Height and weight in children treated for acute lymphoblastic leukemia: relationship to CNS treatment

The Prevalence, Risk Factors and Cardiometabolic Complications of Obesity in Childhood Survivors of Acute Lymphoblastic Leukemia

Prevalence, risk factors and metabolic complications of overweight/obesity (OW/OB) are not well described in the childhood survivors of acute lymphoblastic leukemia (ALL). Longitudinal changes in body mass index-z score (BMIz) from diagnosis to the last follow-up visit after the end of treatment were evaluated in 73 children at first complete remission. Of them, 40 were tested for adipokine profiles at visit. The mean BMIz increased gradually from diagnosis (0.07 ± 1.68) to the end of dexamethasone containing reinduction therapy (0.70 ± 1.48, P:0.007), followed by a fall at the end of treatment (0.15 ± 1.24) and a rise again at visit (0.40 ± 1.23, P:0.007). OW/OB percentage of 15% at diagnosis, increased to 35% at visit (p < 0.05). Post-treatment OW/OB in survivors was related with being OW/OB at diagnosis (OR 5.4, 95% CI [0.94-31.7]; P = 0.02) and after dexamethasone containing reinduction therapy (OR 5.1, 95% CI [1.1-21.4]; P = 0.05), but not with age at diagnosis, gender, treatment intensity and cranial irradiation. Metabolic syndrome (MetS) was more prevalent in survivors (13%) than in Turkish children (2%). As compared with controls, survivors had higher leptin level (8.1 ± 8.6 vs 3.2 ± 2.2 ng/ml, P = 0.01) and leptin/adiponectin ratio (2.1 ± 3.5 vs 0.6 ± 0.5, P = 0.03). Leptin/adiponectin ratio was correlated with HOMA-IR (r: 0.57, P = 0.001). The prevalence of OW/OB and MetS are elevated in the childhood survivors of ALL. Post-treatment OW/OB in survivors is related with OW/OB at diagnosis and dexamethasone containing therapy. Elevated leptin level and leptin: adiponectin ratio may serve as an early sign of metabolic derangement increasing the risk for early cardiovascular disease.

Effect of the tyrosine kinase inhibitors on the growth in children with Philadelphia chromosome-positive acute lymphoblastic leukemia: a case-control study

Background

First-generation ABL-targeted tyrosine kinase inhibitor (TKI) imatinib is known to retard growth in children but it is not known if the second-generation ABL-targeted TKI dasatinib has the same effect. We aimed to determine the impact of the first- or second-generation TKI on the growth of children treated for Philadelphia chromosome-positive (Ph+) childhood acute lymphoblastic leukemia (ALL).

Methods

We evaluated the longitudinal growth changes in 140 children with Ph+ ALL treated with imatinib or dasatinib in additional to intensive cytotoxic chemotherapy and 280 matched controls treated with the same intensity of cytotoxic chemotherapy without TKI on Chinese Children's Cancer Group ALL-2015 protocol between 2015 and 2019. We retrospectively reviewed the height data obtained during routine clinic visits at 4 time points: at diagnosis, the end of therapy, 1 year and 2 years off therapy. Height z Scores were derived with the aid of WHO Anthro version 3.2.2 and WHO AnthroPlus version 1.0.4, global growth monitoring tool.

Findings

This study consisted only patients who have completed all treatment in continuous complete remission without major events, including 33 patients randomized to receive imatinib, 43 randomized to receive dasatinib, and 64 assigned to receive dasatinib. Similar degree of loss of height z scores from diagnosis to the end of therapy was observed for the 33 imatinib- and the 107 dasatinib-treated patients (median △ = -0.84 vs. -0.88, P = 0.41). Adjusting for height z score at diagnosis, puberty status, and sex, there was no significant difference in the longitudinal mean height z scores between patients treated with imatinib and those with dasatinib (0.08, 95% CI, -0.22 to 0.38, P = 0.60). The degree of loss of height z scores from diagnosis to end of therapy was significantly greater in the 140 TKI-treated patients than the 280 controls (median △ = -0.88 vs. -0.18, P < 0.001). The longitudinal mean height z scores in the TKI-treated patients were significantly lower than those of the controls (-0.84, 95% CI, -0.98 to -0.69; P < 0.001).

Interpretation

These data suggest that dasatinib and imatinib have the similar adverse impact on the growth of children with Ph+ ALL.

Funding

This study was supported by the National Natural Science Foundation of China (grant 81670136 [JCai and JT]), the fourth round of Three-Year Public Health Action Plan (2015-2017; GWIV-25 [SS]), Shanghai Health Commission Clinical Research Project (202140161 [JCai]), the US National Cancer institute (CA21765 [C-H Pui]), and the American Lebanese Syrian Associated Charities (CC, JJY, and C-HP). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health.

Does Systemic Chemotherapy Influence Skeletal Growth of Young Osteosarcoma Patients as a Treatment-Related Late Adverse Effect?

The aim of this study was to investigate the influence of systemic chemotherapy on the skeletal growth of young osteosarcoma patients as a treatment-related late adverse effect. We reviewed the height data of 20 osteosarcoma patients (13 males and 7 females) aged ≤18 years. The average (±SD) age at diagnosis was 14.5 (±3.3) years. The average follow-up interval was 89.6 months. After wide resection of the affected bones, reconstruction with tumor prostheses and auto-bone grafting was carried out in 11 and 9 cases, respectively. Pearson’s correlation coefficient was calculated to evaluate the association between actual and predicted (using Paley’s multiplier method) heights. Z-scores were used to compare the initial and final heights with the Japanese national growth curve. Actual and predicted heights were correlated according to Pearson’s correlation coefficient (R = 0.503). Z-analysis showed that statistical significance (p = 0.04) was noted for the height data Z-scores of patients between ≤10 years and >10 years at the final follow-up. Systemic chemotherapy did not reduce skeletal growth in young osteosarcoma patients as a late adverse effect based on two different evaluation methods. However, patients aged ≤10 years at diagnosis may develop a short stature after systemic chemotherapy.

Evaluation of blood pressure in pediatric survivors of acute lymphoblastic leukemia and healthy children; A case-control study

Background:

The exact prevalence of hypertension in children surviving acute lymphoblastic leukemia (ALL) has not been fully estimated. The aim of this study was to investigate the prevalence of arterial hypertension (AH) and to determine the risk factors for the development of AH in children surviving ALL with current treatments.

Materials and Methods:

A total of 150 patients (84 males, 66 females, with an age range of 1–16 years) were included in the study. Demographic and clinical information of patients were initially recorded. Hypertension is defined as average systolic blood pressure (BP) and/or diastolic BP that is greater than the 95^th percentile for gender, age, and height.

Results:

The mean age at the assessment of BP was 11.3 and 9.8 years in the ALL and control group, respectively. A total of 20.6% of survivors of ALL and 10% of controls had high BP. Most patients in both groups had normal BP (65.3% patients in ALL group and 75.4% subjects in the control group). The number of patients with hypertension was significantly higher in ALL patients as compared with the control group (P = 0.026).

Conclusion:

The prevalence of AH in children surviving ALL is higher than in children in the general population, which emphasizes the need for regular monitoring of BP in children surviving ALL and intervention in the lifestyle of this population. Careful follow-up of BP status is warranted for long-term survivors of childhood cancer.

