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Nuijts MA, Stegeman I, Porro GL, Bennebroek CAM, van Seeters T, Proudlock FA, Schouten-van Meeteren AYN, Imhof SM. Diagnostic accuracy of retinal optical coherence tomography in children with a newly diagnosed brain tumour. Acta Ophthalmol 2023; 101:658-669. [PMID: 36924320 DOI: 10.1111/aos.15650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To estimate the diagnostic accuracy of circumpapillary retinal nerve fibre layer (RNFL) thickness and macular ganglion cell layer-inner plexiform layer (GCL-IPL) thickness measurements to discriminate an abnormal visual function (i.e. abnormal age-based visual acuity and/or visual field defect) in children with a newly diagnosed brain tumour. METHODS This cross-sectional analysis of a prospective longitudinal nationwide cohort study was conducted at four hospitals in the Netherlands, including the national referral centre for paediatric oncology. Patients aged 0-18 years with a newly diagnosed brain tumour and reliable visual acuity and/or visual field examination and optical coherence tomography were included. Diagnostic accuracy was evaluated with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS Of 115 patients included in the study (67 [58.3%] male; median age 10.6 years [range, 0.2-17.8 years]), reliable RNFL thickness and GCL-IPL thickness measurements were available in 92 patients (80.0%) and 84 patients (73.0%), respectively. The sensitivity for detecting an abnormal visual function was 74.5% for average RNFL thickness and 41.7% for average GCL-IPL thickness at a specificity of 44.5% and 82.9%, respectively. The PPV and NPV were 33.0% and 82.6% for the average RNFL thickness and 57.1% and 82.2% for the average GCL-IPL thickness. CONCLUSION An abnormal visual function was discriminated correctly by using the average RNFL thickness in seven out of ten patients and by using the average GCL-IPL thickness in four out of ten patients. The relatively high NPVs signified that patients with normal average RNFL thickness and average GCL-IPL thickness measurements had a relative high certainty of a normal visual function.
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Affiliation(s)
- Myrthe A Nuijts
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Inge Stegeman
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Otorhinolaryngology and Head & Neck Surgery University, University Medical Centre Utrecht, Utrecht, The Netherlands
- Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Giorgio L Porro
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Carlien A M Bennebroek
- Department of Ophthalmology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van Seeters
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | | | - Saskia M Imhof
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Ronsley R, Triscott J, Stanek J, Rassekh SR, Lum A, Cheng S, Goddard K, McConnell D, Strahlendorf C, Singhal A, Finlay JL, Yip S, Dunham C, Hukin J. Outcomes of a radiation sparing approach in medulloblastoma by subgroup in young children: an institutional review. Childs Nerv Syst 2023:10.1007/s00381-023-05918-z. [PMID: 37022464 PMCID: PMC10390609 DOI: 10.1007/s00381-023-05918-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/12/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE To describe disease outcomes including overall survival and relapse patterns by subgroup in young pediatric patients treated for medulloblastoma with a radiation-sparing approach. METHODS Retrospective analysis of clinical outcomes includes treatment, relapse, and salvage therapy and late effects in children treated for medulloblastoma with a radiation-sparing approach at British Columbia Children's Hospital (BCCH) between 2000 and 2020. RESULTS There were 30 patients (median age 2.8 years, 60% male) treated for medulloblastoma with a radiation-sparing approach at BCCH. Subgroups included Sonic Hedgehog (SHH) (n = 14), group 3 (n = 7), group 4 (n = 6), and indeterminate status (n = 3). Three- and 5-year event-free survival (EFS) were 49.0% (30.2-65.4%) and 42.0% (24.2-58.9%) and overall survival (OS) 66.0% (95% CI 46.0-80.1%) and 62.5% (95% CI 42.5 and 77.2%), respectively, with a median follow-up of 9.5 years. Relapse occurred in 12/25 patients following a complete response, of whom six (group 4: n = 4; group 3: n = 1; unknown: n = 1) were successfully salvaged with craniospinal axis (CSA) RT and remain alive at a median follow-up of 7 years. Disease/treatment-related morbidity included endocrinopathies (n = 8), hearing loss n = 16), and neurocognitive abnormalities (n = 9). CONCLUSIONS This radiation sparing treatment approach for young patients with medulloblastoma resulted in a durable cure in most patients with SHH subgroup medulloblastoma. In those patients with groups 3 and 4 medulloblastoma, relapse rates were high; however, most group 4 patients were salvaged with RT.
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Affiliation(s)
- Rebecca Ronsley
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street B318, Vancouver, BC V6H 3V4, Canada
| | - Joanna Triscott
- Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Joseph Stanek
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
| | - S Rod Rassekh
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street B318, Vancouver, BC V6H 3V4, Canada
| | - Amy Lum
- Department of Pathology, Vancouver General Hospital, Vancouver, Canada
| | - Sylvia Cheng
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street B318, Vancouver, BC V6H 3V4, Canada
| | - Karen Goddard
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, Canada
| | - Dina McConnell
- Department of Psychology, British Columbia Children's Hospital, Vancouver, Canada
| | - Caron Strahlendorf
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street B318, Vancouver, BC V6H 3V4, Canada
| | - Ash Singhal
- Division of Pediatric Neurosurgery, Department of Surgery, British Columbia Children's Hospital, Vancouver, Canada
| | - Jonathan L Finlay
- Departments of Pediatrics and Radiation Oncology, the Ohio State University College of Medicine, Columbus, OH, USA
| | - Stephen Yip
- Department of Pathology, Vancouver General Hospital, Vancouver, Canada
| | - Christopher Dunham
- Department of Pathology, British Columbia Children's Hospital, Vancouver, Canada
| | - Juliette Hukin
- Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street B318, Vancouver, BC V6H 3V4, Canada.
- Division of Neurology and Division of Hematology Oncology Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, Canada.
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Ioakeim-Ioannidou M, Giantsoudi D, Niemierko A, Sethi R, Kim DW, Yock TI, Tarbell NJ, Simeone FJ, MacDonald SM. Effects of Proton Craniospinal Radiation on Vertebral Body Growth Retardation in Children. Int J Radiat Oncol Biol Phys 2023; 115:572-580. [PMID: 36055432 DOI: 10.1016/j.ijrobp.2022.08.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 07/22/2022] [Accepted: 08/22/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE It is of great interest to physicians and patients/patients' families to be able to predict the amount of growth decrement after craniospinal irradiation (CSI). Little data exist on the effect of proton CSI. Our aim was to determine the effect of proton CSI on vertebral body (VB) growth retardation, and to identify factors associated with growth delay. METHODS AND MATERIALS We performed a retrospective outcome data analysis of 80 patients <16 years old with central nervous system tumors who received proton radiation therapy (PRT) at the Massachusetts General Hospital between 2002 and 2010 with available spinal magnetic resonance imaging. Forty-eight patients received CSI, and 32 patients with brain tumors who received focal cranial irradiation served as controls. VB height was measured midline using sagittal T1-weighted contrast or noncontrast enhanced magnetic resonance imaging of the spine. Measurements were repeated at multiple levels (C3, C3-C4, T4, T4-T5, C3-T6, T4-T7, L3, L1-L5) on available scans for the duration of follow-up. Data were fitted using a mixed-effects multivariable regression model, including follow-up time, CSI dose, age at CSI, and pretreatment VB percentile as parameters. RESULTS Median follow-up was 69.6 months for patients treated with proton CSI and 52.9 months for the control group. There was a significant association of CSI dose, follow-up time, age at treatment, and pretreatment VB percentile with VB growth retardation. Growth retardation was shown to be independent of gender or growth hormone deficiency. CONCLUSIONS Although the current practice of PRT CSI delivery allows for sparing of the organs anterior to the spine, the vertebral column receives radiation therapy because of its close proximity to the targeted spinal canal. In growing children, the whole VB has generally been included so that growth impairment is even across the VB. We present a quantitative model predicting the growth retardation of patients treated with PRT CSI based on age at treatment, CSI dose, follow-up time, and pretreatment growth percentile.
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Affiliation(s)
- Myrsini Ioakeim-Ioannidou
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Drosoula Giantsoudi
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrzej Niemierko
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Roshan Sethi
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel W Kim
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy J Tarbell
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - F Joseph Simeone
- Departments of Diagnostic Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Nuijts MA, Stegeman I, van Seeters T, Borst MD, Bennebroek CAM, Buis DR, Naus NC, Porro GL, van Egmond-Ebbeling MB, Voskuil-Kerkhof ESM, Pott JR, Franke NE, de Vos-Kerkhof E, Hoving EW, Schouten-van Meeteren AYN, Imhof SM. Ophthalmological Findings in Youths With a Newly Diagnosed Brain Tumor. JAMA Ophthalmol 2022; 140:982-993. [PMID: 36107418 PMCID: PMC9478881 DOI: 10.1001/jamaophthalmol.2022.3628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/26/2022] [Indexed: 08/15/2023]
Abstract
Importance Visual impairment is an irreversible adverse effect in individuals who experienced a childhood brain tumor. Ophthalmological evaluation at diagnosis enables early detection of vision loss, decision-making about treatment, and when applicable, the timely use of visual interventions. However, awareness of visual impairment in clinical practice is suboptimal, and adherence to ophthalmological evaluation needs to be improved. Objective To assess the prevalence and types of abnormal ophthalmological findings in youths with a newly diagnosed brain tumor. Design, Setting, and Participants In this nationwide, prospective cohort study, youths aged 0 to 18 years with a newly diagnosed brain tumor between May 15, 2019, and August 11, 2021, were consecutively enrolled in 4 hospitals in the Netherlands, including the dedicated tertiary referral center for pediatric oncology care. Exposures A standardized and comprehensive ophthalmological examination, including orthoptic evaluation, visual acuity testing, visual field examination, and ophthalmoscopy, was performed within 4 weeks from brain tumor diagnosis. Main Outcomes and Measures The main outcomes were prevalence and types of visual symptoms and abnormal ophthalmological findings at brain tumor diagnosis. Results Of 170 youths included in the study (96 [56.5%] male; median age, 8.3 years [range, 0.2-17.8 years]), 82 (48.2%) had infratentorial tumors; 53 (31.2%), supratentorial midline tumors; and 35 (20.6%), cerebral hemisphere tumors. A total of 161 patients (94.7%) underwent orthoptic evaluation (67 [41.6%] preoperatively; 94 [58.4%] postoperatively); 152 (89.4%), visual acuity testing (63 [41.4%] preoperatively; 89 [58.6%] postoperatively); 121 (71.2%), visual field examination (49 [40.4%] preoperatively; 72 [59.6%] postoperatively); and 164 (96.5%), ophthalmoscopy (82 [50.0%] preoperatively; 82 [50.0%] postoperatively). Overall, 101 youths (59.4%) presented with visual symptoms at diagnosis. Abnormal findings were found in 134 patients (78.8%) during ophthalmological examination. The most common abnormal findings were papilledema in 86 of 164 patients (52.4%) who underwent ophthalmoscopy, gaze deficits in 54 of 161 (33.5%) who underwent orthoptic evaluation, visual field defects in 32 of 114 (28.1%) with reliable visual field examination, nystagmus in 40 (24.8%) and strabismus in 32 (19.9%) of 161 who underwent orthoptic evaluation, and decreased visual acuity in 13 of 152 (8.6%) with reliable visual acuity testing. Forty-five of 69 youths (65.2%) without visual symptoms at diagnosis had ophthalmological abnormalities on examination. Conclusions and Relevance The results of this study suggest that there is a high prevalence of abnormal ophthalmological findings in youths at brain tumor diagnosis regardless of the presence of visual symptoms. These findings support the need of standardized ophthalmological examination and the awareness of ophthalmologists and referring oncologists, neurologists, and neurosurgeons for ophthalmological abnormalities in this patient group.
