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Bansal R, Bhojwani D, Sun BF, Sawardekar S, Wayne AS, Ouassil H, Gupte C, Marcelino C, Gonzalez Anaya MJ, Luna N, Peterson BS. Progression of brain injuries associated with methotrexate chemotherapy in childhood acute lymphoblastic leukemia. Pediatr Res 2024:10.1038/s41390-024-03351-9. [PMID: 38951657 DOI: 10.1038/s41390-024-03351-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/18/2024] [Accepted: 06/07/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Brain bases and progression of methotrexate-associated neurotoxicity and cognitive disturbances remain unknown. We tested whether brain abnormalities worsen in proportion to intrathecal methotrexate(IT-MTX) doses. METHODS In this prospective, longitudinal study, we recruited 19 patients with newly diagnosed acute lymphoblastic leukemia 4-to-20 years of age and 20 matched controls. We collected MRI and neuropsychological assessments at a pre-methotrexate baseline and at week 9, week 22, and year 1 during treatment. RESULTS Patients had baseline abnormalities in cortical and subcortical gray matter(GM), white matter(WM) volumes and microstructure, regional cerebral blood flow, and neuronal density. Abnormalities of GM, blood flow, and metabolites worsened in direct proportions to IT-MTX doses. WM abnormalities persisted until week 22 but normalized by year 1. Brain injuries were localized to dorsal and ventral attentional and frontoparietal cognitive networks. Patients had cognitive deficits at baseline that persisted at 1-year follow-up. CONCLUSIONS Baseline abnormalities are likely a consequence of neuroinflammation and oxidative stress. Baseline abnormalities in WM microstructure and volumes, and blood flow persisted until week 22 but normalized by year 1, likely due to treatment and its effects on reducing inflammation. The cytotoxic effects of IT-MTX, however, likely contributed to continued, progressive cortical thinning and reductions in neuronal density, thereby contributing to enduring cognitive deficits. IMPACT Brain abnormalities at a pre-methotrexate baseline likely are due to acute illness. The cytotoxic effects of intrathecal MTX contribute to progressive cortical thinning, reductions in neuronal density, and enduring cognitive deficits. Baseline white matter abnormalities may have normalized via methotrexate treatment and decreasing neuroinflammation. Corticosteroid and leucovorin conferred neuroprotective effects. Our findings suggest that the administration of neuroprotective and anti-inflammatory agents should be considered even earlier than they are currently administered. The neuroprotective effects of leucovorin suggest that strategies may be developed that extend the duration of this intervention or adapt it for use in standard risk patients.
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Affiliation(s)
- Ravi Bansal
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - Deepa Bhojwani
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Bernice F Sun
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Siddhant Sawardekar
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Alan S Wayne
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hannah Ouassil
- College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA, USA
| | - Chaitanya Gupte
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Courtney Marcelino
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Maria J Gonzalez Anaya
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Natalia Luna
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Bradley S Peterson
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
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ChoK-Full of Potential: Choline Kinase in B Cell and T Cell Malignancies. Pharmaceutics 2021; 13:pharmaceutics13060911. [PMID: 34202989 PMCID: PMC8234087 DOI: 10.3390/pharmaceutics13060911] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/17/2021] [Indexed: 12/20/2022] Open
Abstract
Aberrant choline metabolism, characterized by an increase in total choline-containing compounds, phosphocholine and phosphatidylcholine (PC), is a metabolic hallmark of carcinogenesis and tumor progression. This aberration arises from alterations in metabolic enzymes that control PC biosynthesis and catabolism. Among these enzymes, choline kinase α (CHKα) exhibits the most frequent alterations and is commonly overexpressed in human cancers. CHKα catalyzes the phosphorylation of choline to generate phosphocholine, the first step in de novo PC biosynthesis. CHKα overexpression is associated with the malignant phenotype, metastatic capability and drug resistance in human cancers, and thus has been recognized as a robust biomarker and therapeutic target of cancer. Of clinical importance, increased choline metabolism and CHKα activity can be detected by non-invasive magnetic resonance spectroscopy (MRS) or positron emission tomography/computed tomography (PET/CT) imaging with radiolabeled choline analogs for diagnosis and treatment monitoring of cancer patients. Both choline-based MRS and PET/CT imaging have also been clinically applied for lymphoid malignancies, including non-Hodgkin lymphoma, multiple myeloma and central nervous system lymphoma. However, information on how choline kinase is dysregulated in lymphoid malignancies is very limited and has just begun to be unraveled. In this review, we provide an overview of the current understanding of choline kinase in B cell and T cell malignancies with the goal of promoting future investigation in this area.
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Werk RS, Steinhorn DM, Newberg A. The Relationship Between Spirituality and the Developing Brain: A Framework for Pediatric Oncology. JOURNAL OF RELIGION AND HEALTH 2021; 60:389-405. [PMID: 32270366 DOI: 10.1007/s10943-020-01014-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Development, whether motor, language, social, or spiritual, is the functional expression of complex brain processes throughout one's life span, the foundations of which are laid in childhood. The effects of cancer, chemotherapy, radiation, and surgical procedures on early brain development have been measured using neuroimaging and developmental assessment tools. We propose that spiritual development may be substantially affected in children with oncological diseases that impact underlying brain processes. By drawing connections between science, spirituality, and medicine, we can better address the spiritual needs of children as they cope with oncological diseases, by mitigating emotional, cognitive, and physical symptoms and improving outcomes.
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Affiliation(s)
- Rachel S Werk
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 8161 DOT37232-9760, USA.
| | - David M Steinhorn
- Divisions of Pediatric Critical Care and Pediatric Palliative Care, Children's National Medical Center, Washington, DC, USA
| | - Andrew Newberg
- Department of Integrative Medicine and Nutritional Sciences, Marcus Institute of Integrative Health, Thomas Jefferson University, Philadelphia, PA, USA
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Comparison of Unenhanced T1-Weighted Signal Intensities Within the Dentate Nucleus and the Globus Pallidus After Serial Applications of Gadopentetate Dimeglumine Versus Gadobutrol in a Pediatric Population. Invest Radiol 2018; 53:119-127. [PMID: 28976476 DOI: 10.1097/rli.0000000000000419] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate and compare changes in T1-weighted signal intensity (SI) within the dentate nucleus (DN) and globus pallidus (GP) in a pediatric population after serial applications of the linear gadolinium-based magnetic resonance contrast medium gadopentetate dimeglumine and the more stable macrocyclic agent gadobutrol. MATERIALS AND METHODS Institutional review board approval was obtained. Two similar pediatric patient cohorts who underwent at least 3 serial contrast-enhanced magnetic resonance imaging (MRI) examinations with sole application of gadopentetate dimeglumine or gadobutrol were analyzed. All MRI examinations were performed on a 1.5 T system acquiring unenhanced T1-weighted spin echo sequences, which were evaluated on the baseline MRI and after the contrast medium administrations. For analysis of SI changes in the DN, the ratios of the DN to the pons (P) and to the middle cerebellar peduncle (MCP) were assessed. The GP was compared with the thalamus (TH) by dividing the SIs between GP and TH (GP-to-TH ratio). RESULTS Twenty-eight patients (13 boys, 15 girls; mean age, 8.4 ± 6.8 years) who received at least 3 applications of gadopentetate dimeglumine and 25 patients (13 boys, 12 girls; mean age, 9.7 ± 5.4 years) with 3 or more gadobutrol injections were included. After 3 administrations of gadopentetate dimeglumine, the T1-weighted SI ratios significantly increased: mean difference value of 0.036 ± 0.031 (DN-to-P; P < 0.001), 0.034 ± 0.032 (DN-to-MCP; P < 0.001), and 0.025 ± 0.025 (GP-to-TH; P = 0.001). In a subanalysis of 12 patients with more than 3 injections of gadopentetate dimeglumine, the mean differences of the SI ratios were slightly higher: 0.043 ± 0.032 (DN-to-P; P = 0.001), 0.041 ± 0.035 (DN-to-MCP; P = 0.002), and 0.028 ± 0.025 (GP-to-TH; P = 0.003). In contrast, gadobutrol did not show a significant influence on the SI ratios, neither after 3 nor after more than 3 applications. CONCLUSIONS The T1-weighted SI increase within the DN and GP after serial administrations of the linear contrast medium gadopentetate dimeglumine, but not after serial applications of the macrocyclic agent gadobutrol, found in a pediatric population, is consistent with results published for adult patients. The clinical impact of the intracranial T1-hyperintensities is currently unclear. However, in accordance with the recent decision of the Pharmacovigilance and Risk Assessment Committee of the European Medicines Agency, intravenous macrocyclic agents should be preferred and MR contrast media should be used with caution and awareness of the pediatric brain development in children and adolescents.
