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Nadeau G, Samoilenko M, Fiscaletti M, Veilleux LN, Curnier D, Laverdière C, Sinnett D, Krajinovic M, Lefebvre G, Alos N. Predictors of low and very low bone mineral density in long-term childhood acute lymphoblastic leukemia survivors: Toward personalized risk prediction. Pediatr Blood Cancer 2024; 71:e31047. [PMID: 38736190 DOI: 10.1002/pbc.31047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/15/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Cohorts of childhood acute lymphoblastic leukemia (cALL) survivors reaching adulthood are increasing. Approximately 30% of survivors meet criteria for low bone mineral density (BMD) 10 years after diagnosis. We investigated risk factors for low BMD in long-term cALL survivors. METHODS We recruited 245 cALL survivors from the PETALE (Prévenir les effets tardifs des traitements de la leucémie aiguë lymphoblastique chez l'enfant) cohort, who were treated with the Dana Farber Cancer Institute protocols, did not experience disease relapse or hematopoietic stem cell transplants, and presented with more than 5 years of event-free survival. Median time since diagnosis was 15.1 years. RESULTS Prevalence of low DXA-derived BMD (Z-score ≤-1) ranged between 21.9% and 25.3%, depending on site (lumbar spine (LS-BMD), femoral neck (FN-BMD), and total body (TB-BMD), and between 3.7% and 5.8% for very low BMD (Z-score ≤-2). Males had a higher prevalence of low BMD than females for all three outcomes (26%-32% vs. 18%-21%), and male sex acted as a significant risk factor for low BMD in all models. Treatment-related factors such as cumulative glucocorticoid (GC) doses and cranial radiation therapy (CRT) were associated with lower BMDs in the full cohort and in females at the FN-BMD site. CONCLUSION Low and very low BMD is more prevalent in male cALL survivors. Male sex, high cumulative GC doses, CRT, risk group, and low body mass index (BMI) were identified as risk factors for low BMD. A longer follow-up of BMD through time in these survivors is needed to establish if low BMD will translate into a higher risk for fragility fractures through adulthood.
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Affiliation(s)
- Geneviève Nadeau
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Division of Endocrinology, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
| | - Mariia Samoilenko
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Melissa Fiscaletti
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Daniel Curnier
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- School of Kinesiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Caroline Laverdière
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Division of Hemato-Oncology, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
| | - Daniel Sinnett
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Maja Krajinovic
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Department of Pharmacology, University of Montreal, Montreal, Quebec, Canada
| | | | - Nathalie Alos
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Division of Endocrinology, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
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Pourhassan H, Murphy L, Aldoss I. Glucocorticoid Therapy in Acute Lymphoblastic Leukemia: Navigating Short-Term and Long-Term Effects and Optimal Regimen Selection. Curr Hematol Malig Rep 2024:10.1007/s11899-024-00735-w. [PMID: 38867099 DOI: 10.1007/s11899-024-00735-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE OF REVIEW Glucocorticoids are a mainstay in acute lymphoblastic leukemia treatment and lack of early response is predictive for overall disease prognosis. Given the vital position of glucocorticoids and well known long and short-term side effects associated with differing glucocorticoids, we aim to highlight the wide breadth of historical and more contemporary data to describe the current landscape of glucocorticoid use in this arena. RECENT FINDINGS Emerging studies aim to overcome issues such as steroid resistance and to optimize the antileukemic effects of glucocorticoids while aiming to mitigate the risks and side effects associated with their exposure. Glucocorticoids have and likely always will be a fundamental component of acute lymphoblastic leukemia treatment and understanding how to navigate short- and long-term effects and how to optimize regimens is at the heart of continued treatment success.
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Affiliation(s)
- Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Lindsey Murphy
- Department of Pediatrics, City of Hope National Medical Center, Duarte, California, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA.
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Marmol-Perez A, Migueles JH, Ubago-Guisado E, Gil-Cosano JJ, Rodriguez-Solana A, Redondo-Tébar A, Llorente-Cantarero FJ, Labayen I, Ortega FB, Ruiz JR, Gracia-Marco L. Every Move Counts to Improve Bone Health at Clinical Sites in Young Pediatric Cancer Survivors: The iBoneFIT Project. Med Sci Sports Exerc 2024; 56:1085-1093. [PMID: 38306313 DOI: 10.1249/mss.0000000000003397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
PURPOSE We aimed to examine the associations of 24-h movement behaviors (moderate to vigorous physical activity [MVPA], light physical activity [LPA], sedentary behavior [SB], and sleep) with age-, sex-, and race-specific areal bone mineral density (aBMD) z -score parameters at clinical sites in young pediatric cancer survivors. METHODS This cross-sectional multicenter study was carried out within the iBoneFIT framework in which 116 young pediatric cancer survivors (12.1 ± 3.3 yr old; 42% female) were recruited. We obtained anthropometric and body composition data (i.e., body mass, stature, body mass index, and region-specific lean mass), time spent in movement behaviors over at least seven consecutive 24-h periods (wGT3x-BT accelerometer, ActiGraph), and aBMD z -score parameters (age-, sex-, and race-specific total at the body, total hip, femoral neck and lumbar spine). Survivors were classified according to somatic maturity (pre or peri/postpubertal depending on the estimated years from peak height velocity). The adjusted models' coefficients were used to predict the effect of reallocating time proportionally across behaviors on the outcomes. RESULTS In prepubertal young pediatric cancer survivors, reallocating time to MVPA from LPA, SB, and sleep was significantly associated with higher aBMD at total body ( B = 1.765, P = 0.005), total hip ( B = 1.709, P = 0.003), and lumbar spine ( B = 2.093, P = 0.001). In peri/postpubertal survivors, reallocating time to LPA from MVPA, SB, and sleep was significantly associated with higher aBMD at all sites ( B = 2.090 to 2.609, P = 0.003 to 0.038). Reallocating time to SB from MVPA or LPA was significantly associated with lower aBMD at most sites in prepubertal and peri/postpubertal survivors, respectively. Finally, reallocating time to sleep from MVPA, LPA, and SB was significantly associated with lower aBMD at total body ( B = -2.572, P = 0.036) and total hip ( B = -3.371, P = 0.015). CONCLUSIONS These findings suggest that every move counts and underline the benefits of increasing MVPA or LPA, when low MVPA levels are present, for bone regeneration after pediatric cancer treatment completion.
