ON, including description of risk factors and timing of ON across age groups. This awareness is essential in exploring measures to prevent development of ON.
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Affiliation(s)
- Signe Sloth Mogensen
- Department of Pediatrics and Adolescent Medicine, the Juliane Marie Center, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Arja Harila-Saari
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Outi Mäkitie
- Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Ida Hed Myrberg
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Anne Vestli
- Department of Pediatric Oncology and Hematology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Laimonas Griškevicius
- Department of Hematology, Oncology, and Transfusion Medicine Center, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kadri Saks
- Department of Hematology Oncology, Tallinn Children´s Hospital, Tallinn, Estonia
| | - Helene Hallböök
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jens Retpen
- Department of Orthopedic Surgery, University Hospital Herlev Gentofte, Copenhagen, Denmark
| | - Louise Rold Helt
- Department of Pediatrics and Adolescent Medicine, the Juliane Marie Center, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nina Toft
- Department of Hematology, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, the Juliane Marie Center, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, the Juliane Marie Center, University Hospital Rigshospitalet, Copenhagen, Denmark
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131
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Abaji R, Ceppi F, Patel S, Gagné V, Xu CJ, Spinella JF, Colombini A, Parasole R, Buldini B, Basso G, Conter V, Cazzaniga G, Leclerc JM, Laverdière C, Sinnett D, Krajinovic M. Genetic risk factors for VIPN in childhood acute lymphoblastic leukemia patients identified using whole-exome sequencing. Pharmacogenomics 2018; 19:1181-1193. [PMID: 30191766 DOI: 10.2217/pgs-2018-0093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIM To identify genetic markers associated with vincristine-induced peripheral neuropathy (VIPN) in childhood acute lymphoblastic leukemia. PATIENTS & METHODS Whole-exome sequencing data were combined with exome-wide association study to identify predicted-functional germline variants associated with high-grade VIPN. Genotyping was then performed for top-ranked signals (n = 237), followed by validation in independent replication group (n = 405). RESULTS Minor alleles of rs2781377/SYNE2 (p = 0.01) and rs10513762/MRPL47 (p = 0.01) showed increased risk, whereas that of rs3803357/BAHD1 had a protective effect (p = 0.007). Using a genetic model based on weighted genetic risk scores, an additive effect of combining these loci was observed (p = 0.003). The addition of rs1135989/ACTG1 further enhanced model performance (p = 0.0001). CONCLUSION Variants in SYNE2, MRPL47 and BAHD1 genes are putative new risk factors for VIPN in childhood acute lymphoblastic leukemia.
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Affiliation(s)
- Rachid Abaji
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada.,Department of Pharmacology & Physiology, Faculty of Medicine, University of Montreal, Montreal, QC, H3C 3J7, Canada
| | - Francesco Ceppi
- Pediatric Hematology-Oncology Unit & Pediatric Hematology-Oncology Research Laboratory, Division of Pediatrics, Department of Woman-Mother-Child, University Hospital of Lausanne, 1004 Lausanne, Switzerland
| | - Swati Patel
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada
| | - Vincent Gagné
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada
| | - Chang J Xu
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada
| | - Jean-François Spinella
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada
| | - Antonella Colombini
- Department of Pediatrics, University of Milano-Bicocca, Ospedale S Gerardo, 20835 Monza, Italy
| | - Rosanna Parasole
- Department of Pediatric Hemato-Oncology, Santobono-Pausilipon Hospital, 80129 Naples, Italy
| | - Barbara Buldini
- Department of Woman & Child Health, Laboratory of Haematology-Oncology, University of Padova, 35128 Padova, Italy
| | - Giuseppe Basso
- Department of Woman & Child Health, Laboratory of Haematology-Oncology, University of Padova, 35128 Padova, Italy
| | - Valentino Conter
- Department of Pediatrics, University of Milano-Bicocca, Ospedale S Gerardo, 20835 Monza, Italy
| | - Giovanni Cazzaniga
- Centro Ricerca Tettamanti, Department of Pediatrics, University Milano Bicocca, 20835 Monza, Italy
| | - Jean-Marie Leclerc
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada.,Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H4A 3J1, Canada
| | - Caroline Laverdière
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada.,Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H4A 3J1, Canada
| | - Daniel Sinnett
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada.,Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H4A 3J1, Canada
| | - Maja Krajinovic
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T1C5, Canada.,Department of Pharmacology & Physiology, Faculty of Medicine, University of Montreal, Montreal, QC, H3C 3J7, Canada.,Centro Ricerca Tettamanti, Department of Pediatrics, University Milano Bicocca, 20835 Monza, Italy
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132
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Rodríguez-Nogales C, González-Fernández Y, Aldaz A, Couvreur P, Blanco-Prieto MJ. Nanomedicines for Pediatric Cancers. ACS NANO 2018; 12:7482-7496. [PMID: 30071163 DOI: 10.1021/acsnano.8b03684] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Chemotherapy protocols for childhood cancers are still problematic due to the high toxicity associated with chemotherapeutic agents and incorrect dosing regimens extrapolated from adults. Nanotechnology has demonstrated significant ability to reduce toxicity of anticancer compounds. Improvement in the therapeutic index of cytostatic drugs makes this strategy an alternative to common chemotherapy in adults. However, the lack of nanomedicines specifically for pediatric cancer care raises a medical conundrum. This review highlights the current state and progress of nanomedicine in pediatric cancer and discusses the real clinical challenges and opportunities.