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Marusak HA, Iadipaolo AS, Harper FW, Elrahal F, Taub JW, Goldberg E, Rabinak CA. Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes. Neuropsychol Rev 2018; 28:123-175. [PMID: 29270773 PMCID: PMC6639713 DOI: 10.1007/s11065-017-9365-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/08/2017] [Indexed: 01/29/2023]
Abstract
Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.
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Affiliation(s)
- Hilary A Marusak
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA.
| | - Allesandra S Iadipaolo
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA
| | - Felicity W Harper
- Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI, USA
- Department of Oncology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Farrah Elrahal
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA
| | - Jeffrey W Taub
- Department of Pediatrics, School of Medicine, Wayne State University, Detroit, MI, USA
- Children's Hospital of Michigan, Detroit, MI, USA
| | - Elimelech Goldberg
- Department of Pediatrics, School of Medicine, Wayne State University, Detroit, MI, USA
- Kids Kicking Cancer, Southfield, MI, USA
| | - Christine A Rabinak
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Suite 2190, Detroit, MI, 48202, USA
- Department of Pharmaceutical Sciences, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, USA
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Matsos A, Loomes M, Zhou I, Macmillan E, Sabel I, Rotziokos E, Beckwith W, Johnston I. Chemotherapy-induced cognitive impairments: White matter pathologies. Cancer Treat Rev 2017; 61:6-14. [DOI: 10.1016/j.ctrv.2017.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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Long-term brain structural magnetic resonance imaging and cognitive functioning in children treated for acute lymphoblastic leukemia with high-dose methotrexate chemotherapy alone or combined with CNS radiotherapy at reduced total dose to 12 Gy. Neuroradiology 2017; 59:147-156. [PMID: 28074235 PMCID: PMC5371615 DOI: 10.1007/s00234-016-1777-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/14/2016] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The aim of this study was to assess the long-term side effects of central nervous system prophylaxis (high-dose chemotherapy alone vs chemotherapy and CNS radiotherapy) according to the ALL IC-BFM 2002. METHODS Thirty-tree children aged 6.7-19.9 years have been studied. The control group consisted of 12 children newly diagnosed with acute lymphoblastic leukemia. We assessed subcortical gray matter volume using automatic MRI segmentation and cognitive performance to identify differences between two therapeutic schemes and patients prior to treatment. RESULTS Patients treated with chemotherapy and CNS radiotherapy had smaller hippocampi than two other subgroups and lower IQ score than patients treated with chemotherapy alone. Both treated groups, whether with chemotherapy only or in combination with CNS radiotherapy, had significantly lower volumes of caudate nucleus and performed significantly worse on measures of verbal fluency in comparison with patients prior to treatment. There were no differences in the mean volumes of total white matter, total gray matter, thalamus, putamen, and amygdala between the studied groups. CONCLUSION In all children treated according to the ALL IC-BFM 2002 with high-dose chemotherapy, both decreased volume of selected subcortical structures and cognitive impairment was observed, especially in children who received chemotherapy in combination with reduced dose CNS radiotherapy. In all children treated according to the ALL IC-BFM 2002 with high-dose chemotherapy, both decreased volume of selected subcortical structures and cognitive impairment were observed, especially in children who received chemotherapy in combination with CNS radiotherapy.
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Tsujimoto SI, Yanagimachi M, Tanoshima R, Urayama KY, Tanaka F, Aida N, Goto H, Ito S. Influence of ADORA2A gene polymorphism on leukoencephalopathy risk in MTX-treated pediatric patients affected by hematological malignancies. Pediatr Blood Cancer 2016; 63:1983-9. [PMID: 27399166 DOI: 10.1002/pbc.26090] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/17/2016] [Accepted: 05/08/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Methotrexate (MTX) can lead to neurotoxicity and asymptomatic leukoencephalopathy. However, the mechanism of MTX-related leukoencephalopathy is obscure. MTX and its metabolites inhibit 5-aminoimidazole-4-carboxamide ribonucleotide formiltransferase (ATIC) and promote adenosine release. Recently, it has been reported that adenosine and its receptor are related to certain central nervous system diseases. We investigated whether adenosine pathway gene polymorphisms and clinical factors were related to MTX-related leukoencephalopathy in pediatric patients affected by hematological malignancies. PROCEDURE Fifty-six Japanese childhood acute lymphoblastic leukemia or lymphoma patients were investigated. Patients were evaluated by magnetic resonance imaging of the brain before maintenance therapy or stem cell transplantation. Gene polymorphisms within the adenosine pathway (ATIC, adenosine A2A receptor [ADORA2A]) and the MTX pathway (methylenetetrahydrofolate reductase [MTHFR] and ABCB1) were genotyped using TaqMan assays. Clinical data were collected by accessing the medical records. MTX-related leukoencephalopathy was evaluated by a pediatric neurologist. RESULTS Twenty-one (37%) of 56 patients developed MTX-related leukoencephalopathy. Four of 21 patients developed clinical neurotoxicity. The minor allele CC genotype of rs2298383 (ADORA2A) was associated with MTX-related leukoencephalopathy (P = 0.010, odds ratio = 5.81, 95% confidence interval 1.50-22.50). High cumulative dose of systemic MTX was associated with MTX-related leukoencephalopathy after adjusting for sex, ADORA2A polymorphism, and prolonged high MTX concentration (P = 0.042, odds ratio = 1.18, 95% confidence interval 1.01-1.37). CONCLUSIONS ADORA2A rs2298383 and high cumulative dose of systemic MTX administration were significantly associated with MTX-related leukoencephalopathy. Our results indicate that pharmacological intervention within the adenosine pathway may be both a treatment and preventative option for MTX-related leukoencephalopathy.
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Affiliation(s)
- Shin-Ichi Tsujimoto
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama City, Japan
| | - Masakatsu Yanagimachi
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama City, Japan.
| | - Reo Tanoshima
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama City, Japan
| | - Kevin Y Urayama
- Center for Clinical Epidemiology, St. Luke's International University, Chuo-ku, Tokyo, Japan
| | - Fumiko Tanaka
- Department of Pediatrics, Saiseikai Yokohama-Shi Nanbu Hospital, Kounan-ku, Yokohama City, Japan
| | - Noriko Aida
- Department of Radiology, Kanagawa Children's Medical Center, Minami-ku, Yokohama City, Japan
| | - Hiroaki Goto
- Department of Hematology and Oncology, Kanagawa Children's Medical Center, Minami-ku, Yokohama City, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama City, Japan
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Abstract
BACKGROUND A wealth of data shows neuronal demise after general anesthesia in the very young rodent brain. Herein, the authors apply proton magnetic resonance spectroscopy (1HMRS), testing the hypothesis that neurotoxic exposure during peak synaptogenesis can be tracked via changes in neuronal metabolites. METHODS 1HMRS spectra were acquired in the brain (thalamus) of neonatal rat pups 24 and 48 h after sevoflurane exposure on postnatal day (PND) 7 and 15 and in unexposed, sham controls. A repeated measure ANOVA was performed to examine whether changes in metabolites were different between exposed and unexposed groups. Sevoflurane-induced neurotoxicity on PND7 was confirmed by immunohistochemistry. RESULTS In unexposed PND7 pups (N = 21), concentration of N-acetylaspartate (NAA; [NAA]) increased by 16% from PND8 to PND9, whereas in exposed PND7 pups (N = 19), [NAA] did not change and concentration of glycerophosphorylcholine and phosphorylcholine ([GPC + PCh]) decreased by 25%. In PND15 rats, [NAA] increased from PND16 to PND17 for both the exposed (N = 14) and the unexposed (N = 16) groups. Two-way ANOVA for PND7 pups demonstrated that changes over time observed in [NAA] (P = 0.031) and [GPC + PCh] (P = 0.024) were different between those two groups. CONCLUSIONS The authors demonstrated that normal [NAA] increase from PND8 to PND9 was impeded in sevoflurane-exposed rats when exposed at PND7; however, not impeded when exposed on PND15. Furthermore, the authors showed that noninvasive 1HMRS is sufficiently sensitive to detect subtle differences in developmental time trajectory of [NAA]. This is potentially clinically relevant because 1HMRS can be applied across species and may be useful in providing evidence of neurotoxicity in the human neonatal brain.