Bone health in glucocorticoid-treated childhood acute lymphoblastic leukemia

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.

Endocrine Health in Childhood Cancer Survivors

Endocrine late effects, including reproductive disorders and secondary thyroid cancer, have been reported in up to 50 %childhood cancer survivors (CCS) more than 5 years after treatment. Most endocrine disorders are amenable to treatment; awareness of symptoms is therefore of great importance. Recognition of these symptoms may be delayed however because many are nonspecific. Timely treatment of endocrine disorders improves quality of life in CCS and prevents possible consequences, such as short stature, bone and cardiovascular disorders, and depression. At-risk CCS must therefore be regularly and systematically monitored. This article provides a summary of the most commonly reported endocrine late effects in CCS.

Response to GH Treatment After Radiation Therapy Depends on Location of Irradiation

OBJECTIVES

Cancer survivors with GH deficiency (GHD) receive GH therapy (GHT) after 1+ year observation to ensure stable tumor status/resolution.

HYPOTHESIS

Radiation therapy (RT) to brain, spine, or extremities alters growth response to GHT.

AIM

Identify differences in growth response to GHT according to type/location of RT.

METHODS

The Pfizer International Growth Database was searched for cancer survivors on GHT for ≥5 years. Patient data, grouped by tumor type, were analyzed for therapy (surgery, chemotherapy, RT of the focal central nervous system, cranial, craniospinal, or total body irradiation [TBI] as part of bone marrow transplantation), sex, peak stimulated GH, age at GHT start, and duration from RT to GHT start. Kruskal-Wallis test and quantile regression modeling were performed.

RESULTS

Of 1149 GHD survivors on GHT for ≥5 years (male 733; median age 8.4 years; GH peak 2.8 ng/mL), 431 had craniopharyngioma (251, cranial RT), 224 medulloblastoma (craniospinal RT), 134 leukemia (72 TBI), and 360 other tumors. Median age differed by tumor group (P < 0.001). Five-year delta height SD score (SDS) (5-year ∆HtSDS; median [10th-90th percentile]) was greatest for craniopharyngioma, 1.6 (0.3-3.0); for medulloblastoma, 5-year ∆HtSDS 0.9 (0.0-1.9); for leukemia 5-year ∆HtSDS, after TBI (0.3, 0-0.7) versus without RT (0.5, 0-0.9), direct comparison P < 0.001. Adverse events included 40 treatment-related, but none unexpected.

CONCLUSIONS

TBI for leukemia had significant impact on growth response to GHT. Medulloblastoma survivors had intermediate GHT response, whereas craniopharyngioma cranial RT did not alter GHT response. Both craniospinal and epiphyseal irradiation negatively affect growth response to GH therapy compared with only cranial RT or no RT.

Nutritional Status and Growth Deficit in Children and Adolescents with Cancer at Different Moments of Treatment

BACKGROUND

Nutrition deficits are common in children and adolescents undergoing cancer treatment and can contribute to a worse prognosis. There are scarce studies regarding this context considering different moments of treatment. The aim of this study was to evaluate the association between moment of treatment and nutritional status in children and adolescents with cancer.

METHODS

A retrospective study was performed from January 2013 to December 2015, including data from all clinical records of patients under 18 years old with cancer. Clinical, nutritional support and anthropometric data were collected at four moments of treatment from cancer diagnosis: diagnosis (t₀), 3 mo, (t₁), 6 mo, (t₂) and 1 year (t₃). In addition, nutritional indicators were evaluated. Generalized Estimating Equation models were performed to analyze changes on anthropometric indices throughout four moments of treatment.

RESULTS

The sample comprised 73 patients and frequency of nutritional deficits ranged from 13.0% to 18.6%. All nutritional indicators decreased at t₁, showed a modest recovery at t₂ and a stronger recovery at t₃ (p < 0.001). Growth was also impacted during treatment, mainly on patients under 2 years in the first three months of treatment.

CONCLUSIONS

Moment of treatment was associated with growth deficit and decreased percentiles in development indicators.

Investigating fine motor deficits during maintenance therapy in children with acute lymphoblastic leukemia

OBJECTIVES

Children diagnosed with acute lymphoblastic leukemia (ALL) in their early childhood are more susceptible to neuromuscular and musculoskeletal impairments. This cross-sectional study was designed to address different types of fine motor impairments in Egyptian children diagnosed with ALL.

METHODS

Fifty-four children treated for ALL in maintenance phase aged from four to seven years were compared with an age- and sex-matched control group. Fine motor performance was assessed using the total fine motor form of the Bruininks-Oseretsky Test of Motor Proficiency-second edition (BOT-2). Sex- and age-specific norms of BOT-2 were used to calculate scale and standard scores in both groups.

RESULTS

Children with ALL had significantly impaired fine motor skills in all subtests and composites of BOT-2 compared with the typically developing group (P < 0.00001). Cumulative doses of vincristine, methotrexate, and dexamethasone revealed no significant correlation with any BOT-2 measure. Males performed significantly better than females in all BOT-2 scores except for the fine motor integration subtest and the total fine motor control composite as no significant differences were observed. The protocol risk stratum, duration of maintenance treatment, and the age at assessment did not significantly affect the BOT-2 measures.

CONCLUSION

About 67% of children with ALL on maintenance treatment experienced fine motor difficulties. Periodic evaluation along the course of chemotherapy could identify specific impaired fine motor domains providing the base for a successful rehabilitation program.

Nutrition of Children With Cancer in Brazil: A Systematic Review

PURPOSE

The objective of this systematic review was to describe nutrition-related publications on children and adolescents diagnosed with cancer in Brazil.

METHODS

The methodology followed that of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Medline, LILACS (the Latin American & Caribbean Health Sciences Literature), and Embase were searched in April 2019, and data extraction and rating of methodologic study quality (according to the National Institutes of Health quality score assessment) were performed independently by reviewers.

RESULTS

Twenty-seven studies met the inclusion criteria, reporting on 3,509 patients from 1994 to 2018. Most of the studies (74%) were of poor quality in methodology and reporting. Different cancer diagnoses were included in 52% of studies, whereas acute leukemia was the exclusive focus in 41%. The majority of the articles (70%) were from institutions in the Southeast Region of Brazil, mainly the state of São Paulo (74%); no publications were from the North Region of the country. Twelve studies addressed nutritional status and body composition, reporting an abundance of malnourished patients in the Brazilian population of children and adolescents with cancer. Six studies on micronutrients pointed to possible deficiencies in this population, with a yet unclear but promising role for supplementation during treatment.

CONCLUSION

Evidence indicates that there is great interest in the impact of nutrition on childhood cancer treatment and clinical outcomes in Brazil. However, there is a need to focus on high-quality research, particularly with multicentric/national studies. This will help establish research priorities and better planned clinical interventions, adapted to each region of the country.

Endocrine and Metabolic Disorders in Survivors of Childhood Cancers and Health-Related Quality of Life and Physical Activity

CONTEXT

Childhood cancer survivors experience chronic health conditions that impact health-related quality of life (HRQOL) and participation in optimal physical activity.

OBJECTIVE

The study aimed to determine independent effects of endocrine and metabolic disorders on HRQOL and physical activity.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort with longitudinal follow-up of survivors of childhood cancer enrolled in the North American Childhood Cancer Survivor Study.

