Bone mass and bone mineral metabolism at diagnosis and after intensive treatment in children with acute lymphoblastic leukemia

Risk Factors for Hematopoietic Stem Cell Transplantation-Associated Bone Loss

Hematopoietic stem cell transplantation (HSCT), including bone marrow transplantation, is the treatment of choice for many hematologic diseases, including hematologic malignancies and different types of anemia. The use of HSCT is increasing annually, mainly because advanced research that has been conducted in this area has exponentially expanded the indications for HSCT and significantly improved transplantation techniques and supportive care practices. Collectively, these improvements have led to an increase in the overall survival of HSCT patients. However, as post-HSCT survival is increasing, awareness of the potential late complications of HSCT is also growing. Unpredictable bone loss is one of the major post-HSCT complications that can cause significant morbidity and impair the quality of life of survivors. Although the exact mechanism of post-HSCT bone loss is not yet known, previous studies have suggested that numerous factors, including destructive preparative regimens (eg, high-dose chemotherapy, total body irradiation), treatment-related complications (eg, graft-versus-host disease), endocrine abnormalities (eg, diabetes mellitus, thyroid dysfunction, adrenal insufficiency), lack of physical activity, and the underlying disease itself are responsible for HSCT-associated bone loss. Sufficient data have been collected to suggest that post-HSCT bone loss can be prevented and treated using the same preventive and treatment modalities as used for the general population. Various guidelines have been formulated to help keep a check on HSCT recipients' deteriorating bone health.

Bone Mineral Density Evolution and Its Determinants in Long-term Survivors of Childhood Acute Leukemia: A Leucémies Enfants Adolescents Study

This prospective study aimed to analyze determinants that can influence bone mineral density evolution in childhood acute leukemia survivors. Patients included were selected from the long-term follow-up LEA cohort and had dual energy radiograph absorptiometry scan between 10 and 18 years and after the age of 18. All scans were centrally reviewed. Bone mineral density was measured at the lumbar spine, femoral neck, total hip, and whole body, and expressed as z-score. Eighty-nine patients (female 39, lymphoblastic leukemia 68, relapse 25, hematopoietic stem cell transplantation 44, and mean age 15.4 and 20.1 years at the first and second scans, respectively) were studied. The first and second scan z-scores were significantly correlated (P < 10⁻³). Mean femoral neck and total hip z-scores improved significantly between the first and second scans, whereas no significant evolution occurred at the lumbar spine and whole-body level. On the second evaluation, 14.6% of patients had z-score <−2 at the lumbar spine and 4.3% at the femoral neck level. Gender, type of leukemia, transplantation, relapse, cumulative corticosteroid doses, or growth hormone deficiency did not have any significant impact on z-score variation. Younger age at diagnosis (≤8.5 years) proved an unfavorable risk factor for z-score evolution at the lumbar spine (P = 0.041); the trend did not reach statistical significance for metabolic syndrome (P = 0.054). At the femoral neck, both were associated with unfavorable z-score evolution (P = 0.003 and 0.025, respectively). Patients treated at a younger age and those with metabolic syndrome seem to be at higher risk of bone mineral density decline and should benefit from specific interventions.

Bone Loss in Pediatric Survivors of Acute Lymphoblastic Leukemia

Objective

Bone mineral density (BMD) in children may be negatively affected by acute lymphoblastic leukemia (ALL) or its treatment protocol. The aim of our study was to evaluate bone health by measuring BMD after ALL treatment.

Materials and Methods

The age, anthropometric measurements, and lumbar spine BMDs were recorded in 39 pediatric survivors of ALL, with no history of relapse, secondary malignancy, or transplantation. The lumbar spine BMD was measured by dual energy x-ray absorptiometry. The BMD risk factors, pubertal status, age at diagnosis, risk category, the time interval from the completion of the chemotherapy, and cranial radiotherapy were investigated. Serum calcium, phosphate, alkaline phosphates, magnesium, parathormone, and 25-hydroxy vitamin D levels were determined.

