Female survivors of childhood cancer: preterm birth and low birth weight among their children

Cancer treatment and gonadal function: experimental and established strategies for fertility preservation in children and young adults

Preservation of gonadal function is an important priority for the long-term health of cancer survivors of both sexes and all ages at treatment. Loss of opportunity for fertility is a prime concern in both male and female cancer survivors, but endocrine effects of gonadal damage are likewise central to long-term health and wellbeing. Some fertility preservation techniques, such as semen and embryo cryopreservation, are established and successful in adults, and development of oocyte vitrification has greatly improved the potential to cryopreserve unfertilised oocytes. Despite being recommended for all pubertal male patients, sperm banking is not universally practised in paediatric oncology centres, and very few adolescent-friendly facilities exist. All approaches to fertility preservation have specific challenges in children and teenagers, including ethical, practical, and scientific issues. For young women, cryopreservation of ovarian cortical tissue with later replacement has resulted in at least 40 livebirths, but is still regarded as experimental in most countries. For prepubertal boys, testicular biopsy cryopreservation is offered in some centres, but how that tissue might be used in the future is unclear, and so far no evidence suggests that fertility can be restored. For both sexes, these approaches involve an invasive procedure and have an uncertain risk of tissue contamination in haematological and other malignancies. Decision making for all these approaches needs assessment of the individual's risk of fertility loss, and is made at a time of emotional distress. Development of this specialty needs better provision of information for patients and their medical teams, and improvements in service provision, to match technical and scientific advances.

Exposure to radiation therapy is associated with female reproductive health among childhood cancer survivors: a meta-analysis study

BACKGROUND AND AIMS

Many epidemiological studies have revealed a positive correlation between medical radiation exposure and the reproductive health in female childhood cancer survivors. However, because of variations in the samples size, such studies showed partly inconsistent conclusions. The aim of this meta-analysis was to clarify the association between radiotherapy and the risk of reproductive health impairment for female who survived from childhood cancer.

METHODS

Fourteen cohort studies involving childhood radiotherapy were selected as the exposure of interest and the impaired reproductive health condition during the childbearing age as the outcome. Among meta-analysis of observational studies found in Pubmed and Embase from 1900 to 2014, we evaluated those relevant observational studies which surveyed the association of medical radiation and reproductive health in female childhood cancer survivors. Review Manager 5.2 and STATA 12.0 software were used to perform the meta-analysis. Study-specific estimations for each outcome were combined into a pooled relative risk (RR) with 95% confidence interval (CI) by a meta-analytic approach.

RESULTS

Based on a random-effects meta-analysis, significant association between infertility (RR = 1.28, 95% CI = 1.16-1.42), acute ovarian failure (AOF) (RR = 9.51, 95% CI = 5.03-17.96), low level of anti mullerian hormone (AMH) (<1 ng/mL) (RR = 14.79, 95% CI = 3.36-66.64), stillbirth (RR = 1.19, 95% CI = 1.02-1.39) and low birth weight (RR = 2.22, 95% CI = 1.55-3.17) were identified. Conversely, no significant results were found in abortion and congenital malformations.

CONCLUSIONS

To the best of our knowledge, this is the first meta-analysis assessing the effect of medical radiation on female childhood cancer survivors' reproductive capability and pregnancy outcomes. Although there were some limitations, our meta-analysis further supported that radiotherapy was a risk factor for reproductive health problems of female who survived from childhood cancer.

[Gonadal function after treatment for a childhood or adolescent cancer]

Due to high cure rate in childhood and adolescent cancer, fertility preservation is a major concern. Chemotherapy, radiotherapy and surgery may alter gonadal function, and uterine cavity in women. In women, combined toxicity affecting both endocrine function and ovulation are observed leading to premature ovarian insufficiency. In men, spermatogenesis is frequently affected whereas endocrine function is almost always preserved. The current article focuses on investigations concerning gonadal function after treatment for a cancer during childhood or adolescence and treatment of subsequent infertility or hypogonadism. Nevertheless, those therapeutic are still limited and pretherapeutic preservation of fertility is preferred when possible.

Modern radiation therapy and potential fertility preservation strategies in patients with cervical cancer undergoing chemoradiation

Young patients with cervical cancer who undergo chemoradiation might be interested in fertility preservation, not only dependent upon the use of a gestational carrier as maybe achieved by the use of ovarian transposition and cryo-conservation of oocytes or ovarian tissue, but may prefer to carry pregnancy to term after cancer treatment. The latter approach is a non-established concept needing both modern radiation therapy approaches as well as modifications -if at all possible- in current recommendations for target volume delineation to spare dose to the unaffected uterus. Future strategies to serve selected patients in this respect should only be conducted in prospective clinical evaluations and are critically discussed in this article.

Lifestyle, distress, and pregnancy outcomes in the Childhood Cancer Survivor Study cohort

OBJECTIVE

To evaluate associations between prepregnancy lifestyle factors, psychologic distress and adverse pregnancy outcomes among female survivors of childhood cancer.

STUDY DESIGN

We examined pregnancies of 1192 female participants from the Childhood Cancer Survivor Study. Generalized linear models, adjusted for age at diagnosis, age at pregnancy, parity, and education were used to calculate the odds ratio (OR) and confidence interval (CI) for associations between prepregnancy inactivity, overweight or obese status, smoking status, risky drinking, psychologic distress and pregnancy outcomes. Interactions between lifestyle factors, psychologic distress, type of cancer and cancer treatment were assessed in multivariable models.

RESULTS

The median age of study participants at the beginning of pregnancy was 28 years (range, 14-45). Among 1858 reported pregnancies, there were 1300 singleton live births (310 were preterm), 21 stillbirths, 397 miscarriages, and 140 medical abortions. Prepregnancy physical inactivity, risky drinking, distress, and depression were not associated with any pregnancy outcomes. Compared with those who had never smoked, survivors with >5 pack-years smoking history had a higher risk for miscarriage among those treated with >2.5 Gray (Gy) uterine radiation (OR, 53.9; 95% CI, 2.2-1326.1) than among those treated with ≤2.5 Gy uterine radiation (OR, 1.9; 95% CI, 1.2-3.0). There was a significant interaction between smoking and uterine radiation (Pinteraction = .01).

