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Mahajan A, Stavinoha PL, Rongthong W, Brodin NP, McGovern SL, El Naqa I, Palmer JD, Vennarini S, Indelicato DJ, Aridgides P, Bowers DC, Kremer L, Ronckers C, Constine L, Avanzo M. Neurocognitive Effects and Necrosis in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:401-416. [PMID: 33810950 DOI: 10.1016/j.ijrobp.2020.11.073] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/08/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE A PENTEC review of childhood cancer survivors who received brain radiation therapy (RT) was performed to develop models that aid in developing dose constraints for RT-associated central nervous system (CNS) morbidities. METHODS AND MATERIALS A comprehensive literature search, through the PENTEC initiative, was performed to identify published data pertaining to 6 specific CNS toxicities in children treated with brain RT. Treatment and outcome data on survivors were extracted and used to generate normal tissue complication probability (NTCP) models. RESULTS The search identified investigations pertaining to 2 of the 6 predefined CNS outcomes: neurocognition and brain necrosis. For neurocognition, models for 2 post-RT outcomes were developed to (1) calculate the risk for a below-average intelligence quotient (IQ) (IQ <85) and (2) estimate the expected IQ value. The models suggest that there is a 5% risk of a subsequent IQ <85 when 10%, 20%, 50%, or 100% of the brain is irradiated to 35.7, 29.1, 22.2, or 18.1 Gy, respectively (all at 2 Gy/fraction and without methotrexate). Methotrexate (MTX) increased the risk for an IQ <85 similar to a generalized uniform brain dose of 5.9 Gy. The model for predicting expected IQ also includes the effect of dose, age, and MTX. Each of these factors has an independent, but probably cumulative effect on IQ. The necrosis model estimates a 5% risk of necrosis for children after 59.8 Gy or 63.6 Gy (2 Gy/fraction) to any part of the brain if delivered as primary RT or reirradiation, respectively. CONCLUSIONS This PENTEC comprehensive review establishes objective relationships between patient age, RT dose, RT volume, and MTX to subsequent risks of neurocognitive injury and necrosis. A lack of consistent RT data and outcome reporting in the published literature hindered investigation of the other predefined CNS morbidity endpoints.
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Affiliation(s)
- Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Peter L Stavinoha
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Warissara Rongthong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Joshua D Palmer
- Department of Radiation Oncology, James Cancer Hospital at Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Sabina Vennarini
- Proton Therapy Center, Azienda Provinciale per I Servizi Sanitari, Trento, Italy
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Paul Aridgides
- Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, New York
| | - Daniel C Bowers
- Division of Pediatric Hematology and Oncology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Leontien Kremer
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Cecile Ronckers
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg-Theodor Fontane, Neuruppin, Germany
| | - Louis Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Michele Avanzo
- Medical Physics Department, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
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Skurlova M, Holubova K, Kleteckova L, Kozak T, Kubova H, Horacek J, Vales K. Chemobrain in blood cancers: How chemotherapeutics interfere with the brain's structure and functionality, immune system, and metabolic functions. Med Res Rev 2024; 44:5-22. [PMID: 37265248 DOI: 10.1002/med.21977] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 03/28/2023] [Accepted: 04/30/2023] [Indexed: 06/03/2023]
Abstract
Cancer treatment brings about a phenomenon not fully clarified yet, termed chemobrain. Its strong negative impact on patients' well-being makes it a trending topic in current research, interconnecting many disciplines from clinical oncology to neuroscience. Clinical and animal studies have often reported elevated concentrations of proinflammatory cytokines in various types of blood cancers. This inflammatory burst could be the background for chemotherapy-induced cognitive deficit in patients with blood cancers. Cancer environment is a dynamic interacting system. The review puts into close relationship the inflammatory dysbalance and oxidative/nitrosative stress with disruption of the blood-brain barrier (BBB). The BBB breakdown leads to neuroinflammation, followed by neurotoxicity and neurodegeneration. High levels of intracellular reactive oxygen species (ROS) induce the progression of cancer resulting in increased mutagenesis, conversion of protooncogenes to oncogenes, and inactivation of tumor suppression genes to trigger cancer cell growth. These cell alterations may change brain functionality, as well as morphology. Multidrug chemotherapy is not without consequences to healthy tissue and could even be toxic. Specific treatment impacts brain function and morphology, functions of the immune system, and metabolism in a unique mixture. In general, a chemo-drug's effects on cognition in cancer are not direct and/or in-direct, usually a combination of effects is more probable. Last but not least, chemotherapy strongly impacts the immune system and could contribute to BBB disruption. This review points out inflammation as a possible mechanism of brain damage during blood cancers and discusses chemotherapy-induced cognitive impairment.
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Affiliation(s)
- M Skurlova
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - K Holubova
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - L Kleteckova
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - T Kozak
- Department of Developmental Epileptology, Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic
| | - H Kubova
- Department of Internal Medicine and Hematology, Faculty Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - J Horacek
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - K Vales
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
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3
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Yao S, Zhang Q, Yao X, Zhang X, Pang L, Yu S, Cheng H. Advances of neuroimaging in chemotherapy related cognitive impairment (CRCI) of patients with breast cancer. Breast Cancer Res Treat 2023:10.1007/s10549-023-07005-y. [PMID: 37329458 DOI: 10.1007/s10549-023-07005-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Chemotherapy related cognitive impairment (CRCI) has seriously affected the quality of life (QOL) of patients with breast cancer (BCs), thus the neurobiological mechanism of CRCI attracted widespread attention. Previous studies have found that chemotherapy causes CRCI through affecting brain structure, function, metabolism, and blood perfusion. FINDINGS A variety of neuroimaging techniques such as functional magnetic resonance imaging (fMRI), event-related potential (ERP), near-infrared spectroscopy (NIRS) have been widely applied to explore the neurobiological mechanism of CRCI. CONCLUSION This review summarized the progress of neuroimaging research in BCs with CRCI, which provides a theoretical basis for further exploration of CRCI mechanism, disease diagnosis and symptom intervention in the future. Multiple neuroimaging techniques for CRCI research.
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Affiliation(s)
- Senbang Yao
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Cancer and Cognition Laboratory, Anhui Medical University, Hefei, Anhui, China
| | - Qianqian Zhang
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Cancer and Cognition Laboratory, Anhui Medical University, Hefei, Anhui, China
| | - Xinxin Yao
- Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, Anhui, China
| | - Xiuqing Zhang
- Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, Anhui, China
| | - Lulian Pang
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Cancer and Cognition Laboratory, Anhui Medical University, Hefei, Anhui, China
| | - Sheng Yu
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Cancer and Cognition Laboratory, Anhui Medical University, Hefei, Anhui, China
| | - Huaidong Cheng
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.
- Department of Oncology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China.
- Shenzhen Clinical Medical School, Southern Medical University, Shenzhen, Guangdong, China.
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Rübe CE, Raid S, Palm J, Rübe C. Radiation-Induced Brain Injury: Age Dependency of Neurocognitive Dysfunction Following Radiotherapy. Cancers (Basel) 2023; 15:cancers15112999. [PMID: 37296960 DOI: 10.3390/cancers15112999] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/18/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
Cranial radiotherapy is a known risk factor for neurocognitive impairment in cancer survivors. Although radiation-induced cognitive dysfunction is observed in patients of all ages, children seem to be more vulnerable than adults to suffering age-related deficits in neurocognitive skills. So far, the underlying mechanisms by which IR negatively influences brain functions as well as the reasons for the profound age dependency are still insufficiently known. We performed a comprehensive Pubmed-based literature search to identify original research articles that reported on age dependency of neurocognitive dysfunction following cranial IR exposure. Numerous clinical trials in childhood cancer survivors indicate that the severity of radiation-induced cognitive dysfunction is clearly dependent on age at IR exposure. These clinical findings were related to the current state of experimental research providing important insights into the age dependency of radiation-induced brain injury and the development of neurocognitive impairment. Research in pre-clinical rodent models demonstrates age-dependent effects of IR exposure on hippocampal neurogenesis, radiation-induced neurovascular damage and neuroinflammation.
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Affiliation(s)
- Claudia E Rübe
- Department of Radiation Oncology, Saarland University Medical Center, Kirrbergerstrasse Building 6.5, 66421 Homburg, Germany
| | - Silvia Raid
- Department of Radiation Oncology, Saarland University Medical Center, Kirrbergerstrasse Building 6.5, 66421 Homburg, Germany
| | - Jan Palm
- Department of Radiation Oncology, Saarland University Medical Center, Kirrbergerstrasse Building 6.5, 66421 Homburg, Germany
| | - Christian Rübe
- Department of Radiation Oncology, Saarland University Medical Center, Kirrbergerstrasse Building 6.5, 66421 Homburg, Germany
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Cranial MRI in Childhood Acute Leukemia during Treatment and Follow-Up Including the Impact of Intrathecal MTX-A Single-Center Study and Review of the Literature. Cancers (Basel) 2022; 14:cancers14194688. [PMID: 36230611 PMCID: PMC9563423 DOI: 10.3390/cancers14194688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022] Open
Abstract
Due to high survival rates, long-term sequelae, especially neurotoxicity, need to be considered in childhood acute leukemias. In this retrospective analysis of morphologic changes of the brain in children treated for acute leukemias, we included 94 patients (77 ALL, 17 AML; 51 male, 43 female; median age: 5 years) from a single center. We analyzed 170 cranial MRI scans (T2, FLAIR axial) for morphologic alterations of the brain and variations of the ventricular width (GDAH). In addition, the corresponding literature was reviewed. More than 50% of all patients showed cerebral pathomorphologies (CP). They were seen more often in children with ALL (55.8%), ≤ 6 years of age (60.8%), in relapse (58.8%) or after CNS irradiation (75.0%) and included white matter changes, brain atrophy, sinus vein thrombosis and ischemic events. GDAH significantly enlarged mainly in children up to 6 years, with relapse, high-risk leukemias or ALL patients. However, GDAH can normalize again. The number of intrathecal Methotrexate applications (≤12 vs. >12) showed no correlation to morphologic alterations besides a significant increase in GDAH (−0.3 vs. 0.9 mm) between the first and last follow-up MRI in ALL patients receiving >12 ith. MTX applications. The role of ith. MTX on CP needs to be further investigated and correlated to the neurocognitive outcome of children with acute leukemias.
