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Hsu WY, Wang LT, Lin PC, Liao YM, Hsu SH, Chiou SS. Deferasirox Causes Leukaemia Cell Death through Nrf2-Induced Ferroptosis. Antioxidants (Basel) 2024; 13:424. [PMID: 38671872 PMCID: PMC11047367 DOI: 10.3390/antiox13040424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/16/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
Acute lymphoblastic leukaemia (ALL) is the most prevalent cancer in children, and excessive iron buildup resulting from blood transfusions and chemotherapy potentially has a negative impact on treatment outcomes and prognosis in patients with ALL. Therefore, initiating early iron chelation therapy during ALL treatment is a logical approach. Ideally, the selected iron chelator should also possess anti-leukaemia properties. The aim of the present study was to explore the potential impact and underlying mechanism of deferasirox (DFX) in ALL therapy. This study proved that DFX, an iron chelator, is capable of inducing leukaemia cell death through ferroptosis, which is achievable by increasing the expression of acetylated nuclear factor erythroid 2-related factor 2 (NRF2). More specifically, NRF2 acetylation on Lys599 was facilitated by acetyltransferase-p300/CBP. These findings indicate that DFX could serve as a potent adjunctive medication for patients with ALL. Moreover, DFX may offer dual benefits in ALL treatment, functioning as both an iron chelator and NRF2-modulating agent. Further research and clinical trials are necessary to fully elucidate the therapeutic potential of DFX in patients with ALL and incorporate it into treatment protocols.
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Affiliation(s)
- Wan-Yi Hsu
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (W.-Y.H.); (P.-C.L.); (Y.-M.L.)
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Li-Ting Wang
- Department of Life Science, National Taiwan Normal University, Taipei 116, Taiwan;
| | - Pei-Chin Lin
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (W.-Y.H.); (P.-C.L.); (Y.-M.L.)
- Department of Pediatrics, School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yu-Mei Liao
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (W.-Y.H.); (P.-C.L.); (Y.-M.L.)
| | - Shih-Hsien Hsu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Center of Applied Genomics, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Research Center for Precision Environmental Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Shyh-Shin Chiou
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (W.-Y.H.); (P.-C.L.); (Y.-M.L.)
- Center of Applied Genomics, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Sawicka-Zukowska M, Kretowska-Grunwald A, Kania A, Topczewska M, Niewinski H, Bany M, Grubczak K, Krawczuk-Rybak M. Iron Overload in Children with Acute Lymphoblastic and Acute Myeloblastic Leukemia-Experience of One Center. Cancers (Basel) 2024; 16:367. [PMID: 38254856 PMCID: PMC10814127 DOI: 10.3390/cancers16020367] [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: 11/15/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Transfusions of packed red blood cells (PRBCs), given due to an oncological disease and its acute complications, are an indispensable part of anticancer therapy. However, they can lead to post-transfusion iron overload. The study aim was to evaluate the role of ferritin as a nonspecific marker of leukemic growth and marker of transfusion-related iron overload. We performed a longitudinal study of PRBC transfusions and changes in ferritin concentrations during the oncological treatment of 135 patients with childhood acute lymphoblastic and acute myeloblastic leukemia (ALL and AML, median age 5.62 years). At the diagnosis, 41% of patients had a ferritin level over 500 ng/mL, and 14% of patients had a ferritin level over 1000 ng/mL. At the cessation of the treatment, 80% of the children had serum ferritin (SF) over 500 ng/mL, and 31% had SF over 1000 ng/mL. There was no significant difference between SF at the beginning of the treatment between ALL and AML patients, but children with AML finished treatment with statistically higher SF. AML patients had also statistically higher number of transfusions. We found statistically significant positive correlations between ferritin and age, and weight and units of transfused blood. Serum ferritin at the moment of diagnosis can be a useful marker of leukemic growth, but high levels of SF are connected with iron overload in both AML and ALL.
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Affiliation(s)
- Malgorzata Sawicka-Zukowska
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Anna Kretowska-Grunwald
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
- Faculty of Computer Science, Bialystok University of Technology, Wiejska 45A, 15-351 Bialystok, Poland;
| | - Agnieszka Kania
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Magdalena Topczewska
- Faculty of Computer Science, Bialystok University of Technology, Wiejska 45A, 15-351 Bialystok, Poland;
| | - Hubert Niewinski
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Marcin Bany
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Kamil Grubczak
- Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Jerzego Waszyngtona 13, 15-269 Bialystok, Poland;
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
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Wang J, Huang P, Lang C, Luo Y, He Z, Chen Y. The progress in the relationship between trace elements and acute lymphoblastic leukemia. Front Cell Dev Biol 2023; 11:1145563. [PMID: 36968204 PMCID: PMC10033596 DOI: 10.3389/fcell.2023.1145563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/28/2023] [Indexed: 03/11/2023] Open
Abstract
Trace elements are very important substances with low content in the human body. If the content of some trace elements changes, they are also related to diseases. Acute lymphoblastic leukemia (ALL) is a malignant blood tumor, and its relationship with trace elements has also been a concern by scholars. Not only have the trace element levels in ALL patients changed, but the efficacy of different treatment methods has also been linked to the corresponding trace element changes. The characteristics of ALL may be related to the dysregulation of differentiation and proliferation of lymphoid precursor cells. Cell proliferation and differentiation are often affected by changes in DNA levels. However, trace elements are involved in DNA damage and repair mechanisms. In recent years, as an increasing number of studies believe that ALL is related to the abnormal metabolism of trace elements in the body, this paper intends to discuss the research progress on the relationship between trace elements and ALL to provide more information on trace elements for the diagnosis, treatment, and prevention of ALL.