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Reddick WE, Taghipour DJ, Glass JO, Ashford J, Xiong X, Wu S, Bonner M, Khan RB, Conklin HM. Prognostic factors that increase the risk for reduced white matter volumes and deficits in attention and learning for survivors of childhood cancers. Pediatr Blood Cancer 2014; 61:1074-9. [PMID: 24464947 PMCID: PMC4053257 DOI: 10.1002/pbc.24947] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/26/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In children, CNS-directed cancer therapy is thought to result in decreased cerebral white matter volumes (WMV) and subsequent neurocognitive deficits. This study was designed as a prospective validation of the purported reduction in WMV, associated influential factors, and its relationship to neurocognitive deficits in a very large cohort of both acute lymphoblastic leukemia (ALL) and malignant brain tumors (BT) survivors in comparison to an age similar cohort of healthy sibling controls. PROCEDURES The effects of host characteristics and CNS treatment intensity on WMV were investigated in 383 childhood cancer survivors (199 ALL, 184 BT) at least 12 months post-completion of therapy and 67 healthy siblings that served as a control group. t-Tests and multiple variable linear models were used to assess cross-sectional WMV and its relation with neurocognitive function. RESULTS BT survivors had lower WMV than ALL survivors, who had less than the control group. Increased CNS treatment intensity, younger age at treatment, and greater time since treatment were significantly associated with lower WMV. Additionally, cancer survivors did not perform as well as the control group on neurocognitive measures of intelligence, attention, and academic achievement. Reduced WMV had a larger impact on estimated IQ among females and children treated at a younger age. CONCLUSIONS Survivors of childhood cancer that have undergone higher intensity therapy at a younger age have significantly less WMV than their peers and this difference increases with time since therapy. Decreased WMV is associated with significantly lower scores in intelligence, attention, and academic performance in survivors.
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Affiliation(s)
- Wilburn E Reddick
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
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Bhojwani D, Sabin ND, Pei D, Yang JJ, Khan RB, Panetta JC, Krull KR, Inaba H, Rubnitz JE, Metzger ML, Howard SC, Ribeiro RC, Cheng C, Reddick WE, Jeha S, Sandlund JT, Evans WE, Pui CH, Relling MV. Methotrexate-induced neurotoxicity and leukoencephalopathy in childhood acute lymphoblastic leukemia. J Clin Oncol 2014; 32:949-59. [PMID: 24550419 DOI: 10.1200/jco.2013.53.0808] [Citation(s) in RCA: 222] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Methotrexate (MTX) can cause significant clinical neurotoxicity and asymptomatic leukoencephalopathy. We sought to identify clinical, pharmacokinetic, and genetic risk factors for these MTX-related toxicities during childhood acute lymphoblastic leukemia (ALL) therapy and provide data on safety of intrathecal and high-dose MTX rechallenge in patients with neurotoxicity. PATIENTS AND METHODS Prospective brain magnetic resonance imaging was performed at four time points for 369 children with ALL treated in a contemporary study that included five courses of high-dose MTX and 13 to 25 doses of triple intrathecal therapy. Logistic regression modeling was used to evaluate clinical and pharmacokinetic factors, and a genome-wide association study (GWAS) was performed to identify germline polymorphisms for their association with neurotoxicities. RESULTS Fourteen patients (3.8%) developed MTX-related clinical neurotoxicity. Of 13 patients rechallenged with intrathecal and/or high-dose MTX, 12 did not experience recurrence of neurotoxicity. Leukoencephalopathy was found in 73 (20.6%) of 355 asymptomatic patients and in all symptomatic patients and persisted in 74% of asymptomatic and 58% of symptomatic patients at the end of therapy. A high 42-hour plasma MTX to leucovorin ratio (measure of MTX exposure) was associated with increased risk of leukoencephalopathy in multivariable analysis (P = .038). GWAS revealed polymorphisms in genes enriched for neurodevelopmental pathways with plausible mechanistic roles in neurotoxicity. CONCLUSION MTX-related clinical neurotoxicity is transient, and most patients can receive subsequent MTX without recurrence of acute or subacute symptoms. All symptomatic patients and one in five asymptomatic patients develop leukoencephalopathy that can persist until the end of therapy. Polymorphisms in genes related to neurogenesis may contribute to susceptibility to MTX-related neurotoxicity.
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Affiliation(s)
- Deepa Bhojwani
- All authors: St Jude Children's Research Hospital; and Deepa Bhojwani, Jun J. Yang, Hiroto Inaba, Jeffrey E. Rubnitz, Monika L. Metzger, Scott C. Howard, Raul C. Ribeiro, Sima Jeha, John T. Sandlund, and Ching-Hon Pui, University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
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Neurocognitive and neuroradiologic central nervous system late effects in children treated on Pediatric Oncology Group (POG) P9605 (standard risk) and P9201 (lesser risk) acute lymphoblastic leukemia protocols (ACCL0131): a methotrexate consequence? A report from the Children's Oncology Group. J Pediatr Hematol Oncol 2014; 36:8-15. [PMID: 24345882 PMCID: PMC4465396 DOI: 10.1097/mph.0000000000000000] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Concerns about long-term methotrexate (MTX) neurotoxicity in the 1990s led to modifications in intrathecal (IT) therapy, leucovorin rescue, and frequency of systemic MTX administration in children with acute lymphoblastic leukemia. In this study, neurocognitive outcomes and neuroradiologic evidence of leukoencephalopathy were compared in children treated with intense central nervous system (CNS)-directed therapy (P9605) versus those receiving fewer CNS-directed treatment days during intensive consolidation (P9201). A total of 66 children from 16 Pediatric Oncology Group institutions with "standard-risk" acute lymphoblastic leukemia, 1.00 to 9.99 years at diagnosis, without evidence of CNS leukemia at diagnosis were enrolled on ACCL0131: 28 from P9201 and 38 from P9605. Magnetic resonance imaging scans and standard neuropsychological tests were performed ≥2.6 years after the end of treatment. Significantly more P9605 patients developed leukoencephalopathy compared with P9201 patients (68%, 95% confidence interval 49%-83% vs. 22%, 95% confidence interval 5%-44%; P=0.001) identified as late as 7.7 years after the end of treatment. Overall, 40% of patients scored <85 on either Verbal or Performance IQ. Children on both studies had significant attention problems, but P9605 children scored below average on more neurocognitive measures than those treated on P9201 (82%, 14/17 measures vs. 24%, 4/17 measures). This supports ongoing concerns about intensive MTX exposure as a major contributor to CNS late effects.
