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Oosterom N, Gooskens SL, Renfro LA, Perlman EJ, van den Heuvel-Eibrink MM, Hamilton TE, Green DM, Grundy PE, Daw NC, Geller JI, Dome JS, Fernandez CV, Mullen EA. Severe Hepatopathy in National Wilms Tumor Studies 3-5: Prevalence, Clinical Features, and Outcomes After Reintroduction of Chemotherapy. J Clin Oncol 2023; 41:4247-4256. [PMID: 37343199 PMCID: PMC10852371 DOI: 10.1200/jco.22.02555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/01/2023] [Accepted: 04/26/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE The safety of reintroducing chemotherapy in the pediatric renal tumor setting after severe hepatopathy (SH), including sinusoidal obstruction syndrome (SOS), is uncertain. We describe the incidence, severity, outcomes, and impact on subsequent treatment for patients with SH from National Wilms Tumor Study (NWTS) protocols 3-5. PATIENTS AND METHODS Archived charts for patients enrolled on NWTS 3-5 who met study inclusion criteria for SH by using established hepatopathy grading scales and clinical criteria were reviewed for demographics, tumor characteristics, radio- and chemotherapy details, SH-related dose modifications, and oncologic outcomes. Genomic analysis for candidate polymorphisms associated with SH was performed in 14 patients. RESULTS Seventy-one of 8,862 patients (0.8%) met study inclusion criteria. The median time from therapy initiation to SH was 51 days (range, 2-293 days). Sixty percent received radiotherapy, and 56% had right-sided tumors. Grade 1-4 thrombocytopenia was noted in 70% at initial occurrence of SH (median 22,000/microliter). Among 69 of 71 children with SH occurring before the end of therapy (EOT) and post-SH treatment information available, chemotherapy was delayed posthepatopathy for 65% (69% of these at a reduced dose), continued without delay for 20% (57% of these at reduced dose), and stopped completely for 15% (4 of 10 of whom died of SH). Overall, 42% of patients with dose reductions achieved full dose by EOT. The five-year post-SH event-free survival for patients who continued therapy was 89% (95% CI, 81 to 98), with no significant differences by whether delay or dose reduction occurred. We identified no SH-associated pharmacogenomic polymorphism. CONCLUSION The incidence of SH on NWTS 3-5 was low; many had associated severe thrombocytopenia. Careful reintroduction of chemotherapy appeared to be feasible for the majority of patients who developed severe chemotherapy- and/or radiotherapy-induced liver toxicity.
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Affiliation(s)
- Natanja Oosterom
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Lindsay A. Renfro
- University of Southern California and Children's Oncology Group, Los Angeles, CA
| | - Elizabeth J. Perlman
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | - Thomas E. Hamilton
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Daniel M. Green
- Department of Epidemiology and Cancer Control Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Paul E. Grundy
- Department of Pediatric Oncology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Najat C. Daw
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - James I. Geller
- Division of Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Jeffrey S. Dome
- Division of Oncology, Children's National Hospital and Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Conrad V. Fernandez
- Division of Pediatric Hematology and Oncology, IWK Health Centre and Dalhouise University, Halifax, NS, Canada
| | - Elizabeth A. Mullen
- Department of Pediatric Hematology/Oncology, Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, MA
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Tandra HV, Rupakumar T, Vijayasekharan K, V R P, C S G, T PK. A stitch in time saves nine: timely use of N-acetyl cysteine (NAC) for chemotherapy-induced veno-occlusive disease (VOD)-is it a cost-effective alternative? Support Care Cancer 2022; 30:8611-8614. [PMID: 35963952 DOI: 10.1007/s00520-022-07321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/03/2022] [Indexed: 11/26/2022]
Abstract
Chemotherapy-induced veno-occlusive disease (VOD) is a rare liver dysfunction seen among pediatric cancer patients which could lead to severe morbidity and mortality. Defibrotide is the commonly used antidote in the management of both stem cell transplant and chemotherapy-associated VOD along with liver supportive measures. Defibrotide is costly and generally not accessible to majority of patients treated at resource poor settings. In this report, we describe the successful management of chemotherapy-induced VOD with timely administration of N-acetyl cysteine.
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Affiliation(s)
- Harish Varma Tandra
- Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum, Kerala, 695011, India
| | - Thirumala Rupakumar
- Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum, Kerala, 695011, India
| | | | - Prasanth V R
- Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum, Kerala, 695011, India
| | - Guruprasad C S
- Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum, Kerala, 695011, India
| | - Priya Kumari T
- Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum, Kerala, 695011, India
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Chen MJ, Leao CR, Simoes RCP, Belletti FS, Figueiredo MLS, Cypriano MS. Kidney-sparing whole abdominal irradiation in Wilms tumor: Potential advantages of VMAT technique. Pediatr Blood Cancer 2020; 67:e28223. [PMID: 32083396 DOI: 10.1002/pbc.28223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 01/10/2020] [Accepted: 01/27/2020] [Indexed: 11/08/2022]
Abstract
PURPOSE To present a preliminary clinical experience and a dosimetric comparison of kidney-sparing volumetric modulated arc therapy (VMAT) with three-dimensional conformal radiotherapy (3D-CRT) for whole abdominal irradiation (WAI), in the setting of Wilms tumor (WT) treatment. MATERIALS AND METHODS From a total of 20 consecutive WT cases treated with adjuvant irradiation, seven were submitted to WAI with VMAT. Renal function and survival rates were evaluated, and, for comparison purposes, similar VMAT and 3D-CRT treatment plans were performed for WAI patients, and differences were dosimetrically evaluated regarding doses to the remaining kidney and other organs at risk and the planning target volume (PTV). RESULTS After a median follow-up time of 40.8 months (35.3-52.2), no acute significant intestinal toxicity was observed, and median creatinine clearance was 110.1 and 103.3 mL/min/1.73 m², respectively, before treatment and at last follow-up for WAI patients (P = 0.128). For comparative plans, maximum and median doses were lower for the remaining kidney with VMAT than with 3D-CRT. VMAT was associated with better PTV coverage as compared with 3D-CRT, with superior results for all the evaluated parameters (D95, D2, V100%, V98%, V95%; P = 0.018). CONCLUSION The use of VMAT technique is associated with lower radiation doses to the remaining kidney and better coverage to the PTV than 3D-CRT technique for WAI, with preliminary clinical experience showing a favorable toxicity profile. Long-term results from prospective studies might prove the ability of VMAT to spare renal function in the setting of WT treatment.
