Comparative Toxicity by Sex Among Children Treated for Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group

Parents' perception of treatment-related toxicity in children treated according to the NOPHO ALL2008 protocol for acute lymphoblastic leukemia

This study aimed to assess how parents perceived treatment-related side effects during acute lymphoblastic leukemia (ALL) treatment. Parents of children 1-17.9 years at diagnosis in Sweden, Finland, and Denmark who were alive and in first remission ≥6 months after end of ALL treatment were asked to respond on specific items regarding how their child was affected by side effects related to vincristine (VCR), corticosteroids, peg-asparaginase (ASP), and maintenance therapy, as well as overall impact of these treatments, complications in general, and their perception of impact on their child in comparison with other children with ALL. Parents of 307 children responded. More than a third reported that their child had been affected to a high extent by VCR (39.7%) and corticosteroids (35.8%), with walking difficulties, muscular weakness, pain, changes in appetite, and mood swings as the most common and severe symptoms. Reporting of these toxicities was lacking from the NOPHO ALL2008 database, except for peripheral paralysis (12.1%). For distinct toxicities reported in the NOPHO ALL2008 database, for example, thrombosis and pancreatitis, parent reports were similar to the database. Although a high overall negative impact during treatment was reported, parents generally rated the impact on their child as less, or similar, to other children with ALL. Parents perceived VCR and corticosteroid therapy, in particular, to have a negative impact on their child during ALL treatment, which was not captured in the NOPHO ALL2008 toxicity reporting. Our results highlight the importance of including patient/parent-reported outcomes in toxicity reporting.

Costs associated with adverse events from remission induction for children with Acute Lymphoblastic Leukemia (ALL)

Background

ALL is the most frequent hematological tumor in children, so during remission induction chemotherapy protocol (RICP) adverse events (AEs) may appear. The public program in Mexico in charge of financial support to oncologic children without social security delivered a fix amount for ALL chemotherapy, but additional money needed to treat any other unexpected condition should be taken from the budget of the oncologic healthcare providers. So the purpose of our study was to estimate and evaluate the direct medical costs associated to EAs during RICP in children with ALL.

Methods

This study was retrospective, longitudinal, and observational based on medical records review of patients in RICP. The CTCAE was used to identify and classify AEs according to a SOC category. We focused on extracting resources data that were consumed both for inpatients and outpatients AEs. A micro-costing approach was adopted which involve quantification of each healthcare resource consumed by the hospital multiplying them by unit cost. The probability distributions of data were evaluated to identify the appropriated statistical tests to be used for comparisons between groups that were performed with Wilcoxon rank sum test. Generalized linear models (GLM) were adjusted to evaluate the effects of patient characteristics on total cost.

Results

Forty patients accumulated 204 inpatient and 81 outpatient AEs during RICP. Comparison of total costs between groups showed an incremental cost of $7,460.23 likewise attributable to AEs. The total cost of a pediatric patient undergoing RICP without adverse events was $3,078.36 and the total cost of a patient with AEs exceeds it threefold.

Conclusions

The costs associated with AEs during RICP in Mexican children with ALL representing a high burden for the healthcare provider. Generalized linear models showed that variables such as sex, risk category and alive status are associated with the total costs of AEs. This is the first study aiming to analyze the effect of ALL-related AEs on health care costs in pediatric population, so our results may help not only to local decision making but also it may contribute to the research agenda in this field.

Treatment-related toxicities associated with hospitalization in children, adolescents, and young adults with acute lymphoblastic leukemia: population level analysis

Treatment-related toxicities (TRTs) are a potential cause of survival disparities in patients with acute lymphoblastic leukemia (ALL). We aimed to identify the most frequent TRTs associated with hospitalizations at a population level in children, adolescents and young adults (AYAs). We used the California Cancer Registry linked to a statewide hospital discharge database to identify children and AYAs with TRTs within 3 years of diagnosis. We assessed the frequency of TRTs, length of stay (LOS), admission rates associated with TRTs and TRTs impact on survival. Febrile neutropenia, hypertension, and thrombocytopenia were the most common TRTs for both children and AYAs. AYAs had longer median LOS compared to children for most toxicities. AYAs at non-specialized cancer centers (SCCs) had higher frequency of admissions associated with TRTs compared to non-SCC. Cardiovascular, respiratory, gastrointestinal, renal, and infectious TRTs were associated with worse survival. This study demonstrates the burden of TRTs in patients with ALL.

Mortality Among Pediatric Patients With Acute Lymphoblastic Leukemia in Sweden From 1988 to 2017

IMPORTANCE

Acute lymphoblastic leukemia (ALL) constitutes 20% to 30% of all pediatric cancers. The 5-year overall survival among pediatric patients with ALL in high-income countries such as Sweden is currently more than 90%, but long-term unselected nationwide mortality data and mortality data in relation to the general population are lacking.

