Ovarian failure following abdominal irradiation in childhood: natural history and prognosis

Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Fertility preservation in women with haematological malignancies

The incidence of haematological malignancies is increasing in women of childbearing age. Survival rates accompany this increase, making it essential to assess the impact of treatments on their future quality of life, evaluate the impact of each treatment on ovarian reserve and define the fertility preservation techniques used by women with haematologic malignancies. A retrospective study was conducted after data collection from 61 women diagnosed with haematological malignancies and followed-up in a fertility preservation centre between January 2008 and June 2019. Cancer treatments caused a decrease in ovarian reserve, demonstrated by an increase in FSH levels and a decrease in AMH levels. When assessing which treatments have the greatest impact on AMH levels, we found that the BEACOPP regimen, and the agents vincristine, etoposide, procarbazine, prednisone and the haematopoietic stem cell transplantation were mainly responsible. Regarding pregnancy after oncological treatments, of the eleven women who became pregnant, ten did so spontaneously. This study reinforces the importance of referring patients to a fertility preservation consultation before starting oncological treatment, as most of them opt to preserve fertility. This work also helps to clarify the impact of each chemotherapeutic agent on the ovarian reserve.

Analysis of nuclear maturation, DNA damage and repair gene expression of bovine oocyte and cumulus cells submitted to ionizing radiation

Radiotherapy causes destruction of tumor cells, but also threatens the integrity and survival of surrounding normal cells. Then, woman submitted to irradiation for cancer treatment may present permanent ovary damage, resulting in impaired fertility. The objective of this study was to investigate the effects of therapeutic doses of ionizing radiation (IR), used for ovarian cancer treatment in humans, on bovine cumulus-oocyte complexes (COCs) as experimental model. Bovine ovaries were exposed to 0.9 Gy, 1.8 Gy, 3.6 Gy or 18.6 Gy IR, and then COCs were collected and used to evaluate: (a) oocyte nuclear maturation; (b) presence of phosphorylated H2A.X (γH2AX), as an indicator of DNA double-strand breaks (DSBs); and (c) expression of genes involved in DNA repair (TP53BP1, RAD52, ATM, XRCC6 and XRCC5) and apoptosis (BAX). The radiation doses tested in this study had no detrimental effects on nuclear maturation and did not increase γH2AX in the oocytes. However, IR treatment altered the mRNA abundance of RAD52 (RAD52 homolog, DNA repair protein) and BAX (BCL2-associated X protein). We conclude that although IR doses had no apparent effect on oocyte nuclear maturation and DNA damage, molecular pathways involved in DNA repair and apoptosis were affected by IR exposure in cumulus cells.

Radiotherapy exposure directly damages the uterus and causes pregnancy loss

Female cancer survivors are significantly more likely to experience infertility than the general population. It is well established that chemotherapy and radiotherapy can damage the ovary and compromise fertility, yet the ability of cancer treatments to induce uterine damage, and the underlying mechanisms, have been understudied. Here, we show that in mice total-body γ-irradiation (TBI) induced extensive DNA damage and apoptosis in uterine cells. We then transferred healthy donor embryos into ovariectomized adolescent female mice that were previously exposed to TBI to study the impacts of radiotherapy on the uterus independent from effects to ovarian endocrine function. Following TBI, embryo attachment and implantation were unaffected, but fetal resorption was evident at midgestation in 100% of dams, suggesting failed placental development. Consistent with this hypothesis, TBI impaired the decidual response in mice and primary human endometrial stromal cells. TBI also caused uterine artery endothelial dysfunction, likely preventing adequate blood vessel remodeling in early pregnancy. Notably, when pro-apoptotic protein Puma-deficient (Puma-/-) mice were exposed to TBI, apoptosis within the uterus was prevented, and decidualization, vascular function, and pregnancy were restored, identifying PUMA-mediated apoptosis as a key mechanism. Collectively, these data show that TBI damages the uterus and compromises pregnancy success, suggesting that optimal fertility preservation during radiotherapy may require protection of both the ovaries and uterus. In this regard, inhibition of PUMA may represent a potential fertility preservation strategy.

Hormone therapy for uterine and endometrial development in women with premature ovarian insufficiency

BACKGROUND

Premature ovarian insufficiency (POI) is a clinical syndrome resulting from loss of ovarian function before the age of 40. It is a state of hypergonadotropic hypogonadism, characterised by amenorrhoea or oligomenorrhoea, with low ovarian sex hormones (oestrogen deficiency) and elevated pituitary gonadotrophins. POI with primary amenorrhoea may occur as a result of chromosomal and genetic abnormalities, such as Turner syndrome, Fragile X, or autosomal gene defects; secondary amenorrhoea may be iatrogenic after the surgical removal of the ovaries, radiotherapy, or chemotherapy. Other causes include autoimmune diseases, viral infections, and environmental factors; in most cases, POI is idiopathic. Appropriate replacement of sex hormones in women with POI may facilitate the achievement of near normal uterine development. However, the optimal effective hormone therapy (HT) regimen to maximise the reproductive potential for women with POI remains unclear.

OBJECTIVES

To investigate the effectiveness and safety of different hormonal regimens on uterine and endometrial development in women with POI.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in September 2021. We also checked references of included studies, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating the effect of various hormonal preparations on the uterine development of women diagnosed with POI.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcome was uterine volume; secondary outcomes were endometrial thickness, endometrial histology, uterine perfusion, reproductive outcomes, and any reported adverse events.

MAIN RESULTS

We included three studies (52 participants analysed in total) investigating the role of various hormonal preparations in three different contexts, which deemed meta-analysis unfeasible. We found very low-certainty evidence; the main limitation was very serious imprecision due to small sample size. Conjugated oral oestrogens versus transdermal 17ß-oestradiol We are uncertain of the effect of conjugated oral oestrogens compared to transdermal 17ß-oestradiol (mean difference (MD) -18.2 (mL), 95% confidence interval (CI) -23.18 to -13.22; 1 RCT, N = 12; very low-certainty evidence) on uterine volume, measured after 12 months of treatment. The study reported no other relevant outcomes (including adverse events). Low versus high 17ß-oestradiol dose We are uncertain of the effect of a lower dose of 17ß-oestradiol compared to a higher dose of 17ß-oestradiol on uterine volume after three or five years of treatment, or adverse events (1 RCT, N = 20; very low-certainty evidence). The study reported no other relevant outcomes. Oral versus vaginal administration of oestradiol and dydrogesterone We are uncertain of the effect of an oral or vaginal administration route on uterine volume and endometrial thickness after 14 or 21 days of administration (1 RCT, N = 20; very low-certainty evidence). The study reported no other relevant outcomes (including adverse events).

AUTHORS' CONCLUSIONS

No clear conclusions can be drawn in this systematic review, due to the very low-certainty of the evidence. There is a need for pragmatic, well designed, randomised controlled trials, with adequate power to detect differences between various HT regimens on uterine growth, endometrial development, and pregnancy outcomes following the transfer of donated gametes or embryos in women diagnosed with POI.

Successful term pregnancy following cervical cerclage for uterine atrophy secondary to childhood radiotherapy

Pelvic radiotherapy can lead to scarring and atrophy of reproductive organs including the uterus. This may lead to complications, such as preterm birth, during pregnancy. The mechanism by which preterm birth is associated with pelvic radiation is believed to be due to inefficient uterine stretch or a deficient cervix. We report a case of cervical shortening during the second trimester in a pregnant woman with a history of pelvic radiotherapy in childhood. Ultrasound surveillance and cervical cerclage inserted in the shortening cervix successfully prevented preterm labour in this case. Cerclage insertion led to a longer cervix and lower fibronectin. Although cervical cerclage does not influence uterine stretch, it may be able to prevent cervical dilatation and therefore prevent ascending infections and subsequent inflammatory sequelae which results in preterm labour. We recommend cervical surveillance and targeted cerclage interventions to prevent preterm labour in women with prior childhood pelvic radiotherapy.

