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Sakashita K, Komori K, Morokawa H, Kurata T. Screening and interventional strategies for the late effects and toxicities of hematological malignancy treatments in pediatric survivors. Expert Rev Hematol 2024; 17:313-327. [PMID: 38899398 DOI: 10.1080/17474086.2024.2370559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 06/17/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Advancements in pediatric cancer treatment have increased patient survival rates; however, childhood cancer survivors may face long-term health challenges due to treatment-related effects on organs. Regular post-treatment surveillance and early intervention are crucial for improving the survivors' quality of life and long-term health outcomes. The present paper highlights the significance of late effects in childhood cancer survivors, particularly those with hematologic malignancies, stressing the importance of a vigilant follow-up approach to ensure better overall well-being. AREAS COVERED This article provides an overview of the treatment history of childhood leukemia and lymphoma as well as outlines the emerging late effects of treatments. We discuss the various types of these complications and their corresponding risk factors. EXPERT OPINION Standardizing survivorship care in pediatric cancer aims to improve patient well-being by optimizing their health outcomes and quality of life. This involves early identification and intervention of late effects, requiring collaboration among specialists, nurses, and advocates, and emphasizing data sharing and international cooperation.
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Affiliation(s)
- Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Hirokazu Morokawa
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
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2
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Pourhassan H, Murphy L, Aldoss I. Glucocorticoid Therapy in Acute Lymphoblastic Leukemia: Navigating Short-Term and Long-Term Effects and Optimal Regimen Selection. Curr Hematol Malig Rep 2024:10.1007/s11899-024-00735-w. [PMID: 38867099 DOI: 10.1007/s11899-024-00735-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE OF REVIEW Glucocorticoids are a mainstay in acute lymphoblastic leukemia treatment and lack of early response is predictive for overall disease prognosis. Given the vital position of glucocorticoids and well known long and short-term side effects associated with differing glucocorticoids, we aim to highlight the wide breadth of historical and more contemporary data to describe the current landscape of glucocorticoid use in this arena. RECENT FINDINGS Emerging studies aim to overcome issues such as steroid resistance and to optimize the antileukemic effects of glucocorticoids while aiming to mitigate the risks and side effects associated with their exposure. Glucocorticoids have and likely always will be a fundamental component of acute lymphoblastic leukemia treatment and understanding how to navigate short- and long-term effects and how to optimize regimens is at the heart of continued treatment success.
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Affiliation(s)
- Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Lindsey Murphy
- Department of Pediatrics, City of Hope National Medical Center, Duarte, California, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA.
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3
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Gökbuget N, Boissel N, Chiaretti S, Dombret H, Doubek M, Fielding A, Foà R, Giebel S, Hoelzer D, Hunault M, Marks DI, Martinelli G, Ottmann O, Rijneveld A, Rousselot P, Ribera J, Bassan R. Management of ALL in adults: 2024 ELN recommendations from a European expert panel. Blood 2024; 143:1903-1930. [PMID: 38306595 DOI: 10.1182/blood.2023023568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/04/2024] Open
Abstract
ABSTRACT Experts from the European Leukemia Net (ELN) working group for adult acute lymphoblastic leukemia have identified an unmet need for guidance regarding management of adult acute lymphoblastic leukemia (ALL) from diagnosis to aftercare. The group has previously summarized their recommendations regarding diagnostic approaches, prognostic factors, and assessment of ALL. The current recommendation summarizes clinical management. It covers treatment approaches, including the use of new immunotherapies, application of minimal residual disease for treatment decisions, management of specific subgroups, and challenging treatment situations as well as late effects and supportive care. The recommendation provides guidance for physicians caring for adult patients with ALL which has to be complemented by regional expertise preferably provided by national academic study groups.
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Affiliation(s)
- Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, Goethe University, University Hospital, Frankfurt, Germany
| | - Nicolas Boissel
- Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sabina Chiaretti
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Hervé Dombret
- Leukemia Department, University Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Saint-Louis Research Institute, Université Paris Cité, Paris, France
| | - Michael Doubek
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Dieter Hoelzer
- Department of Medicine II, Hematology/Oncology, Goethe University, University Hospital, Frankfurt, Germany
| | - Mathilde Hunault
- Maladies du Sang University Hospital of Angers, FHU Goal, INSERM, National Centre for Scientific Research, Angers, France
| | - David I Marks
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Giovanni Martinelli
- IRCCS Istituto Romagnolo per lo Studio dei Tumori Dino Amadori, Meldola, Italy
| | - Oliver Ottmann
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - Philippe Rousselot
- Clinical Hematology Department, Centre Hospitalier de Versailles, Université Paris-Saclay, Versailles, France
| | - Josep Ribera
- Clinical Hematology Department, Institut Catala d'Oncologia Hospital Germans Trias I Pujol, Josep Carreras Research Institute, Badalona, Spain
| | - Renato Bassan
- Division of Hematology, Ospedale dell'Angelo, Mestre-Venice, Italy
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4
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Gottlich CP, Fisher JC, Diab M. A Current Review in the Orthopedic Management of Osteonecrosis of the knee Secondary to Treatment of Pediatric Hematologic Malignancy. Orthop Rev (Pavia) 2024; 16:115354. [PMID: 38533522 PMCID: PMC10963255 DOI: 10.52965/001c.115354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/05/2024] [Indexed: 03/28/2024] Open
Abstract
Acute Lymphoblastic Leukemia is the most prevalent pediatric hematologic malignancy. The treatment for this illness has advanced significantly, now touting a 90% cure rate. Although these patients often become disease free, treatment can leave devastating effects that last long after their disease burden is alleviated. A commonly experienced result of treatment is osteonecrosis (ON), often occurring in weight bearing joints. Uncertainty exists in the optimal treatment of this cohort of patients. In this review, we describe the etiology and suspected pathogenesis of ON, as well as treatment options described in the literature.
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Affiliation(s)
| | - John C Fisher
- Orthopedic Surgery Texas Tech University Health Sciences Center
| | - Michel Diab
- Orthopedic Surgery Texas Tech University Health Sciences Center
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5
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Hayashi H, Makimoto A, Yuza Y. Treatment of Pediatric Acute Lymphoblastic Leukemia: A Historical Perspective. Cancers (Basel) 2024; 16:723. [PMID: 38398113 PMCID: PMC10887299 DOI: 10.3390/cancers16040723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common disease in pediatric oncology. The history of developmental therapeutics for ALL began in the 1960s with the repetition of "unreliable" medical interventions against this lethal disease. By the 1990s, the development of multi-agent chemotherapy and various types of supportive care rendered ALL treatable. Highly sophisticated, molecular, diagnostic techniques have enabled highly accurate prediction of the relapse risk, and the application of risk-adapted treatments has increased the survival rate in the standard-risk group to nearly 100% in most European nations and North America. Incorporation of state-of-the-art, molecularly targeted agents and novel treatments, including cell and immunotherapy, is further improving outcomes even in the high-risk group. On the other hand, the financial burden of treating children with ALL has increased, imperiling the availability of these diagnostic and treatment strategies to patients in low- and middle-income countries (LMICs). The fundamental treatment strategy, consisting of corticosteroid and classical cytotoxic therapy, has achieved fairly good outcomes and should be feasible in LMICs as well. The present review will discuss the history of developmental therapeutics for childhood ALL in various countries through an extensive literature review with the aim of proposing a model for a treatment backbone for pediatric ALL. The discussion will hopefully benefit LMICs and be useful as a base for future clinical trials of novel treatments.
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Affiliation(s)
- Hiroshi Hayashi
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan; (A.M.); (Y.Y.)
| | - Atsushi Makimoto
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan; (A.M.); (Y.Y.)
- Department of Laboratory Medicine, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan; (A.M.); (Y.Y.)
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Mattano LA, Devidas M, Loh ML, Raetz EA, Chen Z, Winick NJ, Hunger SP, Carroll WL, Larsen EC. Development of osteonecrosis and improved survival in B-ALL: results of Children's Oncology Group Trial AALL0232. Leukemia 2024; 38:258-265. [PMID: 38062123 PMCID: PMC11235418 DOI: 10.1038/s41375-023-02099-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 01/14/2024]
Abstract
Osteonecrosis is a significant toxicity of acute lymphoblastic leukemia (ALL) therapy. In retrospective analyses, superior event-free survival was noted among affected adolescents in an earlier trial. We prospectively assessed osteonecrosis incidence, characteristics, and risk factors in patients 1-30 years with newly diagnosed high-risk B-ALL on COG AALL0232. Patients were randomized to induction dexamethasone vs prednisone, and interim maintenance high-dose methotrexate vs escalating-dose Capizzi methotrexate/pegaspargase. Event-free and overall survival were compared between patients with/without imaging-confirmed osteonecrosis. Osteonecrosis developed in 322/2730 eligible, evaluable patients. The 5-year cumulative incidence was 12.2%. Risk was greater in patients ≥10 years (hazard ratio [HR], 7.23; P < 0.0001), particularly females (HR, 1.37; P = 0.0057), but lower in those with asparaginase allergy (HR, 0.60; P = 0.0077). Among rapid early responders ≥10 years, risk was greater with dexamethasone (HR, 1.84; P = 0.0003) and with prednisone/Capizzi (HR, 1.45; P = 0.044), even though neither therapy was independently associated with improved survival. Patients with osteonecrosis had higher 5-year event-free (HR, 0.51; P < 0.0001) and overall survival (HR, 0.42; P < 0.0001), and this was directly attributable to reduced relapse rates (HR, 0.57; P = 0.0014). Osteonecrosis in high-risk B-ALL patients is associated with improved survival, suggesting an important role for host factors in mediating both toxicity and enhanced efficacy of specific therapies.
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Affiliation(s)
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mignon L Loh
- Division of Pediatric Hematology, Oncology, Bone Marrow Transplantation, and Cellular Therapy, Seattle Children's Hospital, Seattle, WA, USA
- The Ben Towne Center for Childhood Cancer Research, University of Washington, Seattle, WA, USA
| | - Elizabeth A Raetz
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
- Perlmutter Cancer Center at New York University Langone Health, New York, NY, USA
| | - Zhiguo Chen
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Naomi J Winick
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - William L Carroll
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
- Perlmutter Cancer Center at New York University Langone Health, New York, NY, USA
| | - Eric C Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
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7
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Wilson CL, Bjornard KL, Partin RE, Kadan-Lottick NS, Nathan PC, Oeffinger KC, Hayashi RJ, Hyun G, Armstrong GT, Leisenring WM, Howell RM, Yasui Y, Dixon SB, Ehrhardt MJ, Robison LL, Ness KK. Trends in physical functioning in acute lymphoblastic leukemia and non-Hodgkin lymphoma survivors across three decades. J Cancer Surviv 2023:10.1007/s11764-023-01483-1. [PMID: 37938431 DOI: 10.1007/s11764-023-01483-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The impact of changes in therapy for childhood acute lymphoblastic leukemia (ALL) and non-Hodgkin lymphoma (NHL) on the prevalence of physical performance limitations and participation restrictions among survivors is unknown. We aimed to describe the prevalence of reduced function among ALL and NHL survivors by treatment era. METHODS Participants included survivors of childhood ALL and NHL, and a cohort of their siblings, participating in the Childhood Cancer Survivor Study (CCSS). Physical function was measured using questionnaire. The prevalence of reduced function was compared to siblings using generalized estimating equations, overall and stratified by treatment decade. Associations between organ system-specific chronic conditions (CTCAE v4.03) and function were also evaluated. RESULTS Among 6511 survivors (mean age 25.9 years (standard deviation 6.5)) and 4127 siblings, risk of performance limitations (15.2% vs. 12.5%, prevalence ratio [PR] = 1.5, 95%CI = 1.3-1.6), restrictions in personal care (2.0% vs. 0.6%, PR = 3.1, 95% CI = 2.0-4.8), routine activities (5.5% vs. 1.6%, PR = 3.6, 95% CI = 2.7-4.8), and work/school attendance (8.8% vs. 2.1%, PR = 4.5, 95% CI = 3.6-5.7) was increased in survivors vs. siblings. The prevalence of survivors reporting reduced function did not decrease between the 1970s and 1990s. The presence of neurological and cardiovascular conditions was associated with reduced function regardless of treatment decade. CONCLUSIONS Despite changes in therapy, the prevalence of poor physical function remained constant between the 1970s and 1990s. The CCSS clinical trial registration number is NCT01120353 (registered May 6, 2010). IMPLICATIONS FOR CANCER SURVIVORS Our findings support screening for reduced physical function so that early interventions to improve physical performance and mitigate chronic disease can be initiated.
