Dental abnormalities in long-term survivors of head and neck rhabdomyosarcoma

Salivary and Dental Complications in Childhood Cancer Survivors Treated With Radiation Therapy to the Head and Neck: A PENTEC Comprehensive Review

PURPOSE

Radiation therapy (RT) to the head and neck (H&N) region is critical in the management of various pediatric malignancies; however, it may result in late toxicity. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on salivary dysfunction and dental abnormalities in survivors who received RT to the H&N region as children.

MATERIALS & METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method.

RESULTS

Of the 2,164 articles identified through a literature search, 40 were included in a qualitative synthesis and 3 were included in a quantitative synthesis. The dose-toxicity data regarding salivary function demonstrate that a mean parotid dose of 35 to 40 Gy is associated with a risk of acute and chronic grade ≥2 xerostomia of approximately 32% and 13% to 32%, respectively, in patients treated with chemo-radiation therapy. This risk increases with parotid dose; however, rates of xerostomia after lower dose exposure have not been reported. Dental developmental abnormalities are common after RT to the oral cavity. Risk factors include higher radiation dose to the developing teeth and younger age at RT.

CONCLUSIONS

This PENTEC task force considers adoption of salivary gland dose constraints from the adult experience to be a reasonable strategy until more data specific to children become available; thus, we recommend limiting the parotid mean dose to ≤26 Gy. The minimum toxic dose for dental developmental abnormalities is unknown, suggesting that the dose to the teeth should be kept as low as possible particularly in younger patients, with special effort to keep doses <20 Gy in patients <4 years old.

Chemotherapy and Radiotherapy Long-Term Adverse Effects on Oral Health of Childhood Cancer Survivors: A Systematic Review and Meta-Analysis

The survival rate for pediatric cancer has increased over the past few decades, short- and long-term complications have been detected and studied, and oral complications have emerged as an important topic of research. Here, we aimed to highlight the importance of oral manifestations that may only become apparent years or even decades after cancer treatment. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched articles using PubMed via the MEDLINE, Web of Science, and LILACS databases until October 2023. Overall, 35 observational studies were included, and the results estimated a pooled prevalence of the following dental anomalies: discoloration, 53%; crown-root malformations and agenesis, 36%; enamel hypoplasia, 32%; root development alterations, 29%; unerupted teeth, 24%; microdontia, 16%; hypodontia, 13%; and macrodontia, 7%. Most childhood cancer survivors have at least one dental sequela. Childhood cancer survivors presented a higher risk of having dental alterations than control counterparts. Additional analyses reveal possible sex-based differences that should be explored in future studies. These results collectively highlight the importance of oral healthcare and the prevention of disease in childhood cancer survivors.

The Role of Dental Practitioners in the Management of Oncology Patients: The Head and Neck Radiation Oncology Patient and the Medical Oncology Patient

This narrative review addresses the role of a dentist in the management of oncology patients, highlighting the oral complications that arise in head and neck radiation oncology patients and medical oncology patients. The prevention and management of these complications are discussed.

Dental caries and dental developmental defects as adverse effects of antineoplastic treatment in childhood cancer survivors

PURPOSE

To evaluate the prevalence of dental caries and dental developmental defects (DDD) in childhood cancer survivors (CCS) and identify disease and treatment-related risk factors.

METHODS

CCS aged up to 21 years, diagnosed with a malignancy before the age of 10 years and in remission for at least one year were included. Data were collected from patients' medical records and through a clinical examination where presence of dental caries and prevalence of DDD were recorded. Fisher's exact test was used to assess possible correlations and multivariate regression analysis to determine risk factors for defect development.

RESULTS

Seventy CCS with a mean chronological age of 11.2 years at the time of examination, mean age at cancer diagnosis of 4.17 years, and a mean post-treatment follow-up time of 5.48 years were included. Mean DMFT/dmft was 1.31, with 29% of survivors presenting with at least one carious lesion. Younger patients on the day of examination and patients treated with higher radiation dose, showed significantly higher prevalence of dental caries. The prevalence of DDD was 59%, with demarcated opacities being the defect most commonly observed (40%). Age at dental examination, diagnosis, age at diagnosis, and time that have elapsed since the end of treatment were the factors significantly affecting its prevalence. Regression analysis revealed that age at examination was the only factor significantly associated with the presence of coronal defects.

CONCLUSION

A great number of CCS presented with at least one carious lesion or a DDD, with the prevalence being significantly associated with various disease-specific characteristics, but age at dental examination the only significant predictor.

Dental late effects of antineoplastic treatment on childhood cancer survivors: Radiographic findings

BACKGROUND

Dental anomalies are common late side effects of childhood cancer therapy and may lead to anatomical, functional, and aesthetic sequelae.

AIM

The study aimed to record dental late effects of antineoplastic treatment and associate them with disease and treatment characteristics in order to identify possible risk factors.

DESIGN

Orthopantomograms of 70 survivors aged 4-21 years, who were treated at ages 0-10 years for any type of malignancy and completed antineoplastic treatment at least one year before, were examined. Incidence of developmental disturbances was recorded. Their severity was calculated, and odds ratios for the development of severe defects were estimated.

RESULTS

Root defects presented in 62% of the participants, with impaired root growth being the most common (58%). Increased incidence was associated with combination treatment protocols, irradiation to the head and neck region, and administration of antimetabolites, steroids, and vincristine. Mean DeI value was 17.46 with risk factors for the development of severe root defects being diagnosis of acute lymphoblastic leukemia, combination treatment protocols, administration of cyclophosphamide and steroids, and hemopoietic stem cell transplantation.

CONCLUSIONS

Root defects are common among childhood cancer survivors, with their incidence and severity being affected by multiple disease and treatment characteristics.

