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Korhonen L, Mogensen H, Erdmann F, Feychting M, Frederiksen LE, Hirvonen E, Krøyer A, Kyrönlahti A, Malila N, Pedersen C, Pitkäniemi J, Talbäck M, Taskinen M, Winther JF, Madanat‐Harjuoja L. Leaving the parental home, cohabitation, and marriage after a hematologic malignancy in childhood-A register-based cohort study from the SALiCCS research program. Cancer Med 2024; 13:e70067. [PMID: 39087864 PMCID: PMC11292853 DOI: 10.1002/cam4.70067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 07/15/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
INTRODUCTION Transitioning to adulthood often involves achieving independence from the parental home. We assessed whether the likelihood of leaving the parental home, cohabitation, and marriage was similar between patients who experienced a hematologic malignancy at a young age and their peers. METHODS We identified 11,575 patients diagnosed with a hematologic malignancy under the age of 20 years between 1971 and 2011 in Denmark, Finland, and Sweden, 57,727 country-, age-, and sex-matched population comparisons and 11,803 sibling comparisons and obtained annual information on family and marital status by linking to the statistical institute databases. Hazard ratios (HR) for leaving the parental home, cohabitation and marriage were estimated using Cox proportional hazards modeling. RESULTS Young adults with a history of a hematologic malignancy were slightly less likely to leave the parental home (HR 0.89; 95% confidence interval [CI] 0.86-0.92; HR 0.87 [95% CI 0.82-0.92]), cohabit with a nonmarital partner (HR 0.83 [95%CI 0.78-0.87]; HR 0.84 [95% CI 0.77-0.92]) and be married (HR 0.87 [95% CI 0.82-0.91]; HR 0.86 [95% CI 0.79-0.93]), compared with population comparisons and siblings, respectively. CONCLUSIONS Our findings provide reassurance that young adults with a history of a hematologic malignancy show only a slight decrease in their likelihood of gaining independence from their childhood family and forming close interpersonal relationships compared to peers. While most patients are coping well in the long term, integrating structured psychosocial support into long-term follow-up is recommended to facilitate a timely and adequate transition into adulthood.
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Affiliation(s)
- Liisa Korhonen
- Finnish Cancer RegistryHelsinkiFinland
- New Children's HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Hanna Mogensen
- Unit of EpidemiologyInstitute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | - Friederike Erdmann
- Childhood Cancer Research GroupDanish Cancer InstituteCopenhagenDenmark
- Division of Childhood Cancer EpidemiologyInstitute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University MainzMainzGermany
| | - Maria Feychting
- Unit of EpidemiologyInstitute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | | | | | - Anja Krøyer
- Childhood Cancer Research GroupDanish Cancer InstituteCopenhagenDenmark
| | - Anniina Kyrönlahti
- Finnish Cancer RegistryHelsinkiFinland
- New Children's HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | | | - Camilla Pedersen
- Childhood Cancer Research GroupDanish Cancer InstituteCopenhagenDenmark
| | - Janne Pitkäniemi
- Finnish Cancer RegistryHelsinkiFinland
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
- School of Health SciencesUniversity of TampereTampereFinland
| | - Mats Talbäck
- Unit of EpidemiologyInstitute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | - Mervi Taskinen
- Division of Pediatric Hematology, Oncology and Stem Cell TransplantationHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Jeanette Falck Winther
- Childhood Cancer Research GroupDanish Cancer InstituteCopenhagenDenmark
- Department of Clinical Medicine, Faculty of HealthAarhus University and University HospitalAarhusDenmark
| | - Laura Madanat‐Harjuoja
- Finnish Cancer RegistryHelsinkiFinland
- New Children's HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Mogensen H, Tettamanti G, Frederiksen LE, Talbäck M, Härkonen J, Modig K, Pedersen C, Krøyer A, Hirvonen E, Kyrönlahti A, Heyman M, Holmqvist AS, Hasle H, Madanat-Harjuoja L, Malila N, Winther JF, Erdmann F, Feychting M. Educational attainment in survivors of childhood cancer in Denmark, Finland, and Sweden. Br J Cancer 2024; 130:260-268. [PMID: 37993542 PMCID: PMC10803319 DOI: 10.1038/s41416-023-02499-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 10/29/2023] [Accepted: 11/08/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Survivors of childhood cancer may face difficulties at school. We investigated whether childhood cancer affects attainment of upper secondary education, in a register-based cohort study from Denmark, Finland, and Sweden, where we limit bias from selection and participation. METHODS From the national cancer registers, we identified all long-term survivors of childhood cancer diagnosed aged 0-14 years in 1971-2005 (n = 7629), compared them to matched population comparisons (n = 35,411) and siblings (n = 6114), using odds ratios (OR) and 95% confidence intervals (CI). RESULTS Overall, 6127 survivors (80%) had attained upper secondary education by age 25, compared to 84% among comparison groups. Elevated OR for not attaining this level were mainly confined to survivors of central nervous system (CNS) tumours (ORSurv_PopComp2.05, 95%CI: 1.83-2.29). Other risk groups were survivors who had spent more time in hospital around cancer diagnosis and those who had hospital contacts in early adulthood, particularly psychiatric. Survivors of all cancer types were less likely to have attained upper secondary education without delay. CONCLUSIONS Although survivors of childhood cancer experienced delays in their education, many had caught up by age 25. Except for survivors of CNS tumours, survivors attained upper secondary education to almost the same extent as their peers.
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Affiliation(s)
- Hanna Mogensen
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Giorgio Tettamanti
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Mats Talbäck
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Juho Härkonen
- Department of Political and Social Sciences, European University Institute, Florence, Italy
- Department of Sociology, Stockholm University, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Pedersen
- Childhood Cancer Research Group, Danish Cancer Institute, Copenhagen, Denmark
| | - Anja Krøyer
- Childhood Cancer Research Group, Danish Cancer Institute, Copenhagen, Denmark
| | - Elli Hirvonen
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
| | - Anniina Kyrönlahti
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
- New children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mats Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anna Sällfors Holmqvist
- Department of Clinical Sciences, Lund University, Childhood Cancer Center, Skåne University Hospital, Lund, Sweden
| | - Henrik Hasle
- Department of pediatric and adolescent medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Laura Madanat-Harjuoja
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Nea Malila
- Finnish Cancer Registry, Cancer Society of Finland, Helsinki, Finland
| | - Jeanette Falck Winther
- Childhood Cancer Research Group, Danish Cancer Institute, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Friederike Erdmann
- Childhood Cancer Research Group, Danish Cancer Institute, Copenhagen, Denmark
- Research group Aetiology and Inequalities in Childhood Cancer, Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Maria Feychting
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Gebhard A, Lilienthal P, Metzler M, Rauh M, Sager S, Schmiegelow K, Toksvang LN, Zierk J. Pharmacokinetic-pharmacodynamic modeling of maintenance therapy for childhood acute lymphoblastic leukemia. Sci Rep 2023; 13:11749. [PMID: 37474565 PMCID: PMC10359452 DOI: 10.1038/s41598-023-38414-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023] Open
Abstract
In the treatment of childhood acute lymphoblastic leukemia (ALL), current protocols combine initial high-dose multiagent chemotherapy with prolonged oral therapy with 6-mercaptopurine (6MP) and low-dose methotrexate (MTX) maintenance therapy. Decades of research on ALL treatment have resulted in survival rates of approximately 90%. However, dose-response relationships vary widely between patients and insight into the influencing factors, that would allow for improved personalized treatment management, is insufficient. We use a detailed data set with measurements of thioguanine nucleotides and MTX in red blood cells and absolute neutrophil count (ANC) to develop pharmacokinetic models for 6MP and MTX, as well as a pharmacokinetic-pharmacodynamic (PKPD) model capable of predicting individual ANC levels and thus contributing to the development of personalized treatment strategies. Here, we show that integrating metabolite measurements in red blood cells into the full PKPD model improves results when less data is available, but that model predictions are comparable to those of a fixed pharmacokinetic model when data availability is not limited, providing further evidence of the quality of existing models. With this comprehensive model development leading to dynamics similar to simpler models, we validate the suitability of this model structure and provide a foundation for further exploration of maintenance therapy strategies through simulation and optimization.
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Affiliation(s)
- Anna Gebhard
- MathOpt group, Institute of Mathematical Optimization, Faculty of Mathematics, Otto von Guericke University Magdeburg, Magdeburg, Germany.
| | - Patrick Lilienthal
- MathOpt group, Institute of Mathematical Optimization, Faculty of Mathematics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Manfred Rauh
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Sebastian Sager
- MathOpt group, Institute of Mathematical Optimization, Faculty of Mathematics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Linea Natalie Toksvang
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jakob Zierk
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
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Lähteenmäki Taalas T, Järvelä L, Niinikoski H, Huurre A, Harila‐Saari A. Inflammatory biomarkers after an exercise intervention in childhood acute lymphoblastic leukemia survivors. EJHAEM 2022; 3:1188-1200. [PMID: 36467791 PMCID: PMC9713025 DOI: 10.1002/jha2.588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 06/17/2023]
Abstract
Cancer survivors show increased risk for non-communicable diseases and chronic low-grade inflammation characterizes the development of such diseases. We investigated inflammatory plasma protein profiles of survivors of childhood acute lymphoblastic leukemia (ALL) in comparison to healthy controls and after an intervention with a home-based exercise program. Survivors of childhood ALL aged 16-30 years (n = 21) with a median age at diagnosis 4.9 (1.6-12.9) years and a median time of 15.9 years from diagnosis, and sex- and age-matched healthy controls (n = 21) were studied. Stored plasma samples were analyzed with Olink's 92-protein-wide Inflammation panel in 21 ALL long-term survivors at baseline, after a previous 16-week home-based exercise intervention (n = 17) and in 21 age- and sex-matched controls at baseline. Protein expression levels were compared between the groups. Inflammatory protein levels did not differ between the survivors and controls at baseline. Significantly reduced levels after the intervention were found in 11 proteins related to either vascular inflammation, insulin resistance, or both: tumor necrosis factor superfamily member 14 (TNFSF14), oncostatin M (OSM), monocyte chemoattractant protein 1 (MCP-1), MCP-2, fibroblast growth factor 21 (FGF-21), chemokine (C-C motif) ligand 4 (CCL4), transforming growth factor alpha (TGF-α), tumor necrosis factor-related apoptosis-inducing ligand 10 (TRAIL), adenosine deaminase (ADA), chemokine (C-X-C motif) ligand 6 (CXCL6), and latency-associated peptide transforming growth factor beta 1 (LAP TGF-β1). The ALL survivors were not significantly more affected by inflammation than controls at baseline. The survivors' 16-week exercise intervention led to significant reduction in inflammatory protein levels. Physical exercise should be promoted for survivors of childhood cancer.
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Affiliation(s)
- Tuomas Lähteenmäki Taalas
- University of TurkuTurkuFinland
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Liisa Järvelä
- University of TurkuTurkuFinland
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
| | - Harri Niinikoski
- University of TurkuTurkuFinland
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
| | - Anu Huurre
- University of TurkuTurkuFinland
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
| | - Arja Harila‐Saari
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
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The Impact of Exercise on Cardiotoxicity in Pediatric and Adolescent Cancer Survivors: A Scoping Review. Curr Oncol 2022; 29:6350-6363. [PMID: 36135069 PMCID: PMC9497997 DOI: 10.3390/curroncol29090500] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Childhood and adolescent cancer survivors are disproportionately more likely to develop cardiovascular diseases from the late effects of cardiotoxic therapies (e.g., anthracycline-based chemotherapy and chest-directed radiotherapy). Currently, dexrazoxane is the only approved drug for preventing cancer treatment-related cardiac damage. While animal models highlight the beneficial effects of exercise cancer treatment-related cardiac dysfunction, few clinical studies have been conducted. Thus, the objective of this scoping review was to explore the designs and impact of exercise-based interventions for managing cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors. Reviewers used Joanna Briggs Institute’s methodology to identify relevant literature. Then, 4616 studies were screened, and three reviewers extracted relevant data from six reports. Reviewers found that exercise interventions to prevent cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors vary regarding frequency, intensity, time, and type of exercise intervention. Further, the review suggests that exercise promotes positive effects on managing cancer treatment-related cardiac dysfunction across numerous indices of heart health. However, the few clinical studies employing exercise interventions for childhood and adolescent cancer survivors highlight the necessity for more research in this area.
