Bone mineral density and markers of bone turnover in young adult survivors of childhood lymphoblastic leukaemia

Bone Mineral Density Evolution and Its Determinants in Long-term Survivors of Childhood Acute Leukemia: A Leucémies Enfants Adolescents Study

This prospective study aimed to analyze determinants that can influence bone mineral density evolution in childhood acute leukemia survivors. Patients included were selected from the long-term follow-up LEA cohort and had dual energy radiograph absorptiometry scan between 10 and 18 years and after the age of 18. All scans were centrally reviewed. Bone mineral density was measured at the lumbar spine, femoral neck, total hip, and whole body, and expressed as z-score. Eighty-nine patients (female 39, lymphoblastic leukemia 68, relapse 25, hematopoietic stem cell transplantation 44, and mean age 15.4 and 20.1 years at the first and second scans, respectively) were studied. The first and second scan z-scores were significantly correlated (P < 10⁻³). Mean femoral neck and total hip z-scores improved significantly between the first and second scans, whereas no significant evolution occurred at the lumbar spine and whole-body level. On the second evaluation, 14.6% of patients had z-score <−2 at the lumbar spine and 4.3% at the femoral neck level. Gender, type of leukemia, transplantation, relapse, cumulative corticosteroid doses, or growth hormone deficiency did not have any significant impact on z-score variation. Younger age at diagnosis (≤8.5 years) proved an unfavorable risk factor for z-score evolution at the lumbar spine (P = 0.041); the trend did not reach statistical significance for metabolic syndrome (P = 0.054). At the femoral neck, both were associated with unfavorable z-score evolution (P = 0.003 and 0.025, respectively). Patients treated at a younger age and those with metabolic syndrome seem to be at higher risk of bone mineral density decline and should benefit from specific interventions.

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.

Late vertebral side effects in long-term survivors of irradiated childhood brain tumor

Purpose

Long-term side effects of the treatments are common in survivors of irradiated pediatric brain tumors. Ionizing radiation in combination with surgery and chemotherapy during childhood may reduce vertebral height and bone mineral density (BMD), and cause growth failure. The aim of this study was to evaluate the late consequences of tumor treatments on vertebrae in survivors of childhood brain tumors.

Methods

72 adult survivors (mean age 27.8 years, standard deviation 6.7) of irradiated childhood brain tumor were studied by spinal magnetic resonance imaging (MRI) for vertebral abnormalities from the national cohort of Finland. Patients were treated in five university hospitals in Finland between the years 1970 and 2008. Subject height and weight were measured and body mass index (BMI) was calculated. The morphology and height/depth ratio of the vertebrae in the middle of the kyphotic thoracic curvature (Th8) and lumbar lordosis (L3) were examined. Vertebrae were analyzed by Genant’s semiquantative (SQ) method and spinal deformity index (SDI) was calculated. BMD was measured by using dual X-ray absorptiometry.

Results

4.2% (3/72) of the patients had undiagnosed asymptomatic vertebral fracture and 5.6% (4/72) of patients had radiation-induced decreased vertebral body height. Male patients had flatter vertebrae compared with females. Patient age at the time of irradiation, BMI and irradiation area correlated to vertebral morphology differentially in males and females. BMD had no association with the vertebral shape. Patients who had received craniospinal irradiation were shorter than the general population.

Conclusion

Childhood brain tumor survivors had a high number of vertebral abnormalities in young adulthood. Irradiation was associated with abnormal vertebral morphology and compromised final height. Male gender may predispose vertebrae to the side effects of irradiation.

No impact of disease and its treatment on bone mineral density in survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Acute lymphoblastic leukemia (ALL) and its treatment are often implicated in adversely affecting bone health. Conflicting reports in the literature and a paucity of studies from the developing world prompted us to study bone mineral density (BMD) in childhood ALL survivors.

METHODS

BMD lumbar spine (LS) and whole body (WB) were evaluated, using dual energy x-ray absorptiometry in 65 pediatric ALL survivors who had been off-therapy for at least 2 years. The control group constituted of 50 age- and sex-matched healthy siblings. Kernel density plots were used to compare BMD among cases and controls. The disease-, treatment-, hormone- and lifestyle-related factors likely to modulate BMD were analyzed using the Mann-Whitney U test and Student's t-test.