Oral and Dental Abnormalities Caused by a Pediatric Rhabdomyosarcoma Tumor Treatment: A Clinical Case Report

Rhabdomyosarcoma is one of the most common soft-tissue sarcomas in children. The therapy for this condition has evolved significantly over recent decades, as has survival rates. Nevertheless, multiagent chemotherapy, radiation therapy, surgical resection or a combination of these modalities still have to be performed. This case report presents a 16-year-old boy with oral and dental effects after rhabdomyosarcoma treatment, diagnosed at the age of 4 years old. This report highlights the key role of dentists in the clinical management of rhabdomyosarcoma cases before, during and after treatment, and its potential side effects.

Dental and craniofacial alterations in long-term survivors of childhood head and neck rhabdomyosarcoma

OBJECTIVE

Rhabdomyosarcoma (RMS) represents the most common soft tissue sarcoma that affects children. Treatment involves chemoradiotherapy. This study aimed at evaluating the long-term alterations to teeth and cranial bones in children, teenagers, and young adults after oncologic treatment.

STUDY DESIGN

We conducted a cross-sectional study of patients undergoing treatment for head and neck RMS between 1988 and 2011. We evaluated demographic, clinical, and treatment data and performed panoramic radiography, cephalometry, and photography.

RESULTS

We evaluated 27 long-term survivors, most of whom had been treated between ages 0 to 5 years (51.9%). The total radiation dose applied was 50.4 Gy, and the chemotherapy combination included vincristine, actinomycin D, and cyclophosphamide in 51.9% of the cases. We observed 603 dental alterations, among which 377 (62.7%) occurred in patients ages 0 to 5 years, and root shortening was the most frequent alteration observed (24.2%). With regard to facial bones, 74% of the patients had some level of facial asymmetry, 70.4% had reduced facial depth, 48.4% had mandibles of short size, and 77.8% had reduced facial height.

CONCLUSIONS

Children submitted to RMS treatment involving chemotherapy and radiotherapy displayed significant dental and craniofacial alterations, especially when treatment occurred between ages 0 and 5 years.

Prosthetic rehabilitation for a patient treated for embryonal rhabdomyosarcoma

A female patient, now aged 17 years, was diagnosed with rhabdomyosarcoma (RMS) in the right pterygopalatine fossa when she was 3 years old. The RMS was successfully treated by excision, but the subsequent radiation and polychemotherapy resulted in the complete anesthesia of the distribution area of the right trigeminal nerve and loss of vision in the right eye. The patient also experienced pain in the mandibular joints and masticatory muscles. Panoramic radiographs displayed a multiple agenesia of the permanent teeth and underdeveloped apices. Treatment involved the fabrication of a complete maxillary denture. A removable device was fabricated to evaluate her response to an occlusal vertical dimension increase of 6 mm and provide a stable intercuspal position. After wearing the prosthesis for 6 months, the patient reported that she was completely free of symptoms.

Trismus in patients with head and neck cancer: etiopathogenesis, diagnosis and management

BACKGROUND

Trismus indicates severely restricted mouth opening of any aetiology. A mouth opening of 35 mm or less should be regarded as trismus. Aim of this study was to review the etiopathogenesis, incidence, treatment and prevention of trismus in patients with head and neck cancer.

OBJECTIVE OF REVIEW

Trismus is frequently seen in patients suffering from malignant tumours of the head and neck. The reported prevalence of trismus in those patients varies considerably in the literature and ranges from 0 to 100% depending on the tumour site and extension. Trismus may worsen or remain the same over time, or the symptoms may reduce, even in the absence of treatment. When a patient presents with trismus after tumour treatment, it is important to determine whether the trismus is the result of the treatment, or is the first sign of a recurrence. Restricted mouth opening may impede inspection of the oral cavity as needed for dental care, and particularly for oncologic follow-up.

CONCLUSIONS

Mouth opening after radiotherapy (RT) decreases on average by approximately 20% compared to mouth opening prior to RT. The prevalence of trismus increases with increasing doses of RT to mastication structures. The use of intensity-modulated RT seems to lower the percentage and severity of RT-induced trismus. Treatment of trismus can be conservative (with either medical or physical therapy) or surgical. Exercise therapy is the mainstay of treatment and exercise should start as soon as possible after treatment. The prevention of trismus, rather than its treatment, is the most important objective.

Long-term effect of chemotherapy-intensity-modulated radiation therapy (chemo-IMRT) on dentofacial development in head and neck rhabdomyosarcoma patients

Dentofacial developmental abnormalities have been reported in head and neck rhabdomyosarcoma (HNRMS) patients treated with conventional radiotherapy technique and chemotherapy. This current study investigates dentofacial long-term effects among HNRMS survivors managed with intensity-modulated radiotherapy (IMRT) and chemotherapy. In general, IMRT is a more effective 3D-conformal radiotherapy technique, which delivers high doses of radiation to the tumor target while minimizing doses received by the surrounding normal tissues. The medical records and radiographs of thirteen patients were reviewed to identify the following: 1. Facial asymmetry and jaw hypoplasia. 2. Effects on the dental tissue causing tooth agenesis/hypodontia, root agenesis/stunting/malformation, and/or enamel hypoplasia. 3. Trismus, hyposalivation/xerostomia. Seven patients presented with facial asymmetry and jaw hypoplasia, 9 patients presented with effects on the dental tissue [root agenesis/stunting/malformation (9), tooth agenesis/hypodontia (7) and enamel hypoplasia (3)] and 7 patients developed trismus and /or xerostomia. All patients with facial asymmetry and jaw hypoplasia also developed dental abnormalities. Patients with dentofacial developmental abnormalities were ≤7 years of age at treatment. Our study shows that dentofacial developmental abnormalities are still a burden in the era of IMRT and as prognosis of childhood malignancy improves and more patients survive, these late dentofacial sequelae among childhood cancer survivors will become more common. Dental oncologists should be integral members in the management of children with head and neck cancers.

