Evaluating Risk Factors for the Development of Ifosfamide Encephalopathy

Ifosfamide-Induced Encephalopathy Successfully Prevented by Methylene Blue: A Pediatric Case Report and Review of the Literature

Ifosfamide, which is widely used as a chemotherapeutic agent in various kinds of malignancies, sometimes causes neurotoxicity known as ifosfamide-induced encephalopathy (IIE). Herein, we report the case of a three-year-old girl who developed IIE during chemotherapy for Ewing's sarcoma and was treated with methylene blue as a prophylactic agent for IIE, after which she continued with ifosfamide and completed treatment without IIE recurrence. This case suggests that methylene blue may be effective in preventing the recurrence of IIE in pediatric patients. Further studies, including clinical trials, are needed to confirm the efficacy and safety of methylene blue in pediatric patients.

Ifosfamide - History, efficacy, toxicity and encephalopathy

In this review we trace the passage of fundamental ideas through 20^th century cancer research that began with observations on mustard gas toxicity in World War I. The transmutation of these ideas across scientific and national boundaries, was channeled from chemical carcinogenesis labs in London via Yale and Chicago, then ultimately to the pharmaceutical industry in Bielefeld, Germany. These first efforts to checkmate cancer with chemicals led eventually to the creation of one of the most successful groups of cancer chemotherapeutic drugs, the oxazaphosphorines, first cyclophosphamide (CP) in 1958 and soon thereafter its isomer ifosfamide (IFO). The giant contributions of Professor Sir Alexander Haddow, Dr. Alfred Z. Gilman & Dr. Louis S. Goodman, Dr. George Gomori and Dr. Norbert Brock step by step led to this breakthrough in cancer chemotherapy. A developing understanding of the metabolic disposition of ifosfamide directed efforts to ameliorate its side-effects, in particular, ifosfamide-induced encephalopathy (IIE). This has resulted in several candidates for the encephalopathic metabolite, including 2-chloroacetaldehyde, 2-chloroacetic acid, acrolein, 3-hydroxypropionic acid and S-carboxymethyl-L-cysteine. The pros and cons for each of these, together with other IFO metabolites, are discussed in detail. It is concluded that IFO produces encephalopathy in susceptible patients, but CP does not, by a "perfect storm," involving all of these five metabolites. Methylene blue (MB) administration appears to be generally effective in the prevention and treatment of IIE, in all probability by the inhibition of monoamine oxidase in brain potentiating serotonin levels that modulate the effects of IFO on GABAergic and glutamatergic systems. This review represents the authors' analysis of a large body of published research.

Augmented ICE in Patients With Poor-Risk Refractory and Relapsed Lymphomas

BACKGROUND

In patients with relapsed/refractory lymphoma after first line therapy, chemosensitivity to salvage chemotherapy is the main determinant of outcome pre-autologous stem cell transplant . With novel therapies not yet widely available and poor responses to conventional dose salvage therapy such as ifosfamide, carboplatin, and etoposide (ICE) in patients with early relapse within 12 months and primary refractory disease, there is capacity to dose intensify ifosfamide and etoposide (augmented ICE).

METHODS

We retrospectively evaluated patients who received augmented ICE between 2010 and 2020 and report on response, deliverability, toxicities, and outcome. Patients were transplant eligible with diffuse large-B cell lymphoma (DLBCL) or Hodgkin lymphoma (HL) with refractory disease or relapse within 12 months. Dose of augmented ICE versus standard ICE was ifosfamide 10 versus 5 g/m² and etoposide 600 versus 300 mg/m². Carboplatin dose with a calculated area under curve of 5 was unchanged. Anti-CD20 monoclonal antibody was given in patients with CD20 positive lymphoma. Responding patients who achieved complete response or partial response proceeded to transplant.

RESULTS

Twenty-one patients with DLBCL (n = 13) and HL (n = 8) received augmented ICE. Nineteen of 21 completed 2 cycles. Overall response rates were 85% (DLBCL) and 100% (HL). Most patients required transfusion, 2 developed reversible ifosfamide encephalopathy and 86% febrile neutropenia. Eighteen patients proceeded to transplant. 5-year overall survival (OS) and progression-free survival (PFS) in DLBCL were 62% and 45%, and in HL, 100% and 88%, respectively.

CONCLUSION

Augmented ICE is associated with high response rate and transplant realization at the expense of toxicity.

Ifosfamide-Induced Neurotoxicity in Children with Solid Tumors: A Seven Year Retrospective Analysis of Incidence and Risk Factors

Background: Patients with cancer treated with the pro-drug ifosfamide may experience drug-induced neurotoxicity. Ifosfamide-induced neurotoxicity (IIN) is well described in the adult literature, but there is limited knowledge about this toxicity in pediatrics, especially in children with solid tumors. Methods: In this retrospective descriptive study, the author reviewed 7 years of clinical data regarding patients with solid tumors who received ifosfamide at a large, urban pediatric medical center. The author used descriptive statistics and logistic regression to describe the incidence of IIN and identify demographic and clinical factors most likely to be associated with the toxicity. Results: In a sample of 169 pediatric patients who received ifosfamide between 2011 and 2018, 13% developed symptoms of IIN. The author identified ifosfamide doses >2,000 mg/m² to be a risk factor for IIN in the study sample (OR 17.82; 95 CI [2.17, 146.18]; p = .0073) and cited other variables as possible risk factors, though each could be linked to participants' ifosfamide exposure. Discussion: This study is the largest to describe IIN specifically in the pediatric solid tumor population. The study findings suggest the pattern of toxicity observed in adult patients should not be assumed in children. The author identified one risk factor that may predispose children to develop IIN and recommends further attention be paid to this toxicity in the pediatric population.

