Regional cerebral blood flow and neuron-specific enolase in cerebrospinal fluid in children with acute lymphoblastic leukemia during induction treatment

Anthracycline chemotherapy, vascular dysfunction and cognitive impairment: burgeoning topics and future directions

Anthracyclines, chemotherapeutic agents used to treat common forms of cancer, increase cardiovascular (CV) complications, thereby necessitating research regarding interventions to improve the health of cancer survivors. Vascular dysfunction, which is induced by anthracycline chemotherapy, is an established antecedent to overt CV diseases. Potential treatment options for ameliorating vascular dysfunction have largely been understudied. Furthermore, patients treated with anthracyclines have impaired cognitive function and vascular dysfunction is an independent risk factor for the development of mild cognitive impairment. Here, we will focus on: anthracycline chemotherapy associated CV diseases risk; how targeting mechanisms underlying vascular dysfunction may be a means to improve both CV and cognitive health; and research gaps and potential future directions for the field of cardio-oncology.

Expression of liquoral neuroprotection markers in children with acute lymphoblastic leukemia

Brain damage related to intrathecal methotrexate in children with acute lymphoblastic leukemia (ALL) is still unclear. Neuroinflammatory mechanisms and intracerebral production of specific biomarkers, play a key role in determining neuroprotective mechanisms after brain injury. To determine whether the CSF concentrations of neuron-specific enolase (NSE), neurotrophic factors and doublecortin (DCX) are influenced by repeated intrathecal methotrexate administrations, we prospectively collected CSF samples from 10 children with ALL and 10 controls. Our results showed an increased expression of the liquoral markers. This up-regulation could be interpreted as a neuroprotective response of the brain against the neuronal damages induced by MTX.

Cerebrospinal fluid neuron‐specific enolase in non‐selected patients

The degree to which cerebrospinal fluid (CSF) neuron-specific enolase (NSE) contributes to the diagnosis and prognosis of disorders of the central nervous system (CNS) or peripheral nervous system (PNS) is still under debate. The aim of the study was thus to assess the validity of CSF-NSE levels in the diagnostic work-up of these conditions. The study consecutively included 106 adult patients who had undergone a diagnostic spinal tap or myelography during the diagnostic work-up for various CNS or PNS disorders. Thirty-five of these patients (16 F, 19 M, aged 24-88 years) without indication of a CNS disorder and with normal routine CSF investigations served as controls. The remaining 71 patients (31 F, 40 M, aged 28-87 years) constituted the disease group. CSF-NSE was independent of sex and age. The upper reference limit of CSF-NSE was 0.01536 ng/L. CSF-NSE was elevated in 13 of the 71 patients (18%): 6 with metabolic myopathy, 4 with polyneuropathy and 3 with hepatic encephalopathy, multiple sclerosis and paraspasticity, respectively. Only 6 of the 13 patients (46%) showed CNS involvement. The study shows that CSF-NSE is elevated in only one-fifth of unselected patients who consecutively undergo a spinal tap. CSF-NSE is elevated most frequently in patients with metabolic myopathy and polyneuropathy, even in cases without CNS abnormalities.

Neurochemical markers of brain damage in cerebrospinal fluid during induction treatment of acute lymphoblastic leukemia in children

BACKGROUND

Central nervous system (CNS) irradiation has been replaced by systemic high-dose methotrexate (MTX) and intrathecal MTX in acute lymphoblastic leukemia treatment due to the risk of late effects. However, treatment without CNS irradiation might also cause brain damage.

PROCEDURE

Cerebrospinal fluid (CSF) was analyzed in 121 patients in an attempt to detect CNS injury. Seventy-three samples were analyzed for neuron-specific enolase (NSE), 108 for glial fibrillary acidic protein (GFAp), 110 for neurofilament protein light chain (NFp), and 70 for ascorbyl radical (AsR). Samples were taken at day 0, 8, 15, and 29 during induction treatment, including intrathecal MTX. Levels at days 8, 15, and 29 were compared with the levels before treatment.