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Affiliation(s)
- Myrthe A. Nuijts
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Inge Stegeman
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Otorhinolaryngology and Head & Neck Surgery University, University Medical Center Utrecht, Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
- Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Tom van Seeters
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Marloes D. Borst
- Faculty of Medicine, Utrecht University, Utrecht, the Netherlands
| | - Carlien A. M. Bennebroek
- Department of Ophthalmology, location AMC of Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dennis R. Buis
- Department of Pediatric Neurosurgery, location AMC of Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Nicole C. Naus
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Giorgio L. Porro
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - JanWillem R. Pott
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Niels E. Franke
- Department of Neuro-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Evelien de Vos-Kerkhof
- Department of Neuro-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Eelco W. Hoving
- Department of Neuro-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Saskia M. Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
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Gringmuth M, Walther J, Greiser S, Toussaint M, Schwalm B, Kool M, Kortmann RD, Glasow A, Patties I. Enhanced Survival of High-Risk Medulloblastoma-Bearing Mice after Multimodal Treatment with Radiotherapy, Decitabine, and Abacavir. Int J Mol Sci 2022; 23:ijms23073815. [PMID: 35409174 PMCID: PMC8998934 DOI: 10.3390/ijms23073815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 02/04/2023] Open
Abstract
Children with high-risk SHH/TP53-mut and Group 3 medulloblastoma (MB) have a 5-year overall survival of only 40%. Innovative approaches to enhance survival while preventing adverse effects are urgently needed. We investigated an innovative therapy approach combining irradiation (RT), decitabine (DEC), and abacavir (ABC) in a patient-derived orthotopic SHH/TP53-mut and Group 3 MB mouse model. MB-bearing mice were treated with DEC, ABC and RT. Mouse survival, tumor growth (BLI, MRT) tumor histology (H/E), proliferation (Ki-67), and endothelial (CD31) staining were analyzed. Gene expression was examined by microarray and RT-PCR (Ki-67, VEGF, CD31, CD15, CD133, nestin, CD68, IBA). The RT/DEC/ABC therapy inhibited tumor growth and enhanced mouse survival. Ki-67 decreased in SHH/TP53-mut MBs after RT, DEC, RT/ABC, and RT/DEC/ABC therapy. CD31 was higher in SHH/TP53-mut compared to Group 3 MBs and decreased after RT/DEC/ABC. Microarray analyses showed a therapy-induced downregulation of cell cycle genes. By RT-PCR, no therapy-induced effect on stem cell fraction or immune cell invasion/activation could be shown. We showed for the first time that RT/DEC/ABC therapy improves survival of orthotopic SHH/TP53-mut and Group 3 MB-bearing mice without inducing adverse effects suggesting the potential for an adjuvant application of this multimodal therapy approach in the human clinic.
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Affiliation(s)
- Marieke Gringmuth
- Department of Radiation Oncology, University of Leipzig, Stephanstraße 9a, 04103 Leipzig, Germany; (M.G.); (R.-D.K.); (A.G.)
| | - Jenny Walther
- Fraunhofer Center for Microelectronic and Optical Systems for Biomedicine, Herman-Hollerith-Straße 3, 99099 Erfurt, Germany; (J.W.); (S.G.)
- Fraunhofer Institute for Cell Therapy and Immunology, Perlickstraße 1, 04103 Leipzig, Germany
| | - Sebastian Greiser
- Fraunhofer Center for Microelectronic and Optical Systems for Biomedicine, Herman-Hollerith-Straße 3, 99099 Erfurt, Germany; (J.W.); (S.G.)
- Fraunhofer Institute for Cell Therapy and Immunology, Perlickstraße 1, 04103 Leipzig, Germany
| | - Magali Toussaint
- Department of Neuroradiopharmaceuticals, Institute of Radiopharmaceutical Cancer Research Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Research Site Leipzig, Permoserstraße 15, 04318 Leipzig, Germany;
| | - Benjamin Schwalm
- Hopp Children’s Cancer Center (KiTZ), Im Neuenheimer Feld 430, 69120 Heidelberg, Germany; (B.S.); (M.K.)
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Research Consortium (DKTK), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Marcel Kool
- Hopp Children’s Cancer Center (KiTZ), Im Neuenheimer Feld 430, 69120 Heidelberg, Germany; (B.S.); (M.K.)
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Research Consortium (DKTK), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University of Leipzig, Stephanstraße 9a, 04103 Leipzig, Germany; (M.G.); (R.-D.K.); (A.G.)
| | - Annegret Glasow
- Department of Radiation Oncology, University of Leipzig, Stephanstraße 9a, 04103 Leipzig, Germany; (M.G.); (R.-D.K.); (A.G.)
| | - Ina Patties
- Department of Radiation Oncology, University of Leipzig, Stephanstraße 9a, 04103 Leipzig, Germany; (M.G.); (R.-D.K.); (A.G.)
- Correspondence:
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Nuijts MA, Stegeman I, Porro GL, Duvekot JC, van Egmond-Ebbeling MB, van der Linden DCP, Hoving EW, Schouten-van Meeteren AYN, Imhof SM. Ophthalmological Evaluation in Children Presenting With a Primary Brain Tumor. J Neuroophthalmol 2022; 42:e99-e108. [PMID: 34812765 PMCID: PMC8834141 DOI: 10.1097/wno.0000000000001421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children with a brain tumor are prone to develop visual impairment, which to date is often underestimated and unrecognized. Our aim was to assess the prevalence of ophthalmological evaluation and abnormal ophthalmological findings, and investigate whether demographic and tumor-related characteristics are associated with abnormal ophthalmological findings in children presenting with a primary brain tumor. METHODS Medical records of all 90 children diagnosed with a primary brain tumor between June 2018 and May 2019 and treated at the Princess Máxima Center for Pediatric Oncology, a tertiary referral center in the Netherlands, were retrospectively reviewed. Univariate regression analysis was used to investigate associations between demographic, tumor-related and clinical characteristics, and abnormal ophthalmological findings. RESULTS Sixty children (34 male [56.7%]; median [range] age, 9.3 [0-16.9] years) underwent ophthalmological evaluation within 6 weeks before or after diagnosis, 11 children (5 male [45.5%]; median [range] age, 5.7 [0.1-17.2] years) were seen more than 6 weeks before or after diagnosis, and 19 children (7 male [36.8%]; median [range] age, 7.2 [1.9-16.6] years) did not receive ophthalmological evaluation within at least 6 months from diagnosis. A total of 19 children (21.1%) presented with visual symptoms as first sign leading to the diagnosis of a brain tumor. Children who presented with visual symptoms (odds ratio [OR], 22.52; 95% confidence interval [CI], 4.90-103.60) and/or hydrocephalus (OR, 3.60; 95% CI, 1.38-9.36) at diagnosis were more often seen for ophthalmological evaluation. The most common abnormal ophthalmological findings were eye movement disorders (66.0%), papilledema (44.1%), and visual field defects (58.1%). Eye movement disorders occurred more frequently in patients with an infratentorial tumor (OR, 4.71; 95% CI, 1.03-21.65). The risk of papilledema was associated with older age (OR, 1.19; 95% CI, 1.05-1.34), hydrocephalus (OR, 9.63; 95% CI, 2.68-34.61), and infratentorial (OR, 9.11; 95% CI, 1.77-46.78) and supratentorial (OR, 13.13; 95% CI, 1.92-89.52) tumors. CONCLUSIONS In this study, most children with a primary brain tumor underwent ophthalmological evaluation around diagnosis, 21% of the children were not evaluated. The high prevalence of abnormal ophthalmological findings stresses the importance of early standardized ophthalmological evaluation to detect visual impairment and provide timely treatment to potentially prevent permanent visual loss.
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Maciel J, Dias D, Cavaco D, Donato S, Pereira MC, Simões-Pereira J. Growth hormone deficiency and other endocrinopathies after childhood brain tumors: results from a close follow-up in a cohort of 242 patients. J Endocrinol Invest 2021; 44:2367-2374. [PMID: 33683662 DOI: 10.1007/s40618-021-01541-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Brain tumors are the most common solid tumor in children. The prevalence of survivors from these cancers has been increasing, presenting endocrine sequelae in more than 40% of the cases. Our aim was to characterize the endocrinopathies diagnosed in this population, exploring the outcomes of growth hormone treatment. METHODS We have performed a retrospective analysis of the survivors that were followed-up through a close protocol at our endocrine late-effects clinic. RESULTS 242 survivors, followed during 6.4 (0-23.4) years, were considered. The median age at tumor diagnosis was 6.7 (0-18) years and pilocytic astrocytoma was the most frequent neoplasm (33.5%). The prevalence of endocrinopathies was of 71.5%, with growth hormone deficiency being the most frequent (52.9%). An indirect correlation between the age at the beginning of somatropin and growth velocity in the first year of treatment was observed. Those treated with craniospinal radiotherapy presented a smaller final upper/lower segments ratio comparing with those that only received cranial radiotherapy. However, their final height was not compromised when compared to their family height target. We found pubertal delay in 12%; accelerated/precocious puberty in 13.2%; central and primary hypogonadism in 21.9% and 3.3%, respectively; primary and central hypothyroidism in 23.6% and 14.5%, respectively; thyroid nodules in 7.4%; ACTH deficiency in 10.3% and diabetes insipidus in 12%. CONCLUSION This study reveals a higher prevalence of endocrinopathies in brain tumors survivors and explores the influence of craniospinal irradiation in the adult body proportions. It reinforces the importance of routine follow-up among survivors.
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Affiliation(s)
- J Maciel
- Endocrinology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal.
| | - D Dias
- Endocrinology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - D Cavaco
- Endocrinology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - S Donato
- Endocrinology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - M C Pereira
- Endocrinology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - J Simões-Pereira
- Endocrinology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
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8
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Levitch CF, Malkin B, Latella L, Guerry W, Gardner SL, Finlay JL, Sands SA. Long-term neuropsychological outcomes of survivors of young childhood brain tumors treated on the Head Start II protocol. Neurooncol Pract 2021; 8:609-619. [PMID: 34594573 DOI: 10.1093/nop/npab028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background The Head Start treatment protocols have focused on curing young children with brain tumors while avoiding or delaying radiotherapy through using a combination of high-dose, marrow-ablative chemotherapy and autologous hematopoietic cell transplantation (AuHCT). Late effects data from treatment on the Head Start II (HS II) protocol have previously been published for short-term follow-up (STF) at a mean of 39.7 months post-diagnosis. The current study examines long-term follow-up (LTF) outcomes from the same cohort. Methods Eighteen HS II patients diagnosed with malignant brain tumors <10 years of age at diagnosis completed a neurocognitive battery and parents completed psychological questionnaires at a mean of 104.7 months' post-diagnosis. Results There was no significant change in Full Scale IQ at LTF compared to baseline or STF. Similarly, most domains had no significant change from STF, including verbal IQ, performance IQ, academics, receptive language, learning/memory, visual-motor integration, and externalizing behaviors. Internalizing behaviors increased slightly at LTF. Clinically, most domains were within the average range, except for low average mathematics and receptive language. Additionally, performance did not significantly differ by age at diagnosis or time since diagnosis. Of note, children treated with high-dose methotrexate for disseminated disease or atypical teratoid/rhabdoid tumor displayed worse neurocognitive outcomes. Conclusions These results extend prior findings of relative stability in intellectual functioning for a LTF period. Ultimately, this study supports that treatment strategies for avoiding or delaying radiotherapy using high-dose, marrow-ablative chemotherapy and AuHCT may decrease the risk of neurocognitive and social-emotional declines in young pediatric brain tumor survivors.