OBJECTIVE

To compare mortality between pediatric patients with ALL and the general population during a 30-year period in Sweden and to assess the incidence of ALL in Sweden.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included pediatric patients (aged <18 years) with a morphologically verified ALL diagnosis in the Swedish Cancer Register and/or at least 2 ALL diagnoses in the Swedish National Patient Register between January 1, 1988, and December 31, 2017. Data were cross-linked to the Swedish Cause of Death Register. Data were analyzed from May 2019 to January 2022.

MAIN OUTCOMES AND MEASURES

The main outcomes were mortality among patients with ALL compared with that in the general population and mortality in different subgroups within the cohort. Standardized mortality ratios (SMRs) were calculated using the general Swedish population as a reference. Within-cohort survival analyses were performed.

RESULTS

A total of 2397 patients (1354 [56%] male; mean [SD] age at diagnosis, 6.1 [4.7] years) were included in the study. The mean (SD) incidence of pediatric ALL during the study period was 4.11 (0.60) cases per 100 000 persons per year (females, 3.68 [0.65] cases per 100 000 persons per year; males, 4.52 [0.81] cases per 100 000 persons per year; P < .001). The observed number of deaths among pediatric patients with ALL was 409 vs the 9.5 deaths expected in the general population, resulting in an overall SMR of 43.1 (95% CI, 39.0-47.5); females had a higher SMR than males (57.8 [95% CI, 49.5-67.2] vs 34.5 [95% CI, 32.0-41.4]; P < .001). Analysis within the cohort showed a continued decrease in survival throughout the 30-year follow-up. The association between calendar year of ALL diagnosis, corresponding with different ALL treatment protocols, and mortality showed the lowest survival for the 1988-1991 group and the highest for the 2008-2017 group (χ2 = 20.3; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, a consistently high SMR was seen among pediatric patients with ALL. Within the ALL cohort, survival evolved to a similar extent as in the young general population of Sweden. Furthermore, survival among patients with ALL decreased throughout the whole follow-up period without any trend difference after the 5-year follow-up time point. The changes in ALL treatment protocols were associated with overall improved absolute survival over time.

Inflammatory biomarkers after an exercise intervention in childhood acute lymphoblastic leukemia survivors

Cancer survivors show increased risk for non-communicable diseases and chronic low-grade inflammation characterizes the development of such diseases. We investigated inflammatory plasma protein profiles of survivors of childhood acute lymphoblastic leukemia (ALL) in comparison to healthy controls and after an intervention with a home-based exercise program. Survivors of childhood ALL aged 16-30 years (n = 21) with a median age at diagnosis 4.9 (1.6-12.9) years and a median time of 15.9 years from diagnosis, and sex- and age-matched healthy controls (n = 21) were studied. Stored plasma samples were analyzed with Olink's 92-protein-wide Inflammation panel in 21 ALL long-term survivors at baseline, after a previous 16-week home-based exercise intervention (n = 17) and in 21 age- and sex-matched controls at baseline. Protein expression levels were compared between the groups. Inflammatory protein levels did not differ between the survivors and controls at baseline. Significantly reduced levels after the intervention were found in 11 proteins related to either vascular inflammation, insulin resistance, or both: tumor necrosis factor superfamily member 14 (TNFSF14), oncostatin M (OSM), monocyte chemoattractant protein 1 (MCP-1), MCP-2, fibroblast growth factor 21 (FGF-21), chemokine (C-C motif) ligand 4 (CCL4), transforming growth factor alpha (TGF-α), tumor necrosis factor-related apoptosis-inducing ligand 10 (TRAIL), adenosine deaminase (ADA), chemokine (C-X-C motif) ligand 6 (CXCL6), and latency-associated peptide transforming growth factor beta 1 (LAP TGF-β1). The ALL survivors were not significantly more affected by inflammation than controls at baseline. The survivors' 16-week exercise intervention led to significant reduction in inflammatory protein levels. Physical exercise should be promoted for survivors of childhood cancer.

Effect of chewing gum on the management of chemotherapy-induced oral mucositis in children: Systematic review of experimental studies

OBJECTIVE

It was aimed to systematically synthesise the available literature on examining the effect of chewing gum in the management/reduction of chemotherapy-induced oral mucositis in children.

METHODS

The PRISMA was followed for the systematic review. All published studies obtained from the relevant databases were examined while the research question and inclusion and exclusion criteria were considered. The Joanna Briggs Institute (JBI) critical appraisal tools were used to evaluate the quality of the studies.

RESULTS

A total of five studies met the inclusion criteria: three randomised controlled trials (RCT) and two quasi-experimental studies with a total of 461 paediatric oncology patients were included. Heterogeneity was found across all studies regarding the application of gum chewing and regarding the effectiveness of gum chewing. Two RTCs and one quasi-experimental study reported that gum chewing is not effective to reduce severe oral mucositis, but effective to reduce moderate and mild oral mucositis, and one RTC reported that gum chewing is not effective to reduce oral mucositis.

CONCLUSION

Experimental studies particularly randomised controlled trials using rigorous designs, consistent outcome measures, and larger sample sizes are required to determine the efficacy of chewing gum in reducing chemotherapy-induced oral mucositis in paediatric oncology patients. Study was registered in PROSPERO and number was CRD42022328916.