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Affiliation(s)
- Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Kari L Bjornard
- Department of Hematology/Oncology, Riley Children's Hospital, Indianopolis, IN, USA
| | - Robyn E Partin
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nina S Kadan-Lottick
- Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Robert J Hayashi
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Geehong Hyun
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wendy M Leisenring
- Cancer Prevention and Clinical Statistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Rebecca M Howell
- Radiation Physics Department, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Stephanie B Dixon
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew J Ehrhardt
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
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8
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Halton JM, Ma J, Babyn P, Matzinger MA, Kaste SC, Scharke M, Fernandez CV, Miettunen P, Ho J, Alos N, Abish S, Barr R, Cairney E, Dix DB, Grant RM, Israels S, Lewis V, Wilson B, Atkinson S, Cabral D, Cummings E, Rodd C, Stein R, Sbrocchi AM, Jaremko JL, Koujok K, Shenouda N, Rauch F, Siminoski K, Ward LM. Reductions in Bone Mineral Density Are Apparent Early in Children With Prevalent Osteonecrosis Lesions Following Leukemia Therapy. J Bone Miner Res 2023; 38:1104-1115. [PMID: 37326443 DOI: 10.1002/jbmr.4870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/16/2023] [Accepted: 06/14/2023] [Indexed: 06/17/2023]
Abstract
Osteonecrosis (ON) is a serious complication of childhood acute lymphoblastic leukemia. We determined the prevalence of osteonecrotic lesions in our patient population by a one-time multisite magnetic resonance imaging (MRI) more than 1 year following leukemia therapy. MRI findings were evaluated in relationship to clinical factors (including longitudinal changes in bone mineral density [BMD]). Eighty-six children enrolled in the Steroid Associated Osteoporosis in the Pediatric Population (STOPP) study were evaluated for ON at 3.1 ± 1.3 years following therapy. Thirty children had a total of 150 confirmed ON lesions (35%). Lumbar spine (LS) BMD Z-scores (mean ± SD) were low at diagnosis and similar between patients with and without ON (-1.09 ± 1.53 versus -1.27 ± 1.25, p = 0.549). LS BMD Z-scores declined from baseline to 12 months in children with ON (-0.31 ± 1.02) but not in those without (0.13 ± 0.82, p = 0.035); the hip BMD Z-scores from baseline to 24 months declined in both groups, but to a greater extent in those with ON (-1.77 ± 1.22) compared to those without (-1.03 ± 1.07, p = 0.045). At the time of the MRI, mean total hip and total body (TB) BMD Z-scores were lower in children with ON (hip -0.98 ± 0.95 versus -0.28 ± 1.06, p = 0.010; TB -1.36 ± 1.10 versus -0.48 ± 1.50, p = 0.018). Pain occurred in 11/30 (37%) with ON versus 20/56 (36%) without, p = 0.841. In multivariable models, older age at diagnosis (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.15-2.13; p = 0.004), and hip BMD Z-score at MRI (OR 2.23; 95% CI, 1.02-4.87; p = 0.046) were independently associated with ON. Overall, one-third of children demonstrated ON after leukemia therapy. Those with ON had greater reductions in spine and hip BMD Z-scores in the first 1 and 2 years of therapy, respectively. Older age and lower hip BMD Z-scores at MRI were significantly associated with prevalent, off-therapy ON. These data assist in identifying children at risk of ON. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
| | - Jinui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paul Babyn
- Department of Medical Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mary Ann Matzinger
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Maya Scharke
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Conrad V Fernandez
- Department of Pediatric Hematology and Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paivi Miettunen
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Nathalie Alos
- Département de Pédiatrie, Université de Montréal, Montréal, Quebec, Canada
| | - Sharon Abish
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Ronald Barr
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Cairney
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - David B Dix
- Department of Pediatrics, University of British Columbia, Vancouver, British of Columbia, Canada
| | - Ronald M Grant
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Sara Israels
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Victor Lewis
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Beverly Wilson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Stephanie Atkinson
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - David Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, British of Columbia, Canada
| | - Elizabeth Cummings
- Department of Pediatric Hematology and Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Celia Rodd
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Stein
- Department of Paediatrics, Western University, London, Ontario, Canada
| | | | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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9
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Huault A, Michel G, Charon V, Chouklati K, Domenech C, Chastagner P, Dalle JH, Paillard C, Ducassou S, Poirée M, Plat G, Tabone MD, Kanold J, Baruchel A, Berger C, Pellier I, Plantaz D, Theron A, Mustafa A, Auquier P, Gandemer V. Symptomatic osteonecrosis in French survivors of childhood and adolescent leukemia: a clinical and MRI study of LEA cohort. Pediatr Hematol Oncol 2023:1-17. [PMID: 36820621 DOI: 10.1080/08880018.2023.2168810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Osteonecrosis (ON) is a known complication of acute leukemia (AL) management, affecting 1%-10% of young patients and resulting in long-term morbidity. Widespread access to MRI over the past decade has allowed earlier detection and more accurate assessment. This study investigated clinical and MRI features of the 129 (2.5%) patients with symptomatic ON retrospectively recruited from the French LEA (Leucémies de l'Enfant et de l'Adolescent, or child and adolescent leukemias) cohort (n = 4,973). We analyzed data concerning ON risk factors, multifocal involvement, severe lesions detected by MRI, and patient quality of life (QoL). ON patients tended to be >10 years old at the time of AL diagnosis (odds ratio [OR]: 22.46; p < 10-6), female (OR: 1.8; p = 0.002), or treated for relapse (OR: 1.81; p = 0.041). They more frequently suffered from other sequelae (p < 10-6). Most necroses involved weight-bearing joints, and they were multifocal in 69% of cases. Double-blinded review of MRIs for 39 patients identified severe lesions in 14, usually in the hips. QoL of adolescents and adults was poor and permanently impacted after onset of ON. In conclusion, age >10 at time of AL diagnosis, female sex, and relapse occurrence were risk factors for multifocal ON; MRI revealed severe ON in a third of the patients considered; and ON was associated with persistently poor QoL affecting multiple domains. Future studies should include prospective data addressing ON management and seek to identify genetic markers for targeted screening enabling early ON detection and treatment.
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Affiliation(s)
- Alice Huault
- Department of Pediatric Hematology-Oncology, Nantes University Hospital, Nantes, France
| | - Gérard Michel
- Department of Pediatric Oncology, Aix-Marseille University and La Timone Children's Hospital, Marseille, France
| | - Valérie Charon
- Department of Radiology, Rennes University Hospital, Rennes, France
| | - Kamal Chouklati
- Department of Radiology, Rennes University Hospital, Rennes, France
| | - Carine Domenech
- Department of Pediatric Hematology-Oncology, Pediatric Hematology and Oncology Institute (IHOPE), Hospices Civils de Lyon, University Lyon 1, Lyon, France
| | - Pascal Chastagner
- Department of Pediatric Hematology-Oncology, Hôpital d'Enfants de Brabois, Vandoeuvre-lès-Nancy, France
| | - Jean-Hugues Dalle
- Department of Pediatric Hematology, Robert Debré Hospital, Paris, France
| | - Catherine Paillard
- Department of Pediatric Hematology-Oncology, Strasbourg University Hospital, Strasbourg, France
| | - Stéphane Ducassou
- Department of Pediatric Hematology-Oncology, Bordeaux University Hospital, Bordeaux, France
| | - Marilyne Poirée
- Department of Pediatric Hematology-Oncology, Nice University Hospital (L'Archet), Nice, France
| | - Geneviève Plat
- Department of Pediatric Hematology-Oncology, Toulouse University Hospital (Purpan), Toulouse, France
| | - Marie-Dominique Tabone
- Department of Pediatric Hematology-Oncology, Armand Trousseau Hospital, APHP. Sorbonne Université, Paris, France
| | - Justyna Kanold
- Department of Pediatric Hematology-Oncology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - André Baruchel
- Department of Pediatric Hematology, Robert Debré Hospital, Paris, France
| | - Claire Berger
- Department of Pediatric Hematology, Saint-Étienne University Hospital, Saint-Etienne, France
| | | | - Dominique Plantaz
- Department of Pediatric Hematology-Oncology, Grenoble Alpes University Hospital, Grenoble, France
| | - Alexandre Theron
- Department of Pediatric Hematology-Oncology, Montpellier University Hospital, Montpellier, France
| | - Alaa Mustafa
- Department of Public Health, EA 3279 Research Unit, Marseille University Hospital, Aix-Marseille University, Marseille, France
| | - Pascal Auquier
- Department of Public Health, EA 3279 Research Unit, Marseille University Hospital, Aix-Marseille University, Marseille, France
| | - Virginie Gandemer
- Department of Pediatric Hematology and Oncology department, University Hospital, Rennes, France
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10
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Kuhlen M, Kunstreich M, Gökbuget N, Escherich G. [Osteonecrosis-severe side effect of treatment for acute lymphoblastic leukemia]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:792-799. [PMID: 36069910 DOI: 10.1007/s00132-022-04301-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
Osteonecrosis occurs as an acute and long-term serious side effect in children, adolescents, and adults with acute lymphoblastic leukemia. It is associated with severe pain and reduced mobility, ultimately leading to joint destruction and significant long-term morbidity. The cumulative incidence ranges from 11 to 20% in adolescents and young adults. In symptomatic patients, multiple joints are frequently affected, which in turns poses a risk factor for the development of severe osteonecrosis. The genesis of leukemia-associated osteonecrosis is multifactorial. Risk factors include the use of corticosteroids and asparaginase. These exert their effects on the blood supply to the bone through hypercholesterolemia, hypertriglyceridemia, and hypertension. Bacteriemia, genetic susceptibility, and stem cell transplantation pose additional risk factors. The treatment of osteonecrosis is challenging and not evidence based. Preventive measurements have as yet mainly been tested in preclinical models.