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Affiliation(s)
- Jing Wang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Pediatrics, Guizhou Children’s Hospital, Zunyi, China
- Collaborative Innovation Center for Tissue Injury Repair and Regenerative Medicine of Zunyi Medical University, Zunyi, China
| | - Pei Huang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Changhui Lang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yan Luo
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhixu He
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Pediatrics, Guizhou Children’s Hospital, Zunyi, China
- Collaborative Innovation Center for Tissue Injury Repair and Regenerative Medicine of Zunyi Medical University, Zunyi, China
- *Correspondence: Zhixu He, ; Yan Chen,
| | - Yan Chen
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Pediatrics, Guizhou Children’s Hospital, Zunyi, China
- Collaborative Innovation Center for Tissue Injury Repair and Regenerative Medicine of Zunyi Medical University, Zunyi, China
- *Correspondence: Zhixu He, ; Yan Chen,
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Kranjčec I, Matijašić N, Abdović S, Hižar Gašpar I, La Grasta Sabolić L, Jadrijević-Cvrlje F. A challenging case of an adolescent and young adult patient with high-risk acute lymphoblastic leukemia: the need for a multidisciplinary approach: a case report. J Med Case Rep 2022; 16:147. [PMID: 35399095 PMCID: PMC8996482 DOI: 10.1186/s13256-022-03366-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/10/2022] [Indexed: 01/28/2023] Open
Abstract
Abstract
Background
Adolescents and young adults diagnosed with acute lymphoblastic leukemia are treated according to pediatric-based regimens to achieve better results. However, implementation of intensive chemotherapy protocols in this age group is associated with increased treatment-related toxicities, affecting almost every organ and system. In this case, the focus of our interest was on rather rare entities: steroid-induced psychosis that seldom develops in children and adolescents, and choroid plexus hemosiderosis, infrequently identified as a first sign of iron overload.
Case presentation
The aim of this paper is to present a challenging case of a 15-year-old Caucasian male patient treated for high-risk acute lymphoblastic leukemia and who experienced various adverse incidents during intensive chemotherapy, thus necessitating a high-quality multidisciplinary approach. Slow minimal residual disease clearance was an additional concerning issue. Induction and re-induction were complicated by steroid-induced hyperglycemia that required multiple-week insulin. During consolidation, acute kidney injury on the basis of chronic kidney disease was verified, demanding subsequent drug dose modifications. By the end of re-induction, after dexamethasone cessation, infrequent steroid-induced psychosis, presented as incoherent speech, aggressive behavior, and mood swings, required intensive psychiatric support. Neurological evaluation of seizures revealed uncommon choroid plexus hemosiderosis by brain magnetic resonance imaging, warranting appropriate selection of iron chelation therapy in the context of preexisting nephropathy. Ultimately, iron deposits of moderate intensity were verified by liver magnetic resonance imaging, while heart tissue remained intact. The early diagnosis and adequate treatment of aforementioned difficult toxicities resulted in complete recovery of the patient.
Conclusions
Treating adolescents with high-risk acute leukemia and multiple therapy-related morbidities remains a challenge, even in the era of extensive and effective supportive therapy. Superior survival rates might be achieved by prompt recognition of both frequent and rarely encountered adverse episodes, as well as well-timed and appropriate management by a well-coordinated multidisciplinary team.
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Abstract
BACKGROUND Children with leukemia commonly receive red blood cell (RBC) transfusions and transfusion-related iron overload (TRIO) is a major complication. However, few studies have evaluated TRIO in children with leukemia and no guidelines for screening exist. This retrospective, observational cohort study in children with acute leukemia evaluates the prevalence of TRIO and its impact on end-organ function. RESULTS The study included 139 patients; 60% standard-risk acute lymphoblastic leukemia (ALL), 32% high-risk (HR) ALL, and 9% acute myeloid leukemia (AML). The mean age at diagnosis was 6 years (range: 5 mo to 18 y). Patients with HR-ALL and AML were more likely to be transfused with ≥10 RBC units (59% and 92%, respectively) compared with those with standard-risk ALL (18%) (P<0.0001). Ferritin levels were measured in 68% patients and elevated (>1000 mcg/L) in 23%. Endocrinopathies were the most common end-organ abnormality. Hepatic dysfunction was significantly higher in patients with ≥10 RBC units transfused compared with those with <10 units (P=0.008). CONCLUSIONS Although the RBC transfusion burden is highest in patients with AML and HR-ALL, TRIO screening was not commonly performed. Patients who receive ≥10 RBC units are at risk for hepatic and endocrine dysfunction. We recommend routine screening for TRIO in children with leukemia, who are at risk for a higher transfusion burden.