Oral and dental late effects in survivors of childhood cancer: a Children's Oncology Group report

PURPOSE

Multi-modality therapy has resulted in improved survival for childhood malignancies. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers provide practitioners with exposure- and risk-based recommendations for the surveillance and management of asymptomatic survivors who are at least 2 years from completion of therapy. This review outlines the pathophysiology and risks for oral and dental late effects in pediatric cancer survivors and the rationale for oral and dental screening recommended by the Children's Oncology Group.

METHODS

An English literature search for oral and dental complications of childhood cancer treatment was undertaken via MEDLINE and encompassed January 1975 to January 2013. Proposed guideline content based on the literature review was approved by a multi-disciplinary panel of survivorship experts and scored according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus" system.

RESULTS

The Children's Oncology Group oral-dental panel selected 85 relevant citations. Childhood cancer therapy may impact tooth development, salivary function, craniofacial development, and temporomandibular joint function placing some childhood cancer survivors at an increased risk for poor oral and dental health. Additionally, head and neck radiation and hematopoietic stem cell transplantation increase the risk of subsequent malignant neoplasms in the oral cavity. Survivors require routine dental care to evaluate for potential side effects and initiate early treatment.

CONCLUSIONS

Certain childhood cancer survivors are at an increased risk for poor oral and dental health. Early identification of oral and dental morbidity and early interventions can optimize health and quality of life.

A systematic review of dental late effects in survivors of childhood cancer

Survivors of childhood cancer are at risk for dental late effects. This systematic review summarizes associations between treatment exposures and dental late effects among survivors of childhood cancer. We included investigations with at least 20 study participants conducted for 2 or more years after completion of childhood, adolescent, or young adult cancer therapy. This review suggests both independent and additive effects of radiotherapy and chemotherapy on dental complications, and identifies vulnerable groups with specific host and treatment characteristics. This summary provides information that will assist clinicians to prevent, detect, and facilitate early intervention for dental late effects.

A low-grade myofibroblastic sarcoma in the abdominal cavity

Background

Rhabdomyosarcoma is the most common malignant tumor in the nasal and paranasal sinus area at childhood. Multimodal treatment for this disorder has severe side effects due to normal tissue damage. As a result of this treatment, facial growth retardation and oral abnormalities such as malformation of teeth and microstomia can cause esthetic and functional problems.

Case reports

Two cases are presented of patients with severe midfacial hypoplasia and reduced oral function as a result of treatment of rhabdomyosarcoma of the nasopharyngeal and nasal–tonsil region. With a combined surgical (osteotomy, distraction osteogenesis, implants) and prosthetic (implant-based overdenture) treatment, esthetics and function were improved.

Long term chemoradiotherapy-related dental and skeletal complications in a young female with nasopharyngeal carcinoma

We describe the long-term complications six years after chemoradiotherapy in a 20-year old woman with nasopharyngeal carcinoma. We wanted to know whether the radiation dose was constant throughout the oral cavity, and thus uniformly affecting the corresponding dental and skeletal structures. Clinical and radiologic findings are described six years after chemoradiotherapy based on a two-dimensional computerized treatment planning system. This revealed radiation caries limited only to posterior teeth, proximal caries in the anterior teeth, limited but continuous salivary flow, mild periodontal infection, mild xerostomia, and a regenerative capacity of bones and the developmental process. The quantitative assessment of radiation delivered to the mandible revealed a high radiation dose in the posterior area and a minimal dose in the anterior area. This explains the differences in caries manifestation between the anterior and posterior teeth. According to the present study, individualized radiation fields, using a two-dimensional treatment planning system, result in restriction of severe damage of the dental and skeletal structures, which usually follows chemoradiotherapy. Orthodontic treatment could be initiated according to individual patient needs.

Impact of radiation and chemotherapy on risk of dental abnormalities: a report from the Childhood Cancer Survivor Study

BACKGROUND

The current study was performed to describe frequencies and risk factors of altered oral health and odontogenesis in childhood cancer survivors.

METHODS

In total, 9308 survivors who were diagnosed between 1970 and 1986 and 2951 siblings from the Childhood Cancer Survivor Study completed a survey that contained oral-dental health information. The authors analyzed treatment impact, socioeconomic data, and patient demographics on dental outcomes using univariate and multivariate logistic regression models to estimate odds ratios (ORs).

RESULTS

In multivariate analysis, survivors were more likely to report microdontia (OR, 3.0; 95% confidence interval [95% CI], 2.4-3.8), hypodontia (OR, 1.7; 95% CI, 1.4-2.0), root abnormalities (OR, 3.0; 95% CI, 2.2-4.0), abnormal enamel (OR, 2.4; 95% CI, 2.0-2.9), teeth loss>or=6 (OR, 2.6; 95% CI, 1.9-3.6), severe gingivitis (OR, 1.2; 95% CI, 1.0-1.5), and xerostomia (OR, 9.7; 95% CI, 4.8-19.7). Controlling for chemotherapy and socioeconomic factors, radiation exposure of >or=20 Gray to dentition was associated significantly with an increased risk of >or=1 dental abnormality. Dose-dependent alkylating agent therapy significantly increased the risk of >or=1 anatomic/developmental dental abnormalities in survivors who were diagnosed at age<5 years (OR, 1.7, 2.7, and 3.3 for alkylating agent scores of 1, 2, and 3, respectively).