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White GE, Caterini JE, McCann V, Rendall K, Nathan PC, Rhind SG, Jones H, Wells GD. The Psychoneuroimmunology of Stress Regulation in Pediatric Cancer Patients. Cancers (Basel) 2021; 13:4684. [PMID: 34572911 PMCID: PMC8468382 DOI: 10.3390/cancers13184684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
Stress is a ubiquitous experience that can be adaptive or maladaptive. Physiological stress regulation, or allostasis, can be disrupted at any point along the regulatory pathway resulting in adverse effects for the individual. Children with cancer exhibit significant changes to these pathways in line with stress dysregulation and long-term effects similar to those observed in other early-life stress populations, which are thought to be, in part, a result of cytotoxic cancer treatments. Children with cancer may have disruption to several steps in the stress-regulatory pathway including cognitive-affective function, neurological disruption to stress regulatory brain regions, altered adrenal and endocrine function, and disrupted tissue integrity, as well as lower engagement in positive coping behaviours such as physical activity and pro-social habits. To date, there has been minimal study of stress reactivity patterns in childhood illness populations. Nor has the role of stress regulation in long-term health and function been elucidated. We conclude that consideration of stress regulation in childhood cancer may be crucial in understanding and treating the disease.
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Affiliation(s)
- Gillian E. White
- Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (G.E.W.); (J.E.C.); (K.R.)
| | - Jessica E. Caterini
- Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (G.E.W.); (J.E.C.); (K.R.)
| | - Victoria McCann
- School of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada;
| | - Kate Rendall
- Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (G.E.W.); (J.E.C.); (K.R.)
| | - Paul C. Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (P.C.N.); (H.J.)
| | - Shawn G. Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada;
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON M5S 2W6, Canada
| | - Heather Jones
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (P.C.N.); (H.J.)
| | - Greg D. Wells
- Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (G.E.W.); (J.E.C.); (K.R.)
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7
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Alexander TC, Krull KR. Effects of chemotherapy for acute lymphoblastic leukemia on cognitive function in animal models of contemporary protocols: A systematic literature review. Neurosci Biobehav Rev 2021; 129:206-217. [PMID: 34352229 DOI: 10.1016/j.neubiorev.2021.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 10/29/2020] [Accepted: 07/28/2021] [Indexed: 11/20/2022]
Abstract
Survival rates of childhood acute lymphoblastic leukemia (ALL) have improved greatly due to advanced therapies and supportive care. Intrathecal chemotherapy replaced cranial radiation due to radiation-induced neurotoxicity and late-effects. Survivors treated with chemotherapy-only experience neurologic and cognitive problems following cessation of treatment. Very long-term cognitive outcomes remain unclear. Animal models are being generated to assess late-effects of chemotherapy on cognitive function. Although, few address juvenile models of chemotherapy-induced cognitive impairment (CICI) and developing brain, results of this review outline neurocognitive effects of chemotherapy consistent with childhood ALL therapy. Studies demonstrate deficits across cognitive domains including spatial memory, executive function, short-term memory, anxiety and depression. Inflammation, oxidative stress, excitotoxity, and other metabolic disruptions may lead to neurodegeneration associated with cognitive impairment observed in ALL survivors. Interventions directly targeting these mechanisms may prevent and/or promote recovery of cognitive function and improve long-term outcomes. Evidence suggests success of anti-inflammatory and antioxidant treatments in reducing cognitive decline. Animal models provide basis for assessing effects of chemotherapy on neurologic processes to guide future clinical investigations.
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Affiliation(s)
- Tyler C Alexander
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States; Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States.
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8
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Tso WWY, Hui ESK, Lee TMC, Liu APY, Ip P, Vardhanabhuti V, Cheng KKF, Fong DYT, Chang DHF, Ho FKW, Yip KM, Ku DTL, Cheuk DKL, Luk CW, Shing MK, Leung LK, Khong PL, Chan GCF. Brain Microstructural Changes Associated With Neurocognitive Outcome in Intracranial Germ Cell Tumor Survivors. Front Oncol 2021; 11:573798. [PMID: 34164332 PMCID: PMC8216078 DOI: 10.3389/fonc.2021.573798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Childhood intracranial germ cell tumor (GCT) survivors are prone to radiotherapy-related neurotoxicity, which can lead to neurocognitive dysfunctions. Diffusion kurtosis imaging (DKI) is a diffusion MRI technique that is sensitive to brain microstructural changes. This study aimed to investigate the association between DKI metrics versus cognitive and functional outcomes of childhood intracranial GCT survivors. Methods DKI was performed on childhood intracranial GCT survivors (n = 20) who had received cranial radiotherapy, and age and gender-matched healthy control subjects (n = 14). Neurocognitive assessment was performed using the Hong Kong Wechsler Intelligence Scales, and functional assessment was performed using the Lansky/Karnofsky performance scales (KPS). Survivors and healthy controls were compared using mixed effects model. Multiple regression analyses were performed to determine the effects of microstructural brain changes of the whole brain as well as the association between IQ and Karnofsky scores and the thereof. Results The mean Intelligence Quotient (IQ) of GCT survivors was 91.7 (95% CI 84.5 – 98.8), which was below the age-specific normative expected mean IQ (P = 0.013). The mean KPS score of GCT survivors was 85.5, which was significantly lower than that of controls (P < 0.001). Cognitive impairments were significantly associated with the presence of microstructural changes in white and grey matter, whereas functional impairments were mostly associated with microstructural changes in white matter. There were significant correlations between IQ versus the mean diffusivity (MD) and mean kurtosis (MK) of specific white matter regions. The IQ scores were negatively correlated with the MD of extensive grey matter regions. Conclusion Our study identified vulnerable brain regions whose microstructural changes in white and grey matter were significantly associated with impaired cognitive and physical functioning in survivors of pediatric intracranial GCT.
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Affiliation(s)
- Winnie Wan Yee Tso
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing (LKS) Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Edward Sai Kam Hui
- Department of Diagnostic Radiology, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Tatia Mei Chun Lee
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong.,Laboratory of Neuropsychology, The University of Hong Kong, Hong Kong, Hong Kong
| | - Anthony Pak Yin Liu
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing (LKS) Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing (LKS) Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Vince Vardhanabhuti
- Department of Diagnostic Radiology, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | | | | | - Dorita Hue Fung Chang
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong.,Department of Psychology, The University of Hong Kong, Hong, Kong, Hong Kong
| | - Frederick Ka Wing Ho
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Ka Man Yip
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing (LKS) Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Dennis Tak Loi Ku
- Department of Oncology, Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Daniel Ka Leung Cheuk
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Chung Wing Luk
- Department of Oncology, Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Ming Kong Shing
- Department of Oncology, Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Lok Kan Leung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing (LKS) Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Pek Lan Khong
- Department of Diagnostic Radiology, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Godfrey Chi-Fung Chan
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing (LKS) Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
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Elens I, Deprez S, Billiet T, Sleurs C, Labarque V, Uyttebroeck A, Van Gool S, Lemiere J, D’Hooge R. Methylene tetrahydrofolate reductase A1298C polymorphisms influence the adult sequelae of chemotherapy in childhood-leukemia survivors. PLoS One 2021; 16:e0250228. [PMID: 33930029 PMCID: PMC8087097 DOI: 10.1371/journal.pone.0250228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/03/2021] [Indexed: 11/23/2022] Open
Abstract
This retrospective correlation study investigated the putative link between methylene tetrahydrofolate reductase (MTHFR) A1298C mutations and chemotherapy-related brain function changes in adult childhood-leukemia survivors. To this end, we determined the relationship between the particular MTHFR1298 genotype (AA, AC or CC) of 31 adult childhood-leukemia survivors, and (1) their CSF Tau and phosphorylated Tau (pTau) levels at the time of treatment, (2) their adult performance intelligence quotient (PIQ), and (3) their regional brain connectivity using diffusion magnetic resonance imaging (dMRI) and resting-state functional MRI (rsfMRI). We confirmed that neuropathology markers Tau and pTau significantly increased in CSF of children after intrathecal methotrexate administration. Highest concentrations of these toxicity markers were found during the induction phase of the therapy. Moreover, CSF concentrations of Tau and pTau during treatment were influenced by the children’s particular MTHFR1298 genotype. CSF Tau (but not pTau) levels significantly dropped after folinic acid supplementation. At adult age (on average 13.1 years since the end of their treatment), their particular MTHFR1298 genotype (AA, AC or CC) influenced the changes in PIQ and cortical connectivity that we found to be related to their childhood exposure to chemotherapeutics. In summary, we suggest that homozygous MTHFR1298CC individuals are more vulnerable to the adult sequelae of antifolate chemotherapy.
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Affiliation(s)
- Iris Elens
- Laboratory of Biological Psychology, KU Leuven, Leuven, Belgium
- Department of Child and Adolescent Psychiatry, KU Leuven, University Psychiatric Centre Leuven, Leuven, Belgium
- Department of Psychiatry, AZ Delta, Roeselare, Belgium
| | - Sabine Deprez
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Thibo Billiet
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
- Icometrix, Leuven, Belgium
| | - Charlotte Sleurs
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
- Department of Pediatrics, Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
| | - Veerle Labarque
- Department of Pediatrics, Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
- Department of Cardiovascular Medicine, KU Leuven, Leuven, Belgium
| | - Anne Uyttebroeck
- Department of Pediatrics, Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
- Department of Cardiovascular Medicine, KU Leuven, Leuven, Belgium
| | | | - Jurgen Lemiere
- Department of Child and Adolescent Psychiatry, KU Leuven, University Psychiatric Centre Leuven, Leuven, Belgium
- Department of Pediatrics, Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
| | - Rudi D’Hooge
- Laboratory of Biological Psychology, KU Leuven, Leuven, Belgium
- * E-mail:
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10
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Rijmenams I, Moechars D, Uyttebroeck A, Radwan A, Blommaert J, Deprez S, Sunaert S, Segers H, Gillebert CR, Lemiere J, Sleurs C. Age- and Intravenous Methotrexate-Associated Leukoencephalopathy and Its Neurological Impact in Pediatric Patients with Lymphoblastic Leukemia. Cancers (Basel) 2021; 13:cancers13081939. [PMID: 33923795 PMCID: PMC8073318 DOI: 10.3390/cancers13081939] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 12/04/2022] Open
Abstract
Simple Summary In this study, we investigated standardized post-chemotherapy magnetic resonance (MR) scans for leukoencephalopathy and patient- and treatment-related risk factors in childhood leukemia patients. As prevalence numbers are limited, our study provides the required estimations for this population. Furthermore, we demonstrate that younger patients might be more at-risk for development of leukoencephalopathy (LE), and that a higher intravenous methotrexate (IV-MTX) dose has a cumulative toxic effect, while the number of intrathecal administrations was not significantly associated with the extent of LE. This can suggest we should modify chemotherapeutic treatment regimens by decreasing the number of IV-MTX applications, with special attention for younger patients. Abstract Methotrexate (MTX) is associated with leukoencephalopathy (LE) in children treated for lymphoblastic leukemia/lymphoma (ALL/LBL). However, large-scale studies with systematic MR acquisition and quantitative volumetric lesion information remain limited. Hence, the prevalence of lesion burdens and the potential risk factors of LE in this population are still inconclusive. FLAIR-MRI scans were acquired at the end of treatment in children who were treated for ALL/LBL, which were quantitatively analyzed for LE. Voxels were assigned to the lesion segmentation if indicated by two raters. Logistic and linear regression models were used to test whether lesion presence and size were predicted by risk factors such as age at diagnosis, gender, intrathecal (IT-) or intravenous (IV-)MTX dose, CNS invasion, and acute neurological events. Patients with a pre-existing neurological condition or low-quality MR scan were excluded from the analyses. Of the 129 patients, ten (8%) suffered from CNS invasion. Chemotherapy-associated neurological events were observed in 13 patients (10%) during therapy, and 68 patients (53%) showed LE post-treatment. LE was more frequent in cases of lower age and higher cumulative IV-MTX doses, while the extent of LE and neurological symptoms were associated only with IV-MTX doses. Neurological events were not significantly associated with LE, even though symptomatic patients demonstrated a higher ratio of LE (n = 9/13) than asymptomatic patients (n = 59/116). This study suggests leukoencephalopathy frequently occurs in both symptomatic and asymptomatic leukemia patients. Younger children and patients treated with higher cumulative IV-MTX doses might need more regular screening for early detection and follow-up of associated sequelae.