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Affiliation(s)
- Carlos Rodríguez-Nogales
- Pharmacy and Pharmaceutical Technology Department , University of Navarra , Pamplona 31008 , Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA) , Pamplona 31008 , Spain
| | | | - Azucena Aldaz
- Department of Pharmacy , Clínica Universidad de Navarra , Pamplona 31008 , Spain
| | - Patrick Couvreur
- Institut Galien Paris-Sud, UMR CNRS 8612, Université Paris-Sud, Université Paris-Saclay, Châtenay-Malabry Cedex 92296 , France
| | - María J Blanco-Prieto
- Pharmacy and Pharmaceutical Technology Department , University of Navarra , Pamplona 31008 , Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA) , Pamplona 31008 , Spain
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133
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The Use of Ommaya Reservoirs to Deliver Central Nervous System-Directed Chemotherapy in Childhood Acute Lymphoblastic Leukaemia. Paediatr Drugs 2018; 20:293-301. [PMID: 29850985 DOI: 10.1007/s40272-018-0298-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Prophylactic eradication of central nervous system (CNS) leukaemia is the current standard of care in treating childhood acute lymphoblastic leukaemia (ALL). This is conventionally achieved through regular lumbar punctures with intrathecal injections of methotrexate into the cerebrospinal fluid (CSF). Ommaya reservoirs are subcutaneous implantable devices that provide a secure route of drug delivery into the CSF via an intraventricular catheter. They are an important alternative in cases where intrathecal injection via lumbar puncture is difficult. Among UK Paediatric Principal Treatment Centres for ALL we found considerable variation in methotrexate dosing when using an Ommaya reservoir. We review the current safety and theoretical considerations when using Ommaya reservoirs and evidence for methotrexate dose adjustments via this route. We conclude by summarising the pragmatic consensus decision to use 50% of the conventional intrathecal dose of methotrexate when it is administered via Ommaya reservoir in front-line ALL therapy.
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134
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Peng S, Gerasimenko JV, Tsugorka TM, Gryshchenko O, Samarasinghe S, Petersen OH, Gerasimenko OV. Galactose protects against cell damage in mouse models of acute pancreatitis. J Clin Invest 2018; 128:3769-3778. [PMID: 29893744 PMCID: PMC6118583 DOI: 10.1172/jci94714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/06/2018] [Indexed: 12/21/2022] Open
Abstract
Acute pancreatitis (AP), a human disease in which the pancreas digests itself, has substantial mortality with no specific therapy. The major causes of AP are alcohol abuse and gallstone complications, but it also occurs as an important side effect of the standard asparaginase-based therapy for childhood acute lymphoblastic leukemia. Previous investigations into the mechanisms underlying pancreatic acinar cell death induced by alcohol metabolites, bile acids, or asparaginase indicated that loss of intracellular ATP generation is an important factor. We now report that, in isolated mouse pancreatic acinar cells or cell clusters, removal of extracellular glucose had little effect on this ATP loss, suggesting that glucose metabolism was severely inhibited under these conditions. Surprisingly, we show that replacing glucose with galactose prevented or markedly reduced the loss of ATP and any subsequent necrosis. Addition of pyruvate had a similar protective effect. We also studied the effect of galactose in vivo in mouse models of AP induced either by a combination of fatty acids and ethanol or asparaginase. In both cases, galactose markedly reduced acinar necrosis and inflammation. Based on these data, we suggest that galactose feeding may be used to protect against AP.