Long-Term Outcomes among Adolescent and Young Adult Survivors of Acute Leukemia: A Surveillance, Epidemiology, and End Results Analysis

BACKGROUND

There is a growing population of adolescent and young adult (AYA, age 15-39 years) acute leukemia survivors in whom long-term mortality outcomes are largely unknown.

METHODS

The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess long-term outcomes of AYA acute leukemia 5-year survivors. The impact of diagnosis age, sex, race/ethnicity, socioeconomic status, and decade of diagnosis on long-term survival were assessed utilizing an accelerated failure time model.

RESULTS

A total of 1,938 AYA acute lymphoblastic leukemia (ALL) and 2,350 AYA acute myeloid leukemia (AML) survivors diagnosed between 1980 and 2009 were included with a median follow-up of 12.3 and 12.7 years, respectively. Ten-year survival for ALL and AML survivors was 87% and 89%, respectively, and 99% for the general population. Survival for AYA leukemia survivors remained below that of the age-adjusted general population at up to 30 years of follow-up. Primary cancer mortality was the most common cause of death in early survivorship with noncancer causes of death becoming more prevalent in later decades of follow-up. Male AML survivors had significantly worse survival than females (survival time ratio: 0.61, 95% confidence interval: 0.45-0.82).

CONCLUSIONS

AYA leukemia survivors have higher mortality rates than the general population that persist for decades after diagnosis.

IMPACT

While there have been improvements in late mortality, long-term survival for AYA leukemia survivors remains below that of the general population. Studies investigating risk factors for mortality and disparities in late effects among long-term AYA leukemia survivors are needed.

Heart rate response and chronotropic incompetence during cardiopulmonary exercise testing in childhood acute lymphoblastic leukemia survivors

Cardiopulmonary exercise tests (CPET) focusing on analyses of heart rate (HR) responses and chronotropic incompetence (CI) could provide early information about treatment's negative cardiac effects. We examined childhood acute lymphoblastic leukemia (ALL) survivors' HR response during maximal CPET and identified survivors with CI. A total of 250 childhood ALL survivors underwent a CPET on ergocycle to assess their HR response. We used a multiparametric structure of three methods to assess survivors' CI, as follows: 1) age-predicted HR_max (APMHR): failure to achieve 85% of the APMHR at the peak of CPET; 2) HR reserve (HRR): failure to achieve 80% of the HRR at the peak of CPET; and 3) metabolic chronotropic relationship (MCR): failure to reach an MCR slope ratio >0.8 at each stage of the CPET. Among 250 childhood ALL survivors, 216 survivors performed a maximum CPET. We observed that 73 males and 74 females did not achieve their predicted HR_max. We found that 6 survivors did not achieve 85% of their APMHR (80.9 ± 3.9%) and had an MCR below 80% (53.9 ± 13.8%). In addition, 16 survivors did not achieve 80% of their HRR (71.0 ± 7.4%) and among them, 15 survivors had an MCR below 80% (61.0 ± 12.1%). Survivors with CI had a significantly lower cardiorespiratory fitness than those without CI. This study shows that survivors are at risk of developing altered HR responses and CI many years after the end of their cancer treatments. These findings highlight the importance of early detection of cardiac damage due to cancer treatments.

[Gender blindness in medical textbooks: the case of leukemias]

OBJECTIVE

To analyse the existence of sex-differences in the content on leukemias in the Haematology and Internal Medicine textbooks recommended in the Medical Degrees, 2019-2020, by comparison with the sex-differences recognized in the scientific literature.

METHOD

Manifest content analysis of the content of chapters on leukemias in the books on hematology and internal medicine, clinical haematology and haematology undergraduate. Analysis categories: epidemiology, etiopathogenesis, diagnosis, treatment and prognosis of leukemias.

RESULTS

Epidemiological information from the revised books has a greater consideration of sex differences in incidence and prognosis but does not contain data on mortality and survival. Etiopathogenesis is described in all books as the same physiological process for both sexes and no differences in the presentation of symptoms are described in any book. Three books describe a unique treatment that is assumed equal for both sexes; two books mention the treatment of acute myeloid leukemia in pregnant women and one in chronic myeloid leukemia. No book mentions sex-differences in pharmacokinetics, efficacy, or treatment toxicity, although there is greater evidence on unequal behavior between the sexes.

CONCLUSIONS

The contents of sex and gender differences in the leukemia chapters analyzed are insufficient compared to the evidence in the scientific literature today. Hematology textbooks might increase their scientific quality in future editions, including knowledge of sex-gender interaction in the sections of epidemiology, etiology, pathogenesis, diagnosis, treatment, prognosis, and consequences of leukemias, which will contribute to better professional practices, more efficient and equitable.

Incidence and risk factors for oral mucositis in pediatric patients receiving chemotherapy

PURPOSE

To investigate the incidence and risk factors for oral mucositis (OM) in patients with childhood cancer undergoing chemotherapy.