CONCLUSION

Although most lifestyle factors and psychologic distress were not predictive of adverse pregnancy outcomes, the risk for miscarriage was significantly increased among survivors exposed to >2.5 Gy uterine radiation who had a history of smoking.

Oocyte donation outcome after oncological treatment in cancer survivors

OBJECTIVE

To study reproductive outcome in patients cured of cancer who required oocyte donation (OD) owing to iatrogenic ovarian dysfunction.

DESIGN

Multicenter, unmatched, retrospective cohorts study.

SETTING

Private, university-affiliated group of clinics.

PATIENT(S)

Women treated and cured of cancer (n = 142) who underwent 333 cycles of OD (exposed group) and women without a previous cancer diagnosis (n = 17,844) who underwent 29,778 cycles of OD (unexposed cohort) between January 2000 and January 2012.

INTERVENTION(S)

Retrospective chart review.

MAIN OUTCOME MEASURE(S)

Pregnancy, implantation, miscarriage, and ongoing pregnancy rates.

RESULT(S)

There were no differences in terms of pregnancy (55.7% vs. 54.7%), implantation (39.8% vs. 38.2%), miscarriage (29.5% vs. 26.9%), or delivery rates (39.3% vs. 39.9%) between the unexposed group and the patients previously diagnosed and cured of cancer, respectively. There was no correlation between OD outcome and cancer type.

CONCLUSION(S)

Endometrial receptivity in women treated and cured of cancer was comparable to that of general patients without previous malignancies who had received OD, based on the largest series available in the literature.

Vaginal delivery after hemipelvectomy and pelvic radiotherapy for chondrosarcoma

Chondosarcoma of the proximal femur is a rare malignant disorder in women of (pre-) childbearing age, for which a radical resection through a hemipelvectomy could be indicated. We describe a case of a 36-year-old primigravida with a hemipelvectomy (2004) who had a history of radiotherapy of the pelvic and uterine regions after an atypical cartilaginous tumour. After an uncomplicated pregnancy, she had a spontaneous rupture of the membranes at 41+2 weeks and an uncomplicated vaginal delivery with physiological development of the infant. On the basis of the literature review, vaginal delivery after hemipelvectomy should be advocated and discussed with the patient and involved care providers. Women with radiotherapy in the pelvic and uterine areas have an increased risk of stillbirth, placental attachment disorders, impaired fetal growth, fetal malposition and preterm labour, but no association with prolonged rupture of the membranes has been described.

The impact of uterine radiation on subsequent fertility and pregnancy outcomes

Future fertility is of paramount importance to younger cancer survivors. Advances in assisted reproductive technology mean that young women treated with radiation involving the uterus may require clinical guidance regarding whether to attempt a pregnancy themselves. We performed a review of the literature regarding radiation involving uterus (total body irradiation (TBI) and pelvic radiation), fertility, and pregnancy outcomes to come up with a recommendation for our patients. Limited evidence suggests lower fecundity and an increased incidence of pregnancy complications after uterine radiation. Higher radiation doses and direct uterine radiation both significantly increase the risk of an adverse pregnancy outcome. Uterine radiation doses of <4 Gy do not appear to impair uterine function. Adult TBI data (usually 12 Gy) suggest pregnancy is possible but with lower fecundity and more complications. Although there is no clear data indicating the dose of radiation to the uterus, above which a pregnancy would not be sustainable, we suggest patients receiving >45 Gy during adulthood and >25 Gy in childhood be counselled to avoid attempting pregnancy. There is preliminary evidence that menopausal hormone therapy and a combination of pentoxifylline and tocopherol may improve uterine function following irradiation.

Counseling women and men regarding exposures to reproductive and developmental toxicants before conception or women during pregnancy

It should be apparent that determining the reproductive risks of an exposure during pregnancy or the cause of a child's congenital malformations is not a simple process. It involves a careful analysis of the medical and scientific literature pertaining to the reproductive toxic effects of exogenous agents in humans and animals, as well as an evaluation of the exposure and the biological plausibility of the concern of an increased risk or a causal connection between the exposure and a child's congenital malformations. It also involves having available a detailed physical examination of the malformed infant or child and a review of the scientific literature pertaining to genetic and environmental causes of the malformations in question. Abridged counseling on the basis of superficial and incomplete analyses is a disservice to the family. Experienced counselors understand that their primary task is to educate the pregnant women or family members concerning the risk of an environmental exposure. The counselor should advise them on the options available, but not on which option to select.

[Cryoconservation of ovarian tissue: indications and outcome of the patients]

OBJECTIVES

Ovarian Tissue Cryopreservation (OTC) is a very promising approach of fertility preservation for women and young patients who have to follow gonadotoxic treatments (chemotherapy, radiotherapy…). The aim of this study was to analyse the indications and the outcomes of the patients who had OTC in our center during the last 17 years.

PATIENTS AND METHODS

The study is retrospective. Forty-six patients, who underwent OTC in the Laboratory of Reproductive Biology of the University Hospital of Clermont-Ferrand, between January 1997 and December 2009, were included.

RESULTS

The average age on the day of ovarian tissue harvesting was 19.5 years. Fifty-two percent of the patients were minor. In order of decreasing frequency, the diseases for which OTC has been proposed were hematologic, ovarian tumors, sarcoma ou PNET and breast neoplasia. In 93.5 %, the harvesting of ovarian cortex was performed by laparoscopy. After OTC, 82.6 % of the patients were treated by chemotherapy. A bone marrow transplant was performed for 48 % of the study patients. At the time of data collection, 57 % of the patients who had evaluation of their ovarian function presented premature ovarian failure. Eight patients had one or more pregnancies after treatment. It was a natural pregnancy for five of them. The three others were obtained by medically assisted procreation (in vitro fertilization and oocyte donation).