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6
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Sørensen GV, Albieri V, Holmqvist AS, Erdmann F, Mogensen H, Talbäck M, Ifversen M, Lash TL, Feychting M, Schmiegelow K, Heyman MM, Winther JF, Hasle H. Long-Term Risk of Hospitalization for Somatic Diseases Among Survivors of Childhood Acute Lymphoblastic Leukemia. JNCI Cancer Spectr 2022; 6:6554212. [PMID: 35603856 PMCID: PMC9049267 DOI: 10.1093/jncics/pkac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 11/14/2022] Open
Abstract
Background Survivors of childhood acute lymphoblastic leukemia (ALL) may be at increased long-term risk of hospitalization for somatic diseases. However, large population-based cohort studies with risk estimates for survivors successfully cured without experiencing a relapse or requiring hematopoietic stem cell transplantation (HSCT) are lacking. Methods Danish and Swedish patients diagnosed with ALL before age 20 years in 1982-2008 were identified in the national cancer registries. Five-year survivors and matched population comparisons without childhood cancer were followed for hospitalization for 120 somatic disease categories in the national hospital registries from 5 years postdiagnosis until 2017, and disease-specific hospitalization rate ratios (RR) were calculated. The mean cumulative count method was used to estimate the mean number of multiple and recurrent disease-specific hospitalizations per individual. Results A total of 2024 5-year survivors and 9797 population comparisons were included. The overall hospitalization rate was more than twice as high compared with comparisons (RR = 2.30, 95% confidence interval [CI] = 2.09 to 2.52). At 30 years postdiagnosis, the mean cumulative hospitalization count was 1.69 (95% CI = 1.47 to 1.90) per survivor and 0.80 (95% CI = 0.73 to 0.86) per comparison. In the subcohort without relapse or HSCT (n = 1709), the RR was 1.41 (95% CI = 1.27 to 1.58). Conclusions Survivors of childhood ALL were at increased long-term risk for disease-specific hospitalizations; however, in survivors without relapse or HSCT, the rate was only modestly higher than in population comparisons without a childhood cancer. The absolute mean numbers of multiple and recurrent hospitalizations were generally low.
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Affiliation(s)
- Gitte Vrelits Sørensen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark
| | - Vanna Albieri
- Unit of Statistics and Data Analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Anna Sällfors Holmqvist
- Department of Clinical Sciences, Lund University, Pediatric Oncology and Hematology, Skåne University Hospital, Lund, Sweden
| | - Friederike Erdmann
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
- Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Hanna Mogensen
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mats Talbäck
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Ifversen
- Department of Children and Adolescents Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Timothy Lee Lash
- Department of Epidemiology, Rollins School of Public Health, and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria Feychting
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kjeld Schmiegelow
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mats Marshall Heyman
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Jeanette Falck Winther
- Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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7
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Sørensen GV, Belmonte F, Erdmann F, Mogensen H, Albieri V, Holmqvist AS, Madanat-Harjuoja L, Talbäck M, Heyman MM, Malila N, Feychting M, Schmiegelow K, Winther JF, Hasle H. Late mortality among survivors of childhood acute lymphoblastic leukemia diagnosed during 1971-2008 in Denmark, Finland, and Sweden: A population-based cohort study. Pediatr Blood Cancer 2022; 69:e29356. [PMID: 34582112 DOI: 10.1002/pbc.29356] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigate all-cause and cause-specific late mortality after childhood acute lymphoblastic leukemia (ALL) in a population-based Nordic cohort. METHODS From the cancer registries of Denmark, Finland, and Sweden, we identified 3765 five-year survivors of ALL, diagnosed before age 20 during 1971-2008. For each survivor, up to five matched comparison subjects were randomly selected from the general population (n = 18,323). Causes of death were classified as relapse related, health related, and external. Late mortality was evaluated by cumulative incidences of death from 5-year survival date. Mortality hazard ratios (HR) were evaluated with Cox proportional models. RESULTS Among the survivors, 315 deaths occurred during a median follow-up of 16 years from 5-year survival date (range 0-42). The majority were attributable to relapse (n = 224), followed by second neoplasm (n = 45). Cumulative incidence of all-cause late mortality at 15 years from diagnosis decreased gradually over treatment decades, from 14.4% (95% confidence interval [CI]: 11.6-17.2) for survivors diagnosed during 1971-1981, to 2.5% (95% CI: 1.3-3.7) for those diagnosed during 2002-2008. This was mainly attributable to a reduction in relapse-related deaths decreasing from 13.4% (95% CI: 10.7-16.1) for survivors diagnosed during 1971-1981 to 1.9% (95% CI: 0.9-2.8) for those diagnosed during 2002-2008. Health-related late mortality was low and did not change substantially across treatment decades. Compared to comparison subjects, all-cause mortality HR was 40 (95% CI: 26-61) 5-9 years from diagnosis, and 4.4 (95% CI: 3.4-5.6) ≥10 years from diagnosis. CONCLUSIONS Survivors of ALL have higher late mortality than population comparison subjects. Among the survivors, there was a temporal reduction in risk of death from relapse, without increments in health-related death.
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Affiliation(s)
- Gitte V Sørensen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark
| | - Federica Belmonte
- Unit of Statistics and Data Analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Friederike Erdmann
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark.,Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Hanna Mogensen
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Vanna Albieri
- Unit of Statistics and Data Analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Anna S Holmqvist
- Department of Clinical Sciences, Lund University, Pediatric Oncology and Hematology, Skåne University Hospital, Lund, Sweden
| | | | - Mats Talbäck
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mats M Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Nea Malila
- Finnish Cancer Registry, Helsinki, Finland
| | - Maria Feychting
- Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Kjeld Schmiegelow
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jeanette F Winther
- Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark.,Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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8
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Dixon SB. A decreasing cost of cure in childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2022; 69:e29429. [PMID: 34767307 DOI: 10.1002/pbc.29429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Stephanie B Dixon
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Jensen KS, Klug Albertsen B, Schrøder H, Zalounina Falborg A, Schmiegelow K, Rosthøj S, Callesen MT, Vedsted P. Health care utilisation following childhood acute lymphoblastic leukaemia: a population-based matched cohort study. BMJ Open 2021; 11:e049847. [PMID: 34810184 PMCID: PMC8609931 DOI: 10.1136/bmjopen-2021-049847] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Survival among children diagnosed with acute lymphoblastic leukaemia (ALL) has increased considerably. However, morbidity in survivors constitutes a potential increasing burden not limited to secondary health care. Our objectives were to compare health care utilisation, including both primary and secondary health care, between childhood ALL survivors and matched references up to 15 years after curative treatment. Moreover, to increase knowledge on survivors' health service seeking behaviour as time from treatment elapsed. DESIGN AND SETTING A Danish population-based matched cohort study linking multiple nationwide registries. PARTICIPANTS 675 cases, diagnosed with childhood (1.0-17.9 years) ALL between 1994 and 2015, and 6750 matched references sampled randomly from the source population (matched on age, gender and geographical region). PRIMARY OUTCOME MEASURES Repeated consultations in general practice and hospital (outpatient and inpatient) estimated as yearly rates from 2.5 years after diagnosis and onwards. We compared cases and references with yearly incidence rate ratios (IRRs) from negative binomial regression models. RESULTS Survivors of childhood ALL had a mean number of yearly daytime contacts in general practice of 4.75 (95% CI 4.41 to 5.11) the first year, corresponding to an IRR of 1.85 (95% CI 1.71 to 2.00); decreasing to 1.16 (1.01 to 1.34) after 15 years, and without significant impact of gender (p=0.894) or age (p=0.399). For hospital contacts, ALL survivors had a mean number of yearly contacts of 14.21 (13.38-15.08) the first year, corresponding to an IRR of 31.50 (28.29-35.07); decreasing to 2.42 (1.59-3.68) after 15 years. No differences were found across calendar time. CONCLUSIONS ALL survivors used significantly more health care services across sectors than the reference population. Decreasing use over 15 years illustrated the dynamics of health care needs; this knowledge may inform the future organisation of integrated follow-up programmes. TRIAL REGISTRATION NUMBER NCT03985826.
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Affiliation(s)
- Karen Schow Jensen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schrøder
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Alina Zalounina Falborg
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Steen Rosthøj
- Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Thude Callesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
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Khodzhaev K, Ng OH, Tugcu D, Erbilgin Y, Ng YY, Celkan T, Timur C, Karakas Z, Ozdemir GN, Yıldırmak Y, Sayitoglu M. High
TUBB2A
expression in childhood T‐ALL is correlated with the clinical outcome. Int J Lab Hematol 2020. [DOI: 10.1111/ijlh.13235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Khusan Khodzhaev
- Genetics Department Aziz Sancar Institute of Experimental Medicine Istanbul University Istanbul Turkey
- Istanbul University Institute of Health Sciences Istanbul Turkey
| | - Ozden Hatirnaz Ng
- Department of Medical Biology School of Medicine Acibadem Mehmet Ali Aydinlar University Istanbul Turkey
| | - Deniz Tugcu
- Pediatric Hematology Oncology Department Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Yucel Erbilgin
- Genetics Department Aziz Sancar Institute of Experimental Medicine Istanbul University Istanbul Turkey
| | - Yuk Yin Ng
- Genetics and Bioengineering Department Istanbul Bilgi University Istanbul Turkey
| | - Tiraje Celkan
- Pediatric Hematology Oncology Department Istanbul University‐Cerrahpasa Faculty of Medicine Istanbul Turkey
| | - Cetin Timur
- Pediatric Hematology Oncology Department Seven Hill Hospital Istanbul Turkey
| | - Zeynep Karakas
- Pediatric Hematology Oncology Department Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Gul Nihal Ozdemir
- Pediatric Hematology Oncology Department Istanbul University‐Cerrahpasa Faculty of Medicine Istanbul Turkey
- Pediatric Hematology Division Istanbul Kanuni Sultan Suleyman Education and Research Hospital Istanbul Turkey
| | - Yıldız Yıldırmak
- Pediatric Hematology Division Ministry of Health Sisli Etfal Education and Research Hospital Istanbul Turkey
| | - Muge Sayitoglu
- Genetics Department Aziz Sancar Institute of Experimental Medicine Istanbul University Istanbul Turkey
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11
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Egnell C, Ranta S, Banerjee J, Merker A, Niinimäki R, Lund B, Mogensen PR, Jonsson ÓG, Vaitkeviciene G, Lepik K, Forslund A, Heyman M, Harila-Saari A. Impact of body mass index on relapse in children with acute lymphoblastic leukemia treated according to Nordic treatment protocols. Eur J Haematol 2020; 105:797-807. [PMID: 32909636 PMCID: PMC7693088 DOI: 10.1111/ejh.13517] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/01/2022]
Abstract
Objectives High body mass index (BMI) is associated with poorer survival in childhood acute lymphoblastic leukemia (ALL), but the actual impact on the risk of relapse still needs to be clarified. We evaluated the impact of BMI at diagnosis on the risk of relapse in children with ALL treated according to Nordic Society of Paediatric Haematology and Oncology (NOPHO) protocols. Method In a multicenter study, we collected data on BMI at diagnosis and outcome of 2558 children aged 2.0‐17.9 years diagnosed between 1992 and 2016. Patients were divided into four groups according to International Obesity Task Force (IOTF) childhood BMI cut‐offs: underweight, <17; healthy weight, 17‐25; overweight, 25‐30; and obese, ≥30 kg/m2. Results In Cox multivariate regression analyses, an increased risk of relapse was observed in children aged 10‐17.9 years with unhealthy BMI at diagnosis (underweight hazard ratio HR: 2.90 [95% confidence interval: 1.24‐6.78], P = .01; overweight, HR: 1.95 [1.11‐3.43], P = .02, and obese HR: 4.32 [95% 2.08‐8.97], P < .001), compared to children with healthy weight. BMI had no impact on relapse in children under 10 years of age. Conclusion High BMI, and especially obesity at diagnosis, is an independent adverse prognostic factor for relapse in older children with ALL.
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Affiliation(s)
- Christina Egnell
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Joanna Banerjee
- Children and Adolescents Department, Helsinki University Hospital, Helsinki, Finland
| | - Andrea Merker
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Riitta Niinimäki
- PEDEGO Research Unit, Medical Research Center Oulu and Department of Children and Adolescents, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Bendik Lund
- Department of Pediatrics, St. Olavs University Hospital, and the Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pernille Rudebeck Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ólafur G Jonsson
- Children's Hospital, Landspitali University Hospital, Reykjavik, Iceland
| | - Goda Vaitkeviciene
- Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Kristi Lepik
- Department of Haematology and Oncology, Tallin Children's Hospital, Tallin, Estonia
| | - Anders Forslund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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12
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Winick N, Martin PL, Devidas M, Shuster J, Borowitz MJ, Paul Bowman W, Larsen E, Pullen J, Carroll A, Willman C, Hunger SP, Carroll WL, Camitta BM. Randomized assessment of delayed intensification and two methods for parenteral methotrexate delivery in childhood B-ALL: Children's Oncology Group Studies P9904 and P9905. Leukemia 2019; 34:1006-1016. [PMID: 31728054 DOI: 10.1038/s41375-019-0642-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/11/2019] [Accepted: 11/03/2019] [Indexed: 11/12/2022]
Abstract
The delayed intensification (DI) enhanced outcome for patients with acute lymphoblastic leukemia (ALL) treated on BFM 76/79 and CCG 105 after a prednisone-based induction. Childrens Oncology Group protocols P9904/9905 evaluated DI via a post-induction randomization for eligible National Cancer Institute (NCI) standard (SR) and high-risk (HR) patients. A second randomization compared intravenous methotrexate (IV MTX) as a 24- (1 g/m2) vs. 4-h (2 g/m2) infusion. NCI SR patients received a dexamethasone-based three-drug and NCI HR/CNS 3 SR patients a prednisone-based four-drug induction. End induction MRD (minimal residual disease) was obtained but did not impact treatment. DI improved the 10-year continuous complete remission (CCR) rate; 75.5 ± 2.5% vs. 81.8 ± 2.2% p = 0.002, whereas MTX administration did not; 4-h 80.8 ± 1.9%; 24-h 81.4 ± 1.9% (p = 0.7780). Overall survival (OS) at 10 years did not differ with DI: 91.4 ± 1.6% vs. 90.9 ± 1.7% (p = 0.25) without but was higher with the 24-h MTX infusion; 4-h 91.1 ± 1.4%; 24-h 93.9 ± 1.2% (p = 0.0209). MRD predicted outcome; 10-year CCR 87.7 ± 2.2 and 82.1 ± 2.5% when MRD was <0.01% with/without DI (p = 0.007) and 54.3 ± 8% and 44 ± 8% for patients with MRD ≥ 0.01% with/without DI (p = 0.11). DI improved CCR for patients with B-ALL with and without end induction MRD.