CONCLUSIONS

Radiation and chemotherapy were independent risk factors for adverse oral-dental sequelae among childhood cancer survivors. The authors concluded that patients who received receiving alkylating agents at age<5 years should be closely monitored.

Dental implant removal to facilitate suspension laryngoscopy and laser treatment of an obstructed airway

A 29-year-old patient presented with dysphonia, dysphagia and a progressive history of stridor over 6 weeks. His past medical history included childhood nasolabial rhabdomyosarcoma treated by surgery, chemotherapy and radiotherapy. This had resulted in marked abnormalities of the facial skeleton, limited neck extension and restricted mouth opening of 1 cm, in part due to dental implants. After careful discussion and planning within a multidisciplinary team, the airway was optimised by temporary removal of the dental implants. This enabled a suspension laryngoscope to be passed, permitting carbon dioxide laser treatment to an obstruction at the laryngeal inlet and eliminating the need for a tracheostomy.

Health behaviors, medical care, and interventions to promote healthy living in the Childhood Cancer Survivor Study cohort

Childhood cancer survivors are at risk for medical and psychosocial late effects as a result of their cancer and its therapy. Promotion of healthy lifestyle behaviors and provision of regular risk-based medical care and surveillance may modify the evolution of these late effects. This manuscript summarizes publications from the Childhood Cancer Survivor Study (CCSS) that have examined health behaviors, risk-based health care, and interventions to promote healthy lifestyle practices. Long-term survivors use tobacco and alcohol and have inactive lifestyles at higher rates than is ideal given their increased risk of cardiac, pulmonary, and metabolic late effects. Nearly 90% of survivors report receiving some form of medical care. However, only 18% report medical visits related to their prior cancer that include discussion or ordering of screening tests or counseling on how to reduce the specific risks arising from their cancer. One low-cost, peer-driven intervention trial has been successful in improving smoking cessation within the CCSS cohort. On the basis of data from CCSS investigations, several trials to promote improved medical surveillance among high-risk groups within the cohort are underway. Despite their long-term risks, many survivors of childhood cancer engage in risky health behaviors and do not receive adequate risk-based medical care.

Outcome and toxicity of an Ifosfamide-based soft tissue sarcoma treatment protocol in children. The importance of local therapy

Background. Although the survival of children with soft tissue sarcoma (STS) has improved considerably, the outcome of patients with metastatic disease, and those with primary tumours of the extremities or parameningeal sites remains disappointing. We describe the clinical outcome of an ifosfamide-based regimen with local therapy directed only to children who failed to achieve a complete response to initial chemotherapy.

Patients and Methods. Twenty-one children with STS (16 rhabdomyosarcoma) who presented with unresectable tumours were treated with five courses of ifosfamide (9 g/m²) and etoposide (600 mgm²). Patients who did not achieve a complete response then received local therapy. Chemotherapy with ifosfamide combined with etoposide, vincristine (1.5 mg/m² and doxorubicin (60 mg/m²) or vincristine and actinomycin D (1.5 mg/m²) was continued for one year.

Results and Discussion. Objective responses to five courses of ifosfamide and etoposide were seen in all patients. Disease free survival (DFS) at a median follow up of 59 months was 57% (95% CI 29–75%). The DFS of children who received local therapy was 89% compared with 33% in those who received chemotherapy alone (p=0.027). Locoregional recurrences did not occur in children who received radiotherapy to the site of the primary tumour. Ifosfamide-based chemotherapy does not reduce the incidence of loco-regional recurrence in children who do not receive local therapy.

Considerations in the pediatric population with cancer

This article is divided into three time periods according to the different phases of cancer treatment: pre, inter, and postcancer therapy. The purpose of dental protocols prior to cancer therapy and the incidence and management of acute and long term oral complications from cancer therapy in the pediatric population are discussed.

Late effects of pelvic rhabdomyosarcoma and its treatment in female survivors

PURPOSE

To document the spectrum and severity of late effects in female survivors of pelvic rhabdomyosarcoma.

PATIENTS AND METHODS

We reviewed the demographic, diagnostic, treatment, and outcome data of the 26 females treated for pelvic rhabdomyosarcoma at our institution between March 1962 and December 1996 who survived free of disease for 5 or more years. Adverse effects that occurred 5 or more years after diagnosis were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0.

RESULTS

The most common tumor sites were vagina (n = 7), pelvis/retroperitoneum (n = 6), and bladder (n = 4). All patients received chemotherapy (alkylating agent, n = 23; doxorubicin, n = 16); 22 received radiotherapy (median dose, 46 Gy). Median follow-up of the 23 survivors was 20.3 years. Late effects occurred in 24 patients, 23 of whom had grade 3/4 late effects (median grade 3/4 late effects per patient, three; range, zero to 14). Fourteen patients (54%) required surgery for late complications. The 22 patients who had received radiotherapy had a greater median number of late effects per patient than did the remaining four (9.5 v one; P = .002). The median number of late effects per patient was higher in the 12 patients treated during or after 1984 than in the 14 treated earlier (12.5 v 6.5; P = .041).

CONCLUSION

The burden of late effects in girls treated for pelvic rhabdomyosarcoma is significant and does not seem to be diminishing with advances in treatment. Prospective studies are needed to better assess the impact of these late effects on quality of life and functional outcome, and to refine the treatment approach to pelvic rhabdomyosarcoma.