DISCUSSION AND CONCLUSION

We report a long-term follow-up of patients treated in our center for OTC. The originality of our study is to evaluate all aspects of OTC from the decision to propose the patients an OTC to their outcomes several years after the ovarian tissue harvesting. It is therefore a multidisciplinary approach both oncology, gynecological and pediatric whereas OTC is often considered restrictively in the literature. Finally, it seems to be essential to establish a specific medical care for these patients. This monitoring will allow an adequate assessment of pubertal development and ovarian function, management of estrogen deficiency and secondary infertility, supporting patients in their desire for motherhood.

Clinical guide to fertility preservation in hematopoietic cell transplant recipients

With broadening indications, more options for hematopoietic cell transplantation (HCT) and improvement in survival, the number of long-term HCT survivors is expected to increase steadily. Infertility is a frequent problem that long-term HCT survivors and their partners face and it can negatively impact on the quality of life. The most optimal time to address fertility issues is before the onset of therapy for the underlying disease; however, fertility preservation should also be addressed before HCT in all children and patients of reproductive age, with referral to a reproductive specialist for patients interested in fertility preservation. In vitro fertilization (IVF) and embryo cryopreservation, oocyte cryopreservation and ovarian tissue banking are acceptable methods for fertility preservation in adult women/pubertal females. Sperm banking is the preferred method for adult men/pubertal males. Frequent barriers to fertility preservation in HCT recipients may include the perception of lack of time to preserve fertility given an urgency to move ahead with transplant, lack of patient-physician discussion because of several factors (for example, time constraints, lack of knowledge), inadequate access to reproductive specialists, and costs and lack of insurance coverage for fertility preservation. There is a need to raise awareness in the medical community about fertility preservation in HCT recipients.

Survivors of childhood and adolescent cancer: life-long risks and responsibilities

Survival rates for most paediatric cancers have improved at a remarkable pace over the past four decades. In developed countries, cure is now the probable outcome for most children and adolescents who are diagnosed with cancer: their 5-year survival rate approaches 80%. However, the vast majority of these cancer survivors will have at least one chronic health condition by 40 years of age. The burden of responsibility to understand the long-term morbidity and mortality that is associated with currently successful treatments must be borne by many, including the research and health care communities, survivor advocacy groups, and governmental and policy-making entities.

Acute effects of pelvic irradiation on the adult uterus revealed by dynamic contrast-enhanced MRI

OBJECTIVE

Pelvic radiation therapy (RT) can influence fertility in female rectal cancer survivors. Data regarding its effects on the adult uterus are scant. This study aims to evaluate the uterus before and after RT, using dynamic contrast-enhanced MRI.

METHODS

Eligible patients (n=10) received RT for rectal cancer, had an intact uterus and underwent dynamic contrast-enhanced MRI before and after RT. Seven patients were pre-menopausal.

RESULTS

Patients received pelvic RT (median, 50.2 Gy) with concurrent 5-fluorouracil. Five patients were treated with intensity modulated RT (IMRT) and five with a three-field technique. The median D95 of the uterus was 30 Gy; D05 was 48 Gy; and V95 was 97%. The median cervical D95 was 45 Gy; D05, 50 Gy; and V95, 100%. Cervical dose was higher with IMRT than with three-field plans (p≤0.038). On T2 MRI, the junctional zone was visible in nine patients before and in one after RT (p=0.001). Median cervical length (2.3 vs 3.0 cm) and endometrial thickness (2.6 vs 5.9 mm) were reduced after RT (p≤0.008). In pre-menopausal patients, the volume transfer constant, K(trans), (0.069 vs 0.195, p=0.006) and the extracellular extravascular volume fraction, V(e), (0.217 vs 0.520, p=0.053) decreased.

CONCLUSION

Pelvic RT significantly affected uterine anatomy and perfusion. Cervical dose was higher with IMRT than three-field plans, but no attempt was made to constrain the dose.

ADVANCES IN KNOWLEDGE

Pelvic RT significantly affects the adult uterus. These findings are crucial to understand the potential consequences of RT on fertility, and they lay the groundwork for further prospective studies.

Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion

Patients preparing to undergo gonadotoxic medical therapy or radiation therapy or gonadectomy should be provided with prompt counseling regarding available options for fertility preservation. Fertility preservation can best be provided by comprehensive programs designed and equipped to confront the unique challenges facing these patients.

Stillbirth, early death and neonatal morbidity among offspring of female cancer survivors

BACKGROUND

Increased awareness of the adverse effects of cancer treatments has prompted the development of fertility preserving regimens for the growing population of cancer survivors who desire to have children of their own.

MATERIAL AND METHODS

We conducted a registry-based study to evaluate the risk of stillbirth, early death and neonatal morbidity among children of female cancer survivors (0-34 years at diagnosis) compared with children of female siblings. A total of 3501 and 16 908 children of female cancer patients and siblings, respectively, were linked to the national medical birth and cause-of-death registers.

RESULTS

The risk of stillbirth or early death was not significantly increased among offspring of cancer survivors as compared to offspring of siblings: the risk [Odds Ratio (OR)] of early neonatal death, i.e. mortality within the first week was 1.35, with a 95% confidence interval (CI) of 0.58-3.18, within 28 days 1.40, 95% CI 0.46-4.24 and within the first year of life 1.11, 95% CI 0.64-1.93 after adjustment for the main explanatory variables. All these risk estimates were reduced towards one after further adjustment for duration of pregnancy. Measures of serious neonatal morbidity were not significantly increased among the children of survivors. However, there was a significant increase in the monitoring of children of cancer survivors for neonatal conditions (OR 1.56, 95% CI 1.35-1.80), which persisted even after correcting for duration of pregnancy, that might be related to parental cancer and its treatment or increased surveillance among the children.

CONCLUSION

Offspring of cancer survivors were more likely to require monitoring or care in a neonatal intensive care unit, but the risk of early death or stillbirth was not increased after adjustment for prematurity. Due to the rarity of the mortality outcomes studied, collaborative studies may be helpful in ruling out the possibility of an increased risk among offspring of cancer survivors.