MAIN OUTCOME MEASURES

Medical Outcomes Short Form-36 estimated HRQOL, and participation in physical activity was dichotomized as meeting or not meeting recommendations from the Centers for Disease Control and Prevention. Log binomial regression evaluated the association of each endocrine/metabolic disorder with HRQOL scales and physical activity.

RESULTS

Of 7287 survivors, with a median age of 32 years (range, 18 to 54 years) at their last follow-up survey, 4884 (67%) reported one or more endocrine/metabolic disorders. Survivors with either disorder were significantly more likely to be male, older, have received radiation treatment, and have experienced other chronic health conditions. After controlling for covariates, survivors with any endocrine/metabolic disorder were more likely to report poor physical function risk ratio (RR, 1.25; 95% CI, 1.05 to 1.48), increased bodily pain (RR, 1.27; 95% CI, 1.12 to 1.44), poor general health (RR, 1.49; 95% CI, 1.32 to 1.68), and lower vitality (RR, 1.21; 95% CI, 1.09 to 1.34) compared with survivors without. The likelihood of meeting recommended physical activity was lower among survivors with growth disorders (RR, 0.90; 95% CI, 0.83 to 0.97), osteoporosis (RR, 0.87; 95% CI, 0.76 to 0.99), and overweight/obesity (RR, 0.92; 95% CI, 0.88 to 0.96).

CONCLUSION

Endocrine and metabolic disorders are independently associated with poor HRQOL and suboptimal physical activity among childhood cancer survivors.

Changes in body mass index, height, and weight in children during and after therapy for acute lymphoblastic leukemia

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) have an increased risk of obesity and short stature. To the authors' knowledge, data regarding patients treated on contemporary protocols without cranial irradiation are limited.

METHODS

Changes in z scores for body mass index (BMI), height, and weight from the time of diagnosis to 5 years off therapy were evaluated using multivariable analysis in 372 children with ALL who were aged 2 to 18 years at the time of diagnosis and were enrolled on the St. Jude Children's Research Hospital Total XV protocol from 2000 through 2007.

RESULTS

The percentage of overweight/obese patients increased from 25.5% at the time of diagnosis to approximately 50% during the off-therapy period. Median BMI z scores increased significantly during glucocorticoid therapy (induction: ∆0.56; 95% confidence interval [95% CI], 0.29-0.64 [P<.001]; and reinduction II: ∆0.22; 95% CI, 0.13-0.49 [P=.001]) and during the first year after therapy (∆0.18; 95% CI, 0.08-0.46 [P=.006]). Among patients who were of healthy weight/underweight at the time of diagnosis, those aged 2 to <10 years at diagnosis had a significantly higher risk of becoming overweight/obese during or after therapy compared with those aged ≥10 years (P=.001). Height z scores declined during treatment and improved after therapy. Being aged 2 to <10 years at the time of diagnosis, being of low-risk status, having a white blood cell count < 50×10⁹ /L at the time of diagnosis, and having negative central nervous system disease were associated with significantly better improvements in z scores for height during the off-therapy period compared with being aged ≥10 years, being of standard-risk/high-risk status, having a white blood cell count  ≥ 50×10⁹ /L, and having positive central nervous system disease, respectively.

CONCLUSIONS

The results of the current study demonstrate that obesity is prevalent, and height growth, especially in patients with identified risk factors, appears compromised. Multidisciplinary intervention should begin during induction therapy and continue during the off-therapy period.

Hypothalamic-Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To formulate clinical practice guidelines for the endocrine treatment of hypothalamic-pituitary and growth disorders in survivors of childhood cancer.

PARTICIPANTS

An Endocrine Society-appointed guideline writing committee of six medical experts and a methodologist.

CONCLUSIONS

Due to remarkable improvements in childhood cancer treatment and supportive care during the past several decades, 5-year survival rates for childhood cancer currently are >80%. However, by virtue of their disease and its treatments, childhood cancer survivors are at increased risk for a wide range of serious health conditions, including disorders of the endocrine system. Recent data indicate that 40% to 50% of survivors will develop an endocrine disorder during their lifetime. Risk factors for endocrine complications include both host (e.g., age, sex) and treatment factors (e.g., radiation). Radiation exposure to key endocrine organs (e.g., hypothalamus, pituitary, thyroid, and gonads) places cancer survivors at the highest risk of developing an endocrine abnormality over time; these endocrinopathies can develop decades following cancer treatment, underscoring the importance of lifelong surveillance. The following guideline addresses the diagnosis and treatment of hypothalamic-pituitary and growth disorders commonly encountered in childhood cancer survivors.

Overweight and obesity management strategies in survivors of paediatric acute lymphoblastic leukaemia: a systematic review protocol

INTRODUCTION

Acute lymphoblastic leukaemia is the most common paediatric cancer. Survivors of childhood acute lymphoblastic leukaemia (SALL) are at risk of obesity and related cardiometabolic diseases including type 2 diabetes, hypertension, stroke and cardiovascular events. Therefore, it is important to address obesity in this population as this may help mitigate future cardiometabolic comorbidities. In this systematic review, we aim to assess current treatment strategies including lifestyle interventions, pharmacotherapy and bariatric surgery to manage overweight and obesity in SALL.

METHODS AND ANALYSIS

We will search the following databases for primary studies: CINAHL, SPORTDiscus, EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. In addition, unpublished primary studies will be searched in ClinicalTrials.gov as well as conference proceedings, presentations, abstracts, editorials and ProQuest Dissertations and Theses A&I. Reviewers will perform title, abstract, and full-text screening as well as data abstraction and risk of bias assessment independently with a third reviewer to be consulted to resolve disagreements. Searches will be run and updated through May 1st, 2018. The overall quality of the evidence will be determined using the Grading of Recommendations, Assessment, Development, and Evaluation criteria for each outcome. A meta-analysis will be performed if two studies deploying similar interventions, populations, and design and outcomes are identified.

ETHICS AND DISSEMINATION

As individual patient data will not be included, we do not require ethics approval. This review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42016051031.

The influence of genetic variation on late toxicities in childhood cancer survivors: A review

INTRODUCTION

The variability in late toxicities among childhood cancer survivors (CCS) is only partially explained by treatment and baseline patient characteristics. Inter-individual variability in the association between treatment exposure and risk of late toxicity suggests that genetic variation possibly modifies this association. We reviewed the available literature on genetic susceptibility of late toxicity after childhood cancer treatment related to components of metabolic syndrome, bone mineral density, gonadal impairment and hearing impairment.

METHODS

A systematic literature search was performed, using Embase, Cochrane Library, Google Scholar, MEDLINE, and Web of Science databases. Eligible publications included all English language reports of candidate gene studies and genome wide association studies (GWAS) that aimed to identify genetic risk factors associated with the four late toxicities, defined as toxicity present after end of treatment.

RESULTS

Twenty-seven articles were identified, including 26 candidate gene studies: metabolic syndrome (n = 6); BMD (n = 6); gonadal impairment (n = 2); hearing impairment (n = 12) and one GWAS (metabolic syndrome). Eighty percent of the genetic studies on late toxicity after childhood cancer had relatively small sample sizes (n < 200), leading to insufficient power, and lacked adjustment for multiple comparisons. Only four (4/26 = 15%) candidate gene studies had their findings validated in independent replication cohorts as part of their own report.