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Affiliation(s)
- Chantel Cacciotti
- Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
- Department of Pediatric Neuro-Oncology, Dana-Farber/Boston Children's Cancer and Blood Center, Boston, MA
| | - Uma Athale
- Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
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Brissot E, Bernard DG, Loréal O, Brissot P, Troadec MB. Too much iron: A masked foe for leukemias. Blood Rev 2020; 39:100617. [DOI: 10.1016/j.blre.2019.100617] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/20/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
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Pattnaik J, Kayal S, Dubashi B, Basu D, Vinod KV, Nandeesha H, Madasamy P, Kumar RCS, Pillai US, Jadhav N. Profile of anemia in acute lymphoblastic leukemia patients on maintenance therapy and the effect of micronutrient supplementation. Support Care Cancer 2019; 28:731-738. [PMID: 31134344 DOI: 10.1007/s00520-019-04862-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 05/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anemia is a common finding and important cause of morbidity in patients with acute lymphoblastic leukemia (ALL) at diagnosis or during the course of its protracted treatment. We studied profile of anemia in ALL patients on maintenance therapy and evaluated specific micronutrients as cause of this anemia. PATIENTS AND METHODS ALL patients who were on maintenance therapy and had grade ≥ 2 anemia were recruited for the study. Serum iron studies, folate, and vitamin B12 were done to identify micronutrient deficiency and to initiate supplementation with specific components if found to be deficient. Toxicities, improvement of anemia, micronutrient levels, and disease outcome were studied after 3 months. RESULTS From March 2015 to September 2016, 105 ALL patients were found to be on maintenance fulfilling the inclusion criteria. Overall, the proportion of anemia was 80%(N = 84). Majority had normocytic normochromic anemia (71%). Macrocytic anemia was seen in 18% and microcytic hypochromic in 9.5%. In patients with anemia of grade ≥ 2 (N = 84), 38 patients (45%) had biochemical deficiency of serum folate, and 7 (8%) had vitamin B12 deficiency. No biochemical evidence of iron deficiency was found. Supplementation of deficient micronutrients improved anemia: mean hemoglobin significantly increased from 8.06 ± 1.63 to 10.78 ± 1.53 (p < 0.001) at 3 months; and reduced treatment toxicities, mean number of febrile neutropenia episodes (p = 0.007), and treatment interruptions of > 2 weeks (p = 0.002) were lowered. Patients with anemia had significantly more relapses (N = 14,64%) compared to patients without anemia (N = 8,36%), (p = 0.040). CONCLUSION Timely identification and correction of micronutrient deficiencies causing anemia in ALL patients on maintenance can enhance treatment outcomes.
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Affiliation(s)
- Jogamaya Pattnaik
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India
| | - Smita Kayal
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India.
| | - Biswajit Dubashi
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India
| | - Debdatta Basu
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - K V Vinod
- Department of Medicine (Haematology), Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - H Nandeesha
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Ponraj Madasamy
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India
| | - Ranjith C S Kumar
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India
| | - Unni S Pillai
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India
| | - Naresh Jadhav
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, 605006, India
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Tayel SI, El-Hefnway SM, Abo El-Fotoh WMM, El-Zayat RS. The Genetic Variants of IKZF1 Gene Linked with the Growing Risk of Childhood Acute Lymphoblastic Leukaemia. Curr Mol Med 2019; 19:32-39. [PMID: 30806315 DOI: 10.2174/1566524019666190219123900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 01/24/2019] [Accepted: 02/11/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The zinc finger protein IKAROS (IKZF1) is an essential transcription factor in haematopoiesis that is involved primarily in lymphoid tissue differentiation. Many studies have indicated that IKZF1 alterations may be associated with acute lymphoblastic leukaemia, but the results remain controversial. OBJECTIVE We aimed to investigate the association of the rs4132601 T/G and rs10272724 T/C IKZF1 gene polymorphisms with the risk of childhood acute lymphoblastic leukaemia and to determine whether these genetic variants affect the clinical parameters and the iron profiles of these children cohort. METHODS This case control study was conducted on 170 Egyptian children comprising of two groups: group (I) included 90 children diagnosed with acute lymphoblastic leukaemia and group (II) comprised of 80 ages and sex-matched healthy control children. The studied polymorphisms were genotyped using PCR restriction fragment length polymorphism (PCR-RFLP). RESULTS A higher frequency of the mutant GG genotype and G allele of rs4132601 was found in the patient group than in the control group. The results also showed a significant difference among the rs10272724 genotypes, with a higher frequency of the mutant CC genotype and C allele in the patients than in controls. The mutant GG genotype of rs4132601 and the mutant CC genotype of rs10272724 were associated with a higher serum ferritin level and transferrin saturation and an older age at diagnosis of acute lymphoblastic leukaemia than the other genotypes. CONCLUSION IKZF1 rs4132601 and rs10272724 could be considered significant risk contributors to childhood acute lymphoblastic leukaemia and may impact the iron profiles in these children.