Inflammatory Surrogate Parameters for Predicting Ifosfamide-Induced Neurotoxicity in Sarcoma Patients

Sarcomas compromise a heterogenous group of tumors of a mesenchymal origin. Although treatment options in many solid tumors have evolved over the past decades, the treatment of advanced sarcoma is still based on conventional chemotherapeutic agents. Beside anthracyclines, alkylating agents such as ifosfamide are frequently used in sarcoma treatment. However, treatment with ifosfamide can cause severe dose- and treatment-limiting side effects, such as ifosfamide-induced neurotoxicity (IIN). Especially in sarcoma, consecutive risk assessment analyses investigating the individual factors associated with the increased incidence in IIN, remain insufficient so far. In this retrospective analysis, we investigated 172 sarcoma patients treated with ifosfamide. Out of 172 patients, 49 patients (28.5%) developed IIN. While gender, age, histologic origin, and tumor stage were not associated with the occurrence of IIN, infusion times, simultaneous radiotherapy, and concomitant use of opioids or anticonvulsants affected the risk of developing IIN. Sarcoma patients with IIN showed an alteration in several inflammatory markers, including a lower lymphocyte count, hemoglobin levels, and calcium levels, as well as elevated GGT, sodium, and CRP levels. Remarkably, the occurrence of IIN was associated with a worse prognosis regarding progression free and overall survival. In addition, high CTCAE grades were negatively associated with overall survival in sarcoma. The observation that an inflammatory state is associated with an increased risk of IIN in sarcoma patients can be used prospectively to further investigate the relationship of inflammation and IIN. In addition, the easily accessible blood markers used in our study to predict IIN can be incorporated into clinical decision making.

Role of inflammation and oxidative stress in chemotherapy-induced neurotoxicity

Chemotherapeutic agents may adversely affect the nervous system, including the neural precursor cells as well as the white matter. Although the mechanisms are not completely understood, several hypotheses connecting inflammation and oxidative stress with neurotoxicity are now emerging. The proposed mechanisms differ depending on the class of drug. For example, toxicity due to cisplatin occurs due to activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), which alters hippocampal long-term potentiation. Free radical injury is also involved in the cisplatin-mediated neurotoxicity as dysregulation of nuclear factor erythroid 2-related factor 2 (Nrf2) has been seen which protects against the free radical injury by regulating glutathione S-transferases and hemeoxygenase-1 (HO-1). Thus, correcting the imbalance between NF-κB and Nrf2/HO-1 pathways may alleviate cisplatin-induced neurotoxicity. With newer agents like bortezomib, peripheral neuropathy occurs due to up-regulation of TNF-α and IL-6 in the sensory neurons. Superoxide dismutase dysregulation is also involved in bortezomib-induced neuropathy. This article reviews the available literature on inflammation and oxidative stress in neurotoxicity caused by various classes of chemotherapeutic agents. It covers the conventional medicines like platinum compounds, vinca alkaloids, and methotrexate, as well as the newer therapeutic agents like immunomodulators and immune checkpoint inhibitors. A better understanding of the pathophysiology will lead to further advancement in strategies for management of chemotherapy-induced neurotoxicity.

Reversible Encepahlopathy Induced by Ifosfamide with Brain Imaging

Chemotherapy may be responsible for central and/or peripheral neurotoxicity. These neurological complications are frequent but little known. Some molecules are more providers, responsible for acute or late complications, sometimes not reversible. Some manifestations such as acute encephalopathy and acute reversible encephalopathy are increasingly understood. We report here a case of acute ifosfamide-induced encephalopathy (EII) with brain damage resolved after discontinuation of this treatment in a 13-years-old child.

Randomised phase 2 study comparing the efficacy and safety of the oral tyrosine kinase inhibitor nintedanib with single agent ifosfamide in patients with advanced, inoperable, metastatic soft tissue sarcoma after failure of first-line chemotherapy: EORTC-1506-STBSG "ANITA"

PURPOSE

EORTC-1506-STBSG was a prospective, multicentric, randomised, open-label phase 2 trial to assess the efficacy and safety of second-line nintedanib versus ifosfamide in patients with advanced, inoperable metastatic soft tissue sarcoma (STS). The primary end-point was progression-free survival.

PATIENTS/METHODS

Patients with a variety of STS subtypes were randomised 1:1 to nintedanib (200 mg b.i.d. p.o. until disease progression) or ifosfamide (3 g/m² i.v. days 1-3, every 21 days for ≤6 cycles). A Korn design was applied aiming to detect an improvement in median progression-free survival (mPFS) from 3 to 4.5 months (HR = 0.667). An interim look was incorporated to stop the trial for futility if <19 of the first 36 patients treated with nintedanib were progression-free at week 12.