CONCLUSION

Genetic susceptibility associations are not consistent or not replicated and therefore, currently no evidence-based recommendations can be made for hearing impairment, gonadal impairment, bone mineral density impairment and metabolic syndrome in CCS. To advance knowledge related to genetic variation influencing late toxicities among CCS, future studies need adequate power, independent cohorts for replication, harmonization of disease outcomes and sample collections, and (international) collaboration.

Growth and pubertal patterns in young survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Survivors of acute lymphoblastic leukemia (ALL) may experience endocrine dysfunction. This study evaluated growth and pubertal patterns in survivors of childhood ALL.

METHODS

Longitudinal assessment of anthropometric measurements and pubertal status was performed in a retrospective cohort of survivors (n=183). Median age at last endocrine visit was 16.1 years (range 8.2-27.6); median follow-up time was 8.7 years (range 3-21.4).

RESULTS

Treatment with chemotherapy+prophylactic cranial radiation (pCRT, n=29) was associated with lower mean height standard deviation score (SDS) than chemotherapy alone (n=154) (p=0.001) and higher prevalence of adult short stature (13% vs. 2.2%). Mean age at pubertal onset was normal (girls: 10.3±1.3 years; boys: 12.0±1.3 years). Precocious puberty, diagnosed in 8.7% of patients, was more prevalent in pCRT-treated girls. Rates of overweight and obesity were 22.9% and 9.3%, respectively. Predictors of endocrine disorders were pCRT (p=0.031) and female gender (p=0.041); of obesity, higher body mass index (BMI)-SDS at diagnosis (p=0.001); and of short stature, lower height-SDS at diagnosis (p=0.038).

CONCLUSIONS

Most childhood ALL survivors given chemotherapy alone attain normal adult height and puberty. Childhood ALL survivors are at increased risk of overweight, especially those with increased BMI at diagnosis. Clinicians should screen for overweight early in survivorship and introduce early interventions.

Long-Term Effect of Cranial Radiotherapy on Pituitary-Hypothalamus Area in Childhood Acute Lymphoblastic Leukemia Survivors

Survival rates of childhood cancer have improved markedly, and today more than 80 % of those diagnosed with a pediatric malignancy will become 5-year survivors. Nevertheless, survivors exposed to cranial radiotherapy (CRT) are at particularly high risk for long-term morbidity, such as endocrine insufficiencies, metabolic complications, and cardiovascular morbidity. Deficiencies of one or more anterior pituitary hormones have been described following therapeutic CRT for primary brain tumors, nasopharyngeal tumors, and following prophylactic CRT for childhood acute lymphoblastic leukemia (ALL). Studies have consistently shown a strong correlation between the total radiation dose and the development of pituitary deficits. Further, age at treatment and also time since treatment has strong implications on pituitary hormone deficiencies. There is evidence that the hypothalamus is more radiosensitive than the pituitary and is damaged by lower doses of CRT. With doses of CRT <50 Gy, the primary site of radiation damage is the hypothalamus and this usually causes isolated GH deficiency (GHD). Higher doses (>50 Gy) may produce direct anterior pituitary damage, which contributes to multiple pituitary deficiencies. The large group of ALL survivors treated with CRT in the 70–80-ties has now reached adulthood, and these survivors were treated mainly with 24 Gy, and the vast majority of these patients suffer from GHD. Further, after long-term follow-up, insufficiencies in prolactin (PRL) and thyroid stimulating hormone (TSH) have also been reported and a proportion of these patients were also adrenocoticotrophic hormone (ACTH) deficient. CRT to the hypothalamus causes neuroendocrine dysfunction, which means that the choice of GH test is crucial for the diagnosis of GHD.

Comparison of height and weight after 12 vs. 18 Gy cranial radiation therapy in pediatric acute lymphoblastic leukemia (ALL) patients

Purpose

To compare the effect of 12 versus 18 Gy cranial radiation therapy (RT) on height and weight indices among pediatric patients with acute lymphoblastic leukemia (ALL).

Methods and materials

Records of children with ALL who were 2 to 14 years old at the time of RT and were treated at a single institution between 2000 and 2011 were reviewed. Patients' height, weight, and body mass index were converted into z-scores using the Centers for Disease Control growth charts to normalize the values to number of standard deviations from the mean. These values were measured at the pre-RT clinic visit and subsequent yearly intervals. The z-scores of the growth indices were fitted into a generalizing estimating equations model and analyzed by various clinical factors.

Results

A total of 48 patients met the study criteria, including 32 boys and 16 girls. The median age at the time of RT was 7 years (range, 2-14 years). Patients were separated into 2 dose groups: 12 Gy (n = 30) and 18 Gy (n = 18). Median follow-up was 4.9 years (range, 3.0-11.8 years) and 6.0 years (range, 3.1-10.5 years) and the median pre-RT height z-scores were −0.55 (range, −2.2 to 1.4) and −0.85 (range, −3.1 to 0.8) for the 2 groups, respectively (P = .65). Patients who received 18 Gy had a significant difference in change in height compared with those who received 12 Gy, who were able to maintain normal growth during the first 3 years of follow-up. This did not appear to be sex-specific, and there was no difference in change in weight or body mass index.

Conclusions

Compared with 18 Gy, patients with ALL who received 12 Gy of cranial RT had less height impairment in the first 3 years post-RT, but further prospective studies are needed.

The Associations of Height-for-Age, Weight-for-Age, and Weight-for-Height With Pediatric Acute Lymphoblastic Leukemia

Height at diagnosis has been analyzed in connection with acute lymphoblastic leukemia (ALL). Most prior studies have compared cases to national reference data derived from previous birth cohorts. Our objective was to determine the association of height-for-age Z score (HAZ) at time of diagnosis with the odds ratio (OR) of ALL in a case-control study (N=498) with a contemporaneous population of age-matched, sex-matched, and ethnicity-matched controls. We hypothesized that cases would have greater mean HAZ at time of diagnosis/interview, after adjustment for weight-for-age (WAZ) and weight-for-height (WHZ). HAZ was not associated with ALL. For each 1 SD increase in WAZ the OR of ALL was 0.83 (95% confidence interval [CI], 0.68-0.99). The OR of ALL was increased among children who had either a WAZ ≤-2 (OR, 5.10; 95% CI, 1.85-16.75) or WHZ of ≤-2 (OR, 5.27; 95% CI, 1.65-23.61). Previous findings of taller height among ALL cases may arise from the choice of control populations. Children with low WAZ or WHZ were at increased odds of ALL.

A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective From Children's Oncology Group

Over the past few decades, great progress has been made in the survival rates of childhood cancer. As survival rates have improved, there has been an increased focus on supportive care. Nutrition is a supportive-care modality that has been associated with improved tolerance to chemotherapy, improved survival, increased quality of life, and decreased risk of infection in children undergoing anticancer therapy. Guidelines and assessment criteria have been proposed for the nutrition management of a child with cancer; however, there is no consistent use of criteria among institutions treating children with cancer. This review will present the current evidence and standards of practice incorporating aspects of nutrition, nursing, pharmacology, and psychosocial challenges to consider in the nutrition management of a child with cancer. Recommendations for clinical practice are presented.

