Bone mineral density deficits in childhood cancer survivors: Pathophysiology, prevalence, screening, and management

Comparison of psychosocial adaptations among childhood cancer survivors, their siblings and peers in Taiwan

PURPOSE

This study aimed to understand the difference in psychosocial adaptation among childhood cancer survivors, their healthy siblings and peers, and the factors affecting the psychosocial adaptation of these cancer survivors.

DESIGN AND METHODS

A total of 222 children (ages 8-17) including childhood cancer survivors, their siblings, and healthy peers participated in this cross-sectional study. All the children completed the anxiety and quality of life scales for their age groups.

RESULTS

Anxiety levels and quality of life were similar among the childhood cancer survivors, their siblings, and their peers. The anxiety of elementary school-age survivors of acute leukemia was higher than that of those with solid tumors. Elementary school-age survivors who completed three or more years of treatment had lower anxiety than those who completed treatment within the three years. For adolescent survivors, the higher their body mass index, the higher their anxiety, which was associated with low quality of life. Those diagnosed with anxiety and at an older age had lower quality of life.

CONCLUSIONS

Although there were no differences in survivors' psychosocial adaptation compared to their siblings and healthy peers, more than half of these adolescents had moderate to severe anxiety. Future study may need to explore the causes of their anxiety.

PRACTICE IMPLICATIONS

During the follow-ups of the childhood cancer survivors, age-specific adaptive strategies can be discussed to reduce their anxiety and improve their quality of life.

Individual Trajectories of Bone Mineral Density Reveal Persistent Bone Loss in Bone Sarcoma Patients: A Retrospective Study

Multiagent chemotherapy offers an undoubted therapeutic benefit to cancer patients, but is also associated with chronic complications in survivors. Osteoporosis affects the quality of life of oncologic patients, especially at the paediatric age. However, very few studies have described the extent of loss of bone mineral density (BMD) in bone sarcoma patients. We analysed a retrospective series of children and adolescents with primary malignant bone tumours (52 osteosarcoma and 31 Ewing sarcoma) and retrieved their BMD at diagnosis and follow-up as Hounsfield units (HU). We studied their individual BMD trajectories before and after chemotherapy up to 5 years, using routine chest CT scan and attenuation thresholds on T12 vertebrae ROI. At one year, bone sarcoma patients showed significant bone loss compared to diagnosis: 17.6% and 17.1% less for OS and EW, respectively. Furthermore, a bone loss of more than 49.2 HU at one-year follow-up was predictive of the persistence of a reduced bone mass over the following 4 years, especially in patients with EW. At 4 years, only 26% and 12.5% of OS and EW, respectively, had recovered or improved their BMD with respect to the onset, suggesting a risk of developing morbidities related to a low BMD in those subjects.

Osteoporosis in Childhood Cancer Survivors: Physiopathology, Prevention, Therapy and Future Perspectives

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.

Whole-body vibration training for inpatient children and adolescents receiving chemotherapy for first cancer diagnosis: an exploratory feasibility study

Whole-body vibration (WBV) is a feasible and potentially beneficial exercise strategy for managing neuromuscular impairments like decreased strength or flexibility, mobility limitations and bone health in pediatric cancer survivors. However, as starting rehabilitation as early as possible is recommended to preserve physical function, this study investigated the feasibility of WBV for patients receiving cancer treatment for first cancer diagnosis. Eleven patients (various types of cancer, ages 7–17) participated in the supervised WBV intervention concomitant to acute cancer treatment, which involved chemotherapy. Training was implemented as part of a general exercise program and offered 3 days per week during hospitalization (warm-up, four progressive training exercises comprising 60–120 s, 21–27 Hz, 2 mm peak-to-peak-displacement). Feasibility, which was defined as the absence of WBV-related serious adverse events leading to study dropout, was primarily evaluated. Training documentation was additionally analyzed. As a main result, no serious adverse events leading to study dropout were reported. However, two incidents of bleeding (adverse events) were observed in patients with bleeding tendencies and low platelets (thrombocytes < 30,000/μL). After adjusting the platelet count threshold for WBV participation to 30,000/μL, no further incidents occurred. Moreover, due to WBV-related side effects like physical exhaustion, 11% of all training sessions had to be stopped and another 11% required reductions in the vibration load. Patients participated in 48% of the planned sessions. While main reasons for non-attendance were medical issues (35%), only few WBV sessions were missed, not completed or needed modifications due to motivational issues. Consequently, WBV seems to be feasible for inpatient pediatric patients receiving chemotherapy for first cancer diagnosis, given a sufficiently high platelet count of at least 30,000/μL. Although WBV tolerance and training motivation appear high, patient’s reduced medical condition during hospitalization can negatively impact training progression and attendance. Future research is required to confirm our findings on feasibility and to assess efficiency of WBV training for pediatric cancer patients receiving cancer treatment.

