Late effects of treatment of cancer in children

Pediatric sarcoma survivorship: A call for a developmental cascades approach

Survivors of pediatric sarcomas often experience greater psychological and psychosocial difficulties than their non-afflicted peers. We consider findings related to poorer outcomes from a developmental cascade perspective. Specifically, we discuss how physical, neurocognitive, psychological, and psychosocial costs associated with pediatric sarcomas and their treatment function transactionally to degrade well-being in long-term pediatric sarcoma survivors. We situate the sarcoma experience as a broad developmental threat - one stemming from both the presence and treatment of a life-imperiling disease, and the absence of typical childhood experiences. Ways in which degradation in one developmental domain spills over and effects other domains are highlighted. We argue that the aggregate effect of these cascades is two-fold: first, it adds to the typical stress involved in meeting developmental milestones and navigating developmental transitions; and second, it deprives survivors of crucial coping strategies that mitigate these stressors. This position suggests specific moments of intervention and raises specific hypotheses for investigators to explore.

Health Behaviors of Childhood Cancer Survivors

There has been a dramatic increase in the number of childhood cancer survivors living to an old age due to improved cancer treatments. However, these survivors are at risk of numerous late effects as a result of their cancer therapy. Engaging in protective health behaviors and limiting health damaging behaviors are vitally important for these survivors given their increased risks. We reviewed the literature on childhood cancer survivors’ health behaviors by searching for published data and conference proceedings. We examine the prevalence of a variety of health behaviors among childhood cancer survivors, identify significant risk factors, and describe health behavior interventions for survivors.

Effect of the antineoplastic agent busulfan on rat molar root development

OBJECTIVE

The antineoplastic bifunctional-alkylating agent busulfan (Bu) induces developmental anomalies. We examined histopathological changes in the molar roots of rats that received Bu at different stages of root formation.

DESIGN

At different developmental stages, i.e., on postnatal days (P) 13, 15, and 19, rats were administered 7.5 mg/kg of Bu dissolved in dimethyl sulfoxide (DMSO) and then killed on P 30. After micro-computed tomography analysis, the maxillary first molars underwent immunohistochemical analysis for cytokeratin 14 (CK14), nestin, and dentin sialoprotein (Dsp). This was followed by histomorphometric analysis.

RESULTS

The rats receiving Bu at an early stage (i.e., P 13 and P 15) showed osteodentin formation and complete destruction of the Hertwig's epithelial root sheath (HERS). Cells around osteodentin showed nestin and Dsp immunoreactivity. The root lengths in rats treated with Bu at P 13 (1228.44 ± 62.17 μm) and P 15 (1536.08 ± 109.71 μm) were lower than that in the control rats (1674.10 ± 40 μm). A narrowed apical foramen and an increased amount of osteodentin were also present, depending on the rat's age at the time of treatment (P < 0.05).

CONCLUSION

Busulfan treatment in juvenile rats resulted in abnormal root development, depending on the stage at which Bu was administered. This abnormal development may result from the destruction of the HERS. The administration of Bu caused a shortage of HERS cells, which are required for normal root development. This disturbs root formation, resulting in osteodentin formation and a narrowed apex foramen.

The effect of chemotherapy on the growing skeleton

With the increasing use of high dose (poly)chemotherapy schedules in the treatment of childhood cancer it is particularly important to know the adverse effects of these treatments. Growth is a complex mechanism affected not only by chemotherapy but also by the malignancy itself as well as nutritional status, the use of corticosteroids and (cranial) radiation. In vitro and animal studies are often the most useful in determining the effect of a single chemotherapeutic agent on the growing skeleton. In vitro studies have shown doxorubicin, actinomycin D and cisplatin to have a direct effect on growth plate chondrocytes that in animals results in decreased growth and final height. Clinical studies with multiagent chemotherapy have demonstrated that antimetabolites decrease bone growth and final height. Childhood cancer survivors are at risk of a reduced bone mineral density, mainly due to methotrexate, ifosfamide and corticosteroids. This reduced bone mineral density persists into adult life and may increase bone fracture risk at an older age.

Complications of cancer therapy in children: a radiologist's guide

As advances in cancer therapy improve the prognosis of patients with childhood malignancies, awareness of the consequences of treatment methods assumes increasing importance. All cancer treatment modalities are associated with toxic effects, and the spectrum of therapy-induced complications involves all organ systems. Radiologists have a pivotal role in detecting these sequelae, which can be categorized by the affected organ system and by whether they occur (a) at diagnosis or during initial therapy or (b) after the completion of treatment. The first group consists of oncologic emergencies, infectious complications, and irritant effects. Oncologic emergencies can be further categorized as space-occupying lesions (e.g., superior vena cava syndrome or spinal cord compression), vascular abnormalities (e.g., hyperleukocytosis, anemia, coagulopathy), and metabolic emergencies (e.g., tumor lysis syndrome). Common complications developing after completion of treatment include leukoencephalopathy and neurocognitive defects; cataract formation; cardiomyopathy and congestive heart failure; hepatic dysfunction, fibrosis, and cirrhosis; radiation enteritis; renal dysfunction or failure; scoliosis and short stature; hypothyroidism; gonadal dysfunction; graft-versus-host disease; and development of secondary malignancies. Physician awareness of these complications will permit more effective patient surveillance, which may afford patients the opportunity for earlier intervention in these situations and improved quality of life.