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Affiliation(s)
| | | | - Esther Ubago-Guisado
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada, SPAIN
| | | | - Andrea Rodriguez-Solana
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada, SPAIN
| | | | | | - Idoia Labayen
- IS (IS-FOOD), Navarra's Health Research Institute (IdiSNA), Department of Health Sciences, Public University of Navarra, Navarra, SPAIN
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Marmol-Perez A, Gil-Cosano JJ, Ubago-Guisado E, Llorente-Cantarero FJ, Pascual-Gázquez JF, Ness KK, Martinez-Vizcaino V, Ruiz JR, Gracia-Marco L. Muscle strength deficits are associated with low bone mineral density in young pediatric cancer survivors: The iBoneFIT project. JOURNAL OF SPORT AND HEALTH SCIENCE 2024; 13:419-427. [PMID: 38219958 PMCID: PMC11117007 DOI: 10.1016/j.jshs.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/16/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Pediatric cancer survivors are at increased risk of muscle weakness and low areal bone mineral density (aBMD). However, the prevalence of muscle strength deficits is not well documented, and the associations of muscle strength with aBMD are unknown in this population. Therefore, this study aimed to investigate the prevalence of upper- and lower-body muscle strength deficits and to examine the associations of upper- and lower-body muscle strength with age-, sex, and race-specific aBMD Z-scores at the total body, total hip, femoral neck, and lumbar spine. METHODS This cross-sectional study included 116 pediatric cancer survivors (12.1 ± 3.3 years old, mean ± SD; 42.2% female). Upper- and lower-body muscle strength were assessed by handgrip and standing long jump test, respectively. Dual‑energy X‑ray absorptiometry was used to measure aBMD (g/cm2). Associations between muscle strength and aBMD were evaluated in multivariable linear regression models. Logistic regression was used to evaluate the contribution of muscle strength (1-decile lower) to the odds of having low aBMD (Z-score ≤ 1.0). All analyses were adjusted for time from treatment completion, radiotherapy exposure, and body mass index. RESULTS More than one-half of survivors were within the 2 lowest deciles for upper- (56.9%) and lower- body muscle strength (60.0%) in comparison to age- and sex-specific reference values. Muscle strength deficits were associated with lower aBMD Z-scores at all sites (B = 0.133-0.258, p = 0.001-0.032). Each 1-decile lower in upper-body muscle strength was associated with 30%-95% higher odds of having low aBMD Z-scores at all sites. Each 1-decile lower in lower-body muscle strength was associated with 35%-70% higher odds of having low aBMD Z-scores at total body, total hip, and femoral neck. CONCLUSION Muscle strength deficits are prevalent in young pediatric cancer survivors, and such deficits are associated with lower aBMD Z-scores at all sites. These results suggest that interventions designed to improve muscle strength in this vulnerable population may have the added benefit of improving aBMD.
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Affiliation(s)
- Andres Marmol-Perez
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada 18011, Spain; Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Jose J Gil-Cosano
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada 18011, Spain; Department of Communication and Education, Loyola University Andalusia, Seville 41704, Spain
| | - Esther Ubago-Guisado
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada 18011, Spain; Biosanitary Research Institute, ibs.Granada, Granada 18012, Spain
| | - Francisco J Llorente-Cantarero
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba 14004, Spain; CIBEROBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, Madrid 28029, Spain; Department of Specific Didactics, Faculty of Education, University of Cordoba, Cordoba 14071, Spain
| | - Juan Francisco Pascual-Gázquez
- Pediatric and adolescent hematology and oncology service, Pediatrics and Pediatric Surgery Clinical Management Unit, Virgen de las Nieves University Hospital, Granada 18014, Spain
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | | | - Jonatan R Ruiz
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada 18011, Spain; Biosanitary Research Institute, ibs.Granada, Granada 18012, Spain; CIBEROBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, Madrid 28029, Spain
| | - Luis Gracia-Marco
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada, Granada 18011, Spain; Biosanitary Research Institute, ibs.Granada, Granada 18012, Spain; CIBEROBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, Madrid 28029, Spain.
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Geneviève N, Mojgan Y, Nahid Y, Vincenzo F, Simon G, Daniel S, Maja K, Nathalie A, Despoina M. Genetic susceptibility and late bone outcomes in childhood acute lymphoblastic leukemia survivors. J Bone Miner Res 2024; 39:130-138. [PMID: 38477791 DOI: 10.1093/jbmr/zjad013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 03/14/2024]
Abstract
Childhood acute lymphoblastic leukemia (cALL) survivors are at increased risk for bone comorbidities, but accurate screening tools for such comorbidities are limited. Polygenic scores (PGS) could stratify cALL survivors for risk of long-term adverse bone outcomes. We evaluated 214 (51% female) cALL survivors from the Prévenir les Effets TArdifs de la LEucémie study (median age 21 yr). Bone mineral density (BMD) measurements were obtained using dual X-ray absorptiometry at the lumbar spine (LS-BMD), femoral neck (FN-BMD), and total body (TB-BMD), and vertebral fractures (VF) were documented using the vertebral deformity criterion. We computed a PGS for adult heel quantitative ultrasound speed of sound (gSOS), known to be associated with the risk of osteoporotic fracture, using imputed genotype data of the participants, and tested it for association with BMD Z-scores and VF risk, adjusting for clinical risk factors, and in sex and prognostic risk-stratified analyses. We found that a gSOS below the mean was associated with lower BMD in all three sites in univariate and multivariate models. In univariate analyses, 1 SD increase in gSOS conferred a 0.16 SD increase in LS-BMD (95% CI 0.005-0.31), whereas a gSOS above the mean was associated with a 0.31 SD higher LS-BMD (95% CI 0.008-0.61), a 0.36 SD higher TB-BMD (95% CI 0.06-0.67), and a 0.43 SD higher FN-BMD (95% CI 0.13-0.72). Models combining gSOS with clinical risk factors explained up to 16% of the variance of BMD phenotypes and obtained an area under the receiver operating characteristic curve for VF of 0.77 in subgroup analyses. Cranial radiation, high cumulative glucocorticoid doses, high risk group, and male sex were significant risk factors for lower BMD Z-scores. In conclusion, a PGS, in combination with clinical risk factors, could be used as a tool to risk stratify cALL survivors for treatment-related bone morbidity.
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Affiliation(s)
- Nadeau Geneviève
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Yazdanpanah Mojgan
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
| | - Yazdanpanah Nahid
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
| | - Forgetta Vincenzo
- Département des Sciences Fondamentales, Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Girard Simon
- Département des Sciences Fondamentales, Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada
- Centre Intersectoriel en Santé Durable (CISD), Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada
- Centre de Recherche CERVO, Université Laval, Québec, QC G1E 1T2, Canada
| | - Sinnett Daniel
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Krajinovic Maja
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
- Department of Pharmacology, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Alos Nathalie
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Manousaki Despoina
- CHU Sainte-Justine Research Centre, University of Montreal, Montreal, QC H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
- Department of Biochemistry and Molecular Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
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Nigro O, Gattuso G, Sironi G, Podda M, Schiavello E, Spreafico F, Terenziani M. Childhood cancer survivors: improving our practice today to reduce late, major surgical interventions tomorrow. Transl Pediatr 2024; 13:6-9. [PMID: 38323172 PMCID: PMC10839282 DOI: 10.21037/tp-23-417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/11/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Olga Nigro
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanna Gattuso
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanna Sironi
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marta Podda
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elisabetta Schiavello
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo Spreafico
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Terenziani
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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7
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Kárász N, Juhász O, Imrei M, Garami M. Long-Term Prognosis in Relation to Vitamin D Status in Pediatric Solid Tumor Patients. Nutrients 2023; 15:4571. [PMID: 37960224 PMCID: PMC10650320 DOI: 10.3390/nu15214571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Hypovitaminosis D is associated with oncogenesis, and the initial level of Vitamin D may play a role in determining long-term prognosis, relapse-free survival (RFS) and overall survival (OS). The purpose of our study was to follow up pediatric cancer patients for a long time in terms of their baseline Vitamin D level and disease outcomes. METHODS We collected data on the initial 25(OH)D concentration in 117 children and examined their RFS and OS using Kaplan-Meier curves. RESULTS The initial 25(OH)D mean value in the relapsed group was 20.35 ng/mL (SE: 2.05) and in children without relapse it was 26.14 ng/mL (SE: 1.13). Both the relapse-free and overall Kaplan-Meier curves showed a tendency for children with lower serum Vitamin D concentrations to experience cancer recurrence or fatal outcomes sooner than patients with normal serum levels. CONCLUSIONS Our results indicated a possible correlation between higher pretreatment serum Vitamin D concentrations and improved overall and relapse-free survival.