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Affiliation(s)
- Michaela Kuhlen
- Schwäbisches Kinderkrebszentrum, Kinder- und Jugendmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Marina Kunstreich
- Otto-von-Guericke-Universität Magdeburg, Medizinische Fakultät, Universitätskinderklinik, Magdeburg, Deutschland
| | - Nicola Gökbuget
- Medizinische Klinik II, Hämatologie/Onkologie, Universitätsklinikum Frankfurt/Main, Frankfurt/Main, Deutschland
| | - Gabriele Escherich
- Klinik für Pädiatrische Hämatologie und Onkologie, Universitätskinderklinik Hamburg-Eppendorf, Hamburg, Deutschland
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11
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Gore L. What are the Long-Term Complications of Pediatric ALL Treatments and How Can They Be Mitigated? Perspectives on Long-term Complications of Curative Treatment in Childhood ALL. Best Pract Res Clin Haematol 2022; 35:101403. [DOI: 10.1016/j.beha.2022.101403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Watson C, Gadikota H, Barlev A, Beckerman R. A review of the risks of long-term consequences associated with components of the CHOP chemotherapy regimen. J Drug Assess 2022; 11:1-11. [PMID: 35693477 PMCID: PMC9176678 DOI: 10.1080/21556660.2022.2073101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A common chemotherapy regimen in post-transplant lymphoproliferative disease (PTLD) following solid organ transplants (SOT) is cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). This study reviews the quantitative evidence for long-term consequences associated with components of CHOP identified from the Children's Oncology Group Long-Term Follow-Up Guidelines. Cited references were screened using prespecified criteria (English, systematic review, randomized controlled trial n > 100, observation study n > 100, case series n > 20). Relevant data were extracted and synthesized. Of 61 studies, 66% were retrospective cohort studies, 28% were in the US, and 95% enrolled pediatric patients. No study focused specifically on the CHOP regimen. Long-term consequences for CHOP components observed in >3 studies included cardiac toxicity (n = 14), hormone deficiencies/infertility (n = 14), secondary leukemia (n = 7), osteonecrosis (n = 6), and bladder cancer (n = 4). These effects are significant, impact a high percentage of patients, and occur as early as one year after treatment. Although none of the studies focused specifically on the CHOP regimen, 30%, 23%, and 15% evaluated alkylating agents (e.g. cyclophosphamide), anthracyclines (e.g. doxorubicin), and corticosteroids (e.g. prednisone), respectively. All three product classes had a dose-dependent risk of long-term consequences with up to 13.2-fold, 27-fold, 16-fold, 14.5-fold, and 6.2-fold increase in risk of heart failure, early menopause, secondary leukemia, bladder cancer, and osteonecrosis, respectively. Lymphoma patients had significantly elevated risks of cardiac toxicity (up to 12.2-fold), ovarian failure (up to 3.8-fold), and osteonecrosis (up to 6.7-fold). No studies were found in PTLD or SOT. Safe and effective PTLD treatments that potentially avoid these long-term consequences are urgently needed.
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Affiliation(s)
- Crystal Watson
- Atara Biotherapeutics Inc., South San Francisco, CA, USA
| | | | - Arie Barlev
- Atara Biotherapeutics Inc., South San Francisco, CA, USA
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13
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England P, Aoyama JY, Talwar D, Wells L. Patient and Disease Related Risk Factors Associated With Return to Sport Rates After AVN Treatment. THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:193-199. [PMID: 35821946 PMCID: PMC9210403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Avascular necrosis (AVN) is a rare albeit serious condition that has a high risk for long term morbidity given the risk of chronic pain and arthroplasty after diagnoses. The recent rise in sports participation in the pediatric population demonstrates the importance of evaluating functional limitations after AVN treatment. Return to sport (RTS) rates after treatment for AVN have not been evaluated in pediatric or adolescent populations.It is necessary to evaluate all joints impacted by AVN due to heterogenous nature of the disease and the variety of sports that could be impacted by disease specific activity restrictions. Thus, this present study aimed to characterize RTS rate after AVN treatment, determine if there was a difference in RTS rates after operative versus nonoperative management, and identify demographic and treatment factors associated with RTS rates. METHODS This retrospective cohort study evaluated patients ages eight to twenty years old who were treated for symptomatic AVN of any joint between January 2005 and August 2021. Patient records were reviewed for demographic, disease, and treatment variables. Standard descriptive statistics and bivariate analyses were performed to describe and compare groups who did and did not RTS. A generalized estimating model was used to determine variables that were associated with better RTS rates. RESULTS A total of 144 patients and 190 lesions were evaluated in the study, 60 patients (43%) were female with a mean age of 14.36+/-3.24 years. The overall RTS rate after AVN treatment was 67% (64/96). Roughly 8% of patients (5/64) were able to return to multiple sports, however of those that returned to sports, 6% (4/64) reported playing at a lower level of competition. There was not a significant difference between the RTS rate for those who underwent operative versus nonoperative management (70% versus 62%, p=0.38). Males were almost 2.5 times more likely to return to sport than females (OR: 2.46, p=0.018). CONCLUSION The ability to return to sports after AVN treatment has largely remained unknown in the pediatric and adolescent populations. Our data suggests that a majority of patients are able to RTS in the short term follow up with males being twice as likely to RTS compared to females. Physicians should maintain awareness of the long-term morbidity of AVN and understand the unique patient and disease characteristics that optimize functional outcomes in this population. Level of Evidence: III.
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Affiliation(s)
- Patrick England
- Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julien Y. Aoyama
- Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Divya Talwar
- Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lawrence Wells
- Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Osteonecrosis of the Femoral Head. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202205000-00002. [PMID: 35511598 PMCID: PMC9076447 DOI: 10.5435/jaaosglobal-d-21-00176] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
Abstract
Osteonecrosis of the femoral head is a progressive and debilitating condition with a wide variety of etiologies including trauma, steroid use, and alcohol intake. Diagnosis and staging are based on imaging including MRI at any stage and plain radiography in more advanced lesions. The only definitive treatment is total hip arthroplasty, although numerous treatments including disphosphonates and core decompression are used to delay the progression. Lack of satisfactory conservative measures suggests the need for additional research of osteonecrosis including large patient registries to further understand this condition.
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15
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Osteonecrosis in Korean Paediatric and Young Adults with Acute Lymphoblastic Leukaemia or Lymphoblastic Lymphoma: A Nationwide Epidemiological Study. J Clin Med 2022; 11:jcm11092489. [PMID: 35566613 PMCID: PMC9105090 DOI: 10.3390/jcm11092489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
Osteonecrosis (ON) is a serious complication of acute lymphocytic leukaemia (ALL) or lymphoblastic lymphoma (LBL) treatment, and there is little information regarding ON in Korean paediatric and young adult patients. This retrospective cohort study assessed the cumulative incidence of and risk factors for ON using national health insurance claims data from 2008 to 2019 in 4861 ALL/LBL patients. The Kaplan–Meier method was used to estimate the cumulative incidence of ON according to age groups; the Cox proportional hazard regression model was used to identify risk factors related to ON development after diagnosing ALL/LBL. A cause-specific hazard model with time-varying covariates was used to assess the effects of risk factors. Overall, 158 (3.25%) patients were diagnosed with ON, among whom 23 underwent orthopaedic surgeries. Older age, radiotherapy (HR = 2.62, 95% confidence interval (CI) 1.87–3.66), HSCT (HR = 2.40, 95% CI 1.74–3.31), steroid use and anthracycline use (HR = 2.76, CI 1.85–4.14) were related to ON in the univariate analysis. In the multivariate analysis, age and steroid and asparaginase use (HR = 1.99, CI 1.30–3.06) were factors associated with ON. These results suggest that Korean patients with ALL/LBL who used steroids and asparaginase should be closely monitored during follow-up, even among young adult patients.
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16
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Chen CY, Rao SS, Yue T, Tan YJ, Yin H, Chen LJ, Luo MJ, Wang Z, Wang YY, Hong CG, Qian YX, He ZH, Liu JH, Yang F, Huang FY, Tang SY, Xie H. Glucocorticoid-induced loss of beneficial gut bacterial extracellular vesicles is associated with the pathogenesis of osteonecrosis. SCIENCE ADVANCES 2022; 8:eabg8335. [PMID: 35417243 PMCID: PMC9007505 DOI: 10.1126/sciadv.abg8335] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/24/2022] [Indexed: 06/14/2023]
Abstract
Osteonecrosis of the femoral head (ONFH) commonly occurs after glucocorticoid (GC) therapy. The gut microbiota (GM) participates in regulating host health, and its composition can be altered by GC. Here, this study demonstrates that cohousing with healthy mice or colonization with GM from normal mice attenuates GC-induced ONFH. 16S rRNA gene sequencing shows that cohousing with healthy mice rescues the GC-induced reduction of gut Lactobacillus animalis. Oral supplementation of L. animalis mitigates GC-induced ONFH by increasing angiogenesis, augmenting osteogenesis, and reducing cell apoptosis. Extracellular vesicles from L. animalis (L. animalis-EVs) contain abundant functional proteins and can enter the femoral head to exert proangiogenic, pro-osteogenic, and antiapoptotic effects, while its abundance is reduced after exposure to GC. Our study suggests that the GM is involved in protecting the femoral head by transferring bacterial EVs, and that loss of L. animalis and its EVs is associated with the development of GC-induced ONFH.
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Affiliation(s)
- Chun-Yuan Chen
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Shan-Shan Rao
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan 410013, China
| | - Tao Yue
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yi-Juan Tan
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Hao Yin
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Ling-Jiao Chen
- Department of Pathology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510220, China
| | - Ming-Jie Luo
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan 410013, China
| | - Zun Wang
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan 410013, China
| | - Yi-Yi Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Chun-Gu Hong
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yu-Xuan Qian
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Ze-Hui He
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Jiang-Hua Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Fei Yang
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Fei-Yu Huang
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Si-Yuan Tang
- Xiangya School of Nursing, Central South University, Changsha, Hunan 410013, China
| | - Hui Xie
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- Hunan Key Laboratory of Organ Injury, Aging and Regenerative Medicine, Changsha, Hunan 410008, China
- Hunan Key Laboratory of Bone Joint Degeneration and Injury, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
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17
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Finch ER, Janke LJ, Li L, Payton MA, Jenkins DA, Crews KR, Relling MV, Karol SE. Dasatinib does not exacerbate dexamethasone-induced osteonecrosis in murine models of acute lymphoblastic leukemia therapy. Pediatr Blood Cancer 2022; 69:e29490. [PMID: 34866312 PMCID: PMC8860849 DOI: 10.1002/pbc.29490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION There are clinical reports that the incorporation of dasatinib may increase the frequency of osteonecrosis in acute lymphoblastic leukemia (ALL) treatment regimens. No rigorous testing of this hypothesis is available to guide clinicians. METHODS We tested whether oral dasatinib increased the frequency of dexamethasone-induced osteonecrosis in a murine model and tested its effects on dexamethasone's antileukemic efficacy in a murine BCR-ABL+ model of ALL. RESULTS Dasatinib did not change the frequency of osteonecrosis (p = .99) nor of arteriopathy (p = .36) in dexamethasone-treated mice when given at dosages that achieved clinically relevant steady-state dasatinib plasma concentrations of 53.1 ng/ml (95% CI: 43.5-57.3 ng/ml). These dasatinib exposures were not associated with increased dexamethasone plasma exposure in nonleukemia-bearing mice. These same dosages were not associated with any decrement in antileukemic efficacy of dexamethasone in a responsive BCR-ABL+ model of ALL. CONCLUSIONS Based on the results of our preclinical murine studies, we conclude that dasatinib is unlikely to increase the osteonecrotic effects of dexamethasone in ALL regimens.