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Affiliation(s)
- Ilona Rijmenams
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
| | - Daan Moechars
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
| | - Anne Uyttebroeck
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
| | - Ahmed Radwan
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Jeroen Blommaert
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Gynaecological Oncology, KU Leuven, 3000 Leuven, Belgium
| | - Sabine Deprez
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Stefan Sunaert
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Heidi Segers
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
| | - Céline R. Gillebert
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Jurgen Lemiere
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Charlotte Sleurs
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Correspondence:
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11
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Gui C, Vannorsdall TD, Kleinberg LR, Assadi R, Moore JA, Hu C, Quiñones-Hinojosa A, Redmond KJ. A Prospective Cohort Study of Neural Progenitor Cell-Sparing Radiation Therapy Plus Temozolomide for Newly Diagnosed Patients With Glioblastoma. Neurosurgery 2020; 87:E31-E40. [PMID: 32497183 DOI: 10.1093/neuros/nyaa107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/16/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In treating glioblastoma, irradiation of the neural progenitor cell (NPC) niches is controversial. Lower hippocampal doses may limit neurocognitive toxicity, but higher doses to the subventricular zones (SVZ) may improve survival. OBJECTIVE To prospectively evaluate the impact of limiting radiation dose to the NPC niches on tumor progression, survival, and cognition in patients with glioblastoma. METHODS Patients with glioblastoma received resection followed by standard chemoradiation. Radiation dose to the NPC niches, including the bilateral hippocampi and SVZ, was minimized without compromising tumor coverage. The primary outcome was tumor progression in the spared NPC niches. Follow-up magnetic resonance imaging was obtained bimonthly. Neurocognitive testing was performed before treatment and at 6- and 12-mo follow-up. Cox regression evaluated predictors of overall and progression-free survival. Linear regression evaluated predictors of neurocognitive decline. RESULTS A total of 30 patients enrolled prospectively. The median age was 58 yr. Median mean doses to the hippocampi and SVZ were 49.1 and 41.8 gray (Gy) ipsilaterally, and 16.5 and 19.9 Gy contralaterally. Median times to death and tumor progression were 16.0 and 7.6 mo, and were not significantly different compared to a matched historical control. No patients experienced tumor progression in the spared NPC-containing regions. Overall survival was associated with neurocognitive function (P ≤ .03) but not dose to the NPC niches. Higher doses to the hippocampi and SVZ predicted greater decline in verbal memory (P ≤ .01). CONCLUSION In treating glioblastoma, limiting dose to the NPC niches may reduce cognitive toxicity while maintaining clinical outcomes. Further studies are needed to confirm these results.
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Affiliation(s)
- Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Tracy D Vannorsdall
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Ryan Assadi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Joseph A Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Chen Hu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.,Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
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A Review of Chronic Leukoencephalopathy among Survivors of Childhood Cancer. Pediatr Neurol 2019; 101:2-10. [PMID: 31047756 DOI: 10.1016/j.pediatrneurol.2019.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/11/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
Currently, there are an estimated 400,000 long-term survivors of childhood cancer in the United States. Chronic leukoencephalopathy is a potential devastating late effect that can manifest as a range of neurological and neurocognitive sequelae. Survivors of the acute lymphocytic leukemia, central nervous system tumors, and stem cell transplant have frequently been exposed to cranial radiation, systemic and intrathecal chemotherapy, which places them at risk of developing chronic leukoencephalopathy. Defining leukoencephalopathy and its neuroimaging characteristics, the population of survivors at risk, its long-term consequences, and identifying prevention and intervention strategies can potentially mitigate the morbidity of these survivors. Better understanding of those at risk of leukoencephalopathy and its symptoms can lead to an improved quality of life for these cancer survivors.
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Billiet T, Elens I, Sleurs C, Uyttebroeck A, D'Hooge R, Lemiere J, Deprez S. Brain Connectivity and Cognitive Flexibility in Nonirradiated Adult Survivors of Childhood Leukemia. J Natl Cancer Inst 2019. [PMID: 29514304 DOI: 10.1093/jnci/djy009] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background This study aimed to assess functional and structural brain connectivity in adult childhood leukemia survivors and the link with cognitive functioning and previously identified risk factors such as intrathecal methotrexate dose and age at start of therapy. Methods Thirty-one nonirradiated adult childhood leukemia survivors and 35 controls underwent cognitive testing and multimodal magnetic resonance imaging (resting state functional MRI, T1-weighted, diffusion-weighted, and myelin water imaging [MWI]). Analyses included dual regression, voxel-based morphometry, advanced diffusion, and MWI modeling techniques besides stepwise discriminant function analysis to identify the most affected executive cognitive domain. Correlations with discrete intrathecal MTX doses and (semi)continuous variables were calculated using Spearman's rank and Pearson's correlation, respectively. All correlation tests were two-sided. Positive and negative T-contrasts in functional and structural MRI analysis were one-sided. Results Survivors demonstrated lower functional connectivity between the default mode network (DMN) and inferior temporal gyrus (ITG; P < .008). Additionally, we observed higher fractional anisotropy (FA; P = .04) and lower orientation dispersion index (ODI; P = .008) at the left centrum semiovale, which could-given that several fiber bundles cross this region-suggest selective reduced integrity of the respective white matter tracts. Set shifting reaction time, a measure of cognitive flexibility, was mostly impaired and correlated with lower FA (r = -0.53, P = .003) and higher ODI (r = 0.40, P = .04) in survivors but not with DMN-ITG connectivity. There were no statistically significant differences between survivors and controls in WM or GM volume, nor was there a statistically significant correlation between imaging measurements and age at start of therapy or intrathecal methotrexate dose. Conclusions Adult, nonirradiated childhood leukemia survivors show altered brain connectivity, which is linked with cognitive flexibility.
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Affiliation(s)
- Thibo Billiet
- Department of Radiology, University Hospital Leuven, Leuven, Belgium.,Icometrix, Leuven, Belgium
| | - Iris Elens
- Department of Child and Adolescent Psychiatry, KU Leuven, University Psychiatric Centre Leuven, Leuven, Belgium.,Laboratory of Biological Psychology, KU Leuven, Leuven, Belgium
| | - Charlotte Sleurs
- Department of Radiology, University Hospital Leuven, Leuven, Belgium.,Department of Pediatrics, Pediatric Hemato-Oncology, KU Leuven, University Hospital Leuven, Leuven, Belgium
| | - Anne Uyttebroeck
- Department of Pediatrics, Pediatric Hemato-Oncology, KU Leuven, University Hospital Leuven, Leuven, Belgium
| | - Rudi D'Hooge
- Laboratory of Biological Psychology, KU Leuven, Leuven, Belgium
| | - Jurgen Lemiere
- Department of Pediatrics, Pediatric Hemato-Oncology, KU Leuven, University Hospital Leuven, Leuven, Belgium
| | - Sabine Deprez
- Department of Radiology, University Hospital Leuven, Leuven, Belgium.,Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
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Elens I, Deprez S, Danckaerts M, Bijttebier P, Labarque V, Uyttebroeck A, Van Gool S, D'Hooge R, Lemiere J. Neurocognitive Sequelae in Adult Childhood Leukemia Survivors Related to Levels of Phosphorylated Tau. J Natl Cancer Inst 2019; 109:3739023. [PMID: 29982754 DOI: 10.1093/jnci/djw321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 12/05/2016] [Indexed: 01/03/2023] Open
Abstract
Central nervous system-directed prophylactic chemotherapy increases survival in childhood leukemia, but possible late neurocognitive sequelae remain a concern. We compared intellectual performance (WAIS IV), memory (AVLT), and executive functioning (ANT) between adult leukemia survivors (n = 31) and control individuals (n = 35). In survivors, cerebrospinal fluid (CSF) levels of phosphorylated Tau (p-Tau) during treatment and total intrathecal methotrexate dose correlated with adult intellectual performance (Pearson's and Spearman's coefficients, respectively). Long-term memory and attentional control, both maturing before survivors' mean age at diagnosis, were unaffected (P > .05 on all four subtests), in contrast to cognitive flexibility and information processing (P < .05 for eight of the subtests), which mature during adolescence. CSF p-Tau and methotrexate dose negatively correlated with intellectual performance (r = -0.414, P = .04 and r = -0.484, P = .007, respectively), but not with each other (r = 0.219, P = .29). These data identify CSF p-Tau as a predictor of late neurocognitive sequelae (in addition to methotrexate dose). Early identification of children at risk could inspire interventions to prevent or remediate chemotherapy-induced cognitive sequelae.