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Affiliation(s)
- Cara F Levitch
- Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Benjamin Malkin
- Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lauren Latella
- Graduate School of Education, Fordham University, Bronx, New York, USA
| | - Whitney Guerry
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sharon L Gardner
- Department of Pediatrics, NYU Langone Health, New York, New York, USA
| | - Jonathan L Finlay
- Department of Pediatrics and Division of Hematology, Oncology, and Blood & Marrow Transplantation, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Stephen A Sands
- Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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9
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Early signs of metabolic syndrome in pediatric central nervous system tumor survivors after high-dose chemotherapy and autologous stem-cell transplantation and radiation. Childs Nerv Syst 2021; 37:1087-1094. [PMID: 33205297 DOI: 10.1007/s00381-020-04971-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Cancer survivors treated with stem-cell transplant (SCT) and radiation therapy are at a high risk for late effects including the metabolic syndrome. This study reviewed the prevalence of the metabolic syndrome in pediatric central nervous system (CNS) tumor survivors treated with autologous SCT and craniospinal radiation. METHODS A prospective, cross-sectional study in pediatric CNS tumor patients, who underwent a one-time evaluation at least 18 months post-autologous SCT for the presence of components of metabolic syndrome: obesity, hypertension, hyperlipidemia, and abnormal glucose levels. RESULTS Twelve patients were evaluated, and two (16%) met full criteria for the metabolic syndrome. Seven patients (58%) had at least one component of metabolic syndrome: elevated glucose levels in 8% (1/12), obesity 17% (2/12), hypertriglyceridemia 17% (2/12), and reduced HDL cholesterol in 25% (3/12). None had hypertension. Nine patients (75%) demonstrated abnormal fasting lipid profiles with elevated total cholesterol levels, although only 25% (3/12) fulfilled criteria for a diagnosis of dyslipidemia. CONCLUSION Pediatric CNS tumor survivors treated with autologous SCT and craniospinal radiation are at risk for early signs of metabolic syndrome, most commonly hyperlipidemia. Further studies evaluating the progression of these early signs to full criteria for the metabolic syndrome diagnosis are required.
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10
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Dhall G, O'Neil SH, Ji L, Haley K, Whitaker AM, Nelson MD, Gilles F, Gardner SL, Allen JC, Cornelius AS, Pradhan K, Garvin JH, Olshefski RS, Hukin J, Comito M, Goldman S, Atlas MP, Walter AW, Sands S, Sposto R, Finlay JL. Excellent outcome of young children with nodular desmoplastic medulloblastoma treated on "Head Start" III: a multi-institutional, prospective clinical trial. Neuro Oncol 2021; 22:1862-1872. [PMID: 32304218 DOI: 10.1093/neuonc/noaa102] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND "Head Start" III, was a prospective clinical trial using intensive induction followed by myeloablative chemotherapy and autologous hematopoietic cell rescue (AuHCR) to either avoid or reduce the dose/volume of irradiation in young children with medulloblastoma. METHODS Following surgery, patients received 5 cycles of induction followed by myeloablative chemotherapy using carboplatin, thiotepa, and etoposide with AuHCR. Irradiation was reserved for children >6 years old at diagnosis or with residual tumor post-induction. RESULTS Between 2003 and 2009, 92 children <10 years old with medulloblastoma were enrolled. Five-year event-free survival (EFS) and overall survival (OS) rates (±SE) were 46 ± 5% and 62 ± 5% for all patients, 61 ± 8% and 77 ± 7% for localized medulloblastoma, and 35 ± 7% and 52 ± 7% for disseminated patients. Nodular/desmoplastic (ND) medulloblastoma patients had 5-year EFS and OS (±SE) rates of 89 ± 6% and 89 ± 6% compared with 26 ± 6% and 53 ± 7% for classic and 38 ± 13% and 46 ± 14% for large-cell/anaplastic (LCA) medulloblastoma, respectively. In multivariate Cox regression analysis, histology was the only significant independent predictor of EFS after adjusting for stage, extent of resection, regimen, age, and sex (P <0.0001). Five-year irradiation-free EFS was 78 ± 8% for ND and 21 ± 5% for classic/LCA medulloblastoma patients. Myelosuppression was the most common toxicity, with 2 toxic deaths. Twenty-four survivors completed neurocognitive evaluation at a mean of 4.9 years post-diagnosis. IQ and memory scores were within average range overall, whereas processing speed and adaptive functioning were low-average. CONCLUSION We report excellent survival and preservation of mean IQ and memory for young children with ND medulloblastoma using high-dose chemotherapy, with most patients surviving without irradiation.
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Affiliation(s)
- Girish Dhall
- Division of Pediatric Hematology-Oncology, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Sharon H O'Neil
- Division of Neurology and The Saban Research Institute, Children's Hospital Los Angeles (CHLA), Los Angeles, California, USA
| | - Lingyun Ji
- Department of Preventive Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, California, USA
| | - Kelley Haley
- Division of Hematology-Oncology CHLA, Los Angeles, California, USA
| | | | | | - Floyd Gilles
- Department of Pathology CHLA, Los Angeles, California, USA
| | - Sharon L Gardner
- Division of Pediatric Hematology-Oncology, NYU Medical Center, New York, New York, USA
| | - Jeffrey C Allen
- Division of Pediatric Hematology-Oncology, NYU Medical Center, New York, New York, USA
| | - Albert S Cornelius
- Division of Pediatric Hematology-Oncology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Kamnesh Pradhan
- Division of Pediatric Hematology-Oncology, Riley Hospital for Children, Indianapolis, Indiana, USA
| | - James H Garvin
- Division of Pediatric Hematology-Oncology, New York Presbyterian Hospital, New York, New York, USA
| | - Randal S Olshefski
- Division of Pediatric Hematology-Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Juliette Hukin
- Division of Pediatric Hematology-Oncology, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Melanie Comito
- Division of Pediatric Hematology-Oncology, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Stewart Goldman
- Division of Pediatric Hematology-Oncology, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Mark P Atlas
- Division of Pediatric Hematology-Oncology, Children's Medical Center of New York, New York, New York, USA
| | - Andrew W Walter
- Division of Pediatric Hematology-Oncology, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Stephen Sands
- Departments of Psychiatry and Behavioral Sciences and Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard Sposto
- Division of Hematology-Oncology CHLA, Los Angeles, California, USA
| | - Jonathan L Finlay
- Division of Pediatric Hematology-Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
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11
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Recent Advances in Understanding the Role of Autophagy in Paediatric Brain Tumours. Diagnostics (Basel) 2021; 11:diagnostics11030481. [PMID: 33803216 PMCID: PMC8000899 DOI: 10.3390/diagnostics11030481] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/21/2022] Open
Abstract
Autophagy is a degradative process occurring in eukaryotic cells to maintain homeostasis and cell survival. After stressful conditions including nutrient deprivation, hypoxia or drugs administration, autophagy is induced to counteract pathways that could lead to cell death. In cancer, autophagy plays a paradoxical role, acting both as tumour suppressor—by cleaning cells from damaged organelles and inhibiting inflammation or, alternatively, by promoting genomic stability and tumour adaptive response—or as a pro-survival mechanism to protect cells from stresses such as chemotherapy. Neural-derived paediatric solid tumours represent a variety of childhood cancers with unique anatomical location, cellular origins, and clinical presentation. These tumours are a leading cause of morbidity and mortality among children and new molecular diagnostics and therapies are necessary for longer survival and reduced morbidity. Here, we review advances in our understanding of how autophagy modulation exhibits antitumor properties in experimental models of paediatric brain tumours, i.e., medulloblastoma (MB), ependymoma (EPN), paediatric low-grade and high-grade gliomas (LGGs, HGGs), atypical teratoid/rhabdoid tumours (ATRTs), and retinoblastoma (RB). We also discuss clinical perspectives to consider how targeting autophagy may be relevant in these specific paediatric tumours.
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12
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Liu KX, Ioakeim-Ioannidou M, Susko MS, Rao AD, Yeap BY, Snijders AM, Ladra MM, Vogel J, Zaslowe-Dude C, Marcus KJ, Yock TI, Grassberger C, Braunstein SE, Haas-Kogan DA, Terezakis SA, MacDonald SM. A Multi-institutional Comparative Analysis of Proton and Photon Therapy-Induced Hematologic Toxicity in Patients With Medulloblastoma. Int J Radiat Oncol Biol Phys 2020; 109:726-735. [PMID: 33243479 DOI: 10.1016/j.ijrobp.2020.09.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This multi-institutional retrospective study sought to examine the hematologic effects of craniospinal irradiation (CSI) in pediatric patients with medulloblastoma using proton or photon therapy. METHODS AND MATERIALS Clinical and treatment characteristics were recorded for 97 pediatric patients with medulloblastoma who received CSI without concurrent chemotherapy or with concurrent single-agent vincristine from 2000 to 2017. Groups of 60 and 37 patients underwent treatment with proton-based and photon-based therapy, respectively. Overall survival was determined by Kaplan-Meier curves with log-rank test. Comparisons of blood counts at each timepoint were conducted using multiple t tests with Bonferroni corrections. Univariate and multivariate analyses of time to grade ≥3 hematologic toxicity were performed with Cox regression analyses. RESULTS Median age of patients receiving proton and photon CSI was 7.5 years (range, 3.5-22.7 years) and 9.9 years (range, 3.6-19.5 years), respectively. Most patients had a diagnosis of standard risk medulloblastoma, with 86.7% and 89.2% for the proton and photon cohorts, respectively. Median total dose to involved field or whole posterior fossa was 54.0 Gy/Gy relative biological effectiveness (RBE) and median CSI dose was 23.4 Gy/Gy(RBE) (range, 18-36 Gy/Gy[RBE]) for both cohorts. Counts were significantly higher in the proton cohort compared with the photon cohort in weeks 3 to 6 of radiation therapy (RT). Although white blood cell counts did not differ between the 2 cohorts, patients receiving proton RT had significantly higher lymphocyte counts throughout the RT course. Similar results were observed when excluding patients who received vertebral body sparing proton RT or limiting to those receiving 23.4 Gy. Only photon therapy was associated with decreased time to grade ≥3 hematologic toxicity on univariate and multivariable analyses. No difference in overall survival was observed, and lymphopenia did not predict survival. CONCLUSIONS Patients who receive CSI using proton therapy experience significantly decreased hematologic toxicity compared with those receiving photon therapy.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Myrsini Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew S Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Avani D Rao
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antoine M Snijders
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, California
| | - Matthew M Ladra
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jennifer Vogel
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cierra Zaslowe-Dude
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karen J Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephanie A Terezakis
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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13
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Streefkerk N, Fioole LCE, Beijer JGM, Feijen ELAM, Teepen JC, Winther JF, Ronckers CM, Loonen JJ, van Dulmen-den Broeder E, Skinner R, Hudson MM, Tissing WJE, Korevaar JC, Mulder RL, Kremer LCM. Large variation in assessment and outcome definitions to describe the burden of long-term morbidity in childhood cancer survivors: A systematic review. Pediatr Blood Cancer 2020; 67:e28611. [PMID: 32881287 DOI: 10.1002/pbc.28611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/14/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
We systematically reviewed outcome assessment methods, outcome classification, and severity grading of reported outcomes in studies investigating the burden of physical long-term morbidity in childhood cancer survivors (CCS). A MEDLINE and EMBASE search identified 56 studies reporting on three or more types of health conditions in 5-year CCS, for which information was extracted on outcome types and classification, methods of outcome ascertainment, and severity grading. There was substantial variability in classification and types of health conditions reported and in methods of outcome ascertainment. Only 59% of the included studies applied severity grading, mainly the common terminology criteria of adverse events. This large variation in assessment and definition of the burden of physical long-term morbidity in CCS challenges interpretation, comparison, and pooling data across studies. Global collaboration is needed to standardize assessments and harmonize definitions of long-term physical morbidity and associated outcomes in childhood cancer survivorship research.