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Affiliation(s)
- Emily R. Finch
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Laura J. Janke
- Department of Pathology, Division of Comparative Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Lie Li
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Monique A. Payton
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - David A. Jenkins
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Kristine R. Crews
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
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18
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Brivio E, Cossio A, Borra D, Silvestri D, Prunotto G, Colombini A, Verna M, Rizzari C, Biondi A, Conter V, Valsecchi MG, Balduzzi A. Osteonecrosis in paediatric acute lymphoblastic leukaemia: Incidence, risk factors, radiological patterns and evolution in a single-centre cohort. Br J Haematol 2022; 197:602-608. [PMID: 35362095 PMCID: PMC9323502 DOI: 10.1111/bjh.18147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 11/30/2022]
Abstract
Osteonecrosis (ON) is a well‐known sequela of paediatric acute lymphoblastic leukaemia (ALL) treatment. Incidence differs substantially among studies and the clinical significance of radiological findings is not fully established. We analysed 256 consecutive patients with ALL treated in our Institution between October 2010 and December 2016. Within the cohort, 41 developed ON, with a mean 5‐year cumulative incidence of 18.5 (standard error, SE, 5.7)% overall. The mean (SE) 5‐year cumulative incidence of ON was 12.7 (2.1)% after censoring upon stem cell transplantation (SCT) and/or relapse. Patients aged ≥10 years and patients allocated to the high‐risk stratum had a 10‐fold and fivefold higher risk of ON respectively. The risk of ON was more than double in relapsed patients, whereas no significant impact of gender, immunophenotype and SCT was demonstrated. Multiple lesions (median four joints involved per patient) were detected by magnetic resonance imaging in all but one patient, with the knee being the most affected joint. Lesions affecting convex joint surfaces experienced the worst evolution, whereas most lesions on diaphyses and concave surfaces remained radiologically stable or disappeared during follow‐up. ON has a high prevalence in paediatric ALL, presenting with multiple lesions. Lesions involving convex surfaces were at higher risk of radiological deterioration.
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Affiliation(s)
- Erica Brivio
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Andrea Cossio
- Orthopedic Department, Ospedale S. Gerardo, Monza, Italy
| | - Davide Borra
- Orthopedic Department, Ospedale S. Gerardo, Monza, Italy
| | - Daniela Silvestri
- Dipartimento di Medicina e Chirurgia, Centro di Ricerca in Biostatistica per l'Epidemiologia Clinica, Universita' degli Studi di Milano Bicocca, Monza, Italy
| | - Giulia Prunotto
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
| | - Antonella Colombini
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
| | - Marta Verna
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
| | - Carmelo Rizzari
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
| | - Andrea Biondi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
| | - Valentino Conter
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
| | - Maria Grazia Valsecchi
- Dipartimento di Medicina e Chirurgia, Centro di Ricerca in Biostatistica per l'Epidemiologia Clinica, Universita' degli Studi di Milano Bicocca, Monza, Italy
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Monza, Italy
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19
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Valtis YK, Place AE, Silverman LB, Vrooman LM, DeAngelo DJ, Luskin MR. Orthopaedic adverse events among adolescents and adults treated with asparaginase for acute lymphoblastic leukaemia. Br J Haematol 2022; 198:421-430. [PMID: 35312041 DOI: 10.1111/bjh.18093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 01/19/2023]
Abstract
Osteonecrosis (ON) is a complication of acute lymphoblastic leukaemia (ALL) treatment with patient- (age, female sex, genetic polymorphisms, presence of metabolic syndrome) and treatment-specific (glucocorticoid type and schedule) risk factors described. The potential role of asparaginase in increasing risk of ON via effects on coagulation, lipid metabolism, and steroid clearance is now also recognised. Paediatric studies consistently identify age as a key risk factor for ON, with adolescents at higher risk than young children. Fewer studies comprehensively report on risk of ON in adults, but available evidence suggests that adolescents and young adults (AYAs) treated with corticosteroid and asparaginase-containing paediatric-inspired regimens are more at risk than older adults treated with paediatric-inspired or traditional adult regimens. There are few proven strategies to prevent or mitigate the severity of ON and other orthopaedic complications of ALL therapy. Future clinical trials should carefully ascertain orthopaedic adverse events in adults. Evidence-based guidelines should be developed for management of orthopaedic adverse events in adults being treated for ALL, especially high-risk AYAs being treated with paediatric-inspired regimens.
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Affiliation(s)
- Yannis K Valtis
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew E Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lynda M Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marlise R Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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20
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The Impact of a Precision-Based Exercise Intervention in Childhood Hematological Malignancies Evaluated by an Adapted Yo-Yo Intermittent Recovery Test. Cancers (Basel) 2022; 14:cancers14051187. [PMID: 35267495 PMCID: PMC8909675 DOI: 10.3390/cancers14051187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 01/27/2023] Open
Abstract
During cancer treatments in childhood hematological malignancies, reduced exercise tolerance is one of the main hardships. Precision-based training programs help children, adolescents, and young adults and their families to resume regular physical activity, exercise, and sports once they return to their communities after the intensive phases spent in hospital. This study was aimed at verifying whether an intermittent recovery test, the Yo-Yo AD, could provide a simple and valid way to evaluate an individual’s capacity to perform repeated intense exercise and to follow up on the impact of tailored exercise in children, adolescents, and young adults with hematological malignancies. The Yo-Yo AD involved the repetition of several shuttles to muscle exhaustion, at pre-established speeds (walking and slow running). The heart rate (HR) and oxygen saturation (SaO2) were monitored during the test. The total distance and the walking/running ability, measured as the slope of the HR vs. distance correlation, were investigated before (T0) and after 11 weeks (T1) of precision exercise intervention. The Yo-Yo AD was also performed by healthy children (CTRL). Ninety-seven patients (10.58 ± 4.5 years, 46% female) were enrolled. The Yo-Yo AD showed the positive impact of the exercise intervention by increasing the distance covered by the individuals (T0 = 946.6 ± 438.2 vs. T1 = 1352.3 ± 600.6 m, p < 0.001) with a more efficient walking/running ability (T0 = 2.17 ± 0.84 vs. T1 = 1.73 ± 0.89 slope, p < 0.0164). CTRLs performed better (1754.0 ± 444.0 m, p = 0.010). They were equally skillful (1.71 ± 0.27 slope) when compared to the patients after they received the precision-based intervention. No adverse events occurred during the Yo-Yo AD and it proved to be an accurate way of correctly depicting the changes in performance in childhood hematological malignancies.
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21
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Osteopathic Treatment and Evaluation in the Clinical Setting of Childhood Hematological Malignancies. Cancers (Basel) 2021; 13:cancers13246321. [PMID: 34944939 PMCID: PMC8699143 DOI: 10.3390/cancers13246321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Children: adolescents, and young adults who are affected by hematological malignancies and who are undergoing intensive phases of cancer treatment including hematopoietic stem cell transplantation, experience diminished functional ability. This study was aimed at assessing if osteopathic treatment and evaluation can be used when an 11-week precision-based exercise program is run inside the hospital. Our results support that osteopathy plus precision-based intervention could be a desirable support in the clinical prise en charge of these children and adolescents. Osteopathy is a safe method for the evaluation of clinical conditions and requires strong multidisciplinary synergy between pediatricians and exercise physiologists. Abstract Children: adolescents, and young who are adults affected with hematological malignancies (CAYA-H) and who are undergoing intensive phases of cancer treatment, including hematopoietic stem cell transplantation (HSCT), experience diminished functional ability. This study was aimed at assessing the feasibility, efficacy, safety, and satisfaction of an osteopathic intervention in CAYA-H attending an 11-week precision-based exercise program (PEx). All of the participants were given 4–10 treatments according to the prescription ordered by the sports medicine doctor in charge of the PEx, and the following outcomes were assessed: (1) spinal column range of motion (ROM) by palpation; (2) lower and upper limb joints ROM by a goniometer; (3) orthostatic posture by plumb line assessment; (4) chest and abdomen mobility by inspection and palpation; (5) cranial-sacral rhythmic impulse (CRI) by palpation; and (6) adverse effects. Goal attainment scaling (GAS) was used to identify the accomplishment of a desired clinical result. Moreover, HSCT patients who were affected with graft-versus-host disease and/or osteonecrosis had their joints assessed in terms of ROM as tools to monitor the effectiveness of immunosuppressive treatment. A total of 231 CAYA-H were identified, and 104 participated in the study (age 10.66 ± 4.51 yrs; 43% F). PEx plus osteopathy reached positive GAS scores by improving the ROMs of the spinal column and/or limbs (81% and 78%, respectively), chest and abdomen mobility (82%), and CRI (76%). Only minor reversible adverse effects were noticed during the study. Together, our data seem to initiate a new course where osteopathy could be useful in evaluating structural edges due to the clinical history of each CAYA-H. Given the contributions that were obtained by the GAS scores, osteopathic treatment seems to reveal interesting potential that can be targeted in the future.
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Beitrag der Ganzkörper-MRT in der Beurteilung von Osteonekrosen bei Kindern und Jugendlichen mit onkologischen und hämatologischen Grunderkrankungen. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-019-0723-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Orthopedic Toxicities Among Adolescents and Young Adults Treated on DFCI ALL Consortium Trials. Blood Adv 2021; 6:72-81. [PMID: 34610104 PMCID: PMC8753211 DOI: 10.1182/bloodadvances.2021005278] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Orthopedic toxicity was common in adolescent and young adult patients treated on DFCI Consortium ALL pediatric protocols. Younger age and exposure to pegaspargase were associated with higher risk of ON, and patients with ON had superior OS.
Adolescent and young adult patients with acute lymphoblastic leukemia (ALL) have superior outcomes when treated on pediatric regimens. Pediatric ALL regimens rely heavily on corticosteroids and asparaginase and are known to increase the risk of osteonecrosis (ON) and fractures in children, particularly adolescents. Orthopedic toxicity among young adults treated on pediatric-inspired regimens is not well described. Here, we report the symptomatic orthopedic toxicities of patients aged 15 to 50 years treated on sequential Dana-Farber Cancer Institute ALL Consortium protocols. Among 367 patients with a median age of 23 years (range, 15-50 years; 68% aged <30 years), 60 patients were diagnosed with ON (5-year cumulative incidence, 17%; 95% confidence interval [CI], 13-22), and 40 patients experienced fracture (5-year cumulative incidence, 12%; 95% CI, 8-15). Patients aged <30 years were significantly more likely to be diagnosed with ON (5-year cumulative incidence, 21% vs 8%; P = .004). Patients treated more recently on pegaspargase-based protocols were significantly more likely to be diagnosed with ON compared with those treated on earlier trials with native Escherichia coli asparaginase (5-year cumulative incidence, 24% vs 5%; P < .001). Of the 54 ON events for which adequate information was available, surgery was performed in 25 (46%). Patients with ON had superior overall survival (OS) compared with those without (multivariable OS hazard ratio, 0.15; 95% CI, 0.05-0.46; P = .001; ON included as a time-varying exposure). Increased rates of orthopedic toxicity in late-generation protocols may be driven by the pharmacokinetic drug interaction between pegaspargase and dexamethasone, leading to higher dexamethasone exposure.
