Computerized tomography scan findings in children with acute lymphocytic leukemia treated with three different methods of central nervous system prophylaxis

Radiation-Induced Schwannomas of the Neuraxis. Report of Three Cases

We report 3 cases of possible radiation-induced schwannomas observed in our Department. Their salient clinical and pathogenetic features are analyzed and the role of radiation therapy in the oncogenesis of these lesions is discussed. Several cases of radiation-induced tumors, including some of the nervous system, have been reported, but schwannomas have only occasionally been reported in connection with ionizing radiation. The possible adjuvant role of antineoplastic drugs is also discussed, and the literature on this topic is reviewed.

Systematic review and meta-analysis of randomized trials of central nervous system directed therapy for childhood acute lymphoblastic leukemia

Treatment of the central nervous system (CNS) is an essential therapy component for childhood acute lymphoblastic leukemia (ALL). Individual patient data from 47 trials addressing 16 CNS treatment comparisons were analyzed. Event-free survival (EFS) was similar for radiotherapy versus intrathecal (IT), and radiotherapy plus IT versus IV methotrexate (IV MTX) plus IT. Triple intrathecal therapy (TIT) gave similar EFS but poorer survival than intrathecal methotrexate (IT MTX), but additional IV MTX improved both outcomes. One trial resulted in similar EFS and survival with IV MTX plus IT MTX versus TIT alone. Radiotherapy can generally be replaced by IT therapy. TIT should be used with effective systemic therapy such as IV MTX.

Pseudoprogression after high-dose busulfan-thiotepa with autologous stem cell transplantation and radiation therapy in children with brain tumors: Impact on survival

Children with a brain tumor treated with high-dose busulfan-thiotepa with autologous stem cell transplantation (ASCT) and radiation therapy (RT) often experience radiographic changes during follow-up. The purpose of the study was to identify the incidence, time course, risk factors, and clinical outcome of this complication. From May 1988 through May 2007, 110 patients (median age, 3.6 years; range, 1 month to 15.3 years) with a brain tumor had received 1 course of high-dose busulfan-thiotepa with stem cell rescue, followed or preceded by RT as part of their treatment. All MRI follow-up examinations were systematically reviewed. Twenty-three patients (21%) developed neuroradiological abnormalities at a median time of 9.2 months (range, 5.6-17.3 months) after ASCT. All contrast-enhancing lesions appeared in patients who had received RT after ASCT and were localized inside the 50-55Gy isodoses. They disappeared in 14 of 23 patients after a median time of 8 months (range, 3-17 months), leaving microcalcifications in some cases. The presence of MRI abnormalities was an independent prognostic factor for overall survival in the multivariate analysis (hazard ratio, 0.12; 95% confidence interval [CI], 0.04-0.33), with a 5-year overall survival rate of 84% among patients with MRI abnormalities (95% CI, 62-94), compared with 27% (95% CI, 19-37) among those without lesions. MRI-detectable pseudoprogression is a common early finding in children treated with high-dose busulfan-thiotepa followed by radiation therapy and is correlated with a better outcome.

Can guanine-based purines be considered modulators of intestinal motility in rodents?

Adenine-based purines play a pivotal role in the control of gastrointestinal motility in rodents. Recently, guanine-based purines have been also shown to exert extracellular effects in the central nervous system raising the possibility of the existence of distinct receptors for guanine-based purines. Thus, it seems likely to speculate that also guanine-based purines may play a role in the modulation of the intestinal contractility. Spontaneous and neurally-evoked mechanical activity was recorded in vitro as changes in isometric tension in circular muscle strips from mouse distal colon. Guanosine up to 3mM or guanine up to 1mM failed to affect the spontaneous mechanical activity, but reduced the amplitude of the electrical field stimulation (EFS)-induced cholinergic contractions, without affecting the early nitrergic relaxation. Both compounds failed to affect the direct contractile responses evoked by carbachol. No desensitization of the response was observed. Guanine-based purine effects were not altered by theophylline, P1 purinoceptor antagonist, by PPADS or suramin, P2 purinoceptor antagonists, by ODQ, guanilyl cyclase inhibitor, or by DDA, adenylyl cyclase inhibitor. Nucleoside uptake inhibitors, dipyridamole or 6-[(4-Nitrobenzyl)thio]-9-β-D-ribofuranosylpurine (NBTI), antagonized the inhibitory effects induced by guanosine without interfering with guanine. On the contrary, adenine, a competitive inhibitor of nucleobase uptake, antagonized guanine-induced effects. In conclusion, our data indicate that guanosine and guanine are able to modulate negatively the excitatory cholinergic neurotransmission in the circular muscle layer of mouse colon. Guanine-based purines appear to interfere with prejunctional acethylcoline release. Their effects are dependent by their cellular uptake, and independent by adenine-based purine receptors.