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Affiliation(s)
- Michael Jenwei Chen
- Grupo de Apoio ao Adolescente e a Criança com Cancer, Radiation Oncology, Sao Paulo, Brazil.,A.C. Camargo Cancer Center, Radiation Oncology, Sao Paulo, Brazil
| | - Caio Raposo Leao
- A.C. Camargo Cancer Center, Radiation Oncology, Sao Paulo, Brazil
| | | | | | | | - Monica Santos Cypriano
- Grupo de Apoio ao Adolescente e a Criança com Cancer, Radiation Oncology, Sao Paulo, Brazil
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Hill-Kayser CE, Tochner Z, Li Y, Kurtz G, Lustig RA, James P, Balamuth N, Womer R, Mattei P, Grupp S, Mosse YP, Maris JM, Bagatell R. Outcomes After Proton Therapy for Treatment of Pediatric High-Risk Neuroblastoma. Int J Radiat Oncol Biol Phys 2019; 104:401-408. [PMID: 30738983 DOI: 10.1016/j.ijrobp.2019.01.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/04/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Patients with high-risk neuroblastoma (HR-NBL) require radiation to the primary tumor site and sites of persistent metastatic disease. Proton radiation therapy (PRT) may promote organ sparing, but long-term outcomes have not been studied. METHODS AND MATERIALS Sequential patients with HR-NBL received PRT: 2160 cGy (relative biological effectiveness) to primary tumor bed and persistent metastatic sites, with 3600 cGy (relative biological effectiveness) to gross residual disease. RESULTS From September 2010 through September 2015, 45 patients with HR-NBL received PRT after systemic therapy, primary tumor resection, and high-dose chemotherapy with stem cell rescue. Median age was 46 months at the time of PRT (range, 10 months to 12 years); 23 patients (51%) were male. Primary tumors were adrenal in 40 (89%); 11 (24%) received boost. Ten metastatic sites in 8 patients were radiated. Double scattered proton beams were used for 19 (42%) patients, in combination with x-rays for 2 (5%). The remaining 26 (58%) received pencil beam scanning, available since January 2013. We observed 97% freedom from primary site recurrence at 3, 4, and 5 years. Overall survival rates were 89%, 80%, and 80% and disease-free survival rates were 77%, 70%, and 70%, at 3, 4, and 5 years, respectively. With median follow-up of 48.7 months from diagnosis (range, 11-90 months) for all patients (57.4 months for those alive), 37 (82%) patients are alive, and 32 (71%) are without evidence of disease. One patient experienced locoregional recurrence; the remaining 12 (27%) experienced relapse at distant, nonradiated sites. Acute toxicities during treatment were mainly grade 1. No patient has experienced World Health Organization grade 3 or 4 long-term renal or hepatic toxicity. Pencil beam scanning plans required less planning time and resources than double scattered plans. CONCLUSIONS We observe excellent outcomes in patients treated with PRT for HR-NBL from 2010 through 2015, with 82% of patients alive and 97% free of primary site recurrence. No patient has experienced long-term renal or liver toxicity. This treatment maximizes normal tissue preservation and is appropriate for this patient population.
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Affiliation(s)
- Christine E Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Zelig Tochner
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yimei Li
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Goldie Kurtz
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul James
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Naomi Balamuth
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Womer
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Mattei
- Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Grupp
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yael P Mosse
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John M Maris
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rochelle Bagatell
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Totadri S, Trehan A, Bansal D, Jain R. Sinusoidal Obstruction Syndrome during Treatment for Wilms' Tumor: A Life-threatening Complication. Indian J Med Paediatr Oncol 2018; 38:447-451. [PMID: 29333010 PMCID: PMC5759062 DOI: 10.4103/ijmpo.ijmpo_188_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Context: Survival rates exceed 90% in Wilms' tumor (WT). Actinomycin-D (ACT-D) which is indispensable in the management of WT is associated with the development of sinusoidal obstruction syndrome (SOS), a potentially fatal complication. Aims: The aim is to study the presentation, management, and outcome of SOS complicating ACT-D administration in WT. Settings and Design: Retrospective file review conducted in a Pediatric Hematology-Oncology unit. Materials and Methods: Patients diagnosed and treated for WT from January 2012 to December 2015 were analyzed. SOS was diagnosed clinically, based on McDonalds criteria, requiring two of the following: jaundice, hepatomegaly and/or right upper quadrant pain, weight gain with or without ascites. Results: Of 104 patients treated, SOS occurred in 5 (4.8%). Age: 6 months to 5 years, 3 were girls. Tumor involved left kidney in 3, right in 1 and a horseshoe kidney in 1. Histopathology was consistent with WT in 4 and clear cell sarcoma kidney in 1. One had pulmonary metastases. Three developed SOS preoperatively and two during adjuvant chemotherapy. None received radiotherapy. Clinical manifestations comprised of jaundice, hepatomegaly, ascites/weight gain, respiratory distress, hypotension, and encephalopathy. Laboratory findings included thrombocytopenia, elevated serum transaminases, and coagulopathy. Treatment included fluid restriction, broad spectrum antibiotics, and transfusional support. Two children received N-acetyl cysteine infusion. Defibrotide was administered to two patients. Four recovered and one succumbed to multi-organ failure. Two patients were safely re-challenged with 50% doses of ACT-D. Conclusions: SOS is a clinical diagnosis. Systematic supportive care can enable complete recovery. Under close monitoring, re-challenge of ACT-D can be performed in gradually escalating doses.
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Affiliation(s)
- Sidharth Totadri
- Department of Pediatrics, Advanced Pediatrics Center, Pediatric Hematology-Oncology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Department of Pediatrics, Advanced Pediatrics Center, Pediatric Hematology-Oncology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Department of Pediatrics, Advanced Pediatrics Center, Pediatric Hematology-Oncology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Richa Jain
- Department of Pediatrics, Advanced Pediatrics Center, Pediatric Hematology-Oncology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Edgar JA, Molyneux RJ, Colegate SM. Pyrrolizidine Alkaloids: Potential Role in the Etiology of Cancers, Pulmonary Hypertension, Congenital Anomalies, and Liver Disease. Chem Res Toxicol 2014; 28:4-20. [PMID: 25483859 DOI: 10.1021/tx500403t] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Large outbreaks of acute food-related poisoning, characterized by hepatic sinusoidal obstruction syndrome, hemorrhagic necrosis, and rapid liver failure, occur on a regular basis in some countries. They are caused by 1,2-dehydropyrrolizidine alkaloids contaminating locally grown grain. Similar acute poisoning can also result from deliberate or accidental consumption of 1,2-dehydropyrrolizidine alkaloid-containing herbal medicines, teas, and spices. In recent years, it has been confirmed that there is also significant, low-level dietary exposure to 1,2-dehydropyrrolizidine alkaloids in many countries due to consumption of common foods such as honey, milk, eggs, salads, and meat. The level of 1,2-dehydropyrrolizidine alkaloids in these foods is generally too low and too intermittent to cause acute toxicity. However, these alkaloids are genotoxic and can cause slowly developing chronic diseases such as pulmonary arterial hypertension, cancers, cirrhosis, and congenital anomalies, conditions unlikely to be easily linked with dietary exposure to 1,2-dehydropyrrolizidine alkaloids, especially if clinicians are unaware that such dietary exposure is occurring. This Perspective provides a comprehensive review of the acute and chronic toxicity of 1,2-dehydropyrrolizidine alkaloids and their potential to initiate certain chronic diseases, and suggests some associative considerations or indicators to assist in recognizing specific cases of diseases that may have resulted from dietary exposure to these hazardous natural substances. If it can be established that low-level dietary exposure to 1,2-dehydropyrrolizidine alkaloids is a significant cause of some of these costly and debilitating diseases, then this should lead to initiatives to reduce the level of these alkaloids in the food chain.