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Affiliation(s)
- Iris Elens
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Sabine Deprez
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Marina Danckaerts
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Patricia Bijttebier
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Veerle Labarque
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Anne Uyttebroeck
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Stefaan Van Gool
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Rudi D'Hooge
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
| | - Jurgen Lemiere
- Affiliations of authors: Laboratory of Biological Psychology (IE, RDH), Department of Imaging and Pathology (SD), Department of School Psychology and Child and Adolescent Development (PB), Department of Pediatrics, Pediatric Hemato-Oncology (VL, AU, JL), Department of Cardiovascular Medicine (VL), and Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven (IE, MD, JL), KU Leuven, Leuven, Belgium; Department of Radiology, University Hospital Leuven, Leuven, Belgium (SD); Immunologisch Onkologisches Zentrum Köln, Köln, Germany (SVG)
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Neuroimaging in Sepsis: Panacea or Pandora's Box? Pediatr Crit Care Med 2017; 18:716-717. [PMID: 28691959 DOI: 10.1097/pcc.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lai JS, Bregman C, Zelko F, Nowinski C, Cella D, Beaumont JJ, Goldman S. Parent-reported cognitive function is associated with leukoencephalopathy in children with brain tumors. Qual Life Res 2017; 26:2541-2550. [PMID: 28447250 DOI: 10.1007/s11136-017-1583-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2017] [Indexed: 10/10/2023]
Abstract
PURPOSE Cognitive dysfunction is a major concern for children with brain tumors. A valid, user-friendly screening tool could facilitate prompt referral for comprehensive neuropsychological assessments and therefore early intervention. Applications of the pediatric perceived cognitive function item bank (pedsPCF) such as computerized adaptive testing can potentially serve as such a tool given its brevity and user-friendly nature. This study aimed to evaluate whether pedsPCF was a valid indicator of cerebral compromise using the criterion of structural brain changes indicated by leukoencephalopathy grades. METHODS Data from 99 children (mean age = 12.6 years) with brain tumors and their parents were analyzed. Average time since diagnosis was 5.8 years; time since last treatment was 4.3 years. Leukoencephalopathy grade (range 0-4) was based on white matter damage and degree of deep white matter volume loss shown on MRI. Parents of patients completed the pedsPCF. Scores were based on the US general population-based T-score metric (mean = 50; SD = 10). Higher scores reflect better function. RESULTS Leukoencephalopathy grade distributions were as follows: 36 grade 0, 27 grade 1, 22 grade 2, 13 grade 3, and 1 grade 4. The mean pedsPCF T-score was 48.3 (SD = 8.3; range 30.5-63.7). The pedsPCF scores significantly discriminated patients with different leukoencephalopathy grades, F = 4.14, p = 0.0084. Effect sizes ranged from 0.09 (grade 0 vs. 1) to 1.22 (grade 0 vs. 3/4). CONCLUSION This study demonstrates that the pedsPCF is a valid indicator of leukoencephalopathy and provides support for its use as a screening tool for more comprehensive neurocognitive testing.
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Affiliation(s)
- Jin-Shei Lai
- Medical Social Sciences and Pediatrics, Feinberg School of Medicine at Northwestern University, 633 N St Clair, #19-039, Chicago, IL, 60611, USA.
| | - Corey Bregman
- Medical Imaging (Radiology), Ann & Robert H. Lurie Children's Hospital, Chicago, IL, 60611, USA
| | - Frank Zelko
- Pediatric Neuropsychology Service, Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
| | - Cindy Nowinski
- Medical Social Sciences, Feinberg School of Medicine at Northwestern University, Chicago, IL, 60611, USA
| | - David Cella
- Medical Social Sciences, Feinberg School of Medicine at Northwestern University, Chicago, IL, 60611, USA
| | - Jennifer J Beaumont
- Medical Social Sciences, Feinberg School of Medicine at Northwestern University, Chicago, IL, 60611, USA
| | - Stewart Goldman
- Hematology/Oncology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
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Prevention of radiotherapy-induced neurocognitive dysfunction in survivors of paediatric brain tumours: the potential role of modern imaging and radiotherapy techniques. Lancet Oncol 2017; 18:e91-e100. [DOI: 10.1016/s1470-2045(17)30030-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 02/06/2023]
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Rossi A, Biancheri R, Lanino E, Faraci M, Haupt R, Micalizzi C, Tortori-Donati P. Neuroradiology of Pediatric Hemolymphoproliferative Disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140090301600203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hemolymphoproliferative diseases (HLD) are among the most common causes of morbidity and mortality in children. In the past few years, the increased effectiveness of treatment modalities has significantly increased overall survival, but has also disclosed new aspects of the natural history of these disorders, among which central nervous system (CNS) involvement. CNS complications of HLD can basically be categorized into direct localization of primary disease, indirect effects of malignancy such as cerebrovascular or infectious complications, and iatrogenic side effects. Magnetic resonance imaging plays an important, often crucial role in the diagnosis of several of these disorders. Close interdisciplinary collaboration between hemato-oncologists and neuroradiologists is of paramount importance to provide affected children with an early diagnosis and proper treatment.
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Affiliation(s)
| | | | - E. Lanino
- Department of Pediatric Hemato-Oncology, G. Gaslini Children's Research Hospital; Genoa, Italy Servizio di Neuroradiologia, Ospedale Bellaria; Bologna
| | - M. Faraci
- Department of Pediatric Hemato-Oncology, G. Gaslini Children's Research Hospital; Genoa, Italy Servizio di Neuroradiologia, Ospedale Bellaria; Bologna
| | - R. Haupt
- Department of Pediatric Hemato-Oncology, G. Gaslini Children's Research Hospital; Genoa, Italy Servizio di Neuroradiologia, Ospedale Bellaria; Bologna
| | - C. Micalizzi
- Department of Pediatric Hemato-Oncology, G. Gaslini Children's Research Hospital; Genoa, Italy Servizio di Neuroradiologia, Ospedale Bellaria; Bologna
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Zou DF, Zeng HW, Yu J, Mai HR, Yuan XL, Wang LH, Liao JX, Wen FQ. [Brain injury after induction chemotherapy in children with acute lymphoblastic leukemia]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:254-258. [PMID: 26975825 PMCID: PMC7389986 DOI: 10.7499/j.issn.1008-8830.2016.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/09/2016] [Indexed: 09/12/2023]
Abstract
OBJECTIVE To investigate the changes in brain injury after the induction chemotherapy in children with acute lymphoblastic leukemia (ALL) by cranial MRI. METHODS The clinical data and cranial MRI results of 62 children with ALL who were hospitalized from March 2014 to June 2015 were analyzed retrospectively. RESULTS Before chemotherapy, MRI showed bone marrow infiltration of the skull in 33 patients (53%); the children with WBC<20×10(9)/Lhad a significantly lower incidence rate of bone marrow infiltration of the skull than those with WBC≥20×10(9)/L (16 patients/42% vs 17 patients/71%; P<0.05), and the high-risk group had a significantly higher incidence rate of bone marrow infiltration of the skull than the non-high-risk group (71% vs 44%; P<0.05). Before chemotherapy, there were 4 cases (7%) of brain atrophy, and 2 cases (3%) of abnormal signals in the sensory conduction bundle. MRI reexamination in 28 patients after 3 months of chemotherapy showed 3 new cases (11%) of brain atrophy and 1 aggravated case of brain atrophy. CONCLUSIONS The children with ALL have bone marrow infiltration of the skull, brain atrophy, and abnormal signals in the sensory conduction bundle before chemotherapy, especially bone marrow infiltration of the skull, and some changes in brain injury disappear after treatment.
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Affiliation(s)
- Dong-Fang Zou
- Department of Neurology, Shenzhen Children's Hospital of Chongqing Medical University, Shenzhen, Guangdong 518038, China.
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Kut C, Janson Redmond K. New considerations in radiation treatment planning for brain tumors: neural progenitor cell-containing niches. Semin Radiat Oncol 2015; 24:265-72. [PMID: 25219811 DOI: 10.1016/j.semradonc.2014.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The purpose of this critical review is to explore the controversy regarding the relationship between radiation dose to the neural progenitor cell (NPC) niches and patient outcomes, in terms of both toxicity and tumor control. NPCs in the subventricular zone (SVZ) and hippocampus are paradoxically associated with long-term neurocognitive sequelae of brain irradiation, as well as resistance to therapy and tumor recurrence. The reconciliation of these somewhat opposing functions is challenging. Current literature suggests that radiation and other treatments against the NPC in the hippocampus and the SVZ may influence patient outcome. As a result, both the SVZ and the hippocampus could have important implications on radiation treatment planning strategies, and future laboratory and clinical evaluations will be critical in designing studies to optimize treatment outcome, effectiveness, and safety.
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Affiliation(s)
- Carmen Kut
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD
| | - Kristin Janson Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD.
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21
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Increase in oxidative stress as measured by cerebrospinal fluid lipid peroxidation during treatment for childhood acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2015; 37:e86-93. [PMID: 25222054 PMCID: PMC4423740 DOI: 10.1097/mph.0000000000000258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Five-year survival from childhood acute lymphoblastic leukemia (ALL) approaches 90%, but 40% of survivors experience central nervous system (CNS) treatment-related cognitive problems. Despite considerable evidence for cognitive problems, less is known about mechanisms of neurological injury. Our purpose was to investigate oxidative stress, measured by lipid peroxidation, as a mechanism of CNS treatment-related neurological injury. The sample included 55 children (mean age at diagnosis=6.84 y, SD=3.40) who received intrathecal and intravenous chemotherapy for CNS-directed treatment according to Children's Oncology Group protocols. Glycerophospholipids were extracted from cerebrospinal fluid samples obtained at diagnosis and during intrathecal chemotherapy administration. Unoxidized and oxidized phosphatidylcholine (PC) and phosphatidylinositol (PI) were measured by normal phase high-performance liquid chromatography with diode array detection, and analyzed with a general linear model for repeated measures analysis of variance. Compared with the diagnostic cerebrospinal fluid sample, unoxidized and oxidized PC and PI increased significantly across treatment phases. Amount of intravenous methotrexate received was significantly correlated with oxidized PI, and age at time of ALL diagnosis was significantly associated with oxidized PC. These findings support our hypothesis that oxidative stress is a mechanism of neurological injury associated with CNS-directed treatment for ALL.
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22
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Khan RB, Morris EB, Pui CH, Hudson MM, Zhou Y, Cheng C, Ledet DS, Howard SC. Long-term outcome and risk factors for uncontrolled seizures after a first seizure in children with hematological malignancies. J Child Neurol 2014; 29:774-81. [PMID: 23666043 PMCID: PMC4207712 DOI: 10.1177/0883073813488675] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/10/2013] [Indexed: 11/15/2022]
Abstract
Long-term outcomes of seizures that develop during treatment of childhood hematological malignancies have not been described. We analyzed seizure outcome in 62 children with leukemia or lymphoma treated at our institution. There was a median follow-up of 6.5 years since first seizure. Seizure etiology included intrathecal or systemic methotrexate in 24, leucoencephalopathy in 11, brain hemorrhage or thrombosis in 11, meningitis in 4, and no identifiable cause in 12. Seizures remained uncontrolled in 18, and risk factors for poor control included female sex (P = .02), no seizure control with first antiseizure drug (P = .08), and longer interval between cancer diagnosis and seizure onset (P = .09). Poor seizure control after initial antiseizure drug also predicted recurrent seizure after drug withdrawal (P = .04). In conclusion, seizures are controlled with medications in a majority of patients with hematological cancer. After a period without seizures, antiseizure drug withdrawal in appropriately selected patient has a high success rate.