Emergency IVF for embryo freezing to preserve female fertility: a French multicentre cohort study

STUDY QUESTION

What are the outcomes of French emergency IVF procedures involving embryo freezing for fertility preservation before gonadotoxic treatment?

SUMMARY ANSWER

Pregnancy rates after emergency IVF, cryopreservation of embryos, storage, thawing and embryo transfer (embryo transfer), in the specific context of the preservation of female fertility, seem to be similar to those reported for infertile couples undergoing ART.

STUDY DESIGN, SIZE, DURATION

A French retrospective multicentre cohort study initiated by the GRECOT network-the French Study Group for Ovarian and Testicular Cryopreservation. We sent an e-mail survey to the 97 French centres performing the assisted reproduction technique in 2011, asking whether the centre performed emergency IVF and requesting information about the patients' characteristics, indications, IVF cycles and laboratory and follow-up data. The response rate was 53.6% (52/97).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fourteen French centres reported that they performed emergency IVF (56 cycles in total) before gonadotoxic treatment, between 1999 and July 2011, in 52 patients.

MAIN RESULTS AND THE ROLE OF CHANCE

The patients had a mean age of 28.9 ± 4.3 years, and a median length of relationship of 3 years (1 month-15 years). Emergency IVF was indicated for haematological cancer (42%), brain tumour (23%), sarcoma (3.8%), mesothelioma (n = 1) and bowel cancer (n = 1). Gynaecological problems accounted for 17% of indications. In 7.7% of cases, emergency IVF was performed for autoimmune diseases. Among the 52 patients concerned, 28% (n = 14) had undergone previous courses of chemotherapy before beginning controlled ovarian stimulation (COS). The initiation of gonadotoxic treatment had to be delayed in 34% of the patients (n = 19). In total, 56 cycles were initiated. The mean duration of stimulation was 11.2 ± 2.5 days, with a mean peak estradiol concentration on the day on which ovulation was triggered of 1640 ± 1028 pg/ml. Three cycles were cancelled due to ovarian hyperstimulation syndrome (n = 1), poor response (n = 1) and treatment error (n = 1). A mean of 8.2 ± 4.8 oocytes were retrieved, with 6.1 ± 4.2 mature oocytes and 4.4 ± 3.3 pronuclear-stage embryos per cycle. The mean number of embryos frozen per cycle was 4.2 ± 3.1. During follow-up, three patients died from the consequences of their disease. For the 49 surviving patients, 22.5% of the couples concerned (n = 11) requested embryo replacement. A total of 33 embryos were thawed with a post-thawing survival rate of 76%. Embryo replacement was finally performed for 10 couples with a total of 25 embryos transferred, leading to one biochemical pregnancy, one miscarriage and three live births. Clinical pregnancy rate and live birth per couple who wanted a pregnancy after cancer were, respectively, 36% (95% CI = 10.9-69.2%) and 27% (95% CI = 6.0-61%).

LIMITATIONS, REASONS FOR CAUTION

The overall response rate for clinics was 53.6%. Therefore, it is not only that patients may not have been included, but also that those that were included were biased towards the University sector with a response rate of 83% (25/30) for a small number of patients.

WIDER IMPLICATIONS OF THE FINDINGS

According to literature, malignant disease is a risk factor for a poor response to COS. However, patients having emergency IVF before gonadotoxic treatment have a reasonable chance of pregnancy after embryo replacement. Embryo freezing is a valuable approach that should be included among the strategies used to preserve fertility.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was sought for this study. None of the authors has any conflict of interest to declare.

Evidence relevant to untargeted and transgenerational effects in the offspring of irradiated parents

In this article we review health effects in offspring of human populations exposed as a result of radiotherapy and some groups exposed to chemotherapy. We also assess risks in offspring of other radiation-exposed groups, in particular those of the Japanese atomic bomb survivors and occupationally and environmentally exposed groups. Experimental findings are also briefly surveyed. Animal and cellular studies tend to suggest that the irradiation of males, at least at high doses (mostly 1Gy and above), can lead to observable effects (including both genetic and epigenetic) in the somatic cells of their offspring over several generations that are not attributable to the inheritance of a simple mutation through the parental germline. However, studies of disease in the offspring of irradiated humans have not identified any effects on health. The available evidence therefore suggests that human health has not been significantly affected by transgenerational effects of radiation. It is possible that transgenerational effects are restricted to relatively short times post-exposure and in humans conception at short times after exposure is likely to be rare. Further research that may help resolve the apparent discrepancies between cellular/animal studies and studies of human health are outlined.

Birth outcomes among offspring of adult cancer survivors: a population-based study

Do cancer and cancer treatment influence patients' subsequent pregnancies and outcomes for the offspring? In this study, we compared birth outcomes in 3,915 female and male survivors and 144,653 controls from the general population with similar parity, by merging data from the Cancer Registry and the Medical Birth Registry of Norway. The cancer survivors were diagnosed at age 16-45 in the period 1967-2004. Subgroups of nulliparous survivors (childless before cancer) and primiparous (one pregnancy before and one after cancer) were analyzed, using logistic regression to compare birth outcomes with controls, focusing perinatal death, congenital anomalies, preterm birth (<37 gestational weeks) and low birth weight (LBW, <2,500 g). We adjusted for maternal age, birth period and educational level. Nulliparous female survivors' offspring had increased risk of preterm birth (OR = 1.30 [95% CI 1.05-1.61]) but similar risks of LBW and perinatal death as their controls. Primiparous female survivors differed from their controls, with higher frequency of preterm birth (OR = 1.89 [95% CI 1.40-2.56]) and LBW at term (OR = 2.02 [95% CI 1.15-3.55]). A borderline significant increase of perinatal death was seen among offspring of primiparous female survivors, with OR = 1.92 (95% CI 0.98-3.76). Offspring of male survivors did not differ from their controls. For all cancer types combined, no increased risk of congenital anomalies was seen among either female or male survivors' offspring. Pregnant female cancer survivors should be offered close follow-up, as there is an increased risk of adverse birth outcomes, in particular among those with higher parities.