Artificial Ovary for Young Female Breast Cancer Patients

In recent decades, there has been increasing attention toward the quality of life of breast cancer (BC) survivors. Meeting the growing expectations of fertility preservation and the generation of biological offspring remains a great challenge for these patients. Conventional strategies for fertility preservation such as oocyte and embryo cryopreservation are not suitable for prepubertal cancer patients or in patients who need immediate cancer therapy. Ovarian tissue cryopreservation (OTC) before anticancer therapy and autotransplantation is an alternative option for these specific indications but has a risk of retransplantation malignant cells. An emerging strategy to resolve these issues is by constructing an artificial ovary combined with stem cells, which can support follicle proliferation and ensure sex hormone secretion. This promising technique can meet both demands of improving the quality of life and meanwhile fulfilling their expectation of biological offspring without the risk of cancer recurrence.

Systematic review of the immunological landscape of Wilms tumors

Results of immunotherapy in childhood solid cancer have been so far, with the exception of neuroblastoma, quite disappointing. Lack of knowledge of the immune contexture of these tumors may have contributed to the failure of immunotherapies so far. Here, we systematically reviewed the literature regarding the immunology of Wilms tumor (WT), one of the most frequent pediatric solid tumors of the abdomen. In Wilms tumor patients the high cure rate of >90%, achieved by the combination of surgery and radio-chemotherapy, is at the expense of a high early and late toxicity. Moreover, treatment-resistant entities, such as diffuse anaplastic tumors or recurrent disease, still pose unsolved clinical problems. Successful immunotherapy could represent a novel and possibly less-toxic treatment option. Employing the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) method of literature search, we analyzed the current knowledge of the immunological landscape of Wilms tumors in terms of tumor microenvironment, prognostic implications of single biomarkers, and immunotherapy response.

A systematic approach to imaging the pelvis in amenorrhea

This is a pictorial review on the radiological approach to patients with amenorrhea using a level-based framework. The prevalence of amenorrhea is 3 to 4% with wide-ranging causes involving multiple clinical disciplines. Normal menstruation depends on complex coordinated hormonal functions of the hypothalamic-pituitary-ovarian axis exerting its effect on an intact uterine end-organ and outflow tract. A disruption of any of these factors may result in amenorrhea. Categorizing the causes of primary and secondary amenorrhea into uterine, ovarian/gonadal, and intracranial levels provides a logical framework for its evaluation. A systematic level-based approach by targeted ultrasound of the pelvic structures is suggested, with different aims in primary versus secondary amenorrhea. Pelvic sonographic findings of various conditions within the uterine and ovarian/gonadal levels are illustrated. Conditions due to an intracranial cause result in downstream effects on the uterus and ovaries and can often be suspected based on a combination of clinical assessment, ultrasound findings, and laboratory investigations. By correlating pelvic ultrasound findings with underlying pathology, the clinical radiologist is able to provide useful diagnostic information in the management of these patients.

Effects of low-dose X-ray medical diagnostics on female gonads: Insights from large animal oocytes and human ovaries as complementary models

Diagnostic imaging has significantly grown over the last thirty years as indispensable support for diagnostic, prognostic, therapeutic and monitoring procedures of human diseases. This study explored the effects of low-dose X-ray medical diagnostics exposure on female fertility. To aim this, cumulus-oocyte complexes (COCs) recovered from the ovaries of juvenile sheep and human ovaries were used as complementary models for in vitro studies. In the sheep model, the effects of low-dose X-rays on oocyte viability and developmental competence were evaluated. In human ovaries originated from two age group (21–25 and 33–36 years old) subjects with gender dysphoria, X-rays effects on tissue morphology, follicular density and expression of apoptosis-related (NOXA, PUMA, Bcl2, Bak, γH2AX) and cell cycle-related genes (p21 and ki67) were investigated. It was noted that in sheep, the minimum dose of 10 mGy did not influence most of examined parameters at oocyte and embryo levels, whereas 50 and 100 mGy X-ray exposure reduced oocyte bioenergetic/oxidative activity but without any visible effects on oocyte and embryo development. In addition, blastocyst bioenergetic/oxidative status was reduced with all used doses. Overall data on human ovaries showed that low-dose X-rays, similarly as in sheep, did not alter any of examined parameters. However, in women belonging to the 33–36 year group, significantly reduced follicular density was observed after exposure to 50 and 100 mGy, and increased NOXA and Bax expression after exposure at 50 mGy. In conclusion, used low-doses of X-ray exposure, which resemble doses used in medical diagnostics, produce weak damaging effects on female fertility with increased susceptibility in advanced age.

Involved Site Radiotherapy Extends Time to Premature Menopause in Infra-Diaphragmatic Female Hodgkin Lymphoma Patients - An Analysis of GHSG HD14- and HD17-Patients

Introduction

Consolidation radiotherapy in intermediate stage Hodgkin´s lymphoma (HL) has been the standard of care for many years as involved field radiotherapy (IFRT) after chemotherapy. It included initially involved region(s). Based on randomized studies, radiation volumes could be reduced and involved site radiation therapy (ISRT) became the new standard. ISRT includes the initially affected lymph nodes. In young adults suffering from HL, infertility and hypogonadism are major concerns. With regard to these questions, we analyzed the influence of modern radiotherapy concepts such as consolidating ISRT in infradiaphragmatic involvement of HL after polychemotherapy.

Patients and Methods

Five hundred twelve patients treated within German Hodgkin Study Group (GHSG) HD14 and HD17 trials were evaluated. We analyzed log-adjusted follicle-stimulating-hormone (FSH)- and luteinizing-hormone (LH)-levels of HD14-patients with infradiaphragmatic radiotherapy (IDRT) in comparison with HD14-patients, who had a supradiaphragmatic radiotherapy (SDRT). In a second step, we compared IFRT with ISRT of female HD17 patients regarding the effects on ovarian function and premature menopause.

Results

We analyzed FSH- and LH-levels of 258 female and 241 male patients, all treated with IFRT. Of these 499 patients, 478 patients had SDRT and 21 patients had IDRT. In a multiple regression model, we could show that log-adjusted FSH (p=0.0006) and LH values (p=0.0127) were significantly higher after IDRT than after SDRT. The effect of IDRT on gonadal function was comparable to two cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPPesc). We compared the effect of IFRT with ISRT in thirteen female HD17 patients with infradiaphragmatic (ID) involvement. The mean ovarian dose after ISRT was significantly lower than after IFRT. The calculated proportion of surviving non-growing follicles (NGFs) increased significantly from 11.87% to 24.48% in ISRT compared to IFRT, resulting in a significantly longer calculated time to menopause. The younger the age at therapy, the greater the absolute time gain until menopause.

Conclusion

Infradiaphragmatic IFRT impairs gonadal function to a similar extent as two cycles of BEACOPPesc. In comparison, the use of ISRT target volume definition significantly reduced radiation dose to the ovaries and significantly extends the time interval from treatment to premature menopause.