Dental abnormalities in children preparing for pediatric bone marrow transplantation

The purpose of our study was to describe the types and frequencies of altered dental development in pediatric patients preparing for bone marrow transplantation (BMT). Retrospective review of the medical records and panoramic radiographs of all patients who underwent BMT at St Jude Children's Research Hospital between 1990 and 2000 for whom pre-BMT dental examination and panoramic radiography records were available. All patients were treated on institutional protocols. We recorded patient demographics and radiographic evidence of microdontia, hypodontia, taurodontia, root stunting, caries, enamel pearls, and pulpal calcifications. The 259 patients identified (150 male and 109 female) had a median age of 12.82 years (range, 3.18-25.93 years) at the time of BMT. In total, 203 were Caucasian, 38 were African-American, and 18 were of other races. In all, 150 (57.9%) had abnormal dentition. The most common dental abnormalities were caries (n=84), pulpal calcifications (n = 34), and dental extractions (n = 33). Developmental abnormalities occurred less frequently: taurodontia (n = 8), hypodontia (n = 10), microdontia (n = 11), and root stunting (n = 11). Dental abnormalities are prevalent in children undergoing BMT. Pre-transplant oral hygiene and dental examination should be standard care in order to minimize potential sites of infection.

Dental abnormalities after pediatric bone marrow transplantation

Our purpose was to describe the types and frequencies of altered dental development in pediatric patients following bone marrow transplantation (BMT). A retrospective review of the medical records and panoramic radiographs of all patients who underwent BMT at St Jude Children's Research Hospital between 1990 and 2000, for whom pre-BMT and post-BMT dental examination and panoramic radiography records were available, is presented. All patients were treated on institutional protocols. We recorded patient demographics and radiographic evidence of microdontia, hypodontia, taurodontia, root stunting, caries, enamel pearls, dental restorations/extractions and pulpal calcification. The 99 patients identified (52 males, 47 females) had a median age of 13.5 years (range, 3.4-25.9 years) at the time of BMT. In all, 73 were Caucasian, 15 were African-American, and 11 were of other races. The frequency of radiographically evident root stunting in permanent teeth was significantly increased after BMT (P<0.001), but there was no significant change in the frequency of other dental abnormalities after BMT. Dental abnormalities are prevalent in survivors of childhood BMT, but only root stunting appeared to progress with BMT.

An examination of the dental utilization practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

OBJECTIVES

This study characterized the self-reported dental utilization practice of long-term survivors of childhood cancer, a group at increased risk for treatment-induced dental abnormalities.

METHODS

9,434 survivors and a comparison group of 3,858 siblings completed a 289-item survey that included a question on when their last dental visit occurred.

RESULTS

Within the last year 60.4 percent of survivors reported a dental visit. The groups less likely to report a recent dental visit include minority subjects, subjects with low levels of educational attainment, subjects with annual household incomes < dollar 20,000, and those without health insurance. No significant differences between survivors and siblings were seen. Male survivors exposed to cranial radiation were slightly more likely than other male survivors to report a recent dental visit (OR = 1.27, 95% CI = 1.12, 1.44).

CONCLUSIONS

The dental utilization practices among survivors of childhood cancer are below recommended levels, even among those at highest risk for dental abnormalities.

Volumetric considerations in radiotherapy for pediatric parameningeal rhabdomyosarcomas

PURPOSE

To assess the influence of radiation volume on outcome in pediatric parameningeal rhabdomyosarcomas (PM-RMSs).

METHODS AND MATERIALS

Thirty patients ranging in age from 2 to 18 years (median 6) with PM-RMS were treated at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia between August 1988 and December 1999. The histologic subtypes included embryonal (n = 26), alveolar (n = 3), and undifferentiated (n = 1). Twenty-seven patients had Group III and three had Group IV disease. Twenty-seven patients underwent biopsy only and three subtotal resection. All patients were treated with multiple-agent chemotherapy and external beam radiotherapy. In 8 patients, all of whom had intracranial tumor extension, the tumor and whole brain were treated as the initial volume. In the remaining patients, most of those treated before 1992 were treated to the prechemotherapy (CMT) tumor volume for the entire treatment up to the total dose, which ranged from 45 to 59.4 Gy (median dose 57.9). In contrast, patients treated after 1992 generally received radiation initially to the pre-CMT volume (30.6-40 Gy; median dose 36) followed by a conedown to the post-CMT volume to a final dose of 41.4-55.2 Gy (median 50.4).

RESULTS

With a median follow-up of 6.2 years (range 2.1-13.3), the actuarial 5-year overall survival, progression-free survival, and local control rate for the entire group was 82%, 76%, and 76%, respectively. Seven failures and five deaths have been documented. In univariate analysis, histologic type, tumor size, and age at diagnosis were found to be predictive of overall survival and local control. No statistically significant difference in overall survival or local control was seen between patients who received a conedown to the post-CMT volume (n = 13) and patients in whom the pre-CMT volume was included for the entire treatment (n = 9).

CONCLUSION

Radiotherapy delivered to children with PM-RMS using a shrinking field technique with a post-CMT volume boost was effective and appears to give results comparable to those of patients in whom the pre-CMT volume was treated for the entire course. The use of such tailored treatment fields is likely to lead to fewer late effects and warrants further investigation.

Effects of therapy on dentofacial development in long-term survivors of head and neck rhabdomyosarcoma: the memorial sloan-kettering cancer center experience

PURPOSE

To describe potential effects of multimodality therapy on dental and facial development in long-term survivors of head and neck rhabdomyosarcoma.

PATIENTS AND METHODS

The medical records of all patients aged 20 years or less presenting between 1985 and 1996 with a diagnosis of rhabdomyosarcoma and treated by protocol were reviewed. Head and neck rhabdomyosarcoma patients who were followed in the Dental Service and were alive and free of disease with at least a 5-year follow-up were included in the review. Ten patients satisfied the inclusion criteria and form the basis of this report. The median age at diagnosis of the 10 patients was 4.3 years (range 10 months to 19.5 years). All patients were treated with chemotherapy, two patients underwent surgery, and all but one patient received external beam radiation therapy.

