Comparable effects of 1800- and 2400-rad (18- and 24-Gy) cranial irradiation on height and weight in children treated for acute lymphocytic leukemia

Decreased adult height in survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

OBJECTIVE

To determine risk factors associated with reduced adult height in survivors of childhood acute lymphoblastic leukemia (ALL).

STUDY DESIGN

This was a cross-sectional study. Attained adult height was determined among 2434 ALL survivors participating in the Childhood Cancer Survivor Study, a cohort of 5-year survivors of common pediatric cancers diagnosed from 1970 to 1986, and compared with 3009 siblings.

RESULTS

All survivor treatment exposure groups (chemotherapy alone, chemotherapy with cranial or craniospinal radiotherapy) had decreased adult height and an increased risk of adult short stature (height standard deviation score < -2) compared with siblings (P < .001). Compared with siblings, the risk of short stature for survivors treated with chemotherapy alone was elevated (OR, 3.4; 95% CI, 1.9, 6.0). Among survivors, significant risk factors for short stature included diagnosis of ALL before puberty, higher-dose cranial radiotherapy (> or = 20 Gy versus < 20 Gy), any radiotherapy to the spine, and female sex.

CONCLUSIONS

Survivors of childhood ALL are at increased risk of adult short stature, including those treated with chemotherapy alone. Risk is highest for those treated with cranial and craniospinal radiotherapy at a young age.

Long-term outcome of treatment with protocols AL841, AL851, and ALHR88 in children with acute lymphoblastic leukemia: results obtained by the Kyushu-Yamaguchi Children's Cancer Study Group

We analyzed the long-term outcome and late effects of treatment in 187 patients with childhood acute lymphoblastic leukemia (ALL) diagnosed between 1984 and 1990. Overall survival and event-free survival rates were 68.2% +/- 3.7% and 63.2% +/- 3.6% at 15 years, respectively. Of 55 patients who relapsed after achieving the first complete remission (CR), only 17.4% were rescued by salvage therapy. The advantage of stem cell transplantation over chemotherapy was observed only in those patients with bone marrow relapse during therapy. The SD for score height in patients maintaining the first CR significantly decreased at the time of final follow-up compared with that at diagnosis: 0.059 to -0.800 (P < .0001). The decrease was remarkable in patients younger than 5 years at diagnosis. Other late effects included mild liver dysfunction in 18% and hepatitis C virus infection in 9%. Congestive heart failure was observed in only 2.9% of patients despite the high cumulative dose of daunorubicin (450 mg/m2). Although the survival rates of patients on our protocols were comparable to those of other study groups, some modification, including reduction in dose of cranial irradiation and/or anticancer drugs, should be considered to reduce late adverse effects in survivors of childhood ALL.

Growth and growth hormone secretion in children with cancer treated with chemotherapy

OBJECTIVE

To evaluate the effect of chemotherapy on growth and growth hormone (GH) secretion.

METHODS

We analyzed growth and GH secretion in 60 children in complete remission after treatment by chemotherapy and surgery for malignant solid tumors. None of them received cranial radiotherapy. Growth hormone reserve was assessed by at least two stimulation tests (clonidine, L-dopa, growth hormone-releasing hormone). In 12 children the reserve of GH pretreatment was also evaluated.

RESULTS

Growth hormone deficiency (GHD) was observed in 27 of 60 patients (45%). At diagnosis, mean standing height was +0.23 +/- 0.11 standard deviation score (SDS) in the GHD group and +0.16 +/- 0.10 SDS in the non-GHD group. After chemotherapy, mean standing height in the GHD group was -0.28 +/- 0.15 SDS and -0.14 +/- 0.11 in the non-GHD group (p < 0.05), and the growth rate was +0.13 +/- 0.07 SDS in the GHD group and +0.22 +/- 0.18 SDS in the non-GHD group. For a mean follow-up of 30 months, the mean standing height was -0.46 +/- 0.29 SDS in the GHD group and -0.24 +/- 0.16 SDS for the non-GHD group (p < 0.05), and the growth rate was -0.27 +/- 0.19 SDS in the GHD group and -0.16 +/- 0.12 SDS in the non-GHD group (p < 0.05). The GH response to clonidine was significantly less than that found with the other stimuli. There was correlation between the dose intensity of some drugs and the subsequent GH response to stimulation tests. The GHD group was found to have received significantly higher doses of actinomycin D than the non-GHD group (p < 0.05). Growth impairment and GHD were not found to be correlated with duration of treatment and follow-up, tumor type, sex, or age.

CONCLUSIONS

Chemotherapy as the sole form of treatment in children with cancer interferes with growth. The observed impairment of growth depends, at least in part, on a GHD related to chemotherapy. The growth rate in conjunction with the GH response to clonidine provides a sensitive measure of GHD associated with chemotherapy.

An odyssey in search of a cure: the evolution of treatment of childhood acute lymphoblastic leukemia in the United Kingdom

This review charts the evolution of therapy for childhood acute lymphoblastic leukaemia (ALL) in the United Kingdom. The present chemotherapeutic regimen is the result of experience gained from carefully planned randomised cooperative studies carried out during the last two decades. In common with the experience of the West German and American groups, the best results have been in those treated with post remission intensification blocks. With current chemotherapy protocols, almost 70% of children with ALL in U.K. can be cured but there may be a medical cost of such a cure, in terms of both acute and long term toxicity. This was especially true when central nervous system (CNS) therapy with cranial irradiation was used. Therefore present regimens are examining chemotherapeutic options for CNS disease control and the efficacy of additional post remission intensification. Failure of chemotherapy is most often seen in those children with a presenting white cell count of more than 50 x 10(9)/l, very young children and/or the presence of certain chromosomal rearrangements (e.g. t4: 11, t9: 22). At present the optimum therapeutic option for such high risk patients and for the majority of those in second remission, is an allogenic bone marrow transplant if an HLA-matched sibling is available. Modern day therapy is both complicated and costly and will be beyond the resources available for most children with ALL in developing countries. A significant decrease in worldwide mortality due to ALL will only occur if either the disease can be prevented or a simpler cure devised.