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Affiliation(s)
- Safaa I Tayel
- Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Menoufia Governorate, Egypt
| | - Sally M El-Hefnway
- Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Menoufia Governorate, Egypt
| | | | - Rania S El-Zayat
- Pediatric Medicine Departments, Faculty of Medicine, Menoufia University, Menoufia Governorate, Egypt
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Simchick G, Liu Z, Nagy T, Xiong M, Zhao Q. Assessment of MR-based R2* and quantitative susceptibility mapping for the quantification of liver iron concentration in a mouse model at 7T. Magn Reson Med 2018; 80:2081-2093. [PMID: 29575047 PMCID: PMC6107404 DOI: 10.1002/mrm.27173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/15/2018] [Accepted: 02/15/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE To assess the feasibility of quantifying liver iron concentration (LIC) using R2* and quantitative susceptibility mapping (QSM) at a high field strength of 7 Tesla (T). METHODS Five different concentrations of Fe-dextran were injected into 12 mice to produce various degrees of liver iron overload. After mice were sacrificed, blood and liver samples were harvested. Ferritin enzyme-linked immunosorbent assay (ELISA) and inductively coupled plasma mass spectrometry were performed to quantify serum ferritin concentration and LIC. Multiecho gradient echo MRI was conducted to estimate R2* and the magnetic susceptibility of each liver sample through complex nonlinear least squares fitting and a morphology enabled dipole inversion method, respectively. RESULTS Average estimates of serum ferritin concentration, LIC, R2*, and susceptibility all show good linear correlations with injected Fe-dextran concentration; however, the standard deviations in the estimates of R2* and susceptibility increase with injected Fe-dextran concentration. Both R2* and susceptibility measurements also show good linear correlations with LIC (R2 = 0.78 and R2 = 0.91, respectively), and a susceptibility-to-LIC conversion factor of 0.829 ppm/(mg/g wet) is derived. CONCLUSION The feasibility of quantifying LIC using MR-based R2* and QSM at a high field strength of 7T is demonstrated. Susceptibility quantification, which is an intrinsic property of tissues and benefits from being field-strength independent, is more robust than R2* quantification in this ex vivo study. A susceptibility-to-LIC conversion factor is presented that agrees relatively well with previously published QSM derived results obtained at 1.5T and 3T.
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Affiliation(s)
- Gregory Simchick
- Physics and Astronomy, University of Georgia, Athens, GA, United States
- Bio-Imaging Research Center, University of Georgia, Athens, GA, United States
| | - Zhi Liu
- Pharmaceutical & Biomedical Sciences, University of Georgia, Athens, GA United States
| | - Tamas Nagy
- Pathology, College of Veterinary Medicine, University of Georgia, Athens, GA United States
| | - May Xiong
- Pharmaceutical & Biomedical Sciences, University of Georgia, Athens, GA United States
| | - Qun Zhao
- Physics and Astronomy, University of Georgia, Athens, GA, United States
- Bio-Imaging Research Center, University of Georgia, Athens, GA, United States
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Tipirneni-Sajja A, Loeffler RB, Krafft AJ, Sajewski AN, Ogg RJ, Hankins JS, Hillenbrand CM. Ultrashort echo time imaging for quantification of hepatic iron overload: Comparison of acquisition and fitting methods via simulations, phantoms, and in vivo data. J Magn Reson Imaging 2018; 49:1475-1488. [PMID: 30358001 DOI: 10.1002/jmri.26325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Current R2*-MRI techniques for measuring hepatic iron content (HIC) use various acquisition types and fitting models. PURPOSE To evaluate the accuracy and precision of R2*-HIC acquisition and fitting methods. STUDY TYPE Signal simulations, phantom study, and prospective in vivo cohort. POPULATION In all, 132 patients (58/74 male/female, mean age 17.7 years). FIELD STRENGTH/SEQUENCE 2D-multiecho gradient-echo (GRE) and ultrashort echo time (UTE) acquisitions at 1.5T. ASSESSMENT Synthetic MR signals were created to mimic published GRE and UTE methods, using different R2* values (25-2000 s-1 ) and signal-to-noise ratios (SNR). Phantoms with varying iron concentrations were scanned at 1.5T. In vivo data were analyzed from 132 patients acquired at 1.5T. R2* was estimated by fitting using three signal models. Accuracy and precision of R2* measurements for UTE acquisition parameters (SNR, echo spacing [ΔTE], maximum echo time [TEmax ]) and fitting methods were compared for simulated, phantom, and in vivo datasets. STATISTICAL TESTS R2* accuracy was determined from the relative error and by linear regression analysis. Precision was evaluated using coefficient of variation (CoV) analysis. RESULTS In simulations, all models had high R2* accuracy (error <5%) and precision (CoV <10%) for all SNRs, shorter ΔTE (≤0.5 msec), and longer TEmax (≥10.1 msec); except the constant offset model overestimated R2* at the lowest SNR. In phantoms and in vivo, all models produced similar R2* values for different SNRs and shorter ΔTEs (slopes: 0.99-1.06, R2 > 0.99, P < 0.001). In all experiments, R2* results degraded for high R2* values with longer ΔTE (≥1 msec). In vivo, shorter and longer TEmax gave similar R2* results (slopes: 1.02-1.06, R2 > 0.99, P < 0.001) for the noise subtraction model for 25≤R2*≤2000 s-1 . However, both quadratic and constant offset models, using shorter TEmax (≤4.7 msec) overestimated R2* and yielded high CoVs up to ∼170% for low R2* (<250 s-1 ). DATA CONCLUSION UTE with TEmax ≥ 10.1 msec and ΔTE ≤ 0.5 msec yields accurate R2* estimates over the entire clinical HIC range. Monoexponential fitting with noise subtraction is the most robust signal model to changes in UTE parameters and achieves the highest R2* accuracy and precision. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1475-1488.