Evaluation of Endocrine Late Complications in Childhood Acute Lymphoblastic Leukemia Survivors: A Report of a Single-Center Experience and Review of the Literature

Objective:

Improvement in long-term survival in patients with acute lymphoblastic leukemia (ALL) in childhood has led to the need for monitorization of treatment-related morbidity and mortality. In the current study, we aimed to evaluate endocrine side effects of treatment in ALL survivors who were in remission for at least 2 years.

Materials and Methods:

Sixty patients diagnosed with ALL, who were in remission for at least 2 years, were cross-sectionally evaluated for long-term endocrine complications.

Results:

The median age of the patients at the time of diagnosis, at the time of chemotherapy completion, and at the time of the study was 5 years (minimum-maximum: 1.7-13), 8 years (minimum-maximum: 4.25-16), and 11.7 years (minimum-maximum: 7-22), respectively, and median follow-up time was 4 years (minimum-maximum: 2-10.1). At least one complication was observed in 81.6% of patients. Vitamin D insufficiency/deficiency (46.6%), overweight/obesity (33.3%), and dyslipidemia (23.3%) were the three most frequent endocrine complications. Other complications seen in our patients were hyperparathyroidism secondary to vitamin D deficiency (15%), insulin resistance (11.7%), hypertension (8.3%), short stature (6.7%), thyroid function abnormality (5%), precocious puberty (3.3%), and decreased bone mineral density (1.7%). There were no statistically significant correlations between endocrine complications and age, sex, and radiotherapy, except vitamin D insufficiency/deficiency, which was significantly more frequent in pubertal ALL survivors compared to prepubertal ALL survivors (57.5% and 25%, respectively, p=0.011).

Conclusion:

A high frequency of endocrine complications was observed in the current study. The high frequency of late effects necessitates long-term surveillance of this population to better understand the incidence of late-occurring events and the defining of high-risk features that can facilitate developing intervention strategies for early detection and prevention.

Growth in Children Treated for Acute Lymphoblastic Leukemia: Single Institution Report from North India

Survivors of childhood leukemia are at risk of impaired growth and short stature as adults due to intensive combination chemotherapy and radiation injury. This study was undertaken to evaluate anthropometry in children treated for acute lymphoblastic leukemia (ALL). Children treated for ALL and off treatment for a minimum period of 2 years were evaluated for height, weight and BMI. Z scores were calculated for height, weight and BMI: at induction, 6 months after starting treatment, at end of treatment and at 2 years after completion of therapy. Change in z scores were calculated and compared with CDC criteria and Agarwal standards for Indian children. Fifty two boys and 21 girls were analyzed. Height and weight z scores were seen to show a steep decrease during the initial intensive phase of therapy. The gain in height and weight continued to be slow during therapy and catch up occurred after cessation of therapy. On completion of therapy, patients were shorter, but not significantly so. Girls <9 years were significantly shorter. Weight remained on the lower side of normal. Change of z scores was statistically significant for weight at end of treatment (p = 0.032) and 2 years after completion of treatment (p = 0.00). BMI z score increased throughout the study period. Peak growth velocities were also late in the study subjects Anthropometric variables of height, weight and BMI are affected by ALL during therapy. Growth deceleration is maximum during the intensive phase of therapy. Catch up growth occurs but children remain smaller than their peers.

Assessment of Fundamental Movement Skills in Childhood Cancer Patients

BACKGROUND

The improved treatment protocols and subsequent improved survival rates among childhood cancer patients have shifted the focus toward the long-term consequences arising from cancer treatment. Children who have completed cancer treatment are at a greater risk of delayed development, diminished functioning, disability, compromised fundamental movement skill (FMS) attainment, and long-term chronic health conditions. The aim of the study was to compare FMS of childhood cancer patients with an aged matched healthy reference group.

METHODS

Pediatric cancer patients aged 5-8 years (n = 26; median age 6.91 years), who completed cancer treatment (<5 years) at the Sydney Children's Hospital, were assessed performing seven key FMS: sprint, side gallop, vertical jump, catch, over-arm throw, kick, and leap. Results were compared to the reference group (n = 430; 6.56 years).

RESULTS

Childhood cancer patients scored significantly lower on three out of seven FMS tests when compared to the reference group. These results equated to a significantly lower overall score for FMS.

CONCLUSIONS

This study highlighted the significant deficits in FMS within pediatric patients having completed cancer treatment. In order to reduce the occurrence of significant FMS deficits in this population, FMS interventions may be warranted to assist in recovery from childhood cancer, prevent late effects, and improve the quality of life in survivors of childhood cancer.

Evaluation of Relationship Between Demographics and Dental Status in a Defined Group of Iranian Paediatric Patients Undergoing Cancer Therapy

CONTEXT

Cancer is a major cause of death in children under 15 years of age.

AIMS

This study aimed to evaluate relationship between demographics and dental status in a defined group of Iranian paediatric patients undergoing cancer therapy.

SETTINGS AND DESIGN

This cross-sectional study was accomplished on 161 subjects age ranging 8-12 years. There were 76 cancerous patients hospitalized at Mahak Hospital (one of the major children's cancer centers in Tehran) as the study group and 85 healthy children attending at Dental School, International Branch of Shahid Beheshti University of Medical Sciences, Tehran, Iran from 2012 to 2013.

MATERIALS AND METHODS

Demographics were gathered by using data-form. Oral examination and DMFT Index were used to describe teeth status in all teeth and in the first permanent molars. According to Becker's definition, "D" stands for untreated decayed teeth, "M" indicates missing teeth, and "F" shows Filled teeth. It is noteworthy that full coverage crowns are considered as "F" in this Index.

STATISTICAL ANALYSIS

Chi-square, Mann-Whitney U, Student's t-tests and Logistic Regression were used for data analysis.

RESULTS

The most frequent type of cancer was acute lymphoblastic/lymphocytic leukemia (33.3%). Patients were significantly shorter than controls (p=0.03), and their fathers and mothers were of lower educational achievement (p=0.01, p= 0.001). Although DMFT of all dentition showed significantly higher score in cancerous children (p=0.001), DMFT of four first permanent molars (left, right, upper, and lower) was borderline significantly higher in patients (p= 0.06). Moreover, frequency of cancer was borderline significantly higher in children with lower birth order (p= 0.05). According to Logistic Regression, in as much as patients grew elder 1 year, DMFT index increased 1.5 units.

CONCLUSION

Patients under cancer therapy were shorter than healthy ones, and their parents were of lower educational levels. In addition, their teeth status was poorer than controls.

Short stature in retinoblastoma survivors: a cross-sectional study of 138 patients

PURPOSE

Short stature has been reported in pediatric cancer survivors. Data on retinoblastoma survivors are limited. We conducted a cross-sectional study to assess the height in retinoblastoma survivors.

METHOD

The recorded height was compared with median height for age and sex as per the Indian Academy of Pediatrics. Z-score less than -2 was considered short statured.

RESULT

Thirty percent of the survivors were short statured. The mean height was shorter than the mean 50th percentile height (119.7 ± 14.8 vs 128.7 ± 15 cm, p < 0.001). Previous chemotherapy showed a trend toward association (p = 0.09).