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Affiliation(s)
- Shuang Peng
- Cardiff School of Biosciences, Cardiff University, Cardiff, United Kingdom.,Department of Physiology, School of Medicine, Jinan University, Guangzhou, China
| | | | - Tetyana M Tsugorka
- Cardiff School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Oleksiy Gryshchenko
- Cardiff School of Biosciences, Cardiff University, Cardiff, United Kingdom.,Bogomoletz Institute of Physiology, Kiev, Ukraine
| | - Sujith Samarasinghe
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Ole H Petersen
- Cardiff School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Oleg V Gerasimenko
- Cardiff School of Biosciences, Cardiff University, Cardiff, United Kingdom
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135
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Acute lymphoblastic leukemia in adolescent and young adults: treat as adults or as children? Blood 2018; 132:351-361. [DOI: 10.1182/blood-2018-02-778530] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 04/08/2018] [Indexed: 12/21/2022] Open
Abstract
Abstract
Adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) are recognized as a unique population with specific characteristics and needs. In adolescents age 15 to 20 years, the use of fully pediatric protocols is supported by many comparative studies of pediatric and adult cooperative groups. In young adults, growing evidence suggests that pediatric-inspired or even fully pediatric approaches may also dramatically improve outcomes, leading to long-term survival rates of almost 70%, despite diminishing indications of hematopoietic stem-cell transplantation. In the last decade, better knowledge of the ALL oncogenic landscape according to age distribution and minimal residual disease assessments has improved risk stratification. New targets have emerged, mostly in the heterogeneous B-other group, particularly in the Philadelphia-like ALL subgroup, which requires both in-depth molecular investigations and specific evaluations of targeted treatments. The remaining gap in the excellent results reported in children has many other contributing factors that should not be underestimated, including late or difficult access to care and/or trials, increased acute toxicities, and poor adherence to treatment. Specific programs should be designed to take into account those factors and finally ameliorate survival and quality of life for AYAs with ALL.
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136
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Schmiegelow K, Frandsen TL. The cost of cure. LANCET HAEMATOLOGY 2018; 5:e504-e505. [PMID: 29907548 DOI: 10.1016/s2352-3026(18)30070-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Juliane Marie Centre, Righospitalet University Hospital, Copenhagen 2100, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Leth Frandsen
- Department of Paediatrics and Adolescent Medicine, Juliane Marie Centre, Righospitalet University Hospital, Copenhagen 2100, Denmark
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137
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Mauro M, Saggiorato G, Sartori MT, Gallo G, De Bortoli M, Bonetti E, Zaccaron A, Vitale V, Balter R, Chinello M, Cesaro S. Venoocclusive disease due to chemotherapy for pediatric acute lymphoblastic leukemia is associated with increased levels of plasminogen-activator inhibitor-1. Pediatr Blood Cancer 2018; 65:e26963. [PMID: 29350496 DOI: 10.1002/pbc.26963] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 12/23/2022]
Abstract
We describe three cases of sinusoidal obstruction syndrome/venoocclusive disease (SOS) in pediatric patients with acute lymphoblastic leukemia (ALL). All three episodes occurred during or just after the induction or reinduction phase of treatment based on prednisone/dexamethasone, vincristine, daunorubicin, and pegylated-l-asparaginase. SOS episodes were categorized as mild/moderate and resolved in 7, 10, and 16 days using supportive measures or defibrotide therapy. In all three episodes, the clinical diagnosis of SOS was associated with a significant increase in plasminogen-activator inhibitor-1 (PAI-1) that reduced with patient clinical improvement. PAI-1 warrants study as a diagnostic marker for SOS in ALL.
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Affiliation(s)
- Margherita Mauro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | - Giuseppe Gallo
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Elisa Bonetti
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Ada Zaccaron
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Virginia Vitale
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rita Balter
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Chinello
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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138
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Pui CH, Yang JJ, Bhakta N, Rodriguez-Galindo C. Global efforts toward the cure of childhood acute lymphoblastic leukaemia. THE LANCET. CHILD & ADOLESCENT HEALTH 2018; 2:440-454. [PMID: 30169285 PMCID: PMC6467529 DOI: 10.1016/s2352-4642(18)30066-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/31/2018] [Accepted: 02/13/2018] [Indexed: 12/18/2022]
Abstract
Improvements in risk-directed treatment and supportive care, together with increased reliance on both national and international collaborative studies, have made childhood acute lymphoblastic leukaemia (ALL) one of the most curable human cancers. Next-generation sequencing studies of leukaemia cells and the host germline provide new opportunities for precision medicine and thus potential improvements in the cure rate and quality of life of patients. Efforts are underway to assess the global impact of childhood ALL and develop initiatives that can meet the long-term challenge of providing quality care to children with this disease worldwide and improving cure rates globally. This ambitious task will rely on increased collaborative research and international networking so that the therapeutic gains in high-income countries can be translated to patients in low-income and middle-income countries. Ultimately, the greatest obstacle to overcome will be to fully understand leukaemogenesis, enabling measures to decrease the risk of leukaemia development and thus close the last major gap in offering a cure to any child who might have the disease.