Risk Factors for Hematopoietic Stem Cell Transplantation-Associated Bone Loss

Hematopoietic stem cell transplantation (HSCT), including bone marrow transplantation, is the treatment of choice for many hematologic diseases, including hematologic malignancies and different types of anemia. The use of HSCT is increasing annually, mainly because advanced research that has been conducted in this area has exponentially expanded the indications for HSCT and significantly improved transplantation techniques and supportive care practices. Collectively, these improvements have led to an increase in the overall survival of HSCT patients. However, as post-HSCT survival is increasing, awareness of the potential late complications of HSCT is also growing. Unpredictable bone loss is one of the major post-HSCT complications that can cause significant morbidity and impair the quality of life of survivors. Although the exact mechanism of post-HSCT bone loss is not yet known, previous studies have suggested that numerous factors, including destructive preparative regimens (eg, high-dose chemotherapy, total body irradiation), treatment-related complications (eg, graft-versus-host disease), endocrine abnormalities (eg, diabetes mellitus, thyroid dysfunction, adrenal insufficiency), lack of physical activity, and the underlying disease itself are responsible for HSCT-associated bone loss. Sufficient data have been collected to suggest that post-HSCT bone loss can be prevented and treated using the same preventive and treatment modalities as used for the general population. Various guidelines have been formulated to help keep a check on HSCT recipients' deteriorating bone health.

[Endocrine late-effects and bone mineral density after combined treatment of malignant brain tumors in childhood and adolescence]

Обоснование

Обоснование. Внедрение в клиническую практику стандартизированных протоколов комбинированного лечения онкологических заболеваний неизбежно приводит к развитию отдаленных последствий. Поскольку у лиц, излеченных в детском и подростковом возрасте, ожидаемая продолжительность жизни велика, своевременная диагностика и коррекция отдаленных последствий противоопухолевого лечения имеют даже большее значение, чем острые осложнения химиолучевой терапии.

Цель

Цель. Изучить распространенность эндокринных нарушений, оценить распространенность и степень снижения минеральной плотности костной ткани (МПК) у лиц, перенесших комбинированное лечение злокачественных опухолей головного мозга в детском и молодом возрасте.

Материалы и методы

Материалы и методы. Проведено ретроспективное исследование с участием 59 пациентов (31 мужчина; 28 женщин), перенесших в детском и молодом возрасте оперативное лечение злокачественной опухоли головного мозга с последующей лучевой терапией в объеме краниоспинального облучения в сочетании с полихимиотерапией или без нее. I группу составили 37 пациентов, которым комбинированное лечение проводилось в возрасте от 3 до 16 лет. Во II группу были включены 22 пациента, получившие лечение в возрасте от 16 до 38 лет.