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Affiliation(s)
- Nina Streefkerk
- Department of Pediatric Oncology and Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Lisanne C E Fioole
- Department of Pediatric Oncology and Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Josien G M Beijer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Elizabeth Lieke A M Feijen
- Department of Pediatric Oncology and Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jop C Teepen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jeanette F Winther
- Department of Clinical Sciences, Pediatric Oncology and Hematology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Cecile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jaqueline J Loonen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eline van Dulmen-den Broeder
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology/Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rod Skinner
- Department of Paediatric and Adolescent Haematology and Oncology and Children's BMT Unit, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Northern Institute of Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Melissa M Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology/Hematology, Beatrix Children's Hospital/University of Groningen/University Medical Center Groningen, Groningen, The Netherlands
| | - Joke C Korevaar
- Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Renée L Mulder
- Department of Pediatric Oncology and Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leontine C M Kremer
- Department of Pediatric Oncology and Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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14
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The Dutch LATER physical outcomes set for self-reported data in survivors of childhood cancer. J Cancer Surviv 2020; 14:666-676. [PMID: 32363495 PMCID: PMC7473963 DOI: 10.1007/s11764-020-00880-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/25/2020] [Indexed: 12/19/2022]
Abstract
Purposes Studies investigating self-reported long-term morbidity in childhood cancer survivors (CCS) are using heterogeneous outcome definitions, which compromises comparability and include (un)treated asymptomatic and symptomatic outcomes. We generated a Dutch LATER core set of clinically relevant physical outcomes, based on self-reported data. Clinically relevant outcomes were defined as outcomes associated with clinical symptoms or requiring medical treatment. Methods First, we generated a draft outcome set based on existing questionnaires embedded in the Childhood Cancer Survivor Study, British Childhood Cancer Survivor Study, and Dutch LATER study. We added specific outcomes reported by survivors in the Dutch LATER questionnaire. Second, we selected a list of clinical relevant outcomes by agreement among a Dutch LATER experts team. Third, we compared the proposed clinically relevant outcomes to the severity grading of the Common Terminology Criteria for Adverse Events (CTCAE). Results A core set of 74 self-reported long-term clinically relevant physical morbidity outcomes was established. Comparison to the CTCAE showed that 36% of these clinically relevant outcomes were missing in the CTCAE. Implications for Cancer Survivors This proposed core outcome set of clinical relevant outcomes for self-reported data will be used to investigate the self-reported morbidity in the Dutch LATER study. Furthermore, this Dutch LATER outcome set can be used as a starting point for international harmonization for long-term outcomes in survivors of childhood cancer. Electronic supplementary material The online version of this article (10.1007/s11764-020-00880-0) contains supplementary material, which is available to authorized users.
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15
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Cosnarovici MM, Piciu A, Bonci EA, Bădan MI, Bădulescu CI, Stefan AI, Mester A, Cosnarovici R, Larg MI. Post-Treatment Thyroid Diseases in Children with Brain Tumors: A Single-Center Experience at "Prof. Dr. Ion Chiricuță" Institute of Oncology, Cluj-Napoca. Diagnostics (Basel) 2020; 10:diagnostics10030142. [PMID: 32150810 PMCID: PMC7151128 DOI: 10.3390/diagnostics10030142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022] Open
Abstract
Aim of study: The purpose of the study was to evaluate the association of thyroid dysfunction occurring in pediatric patients treated for brain tumors. Patients and methods: A total of 255 patients with brain tumors were treated between 2001 and 2018 at the “Prof. Dr. Ion Chiricuță” Institute of Oncology, Cluj-Napoca. Due to a minimum follow-up of 4 years, we studied 184 out of the 255 patients. The cohort included 69 girls (37.5%) and 109 boys (62.5%), with a median age of 8.4 years. The evaluated tumors included medulloblastomas (47 patients), astrocytomas (44 patients), ependymomas (22 patients), gliomas (20 patients), germ cell tumors (12 patients), primitive neuroectodermal tumors (4 patients), as well as other types of tumors (15 patients); in 20 of the cases, biopsy could not be performed. Results: There was a 60% overall survival rate; among the 120 surviving patients, 11 (9.1%) were diagnosed with iatrogenic thyroid disease. We observed an important number of iatrogenic thyroid disease cases in this group of patients, thus revealing the importance of long-term thyroid function evaluation in all children who finalized their treatment for brain tumors. Through this study, we aimed to provide an accurate image of the methodology of monitoring for thyroid dysfunction in childhood brain tumor survivors. Conclusion: Given the fact that the probability of developing thyroid dysfunction in the pediatric population treated for brain tumors is not rare, we recommend that childhood brain tumor survivors be monitored for iatrogenic thyroid disease, in order to provide early diagnosis and treatment.
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Affiliation(s)
- Maria Margareta Cosnarovici
- Department of Medical Oncology Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Andra Piciu
- Department of Medical Oncology Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Correspondence: ; Tel.: +(40)-744401318
| | - Eduard-Alexandru Bonci
- Department of Surgical Oncology Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Marius-Ioan Bădan
- Department of Anatomy and Pathology Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (M.-I.B.); (C.-I.B.)
| | - Claudiu-Iulian Bădulescu
- Department of Anatomy and Pathology Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (M.-I.B.); (C.-I.B.)
| | - Andreea-Ioana Stefan
- 2nd Pediatric Departament Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Alexandru Mester
- Department of Oral Health Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Rodica Cosnarovici
- Department of Pediatric Oncology “Prof.Dr.IonChiricuță”, Institute of Oncology, 400012 Cluj-Napoca; Romania;
| | - Maria-Iulia Larg
- PhD School Iuliu Hațieganu, University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
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16
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Hidalgo ET, Snuderl M, Orillac C, Kvint S, Serrano J, Wu P, Karajannis MA, Gardner SL. Subgroup-specific outcomes of children with malignant childhood brain tumors treated with an irradiation-sparing protocol. Childs Nerv Syst 2020; 36:133-144. [PMID: 31375903 DOI: 10.1007/s00381-019-04305-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Molecular subgroups of pediatric brain tumors associated with divergent biological, clinical, and prognostic features have been identified. However, data regarding the impact of subgroup affiliation on the outcome of children with malignant brain tumors treated with radiation-sparing protocol is limited. We report long-term clinical outcomes and the molecular subgroups of malignant brain tumors in young children whose first-line treatment was high-dose chemotherapy without irradiation. METHODS Tumor subclassification was performed using the Illumina HumanMethylation450 BeadChip (450k) genome-wide methylation array profiling platform. Clinical information was obtained from chart review. RESULTS Methylation array profiling yielded information on molecular subgroups in 22 children. Median age at surgery was 26 months (range 1-119 months). Among medulloblastomas (MB), all 6 children in the infant sonic hedgehog (SHH) subgroup were long-term survivors, whereas all 4 children in subgroup 3 MB died. There was one long-term survivor in subgroup 4 MB. One out of five children with ependymoma was a long-term survivor (RELPOS). Both children with primitive neuroectodermal tumors died. One child with ATRT TYR and one child with choroid plexus carcinoma were long-term survivors. CONCLUSIONS The efficacy of high-dose chemotherapy radiation-sparing treatment appears to be confined to favorable molecular subgroups of pediatric brain tumors, such as infant SHH MB. Identification of molecular subgroups that benefit from radiation-sparing therapy will aid in the design of prospective, "precision medicine"-driven clinical trials.
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Affiliation(s)
- Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA.
| | - Matija Snuderl
- Department of Pathology, NYU Langone Health, New York, USA
| | - Cordelia Orillac
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
| | - Svetlana Kvint
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
| | | | - Peter Wu
- Department of Pathology, NYU Langone Health, New York, USA
| | - Matthias A Karajannis
- Pediatric Neuro-Oncology, Department of Pediatrics, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
- Pediatric Neuro-Oncology Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA
| | - Sharon L Gardner
- Pediatric Neuro-Oncology, Department of Pediatrics, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
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17
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de Medeiros CB, Moxon-Emre I, Scantlebury N, Malkin D, Ramaswamy V, Decker A, Law N, Kumabe T, Leonard J, Rubin J, Jung S, Kim SK, Gupta N, Weiss W, Faria CC, Vibhakar R, Lafay-Cousin L, Chan J, Kros JM, Janzen L, Taylor MD, Bouffet E, Mabbott DJ. Medulloblastoma has a global impact on health related quality of life: Findings from an international cohort. Cancer Med 2019; 9:447-459. [PMID: 31755223 PMCID: PMC6970040 DOI: 10.1002/cam4.2701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 12/24/2022] Open
Abstract
Background Understanding the global impact of medulloblastoma on health related quality of life (HRQL) is critical to characterizing the broad impact of this disease and realizing the benefits of modern treatments. We evaluated HRQL in an international cohort of pediatric medulloblastoma patients. Methods Seventy‐six patients were selected from 10 sites across North America, Europe, and Asia, who participated in the Medulloblastoma Advanced Genomics International Consortium (MAGIC). The Health Utilities Index (HUI) was administered to patients and/or parents at each site. Responses were used to determine overall HRQL and attributes (ie specific subdomains). The impact of various demographic and medical variables on HRQL was considered—including molecular subgroup. Results The majority of patients reported having moderate or severe overall burden of morbidity for both the HUI2 and HUI3 (HUI2 = 60%; HUI3 = 72.1%) when proxy‐assessed. Self‐care in the HUI2 was rated as higher (ie better outcome) for patients from Western versus Eastern sites, P = .02. Patients with nonmetastatic status had higher values (ie better outcomes) for the HUI3 hearing, HUI3 pain, and HUI2 pain, all P < .05. Patients treated with a gross total resection also had better outcomes for the HUI3 hearing (P = .04). However, those who underwent a gross total resection reported having worse outcomes on the HUI3 vision (P = .02). No differences in HRQL were evident as a function of subgroup. Conclusions By examining an international sample of survivors, we characterized the worldwide impact of medulloblastoma. This is a critical first step in developing global standards for evaluating long‐term outcomes.
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Affiliation(s)
| | - Iska Moxon-Emre
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada.,Pediatric Oncology Group of Ontario, Toronto, ON, Canada
| | - Nadia Scantlebury
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Malkin
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Vijay Ramaswamy
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Alexandra Decker
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
| | - Nicole Law
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
| | | | | | - Josh Rubin
- St. Louis Children's Hospital, St. Louis, MO, USA
| | - Shin Jung
- Chonnam National University, Hwasun-gun, Korea
| | - Seung-Ki Kim
- Seoul National University Hospital, Seoul, Korea
| | - Nalin Gupta
- University of California San Francisco, San Francisco, CA, USA
| | - William Weiss
- University of California San Francisco, San Francisco, CA, USA
| | - Claudia C Faria
- Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | | | - Lucie Lafay-Cousin
- Alberta Children's Hospital, Calgary, AB, Canada.,University of Calgary, Calgary, AB, Canada
| | - Jennifer Chan
- Alberta Children's Hospital, Calgary, AB, Canada.,University of Calgary, Calgary, AB, Canada
| | - Johan M Kros
- Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laura Janzen
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael D Taylor
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, Department of Laboratory Medicine and Pathobiology and Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Eric Bouffet
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Donald J Mabbott
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
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18
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Nuijts MA, Degeling MH, Stegeman I, Schouten-van Meeteren AYN, Imhof SM. Visual impairment in children with a brain tumor: a prospective nationwide multicenter study using standard visual testing and optical coherence tomography (CCISS study). BMC Ophthalmol 2019; 19:220. [PMID: 31706271 PMCID: PMC6842490 DOI: 10.1186/s12886-019-1225-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/23/2019] [Indexed: 01/11/2023] Open
Abstract
Background Children with a brain tumor have a high risk of impaired vision. Up to now, visual acuity measurement, visual field testing and orthoptic testing are the most informative diagnostic investigations for the assessment of visual function. Evaluating vision in children can be challenging given the challenges in cooperation, concentration and age-dependent shifts in visual tests. Since visual loss due to a brain tumor can be progressive and irreversible, we must aim to detect visual impairment as early as possible. Several studies have shown that optical coherence tomography facilitates discovery of nerve fiber damage caused by optic nerve glioma. Consequently, early detection of potential ocular damage will effect treatment decisions and will provide timely referral to visual rehabilitation centers. Methods/design The CCISS study is a prospective, observational, multicenter cohort study in The Netherlands. Patients aged 0–18 years with a newly diagnosed brain tumor are invited for inclusion in this study. Follow-up visits are planned at 6, 12, 18 and 24 months. Primary endpoints are visual acuity, visual field and optical coherence tomography parameters (retinal nerve fiber layer thickness and ganglion cell layer – inner plexiform layer thickness). Secondary endpoints include the course of visual function (measured by visual acuity, visual field and optical coherence tomography at different follow-up visits), course of the disease and types of treatment. Discussion The CCISS study will heighten the awareness of visual impairment in different types of brain tumors in children. This study will show whether optical coherence tomography leads to earlier detection of visual impairment compared to standard ophthalmological testing (i.e. visual acuity, visual field testing) in children with a brain tumor. Furthermore, the systematic approach of ophthalmological follow-up in this study will give us insight in the longitudinal relation between the course of visual function, course of the disease and types of treatment in children with a brain tumor. Trial registration The CCISS study is prospectively registered in the Netherlands Trial Register (NTR) since April 2019. Identifier: NL7697.