METHODS

Eight hundred and twenty-nine cycles of chemotherapy were evaluated in 112 patients with childhood cancer undergoing chemotherapy. Chemotherapy protocol, hematological, hepatic, and renal function parameters were collected and compared to presence and severity of OM, as graded by the World Health Organization (WHO) scale. Patients received counseling on oral hygiene and those who presented with OM (grade ≥1) received photobiomodulation therapy (PBMT).

RESULTS

Age ranged from 0 to 17 years (mean/SD, 8.58 ± 5.05) and fifty-one patients (45.54%) were females. The most common baseline diseases were leukemia (51%) followed by sarcomas (23%) and lymphomas (18%). Eight hundred and twenty-nine cycles of chemotherapy were evaluated, and OM was diagnosed in 527 cycles (63.57%). Higher incidence and severity of OM was observed in protocols using high-dose methotrexate (MTX-HD), MTX-HD cyclophosphamide/doxorubicin combination, and MTX-HD combined with cyclophosphamide (p <0.001). Patients with severe OM had lower levels of leukocytes (p = 0.003), hemoglobin (p = 0.005), platelets (p = 0.034), and higher levels of total bilirubin (p = 0.027), alanine aminotransferase (ALT) (p = 0.001), and creatinine (p = 0.007).

CONCLUSION

The study contributes to the elucidation of the risk factors for OM in pediatric cancer patients. Chemotherapy protocols using MTX-HD, MTX-HD associated with doxorubicin and cyclophosphamide, and MTX-HD and cyclophosphamide a have higher incidence of severe grades of OM. Other toxicities such as hematological, hepatic, and renal also developed in patients with OM.

Risk factors associated with the development of oral mucositis in pediatric oncology patients: Systematic review and meta-analysis

OBJECTIVES

Oral mucositis (OM) is an acute toxicity related to cancer treatment. This systematic review aimed to identify potential risk factors associated with the development of OM in pediatric cancer patients.

METHODS

A search was performed in four electronic databases to identify studies that analyzed risk factors for OM in pediatric cancer patients.

RESULTS

Nineteen articles were included. The incidence of OM ranged from 20% to 80.4%. Chemotherapeutic agents were potential risk factors for OM in eight (42%) studies. Hematological, hepatic, and renal parameters were also considered in eight (42%) studies, while specific individual factors were reported in five (26.3%) studies. Baseline disease, oral microbiota, genetic profile, and biomarkers were reported in four (21.5%) studies each. Meta-analysis showed that groups submitted to high-risk chemotherapy for OM had a 2.79-fold increased risk of OM.

CONCLUSIONS

Identifying risk factors for OM is essential in order to allow individualized and early prevention treatment.

Increased Toxicity Among Adolescents and Young Adults Compared with Children Hospitalized with Acute Lymphoblastic Leukemia at Children's Hospitals in the United States

Purpose: Adolescent and young adult (AYA) patients (15-39 years old) with acute lymphoblastic leukemia (ALL) have less favorable outcomes and higher treatment-related mortality as compared with older children with ALL. Minimal data exist regarding how well AYA patients tolerate the intensity of chemotherapy at doses and regimens designed for children, and the toxicities suffered by this population at children's hospitals have not been thoroughly characterized. Methods: Pediatric Health Information Systems database was queried to analyze health care outcomes in pediatric (ages 10-14) and AYA patients (ages 15-39) with ALL hospitalized between January 1999 and December 2014. We extracted relevant ICD-9 data for each patient related to grades 3 or 4 toxicities as outlined by the NCI. Results: A total of 5345 hospital admissions met inclusion criteria, representing 4046 unique patients. Of these admissions, 2195 (41.1%) were in the AYA age group, and the remainder were in the 10-14-year-old group. AYA patients had a significantly higher incidence of intensive care unit stay but no difference in median hospital stay nor mortality. AYA patients had increased toxicities in almost every organ system as compared with older children. Conclusions: In this large multicenter US database study, we found an overall increased number of toxicities among AYA patients with ALL in children's hospitals. Compared with children between the ages of 10 and 15, AYA patients developed disproportionately higher toxicities from drugs commonly used in pediatric protocols for ALL. Prospective studies are needed to assess whether dose modifications for certain chemotherapeutics may improve the toxicity profile and health care burden of AYA patients with ALL treated in children's hospitals.

Oral Mucositis in Pediatric Oncology Patients: A Nested Case-Control to a Prospective Cohort

Abstract This study aimed to evaluate the factors associated with the occurrence of severe oral mucositis (SOM) in pediatric oncology patients during the chemotherapeutic treatment. This is a nested case-control to a prospective cohort that monitored 105 patients for 10 consecutive weeks after the beginning of the chemotherapy treatment. Logistic regression was used to identify the factors associated with SOM, by group of malignancy (hematologic or solid tumors) (Sig.=5%). To patients with hematologic tumors were found factors associated with SOM in two weeks of treatment: in the 6th week (increase in frequency of chemotherapy doses (OR=3.02)) and in the 7th week (female sex (OR=21.28); and increase in frequency of chemotherapy doses (OR=2.51)); and to patients with solid tumors were found factors associated with SOM in five weeks of treatment: in the 1st week (female sex (OR=14.43); age increase (OR=1.24)); in the 2nd week (Miscellany (OR=6.39)); in the 5th week (Antimetabolites (OR=17.44); Miscellany (OR=45.42); and platelets reduction (OR=1.12)); in the 6th week (creatinine increase (OR=1.63)); and in the 7th week (creatinine increase (OR=2.39)). For patients with hematologic tumors, to be female, and the increase in the frequency of chemotherapy doses increased the risk for SOM and for patients with solid tumors, to be female, the increase in age and in level blood concentration of creatinine, the reduction in number of platelets and the use of chemotherapy with miscellany and antimetabolites agents were associated with an increase in risk for occurrence of SOM.