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Affiliation(s)
- John A Edgar
- CSIRO Food and Nutrition , 11 Julius Avenue, North Ryde, NSW 2113, Australia
| | - Russell J Molyneux
- Daniel K. Inouye College of Pharmacy, University of Hawaii at Hilo , 34 Rainbow Drive, Hilo, Hawaii 96720, United States
| | - Steven M Colegate
- Poisonous Plant Research Laboratory, ARS/USDA , 1150 East 1400 North, Logan, Utah 84341, United States
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Abstract
Most hepatotoxicity secondary to chemotherapy is idiosyncratic and, therefore, neither dose dependent nor predictable. Some chemotherapy is cleared by the liver and requires dose adjustment in the face of significant liver dysfunction. In addition, preexisting abnormal liver function has been shown to increase the risk of hepatotoxicity. In addition to typical hepatocellular injury, other presentations, including cholestasis and hepatic sinusoidal obstruction syndrome, also commonly occur. The outcomes can range from asymptomatic liver function test abnormalities, which resolve spontaneously, to cirrhosis, which occurs despite discontinuation of the chemotherapeutic agent.
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Affiliation(s)
- Ameet V Thatishetty
- Department of Medicine, Memorial Health, University Medical Center, 4700 Waters Avenue, Savannah, GA 31403, USA
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8
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Hill-Kayser C, Tochner Z, Both S, Lustig R, Reilly A, Balamuth N, Womer R, Maris J, Grupp S, Bagatell R. Proton versus photon radiation therapy for patients with high-risk neuroblastoma: the need for a customized approach. Pediatr Blood Cancer 2013; 60:1606-11. [PMID: 23737005 DOI: 10.1002/pbc.24606] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/29/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton therapy for treatment for high-risk neuroblastoma may offer sparing of organs at risk (OAR) when compared to intensity-modulated X-ray therapy (IMXT). PROCEDURE Double-scattered proton plans and IMXT plans delivering 2,160 cGy to the primary tumor site and other residual disease were developed for 13 consecutive HR-NBL patients. Radiation doses to target volumes and OAR were calculated to determine the optimal modality for each. RESULTS All patients received radiation (5/13 ≥ 2 sites). No patient has experienced local recurrence or clinical organ toxicity. Coverage was excellent using both protons and IMXT: median % dose delivered to 95% clinical target volume was 99% and 100%, respectively. For nine patients with lateralized disease, proton therapy offered sparing of the contralateral kidney both with regard to median dose and dose to 20% (median <1 cGy vs. 362 cGy, P = 0.01; median 100 cGy vs. 634 cGy, P = 0.02, respectively). Proton therapy did not reduce ipsilateral kidney dose, and for 2 select patients with lateralized disease IMXT improved overall bilateral renal sparing. Proton therapy improved median bowel (median 33 cGy vs. 590 cGy, P = 0.01), total body (median <1 cGy vs. 30 cGy, P = 0.15), and liver dose (median <1 cGy vs. 529, P < 0.001). When chest RT was required, proton therapy decreased median heart dose and mean lung dose. CONCLUSIONS For most patients (11/13), proton therapy offered the optimal combination of target coverage and organ sparing, and is a feasible treatment for HR-NBL. We recommend a customized approach with careful evaluation of renal dosimetry; IMXT may be preferred for select patients.
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Affiliation(s)
- Christine Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Anker CJ, Ribas A, Grossmann AH, Chen X, Narra KK, Akerley W, Andtbacka RHI, Noyes RD, Shrieve DC, Grossmann KF. Severe Liver and Skin Toxicity After Radiation and Vemurafenib in Metastatic Melanoma. J Clin Oncol 2013; 31:e283-7. [DOI: 10.1200/jco.2012.44.7755] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Antoni Ribas
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA
| | | | | | | | - Wallace Akerley
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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10
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Mondick JT, Gibiansky L, Gastonguay MR, Skolnik JM, Cole M, Veal GJ, Boddy AV, Adamson PC, Barrett JS. Population Pharmacokinetic Investigation of Actinomycin-D in Children and Young Adults. J Clin Pharmacol 2013; 48:35-42. [DOI: 10.1177/0091270007310383] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Sen'kova AV, Mironova NL, Patutina OA, Ageeva TA, Zenkova MA. The Toxic Effects of Polychemotherapy onto the Liver Are Accelerated by the Upregulated MDR of Lymphosarcoma. ISRN ONCOLOGY 2012; 2012:721612. [PMID: 23251817 PMCID: PMC3517856 DOI: 10.5402/2012/721612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 10/15/2012] [Indexed: 11/23/2022]
Abstract
Antitumor therapy of hematological malignancies is impeded due to the high toxicity of polychemotherapy toward liver and increasing multiple drug resistance (MDR) of tumor cells under the pressure of polychemotherapy. These two problems can augment each other and significantly reduce the efficiency of antineoplastic therapy. We studied the combined effect of polychemotherapy and upregulated MDR of lymphosarcoma RLS(40) onto the liver of experimental mice using two treatment schemes. Scheme 1 is artificial: the tumor was subjected to four courses of polychemotherapy while the liver of the tumor-bearing mice was exposed to only one. This was achieved by threefold tumor retransplantation taken from animals subjected to chemotherapy into intact animals. Scheme 2 displays "real-life" status of patients with MDR malignancies: both the tumor and the liver of tumor-bearing mice were subjected to three sequential courses of polychemotherapy. Our data show that the strengthening of MDR phenotype of RLS(40) under polychemotherapy and toxic pressure of polychemotherapy itself has a synergistic damaging effect on the liver that is expressed in the accumulation of destructive changes in the liver tissue, the reduction of the regeneration capacity of the liver, and increasing of Pgp expression on the surface of hepatocytes.