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Janke LJ, Kim J, Payton MA, Jenkins DA, Cai X, Finch ER, Liu Y, Relling MV, Karol SE. Effects of zoledronic acid on osteonecrosis and acute lymphoblastic leukemia treatment efficacy in preclinical models. Pediatr Blood Cancer 2021; 68:e29183. [PMID: 34121318 PMCID: PMC8384719 DOI: 10.1002/pbc.29183] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/28/2021] [Accepted: 05/27/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Osteonecrosis is a devastating side effect of acute lymphoblastic leukemia (ALL) therapy. Associations between bone density loss and osteonecrosis have sparked interest in using bisphosphonates to reduce this complication. PROCEDURE We assessed the impact of zoledronic acid (ZA) on the development of osteonecrosis in murine models when used either throughout therapy (continuous administration) or late in therapy after vascular lesions have developed but before osteonecrosis has occurred. Effects on bone density were measured using microcomputed tomography (μCT)-assessed tibial cortical thickness, while osteonecrosis was assessed histologically in the distal femur. Effects on antileukemic efficacy of chemotherapy were evaluated in both immunocompetent/syngeneic and patient-derived xenograft (PDX) models. RESULTS Continuous administration of ZA with chemotherapy prevented chemotherapy-associated bone loss (p < .001) and reduced osteonecrosis (p = .048). Late initiation of ZA diminished bone loss (p < .001) but had no impact on the development of osteonecrosis (p = .93). In the immunocompetent murine ALL model, mice treated with ZA and chemotherapy succumbed to leukemia sooner than mice treated with chemotherapy alone (p = .046). Analysis using PDX showed a nonsignificant decrease in survival with ZA (p = .17). CONCLUSION Our data indicate ZA may prevent osteonecrosis if begun with chemotherapy but showed no benefit when administered later in therapy. However, ZA may also reduce the antileukemic efficacy of chemotherapy.
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Affiliation(s)
- Laura J. Janke
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jieun Kim
- Center for In Vivo Imaging and Therapeutics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Monique A. Payton
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - David A. Jenkins
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Xiangjun Cai
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Emily R. Finch
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Yiwei Liu
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
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25
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Utriainen P, Niinimäki TT, Huurre AJ, Vepsäläinen KL, Mäkitie OM, Niinimäki RA. Bisphosphonate treatment in children with acute lymphoblastic leukemia and osteonecrosis - radiological and clinical findings in a national cohort. Acta Oncol 2021; 60:1140-1145. [PMID: 34309491 DOI: 10.1080/0284186x.2021.1950928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Osteonecrosis (ON) is a recognized complication of childhood ALL, but its optimal management remains unestablished. This study evaluated the effect of bisphosphonate (BP) treatment on the evolution of ON lesions in childhood ALL.Material and Methods: We included a national cohort of ALL patients diagnosed with symptomatic ON before 18 years of age and treated with BPs (N = 10; five males). Patients were followed both clinically and with serial MRIs. ON lesions were graded according to the Niinimäki classification.Results: The 10 patients had a total of 55 ON lesions. The median age was 13.3 years at ALL diagnosis and 14.8 years at ON diagnosis. Four patients had received HSCT before the ON diagnosis. BPs used were pamidronate (N = 7), alendronate (N = 2) and ibandronate (N = 1). The duration of BP treatment varied between 4 months and 4 years. In 4/10 patients, BP treatment was given during the chemotherapy. BPs were well-tolerated, with no severe complications or changes in kidney function. At the end of follow up 13/55 (24%) ON lesions were completely healed both clinically and radiographically; all these lesions were originally graded 3 or less. In contrast, ON lesions originally classified as grade 5 (joint destruction; N = 4) remained at grade 5. All grade 5 hip joint lesions needed surgical treatment. During BP treatment, the pain was relieved in 7/10 patients. At the end of follow-up, none of the patients reported severe or frequent pain.Conclusion: BP treatment was safe and seemed effective in relieving ON-induced pain in childhood ALL. After articular collapse (grade 5) lesions did not improve with BP treatment. Randomized controlled studies are needed to further elucidate the role of BPs in childhood ALL-associated ON.
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Affiliation(s)
- Pauliina Utriainen
- Children’s Hospital and Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Anu J. Huurre
- Department of Pediatric and Adolescent Medicine, Turku University Hospital, FICAN-West, Turku University, Turku, Finland
| | - Kaisa L. Vepsäläinen
- Department of Pediatrics, Kuopio University Hospital, University of Kuopio, Kuopio, Finland
| | - Outi M. Mäkitie
- Children’s Hospital and Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Riitta A. Niinimäki
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
- PEDEGO Unit, University of Oulu, Finland
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26
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Genetics of osteonecrosis in pediatric acute lymphoblastic leukemia and general populations. Blood 2021; 137:1550-1552. [PMID: 33106839 DOI: 10.1182/blood.2020008471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/18/2020] [Indexed: 12/12/2022] Open
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Ede BC, Diamanti P, Williams DS, Blair A. Non-toxic polymer nanovectors for improved delivery of dexamethasone. Sci Rep 2021; 11:17263. [PMID: 34446801 PMCID: PMC8390661 DOI: 10.1038/s41598-021-96797-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022] Open
Abstract
Dexamethasone (Dex) is a highly insoluble front-line drug used in cancer therapy. Data from clinical trials indicates that the pharmacokinetics of Dex vary considerably between patients and prolonging drug exposure rather than increasing absolute dose may improve efficacy. Non-toxic, fully biodegradable Dex loaded nanovectors (NV) were formulated, via simple direct hydration within 10 min, as a vehicle to extend exposure and distribution in vivo. Dex-NV were just as effective as the free drug against primary human leukemia cells in vitro and in vivo. Importantly, high levels of DMSO solvent were not required in the NV formulations. Broad distribution of NV was seen rapidly following inoculation into mice. NV accumulated in major organs, including bone marrow and brain, known sanctuary sites for ALL. The study describes a non-toxic, more easily scalable system for improving Dex solubility for use in cancer and can be applied to other medical conditions associated with inflammation.
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Affiliation(s)
- Benjamin C Ede
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, Bristol, BS8 1TD, UK
| | - Paraskevi Diamanti
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, Bristol, BS8 1TD, UK
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant Filton, Bristol, UK
| | - David S Williams
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, Bristol, BS8 1TD, UK
| | - Allison Blair
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, Bristol, BS8 1TD, UK.
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant Filton, Bristol, UK.
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Barzilai-Birenboim S, Yacobovich J, Zalcberg Y, Arad-Cohen N, Avrahami G, Gilad G, Litichever N, Izraeli S, Elitzur S. Bone pain at leukemia diagnosis and other risk factors for symptomatic osteonecrosis in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2021; 68:e29033. [PMID: 33788395 DOI: 10.1002/pbc.29033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/25/2021] [Accepted: 03/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Osteonecrosis is a major cause of acute and long-lasting complications of acute lymphoblastic leukemia (ALL) therapy in children. Our study aimed to evaluate the prevalence, characteristics, risk factors, and outcome of osteonecrosis in children with ALL. PROCEDURE The cohort included 559 children aged 1-20 years diagnosed with ALL between 2003 and 2018 at two tertiary medical centers in Israel and enrolled in two consecutive protocols: ALL-IC BFM 2002 and AIEOP-BFM ALL 2009. Symptomatic osteonecrosis was prospectively captured as an adverse event. RESULTS Osteonecrosis occurred in 51 patients (9.1%). Ninety-four percent of the events were graded as moderate or severe (grades 3-4, Ponte di Legno Toxicity Working Group classification) and multiple bone involvement was common. Full resolution of osteonecrosis was documented in only 16% of the children (median follow-up 4.2 years). Stepwise logistic regression identified five risk factors for osteonecrosis, with a high predictive value (AUC = 0.88): older ageat ALL diagnosis, high-risk ALL group, T-cell immunophenotype, female gender, and a novel risk factor: bone pain at the time of leukemia diagnosis. In addition, osteonecrosis was less common among children of Arab ethnicity. Thrombophilia and an elevated age-adjusted body mass index were not confirmed as risk factors for osteonecrosis. CONCLUSION Due to the low rates of osteonecrosis resolution and its debilitating long-term impact, the identification of patients at high risk for osteonecrosis is important for their inclusion in further studies evaluating potential therapeutic adjustments.
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Affiliation(s)
- Shlomit Barzilai-Birenboim
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joanne Yacobovich
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Zalcberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Hematology, Oncology, and Bone Marrow Transplantation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Nira Arad-Cohen
- Department of Pediatric Hematology-Oncology, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, and Technion-Israel Institute of Technology, Haifa, Israel
| | - Galia Avrahami
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Gilad
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naomi Litichever
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Shai Izraeli
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarah Elitzur
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Oskarsson T, Duun-Henriksen AK, Bautz A, Montgomery S, Harila-Saari A, Petersen C, Niinimäki R, Madanat-Harjuoja L, Tryggvadóttir L, Holmqvist AS, Hasle H, Heyman M, Winther JF. Skeletal adverse events in childhood cancer survivors: An Adult Life after Childhood Cancer in Scandinavia cohort study. Int J Cancer 2021; 149:1863-1876. [PMID: 34278568 DOI: 10.1002/ijc.33741] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/04/2021] [Accepted: 06/18/2021] [Indexed: 12/22/2022]
Abstract
The dynamic growth of the skeleton during childhood and adolescence renders it vulnerable to adverse effects of cancer treatment. The lifetime risk and patterns of skeletal morbidity have not been described in a population-based cohort of childhood cancer survivors. A cohort of 26 334 1-year cancer survivors diagnosed before 20 years of age was identified from the national cancer registries of Denmark, Finland, Iceland and Sweden as well as a cohort of 127 531 age- and sex-matched comparison subjects randomly selected from the national population registries in each country. The two cohorts were linked with data from the national hospital registries and the observed numbers of first-time hospital admissions for adverse skeletal outcomes among childhood cancer survivors were compared to the expected numbers derived from the comparison cohort. In total, 1987 childhood cancer survivors had at least one hospital admission with a skeletal adverse event as discharge diagnosis, yielding a rate ratio (RR) of 1.35 (95% confidence interval, 1.29-1.42). Among the survivors, we observed an increased risk for osteonecrosis with a RR of 25.9 (15.0-44.5), osteoporosis, RR 4.53 (3.28-6.27), fractures, RR 1.27 (1.20-1.34), osteochondropathies, RR 1.57 (1.28-1.92) and osteoarthrosis, RR 1.48 (1.28-1.72). The hospitalization risk for any skeletal adverse event was higher among survivors up to the age of 60 years, but the lifetime pattern was different for each type of skeletal adverse event. Understanding the different lifetime patterns and identification of high-risk groups is crucial for developing strategies to optimize skeletal health in childhood cancer survivors.