Chemotherapy in Pediatric Oncology Patients and the Occurrence of Oral Mucositis

BACKGROUND

It is known that chemotherapeutic agents are not equally stomatotoxic and oral cavity lesions are the most frequent complications encountered in antineoplastic chemotherapy.

AIMS

The objective of this study was to evaluate the occurrence of severe oral mucositis during a chemotherapy treatment and to identify its relationship with the chemotherapeutic class used.

MATERIALS AND METHODS

This is a longitudinal, prospective, and observational study that used an intensive direct observation technique for assessing the oral clinical conditions and the chemotherapy treatment administered to 105 patients (both children and adolescents).

RESULTS

Severe oral mucositis occurred in all the 10 weeks of evaluation (ranging from 16.2 to 31.4%) and the association between the type of chemotherapy and the occurrence of severe oral mucositis is recorded only in the 6th week, with the chance to develop severe oral mucositis being 3.07 (3.85-2.29) times higher in patients underwent chemotherapy with antimetabolites than in those who have not used chemotherapy (p = 0.012).

CONCLUSION

It was concluded that the chemotherapeutic agents most related to severe oral mucositis and to the interruption in chemotherapy are those of the class of antimetabolites, especially the methotrexate and the Ara C.

HOW TO CITE THIS ARTICLE

Ribeiro ILA, de Andrade Lima Neto E, et al. Chemotherapy in Pediatric Oncology Patients and the Occurrence of Oral Mucositis. Int J Clin Pediatr Dent 2019;12(4):261-267.

Hepatic late adverse effects after antineoplastic treatment for childhood cancer

BACKGROUND

Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately, the improved prognosis has been accompanied by the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors, the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies, it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. This review is an update of a previously published Cochrane review.

OBJECTIVES

To evaluate all the existing evidence on the association between antineoplastic treatment (that is, chemotherapy, radiotherapy involving the liver, surgery involving the liver and BMT) for childhood cancer and hepatic late adverse effects.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2018, Issue 1), MEDLINE (1966 to January 2018) and Embase (1980 to January 2018). In addition, we searched reference lists of relevant articles and scanned the conference proceedings of the International Society of Paediatric Oncology (SIOP) (from 2005 to 2017) and American Society of Pediatric Hematology/Oncology (ASPHO) (from 2013 to 2018) electronically.

SELECTION CRITERIA

All studies, except case reports, case series, and studies including fewer than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment).

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection and 'risk of bias' assessment. The 'risk of bias' assessment was based on earlier checklists for observational studies. For the original version of the review, two review authors independently performed data extraction. For the update of the review, the data extraction was performed by one reviewer and checked by another reviewer.

MAIN RESULTS

Thirteen new studies were identified for the update of this review. In total, we included 33 cohort studies including 7876 participants investigating hepatic late adverse effects after antineoplastic treatment (especially chemotherapy and radiotherapy) for different types of childhood cancer, both haematological and solid malignancies. All studies had methodological limitations. The prevalence of hepatic late adverse effects, all defined in a biochemical way, varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well-defined as alanine aminotransferase (ALT) above the upper limit of normal, indicating cellular liver injury, resulted in eight studies. In this subgroup, the prevalence of hepatic late adverse effects ranged from 5.8% to 52.8%, with median follow-up durations varying from three to 23 years since cancer diagnosis in studies that reported the median follow-up duration. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal, resulted in five studies, with a prevalence ranging from 0.9% to 44.8%. One study investigated biliary tract injury, defined as gamma-glutamyltransferase (γGT) above the upper limit of normal and above twice the upper limit of normal and reported a prevalence of 5.3% and 0.9%, respectively. Three studies investigated disturbance in biliary function, defined as bilirubin above the upper limit of normal and reported prevalences ranging from 0% to 8.7%. Two studies showed that treatment with radiotherapy involving the liver (especially after a high percentage of the liver irradiated), higher BMI, and longer follow-up time or older age at evaluation increased the risk of cellular liver injury in multivariable analyses. In addition, there was some suggestion that busulfan, thioguanine, hepatic surgery, chronic viral hepatitis C, metabolic syndrome, use of statins, non-Hispanic white ethnicity, and higher alcohol intake (> 14 units per week) increase the risk of cellular liver injury in multivariable analyses. Chronic viral hepatitis was shown to increase the risk of cellular liver injury in six univariable analyses as well. Moreover, one study showed that treatment with radiotherapy involving the liver, higher BMI, higher alcohol intake (> 14 units per week), longer follow-up time, and older age at cancer diagnosis increased the risk of biliary tract injury in a multivariable analysis.