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Affiliation(s)
- Alexandra V Sen'kova
- Institute of Chemical Biology and Fundamental Medicine, Siberian Branch of Russian Academy of Science, Lavrentiev Avenue 8, Novosibirsk 630090, Russia ; Novosibirsk State Medical University, Krasnyi Prospect 52, Novosibirsk 630091, Russia
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Segers H, van den Heuvel-Eibrink MM, Pritchard-Jones K, Coppes MJ, Aitchison M, Bergeron C, de Camargo B, Dome JS, Grundy P, Gatta G, Graf N, Grundy P, Kalapurakal JA, de Kraker J, Perlman EJ, Reinhard H, Spreafico F, Vujanic G, Warwick AB. Management of adults with Wilms' tumor: recommendations based on international consensus. Expert Rev Anticancer Ther 2012; 11:1105-13. [PMID: 21806333 DOI: 10.1586/era.11.76] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since Wilms' tumor occurs rarely in adults, there are no standard treatments available. Most adult patients will be diagnosed unexpectedly following nephrectomy for presumed renal cell carcinoma. Outcome for adults is inferior compared with children, although better results are reported when treated within pediatric trials. Multiple factors, including the unfamiliarity of adult oncologists and pathologists with Wilms' tumors, lack of standardized treatment and consequent delays in initiating the appropriate risk-adapted therapy, may contribute to the poor outcome. A standardized approach for the management of adult Wilms' tumors is proposed with the aim to limit treatment delay after surgery and encourage a uniform approach for this rare disease and thereby improve survival. These recommendations are based on discussions held with representatives of the renal tumor committees of the Society of Paediatric Oncology and Children's Oncology Group, and have been updated with a review of more recently published institutional and trial experience of adults treated on pediatric protocols. They provide a critical evaluation of the current evidence for the management of adult Wilms' tumors and propose details of how current pediatric therapeutic guidelines could be adapted for use in adults.
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Affiliation(s)
- Heidi Segers
- Deptartment of Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Dr Molewaterplein, 603015 GJ, Rotterdam, The Netherlands
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Barriers to the enrollment of children in the Children's Oncology Group study of very low risk Wilms tumor: a report from the Children's Oncology Group. J Pediatr Hematol Oncol 2011; 33:521-3. [PMID: 21941145 PMCID: PMC3496383 DOI: 10.1097/mph.0b013e31821b8dd5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Very low risk Wilms tumor is defined by favorable histology, age below 2 years, tumor weight less than 550 g, and stage I. The Children's Oncology Group is currently studying a nephrectomy-only strategy for these patients but the accrual rate is slightly below expected. Twenty-five of 31 institutions responded with reasons by physicians and/or parents for electing not to participate. Parents were primarily concerned with the experimental nature of the study, whereas physicians were concerned about accurate staging, with some overlap. We point out the necessity of assessing these concerns in predicting feasibility of and accrual to a therapy reduction study.
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Hepatic metastasis at diagnosis in patients with Wilms tumor is not an independent adverse prognostic factor for stage IV Wilms tumor: a report from the Children's Oncology Group/National Wilms Tumor Study Group. Ann Surg 2011; 250:642-8. [PMID: 19730241 DOI: 10.1097/sla.0b013e3181b76f20] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine event free survival (EFS) of children with Wilms tumor (WT) and metastatic liver disease at diagnosis. SUMMARY AND BACKGROUND DATA We reviewed patients with stage IV Wilms tumor treated on National Wilms Tumor Study 4 and 5 to ascertain if they have a worse prognosis than other Stage IV disease. METHODS A total of 742 patients (pts) with stage IV disease were assessed for EFS (95% confidence interval [CI]) at 5 years after diagnosis. Cohorts included those who underwent resection of the liver lesions compared with those who received only chemotherapy and radiotherapy. RESULTS A total of 742 patients with stage IV Wilms tumor were enrolled on NWTS-4 and 5, 111 of who had liver metastases. Of these, 96 had favorable histology disease and are the focus of this analysis. Twenty-two patients had a primary liver resection (wedge resection, 18 and lobectomy, 4). After chemotherapy and/or radiation, 13 patients underwent liver resection (wedge resection, 7; lobectomy, 5; and trisegmentectomy, 1). Seventy-one patients (67%) did not undergo surgery for their liver disease. In 14 patients, the liver disease disappeared with chemotherapy only. Eighty-two patients received abdominal radiation. EFS for the patients with metastatic FH Wilms tumor was 75% (95% confidence interval [CI]: (71%, 78%), EFS by Stage IV category was: lung only 76% (95% CI: 72%, 80%) (513 patients); liver, not lung 76% (95% CI: 58%, 87%) (34 patients), liver and lung 70% (95% CI: 57%, 80%) (62 patients), and other sites 64% (95% CI: 42%, 79%) (25 patients). There were no significant differences among stage IV groups (P = 0.60). EFS (95% CI) for the patients with primary resection of the liver metastases (22 patients) was 86% (63%, 95%) compared with 68% (56%, 78%) (P = 0.09) for the 74 with no primary resection of liver metastases. There was no significant difference in EFS for patients with FH Wilms tumor treated with chemotherapy compared with that of patients treated with chemotherapy and radiation (P = 0.63). The EFS (95% CI) for each of the subsets was; no abdominal radiation: 64% (34%, 83%); abdominal radiation, no boost: 77% (55%, 89%); abdominal radiation, boost: 72% (58%, 82%) (P = 0.05). CONCLUSION Liver metastasis at diagnosis is not an adverse prognostic factor for stage IV metastatic FH WT.
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Lee ACW, Goh PYT. Dactinomycin-induced Hepatic Sinusoidal Obstruction Syndrome Responding to Treatment with N-acetylcysteine. J Cancer 2011; 2:527-31. [PMID: 22043237 PMCID: PMC3204401 DOI: 10.7150/jca.2.527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Accepted: 10/20/2011] [Indexed: 02/05/2023] Open
Abstract
Hepatic sinusoidal obstruction syndrome is commonly described in pediatric oncology as a complication of chemotherapy. It has also been occasionally reported in adult cancer patients. Treatment is largely supportive with fluid restriction. A 16-month-old girl with stage II Wilms tumor receiving post-nephrectomy chemotherapy with dactinomycin and vincristine developed hepatic sinusoidal obstruction syndrome with painful hepatomegaly, ascites with significant weight gain, grossly deranged liver function, severe thrombocytopenia, and reversal of blood flow in the portal vein on Doppler sonography. Treatment with N-acetylcysteine was followed by complete resolution of clinical signs and amelioration of laboratory abnormalities within 72 hours of treatment. N-acetylcysteine is a safe and probably an effective treatment for dactinomycin-induced hepatic sinusoidal obstructive syndrome.