Результаты

Результаты. Недостаточность соматотропного гормона по результатам пробы с инсулиновой гипогликемией выявлена у 48 пациентов (81%), вторичная надпочечниковая недостаточность — у 22 (37%). Большая часть обследованных (33 пациента (56%)) не достигли целевого роста. Лечение рекомбинантным гормоном роста (рГР) получили только 5 человек из I группы. Проведенный корреляционный анализ показал, что возраст на момент лечения — основной фактор, влияющий на конечный рост (r=0,619; p<0,001). Выявлена высокая частота развития гипотиреоза (n=39 (66%)), гипогонадизма (19 женщин; 17 мужчин). По результатам DXA снижение МПК ≤-2,0 SD по Z-критерию в поясничном отделе позвоночника выявлено у 35 из 59 обследованных (59%). МПК у пациентов I группы была значимо ниже по сравнению с пациентами, получившими лечение в более старшем возрасте (p<0,001). Обнаружена умеренная корреляция между МПК в поясничном отделе позвоночника на момент обследования и уровнем эстрадиола в крови у женщин (r=0,596; p<0,05) и тестостерона у мужчин (r=0,472; p<0,05). Выявлена прямая зависимость МПК от возраста на момент заболевания (r=0,781; p<0,01).

Заключение

Заключение. Полученные результаты свидетельствуют о необходимости ежегодного и пожизненного наблюдения пациентов после комбинированного лечения злокачественных опухолей головного мозга на предмет выявления отдаленных последствий лечения. Высокая распространенность остеопенических состояний определяет актуальность и необходимость проведения ранней диагностики для предотвращения дальнейшей потери костной массы, снижения прочности кости и риска переломов.

Endocrine Complications in Children and Adolescents With Non-Central Nervous System Solid Tumors

BACKGROUND

Due to remarkable progress in cancer treatment, endocrine complications are now the major medical issues facing childhood cancer survivors. Although non-central nervous system solid tumors (NCSTs) account for approximately 40% of all pediatric cancers, there have been few studies on endocrine complications associated with NCSTs. This study investigated endocrinopathies following the treatment of pediatric NCSTs.

DESIGN AND SETTING

Retrospective study in a single academic center.

METHODS

This study analyzed 253 survivors of childhood NCSTs who were diagnosed between January of 2000 and December of 2018. The medical charts were reviewed regarding the frequency of endocrinopathies and treatment modalities. The hazard ratios were assessed by multivariable Cox regression analysis. The final height-SDS were analyzed by multivariable linear regression analysis.

RESULTS

There were 76 patients (30%) that developed at least one endocrine complication. Forty-four patients (17.4%) experienced endocrine complications within five years of their cancer diagnosis. The most common endocrine complication was growth failure (n = 35), followed by obesity (n = 18), and primary gonadal failure (n = 16). High cumulative doses of alkylating agents increased the risk of developing at least one endocrine complication. Hematopoietic stem cell transplantation was an important risk factor for primary gonadal failure.

CONCLUSIONS

This study described the comprehensive endocrine outcomes, including growth failure, obesity, primary gonadal failure, primary hypothyroidism, dyslipidemia, and osteoporosis, following the treatment of childhood NCSTs. As endocrinopathies occurred within five years of primary tumor diagnosis, surveillance for endocrine dysfunction is required for early intervention and management.

Bone health in childhood cancer: review of the literature and recommendations for the management of bone health in childhood cancer survivors

In the past decades, new cancer treatment approaches for children and adolescents have led to a decrease in recurrence rates and an increase in long-term survival. Recent studies have focused on the evaluation of the late effects on bone of pediatric cancer-related treatments, such as chemotherapy, radiation and surgery. Treatment of childhood cancer can impair the attainment of peak bone mass, predisposing to premature onset of low bone mineral density, or causing other bone side-effects, such as bone quality impairment or avascular necrosis of bone. Lower bone mineral density and microarchitectural deterioration can persist during adulthood, thereby increasing fracture risk. Overall, long-term follow-up of childhood cancer survivors is essential to define specific groups at higher risk of long-term bone complications, identify unrecognized long-term adverse effects, and improve patient care. Children and adolescents with a cancer history should be carefully monitored, and patients should be informed of possible late complications of their previous medical treatment. The International Osteoporosis Foundation convened a working group to review the bone complications of pediatric cancer survivors, outlining recommendations for the management of bone health, in order to prevent and treat these complications.