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Affiliation(s)
- Raja B. Khan
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - E. Brannon Morris
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Departments of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa M. Hudson
- Departments of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yinmei Zhou
- Departments of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Departments of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Davonna S. Ledet
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Scott C. Howard
- Departments of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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23
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Hile S, Erickson SJ, Agee B, Annett RD. Parental stress predicts functional outcome in pediatric cancer survivors. Psychooncology 2014; 23:1157-64. [DOI: 10.1002/pon.3543] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 03/11/2014] [Accepted: 03/17/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah Hile
- University of New Mexico; Albuquerque NM USA
| | | | | | - Robert D. Annett
- University of New Mexico Health Sciences Center; Albuquerque NM USA
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24
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ElAlfy M, Ragab I, Azab I, Amin S, Abdel-Maguid M. Neurocognitive outcome and white matter anisotropy in childhood acute lymphoblastic leukemia survivors treated with different protocols. Pediatr Hematol Oncol 2014; 31:194-204. [PMID: 24498883 DOI: 10.3109/08880018.2013.871763] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Neurocognitive outcome affects the quality of life of ALL survivors. This study is aimed to assess the prevalence of neurocognitive dysfunction by psychometric and imaging tools in survivors of childhood ALL, treated with 3 different protocols and the effect of time elapsed since the end of chemotherapy. Sixty-two ALL survivors aged 6-18 years and treated in the period 1997-2007 and 60 healthy age and sex matched controls were subjected to neurocognitive testing using Wechsler Intelligence Scale for Children, Benton visual retention (BVRT) and Trail Making test (TMT), followed by diffusion weighed and diffusion tensor MRI for calculation of fraction anisotropy (FA). Survivors underwent revision of protocol and type of CNS therapy. Three different protocols were used: modified BFM 83, BFM 90, and CCG. Survivors treated with modified CCG protocol showed a significant decrease in all cognitive tests compared to control (p<.05); BFM 90 group had a significant lower IQ and longer TMT compared to both control and BFM 83 group and no significant difference was found in results of cognitive tests between BFM 83 and control group. Frontal FA was lower in CCG treated group compared to control, BFM 90 and BFM 83 groups (p<.05); meanwhile it was significantly lower in BFM 90 and BFM 83 groups compared to control group. We concluded that patients treated with modified CCG protocol showed the worst neurocognitive outcome among three assessed protocols. Frontal lobe FA might be an early marker for predicting the neurotoxicity in childhood ALL survivors.
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Affiliation(s)
- Mohsen ElAlfy
- Oncology Unit, Pediatrics Department, Ain Shams University, Cairo, Egypt
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25
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Froklage FE, Oosterbaan LJ, Sizoo EM, de Groot M, Bosma I, Sanchez E, Douw L, Heimans JJ, Reijneveld JC, Lagerwaard FJ, Buter J, Uitdehaag BMJ, Klein M, Postma TJ. Central neurotoxicity of standard treatment in patients with newly-diagnosed high-grade glioma: a prospective longitudinal study. J Neurooncol 2013; 116:387-94. [PMID: 24264531 DOI: 10.1007/s11060-013-1310-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 11/10/2013] [Indexed: 10/26/2022]
Abstract
Following tumor resection, the majority of high-grade glioma (HGG) patients are treated with a combined modality regimen of radiotherapy and temozolomide. As a result of the tumor itself or as treatment-related neurotoxic side-effects, these patients may experience cognitive deficits. Additionally, radiological abnormalities expressed as white matter hyperintensities (WMH) and cerebral atrophy (CA) can develop. In this study, these functional and morphological parameters are evaluated, and their relation is investigated. After surgery, HGG patients underwent chemo-irradiation for six weeks, followed by six cycles of temozolomide. Assessments were performed before chemo-irradiation, post-concomitantly, after the third and sixth adjuvant cycle, and 3 and 7 months after treatment. Degree of WMH and CA was scored on MRI. Patients' neuropsychological performance was compared to healthy matched controls, yielding six cognitive domain z-scores. Development or progression of pre-existing WMH and CA during follow-up was observed in 36 and 45 % of the patients (n = 39) respectively. Cognitive functioning remained stable or improved in 70 % of the patients and deteriorated in 30 % of the patients (n = 33). Of the cognitive decliners, 80 % had tumor progression within 4 months thereafter. No clear association between cognitive functioning and WMH or CA was found. Central neurotoxic effects of combined modality treatment in HGG patients expressed by radiological abnormalities are encountered in approximately 40 % of patients. However, functional impact as indexed by cognitive functioning was found to be limited. Furthermore, development or progression of pre-existing WMH and CA does not consistently result in functional impairment as measured by cognitive tests.
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Affiliation(s)
- F E Froklage
- Department of Neurology, SEIN-Epilepsy Institute in the Netherlands Foundation, Achterweg 5, 2103 SW, Heemstede, The Netherlands,
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26
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Lewis FM, Perry ML, Murdoch BE. Longitudinal language outcomes following intrathecal chemotherapy for acute lymphoblastic leukaemia. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2013; 15:156-164. [PMID: 22663017 DOI: 10.3109/17549507.2012.684888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Intrathecal chemotherapy (ITC) is the treatment option for acute lymphoblastic leukaemia (ALL). Neurocognitive deficits have been described following ITC, but language status post-treatment is yet to be clarified. This study examined the language skills of nine children following ITC for ALL (mean age 7;8 years and 3;2 years post-diagnosis at baseline measurement) and nine age- and sex-matched controls, at baseline then 2 years later, using a battery of tests assessing general language skills. An assessment of cognitively-demanding high level language skills was undertaken on a sub-group of the children (n =12). Statistical analysis revealed no significant difference between children treated with ITC and controls when comparing change in performance scores from baseline measurement to 2 years post-baseline measurement. Descriptive analysis of three of the ALL participants in the Intermediate Stage survivorship at language re-assessment indicated no clinically-significant change in performance over 2 years for all measures except receptive language skills, which improved over the time for two of the children. As language skills continue to develop into late adolescence, the need for the monitoring of language abilities of children treated at a young age with ITC as they enter the Intermediate and Late Stages of survivorship is discussed.
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Affiliation(s)
- Fiona M Lewis
- Centre for Neurogenic Communication Disorders Research, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane 4072, Australia.
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27
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Redmond KJ, Mahone EM, Terezakis S, Ishaq O, Ford E, McNutt T, Kleinberg L, Cohen KJ, Wharam M, Horska A. Association between radiation dose to neuronal progenitor cell niches and temporal lobes and performance on neuropsychological testing in children: a prospective study. Neuro Oncol 2013; 15:360-9. [PMID: 23322748 DOI: 10.1093/neuonc/nos303] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Neurocognitive toxicity from radiation therapy (RT) for brain tumors may be related to damage to neural progenitor cells that reside in the subventricular zone and hippocampus. This prospective study examines the relationship between RT dose to neural progenitor cell niches, temporal lobes, and cerebrum and neurocognitive dysfunction following cranial irradiation. METHODS Standardized assessments of motor speed/dexterity, verbal memory, visual perception, vocabulary, and visuospatial working memory were conducted in 19 pediatric patients receiving cranial RT and 55 controls at baseline and 6, 15, and 27 months following completion of RT. Prescription doses ranged from 12 Gy to 59.4 Gy. Linear mixed effects regression model analyses were used to examine the relationships among neuropsychological performance, age, and radiation dose to the subventricular zone, hippocampus, temporal lobes, and cerebrum. RESULTS Performance on all neuropsychological tests, except vocabulary, was significantly reduced in patients relative to controls, particularly among younger children. Performance on motor speed/dexterity decreased with increasing dose to hippocampus (P < .05) and temporal lobes (P < .035). There was also a significant relationship between (i) reduced performance on verbal learning and increasing dose to the cerebrum (P = .022) and (ii) reduced performance on visual perception and increasing dose to the left temporal lobe (P = .038). There was no association between radiation dose to evaluated structures and performance on vocabulary or visuospatial working memory. CONCLUSIONS These prospective data demonstrate a significant association between increasing RT dose to hippocampus and temporal lobes and decline in neurocognitive skills following cranial irradiation. These findings have important implications for trials, including RTOG 0933 (hippocampal-sparing whole brain radiation therapy for brain metastases).
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, Maryland, USA.
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28
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Bornstein MH, Scrimin S, Putnick DL, Capello F, Haynes OM, de Falco S, Carli M, Pillon M. Neurodevelopmental functioning in very young children undergoing treatment for non-CNS cancers. J Pediatr Psychol 2012; 37:660-73. [PMID: 22300666 DOI: 10.1093/jpepsy/jss003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We initiated a prospective study of very young children with cancer, in comparison with matched healthy children, to investigate neurodevelopmental consequences of non-CNS cancers and treatment. METHODS A total of 61 children (≤42 months) with non-CNS cancers and 61 matched controls underwent an identical age-appropriate neuropsychological test battery. RESULTS Children with cancer manifested deficits compared to healthy controls in motor, mental, and language development, but were similar to controls in cognitive representational abilities and emotional relationships in interaction with their mothers. Better physician-rated health status at diagnosis and mother-rated behavioral status 1 month prior to assessment were associated with better motor and mental performance in the cancer group. CONCLUSIONS This study identifies deficits as well as spared functions in children with non-CNS cancers; the results suggest ways parents and healthcare professionals may plan specific remediations to enhance quality of life in young cancer survivors.
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Affiliation(s)
- Marc H Bornstein
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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29
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Harshman LA, Barron S, Button AM, Smith BJ, Link BK, Lynch CF, Denburg NL. Population-based exploration of academic achievement outcomes in pediatric acute lymphoblastic leukemia survivors. J Pediatr Psychol 2012; 37:458-66. [PMID: 22271791 DOI: 10.1093/jpepsy/jsr119] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Examine academic achievement among pediatric acute lymphoblastic leukemia survivors diagnosed during the years 1993-2008. METHOD A deterministic linkage of the Iowa Cancer Registry and Iowa Testing Programs databases was performed and yielded 147 survivors. Achievement data, in the form of Iowa Percentile Rank scores, were obtained and analyzed by grade and content domain. RESULTS Children diagnosed before age 5 evidenced more underachievement than those diagnosed later (p = .05). Underachievement was noted in mathematics in grades 8 and 11 (p's < .05), in addition to a longitudinal decrease in scores from grades 4 through 11 (p = .01). No differences were found in academic achievement between males and females. CONCLUSIONS Utilization of a population-based approach with a nationally recognized, standardized instrument indicates that academic underachievement is subtle yet exists, most notably in mathematics.