RESULTS

At the interim analysis, among the first 36 eligible and evaluable patients randomised for nintedanib, only 13 (36%) were progression-free at week 12. The trial was closed for further accrual as per protocol. In total, 80 patients were randomised (40 per treatment group). The mPFS was 2.5 months (95% CI: 1.5-3.4) for nintedanib and 4.4 months (95% CI: 2.9-6.7) on ifosfamide (adjusted HR = 1.56 [80% CI: 1.14-2.13], p = 0.070). The median overall survival was 13.7 months (95% CI: 9.4-23.4) on nintedanib and 24.1 months (95% CI: 10.9-NE) on ifosfamide (adjusted HR = 1.65 [95%CI:0.89-3.06], p = 0.111). The clinical benefit rate for nintedanib and ifosfamide was 50% versus 62.5% (p = 0.368), respectively. Common treatment-related adverse events (all grades) were diarrhoea (35.9% of patients), fatigue (25.6%) and nausea (20.5%) for nintedanib; and fatigue (52.6%), nausea (44.7%) and vomiting, anorexia and alopecia (28.9% each) for ifosfamide.

CONCLUSION

The trial was stopped for futility. The activity of nintedanib did not warrant further exploration in non-selected, advanced STSs.

The safety of current pharmacotherapeutic strategies for osteosarcoma

Introduction: Peri-operative chemotherapy is the backbone of treatment for patients with osteosarcoma. Methotrexate, cisplatinum, doxorubicin and ifosfamide are the main drugs used in chemotherapy regimens used for osteosarcoma.Areas covered: We have reviewed here the relevant literature related to the incidence and management of acute and late toxicities of systemic treatment used for the management of patients with osteosarcoma.Expert opinion: Early diagnosis and appropriate management of acute and late toxicities of chemotherapy is crucial for an efficient care of osteosarcoma patients. Although the incidence and management of chemotherapy-related acute toxicities are well known by most oncologists, the use of high doses of methotrexate have the potential to cause fatal toxicities and, therefore, needs careful monitoring. Moreover, the diagnosis of late toxicities is more challenging and requires long-term follow-up for an appropriate management.

Albumin-bilirubin score for predicting neuropsychiatric symptoms in patients receiving ifosfamide-based chemotherapy

WHAT IS KNOWN AND OBJECTIVE

Ifosfamide, an alkylating agent, is widely used in the treatment of malignant diseases. However, these treatments are often limited due to the incidence of neuropsychiatric symptoms such as delirium, seizures, hallucinations and agitation. In this study, we examined risk factors for neuropsychiatric symptoms in patients receiving ifosfamide-based chemotherapy.

METHODS

The study cases were patients with cancer receiving ifosfamide-based chemotherapy between April 2007 and March 2018. Risk analysis for ifosfamide-related neuropsychiatric symptoms was determined by time-dependent Cox proportional hazard regression analysis.

RESULTS AND DISCUSSION

Of 183 eligible patients, 32 patients (17.5%) experienced ifosfamide-related neuropsychiatric symptoms. Time-dependent Cox proportional hazard model showed that the albumin-bilirubin (ALBI) score was significantly correlated with the incidence of ifosfamide-related neuropsychiatric symptoms (hazard ratio [HR] =1.45, 95% confidence interval [CI] = 1.05-2.01, p = 0.025). Additionally, there were correlations between the predicted risk of neuropsychiatric symptoms and ifosfamide-dose per cycle (HR =0.51, 95% CI = 0.27-0.94, p = 0.030) and creatinine clearance (Ccr) (HR = 0.53, 95% CI = 0.28-1.00, p = 0.050). In contrast, neither serum albumin nor total bilirubin was a significant risk factor for neuropsychiatric symptoms.

WHAT IS NEW AND CONCLUSION

These findings indicate that ALBI score may be a useful biomarker for predicting neuropsychiatric symptoms in patients receiving ifosfamide-based chemotherapy.

Incidence of ifosfamide induced encephalopathy in patients receiving concomitant fosaprepitant

INTRODUCTION

The incidence of Ifosfamide-induced encephalopathy (IIE) ranges from 5-30%. Aprepitant and fosaprepitant may increase the risk of IIE; however, data is limited. The objective of this study was to characterize the incidence of IIE in patients receiving concomitant fosaprepitant.

METHODS

This single-center, retrospective chart review included adult patients diagnosed with sarcoma who received at least one administration of high dose ifosfamide (≥1800mg/m²) and fosaprepitant between January 2017 and June 2018. The primary endpoint was the percentage of patient cycles in which IIE was experienced. Secondary endpoints included characterization of IIE management strategies, time to IIE resolution, and the incidence of IIE upon ifosfamide re-challenge. Subgroup analyses were performed to assess whether the following variables predisposed a patient to neurotoxicity: elevated serum creatinine, hypoalbuminemia, metabolic acidosis, hyperbilirubinemia, shorter infusion time, and higher body mass index. The role of CYP2B6 inhibitors and prior cisplatin use were also examined.