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Affiliation(s)
- M A Nuijts
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Room E 03.136, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - M H Degeling
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Stegeman
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - S M Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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Wang H, Zhou J, Yang D, Yi L, Wang X, Ou Y, Yang D, Xu L, Xu M. High expression of the transcriptional coactivator TAZ is associated with a worse prognosis and affects cell proliferation in patients with medulloblastoma. Oncol Lett 2019; 18:5591-5599. [PMID: 31612066 DOI: 10.3892/ol.2019.10851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 04/11/2019] [Indexed: 12/20/2022] Open
Abstract
The transcriptional coactivator tafazzin (TAZ) serves pivotal roles in organ development, tumor initiation and tumor progression. However, to the best of our knowledge, the expression of TAZ and its clinical significance in human medulloblastoma have not been defined. The present study aimed to clarify the clinical and biological significance of TAZ expression in human medulloblastoma. Immunohistochemical staining for TAZ was performed with 72 medulloblastoma and three normal brain tissue samples. A high expression level of TAZ was detected in 65.28% of medulloblastoma tissues, whereas low expression was identified in the normal brain tissues. TAZ expression was significantly associated with medulloblastoma recurrence. However, the expression of TAZ was not associated with sex, age, tumor location, tumor maximal diameter and tumor histology. Furthermore, both the overall survival and tumor-free survival rate of patients with high levels of expression of TAZ were shorter compared with those of patients with tumors expressing low levels of TAZ. In univariate and multivariate Cox regression analyses, TAZ expression was identified as a significant prognostic factor for patients with medulloblastoma. Functionally, downregulation of TAZ inhibited the proliferation and tumor formation of medulloblastoma cells and the expression of cell-cycle associated proteins in Daoy cells. In conclusion, high expression of TAZ may serve as a prognostic marker for patients with medulloblastoma and TAZ may be a potential target for medulloblastoma therapy.
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Affiliation(s)
- Hao Wang
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Ji Zhou
- Department of Neurosurgery, Rocket Force General Hospital, Chinese People's Liberation Army, Beijing 100088, P.R. China
| | - Dong Yang
- Department of Healthy Management, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Liang Yi
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Xuhui Wang
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Yangqing Ou
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Donghong Yang
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Lunshan Xu
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Minhui Xu
- Department of Neurosurgery, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
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20
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AbdelBaki MS, Boué DR, Finlay JL, Kieran MW. Desmoplastic nodular medulloblastoma in young children: a management dilemma. Neuro Oncol 2019; 20:1026-1033. [PMID: 29156007 DOI: 10.1093/neuonc/nox222] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Children with desmoplastic nodular medulloblastoma (DNMB) have excellent survival, leading multiple groups globally to attempt reduction of treatment-related morbidity. In 2013, the Children's Oncology Group began a clinical trial (ACNS1221) eliminating both radiation therapy (RT) and intraventricular methotrexate for children under 3 years of age with localized DNMB, aiming to build upon the excellent outcomes of the German HIT trials. ACNS1221 has recently closed due to increased incidence of recurrences noted at the 2-year interim analysis, raising important questions regarding optimal therapy for DNMB. Methods A review of major clinical trials that included children with DNMB was performed through July 2017. Results One hundred and eighty-eight DNMB patients enrolled on 11 prospective clinical trials were identified. The use of marrow-ablative chemotherapy and autologous hematopoietic cell rescue (AuHCR) or treatment with intraventricular methotrexate has been associated with excellent outcomes. RT was usually required for patients with evidence of disease at the end of therapy. Conclusions The minimal intensity and duration of chemotherapy required to maximally cure children with DNMB without need of RT remains unknown. Further trials are required to better identify a subset of DNMB patients who can be cured without marrow-ablative chemotherapy or intraventricular methotrexate.
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Affiliation(s)
- Mohamed S AbdelBaki
- Division of Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Daniel R Boué
- Department of Pathology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Jonathan L Finlay
- Division of Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Mark W Kieran
- Dana-Farber Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
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21
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Abstract
PURPOSE OF REVIEW To review the recent advances in understanding how primary brain tumors affect vision in children. RECENT FINDINGS Children with primary brain tumors may have vision loss due to involvement of their afferent visual pathways or from papilledema. These vision deficits may go unrecognized until later in life, years after treatment of the primary lesion. Strabismus and cranial nerve palsies may occur as a result of brain tumors. Ophthalmologists can monitor and treat young children at risk for vision loss from amblyopia as a result of effects from their underlying lesion. Advances in imaging techniques have made it possible to quantify damage to the visual pathways with objective tests. SUMMARY Systematic referrals for evaluation by an ophthalmologist should occur early in the course of treatment of primary brain tumors as these evaluations may improve visual outcomes and quality of life.
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22
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Liu Y, Abongwa C, Ashwal S, Deming DD, Winter TW. Referral for Ophthalmology Evaluation and Visual Sequelae in Children With Primary Brain Tumors. JAMA Netw Open 2019; 2:e198273. [PMID: 31373649 PMCID: PMC6681544 DOI: 10.1001/jamanetworkopen.2019.8273] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Visual impairment in children with brain tumors has received limited attention, as most pediatric neuro-oncology clinical trials neither require ophthalmologic evaluation on enrollment nor monitor effects of treatment on visual function during and after treatment. OBJECTIVE To investigate ophthalmology referral patterns for children with primary brain tumors, the prevalence of visual sequelae, and the association between tumor characteristics and vision-related diagnoses. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 141 children with primary brain tumors treated at Loma Linda University Children's Hospital and Eye Institute, a university-based tertiary referral center, between January 2013 and September 2017. Data analysis was completed in March 2019. INTERVENTION Comprehensive ophthalmologic evaluation for children with primary brain tumors. MAIN OUTCOMES AND MEASURES Percentage of patients with ophthalmology evaluation, prevalence of abnormal ophthalmic findings, and their association with tumor characteristics. RESULTS A total of 141 children (73 [52%] male; median [range] age, 7 [0-18] years) with primary brain tumors were enrolled in this study. Seventy-three patients (41 [52%] male; median [range] age, 8 [0-17] years) never had formal ophthalmologic evaluation. Sixty-eight patients (32 [48%] male; median [range] age, 7 [0-18] years) were evaluated by 1 of 4 board-certified, fellowship-trained pediatric and/or neuro-ophthalmologists for any visual impairment over a total of 222 visits. Five-year overall survival for patients who had eye examination was not significantly different from those who did not (mean [SD] survival, 78.3% [6.2%] vs 84.9% [4.7%]). Median (range) time from tumor diagnosis to initial ophthalmologic evaluation was 9 (0-94) months. Only 10 of 68 children (15%) presented with visual symptoms at tumor diagnosis, while 61 of 68 (90%) had abnormal findings on examination, including strabismus (41 [60%]), visual acuity impairment (37 [54%]), amblyopia (26 [38%]), papilledema (24 [35%]), visual field defects (13 [19%]), optic atrophy (12 [18%]), and keratopathy (10 [15%]). Strabismus occurred more frequently in patients with posterior fossa tumors (26 of 68 in posterior fossa vs 15 of 68 in other locations; P = .02). The presence of visual field defects in patients with no visual symptoms was 15% (9 of 58). Radiation was significantly associated with amblyopia (odds ratio, 4.5; 95% CI, 1.2-15.7; P = .02). CONCLUSIONS AND RELEVANCE In this study, more than 50% of children with primary brain tumors were not referred for ophthalmologic evaluation. Although visual symptoms were uncommon, visual impairments occurred more frequently than previously reported. Ophthalmologic evaluation is recommended to identify and manage visual impairment and prevent permanent vision loss in children with brain tumors.
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Affiliation(s)
- Yin Liu
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, California
- Department of Pediatrics and Child Neurology, Loma Linda University Children’s Hospital, Loma Linda, California
| | - Chenue Abongwa
- Department of Pediatrics and Hematology and Oncology, Loma Linda University Children’s Hospital, Loma Linda, California
- Department of Pediatrics and Hematology and Oncology, Children’s Hospital of Orange County, Orange, California
| | - Stephen Ashwal
- Department of Pediatrics and Child Neurology, Loma Linda University Children’s Hospital, Loma Linda, California
| | - Douglas D. Deming
- Department of Pediatrics and Neonatology, Loma Linda University Children’s Hospital, Loma Linda, California
| | - Timothy W. Winter
- Department of Ophthalmology and Neuro-ophthalmology and Pediatric Ophthalmology, Loma Linda University Medical Center, Loma Linda, California
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23
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Elshahoubi A, Khattab E, Halalsheh H, Khaleifeh K, Bouffet E, Amayiri N. Feasibility of high-dose chemotherapy protocols to treat infants with malignant central nervous system tumors: Experience from a middle-income country. Pediatr Blood Cancer 2019; 66:e27464. [PMID: 30251335 DOI: 10.1002/pbc.27464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 08/18/2018] [Accepted: 08/26/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Results of high-dose chemotherapy (HDCT) protocols for the management of malignant central nervous system (CNS) tumors in infants are mostly reported in high-income countries. We evaluated the feasibility and results of such protocols in a middle-income country (Jordan). METHODS A retrospective study of infants' charts with CNS tumors between 2006 and 2015 who were treated according to HeadStart (HS) protocols. Data included patients' demographics, chemotherapy complications, and cost. RESULTS We identified 18 patients with median age 29 months (range, 9-62 months) at diagnosis (12 HS-I and six HS-II). Distribution according to pathology was: atypical teratoid rhabdoid tumors (ATRT) (nine), primitive neuoroectodermal tumors (PNET)/pineoblastoma (five), and medulloblastoma (four). Six patients (33%) had metastatic disease, and 14 (78%) had an incomplete resection. Eleven patients achieved partial or complete remission, two stabilized, and five progressed. Ten patients did not proceed to HDCT due to progression (five), financial reasons (two), failure to collect stem cells (one), and undocumented reasons (two). Seventy-eight chemotherapy cycles were administered (median interval 26 days). Main complications during induction and consolidation were febrile neutropenia (73% and 100%), documented infections (8% and 13%), and mucositis (12% and 88%), respectively. Three patients developed moderate hearing loss. No protocol-related mortality was reported. At the last follow-up, five patients were alive: three with medulloblastoma (19, 29, and 89 months) and two with ATRT (18 and 42 months). Three survivors received focal/craniospinal radiation. The median cost of a complete HS protocol, excluding surgery/radiotherapy, was $103 500 per patient; 39% of the median cost was related to pharmacy expenses. CONCLUSIONS These protocols were manageable in our context of limited health care resources. However, considering the significant costs and the modest survival rate, better selection criteria need to be used to identify patients likely to benefit from this approach.
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Affiliation(s)
- Alya Elshahoubi
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Eman Khattab
- Pediatric Stem Cell Transplantation Unit, King Hussein Cancer Center, Amman, Jordan
| | - Hadeel Halalsheh
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Kawther Khaleifeh
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Eric Bouffet
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Nisreen Amayiri
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
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24
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Benvenga S, Klose M, Vita R, Feldt-Rasmussen U. Less known aspects of central hypothyroidism: Part 1 - Acquired etiologies. J Clin Transl Endocrinol 2018; 14:25-33. [PMID: 30416972 PMCID: PMC6205405 DOI: 10.1016/j.jcte.2018.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/24/2022] Open
Abstract
Central hypothyroidism (CH) is a rare cause of hypothyroidism. CH is frequently overlooked, as its clinical picture is subtle and includes non-specific symptoms; furthermore, if measurement of TSH alone is used to screen for thyroid function, TSH concentrations can be normal or even above the upper normal reference limit. Indeed, certain patients are at risk of developing CH, such as those with a pituitary adenoma or hypophysitis, those who have been treated for a childhood malignancy, have suffered a head trauma, sub-arachnoid hemorrhage or meningitis, and those who are on drugs capable to reduce TSH secretion.
