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Chen YC, Hou CY, Hsu MH, Huang LT, Hsiao CC, Sheen JM. The Impact of Gut Microbiota Changes on Methotrexate-Induced Neurotoxicity in Developing Young Rats. Biomedicines 2024; 12:908. [PMID: 38672262 PMCID: PMC11048417 DOI: 10.3390/biomedicines12040908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Methotrexate (MTX) is an essential part of therapy in the treatment of acute lymphoblastic leukemia (ALL) in children, and inferior intellectual outcomes have been reported in children who are leukemia survivors. Although several studies have demonstrated that the interaction between gut microbiota changes and the brain plays a vital role in the pathogenesis of chemotherapy-induced brain injury, preexisting studies on the effect of MTX on gut microbiota changes focused on gastrointestinal toxicity only. Based on our previous studies, which revealed that MTX treatment resulted in inferior neurocognitive function in developing young rats, we built a young rat model mimicking MTX treatment in a child ALL protocol, trying to investigate the interactions between the gut and brain in response to MTX treatment. We found an association between gut microbiota changes and neurogenesis/repair processes in response to MTX treatment, which suggest that MTX treatment results in gut dysbiosis, which is considered to be related to MTX neurotoxicity through an alteration in gut-brain axis communication.
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Affiliation(s)
- Yu-Chieh Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- Department of Traditional Medicine, Chang Gung University, Taoyuan 333, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804, Taiwan
| | - Chih-Yao Hou
- Department of Seafood Science, College of Hydrosphere, National Kaohsiung University of Science and Technology, Kaohsiung 807, Taiwan
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Li-Tung Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Chih-Cheng Hsiao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- Department of Traditional Medicine, Chang Gung University, Taoyuan 333, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804, Taiwan
| | - Jiunn-Ming Sheen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- Department of Traditional Medicine, Chang Gung University, Taoyuan 333, Taiwan
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Krishna S, Vijayaraghavan A, Philip DSJ, Sundaram S, Sukumaran S. Intrathecal methotrexate induced subacute combined degeneration of spinal cord like presentation in a patient with acute lymphocytic leukaemia. Acta Neurol Belg 2024; 124:679-681. [PMID: 37904078 DOI: 10.1007/s13760-023-02418-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023]
Affiliation(s)
- Sreela Krishna
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Asish Vijayaraghavan
- Comprehensive Neuro-Intensive Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, 695011, India
| | | | - Soumya Sundaram
- Comprehensive Neuro-Intensive Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, 695011, India.
| | - Sajith Sukumaran
- Comprehensive Neuro-Intensive Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, 695011, India
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Dhariwal N, Roy Moulik N, Smriti V, Dhamne C, Chichra A, Srinivasan S, Narula G, Banavali S. Clinico-radiological profile, management and follow-up of methotrexate induced neurotoxicity in children with acute lymphoblastic leukemia. Leuk Lymphoma 2023; 64:1971-1980. [PMID: 37565568 DOI: 10.1080/10428194.2023.2245093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
Methotrexate-induced neurotoxicity is a well-defined side-effect of high-dose and intrathecal methotrexate with characteristic clinico-radiological findings and transient nature. Our experience in managing this entity in children with acute lymphoblastic leukemia(ALL) is reported here. All children with de novo ALLregistered from January 2016 through December 2021 who developed methotrexate-induced neurotoxicity were included. Of children with ALL treated during the study period, thirty-three experienced methotrexate induced neurotoxicity with an incidence of 1.25%. Stroke-like symptoms(36.36%; 12/33) were the most common clinical manifestation followed by seizures(30.3%, 10/33). Twenty-three patients had radiological features consistent with methotrexate-induced leukoencephalopathy. With emerging evidence, thirty-one patients were re-challenged with methotrexate (IV/IT), of whom 4 patients had recurrence of symptoms. No long-term neurological sequalae were noted in our cohort, despite rechallenging. Therefore in our study, methotrexate induced neurotoxicity is a self-limiting toxicity and methotrexate can be re-challenged safely without compromising theintensity of CNS-directed therapy.
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Affiliation(s)
- Nidhi Dhariwal
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Nirmalya Roy Moulik
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Vasundhara Smriti
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Chetan Dhamne
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Akanksha Chichra
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Shyam Srinivasan
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Gaurav Narula
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Shripad Banavali
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
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Snyder EJ, Sarma A, Poussaint TY, Krishnasarma R, Pruthi S. Complications of Cancer Therapy in Children: A Comprehensive Review of Neuroimaging Findings. J Comput Assist Tomogr 2023; 47:820-832. [PMID: 37707414 DOI: 10.1097/rct.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ABSTRACT Complications of cancer therapy in children can result in a spectrum of neurologic toxicities that may occur at the initiation of therapy or months to years after treatment. Although childhood cancer remains rare, increasing survival rates mean that more children will be living longer after cancer treatment. Therefore, complications of cancer therapy will most likely occur with increasing frequency.At times, it is very difficult to differentiate between therapeutic complications and other entities such as tumor recurrence, development of secondary malignancy, and infection (among other conditions). Radiologists often play a key role in the diagnosis and evaluation of pediatric patients with malignancies, and thus, awareness of imaging findings of cancer complications and alternative diagnoses is essential in guiding management and avoiding misdiagnosis. The aim of this review article is to illustrate the typical neuroimaging findings of cancer therapy-related toxicities, including both early and late treatment effects, highlighting pearls that may aid in making the appropriate diagnosis.
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Affiliation(s)
- Elizabeth J Snyder
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Asha Sarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Rekha Krishnasarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Sumit Pruthi
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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Central Nervous System Involvement in Adults with Acute Leukemia: Diagnosis, Prevention, and Management. Curr Oncol Rep 2022; 24:427-436. [PMID: 35141858 DOI: 10.1007/s11912-022-01220-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Recent treatment advances in both acute myeloid leukemia and acute lymphoblastic leukemia have drastically improved outcomes for these diseases, but central nervous system (CNS) relapses still occur. Treatment of CNS disease can be challenging due to the impermeability of the blood-brain barrier to many systemic therapies. RECENT FINDINGS The diagnosis of CNS leukemia relies on assessment of clinical symptoms, cerebrospinal fluid sampling for conventional cytology and/or flow cytometry, and neuroimaging. While treatment of CNS leukemia with systemic or intrathecal chemotherapy and/or radiation can be curative in some patients, these modalities can also lead to serious toxicities. In the modern era, prophylaxis with intrathecal chemotherapy is the most important strategy to prevent CNS relapses in high risk patients. Accurate risk stratification tools and the use of risk-adapted prophylactic therapy are imperative to improving the outcomes of patients with acute leukemias and preventing the development of CNS leukemia.
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Tang W, Tan J. Intrathecal methotrexate-induced aseptic meningitis in a patient with acute lymphoblastic leukemia. Int J Appl Basic Med Res 2022; 12:211-213. [PMID: 36131864 PMCID: PMC9484505 DOI: 10.4103/ijabmr.ijabmr_729_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/31/2022] [Accepted: 05/27/2022] [Indexed: 11/25/2022] Open
Abstract
The central nervous system is often a site of spread for patients with acute lymphoblastic leukemia (ALL). ALL is often treated with ongoing intrathecal chemotherapy with the most common regimens including methotrexate and/or cytarabine. Uncommonly, intrathecal methotrexate has been associated with stroke-like symptoms. To the author’s knowledge, we present the first reported case of a patient who developed symptoms more akin to bacterial meningitis than stroke-like symptoms as a consequence of intrathecal methotrexate chemotherapy.