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Affiliation(s)
- Aaryani Tipirneni-Sajja
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Biomedical Engineering, The University of Memphis, Memphis, Tennessee, USA
| | - Ralf B Loeffler
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Axel J Krafft
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Radiology, Medical Physics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andrea N Sajewski
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Robert J Ogg
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Claudia M Hillenbrand
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Moafi A, Ziaie M, Abedi M, Rahgozar S, Reisi N, Nematollahi P, Moafi H. The relationship between iron bone marrow stores and response to treatment in pediatric acute lymphoblastic leukemia. Medicine (Baltimore) 2017; 96:e8511. [PMID: 29095311 PMCID: PMC5682830 DOI: 10.1097/md.0000000000008511] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Iron is an intracellular element whose accumulation in the body is associated with tissue damage. This study examines the effect of iron on pediatric acute lymphoblastic leukemia (ALL) and its "response to treatment." At the end of the first year of treatment, bone marrow iron store (BMIS) was evaluated in children with ALL and the relationship between iron store and minimal residual disease was investigated. Moreover, the 3-year disease-free survival (3-DFS) of patients was determined. Patients' BMIS were compared with that of subjects with normal bone marrow. The study examined 93 children, including 78 Pre-B and 15 T-cell ALL patients. BMIS did not differ between the children with ALL and those with no evidence of cancer. BMIS was increased in 26.6% of patients at the end of the first year of treatment. Drug resistance and BM relapses were more prevalent in cases with high BMIS in both Pre-B and T-cell groups. Bone marrow iron store is not considered a risk factor for childhood ALL. However, high levels of BMIS are associated with poor response to treatment and the risk of relapse. Bone marrow iron store control during treatment can therefore help achieve better outcomes and improve the chances of recovery.
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Affiliation(s)
- Alireza Moafi
- Departmant of Pediatrics, School of Medicine, Isfahan University of Medical Sciences
| | - Mozhdeh Ziaie
- Departmant of Pediatrics, School of Medicine, Isfahan University of Medical Sciences
| | - Marjan Abedi
- Department of Biology, Faculty of Sciences, University of Isfahan
| | - Soheila Rahgozar
- Department of Biology, Faculty of Sciences, University of Isfahan
| | - Nahid Reisi
- Departmant of Pediatrics, School of Medicine, Isfahan University of Medical Sciences
| | - Pardis Nematollahi
- Department of Pathology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hadi Moafi
- Department of Medicine, School of Medicine, University of Pécs, Pécs, Hungary
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Tipirneni-Sajja A, Song R, McCarville MB, Loeffler RB, Hankins JS, Hillenbrand CM. Automated vessel exclusion technique for quantitative assessment of hepatic iron overload by R2*-MRI. J Magn Reson Imaging 2017; 47:1542-1551. [PMID: 29083524 DOI: 10.1002/jmri.25880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 10/07/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Extraction of liver parenchyma is an important step in the evaluation of R2*-based hepatic iron content (HIC). Traditionally, this is performed by radiologists via whole-liver contouring and T2*-thresholding to exclude hepatic vessels. However, the vessel exclusion process is iterative, time-consuming, and susceptible to interreviewer variability. PURPOSE To implement and evaluate an automatic hepatic vessel exclusion and parenchyma extraction technique for accurate assessment of R2*-based HIC. STUDY TYPE Retrospective analysis of clinical data. SUBJECTS Data from 511 MRI exams performed on 257 patients were analyzed. FIELD STRENGTH/SEQUENCE All patients were scanned on a 1.5T scanner using a multiecho gradient echo sequence for clinical monitoring of HIC. ASSESSMENT An automated method based on a multiscale vessel enhancement filter was investigated for three input data types-contrast-optimized composite image, T2* map, and R2* map-to segment blood vessels and extract liver tissue for R2*-based HIC assessment. Segmentation and R2* results obtained using this automated technique were compared with those from a reference T2*-thresholding technique performed by a radiologist. STATISTICAL TESTS The Dice similarity coefficient was used to compare the segmentation results between the extracted parenchymas, and linear regression and Bland-Altman analyses were performed to compare the R2* results, obtained with the automated and reference techniques. RESULTS Mean liver R2* values estimated from all three filter-based methods showed excellent agreement with the reference method (slopes 1.04-1.05, R2 > 0.99, P < 0.001). Parenchyma areas extracted using the reference and automated methods had an average overlap area of 87-88%. The T2*-thresholding technique included small vessels and pixels at the vessel/tissue boundaries as parenchymal area, potentially causing a small bias (<5%) in R2* values compared to the automated method. DATA CONCLUSION The excellent agreement between reference and automated hepatic vessel segmentation methods confirms the accuracy and robustness of the proposed method. This automated approach might improve the radiologist's workflow by reducing the interpretation time and operator dependence for assessing HIC, an important clinical parameter that guides iron overload management. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1542-1551.