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Affiliation(s)
- Naomi Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Paul L Martin
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jonathan Shuster
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael J Borowitz
- Department of Pathology and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - W Paul Bowman
- Department of Pediatrics, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Eric Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
| | - Jeanette Pullen
- Department of Pediatrics, University of Mississippi, Jackson, MS, USA
| | - Andrew Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cheryl Willman
- Cancer Center and Departments of Internal Medicine and Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - William L Carroll
- Department of Pediatrics and The Perlmutter Cancer Center, New York University Medical Center, New York, NY, USA
| | - Bruce M Camitta
- Department of Pediatrics, Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, WI, USA
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13
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Schmidt D, Kristensen K, Schroeder H, Wehner PS, Rosthøj S, Heldrup J, Damsgaard L, Schmiegelow K, Mikkelsen TS. Plasma creatinine as predictor of delayed elimination of high-dose methotrexate in childhood acute lymphoblastic leukemia: A Danish population-based study. Pediatr Blood Cancer 2019; 66:e27637. [PMID: 30835935 DOI: 10.1002/pbc.27637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Severely delayed elimination of methotrexate (MTX) is difficult to predict in patients treated with high-dose MTX (HD-MTX), but it may cause life-threatening toxicity. It has not been defined how an increase in plasma creatinine can be best used as a predictor for severely delayed MTX elimination, thus providing a guide for therapeutic interventions to minimize renal toxicity. METHODS Pharmacokinetic data were retrospectively collected on 218 Danish children with acute lymphoblastic leukemia treated with HD-MTX 5 or 8 g/m2 on the NOPHO2000 protocol. Moderately delayed MTX elimination was defined as 42-hour plasma MTX ≥ 4.0-9.9 μM, and severely delayed elimination was defined as 42-hour plasma MTX ≥ 10 μM. RESULTS Median 42-hour plasma MTX was 0.61 μM (interquartile range, 0.4-1.06 μM). Of 1295 MTX infusions with 5 g/m2 (n = 140 patients) or 8 g/m2 (n = 78 patients), 5.1% were severely (1.5%) or moderately (3.6%) delayed. The risk of having delayed elimination was highest in the first of eight infusions with MTX 5 g/m² (7.4% vs 0.0 to 4.1% for subsequent MTX infusions) (P < 0.02). A 25 μM increase or a 1.5-fold increase in plasma creatinine within 36 hours from start of the MTX infusion had a sensitivity of 92% (95% CI, 82%-97%) and a specificity of 85% (95% CI, 83%-87%) for predicting 42-hour MTX ≥4.0 μM. CONCLUSIONS A 25 μM increase or a 1.5-fold in plasma creatinine within 36 hours after start of an HD-MTX infusion can predict delayed MTX elimination, thus allowing intensification of hydration and alkalization to avoid further renal toxicity and promote the elimination of MTX.
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Affiliation(s)
- Diana Schmidt
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kim Kristensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Development DMPK, PKPD, Novo Nordisk A/S, Maaløv, Denmark
| | - Henrik Schroeder
- Department of Pediatric Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Peder Skov Wehner
- Department of Pediatric Hematology and Oncology, H.C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Steen Rosthøj
- Department of Pediatric Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Heldrup
- Department of Pediatric Oncology, Lund University Hospital, Lund, Sweden
| | - Linn Damsgaard
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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Nielsen SN, Eriksson F, Rosthoej S, Andersen MK, Forestier E, Hasle H, Hjalgrim LL, Aasberg A, Abrahamsson J, Heyman M, Jónsson ÓG, Pruunsild K, Vaitkeviciené GE, Vettenranta K, Schmiegelow K. Children with low-risk acute lymphoblastic leukemia are at highest risk of second cancers. Pediatr Blood Cancer 2017; 64. [PMID: 28500740 DOI: 10.1002/pbc.26518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/02/2017] [Accepted: 02/09/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The improved survival rates for childhood acute lymphoblastic leukemia (ALL) may be jeopardized by the development of a second cancer, which has been associated with thiopurine therapy. PROCEDURE We retrospectively analyzed three sequential Nordic Society of Paediatric Haematology and Oncology's protocols characterized by increasing intensity of thiopurine-based maintenance therapy. We explored the risk of second cancer in relation to protocols, risk group, thiopurine methyltransferase (TPMT) activity, ALL high hyperdiploidy (HeH), and t(12;21)[ETV6/RUNX1]. RESULTS After median 9.5 years (interquartile range, 5.4-15.3 yrs) of follow-up, 40 of 3,591 patients had developed a second cancer, of whom 38 had non-high-risk B-cell precursor ALL. Patients with standard-risk ALL, who received the longest maintenance therapy, had the highest adjusted hazard of second cancer (hazard ratio [HR], intermediate vs. standard risk: 0.16, 95% CI: 0.06-0.43, P < 0.001; HR, high vs. standard risk: 0.09, 95% CI: 0.02-0.49, P = 0.006); no significant effects of protocol, age, or white blood cell count at diagnosis, ALL HeH, or t(12;21)[ETV6/RUNX1] were observed. A subset analysis on the patients with standard-risk ALL did not show an increased hazard of second cancer from either HeH or t(12;21) (adjusted HR 2.02, 95% CI: 0.69-5.96, P = 0.20). The effect of low TPMT low activity was explored in patients reaching maintenance therapy in clinical remission (n = 3,368); no association with second cancer was observed (adjusted HR 1.43, 95% CI: 0.54-3.76, P = 0.47). CONCLUSIONS The rate of second cancer was generally highest in patients with low-risk ALL, but we could not identify a subset at higher risk than others.
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Affiliation(s)
- Stine N Nielsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frank Eriksson
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Rosthoej
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mette K Andersen
- Department of Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Erik Forestier
- Department of Medical Biosciences, Clinical Genetics, Umeå University, Umeå, Sweden
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Lisa L Hjalgrim
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ann Aasberg
- Department of Paediatrics, University Hospital of Trondheim, Trondheim, Norway
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Heyman
- Department of Paediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Ólafur G Jónsson
- Pediatric Hematology-Oncology, Children's Hospital, Barnaspitali Hringsins, Landspitali University Hospital, Reykjavik, Iceland
| | - Kaie Pruunsild
- Department of Oncology and Hematology, Tallinn Children's Hospital, Tallinn, Estonia
| | - Goda E Vaitkeviciené
- Centre for Paediatric Oncology and Haematology, University Children's Hospital, Vilnius, Lithuania
| | - Kim Vettenranta
- Department of Paediatrics, University of Tampere, Tampere, Finland
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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15
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Kuhlen M, Kunstreich M, Krull K, Meisel R, Borkhardt A. Osteonecrosis in children and adolescents with acute lymphoblastic leukemia: a therapeutic challenge. Blood Adv 2017; 1:981-994. [PMID: 29296741 PMCID: PMC5737600 DOI: 10.1182/bloodadvances.2017007286] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/18/2017] [Indexed: 01/19/2023] Open
Abstract
Osteonecrosis (ON) represents one of the most common and debilitating sequelae of antileukemic treatment in children and adolescents with acute lymphoblastic leukemia (ALL). Systematic screening strategies can focus on early detection and intervention to prevent ON from progressing to stages associated with pain and functional impairment. These strategies hold promise for reducing ON-associated morbidity without the risk of impairing leukemia control. Herein, we critically reviewed clinical data on pharmacological, nonpharmacological/nonsurgical, and surgical (including cellular) treatment options for ON, which are covered in the literature and/or are conceivable based on the supposed underlying ON pathophysiology. Prevention of ON progression is of paramount importance, and attempts seem to be more effective in early (precollapse) disease status than in late-stage (collapse) ON. Based on the results of ongoing prospective magnetic resonance imaging screening studies, which will hopefully identify those patients with a high risk of ON progression and debilitating sequelae, prospective interventional studies are urgently needed. Although there is still a lack of high-quality studies, based on currently available data, core decompression surgery combined with cellular therapies (eg, employing mesenchymal stem cells) appears most promising for preventing joint infraction in children at high risk of developing late-stage ON.
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Affiliation(s)
- Michaela Kuhlen
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Marina Kunstreich
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Kathinka Krull
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Roland Meisel
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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16
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Abstract
Methotrexate is an antifolate agent used in the treatment of autoimmune diseases and various types of cancers. It is a unique antiproliferative agent because it can be administered by multiple routes with a wide variation of dosing. Methotrexate pharmacokinetics have generated numerous papers focusing on descriptive data and pharmacodynamics. Methotrexate is one of the rare anticancer agents which pharmacokinetics are routinely monitoring to control excessive toxicity when administrated at high dose (>1 g/m2). The identification of transporters involved in its disposition has permitted the understanding and the prevention of most drug interactions. Pharmacogenetic factors affecting the expression of MRP2 and OATP1B1 partly explain the interindividual variability of methotrexate clearance. The remaining challenge in methotrexate pharmacokinetics is to further understand unexplained delayed renal elimination despite the implementation of preventive measures.
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17
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Hepatotoxicity During Maintenance Therapy and Prognosis in Children With Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2017; 39:161-166. [PMID: 28060115 DOI: 10.1097/mph.0000000000000733] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hepatotoxicity is a known toxicity to treatment of childhood acute lymphoblastic leukemia. Hepatotoxicity occurs during maintenance therapy and is caused by metabolites of 6-Mercaptopurine (6 MP) and Methotrexate (MTX). Our objective was to investigate the association between alanine aminotransferases (ALAT) levels and relapse rate. We included 385 patients enrolled in the NOPHO ALL-92 protocol. Data on ALAT levels, 6 MP and MTX doses, cytotoxic MTX/6 MP metabolites, and thiopurine methyltransferase (TPMT) activity were prospectively registered. In total, 91% of the patients had a mean ALAT (mALAT) level above upper normal limit (40 IU/L) and ALAT levels were positively correlated to 6 MP doses (rs=0.31; P<0.001). In total, 47 patients suffered a relapse, no difference in mALAT levels were found in these compared with nonrelapse patients (median, 107 vs. 98 IU/L; P=0.39). mALAT levels in patients classified as TPMT high activity (TPMT) were higher than in TPMT low-activity patients (median, 103 vs. 82 IU/L; P=0.03). In a Cox regression model risk of relapse was not associated with ALAT levels (P=0.56). ALAT levels increased 2.7%/month during the last year of maintenance therapy (P<0.001). In conclusion, elevated ALAT levels are associated with TPMT and may indicate treatment adherence in these patients. If liver function is normal, elevated ALAT levels should not indicate treatment adaptation.
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18
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Poganitsch-Korhonen M, Masliukaite I, Nurmio M, Lähteenmäki P, van Wely M, van Pelt AMM, Jahnukainen K, Stukenborg JB. Decreased spermatogonial quantity in prepubertal boys with leukaemia treated with alkylating agents. Leukemia 2017; 31:1460-1463. [PMID: 28270690 PMCID: PMC5467043 DOI: 10.1038/leu.2017.76] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- M Poganitsch-Korhonen
- Division of Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - I Masliukaite
- Center for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Nurmio
- Department of Physiology, Institute of Biomedicine, University of Turku, Turku, Finland.,Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - P Lähteenmäki
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - M van Wely
- Center for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - A M M van Pelt
- Center for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - K Jahnukainen
- Division of Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland.,Department of Women's and Children's Health, NORDFERTIL Research Lab Stockholm, Pediatric Endocrinology Unit, Q2:08, and Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - J-B Stukenborg
- Department of Women's and Children's Health, NORDFERTIL Research Lab Stockholm, Pediatric Endocrinology Unit, Q2:08, and Karolinska Institutet and University Hospital, Stockholm, Sweden
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19
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Taskinen M, Oskarsson T, Levinsen M, Bottai M, Hellebostad M, Jonsson OG, Lähteenmäki P, Schmiegelow K, Heyman M. The effect of central nervous system involvement and irradiation in childhood acute lymphoblastic leukemia: Lessons from the NOPHO ALL-92 and ALL-2000 protocols. Pediatr Blood Cancer 2017; 64:242-249. [PMID: 27748030 DOI: 10.1002/pbc.26191] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/28/2016] [Accepted: 07/18/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Central nervous system irradiation (CNS-RT) has played a central role in the cure of acute lymphoblastic leukemia (ALL), but due to the risk of long-term toxicity, it is now considered a less-favorable method of CNS-directed therapy. PROCEDURES Retrospectively, we estimated the effect of CNS involvement and CNS-RT on events and overall survival (OS) in 835 children treated for high-risk ALL in the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL-92 and ALL-2000 trials. RESULTS We did not observe a statistically significant difference in the OS or event-free survival (EFS) in patients with CNS involvement at diagnosis, but the risk of isolated CNS relapse was higher (hazard ratio [HR] 7.09, P < 0.001). CNS-RT was given to 169 of the 783 patients in first complete remission, of which 16 had CNS involvement at diagnosis. In general, CNS-RT improved EFS (HR 0.58, P < 0.05) but not OS (HR 0.69, P = n.s.). The adjusted HRs for all relapses, isolated bone marrow relapse, CNS-involving relapse, and isolated CNS relapse, were 0.47 (P < 0.01), 0.50 (P < 0.05), 0.34 (P < 0.01), and 0.12 (P < 0.01), respectively, in irradiated patients. CONCLUSIONS CNS-RT was associated with an advantage in EFS by decreasing the risk of relapse but without improving OS.