CONCLUSION

Short stature affects a significant number of retinoblastoma survivors.

The association between glucocorticoid therapy and BMI z-score changes in children with acute lymphoblastic leukemia

PURPOSE

Few studies have addressed the common issue of weight gain in children with acute lymphoblastic leukemia (ALL) during early phases of treatment, and even fewer have used the appropriate measure for weight fluctuation in children, BMI-for-age z-scores (BAZs). The purpose of this study is thus to measure the extent of the weight gain in BAZ during the 150 first days of treatment and to identify factors associated with the weight gain. Furthermore, we wish to raise the question of whether changes in treatment protocols automatically should be followed by an evaluation of the nutritional guidelines.

METHOD

In this retrospective study, the medical records of 51 children with ALL treated with the NOPHO ALL 2008 protocol at Copenhagen University Hospital were assessed. Patient characteristics were extracted, and height, weight, and age during the first 150 days of treatment were converted to BAZ.

RESULTS

During 150 days of treatment, the proportion of overweight/obese patients increased significantly from 9.8 to 33.3 %. The mean change in BAZ (∆BAZ) was +1 standard deviation (0.02 ± 1.16 vs. 1.12 ± 1.44; p < 0.001) and BAZ increased significantly during periods with glucocorticoid (GC) treatment but not in periods without GC. ΔBAZ was larger in boys compared to girls, and ΔBAZ was higher in patients who were under/normal weight at diagnosis, compared to patients who were overweight/obese (1.26 ± 1.29 vs. -0.04 ± 0.41; p = 0.032).

CONCLUSION

BAZ increased significantly in children with ALL during the initial treatment with the NOPHO ALL 2008 protocol. This is likely associated with the GC administration and influenced by gender and initial BAZ.

Impairments that influence physical function among survivors of childhood cancer

Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.

Final height and body mass index in adult survivors of childhood acute lymphoblastic leukemia treated without cranial radiotherapy: a retrospective longitudinal multicenter Italian study

Background

Young adult survivors of childhood acute lymphoblastic leukemia (ALL) treated with protocols including cranial radiotherapy demonstrate a persistent weight gain and reduced final height. Published reports on the effects on growth of different oncologic therapies are conflicting and difficult to interpret because they combined children treated with both cranial irradiation and multi-agent chemotherapy. Our study investigated the effect of chemotherapy alone on body mass index (BMI) and on growth at the achievement of final height in a homogeneous cohort of Italian childhood ALL survivors.

Methods

We retrospectively studied 162 Caucasian patients treated on the Italian Association of Pediatric Hematology and Oncology protocols without radiotherapy between 1989 and 2000 at five Italian centers with 107 inclusions (58 males). Height- and BMI-standard deviation score (SDS) were collected at diagnosis of ALL, at the end of treatment and at the achievement of final height. Changes in height SDS and BMI SDS with time were analyzed using dependent sample Student's t-test.

Results

A significant reduction of height-SDS was documented during treatment in both genders. This reduction of height-SDS was not followed by an appropriate catch-up growth, despite the achievement of a mean final height within the normal range. At diagnosis females showed a lower mean BMI-SDS than males. During treatment, in the whole population, BMI-SDS increased significantly. After it, while males lost BMI-SDS, females showed its persistent increase.

Conclusions

Survivors of childhood ALL generally seemed to achieve a normal final height with a BMI within the normal range. These parameters appeared to be only minimally affected by chemotherapy. Nevertheless, height catch-up growth was not completed after chemotherapy in both genders and all patients experienced an increase of BMI-SDS during chemotherapy that only females seemed to conserve until the achievement of final height.

Energy balance and metabolism after cancer treatment

Unfavorable physiological, biological, and behavioral alterations during and following treatment for cancer may lead to chronic energy imbalance predisposing to a myriad of deleterious health conditions including obesity, dyslipidemia, and the metabolic syndrome. In addition to the cardiovascular and musculoskeletal effects of these conditions, energy imbalance and metabolic changes after cancer treatment can also affect cancer-related morbidity and mortality. To this end, lifestyle interventions such as diet and physical activity are especially relevant to mitigate the deleterious impact of chronic energy imbalance in cancer survivors.

Cranial radiotherapy predisposes to abdominal adiposity in survivors of childhood acute lymphocytic leukemia

Background

Advances in treatment of acute lymphocytic leukemia increased the likelihood of developing late treatment-associated effects, such as abdominal adiposity, increasing the risk of cardiovascular disease in this population. Cranial radiotherapy is one of the factors that might be involved in this process. The aim of this study was to determine the effect of cranial radiotherapy on adiposity indexes in survivors of acute lymphocytic leukemia.

Methods

A comparative cross-sectional study of 56 acute lymphocytic leukemia survivors, chronological age between 15 and 24 years, assigned into two groups according to the exposure to cranial radiotherapy (25 irradiated and 31 non-irradiated), assessed according to body fat (dual energy X-ray absorptiometry), computed tomography scan-derived abdominal adipose tissue, lipid profile, and insulin resistance.

Results

Cranial radiotherapy increased body fat and abdominal adipose tissue and altered lipid panel. Yet, lipids showed no clinical relevance so far. There were significantly more obese patients among those who received cranial radiotherapy (52% irradiated versus 22.6% non-irradiated), based on dual energy X-ray absorptiometry body fat measurements. Nonetheless, no association was observed between cranial radiotherapy and body mass index, waist circumference, waist-to-height ratio or insulin resistance.

Conclusions

Adolescent and young adult survivors of childhood acute lymphocytic leukemia showed an increase in body fat and an alteration of fat distribution, which were related to cranial radiotherapy. Fat compartment modifications possibly indicate a disease of adipose tissue, and cranial radiotherapy imports in this process.

Modeling height for children born small for gestational age treated with growth hormone

The analysis of growth curves of children can be done on either the original scale or in standard deviation scores. The first approach is found in many statistical textbooks, while the second approach is common in endocrinology, for instance in the evaluation of the effect of growth hormone in children that are born small for gestational age that remain small later in childhood. We illustrate here that the second approach may involve more complex modeling and hence a worse model fit.

Differential effects of radiotherapy on growth and endocrine function among acute leukemia survivors: a childhood cancer survivor study report

BACKGROUND

The differential effects of cranial radiotherapy (CRT), spinal radiotherapy (SRT), and total body irradiation (TBI) on growth and endocrine outcomes have rarely been examined in combination among childhood acute leukemia survivors.

PROCEDURE

Self-reported height/weight, hypothyroidism, and pregnancy/live birth were determined among acute lymphoblastic and myeloid leukemia survivors (n = 3,467) participating in the Childhood Cancer Survivor Study, an ongoing cohort study of 5-year survivors of pediatric cancers diagnosed from 1970 to 1986.

RESULTS

Compared with no radiotherapy, risk estimates were consistent across outcomes (adult short stature, hypothyroidism, absence of pregnancy/live birth) with CRT treatment associated with 2-3-fold increased risks, TBI associated with 5-10 fold increased risks, and CRT + TBI associated with >10 fold increased risks. Exposure to any SRT further increased risk of these outcomes 2-3-fold. Changes in body composition were more nuanced as CRT only was associated with an increased risk of being overweight/obese (OR 1.6, 95% CI 1.3-1.9) whereas TBI only was associated with an increased risk of being underweight (OR 6.0, 95% CI 2.4-14.9).