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Affiliation(s)
- Nóra Kárász
- Faculty of Medicine, Semmelweis University, 1085 Budapest, Hungary;
| | - Orsolya Juhász
- Pediatric Center, Semmelweis University, 1094 Budapest, Hungary;
| | - Marcell Imrei
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary;
- Heim Pál National Pediatric Institute, 1089 Budapest, Hungary
| | - Miklós Garami
- Pediatric Center, Semmelweis University, 1094 Budapest, Hungary;
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8
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Ehrhardt MJ, Krull KR, Bhakta N, Liu Q, Yasui Y, Robison LL, Hudson MM. Improving quality and quantity of life for childhood cancer survivors globally in the twenty-first century. Nat Rev Clin Oncol 2023; 20:678-696. [PMID: 37488230 DOI: 10.1038/s41571-023-00802-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 07/26/2023]
Abstract
The contributions of cooperative groups to performing large-cohort clinical trials and long-term survivorship studies have facilitated advances in treatment, supportive care and, ultimately, survival for patients with paediatric cancers. As a result, the number of childhood cancer survivors in the USA alone is expected to reach almost 580,000 by 2040. Despite these substantial improvements, childhood cancer survivors continue to have an elevated burden of chronic disease and an excess risk of early death compared with the general population and therefore constitute a large, medically vulnerable population for which delivery of high-quality, personalized care is much needed. Data from large survivorship cohorts have enabled the identification of compelling associations between paediatric cancers, cancer therapy and long-term health conditions. Effectively translating these findings into clinical care that improves the quality and quantity of life for survivors remains an important focus of ongoing research. Continued development of well-designed clinical studies incorporating dissemination and implementation strategies with input from patient advocates and other key stakeholders is crucial to overcoming these gaps. This Review highlights the global progress made and future efforts that will be needed to further increase the quality and quantity of life-years gained for childhood cancer survivors.
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Affiliation(s)
- Matthew J Ehrhardt
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Global Paediatric Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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9
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Sun R, Zhu L, Li Y, Yasui Y, Robison L. Inference for set-based effects in genetic association studies with interval-censored outcomes. Biometrics 2023; 79:1573-1585. [PMID: 35165890 PMCID: PMC9375811 DOI: 10.1111/biom.13636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 01/24/2022] [Accepted: 02/07/2022] [Indexed: 11/28/2022]
Abstract
The rapid acceleration of genetic data collection in biomedical settings has recently resulted in the rise of genetic compendiums filled with rich longitudinal disease data. One common feature of these data sets is their plethora of interval-censored outcomes. However, very few tools are available for the analysis of genetic data sets with interval-censored outcomes, and in particular, there is a lack of methodology available for set-based inference. Set-based inference is used to associate a gene, biological pathway, or other genetic construct with outcomes and is one of the most popular strategies in genetics research. This work develops three such tests for interval-censored settings beginning with a variance components test for interval-censored outcomes, the interval-censored sequence kernel association test (ICSKAT). We also provide the interval-censored version of the Burden test, and then we integrate ICSKAT and Burden to construct the interval censored sequence kernel association test-optimal (ICSKATO) combination. These tests unlock set-based analysis of interval-censored data sets with analogs of three highly popular set-based tools commonly applied to continuous and binary outcomes. Simulation studies illustrate the advantages of the developed methods over ad hoc alternatives, including protection of the type I error rate at very low levels and increased power. The proposed approaches are applied to the investigation that motivated this study, an examination of the genes associated with bone mineral density deficiency and fracture risk.
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Affiliation(s)
- Ryan Sun
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, U.S.A
| | - Liang Zhu
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas 77030, U.S.A
| | - Yimei Li
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, U.S.A
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, U.S.A
| | - Leslie Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, U.S.A
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10
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Muggeo P, Grassi M, D'Ascanio V, Brescia V, Fontana A, Piacente L, Di Serio F, Giordano P, Faienza MF, Santoro N. Bone Remodeling Markers in Children with Acute Lymphoblastic Leukemia after Intensive Chemotherapy: The Screenshot of a Biochemical Signature. Cancers (Basel) 2023; 15:cancers15092554. [PMID: 37174020 PMCID: PMC10177249 DOI: 10.3390/cancers15092554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
PURPOSE to investigate the effects of intensive chemotherapy and glucocorticoid (GC) treatment on bone remodeling markers in children with acute lymphoblastic leukemia (ALL). METHODS A cross-sectional study was carried out in 39 ALL children (aged 7.64 ± 4.47) and 49 controls (aged 8.7 ± 4.7 years). Osteoprotegerin (OPG), receptor activator of NF-κB ligand (RANKL), osteocalcin (OC), C-terminal telopeptide of type I collagen (CTX), bone alkaline phosphatase (bALP), tartrate-resistant acid phosphatase 5b (TRACP5b), procollagen type I N-terminal propeptide (P1NP), Dickkopf-1 (DKK-1), and sclerostin were assessed. Statistical analysis was conducted using the principal component analysis (PCA) to study patterns of associations in bone markers. RESULTS ALL patients showed significantly higher OPG, RANKL, OC, CTX, and TRACP5b than the controls (p ≤ 0.02). Considering ALL group, we found a strong positive correlation among OC, TRACP5b, P1NP, CTX, and PTH (r = 0.43-0.69; p < 0.001); between CTX and P1NP (r = 0.5; p = 0.001); and between P1NP and TRAcP (r = 0.63; p < 0.001). The PCA revealed OC, CTX, and P1NP as the main markers explaining the variability of the ALL cohort. CONCLUSIONS Children with ALL showed a signature of bone resorption. The assessment of bone biomarkers could help identify ALL individuals who are most at risk of developing bone damage and who need preventive interventions.