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Affiliation(s)
- Anselm Chi-wai Lee
- 1. Children's Haematology and Cancer Centre, Mount Elizabeth Hospital, Singapore
- ✉ Corresponding author: Dr Anselm C.W. Lee, Children's Haematology and Cancer Centre, Level 4, Mount Elizabeth Hospital, 3 Mount Elizabeth, Singapore 228510. Tel: 65-67312673; Fax: 65-62354924;
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Late toxicity in Wilms tumor patients treated with radiotherapy at 15 years of median follow-up. J Pediatr Hematol Oncol 2010; 32:e264-7. [PMID: 20736847 DOI: 10.1097/mph.0b013e3181e7931a] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We report the radiation-induced late morbidity observed in our prospective series of Wilms tumor patients treated at the Second University of Naples. METHODS From April 1981 to April 2000, 98 patients were referred at our institution for treatment of Wilms tumor. Among them, 51 underwent radiotherapy and 34 patients had a minimum follow-up of 5 years. Doses of irradiation and treatment portals were those recommended by the guidelines of the Italian Association of Haematology and Paediatric Oncology according to risk stratification. All eligible patients were reviewed for follow-up every 6 months. Median follow-up was 181 months (range 60 to 264 months). RESULTS Eleven out of 34 patients (32%) did not suffer from any significant late side effect. Out of the remaining 23 (68%), 14 (41%) suffered from scoliosis presenting between 60 and 180 months from completion of treatment. Muscular hypoplasia, length inequality, kyphosis, and iliac wing hypoplasia were seen respectively, in 4 (12%), 4 (12%), 5 (15%), and 3 (9%) patients. The incidence of intestinal occlusion was 20%. One patient had chronic renal insufficiency. Four out of 13 female patients reported ovarian failure. Three out of the 7 patients who had radiotherapy to the lung developed radiation-pneumonitis. Radiation-induced heart disease was seen in 3 (9%) patients. Three patients (9%) suffered from second malignancies arising within the irradiated volume. CONCLUSIONS Our data confirm the high incidence of late radiation morbidity in patients undergoing adjuvant radiotherapy for Wilms tumor. For most organ systems there is a correlation between total dose, morbidity rates, and degree of severity.
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Cefalo MG, Maurizi P, Arlotta A, Scalzone M, Attinà G, Ruggiero A, Riccardi R. Hepatic veno-occlusive disease: a chemotherapy-related toxicity in children with malignancies. Paediatr Drugs 2010; 12:277-84. [PMID: 20799757 DOI: 10.2165/11531840-000000000-00000] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is a major manifestation of liver toxicity associated with conventional and high-dose chemotherapy in children affected by hematologic malignancies and certain solid tumors. Clinically, patients present with jaundice, painful hepatomegaly, and fluid retention, which may evolve into multi-organ failure, a hallmark of severe disease. The pathogenesis is complex and not completely understood, but the damage to sinusoidal endothelium, typically caused by toxic metabolites released from antineoplastic drugs, is thought to play a crucial role, together with cytokine activation, immune deregulation, and coagulopathy. Diagnosis is based on clinical criteria supported by characteristic ultrasound findings, with the gold standard investigation being hepatic-venous pressure gradient measurement and biopsy. Several treatment options have been tested; the most convincing approach to date is the use of defibrotide, a novel oligonucleotide with antithrombotic and antiplatelet aggregating properties, as well as endothelial-stabilizing effects. This agent, together with other specific forms of supportive care, has shown efficacy in the treatment of established VOD and promising results in the prevention of VOD in pediatric patients receiving chemotherapy.
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Giri S, Nieber K, Bader A. Hepatotoxicity and hepatic metabolism of available drugs: current problems and possible solutions in preclinical stages. Expert Opin Drug Metab Toxicol 2010; 6:895-917. [DOI: 10.1517/17425251003792521] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Yap KYL, Kuo EY, Lee JJJ, Chui WK, Chan A. An onco-informatics database for anticancer drug interactions with complementary and alternative medicines used in cancer treatment and supportive care: an overview of the OncoRx project. Support Care Cancer 2009; 18:883-91. [PMID: 19756775 DOI: 10.1007/s00520-009-0729-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 08/13/2009] [Indexed: 11/24/2022]
Abstract
PURPOSE Cancer patients are at high risk of manifesting interactions from use of anticancer drugs (ACDs) and complementary and alternative medicines (CAMs). These interactions can result in sub-therapeutic effects or increased toxicities which may compromise the outcome of chemotherapy. It is important for practitioners to gain convenient access to ACD-CAM interaction information so as to make better-informed decisions in daily practice. This paper describes the creation of an oncology database (OncoRx) that documents ACD-CAM interactions, including traditional Chinese medicines (TCMs) that are commonly used for cancer treatment, prevention, and supportive care therapy. METHODS Information regarding ACDs, CAMs, and drug interactions were collated from 14 sources, inclusive of hardcopy and online resources, and input into a modified web server with a database engine and a programming interface using a combination of software and programming scripts. RESULTS OncoRx currently contains a total of 117 ACDs and 166 CAMs. Users are able to search for interactions based on various CAM uses: cancer treatment or prevention, immune-system-related, alopecia, nausea, and vomiting, peripheral neuropathy and pain, inflammation, fatigue, and non-cancer related. Pharmacokinetic data on ACDs and CAMs, characteristics of CAMs based on TCM principles, and drug interaction parameters such as effects, mechanisms, evidences, and proposed management plans, are shown in the search results. CONCLUSION OncoRx is an oncology database which detects ACD interactions. It is currently able to detect interactions with CAMs. It is hoped that OncoRx will serve as a useful resource to clinicians, educators, trainers, and students working in the oncology setting.
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Affiliation(s)
- Kevin Yi-Lwern Yap
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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Faqih N, Hazin R, Barbar M, Ismael T, Al-Gharabli F, Sultan I. Severe veno-occlusive disease in an overweight infant with a renal tumor. Pediatr Blood Cancer 2009; 52:900. [PMID: 19213075 DOI: 10.1002/pbc.21944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Damen CWN, Israëls T, Caron HN, Schellens JHM, Rosing H, Beijnen JH. Validated assay for the simultaneous quantification of total vincristine and actinomycin-D concentrations in human EDTA plasma and of vincristine concentrations in human plasma ultrafiltrate by high-performance liquid chromatography coupled with tandem mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2009; 23:763-774. [PMID: 19204931 DOI: 10.1002/rcm.3938] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A sensitive, specific and efficient high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS) assay for the simultaneous determination of total vincristine and actinomycin-D concentrations in human plasma and an assay for the determination of unbound vincristine are presented. Electrospray ionization (ESI), atmospheric pressure chemical ionization (APCI) and heated electrospray ionization (H-ESI) were tested as ionization interfaces. For reasons of robustness ESI was chosen followed by tandem mass spectrometry (ESI-MS/MS). For the plasma assay a 30 microL aliquot was protein precipitated with acetonitrile/methanol (50:50, v/v) containing the internal standard vinorelbine and 10 microL volumes were injected onto the HPLC system. To determine unbound vincristine, ultrafiltrate was produced from plasma using 30 kDa centrifugal filter units. The plasma ultrafiltrate was mixed with methanol (50:50, v/v), internal standard vinorelbine was added and 20 microL aliquots were injected onto the HPLC system. Separation was achieved on a 50x2.1 mm i.d. Xbridge C18 column using 1 mM ammonium acetate/acetonitrile (30:70, v/v) adjusted to pH 10.5 with ammonia, run in a gradient with methanol at a flow rate of 0.4 mL/min. HPLC run time was 6 min. The assay quantifies in plasma vincristine from 0.25 to 100 ng/mL and actinomycin-D from 0.5 to 250 ng/mL using plasma sample volumes of only 30 microL. Vincristine in plasma ultrafiltrate can be quantified from 1 to 100 ng/mL. Validation results demonstrate that vincristine and actinomycin-D can be accurately and precisely quantified in human plasma and plasma ultrafiltrate with the presented methods. The assays are now in use to support clinical pharmacological studies in children treated with vincristine and actinomycin-D.