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Affiliation(s)
- Mervi Taskinen
- Division of Pediatric Hematology-Oncology and Stem Cell Transplantation, Children and Adolescents, Helsinki University Hospital, Helsinki, Finland
| | - Trausti Oskarsson
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Mette Levinsen
- Institute of Gynegology, Obstetrics, and Pediatrics, University of Copenhagen, Copenhagen, Denmark.,Department of Pediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Matteo Bottai
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Kjeld Schmiegelow
- Institute of Gynegology, Obstetrics, and Pediatrics, University of Copenhagen, Copenhagen, Denmark.,Department of Pediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mats Heyman
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
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20
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Ranta S, Palomäki M, Levinsen M, Taskinen M, Abrahamsson J, Mellgren K, Niinimäki R, Schmiegelow K, Heyman M, Harila-Saari A. Role of neuroimaging in children with acute lymphoblastic leukemia and central nervous system involvement at diagnosis. Pediatr Blood Cancer 2017; 64:64-70. [PMID: 27555087 DOI: 10.1002/pbc.26182] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/09/2016] [Accepted: 07/12/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Each year approximately 200 children and adolescents are diagnosed with acute lymphoblastic leukemia (ALL) in the five Nordic countries, and 3% of these have central nervous system (CNS) involvement confirmed by leukemic cells in the cerebrospinal fluid (CSF) or neurological symptoms. We sought to determine the significance of neuraxis imaging in such patients. PROCEDURE Magnetic resonance images of children aged 1-17.9 with CNS leukemia at diagnosis of ALL were centrally reviewed and clinical data were retrieved from the medical records and the Nordic leukemia registry. Patients were diagnosed in the period 2000-2012 in Sweden, Finland, or Denmark. RESULTS The cohort comprised 1,877 patients, and 66 (3.5%) had CNS involvement. Forty-five percent (30/66) had CNS related symptoms. Symptoms included vomiting, facial palsy, headache, visual symptoms, and impaired hearing. CNS imaging was performed in 32 of 66 children (48%), and confirmed CNS involvement in 6 of 21 patients with symptoms (29%) and 5 of 11 (45%) without (P = 0.44). There was no difference in the overall survival between CNS-positive patients with and without signs of leukemic involvement by imaging (P = 0.53). CONCLUSIONS Radiological imaging of asymptomatic children with CNS leukemia at diagnosis lacks clinical importance, but may be useful in patients with cranial nerve symptoms and negative CSF, as well as for follow-up. Imaging of symptomatic patients is warranted in order to exclude other causes underlying the symptoms.
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Affiliation(s)
- Susanna Ranta
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Maarit Palomäki
- Department of Radiology, Helsinki University Hospital, Helsinki, Finland
| | - Mette Levinsen
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mervi Taskinen
- Children and Adolescents Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Jonas Abrahamsson
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Mellgren
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark.,Faculty of Medicine, The Institute of Gynecology, Obstetrics, and Pediatrics, University of Copenhagen, Denmark
| | - Mats Heyman
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Arja Harila-Saari
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
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Järvelä LS, Saraste M, Niinikoski H, Hannukainen JC, Heinonen OJ, Lähteenmäki PM, Arola M, Kemppainen J. Home-Based Exercise Training Improves Left Ventricle Diastolic Function in Survivors of Childhood ALL: A Tissue Doppler and Velocity Vector Imaging Study. Pediatr Blood Cancer 2016; 63:1629-35. [PMID: 27198652 DOI: 10.1002/pbc.26051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 04/13/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Advanced echocardiographic methods may reveal signs of late anthracycline cardiac toxicity (ACT) even in asymptomatic patients. We studied echocardiographic tissue Doppler imaging (TDI) and velocity vector imaging (VVI) in long-term survivors of childhood acute lymphoblastic leukemia (ALL) before and after an exercise intervention. METHODS Twenty-one asymptomatic, anthracycline-treated, long-term childhood ALL survivors with matched controls were studied at baseline. Seventeen of the survivors participated in a 3-month home-based exercise program. Echocardiography with TDI and VVI was performed. RESULTS At baseline, ejection fraction (60.7 ± 4.7% vs. 62.3 ± 3.7%, P = 0.22) and fractional shortening (32.6 ± 3.1% vs. 34.0 ± 2.8%, P = 0.13) were similar in survivors and controls. Lateral early diastolic mitral annulus velocity E' (32.81 ± 5.71 cm/sec vs. 38.03 ± 6.21 cm/sec, P = 0.01), E'/A' (1.60 ± 0.48 vs. 2.07 ± 0.63, P = 0.01), and E/E' (2.78 ± 0.35 vs. 2.42 ± 0.62, P = 0.04) were impaired compared to controls. Peak circumferential strain and strain rate were attenuated at apex (-24.50 ± 3.46% vs. -28.06 ± 4.39%, P = 0.01 and -1.47 ± 0.22 sec(-1) vs. -1.68 ± 0.33 sec(-1) , P = 0.02) compared to controls. After the intervention, early diastolic mitral inflow velocity E (87.76 ± 12.54 cm/s vs. 95.28 ± 10.48 cm/s, P = 0.04) and E' increased (31.78 ± 5.50 cm/s vs. 34.96 ± 5.41 cm/s, P < 0.01). Peak circumferential systolic and diastolic strain rates at mid-level (-1.22 ± 0.21 sec(-1) vs. -1.35 ± 0.24 sec(-1) , P = 0.04 and 1.25 ± 0.25 sec(-1) vs. 1.48 ± 0.35 sec(-1) , P < 0.01) improved after the exercise program. CONCLUSIONS A simple home-based exercise program improved cardiac function in asymptomatic childhood ALL survivors. Adding TDI in routine echocardiographic examination may improve the recognition of early signs of ACT, and VVI may bring additional information. The improvements in cardiac function after the exercise program emphasize the importance of physical activity in this population.
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Affiliation(s)
- Liisa S Järvelä
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Markku Saraste
- Department of Clinical Physiology and Nuclear Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Harri Niinikoski
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland.,Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Olli J Heinonen
- Paavo Nurmi Centre, Department of Health and Physical activity, University of Turku, Turku, Finland
| | - Päivi M Lähteenmäki
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Mikko Arola
- Department of Paediatrics, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Jukka Kemppainen
- Department of Clinical Physiology and Nuclear Medicine, University of Turku and Turku University Hospital, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
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Gunnes MW, Lie RT, Bjørge T, Ghaderi S, Ruud E, Syse A, Moster D. Reproduction and marriage among male survivors of cancer in childhood, adolescence and young adulthood: a national cohort study. Br J Cancer 2016; 114:348-56. [PMID: 26794280 PMCID: PMC4742584 DOI: 10.1038/bjc.2015.455] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/24/2015] [Accepted: 12/04/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Increased survival after cancer in young age has made long-term follow-up studies of high external validity important. In this national cohort study, we explored the impact of cancer in young age on reproduction and marital status in male survivors. METHODS Hazard ratios (HRs) and relative risks (RRs) of reproductive and marital outcomes were studied for male survivors of cancer in young age (<25 years) and cancer-free male comparisons, born during 1965-1985, by linking compulsory national registries in Norway. RESULTS Male cancer survivors (n=2687) had reduced paternity (HR: 0.72, 95% confidence interval (CI): 0.68-0.76). This was most apparent in survivors of testicular cancer, brain tumours, lymphoma, leukemia and bone tumours, and when diagnosed with cancer before 15 years of age. Male cancer survivors were more likely to avail of assisted reproduction (RR: 3.32, 95% CI: 2.68-4.11). There was no increased risk of perinatal death, congenital malformations, being small for gestational age, of low birth weight or preterm birth in their first offspring. Male cancer survivors were less likely to marry (HR: 0.93, 95% CI: 0.86-1.00), in particular brain tumour survivors. CONCLUSIONS In this national cohort study, we demonstrated reduced paternity and increased use of assisted reproduction among male cancer survivors, but no adverse outcome for their first offspring at birth.
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Affiliation(s)
- M W Gunnes
- Department of Global Public Health and Primary Care, University of Bergen, Postboks 7804, Bergen 5018, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen 5021, Norway
| | - R T Lie
- Department of Global Public Health and Primary Care, University of Bergen, Postboks 7804, Bergen 5018, Norway
- Norwegian Institute of Public Health, Bergen 5018, Norway
| | - T Bjørge
- Department of Global Public Health and Primary Care, University of Bergen, Postboks 7804, Bergen 5018, Norway
- Cancer Registry of Norway, Oslo 0304, Norway
| | - S Ghaderi
- Norwegian Institute of Public Health, Bergen 5018, Norway
| | - E Ruud
- Department of Pediatric Medicine, Oslo University Hospital, Oslo 0424, Norway
| | - A Syse
- Department of Research, Statistics Norway, Oslo 0033, Norway
| | - D Moster
- Department of Global Public Health and Primary Care, University of Bergen, Postboks 7804, Bergen 5018, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen 5021, Norway
- Norwegian Institute of Public Health, Bergen 5018, Norway
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23
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Yu Y, Qin G, Cnattingius S, Gissler M, Olsen J, Zhao N, Li J. Mortality in Children Aged 0-9 Years: A Nationwide Cohort Study from Three Nordic Countries. PLoS One 2016; 11:e0146669. [PMID: 26744840 PMCID: PMC4706349 DOI: 10.1371/journal.pone.0146669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 12/21/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Mortality in children under five years has been widely studied, whereas mortality at 5-9 years has received little attention. Using unique data from national registers in three Nordic countries, we aimed to characterize mortality directionality in children aged 0 to 9 years. METHODS AND FINDINGS The cohort study included all children born in Denmark from 1973 to 2008 (n = 2,433,758), Sweden from 1973 to 2006 (n = 3,400,212), and a random sample of 89.3% of children born in Finland from 1987 to 2007 (n = 1,272,083). Children were followed from 0 to 9 years, and cumulative mortality and mortality rates were compared by age, gender, cause of death, and calendar periods. Among the 7,105,962 children, there were 48,299 deaths during study period. From 1981-1985 to 2001-2005, all-cause mortality rates were reduced by between 34% and 62% at different ages. Overall mortality rate ratio between boys and girls decreased from 1.25 to 1.21 with the most prominent reduction in children aged 5-9 years (from 1.59 to 1.19). Neoplasms, diseases of the nervous system and transport accidents were the most frequent cause of death after the first year of life. These three leading causes of death declined by 42% (from 6.2 to 3.6 per 100,000 person years), 43% (from 3.7 to 2.1) and 62% (from 3.9 to 1.5) in boys, and 25% (from 4.1 to 3.1 per 100000 person years), 42% (from 3.4 to 1.9) and 63% (from 3.0 to 1.1) in girls, respectively. Mortality from neoplasms was the highest in each age except infants when comparing cause-specific mortality, and half of deaths from diseases of the nervous system occurred in infancy. Mortality rate due to transport accidents increased with age and was highest in boys aged 5-9 years. CONCLUSIONS Mortality rate in children aged 0-9 years has been decreasing with diminished difference between genders over the past decades. Our results suggest the importance of further research on mortality by causes of neoplasms, and causes of transport accidents-especially in children aged 5-9 years.