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Decreased frontal N-acetylaspartate levels in adolescents concurrently using both methamphetamine and marijuana. Behav Brain Res 2013; 246:154-61. [PMID: 23466689 DOI: 10.1016/j.bbr.2013.02.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 02/20/2013] [Accepted: 02/25/2013] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The potential neurochemical toxicity associated with methamphetamine (MA) or marijuana (MJ) use on the developing adolescent brain is unclear, particularly with regard to individuals with concomitant use of MA and MJ (MA+MJ). In this study, proton magnetic resonance spectroscopy (MRS) was utilized to measure in vivo brain N-acetylaspartate plus N-acetylaspartyl glutamate (tNAA, an indicator of intact neuronal integrity) levels. METHODS Three adolescent groups from Cape Town, South Africa completed MRS scans as well as clinical measures including a drug use history. Subjects included (1) nine MA (age=15.7±1.37), (2) eight MA+MJ (age=16.2±1.16) using adolescents and (3) ten healthy controls (age=16.8±0.62). Single voxel spectra were acquired from midfrontal gray matter using a point-resolved spectroscopy sequence (PRESS). The MRS data were post-processed in the fully automated approach for quantitation of metabolite ratios to phosphocreatine plus creatine (PCr+Cr). RESULTS A significant reduction in frontal tNAA/PCr+Cr ratios was seen in the MA+MJ group compared to the healthy controls (p=0.01, by 7.2%) and to the MA group (p=0.04, by 6.9%). Significant relationships were also observed between decreased tNAA/PCr+Cr ratios and drug use history of MA or MJ (total cumulative lifetime dose, age of onset, and duration of MA and MJ exposure) only in the MA+MJ group (all p<0.05). CONCLUSIONS These findings suggest that in adolescents, concomitant heavy MA+MJ use may contribute to altered brain metabolites in frontal gray matter. The significant associations between the abnormal tNAA/PCr+Cr ratios and the drug use history suggest that MA+MJ abuse may induce neurotoxicity in a dose-responsive manner in adolescent brain.
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Supratentorial Neurometabolic Alterations in Pediatric Survivors of Posterior Fossa Tumors. Int J Radiat Oncol Biol Phys 2012; 82:1135-41. [DOI: 10.1016/j.ijrobp.2011.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 03/28/2011] [Accepted: 04/06/2011] [Indexed: 11/19/2022]
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Kesler SR, Tanaka H, Koovakkattu D. Cognitive reserve and brain volumes in pediatric acute lymphoblastic leukemia. Brain Imaging Behav 2010; 4:256-69. [PMID: 20814845 PMCID: PMC3049995 DOI: 10.1007/s11682-010-9104-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is associated with long-term, progressive cognitive deficits and white matter injury. We measured global and regional white and gray matter as well as cognitive function and examined relationships between these variables and cognitive reserve, as indicated by maternal education level, in 28 young survivors of ALL and 31 healthy controls. Results indicated significantly reduced white matter volumes and cognitive testing scores in the ALL group compared to controls. Maternal education was inversely related to both global and regional white matter and directly related to gray matter in ALL and was directly related to both gray and white matter in controls, consistent with the cognitive reserve hypothesis. Cognitive performance was associated with different brain regions in ALL compared to controls. Maternal education was significantly positively correlated with working and verbal memory in ALL as well as processing speed and verbal memory in controls, improving models of cognitive outcome over medical and/or demographic predictors. Our findings suggest that cognitive reserve may be an important factor in brain injury and cognitive outcome in ALL. Additionally, children with ALL may experience some neural reorganization related to cognitive outcome.
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Affiliation(s)
- Shelli R Kesler
- Department of Psychiatry and Behavioral Sciences, Neuropsychology and Neurorehabilitation Laboratory, Stanford University School of Medicine, Palo Alto, CA 94305, USA.
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16
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Miese FR, Schuster FR, Pierstorff K, Karenfort M, Laws HJ, Borkhardt A, Saleh A. Magnetization transfer imaging provides no evidence of demyelination in methotrexate-induced encephalopathy. AJNR Am J Neuroradiol 2010; 32:E110-2. [PMID: 20651019 DOI: 10.3174/ajnr.a2181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Subacute MTX-induced encephalopathy is characterized by an abrupt onset of focal neurologic deficits within days after intrathecal or systemic therapy. Demyelination is one proposed mechanism. We describe the neuroimaging features of 2 patients with clinical symptoms of subacute encephalopathy after intrathecal and systemic MTX therapy. DWI showed restricted diffusion, indicating cytotoxic edema. MTI yielded no evidence of demyelination in either patient because there was no loss of MTR in areas of restricted diffusion.
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Affiliation(s)
- F R Miese
- Institute of Radiology, Center for Child and Adolescent Health, Heinrich-Heine-University, Düsseldorf, Germany.
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Evaluation of the late effects of CNS prophylactic treatment in childhood acute lymphoblastic leukemia (ALL) using magnetic resonance spectroscopy. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010. [PMID: 19812948 DOI: 10.1007/978-3-211-98811-4_36] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
PURPOSE The aim of the study was to evaluate the late changes seen in Magnetic Resonance Spectroscopy (MRS) of the brain in Acute Lymphoblastic Leukemia (ALL) survivors to assess neurotoxicity following prophylactic treatment with cranial irradiation (CRT) and/or intrathecal (ITMTX) and systemic MTX. MATERIALS AND METHODS The study was performed on two groups of patients. The first group consisted of 30 children who received CRT and ITMTX, and the second group was comprised of 15 children treated only with ITMTX. All patients were ALL survivors treated between 1994 and 2002. Radiotherapy was performed using two opposite fields for a total dose of 18 Gy. The children were examined from 6 to 12 years after treatment. All children underwent a physical and neurological examination and MRI/MRS studies. (1)H-MR spectra were acquired from frontal and occipital regions of the brain. Mean values and standard deviations were calculated for following metabolite ratios: NAA/Cr, Cho/Cr, Cho/NAA, and mI/Cr. RESULTS Three of the 45 children (11%) presented with white matter changes upon MRI examination. All children with MRI abnormalities received CRT. In 13 (31%) children, changes in (1)H-MRS metabolite ratios were seen. We observed decreased NAA/Cr and Cho/Cr ratios. MR spectroscopy showed a significant reduction (P < .05) of the mean NAA/Cr ratio in children given CRT. CONCLUSION MRS is a sensitive detector of late metabolic changes after prophylactic treatment for ALL in childhood. It is able to detect metabolic effects of treatment in patients even when no morphologic changes are visible upon MRI.
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18
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Boguszewicz L, Blamek S, Sokół M. Pattern recognition methods in (1)H MRS monitoring in vivo of normal appearing cerebellar tissue after treatment of posterior fossa tumors. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 106:171-175. [PMID: 19812943 DOI: 10.1007/978-3-211-98811-4_31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The objective of this study was to investigate the metabolic responses of normal appearing cerebellar tissue after posterior fossa tumor treatment, and to identify characteristics of the particular treatment method. Moreover, this work examined the metabolic alterations of normal appearing tissue induced by a particular tumor state including resection, stagnation, progression, and recurrence. The studied group consisted of 29 patients treated for posterior fossa tumors. All of them were irradiated with a total dose of 54 Gy at 1.8 Gy/fraction (median values). In addition, 13 underwent chemotherapy, 25 underwent total tumor resection, 18 were tumor-free in control examinations, 5 had a stable disease, and tumor progression or recurrence was observed in 2 and 4 cases, respectively. The 69 spectra, acquired using a MRI/MRS 2T system, were analyzed using Partial Least Squares Discriminant Analysis (PLS-DA) with orthogonal signal correction (OSC) spectral filtering. A significantly elevated spectral region (0.97-1.55 ppm) was observed in patients after total resection in comparison to non-operated subjects. Patients treated with chemotherapy showed an elevated band between 1.15-1.75 and 2.7-3.0 ppm and had decreases in the remaining parts of the spectra. Increases in lactate and decreases in the remaining metabolites were characteristic for the tumor progression/recurrence group. Pattern recognition methods coupled with MRS revealed significant treatment-dependent alterations in normal appearing cerebellar tissue, as well as metabolic changes induced by tumor progression/recurrence.