Evaluation of the late effects of CNS prophylactic treatment in childhood acute lymphoblastic leukemia (ALL) using magnetic resonance spectroscopy

PURPOSE

The aim of the study was to evaluate the late changes seen in Magnetic Resonance Spectroscopy (MRS) of the brain in Acute Lymphoblastic Leukemia (ALL) survivors to assess neurotoxicity following prophylactic treatment with cranial irradiation (CRT) and/or intrathecal (ITMTX) and systemic MTX.

MATERIALS AND METHODS

The study was performed on two groups of patients. The first group consisted of 30 children who received CRT and ITMTX, and the second group was comprised of 15 children treated only with ITMTX. All patients were ALL survivors treated between 1994 and 2002. Radiotherapy was performed using two opposite fields for a total dose of 18 Gy. The children were examined from 6 to 12 years after treatment. All children underwent a physical and neurological examination and MRI/MRS studies. (1)H-MR spectra were acquired from frontal and occipital regions of the brain. Mean values and standard deviations were calculated for following metabolite ratios: NAA/Cr, Cho/Cr, Cho/NAA, and mI/Cr.

RESULTS

Three of the 45 children (11%) presented with white matter changes upon MRI examination. All children with MRI abnormalities received CRT. In 13 (31%) children, changes in (1)H-MRS metabolite ratios were seen. We observed decreased NAA/Cr and Cho/Cr ratios. MR spectroscopy showed a significant reduction (P < .05) of the mean NAA/Cr ratio in children given CRT.

CONCLUSION

MRS is a sensitive detector of late metabolic changes after prophylactic treatment for ALL in childhood. It is able to detect metabolic effects of treatment in patients even when no morphologic changes are visible upon MRI.

White Matter Lesions Detected by Magnetic Resonance Imaging After Radiotherapy and High-Dose Chemotherapy in Children With Medulloblastoma or Primitive Neuroectodermal Tumor

Purpose

White matter lesions (WMLs) have been described as a delayed effect of cranial irradiation in children with brain tumors, or a transient subacute effect characterized by an intralesional or perilesional reaction. We report the occurrence of subacute WMLs detected by magnetic resonance imaging (MRI) in children treated for medulloblastoma or primitive neuroectodermal tumor (PNET) and document the associated clinical, radiologic, and neurocognitive findings.

Patients and Methods

Among 134 patients with medulloblastoma or supratentorial PNET treated prospectively with risk-adjusted craniospinal irradiation and conformal boost to the tumor bed, followed by four high-dose chemotherapy (HDC) cycles with stem-cell rescue, 22 developed WMLs on T1-weighted imaging with and without contrast and/or T2-weighted imaging on MRI. Patients had ≥ 12 months of follow-up. Neurocognitive assessments included intelligence quotient (IQ) tests and tests of academic achievement.

Results

Twenty-two patients developed WMLs at a median of 7.8 months after starting therapy (range, 1.9 to 13.0 months). Lesions were predominantly in the pons (n = 8) and cerebellum (n = 6). Sixteen patients (73%) had WML resolution at a median of 6.2 months (range, 1.68 to 23.5 months) after onset; two patients developed necrosis and atrophy. Three developed persistent neurologic deficits. Cumulative incidence of WMLs at 1 year was 15% ± 3%. Patients with WMLs had a significant decline in estimated IQ (−2.5 per year; P = .03) and math (−4.5 per year; P = .003) scores.

Conclusion

WMLs in medulloblastoma or PNET patients treated with conformal radiotherapy and HDC are typically transient and asymptomatic, and may mimic early tumor recurrence. A minority of patients with WMLs develop permanent neurologic deficits and imaging changes. Overall, the presence of WMLs is associated with greater neurocognitive decline.