RESULTS

At a median of 4.3 years (range, 2-14.8 years) since cessation of therapy, height-adjusted (HA) mean BMD Z-scores of LS (-0.67 ± 1.11, -0.607 ± 1.05, P = 0.759) and WB (-0.842 ± 0.92, -0.513 ± 0.97, P = 0.627) were comparable among the cases and controls. Disease, treatment (chemotherapy, cranial radiotherapy) and endocrine factors did not predict low BMD. However, survivors with calcium intake <800 mg/day (WB, P = 0.018) and hypovitaminosis D (≤25 nmol/L) had lower BMD values (HA-WB, P = 0.046) than the controls. A significant proportion of survivors were overweight or obese and had higher BMD Z-scores (HA-LS, P = 0.003; HA-WB, P = 0.028).

CONCLUSION

BMD Z-scores were similar among ALL survivors and controls. It was reassuring that there was no detrimental impact of the disease or its treatment on BMD. Future studies are required to determine the best possible ways to target the modifiable risk factors (diet, vitamin D) to optimize bone health.

Bone Mineral Density in Survivors of Childhood Acute Lymphoblastic Leukemia

Background:

The objective of this study was to evaluate bone mineral density (BMD) after completion of treatment for childhood acute lymphoblastic leukemia (ALL).

Methods:

In this cross-sectional study, 103 survivors of ALL aged 13.5 ± 0.45 who completed their treatment at least one year earlier were enrolled. Among these, 49.5% and 51.5% received chemotherapy alone and chemotherapy plus cranial radiotherapy, respectively. Bone mineral content, BMD, and bone mineral apparent density in the lumbar spine (LS), femoral neck (FN) and forearm were assessed using dual-energy X-ray absorptiometry (DEXA). BMD Z-scores were classified according to International Society for Clinical Densitometry (ISCD) criteria.

Results:

The mean BMD Z-scores ± SD forLS, FN and forearm were -1.60 ± 0.12, -1.21 ± 0.9 and -2.43 ± 0.14 respectively with significant differences (P<0.001). Considering the lowest BMD Z-score in LS and FN areas (at any site) and according to the ISCD classification, 62.1%, 33% and 4.9% of the patients had normal BMD, low BMD and osteoporosis, respectively. Also, 8.7% of patients had developed fractures after completion of the treatment period, 4.9% having BMD Z-Scores <-2 SD at any site. A direct relationship was apparent between BMD Z-scores at LS and FN at any sites and risk of fracture (P<0.001).

Conclusions:

ALL patients are at risk for low BMD and fracture. Therefore, applying DEXA scanning is recommended after completion of therapy for prevention of BMD reduction and osteoporosis.

Bone turnover in long-term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

We investigated the effects of demographic, lifestyle (self-reported smoking status and physical activity levels), cancer-related treatment factors (radiation and chemotherapy), and diet (calcium and vitamin D intake) on bone turnover and the relationship of bone turnover to lumbar spine bone mineral density (BMD) Z-scores (LS-BMD Z-scores) determined by quantitative computed tomography (QCT) in 418 ≥5-year survivors of childhood acute lymphoblastic leukemia (ALL).

PROCEDURE

Bone turnover was assessed by biomarkers including serum bone-specific alkaline phosphatase (BALP), osteocalcin (OC), and urinary N-telopeptide of type I collagen indexed to creatinine (NTX/Cr). The 215 males ranged in age from 9 to 36 years (median age 17 years).

RESULTS

Age and tanner score were inversely associated with all biomarkers (BALP, OC, NTX/Cr) (P < 0.001). Males had higher BALP and OC than females (P < 0.001). Body mass index (BMI) was inversely associated with OC and NTX/Cr (P < 0.001). There was no significant association of biomarkers with lifestyle related factors, ALL treatment-related factors, dietary calcium, vitamin D, or LS-BMD Z-score.

CONCLUSIONS

In this population of long-term survivors of ALL, bone turnover was significantly associated with age, gender, tanner stage, and BMI. ALL-related treatments did not influence bone turnover and bone turnover was not predictive of volumetric LS-BMD Z-score.

Calcium and cholecalciferol supplementation provides no added benefit to nutritional counseling to improve bone mineral density in survivors of childhood acute lymphoblastic leukemia (ALL)

BACKGROUND

We sought to improve lumbar spine bone mineral density (LS-BMD) in long-term survivors of childhood acute lymphoblastic leukemia (ALL) using calcium and cholecalciferol supplementation.