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Affiliation(s)
- Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Jun J Yang
- Department of Pharmaceutical Science, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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139
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Thromboembolism in acute lymphoblastic leukemia: results of NOPHO ALL2008 protocol treatment in patients aged 1 to 45 years. Blood 2018; 131:2475-2484. [PMID: 29661787 DOI: 10.1182/blood-2018-01-827949] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/30/2018] [Indexed: 01/19/2023] Open
Abstract
Thromboembolism frequently occurs during acute lymphoblastic leukemia (ALL) therapy. We prospectively registered thromboembolic events during the treatment of 1772 consecutive Nordic/Baltic patients with ALL aged 1 to 45 years who were treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol (July 2008-April 2017). The 2.5-year cumulative incidence of thromboembolism (N = 137) was 7.9% (95% confidence interval [CI], 6.6-9.1); it was higher in patients aged at least 10 years (P < .0001). Adjusted hazard ratios (HRas) were associated with greater age (range, 10.0-17.9 years: HRa, 4.9 [95% CI, 3.1-7.8; P < .0001]; 18.0-45.9 years: HRa, 6.06 [95% CI, 3.65-10.1; P < .0001]) and mediastinal mass at ALL diagnosis (HRa, 2.1; 95% CI, 1.0-4.3; P = .04). In a multiple absolute risk regression model addressing 3 thromboembolism risk factors, age at least 10 years had the largest absolute risk ratio (RRage, 4.7 [95% CI, 3.1-7.1]; RRenlarged lymph nodes, 2.0 [95% CI, 1.2-3.1]; RRmediastinal mass, 1.6 [95% CI, 1.0-2.6]). Patients aged 18.0 to 45.9 years had an increased hazard of pulmonary embolism (HRa, 11.6; 95% CI, 4.02-33.7; P < .0001), and patients aged 10.0 to 17.9 years had an increased hazard of cerebral sinus venous thrombosis (HRa, 3.3; 95% CI, 1.5-7.3; P = .003) compared with children younger than 10.0 years. Asparaginase was truncated in 38/128 patients with thromboembolism, whereas thromboembolism diagnosis was unassociated with increased hazard of relapse (P = .6). Five deaths were attributable to thromboembolism, and patients younger than 18.0 years with thromboembolism had increased hazard of dying compared with same-aged patients without thromboembolism (both P ≤ .01). In conclusion, patients aged at least 10 years could be candidates for preemptive antithrombotic prophylaxis. However, the predictive value of age 10 years or older, enlarged lymph nodes, and mediastinal mass remain to be validated in another cohort.
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Abstract
The occurrence of a stroke in children and adolescents constitutes a rare, critical event that is associated with substantial morbidity and mortality. In addition to the individual suffering for the young patient and the medical burden for the affected family, a stroke is also associated with high follow-up costs for the health system because of the necessary long-term rehabilitative treatment. Establishing an early and prompt diagnosis is of great therapeutic importance. Because of the rarity of the illness and the plethora of clinical manifestations, diagnosis is often delayed. The most frequent clinical presentation is an acute focal-neurological deficit, usually in the form of hemiparesis, but headache, seizures or alteration of consciousness may also be seen. Nowadays, the prompt performance of diffusion-weighted, blood-sensitive magnetic resonance imaging (MRI) constitutes the gold standard. The most relevant risk factors for the occurrence of a stroke in this age cohort are vasculopathies, infections, pathological cardiac conditions or coagulopathies. Recurrence of stroke is dependent on the underlying risk factors. In a substantial percentage of patients, residual neurological deficits are seen.Owing to a lack of randomized controlled trials in children and adolescents with stroke, the optimal treatment approach is still under debate. In addition to anti-platelet medication and heparinization, systematic intravenous thrombolysis and endovascular thrombectomy are other potentially effective treatment options. The long-term prognosis in children is dependent on establishing a correct, early diagnosis.
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141
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A Not Uncommon Cause of Stroke Mimicker in Children. Pediatr Neurol 2018; 80:92-93. [PMID: 29229230 DOI: 10.1016/j.pediatrneurol.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/25/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
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142
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Denton CC, Rawlins YA, Oberley MJ, Bhojwani D, Orgel E. Predictors of hepatotoxicity and pancreatitis in children and adolescents with acute lymphoblastic leukemia treated according to contemporary regimens. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26891. [PMID: 29218844 PMCID: PMC7522002 DOI: 10.1002/pbc.26891] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/12/2017] [Accepted: 10/14/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatotoxicity and pancreatitis are common treatment-related toxicities (TRTs) during contemporary treatment regimens for acute lymphoblastic leukemia (ALL). Limited detailed data from Children's Oncology Group (COG) regimens has been previously reported to enable identification of patient and treatment risk factors for these toxicities and their impact on outcomes. PROCEDURE We analyzed a retrospective pediatric ALL cohort treated at a single institution according to COG regimens from 2008 to 2015. The primary endpoint was cumulative incidence of study-defined "severe" hepatotoxicity (Common Terminology Criteria for Adverse Events [CTCAE] Grade ≥ 4 transaminitis or Grade ≥ 3 hyperbilirubinemia) and clinically significant pancreatitis (any grade). Pancreatitis was additionally classified using the Ponte di Legno (PdL) toxicity criteria. Secondary endpoints were chemotherapy interruptions, early disease response (end of induction [EOI] minimal residual disease [MRD]), and event-free survival (EFS). RESULTS We identified 262 patients, of whom 71 (27%) and 28 (11%) developed hepatotoxicity and pancreatitis, respectively. Three cases of pancreatitis did not fulfill PdL criteria despite otherwise consistent presentations. Both TRTs occurred throughout therapy, but approximately 25% of hepatotoxicity (18/71) and pancreatitis (8/28) occurred during induction alone. Both obesity and age (≥10 years) were identified as predictors of hepatotoxicity (subdistribution hazard ratio [SHR] obesity = 1.75, 95% confidence interval [95% CI] 1.04-2.96; SHR age ≥10 = 1.9, 95% CI 1.19-3.10) and pancreatitis (SHR obesity = 2.18, 95% CI 1.01-4.67; SHR age ≥ 10 = 2.76, 95% CI 1.19-6.39, P = 0.018). Dose interruptions were common but neither toxicity influenced EOI MRD nor EFS. CONCLUSIONS Obese and/or older children are particularly at risk for hepatotoxicity and pancreatitis, and may benefit from toxicity surveillance and chemoprotective strategies to prevent or mitigate associated morbidity.