Radiation risk of individual multifactorial diseases in offspring of the atomic-bomb survivors: a clinical health study

There is no convincing evidence regarding radiation-induced heritable risks of adult-onset multifactorial diseases in humans, although it is important from the standpoint of protection and management of populations exposed to radiation. The objective of the present study was to examine whether parental exposure to atomic-bomb (A-bomb) radiation led to an increased risk of common polygenic, multifactorial diseases-hypertension, hypercholesterolaemia, diabetes mellitus, angina pectoris, myocardial infarction or stroke-in the first-generation (F1) offspring of A-bomb survivors. A total of 11,951 F1 offspring of survivors in Hiroshima or Nagasaki, conceived after the bombing, underwent health examinations to assess disease prevalence. We found no evidence that paternal or maternal A-bomb radiation dose, or the sum of their doses, was associated with an increased risk of any multifactorial diseases in either male or female offspring. None of the 18 radiation dose-response slopes, adjusted for other risk factors for the diseases, was statistically significantly elevated. However, the study population is still in mid-life (mean age 48.6 years), and will express much of its multifactorial disease incidence in the future, so ongoing longitudinal follow-up will provide increasingly informative risk estimates regarding hereditary genetic effects for incidence of adult-onset multifactorial disease.

The study of the effects of ionizing and non-ionizing radiations on birth weight of newborns to exposed mothers

OBJECTIVES

Life evolved in an environment filled with a wide variety of ionizing and non-ionizing radiation. It was previously reported that medical exposures to pregnant women increases the risk of low birth weight. This study intends to investigate the relationship between exposure to ionizing and non-ionizing radiation and the risk of low birth weight.

MATERIALS AND METHODS

One thousand two hundred mothers with their first-term labor (vaginal or cesarean) whose newborns' history had been registered in neonates' screening program in Shiraz were interviewed and surveyed. Data collection was performed by the assessment of mother's history of radiography before and during pregnancy, physical examination of the mother for height and weight and weighing and examining the newborn for any diagnosis of disease and anomalies.

RESULTS

There were no statistical significant differences between the mean weight of newborns whose mothers had been exposed to some common sources of ionizing and non-ionizing radiations such as dental or non dental radiographies, mobile phone, cordless phone and cathode ray tube (CRT) and those of non-exposed mothers.

CONCLUSIONS

The findings of this study cast doubt on previous reports, which indicated that exposure to ionizing radiation during pregnancy increased the risk of low birth weight.

Antimüllerian hormone, the assessment of the ovarian reserve, and the reproductive outcome of the young patient with cancer

The accurate assessment of the ovarian reserve has long been a key goal in reproductive medicine. The recognition that serum antimüllerian hormone provides an indirect measure of the ovarian reserve has led to its rapid adoption in assisted conception, and wide exploration of its potential across the reproductive lifespan from the neonate to the menopause. In this short review we discuss its relationship with the ovarian reserve in its varied meanings, and in various contexts. These include in childhood and adolescence, and in the assessment of the impact of cancer therapy on the female reproductive tract. These therapies can adversely impact all aspects of female reproduction, including hypothalamic, pituitary, and ovarian hormonal activity, and the ability of the uterus to support a successful pregnancy.

Maternal and neonatal outcomes in pregnancies following colorectal cancer

BACKGROUND

The risks of adverse obstetric outcomes among young women survivors of colorectal cancer (CRC) are uncertain.

METHODS

This Western Australian, whole-jurisdictional linked-data, retrospective cohort study compared maternal and neonatal outcomes of first postcancer pregnancies among women CRC survivors against randomly selected pregnancies of women with no cancer history. Logistic regression models were used to investigate a range of adverse outcomes independently associated with CRC and its surgical and adjunctive treatments.

RESULTS

Among 627,762 deliveries during the study period (1983-2007), 232 were first pregnancies following CRC. Whether following laparoscopic or open cancer surgery, these pregnancies were independently associated with a significantly increased risk of antepartum hemorrhage [odds ratios (ORs): 1.25; 2.13 for the respective procedures], postpartum hemorrhage (ORs: 1.61; 3.31), Cesarean delivery (ORs: 2.42; 4.24), infant low Apgar score (ORs: 1.32; 2.64), need for neonatal resuscitation (ORs: 1.49; 3.20), and special care admission (ORs: 1.42; 2.87). A history of open (but not laparoscopic) cancer surgery was associated with increased risk of gastrointestinal obstruction during pregnancy (OR 1.17) and prolonged postpartum hospitalization (OR 3.11). Neither was significantly associated with perinatal death. Among women with previous CRC, rectal (versus colonic) malignancy was independently associated with a significantly higher risk of overall maternal and neonatal adverse outcomes (ORs: 3.73 and 2.73, respectively), as was radiotherapy (ORs: 4.24 and 2.81, respectively). Chemotherapy was independently associated with a marginally but significantly higher risk of overall maternal but not neonatal outcomes (ORs: 1.11; 0.98). Open versus laparoscopic cancer surgery was associated with a significantly higher risk of antepartum and postpartum hemorrhage, low Apgar score, need for neonatal resuscitation, and neonatal special care admission.

CONCLUSIONS

Previous CRCs, particularly rectal and radiation-treated tumors, appear to confer an increased likelihood of adverse outcomes in subsequent pregnancies. Laparoscopic technique for CRC surgery may reduce adverse gestational outcomes.

Life after childhood cancer: marriage and offspring in adult long-term survivors--a population-based study in the Piedmont region, Italy

The majority of childhood cancer cases survive to adulthood. We describe the experience of marriage and reproduction as indicators of quality of life, in a population-based cohort of adult long-term survivors after early cancer reported to the Childhood Cancer Registry of Piedmont. The study included 1237 survivors with a malignant neoplasm diagnosed during 1967-2000 when aged 0-14 years, who attained age 18 years. Vital and marital status and number of offspring were assessed through the Vital Statistics Offices. Marriage and fertility deficits were estimated by comparison with the Piedmont population. Among the individuals included in this study, 919 (74.3%) never married and never lived as married. The marriage deficit was 32% [observed/expected 0.68; 95% confidence interval (CI): 0.55-0.83] in men and 18% (observed/expected 0.82; 95% CI: 0.68-0.98) in women. A total of 179 children were born to 120 women, with a fertility deficit of 41% (observed/expected 0.59; 95% CI: 0.51-0.69). In conclusion, the observed decrements in marriage in men and women and fertility in women suggest that efforts should be made to improve the recovery from physical and psychological traumas related to diagnosis and treatment of cancer.