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Affiliation(s)
- Paola Muggeo
- Department of Pediatric Oncology and Hematology, University Hospital of Policlinic, 70124 Bari, Italy
| | - Massimo Grassi
- Department of Pediatric Oncology and Hematology, University Hospital of Policlinic, 70124 Bari, Italy
| | - Vito D'Ascanio
- Institute of Sciences of Food Production (ISPA), Italian National Research Council (CNR), 70126 Bari, Italy
| | - Vincenzo Brescia
- Clinical Pathology Unit, AOU Policlinico Consorziale di Bari-Ospedale Giovanni XXIII, 70124 Bari, Italy
| | - Antonietta Fontana
- Clinical Pathology Unit, AOU Policlinico Consorziale di Bari-Ospedale Giovanni XXIII, 70124 Bari, Italy
| | - Laura Piacente
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University "A. Moro", 70124 Bari, Italy
| | - Francesca Di Serio
- Clinical Pathology Unit, AOU Policlinico Consorziale di Bari-Ospedale Giovanni XXIII, 70124 Bari, Italy
| | - Paola Giordano
- Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Maria Felicia Faienza
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University "A. Moro", 70124 Bari, Italy
| | - Nicola Santoro
- Department of Pediatric Oncology and Hematology, University Hospital of Policlinic, 70124 Bari, Italy
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11
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Ross J, Bowden MR, Yu C, Diaz-Thomas A. Transition of young adults with metabolic bone diseases to adult care. Front Endocrinol (Lausanne) 2023; 14:1137976. [PMID: 37008909 PMCID: PMC10064010 DOI: 10.3389/fendo.2023.1137976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
As more accurate diagnostic tools and targeted therapies become increasingly available for pediatric metabolic bone diseases, affected children have a better prognosis and significantly longer lifespan. With this potential for fulfilling lives as adults comes the need for dedicated transition and intentional care of these patients as adults. Much work has gone into improving the transitions of medically fragile children into adulthood, encompassing endocrinologic conditions like type 1 diabetes mellitus and congenital adrenal hyperplasia. However, there are gaps in the literature regarding similar guidance concerning metabolic bone conditions. This article intends to provide a brief review of research and guidelines for transitions of care more generally, followed by a more detailed treatment of bone disorders specifically. Considerations for such transitions include final adult height, fertility, fetal risk, heritability, and access to appropriately identified specialists. A nutrient-dense diet, optimal mobility, and adequate vitamin D stores are protective factors for these conditions. Primary bone disorders include hypophosphatasia, X-linked hypophosphatemic rickets, and osteogenesis imperfecta. Metabolic bone disease can also develop secondarily as a sequela of such diverse exposures as hypogonadism, a history of eating disorder, and cancer treatment. This article synthesizes research by experts of these specific disorders to describe what is known in this field of transition medicine for metabolic bone diseases as well as unanswered questions. The long-term objective is to develop and implement strategies for successful transitions for all patients affected by these various conditions.
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Affiliation(s)
- Jordan Ross
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- *Correspondence: Jordan Ross,
| | - Michelle R. Bowden
- Division of General Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
| | - Christine Yu
- Endocrinology Division, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alicia Diaz-Thomas
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
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12
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Horiuchi K, Nemoto R, Mizuno T, Susa M, Chiba K. Prevalence of low bone mineral density and risk of fractures in osteosarcoma and Ewing's sarcoma survivors: A scoping review. J Bone Oncol 2022; 38:100464. [PMID: 36560961 PMCID: PMC9763837 DOI: 10.1016/j.jbo.2022.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
Background The clinical outcomes of patients with pediatric cancer have significantly improved over the past few decades. However, the treatments are often highly intensive and can advertently pose a risk for developing various health conditions, including bone mass loss and fragility fractures. Since patients with bone malignancies, such as osteosarcoma (OS) and Ewing's sarcoma (ES), require musculoskeletal surgery as well as chemotherapy, OS/ES survivors are potentially at even greater risk of developing these musculoskeletal conditions than those with other types of cancer. However, these issues in OS/ES survivors are often overlooked by clinicians treating childhood cancers. Thus, this scoping review was designed and conducted to better understand the bone health conditions in OS/ES survivors. Design We conducted a literature search and included the studies that describe bone mineral density in association with bone health in OS/ES survivors for analysis. Data regarding patients' demographic, diagnosis, bone mineral density, laboratory examinations, and incidence of fractures were extracted and evaluated. Results We found that almost half of OS/ES survivors have bone mass deficit and that several factors (such as a frailer physique and younger age at diagnosis) are potentially associated with low bone mass in OS/ES survivors. On the other hand, due to a paucity of information currently available, we could not determine whether long-term OS/ES survivors would ultimately regain bone mass or be at a greater risk of fragility fractures. Conclusions This scoping review reveals a previously unappreciated knowledge gap in our understanding of bone health conditions in OS/ES survivors and raises awareness among clinicians and care providers of this condition that OS/ES patients may encounter after successful treatment.
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Affiliation(s)
- Keisuke Horiuchi
- Department of Orthopedic Surgery, National Defense Medical College, Namiki 3-2, Tokorozawa, Saitama 359-8513, Japan,Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan,Corresponding author at: Department of Orthopedic Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
| | - Ryuji Nemoto
- Department of Orthopedic Surgery, National Defense Medical College, Namiki 3-2, Tokorozawa, Saitama 359-8513, Japan
| | - Tsukasa Mizuno
- Department of Orthopedic Surgery, National Defense Medical College, Namiki 3-2, Tokorozawa, Saitama 359-8513, Japan
| | - Michiro Susa
- Department of Orthopedic Surgery, National Defense Medical College, Namiki 3-2, Tokorozawa, Saitama 359-8513, Japan
| | - Kazuhiro Chiba
- Department of Orthopedic Surgery, National Defense Medical College, Namiki 3-2, Tokorozawa, Saitama 359-8513, Japan
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13
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Rossi F, Tortora C, Paoletta M, Marrapodi MM, Argenziano M, Di Paola A, Pota E, Di Pinto D, Di Martino M, Iolascon G. Osteoporosis in Childhood Cancer Survivors: Physiopathology, Prevention, Therapy and Future Perspectives. Cancers (Basel) 2022; 14:cancers14184349. [PMID: 36139510 PMCID: PMC9496695 DOI: 10.3390/cancers14184349] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Anti-cancer treatments induced an increase in the childhood cancer survival rate. However, they are responsible for several long-term side effects in childhood cancer survivors, including osteoporosis. Cancer itself, a sedentary lifestyle, and an unhealthy diet might adversely affect bone health. Early identification and adequate management of bone fragility in childhood cancer survivors could be useful to prevent osteoporosis onset and consequently fragility fractures. Abstract The improvement of chemotherapy, radiotherapy, and surgical interventions, together with hematopoietic stem cell transplantation, increased childhood cancer survival rate in the last decades, reaching 80% in Europe. Nevertheless, anti-cancer treatments are mainly responsible for the onset of long-term side effects in childhood cancer survivors (CCS), including alterations of the endocrine system function and activity. In particular, the most frequent dysfunction in CCS is a metabolic bone disorder characterized by low bone mineral density (BMD) with increased skeletal fragility. BMD loss is also a consequence of a sedentary lifestyle, malnutrition, and cancer itself could affect BMD, thus inducing osteopenia and osteoporosis. In this paper, we provide an overview of possible causes of bone impairment in CCS in order to propose management strategies for early identification and treatment of skeletal fragility in this population.
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Affiliation(s)
- Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
- Correspondence: ; Tel.: +39-081-566-5423
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Maura Argenziano
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Alessandra Di Paola
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
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14
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Rossi F, Tortora C, Di Martino M, Di Paola A, Di Pinto D, Marrapodi MM, Argenziano M, Pota E. Alteration of osteoclast activity in childhood cancer survivors: Role of iron and of CB2/TRPV1 receptors. PLoS One 2022; 17:e0271730. [PMID: 35862357 PMCID: PMC9302719 DOI: 10.1371/journal.pone.0271730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/06/2022] [Indexed: 11/30/2022] Open
Abstract
Childhood cancer survivors (CCS) are predisposed to the onset of osteoporosis (OP). It is known that iron overload induces osteoclasts (OCs) overactivity and that the iron chelator Deferasirox (DFX) can counteract it. The Cannabinoid Receptor type 2 (CB2) and the transient receptor potential vanilloid type-1 (TRPV1) are potential therapeutic targets for OP. In this study we isolated OCs from peripheral blood of 20 CCS and investigated osteoclast biomarkers expression and iron metabolism evaluating iron release by OCs and the expression of several molecules involved in its regulation. Moreover, we analyzed the effects of CB2 and TRPV1 stimulation in combination with DFX on osteoclast activity and iron metabolism. We observed, for the first time, an osteoclast hyperactivation in CCS suggesting a role for iron in its development. Moreover, we confirmed the well-known role of CB2 and TRPV1 receptors in bone metabolism, suggesting the receptors as possible key biomarkers of bone damage. Moreover, we demonstrated a promising synergism between pharmacological compounds, stimulating CB2 or inhibiting/desensitizing TRPV1 and DFX, in counteracting osteoclast overactivity in CCS to improve their quality of life.