PROCEDURE

This double-blind, placebo-controlled trial randomized 275 participants (median age, 17 [9-36.1] years) with age- and gender-specific LS-BMD Z-scores <0 to receive nutritional counseling with supplementation of 1,000 mg/day calcium and 800 International Unit cholecalciferol or placebo for 2 years. The primary outcome was change in LS-BMD assessed by quantitative computerized tomography (QCT) at 24 months. Linear regression models were employed to identify the baseline risk factors for low LS-BMD and to compare LS-BMD outcomes.

RESULTS

Pre-randomization LS-BMD below the mean was associated with male gender (P = 0.0024), White race (P = 0.0003), lower body mass index (P < 0.0001), and cumulative glucocorticoid doses of ≥ 5,000 mg (P = 0.0012). One hundred eighty-eight (68%) participants completed the study; 77% adhered to the intervention. Mean LS-BMD change did not differ between survivors randomized to supplements (0.33 ± 0.57) or placebo (0.28 ± 0.56). Participants aged 9-13 years and those 22-35 years had the greatest mean increases in LS-BMD (0.50 ± 0.66 and 0.37 ± 0.23, respectively). Vitamin D insufficiency (serum 25[OH]D <30 ng/ml) found in 296 (75%), was not associated with LS-BMD outcomes (P = 0.78).

CONCLUSION

Cholecalciferol and calcium supplementation provides no added benefit to nutritional counseling for improving LS-BMD among adolescent and young adult survivors of ALL (93% of whom had LS-BMD Z-scores above the mean at study entry).

Bone mineral density deficits and fractures in survivors of childhood cancer

Although substantial increases in survival rates among children diagnosed with cancer have been observed in recent decades, survivors are at risk of developing therapy-related chronic health conditions. Among children and adolescents treated for cancer, acquisition of peak bone mass may be compromised by cancer therapies, nutritional deficiencies, and reduced physical activity. Accordingly, failure to accrue optimal bone mass during childhood may place survivors at increased risk for deficits in bone density and fracture in later life. Current recommendations for the treatment of bone density decrements among cancer survivors include dietary counseling and supplementation to ensure adequate calcium and vitamin D intake. Few strategies exist to prevent or treat bone loss. Moving forward, studies characterizing the trajectory of changes in bone density over time will facilitate the development of interventions and novel therapies aimed at minimizing bone loss among survivors of childhood cancer.

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

As chemotherapy and other sophisticated treatment strategies evolve and the number of survivors of long-term childhood cancer grows, the long-term complications of treatment and the cancer itself are becoming ever more important. One of the most important but often neglected complications is osteoporosis and increased risk of fracture during and after cancer treatment. Acquisition of optimal peak bone mass and strength during childhood and adolescence is critical to preventing osteoporosis later in life. However, most childhood cancer patients have multiple risk factors for bone mineral loss. Cancer itself, malnutrition, decreased physical activity during treatment, chemotherapeutic agents such as steroids, and radiotherapy cause bone mineral deficit. Furthermore, complications such as growth hormone deficiency and musculoskeletal deformity have negative effects on bone metabolism. Low bone mineral density is associated with fractures, skeletal deformity, pain, and substantial financial burden not only for childhood cancer survivors but also for public health care systems. Thus, it is important to monitor bone health in these patients and minimize their risk of developing osteoporosis and fragility fractures later in life.

Long-term skeletal consequences of childhood acute lymphoblastic leukemia in adult males: a cohort study

OBJECTIVE

Long-term health sequelae of childhood-onset acute lymphoblastic leukemia (ALL) remain largely unknown. Low bone mineral content (BMC) and bone mineral density (BMD) are recognized complications, but it is unknown whether these persist until adulthood. We evaluated skeletal characteristics and their association with ALL therapy in long-term male ALL survivors.

DESIGN

This cross-sectional cohort study included 49 long-term male ALL survivors and 55 age-matched healthy males.

METHODS

BMD and compression fractures were assessed by dual-energy X-ray absorptiometry; blood biochemistry was obtained for parameters of calcium homeostasis.