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Affiliation(s)
- Lyndsay A Harshman
- Department of Pediatrics, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242-1053, USA
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30
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Chiaretti A, Ruggiero A, Coccia P, Antonelli A, Pierri F, Barone G, Attinà G, Iuvone L, Maurizi P, Riccardi R. Expression of liquoral neuroprotection markers in children with acute lymphoblastic leukemia. Leuk Res 2011; 35:1467-71. [PMID: 21846577 DOI: 10.1016/j.leukres.2011.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 06/20/2011] [Accepted: 07/25/2011] [Indexed: 10/16/2022]
Abstract
Brain damage related to intrathecal methotrexate in children with acute lymphoblastic leukemia (ALL) is still unclear. Neuroinflammatory mechanisms and intracerebral production of specific biomarkers, play a key role in determining neuroprotective mechanisms after brain injury. To determine whether the CSF concentrations of neuron-specific enolase (NSE), neurotrophic factors and doublecortin (DCX) are influenced by repeated intrathecal methotrexate administrations, we prospectively collected CSF samples from 10 children with ALL and 10 controls. Our results showed an increased expression of the liquoral markers. This up-regulation could be interpreted as a neuroprotective response of the brain against the neuronal damages induced by MTX.
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Affiliation(s)
- Antonio Chiaretti
- Department of Pediatric Neurosciences, Catholic University of Rome, Rome, Italy
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31
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Faraci M, Morana G, Bagnasco F, Barra S, Polo P, Hanau G, Fioredda F, Caruso S, Rossi A, Spaziante R, Haupt R. Magnetic resonance imaging in childhood leukemia survivors treated with cranial radiotherapy: a cross sectional, single center study. Pediatr Blood Cancer 2011; 57:240-6. [PMID: 21671360 DOI: 10.1002/pbc.22923] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 10/19/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children treated with cranial radiotherapy (CRT) for leukemia are at risk of developing central nervous system injuries. Magnetic resonance imaging (MRI) represents the examination method of choice for evaluating radiation-induced brain complications. The purpose of this report is to describe the spectrum of MRI abnormalities detected in a group of survivors of leukemia treated with cranial irradiation. PROCEDURES In this cross-sectional, single center study, 56 patients (median age at follow-up 19 years) receiving CRT as cranial prophylaxis (CP) included in the leukemia protocol (total dose 1,800-2,400 cGy) and/or in the total body irradiation regimen (990-1,200 cGy) before hematopoietic stem cell transplant, were evaluated by MRI after a median interval of 11 years (range 2-27) following CRT. RESULTS Fifty-nine MRI abnormalities (32 cavernomas, nine focal areas of gliosis, seven dystrophic mineralizations, five cerebral atrophies, four pituitary atrophies, one diffuse radiation leukoencephalopathy, and one meningioma) were found in 43 patients. The longest interval between CRT and MRI and oldest age at follow-up represented the two risk factors that were statistically associated with MRI lesions (P = 0.032 and 0.033, respectively). Cerebral cavernomas (CC) were the most frequent MRI abnormalities (57%). All patients with CC were asymptomatic at diagnosis and during follow-up, except one who had aspecific neurological manifestations and micro hemorrhages. CONCLUSIONS These results confirm that total doses and modalities of fractionation dose of CRT were not significantly associated with MRI abnormalities. Moreover, in our experience none of the patients developed neurological symptoms related to MRI abnormalities, and furthermore, the CC remained substantially stable during follow-up.
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Affiliation(s)
- Maura Faraci
- Hematology-Oncology Department, G. Gaslini Children's Research Institute, Genova, Italy.
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32
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Long-term neurocognitive outcomes in young adult survivors of childhood acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2011; 33:450-8. [PMID: 21646917 DOI: 10.1097/mph.0b013e31820d86f2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Five-year survival rates of childhood acute lymphoblastic leukemia (ALL) exceed 80% due to central nervous system-directed treatment including cranial radiation (CRT) and chemotherapy. However, these treatments are associated with neurocognitive compromise, the extent of which is correlated with higher dose and younger age at treatment. The aims of this study were to explore long-term neurocognitive outcomes in adult survivors of childhood ALL, and to identify measures sensitive to neurotoxicity in long-term survivors. We examined 24 adults who received 18 Gy CRT and chemotherapy for treatment of ALL between ages 2 and 15 years (median, 5.5). Time since diagnosis ranged from 6 to 26 years (median, 16.6). Younger age at diagnosis and longer time since diagnosis were associated with lower scores on a computerized battery that requires speed and accuracy across a number of domains (MicroCog), and other standardized neurocognitive tests. When compared with population norms, MicroCog indices were below average in survivors diagnosed with ALL before age 5, but only the reasoning/calculation index was below average in survivors diagnosed with ALL after age 5. In contrast, intelligence quotient (IQ) scores were average. In addition to confirming earlier studies showing that younger children are more vulnerable to treatment-related neurotoxicity, here we show that deficits exist many years post treatment even with a relatively lower dose of CRT, and that these deficits are especially evident on tasks involving rapid processing of information.
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Lai JS, Butt Z, Zelko F, Cella D, Krull KR, Kieran MW, Goldman S. Development of a parent-report cognitive function item bank using item response theory and exploration of its clinical utility in computerized adaptive testing. J Pediatr Psychol 2011; 36:766-79. [PMID: 21378106 PMCID: PMC3146757 DOI: 10.1093/jpepsy/jsr005] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 01/04/2011] [Accepted: 01/10/2011] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The purpose of this study is to report the reliability, validity, and clinical utility of a parent-report perceived cognitive function (pedsPCF) item bank. METHODS From the U.S. general population, 1,409 parents of children aged 7-17 years completed 45 pedsPCF items. Their psychometric properties were evaluated using Item Response Theory (IRT) approaches. Receiver operating characteristic (ROC) curves and discriminant function analysis were used to predict clinical problems on child behavior checklist (CBCL) scales. A computerized adaptive testing (CAT) simulation was used to evaluate clinical utility. RESULTS The final 43-item pedsPCF item bank demonstrates no item bias, has acceptable IRT parameters, and provides good prediction of related clinical problems. CAT simulation resulted in correlations of 0.98 between CAT and the full-length pedsPCF. CONCLUSIONS The pedsPCF has sound psychometric properties, U.S. general population norms, and a brief-yet-precise CAT version is available. Future work will evaluate pedsPCF in other clinical populations in which cognitive function is important.
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Affiliation(s)
- Jin-Shei Lai
- Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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34
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Fulbright JM, Raman S, McClellan WS, August KJ. Late Effects of Childhood Leukemia Therapy. Curr Hematol Malig Rep 2011; 6:195-205. [DOI: 10.1007/s11899-011-0094-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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35
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Iuvone L, Peruzzi L, Colosimo C, Tamburrini G, Caldarelli M, Di Rocco C, Battaglia D, Guzzetta F, Misciagna S, Di Giannatale A, Ruggiero A, Riccardi R. Pretreatment neuropsychological deficits in children with brain tumors. Neuro Oncol 2011; 13:517-24. [PMID: 21372071 DOI: 10.1093/neuonc/nor013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Treatment of childhood brain cancer has been associated with long-term cognitive morbidity in children. In the present study, the cognitive status of children with brain tumors was examined prior to any treatment to single out the role of tumor and tumor-related factors in cognitive deficits. Eighty-three children with newly diagnosed brain tumors (mean age, 8.6 years; range, 7 months to 16.6 years; median, 9.4 years) completed an extensive battery of age-related tests to assess cognitive function before any therapeutic intervention. Magnetic resonance imaging (MRI) was used to determine tumor site and volume and tumor-related factors. Performance under test was compared with symptom duration, neurological status, epilepsy, and MRI. Cognitive difficulties are detected at diagnosis in as many as 50% of patients for some cognitive domains; 6% of patients present with true-diagnosed mental retardation. The location of the tumor is the principal determinant of cognitive deficits, with major impairment in children with cortical tumors. Symptom duration and the presence of epilepsy are significantly associated with neuropsychological disabilities, while neuroradiological tumor-related variables do not correlate clearly with neurocognitive performance. The knowledge of the pre-existing cognitive deficits is critical to evaluate the results of treatment, providing a baseline for assessing the true impact of therapy in determining cognitive decline. In addition, the study suggests that some clinical variables require careful monitoring, because they could be specifically implicated in the neuropsychological outcome; the efforts to reduce the impact of these factors could ameliorate long-term prognosis.
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Affiliation(s)
- L Iuvone
- Don Gnocchi Onlus Foundation, Italy
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36
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A radiotherapy technique to limit dose to neural progenitor cell niches without compromising tumor coverage. J Neurooncol 2011; 104:579-87. [PMID: 21327710 DOI: 10.1007/s11060-011-0530-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 01/31/2011] [Indexed: 12/13/2022]
Abstract
Radiation therapy (RT) for brain tumors is associated with neurocognitive toxicity which may be a result of damage to neural progenitor cells (NPCs). We present a novel technique to limit the radiation dose to NPC without compromising tumor coverage. A study was performed in mice to examine the rationale and another was conducted in humans to determine its feasibility. C57BL/6 mice received localized radiation using a dedicated animal irradiation system with on-board CT imaging with either: (1) Radiation which spared NPC containing regions; (2) Radiation which did not spare these niches; or (3) Sham irradiation. Mice were sacrificed 24 h later and the brains were processed for immunohistochemical Ki-67 staining. For the human component of the study, 33 patients with primary brain tumors were evaluated. Two intensity modulated radiotherapy (IMRT) plans were retrospectively compared: a standard clinical plan and a plan which spares NPC regions while maintaining the same dose coverage of the tumor. The change in radiation dose to the contralateral NPC-containing regions was recorded. In the mouse model, non-NPC-sparing radiation treatment resulted in a significant decrease in the number of Ki67(+) cells in dentate gyrus (DG) (P = 0.008) and subventricular zone (SVZ) (P = 0.005) compared to NPC-sparing radiation treatment. In NPC-sparing clinical plans, NPC regions received significantly lower radiation dose with no clinically relevant changes in tumor coverage. This novel radiation technique should significantly reduce radiation doses to NPC containing regions of the brain which may reduce neurocognitive deficits following RT for brain tumors.
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37
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De Luca CR, Conroy R, McCarthy MC, Anderson VA, Ashley DM. Neuropsychological impact of treatment of brain tumors. Cancer Treat Res 2010; 150:277-96. [PMID: 19834674 DOI: 10.1007/b109924_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Cinzia R De Luca
- Children's Cancer Centre, Royal Children's Hospital, Melbourne, VIC, Australia.