Low bone mineral density is associated with hypogonadism and cranial irradiation in male childhood cancer survivors

We investigated if bone mineral density was related to testosterone deficiency and/or previous cancer treatment in men who were childhood cancer survivors. Men with untreated testosterone deficiency or previous treatment with cranial irradiation were at increased risk of impaired bone health. Prevention of osteoporosis should be considered in their follow-up.

INTRODUCTION

Childhood cancer survivors (CCS) are at increased risk of hypogonadism. Reduced bone mineral density (BMD) has been reported in CCS but it is unclear whether this is due to hypogonadism or a direct effect of cancer therapy. This study investigated BMD in CCS, and association with hypogonadism, previous treatment and cancer type.

METHODS

Investigation of 125 CCS (median age 33.7 at inclusion; 9.6 at diagnosis) and 125 age-matched population controls. Serum testosterone and luteinizing hormone were assayed and BMD at total hip and lumbar spine L1-L4 measured. The mean difference in BMD (g/cm²; 95% CI) between CCS and controls was analysed. Odds ratios (OR; 95% CI) for low BMD were also calculated.

RESULTS

Overall, BMD in the CCS cohort did not significantly differ from controls. However, compared with eugonadal CCS, the CCS with untreated hypogonadism had lower BMD at the hip (mean difference - 0.139 (- 0.210; - 0.067); p < 0.001) and spine (- 0.102 (- 0.174; - 0.030); p = 0.006). They also had a higher risk of low hip BMD (OR 4.1 (1.3; 14); p = 0.018). CCS treated with cranial irradiation also had lower BMD (hip - 0.076 (- 0.133; - 0.019); p = 0.009; spine - 0.071 (- 0.124; - 0.018); p = 0.009) compared with controls. The latter associations remained statistically significant after adjustment for hypogonadism.

CONCLUSIONS

CCS with hypogonadism or previously treated with cranial irradiation are at increased risk of impaired bone health. Prevention of osteoporosis should be considered as an important part in future follow-up of these men.

Bone morbidity in pediatric acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL), currently the most common pediatric leukemia, has a high curability rate of up to 90%. Endocrine disorders are highly prevalent in children with ALL, and skeletal morbidity is a major issue induced by multiple factors associated with ALL. Leukemia itself is a predominant risk factor for decreased bone formation, and major bone destruction occurs secondary to chemotherapeutic agents. Glucocorticoids are cornerstone drugs used throughout the course of ALL treatment that exert significant effects on demineralization and osteoclastogenesis. After completion of treatment, ALL survivors are prone to multiple hormone deficiencies that eventually affect bone mineral accrual. Dual-energy X-ray absorptiometry, the most widely used method of measuring bone mineral density, is used to determine the presence of childhood osteoporosis and vertebral fracture. Supplementation with calcium and vitamin D, administration of pyrophosphate analogues, and promotion of mobility and exercise are effective options to prevent further bone resorption and fracture incidence. This review focuses on addressing bone morbidity after pediatric ALL treatment and provides an overview of bone pathology based on skeletal outcomes to increase awareness among pediatric hemato-oncologists and endocrinologists.

Therapeutic Effect of Strontium Ranelate on Bone in Chemotherapy-Induced Osteopenic Rats via Increased Bone Volume and Reduced Bone Loss