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Rozalski R, Gackowski D, Skalska-Bugala A, Starczak M, Siomek-Gorecka A, Zarakowska E, Modrzejewska M, Dziaman T, Szpila A, Linowiecka K, Guz J, Szpotan J, Gawronski M, Labejszo A, Gackowska L, Foksinski M, Olinska E, Wasilow A, Koltan A, Styczynski J, Olinski R. The urinary excretion of epigenetically modified DNA as a marker of pediatric ALL status and chemotherapy response. Sci Rep 2021; 11:21345. [PMID: 34725426 PMCID: PMC8560782 DOI: 10.1038/s41598-021-00880-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/19/2021] [Indexed: 12/04/2022] Open
Abstract
The active DNA demethylation process may be linked to aberrant methylation and may be involved in leukemogenesis. We investigated the role of epigenetic DNA modifications in childhood acute lymphoblastic leukemia (ALL) diagnostics and therapy monitoring. We analyzed the levels of 5-methyl-2′-deoxycytidine (5-mdC) oxidation products in the cellular DNA and urine of children with ALL (at diagnosis and during chemotherapy, n = 55) using two-dimensional ultra-performance liquid chromatography with tandem mass spectrometry (2D UPLC–MS/MS). Moreover, the expression of Ten Eleven Translocation enzymes (TETs) at the mRNA and protein levels was determined. Additionally, the ascorbate level in the blood plasma was analyzed. Before treatment, the ALL patients had profoundly higher levels of the analyzed modified DNA in their urine than the controls. After chemotherapy, we observed a statistically significant decrease in active demethylation products in urine, with a final level similar to the level characteristic of healthy children. The level of 5-hmdC in the DNA of the leukocytes in blood of the patient group was significantly lower than that of the control group. Our data suggest that urinary excretion of epigenetic DNA modification may be a marker of pediatric ALL status and a reliable marker of chemotherapy response.
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Affiliation(s)
- Rafal Rozalski
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland.
| | - Daniel Gackowski
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Aleksandra Skalska-Bugala
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Marta Starczak
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Agnieszka Siomek-Gorecka
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Ewelina Zarakowska
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Martyna Modrzejewska
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Tomasz Dziaman
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Anna Szpila
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Kinga Linowiecka
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland.,Department of Human Biology, Institute of Biology, Faculty of Biological and Veterinary Sciences, Nicolaus Copernicus University in Toruń, 87-100, Toruń, Poland
| | - Jolanta Guz
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Justyna Szpotan
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland.,Department of Human Biology, Institute of Biology, Faculty of Biological and Veterinary Sciences, Nicolaus Copernicus University in Toruń, 87-100, Toruń, Poland
| | - Maciej Gawronski
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Anna Labejszo
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland.,Department of Geriatrics, Division of Biochemistry and Biogerontology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Lidia Gackowska
- Department of Immunology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Marek Foksinski
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Elwira Olinska
- District Health Center in Kartuzy, 83-300, Kartuzy, Poland
| | - Aleksandra Wasilow
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Andrzej Koltan
- Department of Pediatric, Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Jan Styczynski
- Department of Pediatric, Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland
| | - Ryszard Olinski
- Department of Clinical Biochemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-092, Bydgoszcz, Poland.
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Ghoneum M, El-Gerbed MSA. Human placental extract ameliorates methotrexate-induced hepatotoxicity in rats via regulating antioxidative and anti-inflammatory responses. Cancer Chemother Pharmacol 2021; 88:961-971. [PMID: 34505929 PMCID: PMC8536621 DOI: 10.1007/s00280-021-04349-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/27/2021] [Indexed: 01/24/2023]
Abstract
Purpose Methotrexate (MTX) induces hepatotoxicity, limiting its clinical efficacy as a widely known chemotherapy drug. In the current study, we examined the protective effect of human placenta extract (HPE) against MTX-induced liver damage in rats, as well as its ability to regulate antioxidative and anti-inflammatory liver responses. Methods Male rats were orally administered MTX at a daily dose of 5 mg/kg-body-weight in the presence or absence of HPE (10.08 mg/kg) for 2 weeks. We measured the biological effects of MTX and HPE on the levels of liver enzymes, lipid profile, lipid peroxidation, oxidative stress biomarkers, and cytokines [tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and interleukin-10 (IL-10)]. In addition, histological examination and histopathological scoring of liver tissues were performed. Results MTX-treated rats showed significantly increased (p < 0.001) liver enzyme levels for aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), total bilirubin, total cholesterol, and triglyceride levels. However, HPE supplementation in MTX-treated rats significantly decreased (p < 0.001) these elevated levels. HPE supplementation also significantly reduced the oxidative stress biomarker malondialdehyde (MDA), reversed the reduction in glutathione (GSH), and markedly increased the antioxidant enzyme activities of catalase (CAT) and superoxide dismutase (SOD) in the livers of MTX-treated rats. Furthermore, HPE supplementation significantly decreased the MTX-elevated levels of the pro-inflammatory cytokines TNF-α, IL-6, and IL-10. Histopathological examinations showed that MTX produced severe cellular damage and inflammatory lesions in liver tissues, while treatment with HPE improved hepatic histologic architecture. Conclusion HPE has the ability to ameliorate methotrexate-induced liver injury in rats by mechanisms that include boosting antioxidative responses and down-regulating MDA and pro-inflammatory cytokine production.
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Affiliation(s)
- Mamdooh Ghoneum
- Department of Surgery, Charles R. Drew University of Medicine and Science, 1621 E. 120th Street, Los Angeles, CA, 90059, USA. .,Department of Surgery, University of California Los Angeles, Los Angeles, CA, 90095, USA.
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Chen YC, Sheen JM, Wang SC, Hsu MH, Hsiao CC, Chang KA, Huang LT. Methotrexate Neurotoxicity Is Related to Epigenetic Modification of the Myelination Process. Int J Mol Sci 2021; 22:6718. [PMID: 34201550 PMCID: PMC8267729 DOI: 10.3390/ijms22136718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/12/2021] [Accepted: 06/17/2021] [Indexed: 12/29/2022] Open
Abstract
With the improvement of the survival rate of acute lymphoblastic leukemia (ALL) in children, some children ALL survivors reveal inferior intellectual and cognition outcome. Methotrexate (MTX), while serving as an essential component in ALL treatment, has been reported to be related to various neurologic sequelae. Using combined intrathecal (IT) and intraperitoneal (IP) MTX model, we had demonstrated impaired spatial memory function in developing rats, which can be rescued by melatonin treatment. To elucidate the impact of MTX treatment on the epigenetic modifications of the myelination process, we examined the change of neurotrophin and myelination-related transcriptomes in the present study and found combined IT and IP MTX treatment resulted in altered epigenetic modification on the myelination process, mainly in the hippocampus. Further, melatonin can restore the MTX effect through alterations of the epigenetic pathways.
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Affiliation(s)
- Yu-Chieh Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (J.-M.S.); (S.-C.W.); (M.-H.H.); (C.-C.H.)
- Department of Traditional Medicine, Chang Gung University, Guishan, Taoyuan 333, Taiwan
| | - Jiunn-Ming Sheen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (J.-M.S.); (S.-C.W.); (M.-H.H.); (C.-C.H.)
- Department of Traditional Medicine, Chang Gung University, Guishan, Taoyuan 333, Taiwan
| | - Su-Chen Wang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (J.-M.S.); (S.-C.W.); (M.-H.H.); (C.-C.H.)
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (J.-M.S.); (S.-C.W.); (M.-H.H.); (C.-C.H.)
| | - Chih-Cheng Hsiao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (J.-M.S.); (S.-C.W.); (M.-H.H.); (C.-C.H.)
- Department of Traditional Medicine, Chang Gung University, Guishan, Taoyuan 333, Taiwan
| | - Kow-Aung Chang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Li-Tung Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (J.-M.S.); (S.-C.W.); (M.-H.H.); (C.-C.H.)
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10
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Goodenough CG, Partin RE, Ness KK. Skeletal Muscle and Childhood Cancer: Where are we now and where we go from here. AGING AND CANCER 2021; 2:13-35. [PMID: 34541550 PMCID: PMC8445321 DOI: 10.1002/aac2.12027] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/03/2021] [Indexed: 12/22/2022]
Abstract
Skeletal muscle (muscle) is essential for physical health and for metabolic integrity, with sarcopenia (progressive muscle mass loss and weakness), a pre-curser of aging and chronic disease. Loss of lean mass and muscle quality (force generation per unit of muscle) in the general population are associated with fatigue, weakness, and slowed walking speed, eventually interfering with the ability to maintain physical independence, and impacting participation in social roles and quality of life. Muscle mass and strength impairments are also documented during childhood cancer treatment, which often persist into adult survivorship, and contribute to an aging phenotype in this vulnerable population. Although several treatment exposures appear to confer increased risk for loss of mass and strength that persists after therapy, the pathophysiology responsible for poor muscle quantity and quality is not well understood in the childhood cancer survivor population. This is partly due to limited access to both pediatric and adult survivor muscle tissue samples, and to difficulties surrounding non-invasive investigative approaches for muscle assessment. Because muscle accounts for just under half of the body's mass, and is essential for movement, metabolism and metabolic health, understanding mechanisms of injury responsible for both initial and persistent dysfunction is important, and will provide a foundation for intervention. The purpose of this review is to provide an overview of the available evidence describing associations between childhood cancer, its treatment, and muscle outcomes, identifying gaps in current knowledge.