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Affiliation(s)
- Aaryani Tipirneni-Sajja
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee, USA
| | - Ruitian Song
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - M Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ralf B Loeffler
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Claudia M Hillenbrand
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Radial Ultrashort TE Imaging Removes the Need for Breath-Holding in Hepatic Iron Overload Quantification by R2* MRI. AJR Am J Roentgenol 2017; 209:187-194. [PMID: 28504544 DOI: 10.2214/ajr.16.17183] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate radial free-breathing (FB) multiecho ultrashort TE (UTE) imaging as an alternative to Cartesian FB multiecho gradient-recalled echo (GRE) imaging for quantitative assessment of hepatic iron content (HIC) in sedated patients and subjects unable to perform breath-hold (BH) maneuvers. MATERIALS AND METHODS FB multiecho GRE imaging and FB multiecho UTE imaging were conducted for 46 test group patients with iron overload who could not complete BH maneuvers (38 patients were sedated, and eight were not sedated) and 16 control patients who could complete BH maneuvers. Control patients also underwent standard BH multiecho GRE imaging. Quantitative R2* maps were calculated, and mean liver R2* values and coefficients of variation (CVs) for different acquisitions and patient groups were compared using statistical analysis. RESULTS FB multiecho GRE images displayed motion artifacts and significantly lower R2* values, compared with standard BH multiecho GRE images and FB multiecho UTE images in the control cohort and FB multiecho UTE images in the test cohort. In contrast, FB multiecho UTE images produced artifact-free R2* maps, and mean R2* values were not significantly different from those measured by BH multiecho GRE imaging. Motion artifacts on FB multiecho GRE images resulted in an R2* CV that was approximately twofold higher than the R2* CV from BH multiecho GRE imaging and FB multiecho UTE imaging. The R2* CV was relatively constant over the range of R2* values for FB multiecho UTE, but it increased with increases in R2* for FB multiecho GRE imaging, reflecting that motion artifacts had a stronger impact on R2* estimation with increasing iron burden. CONCLUSION FB multiecho UTE imaging was less motion sensitive because of radial sampling, produced excellent image quality, and yielded accurate R2* estimates within the same acquisition time used for multiaveraged FB multiecho GRE imaging. Thus, FB multiecho UTE imaging is a viable alternative for accurate HIC assessment in sedated children and patients who cannot complete BH maneuvers.
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Brierley CK, Revuelta Iniesta R, Storrar N, Thomas AE. Hyperferritinemia in Pediatric Acute Lymphoblastic Leukemia: What Does it Mean? J Pediatr Hematol Oncol 2017; 39:238. [PMID: 27879547 DOI: 10.1097/mph.0000000000000712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Charlotte K Brierley
- *Department of Paediatric Haematology Royal Hospital for Sick Children †Department of Child Life and Health University of Edinburgh ‡Queen Margaret University, Musselburgh §Department of Haematology, Western General Hospital, Edinburgh, UK
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Rompola M. QUESTION 1: Are paediatric oncology patients at risk of transfusional iron overload? Arch Dis Child 2016; 101:586-590. [PMID: 27102759 DOI: 10.1136/archdischild-2016-310836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/01/2016] [Indexed: 01/19/2023]
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17
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Al-Darwish M, Farhan N, Al-Jebreen A, Allam R, Al-Ahmari A, Seraihy A, Al-Sweedan S, El-Solh H, Belgaumi AF. The contribution of multiple packed red blood cell transfusions toward cardiac and liver dysfunction in pediatric patients with acute myeloid leukemia. Leuk Lymphoma 2016; 57:2472-5. [PMID: 26916606 DOI: 10.3109/10428194.2016.1151509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mohammed Al-Darwish
- a Department of Pediatric Hematology/Oncology King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Neameh Farhan
- c Division of Nursing , King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Abdullah Al-Jebreen
- b Department of Radiology and the King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Reem Allam
- b Department of Radiology and the King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Ali Al-Ahmari
- a Department of Pediatric Hematology/Oncology King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Amal Seraihy
- a Department of Pediatric Hematology/Oncology King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Suleiman Al-Sweedan
- a Department of Pediatric Hematology/Oncology King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Hassan El-Solh
- a Department of Pediatric Hematology/Oncology King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia ;,d College of Medicine, AlFaisal University , Riyadh , Saudi Arabia
| | - Asim F Belgaumi
- a Department of Pediatric Hematology/Oncology King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia ;,e Sidra Medical and Research Center , Doha , Qatar
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Reitman AJ, Coates TD, Freyer DR. Early Cardiac Iron Overload in a Child on Treatment of Acute Lymphoblastic Leukemia. Pediatrics 2015; 136:e697-700. [PMID: 26283784 PMCID: PMC7514881 DOI: 10.1542/peds.2014-3770] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/24/2022] Open
Abstract
An 11-year-old boy with Down syndrome and acute lymphoblastic leukemia developed hepatic dysfunction after only 10 months of treatment. MRI revealed severe iron deposition in the liver, pancreas, and heart. In stark contrast to what is seen in hemoglobinopathies, pancreatic and cardiac iron overload occurred with relatively low transfusion exposure and in a very short time period in this patient. Although extensive experience managing iron overload in hemoglobinopathies informs our approach in other diseases, it is clear that factors not present in hemoglobinopathies may be operative in patients with malignancy undergoing intense chemotherapy that lead to high levels of free iron and rapid loading of the heart and endocrine organs.