The purpose of this study was to determine whether treatment with strontium ranelate (SrR) can restore bone mass and strength at a skeletal site with established osteopenia in chemotherapy-induced rats. Forty-five Sprague-Dawley male rats were randomly assigned to three study groups (n = 15 rats per group): normal rats (control group), osteopenic rats (chemo group), and osteopenic rats with SrR (chemo-SrR group). We chose a male rat model that mimicked a clinical setting by weekly intravenous injection of cyclophosphamide at 20 mg/kg. The control and chemo groups were maintained without treatment, and the chemo-SrR group was intragastrically administered strontium ranelate at a dosage of 900 mg/kg/day. All animals were fed a standard laboratory diet, and blood samples were collected for biochemical analysis. After 12 weeks of treatment, micro-CT, biomechanical testing, and histomorphometry were examined. In addition, bone samples were obtained to evaluate the content of mineral substances in bones. SrR treatment of chemo rats significantly increased tibial trabecular bone volume, trabecular thickness, and BV/TV. Serum levels of the bone formation marker alkaline phosphatase (ALP) in the SrR group were significantly higher than those in the chemo animals, which was accompanied by an increase in the bone mineral content, bone calcium and phosphate, as well as reduced serum Ca and P concentrations. The serum level of tartrate-resistant acid phosphatase (TRAP) in the SrR treatment group showed no obvious changes. Histomorphological analyses revealed that chemotherapy resulted in decreased osteoclast number, which may be due to the inhibition of bone turnover. However, SrR treatment enhanced the number of osteoblasts while restoring bone mass and improving bone strength in chemo rats. Therefore, the results of this study indicate that SrR treatment has a positive effect on bone in chemotherapy-induced osteoporosis.

Mandibular radiomorphometric assessment of bone mineral density in survivors of pediatric hematopoietic stem-cell transplantation

OBJECTIVE

Hematopoietic stem-cell transplantation (HSCT) childhood survivors of hematologic malignancies are prone to develop late osteopenia and osteoporosis. The purpose of this retrospective study was to quantitatively and qualitatively assess bone mineral density (BMD) in HSCT childhood survivors and to compare the effectiveness of both qualitative and quantitative assessment methods.

METHODS

DESIGN BMD assessment using panoramic radiographs of childhood HSCT survivors aged 3.69-18.88 years using two radiomorphometric indexes. Case-control double-blinded comparison of panoramic radiographic images from childhood HSCT survivors and age- and sex-matched healthy controls. Quantitative assessment was performed by measuring the cortical bone width bilaterally at the mental foramen level. Qualitative assessment was performed using the mandibular cortical index bilaterally on all panoramic images.

RESULTS

Radiographs were taken 6.59-83.95 months after bone marrow transplantation [median±SD=25.92±24.9 months]. Fifty-two panoramic radiographic images were analyzed: 21 from HSCT survivors and 31 from healthy controls aged 3.69-25.1 years [mean±SD=11.89±5.28 years]. The mandibular cortical bone width was 17% smaller in childhood HSCT survivors than in healthy controls (case group: 2.420, control group: 3.307; p=0.00617). Qualitative analysis revealed an increased frequency of severe mandibular cortical erosion in childhood HSCT survivors, although no significant difference was observed (case group: 1.540, control group: 1.490; p=0.32). The interobserver agreement was 85% (Kappa index).

CONCLUSIONS

HSCT childhood survivors exhibit quantitative and qualitative mandibular bone impairments. Further studies are needed to establish an association between mandibular cortical bone impairment and osteoporosis.

Exposure to Low-Dose X-Ray Radiation Alters Bone Progenitor Cells and Bone Microarchitecture

Exposure to high-dose ionizing radiation during medical treatment exerts well-documented deleterious effects on bone health, reducing bone density and contributing to bone growth retardation in young patients and spontaneous fracture in postmenopausal women. However, the majority of human radiation exposures occur in a much lower dose range than that used in the radiation oncology clinic. Furthermore, very few studies have examined the effects of low-dose ionizing radiation on bone integrity and results have been inconsistent. In this study, mice were irradiated with a total-body dose of 0.17, 0.5 or 1 Gy to quantify the early (day 3 postirradiation) and delayed (day 21 postirradiation) effects of radiation on bone microarchitecture and bone marrow stromal cells (BMSCs). Female BALBc mice (4 months old) were divided into four groups: irradiated (0.17, 0.5 and 1 Gy) and sham-irradiated controls (0 Gy). Micro-computed tomography analysis of distal femur trabecular bone from animals at day 21 after exposure to 1 Gy of X-ray radiation revealed a 21% smaller bone volume (BV/TV), 22% decrease in trabecular numbers (Tb.N) and 9% greater trabecular separation (Tb.Sp) compared to sham-irradiated controls (P < 0.05). We evaluated the differentiation capacity of bone marrow stromal cells harvested at days 3 and 21 postirradiation into osteoblast and adipocyte cells. Osteoblast and adipocyte differentiation was decreased when cells were harvested at day 3 postirradiation but enhanced in cells isolated at day 21 postirradiation, suggesting a compensatory recovery process. Osteoclast differentiation was increased in 1 Gy irradiated BMSCs harvested at day 3 postirradiation, but not in those harvested at day 21 postirradiation, compared to controls. This study provides evidence of an early, radiation-induced decrease in osteoblast activity and numbers, as well as a later recovery effect after exposure to 1 Gy of X-rays, whereas osteoclastogenesis was enhanced. A better understanding of the effects of radiation on osteoprogenitor cell populations could lead to more effective therapeutic interventions that protect bone integrity for individuals exposed to low-dose ionizing radiation.