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Affiliation(s)
- Trausti Oskarsson
- Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Andrea Bautz
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Clinical Epidemiology Division, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
| | - Arja Harila-Saari
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Cecilia Petersen
- Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Laura Madanat-Harjuoja
- Finnish Institute for Statistical and Epidemiological Cancer Research, Finnish Cancer Registry, Helsinki, Finland.,Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pediatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laufey Tryggvadóttir
- The Icelandic Cancer Registry, Icelandic Cancer Society, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anna Sällfors Holmqvist
- Division of Paediatric Oncology and Haematology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Heyman
- Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jeanette Falck Winther
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark
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30
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van Atteveld JE, de Winter DTC, Pieters R, Neggers SJCMM, van den Heuvel-Eibrink MM. Recent perspectives on the association between osteonecrosis and bone mineral density decline in childhood acute lymphoblastic leukemia. Fac Rev 2021; 10:57. [PMID: 34308423 PMCID: PMC8265561 DOI: 10.12703/r/10-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The attention to treatment-related toxicity has increased since the survival of children with acute lymphoblastic leukemia (ALL) has improved significantly over the past few decades. Intensive ALL treatment schedules including corticosteroids and asparaginase have been shown to give rise to skeletal abnormalities such as osteonecrosis and low bone mineral density (BMD), which may lead to debilitating sequelae in survivors. Although osteonecrosis and low BMD are different entities with suggested separate pathophysiological mechanisms, recent studies indicate that osteonecrosis is associated with accelerated BMD decline. Common underlying mechanisms for osteonecrosis and BMD decline are considered, such as an enhanced sensitivity to corticosteroids in children who suffer from both osteonecrosis and low BMD. In addition, restriction of weight-bearing activities, which is generally advised in patients with osteonecrosis, could aggravate BMD decline. This induces a clinical dilemma, since bone stimulation is important to maintain BMD but alternative interventions for osteonecrosis are limited. Furthermore, this recent finding of accelerated BMD decline in children with osteonecrosis emphasizes the need to develop effective preventive measures for osteonecrosis, which may include targeting BMD decline.
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Affiliation(s)
- Jenneke E van Atteveld
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Demi TC de Winter
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Sebastian JCMM Neggers
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
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31
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Maintenance therapy and risk of osteonecrosis in children and young adults with acute lymphoblastic leukemia: a NOPHO ALL2008 sub-study. Cancer Chemother Pharmacol 2021; 88:911-917. [PMID: 34145469 DOI: 10.1007/s00280-021-04316-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Osteonecrosis is a burdensome treatment-related toxicity that is mostly diagnosed during or soon after 6-mercaptopurine (6MP)/methotrexate (MTX) maintenance therapy for acute lymphoblastic leukemia (ALL), possibly indicating a pathogenic role of these drugs. METHODS We prospectively registered symptomatic osteonecrosis during treatment of 1234 patients aged 1.0-45.9 years treated according to the Nordic Society of Hematology and Oncology (NOPHO) ALL2008 protocol. MTX/6MP metabolites were measured as part of the NOPHO ALL2008 maintenance therapy study. RESULTS After a median follow-up of 5.6 years [interquartile range (IQR) 3.6-7.5], 68 patients had been diagnosed with symptomatic osteonecrosis. The cumulative incidence was 2.7% [95% confidence interval (CI) 1.6-3.8%] for patients aged < 10 years, 14.9% (95% CI 9.7-20.2%) for patients aged 10.0-17.9 years, and 14.4% (95% CI 8.0-20.8%) for patients aged ≥ 18 years. The median time from diagnosis of ALL to diagnosis of osteonecrosis in these age groups was 1.0 year (IQR 0.7-2.0), 2.0 years (IQR 1.1-2.4), and 2.2 years (IQR 1.8-2.8), respectively (p = 0.001). With 17,854 blood samples available for MTX and 6MP metabolite analysis, neither erythrocyte levels of 6-thioguanine (TG) nucleotides (p > 0.99), methylated 6MP metabolites (p = 0.37), MTX polyglutamates (p = 0.98) nor DNA-TG (p = 0.53) were significantly associated with the hazard of osteonecrosis in Cox models stratified by the three age groups and adjusted for sex. CONCLUSION Maintenance therapy intensity determined by 6MP and MTX metabolites was not associated with the risk of developing osteonecrosis in the NOPHO ALL2008 cohort.
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32
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Sherief LM, Beshir M, Raafat N, Abdelkhalek ER, Mokhtar WA, Elgerby KM, Soliman BK, Salah HE, Mokhtar GA, Kamal NM, ELsayed H, Zakaria M. Genetic polymorphism of vitamin D receptors and plasminogen activator inhibitor-1 and osteonecrosis risk in childhood acute lymphoblastic leukemia. Mol Genet Genomic Med 2021; 9:e1700. [PMID: 34042331 PMCID: PMC8372120 DOI: 10.1002/mgg3.1700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/11/2021] [Accepted: 04/13/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Osteonecrosis (ON) is one of the major therapy-related complications in childhood acute lymphoblastic leukemia (ALL). The purpose of the current study is to assess the frequency of ON in children with ALL and to detect whether polymorphisms in vitamin D receptor gene (VDR) and plasminogen activator inhibitor-1 (PAI-1) gene can affect the risk of ON. PATIENTS AND METHODS Nighty-six ALL children were enrolled. Serum 25-hydroxyvitamin D 25(OH)D levels were performed in addition to the detection of polymorphisms in PAI-1and VDR genes by polymerase chain reaction. RESULTS Ten out of 96 patients had ON (four males and six females aged above 10 years) and had an insufficient level of 25(OH)D. Fifty-two percent of patients had PAI-1 GG genotype while 48% had PAI-1 GA genotype. PAI-1 polymorphism was detected in 60% of all ON cases. The frequencies of VDR genotypes were CT (56.3%), CC (39.6%), and TT (4.2%). Osteonecrosis was found in eight patients with CC genotype and in two patients with CT genotype. CONCLUSION Osteonecrosis can develop early during the therapy of ALL. Older age and insufficient level of 25(OH)D were considered important risk factor for the development of osteonecrosis. PAT-1 and VDR gene polymorphism may be a genetic risk factor in its pathogenesis.
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Affiliation(s)
- Laila M Sherief
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Beshir
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nermin Raafat
- Department of Medical Biochemistry, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Elhamy R Abdelkhalek
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Wesam A Mokhtar
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Khaled M Elgerby
- Department of Radiodiagnosis, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Basma K Soliman
- Department of Radiodiagnosis, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hosam E Salah
- Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ghada A Mokhtar
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Naglaa M Kamal
- Pediatric Department, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Heba ELsayed
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Marwa Zakaria
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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33
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Kuhlen M, Kunstreich M, Gökbuget N. Osteonecrosis in Adults With Acute Lymphoblastic Leukemia: An Unmet Clinical Need. Hemasphere 2021; 5:e544. [PMID: 33718802 PMCID: PMC7951118 DOI: 10.1097/hs9.0000000000000544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/13/2021] [Indexed: 11/26/2022] Open
Abstract
Osteonecrosis is a serious complication of antileukemic therapy associated with severe pain and reduced mobility, ultimately leading to joint destruction and significant long-term morbidity. The 5-year cumulative incidence of osteonecrosis ranges from 11% to 20% in adolescents and young adults to 3% to 8% in patients aged 30 years and older. Most symptomatic patients have multiple joints affected, which in turn poses a risk factor for developing severe osteonecrosis. Osteonecrosis has a multifactorial genesis. Treatment-associated risk factors for developing osteonecrosis depend on the therapeutic context including the use of glucocorticosteroids and the simultaneous and/or intensified use of asparaginase (ASP) which may, among others, exert its effect on blood supply to the bone through hypertriglyceridemia, hypercholesterolemia, and hypertension. Allogeneic hematopoietic stem cell transplantation, bloodstream infections, and genetic factors may additionally impact the risk of osteonecrosis. In this article, the authors used the best available evidence in the literature to develop management recommendations for the use in the context of steroid and asparaginase containing regimens. These considerations may be helpful for similar treatment approaches.
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Affiliation(s)
- Michaela Kuhlen
- Swabian Children’s Cancer Center, Paediatric and Adolescent Medicine, University Medical Center Augsburg, Germany
| | - Marina Kunstreich
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, University Hospital, Goethe University, Frankfurt, Germany
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van Atteveld JE, de Groot-Kruseman HA, Fiocco M, Lequin MH, Neggers SJCMM, Pluijm SMF, van der Sluis IM, Pieters R, van den Heuvel-Eibrink MM. Effect of post-consolidation regimen on symptomatic osteonecrosis in three DCOG acute lymphoblastic leukemia protocols. Haematologica 2021; 106:1198-1201. [PMID: 32646890 PMCID: PMC8018109 DOI: 10.3324/haematol.2020.257550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology
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35
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Bostrom B. Comment on: "Team approach: Management of osteonecrosis in children with acute lymphoblastic leukemia: An ounce of prevention is worth a pound of cure: Consideration of prophylactic pamidronate. Pediatr Blood Cancer 2021; 68:e28720. [PMID: 33047874 DOI: 10.1002/pbc.28720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/08/2022]
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36
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Gupta A, Damania RC, Talati R, O'Riordan MA, Matloub YH, Ahuja SP. Increased Toxicity Among Adolescents and Young Adults Compared with Children Hospitalized with Acute Lymphoblastic Leukemia at Children's Hospitals in the United States. J Adolesc Young Adult Oncol 2021; 10:645-653. [PMID: 33512257 DOI: 10.1089/jayao.2020.0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose: Adolescent and young adult (AYA) patients (15-39 years old) with acute lymphoblastic leukemia (ALL) have less favorable outcomes and higher treatment-related mortality as compared with older children with ALL. Minimal data exist regarding how well AYA patients tolerate the intensity of chemotherapy at doses and regimens designed for children, and the toxicities suffered by this population at children's hospitals have not been thoroughly characterized. Methods: Pediatric Health Information Systems database was queried to analyze health care outcomes in pediatric (ages 10-14) and AYA patients (ages 15-39) with ALL hospitalized between January 1999 and December 2014. We extracted relevant ICD-9 data for each patient related to grades 3 or 4 toxicities as outlined by the NCI. Results: A total of 5345 hospital admissions met inclusion criteria, representing 4046 unique patients. Of these admissions, 2195 (41.1%) were in the AYA age group, and the remainder were in the 10-14-year-old group. AYA patients had a significantly higher incidence of intensive care unit stay but no difference in median hospital stay nor mortality. AYA patients had increased toxicities in almost every organ system as compared with older children. Conclusions: In this large multicenter US database study, we found an overall increased number of toxicities among AYA patients with ALL in children's hospitals. Compared with children between the ages of 10 and 15, AYA patients developed disproportionately higher toxicities from drugs commonly used in pediatric protocols for ALL. Prospective studies are needed to assess whether dose modifications for certain chemotherapeutics may improve the toxicity profile and health care burden of AYA patients with ALL treated in children's hospitals.
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Affiliation(s)
- Ajay Gupta
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Rahul C Damania
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Ravi Talati
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Mary Ann O'Riordan
- Women's & Children's Services, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
| | - Yousif H Matloub
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sanjay P Ahuja
- Division of Pediatric Hematology/Oncology, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
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37
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Jones LC, Kaste SC, Karol SE, DeFeo B, Kim HKW, Neel MD, Levin AS. Team approach: Management of osteonecrosis in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2020; 67:e28509. [PMID: 32860663 DOI: 10.1002/pbc.28509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 11/08/2022]
Abstract
With current treatments for acute lymphoblastic leukemia (ALL), the overall prognosis for survival is favorable. Increasing emphasis is placed on recognizing and managing the long-term consequences of ALL and its treatment, particularly involving osteonecrosis. Early osteonecrosis diagnosis and management may improve outcomes and is best accomplished through coordinated teams that may include hematologic oncologists, radiologists, orthopedic surgeons, physical therapists, and the patient and their family. Magnetic resonance imaging is the "gold standard" for diagnosis of early-stage and/or multifocal osteonecrosis. Treatments for osteonecrosis in ALL patients are risk stratified and may include observation, corticosteroid or chemotherapy adjustment, and pharmaceutical or surgical approaches.