Mortality among offspring of women diagnosed with cancer: a population-based cohort study

One in five cancers in women is diagnosed prior to and during a woman's fertile years. Our study evaluates mortality risks in offspring of mothers with history of cancer. From the Swedish Multi-generation Register and the Cancer Register, we identified all 174,893 children whose mother had been diagnosed with cancer between 1958 and 2001. We categorized offspring into those born before (>1 year before), around (within 1 year before and after diagnosis) and after (>1 year after) their mother's cancer diagnosis and compared their risks of death (standardized mortality ratios, SMRs) and causes of death to the background population. Overall, offspring of mothers diagnosed with cancer had no increased mortality risk (SMR, 1.00; 95% confidence interval [CI], 0.97-1.03). Increased mortality risks were found in offspring of mothers with tobacco-related cancers (head and neck, thoracic and cervical) (SMR, 1.23; 95% CI, 1.13-1.33), in children born around their mother's diagnosis (SMR, 1.66; 95% CI, 1.25-2.13) and in children born after their mother's hematopoietic cancer diagnosis (SMR, 2.07; 95% CI, 1.10-3.35). Compared to the background population, children born around their mother's diagnosis were more likely to die of congenital and perinatal conditions. Overall, offspring of women diagnosed with cancer were not at increased risk of death, except for certain subgroups. Timing of pregnancy in relation to diagnosis and cancer site modifies mortality risks in the offspring.

Pediatric and young adult patients and oncofertility

OPINION STATEMENT

With improving survival rates for pediatric and young adult cancer patients, considerations regarding the long-term effects of therapy have become more important. Cancer therapies are known to pose reproductive risks, though the effects may be unpredictable. All at-risk patients should have a discussion about potential treatment-related infertility before the onset of cancer therapy, and should be offered appropriate fertility preservation options. Embryo and sperm cryopreservation are considered standard therapy, though oocyte cryopreservation is gaining acceptance. Ovarian tissue cryopreservation, while still experimental, is showing great promise. It is the only option currently available to prepubertal girls. No fertility preservation options exist for prepubertal boys though some institutions may offer experimental testicular tissue cryopreservation.

Ovarian reserve in women treated for acute lymphocytic leukemia or acute myeloid leukemia with chemotherapy, but not stem cell transplantation

Purpose. It is well known that chemotherapy regimens may have a negative effect on ovarian reserve, leading to amenorrhea or premature ovarian failure. There are little data regarding the effects of leukemia chemotherapy on ovarian reserve, specifically in women who received the chemotherapy as adults and are having regular menstrual periods. Our primary objective was to determine if premenopausal women with a history of chemotherapy for leukemia, without subsequent stem cell transplantation, have decreased ovarian reserve. Materials and Methods. We measured ovarian reserve in five women who had been treated for acute lymphocytic leukemia (ALL) or acute myeloid leukemia (AML) and compared them to age-matched control women without a history of chemotherapy. Results. There appeared to be a trend towards lower antimullerian hormone and antral follicle counts and higher follicle-stimulating hormone levels in the leukemia group. Conclusion. Our results indicate that chemotherapy for AML or ALL without stem cell transplantation may compromise ovarian reserve. Although our results should be confirmed by a larger study, oncologists, infertility specialists, and patients should be aware of the potential risks to ovarian function and should be counseled on options for fertility preservation.

A novel sLRP6E1E2 inhibits canonical Wnt signaling, epithelial-to-mesenchymal transition, and induces mitochondria-dependent apoptosis in lung cancer

Aberrant activation of the Wnt pathway contributes to human cancer progression. Antagonists that interfere with Wnt ligand/receptor interactions can be useful in cancer treatments. In this study, we evaluated the therapeutic potential of a soluble Wnt receptor decoy in cancer gene therapy. We designed a Wnt antagonist sLRP6E1E2, and generated a replication-incompetent adenovirus (Ad), dE1-k35/sLRP6E1E2, and a replication-competent oncolytic Ad, RdB-k35/sLRP6E1E2, both expressing sLRP6E1E2. sLRP6E1E2 prevented Wnt-mediated stabilization of cytoplasmic β-catenin, decreased Wnt/β-catenin signaling and cell proliferation via the mitogen-activated protein kinase, and phosphatidylinositol 3-kinase pathways. sLRP6E1E2 induced apoptosis, cytochrome c release, and increased cleavage of PARP and caspase-3. sLRP6E1E2 suppressed growth of the human lung tumor xenograft, and reduced motility and invasion of cancer cells. In addition, sLRP6E1E2 upregulated expression of epithelial marker genes, while sLRP6E1E2 downregulated mesenchymal marker genes. Taken together, sLRP6E1E2, by inhibiting interaction between Wnt and its receptor, suppressed Wnt-induced cell proliferation and epithelial-to-mesenchymal transition.

Reproductive late effects in female survivors of childhood cancer

Childhood cancer treatments can cause female reproductive late effects. Radiation to the hypothalamic-pituitary-ovarian axis is associated with altered menarche, miscarriage, and implantation failure. Patients who receive chemotherapy and/or ovarian radiation are at risk of premature ovarian failure; the risk increases with increasing radiation dose, alkylating agent score, combination therapy, and older age at treatment. Ovarian reserve may be assessed using antimullerian hormone assay and ultrasound measurements of ovarian volume and antral follicle count; however, their efficacy is poorly established in this cohort. Fertility preservation options including cryopreservation, oophoropexy, and gonadotropin-releasing hormone analogues may be initiated prior to treatment, although most are still considered experimental. Uterine radiation has been linked to pregnancy complications including miscarriage, premature delivery, stillbirth, low-birth-weight and small-for-gestational-age infants. This paper summarises the literature on female reproductive late effects. The information should facilitate counseling and management of female survivors throughout their reproductive lives.