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Affiliation(s)
- Christopher C. Denton
- Division of Hematology, Oncology, & BMT, Children’s Hospital Los Angeles, Los Angeles, California
| | - Yasmin A. Rawlins
- College of Physicians and Surgeons, Columbia University, New York, New York
| | - Matthew J. Oberley
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Deepa Bhojwani
- Division of Hematology, Oncology, & BMT, Children’s Hospital Los Angeles, Los Angeles, California,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Etan Orgel
- Division of Hematology, Oncology, & BMT, Children’s Hospital Los Angeles, Los Angeles, California,Keck School of Medicine, University of Southern California, Los Angeles, California
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Therapeutic Drug Monitoring of Asparaginase Activity—Method Comparison of MAAT and AHA Test Used in the International AIEOP-BFM ALL 2009 Trial. Ther Drug Monit 2018; 40:93-102. [DOI: 10.1097/ftd.0000000000000472] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sakamoto K, Imamura T, Kihira K, Suzuki K, Ishida H, Morita H, Kanno M, Mori T, Hiramatsu H, Matsubara K, Terui K, Takahashi Y, Suenobu SI, Hasegawa D, Kosaka Y, Kato K, Moriya-Saito A, Sato A, Kawasaki H, Yumura-Yagi K, Hara J, Hori H, Horibe K. Low Incidence of Osteonecrosis in Childhood Acute Lymphoblastic Leukemia Treated With ALL-97 and ALL-02 Study of Japan Association of Childhood Leukemia Study Group. J Clin Oncol 2018; 36:900-907. [PMID: 29360413 DOI: 10.1200/jco.2017.75.5066] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Osteonecrosis (ON) is a serious complication of the treatment of childhood acute lymphoblastic leukemia (ALL); however, data relating to ON in Asian pediatric patients with ALL are scarce. Therefore, we performed a retrospective analysis of cohorts of Japanese patients with ALL to clarify the incidence, clinical characteristics, and risk factors of ON. Patients and Methods The incidence and characteristics of ON were determined in patients with ALL (n = 1,662) enrolled in two studies from the Japan Association of Childhood Leukemia Study (JACLS) group (n = 635 and n = 1,027 patients treated with the ALL-97 and ALL-02 protocols, respectively). Results In total, 24 of 1,662 patients suffered from ON, of which 12 of 635 and 12 of 1,027 patients were treated with the ALL-97 and the ALL-02 protocol, respectively. Of the 24 patients, 23 were older than 10 years. In multivariate analysis, age (≥ 10 years) was the sole significant risk factor for ON ( P < .001). Separate evaluation of patients ≥ 10 years of age indicated a 5-year cumulative incidence of ON of 7.2% (95% CI, 4.0% to 12.6%) and 5.9% (95% CI, 3.3% to 10.4%) in the ALL-97 and the ALL-02 protocol, respectively, which was lower than reported previously, despite an administration of dexamethasone (DEX) similar to that in comparable studies; however, concomitant administration of DEX and l-asparaginase was reduced in the JACLS protocols. Conclusion We identified a low frequency of ON in the JACLS ALL-97 and ALL-02 studies. Although the sole risk factor for ON was age (≥ 10 years), even among high-risk patients, ON incidence was significantly lower than that reported in previous studies. These results suggest that, not only the total amount of DEX, but also how DEX and l-asparaginase are administered, which affects the clearance of DEX, may be associated with ON incidence in patients with ALL.