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Affiliation(s)
- Lynne C Jones
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee.,Leukemia/Lymphoma Division, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Seth E Karol
- Leukemia/Lymphoma Division, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Brian DeFeo
- Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Harry K W Kim
- Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children, UT Southwestern Medical Center, Dallas, Texas
| | - Michael D Neel
- Division of Orthopaedics, St. Jude Children's Research Hospital, Memphis, TN
| | - Adam S Levin
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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38
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Abstract
The last decade has witnessed great advances in our understanding of the genetic and biological basis of childhood acute lymphoblastic leukemia (ALL), the development of experimental models to probe mechanisms and evaluate new therapies, and the development of more efficacious treatment stratification. Genomic analyses have revolutionized our understanding of the molecular taxonomy of ALL, and these advances have led the push to implement genome and transcriptome characterization in the clinical management of ALL to facilitate more accurate risk-stratification and, in some cases, targeted therapy. Although mutation- or pathway-directed targeted therapy (e.g., using tyrosine kinase inhibitors to treat Philadelphia chromosome [Ph]-positive and Phlike B-cell-ALL) is currently available for only a minority of children with ALL, many of the newly identified molecular alterations have led to the exploration of approaches targeting deregulated cell pathways. The efficacy of cellular or humoral immunotherapy has been demonstrated with the success of chimeric antigen receptor T-cell therapy and the bispecific engager blinatumomab in treating advanced disease. This review describes key advances in our understanding of the biology of ALL and optimal approaches to risk-stratification and therapy, and it suggests key areas for basic and clinical research.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN.
| | - Charles G Mullighan
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN.
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39
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Öztürk AP, Koç B, Zülfikar B. Acute Complications and Survival Analysis of Childhood Acute Lymphoblastic Leukemia: A 15-year Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:e39-e47. [PMID: 33046422 DOI: 10.1016/j.clml.2020.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/22/2020] [Accepted: 08/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND We evaluated the acute complications that occurred during the treatment of childhood acute lymphoblastic leukemia (ALL) and documented the survival rates of children with ALL. MATERIALS AND METHODS We retrospectively evaluated 110 children with a diagnosis of ALL treated with the Children's Oncology Group protocol from 1999 to 2014. The demographic, clinical, and laboratory data of 110 patients and acute complications of eligible and evaluable 105 patients were recorded. RESULTS Of the 110 patients, 65 were male and 45 were female. The mean age at admission was 8.3 ± 5.2 years. Ninety-seven patients (88.2%) had been diagnosed with pre-B-cell ALL, 11 (10%) with T-cell ALL, 1 (0.9%) with mixed phenotype acute leukemia, and 1 (0.9%) with mature B-cell acute leukemia. Of the 110 patients, 40 (36.3%) were in the standard-risk group and 70 (63.7%) were in high-risk group. Of the 110 patients, 105 had been followed up regularly and evaluated for acute complications. Infection was the most common complication (n = 93; 88.5%), followed by gastrointestinal (n = 29; 27.6%), neurologic (n = 28; 26.6%), metabolic/endocrine (n = 16; 15.2%), drug-related hypersensitivity (n = 16; 15.2%), avascular necrosis (n = 13; 12.3%), thrombotic (n = 11; 10.4%), severe psychiatric (n = 2; 1.9%), and various other (n = 12; 11.4%) complications. Of the 110 patients, 98 were assessed in terms of survival analysis. The 5- and 10-year overall survival rates were both 85.9% (standard error [SE], 3.6%). The relapse-free survival rates at 1, 3, and 5 years were 97.9% (SE, 1.5%), 91.3% (SE, 3%), and 86.3% (SE, 3.7%), respectively. CONCLUSION Childhood ALL, although categorized as curable malignancy owing to the improvements in treatment strategies in recent years, can cause acute complications affecting various systems. Thus, patients should be treated and followed up by multidisciplinary medical teams with high expertise.
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Affiliation(s)
- Ayşe Pınar Öztürk
- Department of Pediatrics, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul, Turkey.
| | - Başak Koç
- Department of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey
| | - Bülent Zülfikar
- Department of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey
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40
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Franca R, Zudeh G, Lucafò M, Rabusin M, Decorti G, Stocco G. Genome wide association studies for treatment-related adverse effects of pediatric acute lymphoblastic leukemia. WIREs Mech Dis 2020; 13:e1509. [PMID: 33016644 DOI: 10.1002/wsbm.1509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/01/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric hematological malignancy; notwithstanding the success of ALL therapy, severe adverse drugs effects represent a serious issue in pediatric oncology, because they could be both an additional life threatening condition for ALL patients per se and a reason to therapy delay or discontinuation with important fallouts on final outcome. Cancer treatment-related toxicities have generated a significant need of finding predictive pharmacogenomic markers for the a priori identification of at risk patients. In the era of precision medicine, high throughput genomic screening such as genome wide association studies (GWAS) might provide useful markers to tailor therapy intensity on patients' genetic profile. Furthermore, these findings could be useful in basic research for better understanding the mechanistic and regulatory pathways of the biological functions associated with ALL treatment toxicities. The purpose of this review is to give an overview of high throughput genomic screening of the last 10 years that had investigated the landscape of ALL treatment-associated toxicities. This article is categorized under: Cancer > Genetics/Genomics/Epigenetics.
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Affiliation(s)
- Raffaella Franca
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulia Zudeh
- University of Trieste, PhD Course in Reproductive and Developmental Sciences, Trieste, Italy
| | - Marianna Lucafò
- Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Marco Rabusin
- Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Giuliana Decorti
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Gabriele Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
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41
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Rank CU, Schmiegelow K. Optimal approach to the treatment of young adults with acute lymphoblastic leukemia in 2020. Semin Hematol 2020; 57:102-114. [PMID: 33256899 DOI: 10.1053/j.seminhematol.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
Akin to the introduction of tyrosine kinase inhibitors to Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL), pediatric-based asparaginase-heavy approaches have revolutionized the treatment of young adults with the Philadelphia chromosome-negative subset the past decades. Once again, we are approaching a new era. An era of precision medicine with immunotherapy and other molecularly targeted treatments that offers unique opportunities to customize treatment intensity with or without hematopoietic stem cell transplantation, reduce the burden of toxicities, and combat persistent residual disease. Recently approved agents for refractory/relapsed B-cell precursor ALL include the chimeric antigen receptor-modified T-cells, the anti-CD22 monoclonal antibody-drug conjugate, inotuzumab ozogamicin, and the bispecific anti-CD19 T-cell engager, blinatumomab. These agents are expected to move widely into the frontline setting along with the proteasome inhibitors, bortezomib and carfilzomib, as well as tyrosine kinase inhibitors for Philadelphia-like rearrangements that are especially frequent among young adults. To this add the BH3 mimetics, venetoclax and navitoclax, which are being widely explored in refractory/relapsed as well as frontline settings for B- and T-cell ALL. The promising anti-CD38 monoclonal antibody, daratumumab, is entering the scene of refractory/relapsed T-ALL, whereas the old purine analogue, nelarabine, is being evaluated in a new upfront setting. This review focuses on 2 main questions: How do we optimize frontline as well as salvage ALL treatment of young adults in the 2020s? Not least, how do we address the current burden of serious toxicities unique to young adults?
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Affiliation(s)
- Cecilie Utke Rank
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
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42
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Inaba H, Varechtchouk O, Neel MD, Ehrhardt MJ, Metzger ML, Karol SE, Ness KK, Ribeiro RC, Pui CH, Relling MV, Sandlund JT, Kaste SC. Whole-joint magnetic resonance imaging to assess osteonecrosis in pediatric patients with acute lymphoblastic lymphoma. Pediatr Blood Cancer 2020; 67:e28336. [PMID: 32472969 PMCID: PMC7391358 DOI: 10.1002/pbc.28336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/04/2020] [Accepted: 03/25/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Osteonecrosis is a debilitating complication in children and adolescents with acute lymphoblastic leukemia or acute lymphoblastic lymphoma (LLy). An objective screening test to identify patients at risk for symptomatic, extensive joint involvement will help manage osteonecrosis. METHODS We performed a prospective, longitudinal pilot study with whole-joint magnetic resonance imaging (MRI) of shoulders, elbows, hips, knees, ankles, and hindfeet to evaluate the incidence and timing of osteonecrosis involving multiple joints in 15 patients with LLy aged 9-21 years at diagnosis. RESULTS Osteonecrosis affecting ≥30% of the epiphysis occurred in eight of 15 patients, with a high prevalence in hips (12 of 26 examined [46%]) and knees (10 of 26 [38%]) post reinduction I and in shoulders (seven of 20 [35%]) post reinduction II. Most osteonecrotic hips and knees with ≥30% epiphyseal involvement became symptomatic and/or underwent surgery (100% and 82%, respectively). All eight patients with ≥30% epiphyseal involvement had multijoint involvement. Seven of these patients had hip or knee osteonecrosis by the end of remission induction, and only these patients developed osteonecrosis that became symptomatic and/or underwent surgery in their hips, knees, shoulders, ankles, and/or feet; all of these joints were associated with epiphyseal abnormalities on post reinduction I imaging. CONCLUSIONS MRI screening in adolescent patients with LLy revealed osteonecrosis in multiple joints. Initial screening with hip and knee MRI at the end of induction may identify susceptible patients who could benefit from referrals to subspecialties, more extensive follow-up imaging of other joints, and early medical and surgical interventions.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Olga Varechtchouk
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Michael D. Neel
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Matthew J. Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Monika L. Metzger
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Raul C. Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
| | - John T. Sandlund
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sue C. Kaste
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee
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43
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Dixon SB, Chen Y, Yasui Y, Pui CH, Hunger SP, Silverman LB, Ness KK, Green DM, Howell RM, Leisenring WM, Kadan-Lottick NS, Krull KR, Oeffinger KC, Neglia JP, Mertens AC, Hudson MM, Robison LL, Armstrong GT, Nathan PC. Reduced Morbidity and Mortality in Survivors of Childhood Acute Lymphoblastic Leukemia: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2020; 38:3418-3429. [PMID: 32706634 DOI: 10.1200/jco.20.00493] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Risk-stratified therapy, which modifies treatment on the basis of clinical and biologic features, has improved 5-year overall survival of childhood acute lymphoblastic leukemia (ALL) to 90%, but its impact on long-term toxicity remains unknown. METHODS We assessed all-cause and health-related late mortality (including late effects of cancer therapy), subsequent malignant neoplasms (SMNs), chronic health conditions, and neurocognitive outcomes among 6,148 survivors of childhood ALL (median age, 27.9 years; range, 5.9-61.9 years) diagnosed between 1970 and 1999. Therapy combinations and treatment intensity defined 6 groups: 1970s-like (70s), standard- or high-risk 1980s-like (80sSR, 80sHR) and 1990s-like (90sSR, 90sHR), and relapse/transplantation (R/BMT). Cumulative incidence, standardized mortality ratios, and standardized incidence ratios were compared between treatment groups and with the US population. RESULTS Overall, 20-year all-cause late mortality was 6.6% (95% CI, 6.0 to 7.1). Compared with 70s, 90sSR and 90sHR experienced lower health-related late mortality (rate ratio [95% CI]: 90sSR, 0.2 [0.1 to 0.4]; 90sHR, 0.3 [0.1 to 0.7]), comparable to the US population (standardized mortality ratio [95% CI]: 90sSR, 1.3 [0.8 to 2.0]; 90sHR, 1.7 [0.7 to 3.5]). Compared with 70s, 90sSR had a lower rate of SMN (rate ratio [95% CI], 0.3 [0.1 to 0.6]) that was not different from that of the US population (standardized incidence ratio [95% CI], 1.0 [0.6 to 1.6]). The 90sSR group had fewer severe chronic health conditions than the 70s (20-year cumulative incidence [95% CI], 11.0% [9.7% to 12.3%] v 22.5% [19.4% to 25.5%]) and a lower prevalence of impaired memory (prevalence ratio [95% CI], 0.7 [0.6 to 0.9]) and task efficiency (0.5 [0.4 to 0.7]). CONCLUSION Risk-stratified therapy has reduced late morbidity and mortality among contemporary survivors of standard-risk ALL, represented by 90sSR. Health-related late mortality and SMN risks among 5-year survivors of contemporary, standard-risk childhood ALL are comparable to the general population.