Pegylated interferon α/ribavirin therapy enhances bone mineral density in children with chronic genotype 4 HCV infection

BACKGROUND

The impact of chronic hepatitis C (CHC) on bone mineral density (BMD) has been well studied in adults with a relative paucity of data in children, especially concerning effect of treatment with pegylated interferon (PEG-IFN) plus ribavirin (RV). In the current work, we assessed prospectively changes in BMD in children with CHC before, during, and after treatment.

METHODS

Forty-six consecutive children with noncirrhotic genotype 4 CHC were subjected to dual-energy X-ray absorptiometry at baseline, 24 weeks, 48 weeks of therapy and 24 weeks after treatment. BMD, bone mineral content (BMC), and Z score of lumbar spine (L2-L4) were reported. Tanner pubertal stage, viral load, liver function tests, serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and liver histopathology were assessed in all included children.

RESULTS

Thirty (65.2%) patients had normal BMD, 10 (21.7%) were at risk for low BMD, and 6 (13.1%) had low BMD for chronological age. Patients with low BMD were significantly older (P=0.001), with higher frequency of delayed puberty than other groups (P=0.002). Baseline densitometric parameters (BMD & BMC) were significantly positively correlated with patients' age, weight, height, body mass index and hemoglobin level; while they were insignificantly correlated with basal viral load, histopathology activity index and fibrosis score. Densitometric parameters improved significantly on PEG-IFN plus RV treatment, this improvement was found to be sustainable 24 weeks after therapy.

CONCLUSIONS

Low BMD is detectable in a proportion of CHC children. Antiviral therapy leads to a sustainable increase in BMD.

Changes in Bone Health During the First Year of Cancer Treatment in Children

This study aimed to evaluate longitudinal changes in bone mineral density (BMD) and bone mineral content (BMC) in children with cancer during the first year of treatment. Thirty pediatric cancer patients (median age 11.2 [range 3.8-17.4] yr; 21 boys, 9 girls; 19 hematologic malignancies, 11 solid tumors) and 30 healthy controls were enrolled. Dual energy X-ray absorptiometry was performed at baseline and at 1, 6, and 12 mo for each pediatric cancer patient. There were no significant differences in age, sex, body weight, height, body mass index, serum vitamin D levels, BMD, and BMC among children with hematologic malignancies, those with solid tumors, and the controls at baseline. When the medians of BMD Z-scores were compared between different time intervals, whole-body BMD Z-score significantly decreased during the first year of cancer treatment (p = 0.001) in children with hematologic malignancies, especially during the first month (p = 0.002), and between 1 and 6 mo (p = 0.006). In children with solid tumors, whole-body BMD Z-score changed significantly only between 6 and 12 mo after treatment (p = 0.043). Generalized estimation equations for the analysis of trends in the whole-body BMD Z-scores revealed that there were significant downward trends between BMD Z-scores at baseline and those at 12 mo in children with hematologic malignancies and those with solid tumors. Cancer treatment significantly affects the bone health status at least during the first year, causing a significant decrease in BMD, especially during the first 6 mo for patients with hematologic malignancies and during the last 6 mo for those with solid tumors. Better strategies for treating changes in BMD based on the underlying cancer are necessary during cancer treatment in children.