RESULTS

Clinical or radiographic dentofacial abnormalities were observed in 8 of the 10 (80%) patients. Abnormalities included enamel defects, bony hypoplasia/facial asymmetry, trismus, velopharyngeal incompetency, tooth/root agenesis, and disturbance in root development. Bony hypoplasia and disturbance in root formation were the most common findings.

CONCLUSIONS

Multimodality therapy for head and neck rhabdomyosarcoma can result in dentofacial abnormalities that affect the patient's quality of life. The care of the long-term survivor requires a multidisciplinary approach, including early involvement of the dental team.

Results from the IRS-IV randomized trial of hyperfractionated radiotherapy in children with rhabdomyosarcoma--a report from the IRSG

PURPOSE

To evaluate the outcome and toxicity of hyperfractionated radiotherapy (HFRT) vs. conventionally fractionated radiotherapy (CFRT) in children with Group III rhabdomyosarcoma (RMS).

METHODS AND MATERIALS

Five hundred fifty-nine children were enrolled into the Intergroup Rhabdomyosarcoma Study IV with Group III RMS. Sixty-nine were ineligible for the analysis because of incorrect group or pathologic findings. Of the 490 remaining, 239 were randomized to HFRT (59.4 Gy in 54 1.1-Gy twice daily fractions) and 251 to CFRT (50.4 Gy in 28 1.8-Gy daily fractions). The age range was <1-21 years. All patients received chemotherapy. RT began at Week 9 after induction chemotherapy for all but those with high-risk parameningeal tumors who received RT during induction chemotherapy. The patient groups were equally balanced. The median follow-up was 3.9 years.

RESULTS

Analysis by randomized treatment assignment (intent to treat) revealed an estimated 5-year failure-free survival (FFS) rate of 70% and overall survival (OS) of 75%. In the univariate analysis, the factors associated with the best outcome were age 1-9 years at diagnosis; noninvasive tumors; tumor size <5 cm; uninvolved lymph nodes; Stage 1 or 2 disease; primary site in the orbit or head and neck; and embryonal histologic features (p = 0.001 for all factors). No differences in the FFS or OS between the two RT treatment methods and no differences in the FFS or OS between HFRT and CFRT were found when analyzed by age, gender, tumor size, tumor invasiveness, nodal status, histologic features, stage, or primary site. Treatment compliance differed by age. Of the children <5 years, 57% assigned to HFRT received HFRT and 77% assigned to CFRT received CFRT. Of the children >or=5 years, 88% assigned to both HFRT and CFRT received their assigned treatment. The reasons for not receiving the appropriate randomized treatment were progressive disease, early death, parent or physician refusal, young age, or surgery. The toxicity assessment revealed more mucositis with HFRT (66%) than with CFRT (46%) (p = 0.03) for the parameningeal patients, and more skin reactions (16%) and nausea/vomiting (13%) with HFRT than with CFRT (7% and 5%, respectively) for patients with nonparameningeal primary tumors (p = 0.03 and p = 0.02, respectively). The analysis by treatment actually received revealed a 5-year FFS rate of 73% and OS rate of 77%, with no difference between CFRT and HFRT. As well, there was no difference in FFS or OS between CFRT and HFRT when analyzed by age, gender, tumor size, tumor invasiveness, modal status, histology, stage or site of primary. The 5-year estimated cumulative incidence of failure for the irradiated patients was local, 13%; regional, 3%; and distant, 13%; with no differences between HFRT and CFRT. The 5-year local failure rate by site was orbit, 5%; head and neck, 12%; parameningeal, 16%; bladder/prostate, 19%; extremity, 7%; and all others, 14%. The 5-year regional failure rate was parameningeal,1%; extremity, 20%; and all others, 5%. The 5-year distant failure rate was orbit, 2%; head and neck, 6%; parameningeal, 11%; bladder/prostate, 15%; extremity, 28%; and all others, 17%.

CONCLUSIONS

HFRT, as given in this study, did not improve local/regional control, FFS, or OS compared with CFRT. The risk of local/regional failure was comparable to that of distant failure in children with Group III RMS. The standard of care for Group III RMS continues to be CFRT with chemotherapy.

Impairment of nasal mucociliary clearance after radiotherapy for childhood head cancer

BACKGROUND

Radiotherapy of the head region in children is known to cause long-term sequelae, such as facial, dental, and ocular abnormalities. We investigated whether a decreased nasal mucociliary function occurs after radiotherapy of the head in children.

METHODS

A saccharin/charcoal test was performed in 20 children treated with radiotherapy of the head and in 20 controls, age-matched and gender-matched.

RESULTS

We found a decreased nasal mucociliary clearance (lower percentage of responses (p = 0083) and longer mucociliary transport times (p =.0001) in the patients compared with the controls. The radiotherapy dosage influenced the response to the test (p =.0046).

CONCLUSIONS

Irradiation of the head in children may cause impairment of mucociliary function, even permanently, which may predispose children to upper respiratory infections. We would suggest careful monitoring of such patients to detect as early as possible the clinical effects of the functional changes and to prevent the evolution to chronic diseases.

Late effects of therapy in 94 patients with localized rhabdomyosarcoma of the orbit: Report from the Intergroup Rhabdomyosarcoma Study (IRS)-III, 1984-1991

BACKGROUND

We reviewed the late complications of therapy in 94 patients with localized, primary rhabdomyosarcoma of the orbit treated on the Intergroup Rhabdomyosarcoma Study (IRS)-III protocol (1984-1991).

PROCEDURE

A questionnaire was sent to the institutions that had registered 106 patients with orbital RMS on the IRS-III protocol, seeking information about vision, periocular structures, and growth and development of the 102 survivors.