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Key Words
- ADH, antidiuretic hormone
- AT/RT, atypical teratoid/rhabdoid tumor
- CH, central hypothyroidism
- CNS, central nervous system
- CPI, conformal primary-site irradiation
- CRI, cranial irradiation
- Central hypothyroidism
- Congenital hypothyroidism
- DDMS, Dyke-Davidoff-Masson syndrome
- FSH, follicle-stimulating hormone
- FT3, free triiodothyronine
- FT4, free thyroxine
- GCT, germ cell tumor
- GH, growth hormone
- Hypopituitarism
- IGF-1, insulin growth factor-1
- LH, luteinizing hormone
- MB, medulloblastoma
- PD-1, programmed cell death-1 receptor
- PNET, primitive neuroectodermal tumor
- PRL, prolactin
- SAH, subarachnoid hemorrhage
- TBI, traumatic brain injury
- TRH, TSH-releasing hormone
- TSH, thyrotropin
- Thyrotropin deficiency
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Affiliation(s)
- Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital Policlinico G. Martino, Messina, Italy
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark
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25
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Feldt-Rasmussen U, Klose M, Benvenga S. Interactions between hypothalamic pituitary thyroid axis and other pituitary dysfunctions. Endocrine 2018; 62:519-527. [PMID: 30191443 DOI: 10.1007/s12020-018-1738-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 08/23/2018] [Indexed: 12/16/2022]
Abstract
Central hypothyroidism is defined as low circulating free thyroxine (free T4) with inappropriately low circulating thyrotropin (TSH), in context of a hypothalamic pituitary pathology. Rare cases of idiopathic central hypothyroidism caused by a functional defect may occur, and the condition is often overlooked due to difficulty in achieving the correct diagnosis, sparse symptomatology of the condition and a high risk of misinterpretion of the biochemical changes in central hypothyroidism. Central hypothyroidism is mainly seen in patients with hypothalamic-pituitary pathology due to one of many possible aetiologies, where other hormone deficiencies often co-exist, and both the presence of other deficiencies and their replacement have a strong influence on the measurement of the thyroid-related hormones and thereby interpretation of the thyroid function variables in relation to the clinical impact of thyroid hormone substitution therapy. Conversely, lack of thyroid hormone has a similar strong influence on the interpretation of other pituitary hormone axes, as well as their replacement. Undertreating patients with central hypothyroidism may have serious metabolic consequences with a potentially increased risk of cardiovascular morbidity. The present review thus aims at describing central hypothyroidism, by an overview of interactions of hypothyroidism with other pituitary hormones, diagnosing/testing for central hypothyroidism, and focusing on consequences of undertreatment. Finally, it is mentioned how to deal with new diagnostic settings with lower a priori likelihood of hypopituitarism, particularly in view of the importance of stringent diagnostic testing in order to avoid overdiagnosing central hypothyroidism.
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Affiliation(s)
- Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark.
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University hospital Policlinico G. Martino, Messina, Italy
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26
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Bernier V, Klein O. Late effects of craniospinal irradiation for medulloblastomas in paediatric patients. Neurochirurgie 2018; 67:83-86. [PMID: 30149928 DOI: 10.1016/j.neuchi.2018.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/20/2017] [Accepted: 01/27/2018] [Indexed: 01/18/2023]
Abstract
Along with surgery, radiation therapy (RT) remains an essential option to cure patients suffering from medulloblastoma. However, its long-term adverse effects, particularly due to craniospinal irradiation (CSI), which is necessary to eradicate microscopic spread, are a limiting factor. The most frequent sequelae involve neurocognitive and endocrine impairment, which occurs in nearly all patients. Recent progress achieved through genetic and molecular biology offers the possibility to better stratify patients according to risk factors such as age, post-resection tumour residue and metastasis. Thus, new therapeutic studies assess the possibility to reduce radiation dose and/or radiation field size for patients with the most favourable prognosis. New radiotherapy techniques are also used such as Intensity-Modulated Radiotherapy (IMRT), tomotherapy and proton therapy, which aim at reducing the dose delivered to normal tissue. Conventional photon-based therapy has a relatively high exit dose in contrast with proton therapy which causes less damage to surrounding healthy tissue. It is noteworthy that each technique requires a long follow-up in order to prove that late effects could be reduced without compromising survival rates. Dosimetric comparison theoretically suggests that proton therapy may be the superior method for CSI in terms of late effects, but further research is needed to firmly establish this. Whatever the technique used, the great complexity of CSI requires discipline and expertise along with an external quality control online before the first RT session.
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Affiliation(s)
- V Bernier
- Département de radiothérapie, Institut de cancérologie de Lorraine, 54500 Vandœuvre-les-Nancy, France
| | - O Klein
- Service de neurochirurgie et chirurgie de la face pédiatrique, hôpital d'Enfants, CHRU de Nancy, université de Lorraine, 4, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
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27
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Wong KK, Ragab O, Tran HN, Pham A, All S, Waxer J, Olch AJ. Acute toxicity of craniospinal irradiation with volumetric-modulated arc therapy in children with solid tumors. Pediatr Blood Cancer 2018; 65:e27050. [PMID: 29630782 DOI: 10.1002/pbc.27050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/30/2018] [Accepted: 02/14/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is an important part of curative radiation therapy (RT) for many types of pediatric brain or solid tumors. After conventional CSI, long term survivors may experience sequelae due to unintended dose to normal tissue. Volumetric modulated arc therapy (VMAT) CSI reduces off-target doses at the cost of greater complexity and error risk, and we describe our initial experience in a group of pediatric patients with solid tumors presenting with disseminated or recurrent disease. PROCEDURE Pediatric patients with brain tumors were identified at Children's Hospital Los Angeles from 2013 to 2015. Clinical characteristics, acute toxicity, and radiotherapy data were abstracted from their medical records. We identified 19 patients who received VMAT CSI. Quality assurance was performed with a cylindrical detector array and ion chamber measurements at the arc junctions. RESULTS Patients had medulloblastoma or supratentorial primitive neuro-ectodermal tumor (n = 14, 11 high risk), germ cell tumors (two), relapsed neuroblastoma (two), and atypical teratoid/rhabdoid tumor (one). The most common acute toxicity was hematologic, including leukopenia (11% grade [Gr] 2, 26% Gr 3, and 63% Gr 4), anemia (89% Gr 2), and thrombocytopenia (16% Gr 1-2, 26% Gr 3, and 37% Gr 4). Despite leukopenia, we encountered only two Gr 3 infections (urinary tract and lung). The majority required blood products (89% red blood cells and 68% platelets). Weight loss was also common (47% Gr 1 and 26% Gr 2). CONCLUSIONS VMAT CSI, along with chemotherapy and anesthesia, is feasible with supportive care. Daily image-guided RT improves accuracy and reduces the risk of spinal cord overdose without increasing treatment time. Further research is needed to determine whether reducing doses to organs, such as thyroid, heart, or hippocampus, offsets the risk of increased volume of low-dose irradiation.
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Affiliation(s)
- Kenneth K Wong
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Omar Ragab
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Hung N Tran
- Pediatric Neuro-Oncology, Department of Pediatrics, Kaiser Permanente, Los Angeles, California
| | - Anthony Pham
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sean All
- College of Medicine, University of Central Florida, Orlando, Florida
| | - Jonathan Waxer
- School of Medicine, Tulane University, New Orleans, Louisiana
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
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28
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Jin SY, Choi JY, Park KD, Kang HJ, Shin HY, Phi JH, Kim SK, Wang KC, Kim IH, Lee YA, Shin CH, Yang SW. Thyroid dysfunction in patients with childhood-onset medulloblastoma or primitive neuroectodermal tumor. Ann Pediatr Endocrinol Metab 2018; 23:88-93. [PMID: 29969880 PMCID: PMC6057023 DOI: 10.6065/apem.2018.23.2.88] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/22/2017] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We investigated the clinical characteristics of patients who developed thyroid dysfunction and evaluated the risk factors for hypothyroidism following radiotherapy and chemotherapy in pediatric patients with medulloblastoma or primitive neuroectodermal tumor (PNET). METHODS The medical records of 66 patients (42 males) treated for medulloblastoma (n=56) or PNET (n=10) in childhood between January 2000 and December 2014 at Seoul National University Children's Hospital were retrospectively reviewed. A total of 21 patients (18 high-risk medulloblastoma and 3 PNET) underwent high-dose chemotherapy and autologous stem cell rescue (HDCT/ASCR). RESULTS During the median 7.6 years of follow-up, 49 patients (74%) developed transient (n=12) or permanent (n=37) hypothyroidism at a median 3.8 years of follow-up (2.9-4.6 years). Younger age (<5 years) at radiation exposure (P=0.014 vs. ≥9 years) and HDCT (P=0.042) were significantly predictive for hypothyroidism based on log-rank test. However, sex, type of tumor, and dose of craniospinal irradiation (less vs. more than 23.4 Gy) were not significant predictors. Cox proportional hazard model showed that both younger age (<5 years) at radiation exposure (hazard ratio [HR], 3.1; vs. ≥9 years; P=0.004) and HDCT (HR, 2.4; P=0.010) were significant predictors of hypothyroidism. CONCLUSION Three-quarters of patients with pediatric medulloblastoma or PNET showed thyroid dysfunction, and over half had permanent thyroid dysfunction. Thus, frequent monitoring of thyroid function is mandatory in all patients treated for medulloblastoma or PNET, especially, in very young patients and/or high-risk patients recommended for HDCT/ASCR.