Diagnosis and management of central nervous system metastases from breast cancer

The brain, cranial nerves, leptomeninges, spinal cord, and eye compose the central nervous system (CNS) and are at risk for the development of metastases from breast cancer. Such metastases are diagnosed on the basis of clinical suspicion and substantiated by neuroimaging, resection when indicated, and sampling of cerebrospinal fluid when leptomeningeal metastasis (LM) is suspected. Treatment is aimed at palliation of symptoms and preservation of neurologic function. Historically, conventional radiation therapy has been the mainstay of palliative treatment for brain, cranial nerve, spinal cord, and ocular metastases. However, additional treatment options for brain metastases have been brought about by technological advances in surgery to resect brain metastases, and stereotactic radiosurgery (SRS) to focally irradiate metastases, both of which have been substantiated by data from randomized trials. Ongoing research is aimed at refining criteria to select which patients with brain metastases should undergo surgery and SRS and how these focal therapies should be optimally integrated with whole-brain radiotherapy. Therapy for LM must carefully balance the potential risks and perceived benefits associated with CNS-directed therapies. Despite advances in neuroimaging, surgery, and radiation therapy, novel treatments are needed to improve the effectiveness of treatments for CNS metastases, especially LM, while reducing attendant neurotoxicity.

CNS-directed therapy for childhood acute lymphoblastic leukemia: Childhood ALL Collaborative Group overview of 43 randomized trials

PURPOSE

A collaborative meta-analysis was performed to clarify the relative effects on relapse and survival of different types of therapies directed at the CNS in childhood acute lymphoblastic leukemia.

MATERIALS AND METHODS

Data were sought for each individual patient in all trials started in or before 1993 that included unconfounded randomized comparisons of such treatments. Log-rank survival analyses were performed for each trial, and overall results for groups of trials addressing similar questions were obtained from the totals of the observed minus expected number of events and their variances.

RESULTS

Radiotherapy and long-term intrathecal therapy gave similar outcomes, with no significant difference in event-free survival despite random assignment of treatment to 2,848 patients, 1,001 of whom suffered relapse or death. Intravenous methotrexate reduced non-CNS rather than CNS relapses, and hence, the addition of intravenous methotrexate to a treatment regimen including radiotherapy or long-term intrathecal therapy improved event-free survival, with a 17% reduction in the event rate (95% confidence interval, 6% to 27%; P =.003). The event-free survival at 10 years in these trials was 61.9% without intravenous methotrexate and 68.1% with intravenous methotrexate. There was no significant difference in survival (14% death rate reduction; P =.09). There were insufficient randomly assigned patients to adequately address other questions, such as effect of different doses. No evidence was found of differences, between trials or between subgroups of different types of patients, in the relative effects of treatment.

CONCLUSION

Radiotherapy can be replaced by long-term intrathecal therapy. Intravenous methotrexate gives some additional benefit by reducing non-CNS relapses.

Toxicity of treatment for neoplastic meningitis

Neoplastic seeding of the leptomeninges often signifies limited life expectancy. Still, patients are frequently offered aggressive multimodality therapies to palliate symptoms, and, one hopes, to prolong survival. Treatment modalities directed at the central nervous system (CNS) include radiotherapy, intra-cerebrospinal fluid (CSF) chemotherapy, standard systemic chemotherapy, and systemic high-dose chemotherapy. Because many of these modalities are used in combination, it is often difficult to discern which mode is the predominant cause of either acute or delayed complications. This review summarizes the incidence, clinical manifestations, laboratory findings, and pathology related to acute and delayed toxicity of treatment. It describes complications associated with radiotherapy, the use of an intraventricular implanted device (ie, Ommaya device), adverse effects of intra-CSF chemotherapy, and neurotoxicity, either associated with high-dose chemotherapy or manifested as delayed and chronic complications of combined therapies. All CNS-directed therapies are associated with a high rate of complications. The adverse effects of therapy profoundly affect the patient's quality of life, both at the acute phase of treatment and in late and chronic complications after therapy is completed. Intra-CSF chemotherapy is associated with a high rate of acute, reversible adverse effects that sometimes evolve into life-threatening medical conditions. Devastating delayed complications, mainly described as leukoencephalopathy, develop in more than 50% of patients who survive for extended periods and often lead to progressive loss of cognitive capacities. Careful assessment of the benefits and potential adverse reactions to a particular therapy regimen is mandated.