Comparison of mandibular cortical thickness and QCT-derived bone mineral density (BMD) in survivors of childhood acute lymphoblastic leukemia: a retrospective study

OBJECTIVE

To examine whether panoramic radiograph-determined mandibular cortical thickness correlated with quantitative computed tomography-derived bone mineral density (BMD) in survivors of childhood acute lymphoblastic leukemia (ALL).

METHODS

We identified patients treated for ALL at St. Jude Children's Research Hospital, seen in the After Completion of Therapy (ACT) Clinic between January of 2006 and January of 2014 who had QCT-derived BMD and panoramic radiographs obtained within 1 month of each other. Panoramic radiographs were independently scored by a pediatric radiologist, two pediatric dentists, and a general dentist using the Klemetti technique. We used the Spearman's rank correlation test and the multivariate regression model to investigate the effect of evaluator experience on results.

RESULTS

The study cohort comprised 181 patients with 320 paired studies: 112 (62%) male, 112 (71%) were white. Median age at ALL diagnosis was 6.4 (range, 0-18.8) years. Median age at study was 11.9 (range, 3.3 to 29.4) years. The median average BMD was 154.6 (range, 0.73-256) mg/cc; median QCT Z-score (age and gender adjusted) was -0.875 (range, -5.04 to 3.2). We found very weak association between panoramic radiograph score and both QCT-BMD average (P = 0.53) and QCT Z-score (P = 0.39). Results were not influenced by level of reader experience.

CONCLUSIONS

The Klemetti technique of estimating BMD does not predict BMD deficits in children and young adult survivors of ALL, regardless of reviewer expertise. Alternative methods are needed whereby dental healthcare providers can identify and refer patients at risk for BMD deficits for detailed assessment and intervention.

Poor bone health at the end of puberty in childhood cancer survivors

BACKGROUND

Although the survival rate following childhood cancer is >80%, late effects are a major concern. We aimed to determine the clinical factors affecting bone health after puberty in childhood cancer survivors at risk for low bone mineral density (BMD).

PROCEDURES

We performed dual-energy X-ray absorptiometry at the lumbar spine, femoral neck, and total hip regions for survivors with the following bone densitometry indications (BDIXs): brain or nasopharyngeal cancer, head or neck area radiotherapy, or corticosteroid treatment (N = 92). Additionally, we evaluated 16 survivors without these BDIXs but with other clinical factors that could affect bone health. We assessed the effects of these factors on BMD using univariate and logistic regression analyses. Moderate BMD deficit was defined as a Z-score of <-1.0 and ≥-2.0, and severe BMD deficit was defined as <-2.0.

RESULTS

Severe BMD deficits were found in 18 survivors (16.7%) and moderate BMD deficits were in 39 (36.1%) in at least one bone region. BMD deficits tended to increase as the number of BDIXs increased (P < 0.010). There were no severe BMD deficits in survivors without BDIXs. The duration since cancer treatment completion was correlated with higher BMD (P < 0.05). Endocrine dysfunction was a significant risk factor for decreased BMD in univariate and multivariate analyses (P < 0.05 for both).

CONCLUSIONS

Decreased BMD was prevalent in our study cohort. Endocrine dysfunction was found to be a significant risk factor, and it should be managed in survivors to ensure future bone health.

Aggravated bone density decline following symptomatic osteonecrosis in children with acute lymphoblastic leukemia

