Adiposity in Survivors of Cancer in Childhood: How is it Measured and Why Does it Matter?

Sarcopenia in long-term survivors of cancer in childhood and adolescence: A cross-sectional study of calf muscle mass by peripheral quantitative computed tomography with an examination of the muscle-bone unit

BACKGROUND

Sarcopenia, a loss of systemic skeletal muscle mass (SMM), is prevalent in childhood cancer survivors and often accompanied by increased fat mass (sarcopenic obesity [SO]). We examined whether calf muscle cross-sectional area (CSA), measured by peripheral quantitative computed tomography (pQCT), can identify sarcopenia and SO in long-term survivors of pediatric acute lymphoblastic leukemia (ALL), and explored its relationship with adjacent bone geometry.

PROCEDURES

Calf muscle CSA and CSA Z scores at the 38% tibia in 70 subjects (median survival 15 years) were compared between sexes and ALL risk group, and their association with sarcopenia and SO evaluated. Relationships between bone strength and muscle mass were assessed further using linear regression and methods described by Schoenau et al. for evaluation of a functional muscle-bone unit.

RESULTS

A calf muscle CSA Z score of less than or equal to zero is 73.81% sensitive and 84.62% specific for detecting sarcopenia defined by height-adjusted appendicular lean mass measured by dual-energy x-ray absorptiometry. No significant difference in CSA Z scores was noted between sexes or ALL risk groups; however, Z scores were markedly higher in those without SO (adjusted odds ratio 0.529, 95% confidence interval [CI]: 0.340-0.824). Ratios of calf muscle mass to height and total bone mineral content at the 38% tibia are "sufficient" and consistent with estimated reference ranges for a healthy population.

CONCLUSIONS

CSA Z scores may represent a useful clinical measure of SMM and are predictive of SO in this population. Our results are supportive of a functional muscle-bone unit in long-term survivors of pediatric ALL.

Fat-to-lean mass ratio as a tool to detect the dysmetabolic profile in childhood cancer survivors

INTRODUCTION

Survival after childhood cancer has significantly improved in recent decades. Nevertheless, an increased incidence of metabolic syndrome and cardiovascular disease among childhood cancer survivors (CCS) has been reported. The aim of this study was to evaluate whether fat-to-lean mass ratio (FLR) is associated with a dysmetabolic profile in CCS.

METHODS

At least 2 years from completion of therapy, data from CCS aged 10 to 16 years at follow-up and without any concurrent steroid treatment were collected. Body mass index, waist circumference (WC), WC-to-height ratio, laboratory blood tests, and FLR calculated by dual-energy X-ray absorptiometry measurements were considered. Body mass index >85th percentile and >97th percentile, WC >90th percentile, and WC-to-height ratio > 0.5 were chosen as criteria of overweight and obesity, visceral obesity, and increased cardiovascular risk, respectively.

RESULTS

We enrolled 205 CCS previously treated for hematologic cancer or solid or central nervous system tumor. The best cutoff of FLR was 0.6. CCS; those with FLR ≥0.6 (43%) were more frequently overweight and obese (P < 0.001), and presented with higher levels of triglycerides (P = 0.011), homeostatic model assessment for insulin resistance (P = 0.001), alanine transaminase (P = 0.004), and trunk fat (P < 0.001) and lower levels of insulin-like growth factor 1 (P < 0.001) and lean mass (P = 0.009). WC >90th percentile (P = 0.007), insulin-like growth factor 1 (P = 0.002), and trunk fat (P = 0.006) were independent predictors of FLR ≥0.6 in a model including all the previous variables.

CONCLUSIONS

An increased FLR is suggestive of altered body composition phenotype, allowing identification of CCS at higher risk of metabolic syndrome. Diet and physical activity are needed from commencement of oncological treatments to preserve overall nutritional status and maintain it over the long term.

Detecting Sarcopenic Obesity in Survivors of Pediatric Acute Lymphoblastic Leukemia: An Exploration of Body Mass Index and Triponderal Mass Index as Potential Surrogate Markers

Survivors of pediatric acute lymphoblastic leukemia (ALL) often have altered body composition secondary to treatment effects, including sarcopenic obesity (SO), which increases the risk of both metabolic complications and frailty. SO is difficult to detect without using advanced imaging techniques to which access is often limited. To explore whether common clinical indices can reliably identify the presence of SO in a cohort of long-term survivors of ALL, the discriminatory capacity of body mass index (BMI) or triponderal mass index (TMI, kg/m 3 ) for detecting SO was assessed. Thresholds of BMI and TMI associated with overweight or obesity status had poor sensitivity (<50%) and specificity for detecting SO. Total misclassification rates at these thresholds exceeded 50% and positive likelihood ratios were nonsignificant. Notably, TMI is more strongly correlated with elevated adiposity than is BMI in this survivor population ( R2 =0.73 vs. 0.57), suggesting further exploration is warranted. Our study is limited by the sample size, precluding detailed regression analysis. This study highlights the challenges of identifying SO in survivors of pediatric ALL using common clinical indices. Prospective evaluation of additional potential surrogate markers in survivors, in conjunction with the component features of SO, should be a key focus of future research.