Rehabilitation of patients with advanced cancer

Despite growing interest in advanced cancer patients' quality of life, little attention has been directed toward preservation or recovery of their function. Although there is a dearth of supportive literature, extensive experience with other advanced disease populations suggests that standard, widely available rehabilitation strategies can enhance function in cancer. Logistic challenges to the provision of adequate rehabilitation to advanced cancer patients is discussed in this article, based on the author's experience and discussions in the literature. Common sources of functional impairment are reviewed with elucidation of rehabilitation approaches likely to benefit affected patients. Appropriate physical and occupational therapy techniques, as well as appropriate orthotics, assistive devices, and environmental modifications, are outlined for each of these impairments. In the author's view, rehabilitation should be considered for all advanced cancer patients experiencing functional decline. Pathways and referral patterns need to be established so that timely and appropriate functional restoration may occur.

Long-term cerebral metabolite changes on proton magnetic resonance spectroscopy in patients cured of acute lymphoblastic leukemia with previous intrathecal methotrexate and cranial irradiation prophylaxis

PURPOSE

To evaluate the long-term brain metabolite changes on (1)H-MRS in acute lymphoblastic leukemia (ALL) patients who had intrathecal methotrexate (ITMTX) and cranial irradiation (CRT) for central nervous system (CNS) prophylaxis against CNS relapse.

METHODS AND MATERIALS

Thirty-seven ALL patients (12 females, 25 males) with history of ITMTX and CRT for CNS prophylaxis were studied. Age ranges at the time of diagnosis and at magnetic resonance examination were 0.8-13 years and 12-27 years, respectively. The interval since diagnosis was 5.6-19 years. T2-weighted and gradient-recalled echo (GRE) magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy ((1)H-MRS) were performed to assess brain injury.

RESULTS

On MRI, 3 leukoencephalopathy (LEP) and 1 infarct were detected. Twenty-two patients had evidence of hemosiderin. On (1)H-MRS no statistically significant difference in choline (Cho)/creatine (Cr) and N-acetylaspartate (NAA)/Cr was associated with LEP. A lower Cho/Cr (p = 0.006) and NAA/Cr (p = 0.078) was observed in brains with hemosiderin. Linear-regression analysis showed no statistically significant relationship between NAA/Cr or Cho/Cr with age at diagnosis, but there was a statistically significant decreasing trend of NAA/Cr and Cho/Cr with the interval since diagnosis.

CONCLUSION

Long-term brain injury in ALL survivors after CNS prophylaxis with ITMTX and CRT was reflected by decreasing NAA/Cr and Cho/Cr with the interval since diagnosis. The lower Cho/Cr associated with hemosiderin but not LEP suggested a different pathophysiology for these brain lesions.

CNS late effects after ALL therapy in childhood. Part I: Neuroradiological findings in long-term survivors of childhood ALL--an evaluation of the interferences between morphology and neuropsychological performance. The German Late Effects Working Group

The effect of cranial irradiation on possible therapy-induced morphological central nervous system (CNS) side effects of children cured from acute lymphoblastic leukemia (ALL) is controversially discussed. In a retrospective multicenter study, 118 former ALL patients in first continuous remission were investigated using cranial computerised tomography (CCT) or magnetic resonance imaging (MRI) scans to evaluate CNS related impairments. Corresponding to the different kinds of CNS prophylaxis, the patient sample was divided: group A (n = 39) receiving intrathecal methotrexate (ITMTX) and systemical medium-high-dose methotrexate (SMHDMTX), group B (n = 41) cranial irradiated (in mean 16.8 Gy) and administering ITMTX and SMHDMTX, group C (n = 38) irradiated (in mean 17.1 Gy) and getting ITMTX. Pathologic scans showed atrophy, leukoencephalopathy, calcifications or grey matter changes. These findings were compared with the neuropsychological test results. Abnormal MRI or CCI scans were found in 61/118 patients (51.7%). Fifteen belonged to group A (38.5%), 23 to B (56.1%) and 23 to C (60.5%). Patients with definite CNS changes show reduced neuropsychological test results. The prevalence of brain alterations seems to appear twice increased after lengthening the posttherapeutic interval in irradiated patients as in nonirradiated patients. Irradiated patients as an age younger than 2 years at diagnosis may show a lower prevalence for developing CNS alterations. CNS alterations are not sex-related. Children treated with cranial irradiation in combination with SMHDMTX and/or ITMTX were at greater risk of developing morphological brain alterations than patients with chemotherapy alone. These alterations are partly correlated with reduced neuropsychological performances and seem to stay with a longer posttherapeutic interval.