RESULTS

NSE levels were 9.0 (+/-3.5) microg/L (mean (+/-SD)) at day 0, 15.0 (+/-5.3) at day 8 (P < 0.001), 13.6 (+/-4.7) at day 15 (P < 0.001) and 11.1 (+/-4.3) at day 29 (P < 0.001). GFAp were 177 (+/-98) ng/L at day 0, 206 (+/-101) at day 8 (P < 0.001), 200 (+/-106) at day 15 (n.s.) and 228 (+/-137) at day 29 (P < 0.001). NFp were below the detection limit 125 ng/L at day 0 in all 110 CSF samples analyzed, and increased significantly above the detection limit in 6/77 samples at day 8, in 11/84 at day 15 and in 22/91 at day 29. The AsR content did not change significantly.

CONCLUSIONS

Levels of NSE, GFAp, and NFp increased in CSF, which can be interpreted as early signs of brain damage. AsR levels do not show any convincing signs of oxidative stress.

The Role of Functional Imaging in the Diagnosis and Management of Late Normal Tissue Injury

Normal tissue injury after radiation therapy (RT) can be defined based on either clinical symptoms or laboratory/radiologic tests. In the research setting, functional imaging (eg, single-photon emission computed tomography [SPECT], positron-emission tomography [PET], and magnetic resonance imaging [MRI]) is useful because it provides objective quantitative data such as metabolic activity, perfusion, and soft-tissue contrast within tissues and organs. For RT-induced lung, heart, and parotid gland injury, pre- and post-RT SPECT images can be compared with the dose- and volume-dependent nature of regional injury. In the brain, SPECT can detect changes in perfusion and blood flow post-RT, and PET can detect metabolic changes, particularly to regions of the brain that have received doses above 40 to 50 Gy. On MRI, changes in contrast-enhanced images, T(1) and T(2) relaxation times, and pulmonary vascular resistance at different intervals pre- and post-RT show its ability to detect and distinguish different phases of radiation pneumonitis. Similarly, conventional and diffusion-weighted MRI can be used to differentiate between normal tissue edema, necrosis, and tumor in the irradiated brain, and magnetic resonance spectroscopy can measure changes in compounds, indicative of membrane and neuron disruption. The use of functional imaging is a powerful tool for early detection of RT-induced normal tissue injury, which may be related to long-term clinically significant injury.

Cerebrospinal fluid neurone-specific enolase in mitochondrial encephalomyopathies

Whether cerebrospinal fluid (CSF) neurone-specific enolase (NSE) contributes to the diagnosis of mitochondrial encephalomyopathies (MEMs) is unknown. Aim of the present study was thus to assess the validity of CSF-NSE in the diagnosis of MEM. CSF-NSE was determined in 24 controls, aged 28-88 years; and 23 MEM patients, aged 47-81 years. In controls, CSF-NSE was independent of sex (p = 0.849) and age (p = 0.346). Twenty-one MEM patients had clinical CNS involvement and two CNS abnormalities on imaging investigations exclusively. CSF cells were increased in 7, CSF protein in 17, CSF glucose in 1, and CSF lactate in 2 MEM patients. The upper reference limit of CSF-NSE was 14.66 ng/mL. CSF-NSE was elevated in 6 (26%) MEM patients. CSF-NSE was increased in a single MEM patient with subclinical CNS involvement. This study shows that CSF-NSE is elevated in only one quarter of the MEM patients. Determination of CSF-NSE appears to be of minor importance for the assessment of clinical or subclinical CNS involvement in MEM.

Correlation of cerebrospinal fluid beta-glucuronidase activity with plasma methotrexate concentrations in leukemic children receiving high-dose methotrexate

BACKGROUND

The activity of lysosomal enzymes is increased in body fluids during inflammation, in which cellular malfunction and cellular death occurs. Because chemotherapy also causes cell malfunction and death, for identifying a neurologic effect, we studied the activity of beta-glucuronidase in the cerebrospinal fluid (CSF) of leukemic children during treatment.