RESULTS

Ninety-four questionnaires were returned. The median follow-up interval was 7.6 years. The affected eye was removed from 13 patients because of local recurrence (N = 10) or other causes (N = 3). Seventy-nine of the eighty-one remaining patients had received radiation therapy. Sixty-five of these seventy-nine patients (82%) developed a cataract, and 43 of them (66%) underwent cataract surgery. Fifty-five patients (70%) had decreased visual acuity. Twenty-four patients had a dry eye, and 22 had chronic keratitis, conjunctivitis, or corneal changes. Strabismus, diplopia, retinopathy, and uveitis were uncommon. The orbit was hypoplastic in 48 of 82 patients assessed (59%). Ptosis and enophthalmos were reported in 22 patients. Decreased statural growth was noted in 13 of the 53 irradiated patients aged 3-14 years at diagnosis with sufficient data (24%).

CONCLUSIONS

The overall survival rate was 96% (102/106). The eye was preserved in 86% of the patients, but vision was impaired in 70% of them. Other frequent complications were cataract, orbital hypoplasia, keratoconjunctivitis, and ptosis/enophthalmos. The current IRS-V study recommends decreasing the dose of irradiation and using conformal techniques in an attempt to minimize these complications.

Late complications of therapy in 213 children with localized, nonorbital soft-tissue sarcoma of the head and neck: A descriptive report from the Intergroup Rhabdomyosarcoma Studies (IRS)-II and - III. IRS Group of the Children's Cancer Group and the Pediatric Oncology Group

BACKGROUND

This review of children and adolescents with nonorbital soft-tissue sarcoma of the head and neck was undertaken to describe late sequelae of treatment, as manifested primarily by problems with statural growth, facial and nuchal symmetry, dentition, vision and hearing, and school performance.

PROCEDURE

Four hundred sixty-nine patients entered the IRS-II and -III protocols with localized, nonorbital soft-tissue sarcomas of the head and neck from 1978 through 1987. Their overall survival rate was 53% (250/469) at 5 years. Two hundred thirteen patients were surviving relapse-free 5 or more years after diagnosis, for whom there were serial height measurements at 2 or more years after initiation of therapy. Their median age at diagnosis was 5 years; the median length of follow-up was 7 years. All received multiple-agent chemotherapy, and all but 3 received irradiation to the primary tumor volume. Sixty-eight percent of the tumors arose in cranial parameningeal sites, 22% in nonparameningeal sites, and 10% in the neck. We reviewed flow sheets submitted to the IRS Group Statistical Office to ascertain which late sequelae were recorded.

RESULTS

One hundred sixty-four patients (77%) had one or more problems recorded. One hundred ninety of the two hundred thirteen patients (89%) were under 15 years of age at study entry, and at follow-up 92 (48%) had failed to maintain their initial height velocity, which had decreased by more than 25 percentile points from the original value. Thirty-six of the one hundred ninety patients (19%) were receiving growth hormone injections. Hypoplasia or asymmetry of tissues in the primary tumor site was reported in 74 patients, and 13 underwent reconstructive surgery. Poor dentition or malformed teeth were noted in 61 patients. Impaired vision developed in 37 patients, owing primarily to cataracts, corneal changes, and optic atrophy. Thirty-six patients had decreased hearing acuity, and 9 were fitted with hearing aids; 5 of these 9 had received cisplatin. Thirty-five patients were noted to have problems learning in school. Four patients developed a second malignancy (two sarcomas, one carcinoma, one leukemia).

CONCLUSIONS

Late sequelae affected the majority of these patients treated for soft-tissue sarcoma of the head and neck on IRS-II and -III. The potential impact of certain sequelae could be reduced by specific measures, such as surgical reconstruction and hormonal therapy. Late sequelae must be taken into account in designing future curative treatments.

Late effects of treatment for germ cell tumors during childhood and adolescence

PURPOSE

To evaluate the long-term sequelae of treatment for malignant germ cell tumors (GCT) during childhood and adolescence.

PATIENTS AND METHODS

Of 128 patients treated for GCT at St. Jude Children's Research Hospital between 1962 and 1988, 73 are long-term survivors (continuously disease-free for > or =5 years after diagnosis), with a median follow-up of 11.3 years). Survivors' ages at diagnosis ranged from birth to 18.3 years (median, 9.2 years); 64% (47 patients) were female. Initial surgical resection was followed by observation for stage I germinomas (n = 2), testicular tumors (n = 13), and selected cases of ovarian or sacrococcygeal tumors (n = 2), and by radiation therapy (RT) for patients with stage II to III germinoma (n = 8). The remaining 48 patients received postoperative chemotherapy (vincristine, dactinomycin, and cyclophosphamide [VAC] +/- doxorubicin, 1962 to 1978; VAC and/or cisplatin, vinblastine, and bleomycin [PVB], 1979 to 1988). RT was added to the chemotherapy for 21 patients. Late complications involving various organ systems and their relationship to treatment were evaluated.

RESULTS

More than two-thirds of long-term survivors (n = 50) had at least 1 complication, and half (n = 38) had > 1 organ system affected. The systems most often involved included the musculoskeletal (41% of survivors), endocrine (42%), cardiovascular (16% excluding those who had only abnormal chest radiograph), gastrointestinal (25%), genitourinary tract (23%), pulmonary (19%), and neurologic (16%) systems. High-frequency hearing loss occurred in 58% (11 of 19) of patients treated with cisplatin. Musculoskeletal, gastrointestinal, and urinary tract abnormalities were most frequent in patients whose treatment included RT.

CONCLUSIONS

A high frequency of late effects after treatment for pediatric GCT, particularly in patients who received RT, was demonstrated. Treatment sequelae could be anticipated from the intensity and type of therapeutic modalities. Treatment-directed screening evaluations may improve quality of life in long-term survivors of pediatric GCT through timely identification of sequelae that can be prevented or ameliorated.