Fertility Preservation and Long-Term Monitoring of Gonadotoxicity in Girls, Adolescents and Young Adults Undergoing Cancer Treatment

Chemo- and radio-therapy can often affect reproductive organs impairing hormonal regulation, fertility, and sexual function. As cancer treatments become more effective and many patients have long term survival, concerns related to patient's quality of life and reproductive health become relevant. It is especially important for girls and young females facing cancer therapy who have not yet started family planning. Chemotherapy protocols using alkylating agents and abdominal radiotherapy, which are frequently used in the treatment of childhood and adolescent cancer, can cause gonadal injury. The most common clinical manifests are ovarian hormone insufficiency, premature ovarian insufficiency, early menopause and infertility. In this review we assess current literature and summarize current recommendations on the reproductive function of girls and young females undergoing cancer treatment and their follow-up. Fertility preservation methods are discussed, including psychological and ethical considerations and barriers. Improvement of reproductive health and quality of life of adolescents and young adults (AYA) undergoing cancer treatment is an important issue. Further research should be continued to develop efficient and accessible methods for fertility preservation in young patients. An expert panel including oncologists, radiation oncologists, endocrinologists and gynecologists should always consider fertility preservation in pediatric, adolescent and AYA cancer patients, minding patients' medical condition, cancer staging and potential risk of treatment-related gonadotoxicity.

Endocrine Complications in Children and Adolescents With Non-Central Nervous System Solid Tumors

BACKGROUND

Due to remarkable progress in cancer treatment, endocrine complications are now the major medical issues facing childhood cancer survivors. Although non-central nervous system solid tumors (NCSTs) account for approximately 40% of all pediatric cancers, there have been few studies on endocrine complications associated with NCSTs. This study investigated endocrinopathies following the treatment of pediatric NCSTs.

DESIGN AND SETTING

Retrospective study in a single academic center.

METHODS

This study analyzed 253 survivors of childhood NCSTs who were diagnosed between January of 2000 and December of 2018. The medical charts were reviewed regarding the frequency of endocrinopathies and treatment modalities. The hazard ratios were assessed by multivariable Cox regression analysis. The final height-SDS were analyzed by multivariable linear regression analysis.

RESULTS

There were 76 patients (30%) that developed at least one endocrine complication. Forty-four patients (17.4%) experienced endocrine complications within five years of their cancer diagnosis. The most common endocrine complication was growth failure (n = 35), followed by obesity (n = 18), and primary gonadal failure (n = 16). High cumulative doses of alkylating agents increased the risk of developing at least one endocrine complication. Hematopoietic stem cell transplantation was an important risk factor for primary gonadal failure.

CONCLUSIONS

This study described the comprehensive endocrine outcomes, including growth failure, obesity, primary gonadal failure, primary hypothyroidism, dyslipidemia, and osteoporosis, following the treatment of childhood NCSTs. As endocrinopathies occurred within five years of primary tumor diagnosis, surveillance for endocrine dysfunction is required for early intervention and management.

Do cancer therapies damage the uterus and compromise fertility?

BACKGROUND

As cancer survival rates improve, understanding and preventing the adverse off-target and long-term impacts of cancer treatments, including impacts on fertility, have become increasingly important. Cancer therapy-mediated damage to the ovary and depletion of the primordial follicle reserve are well characterised. However, our knowledge of the full extent of damage to the rest of the female reproductive tract, in particular the uterus, is limited.

OBJECTIVE AND RATIONALE

Improving our understanding of the off-target effects of cancer therapies on the entire female reproductive tract is a critical step towards developing truly effective strategies to protect the fertility of cancer survivors. The objective of this narrative review was to critically evaluate the available literature regarding the capacity for the uterus to sustain a healthy pregnancy following exposure to radiotherapy or chemotherapy.

SEARCH METHODS

The authors performed PubMed (Medline) searches using the following key words: uterus, cancer survivors, radiotherapy, chemotherapy, pregnancy outcome, fertility preservation, infertility. There were no limits placed on time of publication.

OUTCOMES

Overall, there were major limitations to the current available literature, meaning that interpretations should be taken with caution. Despite these drawbacks, data suggest that the uterus may sustain off-target damage, with the extent of damage dependent on the type of cancer treatment and patient age. Specifically, uterine growth is stunted and resistant to hormone replacement therapy in prepubertal girls receiving abdominal, pelvic or whole-body radiotherapy. In contrast, females treated with radiotherapy post-puberty can benefit from hormone replacement therapy, as demonstrated by increased uterine volume and function. No live births have been reported in women previously exposed to radiotherapy after transplantation of cryopreserved ovarian tissue, even when menstruation returns. However, this technique has proven to be a successful fertility preservation method for women previously treated with chemotherapy. Obstetricians commonly report that women who maintain sufficient ovarian function can achieve pregnancy naturally following radiotherapy, but they have thin and/or fibrotic myometrium at delivery, compromising safe delivery and subsequent pregnancy. Furthermore, women exposed to either radiotherapy or chemotherapy have a higher prevalence of preterm birth and low birth weight infants, even in those with normal ovarian function or when oocyte donation is utilised. The mechanisms of potential uterine damage are poorly understood. While the myometrium, vasculature and endometrial progenitor cells are possibly targets, further studies are clearly required and well-controlled animal models could provide the best avenue for these types of future investigations.

WIDER IMPLICATIONS

Female cancer survivors experience greater rates of early pregnancy loss and complications, suggesting that cancer therapy-induced damage to the uterus contributes to infertility. Despite clinical reports dating back to 1989, we highlight a surprising lack of detail in the literature regarding the precise nature and extent of off-target damage inflicted to the uterus in response to cancer therapies. Young women requiring cancer treatment, and the clinicians treating them, must be equipped with accurate information to aid informed decision-making regarding cancer treatment regimens as well as the development and use of effective fertility preservation measures. As the current literature on the impacts of cancer treatments is limited, we hope that our narrative review on this subject will stimulate more research in this important field.

Reproductive Effects of Exposure to Low-Dose Ionizing Radiation: A Long-Term Follow-Up of Immigrant Women Exposed to the Chernobyl Accident

The Chernobyl accident in 1986 spread ionizing radiation over extensive areas of Belarus and Ukraine, leading to adverse health effects in exposed children. More than 30 years later, exposed children have grown and became parents themselves. This retrospective study from Israel was aimed to evaluate whether Chernobyl-exposed women are at higher risk for adverse reproductive outcomes. Exposed immigrants were identified as high or low exposure based on Caesium-137 soil contamination levels registered in the town they lived in. The exposed group was age matched with three comparison groups: non-exposed immigrant women from the Former Soviet Union (FSU) excluding Belarus and the Ukraine, immigrants from other countries (Non FSU) and Israeli-born women at a ratio of 1:10. Chernobyl-exposed women were more likely to be nulliparous and have fewer children (2.1 + 0.8 vs. 3.1 + 1.8, p < 0.001), were more likely to undergo fertility treatments (8.8% vs. 5.8%, adjusted OR = 1.8, 95%CI 1.04-3.2, p = 0.036), and were also more likely to have anemia after delivery (49.4% vs. 36.6%, OR = 1.7, 95%CI 1.2-2.3, p = 0.001), compared to women in the combined comparison groups. The overall fertility of Chernobyl-exposed women seems to be reduced as reflected by the lower number of children and their greater need for fertility treatments.

Uterine irradiation as a determinant of infertility and pregnancy losses in young cancer survivors

Several concerns exist regarding the impact of anticancer treatments on fertility and pregnancy outcome. The detrimental effects of both chemotherapy and radiotherapy on the ovaries are well reported in the available literature. Fewer data are focused on the importance of a functioning uterus to conceive and carry on a healthy pregnancy. The aim of this paper is to provide a narrative review of the current literature to assess the role of uterine irradiation as a potential determinant of infertility and poor obstetrical outcomes. This review addresses the need for multidisciplinary counselling in order to face the poor reproductive and obstetrical outcomes of women who had uterine radiation, according to the different backgrounds (radiotherapy during adulthood versus childhood; total body irradiation versus pituitary, spinal and/or abdominal-pelvic irradiation).