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Affiliation(s)
- Yongfu Yu
- Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
- * E-mail:
| | - Guoyou Qin
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Sven Cnattingius
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Mika Gissler
- Information Department, THL National Institute for Health and Welfare, Helsinki, Finland
| | - Jørn Olsen
- Department of Epidemiology, School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Naiqing Zhao
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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24
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Brandalise SR, Viana MB, Pinheiro VRP, Mendonça N, Lopes LF, Pereira WV, Lee MLM, Pontes EM, Zouain-Figueiredo GP, Azevedo ACAC, Pimentel N, Fernandes MZ, Oliveira HM, Vianna SR, Scrideli CA, Werneck FA, Álvares MN, Boldrini É, Loggetto SR, Bruniera P, Mastellaro MJ, Souza EM, Araújo RA, Bandeira F, Tan DM, Carvalho NA, Salgado MAS. Shorter Maintenance Therapy in Childhood Acute Lymphoblastic Leukemia: The Experience of the Prospective, Randomized Brazilian GBTLI ALL-93 Protocol. Front Pediatr 2016; 4:110. [PMID: 27800472 PMCID: PMC5066157 DOI: 10.3389/fped.2016.00110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/26/2016] [Indexed: 11/29/2022] Open
Abstract
AIM Maintenance therapy is an important phase of the childhood ALL treatment, requiring 2-year long therapy adherence of the patients and families. Weekly methotrexate with daily 6-mercaptopurine (6MP) constitutes the backbone of maintenance therapy. Reduction in the maintenance therapy could overweight problems related with poverty of children with ALL living in limited-income countries (LIC). OBJECTIVE To compare, prospectively, the EFS rates of children with ALL treated according to two maintenance regimens: 18 vs. 24 months duration. MATERIALS AND METHODS From October 1993 to September 1999, 867 consecutive untreated ALL patients <18 years of age were treated according to the Brazilian Cooperative Group for Childhood ALL Treatment (GBTLI) ALL-93 protocol. Risk classification was based exclusively on patient's age and leukocyte count (NCI risk group) and clinical extra medullary involvement of the disease. Data were analyzed by the intention-to-treat approach. RESULTS Fourteen patients (1.6%) were excluded: wrong diagnosis (n = 7) and previous corticosteroid (n = 7). Of the 853 eligible patients, 421 were randomly allocated, at study enrollment, to receive 18-month (group 1) and 432 to receive 24-month (group 2) maintenance therapy. Complete remission rate was achieved in 96% of the patients (817/853). Twenty-eight patients (3.4%) died during the induction phase. Thirty-four patients (4.0%) were lost to follow-up. The overall EFS was 66.1 ± 1.7% at 15 years. No difference was seen according to maintenance: EFS15y was 65.8 ± 2.3% (group 1) and 66.3 ± 2.3% (group 2; p = 0.79). No difference between regimens was detected after stratifying the analyses according to factors associated with adverse prognosis in this study (age group <1 year or >10 years and high WBC at diagnosis). Overall death in remission rate was 6.85% (56 patients). Deaths during maintenance were 13 in group 1 and 12 in group 2, all due to infection. Over 15 years of follow-up, two patients both from group 2 presented a second malignancy (Hodgkin's disease and thyroid carcinoma) after 8.3 and 11 years off therapy, respectively. CONCLUSION Six-month reduction of maintenance therapy in ALL children treated according to the GBTLI ALL-93 protocol provided the same overall outcome as 2-year duration regimen.
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Affiliation(s)
| | - Marcos B Viana
- Federal University of Minas Gerais , Belo Horizonte , Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Bandeira
- Hematology and Hemotherapy Foundation (HEMOPE) , Recife , Brazil
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25
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Song J, Shao H. SNP Array in Hematopoietic Neoplasms: A Review. MICROARRAYS 2015; 5:microarrays5010001. [PMID: 27600067 PMCID: PMC5003446 DOI: 10.3390/microarrays5010001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 11/13/2015] [Accepted: 12/14/2015] [Indexed: 12/03/2022]
Abstract
Cytogenetic analysis is essential for the diagnosis and prognosis of hematopoietic neoplasms in current clinical practice. Many hematopoietic malignancies are characterized by structural chromosomal abnormalities such as specific translocations, inversions, deletions and/or numerical abnormalities that can be identified by karyotype analysis or fluorescence in situ hybridization (FISH) studies. Single nucleotide polymorphism (SNP) arrays offer high-resolution identification of copy number variants (CNVs) and acquired copy-neutral loss of heterozygosity (LOH)/uniparental disomy (UPD) that are usually not identifiable by conventional cytogenetic analysis and FISH studies. As a result, SNP arrays have been increasingly applied to hematopoietic neoplasms to search for clinically-significant genetic abnormalities. A large numbers of CNVs and UPDs have been identified in a variety of hematopoietic neoplasms. CNVs detected by SNP array in some hematopoietic neoplasms are of prognostic significance. A few specific genes in the affected regions have been implicated in the pathogenesis and may be the targets for specific therapeutic agents in the future. In this review, we summarize the current findings of application of SNP arrays in a variety of hematopoietic malignancies with an emphasis on the clinically significant genetic variants.
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Affiliation(s)
- Jinming Song
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA.
| | - Haipeng Shao
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA.
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26
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Wilejto M, Di Giuseppe G, Hitzler J, Gupta S, Abla O. Treatment of young children with CNS-positive acute lymphoblastic leukemia without cranial radiotherapy. Pediatr Blood Cancer 2015; 62:1881-5. [PMID: 26154757 DOI: 10.1002/pbc.25620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 04/21/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Due to the long-term sequelae of cranial radiotherapy (CRT), contemporary treatment protocols for children with acute lymphoblastic leukemia (ALL) aim to limit the use of prophylactic CRT. For patients with central nervous system (CNS) involvement with ALL at diagnosis, the use of CRT remains common. Children <5 years of age are a particularly challenging subgroup in whom the consequences of CRT can be devastating. PROCEDURE This study retrospectively describes the overall (OS) and event-free survival (EFS) of young children (1-5 years) who were treated for CNS-positive ALL at the Hospital for Sick Children between 2000 and 2013. RESULTS Of a total of 19 patients, two were treated with upfront CRT, both as part of the conditioning regimen prior to HSCT. All patients received intensification of CNS-directed chemotherapy by triple intra-thecal chemotherapy (84.2%), use of dexamethasone in induction (57.9%) and maintenance (66.7%), and high-dose methotrexate (77.8%). The OS was 84.2 ± 8.4% and EFS was 79.0 ± 9.4% with a median follow-up time of 4.3 years (range, 2.6-8.2). The cumulative incidence of CNS relapse was 5.2 ± 5.1%. CONCLUSIONS We conclude that omission of CRT from the treatment of young children with ALL involving the CNS is associated with acceptable survival and avoids potentially devastating late effects in this group.
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Affiliation(s)
- Marta Wilejto
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Giancarlo Di Giuseppe
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Johann Hitzler
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Sumit Gupta
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Oussama Abla
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
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Dental abnormalities after chemotherapy in long-term survivors of childhood acute lymphoblastic leukemia 7–40 years after diagnosis. Support Care Cancer 2015; 24:1497-506. [DOI: 10.1007/s00520-015-2940-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
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28
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Ranta S, Nilsson F, Harila-Saari A, Saft L, Tani E, Söderhäll S, Porwit A, Hultdin M, Noren-Nyström U, Heyman M. Detection of central nervous system involvement in childhood acute lymphoblastic leukemia by cytomorphology and flow cytometry of the cerebrospinal fluid. Pediatr Blood Cancer 2015; 62:951-6. [PMID: 25545289 DOI: 10.1002/pbc.25363] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 10/27/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Therapy directed at the central nervous system (CNS) is an essential part of the treatment for childhood acute lymphoblastic leukemia (ALL). The current evaluation of CNS involvement based on cytomorphological examination of the cerebrospinal fluid (CSF) alone is not as sensitive with low cell counts as flow cytometric immunophenotyping (FCI) of the CSF. However, the importance of low CSF blasts counts at diagnosis is uncertain. We sought to determine the significance of FCI in relation to conventional morphological examination. PROCEDURE We retrospectively compared FCI of the CSF with cytomorphology at diagnosis or relapse of childhood ALL. All patients were diagnosed 2000-2012 in Stockholm or Umeå, Sweden. Clinical data were collected from medical records and the Nordic leukemia registry. Treatment assignment was based on morphological examination only. RESULTS The cohort was comprised of 214 patients with ALL. CSF involvement was detected by both methods in 20 patients, in 17 by FCI alone, and in one patient by cytomorphology alone. The relapse rate was higher for patients with negative cytology but positive FCI compared to those without CNS involvement using both methods. The difference was especially marked in the current protocol. However, none of the patients with negative CSF cytology but positive FCI had a CNS relapse. CONCLUSIONS FCI of the CSF increased the detection rate of CNS involvement of ALL approximately two times compared to cytomorphology. Patients with low-level CNS involvement may benefit from additional intensified systemic or CNS-directed therapy, but larger studies are needed.
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Affiliation(s)
- Susanna Ranta
- Childhood Cancer Research Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
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Educational attainment among long-term survivors of cancer in childhood and adolescence: a Norwegian population-based cohort study. J Cancer Surviv 2015; 10:87-95. [PMID: 25929213 DOI: 10.1007/s11764-015-0453-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/13/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The number of young cancer survivors has increased over the past few decades due to improvement in treatment regimens, and understanding of long-term effects among the survivors has become even more important. Educational achievements and choice of educational fields were explored here. METHODS Five-year cancer survivors born in Norway during 1965-1985 (diagnosed <19 years) were included in our analysis by linking Norwegian population-based registries. Cox regression was applied to study the educational attainment among survivors of central nervous system (CNS) tumours, those assumed to have received CNS-directed therapy, and other cancer survivors relative to the cancer-free population. Logistic regression was used to compare the choice of educational fields between the cancer survivors at undergraduate and graduate level and the cancer-free population. RESULTS Overall, a lower proportion of the cancer survivors completed intermediate (67 vs. 70 %), undergraduate (31 vs. 35 %) and graduate education (7 vs. 9 %) compared with the cancer-free population. Deficits in completion of an educational level were mainly observed among survivors of CNS-tumours and those assumed to have received CNS-directed therapy. Choices of educational fields among cancer survivors were in general similar with the cancer-free population at both undergraduate and graduate levels. CONCLUSION Survivors of CNS-tumours and those assumed to have received CNS-directed therapy were at increased risk for educational impairments compared with the cancer-free population. Choices of educational fields were in general similar. IMPLICATIONS FOR CANCER SURVIVORS Careful follow-up of the survivors of CNS-tumours and those assumed to have received CNS-directed therapy is important at each level of education.
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Karrman K, Castor A, Behrendtz M, Forestier E, Olsson L, Ehinger M, Biloglav A, Fioretos T, Paulsson K, Johansson B. Deep sequencing and SNP array analyses of pediatric T-cell acute lymphoblastic leukemia reveal NOTCH1 mutations in minor subclones and a high incidence of uniparental isodisomies affecting CDKN2A. J Hematol Oncol 2015; 8:42. [PMID: 25903014 PMCID: PMC4412034 DOI: 10.1186/s13045-015-0138-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/13/2015] [Indexed: 12/22/2022] Open
Abstract
Background Pediatric T-cell acute lymphoblastic leukemia (T-ALL) is a genetically heterogeneous disease that arises in a multistep fashion through acquisition of several genetic aberrations, subsequently giving rise to a malignant, clonal expansion of T-lymphoblasts. The aim of the present study was to identify additional as well as cooperative genetic events in T-ALL. Methods A population-based pediatric T-ALL series comprising 47 cases was investigated by SNP array and deep sequencing analyses of 75 genes, in order to ascertain pathogenetically pertinent aberrations and to identify cooperative events. Results The majority (92%) of cases harbored copy number aberrations/uniparental isodisomies (UPIDs), with a median of three changes (range 0–11) per case. The genes recurrently deleted comprised CDKN2A, CDKN2B, LEF1, PTEN, RBI, and STIL. No case had a whole chromosome UPID; in fact, literature data show that this is a rare phenomenon in T-ALL. However, segmental UPIDs (sUPIDs) were seen in 42% of our cases, with most being sUPID9p that always were associated with homozygous CDKN2A deletions, with a heterozygous deletion occurring prior to the sUPID9p in all instances. Among the 75 genes sequenced, 14 (19%) were mutated in 28 (72%) of 39 analyzed cases. The genes targeted are involved in signaling transduction, epigenetic regulation, and transcription. In some cases, NOTCH1 mutations were seen in minor subclones and lost at relapse; thus, such mutations can be secondary events. Conclusions Deep sequencing and SNP array analyses of T-ALL revealed lack of wUPIDs, a high proportion of sUPID9p targeting CDKN2A, NOTCH1 mutations in subclones, and recurrent mutations of genes involved in signaling transduction, epigenetic regulation, and transcription. Electronic supplementary material The online version of this article (doi:10.1186/s13045-015-0138-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristina Karrman
- Department of Clinical Genetics, University and Regional Laboratories, Region Skåne, SE-221 85, Lund, Sweden. .,Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden.
| | - Anders Castor
- Department of Pediatrics, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Mikael Behrendtz
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden.
| | - Erik Forestier
- Department of Medical Biosciences, Clinical Genetics, Umeå University, Umeå, Sweden.
| | - Linda Olsson
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden.
| | - Mats Ehinger
- Department of Pathology, University and Regional Laboratories, Region Skåne, Lund, Sweden.
| | - Andrea Biloglav
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden.
| | - Thoas Fioretos
- Department of Clinical Genetics, University and Regional Laboratories, Region Skåne, SE-221 85, Lund, Sweden. .,Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden.
| | - Kajsa Paulsson
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden.
| | - Bertil Johansson
- Department of Clinical Genetics, University and Regional Laboratories, Region Skåne, SE-221 85, Lund, Sweden. .,Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden.
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Adverse health events and late mortality after pediatric allogeneic hematopoietic SCT-two decades of longitudinal follow-up. Bone Marrow Transplant 2015; 50:850-7. [PMID: 25798676 DOI: 10.1038/bmt.2015.43] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/19/2015] [Accepted: 02/02/2015] [Indexed: 01/19/2023]
Abstract
Treatment-related late toxicities after pediatric allogeneic hematopoietic SCT (allo-HSCT) are increasingly important as long-term survival has become an expected outcome for many transplanted children and adolescents. In a retrospective cohort study, we assessed long-term health outcomes in 204 allo-HSCT survivors transplanted in childhood or adolescence (<20 years) between 1978 through 2000 after a median follow-up time of 12 (range 4-28) years. Data on conditioning regimen, adverse health events (AE) and growth and hormonal substitutions (hormone replacement therapies (HRTs)) were obtained from medical records. AEs were graded retrospectively according to Common Terminology Criteria for Adverse Events v3.0. Late deaths (⩾48 months after allo-HSCT) were evaluated separately. Multivariate analysis demonstrated that chronic GVHD (P<0.000) and longer follow-up time (P<0.05) correlated with AEs, whereas CY-based conditioning was inversely correlated (P<0.002). TBI and longer follow-up duration predicted more severe AEs (P<0.001 and P<0.001, respectively). HRTs were more frequent after TBI. Diabetes type II, dyslipidemia and hypertension were detected in 9, 7 and 7% of the survivors, respectively. Late deaths (n=22) were most frequently due to pulmonary failure (n=7), followed by secondary malignancy (n=5). The occurrence of AEs after pediatric allo-HSCT is high and likely to increase during extended follow-up, particularly in patients who have received TBI.