RESULTS

Fifty-one patients who received 215 total cycles of ifosfamide were included. Twenty (9.3%) patient cycles included documented evidence of IIE. The most common management strategies were to prolong the infusion time and administer methylene blue. The mean time to resolution of IIE was 2.58 days. The incidence of secondary IIE upon re-challenge was 26.3%. Baseline albumin <3.5 g/dL (p<0.001) was statistically associated with the development of IIE.

CONCLUSION

Co-administration of fosaprepitant and ifosfamide in sarcoma appears to be safe. Hypoalbuminemia was a notable risk factor confirmed in this study. Further research is needed to delineate IIE risk factors.

Methylene blue and ifosfamide-induced encephalopathy: Myth or reality?

BACKGROUND

Ifosfamide-induced encephalopathy (IIE) is a rare and serious adverse reaction. Thus far, no standard medication has been documentedto be efficient in the reversal of IIE, and while ifosfamide infusion interruption and hydration are recommended, methylene blue (MB) administration remains controversial.

METHODS

We retrospectively reviewed medical records to assess cases with IIE after ifosfamide infusion. We included all patients having received an ifosfamide infusion during their hospitalization in the medical oncology unit of the National Institute of Oncology in Rabat, Morocco, between September 2016 and September 2017. We subsequently conducted a literature review to determine the role of MB in IIE by searching PubMed using the terms "Methylene Blue" and "Ifosfamide".

RESULTS

A total of 88 patients received ifosfamide, and four patients had IIE. Ifosfamide infusion was stopped immediately after the IIE occurrence, and patients underwent renal function correction with hydration. All patients received MB infusion, and three patients had an improvement of their neurological status. As regards the literature review, 34 articles were reviewed and 16 items were included in the review. Overall, 38 (65.5%) patients received MB infusion and 28 (75.6%) patients responded favorably to the treatment.

CONCLUSIONS

Methylene blue can be used as a treatment for IIE owing to the severity of the IIE as well as absence of standard medication. Nonetheless, side effects such as serotonergic syndrome should be investigated. More broadly, prospective studies and controlled trials are needed to explore the contribution of MB in IIE management and encourage its use.

Ifosfamide induced encephalopathy in a child with osteosarcoma

BACKGROUND

Ifosfamide (IFO) is an alkylating agent used to treat broad range of malignancies. One of the life-threatening toxic effects is reversible neurotoxicity. In this report; we presented a case report of ifosfamide induced encephalopathy (IIE) in a child with osteosarcoma in order to emphize that it is important to continue ifosfamide treatment as well as the importance of this potentially fatal complication.

CASE REPORT

Following the 20th week of ifosfamide treatment, the patient's follow-up with the diagnosis of osteosarcoma developed neurological findings. Laboratory analyzes before and after ifosfamide infusion were normal. No pathological findings were seen on MR imaging. Hypoglycemia, electrolyte disturbances, encephalitis, meningitis, metastasis and posterior reversible encephalopathy syndrome (PRES) were not considered. Electroencephalography was found compatible with neuronal hyperexcitability originating from the left hemisphere. With the diagnosis of ifosfamide induced encephalopathy, prophylaxis with methylene blue was received before the next infusion of ifosfamide. Neurological findings were not observed in the patient's follow-up.

CONCLUSION

Patients who develop IIE can continue their treatment protocol with methylene blue prophylaxis and supportive therapy.

Delirium incidence, risk factors, and treatments in older adults receiving chemotherapy: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer are at increased risk of delirium due to age, comorbidities, medications, cognitive impairment, and possibly cancer treatments. However, there is scant information on the risks of delirium with chemotherapy and approaches to prevent or treat it. We performed a systematic review and meta-analysis to summarize available evidence.

MATERIALS AND METHODS

We systematically searched peer-reviewed journal articles in English, French, German, and Dutch from five databases from 1990 to May 2019 to identify studies examining delirium in adult patients receiving chemotherapy. We also attempted to identify delirium risk prediction models and prevention or treatment trials. All reviews and data extraction were performed by two independent reviewers. Summary estimates were derived from random effects models.

RESULTS

A total of 23,389 titles and abstracts were screened, and 1272 full-text articles were reviewed. Nineteen articles reported on delirium using an acceptable diagnostic standard. Sample sizes varied from 7 to 324. The incidence of delirium ranged from 0 to 51% (weighted mean 9%, 95% confidence interval 5-16%). In a sensitivity analysis including 122 studies that used terminology suggestive of delirium but did not meet our inclusion criteria, the weighted incidence of delirium was 10% (95% confidence interval 8-12%). Age was not consistently associated with increased delirium risk. No intervention studies to prevent or treat delirium were identified.

CONCLUSIONS

Delirium may occur in 1 in 11 older adults receiving chemotherapy; however, there were substantial limitations in reported studies. This systemic review highlights key gaps in knowledge, particularly regarding risk factors, prevention, and treatments.