PROCEDURE

The beta-glucuronidase activity in CSF was determined in 13 patients with B-precursor acute lymphoblastic leukemia (ALL) treated with the medium risk arm of ALL Berlin-Frankfurt-Munster (BFM) 95 protocol. Plasma methotrexate (MTX) levels were determined at 24 and 48 hr after the infusion of high-dose (5 g/m(2)/24 hr) MTX (MCA phase).

RESULTS

The mean (SD) beta-glucuronidase activity prior to the onset of chemotherapy was 19.9 (5.6) nmoles/4-methylumbelliferone/ml/hr. No significant changes in activity were noted during the phases of the protocol except of the MCA3. The activity was 24.4 (6.8) on MCA2, 28.4 (9.3) on MCA3, and 24.1 (9.5) on MCA4. The beta-glucuronidase activity was positively correlated with the plasma MTX levels at both 24 hr (r = 0.483, P = 0.006) and 48 hr (r = 0.676, P < 0.0001). No progressive changes were noted during the different phases of the protocol. The greatest beta-glucuronidase activity was measured in two patients with neurotoxicity.

CONCLUSIONS

The beta-glucuronidase activity is increased in the CSF of leukemic children receiving high-dose MTX and particularly in neurotoxicity. It is positively correlated with plasma MTX levels. No cumulative effect of the chemotherapy was observed. The increased beta-glucuronidase activity is most likely due to enzyme leakage through the cell membranes caused mainly by a toxic effect of MTX on the cells of the central nervous system (CNS).

MR perfusion, diffusion and BOLD imaging of methotrexate-exposed swine brain

PURPOSE

To evaluate the methotrexate (MTX)-exposed swine brain, functional magnetic resonance imaging (MRI), including perfusion, diffusion, and blood-oxygen-level-dependent (BOLD) contrast imaging, was used.

MATERIAL AND METHODS

Juvenile pigs received either 2 x 5 g/m(2), or 5 x 2 g/m(2) MTX intravenously within one month. MRI was performed (sedative: propofol) before (14-17 kg, N = 6) and after (21-27 kg, N = 4) the MTX exposure. Also, age-matched controls (22-27 kg, N = 4) were imaged.

RESULTS

After the MTX exposure, reduced (from 2%-4% to 0%-1%) or negative (-2% to -3%) BOLD responses were detected; apparent diffusion coefficient (ADC) or relative perfusion values did not change.

CONCLUSION

This study suggests that MTX-related changes in the brain may be detected as changes in flow-metabolism coupling as reduced or negative response (for somatosensory activation) in the BOLD contrast MRI. The contrast agent perfusion MRI, without absolute quantification, may not show global damage in brain perfusion related to the MTX exposure in the swine model used. ADC (in one direction) may not indicate MTX-related changes in the brain.

Clinical use of tumor markers in childhood malignancies

Tumor markers are developmentally regulated proteins or carbohydrate molecules, which are expressed in specific tissues in the fetus during certain developmental periods. With malignant transformation, these molecules are reexpressed in neoplastic tissues. Some developmental or metabolic disorders can also lead to the expression of tumor marker genes, hereditary tyrosinaemia and ataxia teleangiectasia associating with elevated serum alpha-fetoprotein are examples of such conditions. In pediatric malignancies, the most common markers in clinical use are alpha-fetoprotein in liver and yolk sac tumors, chorionic gonadotropin in germ cell tumors, and catecholamines and neuron specific enolase in neuroblastoma. Several other molecules including carbohydrate antigens CA 19-9 and CA 125 may also have a role in the diagnosis and follow-up of distinct types of childhood malignancies. The non-specificity of several markers, such as tissue polypeptide antigen and sialic acid, greatly hampers their clinical use. In this review we will discuss the biology and current knowledge on the use of serum and urine tumor markers. We also highlight the putative future use of these molecules in cancer diagnosis and therapy, including the use of monoclonal antibodies directed against these antigens.