Brain atrophy in children undergoing systemic chemotherapy for extracranial solid tumors

It has been shown that intrathecal chemotherapy may cause brain damage, which can be depicted in neuroimaging studies. The aim of this work was to examine possible morphologic alterations in the brain of children with extracranial solid tumors, without CNS complications, treated with systemic chemotherapy. Brain CT images of 69 children with extracranial malignancies were reviewed and the extent of 12 CSF compartments was measured in 49 CT examinations performed during intravenously given chemotherapy and in 20 after therapy completion. Measurements were compared with corresponding normative data. About half of the children undergoing chemotherapy and half of the patients examined after treatment were found to have diffuse brain atrophy. Focal lesions that might be associated with therapy toxicity were not observed. Chemotherapy, even when administered via the systemic route, may cause brain damage, which is observed long after the end of treatment.

Quantitative assessment of cerebral atrophy during and after treatment in children with acute lymphoblastic leukemia

RATIONALE AND OBJECTIVES

The authors evaluate quantitatively brain atrophy induced by central nervous system prophylaxis in children treated for acute lymphoblastic leukemia during and after therapy completion.

METHODS

Measurements of the width of the subarachnoid compartments were performed in 243 brain computed tomography (CT) examinations of 196 children examined during (125) and/or after (71) treatment for acute lymphoblastic leukemia without central nervous system involvement. Data were compared with normative data. RESULTS. Diffuse brain atrophy was observed in 74% and 65% of the CT examinations performed during and after cessation of treatment, respectively. The highest incidence of brain atrophy (78%) occurred during the administration of intrathecal chemotherapy. All children younger than 2 years of age exhibited brain atrophy.

CONCLUSIONS

Brain atrophy is the principal CT finding in the majority of children treated for acute lymphoblastic leukemia and it can be attributed mainly to intrathecal chemotherapy. This finding can be observed long after therapy completion.

Reversal of CNS-prophylaxis-related leukoencephalopathy after CSF shunting: case histories of identical twins

We report the case histories of identical twin brothers who developed concordant acute lymphoblastic leukemia at the age of 4 years and who later developed leukoencephalopathy and hydrocephalus related to central nervous system prophylaxis by, in the first case intrathecally administered methotrexate and, in the second by intrathecally administered methotrexate and cranial irradiation. The delayed encephalopathy developed 9 and 22 months respectively after the first dose of intrathecal methotrexate. Both patients underwent cerebrospinal fluid shunting mainly for their hydrocephalus. The imaging studies have shown that both hydrocephalus and leukoencephalopathy have improved significantly after ventriculoperitoneal shunt insertion. We review the pathophysiology of prophylaxis-related encephalopathy in leukemia patients and summarize its clinical, histological, and radiological characteristics. We also discuss the possible contribution of altered cerebrospinal fluid dynamics in the development of leukoencephalopathy.

Leukoencephalopathy in childhood hematopoietic neoplasm caused by moderate-dose methotrexate and prophylactic cranial radiotherapy--an MR analysis

PURPOSE

The main purpose of this study was to determine influential factors related to minor leukoencephalopathy (LEP) caused by moderate-dose methotrexate (MTX) and prophylactic cranial radiotherapy (CRT) in childhood hematopoietic malignancies. We also compared the incidence of LEP following this treatment to that reported in the literature following treatment with high-dose MTX alone.

METHODS AND MATERIALS

Thirty-eight pediatric patients of hematopoietic malignancies (37 acute lymphoblastic leukemias, 1 non-Hodgkin lymphoma) who were given CRT (18-24 Gy) as well as prophylactic intrathecal and per os MTX were studied for leukoencephalopathy by magnetic resonance (MR) imaging. All the patients were free from grave neuropsychiatric disturbances. The data were examined to elucidate the influential ones of five factors (patients' age, doses of intrathecal and per os MTX, dose of CRT, interval between treatment, and MR study) to develop LEP using multiple regression analysis. To compare the effect of moderate-dose MTX and prophylactic CRT on LEP to that of high-dose MTX alone, we conducted literature review.

RESULTS

Seven out of 38 patients (18%) developed LEP. From multiple regression analysis and partial correlation coefficients, the age and CRT dose seemed influential in the subsequent development of LEP. The incidence of LEP following treatment with moderate-dose MTX and prophylactic CRT appears to be less than that reported in the literature following treatment with intravenous high-dose MTX. However, even moderate-dose MTX in combination with CRT can result in a significant incidence of MR-detectable LEP, particularly in children 6 years of age or younger receiving 24 Gy.