Analysis of the clinical characteristics of pediatric patients who experience ifosfamide-induced encephalopathy

BACKGROUND

Several kinds of pediatric hematological and/or malignant diseases are treated with chemotherapy regimens including ifosfamide (IFO). IFO-induced encephalopathy (IIE) is one of the serious side effects, but there is not enough evidence regarding the clinical features of IIE in children.

PROCEDURE

We performed a retrospective study on pediatric patients treated with chemotherapy regimens, including IFO, at a single center. We recorded the clinical characteristics of all patients; we compared the clinical characteristics between patients who developed IIE and those who did not.

RESULTS

In total, 88 patients received a chemotherapy regimen including IFO. IIE developed in seven patients (8.0%). The median age of patients at the time of IIE development was 4.3 (range 1.4-6.5) years in the younger population. Six of seven patients with IIE improved with supportive therapy only; however, one patient died due to heart failure. Overall survival was not different between the two groups. Multivariable analysis revealed that the co-administration of cisplatin (CDDP) or carboplatin (CBDCA) was a significant risk factor associated with IIE. Although there was no significant difference in laboratory data between the groups before chemotherapy, patients who developed IIE showed exacerbation in several laboratory tests, including those for renal and liver functions.

CONCLUSIONS

Renal dysfunction caused by the combination of nephrotoxic agents (IFO and CDDP/CBDCA) seems to be important for the development of pediatric IIE. It was thought to be difficult to predict IIE onset based on laboratory data before the initiation of chemotherapy regimens; however, careful observation of laboratory data during IFO chemotherapy regimens may help predict IIE onset and facilitate early treatment.

Adverse event profiles of ifosfamide-induced encephalopathy analyzed using the Food and Drug Administration Adverse Event Reporting System and the Japanese Adverse Drug Event Report databases

PURPOSE

Ifosfamide is extensively used to treat several malignant conditions. Administration of ifosfamide can cause encephalopathy and other neurotoxic effects. The aim of this study was to obtain novel information on the onset profiles of ifosfamide-induced encephalopathy (IIE) considering other associated clinical factors using the US Food and Drug Administration Adverse Event Reporting System (FAERS) and the Japanese Adverse Drug Event Report (JADER) databases.

METHODS

We analyzed the reports of encephalopathy between 2004 and 2018 from the FAERS and JADER databases. To define IIE, we used the Medical Dictionary for Regulatory Activities (MedDRA) preferred terms and standardized queries. The reporting odds ratios (ROR) at 95% confidence interval (CI) was used to detect the signal for IIE and adjusted for covariates using a multivariate logistic regression technique. We evaluated the time-to-onset profile of IIE and used the association rule mining technique to discover undetected associations, such as potential risk factors.

RESULTS

In the FAERS database, the ROR (CI) for encephalopathy (preferred term, PT) and encephalopathy (standardized MedDRA queries, SMQ) was 56.58 (51.69-61.93) and 1.57 (1.48-1.67), respectively. In the JADER database, the ROR (95% CI) for encephalopathy (PT) and encephalopathy (SMQ) was 13.54 (9.91-18.50) and 1.24 (1.01-1.53), respectively. The multivariate logistic regression analysis showed a significant contribution in IIE signal in the ≥ 60 year group (p = 0.00094; vs. < 60 year group) and ≥ 2000 mg/m² dosage group (p = 0.00045; vs. < 2000 mg/m² dosage group). The association rules of {ifosfamide, aprepitant} → {encephalopathy (SMQ)} demonstrated high lift values. The average dose of ifosfamide in patients with encephalopathy (PT) and without encephalopathy (PT) was 2022.8 ± 592.8 (mean ± standard deviation) and 1568.5 ± 703.2 mg/m², respectively (p < 0.05). Encephalopathy within the first 7 days of ifosfamide administration was 94.1% for encephalopathy (PT) and 87.7% for encephalopathy (SMQ), respectively.

CONCLUSIONS

The present analysis demonstrated that the incidence of encephalopathy with ifosfamide should be closely monitored for a short onset (within 7 days). The patients who are administered a high dose of ifosfamide or co-administrated aprepitant should be carefully monitored for the development of encephalopathy.

Clinical and EEG Characteristics of Ifosfamide-Related Encephalopathy

PURPOSE

Ifosfamide can lead to a syndrome of central nervous system toxicity. Here, we investigate the clinical and EEG characteristics of patients with ifosfamide-related encephalopathy.

METHODS

Retrospective data were collected on patients from Memorial Sloan Kettering Cancer Center, who developed encephalopathy associated with ifosfamide between 2007 and 2017. Patients who had an EEG performed were included. Clinical and laboratory data were retrospectively collected. Each EEG recording was reviewed and compared with the originally documented EEG report.