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Affiliation(s)
- Lukasz Boguszewicz
- Department of Medical Physics, Maria Skcapital VE, Cyrillicodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland.
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Reddick WE, Glass JO, Johnson DP, Laningham FH, Pui CH. Voxel-based analysis of T2 hyperintensities in white matter during treatment of childhood leukemia. AJNR Am J Neuroradiol 2009; 30:1947-54. [PMID: 19643920 PMCID: PMC2783231 DOI: 10.3174/ajnr.a1733] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 05/14/2009] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE White matter (WM) hyperintensities on T2-weighted MR imaging are the most common imaging manifestation of neurotoxic effects of therapy for central nervous system (CNS) prophylaxis in childhood acute lymphoblastic leukemia (ALL). This study uses voxel-based analyses (VBA) of T2-weighted imaging of patients during treatment to identify which WM regions are preferentially damaged. MATERIALS AND METHODS Two sets of conventional T2-weighted axial images were acquired on a 1.5T MR imaging scanner from 197 consecutive patients (85 female, 112 male; aged 1.0-18.9 years) enrolled on an institutional ALL treatment protocol. Images were acquired after completion of induction therapy and after the final of the 4 courses of intravenous high-dose methotrexate in consolidation therapy (3.9 +/- 0.8 months apart). Voxel-wise statistical testing of the incremental change between normalized longitudinal T2 images was performed with radiologist reading (normal or abnormal) and treatment risk-group as covariates. RESULTS Two highly significant bilateral clusters of T2 signal intensity change were identified in both 1-group and 2-group analyses. The regions were symmetric in size, shape, and average signal intensity. Increased T2-weighted signal intensity from these regions both within and between examinations were nonlinear functions of age at examination, and the difference between the examinations was greater for older subjects who received more intense therapy. CONCLUSIONS These analyses identified specific WM tracts involving predominantly the anterior, superior, and posterior corona radiata and superior longitudinal fasciculus, which were at increased risk for the development of T2-weighted hyperintensities during therapy for childhood ALL. These vulnerable regions may be the cause of subsequent cognitive difficulties consistently observed in survivors.
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Affiliation(s)
- W E Reddick
- Division of Translational Imaging Research, St. Jude Children's Research Hospital, Memphis, TN, USA.
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20
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Hamamoto K, Oriuchi N, Kanazawa T, Higuchi T, Endo K. Mesial temporal sclerosis associated with methotrexate-induced leukoencephalopathy. Pediatr Neurol 2009; 40:306-9. [PMID: 19302946 DOI: 10.1016/j.pediatrneurol.2008.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 08/25/2008] [Accepted: 10/30/2008] [Indexed: 11/19/2022]
Abstract
Mesial temporal sclerosis is a common form of symptomatic, localization-related epilepsy in children and adolescents, but its occurrence with acute lymphoblastic leukemia is rare. We present clinical records and neuroimaging results of a 13-year-old patient with acute lymphoblastic leukemia who developed recurrent partial seizures after an episode of leukoencephalopathy thought to be caused by methotrexate. Neuroradiologic images revealed hippocampal abnormalities consistent with the findings of mesial temporal sclerosis. Mesial temporal sclerosis was not previously reported in acute lymphoblastic leukemia patients with methotrexate-induced leukoencephalopathy. However, our case suggests that the pathogenesis of mesial temporal sclerosis may be associated with methotrexate-induced neurotoxicity.
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Affiliation(s)
- Kouhei Hamamoto
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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21
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Buizer AI, de Sonneville LMJ, Veerman AJP. Effects of chemotherapy on neurocognitive function in children with acute lymphoblastic leukemia: a critical review of the literature. Pediatr Blood Cancer 2009; 52:447-54. [PMID: 19061221 DOI: 10.1002/pbc.21869] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Chemotherapy-only treatment has increasingly become the standard of treatment for childhood acute lymphoblastic leukemia (ALL). The objective of this review is to assess the present state of knowledge of the neurocognitive effects of central nervous system (CNS)-directed chemotherapy in children with ALL, and to formulate directions for future research. We performed a review of studies published since 1997, that included an ALL group treated with chemotherapy only and a control group. Twenty-one studies met our inclusion criteria. There is evidence of subtle long-term neurocognitive deficits survivors of childhood ALL after treatment with chemotherapy only. These involve mainly processes of attention and of executive functioning, while global intellectual function is relatively preserved. Young age at diagnosis and female sex emerged as risk factors.
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Affiliation(s)
- Annemieke I Buizer
- Department of Pediatric Hematology-Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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22
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Anderson FS, Kunin-Batson AS. Neurocognitive late effects of chemotherapy in children: the past 10 years of research on brain structure and function. Pediatr Blood Cancer 2009; 52:159-64. [PMID: 18680151 DOI: 10.1002/pbc.21700] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Advances in the treatment of childhood cancers have greatly improved survivorship. Success has not come without cost, however, as survivors are at risk for late effects of treatment, including neurocognitive late effects (e.g., difficulties with thinking and reasoning). In the advent of chemotherapy-only protocols, researchers are examining neurocognitive sequelae of these agents to understand the specific role of chemotherapy in neurocognitive changes and the mechanism through which these occur. In this review, we examine the state of the literature on neurocognitive late effects after chemotherapy and their proposed neural mechanisms.
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Affiliation(s)
- Fiona S Anderson
- Division of Pediatric Clinical Neuroscience, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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23
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Brugnoletti F, Morris EB, Laningham FH, Patay Z, Pauley JL, Pui CH, Jeha S, Inaba H. Recurrent intrathecal methotrexate induced neurotoxicity in an adolescent with acute lymphoblastic leukemia: Serial clinical and radiologic findings. Pediatr Blood Cancer 2009; 52:293-5. [PMID: 18831032 PMCID: PMC2605174 DOI: 10.1002/pbc.21764] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Systemic and intrathecal methotrexate (MTX) are integral components of acute lymphoblastic leukemia (ALL) therapy, but can be associated with neurotoxicity. We describe here the case of an adolescent male with T-cell ALL who developed recurrent episodes of subacute neurotoxicity characterized by slurred speech, emotional lability, and hemiparesis after intrathecal MTX administration. Serial magnetic resonance imaging with diffusion-weighted imaging showed recurrent areas of restricted diffusion within cerebral hemispheric white matter, which correlated chronologically with the administration of intrathecal therapy and severity of clinical symptoms. Resolution of diffusion abnormalities did not preclude further toxicity and a large lesion could cause persisting symptoms.
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Affiliation(s)
- Fulvia Brugnoletti
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - E. Brannon Morris
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Fred H. Laningham
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN,Department of Radiology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Zoltán Patay
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN,Department of Radiology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Jennifer L Pauley
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN,College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN
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Steffen-Smith EA, Wolters PL, Albert PS, Baker EH, Shimoda KC, Barnett AS, Warren KE. Detection and characterization of neurotoxicity in cancer patients using proton MR spectroscopy. Childs Nerv Syst 2008; 24:807-13. [PMID: 18293002 PMCID: PMC2398763 DOI: 10.1007/s00381-007-0576-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The study objective was to detect abnormalities and identify relationships between brain metabolic ratios determined by proton magnetic resonance spectroscopic imaging ((1)H-MRSI) and neuropsychological (NP) function in cancer patients at risk for neurotoxicity. METHODS Thirty-two patients received (1)H-MRSI using a multi-slice, multi-voxel technique on a 1.5T magnet. Cho/NAA, NAA/Cr, and Cho/Cr ratios were identified in seven pre-determined sites without tumor involvement. A battery of age-appropriate NP tests was administered within 7 days of imaging. Relationships were examined between test scores and metabolite ratios. CONCLUSIONS This study identifies relationships between brain metabolite ratios and cognitive functioning in cancer patients. (1)H-MRSI may be useful in early detection of neurotoxic effects, but prospective longitudinal studies in a homogeneous population are recommended to determine the prognostic value.