Osteonecrosis and decline of bone density are serious side effects during and after treatment of childhood acute lymphoblastic leukemia. It is unknown whether osteonecrosis and low bone density occur together in the same patients, or whether these two osteogenic side-effects can mutually influence each other's development. Bone density and the incidence of symptomatic osteonecrosis were prospectively assessed in a national cohort of 466 patients with acute lymphoblastic leukemia (4-18 years of age) who were treated according to the dexamethasone-based Dutch Child Oncology Group-ALL9 protocol. Bone mineral density of the lumbar spine (BMDLS) (n=466) and of the total body (BMDTB) (n=106) was measured by dual X-ray absorptiometry. Bone density was expressed as age- and gender-matched standard deviation scores. Thirty patients (6.4%) suffered from symptomatic osteonecrosis. At baseline, BMDLS and BMDTB did not differ between patients who did or did not develop osteonecrosis. At cessation of treatment, patients with osteonecrosis had lower mean BMDLS and BMDTB than patients without osteonecrosis (respectively, with osteonecrosis: -2.16 versus without osteonecrosis: -1.21, P<0.01 and with osteonecrosis: -1.73 versus without osteonecrosis: -0.57, P<0.01). Multivariate linear models showed that patients with osteonecrosis had steeper BMDLS and BMDTB declines during follow-up than patients without osteonecrosis (interaction group time, P<0.01 and P<0.01). We conclude that bone density status at the diagnosis of acute lymphoblastic leukemia does not seem to influence the occurrence of symptomatic osteonecrosis. Bone density declines from the time that osteonecrosis is diagnosed; this suggests that the already existing decrease in bone density during acute lymphoblastic leukemia therapy is further aggravated by factors such as restriction of weight-bearing activities and destruction of bone architecture due to osteonecrosis. Osteonecrosis can, therefore, be considered a risk factor for low bone density in children with acute lymphoblastic leukemia.

Bone mineral density change during adjuvant chemotherapy in pediatric osteosarcoma

PURPOSE

Osteoporosis is currently receiving particular attention as a sequela in survivors of childhood osteosarcoma. The aim of this study was to evaluate bone mineral density (BMD) changes during methotrexate-based chemotherapy in children and adolescents with osteosarcoma.

METHODS

Nine patients with osteosarcoma were included in this retrospective study and compared with eight healthy controls. BMD of the lumbar spine and unaffected femur neck of patients was serially measured by dual-energy x-ray absorptiometry (DXA) before and just after chemotherapy and compared with controls.

RESULTS

Four patients (44%) showed decreased lumbar spine BMD and seven patients (78%) showed decreased femur neck BMD, while all controls showed increased lumbar and femur BMD (P=0.024 and P=0.023). The femur neck BMD z-scores decreased from -0.49±1.14 to -1.63±1.50 (P=0.032). At the end of therapy, five patients (56%) showed femur neck BMD z-scores below -2.0.

CONCLUSION

The bone metabolism is disturbed during therapy in children with osteosarcoma, resulting in a reduced BMD with respect to healthy controls. Since a reduced BMD predisposes to osteoporosis, specific attention and therapeutic interventions should be considered.

The bone-fat interface: basic and clinical implications of marrow adiposity

Obesity and osteoporosis are two of the most common chronic disorders of the 21st century. Both are accompanied by significant morbidity. The only place in the mammalian organism where bone and fat lie adjacent to each other is in the bone marrow. Marrow adipose tissue is a dynamic depot that probably exists as both constitutive and regulated compartments. Adipocytes secrete cytokines and adipokines that either stimulate or inhibit adjacent osteoblasts. The relationship of marrow adipose tissue to other fat depots is complex and might play very distinct parts in modulation of metabolic homoeostasis, haemopoiesis, and osteogenesis. Understanding of the relationship between bone and fat cells that arise from the same progenitor within the bone marrow niche provides insight into the pathophysiology of age-related osteoporosis, diabetes, and obesity.

Does this chest radiograph belong to a survivor of childhood cancer? Radiographic findings suggesting previous treatment for childhood cancer - a review

The growing population of long-term survivors of childhood cancer in the United States estimated in 2009 to be nearly 330,000 mandates familiarity with imaging findings that may be related to prior disease, therapy and toxicities. More than 24% of these patients have survived more than 30 years from the time of diagnosis of their malignancy. Thus, imagers of adult as well as pediatric patients should be cognizant of findings seen in this patient cohort. This image-based review will discuss findings demonstrated on chest radiographs that may suggest that the imaged patient is a childhood cancer survivor.