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Affiliation(s)
- Chelsea G. Goodenough
- Epidemiology and Cancer Control Department, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Robyn E. Partin
- Epidemiology and Cancer Control Department, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kirsten K. Ness
- Epidemiology and Cancer Control Department, St. Jude Children’s Research Hospital, Memphis, TN, USA
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11
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Williams AM, Cole PD. Biomarkers of Cognitive Impairment in Pediatric Cancer Survivors. J Clin Oncol 2021; 39:1766-1774. [PMID: 33886369 DOI: 10.1200/jco.20.02436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- AnnaLynn M Williams
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Peter D Cole
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
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12
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Vazi EPG, Holanda F, Santos NA, Cardoso CV, Martins MFM, Bondan EF. Short-term systemic methotrexate administration in rats induces astrogliosis and microgliosis. Res Vet Sci 2021; 138:39-48. [PMID: 34091228 DOI: 10.1016/j.rvsc.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
Methotrexate (MTX), an antifolate drug, is widely used in chemotherapeutic protocols for metastatic and primary brain tumors and some autoimmune diseases. Its efficacy for brain tumors is limited by the high incidence of central nervous system (CNS) complications. This investigation aimed to observe the morphological effects, including astroglial and microglial responses, following systemic short-term MTX administration in adult rats. Male Wistar rats received 5 or 10 mg/kg/day of MTX by intraperitoneal route for 4 consecutive days (respectively, MTX5 and MTX10 groups) or the same volume of 0.9% saline solution (control group). On the 5th day, brain samples were collected for hematoxylin-eosin and luxol fast blue staining techniques, as well as for immunohistochemical staining for glial fibrillary acidic protein (GFAP) expression in astrocytes and Iba1 (ionized calcium binding adaptor molecule 1) for microglia in the frontal cortex, hippocampus, hypothalamus and molecular/granular layers of the cerebellum. Morphometric analyses were performed using Image Pro-Plus software. Brain levels of the proinflammatory cytokines TNF-α and IL-1β were determined by ELISA. No signs of neuronal loss or demyelination were observed in all groups. Increased GFAP and Iba1 expression was found in all areas from the MTX groups, although it was slightly higher in the MTX10 group compared to the MTX5. Both TNF-α and IL-1β levels were decreased in the MTX5 group compared to controls. In the MTX10 group, TNF-α decreased, although IL-1β was increased relative to controls. MTX administration induced microglial reaction and astrogliosis in several CNS areas. In the MTX5 group, it apparently occurred in the presence of decreased proinflammatory cytokines.
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Affiliation(s)
- E P G Vazi
- Graduate Program in Environmental and Experimental Pathology, University Paulista, São Paulo, SP, Brazil
| | - F Holanda
- Department of Veterinary Medicine, University Cruzeiro do Sul, São Paulo, SP, Brazil
| | - N A Santos
- Graduate Program in Environmental and Experimental Pathology, University Paulista, São Paulo, SP, Brazil
| | - C V Cardoso
- Graduate Program in Environmental and Experimental Pathology, University Paulista, São Paulo, SP, Brazil
| | - M F M Martins
- Department of Veterinary Medicine, University Cruzeiro do Sul, São Paulo, SP, Brazil
| | - E F Bondan
- Graduate Program in Environmental and Experimental Pathology, University Paulista, São Paulo, SP, Brazil; Department of Veterinary Medicine, University Cruzeiro do Sul, São Paulo, SP, Brazil.
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Pryweller JR, Glass JO, Sabin ND, Laningham FH, Li Y, Jacola LM, Conklin HM, Reddick WE. Characterization of Leukoencephalopathy and Association With Later Neurocognitive Performance in Pediatric Acute Lymphoblastic Leukemia. Invest Radiol 2021; 56:117-126. [PMID: 32769417 PMCID: PMC8059361 DOI: 10.1097/rli.0000000000000715] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The most common form of pediatric cancer is acute lymphoblastic leukemia (ALL). Magnetic resonance (MR) neuroimaging studies have revealed leukoencephalopathy (LE) in pediatric ALL, but the impact of LE on long-term neurocognitive performance remains unknown. This study aims to objectively characterize the prevalence, extent, and intensity of LE, and their association with later neurocognitive performance. MATERIALS AND METHODS Pediatric patients (N = 377) treated for ALL without irradiation underwent MR neuroimaging at 4 time points throughout therapy (end of remission induction [MR1], end of consolidation [MR2], and week 31 [MR3] and week 120 [end therapy, MR4] of continuation treatment) and neurocognitive evaluations at the end of therapy and 2 years later. Generalized estimation equation models with logit link were developed to explore the association between LE prevalence and extent with time points throughout therapy, age at diagnosis (≤5 years or >5 years), treatment risk arm (low risk or standard/high risk), and sex. General linear models were also developed to investigate the association between neuroimaging metrics during treatment and neurocognitive performance at 2-year follow-up. RESULTS The prevalence of LE was greatest (22.8%, 74/324) after consolidation therapy. The prevalence of LE increased at MR2 relative to MR1 regardless of treatment risk arm (both P's < 0.001), age group (both P's < 0.001), or sex (male, P < 0.001; female, P = 0.013). The extent of white matter affected also increased at MR2 relative to MR1 regardless of treatment risk arm (standard/high risk, P < 0.001; low risk, P = 0.004), age group (both P's < 0.001), or sex (male, P < 0.001; female, P = 0.001). Quantitative relaxation rates were significantly longer in LE compared with that in normal-appearing white matter in the same examination (T1, P < 0.001; T2, P < 0.001). The LE prevalence early in therapy was associated with increased parent ratings of conduct problems (P = 0.039) and learning difficulties (P = 0.036) at 2-year follow-up compared with that at the end of therapy. A greater extent of LE early in therapy was associated with decreasing performance on a measure of processing speed (P = 0.003) from the end of therapy to 2-year follow-up. A larger extent of LE at the end of therapy was associated with decreased performance in reading (P = 0.004), spelling (P = 0.003), and mathematics (P = 0.019) at 2-year follow-up and increasing problems with attention (omissions, P = 0.045; β, P = 0.015) and memory (list A total recall, P = 0.010) at 2-year follow-up compared with that at the end of therapy. CONCLUSIONS In this large cohort of pediatric patients treated for ALL without irradiation, asymptomatic LE during therapy can be seen in almost a quarter of patients, involves as much as 10% of the white matter volume, and is associated with decreasing neurocognitive performance, increasing parent reports of conduct problems, and learning difficulties in survivors.