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Health status and quality of life of long-term survivors of childhood acute leukemia: the impact of central nervous system irradiation. J Pediatr Hematol Oncol 2015; 37:109-16. [PMID: 24936742 DOI: 10.1097/mph.0000000000000209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We evaluated the impact of central nervous system irradiation (CNSI) on long-term health status and quality of life (QoL) of childhood lymphoblastic leukemia survivors included in the French L.E.A. (Childhood and Adolescent Leukemia) multicentric cohort. QoL was self-reported in adults and assessed by parents in children and adolescents, using adapted questionnaires. From 2004 to 2009, 630 nongrafted patients were assessed after 11.8±6.3 years from diagnosis. Patients receiving CNSI (18.6%) or chemotherapy alone (81.4%) were compared. The risk of having long-term physical effects was increased with CNSI (odds ratio=3.3; 95% confidence interval, 1.8-5.9), especially regarding growth failure, second tumor, cataract, and overweight. QoL did not differ significantly according to the treatment received, despite a tendency toward lower scores with CNSI in children and adolescents (summary score 63.6±13.3 vs. 71.7±12.4, P=0.14). Compared with French norms, adult survivors had an impaired QoL, especially in mental domains (mental composite score 45.2±9.8 vs. 47.9±2.1, P<0.001). In pediatric survivors, QoL was not impaired and even tended to be higher than population norms (summary score 71.7±12.4 vs. 70.0±4.2, P=0.054), mainly in social and relational domains. In conclusion, QoL seems to be impaired by the trauma of a life-threatening illness in childhood, as well as by the treatment received.
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Comprehensive craniospinal radiation for controlling central nervous system leukemia. Int J Radiat Oncol Biol Phys 2015; 90:1119-25. [PMID: 25539370 DOI: 10.1016/j.ijrobp.2014.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/18/2014] [Accepted: 08/02/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the benefit of radiation therapy (RT) in resolution of neurologic symptoms and deficits and whether the type of RT fields influences central nervous system (CNS) control in adults with CNS leukemia. METHODS AND MATERIALS A total of 163 adults from 1996 to 2012 were retrospectively analyzed. Potential associations between use of radiation and outcome were investigated by univariate and multivariate analysis. RESULTS The median survival time was 3.8 months after RT. Common presenting symptoms were headache in 79 patients (49%), cranial nerve VII deficit in 46 (28%), and cranial nerve II deficit in 44 (27%). RT was delivered to the base of skull in 48 patients (29%), to the whole brain (WB) in 67 (41%), and to the craniospinal axis (CS) in 48 (29%). Among 149 patients with a total of 233 deficits, resolution was observed in 34 deficits (15%), improvement in 126 deficits (54%), stability in 34 deficits (15%), and progression in 39 deficits (17%). The 12-month CNS progression-free survival was 77% among those receiving CS/WB and 51% among those receiving base of skull RT (P=.02). On multivariate analysis, patients who did not undergo stem cell transplantation after RT and base of skull RT were associated with worse CNS progression-free survival. CONCLUSIONS Improvement or resolution of symptoms occurred in two thirds of deficits after RT. Comprehensive radiation to the WB or CS seems to offer a better outcome, especially in isolated CNS involvement.
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Gregers J, Gréen H, Christensen IJ, Dalhoff K, Schroeder H, Carlsen N, Rosthoej S, Lausen B, Schmiegelow K, Peterson C. Polymorphisms in the ABCB1 gene and effect on outcome and toxicity in childhood acute lymphoblastic leukemia. THE PHARMACOGENOMICS JOURNAL 2015; 15:372-9. [PMID: 25582575 PMCID: PMC4762905 DOI: 10.1038/tpj.2014.81] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 10/12/2014] [Accepted: 11/05/2014] [Indexed: 01/16/2023]
Abstract
The membrane transporter P-glycoprotein, encoded by the ABCB1 gene, influences the pharmacokinetics of anti-cancer drugs. We hypothesized that variants of ABCB1 affect outcome and toxicity in childhood acute lymphoblastic leukemia (ALL). We studied 522 Danish children with ALL, 93% of all those eligible. Risk of relapse was increased 2.9-fold for patients with the 1199GA variant versus 1199GG (P=0.001), and reduced 61% and 40%, respectively, for patients with the 3435CT or 3435TT variants versus 3435CC (overall P=0.02). The degree of bone marrow toxicity during doxorubicin, vincristine and prednisolone induction therapy was more prominent in patients with 3435TT variant versus 3435CT/3435CC (P=0.01/P<0.0001). We observed more liver toxicity after high-dose methotrexate in patients with 3435CC variant versus 3435CT/TT (P=0.03). In conclusion, there is a statistically significant association between ABCB1 polymorphisms, efficacy and toxicity in the treatment of ALL, and ABCB1 1199G>A may be a new possible predictive marker for outcome in childhood ALL.
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Affiliation(s)
- J Gregers
- 1] Clinical Pharmacology, Faculty of Health Sciences, Division of Drug Research, Department of Medical and Health Sciences, Linköpings Universitet, Linköping, Sweden [2] Laboratory of Molecular Medicine, Department of Clinical Immunology 7631, Rigshospitalet, University Hospital in Copenhagen, Copenhagen, Denmark
| | - H Gréen
- 1] Clinical Pharmacology, Faculty of Health Sciences, Division of Drug Research, Department of Medical and Health Sciences, Linköpings Universitet, Linköping, Sweden [2] Science for Life Laboratory, Division of Gene Technology, School of Biotechnology, KTH Royal Institute of Technology, Solna, Sweden [3] Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| | | | - K Dalhoff
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - H Schroeder
- Department of Pediatric, University Hospital in Skejby, Aarhus, Denmark
| | - N Carlsen
- Department of Pediatric, University Hospital in Odense, Odense, Denmark
| | - S Rosthoej
- Department of Pediatric, University Hospital in Aalborg, Aalborg, Denmark
| | - B Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - K Schmiegelow
- 1] Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark [2] The Medical Faculty, Institute of Gynecology, Obstetrics and Pediatrics, University of Copenhagen, Copenhagen, Denmark
| | - C Peterson
- Clinical Pharmacology, Faculty of Health Sciences, Division of Drug Research, Department of Medical and Health Sciences, Linköpings Universitet, Linköping, Sweden
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Levinsen M, Rosthøj S, Nygaard U, Heldrup J, Harila-Saari A, Jonsson OG, Bechensteen AG, Abrahamsson J, Lausen B, Frandsen TL, Weinshilboum RM, Schmiegelow K. Myelotoxicity after high-dose methotrexate in childhood acute leukemia is influenced by 6-mercaptopurine dosing but not by intermediate thiopurine methyltransferase activity. Cancer Chemother Pharmacol 2014; 75:59-66. [PMID: 25347948 DOI: 10.1007/s00280-014-2613-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/14/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Through enhancement of 6-mercaptopurine (6MP) bioavailability and inhibition of purine de novo synthesis, high-dose methotrexate (HD-MTX) may increase incorporation into DNA of 6-thioguanine nucleotides, the cytotoxic metabolites of 6MP. Patients with intermediate activity of thiopurine methyltransferase (TPMT(IA)) have higher cytosol 6-thioguanine nucleotide levels. We investigated toxicity following HD-MTX during MTX/6MP maintenance therapy in relation to 6MP and TPMT. METHODS Using linear mixed models, we explored myelo- and hepatotoxicity in relation to 6MP dosage and TPMT phenotype following 1,749 HD-MTX courses to 411 children with acute lymphoblastic leukemia on maintenance therapy. RESULTS The degree of myelosuppression following HD-MTX was similar for patients with TPMT(IA) and patients with high TPMT activity (TPMT(HA)), when HD-MTX started with same blood counts and 6MP doses. However, since TPMT(IA) had lower blood counts at initiation of HD-MTX compared with TPMT(HA) patients (median WBC 2.8 vs. 3.3 × 10⁹/L, P = 0.01; median ANC 1.4 vs. 1.7 × 10⁹/L, P = 0.02), TPMT(IA) continued to have lower WBC and ANC levels compared with TPMT(HA) during all 28 days after HD-MTX [relative difference 9 % (95 % CI 2-17), P = 0.02 and 21 % (95 % CI 6-39), P = 0.005]. Still, the fractional decrease in WBC and ANC levels after HD-MTX did not differ between TPMT(IA) and TPMT(HA) patients (P = 0.47; P = 0.38). The degree of leukopenia, neutropenia, thrombocytopenia and rise in aminotransferases were all significantly related to 6MP dose (P < 0.001 for all analyses). CONCLUSION For both TPMT(IA) and TPMT(HA) patients, dose of 6MP prior to HD-MTX should be guided by pre-HD-MTX blood counts, but not by TPMT activity.
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Affiliation(s)
- Mette Levinsen
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
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Levinsen M, Taskinen M, Abrahamsson J, Forestier E, Frandsen TL, Harila-Saari A, Heyman M, Jonsson OG, Lähteenmäki PM, Lausen B, Vaitkevičienė G, Asberg A, Schmiegelow K. Clinical features and early treatment response of central nervous system involvement in childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2014; 61:1416-21. [PMID: 24623619 DOI: 10.1002/pbc.24981] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 01/16/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Central nervous system (CNS) involvement in childhood acute lymphoblastic leukemia (ALL) remains a therapeutic challenge. PROCEDURE To explore leukemia characteristics of patients with CNS involvement at ALL diagnosis, we analyzed clinical features and early treatment response of 744 patients on Nordic-Baltic trials. CNS status was classified as CNS1 (no CSF blasts), CNS2 (<5 leukocytes/µl CSF with blasts), CNS3 (≥5 leukocytes/µl with blasts or signs of CNS involvement), TLP+ (traumatic lumbar puncture with blasts), and TLP- (TLP with no blasts). RESULTS Patients with CNS involvement had higher leukocyte count compared with patients with CNS1 (P < 0.002). Patients with CNS3 more often had T-ALL (P < 0.001) and t(9;22)(q34;q11)[BCR-ABL1] (P < 0.004) compared with patients with CNS1. Among patients with CNS involvement headache (17%) and vomiting (14%) were most common symptoms. Symptoms or clinical findings were present among 27 of 54 patients with CNS3 versus only 7 of 39 patients with CNS2 and 15 of 75 patients with TLP+ (P < 0.001). The majority of patients with CNS involvement received additional induction therapy. The post induction bone marrow residual disease level did not differ between patients with CNS involvement and patients with CNS1 (P > 0.15). The 12-year event-free survival for patients with leukemic mass on neuroimaging did not differ from patients with negative or no scan (0.50 vs. 0.60; P = 0.7) or between patients with symptoms or signs suggestive of CNS leukemia and patients without such characteristics (0.50 vs. 0.61; P = 0.2). CONCLUSION CNS involvement at diagnosis is associated with adverse prognostic features but does not indicate a less chemosensitive leukemia.
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Affiliation(s)
- Mette Levinsen
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
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Wilhelmsson M, Vatanen A, Borgström B, Gustafsson B, Taskinen M, Saarinen-Pihkala UM, Winiarski J, Jahnukainen K. Adult testicular volume predicts spermatogenetic recovery after allogeneic HSCT in childhood and adolescence. Pediatr Blood Cancer 2014; 61:1094-100. [PMID: 24851267 DOI: 10.1002/pbc.24970] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Testicular dysfunction and infertility are of major concern in long-term survivors after allogeneic hematopoietic stem cell transplantation (HSCT). This study assesses predictive factors for very long-term testicular recovery after allogeneic HSCT in childhood and adolescence. PROCEDURE Testicular volume, sperm production and long-term need of testosterone substitution were evaluated among 106 male survivors transplanted at Huddinge and Helsinki University Hospitals from 1978 through 2000, at a mean age of 8 ± 4.6 years (range 1-17). A mean ± SD of 13 ± 4.8 years (range 4-28) had elapsed since their HSCT and the mean age of the participants was 22 ± 6.0 years (range 12-42). An adult testicular volume was recorded in 74 patients at a mean age of 19 ± 3.3 years (range 14-36). RESULTS Recipients conditioned with busulfan-based regimens or regimens containing only cyclophosphamide had significantly larger adult testicular volumes (mean volume 18 ml and 16 ml vs. 9 ml, P < 0.00001, respectively) and lower serum levels of FSH (mean 9 IU and 5 IU vs. 19 IU, P < 0.01 and 0.001, respectively) compared to those conditioned with total body irradiation (TBI). Multivariate analysis demonstrated that a non-leukemia diagnosis (P < 0.01) and adult testicular volume ≥ 15 ml (P < 0.03) positively impacted spermatogenetic recovery. CONCLUSIONS A larger adult testicular volume, normal serum levels of FSH and spermatozoa detected in a majority of seminal fluids after busulfan-based or cyclophosphamide conditionings suggest very long-term recovery of spermatogenesis after chemotherapy-based regimens. A simple measurement of adult testicular volume may help predict spermatogenetic potential among pediatric HSCT survivors.