Management and long-term complications of pediatric cancer

The impact of recently intensified and novel therapies for the treatment of childhood cancer has been an increased number of survivors and an increase in the number of treatment complications among survivors. Thus, it is important for the primary care practitioner to be aware of not only acute but chronic complications of therapy, including the possibility of second malignancies. Long-term follow-up is essential, and continuous education of patients and health care personnel is an important aspect for the complete success of treatment. Primary care practitioners also need to incorporate other subspecialties in the management of these patients to ensure that they receive complete evaluation and treatment.

The effects of radiation on craniofacial skeletal growth: a quantitative study

To determine whether radiation delivered to children treated for head and neck cancer causes deformity, we performed a quantitative analysis for craniofacial asymmetry. A total of 42 patients, with either rhabdomyosarcoma or nasopharyngeal carcinoma, treated between 1980 and 1991, were analyzed. Exclusions included 16 subjects, leaving 26 children of mixed race and gender with a median age at diagnosis of 13 years (range: 2-18) and a median age at follow-up of 4 years (range: 3-37). Data from 14 measurements of the cranium and facial skeleton, for which normative data exist, were recorded. Symmetry of the face and head were determined and each measurement was compared to age specific standards. Deviation occurred in the cranial vault, the anterior and mid-interorbital distances and lateral orbital wall length. Asymmetry existed in the medial and lateral orbital wall lengths and the zygomatic arches. We conclude that, children irradiated for head and neck malignancies, have significant alterations in some skeletal measurements indicative of treatment induced asymmetry and potential deformity.

Dental abnormalities in children treated for neuroblastoma

PURPOSE

To determine the frequency and types of dental abnormalities among children treated at a young age for cancer, as represented by neuroblastoma.

PATIENTS AND METHODS

We retrospectively reviewed the dental records and panoramic radiographs of 542 children who were treated for neuroblastoma at our institution over a 31-year period. Patients in our study had to meet the following criteria: they were treated on an institutional protocol, they had undergone panoramic radiography, and their dental follow-up continued for at least 2 years after diagnosis. We evaluated the frequency of clinically or radiographically apparent microdontia, excessive caries, root stunting, hypodontia, and enamel hypoplasia in our study population.

RESULTS

Of the 52 patients who met the study criteria, 71% developed dental abnormalities, comprising microdontia in 38%, excessive caries in 29%, root stunting in 17%, hypodontia in 17%, and enamel hypoplasia in 17%. In nearly half (23) of our patients, neuroblastoma was diagnosed on or before their first birthday.

CONCLUSION

Children treated for neuroblastoma are at high risk for abnormal dental development. The abnormalities in these patients may require extensive dental care and can compromise their quality of life. Frequent dental examinations and an intense oral hygiene program before, during, and after treatment may improve overall dental health.

Effects of actinomycin D on developing hamster molar tooth germs in vitro

The aim of this study was to evaluate the toxic effects of actinomycin D on the developing hamster tooth germ in organ culture. Hamster tooth germs during early secretory amelogenesis were exposed in vitro for 24 h to 10(-9) M-5 x 10(-5) M actinomycin D. Actinomycin D dose-dependently (> or = 10(-7) M) decreased the tooth germ dry weight but mineralization was affected only by doses > or = 10(-5) M. However, the uptakes of TCA-insoluble 32P and [3H]thymidine were significantly reduced dose-dependently from > or = 10(-8) M actinomycin D, indicating that the drug inhibits the synthesis of phosphate-containing macromolecules as well as DNA synthesis. Histologically, 10(-8) M actinomycin D was the lowest dose which was not toxic to any cell type in the developing tooth germ. At 10(-7) M actinomycin D, the most sensitive cells were the proliferating pre-odontoblasts followed by pre-ameloblasts; the mature secretory ameloblasts and odontoblasts appeared unaffected. Higher doses resulted in increased cytotoxicity to the secretory cells and, eventually, total degeneration of most cells. The data suggest that children treated for cancer during tooth development using anti-chemotherapy cocktails containing actinomycin D (serum levels > 10(-7) M) may develop defects later on in the mature dentition as a direct consequence of the toxicity of the drug to the tooth organ.

Influence of antineoplastic therapy on function of the masticatory system, tooth development, and cariogenic status: a case report

Antineoplastic therapy causes developmental disturbances in the dental enamel and root if children are treated during tooth development. Increased caries activity has also been reported. The effect of anticancer therapy on the function of the masticatory system (i.e. jaws, dentition, masticatory muscles) is not well known. A case report of a 9-year-old girl with right auricular rhabdomyosarcoma is presented. She received irradiation of 50 Gy to the right auricular area and chemotherapy. A year and a half after cessation of cancer therapy, she was disease free and the clinical stomatognathic examination combined with electromyogram (EMG) registration of the masseter and temporal muscles and magnetic resonance imaging (MRI) examination of the temporomandibular joints (TMJ) revealed a strongly restricted mouth opening capacity, painful right TMJ, and flattened head of the right mandibular condyle. Muscle atrophy in the right masseter muscle was clearly visible but EMG activities of the masseter and temporal muscles, however, were higher on the right than on the left. More severe developmental defects, and worse gingival and cariological health were observed on the right side than on the left side. She developed 12 carious lesions and all the lesions were on the right maxilla or mandible or on anterior teeth. The left side was not affected. Intensive prophylactic dental care after cancer treatment is important in order to prevent caries and gingival inflammation. Stomatognathic treatment (i.e. management of occlusal and dysfunctional problems) may improve the mouth opening capacity and relieve pain.