AUTHORS' CONCLUSIONS

The prevalence of hepatic late adverse effects among studies with an adequate outcome definition varied considerably from 1% to 53%. Evidence suggests that radiotherapy involving the liver, higher BMI, chronic viral hepatitis and longer follow-up time or older age at follow-up increase the risk of hepatic late adverse effects. In addition, there may be a suggestion that busulfan, thioguanine, hepatic surgery, higher alcohol intake (>14 units per week), metabolic syndrome, use of statins, non-Hispanic white ethnicity, and older age at cancer diagnosis increase the risk of hepatic late adverse effects. High-quality studies are needed to evaluate the effects of different therapy doses, time trends, and associated risk factors after antineoplastic treatment for childhood cancer.

Early vs. late MRD response- and risk-based treatment intensification of childhood acute lymphoblastic leukemia: a prospective pilot study from Saudi Arabia

Background

Refinement of risk-based treatment stratification by minimal residual disease (MRD) at different time points has improved outcomes of childhood acute lymphoblastic leukemia (ALL). In this prospective study we evaluated effects of such stratification, including intensification of therapy based on response assessment at day-15 and MRD at day-29 of induction to test if treatment intensification would improve outcomes.

Methods

241 patients, 1-14 years old, newly diagnosed with ALL, were recruited and stratified by risk and MRD response into three treatment Arms (A, B, or C). Arm A was modified from COG AALL0331, B from AALL0232, and C from AALL0232 and AALL0434. Assignments were according to NCI risk, phenotype, rapid vs. slow early response (SER), steroid pretreatment, MLL rearrangement (MLLR), CNS3, and testicular involvement. Patients on Arm A had treatment intensified early based on day-15 marrow results or late based on end-of-induction MRD.

Results

5-year OS, EFS, and CIR were 89.5% ± 4.0%, 87.6% ± 4.3%, and 7.1% ± 3.5%. No significant difference was found by B- vs. T cell phenotype. 5-year OS, EFS, and CIR for B-cell ALL were 90.5% ± 2.4%, 88.7% ± 2.6%, and 6.4% ± 2.0%. Outcomes for patients with t(1;19)/TCF3-PBX1 and MLLR were significantly (p ≤ 0.05) worse than for other patients. MRD level at end-of-induction associated with outcomes, but association with a specific MRD value at end-of-induction varied significantly by NCI-risk group. Late treatment intensification based on end-of-induction MRD significantly improved survival outcomes for NCI-SR patients, however, patients with NCI-HR and positive MRD at end-of-induction had significantly inferior outcomes despite intensification. MRD transitions between day-15 and day-29 of induction associated with differences for OS and EFS.

Conclusions

Arm switching to a more intensive protocol had mixed results. Assigning patients by end-of-induction MRD-risk alone did not reflect response kinetics of the different NCI-risk groups. Although late treatment intensification improved outcomes of NCI-SR patients with positive MRD at end-of-induction, further refinement is needed to improve outcomes of NCI-HR with SER. Integration of NCI-risk group with specific MRD value and time point allows more refined treatment stratification.Trial Registration Protocols were approved by King Abdullah International Medical Research Center and Ethics Review Committee RC08053J.

High-dose methotrexate vs. Capizzi methotrexate for the treatment of childhood T-cell acute lymphoblastic leukemia

Sixty-three children (1-14 years of age) newly diagnosed with T-cell acute lymphoblastic leukemia were treated from January 2001 to December 2014. Patient outcomes were evaluated based on the regimen received; Capizzi methotrexate (C-MTX) vs. high-dose methotrexate (HDMTX). Complete remission (CR) was achieved in 54 of 60 (90.0%) patients and 3 patients died during induction. The 5-year overall survival (OS) and disease-free survival (DFS) were 88.3 ± 6.5% and 85 ± 7.5%, respectively. Post-induction, 35 patients were treated with HDMTX and 25 with C-MTX. There was no difference in OS or DFS for patients treated with HDMTX vs. C-MTX (P > 0.05 for both). Central nervous system involvement (CNS3) was associated with inferior survival outcomes compared to Non-CNS3 patients (OS, CNS3 73.3 ± 9.1% vs.non-CNS3 93.2 ± 2.6%, (P = 0.045) and DFS, CNS3 66.7 ± 10.4% vs. non-CNS3 90.9 ± 3.1% (P = 0.0163)). Delayed radiation in CNS3 was associated with relapse (P = 0.0037) regardless of regimen. Thus optimization of CNS-directed therapy for patients with CNS3 is needed.