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Affiliation(s)
- Emilie A. Steffen-Smith
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health (NIH), Bethesda, MD
| | - Pamela L. Wolters
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health (NIH), Bethesda, MD
- Medical Illness Counseling Center, Chevy Chase, MD
| | - Paul S. Albert
- Biometric Research Branch, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Eva H. Baker
- Clinical Center, National Institutes of Health, Bethesda, MD
| | | | - Alan S. Barnett
- National Institute of Mental Health, CBDB, National Institutes of Health, Bethesda, MD
| | - Katherine E. Warren
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health (NIH), Bethesda, MD
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25
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Porto L, Preibisch C, Hattingen E, Bartels M, Lehrnbecher T, Dewitz R, Zanella F, Good C, Lanfermann H, DuMesnil R, Kieslich M. Voxel-based morphometry and diffusion-tensor MR imaging of the brain in long-term survivors of childhood leukemia. Eur Radiol 2008; 18:2691-700. [PMID: 18491104 DOI: 10.1007/s00330-008-1038-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 03/06/2008] [Accepted: 04/06/2008] [Indexed: 11/25/2022]
Abstract
The aims of this study were to detect morphological changes in neuroanatomical components in adult survivors of acute lymphoblastic leukemia (ALL). Voxel-based morphometry (VBM) can be used to detect subtle structural changes in brain morphology and via analysis of fractional anisotropy (FA), diffusion-tensor imaging (DTI) can non-invasively probe white matter (WM) integrity. We used VBM and DTI to examine 20 long-term survivors of ALL and 21 healthy matched controls. Ten ALL survivors received chemotherapy and irradiation; ten survivors received chemotherapy alone during childhood. Imaging was performed on a 3.0-T MRI. For VBM, group comparisons of segmented T1-weighted grey matter (GM) and WM images from controls and ALL survivors were performed separately for patients who received chemotherapy alone and who received chemotherapy and irradiation. For DTI, FA in WM was compared for the same groups. Survivors of childhood ALL who underwent cranial irradiation during childhood had smaller WM volumes and reduced GM concentration within the caudate nucleus and thalamus. The FA in WM was reduced in adult survivors of ALL but the effect was more severe after combined treatment with irradiation and chemotherapy. Our results indicate that DTI and VBM can reveal persistent long-term WM and caudate changes in children after ALL treatment, even without T2 changes in conventional imaging.
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Affiliation(s)
- L Porto
- Department of Neuroradiology, Klinikum Goethe Universität, Frankfurt, Germany.
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Carey ME, Haut MW, Reminger SL, Hutter JJ, Theilmann R, Kaemingk KL. Reduced frontal white matter volume in long-term childhood leukemia survivors: a voxel-based morphometry study. AJNR Am J Neuroradiol 2008; 29:792-7. [PMID: 18184841 DOI: 10.3174/ajnr.a0904] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE To our knowledge, no published studies have examined whole-brain regional differences to identify more discrete volumetric changes in the brains of childhood leukemia survivors. We used voxel-based morphometry (VBM) to examine regional gray and white matter differences in a group of long-term survivors of acute lymphoblastic leukemia (ALL) compared with a group of healthy controls. Differences in regional white matter volume were expected, given previous reports of white matter changes during treatment for ALL and reduced brain white matter volumes in long-term survivors. Follow-up analyses examined the relationship of regional brain volumes to cognitive function. MATERIALS AND METHODS We compared 9 long-term survivors of ALL with 14 healthy controls. Survivors of ALL were treated with systemic and intrathecal chemotherapy only. T1-weighted axial 3D spoiled gradient high-resolution images collected on a 1.5T MR imaging scanner were used for the VBM analysis. Neuropsychological evaluations were conducted within 2 months of the MR imaging to assess cognitive function. RESULTS VBM analysis revealed 2 specific regions of reduced white matter in the right frontal lobes of survivors of ALL compared with healthy controls. Survivors of ALL had lower performances on tests of attention, visual-constructional skills, mental flexibility, and math achievement compared with healthy individuals. Decreased performance on neuropsychological measures was associated with decreased regional white matter volumes. No differences were found between the groups with respect to gray matter regions. CONCLUSION These findings are consistent with previous literature describing the long-term cognitive, academic, and imaging findings of survivors of ALL and suggest that right frontal white matter is particularly vulnerable to disruption following intensive chemotherapy for ALL. Future studies should focus on further clarifying the white matter changes observed.
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Affiliation(s)
- M E Carey
- Departments of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV 26505, USA.
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Anderson FS, Kunin-Batson AS, Perkins JL, Scott Baker K. White versus gray matter function as seen on neuropsychological testing following bone marrow transplant for acute leukemia in childhood. Neuropsychiatr Dis Treat 2008; 4:283-8. [PMID: 18728772 PMCID: PMC2515926 DOI: 10.2147/ndt.s2361] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Current theory suggests that neurocognitive late effects of treatments for childhood cancer such as difficulties with attention, processing speed and visual-motor ability are the result of white matter damage. Neuroimaging studies have produced a variety of white matter findings. However, although white matter is thought to be differentially affected, previous studies have not demonstrated a discrepancy between white and gray matter function. The present study included 36 children treated for childhood leukemia with hematopoietic stem cell transplant (HCT). Their performance on neurocognitive measures traditionally thought to measure white matter was compared to performance on measures thought to measure gray matter function. Composite white and gray matter standard scores were created based on neuropsychological measures that individuals with known white or gray matter damage perform poorly. As predicted, composite white matter scores (mean = 98.1) were significantly lower (t = 2.26, p = 0.03) than composite gray matter scores (mean = 102.5). Additionally, as gray matter performance increased, the difference between gray and white matter scores increased (R = 0.353, p = 0.035). Overall, the results of this study support the current theory that white matter damage is responsible for the more subtle neurocognitive late effects resulting from treatment for childhood leukemia.
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Affiliation(s)
- Fiona S Anderson
- Divisions of Pediatric Clinical Neuroscience Minneapolis, MN, USA.
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Hockenberry M, Krull K, Moore K, Gregurich MA, Casey ME, Kaemingk K. Longitudinal evaluation of fine motor skills in children with leukemia. J Pediatr Hematol Oncol 2007; 29:535-9. [PMID: 17762494 DOI: 10.1097/mph.0b013e3180f61b92] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Improved survival for children with acute lymphocytic leukemia (ALL) has allowed investigators to focus on the adverse or side effects of treatment and to develop interventions that promote cure while decreasing the long-term effects of therapy. Although much attention has been given to the significant neurocognitive sequelae that can occur after ALL therapy, limited investigation is found addressing fine motor function in these children and motor function that may contribute to neurocognitive deficits in ALL survivors. METHODS Fine motor and sensory-perceptual performances were examined in 82 children with ALL within 6-months of diagnosis and annually for 2 years (year 1 and year 2, respectively) during therapy. RESULTS Purdue Pegboard assessments indicated significant slowing of fine motor speed and dexterity for the dominant hand, nondominant hand, and both hands simultaneously for children in this study. Mean Visual-Motor Integration (VMI) scores for children with low-risk and high-risk ALL decreased from the first evaluation to year 1 and again at year 2. Mean VMI scores for children with standard risk ALL increased from the first evaluation to year 1 and then decreased at year 2. Significant positive correlations were found between the Purdue and the VMI at both year 1 and year 2, suggesting that the Pegboard performance consistently predicts the later decline in visual-motor integration. Significant correlations were found between the Purdue Pegboard at baseline and the Performance IQ during year 1, though less consistently during year 2. A similar pattern was also observed between the baseline Pegboard performance and performance on the Coding and Symbol Search subtests during year 1 and year 2. CONCLUSIONS In this study, children with ALL experienced significant and persistent visual-motor problems throughout therapy. These problems continued during the first and second years of treatment. These basic processing skills are necessary to the development of higher-level cognitive abilities, including nonverbal intelligence and academic achievement, particularly in arithmetic and written language.