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Affiliation(s)
- Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
- * E-mail:
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Alessandra Di Paola
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Maura Argenziano
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
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15
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Khan A, Zeb J, Farooq N, Farid N, Zeb R, Shoaib M. Evaluating the Effect of Induction Chemotherapy on Bone Metabolizing Nutrients in Patients of Acute Lymphoblastic Leukemia. Cureus 2022; 14:e25403. [PMID: 35774667 PMCID: PMC9239291 DOI: 10.7759/cureus.25403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/07/2022] Open
Abstract
Objective: To determine the levels of bone metabolizing nutrients (vitamin D, calcium, magnesium, potassium) in patients with acute lymphoblastic leukemia (ALL) before and after induction chemotherapy, and to correlate the effect of induction chemotherapy on their bone mass (BM). Materials and methods: This quasi-experimental study was carried out at Hayatabad Medical Complex (HMC) and Khyber Medical University (KMU) in Peshawar, Pakistan, in one year. A total of 69 newly diagnosed patients with ALL were enrolled in the study. They were to begin the induction phase of chemotherapy at HMC oncology ward for about four weeks, following standard protocols. Data was collected using a predesigned questionnaire, and blood samples were obtained from all the patients by applying a non-probability consecutive sampling technique. The bone biomarkers levels were measured before therapy and after induction chemotherapy for comparison. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corp., Armonk, NY, USA), and a p-value of <0.05 was considered significant. Results: The mean age was 13 ± 5.23 years. Out of the 69 patients enrolled in the study, 36 (52%) were male and 33 (48%) were female. After the four-week induction chemotherapy, there was a significant reduction in bone contents levels. Vitamin D, calcium, magnesium and potassium levels were below the levels documented prior to the treatment with a p-value < 0.05. The bone mass remained unchanged after the four weeks of chemotherapy. Conclusion: The induction phase of chemotherapy causes a significant reduction in the levels of bone bio contents and results in bone morbidities.
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16
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Verwaaijen EJ, Ma J, de Groot-Kruseman HA, Pieters R, van der Sluis IM, van Atteveld JE, Halton J, Fernandez CV, Hartman A, de Jonge R, Lequin MH, Te Winkel ML, Alos N, Atkinson SA, Barr R, Grant RM, Hay J, Huber AM, Ho J, Jaremko J, Koujok K, Lang B, Matzinger MA, Shenouda N, Rauch F, Rodd C, van den Heuvel-Eibrink MM, Pluijm SMF, Ward LM. A Validated Risk Prediction Model for Bone Fragility in Children With Acute Lymphoblastic Leukemia. J Bone Miner Res 2021; 36:2290-2299. [PMID: 34610647 DOI: 10.1002/jbmr.4442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 11/06/2022]
Abstract
Although bone fragility may already be present at diagnosis of pediatric acute lymphoblastic leukemia (ALL), routine performance of dual-energy X-ray absorptiometry (DXA) in every child is not universally feasible. The aim of this study was to develop and validate a risk prediction model for low lumbar spine bone mineral density (LS BMD Z-score ≤ -2.0) at diagnosis, as an important indicator for fracture risk and further treatment-related BMD aggravation. Children with ALL (4-18 years), treated according to the Dutch Childhood Oncology Group protocol (DCOG-ALL9; model development; n = 249) and children from the Canadian Steroid-Associated Osteoporosis in the Pediatric Population cohort (STOPP; validation; n = 99) were included in this study. Multivariable logistic regression analyses were used to develop the prediction model and to confirm the association of low LS BMD at diagnosis with symptomatic fractures during and shortly after cessation of ALL treatment. The area under the receiver operating characteristic curve (AUC) was used to assess model performance. The prediction model for low LS BMD at diagnosis using weight (β = -0.70) and age (β = -0.10) at diagnosis revealed an AUC of 0.71 (95% CI, 0.63-0.78) in DCOG-ALL9 and 0.74 (95% CI, 0.63-0.84) in STOPP, and resulted in correct identification of 71% of the patients with low LS BMD. We confirmed that low LS BMD at diagnosis is associated with LS BMD at treatment cessation (OR 5.9; 95% CI, 3.2-10.9) and with symptomatic fractures (OR 1.7; 95% CI, 1.3-2.4) that occurred between diagnosis and 12 months following treatment cessation. In meta-analysis, LS BMD at diagnosis (OR 1.6; 95% CI, 1.1-2.4) and the 6-month cumulative glucocorticoid dose (OR 1.9; 95% CI, 1.1-3.2) were associated with fractures that occurred in the first year of treatment. In summary, a prediction model for identifying pediatric ALL patients with low LS BMD at diagnosis, as an important indicator for bone fragility, was successfully developed and validated. This can facilitate identification of future bone fragility in individual pediatric ALL patients. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Emma J Verwaaijen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hester A de Groot-Kruseman
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Dutch Childhood Oncology Group, Utrecht, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | | | | | | | - Annelies Hartman
- Department of Pediatric Physiotherapy, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Academic Medical Center, Amsterdam, The Netherlands
| | - Maarten H Lequin
- Department of Radiology, University Medical Center, Amsterdam, The Netherlands
| | | | - Nathalie Alos
- Département de Pédiatrie, Université de Montréal, Montréal, QC, Canada
| | | | - Ronald Barr
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Ronald M Grant
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - John Hay
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Adam M Huber
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Jacob Jaremko
- Department of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Celia Rodd
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | | | - Saskia M F Pluijm
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
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- Canadian Pediatric Bone Health Working Group, Ottawa, ON, Canada
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17
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Al-Mahayri ZN, AlAhmad MM, Ali BR. Long-Term Effects of Pediatric Acute Lymphoblastic Leukemia Chemotherapy: Can Recent Findings Inform Old Strategies? Front Oncol 2021; 11:710163. [PMID: 34722258 PMCID: PMC8554193 DOI: 10.3389/fonc.2021.710163] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/30/2021] [Indexed: 02/05/2023] Open
Abstract
During the last few decades, pediatric acute lymphoblastic leukemia (ALL) cure rates have improved significantly with rates exceeding 90%. Parallel to this remarkable improvement, there has been mounting interest in the long-term health of the survivors. Consequently, modified treatment protocols have been developed and resulted in the reduction of many adverse long-term consequences. Nevertheless, these are still substantial concerns that warrant further mitigation efforts. In the current review, pediatric-ALL survivors’ late adverse events, including secondary malignant neoplasms (SMNs), cardiac toxicity, neurotoxicity, bone toxicity, hepatic dysfunction, visual changes, obesity, impact on fertility, and neurocognitive effects have been evaluated. Throughout this review, we attempted to answer a fundamental question: can the recent molecular findings mitigate pediatric-ALL chemotherapy’s long-term sequelae on adult survivors? For SMNs, few genetic predisposition factors have been identified including TP53 and POT1 variants. Other treatment-related risk factors have been identified such as anthracyclines’ possible association with breast cancer in female survivors. Cardiotoxicity is another significant and common adverse event with some germline variants been found, albeit with conflicting evidence, to increase the risk of cardiac toxicity. For peripheral neurotoxicity, vincristine is the primary neurotoxic agent in ALL regimens. Some germline genetic variants were found to be associated with the vincristine neurotoxic effect’s vulnerability. However, these were mainly detected with acute neuropathy. Moreover, the high steroid doses and prolonged use increase bone toxicity and obesity risk with some pharmacogenetic biomarkers were associated with increased steroid sensitivity. Therefore, the role of these biomarkers in tailoring steroid choice and dose is a promising research area. Future directions in pediatric ALL treatment should consider the various opportunities provided by genomic medicine. Understanding the molecular bases underlying toxicities will classify patients into risk groups and implement a closer follow-up to those at higher risk. Pharmacogenetic-guided dosing and selecting between alternative agents have proven their efficacy in the short-term management of childhood ALL. It is the right time to think about a similar approach for the life-long consequences on survivors.