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Affiliation(s)
- Kenichi Sakamoto
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Toshihiko Imamura
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Kentaro Kihira
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Koji Suzuki
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Hisashi Ishida
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Hiromi Morita
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Miyako Kanno
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Takeshi Mori
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Hidefumi Hiramatsu
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Kousaku Matsubara
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Kiminori Terui
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Takahashi
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - So-Ichi Suenobu
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Daiichiro Hasegawa
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Yoshiyuki Kosaka
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Koji Kato
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Akiko Moriya-Saito
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Atsushi Sato
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Hirohide Kawasaki
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Keiko Yumura-Yagi
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Junichi Hara
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Hiroki Hori
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
| | - Keizo Horibe
- Kenichi Sakamoto and Toshihiko Imamura, Kyoto Prefectural University of Medicine; Hidefumi Hiramatsu, Kyoto University, Kyoto; Kenichi Sakamoto, Toshihiko Imamura, Akiko Moriya-Saito, and Keizo Horibe, National Hospital Organization Nagoya Medical Center; Koji Kato, Japanese Red Cross Nagoya First Hospital, Nagoya; Kentaro Kihira and Hiroki Hori, Mie University, Mie; Koji Suzuki, University of Fukui Faculty of Medical Sciences, Fukui; Hisashi Ishida, Okayama University, Okayama; Hiromi Morita, University of Occupational and Environmental Health, Iseigaoka; Miyako Kanno, Yamagata University, Yamagata; Takeshi Mori, Kobe University; Kousaku Matsubara, Kobe City Nishi-Kobe Medical Center; Daiichiro Hasegawa and Yoshiyuki Kosaka, Hyogo Prefectural Children's Hospital, Kobe; Kiminori Terui, Hirosaki University, Hirosaki; Yoshihiro Takahashi, Aomori Prefectural Central Hospital, Aomori; So-ichi Suenobu, Oita University, Oita; Atsushi Sato, Miyagi Children's Hospital, Sendai; Hirohide Kawasaki, Kansai Medical University; Keiko Yumura-Yagi, Yumura Clinic; and Junichi Hara, Osaka City General Hospital, Osaka, Japan
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Posterior Reversible Encephalopathy Syndrome: Risk Factors and Impact on the Outcome in Children With Acute Lymphoblastic Leukemia Treated With Nordic Protocols. J Pediatr Hematol Oncol 2018; 40:e13-e18. [PMID: 29200159 DOI: 10.1097/mph.0000000000001009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) in children with acute lymphoblastic leukemia has been increasingly recognized as a clinicoradiological entity. Our aim was to describe the incidence of PRES in pediatric patients with ALL, identify its risk factors, and examine its prognostic importance. For this research, we conducted a systematic, retrospective review of the patient records in a population-based series of children with acute lymphoblastic leukemia (n=643) treated in Finland from 1992 to 2008. Of the patients with ALL, 4.5% (n=29) developed radiologically confirmed PRES, of which 28 cases occurred during induction. Hypertension (P=0.006; odds ratio [OR], 4.10, confidence interval [CI], 1.50-11.25), constipation (P=0.001; OR, 5.60; CI, 2.02-15.52), and >14 days of alkalinization (P=0.017; OR, 3.27; CI, 1.23-8.68) were significant independent risk factors for PRES. One-third of the patients developed epilepsy. Relapses occurred significantly more often in those patients with PRES (P=0.001), which was associated with worse overall survival (P=0.040; 5-year survival=75.9% [60.3%-91.4%] vs. 88.4% [85.8%-90.9%]). Using NOPHO-ALL 92/2000 protocols, PRES is a significant early complication of therapy in ALL, and was associated with a poorer prognosis and significant neurological morbidity.
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Hough R, Vora A. Crisis management in the treatment of childhood acute lymphoblastic leukemia: putting right what can go wrong (emergency complications of disease and treatment). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:251-258. [PMID: 29222263 PMCID: PMC6142611 DOI: 10.1182/asheducation-2017.1.251] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The improvement in overall survival in children with acute lymphoblastic leukemia (ALL) over the last 5 decades has been considerable, with around 90% now surviving long term. The risk of relapse has been reduced to such an extent that the risk of treatment-related mortality is now approaching that of mortality caused by relapse. Toxicities may also lead to the suboptimal delivery of chemotherapy (treatment delays, dose reductions, dose omissions), potentially increasing relapse risk, and short- and long-term morbidity, adding to the "burden of therapy" in an increasing number of survivors. Thus, the need to reduce toxicity in pediatric ALL is becoming increasingly important. This work focuses on the risk factors, pathogenesis, clinical features, and emergency management of the life-threatening complications of ALL at presentation and during subsequent chemotherapy, including leucostasis, tumor lysis syndrome, infection, methotrexate encephalopathy, thrombosis, and pancreatitis. Potential strategies to abrogate these toxicities in the future are also discussed.