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Affiliation(s)
- Mari Wilhelmsson
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
- Department of Pediatrics; Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge; Stockholm Sweden
| | - Anu Vatanen
- Division of Haematology-Oncology and Stem Cell Transplantation; Children's Hospital, University of Helsinki, Helsinki University Central Hospital; Helsinki Finland
| | - Birgit Borgström
- Department of Pediatrics; Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge; Stockholm Sweden
- Department of Clinical Science; Intervention, and Technology, Karolinska Institutet; Stockholm Sweden
| | - Britt Gustafsson
- Department of Pediatrics; Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge; Stockholm Sweden
- Department of Clinical Science; Intervention, and Technology, Karolinska Institutet; Stockholm Sweden
| | - Mervi Taskinen
- Division of Haematology-Oncology and Stem Cell Transplantation; Children's Hospital, University of Helsinki, Helsinki University Central Hospital; Helsinki Finland
| | - Ulla M. Saarinen-Pihkala
- Division of Haematology-Oncology and Stem Cell Transplantation; Children's Hospital, University of Helsinki, Helsinki University Central Hospital; Helsinki Finland
| | - Jacek Winiarski
- Department of Pediatrics; Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge; Stockholm Sweden
- Department of Clinical Science; Intervention, and Technology, Karolinska Institutet; Stockholm Sweden
| | - Kirsi Jahnukainen
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
- Division of Haematology-Oncology and Stem Cell Transplantation; Children's Hospital, University of Helsinki, Helsinki University Central Hospital; Helsinki Finland
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Levinsen M, Rotevatn EØ, Rosthøj S, Nersting J, Abrahamsson J, Appell ML, Bergan S, Bechensteen AG, Harila-Saari A, Heyman M, Jonsson OG, Maxild JBC, Niemi M, Söderhäll S, Schmiegelow K. Pharmacogenetically based dosing of thiopurines in childhood acute lymphoblastic leukemia: influence on cure rates and risk of second cancer. Pediatr Blood Cancer 2014; 61:797-802. [PMID: 24395436 DOI: 10.1002/pbc.24921] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 11/05/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Previous studies have indicated that patients with thiopurine methyltransferase (TPMT) low activity (TPMT(LA)) have reduced risk of relapse but increased risk of second malignant neoplasm (SMN) compared to patients with TPMT wild-type (TPMT(WT)) when treated with 6 MP maintenance therapy starting doses of 75 mg/m(2)/day. To reduce SMN risk, 6MP starting doses were reduced to 50 mg/m(2)/day for patients with TPMT heterozygosity in the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2000 protocol. PROCEDURE We explored the pattern of SMN and relapse in the NOPHO ALL2000 protocol (n = 674) and NOPHO ALL92 protocol (n = 601) in relation to TPMT pheno- and/or genotype. RESULTS The overall risk of any event did not differ significantly between the two protocols. However, in event pattern analyses considering only the patients with TPMT(LA) who experienced relapse or SMN, the risk of SMN versus leukemia relapse was significantly lower in the ALL2000 cohort for patients with a 6MP starting dose <75 mg/m(2)/day when compared to the patients in ALL92 (relapse (n = 11) and SMN (n = 0) in ALL2000 versus relapse (n = 5) and SMN (n = 4) in ALL92, P = 0.03). Furthermore, the 8-year cumulative incidence of relapse for patients with TPMT(LA) was significantly higher in the ALL2000 compared to the ALL92 cohort (19.7% (11.6-33.3%) vs. 6.7% (2.9-15.5%), P = 0.03). CONCLUSION This study indicates that reducing 6MP starting dose for patients with TPMT(LA) may reduce SMN risk but lead to a relapse risk similar to that of patients with TPMT(WT).
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Affiliation(s)
- Mette Levinsen
- Department of Pediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
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Lundin C, Forestier E, Klarskov Andersen M, Autio K, Barbany G, Cavelier L, Golovleva I, Heim S, Heinonen K, Hovland R, Johannsson JH, Kjeldsen E, Nordgren A, Palmqvist L, Johansson B. Clinical and genetic features of pediatric acute lymphoblastic leukemia in Down syndrome in the Nordic countries. J Hematol Oncol 2014; 7:32. [PMID: 24726034 PMCID: PMC4022076 DOI: 10.1186/1756-8722-7-32] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/08/2014] [Indexed: 11/23/2022] Open
Abstract
Background Children with Down syndrome (DS) have an increased risk for acute lymphoblastic leukemia (ALL). Although previous studies have shown that DS-ALL differs clinically and genetically from non-DS-ALL, much remains to be elucidated as regards genetic and prognostic factors in DS-ALL. Methods To address clinical and genetic differences between DS-ALL and non-DS-ALL and to identify prognostic factors in DS-ALL, we ascertained and reviewed all 128 pediatric DS-ALL diagnosed in the Nordic countries between 1981 and 2010. Their clinical and genetic features were compared with those of the 4,647 B-cell precursor (BCP) ALL cases diagnosed during the same time period. Results All 128 DS-ALL were BCP ALL, comprising 2.7% of all such cases. The 5-year event-free survival (EFS) and overall survival (OS) were significantly (P = 0.026 and P = 0.003, respectively) worse for DS-ALL patients with white blood cell counts ≥50 × 109/l. The age distributions varied between the DS and non-DS cases, with age peaks at 2 and 3 years, respectively; none of the DS patients had infant ALL (P = 0.029). The platelet counts were lower in the DS-ALL group (P = 0.005). Abnormal karyotypes were more common in non-DS-ALL (P < 0.0001), and there was a significant difference in the modal number distribution, with only 2% high hyperdiploid DS-ALL cases (P < 0.0001). The 5-year EFS and 5-year OS were significantly worse for DS-ALL (0.574 and 0.691, respectively) compared with non-DS-ALL (0.783 and 0.894, respectively) in the NOPHO ALL-1992/2000 protocols (P < 0.001). Conclusions The present study adds further support for genetic and clinical differences between DS-ALL and non-DS-ALL.
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Affiliation(s)
- Catarina Lundin
- Department of Clinical Genetics, University and Regional Laboratories Region Skåne, SE-221 85 Lund, Sweden.
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Kotecha RS, Gottardo NG, Kees UR, Cole CH. The evolution of clinical trials for infant acute lymphoblastic leukemia. Blood Cancer J 2014; 4:e200. [PMID: 24727996 PMCID: PMC4003413 DOI: 10.1038/bcj.2014.17] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 02/20/2014] [Indexed: 02/07/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) in infants has a significantly inferior outcome in comparison with older children. Despite initial improvements in survival of infants with ALL since establishment of the first pediatric cooperative group ALL trials, the poor outcome has plateaued in recent years. Historically, infants were treated on risk-adapted childhood ALL protocols. These studies were pivotal in identifying the need for infant-specific protocols, delineating prognostic categories and the requirement for a more unified approach between study groups to overcome limitations in accrual because of low incidence. This subsequently led to the development of collaborative infant-specific studies. Landmark outcomes have included the elimination of cranial radiotherapy following the discovery of intrathecal and high-dose systemic therapy as a superior and effective treatment strategy for central nervous system disease prophylaxis, with improved neurodevelopmental outcome. Universal prospective identification of independent adverse prognostic factors, including presence of a mixed lineage leukemia rearrangement and young age, has established the basis for risk stratification within current trials. The infant-specific trials have defined limits to which conventional chemotherapeutic agents can be intensified to optimize the balance between treatment efficacy and toxicity. Despite variations in therapeutic intensity, there has been no recent improvement in survival due to the equilibrium between relapse and toxicity. Ultimately, to improve the outcome for infants with ALL, key areas still to be addressed include identification and adaptation of novel prognostic markers and innovative therapies, establishing the role of hematopoietic stem cell transplantation in first complete remission, treatment strategies for relapsed/refractory disease and monitoring and timely intervention of late effects in survivors. This would be best achieved through a single unified international trial.
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Affiliation(s)
- R S Kotecha
- 1] Department of Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia [2] Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia [3] School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - N G Gottardo
- 1] Department of Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia [2] Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia [3] School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - U R Kees
- Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - C H Cole
- 1] Department of Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia [2] Telethon Institute for Child Health Research, University of Western Australia, Perth, Western Australia, Australia [3] School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
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Clemmensen KKB, Christensen RH, Shabaneh DN, Harila-Saari A, Heyman M, Jonsson OG, Wesenberg F, Rosthøj S, Schmiegelow K. The circadian schedule for childhood acute lymphoblastic leukemia maintenance therapy does not influence event-free survival in the NOPHO ALL92 protocol. Pediatr Blood Cancer 2014; 61:653-8. [PMID: 24265159 DOI: 10.1002/pbc.24867] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/24/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND The event-free survival of childhood acute lymphoblastic leukemia (ALL) has been reported to be superior when oral methotrexate (MTX) and 6-mercaptopurine (6MP) maintenance therapy (MT) is administered in the evening compared to the morning. PROCEDURE In the ALL92 MT study we prospectively registered the intake of MTX/6MP. The registration was done when blood samples for erythrocyte MTX/6MP metabolite measurements were collected, and referred to the time of intake in the period since last registration. Nine thousand one hundred ninety-five registrations in total. The administration of MTX/6MP was scored as morning, midday, or evening. RESULTS Of 532 patients, 296 took their medication consistently in the evening, 129 in the evening 50.0-99.9% of the time, and 101 in the evening <50% of the time, six did not have any registrations. The circadian schedule did not differ significantly by age, sex, MTX/6MP doses, and average absolute neutrophil counts. The circadian schedule groups did differ on risk groups (P = 0.003) with fewer HR patients in the 50-99.9% group, and there was a negative correlation between percentage of time on evening schedule and average WBC (Spearman's rho -0.15; P = 0.0004). Average WBC was not associated with relapse on ALL92. In a Cox multivariate model the circadian schedule of MTX/6MP was not of prognostic significance for the risk of relapse, and the 10-year cumulative relapse risk was below 20% in all groups. CONCLUSION An evening schedule may still be recommended based on the previous publications, but in this study morning administration of MTX and 6MP does not seem to impact EFS.
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Affiliation(s)
- Kim K B Clemmensen
- Clinic for Pediatrics and Adolescent Medicine, The Juliane Marie Centre, The University Hospital Rigshospitalet, Copenhagen, Denmark
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Vatanen A, Wilhelmsson M, Borgström B, Gustafsson B, Taskinen M, Saarinen-Pihkala UM, Winiarski J, Jahnukainen K. Ovarian function after allogeneic hematopoietic stem cell transplantation in childhood and adolescence. Eur J Endocrinol 2014; 170:211-8. [PMID: 24179099 DOI: 10.1530/eje-13-0694] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate long-term ovarian function after allogeneic hematopoietic stem cell transplantation (HSCT) in childhood and adolescence. SUBJECTS AND METHODS Predictive factors for ovarian function were evaluated among 92 adult or pubertal female survivors transplanted at Huddinge and Helsinki University Hospital during 1978-2000, at a mean age of 9±4.3 years (range 1-19). At the time of the study a mean±s.d. of 13±5.5 years (range 6-27) had elapsed since the HSCT and the mean age of the participants was 22±6.3 years (range 9-41). RESULTS Spontaneous puberty based on breast development occurred in 40 and menarche in 30 of the 70 girls who were prepubertal at transplantation. Six out of 20 girls who received HSCT after initiation of pubertal development recovered their ovarian function. Younger age at HSCT, conditioning without total body irradiation (TBI), and a non-leukemia diagnosis predicted the spontaneous menarche. The incidence of menarche was higher after fractioned vs single fraction TBI (P<0.05), cyclophosphamide (Cy) vs busulfan (Bu)-based conditioning (P<0.05), and among leukemia patients transplanted at first remission vs later remissions (P<0.01) and with no cranial irradiation (cranial radiotherapy, CRT) vs given CRT (14-24 Gy) (P<0.01). The majority of recipients conditioned with only Cy vs TBI (P<0.001) or vs Bu-based regimens (P<0.01) showed preserved ovarian function and required no estrogen replacement at their latest follow-up visit at a mean age of 23±6.3 years (range 15-41). Ten women became pregnant. CONCLUSIONS Patients conditioned with TBI or Bu-based regimes are at high risk of ovarian failure. Intensive anti-leukemia therapy before HSCT including CRT especially among relapsed patients may further decrease the possibility of spontaneous menarche.