RESULTS

Sixteen patients with ifosfamide-related encephalopathy were included, with primary tumors consisting of lymphoma (N = 9), sarcoma (N = 4), poorly differentiated ovarian cancer (N = 1), neuroblastoma (N = 1), and papillary serous adenocarcinoma (N = 1). Laboratory results ruled out other etiologies of encephalopathy. Generalized periodic discharges with or without triphasic morphology were seen most commonly (N = 9), with a distinct pattern of interspersed intermittent background attenuation seen in five patients. Background slowing and intermittent rhythmic delta activity (N = 4), bursts of bilateral synchronized delta activity (N = 2), and frontal predominant intermittent delta activity (N = 1) were also seen. One patient demonstrated a pattern consistent with nonconvulsive status epilepticus. Although most patients experienced resolution of symptoms, those who died demonstrated a variety of EEG abnormalities. Abnormal movements were common, with six patients demonstrating characteristic orofacial myoclonus.

CONCLUSIONS

Ifosfamide-related encephalopathy commonly results in a distinct pattern of generalized periodic discharges admixed with intermittent background attenuation on EEG. Abnormal movements, in particular orofacial myoclonus, are also common. Recognizing these clinical and EEG features might lead to early detection of ifosfamide-related encephalopathy.

Neurological Complications of the Treatment of Pediatric Neoplastic Disorders

Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.

Possible role of CYP2B6 genetic polymorphisms in ifosfamide-induced encephalopathy: report of three cases

Ifosfamide (IFA) is a potent alkylating antitumoral agent, but its use is limited by neurological side effects. IFA is a racemic mixture of two enantiomeric forms, R-IFA and S-IFA with a stereoselective metabolism by CYP3A4 and CYP2B6, leading either to bioactive or to toxic pathways. In three consecutive cases of pediatric patients who exhibited IFA-induced encephalopathy (IIE), genotyping of clinically relevant single-nucleotide polymorphisms associated with decreased CYP3A4 and CYP2B6 activities was performed. Genetic investigations revealed the presence of CYP2B6 rs4803419 (C>T) in one patient while the two others carried the CYP2B6*6 allelic variant. All patients carried CYP3A4 wild-type genotype (CYP3A4*1/*1). Because CYP2B6-deficient alleles may be responsible for an increased conversion of S-IFA into neurotoxic metabolites, screening for CYP2B6 polymorphisms may help to avoid IIE and improve clinical outcomes.

The Use of Continuous Veno-Venous Hemodiafiltration in the Management of Ifosfamide-induced Encephalopathy: A Case Report

Encephalopathy is a common side effect of ifosfamide, occurring in up to 30% of patients. Although self-resolving in most cases, death secondary to severe encephalopathy has been reported. Methylene blue and thiamine have been occasionally successful as treatment. We report a case of an 11-year-old girl with relapsed neuroblastoma who developed grade 4 ifosfamide-induced encephalopathy. She showed no initial response to methylene blue and thiamine. She remained neurologically impaired and continuous veno-venous hemodiafiltration was started, with rapid resolution of encephalopathy. This is the first report of continuous veno-venous hemodiafiltration use for suspected ifosfamide-induced encephalopathy in the pediatric population.

Role of thiamine in managing ifosfamide-induced encephalopathy

Encephalopathy is a well known side effect of ifosfamide, developing in approximately 10–30% of patients exposed to the drug. It is generally reversible after discontinuing the therapy;however cases of fatal neurotoxicity have been reported. Methylene blue is commonly used in the treatment and prophylaxis of ifosfamide induced encephalopathy;however its efficacy is moderate at best. We report here the utility of thiamine in both treating and preventing ifosfamide induced neurotoxicity in three patients. With the use of intravenous thiamine encephalopathy resolved in all of our patients within a mean time of 17 hours (range 10–30 hours). In three cycles where thiamine was used as prophylaxis no evidence of ifosfamide induced encephalopathy was seen. Thiamine appears to be a safe and effective treatment for reversing encephalopathy resulting form ifosfamide infusion, without any significant side effects.

Chemotherapy-induced neurotoxicity in pediatric solid non-CNS tumor patients: An update on current state of research and recommended future directions

Neurocognitive sequelae are known to be induced by cranial radiotherapy and central-nervous-system-directed chemotherapy in childhood Acute Lymphoblastic Leukemia (ALL) and brain tumor patients. However, less evidence exists for solid non-CNS-tumor patients. To get a better understanding of the potential neurotoxic mechanisms of non-CNS-directed chemotherapy during childhood, we performed a comprehensive literature review of this topic. Here, we provide an overview of preclinical and clinical studies investigating neurotoxicity associated with chemotherapy in the treatment of pediatric solid non-CNS tumors. Research to date suggests that chemotherapy has deleterious biological and psychological effects, with animal studies demonstrating histological evidence for neurotoxic effects of specific agents and human studies demonstrating acute neurotoxicity. Although the existing literature suggests potential neurotoxicity throughout neurodevelopment, research into the long-term neurocognitive sequelae in survivors of non-CNS cancers remains limited. Therefore, we stress the critical need for neurodevelopmental focused research in children who are treated for solid non-CNS tumors, since they are at risk for potential neurocognitive impairment.

An assessment of risk factors associated with ifosfamide-induced encephalopathy in a large academic cancer center

PURPOSE

Ifosfamide-induced encephalopathy is a neurotoxic adverse effect of ifosfamide chemotherapy. The objective of this study was to determine the incidence of encephalopathy in patients with lymphoma and sarcoma receiving ifosfamide chemotherapy and assess for potential risk factors that influence the incidence of encephalopathy.