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Affiliation(s)
- Rachael Hough
- Department of Adolescent Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom; and
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children, London, United Kingdom
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147
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Völler S, Pichlmeier U, Zens A, Hempel G. Pharmacokinetics of recombinant asparaginase in children with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2017; 81:305-314. [DOI: 10.1007/s00280-017-3492-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/27/2017] [Indexed: 11/28/2022]
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148
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Schrappe M, Bleckmann K, Zimmermann M, Biondi A, Möricke A, Locatelli F, Cario G, Rizzari C, Attarbaschi A, Valsecchi MG, Bartram CR, Barisone E, Niggli F, Niemeyer C, Testi AM, Mann G, Ziino O, Schäfer B, Panzer-Grümayer R, Beier R, Parasole R, Göhring G, Ludwig WD, Casale F, Schlegel PG, Basso G, Conter V. Reduced-Intensity Delayed Intensification in Standard-Risk Pediatric Acute Lymphoblastic Leukemia Defined by Undetectable Minimal Residual Disease: Results of an International Randomized Trial (AIEOP-BFM ALL 2000). J Clin Oncol 2017; 36:244-253. [PMID: 29148893 DOI: 10.1200/jco.2017.74.4946] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Delayed intensification (DI) is an integral part of treatment of childhood acute lymphoblastic leukemia (ALL), but it is associated with relevant toxicity. Therefore, standard-risk patients of trial AIEOP-BFM ALL 2000 (Combination Chemotherapy Based on Risk of Relapse in Treating Young Patients With ALL) were investigated with the specific aim to reduce treatment intensity. Patients and Methods Between July 2000 and July 2006, 1,164 patients (1 to 17 years of age) with standard-risk ALL (defined as the absence of high-risk cytogenetics and undetectable minimal residual disease on days 33 and 78) were randomly assigned to either experimental reduced-intensity DI (protocol III; P-III) or standard DI (protocol II; P-II). Cumulative drug doses of P-III were reduced by 30% for dexamethasone and 50% for vincristine, doxorubicin, and cyclophosphamide, which shortened the treatment duration from 49 to 29 days. The study aimed at noninferiority of reduced-intensity P-III; analyses were performed according to treatment given. Results For P-III and P-II, respectively, the 8-year rate of disease-free survival (± SE) was 89.2 ± 1.3% and 92.3 ± 1.2% ( P = .04); cumulative incidence of relapse, 8.7 ± 1.2% and 6.4 ± 1.1% ( P = .09); and overall survival, 96.1 ± 0.8% and 98.0 ± 0.6% ( P = .06). Patients with ETV6-RUNX1-positive ALL and patients 1 to 6 years of age performed equally well in both arms. The incidence of death during remission was comparable, which indicates equivalent toxicity. The 8-year cumulative incidence rate of secondary malignancies was 1.3 ± 0.5% and 0.6 ± 0.4% for P-III and P-II, respectively ( P = .37). Conclusion Although the criteria used for the standard-risk definition in this trial identified patients with exceptionally good prognosis, reduction of chemotherapy was not successful mainly because of an increased rate of relapse. The data suggest that treatment reduction is feasible in specific subgroups, which underlines the biologic heterogeneity of this cohort selected according to treatment response.
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Affiliation(s)
- Martin Schrappe
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Kirsten Bleckmann
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Martin Zimmermann
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Andrea Biondi
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Anja Möricke
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Franco Locatelli
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Gunnar Cario
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Carmelo Rizzari
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Andishe Attarbaschi
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Maria Grazia Valsecchi
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Claus R Bartram
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Elena Barisone
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Felix Niggli
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Charlotte Niemeyer
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Anna Maria Testi
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Georg Mann
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Ottavio Ziino
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Beat Schäfer
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Renate Panzer-Grümayer
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Rita Beier
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Rosanna Parasole
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Gudrun Göhring
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Wolf-Dieter Ludwig
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Fiorina Casale
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Paul-Gerhardt Schlegel
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Giuseppe Basso
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
| | - Valentino Conter