Fertility Preservation in Women: Indications and Options for Therapy

Fertility preservation (FP) is a vital issue for individuals in either reproductive or prepubescent stage of life when future fertility may be compromised. The objective of any FP intervention is to minimize or eliminate primary disease burden and to ensure maintaining or preserving reproductive health. Fertility potential can be affected by cancer therapy and numerous other factors, including advancing age, metabolic conditions, autoimmune diseases, specific surgical interventions, and sex affirmation procedures. A paradigm shift focusing on quality-of-life issues and long-term survivorship has emerged, especially because of advances in cancer diagnostics and treatment. Several FP techniques have been widely distributed, while others are still in the research stage. In addition, specific procedures and some potentially fertoprotective agents are being developed, aiming to minimize the hazards of gonadal damage caused by cancer therapy and decrease the need for more costly, invasive, and time-consuming FP methods. This review highlights the advances, indications, and options for FP, both experimental and well-established, in females of various age groups. An electronic search in PubMed, Embase, and Google Scholar databases was conducted, including retrospective studies, prospective clinical trials, meta-analyses, original reviews, and online abstracts published up to June 30, 2019. The search terms used included fertility preservation, oncofertility, embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation. The meeting proceedings of the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology were also hand searched.

The impact of childhood cancer and its treatment on puberty and subsequent hypothalamic pituitary and gonadal function, in both boys and girls

Childhood cancer survivors (CCS) are at an increased risk of endocrine disorders. Disorders of the hypothalamic-pituitary-gonadal (HPG) axis are a particular concern because of their impact on pubertal development and future fertility and may be of central (hypothalamic or pituitary damage) or primary (gonadal) origin. Hypogonadism may present as pubertal disorders during adolescence and subsequent infertility in adulthood but should be anticipated to ensure appropriate surveillance is in place to address these issues at an appropriate age. Those at risk of HPG axis dysfunction include those with tumours primarily affecting the hypothalamus, pituitary or gonads themselves or due to their treatment with surgery, radiotherapy and chemotherapy. CCS who have had cranial irradiation of more than 30 Gy are at risk of gonadotrophin deficiency. Those who have had gonadotoxic chemotherapy, especially alkylating agents or radiotherapy to the gonads are at risk of primary gonadal failure. HSCT survivors who have had chemotherapy and total body irradiation are at risk of primary gonadal failure but may also have gonadotrophin deficiency. Understanding those at risk is essential to appropriate counselling and long-term follow-up. This chapter gives an overview on the impact of childhood cancer and its treatment on puberty, gonadal function and fertility in childhood cancer survivors.

Scattered Dose to Ovary From Radiotherapy for Neuroblastoma in Female Children

Purpose:

To measure the scattered dose to ovary from radiotherapy for neuroblastoma in female children and to evaluate the relevant risks for radiation-induced ovarian damage.

Material and Methods:

Radiotherapy for child neuroblastoma was simulated on the water phantom. The scattered dose to ovary is measured by ionization chamber on the linear accelerator with 3-dimensional conformal radiation therapy and intensity-modulated radiation therapy treatment producing 6MV and 10MV X-rays. The treatment planning procedure was carried out on a computer system (TPS, Oncentra). Optimization of the number and orientation of beams were performed in order to minimize the ovarian dose.

Results:

For the target dose of 21.6 Gy, the scattered dose to ovary was ranged from 1.3 to 46.8 cGy depending on the treatment method and the energy of the beams. The ovarian dose of intensity-modulated radiation therapy is 1.32 to 1.64 times higher than that of 3-dimensional conformal radiation therapy. The ovarian dose of 6MV beam’s energy is 1.52 to 1.64 times higher than that of 10MV beam’s energy. For the radiotherapy, the scattered dose of ovaries on phantom by ionization chamber was 1.40 to 2.32 times higher than that on TPS calculated.

Conclusion:

The dosimetric data suggest that pediatric radiotherapy is not associated with a risk for permanent damage to the ovaries in female children. Through choosing the beams’ energy and treatment plan’s method, the scattered dose of ovaries can be reduced. The risk for development of hereditary disorders in offspring conceived after exposure is low.

Reproductive Outcomes After a Childhood and Adolescent Young Adult Cancer Diagnosis in Female Cancer Survivors: A Systematic Review and Meta-analysis

Improvements in cancer therapy for childhood and adolescent and young adult (AYA) survivors have increased in excess of 80% among pediatric patients and in excess of 85% among AYA cancer patients. Our research group explored the late effects consequences of cancer treatment on pregnancy and birth outcomes subsequent to a childhood (0-14 years) or AYA (15-25 years) diagnosis of cancer in female cancer survivors. Embase and Medline databases were searched. There were 17 review (n = 10 matched and n = 7 unmatched) studies that met the inclusion criteria. Subanalyses were conducted on 10 matched studies. The median age for all studies for patients at diagnosis and birth was 11 and 27 years, respectively. In matched cohort studies, female childhood and AYA cancer patients, who received chemotherapy alone, had a pooled estimated rate of 18% of experiencing a live birth compared with 10% of females who received radiotherapy alone and subsequently had a live birth. Females who received surgery alone reported higher pooled estimated rates of 44% for a live birth. For matched retrospective review studies, 79% (n = 973) of women experienced a live birth, of which 22% of these babies were born preterm. This meta-analysis found lower birth rates for survivors. Access to fertility-related information and discussions around fertility preservation options and oncofertility psychosocial support should be offered to all cancer patients and their families before starting cancer treatment.

Successful Spontaneous Pregnancy after Treatment for Ewing Sarcoma including Sacrectomy

Ewing sarcomas are highly malignant bone tumors and usually occur in childhood. Radiation therapy, chemotherapy, and surgical methods increase the survival rate of the affected patient, but infertility and reduced reproductive capacity are common late effects of pediatric cancer treatment.

Radiation-induced ovarian follicle loss occurs without overt stromal changes

Radiation damage due to total body irradiation (TBI) or targeted abdominal radiation can deplete ovarian follicles and accelerate reproductive aging. We characterized a mouse model of low-dose TBI to investigate how radiation affects the follicular and stromal compartments of the ovary. A single TBI dose of either 0.1 Gy or 1 Gy (Cesium-137 γ) was delivered to reproductively adult CD1 female mice, and sham-treated mice served as controls. Mice were euthanized either 2 weeks or 5 weeks post exposure, and ovarian tissue was harvested. To assess the ovarian reserve, we classified and counted the number of morphologically normal follicles in ovarian histologic sections for all experimental cohorts using an objective method based on immunohistochemistry for an oocyte-specific protein (MSY2). 0.1 Gy did not affect that total number of ovarian follicles, whereas 1 Gy resulted in a dramatic loss. At two weeks, there was a significant reduction in all preantral follicles, but early antral and antral follicles were still present. By five weeks, there was complete depletion of all follicle classes. We examined stromal quality using histologic stains to visualize ovarian architecture and fibrosis and by immunohistochemistry and quantitative microscopy to assess cell proliferation, cell death and vasculature. There were no differences in the ovarian stroma across cohorts with respect to these markers, indicating that this compartment is more radio-resistant relative to the germ cells. These findings have implications for reproductive health and the field of fertility preservation because the radiation doses we examined mimic scatter doses experienced in typical therapeutic regimens.