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Affiliation(s)
- Zeina N Al-Mahayri
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Mohammad M AlAhmad
- Department of Clinical Pharmacy, College of Pharmacy, Al-Ain University, Al-Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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18
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Velentza L, Zaman F, Sävendahl L. Bone health in glucocorticoid-treated childhood acute lymphoblastic leukemia. Crit Rev Oncol Hematol 2021; 168:103492. [PMID: 34655742 DOI: 10.1016/j.critrevonc.2021.103492] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/05/2021] [Accepted: 09/08/2021] [Indexed: 12/30/2022] Open
Abstract
Glucocorticoids (GCs) are widely used in the treatment of childhood acute lymphoblastic leukemia (ALL), but their long-term use is also associated with bone-related morbidities. Among others, growth deficit, decreased bone mineral density (BMD) and increased fracture rate are well-documented and severely impact quality of life. Unfortunately, no efficient treatment for the management of bone health impairment in patients and survivors is currently available. The overall goal of this review is to discuss the existing data on how GCs impair bone health in pediatric ALL and attempts made to minimize these side effects.
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Affiliation(s)
- Lilly Velentza
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Farasat Zaman
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Sävendahl
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
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19
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van Atteveld JE, Mulder RL, van den Heuvel-Eibrink MM, Hudson MM, Kremer LCM, Skinner R, Wallace WH, Constine LS, Higham CE, Kaste SC, Niinimäki R, Mostoufi-Moab S, Alos N, Fintini D, Templeton KJ, Ward LM, Frey E, Franceschi R, Pavasovic V, Karol SE, Amin NL, Vrooman LM, Harila-Saari A, Demoor-Goldschmidt C, Murray RD, Bardi E, Lequin MH, Faienza MF, Zaikova O, Berger C, Mora S, Ness KK, Neggers SJCMM, Pluijm SMF, Simmons JH, Di Iorgi N. Bone mineral density surveillance for childhood, adolescent, and young adult cancer survivors: evidence-based recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Diabetes Endocrinol 2021; 9:622-637. [PMID: 34339631 PMCID: PMC8744935 DOI: 10.1016/s2213-8587(21)00173-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 02/01/2023]
Abstract
Childhood, adolescent, and young adult cancer survivors are at increased risk of reduced bone mineral density. Clinical practice surveillance guidelines are important for timely diagnosis and treatment of these survivors, which could improve bone mineral density parameters and prevent fragility fractures. Discordances across current late effects guidelines necessitated international harmonisation of recommendations for bone mineral density surveillance. The International Late Effects of Childhood Cancer Guideline Harmonization Group therefore established a panel of 36 experts from ten countries, representing a range of relevant medical specialties. The evidence of risk factors for very low and low bone mineral density and fractures, surveillance modality, timing of bone mineral density surveillance, and treatment of very low and low bone mineral density were evaluated and critically appraised, and harmonised recommendations for childhood, adolescent, and young adult cancer survivors were formulated. We graded the recommendations based on the quality of evidence and balance between potential benefits and harms. Bone mineral density surveillance is recommended for survivors treated with cranial or craniospinal radiotherapy and is reasonable for survivors treated with total body irradiation. Due to insufficient evidence, no recommendation can be formulated for or against bone mineral density surveillance for survivors treated with corticosteroids. This surveillance decision should be made by the survivor and health-care provider together, after careful consideration of the potential harms and benefits and additional risk factors. We recommend to carry out bone mineral density surveillance using dual-energy x-ray absorptiometry at entry into long-term follow-up, and if normal (Z-score > -1), repeat when the survivor is aged 25 years. Between these measurements and thereafter, surveillance should be done as clinically indicated. These recommendations facilitate evidence-based care for childhood, adolescent, and young adult cancer survivors internationally.
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Affiliation(s)
| | - Renée L Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Melissa M Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and Newcastle University Centre for Cancer, Newcastle upon Tyne, UK
| | - W Hamish Wallace
- Department of Paediatric Oncology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Sue C Kaste
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital, and PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, The Children's Hospital of Philadelphia, and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nathalie Alos
- Department of Pediatrics, Endocrinology Division, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Danilo Fintini
- Endocrinology Unit, University-Hospital Pediatric Department, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Kimberly J Templeton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Eva Frey
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
| | | | - Vesna Pavasovic
- Department of Paediatric Haematology and Oncology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Seth E Karol
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Nadia L Amin
- Department of Paediatric Haematology, Leeds Children's Hospital, Leeds, UK
| | - Lynda M Vrooman
- Dana-Farber Cancer Institute, and Boston Children's Hospital, Boston, MA, USA
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Charlotte Demoor-Goldschmidt
- INSERM U1018, Paris-Sud XI University, Paris-Saclay University, Centre for Research in Epidemiology and Population Health, Cancer & Radiations Group, Gustave Roussy Cancer Campus, Villejuif, France; Department of Pediatric Onco-hematology, CHU Angers, Angers, France; Department of Radiotherapy, François Baclesse Center, Caen, France
| | - Robert D Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Edit Bardi
- St Anna Children's Hospital, Vienna, Austria; Department of Pediatrics and Adolescent Medicine, Kepler Universitätsklinikum, Linz, Austria
| | - Maarten H Lequin
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Felicia Faienza
- Department of Biomedical Sciences and Human Oncology, Pediatric Unit, University A Moro, Bari, Italy
| | - Olga Zaikova
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Claire Berger
- Department for Pediatric Hematology and Oncology CHU Nord, University Hospital Saint-Etienne, Saint-Priest en Jarez, France; 28U1059 Sainbiose, University Jean Monnet, Saint-Etienne, France
| | - Stefano Mora
- Laboratory of Pediatric Endocrinology and Pediatric Bone Density Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Saskia M F Pluijm
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jill H Simmons
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Natascia Di Iorgi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Italy and Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
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20
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Oskarsson T, Duun-Henriksen AK, Bautz A, Montgomery S, Harila-Saari A, Petersen C, Niinimäki R, Madanat-Harjuoja L, Tryggvadóttir L, Holmqvist AS, Hasle H, Heyman M, Winther JF. Skeletal adverse events in childhood cancer survivors: An Adult Life after Childhood Cancer in Scandinavia cohort study. Int J Cancer 2021; 149:1863-1876. [PMID: 34278568 DOI: 10.1002/ijc.33741] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/04/2021] [Accepted: 06/18/2021] [Indexed: 12/22/2022]
Abstract
The dynamic growth of the skeleton during childhood and adolescence renders it vulnerable to adverse effects of cancer treatment. The lifetime risk and patterns of skeletal morbidity have not been described in a population-based cohort of childhood cancer survivors. A cohort of 26 334 1-year cancer survivors diagnosed before 20 years of age was identified from the national cancer registries of Denmark, Finland, Iceland and Sweden as well as a cohort of 127 531 age- and sex-matched comparison subjects randomly selected from the national population registries in each country. The two cohorts were linked with data from the national hospital registries and the observed numbers of first-time hospital admissions for adverse skeletal outcomes among childhood cancer survivors were compared to the expected numbers derived from the comparison cohort. In total, 1987 childhood cancer survivors had at least one hospital admission with a skeletal adverse event as discharge diagnosis, yielding a rate ratio (RR) of 1.35 (95% confidence interval, 1.29-1.42). Among the survivors, we observed an increased risk for osteonecrosis with a RR of 25.9 (15.0-44.5), osteoporosis, RR 4.53 (3.28-6.27), fractures, RR 1.27 (1.20-1.34), osteochondropathies, RR 1.57 (1.28-1.92) and osteoarthrosis, RR 1.48 (1.28-1.72). The hospitalization risk for any skeletal adverse event was higher among survivors up to the age of 60 years, but the lifetime pattern was different for each type of skeletal adverse event. Understanding the different lifetime patterns and identification of high-risk groups is crucial for developing strategies to optimize skeletal health in childhood cancer survivors.