RESULTS

The ALL survivors (median age 29 years, range 25-38 years), assessed 10-38 years after ALL diagnosis, had lower lumbar spine (P<0.001), femoral neck (P<0.001), and whole-body (P=0.017) BMD than expected based on normative values. When compared with the controls (median age 30 years, range 24-36 years), the ALL survivors had lower lumbar spine BMC (P=0.014), lower whole-body BMC (P<0.001), and lower whole-body BMD (P<0.001), but the differences were partly explained by differences in height. Altogether, 20% of the ALL survivors had spinal compression fractures, but these were equally prevalent in the controls. Males diagnosed with ALL before age 5 years had significantly lower BMD values. Other recognized risk factors included untreated hypogonadism, vitamin D deficiency, hypophosphatemia, low IGF-binding protein-3, and low physical activity.

CONCLUSIONS

At young adulthood, long-term male ALL survivors have significantly reduced BMC and BMD and a high prevalence of spinal compression fractures. Careful follow-up and active treatment of the recognized risk factors are warranted.

Predictors of bone loss in childhood hematologic malignancies: a prospective study

SUMMARY

Twenty-nine children with malignancies and age, gender-matched controls were prospectively studied over 14 months. Patients had higher parathyroid hormone (PTH) levels and fat mass, lower bone mass, and bone mass increments at follow-up than controls. Lean mass, age at diagnosis, systemic and intrathecal therapy were predictors of bone mass changes on adjusted analyses.

INTRODUCTION

Children with hematologic malignances have low bone mass. We prospectively investigated anthropometric, clinical, and hormonal predictors of changes in bone mass in children receiving cancer therapy.

METHODS

Twenty-nine children, mean age of 9 ± 2.9 years and 32 age and gender-matched controls, were studied. Seven had completed their course 40 ± 22 weeks prior, while 22 were still receiving therapy for 80 ± 28 weeks. Age at diagnosis, calcium intake, exercise activity, systemic corticosteroids in dexamethasone (Dex) dose, and methotrexate (MTX), and intrathecal MTX therapy received within follow-up period were assessed. Routine chemistries, PTH, 25-hydroxy vitamin D (25-OHD), bone remodeling markers, bone mass, and body composition were measured at baseline and 14 months.

RESULTS

Patients had lower exercise activity, sun exposure, and bone markers levels than controls. They had higher PTH levels and fat mass, lower bone mass at the spine, hip, and total body, and lower increments at these sites on follow-up. Predictors of bone mass changes on univariate analyses were: age at diagnosis (R = -0.50 to -0.44, p < 0.05), Dex-MTX doses (R = -0.58 to -0.41, p < 0.05), intrathecal therapy (p < 0.03),% changes in lean mass (R = 0.37 to 0.54, p < 0.04), 25-OHD levels (R = 0.39, p < 0.03), and PTH levels (R = -0.47 to -0.41, p < 0.05). Lean mass, age at diagnosis, systemic and intrathecal therapy were predictors of bone mass changes on adjusted analyses.

CONCLUSION

This study provides insight into the pathophysiology of bone loss in children receiving cancer therapy and possible interventions to optimize their skeletal health.

Little evidence of low bone mass in acute lymphoblastic leukemia survivors

Childhood acute lymphoblastic leukemia (ALL) survivors represent a specific group at risk for many health problems, including skeletal complications and osteoporosis. The objective of this study was to assess the risk of osteoporosis associated with the prevalence of low bone mass (according to the guidelines of the Pediatric Official Positions of the International Society for Clinical Densitometry 2007) in survivors of childhood ALL. The cross-sectional study was conducted in a cohort of 69 Caucasian children and adolescents (46 boys and 23 girls) aged 12.15 ± 0.5yr diagnosed with ALL and screened up to 5 yr after cessation of the treatment. Total body bone mineral content (TB BMC, g), total body bone mineral density (TB BMD, g/cm(2)), and lumbar spine BMD (LS BMD, g/cm(2)) were determined using dual-energy X-ray absorptiometry. Time interval from the completion of the treatment to the beginning of this study (subgroup I<2 yr or subgroup II>2 yr after treatment), methotrexate (MTX) doses (subgroup I-MTX ranging from 0.5 to 1.0g/m(2); subgroup II-MTX>2.0 g/m(2)), cranial irradiation (subgroup I-without radiotherapy (RTX) and subgroup II receiving RTX of 12-18 Gy), cumulative steroid dose, and impaired endocrine function were considered as potential factors affecting bone metabolism and included in the analysis. No differences were found in bone traits (BMC, TB BMD, LS BMD) in relation to examined risk factors. In multiple regression model that included therapeutical factors, a risk group and central nervous system irradiation were of an important influence on bone mass, and risk group predicted TB BMD in small degree. Risk group and irradiation status lost their significance after the inclusion of anthropometric, age-connected, and time-connected factors. This study suggests that ALL survivors are not at increased risk for low bone mass. However, from the clinical perspective all patients after childhood ALL should be screened for clinical signs, fracture history, and lifestyle risk factors for low bone mass and osteoporosis. They should be referred to bone density evaluation only as often as may be necessary from the clinical evaluation.