CONCLUSIONS

Although patients treated with CRT + TBI were at greatest risk for short stature, hypothyroidism, and a reduced likelihood of pregnancy/live birth, those treated with either modality alone had significantly increased risks as well, including altered body composition. Any SRT exposure further increased risk in an independent fashion.

Tolerance and efficacy of preventive gastrostomy feeding in pediatric oncology

BACKGROUND

Malnutrition in pediatric oncology remains underestimated, although having a negative impact on outcome. Enteral nutrition (EN) using percutaneous endoscopic gastrostomy (PEG) may prevent or reverse malnutrition consequences. We aimed to evaluate both efficacy and safety of early EN during tumors treatment in children.

PROCEDURES

Medical records of pediatric patients having a PEG tube inserted between 1995 and 2009 were retrospectively reviewed. We compared type and incidence of complications in Group 1, including 74 patients suffering from cancer, and control Group 2, including 57 patients with neurological impairment. Efficacy of EN was evaluated through nutritional parameters [Z-scores weight for height (W/H) and height for age (H/A)], post-operative complications and relapse rates. Statistical significance was set for P < 0.05.

RESULTS

PEG tolerance was similar in both groups, as shown by comparable complication rates (62% vs. 76%, NS). EN allowed improvement or stabilization of Z-score W/H in 76% of oncologic patients. The final height loss was lower (-0.5 vs. -1.2 SD of Z-scores H/A) when EN was started at the beginning of the oncologic treatment. In bone tumors, EN prevented weight loss during chemotherapy, and tended to lessen surgical complications, relapses and deaths.

CONCLUSIONS

Early gastrostomy feeding represents a relatively safe way to prevent malnutrition in children with cancer, and might play a role in bone tumors oncological outcome. Further prospective studies are needed to confirm these results and assess the impact of EN and PEG on quality of life.

Longitudinal changes in body mass and composition in survivors of childhood hematologic malignancies after allogeneic hematopoietic stem-cell transplantation

PURPOSE

To measure longitudinal changes in body mass and composition in survivors of childhood hematologic malignancies after allogeneic hematopoietic stem-cell transplantation (HSCT).

PATIENTS AND METHODS

Body mass index (BMI) was analyzed in 179 survivors by category (underweight, healthy-weight, overweight, and obese) and by z score. Fat and lean body mass measured by dual-energy x-ray absorptiometry was analyzed as z scores.

RESULTS

Over a median 6.6 years of follow-up, BMI z scores diminished significantly (0.32 pre-HSCT v -0.60 at 10 years post-HSCT; P < .001). Mean z scores for fat mass stayed within population norms, but those for lean mass remained below normal levels and diminished significantly over time (P = .018). Pre-HSCT BMI category and/or z score were strongly predictive of post-HSCT BMI (P < .001) and of fat and lean mass z scores (both P < .001). Survivors with extensive chronic graft-versus-host disease were more likely than others to have low BMI (P = .004) and low lean mass (P < .001) post-HSCT. Older age at HSCT (P = .015) and T-cell-depleted graft (P = .018) were predictive of lower post-HSCT BMI. Female patients had higher body fat (P = .002) and lower lean mass (P = .013) z scores than male patients, and black patients had higher fat mass z scores than white patients (P = .026).

CONCLUSION

BMI declines significantly after allogeneic HSCT for childhood hematologic malignancies, reflecting primarily a substantial decrease in lean mass but not fat mass. Monitoring and preservation of BMI and lean mass are vital, especially in those with the identified risk factors.

C-type Natriuretic Peptide: a novel biomarker of steroid induced bone toxicity in children with acute lymphoblastic leukemia (ALL)

Impaired bone growth and mineralization, and osteonecrosis are significant and common long-term sequelae of chemotherapy for childhood acute lymphoblastic leukemia (ALL). Here we have evaluated the relationship between linear bone growth during chemotherapy for ALL and bone derived C-type Natriuretic Peptide (CNP). CNP is known to be critical to normal endochondral bone growth in both rodents and humans, and plasma concentration of the amino terminal pro CNP (NTproCNP) is strongly correlated with concurrent height velocity in children. Plasma NTproCNP and CNP were measured by radio-immunoassay in 12 children aged 2-9 years during induction and maintenance chemotherapy for children with ALL. Height velocity was calculated from stadiometer readings at intervals of 3-12 months and related to plasma NTproCNP during each growth interval. Plasma NTproCNP was markedly suppressed in all subjects during induction chemotherapy. Brief periods of NTproCNP decline and rapid rebound during maintenance treatment coincided with the use of dexamethasone but not with other chemotherapeutics. Height velocity was markedly reduced during ALL induction but unaffected in maintenance phase, and these changes in growth were strongly correlated with plasma NTproCNP concentration. Plasma NTproCNP has potential use as a biomarker of glucocorticoid-induced bone toxicity.

Role of genetic susceptibility in development of treatment-related adverse outcomes in cancer survivors

Clear and unambiguous associations have been established between therapeutic exposures and specific complications. However, considerable interindividual variability is observed in the risk of developing an outcome for a given therapeutic exposure. Genetic predisposition and especially its interaction with therapeutic exposures can potentially exacerbate the toxic effect of treatment on normal tissues and organ systems, and can possibly explain the interindividual variability. This article provides a brief overview of the current knowledge about the role of genomic variation in the development of therapy-related complications. Relatively common outcomes with strong associations with therapeutic exposures, including cardiomyopathy, obesity, osteonecrosis, ototoxicity, and subsequent malignancies are discussed here. To develop a deeper understanding of the molecular underpinnings of therapy-related complications, comprehensive and near-complete collection of clinically annotated samples is critical. Methodologic issues such as study design, definition of the endpoints or phenotypes, identification of appropriate and adequately sized study population together with a reliable plan for collecting and maintaining high-quality DNA, and selection of an appropriate approach or platform for genotyping are also discussed. Understanding the etiopathogenetic pathways that lead to the morbidity is critical to developing targeted prevention and intervention strategies, optimizing risk-based health care of cancer survivors, thus minimizing chronic morbidities and improving quality of life.

Blood pressure and body composition in long-term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Long-term survivors of acute lymphoblastic leukemia (ALL) in childhood are at increased risk of late effects of cancer treatment, among which are cardiovascular sequelae. Purpose of this study was to assess blood pressure and body composition in childhood ALL survivors and compare data to reference values from the general population.

PROCEDURE

This single-center retrospective study included 68 survivors of childhood ALL with a median age of 25 years (range 16.4-39.5) and a median follow-up of 16.0 years (range 5.3-30.4). Data on previous treatment, blood pressure and measurements of weight and height at diagnosis and at long-term follow-up (from which body mass index (BMI) was calculated) were obtained from medical records. All data were converted to control-referenced standard deviation scores.

RESULTS

Of the ALL survivors 48½% were prehypertensive and 22.1% were hypertensive. Both the mean systolic (mean SDS 0.736, P < 0.001) and diastolic blood pressure (mean SDS 0.409, P < 0.001) of survivors was significantly higher compared to reference control values. Based on BMI values, 38.2% of the survivors were considered overweight/obese and females, in contrast to males had a significantly higher BMI (mean SDS 1.355, P < 0.001) compared to reference values. In addition, females who had received cranial radiotherapy (mean SDS 2.078) had a significantly higher BMI than females who had not (mean SDS 0.512) (P = 0.009).