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Affiliation(s)
- Jennifer R. Pryweller
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - John O. Glass
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Noah D. Sabin
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Fred H. Laningham
- Department of Diagnostic Radiology, Children’s Hospital Central California, Madera, California
| | - Yimei Li
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Lisa M. Jacola
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Heather M. Conklin
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Wilburn E. Reddick
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
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John J, Kinra M, Mudgal J, Viswanatha GL, Nandakumar K. Animal models of chemotherapy-induced cognitive decline in preclinical drug development. Psychopharmacology (Berl) 2021; 238:3025-3053. [PMID: 34643772 PMCID: PMC8605973 DOI: 10.1007/s00213-021-05977-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 08/31/2021] [Indexed: 12/23/2022]
Abstract
RATIONALE Chemotherapy-induced cognitive impairment (CICI), chemobrain, and chemofog are the common terms for mental dysfunction in a cancer patient/survivor under the influence of chemotherapeutics. CICI is manifested as short/long term memory problems and delayed mental processing, which interferes with a person's day-to-day activities. Understanding CICI mechanisms help in developing therapeutic interventions that may alleviate the disease condition. Animal models facilitate critical evaluation to elucidate the underlying mechanisms and form an integral part of verifying different treatment hypotheses and strategies. OBJECTIVES A methodical evaluation of scientific literature is required to understand cognitive changes associated with the use of chemotherapeutic agents in different preclinical studies. This review mainly emphasizes animal models developed with various chemotherapeutic agents individually and in combination, with their proposed mechanisms contributing to the cognitive dysfunction. This review also points toward the analysis of chemobrain in healthy animals to understand the mechanism of interventions in absence of tumor and in tumor-bearing animals to mimic human cancer conditions to screen potential drug candidates against chemobrain. RESULTS Substantial memory deficit as a result of commonly used chemotherapeutic agents was evidenced in healthy and tumor-bearing animals. Spatial and episodic cognitive impairments, alterations in neurotrophins, oxidative and inflammatory markers, and changes in long-term potentiation were commonly observed changes in different animal models irrespective of the chemotherapeutic agent. CONCLUSION Dyscognition exists as one of the serious side effects of cancer chemotherapy. Due to differing mechanisms of chemotherapeutic agents with differing tendencies to alter behavioral and biochemical parameters, chemotherapy may present a significant risk in resulting memory impairments in healthy as well as tumor-bearing animals.
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Affiliation(s)
- Jeena John
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka India 576104
| | - Manas Kinra
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka India 576104
| | - Jayesh Mudgal
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka India 576104
| | - G. L. Viswanatha
- Independent Researcher, Kengeri, Bangalore, Karnataka India 560060
| | - K. Nandakumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka India 576104
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Rodríguez Martín B, Fernández Rodríguez EJ, Rihuete Galve MI, Cruz Hernández JJ. Study of Chemotherapy-Induced Cognitive Impairment in Women with Breast Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17238896. [PMID: 33265966 PMCID: PMC7730121 DOI: 10.3390/ijerph17238896] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/02/2020] [Accepted: 11/26/2020] [Indexed: 11/29/2022]
Abstract
Background: Oncology patients experience a large number of symptoms and, those referring to cognitive performance has an ever-increasing importance in clinical practice, due to the increase in survival rates and interest in the patient’s quality of life. The studies reviewed showed that chemotherapy-related cognitive impairment might occur in 15 and 50% of oncology patients. The main objective of this research was to study the impact of chemotherapy on the cognitive function of patients with locoregional breast cancer. Method: Analytical, prospective, longitudinal study using three measures, unifactorial intrasubject design, non-probability, and random selection sampling. The sample comprised women newly diagnosed with locoregional breast cancer in stages I, II, IIIA who received chemotherapy at the University Hospital of Salamanca (Complejo Asistencial Universitario de Salamanca), randomly selected for three years. Semi-structured interviews were conducted, and anxiety and depression (Hospital Anxiety and Depression scale, HAD); quality of life (QLQ-BR23 scale) and the following cognitive variables were assessed—processing speed, attention, memory, and executive functions (subtests of the Wechsler Intelligence Scale and the Trail Making Test). Results: The final sample size included 151 participants; 23 were excluded. A decline in cognitive performance was observed in patients, which did not completely recover two months after chemotherapy was completed. Additionally, worse cognitive performance was observed in patients with anxious or depressive symptoms. There was a negative impact on the quality of life. Conclusion: Chemotherapy had an impact on the cognitive performance of oncology patients in most cognitive domains studied.
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Affiliation(s)
- Blanca Rodríguez Martín
- Medical Oncology Service, Salamanca University Hospital, 37007 Salamanca, Spain; (E.J.F.R.); (M.I.R.G.); (J.J.C.H.)
- Correspondence:
| | - Eduardo José Fernández Rodríguez
- Medical Oncology Service, Salamanca University Hospital, 37007 Salamanca, Spain; (E.J.F.R.); (M.I.R.G.); (J.J.C.H.)
- Nursing and Physiotherapy Department, University of Salamanca, 37007 Salamanca, Spain
| | - María Isabel Rihuete Galve
- Medical Oncology Service, Salamanca University Hospital, 37007 Salamanca, Spain; (E.J.F.R.); (M.I.R.G.); (J.J.C.H.)
- Nursing and Physiotherapy Department, University of Salamanca, 37007 Salamanca, Spain
| | - Juan Jesús Cruz Hernández
- Medical Oncology Service, Salamanca University Hospital, 37007 Salamanca, Spain; (E.J.F.R.); (M.I.R.G.); (J.J.C.H.)
- Medicine Department, University of Salamanca, 37007 Salamanca, Spain
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Abstract
Neurotoxicity is a well-documented adverse effect of methotrexate in the treatment of pediatric cancers. The spectrum of symptoms is broad, can include stroke-like episodes and seizures, and classically resolves within days. The majority of patients tolerate subsequent doses without recurrence of symptoms. The population of patients who experience persistent and irreversible neurologic symptoms is poorly described, with the existing literature suggestive of a relationship with radiation therapy. The authors present a case series of 2 patients with pre-B-cell acute lymphoblastic leukemia who developed severe and ultimately fatal methotrexate-related neurotoxicity in the absence of radiation.
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Franca R, Zudeh G, Lucafò M, Rabusin M, Decorti G, Stocco G. Genome wide association studies for treatment-related adverse effects of pediatric acute lymphoblastic leukemia. WIREs Mech Dis 2020; 13:e1509. [PMID: 33016644 DOI: 10.1002/wsbm.1509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/01/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric hematological malignancy; notwithstanding the success of ALL therapy, severe adverse drugs effects represent a serious issue in pediatric oncology, because they could be both an additional life threatening condition for ALL patients per se and a reason to therapy delay or discontinuation with important fallouts on final outcome. Cancer treatment-related toxicities have generated a significant need of finding predictive pharmacogenomic markers for the a priori identification of at risk patients. In the era of precision medicine, high throughput genomic screening such as genome wide association studies (GWAS) might provide useful markers to tailor therapy intensity on patients' genetic profile. Furthermore, these findings could be useful in basic research for better understanding the mechanistic and regulatory pathways of the biological functions associated with ALL treatment toxicities. The purpose of this review is to give an overview of high throughput genomic screening of the last 10 years that had investigated the landscape of ALL treatment-associated toxicities. This article is categorized under: Cancer > Genetics/Genomics/Epigenetics.
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Affiliation(s)
- Raffaella Franca
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulia Zudeh
- University of Trieste, PhD Course in Reproductive and Developmental Sciences, Trieste, Italy
| | - Marianna Lucafò
- Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Marco Rabusin
- Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Giuliana Decorti
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Gabriele Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
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Chen YC, Sheen JM, Hsu MH, Hsiao CC, Wang SC, Huang LT. Melatonin rescued methotrexate-induced spatial deficit and hyperhomocysteinemia and increased asymmetric dimethylarginine in plasma and dorsal hippocampus in developing rats. Life Sci 2019; 242:116931. [PMID: 31618610 DOI: 10.1016/j.lfs.2019.116931] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/02/2019] [Accepted: 10/02/2019] [Indexed: 01/08/2023]
Abstract
AIMS With the improvement of the survival rates in children acute lymphoblastic leukemia (ALL), some children ALL survivors show impaired cognitive function. Methotrexate (MTX), an essential component in ALL treatment, has been reported to be related to neurologic sequelae and to increased oxidative stress through its interactions with enzymes in the folate pathway. Asymmetric dimethylarginine (ADMA) is the main endogenous inhibitor of nitric oxide synthase, and increased ADMA may result from increased oxidants. Melatonin is an antioxidant; however, its role in MTX neuropathy is not well studied. We developed a rat model mimicking child ALL treatment to explore peripheral and central homocysteine and ADMA regulation after MTX and found potential treatment choice. MAIN METHODS Preweaning male Sprague-Dawley rats were used in this study. Experiment 1 evaluated spatial performance in rats with intrathecal (IT) MTX, intraperitoneal (IP) MTX, or combined IT and IP MTX, protocols mimicking ALL treatment in children. Experiment 2 focused on rats with combined IT and IP MTX, evaluating spatial performance and plasma and dorsal hippocampal homocysteine and ADMA levels, their regulation, and the protective effect of melatonin. KEY FINDINGS Combined IT and IP MTX treatment caused in spatial deficits in developing rats, and melatonin restored the spatial performance. Alterations in peripheral and central homocysteine and ADMA concentrations and their regulation were found and could be alleviated by melatonin treatment. SIGNIFICANCES Combined IP and IT MTX treatment caused spatial deficits in developing rats. Melatonin could restore spatial performance through alleviating the effects on the imbalance of oxidative stress.