Quality of life in adult survivors of childhood cancer

Sixty-four adult survivors of childhood cancer, recruited via Israel's largest pediatric cancer treatment center, participated in a multi-dimensional assessment of long-term adjustment and quality of life in the domains of educational achievement, employment status, military service, family status, health, and psychological well-being. Subjects had been diagnosed with cancer prior to age 18, were three years or more off therapy with no evidence of disease, and over 18 years old at the time of the study. Data from structured interviews were compared to responses on similar items from a control group with no history of serious illness during childhood, matched for age, sex, and parental education levels. Results indicated an overall pattern of integration into the social mainstream, with similar objective levels of achievement for survivors and controls for most measures of education, employment, significant relationships, and psychological well-being. Results also indicated certain areas of disadvantage, such as military recruitment difficulties, lower income levels, and higher rates of workplace rejection. Significantly, almost half of the survivor sample reported subjective feelings that their illness experience had impaired their achievement in several domains. Quality of life is considered an important outcome parameter in terms of clinical decision making as well as in guiding preventive and supportive intervention efforts.

CD4+ T-lymphocytopenia in long-term survivors following intensive chemotherapy in childhood cancers

BACKGROUND

It is generally believed the effects of short intensive courses of therapy are rapidly reversible in childhood cancers, and immunologic function following years of maintenance treatment with chemotherapy usually returns to normal by 6 months or less when treatment is terminated. However, we previously demonstrated that dysregulation of immunoglobulins, especially IgD, was observed in long-term survivors following intensive chemotherapy in cancer patients. With regard to cellular immunity, investigators reported that antineoplastic chemotherapy significantly reduces the number of CD4+ T-lymphocytes, and production of newly developing CD4+ T-lymphocytes was inversely related to the patients' age. However, the incidence of CD4+ lymphocytopenia in long-term survivors of childhood cancers is not known.

PROCEDURE

Here, we report the flow cytometric analysis of peripheral blood from long-term survivors who continue complete remission off chemotherapy for more than 5 years.

RESULTS

Six out of 74 long-term survivors (8.1%), showed low CD4+ T-lymphocyte count (<300/mm3). Three of six patients showed continued CD4+ T-lymphocytopenia over a year. In spite of the persistent low levels of CD4+ T cells, these three patients were not susceptible to severe infections.

COMMENT

Intriguingly, in patients with CD4+ T-lymphocytopenia there has been a tendency toward increased numbers of natural killer cells or gamma delta T cells that may be operating as a thymus-independent compensatory mechanism to defend the hosts.

Influence of the antineoplastic agent cyclophosphamide on dental development in rat molars

The effect of cyclophosphamide (Cy) on tooth development was studied in molars of 18 young Sprague-Dawley rats. Doses of 30 mg/kg body weight of Cy dissolved in 1 ml 0.9% NaCl were administered to 18 experimental rats and 1 ml 0.9% NaCl to 18 control rats at 10 and 13 days of age. The most obvious changes in the experimental teeth could be seen in the developing pulp of the third molar and developing roots of the first and second molars. Wide cell-free areas appeared in the third molar 2 days after the last injection; later these areas turned into mineralized osteodentin. Similar areas could be observed also in the roots of the first and second molars. These changes were related to the developmental stage of the area.

Nutrients, signal transduction and carcinogenesis

Choline phospholipids play major roles in cellular regulation in addition to their essential function as structural components of membranes and lipoproteins. The unique functions of choline phospholipids as hormones (platelet activating factor, 1-alkyl, 2-acetylphosphatidylcholine, PAF) and sources (phosphatidylcholine, sphingolipids) of second messengers (sphingosine, diacylglycerol, lysophospholipids, arachidonic acid and its metabolites) may explain how dietary choline influences normal physiological processes as well as a diverse group of pathological processes, including carcinogenesis.

Stereotactic radiotherapy for pediatric and adult brain tumors: preliminary report

PURPOSE

Stereotactic radiotherapy is a new modality that combines the accurate focal dose delivery of stereotactic radiosurgery with the biological advantages of conventional radiotherapy (1.8-2.0 Gy/day using 25-30 fractions). The modality requires sophisticated treatment planning, dedicated high-energy linear accelerator, and relocatable immobilization devices. We report here our early experience using stereotactic radiotherapy for intracranial neoplasms.