METHODS

A retrospective study of sarcoma and lymphoma patients receiving ifosfamide chemotherapy was performed at the participating institutions. Enrollment began 1 July 2011 and continued chronologically backwards until 100 sarcoma and 100 lymphoma patients were enrolled. Identification of ifosfamide-induced encephalopathy events was performed by reviewing provider documentation of ifosfamide infusions. Logistic regression was employed to determine associations between risk factors and ifosfamide-induced encephalopathy events.

RESULTS

Of the 200 patients enrolled, 29 (14.5%) patients experienced encephalopathy. Ifosfamide-induced encephalopathy occurred more frequently in the sarcoma population than the lymphoma population (24 vs. 5 patients, p < 0.001). In addition to cancer type, prior use of cisplatin, concomitant opioids, and use of CYP2B6 inhibitors remained as significant variables in the multivariate model conferring a 12.47, 2.81, and 5.17 increased odds of experiencing encephalopathy, respectively. The odds of experiencing encephalopathy were 9.0 and 1.37 times higher for a one-unit increase in serum creatinine and hemoglobin, respectively, and 0.15 times lower for a one-unit increase in albumin.

CONCLUSIONS

This is the first study to demonstrate that patients with sarcoma experienced ifosfamide-induced encephalopathy more often than those with lymphoma. For all patients, predisposing factors for ifosfamide-induced encephalopathy included previous cisplatin exposure, concomitant opioids and CYP2B6 inhibitors. Laboratory values that increased ifosfamide-induced encephalopathy risk included low serum albumin, increased serum creatinine, and increased hemoglobin.

Testicular-cancer survivors experience compromised language following chemotherapy: findings in a Swedish population-based study 3-26 years after treatment

BACKGROUND

Studies suggest an increased risk for compromised cognitive function among cancer survivors. It is unclear to what extent chemotherapy is the cause and how the dysfunction, when present, affects everyday life. The objective was to study self-reported behaviours that may depend on cognitive function, among testicular-cancer survivors who received various cycles of cisplatin-based chemotherapy by comparing them with those who did not.

MATERIAL AND METHODS

We identified 1173 eligible men diagnosed with non-seminomatous testicular cancer treated according to the national cancer-care programs SWENOTECA I-IV between 1981 and 2004. During an 18-month qualitative phase we constructed a study-specific questionnaire including questions about specific activities and behaviour in everyday life.

RESULTS

We obtained information from 960 of 1173 (82%) testicular-cancer survivors diagnosed on average 11 years previously. The prevalence of "saying similar but incorrect words" at least once a week was 5% among those having received no chemotherapy versus 16% among those having received five or more cycles, giving a prevalence ratio ("relative risk", RR) of 3.3 with a 95% confidence interval of 1.5 to 7.1. The corresponding figure for "saying words in the wrong order" was 3.1 (1.7-5.8), for "difficulties understanding what other people mean" 3.1 (1.3-7.7), for "saying words other than planned" 2.2 (1.1-4.5) and for "difficulties completing sentences" 2.0 (1.0-3.6). The relative risks for those with a low level of education ranged between 4.9 (1.6-14.9) and 15.3 (1.9-120.5).

CONCLUSION

Testicular-cancer survivors in Sweden who have received five or more cycles of cisplatin-based chemotherapy experience an increased incidence of long-term compromised language; the effect is primarily seen among men with a low level of education.

Fatal Ifosfamide-induced metabolic encephalopathy in patients with recurrent epithelial ovarian cancer: report of two cases

Central nervous system (CNS) toxicity has been reported in approximately 10-30% of patients receiving intravenous infusions of ifosfamide. Encephalopathy is a rare but serious CNS adverse reaction in these patients, and although usually transient and reversible, may cause persistent neurological dysfunction or death. Clinical features range from fatigue and confusion to coma and death. Although methylene blue can be used to treat ifosfamide-induced neurotoxicity, including encephalopathy, its mechanism of action remains poorly defined. We describe here two patients with recurrent epithelial ovarian cancer who experienced fatal encephalopathy following ifosfamide/mesna treatment.

Evaluation of methylene blue, thiamine, and/or albumin in the prevention of ifosfamide-related neurotoxicity

SUMMARY

A serious adverse effect that can limit the utility of ifosfamide is neurotoxicity, known as ifosfamide-induced encephalopathy (IIE). Information regarding the usefulness of prophylactic administration of methylene blue, thiamine, and albumin to reduce the incidence of IIE is scarce. We present the results of a retrospective chart review evaluating the incidence of IIE in adult patients who received ifosfamide to treat sarcoma at the University of Washington within a 2-year period. Patients who received methylene blue, thiamine, and/or albumin were compared to patients who did not receive these prophylactic agents concurrently with ifosfamide. The primary objective was to evaluate if prophylaxis is associated with a reduced incidence of IIE. Identifying risk factors associated with IIE was a secondary objective. The cost of using prophylaxis with ifosfamide administration was reviewed.