Ovarian and Uterine Functions in Female Survivors of Childhood Cancers

Adult survivors of childhood cancers are more prone to developing poor reproductive and obstetrical outcomes than their siblings and the general population as a result of previous exposure to chemotherapy and radiation during childhood. Chemotherapy drugs exert cytotoxic effects systemically and therefore can damage the ovaries, leading to infertility, premature ovarian failure, and, to a lesser extent, spontaneous abortions. They have very limited or no deleterious effects on the uterus that can be recognized clinically. By contrast, radiation is detrimental to both the ovaries and the uterus, thereby causing a greater magnitude of adverse effects on the female reproductive function. These include infertility, premature ovarian failure, miscarriage, fetal growth restrictions, perinatal deaths, preterm births, delivery of small-for-gestational-age infants, preeclampsia, and abnormal placentation. Regrettably, the majority of these adverse outcomes arise from radiation-induced uterine injury and are reported at higher incidence in the adult survivors of childhood cancers who were exposed to uterine radiation during childhood in the form of pelvic, spinal, or total-body irradiation. Recent findings of long-term follow-up studies evaluating reproductive performance of female survivors provided some reassurance to female cancer survivors by documenting that pregnancy and live birth rates were not significantly compromised in survivors, including those who had been treated with alkylating agents and had not received pelvic, cranial, and total-body irradiation. We aimed in this narrative review article to provide an update on the impact of chemotherapy and radiation on the ovarian and uterine function in female survivors of childhood cancer.

IMPLICATIONS FOR PRACTICE

Adult survivors of childhood cancers are more prone to developing a number of poor reproductive and obstetrical outcomes than their siblings and the general population as a result of previous exposure to chemotherapy and radiation during childhood. The impact of radiation therapy on the female genital system is greater than chemotherapy regimens because radiation is detrimental to both the uterus and the ovaries, whereas toxic effects of chemotherapy drugs are confined to the ovaries. Therefore, radiation-induced uterine damage accounts for most poor obstetrical outcomes in the survivors. These include infertility, miscarriages, stillbirths, fetal growth restrictions, preeclampsia, and preterm deliveries.

A review of late complications of allogeneic hematopoietic stem cell transplantations

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective and curative treatment of different malignant and non-malignant diseases. Early transplant-related mortality after allo-HSCT has decreased with reduced-intensity conditioning regimens and effective anti-infectious treatments, but late transplant-related mortality is still a problem. Physicians are now paying more attention to late complications that may worsen the quality of life of many transplant recipients. Chronic graft versus host disease (cGVHD) is one of the major causes of late transplant-related mortality after allo-HSCT. This review discusses recent advances that have been made in clinical evaluation and treatment of late transplant-related complications including cGVHD. The different sites of involvement are organs, especially the skin and eye, and the gastrointestinal, endocrinologic, metabolic, renal, cardiologic, pulmonary, connective tissue, and neurological systems. In addition, this review includes infections and secondary malignancies in post-transplant settings that worsen quality of life in long-term follow-ups.

Toward precision medicine for preserving fertility in cancer patients: existing and emerging fertility preservation options for women

As the number of young cancer survivors increases, quality of life after cancer treatment is becoming an ever more important consideration. According to a report from the American Cancer Society, approximately 810,170 women were diagnosed with cancer in 2015 in the United States. Among female cancer survivors, 1 in 250 are of reproductive age. Anticancer therapies can result in infertility or sterility and can have long-term negative effects on bone health, cardiovascular health as a result of reproductive endocrine function. Fertility preservation has been identified by many young patients diagnosed with cancer as second only to survival in terms of importance. The development of fertility preservation technologies aims to help patients diagnosed with cancer to preserve or protect their fertility prior to exposure to chemo- or radiation therapy, thus improving their chances of having a family and enhancing their quality of life as a cancer survivor. Currently, sperm, egg, and embryo banking are standard of care for preserving fertility for reproductive-age cancer patients; ovarian tissue cryopreservation is still considered experimental. Adoption and surrogate may also need to be considered. All patients should receive information about the fertility risks associated with their cancer treatment and the fertility preservation options available in a timely manner, whether or not they decide to ultimately pursue fertility preservation. Because of the ever expanding number of options for treating cancer and preserving fertility, there is now an opportunity to take a precision medicine approach to informing patients about the fertility risks associated with their cancer treatment and the fertility preservation options that are available to them.

Low Anti-Müllerian Hormone in Pediatric Cancer Survivors in the Early Years after Gonadotoxic Therapy

STUDY OBJECTIVE

To obtain anti-Müllerian hormone (AMH) levels in female childhood cancer survivors and determine the association of therapeutic exposures with diminished ovarian reserve (DOR).

DESIGN

Cross-sectional study.

SETTING

Academic medical center.

PARTICIPANTS

Forty-nine survivors (mean age = 14.9 years, SD = 3.3 years; mean time without therapy = 7.5 years, SD = 3.6 years) who received alkylator/heavy metal chemotherapy, and/or radiation exposure to the ovaries with 2 or more years without therapy were recruited.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

AMH, follicle stimulating hormone (FSH) levels (random), and therapeutic characteristics such as cyclophosphamide equivalent dose (CED), heavy metal exposure, and bilateral ovarian radiation exposure were determined for each subject. DOR was defined as a low AMH (less than the fifth percentile for age-matched controls), and premature ovarian insufficiency as an FSH greater than 40 IU/L with AMH less than the fifth percentile.

RESULTS

Fourteen subjects (28.6%) had DOR, and 5 (10.2%) had premature ovarian insufficiency. Those with a low AMH were more likely exposed to a higher CED (P = .001) and/or bilateral ovarian radiation exposure (P = .048). In the multivariate model of DOR adjusted for age at diagnosis, DOR was associated with bilateral radiation (odds ratio = 39.9; 95% confidence interval 2.1-759.7; P = .04). There was a nonsignificant trend with increasing odds of low AMH with increased CED.

CONCLUSION

DOR, defined by an AMH less than the fifth percentile, was observed in more than one-quarter of pediatric cancer survivors exposed to gonadotoxic cancer therapy and was significantly associated with bilateral ovarian irradiation. Identifying risk factors for low AMH prompts AMH and FSH surveillance in the early years after cancer therapy and, if needed, early referral to a reproductive specialist.

Self-collected dried blood spots as a tool for measuring ovarian reserve in young female cancer survivors

STUDY QUESTION

Are female young cancer survivors (YCS) able to self-collect high-quality dried blood spots (DBSs) at home to provide biospecimens for studying ovarian reserve?

SUMMARY ANSWER

YCS can self-collect high-quality DBS specimens in non-clinical settings, and anti-Mullerian hormone (AMH) levels can be assayed in such specimens.

WHAT IS KNOWN ALREADY

Large-scale biosample collection is a barrier to studying ovarian reserve in YCS. DBS collected by research personnel has high acceptability. AMH levels measured in DBS are highly correlated with those measured by serum-based methods.

STUDY DESIGN, SIZE, DURATION

In a prospective cohort study, YCS were recruited to self-collect DBS samples. AMH levels were assayed in 112 samples.