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Affiliation(s)
- Carola W N Damen
- Department of Pharmacy & Pharmacology, Slotervaart Hospital/The Netherlands Cancer Institute, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
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Cecen E, Uysal KM, Ozguven A, Gunes D, Irken G, Olgun N. Veno-occlusive disease in a child with rhabdomyosarcoma after conventional chemotherapy: report of a case and review of the literature. Pediatr Hematol Oncol 2007; 24:615-21. [PMID: 18092252 DOI: 10.1080/08880010701640390] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although veno-occlusive disease of the liver is a well-known complication of high-dose chemotherapy and bone marrow transplantation, it has rarely been observed in children who receive conventional chemotherapy. Most cases in the literature consists of children with Wilms tumor. It has been very uncommon in rhabdomyosarcoma patients until recently, although they commonly receive similar anticancer agents. Here the authors report a 2-year-old boy with rhabdomyosarcoma who developed veno-occlusive disease while receiving VAC (vincristine, actinomycin D, cyclophosphamide) chemotherapy regimen according to the IRS-IV protocol. The patient gradually recovered during 2 weeks with supportive treatment only.
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Affiliation(s)
- Emre Cecen
- Department of Pediatric Oncology, Dokuz Eylül University, Institute of Oncology, Izmir, Turkey.
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Elli M, Pinarli FG, Dagdemir A, Acar S. Veno-occlusive disease of the liver in a child after chemotherapy for brain tumor. Pediatr Blood Cancer 2006; 46:521-3. [PMID: 16317738 DOI: 10.1002/pbc.20338] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Veno-occlusive disease (VOD) of the liver is a life-threatening state generally occurring as a complication of bone marrow transplantation or chemotherapy for Wilms' tumor. Veno-occlusive disease after standard dose chemotherapy in malignancies other than Wilms' tumor is rare and only a few cases have been published in children. We report a 19 month-old-girl with medulloblastoma who experienced fatal VOD of liver after only one course of chemotherapy including carboplatin, vincristine and CCNU for medulloblastoma. As our knowledge, this is the first report of VOD after standard dose chemotherapy for brain tumor in childhood.
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Affiliation(s)
- Murat Elli
- Department of Pediatric Oncology, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
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Madani A, Zafad S, Harif M, Yaakoubi M, Zamiati S, Sahraoui S, Benjelloun A, Fehri M, Benchekroun S. Treatment of Wilms tumor according to SIOP 9 protocol in Casablanca, Morocco. Pediatr Blood Cancer 2006; 46:472-5. [PMID: 16035094 DOI: 10.1002/pbc.20436] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Childhood Wilms tumor represents one of the challenge for pediatric oncologists in developing countries. We report the characteristics and treatment results of patients with Wilms tumor according to SIOP 9 protocol in Morocco. PROCEDURE From January 1989 to December 2000, 86 children with Wilms tumor were admitted. The diagnosis was based on physical exam and abdominal ultrasound. The metastatic work-up was based on abdominal ultrasound and chest X-ray. RESULTS The mean age was 36 months (3-120 months). The sex-ratio was 1. Abdominal mass was the main symptom at presentation (84 cases). There were 13 metastatic cases. Treatment applied was according to SIOP 9 Protocol without randomization. Local deases was present in 75 patients with stage I in 38 cases (50%), IIN0 in 4 cases (6%), IIN1 in 9 cases, and III in 24 cases (44%). The distribution of pathologic groups was: favorable in 4 cases, standard in 69 cases, and unfavorable anaplastic type in 2 cases. Sixty-nine patients were evaluable for therapeutic evaluation. Other patients were lost to follow-up. Three patients died of treatment related toxicity and 13 patients relapsed. With a median follow-up of 70 months, the 5-year EFS and 5 years overall survival for evaluable patients are 77.4% and 79%, respectively while the 5-year EFS for all patients was 56%. CONCLUSION These results are encouraging for a developing country but special efforts should be done to reduce the rate of abandonment.
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Affiliation(s)
- Abdellah Madani
- Hematology and Pediatric Oncology Department, Hôpital du 20 Août, Casablanca, Morocco.
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Skolnik JM, Barrett JS, Shi H, Adamson PC. A liquid chromatography-tandem mass spectrometry method for the simultaneous quantification of actinomycin-D and vincristine in children with cancer. Cancer Chemother Pharmacol 2005; 57:458-64. [PMID: 16187113 DOI: 10.1007/s00280-005-0065-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 06/23/2005] [Indexed: 10/25/2022]
Abstract
Actinomycin-D (Act-D) and vincristine (VCR) are cytotoxic agents commonly used in the treatment of pediatric cancers. To date, there are few published methods on quantifying Act-D or VCR and no published methods on quantifying the two drugs together. We present a methodology for the simultaneous quantification of Act-D and VCR in human plasma using liquid chromatography-tandem mass spectrometry (LC/MS/MS) detection. Following solid phase extraction, plasma samples were separated and analyzed using electrospray ionization (ESI). The lower limit of quantitation (LLOQ) for both Act-D and VCR was 0.5 ng/ml. The analytical accuracy for detection of both Act-D and VCR was > or = 90%. The analytical precision, as estimated by the coefficient of variation was < or = 6% for Act-D and < or = 11% for VCR. Given the prevalence of the use of the two drugs as combination therapy in a variety of pediatric oncological indications, the small sample volume requirements and the assay sensitivity, this methodology is expected to support several ongoing and future pediatric trials.