Prevalence and Risk Factors of Metabolic Syndrome Components in Childhood Cancer Survivors

Purpose: It is crucial for childhood cancer survivors (CCSs) to manage metabolic syndrome. The prevalence and predictive factors of metabolic syndrome components in CCSs were investigated. Methods: This study included CCSs who were diagnosed with cancer under the age of 20 and completed therapy more than 1 year ago. The anthropometric and laboratory data were obtained from the medical records retrospectively. The reference group was extracted from the Korea National Health and Nutrition Examination Survey (2016-2019). Results: Of the participants, 29.1% (75 of 258) of the CCSs and 26.4% (1339 of 5081) of the reference group were obese. Blood pressure and triglyceride levels were significantly different in the two groups. Metabolic syndrome was identified in 35 of 258 (13.6%) patients. The reference group showed a 9.4% of prevalence (480 of 5086) (p = 0.028). A total of 127 of 230 (59.6%) met at least one of the dyslipidemia criteria. In multivariate analysis, current age and growth hormone deficiency (GHD) (OR = 5.905) were significant prognostic factors for dyslipidemia, and GHD was a significant prognostic factor for hypertriglyceridemia (OR = 2.864, p = 0.0316) and hypercholesterolemia (OR = 3.053, p = 0.0467). Cranial radiotherapy (RT) was a prognostic variable for hyper low-density lipoprotein cholesterolemia (OR = 2.866, p = 0.0032). Conclusions: The frequency of metabolic syndrome was higher in CCSs compared with the reference group. Dyslipidemia was common in CCSs with clinical parameters such as GHD and cranial RT. Risk-based long-term follow-up is needed, and early intervention is required for CCSs.

Growth and Nutritional Outcomes in Children Post-Haematopoietic Stem Cell Transplant without Exposure to Total Body Irradiation

AIMS

Poor growth in childhood cancer survivors who undergo haematopoietic stem cell transplant (HSCT) without exposure to radiation is reported anecdotally, although literature to support this is limited. The aims of this study were to assess the change in height standard deviation score (SDS) and the final adult height (FAH) in children who underwent chemotherapy-only conditioned HSCT and to identify predictors of poor growth.

MATERIALS AND METHODS

We conducted a retrospective hospital medical record review (1984-2010) of children (1-10 years) who underwent chemotherapy-only conditioned HSCT, noting anthropology measurements at cancer diagnosis, HSCT, 10 years old and FAH.

RESULTS

The median age at HSCT of the 53 patients was 4.5 years, 75% had a haematological malignancy and 25% a solid tumour. Half of the cohort underwent allogenic HSCT and most (89%) conditioned with busulphan. The mean change in height SDS from primary cancer diagnosis to FAH was -1.21 (±1.18 SD), equivalent to 7-8.5 cm loss, with a mean FAH of -0.91 SDS (±1.10 SD). The greatest height loss occurred between diagnosis and HSCT (-0.77 SDS, 95% confidence interval -1.42, -0.12, P = 0.01), with no catch-up growth seen by FAH. Patients with solid tumours had the greatest height loss. Overall body mass index SDS did not change significantly over time, or by cancer type.

CONCLUSIONS

Chemotherapy-only conditioned HSCT during childhood can impact FAH, with the greatest height loss occurring prior to HSCT and no catch-up growth after treatment finishes. Children transplanted for a solid tumour malignancy seem to be more at risk, possibly due to intensive treatment regimens, both pre-transplant and during conditioning.

Dimethylarginines in Children after Anti-Neoplastic Treatment

Background and Objectives: According to a recent Cochrane systematic review, renal impairment can develop in 0–84% of childhood cancer survivors in the future. The renal function impairment in this patient group can be related to nephrectomy, nephrotoxic agents therapy, abdominal radiotherapy, and combinations of these treatment methods. In this study, in a population of patients after anti-neoplastic therapy, with particular emphasis on patients after Wilms’ tumour treatment, we compared new substances which play role in the chronic kidney disease (CKD) pathogenesis (asymmetric dimethylarginine—ADMA, symmetric dimethylarginine—SDMA) with standard renal function markers (e.g., creatinine and cystatin C in serum, creatinine in urine, etc.) to assess the usefulness of the former. Materials and Methods: Eighty-four children, without CKD, bilateral kidney tumours, congenital kidney defects, or urinary tract infections, with a minimum time of 1 year after ending anti-neoplastic treatment, aged between 17 and 215 months, were divided into three groups: group 1—patients after nephroblastoma treatment (n = 21), group 2—after other solid tumours treatment (n = 44), and group 3—after lymphoproliferative neoplasms treatment (n = 19). The patients’ medical histories were taken and physical examinations were performed. Concentrations of blood urea nitrogen (BUN), creatinine, cystatin C, C-reactive protein (CRP), ADMA, and SDMA in blood and albumin in urine were measured, and a general urine analysis was performed. The SDMA/ADMA ratio, albumin–creatine ratio, and estimated glomerular filtration rate (eGFR) were calculated. eGFR was estimated by three equations recommended to the paediatric population by the KDIGO from 2012: the Schwartz equation (eGFR1), equation with creatinine and urea nitrogen (eGFR2), and equation with cystatin C (eGFR3). Results: Both the eGFR1 and eGFR2 values were significantly lower in group 1 than in group 3 (eGFR1: 93.3 (83.1–102.3) vs. 116.5 (96.8–126.9) mL/min/1.73 m², p = 0.02; eGFR2: 82.7 (±14.4) vs. 94.4 (±11.9) mL/min/1.73 m², p = 0.02). Additionally, there were weak positive correlations between SDMA and creatinine (p < 0.05, r = 0.24), and cystatin C (p < 0.05, r = 0.32) and weak negative correlations between SDMA and eGFR1 (p < 0.05, r = −0.25), eGFR2 (p < 0.05, r = −0.24), and eGFR3 (p < 0.05, r = −0.32). Conclusions: The usefulness of ADMA and SDMA in the diagnosis of renal functional impairment should be assessed in further studies. eGFR, calculated according to equations recommended for children, should be used in routine paediatric practice.