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Affiliation(s)
- Trausti Oskarsson
- Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Andrea Bautz
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Clinical Epidemiology Division, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
| | - Arja Harila-Saari
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Cecilia Petersen
- Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Laura Madanat-Harjuoja
- Finnish Institute for Statistical and Epidemiological Cancer Research, Finnish Cancer Registry, Helsinki, Finland.,Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pediatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laufey Tryggvadóttir
- The Icelandic Cancer Registry, Icelandic Cancer Society, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anna Sällfors Holmqvist
- Division of Paediatric Oncology and Haematology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Heyman
- Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jeanette Falck Winther
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark
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21
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van Atteveld JE, de Winter DTC, Pieters R, Neggers SJCMM, van den Heuvel-Eibrink MM. Recent perspectives on the association between osteonecrosis and bone mineral density decline in childhood acute lymphoblastic leukemia. Fac Rev 2021; 10:57. [PMID: 34308423 PMCID: PMC8265561 DOI: 10.12703/r/10-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The attention to treatment-related toxicity has increased since the survival of children with acute lymphoblastic leukemia (ALL) has improved significantly over the past few decades. Intensive ALL treatment schedules including corticosteroids and asparaginase have been shown to give rise to skeletal abnormalities such as osteonecrosis and low bone mineral density (BMD), which may lead to debilitating sequelae in survivors. Although osteonecrosis and low BMD are different entities with suggested separate pathophysiological mechanisms, recent studies indicate that osteonecrosis is associated with accelerated BMD decline. Common underlying mechanisms for osteonecrosis and BMD decline are considered, such as an enhanced sensitivity to corticosteroids in children who suffer from both osteonecrosis and low BMD. In addition, restriction of weight-bearing activities, which is generally advised in patients with osteonecrosis, could aggravate BMD decline. This induces a clinical dilemma, since bone stimulation is important to maintain BMD but alternative interventions for osteonecrosis are limited. Furthermore, this recent finding of accelerated BMD decline in children with osteonecrosis emphasizes the need to develop effective preventive measures for osteonecrosis, which may include targeting BMD decline.
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Affiliation(s)
- Jenneke E van Atteveld
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Demi TC de Winter
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Sebastian JCMM Neggers
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
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22
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van Atteveld JE, Verhagen IE, van den Heuvel-Eibrink MM, van Santen HM, van der Sluis IM, Di Iorgi N, Simmons JH, Ward LM, Neggers SJCMM. Vitamin D supplementation for children with cancer: A systematic review and consensus recommendations. Cancer Med 2021; 10:4177-4194. [PMID: 34100559 PMCID: PMC8267124 DOI: 10.1002/cam4.4013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/29/2022] Open
Abstract
Background Prevalent vitamin D deficiency (VDD) and low bone mineral density (BMD) have led to vitamin D supplementation for children with cancer, regardless vitamin D status. However, it remains unsettled whether this enhances bone strength. We sought to address this issue by carrying out a systematic review of the literature. Methods We conducted a literature search using PubMed, Embase, and Cochrane databases. Studies including children up to 5 years after cancer therapy were assessed for the association between 25‐hydroxyvitamin D (25OHD) levels and BMD Z‐scores or fractures, and the effect of vitamin D supplementation on BMD or fractures. Evidence quality was assessed using the GRADE methodology. Results Nineteen studies (16 observational and 3 interventional, mainly involving children with hematologic malignancies) were included. One study which analyzed 25OHD as a threshold variable (≤10 ng/ml) found a significant association between 25OHD levels and BMD Z‐scores, while 25OHD as a continuous variable was not significantly associated with BMD Z‐scores in 14 observational studies. We found neither a significant association between lower 25OHD levels and fractures (2 studies), nor between vitamin D (and calcium) supplementation and BMD or fracture frequency (3 studies) (very low quality evidence). Conclusion There is a lack of evidence for an effect of vitamin D (and calcium) supplementation on BMD or fractures in children with cancer. Further research is needed; until then, we recommend dietary vitamin D/calcium intake in keeping with standard national guidelines, and periodic 25OHD monitoring to detect levels <20 ng/ml. Vitamin D/calcium supplementation is recommended in children with low levels, to maintain levels ≥20 ng/ml year‐long.