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Affiliation(s)
- Marilyn Hockenberry
- Department of Pediatric/Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA.
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29
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Reddick WE, Laningham FH, Glass JO, Pui CH. Quantitative morphologic evaluation of magnetic resonance imaging during and after treatment of childhood leukemia. Neuroradiology 2007; 49:889-904. [PMID: 17653705 PMCID: PMC2386666 DOI: 10.1007/s00234-007-0262-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Accepted: 05/21/2007] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Medical advances over the last several decades, including CNS prophylaxis, have greatly increased survival in children with leukemia. As survival rates have increased, clinicians and scientists have been afforded the opportunity to further develop treatments to improve the quality of life of survivors by minimizing the long-term adverse effects. When evaluating the effect of antileukemia therapy on the developing brain, magnetic resonance (MR) imaging has been the preferred modality because it quantifies morphologic changes objectively and noninvasively. METHOD AND RESULTS Computer-aided detection of changes on neuroimages enables us to objectively differentiate leukoencephalopathy from normal maturation of the developing brain. Quantitative tissue segmentation algorithms and relaxometry measures have been used to determine the prevalence, extent, and intensity of white matter changes that occur during therapy. More recently, diffusion tensor imaging has been used to quantify microstructural changes in the integrity of the white matter fiber tracts. MR perfusion imaging can be used to noninvasively monitor vascular changes during therapy. Changes in quantitative MR measures have been associated, to some degree, with changes in neurocognitive function during and after treatment. CONCLUSION In this review, we present recent advances in quantitative evaluation of MR imaging and discuss how these methods hold the promise to further elucidate the pathophysiologic effects of treatment for childhood leukemia.
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Affiliation(s)
- Wilburn E Reddick
- Division of Translational Imaging Research (MS #210), Department of Radiological Sciences, St. Jude Children's Research Hospital, 332 N. Lauderdale Street, Memphis, TN, 38105-2794, USA.
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Eichler AF, Batchelor TT, Henson JW. Diffusion and perfusion imaging in subacute neurotoxicity following high-dose intravenous methotrexate. Neuro Oncol 2007; 9:373-7. [PMID: 17522329 PMCID: PMC1907407 DOI: 10.1215/15228517-2007-015] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Methotrexate (MTX) is a widely used chemotherapeutic agent that can cause acute, subacute, and chronic neurological complications. Subacute MTX neurotoxicity is manifest by abrupt onset of focal cerebral dysfunction occurring days to weeks after MTX administration, usually in children. We describe the neuroimaging features of an adult patient with primary CNS lymphoma who presented with transient aphasia and right hemiparesis 12 days after receiving intravenous high-dose MTX (8 g/m2) chemotherapy. Imaging within 1 h of symptom onset showed bilateral symmetrical restricted diffusion involving white matter of the cerebral hemispheres. CT angiogram and dynamic susceptibility MRI showed no evidence of vasospasm or perfusion defect. MRI five days later showed near-complete resolution of the abnormalities. MRI 3(1/2) months later showed normal diffusion but new hyperintense T2-weighted signal changes in the subcortical white matter corresponding to previous areas of restricted diffusion. The absence of vascular or perfusion abnormalities suggests that transient cytotoxic edema in white matter may explain the syndrome of subacute MTX neurotoxicity.
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Affiliation(s)
| | | | - John W. Henson
- Address correspondence to John W. Henson, Pappas Center for Neuro-Oncology, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA (
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Abstract
Neurologic dysfunction is a well-recognized adverse effect of cancer therapeutics. The most common manifestations include peripheral neuropathy and encephalopathy. Often, symptoms resolve or improve upon removal of the offending agent; therefore, it is essential that clinicians recognize the symptoms and signs of injury. Occasionally, symptoms persist or develop after discontinuation of medication and may culminate in disability and diminished quality of life. As our understanding of neurotoxicity improves, medications with less potential for injury may be developed. In addition, potential antidotes to prevent or reverse injury may emerge. This review focuses on the clinical features, mechanisms, and possible therapeutics of the neurotoxicity of chemotherapy. In particular, oxaliplatin, thalidomide, methotrexate, ifosfamide, cytarabine, amifostine, acetyl-L-carnitine, methylene blue, cytokines, and neurotrophins are discussed.
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Affiliation(s)
- Robert Cavaliere
- Ohio State University, Department of Neurology, Room 463 Means Hall, 1654 Upham Drive, Columbus, OH 43210, USA.
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Jansen JFA, Backes WH, Nicolay K, Kooi ME. 1H MR spectroscopy of the brain: absolute quantification of metabolites. Radiology 2006; 240:318-32. [PMID: 16864664 DOI: 10.1148/radiol.2402050314] [Citation(s) in RCA: 291] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hydrogen 1 (1H) magnetic resonance (MR) spectroscopy enables noninvasive in vivo quantification of metabolite concentrations in the brain. Currently, metabolite concentrations are most often presented as ratios (eg, relative to creatine) rather than as absolute concentrations. Despite the success of this approach, it has recently been suggested that relative quantification may introduce substantial errors and can lead to misinterpretation of spectral data and to erroneous metabolite values. The present review discusses relevant methods to obtain absolute metabolite concentrations with a clinical MR system by using single-voxel spectroscopy or chemical shift imaging. Important methodological aspects in an absolute quantification strategy are addressed, including radiofrequency coil properties, calibration procedures, spectral fitting methods, cerebrospinal fluid content correction, macromolecule suppression, and spectral editing. Techniques to obtain absolute concentrations are now available and can be successfully applied in clinical practice. Although the present review is focused on 1H MR spectroscopy of the brain, a large part of the methodology described can be applied to other tissues as well.
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Affiliation(s)
- Jacobus F A Jansen
- Department of Radiology, Maastricht University Hospital, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands.
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Glass JO, Reddick WE, Li CS, Laningham FH, Helton KJ, Pui CH. Computer-aided detection of therapy-induced leukoencephalopathy in pediatric acute lymphoblastic leukemia patients treated with intravenous high-dose methotrexate. Magn Reson Imaging 2006; 24:785-91. [PMID: 16824973 PMCID: PMC2396783 DOI: 10.1016/j.mri.2006.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2005] [Accepted: 02/23/2006] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to use objective quantitative magnetic resonance imaging (MRI) methods to develop a computer-aided detection (CAD) tool to differentiate white matter (WM) hyperintensities into either leukoencephalopathy (LE) induced by chemotherapy or normal maturational processes in children treated for acute lymphoblastic leukemia without irradiation. A combined MRI set consisting of T1-weighted, T2-weighted, proton-density-weighted and fluid-attenuated inversion recovery images and WM, gray matter and cerebrospinal fluid proportional volume maps from a spatially normalized atlas were analyzed with a neural network segmentation based on a Kohonen self-organizing map (SOM). Segmented maps were manually classified to identify the most hyperintense WM region and the normal-appearing genu region. Signal intensity differences normalized to the genu within each examination were generated for four time points in 228 children. A second Kohonen SOM was trained on the first examination data and divided the WM into normal-appearing or LE groups. Reviewing labels from the CAD tool revealed a consistency measure of 89.8% (167 of 186) within patients. The overall agreement between the CAD tool and the consensus reading of two trained observers was 84.1% (535 of 636), with 84.2% (170 of 202) agreement in the training set and 84.1% (365 of 434) agreement in the testing set. These results suggest that subtle therapy-induced LE can be objectively and reproducibly detected in children treated for cancer using this CAD approach based on relative differences in quantitative signal intensity measures normalized within each examination.