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Affiliation(s)
- Jeffrey M Skolnik
- Division of Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Abramson Research Center, Suite 916, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Weirich A, Ludwig R, Graf N, Abel U, Leuschner I, Vujanic GM, Mehls O, Boos J, Beck J, Royer-Pokora B, Voûte PA. Survival in nephroblastoma treated according to the trial and study SIOP-9/GPOH with respect to relapse and morbidity. Ann Oncol 2004; 15:808-20. [PMID: 15111352 DOI: 10.1093/annonc/mdh171] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recent Wilms' tumor (WT) trials and studies have tried to determine the minimal therapy needed for cure. The goal was survival without morbidity. PATIENTS AND METHODS From January 1989 to March 1994 the German Society of Pediatric Oncology and Hematology registered 440 patients (median age 2.9 years; 231 male, 209 female) with WTs (preoperative chemotherapy 362) for therapy according to the International Society of Pediatric Oncology Trial and Study 9. Therapy for relapse depended on site of relapse and therapy already received. Follow-up included inquiries for morbidity. Prognostic factors for relapse and death were evaluated. RESULTS Five-year survival of WTs was 89.5%; 98.2% (385 of 392) of survivors had a follow-up of 5 years (range 0.8-12.6; median 8). In non-anaplastic WTs, young age (<2 years) was of significance (P = 0.026) for a better survival. Non-anaplastic WTs (407 patients) had a 5-year survival of 92.3%, versus 48.5% in anaplastic WTs (33 patients), and a 5-year relapse-free survival of 87.6% versus 42.4%. Survival after relapse was significantly worse for anaplastic than for non-anaplastic WTs (residual 3-year survival 11.8% versus 54.3%; P <0.0001). In preoperatively treated WTs, anaplasia was a strong prognostic factor for death [relative risk (RR) 4.7], followed by poor response to preoperative therapy (RR 3.6), stage IV (RR 3.2) and abdominal stage III (RR 2.2). Low abdominal stages (<III) dominated (280 versus 82). In the 334 unilateral stage I-IV WTs (median age 3.2 years), diffuse anaplasia (21 patients) had a 5-year relapse-free survival of 38.1%, versus 58.4% in blastemal WTs (25 patients); survival was 42.9% in diffuse anaplasia versus 84% in blastemal WTs. None of 46 patients (median age 1.9 years; 91.3% stages I or II) with differentiated WTs (nine epithelial, 37 stromal) relapsed despite their non-response; two died (one therapy related, one due to bilaterization). In the 25 non-anaplastic bilateral WTs, differentiated cases (one epithelial, eight stromal, 33.3% abdominal stage III) were more frequent (P = 0.048) than in unilateral WTs (one stromal, abdominal stage III relapsed). In all, 52.9% of the 5-year survivors had received adriamycin (250-400 mg/m(2)), 25.7% radiation, 6.4% ifosfamide (24-30 g/m(2)) and 6.7% carboplatin plus etoposide. Abnormal parameters according to the National Cancer Institute score were seen in 18.9% during follow-up, but only 6.4% were treated for morbidity at the end of follow-up. Three WTs developed renal failure due to Drash syndrome, but none due to tumor therapy. After adriamycin 1.9% of WTs (9% of those receiving 400 mg/m(2)) required therapy for cardiac toxicity. CONCLUSIONS Initial therapy should be more individualized, taking the above risk groups (age in non-anaplastic WTs, poor response, anaplasia, etc.) into account, as morbidity even after relapse therapy with ifosfamide, carboplatin and etoposide was not high. Milder therapy in low stages of differentiated and of well responding WTs should be tested.
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Affiliation(s)
- A Weirich
- Department of Pediatric Oncology, University of Heidelberg, Im Neuenheimer Feld 150, D-69120 Heidelberg, Germany.
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Veal GJ, Errington J, Sludden J, Griffin MJ, Price L, Parry A, Hale J, Pearson ADJ, Boddy AV. Determination of anti-cancer drug actinomycin D in human plasma by liquid chromatography-mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2004; 795:237-43. [PMID: 14522028 DOI: 10.1016/s1570-0232(03)00573-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Actinomycin D is an anti-cancer drug commonly used in the treatment of paediatric malignancies such as Wilms' tumour, Ewing's sarcoma and rhabdomyosarcoma. Despite its long history of clinical use, little is known about the pharmacokinetics of actinomycin D in humans, largely due to problems in developing an analytical assay with the required sensitivity to measure relevant clinical concentrations. As actinomycin D treatment in children with cancer is associated with veno-occlusive disease (VOD), and as the dose intensity of actinomycin D treatment has been defined as a significant risk factor for the development of this potentially life-threatening hepatic toxicity, pharmacokinetic studies of actinomycin D may be beneficial in optimizing treatment with this drug. In order to investigate this issue, we developed a sensitive liquid chromatography-mass spectrometry (LC-MS) method for the determination of actinomycin D in human plasma samples. Extraction of analytical samples was carried out with acetonitrile and analysis performed on an API 2000 LC/MS/MS using an internal standard of 7-aminoactinomycin D. A limit of quantitation of 1.0 ng/ml was determined, allowing the reliable measurement of actinomycin D in plasma samples obtained from patients receiving this drug clinically. The method demonstrated good reproducibility, over the calibration curve range of 1.0-100 ng/ml, with intra- and inter-assay precision CVs of 2.7-11.3 and 2.3-7.8%, respectively. Accuracy data showed relative errors of 2.0-16.4 and 10.4-15.2% for intra-assay (n=10) and inter-assay (n=7) experiments, respectively. Initial results of actinomycin D pharmacokinetics in paediatric patients are shown.
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Affiliation(s)
- Gareth J Veal
- Northern Institute for Cancer Research, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, UK.
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Arndt C, Hawkins D, Anderson JR, Breitfeld P, Womer R, Meyer W. Age is a risk factor for chemotherapy-induced hepatopathy with vincristine, dactinomycin, and cyclophosphamide. J Clin Oncol 2004; 22:1894-901. [PMID: 15143082 DOI: 10.1200/jco.2004.08.075] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the spectrum of and determine the risk factors for the development of liver toxicity (hepatopathy) after therapy with vincristine, dactinomycin, and cyclophosphamide (VAC) for rhabdomyosarcoma in children and adolescents. PATIENTS AND METHODS We prospectively captured all events of hepatopathy occurring on the ongoing Children's Oncology Group intermediate risk protocol, D9803, for children with rhabdomyosarcoma. Patients enrolled onto this trial were randomly assigned to receive either VAC alone or VAC alternating with vincristine, topotecan, and cyclophosphamide. In addition, we reviewed the toxicity database and requested additional information for all patients with elevated bilirubin or transaminase levels. Risk factors were analyzed. RESULTS Of 339 patients enrolled through August 2002, 18 developed hepatopathy. All events were captured by mandated toxicity reporting and filing of MedWatch forms, with no additional cases found after the additional search of the database. Four children died after developing this toxicity. All cases occurred after cycles of VAC (n = 16) or vincristine and cyclophosphamide with concomitant abdominal radiotherapy (n = 2). The onset of hepatopathy was 5 to 16 days from the start of a treatment cycle. For the 89 patients under 36 months of age, the risk of hepatopathy was 15%, with two deaths. For the 239 children 3 years of age or older, the risk for hepatopathy was 4%, with two deaths. CONCLUSION The greatest risk factor for development of hepatopathy after VAC therapy was age. Dose modifications for younger children receiving VAC therapy are recommended.