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Affiliation(s)
- Yu-Chieh Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Traditional Medicine, Chang Gung University, Linkow, Taiwan
| | - Jiunn-Ming Sheen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Traditional Medicine, Chang Gung University, Linkow, Taiwan
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Cheng Hsiao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Traditional Medicine, Chang Gung University, Linkow, Taiwan
| | - Su-Chen Wang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Li-Tung Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Traditional Medicine, Chang Gung University, Linkow, Taiwan.
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Pope S, Artuch R, Heales S, Rahman S. Cerebral folate deficiency: Analytical tests and differential diagnosis. J Inherit Metab Dis 2019; 42:655-672. [PMID: 30916789 DOI: 10.1002/jimd.12092] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/19/2019] [Accepted: 03/25/2019] [Indexed: 11/07/2022]
Abstract
Cerebral folate deficiency is typically defined as a deficiency of the major folate species 5-methyltetrahydrofolate in the cerebrospinal fluid (CSF) in the presence of normal peripheral total folate levels. However, it should be noted that cerebral folate deficiency is also often used to describe conditions where CSF 5-MTHF is low, in the presence of low or undefined peripheral folate levels. Known defects of folate transport are deficiency of the proton coupled folate transporter, associated with systemic as well as cerebral folate deficiency, and deficiency of the folate receptor alpha, leading to an isolated cerebral folate deficiency associated with intractable seizures, developmental delay and/or regression, progressive ataxia and choreoathetoid movement disorders. Inborn errors of folate metabolism include deficiencies of the enzymes methylenetetrahydrofolate reductase, dihydrofolate reductase and 5,10-methenyltetrahydrofolate synthetase. Cerebral folate deficiency is potentially a treatable condition and so prompt recognition of these inborn errors and initiation of appropriate therapy is of paramount importance. Secondary cerebral folate deficiency may be observed in other inherited metabolic diseases, including disorders of the mitochondrial oxidative phosphorylation system, serine deficiency, and pyridoxine dependent epilepsy. Other secondary causes of cerebral folate deficiency include the effects of drugs, immune response activation, toxic insults and oxidative stress. This review describes the absorption, transport and metabolism of folate within the body; analytical methods to measure folate species in blood, plasma and CSF; inherited and acquired causes of cerebral folate deficiency; and possible treatment options in those patients found to have cerebral folate deficiency.
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Affiliation(s)
- Simon Pope
- Neurometabolic Unit, National Hospital for Neurology, London, UK
| | - Rafael Artuch
- Clinical Biochemistry Department, Institut de Recerca Sant Joan de Déu and CIBERER, ISCIII, Barcelona, Spain
| | - Simon Heales
- Neurometabolic Unit, National Hospital for Neurology, London, UK
- Department of Chemical Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Mitochondrial Research Group, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Shamima Rahman
- Mitochondrial Research Group, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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20
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Sleurs C, Madoe A, Lagae L, Jacobs S, Deprez S, Lemiere J, Uyttebroeck A. Genetic Modulation of Neurocognitive Development in Cancer Patients throughout the Lifespan: a Systematic Review. Neuropsychol Rev 2019; 29:190-219. [DOI: 10.1007/s11065-019-09399-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 02/19/2019] [Indexed: 12/14/2022]
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21
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Shao Y, Tan B, Shi J, Zhou Q. Methotrexate induces astrocyte apoptosis by disrupting folate metabolism in the mouse juvenile central nervous system. Toxicol Lett 2019; 301:146-156. [DOI: 10.1016/j.toxlet.2018.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 01/23/2023]
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22
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Voeller J, Ikonomidou C, Brucker J, Diamond C, Frierdich S, Patel N. Autoimmune Ataxia During Maintenance Therapy for Acute Lymphoblastic Leukemia. Child Neurol Open 2018; 5:2329048X18819235. [PMID: 30574519 PMCID: PMC6295710 DOI: 10.1177/2329048x18819235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/16/2018] [Accepted: 11/24/2018] [Indexed: 01/12/2023] Open
Abstract
Neurologic dysfunction during acute lymphoblastic leukemia treatment is commonly associated with chemotherapy. Nonchemotherapy contributions should be considered for persistent atypical symptoms. We describe a boy with acute lymphoblastic leukemia who developed recurrent fevers, diarrhea, progressive ataxia, and neuropsychiatric impairment during maintenance chemotherapy. He was found to have cytomegalovirus in his serum and colon, but not in his cerebrospinal fluid. Instead, his cerebrospinal fluid revealed oligoclonal bands not present in the serum, suggesting an autoimmune process. Prompt treatment with ganciclovir and immunotherapy resulted in marked clinical improvement. Early recognition and treatment of an autoimmune encephalitis is paramount for optimal clinical outcome.
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Affiliation(s)
- Julie Voeller
- Division of Pediatric Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - Chrysanthy Ikonomidou
- Section of Pediatric Neurology, Department of Neurology, University of Wisconsin, Madison, WI, USA
| | - Justin Brucker
- Section of Neuroradiology, Department of Radiology, University of Wisconsin, Madison, WI, USA
| | - Carol Diamond
- Division of Pediatric Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | | | - Neha Patel
- Division of Pediatric Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, University of Wisconsin, Madison, WI, USA
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Tariq H, Gilbert A, Sharkey FE. Intrathecal Methotrexate-Induced Necrotizing Myelopathy: A Case Report and Review of Histologic Features. Clin Med Insights Pathol 2018; 11:1179555718809071. [PMID: 30450009 PMCID: PMC6236481 DOI: 10.1177/1179555718809071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 09/28/2018] [Indexed: 11/22/2022] Open
Abstract
Central nervous system (CNS) relapse of acute lymphoblastic leukemia (ALL) is
associated with a poor prognosis. However, prophylactic measures, including
intrathecal (IT) methotrexate, reduce the incidence of CNS relapse in these
patients considerably. Unfortunately, IT methotrexate can cause several
neurologic complications, including transverse myelopathy; ie, the development
of isolated spinal cord dysfunction over hours or days following the IT infusion
of methotrexate, but in the absence of a compressive lesion. Transverse
myelopathy following IT methotrexate is a well-established clinical phenomenon,
but the histologic features have been described only very rarely. We report the
autopsy findings from a 31-year-old man with a history of T-cell ALL who
received prophylactic IT methotrexate in anticipation of a bone marrow
transplant. Microscopic examination showed transverse necrosis of the thoracic
cord, with massive infiltration by macrophages and lymphocytes, and perivascular
lymphocytic infiltrates. There was cavitary necrosis of cervical and lumbar
spinal cord involving the entire gray matter and focal white matter, as well as
extensive subpial vacuolar degeneration of the dorsal and lateral columns.