RESULTS

A total of 166 cycles were included. For the primary endpoint, more cycles in the prophylaxis group had patients with symptoms of IIE (21.1% in the prophylaxis group vs. 8.4% in the nonprophylaxis group); p =0.026. The average number of risk factors per cycle was the same in each group; however, the type of risk factors differed.

CONCLUSIONS

Prophylaxis was not associated with a reduced incidence of IIE, and it does not appear to delay time to onset of symptoms at our institution.

RESULT

of this study provide no support for using methylene blue, thiamine, and/or albumin as routine prophylaxis when administering ifosfamide to adults with sarcoma.

Ifosfamide-induced encephalopathy in patients with uterine sarcoma

OBJECTIVE

To report two cases of recurrent uterine sarcoma that developed ifosfamide-induced encephalopathy (IIE) with successful management.

CASE REPORTS

The patient in the first case developed grade 4 toxicity and had a partial response after the fourth dose of intravenous methylene blue was administered. Full recovery occurred 4 days after the development of IIE. The patient in the second case, who had grade 3 toxicity, had completely recovered 32 hours after the first dose of thiamine.

CONCLUSION

Careful evaluation of patients with recurrent gynecologic cancers and vigilance during infusion of chemotherapeutic regimens are important in reducing the risk and timely management of IIE. Both methylene blue and thiamine appear to be effective treatments for IIE.

Ifosfamide-induced encephalopathy and movement disorder

Ifosfamide is a widely used chemotherapeutic agent for the treatment of a broad spectrum of solid tumors. CNS toxicity is a well-described side effect of ifosfamide, but the mechanism of ifosfamide-induced neurotoxicity remains poorly defined. We present two pediatric cases of hemiballismic limb movements in the setting of ifosfamide-associated encephalopathy. To our knowledge, there have been no prior reports of ifosfamide-induced hemiballism in pediatric patients. One of our patient's encephalopathy and abnormal movements may have improved after the administration of methylene blue and thiamine.

Bevacizumab in combination with sequential high-dose chemotherapy in solid cancer, a feasibility study

We evaluated the feasibility and toxicity of bevacizumab in combination with sequential high-dose (HD) ifosfamide, carboplatin and etoposide refractory to standard chemotherapy in patients with sarcoma and germ cell cancer (GCC). Sixteen patients (13 sarcomas, 3 GCC) received SD-ICE followed by 4 cycles of HD-ICE, qd22 with stem cell support in combination with bevacizumab. All 16 patients were evaluable for toxicity and efficacy, and received 51 cycles (median 3.3). There was no increase in toxicity except of a relatively high incidence of ifosfamide encephalopathy in 17 cycles when compared with previous HD-ICE protocols. One almost complete response in the patient with GCC, previously progressive with three preceding protocols, was observed. Six patients had a partial response (sarcoma 4/13 patients; GCC 2/3 patients), and five patients stable disease (sarcoma 5/13 patients). The median PFS/OS for sarcoma was 5 months (confidence interval (CI): 3.1-6.9) and 13 months (CI: 3.6-24.4), respectively. To our knowledge, this is the first report of the addition of bevacizumab to HD-ICE. This combination did not show new unexpected toxicities except for a relatively high rate of ifosfamide encephalopathy. The efficacy in these heavily pretreated patients including possible reversal of chemotherapy resistance by the addition of bevacizumab indicates a possible potential of bevacizumab in this combination.

Successful treatment of ifosfamide neurotoxicity with dexmedetomidine

Neurotoxicity related to the use of ifosfamide is a well-known complication. While the use of methylene blue is a known antidote, symptomatic treatment of the central nervous system (CNS) effects can be challenging. We present a case of class IV neurotoxicity with the successful treatment of symptomology. In this case report we present a 2-year-old female with relapsed alveolar rhabdomyosarcoma undergoing palliative chemotherapy. Patient received ifosfamide in addition to etoposide and mesna. The patient developed acute hallucinations, agitation, and delirium. The patient was transferred to the pediatric intensive care unit where she was administered dexmedetomidine overnight in addition to methylene blue. The patient awoke the next morning following discontinuation of the dexmedetomidine infustion and subsequently had no further central nervous system effects. This case demonstrates the novel use of an alpha-2 agonist in the treatment of neurotoxicity related to ifosfamide administration.

Central and peripheral nervous system toxicity of common chemotherapeutic agents

Central and peripheral nervous system toxicity are frequent complications of most chemotherapy regimens, often leading to reduction of dosages or cessation of the responsible drugs. However, sometimes the afflicted toxicity may not be reversible, especially if it is not recognized early, further compromising the quality of life of the cancer patients. The most common chemotherapeutic agents that might cause CNS toxicity manifested as encephalopathy of various severities include methotrexate, vincristine, ifosfamide, cyclosporine, fludarabine, cytarabine, 5-fluorouracil, cisplatin and the interferons (alpha > beta). Involvement of the peripheral nervous system manifested as distal peripheral neuropathy results after therapy with cisplatin, vincristine, taxanes, suramin and thalidomide. Although several compounds have been proposed as neuroprotective agents, few have been shown to be active against the chemotherapy induced neurotoxicity.