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Protas PT, Muszynska-Roslan K, Holownia A, Krawczuk-Rybak M, Braszko JJ. Cerebrospinal fluid oxidative stress during chemotherapy of acute lymphoblastic leukemia in children. Pediatr Hematol Oncol 2010; 27:306-13. [PMID: 20426521 DOI: 10.3109/08880011003639960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this study the authors addressed the question whether neurotoxicity due to the chemotherapy of acute lymphoblastic leukemia (ALL) is associated with cerebrospinal fluid (CSF) oxidative stress. Examination of 38 ALL patients revealed significant increases in 8-isoprostane concentration and important decreases in total antioxidative capacity of CSF during therapy. The mean 8-isoprostane level at diagnosis was 9.05 +/- 1.62 pg/mL, and no correlations with initial leukocytosis, organomegaly, and lactate dehydrogenase levels were noted. 8-Isoprostane concentrations were increased on the 59th day of treatment (mean level: 24.85 +/- 7.59 pg/mL [P < .01]) and remained elevated at 4 points of the consolidation phase (17.28 +/- 2.16 pg/mL [P < .05]; 22.72 +/- 6.04 pg/mL [P < .05]; 24.92 +/- 6.31 pg/mL [P < .01]; 32.32 +/- 7.94 pg/mL [P < .01]) as compared to their level at diagnosis. The mean total antioxidative capacity at diagnosis was 203.08 +/- 6.17 mumol/L and was remarkably decreased on the 59th day of treatment (189.76 +/- 1.9 mumol/L [P < .05]) and at one point of the consolidation phase (188.29 +/- 3.46 mumol/L [P < .05]) as compared to the level at diagnosis. This study indicates that neurotoxicity of standard ALL treatment may be related to oxidative stress.
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Affiliation(s)
- Piotr T Protas
- Departament of Clinical Pharmacology, Medical University of Bialystok, Bialystok, Poland.
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Sands SA, Oberg JA, Gardner SL, Whiteley JA, Glade-Bender JL, Finlay JL. Neuropsychological functioning of children treated with intensive chemotherapy followed by myeloablative consolidation chemotherapy and autologous hematopoietic cell rescue for newly diagnosed CNS tumors: an analysis of the Head Start II survivors. Pediatr Blood Cancer 2010; 54:429-36. [PMID: 20052775 DOI: 10.1002/pbc.22318] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND To evaluate the neuropsychological late effects amongst survivors treated on the Head Start II protocol between 1997 and 2003. PROCEDURES Forty-nine patients (mean age 2.9 years) diagnosed with a malignant brain tumor underwent baseline neuropsychological assessment prior to autologous hematopoietic cell transplantation (AuHCT). Twenty-six survivors were retested after 3 years of follow-up as 20 patients did not survive. Patients were evaluated for intelligence, academic achievement, receptive language, visual-motor integration (VMI), learning/memory, social-emotional and behavioral functioning based upon age at testing. RESULTS Overall intelligence and VMI at baseline were low average while verbal and non-verbal intelligence, academic achievement, and receptive vocabulary were in average range. Parents reported social-emotional and behavioral functioning within normal limits. Serial testing revealed Full Scale (FSIQ)/Mental Development Index (MDI), Verbal (VIQ), and Performance (PIQ) Intelligence to be generally stable over 3-year follow-up. Group-average analysis at follow-up demonstrated low average intelligence, academic achievement, receptive language, and VMI. Age at diagnosis was positively correlated with internalizing symptoms and visual immediate memory, while time since diagnosis was inversely correlated with FSIQ, VIQ, PIQ, reading and delayed verbal memory. Craniospinal irradiation (CSI) was avoided in two-thirds of patients. CONCLUSION Induction, with or without intensification using intravenous methotrexate, followed by myeloablative consolidation chemotherapy with AuHCT, may avoid or delay CSI, with possible stabilization of neuropsychological functioning, including those younger at diagnosis. Continued follow-up is necessary to determine the preservation of neuropsychological, academic, social-emotional and behavioral functioning.
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Affiliation(s)
- Stephen A Sands
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
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Kadan-Lottick NS, Brouwers P, Breiger D, Kaleita T, Dziura J, Northrup V, Chen L, Nicoletti M, Bostrom B, Stork L, Neglia JP. Comparison of neurocognitive functioning in children previously randomly assigned to intrathecal methotrexate compared with triple intrathecal therapy for the treatment of childhood acute lymphoblastic leukemia. J Clin Oncol 2009; 27:5986-92. [PMID: 19884541 DOI: 10.1200/jco.2009.23.5408] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For the majority of children with acute lymphoblastic leukemia (ALL), CNS prophylaxis consists of either intrathecal (IT) methotrexate or triple IT therapy (ie, methotrexate with both cytarabine and hydrocortisone). The long-term neurotoxicities of these two IT strategies have not yet been directly compared. PATIENTS AND METHODS In this multisite study, 171 children with standard-risk ALL, age 1 to 9.99 years at diagnosis, previously randomly assigned to IT methotrexate (n = 82) or to triple IT therapy (n = 89) on CCG 1952, underwent neurocognitive evaluation by a licensed psychologist at a mean of 5.9 years after random assignment. RESULTS Patients who received IT methotrexate had a mean Processing Speed Index that was 3.6 points lower, about one fourth of a standard deviation, than those who received triple IT therapy (P = .04) after analysis was adjusted for age, sex, and time since diagnosis. Likewise, 19.5% of children in the IT methotrexate group had a Processing Speed Index score in the below-average range compared with 6.9% in the triple IT therapy group (P = .02). Otherwise, the groups performed similarly on tests of full-scale intelligence quotient, academic achievement, attention/concentration, memory, and visual motor integration. The association of treatment with measures of cognitive functioning was not modified by sex or age at diagnosis. In the post-therapy period, there were no group differences in special education services, neurologic events, or use of psychotropic medications. CONCLUSION This study did not show any clinically meaningful differences in neurocognitive functioning between patients previously randomly assigned to IT methotrexate or triple IT therapy except for a small difference in processing speed in the IT methotrexate group.
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Affiliation(s)
- Nina S Kadan-Lottick
- Section of Pediatric Hematology-Oncology, Yale University School of Medicine, New Haven, CT, USA.
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Jain N, Brouwers P, Okcu MF, Cirino PT, Krull KR. Sex-specific attention problems in long-term survivors of pediatric acute lymphoblastic leukemia. Cancer 2009; 115:4238-45. [PMID: 19536898 DOI: 10.1002/cncr.24464] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Neurocognitive problems are a frequent outcome of chemotherapy for pediatric leukemia, although individual differences exist in patient outcome. Sex of the patient and age at diagnosis are 2 characteristics that have been associated with differential outcomes. The relation between these patient characteristics and specific attention deficits (ie, initiating, inhibiting, shifting, focusing, sustaining attention, and working memory) has not been well researched. The purpose of this study was to evaluate the pattern of attention problems in male and female long-term survivors of pediatric acute lymphoblastic leukemia (ALL). METHODS One hundred three long-term survivors (ie, >or=5 years from diagnosis; 51% boys, mean age at diagnosis of 3.9 years, and mean time since diagnosis 7.5 years) completed standardized measures of basic and complex attention skills related to anterior (ie, inhibition, shifting attention, working memory), posterior (ie, focusing), and subcortical brain systems (ie, sustaining). RESULTS Treatment intensity was related to sustained attention, with those patients treated on high-risk protocols displaying significantly lower performance. Girls performed worse than boys on measures related to the anterior attention system (ie, shifting attention, P<.042) and the subcortical attention system (ie, sustained attention, P<.001), whereas boys performed worse than girls on different measures of anterior control (ie, inhibition, P<.039; working memory, P<.003). CONCLUSIONS The results of this study suggest that children diagnosed with and treated for pediatric ALL perform poorly on select measures of attention and executive control, and that this performance is influenced by sex and treatment intensity.
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Affiliation(s)
- Neelam Jain
- Department of Psychology, University of Houston, and Child Psychology, Texas Children's Hospital, Houston, Texas, USA.
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Cognitive and radiological effects of radiotherapy in patients with low-grade glioma: long-term follow-up. Lancet Neurol 2009; 8:810-8. [PMID: 19665931 DOI: 10.1016/s1474-4422(09)70204-2] [Citation(s) in RCA: 465] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Our previous study on cognitive functioning among 195 patients with low-grade glioma (LGG) a mean of 6 years after diagnosis suggested that the tumour itself, rather than the radiotherapy used to treat it, has the most deleterious effect on cognitive functioning; only high fraction dose radiotherapy (>2 Gy) resulted in significant added cognitive deterioration. The present study assesses the radiological and cognitive abnormalities in survivors of LGG at a mean of 12 years after first diagnosis. METHODS Patients who have had stable disease since the first assessment were invited for follow-up cognitive assessment (letter-digit substitution test, concept shifting test, Stroop colour-word test, visual verbal learning test, memory comparison test, and categoric word fluency). Compound scores in six cognitive domains (attention, executive functioning, verbal memory, working memory, psychomotor functioning, and information processing speed) were calculated to detect differences between patients who had radiotherapy and patients who did not have radiotherapy. White-matter hyperintensities and global cortical atrophy were rated on MRI scans. FINDINGS 65 patients completed neuropsychological follow-up at a mean of 12 years (range 6-28 years). 32 (49%) patients had received radiotherapy (three had fraction doses >2 Gy). The patients who had radiotherapy had more deficits that affected attentional functioning at the second follow-up, regardless of fraction dose, than those who did not have radiotherapy (-1.6 [SD 2.4] vs -0.1 [1.3], p=0.003; mean difference 1.4, 95% CI 0.5-2.4). The patients who had radiotherapy also did worse in measures of executive functioning (-2.0 [3.7] vs -0.5 [1.2], p=0.03; mean difference 1.5, 0.2-2.9) and information processing speed (-2.0 [3.7] vs -0.6 [1.5], p=0.05; mean difference 0.8, 0.009-1.6]) between the two assessments. Furthermore, attentional functioning deteriorated significantly between the first and second assessments in patients who had radiotherapy (p=0.25). In total, 17 (53%) patients who had radiotherapy developed cognitive disabilities deficits in at least five of 18 neuropsychological test parameters compared with four (27%) patients who were radiotherapy naive. White-matter hyperintensities and global cortical atrophy were associated with worse cognitive functioning in several domains. INTERPRETATION Long-term survivors of LGG who did not have radiotherapy had stable radiological and cognitive status. By contrast, patients with low-grade glioma who received radiotherapy showed a progressive decline in attentional functioning, even those who received fraction doses that are regarded as safe (</=2 Gy). These cognitive deficits are associated with radiological abnormalities. Our results suggest that the risk of long-term cognitive and radiological compromise that is associated with radiotherapy should be considered when treatment is planned. FUNDING Kaptein Fonds; Schering Plough.
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Protas PT, Muszynska-Roslan K, Holownia A, Grabowska A, Wielgat P, Krawczuk-Rybak M, Braszko JJ. Negative correlation between cerebrospinal fluid tau protein and cognitive functioning in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2009; 53:105-8. [PMID: 19309718 DOI: 10.1002/pbc.22029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The aim of the study was to assess whether cerebrospinal fluid tau protein is associated with cognitive changes in children with acute lymphoblastic leukemia (ALL). Examination of 38 ALL patients revealed a statistically significant increase in tau protein on treatment day 59 and at two points during consolidation phase. Cognitive functioning was examined in 19 patients at an average of 3.7 years after diagnosis. The level of tau at the initiation of maintenance therapy was negatively correlated with verbal abilities measured on an intellectual scale. The study suggests that standard ALL treatment may cause a decline in cognitive functioning.