PARTICIPANTS/MATERIALS, SETTING, METHODS

YCS participants, ages 18-44, were recruited from a nationwide longitudinal cohort and DBS collection materials were posted to them. AMH levels were assayed by the Ansh DBS AMH ELISA and compared according to participant characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 163 potential participants, 123 (75%) were enrolled. Of those enrolled, 112 (91%) were able to complete DBS self-collection and submit mailed samples adequate for measuring AMH. Participants (mean age 31.6 [SD 5.5]) were 85% white, 87% college graduates and 46% reported higher income. Common cancer types were lymphoma and leukemia (34%), breast cancer (30%) and thyroid or skin cancer (8%). The geometric mean (95% confidence interval) AMH level in DBS samples was 0.24 ng/ml (0.16-0.36). In adjusted analysis, AMH levels for survivors of breast cancer (0.02 ng/ml [0.01-0.07]) or leukemia/lymphoma (0.03 ng/ml [0.01-0.08]) were lower than the levels in thyroid or skin cancer survivors (0.12 ng/ml [0.03-0.44]). Pelvic radiation remained associated with lower AMH levels (0.20 ng/ml [0.10-0.40] in unexposed versus 0.02 ng/ml [0.01-0.06] in exposed). Amenorrheic survivors had AMH levels (0.02 ng/ml [0.01-0.06]) that were lower than those of YCS with 7-9 (0.09 ng/ml [0.03-0.32]) or ≥10 (0.17 ng/ml [0.08-0.37]) menstrual periods in the past year.

LIMITATIONS, REASONS FOR CAUTION

The results are generalizable to a population of highly educated, higher income YCS. It is unclear how generalizable the results are to other populations.

WIDER IMPLICATIONS OF THE FINDINGS

Self-collected DBS is a patient-friendly and minimally invasive tool for studying ovarian reserve in geographically diverse populations.

STUDY FUNDING/COMPETING INTERESTS

Research related to the development of this paper was supported by the National Institutes of Health, grants UL1 RR024926 pilot and HD080952-02, and by the American Cancer Society MRSG-08-110-01-CCE. The authors report no competing interests.

Pregnancy Incidence in Female Nasopharyngeal Carcinoma Survivors of Reproductive Age: A Population-Based Study

This study evaluated the pregnancy incidence in female nasopharyngeal carcinoma (NPC) survivors of reproductive age.In a nationwide cohort, 2816 female patients 15 to 50 years of age from 1998 to 2010 were identified from the Taiwan National Health Insurance Research database. Comorbidities, complications during pregnancy, and delivery status were recorded. All patients were followed up until a diagnosis of pregnancy, withdrawal from the National Health Insurance system, or December 31, 2011.Overall, 155 patients (incidence rate [IR] = 9.50) were pregnant in the NPC group, whereas 251 patients (IR = 12.80) were pregnant in the non-NPC group. The cumulative incidence of pregnancy in the NPC group was lower than that in the non-NPC group (incidence rate ratio = 0.74, 95% CI = 0.61-0.91). The adjusted hazard ratio of pregnancy in the NPC group was 0.79 with 95% CI = 0.61-0.96, compared with the non-NPC group.The incidence of pregnancy is significantly lower among female NPC survivors of reproductive age than among those without NPC.

[Fertility preservation in women of the childbearing age: Indications and strategies]

Advances on cryopreservation techniques now allow considering oocyte, embryo or ovarian tissue freezing for female fertility preservation. Originally developed for patients suffering from cancer, fertility preservation has rapidly invaded others medical fields, and represents now the standard of care for all young patient diagnosed with a disease that could impair fertility or having to receive possibly gonadotoxic treatment. As a result, autoimmune diseases, some genetic pathologies or iterative pelvic surgeries, at risk of premature ovarian failure, have become common indications of fertility preservation. In addition, the social egg freezing aiming at preventing the age-related fertility decline is still debated in France, although authorized in numerous countries. This review will discuss the different strategies of fertility preservation in young girls and women of reproductive age, regarding different medical or non-medical indications.

Exposure to radiation therapy is associated with female reproductive health among childhood cancer survivors: a meta-analysis study

BACKGROUND AND AIMS

Many epidemiological studies have revealed a positive correlation between medical radiation exposure and the reproductive health in female childhood cancer survivors. However, because of variations in the samples size, such studies showed partly inconsistent conclusions. The aim of this meta-analysis was to clarify the association between radiotherapy and the risk of reproductive health impairment for female who survived from childhood cancer.

METHODS

Fourteen cohort studies involving childhood radiotherapy were selected as the exposure of interest and the impaired reproductive health condition during the childbearing age as the outcome. Among meta-analysis of observational studies found in Pubmed and Embase from 1900 to 2014, we evaluated those relevant observational studies which surveyed the association of medical radiation and reproductive health in female childhood cancer survivors. Review Manager 5.2 and STATA 12.0 software were used to perform the meta-analysis. Study-specific estimations for each outcome were combined into a pooled relative risk (RR) with 95% confidence interval (CI) by a meta-analytic approach.

RESULTS

Based on a random-effects meta-analysis, significant association between infertility (RR = 1.28, 95% CI = 1.16-1.42), acute ovarian failure (AOF) (RR = 9.51, 95% CI = 5.03-17.96), low level of anti mullerian hormone (AMH) (<1 ng/mL) (RR = 14.79, 95% CI = 3.36-66.64), stillbirth (RR = 1.19, 95% CI = 1.02-1.39) and low birth weight (RR = 2.22, 95% CI = 1.55-3.17) were identified. Conversely, no significant results were found in abortion and congenital malformations.

CONCLUSIONS

To the best of our knowledge, this is the first meta-analysis assessing the effect of medical radiation on female childhood cancer survivors' reproductive capability and pregnancy outcomes. Although there were some limitations, our meta-analysis further supported that radiotherapy was a risk factor for reproductive health problems of female who survived from childhood cancer.

Evidence to incorporate inclusive reproductive health measures in guidelines for childhood and adolescent cancer survivors

OBJECTIVE

Female childhood cancer survivors are at an increased risk of reproductive health impairment. We compared reproductive health outcomes with the recommended standard in a cohort of childhood cancer survivors.

STUDY DESIGN AND PARTICIPANTS

A retrospective chart review of 222 female childhood cancer survivors aged 21 years or younger that presented to a tertiary referral center between 1997-2008 was initiated. The main outcome measures were the compliance with the American Society of Clinical Oncology guidelines for childhood cancer survivor management of reproductive health. In particular, we evaluated menstrual cycle regularity, fertility preservation counseling, and endocrine profile, as defined by follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH) levels as surrogate markers for ovarian reserve. Secondary outcomes were to study the contribution of survivor clinics in enforcing these guidelines.

RESULTS

Of 136 patients older than 13 years at their last visit, 58 patients (43%) had FSH data available and none had AMH data. Patients were stratified into 3 groups according to FSH levels. Forty of 58 patients (69%) have normal ovarian reserve (FSH level < 10), 10 of 58 patients (17%) have decreased ovarian reserve (FSH levels 10-40), and 8 of 58 patients (14%) have premature menopause, defined as FSH > 40. Most patients with amenorrhea have elevated FSH levels indicating primary ovarian insufficiency, while 3 patients (2.2%) have low FSH levels consistent with hypothalamic amenorrhea. None of the patients were counseled on fertility preservation.

CONCLUSIONS

Reproductive health follow-up in children with cancer, including FSH and AMH measurement when indicated, should be established and strictly adhered.

Ovarian function in survivors of childhood medulloblastoma: Impact of reduced dose craniospinal irradiation and high-dose chemotherapy with autologous stem cell rescue

BACKGROUND

Data on ovarian function (OvF) in medulloblastoma (MB) survivors is limited, with most studies describing outcomes in survivors treated with craniospinal irradiation (CSI) doses >24 Gy ± standard chemotherapy. The objective of the current study is to report on OvF: (i) across a range of CSI doses; and (ii) following high-dose chemotherapy with autologous stem cell rescue (ASCR).