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Affiliation(s)
- Aaron J. Reitman
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, California; and
| | - Thomas D. Coates
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, California; and ,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California ,Address correspondence to Thomas D. Coates, MD, Department of Pediatrics, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #64, Los Angeles, CA 90027. E-mail:
| | - David R. Freyer
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, California; and ,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Rascon J, Rageliene L, Stankeviciene S, Palionis D, Tamosiunas AE, Valeviciene N, Zvirblis T. An assessment of iron overload in children treated for cancer and nonmalignant hematologic disorders. Eur J Pediatr 2014; 173:1137-46. [PMID: 24659311 DOI: 10.1007/s00431-014-2295-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/17/2014] [Accepted: 03/03/2014] [Indexed: 01/19/2023]
Abstract
UNLABELLED Our goal was to assess the natural fate of iron overload (IO) following transfusions of packed red blood cells (PRBCs) in children treated for cancer and nonmalignant disorders according to the intensity level of their treatment. Sixty-six children were followed up from February 2010 to March 2013. The transfusion burden was compared between three treatment intensity groups assigned according to the Intensity of Treatment Rating Scale 3.0 (ITR-3). IO was assessed by serial measurements of serum ferritin (SF) (n= 66) and quantification of tissue iron by magnetic resonance imaging (MRI) (n=12). Of the children studied, 36 % (24/66) received moderately intensive treatment (level 2), 21 % (14/ 66) received very intensive treatment (level 3), and 42 % (28/ 66) received the most intensive treatment (level 4). The number of PRBC (p=0.016), the total transfused volume (p= 0.026), and transfused volume adjusted to body weight (p= 0.004) were significantly higher in the level 4 group. By the median follow-up time of 35.5 months (range 8–133), 21– 29 % of patients (including level 2 and level 3 children) had SF >1,000 μg/l 1 year after cessation of transfusions. The slowest decrease of SF was observed in the level 4 group. Initial MRI examination demonstrated either mild or moderate IO in the liver and spleen. Repetitive MRI showed significant improvement in relaxation time between the initial and follow-up MRI performances in the liver (5.9 vs. 8.6 ms, p= 0.03) and the spleen (4.3 vs. 8.8 ms, p=0.03). CONCLUSION IO diminished over time, but in the level 4 patients, it was detectable for years after cessation of transfusions.
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Ruccione KS, Wood JC, Sposto R, Malvar J, Chen C, Freyer DR. Characterization of transfusion-derived iron deposition in childhood cancer survivors. Cancer Epidemiol Biomarkers Prev 2014; 23:1913-9. [PMID: 24962841 DOI: 10.1158/1055-9965.epi-14-0292] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Childhood cancer survivors (CCS) receiving packed red blood cell (PRBC) transfusions may have increased risk for vital organ iron deposition causing serious late effects. METHODS This cross-sectional cohort study of a CCS cohort quantified organ iron content by magnetic resonance imaging. Iron status by serum markers and hemochromatosis gene mutation status were assessed. RESULTS Seventy-five patients who had received a range (0-392 mL/kg) of cumulative PRBC transfusion volumes were enrolled (median age 14 years, range 8-25.6 years at evaluation). Median follow-up time was 4.4 years, and median time since last transfusion was 4.9 years. Cancer diagnoses included acute lymphoblastic or myelogenous leukemia (ALL/AML; n = 33) and solid tumors (n = 42). Liver and pancreatic iron concentrations were elevated in 36 of 73 (49.3%) and 19 of 72 (26.4%) subjects, respectively. Cardiac iron concentration was not increased in this cohort. In multivariate analysis, cumulative PRBC volume (P < 0.0001) and older age at diagnosis (P < 0.0001) predicted elevated liver iron concentration. CONCLUSIONS Iron overload (IO) may occur in children and adolescents/young adults treated for cancer and is associated with cumulative PRBC transfusion volume and age at diagnosis. IMPACT These findings have implications for development of monitoring and management guidelines for cancer patients and survivors at risk for IO, exploration of the additive risk of liver/pancreatic damage from chemotherapeutic exposures, and health education to minimize further liver/pancreatic damage from exposures such as excessive alcohol intake and hepatotoxic medications.
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Affiliation(s)
| | - John C Wood
- Pediatric Cardiology and Radiology. Departments of Pediatrics and Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | - Jemily Malvar
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles. Divisions of
| | - Cheng Chen
- Keck School of Medicine of the University of Southern California, Los Angeles, California
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de Ville de Goyet M, Moniotte S, Robert A, Dupont S, Vermylen C, Veyckemans F, Brichard B. Iron overload in children undergoing cancer treatments. Pediatr Blood Cancer 2013; 60:1982-7. [PMID: 23897631 DOI: 10.1002/pbc.24705] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/04/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Iron overload is responsible for severe morbidity and mortality in polytransfused patients. Although repeated blood transfusions are needed during the treatment of most cancers, pediatric patients are not routinely screened for subsequent iron overload. PROCEDURE Seventy-five patients were identified as candidates for cancer treatment and enrolled prospectively in a yearly protocol including a cardiac and liver magnetic resonance imaging coupled with ferritin level measurements. Patients were divided into four groups using the intensity of treatment rating (ITR-3). RESULTS Fifty-nine patients reached 1-year of follow-up and liver iron overload was found in up to 66% of them. Such overload correlated with the total volume of red blood cells transfused and persisted at least 2 years after the initiation of therapy. Moderate myocardial overload was also, but less frequently (14%), observed in these patients. CONCLUSIONS Our study demonstrated that severe liver iron overload as well as moderate myocardial iron overload can be found 1 year after cancer treatment and that this overload persists overtime. The patients with higher ITR and those who have received more than a liter of blood red cells per square meter, regardless of their diagnosis or ITR, are at risk of iron overload and should be screened carefully.