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Affiliation(s)
| | - Iris E Verhagen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Hanneke M van Santen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Endocrinology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Natascia Di Iorgi
- Department of Pediatrics, University of Genova, IRCCS Istituto Giannina Gaslini, Genova, GE, Italy
| | - Jill H Simmons
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Sebastian J C M M Neggers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Endocrinology, Erasmus Medical Center, Rotterdam, The Netherlands
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23
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Im C, Li N, Moon W, Liu Q, Morton LM, Leisenring WM, Howell RM, Chow EJ, Sklar CA, Wilson CL, Wang Z, Sapkota Y, Chemaitilly W, Ness KK, Hudson MM, Robison LL, Bhatia S, Armstrong GT, Yasui Y. Genome-wide Association Studies Reveal Novel Locus With Sex-/Therapy-Specific Fracture Risk Effects in Childhood Cancer Survivors. J Bone Miner Res 2021; 36:685-695. [PMID: 33338273 PMCID: PMC8044050 DOI: 10.1002/jbmr.4234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 12/18/2022]
Abstract
Childhood cancer survivors treated with radiation therapy (RT) and osteotoxic chemotherapies are at increased risk for fractures. However, understanding of how genetic and clinical susceptibility factors jointly contribute to fracture risk among survivors is limited. To address this gap, we conducted genome-wide association studies of fracture risk after cancer diagnosis in 2453 participants of European ancestry from the Childhood Cancer Survivor Study (CCSS) with 930 incident fractures using Cox regression models (ie, time-to-event analysis) and prioritized sex- and treatment-stratified genetic associations. We performed replication analyses in 1417 survivors of European ancestry with 652 incident fractures from the St. Jude Lifetime Cohort Study (SJLIFE). In discovery, we identified a genome-wide significant (p < 5 × 10-8 ) fracture risk locus, 16p13.3 (HAGHL), among female CCSS survivors (n = 1289) with strong evidence of sex-specific effects (psex-heterogeneity < 7 × 10-6 ). Combining discovery and replication data, rs1406815 showed the strongest association (hazard ratio [HR] = 1.43, p = 8.2 × 10-9 ; n = 1935 women) at this locus. In treatment-stratified analyses in the discovery cohort, the association between rs1406815 and fracture risk among female survivors with no RT exposures was weak (HR = 1.22, 95% confidence interval [CI] 0.95-1.57, p = 0.11) but increased substantially among those with greater head/neck RT doses (any RT: HR = 1.88, 95% CI 1.54-2.28, p = 2.4 × 10-10 ; >36 Gray only: HR = 3.79, 95% CI 1.95-7.34, p = 8.2 × 10-5 ). These head/neck RT-specific HAGHL single-nucleotide polymorphism (SNP) effects were replicated in female SJLIFE survivors. In silico bioinformatics analyses suggest these fracture risk alleles regulate HAGHL gene expression and related bone resorption pathways. Genetic risk profiles integrating this locus may help identify female survivors who would benefit from targeted interventions to reduce fracture risk. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Cindy Im
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Nan Li
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wonjong Moon
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Lindsay M Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca M Howell
- Department of Radiation Physic, MD Anderson Cancer Center, Houston, TX, USA
| | - Eric J Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, NY, New York, USA
| | - Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Zhaoming Wang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yadav Sapkota
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wassim Chemaitilly
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.,Division of Endocrinology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- School of Public Health, University of Alberta, Edmonton, Canada.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
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24
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Latoch E, Konstantynowicz J, Krawczuk-Rybak M, Panasiuk A, Muszyńska-Rosłan K. A long-term trajectory of bone mineral density in childhood cancer survivors after discontinuation of treatment: retrospective cohort study. Arch Osteoporos 2021; 16:45. [PMID: 33635381 DOI: 10.1007/s11657-020-00863-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/07/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Low bone mineral density (BMD) was diagnosed in 24% of childhood cancer survivors (CCS), whereas very low BMD was relatively uncommon at 8%. We suggest that low BMD in CCS may become alleviated over time. Stem cell transplantation, radiotherapy, and underweight were the strongest independent predictors of decreased BMD. PURPOSE Childhood cancer survivors (CCS) are at risk of premature bone loss, although published studies are inconsistent. The objective of this study was to evaluate the prevalence and pattern of low bone mineral density (BMD) in short- and long-term CCS, and to determine clinical factors affecting skeleton after anticancer treatment. METHODS This retrospective study was conducted in a cohort of 326 children and young adult CCS (147 females) who completed anticancer treatment. BMD was determined by dual-energy X-ray absorptiometry (DXA). Low BMD was defined as a Z-score ≤ - 1.0, and the very low BMD as a Z-score ≤ - 2.0. Additionally, the changes in BMD over time were studied in 123 CCS who had been re-examined by DXA during follow-up. RESULTS Median age at diagnosis was 7.27 years (range, 4.4-10.6); median time between end of treatment and DXA was 6.12 (range, 4.0-22.0). Low BMD was found in 24% of CCS, while very low BMD was relatively uncommon (8%). Based on multivariate analysis, the following were significantly associated with low BMD at the follow-up: hematopoietic stem cell transplantation (OR 3.13, 95% CI 1.02-9.63), head and neck radiotherapy (OR 2.54, 95% CI 1.32-4.90), and body weight below the standard reference (OR 3.57, 95% CI 1.24-10.23). The time-related trajectory showed an improvement (BMDLS) or stabilization (BMDTB) in Z-scores values. CONCLUSION These data based on serial DXA measurements, encompassing a long-lasting observation period, show that CCS may not be at risk of premature bone loss in young adulthood. However, it is unknown how the scenario for skeletal mass is until the CCS will achieve older or postmenopausal age.
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Affiliation(s)
- Eryk Latoch
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Białystok, Poland
| | - Jerzy Konstantynowicz
- Department of Pediatrics, Rheumatology, Immunology and Metabolic Bone Diseases, Medical University of Bialystok, University Children's Hospital 'Dr Ludwik Zamenhof', ul. Waszyngtona 17, 15-274, Białystok, Poland.
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Białystok, Poland
| | - Anna Panasiuk
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wrocław, Poland
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25
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Schulte F, Forbes C, Wurz A, Patton M, Russell KB, Pluijm S, Krull KR. Childhood Cancer Survivorship: Daily Challenges. Pediatr Clin North Am 2020; 67:1083-1101. [PMID: 33131536 DOI: 10.1016/j.pcl.2020.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Survivors of childhood cancer are at risk of experiencing fatigue, pain, lower levels of physical activity, increased engagement in risky health behavior, and poor social adjustment, after finishing treatment. Risks are more pronounced for survivors of specific diagnoses or receiving specific treatment protocols. Interventions to address these outcomes are in their infancy. Future research should focus on exploring the antecedents and consequences of these outcomes. In the meantime, researchers and cancer centers should attempt to provide high-quality and accessible health information to survivors through various media outlets to encourage healthy behaviors.
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Affiliation(s)
- Fiona Schulte
- Department of Oncology, Division of Psychosocial Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Hematology, Oncology and Transplant Program, Alberta Children's Hospital, Calgary, Alberta, Canada.
| | - Caitlin Forbes
- University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Amanda Wurz
- University of Calgary, Calgary, Alberta, Canada
| | | | | | - Saskia Pluijm
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Kevin R Krull
- St. Jude Children's Research Hospital, Memphis, TN, USA
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26
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Jin HY, Lee JA. Low bone mineral density in children and adolescents with cancer. Ann Pediatr Endocrinol Metab 2020; 25:137-144. [PMID: 33017885 PMCID: PMC7538298 DOI: 10.6065/apem.2040060.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
Maximizing accumulation of bone mass during childhood and adolescence is essential to attaining optimal peak bone mass. Childhood cancer survivors (CCS) have lower bone mineral density (BMD) than the general population. Chemotherapeutic agents including steroids and radiotherapy can affect BMD. Cancer itself, hormonal insufficiency, a poor nutritional state, and a deficit of physical activities during or after treatment also influence BMD in CCS, resulting in failure to achieve appropriate peak bone mass. Low BMD in childhood and adolescence can lead to osteoporosis in adult life and complications such as bone pain, bone deformity, and fractures. Thus, BMD in CCS should be monitored with appropriate intervention. Adequate intake of calcium and vitamin D and an increase in physical activity are recommended. Timely supplements of hormones are needed in some cases. Some publications have reported that bisphosphonate therapies using pamidronate or alendronate were well tolerated in CCS and helped increase BMD.
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Affiliation(s)
- Hye Young Jin
- Department of Pediatrics, Center for Pediatric Cancer, National Cancer Center, Goyang, Korea
| | - Jun Ah Lee
- Department of Pediatrics, Center for Pediatric Cancer, National Cancer Center, Goyang, Korea,Address for correspondence: Jun Ah Lee, MD, PhD Department of Pediatrics, Center for Pediatric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, Korea Tel: +82-31-920-1604 Fax: +82-31-920-1244 E-mail:
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