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Affiliation(s)
- Hamza Tariq
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Andrea Gilbert
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Francis E Sharkey
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, TX, USA
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Treatment and Survival of Patients With Primary Effusion Lymphoma in the Netherlands: A Population-based Analysis, 2002-2015. Hemasphere 2018; 2:e143. [PMID: 30887007 PMCID: PMC6407798 DOI: 10.1097/hs9.0000000000000143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text
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25
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Forster VJ, McDonnell A, Theobald R, McKay JA. Effect of methotrexate/vitamin B 12 on DNA methylation as a potential factor in leukemia treatment-related neurotoxicity. Epigenomics 2017; 9:1205-1218. [PMID: 28809129 PMCID: PMC5638018 DOI: 10.2217/epi-2016-0165] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Methotrexate (MTX) is administered to treat childhood acute lymphoblastic leukemia (ALL). It acts by inhibiting dihydrofolate reductase which reduces methyltetrahydrofolate, a key component in one carbon metabolism, thus reducing cell proliferation. Further perturbations to one carbon metabolism, such as reduced vitamin B12 levels via the use of nitrous oxide for sedation during childhood ALL treatment, may increase neurotoxicity risk. With B12 as an enzymatic cofactor, methyltetrahydrofolate is essential to produce methionine, which is critical for DNA methylation. We investigated global and gene specific DNA methylation in neuronal cell lines in response to MTX treatment and vitamin B12 concentration individually, and in combination. Results: MTX treatment alone significantly increased LINE-1 methylation in SH-SY5Y (p = 0.040) and DAOY (p < 0.001), and increased FKBP5 methylation in MO3.13 cells (p = 0.009). Conclusion: We conclude that altered DNA methylation of brain/central nervous system cells could be one mechanism involved in MTX treatment-related neurotoxicities and neurocognitive late effects in ALL survivors.
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Affiliation(s)
- Victoria J Forster
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Alex McDonnell
- Institute of Health & Society, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Theobald
- Institute of Health & Society, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Jill A McKay
- Institute of Health & Society, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
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Cohen IJ. Neurotoxicity after high-dose methotrexate (MTX) is adequately explained by insufficient folinic acid rescue. Cancer Chemother Pharmacol 2017; 79:1057-1065. [PMID: 28455583 DOI: 10.1007/s00280-017-3304-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 04/11/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To challenge the view that the dose of folinic acid rescue after high-dose methotrexate (MTX) has no significance in the prevention of neurotoxicity and to present the minority view that neurotoxicity can be prevented by an adequate dose of folinic acid, without compromising treatment results. Several fallacies that led to the misunderstanding of post MTX neurotoxicity are presented. METHODS Data mining using search engines was used to find relevant publications, and an e-mail survey of more than 60 authors of articles in this field was performed. All relevant articles identified were read in their entirety. RESULTS Examples of clinical studies with neurotoxicity following inadequate rescue are given. Some studies demonstrated no neurotoxicity when adequate doses of folinic acid rescue were started 24-36 h after the start of HDMTX rescue even after mega doses of MTX. Rescue started after 42 h was associated with neurotoxicity except in patients with low serum MTX levels after 24 and 36 h. ALL protocols with neurotoxicity, especially BFM-like protocols, are presented. Protocol is reported in which single protocol changes prevented neurotoxicity. CONCLUSIONS From the published data, when folinic acid rescue is given in a sufficiently high enough dose and is started 24-36 h after the beginning of the methotrexate exposure, and virtually all forms of post MTX neurotoxicity can be prevented without compromising therapeutic results.
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Affiliation(s)
- Ian Joseph Cohen
- The Rina Zaizov Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
- , 139 Shir Hashirim St., 44814, Elkana, Israel.
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Zekri W, Sedky M, Khalifa M. The impact of homocysteine level on methotrexate induced neurotoxicity in children treated with St. Jude total XV acute lymphoblastic leukemia protocol. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2016. [DOI: 10.14319/ijcto.41.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Sramek M, Neradil J, Sterba J, Veselska R. Non-DHFR-mediated effects of methotrexate in osteosarcoma cell lines: epigenetic alterations and enhanced cell differentiation. Cancer Cell Int 2016; 16:14. [PMID: 26929741 PMCID: PMC4770555 DOI: 10.1186/s12935-016-0289-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/12/2016] [Indexed: 12/24/2022] Open
Abstract
Background Methotrexate is an important chemotherapeutic drug widely known as an inhibitor of dihydrofolate reductase (DHFR) which inhibits the reduction of folic acid. DHFR-mediated effects are apparently responsible for its primary antineoplastic action. However, other non-DHFR-mediated effects of methotrexate have been recently discovered, which might be very useful in the development of new strategies for the treatment of pediatric malignancies. The principal goal of this study was to analyze the possible impact of clinically achievable methotrexate levels on cell proliferation, mechanisms of epigenetic regulation (DNA methylation and histone acetylation), induced differentiation and the expression of differentiation-related genes in six osteosarcoma cell lines. Methods The Saos-2 reference cell line and five other patient-derived osteosarcoma cell lines were chosen for this study. The MTT assay was used to assess cell proliferation, DNA methylation and histone acetylation were detected using ELISA, and western blotting was used for a detailed analysis of histone acetylation. The expression of differentiation-related genes was quantified using RT-qPCR and the course of cell differentiation was evaluated using Alizarin Red S staining, which detects the level of extracellular matrix mineralization. Results Methotrexate significantly decreased the proliferation of Saos-2 cells exclusively, suggesting that this reference cell line was sensitive to the DHFR-mediated effects of methotrexate. In contrast, other results indicated non-DHFR-mediated effects in patient-derived cell lines. Methotrexate-induced DNA demethylation was detected in almost all of them; methotrexate was able to lower the level of 5-methylcytosine in treated cells, and this effect was similar to the effect of 5-aza-2′-deoxycytidine. Furthermore, methotrexate increased the level of acetylated histone H3 in the OSA-06 cell line. Methotrexate also enhanced all-trans retinoic acid-induced cell differentiation in three patient-derived osteosarcoma cell lines, and the modulation of expression of the differentiation-related genes was also shown. Conclusions Overall non-DHFR-mediated effects of methotrexate were detected in the patient-derived osteosarcoma cell lines. Methotrexate acts as an epigenetic modifier and has a potential impact on cell differentiation and the expression of related genes. Furthermore, the combination of methotrexate and all-trans retinoic acid can be effective as a differentiation therapy for osteosarcoma.
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Affiliation(s)
- Martin Sramek
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Kotlarska 2, 611 37 Brno, Czech Republic ; Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Cernopolni 9, 613 00 Brno, Czech Republic
| | - Jakub Neradil
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Kotlarska 2, 611 37 Brno, Czech Republic ; Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Cernopolni 9, 613 00 Brno, Czech Republic
| | - Jaroslav Sterba
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Cernopolni 9, 613 00 Brno, Czech Republic
| | - Renata Veselska
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Kotlarska 2, 611 37 Brno, Czech Republic ; Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Cernopolni 9, 613 00 Brno, Czech Republic
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Energy balance and fitness in adult survivors of childhood acute lymphoblastic leukemia. Blood 2015; 125:3411-9. [PMID: 25814529 DOI: 10.1182/blood-2015-01-621680] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/16/2015] [Indexed: 11/20/2022] Open
Abstract
There is limited information on body composition, energy balance, and fitness among survivors of childhood acute lymphoblastic leukemia (ALL), especially those treated without cranial radiation therapy (CRT). This analysis compares these metrics among 365 ALL survivors with a mean age of 28.6 ± 5.9 years (149 treated with and 216 without CRT) and 365 age-, sex-, and race-matched peers. We also report risk factors for outcomes among survivors treated without CRT. Male survivors not exposed to CRT had abnormal body composition when compared with peers (% body fat, 26.2 ± 8.2 vs 22.7 ± 7.1). Survivors without CRT had similar energy balance but had significantly impaired quadriceps strength (-21.9 ± 6.0 Newton-meters [Nm]/kg, 60°/s) and endurance (-11.4 ± 4.6 Nm/kg, 300°/s), exercise capacity (-2.0 ± 2.1 ml/kg per minute), low-back and hamstring flexibility (-4.7 ± 1.6 cm), and dorsiflexion range of motion (-3.1 ± 0.9°) and higher modified total neuropathy scores (+1.6 ± 1.1) than peers. Cumulative asparaginase dose ≥120,000 IU/m(2) was associated with impaired flexibility, vincristine dose ≥39 mg/m(2) with peripheral neuropathy, glucocorticoid (prednisone equivalent) dose ≥8000 mg/m(2) with hand weakness, and intrathecal methotrexate dose ≥225 mg with dorsiflexion weakness. Physical inactivity was associated with hand weakness and decreased exercise capacity. Smoking was associated with peripheral neuropathy. Elimination of CRT from ALL therapy has improved, but not eliminated, body-composition outcomes. Survivors remain at risk for impaired fitness.