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Affiliation(s)
- Seung Young Jin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Yoon Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Duk Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu-Chang Wang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Address for correspondence: Young Ah Lee, MD, PhD Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-2308 Fax: +82-2-2072-3917 E-mail:
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Robinson GW, Rudneva VA, Buchhalter I, Billups CA, Waszak SM, Smith KS, Bowers DC, Bendel A, Fisher PG, Partap S, Crawford JR, Hassall T, Indelicato DJ, Boop F, Klimo P, Sabin ND, Patay Z, Merchant TE, Stewart CF, Orr BA, Korbel JO, Jones DTW, Sharma T, Lichter P, Kool M, Korshunov A, Pfister SM, Gilbertson RJ, Sanders RP, Onar-Thomas A, Ellison DW, Gajjar A, Northcott PA. Risk-adapted therapy for young children with medulloblastoma (SJYC07): therapeutic and molecular outcomes from a multicentre, phase 2 trial. Lancet Oncol 2018; 19:768-784. [PMID: 29778738 PMCID: PMC6078206 DOI: 10.1016/s1470-2045(18)30204-3] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Young children with medulloblastoma have a poor overall survival compared with older children, due to use of radiation-sparing therapy in young children. Radiotherapy is omitted or reduced in these young patients to spare them from debilitating long-term side-effects. We aimed to estimate event-free survival and define the molecular characteristics associated with progression-free survival in young patients with medulloblastoma using a risk-stratified treatment strategy designed to defer, reduce, or delay radiation exposure. METHODS In this multicentre, phase 2 trial, we enrolled children younger than 3 years with newly diagnosed medulloblastoma at six centres in the USA and Australia. Children aged 3-5 years with newly diagnosed, non-metastatic medulloblastoma without any high-risk features were also eligible. Eligible patients were required to start therapy within 31 days from definitive surgery, had a Lansky performance score of at least 30, and did not receive previous radiotherapy or chemotherapy. Patients were stratified postoperatively by clinical and histological criteria into low-risk, intermediate-risk, and high-risk treatment groups. All patients received identical induction chemotherapy (methotrexate, vincristine, cisplatin, and cyclophosphamide), with high-risk patients also receiving an additional five doses of vinblastine. Induction was followed by risk-adapted consolidation therapy: low-risk patients received cyclophosphamide (1500 mg/m2 on day 1), etoposide (100 mg/m2 on days 1 and 2), and carboplatin (area under the curve 5 mg/mL per min on day 2) for two 4-week cycles; intermediate-risk patients received focal radiation therapy (54 Gy with a clinical target volume of 5 mm over 6 weeks) to the tumour bed; and high-risk patients received chemotherapy with targeted intravenous topotecan (area under the curve 120-160 ng-h/mL intravenously on days 1-5) and cyclophosphamide (600 mg/m2 intravenously on days 1-5). After consolidation, all patients received maintenance chemotherapy with cyclophosphamide, topotecan, and erlotinib. The coprimary endpoints were event-free survival and patterns of methylation profiling associated with progression-free survival. Outcome and safety analyses were per protocol (all patients who received at least one dose of induction chemotherapy); biological analyses included all patients with tissue available for methylation profiling. This trial is registered with ClinicalTrials.gov, number NCT00602667, and was closed to accrual on April 19, 2017. FINDINGS Between Nov 27, 2007, and April 19, 2017, we enrolled 81 patients with histologically confirmed medulloblastoma. Accrual to the low-risk group was suspended after an interim analysis on Dec 2, 2015, when the 1-year event-free survival was estimated to be below the stopping rule boundary. After a median follow-up of 5·5 years (IQR 2·7-7·3), 5-year event-free survival was 31·3% (95% CI 19·3-43·3) for the whole cohort, 55·3% (95% CI 33·3-77·3) in the low-risk cohort (n=23) versus 24·6% (3·6-45·6) in the intermediate-risk cohort (n=32; hazard ratio 2·50, 95% CI 1·19-5·27; p=0·016) and 16·7% (3·4-30·0) in the high-risk cohort (n=26; 3·55, 1·66-7·59; p=0·0011; overall p=0·0021). 5-year progression-free survival by methylation subgroup was 51·1% (95% CI 34·6-67·6) in the sonic hedgehog (SHH) subgroup (n=42), 8·3% (95% CI 0·0-24·0%) in the group 3 subgroup (n=24), and 13·3% (95% CI 0·0-37·6%) in the group 4 subgroup (n=10). Within the SHH subgroup, two distinct methylation subtypes were identified and named iSHH-I and iSHH-II. 5-year progression-free survival was 27·8% (95% CI 9·0-46·6; n=21) for iSHH-I and 75·4% (55·0-95·8; n=21) for iSHH-II. The most common adverse events were grade 3-4 febrile neutropenia (48 patients [59%]), neutropenia (21 [26%]), infection with neutropenia (20 [25%]), leucopenia (15 [19%]), vomiting (15 [19%]), and anorexia (13 [16%]). No treatment-related deaths occurred. INTERPRETATION The risk-adapted approach did not improve event-free survival in young children with medulloblastoma. However, the methylation subgroup analyses showed that the SHH subgroup had improved progression-free survival compared with the group 3 subgroup. Moreover, within the SHH subgroup, the iSHH-II subtype had improved progression-free survival in the absence of radiation, intraventricular chemotherapy, or high-dose chemotherapy compared with the iSHH-I subtype. These findings support the development of a molecularly driven, risk-adapted, treatment approach in future trials in young children with medulloblastoma. FUNDING American Lebanese Syrian Associated Charities, St Jude Children's Research Hospital, NCI Cancer Center, Alexander and Margaret Stewart Trust, Sontag Foundation, and American Association for Cancer Research.
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Affiliation(s)
- Giles W Robinson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Vasilisa A Rudneva
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ivo Buchhalter
- Division of Applied Bioinformatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Catherine A Billups
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Sebastian M Waszak
- European Molecular Biology Laboratory (EMBL), Genome Biology Unit, Heidelberg, Germany
| | - Kyle S Smith
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Daniel C Bowers
- Department of Pediatric Hematology and Oncology, University of Southwestern Medical Center, Dallas, TX, USA
| | - Anne Bendel
- Department of Pediatric Hematology and Oncology, Children's Hospitals and Clinics of Minnesota, MN, USA
| | - Paul G Fisher
- Department of Pediatric Neurology, Stanford University, Palo Alto, CA, USA
| | - Sonia Partap
- Department of Pediatric Neurology, Stanford University, Palo Alto, CA, USA
| | - John R Crawford
- Department of Pediatric Hematology and Oncology, Rady Children's Hospital, San Diego, CA, USA
| | - Tim Hassall
- Department of Paediatric Oncology, Lady Cilento Children's Hospital, Brisbane, QLD, Australia
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Frederick Boop
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphy Neurologic and Spine Institute, Memphis, TN
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphy Neurologic and Spine Institute, Memphis, TN
| | - Noah D Sabin
- Department of Radiology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Zoltan Patay
- Department of Radiology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Clinton F Stewart
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Brent A Orr
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jan O Korbel
- European Molecular Biology Laboratory (EMBL), Genome Biology Unit, Heidelberg, Germany
| | - David T W Jones
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Hopp Children's Cancer Center at the NCT (KiTZ), Heidelberg, Germany
| | - Tanvi Sharma
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Hopp Children's Cancer Center at the NCT (KiTZ), Heidelberg, Germany
| | - Peter Lichter
- Division of Molecular Genetics, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marcel Kool
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Hopp Children's Cancer Center at the NCT (KiTZ), Heidelberg, Germany
| | - Andrey Korshunov
- CCU Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
| | - Stefan M Pfister
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Hopp Children's Cancer Center at the NCT (KiTZ), Heidelberg, Germany; Department of Hematology and Oncology, University Hospital, Heidelberg, Germany
| | | | - Robert P Sanders
- Department of Pediatrics, Methodist Children's Hospital of South Texas, San Antonio, TX, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - David W Ellison
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul A Northcott
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN, USA
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Cochrane AM, Cheung C, Rangan K, Freyer D, Nahata L, Dhall G, Finlay JL. Long-term follow-up of endocrine function among young children with newly diagnosed malignant central nervous system tumors treated with irradiation-avoiding regimens. Pediatr Blood Cancer 2017; 64. [PMID: 28475292 DOI: 10.1002/pbc.26616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/27/2017] [Accepted: 03/27/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND The adverse effects of irradiation on endocrine function among patients with pediatric brain tumor are well documented. Intensive induction chemotherapy followed by marrow-ablative chemotherapy with autologous hematopoietic cell rescue (AuHCR) without central nervous system (CNS) irradiation has demonstrated efficacy in a proportion of very young children with some malignant CNS tumors. This study assessed the long-term endocrine function of young children following chemotherapy-only treatment regimens. PROCEDURES A retrospective chart review was performed on 99 patients under 6 years of age with malignant brain tumors newly diagnosed between May 1991 and October 2010 treated with irradiation-avoiding strategies. Thirty patients survived post-AuHCR without cranial irradiation for a mean of 8.1 years (range 3.0-22.25 years). The patient cohort included 18 males and 12 females (mean age at AuHCR of 2.5 years, range 0.8-5.1 years). RESULTS All 30 surviving patients had documented normal age-related thyroid function, insulin-like growth factor binding protein 3 (IGF-BP3), prolactin, testosterone, and estradiol levels. Insulin-like growth factor 1 age-related levels were abnormal in one child with normal height. Ninety-seven percent of patients had normal cortisol levels, while follicle-stimulating hormone and LH levels among females were normal in 83% and 92%, respectively, and in 100% of males. Growth charts demonstrated age-associated growth within 2 standard deviations of the mean in 67% of patients. Of 10 patients (33%) with short stature, 6 had proportional diminutions in both height and weight. CONCLUSIONS These findings demonstrate that the use of relatively brief, intensive chemotherapy regimens including marrow-ablative chemotherapy with AuHCR results in fewer endocrine sequelae than treatment schemes utilizing CNS irradiation.
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Affiliation(s)
- Anne M Cochrane
- Division of Hematology and Oncology, Children's Hospital Los Angeles, California
| | - Clement Cheung
- Division of Endocrinology, Children's Hospital Los Angeles, California
| | - Kasey Rangan
- Division of Hematology and Oncology, Children's Hospital Los Angeles, California
| | - David Freyer
- Division of Hematology and Oncology, Children's Hospital Los Angeles, California
| | - Leena Nahata
- Division of Endocrinology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Girish Dhall
- Division of Hematology and Oncology, Children's Hospital Los Angeles, California
| | - Jonathan L Finlay
- Division of Hematology, Oncology and BMT, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Abstract
OBJECTIVE Most children with cancer are diagnosed in early childhood, potentially resulting in missed developmental opportunities. The most common diagnoses-brain tumors, leukemia-are also associated with increased risk of neurocognitive deficits. Unfortunately, research regarding the functioning of preschool-aged children with cancer is limited. Our objective is to describe the cognitive and psychosocial functioning of preschool-aged children with cancer who completed a clinical evaluation at a hospital-based psychology clinic. METHODS Assessment data from 98 preschool-aged children with cancer (M = 5.17 years old, SD = 0.54; 54.1% male) who completed clinically referred evaluations from 2011 to 2015 were abstracted. Because of variability in assessment measures used across clinicians, indicators of cognitive, adaptive, preacademic, and emotional/behavioral functioning were collapsed before analyses. RESULTS Children were 2.56 years from diagnosis (SD = 1.46, range 0-5.25 years) and most were off therapy (79.6%). Primary diagnostic categories were represented: brain tumor (68.4%), solid tumor (15.3%), and leukemia (16.3%). Mean IQ scores were significantly below expectations (t[80] = -7.95, p < .001). There were no differences based on diagnostic category, treatment status, or sex. Adaptive functioning (t[73] = -8.42, p < .001) and preacademic skills (t[77] = -6.20, p < .001) were also significantly below expectations. Mean scores on a measure of parent-reported emotional/behavioral functioning were in the average range. CONCLUSION Young children with cancer may be at significant risk of deficits in intellectual, adaptive, and preacademic functioning. Although our sample is biased by those who were referred for clinical evaluations, the severity of deficits highlights the potential vulnerability of young patients, even before most have entered formal school. Interventions-such as hospital-based preschool programs to increase preacademic skills-should be designed that explicitly target preschool-aged children and focus on a wide range of domains.
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Schulte F, Russell KB, Cullen P, Embry L, Fay-McClymont T, Johnston D, Rosenberg AR, Sung L. Systematic review and meta-analysis of health-related quality of life in pediatric CNS tumor survivors. Pediatr Blood Cancer 2017; 64. [PMID: 28266804 DOI: 10.1002/pbc.26442] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/10/2016] [Accepted: 12/12/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pediatric central nervous system (CNS) tumor survivors are at high risk for numerous late effects including decreased health-related quality of life (HRQOL). Our objective was to summarize studies describing HRQOL in pediatric CNS tumor survivors and compare HRQOL outcomes in studies that included a comparison group. PROCEDURE EMBASE, MEDLINE, and PsychINFO were used to identify relevant articles published until August, 2016. Eligible studies reported outcomes for pediatric CNS tumor survivors diagnosed before age 21, at least 5 years from diagnosis and/or 2 years off therapy and used a standardized measure of HRQOL. All data were abstracted by two reviewers. Random-effects meta-analyses were performed using Review Manager 5.0. RESULTS Of 1,912 unique articles identified, 74 were included in this review. Papers described 29 different HRQOL tools. Meta-analyses compared pediatric CNS tumor survivors to healthy comparisons and other pediatric cancer survivors separately. HRQOL was significantly lower for CNS (n = 797) than healthy comparisons (n = 1,397) (mean difference = -0.54, 95% confidence interval [CI] = -0.72 to -0.35, P < 0.001, I2 = 35%). HRQOL was also significantly lower for CNS (n = 244) than non-CNS survivors (n = 414) (mean difference = -0.56, 95% CI = -0.73 to -0.38, P < 0.00001, I2 = 0%). CONCLUSIONS Pediatric CNS tumor survivors experience worse HRQOL than healthy comparisons and non-CNS cancer survivors. Future HRQOL work should be longitudinal, and/or multisite studies that examine HRQOL by diagnosis and treatment modalities.