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Affiliation(s)
- John O Glass
- Division of Translational Imaging Research, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Khong PL, Leung LHT, Fung ASM, Fong DYT, Qiu D, Kwong DLW, Ooi GC, McAlonan G, McAlanon G, Cao G, Chan GCF. White Matter Anisotropy in Post-Treatment Childhood Cancer Survivors: Preliminary Evidence of Association With Neurocognitive Function. J Clin Oncol 2006; 24:884-90. [PMID: 16484697 DOI: 10.1200/jco.2005.02.4505] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose We aim to determine if the loss of white matter fractional anisotropy (FA), measured by diffusion tensor magnetic resonance imaging (DTI), in post-treatment childhood medulloblastoma (MED) and acute lymphoblastic leukemia (ALL) survivors correlate with intelligence quotient (IQ) scores. Materials and Methods MED and ALL survivors (n = 30; 20 male, 10 female; age range, 6.0 to 22.1 years; mean, 13.1 years) were recruited for DTI and IQ tests. In this cross-sectional study, age-matched normal control (n = 55; 32 male, 23 female; age range, 6.0 to 23 years; mean, 12.1 years) DTI was obtained to compute percentage difference in white matter FA (ΔFA%) for each patient compared with the age-matched control group. Multivariate regression analysis was performed to determine the relationships between ΔFA%, age at treatment, irradiation dose, time interval from treatment, and full-scale IQ (FSIQ), verbal IQ (VIQ), and performance IQ (PIQ). Receiver operating characteristics curves were used to determine the best ΔFA% cutoffs for predicting FSIQ, VIQ, and PIQ of less than 85. Results ΔFA% had a significant effect on FSIQ (adjusted r2 = 0.439; P < .001), VIQ (adjusted r2 = 0.237; P = .028), and PIQ (adjusted r2 = 0.491; P < .001) after adjusting for the effects of age at treatment, irradiation dose, and time interval from treatment. The best ΔFA% value to predict less than 85 scores in FSIQ, VIQ, and PIQ was −3.3% with specificities of 100% and sensitivities ranging from 77.8% to 87.5%. Conclusion Our preliminary findings suggest that white matter FA may be a clinically useful biomarker for the assessment of treatment-related neurotoxicity in post-treatment childhood cancer survivors.
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Affiliation(s)
- Pek-Lan Khong
- Department of Diagnostic Radiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.
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Reddick WE, Shan ZY, Glass JO, Helton S, Xiong X, Wu S, Bonner MJ, Howard SC, Christensen R, Khan RB, Pui CH, Mulhern RK. Smaller white-matter volumes are associated with larger deficits in attention and learning among long-term survivors of acute lymphoblastic leukemia. Cancer 2006; 106:941-9. [PMID: 16411228 PMCID: PMC2396784 DOI: 10.1002/cncr.21679] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The primary objective of this study was to test the hypothesis that survivors of childhood acute lymphoblastic leukemia (ALL) have deficits in neurocognitive performance, and smaller white-matter volumes are associated with these deficits. METHODS The patients studied included 112 ALL survivors (84 patients who had received chemotherapy only, 28 patients who had received chemotherapy and irradiation; 63 males, 49 females; mean age +/- standard deviation, 4.1 yrs +/- 2.6 yrs at diagnosis; mean +/- standard deviation yrs since diagnosis, 6.0 +/- 3.5 yrs), and 33 healthy siblings who participated as a control group. Neurocognitive tests of attention, intelligence, and academic achievement were performed; and magnetic resonance images were obtained and subsequently were segmented to yield tissue volume measurements. Comparisons of neurocognitive measures and tissue volumes between groups were performed, and the correlations between volumes and neurocognitive performance measures were assessed. RESULTS Most performance measures demonstrated statistically significant differences from the normative test scores, but only attention measures exceeded 1.0 standard deviation from normal. Patients who had received chemotherapy alone had significantly larger volumes of white matter than patients who had received treatment that also included cranial irradiation, but their volumes remained significantly smaller than the volumes in the control group. Smaller white-matter volumes were associated significantly with larger deficits in attention, intelligence, and academic achievement. CONCLUSIONS Survivors of childhood ALL had significant deficits in attention and smaller white-matter volumes that were associated directly with impaired neurocognitive performance. Cranial irradiation exacerbated these deficits.
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Affiliation(s)
- Wilburn E Reddick
- Division of Translational Imaging Research, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Affiliation(s)
- Louis-Gilbert Vézina
- Children's National Medical Center, Radialogy and Pediatrics, 111 Nichigan Avenue NW, Washington, DC, 20010-2970, USA.
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Yamamoto A, Miki Y, Adachi S, Kanagaki M, Fushimi Y, Okada T, Kobayashi M, Hiramatsu H, Umeda K, Nakahata T, van Buchem MA, Togashi K. Whole brain magnetization transfer histogram analysis of pediatric acute lymphoblastic leukemia patients receiving intrathecal methotrexate therapy. Eur J Radiol 2005; 57:423-7. [PMID: 16314063 DOI: 10.1016/j.ejrad.2005.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 08/04/2005] [Accepted: 09/30/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this prospective study was to evaluate the hypothesis that magnetization transfer ratio (MTR) histogram analysis of the whole brain could detect early and subtle brain changes nonapparent on conventional magnetic resonance imaging (MRI) in children with acute lymphoblastic leukemia (ALL) receiving methotrexate (MTX) therapy. MATERIALS AND METHODS Subjects in this prospective study comprised 10 children with ALL (mean age, 6 years; range, 0-16 years). In addition to conventional MRI, magnetization transfer images were obtained before and after intrathecal and intravenous MTX therapy. MTR values were calculated and plotted as a histogram, and peak height and location were calculated. Differences in peak height and location between pre- and post-MTX therapy scans were statistically analyzed. Conventional MRI was evaluated for abnormal signal area in white matter. RESULTS MTR peak height was significantly lower on post-MTX therapy scans than on pre-MTX therapy scans (p = 0.002). No significant differences in peak location were identified between pre- and post-chemotherapy imaging. No abnormal signals were noted in white matter on either pre- or post-MTX therapy conventional MRI. CONCLUSIONS This study demonstrates that MTR histogram analysis allows better detection of early and subtle brain changes in ALL patients who receive MTX therapy than conventional MRI.
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Affiliation(s)
- Akira Yamamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto-shi Kyoto 606-8507, Japan.
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Buizer AI, De Sonneville LMJ, van den Heuvel-Eibrink MM, Njiokiktjien C, Veerman AJP. Visuomotor control in survivors of childhood acute lymphoblastic leukemia treated with chemotherapy only. J Int Neuropsychol Soc 2005; 11:554-65. [PMID: 16212682 DOI: 10.1017/s1355617705050666] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Revised: 04/12/2005] [Accepted: 04/14/2005] [Indexed: 11/06/2022]
Abstract
Treatment for childhood acute lymphoblastic leukemia (ALL), which includes CNS prophylaxis, is associated with central and peripheral neurotoxicity. The purpose of the present study was to analyze the effects of chemotherapy on various levels of visuomotor control in survivors of childhood ALL treated without cranial irradiation, and to identify risk factors for possible deficits. Visuomotor function was compared between children after treatment for ALL (n = 34), children after treatment for Wilms tumor, which consists of non-CNS directed chemotherapy (n = 38), and healthy controls (n = 151). Three tasks were administered: a simple visual reaction time task and two tasks measuring visuomotor control with one requiring a higher level of cognitive control than the other. Visuomotor deficits were detected only in the ALL group, with poorer performance restricted to the condition requiring the highest level of control. Significant risk factors for poorer performance were female gender and a short time since end of treatment, and a trend was found for a young age at diagnosis. A high cumulative methotrexate dose was an adverse predictive factor in girls. The results indicate that chemotherapy-induced central neurotoxicity in childhood ALL treatment is associated with higher order visuomotor control deficits. Girls appear to be particularly vulnerable.
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Affiliation(s)
- Annemieke I Buizer
- Department of Pediatrics, VU University Medical Center, Amsterdam, The Netherlands.
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