Embryo banking between induction and consolidation chemotherapy in women with leukemia

OBJECTIVE

To report the results of controlled ovarian hyperstimulation (COH) after long-acting GnRH agonist (GnRH-a) and chemotherapy for the purposes of embryo cryopreservation.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

Two premenopausal women with acute myelogenous leukemia with recent treatment with GnRH-a and induction chemotherapy for hematopoietic cell transplantation (HCT).

INTERVENTION(S)

COH with embryo cryopreservation.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes and embryos cryopreserved.

RESULT(S)

Both patients responded to gonadotropin stimulation and cryopreserved embryos.

CONCLUSION(S)

Women who have received recent long-acting GnRH-a and chemotherapy may respond to gonadotropin stimulation. The option of embryo banking can be offered to leukemia patients who are preparing for HCT.

[Cryopreserved ovaries: models of experimental grafting]

Childhood cancers account for 1% of malignant tumors. As a result of advances in treatment, almost 80% of children and adolescents who currently receive a diagnosis of cancer become long-term survivors. Assessment of potential for fertility preservation should thus be a systematic element of care for children treated for a malignant tumor (high-dose chemotherapy with alkylizing agents, radiation therapy including the gonads) or those receiving hematopoietic stem cell grafts for malignant or benign disease (sickle-cell anemia, immune deficit). Potential adverse consequences of treatment include impaired puberty and fertility due to gonadal removal, genital tract injury or damage to germ cells from adjuvant therapy. Advances in assisted reproductive technologies have led to new possibilities for the prevention and treatment of infertility. Among them, cryopreservation of ovarian tissue appears to be the most promising, or perhaps the only one available before puberty with encouraging results. Nevertheless the uncertainties, or even risks, related to these treatments, should not be neglected. We review experimental data in mouse and sheep animal models. The results demonstrate that immature ovarian grafting can restore spontaneous puberty and fertility in both models. This study addresses the very important issue of epigenetics, and provides valuable information for the study of ovarian transplantation, suggesting that these procedures do not perturb normal epigenetic marks. These results are highly relevant to the question of immature cortex reimplantation.

Multiple approaches for individualized fertility protective therapy in cancer patients

In the last decade, fertility preservation has risen as a major field of interest, creating new interactions between oncologists and gynecologists. Various options, such as cryopreservation of ovarian tissue, have been developed and are currently routinely proposed in many centers. However, many of the options remain experimental and should be offered to patients only after adequate counseling. This paper addresses the efficiency and the potential of the different fertility preservation approaches.

Genetic disease in the children of Danish survivors of childhood and adolescent cancer

PURPOSE

Preconception radiation and chemotherapy have the potential to produce germ cell mutations leading to genetic disease in the next generation. Dose-response relationships were evaluated between cancer treatments and untoward pregnancy outcomes.

PATIENTS AND METHODS

A case-cohort study was conducted involving 472 Danish survivors of childhood and adolescent cancer and their 1,037 pregnancies. Adverse outcomes included 159 congenital malformations, six chromosomal abnormalities, seven stillbirths, and nine neonatal deaths. Preconception radiation doses to the gonads, uterus, and pituitary gland and administered chemotherapy were quantified based on medical records and related to adverse outcomes using a generalized estimating equation model.

RESULTS

No statistically significant associations were found between genetic disease in children and parental treatment with alkylating drugs or preconception radiation doses to the testes in male and ovaries in female cancer survivors. Specifically, the risk of genetic disease was similar among the children of irradiated survivors when compared with nonirradiated survivors (relative risk [RR], 1.02; 95% CI, 0.59 to 1.44; P = .94). A statistically significant association between abdomino-pelvic irradiation and malformations, stillbirths, and neonatal deaths was not seen in the children of female survivors overall (P = .07) or in the children of mothers receiving high uterine doses (mean, 13.5 Gy; max, 100 Gy; RR, 2.3; 95% CI, 0.95 to 5.56).

CONCLUSION

Mutagenic chemotherapy and radiotherapy doses to the gonads were not associated with genetic defects in children of cancer survivors. However, larger studies need to be conducted to further explore potential associations between high-dose pelvic irradiation and specific adverse pregnancy outcomes.

NCI, NHLBI/PBMTC first international conference on late effects after pediatric hematopoietic cell transplantation: endocrine challenges-thyroid dysfunction, growth impairment, bone health, & reproductive risks

The endocrine system is highly susceptible to damage by high-dose chemotherapy and/or irradiation before hematopoietic cell transplantation (HCT) during childhood. The specific endocrine organs most affected by HCT include the thyroid gland, the pituitary, and the gonads. In addition, hormones that support development and stability of the skeletal system are also affected. Insufficiency of thyroid hormone is 1 of the most common late sequelae of HCT, and occurs more often in young children. Deficiency in the pituitary's production of growth hormone is a problem of unique concern to the pediatric population. The reproductive risks of HCT depend on the patient's gender and pubertal status at the time of HCT. Pubertal or gonadal failure frequently occurs, especially in females. Infertility risks for both genders remain high, whereas methods of fertility preservation are limited in all but postpubertal males. Bone health post-HCT can be compromised by low bone mineral density as well as avascular necrosis, but the data on both problems in the pediatric HCT population are limited. In this paper, the current state of knowledge, gaps in that knowledge, and recommendations for future research are addressed in detail for each of these systems.