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Primary effusion lymphoma in an elderly patient effectively treated by lenalidomide: case report and review of literature. Blood Cancer J 2014; 4:e190. [PMID: 24608734 PMCID: PMC3972705 DOI: 10.1038/bcj.2014.6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/24/2014] [Indexed: 12/27/2022] Open
Abstract
Primary effusion lymphoma (PEL) is a rare aggressive subset of non-Hodgkin B-cell lymphoma. It is caused by Kaposi sarcoma-associated herpesvirus/human herpesvirus type 8 (KSHV/HHV8). It occurs mainly, but not exclusively, in HIV-positive patients. PEL predominantly develops in serous cavities and occasionally in extracavitary regions. PEL carries a very poor prognosis with a median survival time of <6 months. Indeed, currently used treatment modalities such as CHOP chemotherapy are far from achieving complete and sustainable remission. Therefore, there is no clear standard of care established in the treatment of PEL patients, stressing the need for novel-targeted approaches. Here, we have attempted a comprehensive assessment of the treatment of PEL, discussed avant-garde therapies and updated the state of preclinical research with promising clinical applications in the field. These include inhibitors of viral replication, modulators of cell signaling and inflammation, nuclear factor kappa B (NF-κB) and histone deacetylase inhibitors, and recently the combination of arsenic trioxide and interferon-alpha. Some of these targeted therapies have not yet reached clinical studies, although others were used in a few individual case reports with low numbers of patients. We also describe the first case of a 77-year-old, HIV-negative, HHV8-positive patient diagnosed with PEL limited to the pleural and peritoneal cavities. He received lenalidomide 25 mg/day for 21 days every 28 days. Treatment was well tolerated with no side effects. He rapidly improved after 1 month of treatment and progressively achieved complete remission persistent after 18 months of therapy. We believe that this review will bridge an important gap between classical chemotherapy and modern approaches of targeted therapy. Finally, our findings warrant further evaluation of lenalidomide in future prospective clinical studies.
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Bhojwani D, Sabin ND, Pei D, Yang JJ, Khan RB, Panetta JC, Krull KR, Inaba H, Rubnitz JE, Metzger ML, Howard SC, Ribeiro RC, Cheng C, Reddick WE, Jeha S, Sandlund JT, Evans WE, Pui CH, Relling MV. Methotrexate-induced neurotoxicity and leukoencephalopathy in childhood acute lymphoblastic leukemia. J Clin Oncol 2014; 32:949-59. [PMID: 24550419 DOI: 10.1200/jco.2013.53.0808] [Citation(s) in RCA: 222] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Methotrexate (MTX) can cause significant clinical neurotoxicity and asymptomatic leukoencephalopathy. We sought to identify clinical, pharmacokinetic, and genetic risk factors for these MTX-related toxicities during childhood acute lymphoblastic leukemia (ALL) therapy and provide data on safety of intrathecal and high-dose MTX rechallenge in patients with neurotoxicity. PATIENTS AND METHODS Prospective brain magnetic resonance imaging was performed at four time points for 369 children with ALL treated in a contemporary study that included five courses of high-dose MTX and 13 to 25 doses of triple intrathecal therapy. Logistic regression modeling was used to evaluate clinical and pharmacokinetic factors, and a genome-wide association study (GWAS) was performed to identify germline polymorphisms for their association with neurotoxicities. RESULTS Fourteen patients (3.8%) developed MTX-related clinical neurotoxicity. Of 13 patients rechallenged with intrathecal and/or high-dose MTX, 12 did not experience recurrence of neurotoxicity. Leukoencephalopathy was found in 73 (20.6%) of 355 asymptomatic patients and in all symptomatic patients and persisted in 74% of asymptomatic and 58% of symptomatic patients at the end of therapy. A high 42-hour plasma MTX to leucovorin ratio (measure of MTX exposure) was associated with increased risk of leukoencephalopathy in multivariable analysis (P = .038). GWAS revealed polymorphisms in genes enriched for neurodevelopmental pathways with plausible mechanistic roles in neurotoxicity. CONCLUSION MTX-related clinical neurotoxicity is transient, and most patients can receive subsequent MTX without recurrence of acute or subacute symptoms. All symptomatic patients and one in five asymptomatic patients develop leukoencephalopathy that can persist until the end of therapy. Polymorphisms in genes related to neurogenesis may contribute to susceptibility to MTX-related neurotoxicity.
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Affiliation(s)
- Deepa Bhojwani
- All authors: St Jude Children's Research Hospital; and Deepa Bhojwani, Jun J. Yang, Hiroto Inaba, Jeffrey E. Rubnitz, Monika L. Metzger, Scott C. Howard, Raul C. Ribeiro, Sima Jeha, John T. Sandlund, and Ching-Hon Pui, University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
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Cohen IJ, Wolff JE. How long can folinic acid rescue be delayed after high-dose methotrexate without toxicity? Pediatr Blood Cancer 2014; 61:7-10. [PMID: 24038885 DOI: 10.1002/pbc.24770] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/20/2013] [Indexed: 11/11/2022]
Abstract
To determine the optimal time of folinic acid rescue after methotrexate (MTX) treatment in patients with ALL, we selected and evaluated relevant studies that included doses, rescue delay, and side effects. Rescue at 42-48 hours resulted in considerable toxicity, except when low doses of MTX were used (1 g/m(2)) or serum MTX levels remained consistently low at 24, 30, and 36 hours. Rescue started at 30-36 hours was safe. In the absence of evidence that later rescue improves prognosis, we suggest that folinic acid rescue (105 mg/m(2)) be started no later than 36 hours from the start of MTX (5-6 g/m(2)).
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Affiliation(s)
- Ian Joseph Cohen
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rueda Arenas E, García Corzo J, Franco Ospina L. Hemiparesia y parálisis facial transitorias causadas por metotrexato. An Pediatr (Barc) 2013; 79:385-9. [DOI: 10.1016/j.anpedi.2013.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/29/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022] Open
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de Broucker T, Leclercq D, Jarquin S, Henry C. Acute leukoencephalopathy due to pyrimethamine. An insight into methotrexate neurotoxicity? J Neurol Sci 2013; 335:201-3. [PMID: 24157308 DOI: 10.1016/j.jns.2013.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 09/22/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
A unique case of pyrimethamine-related stroke-like leukoencephalopathy is described. The imputability of the drug is discussed as well as the similarities with the well-known methotrexate neurotoxicity. Owing to the same mode of action of both drugs by inhibition of the enzyme dihydrofolate reductase, this case is highly suggestive of the pathogenetic role of methylation pathway blockade on myelin synthesis resulting in delayed demyelination. This complication could be avoided by a concurrent folinic acid supplementation.
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Affiliation(s)
- Thomas de Broucker
- Service de Neurologie, Hôpital Delafontaine, 2, rue du Dr Delafontaine, 93200 Saint-Denis, France.
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Hariram J, Jegan Y. Contribution of methotrexate in precipitation of manic episode in bipolar affective disorder explored: a case report. Ther Adv Psychopharmacol 2013; 3:251-4. [PMID: 24167698 PMCID: PMC3805433 DOI: 10.1177/2045125313477103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Bipolar affective disorder is characterized by recurring episodes of mania with or without, but commonly with, episodes of depression. It usually begins in adolescence and can cause enduring and substantial impairment if left untreated. It needs a long-term treatment with mood stabilizers to prevent relapses. Elevated or depressed mood relapses can be either primary or secondary. However, primary mood relapses can occur without a significant precipitating factor, more often tending to occur following stressful life events or discontinuation of mood stabilizer medications. Secondary mood relapses can be caused by many conditions, such as physical illnesses, substance misuse and medications. When a mental illness coexists with another physical illness and the treatment of one complicates the other, it adds complexity to the selection of appropriate pharmacological regime for either condition. In this paper, the authors present a case of bipolar affective disorder who had two episodes of mania likely precipitated by methotrexate, which were reversed by the withdrawal of the offending drug (methotrexate). To the best of the authors' knowledge, to date there have been no published reports in the literature in which methotrexate, an immunosuppressive and a cytotoxic drug, precipitated a manic episode in a patient with bipolar affective disorder.