Results

The mean BMD value was calculated as 0.668±0.176 g/cm². Osteopenia and osteoporosis were detected in nine patients (23.1%) and three patients (7.7%), respectively, according to previously published data of healthy age- and sex-related Turkish children's BMD values. The mean age at diagnosis of patients with ALL, having the Z-score above -1 was lower than in patients having bone defect (Z score <-1).

Conclusion

Early detection and intervention strategies to optimize bone health are essential in pediatric patients with ALL.

Skeletal, neuromuscular and fitness impairments among children with newly diagnosed acute lymphoblastic leukemia

This study describes skeletal, neuromuscular and fitness impairments among 109 children (median age 10 [range 4-18] years, 65.1% male, 63.3% white) with acute lymphoblastic leukemia (ALL). Outcomes were measured 7-10 days after diagnosis and compared to age- and sex-specific expected values. Associations between function and health-related quality of life (HRQL) were evaluated with logistic regression. Children with ALL had sub-optimal bone mineral density (BMD) Z-score/height (mean ± standard error: - 0.53 ± 0.16 vs. 0.00 ± 0.14, p < 0.01), body mass index percentile (57.6 ± 3.15 vs. 50.0 ± 3.27%, p = 0.02), quadriceps strength (201.9 ± 8.3 vs. 236.1 ± 5.4 N, p < 0.01), 6 min walk distance (385.0 ± 13.1 vs. 628.2 ± 7.1 m, p < 0.001) and Bruininks-Oseretsky Test of Motor Proficiency scores (23 ± 2.5 vs. 50 ± 3.4%, p < 0.01). Quadriceps weakness was associated with a 20.9-fold (95% confidence interval 2.5-173.3) increase in poor physical HRQL. Children with newly diagnosed ALL have weakness and poor endurance and may benefit from early rehabilitation that includes strengthening and aerobic conditioning.

Evaluation of bone mineral density at different phases of therapy of childhood all

In the present study the authors evaluated the status of spinal bone mineral density (BMD) using dual-energy X-ray absorptiometry in a group of 31 children with acute lymphoblastic leukemia, treated by ALL-BFM protocols without irradiation, at different phases of their treatment. These patients were studied (1) within 2 months of diagnosis (group 1, n = 17, median time postdiagnosis 17 days), (2) during chemotherapy (group 2, n = 16, median time on treatment 22 months), and (3) shortly after completion of therapy (group 3, n = 10, median time postchemotherapy 13 months). Twelve patients underwent serial measurements in either of the groups they entered (6 patients of group 1 and 6 patients of group 2). The mean cumulative prednisone dose was 0.8, 4.3, and 5 g/m2 in groups 1, 2, and 3, respectively. A gradual decline of BMD from group 1 through group 3 was observed. The mean value of age- and sex-specific BMD z-score was -0.74 (+/-0.32) in group 1, -1.59 (+/-0.24) in group 2, and -2.03 (+/-0.27) in group 3; there was a statistically significant difference between groups 1 and 3 (p = .022). A BMD z-score < -2 was found in 3 (17%), 4 (25%), and 5 (50%) patients of groups 1, 2, and 3, respectively. In conclusion, a high incidence of reduced bone mass was observed during and shortly after treatment. These findings could have significant consequences in long-term survivors.

Endocrine late effects of cancer treatment

Endocrinopathies are significant consequences of the treatment of childhood cancers. The risk of developing these adverse events is related to the underlying disease and its treatment with cytotoxic agents and radiation therapy. This article reviews hypothalamic-pituitary, thyroid, and gonadal dysfunction, as well as osteopenia-osteoporosis and obesity.

Potential benefits of physical activity for children with acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is the most common form of paediatric leukaemia. The survival rate in children with ALL has improved significantly over the past several years, which makes quality of life an important focus for researchers. Some of the side effects of treatment (i.e. osteoporosis and obesity) are not realized until years after conclusion of therapy. Few studies have addressed the impact of physical activity (PA) on the side effects that occur during treatment of children with ALL. This paper discusses the increased risk for both osteoporosis and obesity due to treatment for ALL and suggests ways that PA may attenuate bone loss and risk of obesity by discussing what is known about effects of PA in healthy children and children with other chronic diseases. Recommendations will be made for PA interventions and future research in children with ALL.