Incidence of upper digestive tract inflammation in children with acute lymphoblastic leukemia at diagnosis

Inflammatory lesions in upper digestive tract are common adversary events in children with acute lymphoblastic leukemia (ALL). However, when these lesions initiate is still not clear. In this study, we retrospectively analyzed the endoscopic detection results of 129 children who suffered from ALL at diagnosis. 107 (82%) patients were found with gastrointestinal inflammation, of which 101 patients had lesions in the stomach, 11 had lesions in the esophagus and 51 had lesions in the duodenal bulb. Only 2 patients were found with helicobacter pylori infection, and 1 patient was found with a mycotic infection in the esophagus. We demonstrate that most patients with ALL have gastrointestinal inflammation at the diagnosis of the basic disease, and in contrast to adult patients in China, these inflammatory lesions were mostly not caused by HP infection.

Treatment-related mortality in relapsed childhood acute lymphoblastic leukemia

BACKGROUND

Treatment of relapsed childhood acute lymphoblastic leukemia (ALL) is particularly challenging due to the high treatment intensity needed to induce and sustain a second remission. To improve results, it is important to understand how treatment-related toxicity impacts survival.

PROCEDURE

In this retrospective population-based study, we described the causes of death and estimated the risk for treatment-related mortality in patients with first relapse of childhood ALL in the Nordic Society of Paediatric Haematology and Oncology ALL-92 and ALL-2000 trials.

RESULTS

Among the 483 patients who received relapse treatment with curative intent, we identified 52 patients (10.8%) who died of treatment-related causes. Twelve of these died before achieving second remission and 40 died in second remission. Infections were the cause of death in 38 patients (73.1%), predominantly bacterial infections during the chemotherapy phases of the relapse treatment. Viral infections were more common following hematopoietic stem cell transplantation (HSCT) in second remission. Independent risk factors for treatment-related mortality were as follows: high-risk stratification at relapse (hazard ratio [HR] 2.2; 95% confidence interval [CI] 1.3-3.9; P < 0.01), unfavorable cytogenetic aberrations (HR 3.4; 95% CI 1.3-9.2; P = 0.01), and HSCT (HR 4.64; 95% CI 2.17-9.92; P < 0.001). In contrast to previous findings, we did not observe any statistically significant sex or age differences. Interestingly, none of the 17 patients with Down syndrome died of treatment-related causes.

CONCLUSIONS

Fatal treatment complications contribute significantly to the poor overall survival after relapse. Implementation of novel therapies with reduced toxicity and aggressive supportive care management are important to improve survival in relapsed childhood ALL.

Gender disparity in pediatrics: a review of the current literature

BACKGROUND

Gender-based medicine is an innovative branch of biomedical research and represents a new perspective for the future of health research. Many studies have been published on gender medicine in adults but very few data regarding children are available.

LITERATURE SEARCH AND RESULTS

A literature search covering articles published between 1stJuly, 2006 and 1st February, 2017 and concerning children only was conducted using multiple keywords and standardized terminology in Pubmed database. The search was limited to English-language publications. All relevant articles on endocrines, neurological, psychiatric, gastrointestinal, immunological, oncological, rheumatic, pneumological disorders, infectious diseases and analgesia were evaluated and pertinent articles were included in this review. Most of the available studies on gender disparity in childhood are about endocrine and neuro-psychiatric disorders, while there are few data in other areas of medicine.

CONCLUSIONS

Even if several studies on pediatric gender differences can be found on literature, few of them move forwards to analyze the reasons of the observed diversity. No data on pharmacokinetic and pharmacodynamic differences between boys and girls can be found. Hence, more efforts should be directed to investigate these topics in childhood.

Improving outcome of acute lymphoblastic leukemia with a simplified protocol: report from a tertiary care center in north India

BACKGROUND

The outcome of malignancies in low- and middle-income countries (LMICs) is hampered owing to numerous factors. Current protocols are complex, demanding supportive care, often not optimally available. We de-escalated the UKALL 2003 protocol to improve the outcome of acute lymphoblastic leukemia (ALL) at our center.

METHODS

In 2007-2009, children were treated as per the UKALL 2003 protocol (protocol 1). In 2010 and 2011, a modified version of the UKALL 2003 (protocol 2) was followed.

RESULTS

Three hundred and seventy-four children aged 5.71+3.1 (1-13) years were treated. Remission was achieved in 335 of the 338 who completed induction. Treatment-related mortality decreased significantly with the modified protocol (P ≤ 0.001). Relapses were similar with both protocols. Protocol used, regimen, counts at diagnosis, weight for age, gender, education of parents and occupation of caregiver were associated with the outcome of death (P < 0.05). On Cox proportional hazard analysis, patients on protocol 1, female gender and weight ≤5th centile had a greater hazard of dying (0.46 [P < 0.0001]; 1.5 [P = 0.04] and 1.64 [P = 0.01]). The 3 years overall survival (OS) with protocols 1 and 2 was 54.8% (95% CI 47.4-61.7%) and 73.9% (95% CI 66-79%) (P < 0.001), respectively. The event-free survival with protocols 1 and 2 was 50.8% (95% CI 43-57%) and 65.7% (95% CI 58-72%) (P < 0.001), respectively.

CONCLUSIONS

A steady improvement in survival has been observed at our center to a 3-year present OS of 73.9% with reduction in treatment intensity. The way forward for LMICs is to formulate rational treatment protocols at par with resources.