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Affiliation(s)
- C Arndt
- Department of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
Our understanding of the clinical and cellular pharmacology of drugs commonly used in the treatment of childhood cancer have increased greatly over the past two decades. However, with the exception of childhood acute lymphoblastic leukaemia (ALL), our current knowledge of factors such as inter-patient pharmacokinetic variability and cellular determinants of chemosensitivity has not been utilized in the design of integrated clinical studies. Recent pre-clinical and clinical evaluation of the topoisomerase I inhibitors topotecan and irinotecan has highlighted the potential importance of pharmacological factors in their effectiveness as cytotoxics. In this review, the clinical and cellular pharmacology of vincristine, actinomycin D, doxorubicin, cyclophosphamide, ifosfamide, cisplatin, carboplatin and etoposide will be discussed in relation to the major paediatric solid tumours. For each disease type, knowledge of the clinical and cellular pharmacology of a candidate drug will be related to pharmacodynamic responses such as response, toxicity and prognosis. For diseases such as Wilms' tumour, osteogenic sarcoma and Ewing's tumour, histological response to initial induction chemotherapy is of prognostic significance, and the depth of response is increasingly recognised as an important determinant of prognosis for high-risk neuroblastoma. For several of these tumour types, the dose-intensity of chemotherapy may be an important variable in determining prognosis. However the relationship between pharmacokinetic variability, cellular pharmacology and the major determinants of chemosensitivity to those drugs employed in first line therapy is unknown. The study of these relationships, by means of up front window studies in children who present with high-risk disease, may be as important as the introduction of new agents. Indeed, the optimisation of current therapies may be required to allow a fully informed selection of those children for whom novel therapies are truly needed. Funding and international collaboration at the clinical and scientific level would be required to achieve these aims.
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Affiliation(s)
- E J Estlin
- Department of Paediatric Oncology, Royal Manchester Children's Hospital, Pendlebury, Manchester, M27 4HA, UK.
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Abstract
After assessment of tumor histology, the next important factor to consider in the selection of a chemotherapy regime is organ function. Patients who are to receive chemotherapy require careful assessment of liver function prior to treatment to determine which drugs may not be appropriate, and which drug doses should be modified. Following therapy abnormalities of liver function tests may be due to the therapy rather than to progressive disease, and this distinction is of critical importance. Furthermore, not all abnormalities in liver function are due to the tumor or its treatment, and other processes, such as hepatitis, must be kept in mind. This article reviews the hepatic toxicity of chemotherapeutic agents, and suggests dose modifications based upon liver function abnormalities. Emphasis is placed on agents known to be hepatotoxic, and those agents with hepatic metabolism.
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Affiliation(s)
- P D King
- Gastroenterology and Hepatology, Department of Internal Medicine, University of Missouri-Columbia, Columbia, MO 65203, USA
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D'Antiga L, Baker A, Pritchard J, Pryor D, Mieli-Vergani G. Veno-occlusive disease with multi-organ involvement following actinomycin-D. Eur J Cancer 2001; 37:1141-8. [PMID: 11378345 DOI: 10.1016/s0959-8049(01)00097-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Actinomycin-D (Act-D) is a rare cause of veno-occlusive disease (VOD). Between 1993 and 1998, we managed 6 patients, all male, median age 19 months (range 6-48 months) who received Act-D for Wilms' tumour (n=4), clear cell sarcoma (n=1) or rhabdomyosarcoma (n=1). VOD presented with a median platelet count of 12 x 10(9)/l, INR 3.8, fibrinogen 16 mg/l, fibrinogen degradation products (FDPs) > or =80 microg/l, aspartate aminotransferase (AST) 6922 IU/l, bilirubin 47 micromol/l. In 3 cases, transient liver dysfunction and thrombocytopenia without neutropenia had been observed after a previous course of Act-D. All six children developed encephalopathy, hepatomegaly, ascites, reversed portal flow and renal impairment. All received mechanical ventilation and two required haemofiltration. The treatment was supportive. Severe Adult Respiratory Distress Syndrome developed in 3 patients, all of whom died. 3 patients recovered. The outcome of VOD with multi-organ failure is poor. Intravascular coagulopathy precedes and characterises severe VOD during Act-D treatment.
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Affiliation(s)
- L D'Antiga
- Department of Child Health, King's College Hospital, Denmark Hill, SE5 9RS, London, UK
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Tournade MF, Com-Nougué C, de Kraker J, Ludwig R, Rey A, Burgers JM, Sandstedt B, Godzinski J, Carli M, Potter R, Zucker JM. Optimal duration of preoperative therapy in unilateral and nonmetastatic Wilms' tumor in children older than 6 months: results of the Ninth International Society of Pediatric Oncology Wilms' Tumor Trial and Study. J Clin Oncol 2001; 19:488-500. [PMID: 11208843 DOI: 10.1200/jco.2001.19.2.488] [Citation(s) in RCA: 173] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the optimal duration of preoperative chemotherapy to further increase the proportion of stage I tumors by comparison of two regimens in the treatment of patients older than 6 months who have unilateral Wilms' tumor. PATIENTS AND METHODS Eligible patients (n = 382) initially received four weekly doses of vincristine (VCR) and two courses of actinomycin D (AMD) and were randomized either to be operated on (4-week group [n = 193]) or to receive 4 more weeks of the same chemotherapy regimen (8-week group [n = 189]). The assessment criterion was the observed percentage of stage I tumors. After surgery, patients were assigned according to tumor stage and histology to four different treatment groups: stage I and favorable histology (n = 5) were to have no further treatment (NFT); stage I and standard histology or anaplasia (n = 244), VCR and AMD for 17 weeks (AV); stages II and III and favorable or standard histology, VCR, AMD, and an anthracycline for 27 weeks (AVE) with no abdominal radiotherapy for stage II N0 disease (n = 75) or with a 15-Gy dose of abdominal irradiation (RTH) in case of stages IIN1 and III (n = 56). Anaplastic tumors staged higher than I or clear-cell sarcoma of the kidney (14), AMD, VCR, an anthracycline, and ifosfamide for 36 weeks (DEVI). RESULTS No advantage was found in favor of prolonged preoperative treatment. The percentages obtained for the 4-week and the 8-week groups, respectively, were as follows: stage I, 64% versus 62%; intraoperative tumor rupture rate, 1% versus 3%; 2-year EFS, 84% versus 83%; and 5-year OS, 92% versus 87%. Two-year EFS and 5-year OS rates, respectively, of the different treatment groups were as follows: NFT, 100% for both EFS and OS; AV, 88% and 93%; AVE, 84% and 88%; AVE RTH, 71% and 85%; and DEVI, 71% and 71%. The rate of abdominal recurrences in stage II N0 nonirradiated patients was 6.6%. CONCLUSION The 4-week schedule pre-nephrectomy chemotherapy regimen should be considered the standard treatment. Clinical trials should continue to improve the cure rate of high-risk patients and the quality of life of children with a more favorable prognosis.
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Abstract
Advances in our knowledge of pediatric genitourinary tumors are being made at both the basic science and clinical levels. The molecular mechanisms underlying these pediatric malignancies are being uncovered and will aid in uncovering novel treatments. Because of the high success rate in treating these tumors, treatment options are being modified to decrease both short- and long-term morbidity, while maintaining the improved survival.
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Affiliation(s)
- D Herz
- Division of Urology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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