CONCLUSION

Leukoencephalopathy was caused by moderate-dose MTX and prophylactic CRT in pediatric patients, probably less frequently than by high-dose MTX treatment alone. The influential factors were patient's age and CRT dose.

Evaluation of serious adverse events in patients treated with protocols including methotrexate infusions

During the period 1979 to 1992 we treated 141 children for various malignant diseases with protocols including methotrexate (MTX) infusions in doses ranging from 0.5 to 33.6 g/m2. During a total of 922 courses, there were no fatal complications associated with MTX treatment. Serum MTX concentration and pharmacokinetic data were monitored continuously during the infusions. In this study, we evaluated the occurrence of serious untoward reactions to MTX infusions. Impaired renal function with delayed drug elimination was seen in seven patients, all boys, especially after short infusion times. All recovered completely without any serious clinical symptoms. In three leukemia patients who later died from resistant disease, we observed late neurological disturbances and computer tomography (CT) brain scan abnormalities. Pharmacokinetic data from the patients with complications are described and confirm that serial MTX concentration monitoring is the most important early indicator of renal toxicity.

White matter changes in children treated for acute lymphoblastic leukemia

BACKGROUND AND METHODS

Twenty-seven children with acute lymphoblastic leukemia (ALL) were studied by magnetic resonance (MR) imaging after central nervous system (CNS) treatment. The children were followed by clinical evaluations and computed tomographic (CT) brain scans. Two CNS treatment techniques were used. Eleven patients received intravenous and intrathecal methotrexate; 16 patients received 18-30 Gy of cranial radiation therapy in addition to systemic chemotherapy. The time interval between the CNS treatment and MR scans varied from 9 months to 4 years 8 months.

RESULTS

Four of the 27 children (15%) showed white matter changes on the MR scans attributable to therapy, but only one had hypodensity on CT. Three of the 16 children (19%) receiving radiation therapy in addition to chemotherapy had white matter changes. One of the 11 patients (9%) from the group receiving only chemotherapy did so. The difference between the two treatment groups was not significant.

CONCLUSIONS

Radiation therapy or chemotherapy (alone or in combination) may have been responsible for the white matter changes. MR imaging is a sensitive detector of white matter changes in children with ALL, but its value and significance during follow-up should be assessed in well-designed longitudinal research studies.

Nuclear magnetic resonance abnormalities of the cerebral white matter in children with acute lymphoblastic leukemia and malignant lymphoma during and after central nervous system prophylactic treatment with intrathecal methotrexate

BACKGROUND

A prospective study was conducted to test the feasibility of nuclear magnetic resonance (NMR) imaging in the early diagnosis of treatment-induced leukoencephalopathy.

METHODS

The study group included 16 patients with acute lymphoblastic leukemia and 4 patients with malignant lymphoma. All were given intravenous and intrathecal (IT) methotrexate (MTX) for central nervous system prophylaxis. Serial NMR studies were performed before and/or during induction-consolidation cycles.

RESULTS

NMR imaging disclosed leukoencephalopathy in 8 of the 20 patients (40%) in the early stages of treatment. In six of the eight, the leukoencephalopathy was resolved after temporary or permanent interruption of IT MTX, and chemotherapy was completed successfully. The other two patients are being treated. Transient neurologic abnormalities developed in two of the eight patients.

CONCLUSIONS

The possible causal relationship between leukoencephalopathy and the antimetabolic effects of MTX is discussed. This study clearly shows that NMR imaging is valuable in the early diagnosis and management of treatment-induced leukoencephalopathy.

Late effects of childhood acute leukemia and its treatment

Late effects of childhood acute leukemia and its treatment were studied in 776 patients (684 ALL, 73 ANLL, and 9 others) in Japan who had remained in remission for more than 1 year after their first complete remission. Delayed adverse sequelae involve a wide variety of organs and their functions. Short stature was present in 2.61%, obesity in 3.79%, abnormalities of growth hormone secretion in 1.5%, delayed secondary sex characteristics in 1.5% of males and 0.6% of females, motor disturbances in 1.17%, sensory disturbances in 0.91%, intellectual and learning disabilities in 2.48%, abnormal findings in routine neurologic examinations in 1.31%, EEG abnormalities in 4.30%, brain CT abnormalities in 5.09% and cardiac dysfunction in 1.07%. Various other disorders were seen in 20 patients. Many of these delayed adverse sequelae are caused by or related to central nervous system prophylaxis and systemic combination chemotherapy. The results suggest that it is needed to improve therapeutic methods through the stratification of patients by risk factors and detailed analysis of prognostic factors. Moreover it is important to render medical and psychosocial support to long-term survivors of childhood leukemia through interactions between the patient, parents and medical staff.