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Population PK/PD model of homocysteine concentrations after high-dose methotrexate treatment in patients with acute lymphoblastic leukemia. PLoS One 2012; 7:e46015. [PMID: 23049924 PMCID: PMC3457953 DOI: 10.1371/journal.pone.0046015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 08/27/2012] [Indexed: 11/25/2022] Open
Abstract
Elevated homocysteine concentrations have been associated with methotrexate-induced neurotoxicity. Based on methotrexate and homocysteine plasma concentrations of 494 children with acute lymphoblastic leukemia treated with high-dose methotrexate in the TOTAL XV study, a pharmacokinetic/pharmacodynamic (PK/PD) model was built with NONMEM. Several compartment and indirect response models were investigated. The pharmacokinetic disposition of methotrexate was best described by a two-compartment model. Homocysteine concentrations were included by an indirect response model where methotrexate inhibition of the homocysteine elimination rate was described by an Emax model. The homocysteine baseline level was found to be age-dependent. Simulations revealed that folinate rescue therapy does not affect peak concentrations of homocysteine but leads to a modestly reduced homocysteine exposure. In conclusion, our PK/PD model describes the increase of methotrexate-induced HCY concentrations with satisfactory precision and can be applied to assess the effect of folinate regimens on the HCY concentration-time course.
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Vagace JM, de la Maya MD, Caceres-Marzal C, Gonzalez de Murillo S, Gervasini G. Central nervous system chemotoxicity during treatment of pediatric acute lymphoblastic leukemia/lymphoma. Crit Rev Oncol Hematol 2012; 84:274-86. [PMID: 22578745 DOI: 10.1016/j.critrevonc.2012.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 04/02/2012] [Accepted: 04/13/2012] [Indexed: 02/02/2023] Open
Abstract
In the last decades, increasing success rates are being obtained in the chemotherapy of pediatric leukemia and lymphoma. However, the cornerstone of this treatment is still formed by a reduced number of drugs with a highly toxic profile. In particular, central nervous system complications remain a challenging clinical problem, requiring rapid detection and prompt treatment to limit permanent damage. Furthermore, clinicians are often challenged to discriminate between CNS involvement by the disease, toxicity of drugs or infections. This clinically oriented review will help recognize and handle the main neurologic adverse effects induced by chemotherapy in pediatric patients with lymphoblastic leukemia/lymphoma. Different clinical entities and putative drugs involved are discussed in each chapter, with clinical cases illustrating the most relevant and challenging events. In addition, specific clinical-radiological patterns of some of these neurologic events are detailed. Finally, the role of pharmacogenetics, with special focus on those polymorphisms that could help explain the occurrence of neurotoxicity, is also discussed.
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Affiliation(s)
- Jose Manuel Vagace
- Service of Pediatric Hematology, Materno Infantil Hospital, Badajoz, Spain.
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Kamdar KY, Krull KR, El-Zein RA, Brouwers P, Potter BS, Harris LL, Holm S, Dreyer Z, Scaglia F, Etzel CJ, Bondy M, Okcu MF. Folate pathway polymorphisms predict deficits in attention and processing speed after childhood leukemia therapy. Pediatr Blood Cancer 2011; 57:454-60. [PMID: 21618410 PMCID: PMC3134130 DOI: 10.1002/pbc.23162] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 03/23/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neurocognitive impairment occurs in 20-40% of childhood acute lymphoblastic leukemia (ALL) survivors, possibly mediated by folate depletion and homocysteine elevation following methotrexate treatment. We evaluated the relationship between folate pathway polymorphisms and neurocognitive impairment after childhood ALL chemotherapy. PROCEDURE Seventy-two childhood ALL survivors treated with chemotherapy alone underwent a neurocognitive battery consisting of: Trail Making Tests A (TMTA) and B (TMTB), Grooved Pegboard Test Dominant-Hand and Nondominant-Hand, Digit Span subtest, and Verbal Fluency Test. We performed genotyping for: 10-methylenetetrahydrofolate reductase (MTHFR 677C>T and MTHFR 1298A>C), serine hydroxymethyltransferase (SHMT 1420C>T), methionine synthase (MS 2756 A>G), methionine synthase reductase (MTRR 66A>G), and thymidylate synthase (TSER). Student's two sample t-test and analysis of covariance were used to compare test scores by genotype. RESULTS General impairment on the neurocognitive battery was related to MTHFR 1298A>C (P = 0.03) and MS 2756A>G (P = 0.05). Specifically, survivors with MTHFR 1298AC/CC genotypes scored, on average, 13 points lower on TMTB than those with MTHFR 1298AA genotype (P = 0.001). The MS 2756AA genotype was associated with a 12.2 point lower mean TMTA score, compared to MS 2756 AG/GG genotypes (P = 0.01). The TSER 2R/3R and 3R/3R genotypes were associated with an 11.4 point lower mean score on TMTB, compared to the TSER 2R/2R genotype (P = 0.03). Survivors with ≥6 folate pathway risk alleles demonstrated a 9.5 point lower mean TMTA score (P = 0.06) and 14.5 point lower TMTB score (P = 0.002) than survivors with <6 risk alleles. CONCLUSIONS Folate pathway polymorphisms are associated with deficits in attention and processing speed after childhood ALL therapy.
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Affiliation(s)
- Kala Y. Kamdar
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Houston, TX, Childhood Cancer Epidemiology and Prevention Center, Houston, TX
| | - Kevin R. Krull
- Department of Epidemiology & Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Randa A. El-Zein
- Childhood Cancer Epidemiology and Prevention Center, Houston, TX, Department of Epidemiology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Pim Brouwers
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Houston, TX, Division of AIDS Research, NIMH, Rockville, MD
| | - Brian S. Potter
- Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Lynnette L. Harris
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Houston, TX
| | - Suzanne Holm
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Houston, TX
| | - ZoAnn Dreyer
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Houston, TX
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Carol J. Etzel
- Department of Epidemiology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Melissa Bondy
- Childhood Cancer Epidemiology and Prevention Center, Houston, TX, Department of Epidemiology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - M. Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Houston, TX, Childhood Cancer Epidemiology and Prevention Center, Houston, TX
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Aradillas E, Arora R, Gasperino J. Methotrexate-induced posterior reversible encephalopathy syndrome. J Clin Pharm Ther 2010; 36:529-36. [PMID: 21210832 DOI: 10.1111/j.1365-2710.2010.01207.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) is described clinically as an acute neurologic deterioration characterized by headache, change in mental status and seizures. Although the mechanism(s) for this syndrome is not fully understood, PRES results from vasogenic edema in areas of the brain supplied by the posterior circulation. Methotrexate (MTX)-induced neurotoxicity is a well-known complication of therapy in the paediatric population but is uncommon in adults. DETAILS OF THE CASE We describe a 55-year-old woman with an acute presentation of PRES caused by intrathecal MTX given as part of a treatment regimen for diffuse large B-cell type lymphoma. Both clinical symptoms and radiographic abnormalities resolved 5 days after cessation of treatment. WHAT IS NEW AND CONCLUSION We describe what we believe to be the first report of intrathecal MTX-induced PRES in an adult. Clinicians should include MTX-induced PRES in the differential diagnosis of acute neurologic changes in patients receiving this medication. The incidence of MTX-induced neurotoxicity may be under recognized in adults.
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Affiliation(s)
- E Aradillas
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102-1192, USA
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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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Systemic methotrexate induces spatial memory deficits and depletes cerebrospinal fluid folate in rats. Pharmacol Biochem Behav 2010; 94:454-63. [DOI: 10.1016/j.pbb.2009.10.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 10/01/2009] [Accepted: 10/22/2009] [Indexed: 11/20/2022]
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Cohen IJ. Methotrexate-associated alterations of the folate and methyl-transfer pathway in the CSF of ALL patients with and without symptoms of neurotoxicity. Pediatr Blood Cancer 2009; 53:127; author reply 127-8. [PMID: 19340855 DOI: 10.1002/pbc.21990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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