Effects of growth hormone therapy on bone mass, metabolic balance, and well-being in young adult survivors of childhood acute lymphoblastic leukemia

Growth hormone deficiency (GHD), mostly after cranial radiotherapy (CRT), may lead to several negative effects. Young adult survivors of acute lymphoblastic leukemia (ALL) could benefit from GH therapy in different ways. Twenty ALL survivors (17.1 ± 4.3 y after diagnosis) with low bone mineral densities and/or low insulin-like growth factor-1 were included. Two of the 3 patients who only received chemotherapy had GHD. Of the 20 patients, 17 started with GH therapy and 14 completed the 2-year study period. At several time points, bone mineral density (BMD) was measured. Psychological functioning was assessed. At the start of the study, standard deviation scores of height, insulin-like growth factor-1, lumbar spine, and femoral neck BMD were all below -1. After 2 years of GH therapy, total body BMD and lean mass were significantly higher (P < 0.01 and P < 0.001, respectively), whereas the percentage fat was significantly lower (P < 0.02). Several psychological measures improved significantly after 2 years. In conclusion, GH therapy during 2 years in young adult survivors of childhood ALL did have a number of benefits, such as improvement of total body bone density and body composition. Results also suggest improvement of psychological well being. Furthermore, it also became clear that patients after chemotherapy alone should be tested for GHD.

Bone mineral density in adult survivors of childhood acute leukemia: impact of hematopoietic stem cell transplantation and other treatment modalities

Femoral and lumbar bone mineral densities (BMDs) were measured in 159 adults enrolled in the Leucémies de l'Enfant et de l'Adolescent program, a French prospective multicentric cohort of childhood leukemia survivors. BMDs were expressed as Z-scores, and multivariate linear regression analyses were used to construct association models with potential risk factors. Mean age at evaluation and follow-up was 23 and 14.7 years, respectively. In the whole cohort, mean femoral Z-score was -0.19 ± 0.08. Two factors were associated with lower femoral BMD transplantation (-0.49 ± 0.15 vs -0.04 ± 0.10 in the chemotherapy group; P = .006) and female sex (-0.34 ± 0.10 vs -0.03 ± 0.13; P = .03). Among patients who received a transplant, the only significant risk factor was hypogonadism (-0.88 ± 0.16 vs -0.10 ± 0.23; P = .04). A slight reduction in lumbar BMD (mean Z-score, -0.37 ± 0.08) was detected in the whole cohort without difference between the transplantation and chemotherapy groups. Among patients who received a transplant, younger age at transplantation was correlated with a low lumbar BMD (P = .03). We conclude that adults who had received only chemotherapy for childhood leukemia have a slight reduction in their lumbar BMD and a normal femoral BMD. Patients who received a transplant with gonadal deficiency have a reduced femoral BMD which might increase the fracture risk later in life.

Bone loss after childhood acute lymphoblastic leukaemia: an observational study with and without GH therapy

OBJECTIVE

Bone mineral density (BMD) in survivors of acute lymphoblastic leukaemia (ALL) seems to vary with time, type of treatments and GH status. We aimed to evaluate BMD in ALL patients with GH deficiency (GHD), with and without GH therapy.

DESIGN

Case-control study.

METHODS

We examined 44 (21 women) GHD patients (median 25 years) treated with cranial radiotherapy (18-24 Gy) and chemotherapy and matched population controls for BMD with dual-energy X-ray absorptiometry. For 5 and 8 years, two subgroups with (0.5 mg/day) (n=16) and without GH therapy (n=13) and matched controls were followed respectively.

RESULTS

At baseline, no significant differences in BMD or Z-scores at femoral neck and L2-L4 were recorded (all P>0.3). After another 8 years with GHD, the Z-scores at femoral neck had significantly decreased compared with baseline (0.0 to -0.5; P<0.03) and became lower at the femoral neck (P=0.05), and at L2-L4 (P<0.03), compared with controls. After 5 years of GH therapy, only female ALL patients had a significantly lower femoral neck Z-scores (P=0.03). The female ALL patients reached an IGF1 level of -0.7 s.d. and male patients reached the level of +0.05 s.d.