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Affiliation(s)
- Maëlle de Ville de Goyet
- Department of Paediatric Haematology and Oncology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
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Amid A, Barrowman N, Vijenthira A, Lesser P, Mandel K, Ramphal R. Risk factors for hyperferritinemia secondary to red blood cell transfusions in pediatric cancer patients. Pediatr Blood Cancer 2013; 60:1671-5. [PMID: 23776184 DOI: 10.1002/pbc.24629] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/17/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transfusion of packed red blood cells is common in pediatric cancer patients who receive chemotherapy. This study was done to identify characteristics of pediatric cancer patients at risk of hyperferritinemia secondary to frequent transfusions. PROCEDURE In this retrospective chart review, all pediatric cancer patients who completed chemotherapy from January 2007 to January 2012 and had an assessment of serum ferritin 6 months after the end of treatment were included. Variables included: age, sex, type of cancer diagnosis, weight and body surface area (BSA) at the time of diagnosis, number of transfusions, total transfused volume (TTV), total transfused volume per body weight (TVPBW), and weight and BSA change from the time of diagnosis to the time of ferritin check. RESULTS Of 109 eligible patients, 85 (78%) received transfusions. Sixteen patients (14.7%) had ferritin levels > 200 µg/L and four (3.7%) had ferritin levels > 1,000 µg/L. Although age, weight and BSA at cancer diagnosis, number of transfusions and TVPBW were correlated with the level of ferritin, independent risk factors were TTV (range 1,961-30,090 ml in patients with hyperferritinemia, P < 0.001) and BSA change from the time of diagnosis to the time of ferritin check (range -0.15 to 0.31 m(2) in patients with hyperferritinemia, P < 0.001). Increase in BSA was correlated with reduction of hyperferritinemia in follow-up ferritin measurements (P = 0.049). CONCLUSIONS In addition to TTV, change in BSA is an independent predictor for the degree and possibly persistence of hyperferritinemia in pediatric cancer patients and should be considered in decisions to initiate interventions.
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Affiliation(s)
- Ali Amid
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.
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Nottage K, Gurney JG, Smeltzer M, Castellanos M, Hudson MM, Hankins JS. Trends in transfusion burden among long-term survivors of childhood hematological malignancies. Leuk Lymphoma 2012; 54:1719-23. [PMID: 23163568 DOI: 10.3109/10428194.2012.750724] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The risk from cumulative erythrocyte transfusions is poorly understood in oncology populations. This analysis among long-term survivors explored variation in transfusional burden over progressive eras of treatment identifying those at risk for iron overload. Transfusion records of 982 survivors of hematological malignancies treated at St. Jude were reviewed. After exclusions, 881 (90%) were assessed for cumulative volume, weight-adjusted volume and transfusion number. Treatment intensity was assigned using the Intensity of Treatment Rating Scale version 3.0 (ITR-3). Hematopoietic stem cell transplant and acute myeloid leukemia survivors had greater transfusional burden than conventional therapy recipients and acute lymphoblastic leukemia survivors, respectively. Survivors of 5-10 years were more likely than survivors of > 10 years to receive ≥ 10 transfusions (odds ratio = 2.0, 95% confidence interval 1.5-2.8). Those with higher ITR-3 scores and more recent decades of treatment had a higher transfusional burden. Comprehensive transfusion histories are useful in identifying those at highest risk for iron overload.
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Affiliation(s)
- Kerri Nottage
- Department of Hematology, St. Jude Children ’ s Research Hospital, Memphis, TN 38105-3678, USA.
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Ruccione KS, Mudambi K, Sposto R, Fridey J, Ghazarossian S, Freyer DR. Association of projected transfusional iron burden with treatment intensity in childhood cancer survivors. Pediatr Blood Cancer 2012; 59:697-702. [PMID: 22190481 DOI: 10.1002/pbc.24046] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 11/18/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Packed red blood cell (PRBC) transfusion is a mainstay in childhood cancer treatment, but has potential for inducing iron overload. The purpose of this study was to determine whether treatment intensity is predictive of projected iron burden resulting from PRBC transfusions among survivors of several forms of childhood cancer. PROCEDURE This retrospective cohort study involved patients treated at Children's Hospital Los Angeles (CHLA) between June 1, 2004 and December 31, 2009. Clinical/demographic data were abstracted from medical records. Treatment Intensity Level was determined for each patient using a published scale. Adjusted cumulative PRBC transfusion volume for each patient (ml/kg) was used to compute the adjusted total iron burden (mg/kg) based upon the average hematocrit of the product. RESULTS Median age of the cohort (n = 214) was 7.9 years (range 0.2-20.2). One hundred and fourteen (53.3%) were male and 129 (60.3%) were Hispanic/Latino. Diagnoses included acute leukemia and six solid tumors, management of which represents a range of cancer treatment intensities. The number of transfusions, transfusion volumes, and projected iron burden were significantly increased and exceeded upper limits of normal among patients with higher treatment intensity. Multivariate analysis found younger age and lower hemoglobin at diagnosis to be associated with greater iron burden after adjusting for treatment intensity. CONCLUSION Greater treatment intensity is associated with need for more PRBC transfusions, and thus increased risk of iron overload among childhood cancer survivors. Iron overload may represent another clinically significant late effect following childhood cancer treatment.
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Affiliation(s)
- Kathleen S Ruccione
- LIFE Cancer Survivorship & Transition Program, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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