METHODS AND MATERIALS

Between June 1992 and September 1993, we treated 82 patients with central nervous system lesions using stereotactic radiotherapy, delivered from a dedicated 6 MV stereotactic linear accelerator. A head fixation frame provided daily relocatable setup using a dental plate for all patients over 8 years of age. A modified head frame, which does not require a mouthpiece, was used for children requiring anesthesia. The patients ranged in age from 9 months to 76 years. Thirty-three patients were children less than 21 years of age. Selection criteria for the protocol included: (a) focal, small (< 5 cm) radiographically distinct lesions known to be radiocurable (pituitary adenoma, craniopharyngioma, meningioma, acoustic neuroma, pilocytic astrocytoma, retinoblastoma), and (b) lesions located in regions not amenable to surgery or radiosurgery such as the brain stem or chiasm. Standard fractionation and conventional doses were delivered. Patients with low-grade astrocytoma, oligodendroglioma, or ependymoma were treated using a dose escalation regime consisting of conventional doses plus a 10% increase.

RESULTS

Although follow-up is 16 months (range 3-16 months), posttreatment radiographic studies in 77 patients have been consistent with changes similar to those found after conventional radiation therapy. To date, reduction of up to 50% of the original volume has been noted in 19 out of 77 patients, and 4 patients had a complete response, 2 with dysgerminoma, and 1 each with astrocytoma and retinoblastoma. In 56 patients disease was either stable or the follow-up was too short for evaluation. While the follow-up is relatively short, there have been no in-field or marginal recurrences. The only unexpected radiographic findings were in three patients with pilocytic astrocytomas, who developed asymptomatic edema in the treatment volume. Accuracy in daily fractionation was excellent. In over 2000 patient setups with 41,000 scalp measurements, reproducibility was found to be within 0.41 mm (median) of baseline readings, allowing for precise immobilization throughout the treatment course. The treatment in all cases was well tolerated with minimal acute effects. Our stereotactic radiotherapy facility can provide fractionated therapy for 10-12 patients a day efficiently and accurately.

CONCLUSIONS

The treatment and relocatable stereotactic head frames were well tolerated with minimal acute effects. No long-term sequelae have been noted, although the observation period is short. To fully define the role of stereotactic radiotherapy, we are conducting prospective studies to evaluate neurocognitive and neuroendocrine effects. We expect that this innovative approach will make a significant impact on the treatment of intracranial neoplasms, particularly in children.

The practice patterns of adult oncologists' care of pediatric oncology patients

The role of the adult oncologists in the area of pediatric cancer treatment previously has been unmeasured. A questionnaire bearing regarding the practice of 447 adult oncologists was administered in June 1991. The membership list of the Association of Community Cancer Centers was used to identify contact oncologists. One hundred thirty-one questionnaires (29.3%) were returned for analysis. The data reveal that 204 patients younger than 21 years of age were treated during the last year in 63 adult oncology practices. Most of these patients were more than 15 years of age. Only a minority (53) were treated in rural practices. In addition, only a minority (27%) of these patients are reported to be enrolled in clinical trials. In addition, adult oncologists appear to regard physiologically mature adolescents (age 16-21 years) as adults. They do not seem to make a distinction between patients 16-21 years old and those older than 21 years.

Spinal deformity induced by radiotherapy for solid tumours in childhood: a long-term follow up study

A group of 44 individuals were re-evaluated at a median follow up time of 19 years after radiotherapy for childhood cancer involving some part of the vertebral column. The median age at diagnosis was 2.6 years. The diagnosis included Wilms' tumour (n = 24), neuroblastoma (n = 9) and other solid tumours (n = 11). Scoliosis with or without kyphosis was the most common spinal deformity and was found in 40/44 patients. The apex of the major curvature was on the lumbar vertebral body 1-3 in 23 cases. The kyphosis and lordosis were greater in the subjects with tumour other than Wilms' (P = 0.04 both). Of the subjects restudied, 35 had detectable local soft tissue atrophy in the region of irradiation. Scoliotic deformity often enhanced cosmetic handicap/defect. Five subjects reported some symptoms related to the back; they had more severe scoliotic and kyphotic deformity (P = 0.02). Spinal abnormalities were common in these survivors, but subjective complaints were unusual.

Alterations in self-perceptions among adolescent cancer survivors

Psychosocial adjustment in adolescent cancer survivors has been documented to be quite variable. Factors mediating adjustment need to be identified. The current study is an exploration of the impact that cancer diagnosis and treatment has on adolescent's self-perceptions and the role this has in mediating adjustment in this group. Fifty-eight adolescent survivors of hematologic malignancies were interviewed about alterations in self-perceptions related to their cancer experience and completed a cancer-specific social problem-solving task. Initial findings suggest that cancer universally alters the way adolescent survivors view themselves, but that the alteration can be both positive or negative depending on the meaning ascribed to it.