PROCEDURE

Retrospective review of female MB survivors who were diagnosed in childhood and followed at Memorial Sloan Kettering Cancer Center. Patients were divided into three groups: (i) CSI ≤24 Gy +/- standard chemotherapy; (ii) CSI ≥35 Gy +/- standard chemotherapy; and (iii) high-dose chemotherapy with ASCR +/- CSI.

RESULTS

Primary ovarian dysfunction (POD) occurred in 2/17 subjects in group 1, 3/9 subjects in group 2 and 5/5 subjects in group 3 (P < 0.01). Normalization of function was noted in four subjects with POD. Persistent POD requiring hormone replacement (POF) was observed in 1/17 subjects in group 1, 2/9 in group 2, and 3/5 in group 3 (P = 0.02). Neither age at treatment nor type of standard chemotherapy correlated with risk of POD or POF.

CONCLUSIONS

Both POD and POF appear to occur in a small proportion of patients who are treated with contemporary doses of CSI +/- standard chemotherapy. However, ovarian dysfunction requiring hormone replacement therapy is common following high-dose chemotherapy associated with ASCR. These findings will assist clinicians in counseling patients regarding fertility preservation and risk of impaired ovarian function/future fertility. Pediatr Blood Cancer 2015;62:317-321. © 2014 Wiley Periodicals, Inc.

Fertility preservation in young females with hematological malignancies

Impaired reproductive function and possible infertility are major concerns in long-term survivors of hematological malignancies. The ongoing increase in the survival rates of these patients is therefore accompanied with a growing demand for effective, safe and specifically tailored fertility preservation options. When approaching patients facing hematological malignancy, an individual evaluation of potential infertility risks and possible preventive or preserving measures should be performed. This review aims to provide up-to-date knowledge on female reproductive risks, and ovarian, uterine and genital injuries associated with therapy regimens currently used in hemato-oncological disorders. Recent progress in fertility preservation methods including ovarian tissue cryopreservation and transplantation, egg and embryo freezing, ovarian transposition and their specific role in hematological disorders are presented. The efficacy of these methods, possible risks and future challenges are critically discussed.

The impact of uterine radiation on subsequent fertility and pregnancy outcomes

Future fertility is of paramount importance to younger cancer survivors. Advances in assisted reproductive technology mean that young women treated with radiation involving the uterus may require clinical guidance regarding whether to attempt a pregnancy themselves. We performed a review of the literature regarding radiation involving uterus (total body irradiation (TBI) and pelvic radiation), fertility, and pregnancy outcomes to come up with a recommendation for our patients. Limited evidence suggests lower fecundity and an increased incidence of pregnancy complications after uterine radiation. Higher radiation doses and direct uterine radiation both significantly increase the risk of an adverse pregnancy outcome. Uterine radiation doses of <4 Gy do not appear to impair uterine function. Adult TBI data (usually 12 Gy) suggest pregnancy is possible but with lower fecundity and more complications. Although there is no clear data indicating the dose of radiation to the uterus, above which a pregnancy would not be sustainable, we suggest patients receiving >45 Gy during adulthood and >25 Gy in childhood be counselled to avoid attempting pregnancy. There is preliminary evidence that menopausal hormone therapy and a combination of pentoxifylline and tocopherol may improve uterine function following irradiation.

A fixed-jaw method to protect critical organs during intensity-modulated radiotherapy

Intensity-modulated radiotherapy (IMRT) plays an important role in cancer radiotherapy. For some patients being treated with IMRT, the extremely low tolerances of critical organs (such as lens, ovaries, and testicles) cannot be met during treatment planning. The aim of this article is to introduce a new planning method to overcome that problem. In current planning practice, jaw positions are automatically set to cover all target volumes by the planning system (e.g., Pinnacle(3) system). Because of such settings, critical organs may be fully blocked by the multileaf collimator (MLC), but they still sit in the field that is shaped by collimator jaws. These critical organs receive doses from the transmission and leakage of MLC leaves. We manually fixed jaw positions to block them to further reduce such doses. This method has been used for different treatment sites in our clinic, and it was thoroughly evaluated in patients with radical hysterectomy plus ovarian transposition after surgery. For each patient, 2 treatment plans were designed with the same optimization parameters: the original plan with automatically chosen jaw positions (called O-plan) and the plan with fixed-jaw positions (named F-plan). In the F-plan, the jaws were manually fixed to block the ovaries. For target coverage, the mean conformity index (CI) of the F-plan (1.28 ± 0.02) was remarkably lower than that of the O-plan (1.53 ± 0.09) (p < 0.05). The F-plan and the O-plan performed similarly in target dose homogeneity. Meanwhile, for the critical organ sparing, the mean dose of both ovaries were much lower in the F-plan than that in the O-plan (p < 0.05). The V20, V30, and V40 of bladder were also lower in the F-plan (93.57 ± 1.98, 73.99 ± 5.76, and 42.33 ± 3.7, respectively) than those in the O-plan (97.98 ± 1.11, 85.07 ± 4.04, and 49.71 ± 3.63, respectively) (p < 0.05). The maximum dose to the spinal cord planning organ at risk (OAR) volume (PRV) in the O-plan (3940.24 ± 102.8) was higher than that in the F-plan (3628.18 ± 131.45) with significant differences (p < 0.01). For other OARs, there were no significant differences in doses between these 2 plans except that the high-dose regions of the rectum were higher for V40 in the O-plan than that in the F-plan (p < 0.01). But the monitor units (MUs) in the F-plan were 1.4 times as much as that in the O-plan. Thus the treatment time could be longer by using the F-plan. As it results in more MUs in spite of better plan quality, it is recommended to be used only in situations in which clinical requirements to critical organs cannot be met with the regular method.

Endocrinopathies after allogeneic and autologous transplantation of hematopoietic stem cells

Early and late endocrine disorders are among the most common complications in survivors after hematopoietic allogeneic- (allo-) and autologous- (auto-) stem cell transplant (HSCT). This review summarizes main endocrine disorders reported in literature and observed in our center as consequence of auto- and allo-HSCT and outlines current options for their management. Gonadal impairment has been found early in approximately two-thirds of auto- and allo-HSCT patients: 90–99% of women and 60–90% of men. Dysfunctions of the hypothalamus-pituitary-growth hormone/insulin growth factor-I axis, hypothalamus-pituitary-thyroid axis, and hypothalamus-pituitary-adrenal axis were documented as later complicances, occurring in about 10, 30, and 40–50% of transplanted patients, respectively. Moreover, overt or subclinical thyroid complications (including persistent low-T3 syndrome, chronic thyroiditis, subclinical hypo- or hyperthyroidism, and thyroid carcinoma), gonadal failure, and adrenal insufficiency may persist many years after HSCT. Our analysis further provides evidence that main recognized risk factors for endocrine complications after HSCT are the underlying disease, previous pretransplant therapies, the age at HSCT, gender, total body irradiation, posttransplant derangement of immune system, and in the allogeneic setting, the presence of graft-versus-host disease requiring prolonged steroid treatment. Early identification of endocrine complications can greatly improve the quality of life of long-term survivors after HSCT.

Impact of chemotherapy and radiotherapy in childhood on fertility in adulthood: the FeCt-survey of childhood cancer survivors in Germany

PURPOSE

Improved treatment for childhood cancer has led to better survival rates of 83 % today. However, long-term side effects including infertility of pediatric patients receiving oncologic treatment remain unclear. We examined the association of chemotherapy and radiotherapy with infertility in survivors of pediatric cancer.