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Affiliation(s)
- Fiona Schulte
- Departments of Oncology and Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Haematology, Oncology and Transplant Program, Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - K Brooke Russell
- Haematology, Oncology and Transplant Program, Alberta Children's Hospital, Calgary, Alberta, Canada.,Departments of Oncology and Psychology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Patricia Cullen
- Loretto Heights School of Nursing, Regis University, Denver, Colorado
| | - Leanne Embry
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Taryn Fay-McClymont
- Departments of Oncology and Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Donna Johnston
- Department of Haematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Abby R Rosenberg
- Department of Hematology/Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Lillian Sung
- Department of Haematology/Oncology, SickKids Hospital, Toronto, Ontario, Canada
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Casco S, Soto-Vega E. Development of Metabolic Syndrome Associated to Cancer Therapy: Review. Discov Oncol 2016; 7:289-295. [PMID: 27704369 DOI: 10.1007/s12672-016-0274-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/21/2016] [Indexed: 01/25/2023] Open
Abstract
Long-term childhood cancer survivors are at great risk of developing late adverse effects after treatment, such as, reduced growth, obesity, decreased fertility, high blood pressure, cardiovascular diseases, impaired glucose, another form of cancer, among others organ dysfunctions, some of them are part of the metabolic syndrome. Metabolic syndrome and cancer connection is still not entirely understood, but there are some notions about it. Metabolic alterations produced during childhood cancer are more likely determined by treatments like radiotherapy, chemotherapy, glucocorticoids therapy, and surgery. Cancer treatment is associated to vascular alterations, hormone deficiencies, changes in insulin sensitivity, lipid metabolism, and inflammatory mediators. Obesity has been considered a crucial component in metabolic syndrome; obesity risk factors during childhood cancer include cranial radiation, female gender, and exposure to glucocorticoids such as dexamethasone. In addition, local radiotherapy or surgery may cause endocrine deficiencies, depends on the directly damage of endocrine organs. Patients who received some types of cancer treatment should be evaluated periodically to early diagnostic metabolic disorders associated to antineoplastic therapy.
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Affiliation(s)
- Stephania Casco
- Decanato de Ciencias de la Salud, Universidad Popular Autónoma del Estado de Puebla, Puebla, Mexico
| | - Elena Soto-Vega
- Centro de Investigación Oncológica UNE-UPAEP, Una Nueva esperanza A.B.P., Puebla, Mexico.
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Sands SA. Proton Beam Radiation Therapy: The Future May Prove Brighter for Pediatric Patients With Brain Tumors. J Clin Oncol 2016; 34:1024-6. [PMID: 26811526 DOI: 10.1200/jco.2015.65.4350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Lown EA, Phillips F, Schwartz LA, Rosenberg AR, Jones B. Psychosocial Follow-Up in Survivorship as a Standard of Care in Pediatric Oncology. Pediatr Blood Cancer 2015; 62 Suppl 5:S514-84. [PMID: 26700918 PMCID: PMC5242467 DOI: 10.1002/pbc.25783] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 01/08/2023]
Abstract
Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory.
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Affiliation(s)
- E. Anne Lown
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California
| | - Farya Phillips
- School of Social Work, The University of Texas at Austin, Austin, Texas
| | - Lisa A. Schwartz
- The Children’s Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abby R. Rosenberg
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Barbara Jones
- School of Social Work, The University of Texas at Austin, Austin, Texas
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Treatment outcome and patterns of failure in patients of non-pineal supratentorial primitive neuroectodermal tumor: review of literature and clinical experience form a regional cancer center in north India. Acta Neurochir (Wien) 2015; 157:1251-66. [PMID: 25990846 DOI: 10.1007/s00701-015-2444-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Supra-tentorial primitive neuroectodermal tumors (SPNET) are high-grade, hemispheric tumors, which account for around 2-3 % of pediatric brain tumors. We herein intend to report the clinical features and treatment outcome of patients with nonpineal SPNET treated at our institute. METHODS Clinical data were collected by retrospective chart review from 2006 to 2012. Histopathology slides were reviewed, and relevant immunohistochemistry stains were done. Overall survival (OS), recurrence-free survival (RFS) and event-free survival (EFS) were analyzed by the Kaplan-Meier product-limit method. RESULTS Fifteen patients met the study criterion (male: female = 2:1). Median age at presentation was 11 years (range 3-49 years). Surgical resection was gross total in 6 (40%) and subtotal in 8 (53.33%) patients. At presentation, two patients had leptomeningeal dissemination. Radiation therapy was delivered in 11 (73.33%) patients: craniospinal irradiation in 8 (36 Gy/20 fractions/4 weeks to the craniospinal axis followed by a local boost of 20 Gy/10 fractions/2 weeks) and focal RT in 3 patients. Systemic chemotherapy (median 6 cycles; range 1-16 cycles), given in 13 (86.67%) patients, included the VAC regimen (vincristine, adriamycin, cyclophosphamide) alternating with IE (ifosfamide,etoposide). After a median follow-up of 22.6 months (mean, 24.47 months), complete response and progressive disease were noted in 8 (53.33%) and 7 (46.67%) patients, respectively. Median OS was not reached, and estimated median EFS was noted to be 4.12 years (actuarial rate of EFS at 2 years, 55.2%). CONCLUSION Maximal safe resection followed by craniospinal irradiation and systemic chemotherapy with 6-12 cycles of an alternating regimen of VAC and IE is a reasonable treatment strategy in patients with nonpineal SPNET.
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Health-related Quality of Life in Long-term Survivors of Brain Tumors in Childhood and Adolescence: A Serial Study Spanning a Decade. J Pediatr Hematol Oncol 2015; 37:362-7. [PMID: 26018809 DOI: 10.1097/mph.0000000000000365] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Survivors of brain tumors in childhood experience adverse sequelae that are greater in prevalence and severity than those encountered by survivors of all other forms of cancer in early life, reflected in a burden of morbidity by instruments measuring health-related quality of life (HRQL). However, there are few studies of the change in HRQL over time in such populations. Patients who were above 5 years of age, at least 2 years from completion of therapy, and able to communicate in English were eligible for study of HRQL by the Health Utilities Index HUI2 and HUI3 at study entry, and again 5 and 10 years later. An initial cohort of 40 patients was reduced to 37 and 25 at the second and third time points, respectively, although only 1 death occurred during the study. HRQL showed a progressive decline over the decade, reaching conventional levels of clinical significance for the sizes of the changes. Median scores for HUI2 were 0.93, 0.90, and 0.88; and for HUI3 were 0.88, 0.85, and 0.77 at baseline, 5, and 10 years, respectively. The serial decline in HRQL demands further examination and an exploration of potential targets for therapeutic intervention.
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Olson K, Sands SA. Cognitive training programs for childhood cancer patients and survivors: A critical review and future directions. Child Neuropsychol 2015; 22:509-36. [PMID: 26070928 DOI: 10.1080/09297049.2015.1049941] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A robust literature has developed documenting neurocognitive late effects in survivors of leukemia and central nervous system (CNS) tumors, the most frequent cancer diagnoses of childhood. Patterns of late effects include deficits in attention and concentration, working memory, processing speed, and executive function, as well as other domains. As childhood cancer survivors are living longer, ameliorating deficits both in broad and specific neurocognitive domains has been increasingly recognized as an endeavor of paramount importance. Interventions to improve cognitive functioning were first applied to the field of pediatric oncology in the 1990s, based on strategies used effectively with adults who had sustained a traumatic brain injury (TBI). Compilation and modification of these techniques has led to the development of structured cognitive training programs, with the effectiveness and feasibility of such interventions currently an active area of research. Consequently, the purpose of this critical review is to: (1) review cognitive training programs intended to remediate or prevent neurocognitive deficits in pediatric cancer patients and survivors, (2) critically analyze training program strengths and weaknesses to inform practice, and (3) provide recommendations for future directions of clinical care and research.
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Affiliation(s)
- Katie Olson
- a Children's National Medical Center , Divisions of Hematology and Oncology , Washington , DC , USA
| | - Stephen A Sands
- b Columbia University Medical Center, Herbert Irving Division of Child & Adolescent Oncology , New York , NY , USA
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Zaky W, Dhall G, Khatua S, Brown RJ, Ginn KF, Gardner SL, Yildiz VO, Yankelevich M, Finlay JL. Choroid plexus carcinoma in children: the Head Start experience. Pediatr Blood Cancer 2015; 62:784-9. [PMID: 25662896 DOI: 10.1002/pbc.25436] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/26/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Choroid plexus carcinoma (CPC) is a rare aggressive intracranial neoplasm with a predilection for young children and a historically poor outcome. Currently, no defined optimal therapeutic strategy exists. The Head Start (HS) regimens have included irradiation-avoiding strategies in young children with malignant brain tumors using high dose chemotherapy to improve survival and minimize neurocognitive sequelae. PROCEDURE Three sequential HS studies have been conducted from 1991 to 2009. HS treatment strategy has consisted of maximal surgical resection followed by five cycles of intensive induction followed by consolidation myeloablative chemotherapy with autologous hematopoietic stem cell rescue (AuHCR). Irradiation was given following recovery from consolidation based on the patient's age and evidence of residual disease. RESULTS Twelve children with CPC (median age of 19.5 months) have been treated with HS regimens. Ten patients had >95% resection. Three patients had disseminated disease at diagnosis. Ten patients completed consolidation of whom five are alive, irradiation and disease free at 29, 43, 61, 66 and 89 months from diagnosis. Seven patients experienced tumor recurrence/progression at a median time of 13 months (range 2-43 months). Five patients received irradiation, one for residual disease and four upon progression or recurrence, of whom one is alive at 61 months. The 3- and 5-year progression-free survivals are 58% and 38% and overall survivals 83% and 62% respectively. Late deaths from disease beyond 5 years were also noted. CONCLUSION Head Start strategies may produce long-term remission in young children with newly diagnosed CPC with avoidance of cranial irradiation.
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Affiliation(s)
- Wafik Zaky
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Wilson CL, Gawade PL, Ness KK. Impairments that influence physical function among survivors of childhood cancer. CHILDREN (BASEL, SWITZERLAND) 2015; 2:1-36. [PMID: 25692094 PMCID: PMC4327873 DOI: 10.3390/children2010001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/18/2014] [Indexed: 11/29/2022]
Abstract
Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.
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Affiliation(s)
- Carmen L. Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS-735 Memphis, TN 38105, USA; E-Mails: (P.L.G.); (K.K.N.)
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Nelson MB, Macey PM, Harper RM, Jacob E, Patel SK, Finlay JL, Nelson MD, Compton P. Structural brain alterations in children an average of 5 years after surgery and chemotherapy for brain tumors. J Neurooncol 2014; 119:317-26. [PMID: 24830985 DOI: 10.1007/s11060-014-1480-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 05/05/2014] [Indexed: 12/01/2022]
Abstract
Young children with brain tumors are often treated with high-dose chemotherapy after surgery to avoid brain tissue injury associated with irradiation. The effects of systemic chemotherapy on healthy brain tissue in this population, however, are unclear. Our objective was to compare gray and white matter integrity using MRI procedures in children with brain tumors (n = 7, mean age 8.3 years), treated with surgery and high-dose chemotherapy followed by autologous hematopoietic cell rescue (AuHCR) an average of 5.4 years earlier, to age- and gender-matched healthy controls (n = 9, mean age 9.3 years). Diffusion tensor imaging data were collected to evaluate tissue integrity throughout the brain, as measured by mean diffusivity (MD), a marker of glial, neuronal, and axonal status, and fractional anisotropy (FA), an index of axonal health. Individual MD and FA maps were calculated, normalized, smoothed, and compared between groups using analysis of covariance, with age and sex as covariates. Higher MD values, indicative of injury, emerged in patients compared with controls (p < .05, corrected for multiple comparisons), and were especially apparent in the central thalamus, external capsule, putamen, globus pallidus and pons. Reduced FA values in some regions did not reach significance after correction for multiple comparisons. Children treated with surgery and high-dose chemotherapy with AuHCR for brain tumors an average of 5.4 years earlier show alterations in white and gray matter in multiple brain areas distant from the tumor site, raising the possibility for long-term consequences of the tumor or treatment.
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Affiliation(s)
- Mary Baron Nelson
- Children's Hospital Los Angeles, 4650 Sunset Blvd. MS #54, Los Angeles, CA, 90027, USA,
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