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Affiliation(s)
- Piotr T Protas
- Department of Clinical Pharmacology, Medical University of Bialystok, Bialystok, Waszyngtona, Poland.
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Janzen LA, Spiegler BJ. Neurodevelopmental sequelae of pediatric acute lymphoblastic leukemia and its treatment. ACTA ACUST UNITED AC 2009; 14:185-95. [PMID: 18924154 DOI: 10.1002/ddrr.24] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This review will describe the neurocognitive outcomes associated with pediatric acute lymphoblastic leukemia (ALL) and its treatment. The literature is reviewed with the aim of addressing methodological issues, treatment factors, risks and moderators, special populations, relationship to neuroimaging findings, and directions for future research. It is concluded that neurocognitive outcomes for the majority of children with standard-risk ALL treated according to current chemotherapy protocols is relatively good, but subgroups of children are more significantly compromised. As medical treatments advance and survival rates continue to improve, neurocognitive outcomes and other quality of life indicators will become increasingly important. Preventing or ameliorating treatment-related neuropsychological sequelae represents the next major challenge in pediatric ALL.
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Affiliation(s)
- Laura A Janzen
- Department of Psychology, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Trask CL, Welch JJG, Manley P, Jelalian E, Schwartz CL. Parental needs for information related to neurocognitive late effects from pediatric cancer and its treatment. Pediatr Blood Cancer 2009; 52:273-9. [PMID: 18985741 DOI: 10.1002/pbc.21802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Parents' needs for information about neurocognitive late effects (NCLE) associated with cancer treatment may differ as to the preferred source, format, timing, and amount of information about potential NCLE from treatment. Parental characteristics, treatment variables, and other risk factors may also modulate the needs for information about NCLE. PROCEDURE A total of 90 parents completed a series of questionnaires related to their perceived knowledge of NCLE and need for further information about NCLE, coping style, stress, perceived risk for NCLE, and information related to their child's diagnosis and treatment. RESULTS These findings indicate that although parents report feeling knowledgeable about NCLE, they continue to have a need for further information. Many parents would prefer multi-modal presentation of this material, but they do not have a clear consensus about the optimal time to first discuss this risk. Parents who reported higher levels of emotional distress expressed a preference to receive information earlier. Stepwise regression analyses revealed that parents of children who received cranial radiation reported being well informed about NCLE, whereas parents of children who received chemotherapy reported wanting more information about NCLE. CONCLUSIONS It is important to recognize the high level of need for information about potential NCLE in caregivers of children with cancer. Further research is needed to understand how to tailor the timing and mode of presentation to individual families.
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Affiliation(s)
- Christine L Trask
- Neuropsychology Program, Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island.
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Cole PD, Beckwith KA, Vijayanathan V, Roychowdhury S, Smith AK, Kamen BA. Folate homeostasis in cerebrospinal fluid during therapy for acute lymphoblastic leukemia. Pediatr Neurol 2009; 40:34-41. [PMID: 19068252 DOI: 10.1016/j.pediatrneurol.2008.09.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 08/25/2008] [Accepted: 09/03/2008] [Indexed: 10/21/2022]
Abstract
The neurotoxic effects of therapy for childhood acute lymphoblastic leukemia can result in leukoencephalopathy or measurable deficits in cognitive function. However, there are no validated biomarkers that allow the identification of those patients at greatest risk. With the objective of identifying such predictors, cerebrospinal fluid collected from 53 patients over 2.5 years of therapy for childhood acute lymphoblastic leukemia was retrospectively studied. Cerebrospinal fluid folate, concentrated relative to serum folate prior to therapy, dropped during the first month of therapy and remained below baseline throughout treatment. Cerebrospinal fluid homocysteine was inversely related to cognitive function prior to treatment. Oral methotrexate was associated with decreased cerebrospinal fluid folate and increased cerebrospinal fluid homocysteine, but these changes were not seen with oral aminopterin. Of 36 patients who had imaging after completion of therapy, 9 had periventricular or subcortical white matter abnormalities consistent with leukoencephalopathy. Peak cerebrospinal fluid tau concentrations during therapy were higher among patients who had leukoencephalopathy after completion of therapy than among those with normal imaging studies at the end of therapy. If confirmed prospectively, these markers may allow the identification of those patients at greatest risk of developing treatment-induced neurocognitive dysfunction, thus guiding preventive interventions.
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Affiliation(s)
- Peter D Cole
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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White matter fractional anisotropy correlates with speed of processing and motor speed in young childhood cancer survivors. Int J Radiat Oncol Biol Phys 2008; 74:837-43. [PMID: 19117694 DOI: 10.1016/j.ijrobp.2008.08.060] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 08/21/2008] [Accepted: 08/26/2008] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine whether childhood medulloblastoma and acute lymphoblastic leukemia (ALL) survivors have decreased white matter fractional anisotropy (WMFA) and whether WMFA is related to the speed of processing and motor speed. METHODS AND MATERIALS For this study, 17 patients (6 medulloblastoma, 5 ALL treated with high-dose methotrexate (MTX) (4 x 5 g/m(2)) and 6 with low-dose MTX (3 x 2 g/m(2))) and 17 age-matched controls participated. On a 3.0-T magnetic resonance imaging (MRI) scanner, diffusion tensor imaging (DTI) was performed, and WMFA values were calculated, including specific regions of interest (ROIs), and correlated with the speed of processing and motor speed. RESULTS Mean WMFA in the patient group, mean age 14 years (range 8.9 - 16.9), was decreased compared with the control group (p = 0.01), as well as WMFA in the right inferior fronto-occipital fasciliculus (IFO) (p = 0.03) and in the genu of the corpus callosum (gCC) (p = 0.01). Based on neurocognitive results, significant positive correlations were present between processing speed and WMFA in the splenium (sCC) (r = 0.53, p = 0.03) and the body of the corpus callosum (bCC) (r = 0.52, p = 0.03), whereas the right IFO WMFA was related to motor speed (r = 0.49, p < 0.05). CONCLUSIONS White matter tracts, using a 3.0-T MRI scanner, show impairment in childhood cancer survivors, medulloblastoma survivors, and also those treated with high doses of MTX. In particular, white matter tracts in the sCC, bCC and right IFO are positively correlated with speed of processing and motor speed.
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Abstract
Neurocognitive late effects are common sequelae of cancer in children, especially in those who have undergone treatment for brain tumors or in those receiving prophylactic cranial radiation therapy to treat leukemia. Neurocognitive morbidity in attention, executive functioning, processing speed, working memory, and memory frequently occurs and contributes to declines in intellectual and academic abilities. Oncologists are faced with the challenge of using the most effective, often the most intense, therapy to achieve the primary goal of medical success, balanced with the desire to prevent adverse late effects. Not all children with similar diagnoses and treatment have identical neurocognitive outcomes; some do very poorly and some do well. Attention now turns to the reliable prediction of risk for poor outcomes and then, using risk-adapted therapy, to preserve neurocognitive function. Prevention of late effects through rehabilitative strategies, continuation of school, and pharmacotherapy will be explored.
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Affiliation(s)
- Martha A. Askins
- Department of Pediatrics, Children’s Cancer Hospital, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030
| | - Bartlett D. Moore
- Department of Pediatrics, Children’s Cancer Hospital, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030
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Dellani PR, Eder S, Gawehn J, Vucurevic G, Fellgiebel A, Müller MJ, Schmidberger H, Stoeter P, Gutjahr P. Late structural alterations of cerebral white matter in long-term survivors of childhood leukemia. J Magn Reson Imaging 2008; 27:1250-5. [PMID: 18504742 DOI: 10.1002/jmri.21364] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To look for the presence and age-dependence of late structural alterations of otherwise normal-appearing cerebral gray and white matter after radiation and chemotherapy in adult survivors of acute lymphoblastic leukemia (ALL) during childhood. MATERIALS AND METHODS In a group of 13 adult survivors 17-37 years old, who had been treated by total brain radiation (18-24 Gy) and chemotherapy 16-28 years ago, prospective MR examinations including diffusion tensor imaging (DTI) were performed. Evaluation included volumetry, calculation of mean diffusivity (MD) and fractional anisotropy (FA), and comparison of results to an age-matched control group. RESULTS DTI showed significantly reduced FA values in the temporal lobes (difference of 0.069 units, P < 0.001), hippocampi (difference of 0.033 units, P < 0.001), and thalami (difference of 0.046 units, P = 0.001), which were accompanied by significant white matter volume loss (difference of 92 cm(3), P < 0.001). Significant elevations of MD were limited to the temporal white matter (difference of 42 x 10(-6) mm(2)/s, P = 0.005). Global and frontal white matter MD correlated negatively to increasing age of the survivors (P < 0.01). CONCLUSION With regard to structural white matter alterations, adult long-term survivors of childhood ALL, who had received total brain radiation and chemotherapy, apparently show the same overall age dependence as controls. Follow-up studies are needed for confirmation.
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Affiliation(s)
- Paulo R Dellani
- Institute of Neuroradiology, University Clinic, Mainz, Germany.
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Steffen-Smith EA, Wolters PL, Albert PS, Baker EH, Shimoda KC, Barnett AS, Warren KE. Detection and characterization of neurotoxicity in cancer patients using proton MR spectroscopy. Childs Nerv Syst 2008; 24:807-13. [PMID: 18293002 PMCID: PMC2398763 DOI: 10.1007/s00381-007-0576-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The study objective was to detect abnormalities and identify relationships between brain metabolic ratios determined by proton magnetic resonance spectroscopic imaging ((1)H-MRSI) and neuropsychological (NP) function in cancer patients at risk for neurotoxicity. METHODS Thirty-two patients received (1)H-MRSI using a multi-slice, multi-voxel technique on a 1.5T magnet. Cho/NAA, NAA/Cr, and Cho/Cr ratios were identified in seven pre-determined sites without tumor involvement. A battery of age-appropriate NP tests was administered within 7 days of imaging. Relationships were examined between test scores and metabolite ratios. CONCLUSIONS This study identifies relationships between brain metabolite ratios and cognitive functioning in cancer patients. (1)H-MRSI may be useful in early detection of neurotoxic effects, but prospective longitudinal studies in a homogeneous population are recommended to determine the prognostic value.
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Affiliation(s)
- Emilie A. Steffen-Smith
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health (NIH), Bethesda, MD
| | - Pamela L. Wolters
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health (NIH), Bethesda, MD
- Medical Illness Counseling Center, Chevy Chase, MD
| | - Paul S. Albert
- Biometric Research Branch, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Eva H. Baker
- Clinical Center, National Institutes of Health, Bethesda, MD
| | | | - Alan S. Barnett
- National Institute of Mental Health, CBDB, National Institutes of Health, Bethesda, MD
| | - Katherine E. Warren
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health (NIH), Bethesda, MD
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