METHODS

A questionnaire on fertility was sent to adult survivors listed in the German Childhood Cancer Registry. Fertility status was defined based on information on attempts to conceive, pregnancies, births, menstrual cycle and previous fertility test results.

RESULTS

Therapeutic data were obtained from treatment optimization trials. We included 618 childhood cancer survivors (384 women) who reported information allowing us to classify their current fertility status as 'fertile/probably fertile' or 'probably infertile'. Thirty-one percent of 83 female and 29 % of 117 male survivors reported infertility based on previous fertility tests. 'Probably infertile' adult survivors were more likely to have received pelvic radiotherapy (women: adjusted OR 20.24, 95 % CI 4.69-87.29; men: 12.22; 1.18-126.70) than those who were 'fertile/probably fertile'. Etoposide, particularly ≥5,000 mg/m(2) in women, and carboplatin and/or cisplatin in both sexes seemed to have independent risk potential for infertility. Similarly, cancer treatment during or post-puberty compared to treatment before puberty showed a trend toward increased infertility, particularly in male survivors.

CONCLUSIONS

Patients and families need to be informed about fertility-preserving measures prior to and also after chemotherapy and radiotherapy.

Current approach to fertility preservation by embryo cryopreservation

The ovaries are susceptible to damage following treatment with gonadotoxic chemotherapy, pelvic radiotherapy, and/or ovarian surgery. Gonadotoxic treatments have also been used in patients with various nonmalignant systemic diseases. Any women of reproductive age with a sufficiently high risk of developing future ovarian failure due to those medical interventions may benefit from embryo cryopreservation though the tools of assessment of such a risk are still not very precise. Furthermore, the risk assessment can be influenced by many other factors such as the delay expected after chemotherapy and the number of children desired in the future. Embryo cryopreservation is an established and most successful method of fertility preservation when there is sufficient time available to perform ovarian stimulation. This publication will review the current state, approach, and indications of embryo cryopreservation for fertility preservation.

Antimüllerian hormone, the assessment of the ovarian reserve, and the reproductive outcome of the young patient with cancer

The accurate assessment of the ovarian reserve has long been a key goal in reproductive medicine. The recognition that serum antimüllerian hormone provides an indirect measure of the ovarian reserve has led to its rapid adoption in assisted conception, and wide exploration of its potential across the reproductive lifespan from the neonate to the menopause. In this short review we discuss its relationship with the ovarian reserve in its varied meanings, and in various contexts. These include in childhood and adolescence, and in the assessment of the impact of cancer therapy on the female reproductive tract. These therapies can adversely impact all aspects of female reproduction, including hypothalamic, pituitary, and ovarian hormonal activity, and the ability of the uterus to support a successful pregnancy.

Evaluation of ovarian and testicular tissue cryopreservation in children undergoing gonadotoxic therapies

OBJECTIVE

Ovarian and testicular tissue cryopreservation are the only fertility preservation options for sexually immature individuals. Because of their experimental nature, it is important to determine safety and possible bundling with other medicallyindicated procedures.

STUDY DESIGN

Prospective observational.

RESULTS

Cryopreservation indications included cancer in 75 % of females and 50 % of males, while non-cancer indications included various hematological conditions. Similar numbers of females (12/28) and males (3/9) underwent prior chemotherapy. Females underwent laparoscopic (27/28) or robotic (1/28) approaches while incisional biopsy was used in males. Bundling of ovarian and testicular harvesting with other medicallyindicated procedures was performed in 42 % and 22 %, respectively. The operative time inclusive of bundled procedures was similar (1.6 ± 0.1 vs. 0.9 ± 0.3 h) but the discharge time was significantly longer for females than males (10.4 ± 0.6 vs. 4.6 ± 0.6 h, p<0.05) due to frequent bundling of medically-indicated procedures in females. All procedures were successfully completed without complications or significant blood loss.

CONCLUSIONS

Pediatric gonadal tissue cryopreservation can be combined with other medically-indicated procedures to minimize the potential inconvenience, additional anesthetic risks, and costs.

The management of children with lymphomas

Lymphomas account for 10-15% of all paediatric malignancies. They are highly curable with 5 year survival rates of up to 95% for Hodgkin lymphoma and 82% for non-Hodgkin lymphoma. These excellent results have focused recent attention on reducing the burden of treatment-related morbidity while maintaining the excellent outcomes. Lymphomas are highly radiosensitive and radiotherapy was used historically in the treatment of both paediatric Hodgkin and non-Hodgkin lymphomas. As the late effects of radiotherapy, including second tumours, were recognised, successive protocols seeking to minimise late effects were developed that reduced the use of radiotherapy. Current treatment protocols for non-Hodgkin lymphoma are chemotherapy based and radiotherapy has been virtually eliminated. In contrast, current paediatric Hodgkin lymphoma protocols continue to use radiotherapy as part of combined modality treatment, targeted according to risk factors and response and at the minimum effective dose. This article reviews the treatment of Hodgkin lymphoma in children with particular emphasis on the role of radiotherapy.

Recommendations for fertility preservation in patients with lymphomas

PURPOSE

This guideline aims to serve as a reference for fertility specialists and other specialists working with young patients at risk of premature ovarian insufficiency (POI) or testicular dysfunction (TD) due to treatment of Hodgkin or Non-Hodgkin lymphoma.

METHODS

PubMed search of articles addressing risk of POI and TD according to different treatment protocols used in lymphoma patients. PubMed search of articles presenting different options for fertility treatment in cancer patients.

RESULTS

The risk of POI/TD depends on the protocol used with the highest risk in patients treated with haematopoietic stem cell transplantation/bone marrow transplantation (HSCT/BMT) and the lowest risk in patients treated with ABVD (Adriamycin, Bleomycin, Vincristine and Decarbazine). The different options of fertility preservation are discussed and their relevance according to treatment protocol, age of the patient and urgency to start treatment.

CONCLUSION

Fertility issues should be discussed with all women of fertile age. Fertility preservation should be offered to young women when relevant. Children should be informed together with their parents. All men should be offered semen cryopreservation regardless of protocol used. At present, there are no established methods of fertility preservation in pre-pubertal boys. This guideline offers suggestions to the most preferred methods of fertility preservation according to treatment protocol, age of the patient, and urgency to start treatment.

Assessment of ovarian movement on consecutive pelvic MRI examinations in patients with gynaecological malignancies: what is the planning organ-at-risk volume for radiotherapy?

OBJECTIVES

The aims of this study are to assess the extent of ovarian movement on consecutive MRI examinations in patients with gynaecological malignancies and to define potential safety volumes around the ovaries that may avoid ovarian ablation during pelvic irradiation.

METHODS

Patients with cervical, vaginal and endometrial cancer who underwent MRI examinations of the pelvis before and during radiotherapy were included in the study. The position of the ovaries was retrospectively determined on two consecutive axial and sagittal T(2) weighted MRI examinations of the pelvis. Ovarian movement was determined in craniocaudal, anteroposterior and mediolateral directions. Safety volumes were calculated by computing elliptical volumes based on the derived 95% and 99% reference intervals.

RESULTS

30 patients with a gynaecological malignancy were included. Both ovaries could be identified on the MRI examinations in all cases. The safety volumes around the ovaries encompassing 95% and 99% of ovarian movement were 11 and 25 cm(3) (95%), and 24 and 54 cm(3) (99%), for the left and right ovary, respectively.

CONCLUSION

Adding a safety volume around the ovaries may reduce the high radiation dose to the ovaries. This could potentially avoid ovarian ablation, reducing significant fertility morbidity.