Prospective neurophysiological study in children treated for acute lymphoblastic leukaemia: serial EEG during treatment and long-term follow up with evoked potentials

In 79 children treated for acute lymphoblastic leukaemia according to protocol ALL-BFM 81, serial EEG examinations were performed before, during and after therapy. Diffuse changes of the background activity were observed in 64% of the children at the time of diagnosis. During induction and reinduction treatment with vincristine and L-asparaginase, and with some delay after CNS irradiation, a marked slowing developed in up to 65% of patients. Children who had not been irradiated showed transient disturbances during treatment with medium-dose-methotrexate. Reinduction induced more abnormal EEGs in the children who had been irradiated. At the end of maintenance therapy, only slight EEG changes were found. No differences between the irradiated and non-irradiated group were then seen. Children with CNS leukaemia or seizures differed from those with an uncomplicated treatment in that they more often showed focal and persistent disturbances. In 39 patients who stayed in first remission for at least 18 months after the termination of treatment, a follow up investigation was performed. From the EEG examination, including power spectral analysis, no differences were found between irradiated and non-irradiated patients. Slowing of the dominant frequency was seen in the patients with more severe leukaemia and in those whose EEG had been markedly abnormal at diagnosis. The visually evoked potentials were normal in all groups of patients. In the brainstem auditory evoked potential, a prolongation of the latency of wave I and a decrease of the I-V interval was found in irradiated patients. We conclude that the diffuse EEG changes frequently emerging during treatment are reversible. Persistent or lateralized changes can indicate a neurological complication.(ABSTRACT TRUNCATED AT 250 WORDS)

Major complications of the central nervous system after bone marrow transplantation in children with acute lymphoblastic leukemia

After the first ten bone marrow transplantations for acute lymphoblastic leukemia in children, we evaluated the cerebral outcome as severe cerebral complications had occurred in these patients. From these data we deduced a score of risk factors (SRF) encompassing the facts known to cause cerebral damage in leukemia treatment. In the following 13 patients, we lowered, in the individual patient, the SRF. The number of patients with cerebral damage was lower and no cerebral death occurred.

Brain damage after treatment for acute lymphoblastic leukemia. A report on 34 patients with special regard to MRI findings

In 34 patients treated for acute lymphoblastic leukemia (ALL), central nervous system (CNS) damage was assessed by clinical evaluation and brain magnetic resonance imaging (MRI). Twenty-seven of them had been off therapy from 5 to 109 months (median 64 months) while 7 had not completed the maintenance phase of their treatment. All the patients were disease-free when evaluated. None of the 3 patients who showed clinical CNS damage during the follow-up was symptomatic when submitted to MRI, while periventricular hyperintensity in T2-weighted images, suggestive of leukoencephalopathy, was present in 8 of the 34 patients. These subclinical abnormalities appear to be more frequent, transient in nature and treatment-related in patients evaluated shortly after the induction phase. Similar MRI findings seem, on the contrary, to be consequences of the disease on the CNS when appearing in long-term survivors.

Late effects of antileukemic treatment

Increasing numbers of childhood ALL survivors have increased the need to assess the physical and psychosocial functioning of this group in a careful manner. This article reviews data on the frequency and types of second malignancies, structural and functional changes in the central nervous system, endocrine effects on growth and reproduction, and psychosocial aspects of development. Most long-term survivors of ALL do not have serious or life-threatening medical problems; however, medical and psychosocial problems may not be insignificant and may require coordinated management over prolonged periods.

Late multifocal gliomas in adolescents previously treated for acute lymphoblastic leukemia

Three of 37 adolescents in long-term remission from childhood acute lymphoblastic leukemia (ALL) developed malignant multifocal gliomas several years after completing treatment that included central nervous system (CNS) prophylaxis with radiation (RT) and intrathecal methotrexate (IT-MTX). No recurrence of the leukemia was evident when the CNS tumors were discovered. Seventeen other similar cases have been recorded. The occurrence of second malignancies is reviewed in the context of this development and of the oncogenic effects of radiation. It is probable that prolonged exposure to IT-MTX may have had a synergistic effect with radiation in contributing to the unusual incidence of glial tumors in these patients.