Treatment delay and the risk of relapse in pediatric acute lymphoblastic leukemia

Delays or interruptions in chemotherapy due to toxicity such as neutropenia or severe infections are common in the treatment of pediatric acute lymphoblastic leukemia (ALL). Based on the reports of worse outcomes in children with poorer compliance with therapy, there has been concern that toxicity-induced therapy interruptions could also compromise treatment outcome. In a retrospective study of treatment delays in our hospital between 2003 and 2013, the case notes of 141 patients were reviewed. The cumulative lengths of delays during the whole length of chemotherapy, during the intensive phase of treatment, and during maintenance treatment were analyzed. Within these categories, delays were split between less and more than the median value. The risk of relapse did not differ between patients with a longer or shorter delay during the total length of treatment or during the intensive phase. In addition, there was a trend when comparing patients above vs below the mean in length of treatment delays during maintenance, and there was a statistically significant difference in relapses when comparing patients in the lowest and highest quartiles of maintenance delays, with fewer relapses among those patients in the highest quartile for treatment delays.

Modifiable Factors Associated With Aging Phenotypes Among Adult Survivors of Childhood Acute Lymphoblastic Leukemia

PURPOSE

Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for low bone mineral density (BMD) and frail health, outcomes potentially modifiable by altering health behaviors and/or treating endocrine abnormalities. We evaluated associations between lifestyle and hormonal deficits with risk of low BMD and frailty among survivors of ALL.

PATIENTS AND METHODS

Participants included 862 survivors of ALL (median age, 31.3 years [range, 18.4 to 59.7 years]) enrolled in the St Jude Lifetime Cohort study. Bone density was measured using quantitative computed tomography of L1 through L2 vertebrae; low BMD was defined as an age- and sex-standardized z score < -1. The presence of frailty or prefrailty was defined as having at least two of the following: low muscle mass, self-reported exhaustion, low energy expenditure, slow walking speed, and weakness. Hormonal deficiencies were determined according to medical history, medications, and laboratory findings (insulin-like growth factor 1, follicle-stimulating hormone, luteinizing hormone, and testosterone levels). Logistic regression was used to examine associations between lifestyle (smoking, alcohol consumption, and activity levels) and deficiencies in growth hormone (GHD) and/or sex steroids with low BMD and frailty.

RESULTS

Thirty percent of survivors met criteria for low BMD, and 18.6% for frailty/prefrailty. After adjusting for body mass index, low BMD was associated with GHD (odds ratio [OR], 1.59; 95% CI, 1.02 to 2.13) and current smoking (OR, 1.71; 95% CI, 1.02 to 2.85) among men; and GHD (OR, 2.18; 95% CI, 1.26 to 3.78) and moderate alcohol consumption (OR, 2.09; 95% CI, 1.14 to 3.83) among women. After adjusting for current age, the odds of frailty/prefrailty were increased among men with GHD (OR, 2.97; 95% CI, 1.56 to 5.67) and those who smoked (OR, 3.26; 95% CI, 1.65 to 6.43); there were no significant associations among women.

CONCLUSION

The findings suggest that survivors of ALL should receive counseling regarding lifestyle and undergo screening for hormonal deficits to minimize the risk of low BMD and frailty.

Sex-Related Differences of Lipid Metabolism Induced by Triptolide: The Possible Role of the LXRα/SREBP-1 Signaling Pathway

Triptolide, a diterpenoid isolated from the plant Tripterygium wilfordii Hook. f., exerts a unique bioactive spectrum of anti-inflammatory and anticancer activities. However, triptolide's clinical applications are limited due to its severe toxicities. Fatty liver toxicity occurs in response to triptolide, and this toxic response significantly differs between males and females. This report investigated the pathogenesis underlying the sex-related differences in the dyslipidosis induced by triptolide in rats. Wistar rats were administered 0, 150, 300, or 450 μg triptolide/kg/day by gavage for 28 days. Ultrastructural examination revealed that more lipid droplets were present in female triptolide-treated rats than in male triptolide-treated rats. Furthermore, liver triglyceride, total bile acid and free fatty acid levels were significantly increased in female rats in the 300 and 450 μg/kg dose groups. The expression of liver X receptor α (LXRα) and its target genes, cholesterol 7α-hydroxylase (CYP7A1) and Sterol regulatory element-binding transcription factor 1(SREBP-1), increased following triptolide treatment in both male and female rats; however, the female rats were more sensitive to triptolide than the male rats. In addition, the expression of acetyl-CoA carboxylase 1(ACC1), a target gene of SREBP-1, increased in the female rats treated with 450 μg triptolide/kg/day, and ACC1 expression contributed to the sex-related differences in the triptolide-induced dysfunction of lipid metabolism. Our results demonstrate that the sex-related differences in LXR/SREBP-1-mediated regulation of gene expression in rats are responsible for the sex-related differences in lipid metabolism induced by triptolide, which likely underlie the sex-related differences in triptolide hepatotoxicity. This study will be important for predicting sex-related effects on the pharmacokinetics and toxicity of triptolide and for improving its safety.