Long-term cardiac sequelae after treatment of malignant tumors with radiotherapy or cytostatics in childhood

A series of 41 individuals were restudied after childhood cancer with a median follow-up time of 17 years after chest irradiation or treatment with cyclophosphamide or Adriamycin (doxorubicin). Radiotherapy of the chest had been used in 21 patients, and in 13 of these irradiation was also directed at the heart. Thirty-five patients received cyclophosphamide and five received Adriamycin therapy. All patients were investigated by a pediatric cardiologist. Investigations included an electrocardiogram (ECG), a chest radiographic film, an echocardiogram, an exercise test, and a 24-hour ECG. Altogether 20 patients (49%) showed some abnormality in cardiac tests. Each additional year of follow-up was associated with a 1.3-fold (95% confidence limits, 1.04-1.66; P less than 0.05) increase in the risk for pathologic cardiac findings. The risk for an abnormal cardiac test result in the 13 patients who had received cardiac irradiation was 12.8-fold (95% confidence limits, 1.8-90.8; P less than 0.02) that of the other patients. However, abnormalities in cardiac function were mild.

Astrocytoma in childhood: survival and performance

Seventy-nine children (35 female, 44 male) with proven or presumed astrocytoma were treated from 1967 to 1987. The tumors were supratentorial located in 24 children, cerebellar in 21 children, and pontine in 34 children. If possible, a radical tumor resection (4%), a subtotal tumor resection (51%), or a biopsy (8%) was performed. The predominant pathological Kernohan grading for the supratentorial, cerebellar, and pontine located tumors were grades II, II, and IV respectively. Histology was unknown in 15 out of 34 pontine tumors and in 1 out of 24 supratentorial tumors. Low-graded tumors (46%) were irradiated with a local field (1.8/45-50 Gy) and children with high-graded tumors (34%) received a total brain irradiation (1.8/40 Gy) followed by a boost irradiation (10 Gy) in 5 or 6 fractions. Overall 1-, 5-, and 10-year survivals of children with supratentorial, cerebellar, and pontine located tumors were 96%-91%-46%, 95%-95%-95%, and 35%-20%-20% respectively. For all tumor locations, 77% of deaths occurred within 2 years of treatment. The performance status of both children with supratentorial and cerebellar astrocytoma showed an increase during the first year of treatment and then stabilized on a rather high level (mean performance after 5 years of 60% and 70% respectively). Children with pontine tumors showed a steep decrease in performance status during the first year of treatment and then stabilized on a low level (mean performance after 5 years of 15%). In our study, children with supratentorial astrocytoma showed improvement in both survival and performance status after irradiation following surgical removal of the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term quality of life and psychosocial coping after treatment of solid tumours in childhood. A population-based study of 94 patients 11-28 years after their diagnosis

In order to assess the long-term quality of life after childhood cancer, we examined and interviewed 94 survivors of childhood solid tumours (excluding brain tumors) diagnosed in our hospital between 1960 and 1976. Their follow-up times ranged form 10.7 to 27.7 years, and their ages at the time of this study form 11.3 to 41.5 years. The subjects had a higher educational level than the Finnish general population. Fewer of the females and as many of the males were married as in the general population. Eight healthy men had been rejected for military service because of the history of cancer. An unsatisfied desire to know more about their own medical history was evident. According to our findings, some subjects after childhood solid tumour are at risk of developing emotional and social problems. However, the great majority of the survivors were well balanced psychologically, living a normal social life and showing adequate capacity to cope.

Radiation-induced sarcoma of the breast in a female adolescent. Case report with histologic and therapeutic considerations

A 14-year-old girl developed a radiation-induced sarcoma of the left breast after successful combined surgical and radiation therapy of a left adrenal carcinoma when she was 9 months old. The breast lesion was histologically described as a stromal sarcoma with fibrosarcomatous and myxosarcomatous areas. The second primary lesion and local recurrence of this was treated with surgery. At each recurrence the tumor became more aggressive both clinically and histologically, and eventually proved fatal.

The prevalence of cancer. Estimates based on the Connecticut Tumor Registry

Cancer incidence and mortality do not fully reflect the effect of cancer. To estimate the number of persons alive who have a history of cancer, we derived prevalence rates based on data from the Connecticut Tumor Registry. We did not attempt to distinguish between people who had been cured of cancer and those who still had the disease. In 1982 the age-adjusted prevalence rates of cancer among males and females were 1,789 and 2,222, respectively, per 100,000. Age-specific prevalence rates were highest among the elderly; 12 percent of men and 11 percent of women over 70 had previously been given a diagnosis of cancer. Breast cancer in females and prostate cancer in males were the two most prevalent malignant diseases. We estimate that about 5 million persons alive in the United States today have at one time received a diagnosis of cancer.