Fertility preservation in girls and young women

There is increasing interest and experience in the options available to preserve fertility in those about to undergo potentially gonadotoxic chemotherapy or radiation therapy, usually related to treatment for cancer. Recent years have seen the development of methods for prepubertal girls, female adolescents and adult women, although these remain less established than sperm cryopreservation for men. At present, the options for prepubertal boys remain experimental. Embryo cryopreservation following ovarian stimulation and IVF is a routine procedure technically and its success in the management of infertility is established. However, there are no data on uptake or success rates in the context of fertility preservation in women with cancer. Oocyte cryopreservation is technically challenging and requires ovarian stimulation, thus potentially resulting in a delay in cancer treatment. Oocyte vitrification offers increased success rates in comparison with slow freezing; however, this approach is also limited by the number of oocytes that can be obtained. The third possibility, ovarian tissue cryopreservation, can be performed without significant delay and is the only option for prepubertal girls. Worldwide, a small number of children have been born following reimplantation of frozen/thawed ovarian tissue. It is clear that fertility preservation is important for some girls and young women facing treatments that will compromise their fertility, but the availability of all approaches varies widely. Effective approaches for prepubertal boys are also required.

[Female fertility preservation: feasibility of emergency IVF for embryo freezing]

With the improvement of the anticancerous treatments, the preservation of the feminine fertility before gonadotoxic treatment tends at present to stand out as a legal obligation, with a duty of information to patients. When emergency IVF can be performed, the cryopreservation of embryos is the best mastered method which offers most chances to patients to obtain a pregnancy after cancer remission thanks to the transfer of frozen embryos. This article proposes an overview about the indications, the feasibility and the ethical and practical limitations of IVF emergency for embryo freezing before gonadotoxic anticancerous treatment.

Hospitalizations among children of survivors of childhood and adolescent cancer: a population-based cohort study

Curative but potentially mutagenic cancer therapy might lead to untoward disorders and increased hospitalization among the offspring of childhood cancer survivors. Hospitalizations in childhood were evaluated in a population-based cohort of 1,920 offspring of 3,963 childhood cancer survivors, 6,394 offspring of 5,657 siblings and 9,594 population-based comparisons. The Danish Cancer Registry, Central Population Register and National Hospital Register were used to identify study subjects and hospitalizations. The probability for children in the offspring cohorts of being hospitalized before a given age was estimated using the Kaplan-Meier method. Hospitalization rate ratios (HRRs) were calculated using a Cox proportional hazards model with population comparisons as referent. Little differences in hospitalization histories were seen among offspring in the 3 cohorts. HRRs of overall hospitalization was 1.05 (95% CI, 0.98-1.12) for offspring of survivors and 1.01 (95% CI, 0.97-1.05) for offspring of siblings, neither of which was significantly different from that of population comparisons. No significant associations were seen for most of the main diagnostic groups of diseases including infections and perinatal disorders. A 6-fold excess risk of hospitalization for malignant tumors in survivors' offspring, however, could largely be explained by hereditary cancer syndromes, and part of the 2-fold excess hospitalization for benign tumors might similarly be explained by an underlying genetic susceptibility or by increased surveillance of children born to survivors. Assuming that hospitalization is an indicator of multifactorial genetic disease, the findings provide further reassurance that cancer therapies do not confer a high risk of such conditions in offspring born after treatments.

Detection of DNA damage in oocytes of small ovarian follicles following phosphoramide mustard exposures of cultured rodent ovaries in vitro

Healthy oocytes are critical for producing healthy children, but little is known about whether or not oocytes have the capacity to identify and recover from injury. Using a model ovotoxic alkylating drug, cyclophosphamide (CPA), and its active metabolite, phosphoramide mustard (PM), we previously showed that PM (≥3μM) caused significant follicle loss in postnatal day 4 (PND4) mouse ovaries in vitro. We now investigate whether PM induces DNA damage in oocytes, examining histone H2AX phosphorylation (γH2AX), a marker of DNA double-strand breaks (DSBs). Exposure of cultured PND4 mouse ovaries to 3 and 0.1μM PM induced significant losses of primordial and small primary follicles, respectively. PM-induced γH2AX was observed predominantly in oocytes, in which foci of γH2AX staining increased in a concentration-dependent manner and peaked 18-24h after exposure to 3-10μMPM. Numbers of oocytes with ≥5 γH2AX foci were significantly increased both 1 and 8days after exposure to ≥1μMPM compared to controls. Inhibiting the kinases that phosphorylate H2AX significantly increased follicle loss relative to PM alone. In adult mice, CPA also induced follicle loss in vivo. PM also significantly decreased primordial follicle numbers (≥30μM) and increased γH2AX foci (≥3μM) in cultured PND4 Sprague-Dawley rat ovaries. Results suggest oocytes can detect PM-induced damage at or below concentrations which cause significant follicle loss, and there are quantitative species-specific differences in sensitivity. Surviving oocytes with DNA damage may represent an increased risk for fertility problems or unhealthy offspring.

Chemotherapy-induced late transgenerational effects in mice

To our knowledge, there is no report on long-term reproductive and developmental side effects in the offspring of mothers treated with a widely used chemotherapeutic drug such as doxorubicin (DXR), and neither is there information on transmission of any detrimental effects to several filial generations. Therefore, the purpose of the present paper was to examine the long-term effects of a single intraperitoneal injection of DXR on the reproductive and behavioral performance of adult female mice and their progeny. C57BL/6 female mice (generation zero; G0) were treated with either a single intraperitoneal injection of DXR (G0-DXR) or saline (G0-CON). Data were collected on multiple reproductive parameters and behavioral analysis for anxiety, despair and depression. In addition, the reproductive capacity and health of the subsequent six generations were evaluated. G0-DXR females developed despair-like behaviors; delivery complications; decreased primordial follicle pool; and early lost of reproductive capacity. Surprisingly, the DXR-induced effects in oocytes were transmitted transgenerationally; the most striking effects being observed in G4 and G6, constituting: increased rates of neonatal death; physical malformations; chromosomal abnormalities (particularly deletions on chromosome 10); and death of mothers due to delivery complications. None of these effects were seen in control females of the same generations. Long-term effects of DXR in female mice and their offspring can be attributed to genetic alterations or cell-killing events in oocytes or, presumably, to toxicosis in non-ovarian tissues. Results from the rodent model emphasize the need for retrospective and long-term prospective studies of survivors of cancer treatment and their offspring.