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Affiliation(s)
- Stephanie B Dixon
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Yan Chen
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Stephen P Hunger
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Daniel M Green
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Rebecca M Howell
- Radiation Physics Department, The University of Texas at MD Anderson Cancer Center, Houston, TX
| | - Wendy M Leisenring
- Cancer Prevention and Clinical Statistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN.,Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
| | | | - Joseph P Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Ann C Mertens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Melissa M Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.,Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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44
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Karol SE, Pui CH. Personalized therapy in pediatric high-risk B-cell acute lymphoblastic leukemia. Ther Adv Hematol 2020; 11:2040620720927575. [PMID: 32537116 PMCID: PMC7268159 DOI: 10.1177/2040620720927575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Although cure rates for pediatric acute lymphoblastic leukemia (ALL) have now risen to more than 90%, subsets of patients with high-risk features continue to experience high rates of treatment failure and relapse. Recent work in minimal residual disease stratification and leukemia genomics have increased the ability to identify and classify these high-risk patients. In this review, we discuss this work to identify and classify patients with high-risk ALL. Novel therapeutics, which may have the potential to improve outcomes for these patients, are also discussed.
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Affiliation(s)
- Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Pl., Mail Stop 260, Memphis, TN 38105, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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45
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Doğan I, Kalyoncu U, Kiliç L, Akdoğan A, Karadağ Ö, Kiraz S, Bilgen ŞA, Ertenli I. Avascular necrosis less frequently found in systemic lupus erythematosus patients with the use of alternate day corticosteroid. Turk J Med Sci 2020; 50:219-224. [PMID: 31905492 PMCID: PMC7080371 DOI: 10.3906/sag-1908-182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/02/2020] [Indexed: 01/11/2023] Open
Abstract
Background/aim Avascular necrosis (AVN) is the death of bone due to compromise of blood flow. The etiology of AVN is multifactorial; corticosteroid usage is the second most significant factor after trauma, and systemic lupus erythematosus (SLE) is the most common underlying disease. The objective of this study was to assess the factors of AVN in SLE patients. Materials and methods The study included 127 patients with SLE who fulfilled 1997 American College of Rheumatology (ACR) revised criteria. Demographic data, age at SLE diagnosis, disease duration, disease activity, body mass index, clinical findings, antiphospholipid syndrome, steroid usage, dose and duration, comorbid diseases, and smoking history were recorded. Results AVN was found in 11 of 127 (8.7%) SLE patients. Hyperlipidemia (P < 0.001), cushingoid body habitus (P < 0.001), and proteinuria (P = 0.013) were found at higher rates in the AVN group. All of the 11 AVN cases had osteoporosis (P < 0.02). In multivariate regression analysis, daily steroid usage was the only factor for development of AVN in SLE. Conclusion The hypothesis of our study was that an alternate day steroid regimen may decrease AVN frequency in SLE patients.
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Affiliation(s)
- Ismail Doğan
- Division of Rheumatology, Department of Internal Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Levent Kiliç
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Akdoğan
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Sedat Kiraz
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Şule A Bilgen
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Ihsan Ertenli
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
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Abstract
Glucocorticoids (GC) are an important risk factor for bone fragility in children with serious illnesses, largely due to their direct adverse effects on skeletal metabolism. To better appreciate the natural history of fractures in this setting, over a decade ago the Canadian STeroid-associated Osteoporosis in the Pediatric Population ("STOPP") Consortium launched a 6 year, multi-center observational cohort study in GC-treated children. This study unveiled numerous key clinical-biological principles about GC-induced osteoporosis (GIO), many of which are unique to the growing skeleton. This was important, because most GIO recommendations to date have been guided by adult studies, and therefore do not acknowledge the pediatric-specific principles that inform monitoring, diagnosis and treatment strategies in the young. Some of the most informative observations from the STOPP study were that vertebral fractures are the hallmark of pediatric GIO, they occur early in the GC treatment course, and they are frequently asymptomatic (thereby undetected in the absence of routine monitoring). At the same time, some children have the unique, growth-mediated ability to restore normal vertebral body dimensions following vertebral fractures. This is an important index of recovery, since spontaneous vertebral body reshaping may preclude the need for osteoporosis therapy. Furthermore, we now better understand that children with poor growth, older children with less residual growth potential, and children with ongoing bone health threats have less potential for vertebral body reshaping following spine fractures, which can result in permanent vertebral deformity if treatment is not initiated in a timely fashion. Therefore, pediatric GIO management is now predicated upon early identification of vertebral fractures in those at risk, and timely intervention when there is limited potential for spontaneous recovery. A single, low-trauma long bone fracture can also signal an osteoporotic event, and a need for treatment. Intravenous bisphosphonates are currently the recommended therapy for pediatric GC-induced bone fragility, typically prescribed to children with limited potential for medication-unassisted recovery. It is recognized, however, that even early identification of bone fragility, combined with timely introduction of intravenous bisphosphonate therapy, may not completely rescue the osteoporosis in those with the most aggressive forms, opening the door to novel strategies.
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Hypertension is a modifiable risk factor for osteonecrosis in acute lymphoblastic leukemia. Blood 2019; 134:983-986. [PMID: 31409674 DOI: 10.1182/blood.2019000006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Affiliation(s)
- Joel A Kaplan
- Department of Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, NC
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Amin N, Kinsey S, Feltbower R, Kraft J, Whitehead E, Velangi M, James B. British OsteoNEcrosis Study (BONES) protocol: a prospective cohort study to examine the natural history of osteonecrosis in older children, teenagers and young adults with acute lymphoblastic leukaemia and lymphoblastic lymphoma. BMJ Open 2019; 9:e027204. [PMID: 31122988 PMCID: PMC6538027 DOI: 10.1136/bmjopen-2018-027204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Osteonecrosis is a well-recognised treatment-related morbidity risk in patients diagnosed with acute lymphoblastic leukaemia (ALL) and lymphoblastic lymphoma (LBL), with a high rate of affected patients requiring surgical intervention. Patients may have asymptomatic changes on imaging studies that spontaneously regress, and little is known about the natural history of osteonecrotic changes seen. The main aim of the British OsteoNEcrosis Study (BONES) is to determine the incidence of symptomatic and asymptomatic osteonecrosis in the lower extremities of survivors of ALL or LBL diagnosed aged 10-24 years in the UK at different time points in their treatment. This study also aims to identify risk factors for progression and the development of symptomatic osteonecrosis in this population, as well as specific radiological features that predict for progression or regression in those with asymptomatic osteonecrosis METHODS AND ANALYSIS: BONES is a prospective, longitudinal cohort study based at principal treatment centres around the UK. Participants are patients aged 10-24 years diagnosed with ALL or LBL under standard criteria. Assessment for osteonecrosis will be within 4 weeks of diagnosis, at the end of delayed intensification and 1, 2 and 3 years after the start of maintenance therapy. Assessment will consist of MRI scans of the lower limbs and physiotherapy assessment. Clinical and biochemical data will be collected at each of the time points. Bone mineral density data and vertebral fracture assessment using dual-energy X-ray absorptiometry will be collected at diagnosis and annually for 3 years after diagnosis of malignancy. ETHICS AND DISSEMINATION Ethical approval has been obtained through the Yorkshire and Humber Sheffield Research Ethics Committee (reference number: 16/YH/0206). Study results will be published on the study website, in peer-reviewed journals and presented at relevant conferences and via social media. TRIAL REGISTRATION NUMBER NCT02598401; Pre-results.
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Affiliation(s)
- Nadia Amin
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Sally Kinsey
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Department of Paediatric Haematology, Leeds Children’s Hospital, Leeds, UK
| | | | - Jeannette Kraft
- Department of Radiology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | | | - Mark Velangi
- Department of Paediatric Haematology, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Beki James
- Department of Paediatric Haematology, Leeds Children’s Hospital, Leeds, UK
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50
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Karol SE, Janke LJ, Panetta JC, Ramsey LB, Cai X, Payton MA, Jenkins DA, Evans WE, Relling MV. Asparaginase combined with discontinuous dexamethasone improves antileukemic efficacy without increasing osteonecrosis in preclinical models. PLoS One 2019; 14:e0216328. [PMID: 31059548 PMCID: PMC6502315 DOI: 10.1371/journal.pone.0216328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/19/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Combination therapy for acute lymphoblastic leukemia (ALL) is highly effective but results in significant toxicity including osteonecrosis. Asparaginase is known to potentiate both the antileukemic and osteonecrosis-inducing effects of dexamethasone. The schedule of dexamethasone alters osteonecrosis risk. However, the effects of the interaction with asparaginase are unknown when dexamethasone is given on a discontinuous schedule. Methods Using the murine model of osteonecrosis, we compared the frequency of osteonecrosis in mice receiving discontinuous dexamethasone (3.5 days/ week) with mice receiving asparaginase and discontinuous dexamethasone. We then tested the effect on antileukemic efficacy using six pediatric ALL xenografts. Results The addition of asparaginase to discontinuous dexamethasone did not alter the rate of osteonecrosis compared to dexamethasone alone (7/35 in dexamethasone with asparaginase combination vs. 10/36 in dexamethasone alone, p = 0.62) despite increasing steady-state plasma dexamethasone levels (103.9 nM vs. 33.4 nM, p = 9.2x10-7). Combination therapy with asparaginase and dexamethasone demonstrated synergistic antileukemic effects across all six xenografts studied. Conclusions When discontinuous dexamethasone was given, its anti-leukemic activity synergized with asparaginase but the osteonecrosis-worsening effects of asparaginase (above dexamethasone alone) were not observed. Thus, there is a favorable drug interaction (unchanged toxicity, synergistic efficacy) between discontinuous dexamethasone and asparaginase.
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Affiliation(s)
- Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
- * E-mail:
| | - Laura J. Janke
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - John C. Panetta
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Laura B. Ramsey
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Xiangjun Cai
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Monique A. Payton
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - David A. Jenkins
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - William E. Evans
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
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