- Martin Schrappe, Kirsten Bleckmann, Anja Möricke, and Gunnar Cario, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; Martin Zimmermann and Gudrun Göhring, Hannover Medical School, Hannover; Claus R. Bartram, Institute of Human Genetics, Ruprecht-Karls University, Heidelberg; Charlotte Niemeyer, University of Freiburg, Freiburg; Rita Beier, University Hospital, Essen; Wolf-Dieter Ludwig, HELIOS Medical Center Berlin-Buch, Berlin; Paul-Gerhardt Schlegel, University of Würzburg, Würzburg, Germany; Andrea Biondi, Carmelo Rizzari, Maria Grazia Valsecchi, and Valentino Conter, University of Milano-Bicocca; Andrea Biondi, Carmelo Rizzari, and Valentino Conter, Ospedale San Gerardo, Monza; Franco Locatelli, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù; Anna Maria Testi, University La Sapienza, Rome; Elena Barisone, Regina Margherita Children's Hospital, Turin; Ottavio Ziino, Azienda di Rilievo Nazionale ad Alta Specializzazione Ospedali Civico Di Cristina, Palermo; Rosanna Parasole, Santobono-Pausilipon Children's Hospital; Fiorina Casale, University of Naples, Naples; Giuseppe Basso, University of Padova, Padova, Italy; Andishe Attarbaschi, Georg Mann, and Renate Panzer-Grümayer, St Anna Children's Hospital and Medical University of Vienna, Vienna, Austria; and Felix Niggli and Beat Schäfer, University Hospital Zürich, Zürich, Switzerland
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Zama D, Gasperini P, Berger M, Petris M, De Pasquale MD, Cesaro S, Guerzoni ME, Mastrodicasa E, Savina F, Ziino O, Kiren V, Muggeo P, Mura RM, Melchionda F, Zanazzo GA. A survey on hematology-oncology pediatric AIEOP centres: The challenge of posterior reversible encephalopathy syndrome. Eur J Haematol 2017; 100:75-82. [PMID: 29032616 DOI: 10.1111/ejh.12984] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Posterior reversible encephalopathy syndrome (PRES) is one of the most common neurological complications in hematology-oncology pediatric patients. Despite an increasingly recognized occurrence, no clear consensus exists regarding how best to manage the syndrome, because most cases of PRES have reported in single-case reports or small series. Aim of this paper is to identify incidence, clinical features, management, and outcome of PRES in a large series of hematology-oncology pediatric patients. METHODS The cases of PRES occurred in twelve centers of the Italian Association of Pediatric Hematology and Oncology were reported. RESULTS One hundred and twenty-four cases of PRES in 112 pediatric patients were recorded with an incidence of 2.1% and 4.7%, respectively, in acute lymphoblastic leukemia in first complete remission and hematopoietic stem cell transplantation (HSCT). The majority of cases occurred after a cycle of chemotherapy rather than after stem cell transplant. PRES after chemotherapy significantly differs from that after HSCT for diagnosis, time of presentation, risk factors, management, and outcome. CONCLUSIONS This study demonstrates that PRES is a common neurological complication and occurring preferentially in course of induction treatment of some hematologic malignancies, as ALL and after HSCT. It also highlights great clinical differences in the management and outcome in patients with PRES occurring after chemotherapy or after HSCT.
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Affiliation(s)
- Daniele Zama
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pietro Gasperini
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Massimo Berger
- Pediatric Onco-Hematology and Stem Cell Transplant Division, City of Health and Science, Regina Margherita Children's Hospital, Turin, Italy
| | | | - Maria D De Pasquale
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Rome, Italy
| | - Simone Cesaro
- Department of Paediatrics, Paediatric Haematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Maria E Guerzoni
- Department of Medical and Surgical Sciences for Mothers, Children and Adults, Onco-hematology Pediatric Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Mastrodicasa
- Pediatric Onco-Hematology and Stem Cell Transplant Unit, S.Maria della Misericordia Hospital, Perugia, Italy
| | | | - Ottavio Ziino
- Pediatric Hematology-Oncology, ARNAS Civico, Palermo, Italy
| | - Valentina Kiren
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Rosa M Mura
- Paediatric Haematology-Oncology, Ospedale Pediatrico Microcitemico, Cagliari, Italy
| | - Fraia Melchionda
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giulio A Zanazzo
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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Mogensen SS, Harila-Saari A, Frandsen TL, Lähteenmäki P, Castor A, Kohonen I, Schmiegelow K, Mäkitie O. Early presentation of osteonecrosis in acute lymphoblastic leukemia: Two children from the Nordic and Baltic cohort. Pediatr Blood Cancer 2017; 64. [PMID: 28521072 DOI: 10.1002/pbc.26624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/03/2017] [Accepted: 04/07/2017] [Indexed: 12/27/2022]
Abstract
Osteonecrosis (ON) is usually considered treatment related in patients with acute lymphoblastic leukemia (ALL). We report two patients with presentation of ON at the time of ALL diagnosis. Both were females and diagnosed with ALL at age 8 and 14 years. In the latter, some symptoms and radiologically verified ON in both knees were still present after the end of ALL therapy. No pediatric patients have previously been reported with ON presenting before initiation of ALL therapy.
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Affiliation(s)
- Signe Sloth Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Arja Harila-Saari
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Päivi Lähteenmäki
- Department of Pediatric and Adolecent Medicine, Turku University Hospital and University of Turku, Finland
| | - Anders Castor
- Department of Pediatric Oncology, Skane University Hospital, Lund, Sweden
| | - Ia Kohonen
- Medical Imaging of Southwest Finland, University of Turku, Turku, Finland
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Outi Mäkitie
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden.,Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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