CONCLUSIONS

Both diastolic and systolic blood pressure are significantly increased in survivors of childhood ALL. Female survivors treated with cranial radiation therapy have the highest prevalence and greatest risk of overweight/obesity. Therefore, survivors of childhood ALL are likely to be at an increased risk of cardiovascular disease later in life, which stresses the need for follow-up and adequate medical and/or life style interventions.

Obesity in patients with acute lymphoblastic leukemia in childhood

Acute lymphoblastic leukemia is the most common malignancy in childhood. Continuous progress in risk-adapted treatment for childhood acute lymphoblastic leukemia has secured 5-year event-free survival rates of approximately 80% and 8-year survival rates approaching 90%. Almost 75% of survivors, however, have a chronic health condition negatively impacting on cardiovascular morbidity and mortality. Obesity can be considered one of the most important health chronic conditions in the general population, with an increasing incidence in patients treated for childhood cancers and especially in acute lymphoblastic leukemia survivors who are, at the same time, more at risk of experiencing precocious cardiovascular and metabolic co-morbidities. The hypothalamic-pituitary axis damage secondary to cancer therapies (cranial irradiation and chemotherapy) or to primary tumor together with lifestyle modifications and genetic factors could affect long-term outcomes. Nevertheless, the etiology of obesity in acute lymphoblastic leukemia is not yet fully understood. The present review has the aim of summarizing the published data and examining the most accepted mechanisms and main predisposing factors related to weight gain in this particular population.

Height impairment after lower dose cranial irradiation in children with acute lymphoblastic leukemia

PURPOSE

The purpose of this study is to determine whether height measurements are affected by cranial radiation doses of 12-18 Gy.

PATIENTS AND METHODS

From 1997 to 2007, 23 children received cranial RT for T-cell or pre-B-cell acute lymphoblastic leukemia (ALL). Dose fractionation schemes included 18 Gy in 9 fractions (n = 8), 18 Gy in 10 fractions (n = 5), 12.6 Gy in 7 fractions (n = 6), and 12 Gy in 8 fractions (n = 4). These patients were matched and compared to a control group of 23 patients who had ALL but no cranial RT. Height z-scores at diagnosis and last follow-up were compared using the paired Student's t-test. Differences in z-scores according to host and treatment parameters were compared using the unpaired Student's t-test. Median follow-up for irradiated patients was 63.5 months while for unirradiated patients was 91 months.

RESULTS

The mean z-scores at initial diagnosis and last follow-up were 0.14 and -0.48 for patients receiving 12-12.6 Gy (P = 0.016), -0.16 and -0.89 for 18 Gy (P = 0.003), and 0.34 and 0.22 for no RT (P = 0.62). For children receiving RT, the mean difference in z-scores at initial diagnosis and last follow-up was -0.67 while for those not receiving RT, it was -0.10 (P = 0.043).

CONCLUSION

Children receiving 12-18 Gy cranial RT for ALL were found to have height impairment compared to those not receiving RT.

Body mass index and annual increase of body mass index in long-term childhood cancer survivors; relationship to treatment

Purpose

Evaluation of body mass index (BMI) at final height (FH) and annual BMI increase in adult childhood cancer survivors (CCS) after treatment with anthracyclines, platinum, and/or radiotherapy.

Methods

BMI (weight/height²) was calculated retrospectively from diagnosis until FH. The prevalence of underweight (BMI < 18.5 kg/m²) and overweight (BMI ≥ 25 kg/m²)/obesity (BMI ≥ 30 kg/m²) at FH was compared with age-matched controls. The association between underweight/overweight at FH and treatment was assessed by multivariate logistic regression. Annual BMI increase after treatment was assessed by multilevel analysis. Analyses were adjusted for age and underweight/overweight at diagnosis, and age at FH.

Results

At FH the prevalence of overweight had not increased, while CCS experienced more underweight as compared to controls (14% vs. 4%, P < 0.001). Overweight at FH was associated with cranial/craniospinal radiotherapy (CRT; OR, 2.23; 95% CI, 1.17–4.26) and underweight at FH with anthracyclines > 300 mg/m² (OR, 2.84; 95% CI, 1.33–6.06). Annual BMI increase was +0.47 (0.34–0.60) kg/m²/year. In CCS, the annual BMI increase was greater in those with CRT ≥ 30 Gy as compared with those with less or no CRT (+0.15 kg/m²/year [0.04–0.25 kg/m²/year], P = 0.008) and smaller in those with a higher cumulative anthracycline dose (−0.03 kg/m²/year [−0.05 to −0.0005 kg/m²/year] per 100 mg/m², P = 0.046).

Conclusions

After treatment with anthracyclines, platinum, and/or radiotherapy, CRT-treated survivors have more overweight at FH, and a greater annual BMI increase, while anthracycline-treated survivors have more underweight at FH and a lower annual BMI increase.

Growth in children with acute lymphoblastic leukemia during treatment

Obesity is increasingly prevalent in affluent societies and portends considerable morbidity. This is especially true in children with acute lymphoblastic leukemia (ALL) in whom the metabolic syndrome may begin during therapy, demanding clarification of the trajectory of weight gain so that effective interventions may be developed. In this retrospective study of body mass index from a single institution over a 20-year period, almost 15% of children with ALL were at risk of overweight or frankly overweight (body mass index >85th centile) at diagnosis. This proportion increased steadily, reaching 40% at the end of treatment. Strategies to limit weight gain will have to be instituted early in the management of children with ALL, and will probably have to be maintained throughout and after the completion of active treatment.

Weight patterns in children with higher risk ALL: A report from the Children's Oncology Group (COG) for CCG 1961

BACKGROUND

This retrospective analysis defined and described patterns and predictors of weight change during treatment in children with acute lymphocytic leukemia (ALL) with high-risk features who received treatment on Children's Cancer Group protocol CCG 1961.

PROCEDURE

Patients (1,638) were enrolled in CCG 1961 from November 1996 to May 2002. Weight was measured as BMI percent (%), specific for age and gender, and defined as 100 x ln(BMI/median BMI).

RESULTS

By the end of treatment, 23% of children were obese (BMI >or=95%), compared with 14% at diagnosis. Children who received post-induction intensified therapy (arms C, D, SER with Doxorubicin or Idarubicin) had higher gastrointestinal toxicities and lower BMI% from consolidation through interim maintenance 1. BMI% then increased for all arms between delayed intensification and maintenance 1 or 2. Children who were of Black or Hispanic race, obese at diagnosis, or who had grade 3 or 4 pancreatitis/glucose toxicities during induction had higher BMI% throughout treatment. Children were more likely to be obese at the end of the study if they were aged 5-9 years at diagnosis or female gender. Cranial radiation was not a predictor of obesity.

CONCLUSIONS

Successful treatment of higher risk childhood ALL was associated with obesity, independent of cranial irradiation. The beginning of maintenance therapy may be the best time to intervene with nutritional and behavioral interventions, particularly for children who are obese or aged 5-9 years at diagnosis, female, Black or Hispanic, or those with metabolic toxicities during induction.