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Affiliation(s)
- A Vatanen
- Division of Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, FIN-00029 HUS Helsinki, Finland
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Lund B, Wesolowska-Andersen A, Lausen B, Borst L, Rasmussen KK, Müller K, Klungland H, Gupta R, Schmiegelow K. Host genome variations and risk of infections during induction treatment for childhood acute lymphoblastic leukaemia. Eur J Haematol 2014; 92:321-30. [DOI: 10.1111/ejh.12243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Bendik Lund
- Department of Paediatrics; St. Olavs Hospital; Trondheim Norway
- Department of Laboratory Medicine, Children's and Women's Health; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
| | | | - Birgitte Lausen
- Department of Paediatrics and Adolescent Medicine; The University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Louise Borst
- Department of Paediatrics and Adolescent Medicine; The University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Kirsten Kørup Rasmussen
- Department of Paediatrics and Adolescent Medicine; The University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Klaus Müller
- Department of Paediatrics and Adolescent Medicine; The University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Helge Klungland
- Department of Laboratory Medicine, Children's and Women's Health; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
| | - Ramneek Gupta
- Center for Biological Sequence Analysis; Technical University of Denmark; Lyngby Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine; The University Hospital, Rigshospitalet; Copenhagen Denmark
- The Institute of Gynaecology, Obstetrics and Paediatrics; The Faculty of Health Sciences; The University of Copenhagen; Copenhagen Denmark
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Niinimäki R, Hansen LM, Niinimäki T, Olsen JH, Pokka T, Sankila R, Vettenranta K, Hasle H, Harila-Saari A. Incidence of Severe Osteonecrosis Requiring Total Joint Arthroplasty in Children and Young Adults Treated for Leukemia or Lymphoma: A Nationwide, Register-Based Study in Finland and Denmark. J Adolesc Young Adult Oncol 2013; 2:138-144. [PMID: 24380033 DOI: 10.1089/jayao.2013.0006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: The population-based incidence of severe osteonecrosis (ON) necessitating total joint arthroplasty (TJA) in patients with hematological cancer is unknown. This study assessed the incidence of ON requiring primary TJA in children and young adults treated for leukemia or lymphoma. Methods: Patients diagnosed with leukemia or lymphoma before 31 years of age were identified from the Finnish and Danish Cancer Registries. These data were combined with those from the National Hospital Discharge and the Finnish Arthroplasty Registers. Data on the orthopedic procedures performed and the appropriate diagnosis codes given before the age of 40 were also retrieved. Results: The estimated cumulative incidence of TJA was 4.5% at 20 years for patients treated for chronic myeloid leukemia, followed by 2.1% for patients treated for acute myeloid leukemia. It was considerably lower in patients with acute lymphoblastic leukemia (ALL; 0.4%). Multivariate analysis revealed that allogeneic stem cell transplantation (allo-SCT) increased the risk of TJA (hazard ratio [HR]=9.4; 95% CI: 5.3-16.9). The risk of TJA was higher in patients diagnosed with cancer at 10-19 and 20-30 years of age than in those diagnosed before the age of 10 (HR=24; 95% CI: 3.1-176 and HR=26; 95% CI: 3.6-192 respectively). Conclusion: The incidence of ON requiring TJA was highest among patients with myeloid leukemias and lowest in patients treated for ALL. Allo-SCT and age ≥10 years at diagnosis were the most important risk factors for ON requiring TJA in hematological malignancies.
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Affiliation(s)
- Riitta Niinimäki
- Department of Pediatrics, Oulu University Hospital , Oulu, Finland
| | | | | | - Jørgen H Olsen
- Danish Cancer Society, Institute of Cancer Epidemiology , Copenhagen, Denmark
| | - Tytti Pokka
- Department of Pediatrics, Oulu University Hospital , Oulu, Finland
| | - Risto Sankila
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research , Helsinki, Finland
| | - Kim Vettenranta
- Division of Hematology-Oncology and Stem Cell Transplantation, Department of Pediatrics, Helsinki University Central Hospital , Helsinki, Finland
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital , Aarhus, Denmark
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Järvelä LS, Niinikoski H, Heinonen OJ, Lähteenmäki PM, Arola M, Kemppainen J. Endothelial function in long-term survivors of childhood acute lymphoblastic leukemia: effects of a home-based exercise program. Pediatr Blood Cancer 2013; 60:1546-51. [PMID: 23606359 DOI: 10.1002/pbc.24565] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 03/20/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND The risk for cardiovascular disease (CVD) is increased in long-term survivors of childhood acute lymphoblastic leukemia (ALL). Chemotherapy may have direct toxic effects on vascular endothelium, potentially increasing the significance of endothelial dysfunction in the development of CVD in ALL survivors. Endothelial structure and function can be measured with carotid intima media thickness (IMT) and brachial flow mediated dilation (FMD). IMT and FMD are intermediate markers of CVD. We studied endothelial function and the effects of an exercise program on vascular endothelium in long-term survivors of childhood ALL. PROCEDURE Twenty-one 16-30 year old long-term survivors of ALL (age at diagnosis ≤16 years) and 21 healthy controls were studied at baseline, and 17 of the ALL survivors participated in a 16 week home-based exercise program. IMT and FMD were studied before and after the exercise program. RESULTS At baseline, the ALL survivors had impaired overall FMD response (FMDauc, P = 0.02). FMDmax(%) was 22% lower (P = 0.06) and FMD at 40 seconds 44% lower (P = 0.01) compared to healthy controls. After the exercise program, FMD at 40 seconds (P < 0.01) and IMT (P = 0.02) improved. The mean overall FMD response increased by 25% after the exercise program, but this change was not statistically significant (P = 0.27). CONCLUSIONS Our results show that the excess burden of CVD morbidity in this population may possibly be alleviated by simple means. The importance of physical activity on the health of childhood ALL survivors should be emphasized. Longer, controlled studies are needed to confirm our findings.
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Affiliation(s)
- Liisa S Järvelä
- Department of Pediatrics, Turku University Hospital, Turku, Finland.
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Borssén M, Palmqvist L, Karrman K, Abrahamsson J, Behrendtz M, Heldrup J, Forestier E, Roos G, Degerman S. Promoter DNA methylation pattern identifies prognostic subgroups in childhood T-cell acute lymphoblastic leukemia. PLoS One 2013; 8:e65373. [PMID: 23762353 PMCID: PMC3675104 DOI: 10.1371/journal.pone.0065373] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 04/26/2013] [Indexed: 11/27/2022] Open
Abstract
Background Treatment of pediatric T-cell acute lymphoblastic leukemia (T-ALL) has improved, but there is a considerable fraction of patients experiencing a poor outcome. There is a need for better prognostic markers and aberrant DNA methylation is a candidate in other malignancies, but its potential prognostic significance in T-ALL is hitherto undecided. Design and Methods Genome wide promoter DNA methylation analysis was performed in pediatric T-ALL samples (n = 43) using arrays covering >27000 CpG sites. Clinical outcome was evaluated in relation to methylation status and compared with a contemporary T-ALL group not tested for methylation (n = 32). Results Based on CpG island methylator phenotype (CIMP), T-ALL samples were subgrouped as CIMP+ (high methylation) and CIMP− (low methylation). CIMP− T-ALL patients had significantly worse overall and event free survival (p = 0.02 and p = 0.001, respectively) compared to CIMP+ cases. CIMP status was an independent factor for survival in multivariate analysis including age, gender and white blood cell count. Analysis of differently methylated genes in the CIMP subgroups showed an overrepresentation of transcription factors, ligands and polycomb target genes. Conclusions We identified global promoter methylation profiling as being of relevance for subgrouping and prognostication of pediatric T-ALL.
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Affiliation(s)
- Magnus Borssén
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Lars Palmqvist
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Karrman
- Department of Clinical Genetics, University and Regional Laboratories, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jonas Abrahamsson
- Institute of Clinical Sciences, Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Behrendtz
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - Jesper Heldrup
- Department of Pediatrics, Skåne University Hospital, Lund, Sweden
| | - Erik Forestier
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Göran Roos
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Sofie Degerman
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
- * E-mail:
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Kanellopoulos A, Hamre HM, Dahl AA, Fosså SD, Ruud E. Factors associated with poor quality of life in survivors of childhood acute lymphoblastic leukemia and lymphoma. Pediatr Blood Cancer 2013; 60:849-55. [PMID: 23335116 DOI: 10.1002/pbc.24375] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 09/27/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Previous studies of health-related quality of life (QoL) in childhood cancer survivors have hardly focused on factors associated with poor QoL. THE AIMS OF OUR STUDY WERE (1) to assess QoL in long-term survivors (LTSs) of childhood acute lymphoblastic leukemia (ALL) and lymphomas compared to age-matched controls from the general population (NORMs). (2) To investigate factors associated with poor QoL in LTSs. PROCEDURE This population-based cross-sectional study enrolled 285 LTSs of ALL and lymphomas diagnosed between 1970 and 2002 at age <18 years. The LTSs completed an extensive mailed questionnaire including the Short Form 36 (SF-36) as QoL-measure. NORMs consisted of five age-matched controls for each LTS (N = 1,425). Poor QoL was defined as SF-36 physical or mental component summary score <40. RESULTS The median age of LTSs' at survey was 30 years (range: 18-54), median follow-up time 21 years (range: 7-39). Compared to NORMs, LTSs scored significantly lower on 7 of 8 SF-36 subscales. Among LTSs 32% reported poor QoL versus 19% among NORMs (P < 0.001). Among LTSs, psychosocial, lifestyle- and health-related variables, but not type of malignancy, treatment factors or socio-demographic factors were clinically significantly associated with poor QoL in bivariate regression analyses. In multivariate analysis, levels of fatigue, anxiety and depression, as well as obesity and insomnia remained significantly associated with poor QoL. CONCLUSION Significantly more LTSs than age-matched NORMs experienced poor QoL. Clinically significant associations with fatigue, anxiety, depression, obesity and insomnia were observed, which may be amenable for interventions, and thereby improvement of QoL in LTSs.
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Affiliation(s)
- Adriani Kanellopoulos
- Department of Paediatric Medicine, Women and Children's Division, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
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Lewis FM, Perry ML, Murdoch BE. Longitudinal language outcomes following intrathecal chemotherapy for acute lymphoblastic leukaemia. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2013; 15:156-164. [PMID: 22663017 DOI: 10.3109/17549507.2012.684888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Intrathecal chemotherapy (ITC) is the treatment option for acute lymphoblastic leukaemia (ALL). Neurocognitive deficits have been described following ITC, but language status post-treatment is yet to be clarified. This study examined the language skills of nine children following ITC for ALL (mean age 7;8 years and 3;2 years post-diagnosis at baseline measurement) and nine age- and sex-matched controls, at baseline then 2 years later, using a battery of tests assessing general language skills. An assessment of cognitively-demanding high level language skills was undertaken on a sub-group of the children (n =12). Statistical analysis revealed no significant difference between children treated with ITC and controls when comparing change in performance scores from baseline measurement to 2 years post-baseline measurement. Descriptive analysis of three of the ALL participants in the Intermediate Stage survivorship at language re-assessment indicated no clinically-significant change in performance over 2 years for all measures except receptive language skills, which improved over the time for two of the children. As language skills continue to develop into late adolescence, the need for the monitoring of language abilities of children treated at a young age with ITC as they enter the Intermediate and Late Stages of survivorship is discussed.
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Affiliation(s)
- Fiona M Lewis
- Centre for Neurogenic Communication Disorders Research, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane 4072, Australia.
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Increased uptake of social security benefits among long-term survivors of cancer in childhood, adolescence and young adulthood: a Norwegian population-based cohort study. Br J Cancer 2013; 108:1525-33. [PMID: 23481179 PMCID: PMC3629421 DOI: 10.1038/bjc.2013.107] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND As the number of cancer survivors increases, their health and welfare have come into focus. Thus, long-term medical consequences of cancer at a young age (<25 years), obtained from social security benefit records, were studied. METHODS Standardised incidence ratios (SIRs) of long-term medical consequences for 5-year cancer survivors, born during 1965-1985, were explored by linking population-based registries in Norway. RESULTS Among the 5-year cancer survivors (4031 individuals), 29.7% received social security benefits. The survivors had an overall 4.4 times (95% confidence interval (95% CI): 4.1-4.6) higher risk of social security benefit uptake than the cancer-free population. Survivors of malignancies of bone and connective tissues (SIR: 10.8; 95% CI: 9.1-12.9), CNS tumours (SIR: 7.7; 95% CI: 6.9-8.6) and malignancies of the haematopoietic system (SIR: 6.1; 95% CI: 5.3-7.0) had the highest risks of social security benefits uptake. The most notified causes of social security benefit uptake were diseases of the nervous system, and injury and poisoning. CONCLUSION The uptake of social security benefits among 5-year cancer survivors increased substantially and it may represent a solid outcome measure for the burden of the most severe late effects, especially in countries with comparable social welfare systems.
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Hamre H, Zeller B, Kanellopoulos A, Kiserud CE, Aakhus S, Lund MB, Loge JH, Fosså SD, Ruud E. High Prevalence of Chronic Fatigue in Adult Long-Term Survivors of Acute Lymphoblastic Leukemia and Lymphoma During Childhood and Adolescence. J Adolesc Young Adult Oncol 2013. [DOI: 10.1089/jayao.2012.0015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hanne Hamre
- National Resource Center for Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Bernward Zeller
- Department of Paediatric Medicine, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Adriani Kanellopoulos
- Department of Paediatric Medicine, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Cecilie E. Kiserud
- National Resource Center for Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - May B. Lund
- Department of Respiratory Medicine, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Jon H. Loge
- National Resource Center for Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
- Department of Behavioral Sciences in Medicine, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | | | - Ellen Ruud
- Department of Paediatric Medicine, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
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