CONCLUSIONS

On average, 25 years after diagnosis, GH-deficient ALL patients experienced a significant decrease in Z-scores at femoral neck, and if Z-scores continue to decrease, there could be a premature risk for osteoporosis. GH therapy was not shown to have a clear beneficial effect on BMD. Whether higher GH doses, particularly in women, will improve Z-scores needs further investigation.

Prospective bone ultrasound patterns during childhood acute lymphoblastic leukemia treatment

OBJECTIVE

Bone impairment is a well-known complication in childhood acute lymphoblastic leukemia (ALL) survivors but less is known about bone dynamics during ALL therapy. We longitudinally assessed by Quantitative Ultrasound (QUS) skeletal modifications during this treatment.

MATERIALS AND METHODS

Forty-four newly diagnosed ALL children underwent bone measurement by QUS parameters BTT (Bone Transmission Time) and AD-SoS (Amplitude-Dependent Speed of Sound), mainly reliant on bone density and cortical thickness, respectively. Measurements were performed at diagnosis, and 6, 12, and 24 months thereafter. The occurrence of skeletal complications such as fractures, vertebral collapse, osteonecrosis, and osteopenia was related to measurement outcome.

RESULTS

A rapid deterioration of bone properties measured by BTT and AD-SoS was evident in the first semester of therapy (p<0.001). Subsequently, the next measurements were characterized by progressive uncoupling of the two QUS parameters (p<0.001). These were both significantly reduced at the end of therapy (p<0.001). Twelve subjects with in-treatment skeletal complications displayed an almost two-fold decrease of both parameters (p<0.001). BTT decreasing more than 1 Standard Deviation (SD) over 6 months of therapy was able to predict skeletal complication occurrence (p<0.001).

CONCLUSION

This report represents the largest longitudinal cohort systematically submitted to bone condition assessment from the beginning to the end of therapy for childhood ALL. Bone deterioration occurs early and persists throughout therapy, consistent with bone properties uncoupling. This pattern possibly reflects an initial impairment of both mineral density and cortical thickness with a subsequent recovery of this latter. QUS permits an early detection of bone deterioration and related skeletal complications in childhood ALL.

Modeling pathways for low bone mass in children with malignancies

Children with malignancies have low bone mass. Pathways for metabolic bone disease were investigated in children with cancer by concomitantly assessing lifestyle, clinical, and biochemical predictors of bone mass. Forty-one children who were receiving cancer therapy for 61 weeks and 39 controls were studied. Data on lifestyle factors, biochemical and hormonal parameters, dual-energy X-ray absorptiometry bone mass measurements, body composition, and bone age were obtained. Compared with controls, patients had higher weight percentile and fat mass, a 6-month delay in bone age, and lower estradiol levels. They also had higher parathyroid hormone levels and lower bone remodeling markers and bone mass. Age, height, lean mass, fat mass, and bone maturation correlated positively with several bone mass variables, so did serum estradiol, testosterone, and markers of bone remodeling. Conversely, corticosteroids, methotrexate (MTX), and intrathecal therapy negatively correlated with bone mass at the spine and hip (R = -0.33 to 0.40, p < 0.04). In the adjusted analyses, bone maturation, serum osteocalcin level, MTX, and intrathecal therapy were significant predictors of lumbar spine and total body Z-scores, bone maturation accounting for the largest proportion in Z-score variance. Chemotherapy-induced delay in bone maturation and suppression of bone modeling are major pathophysiologic pathways predicting bone mass in children with malignancies.

Severe osteoporosis and high level TSH in a child before the diagnosis of acute lymphoblastic leukemia

Osteoporosis in children is rare and mostly secondary to such conditions as prolonged immobilization, malabsorption syndromes, corticosteroid excess, osteogenesis imperfecta, celiac disease, Turner syndrome, and malignancy. Idiopathic juvenile osteoporosis (IJO) is a very rare condition of primary bone demineralization that presents in childhood. IJO, a disease of unknown etiology, manifests typically by pain, bone deformities, and fractures. Diagnosis of IJO was made by excluding other common causes of osteoporosis in this age. Bisphosphonates, calcitriol, fluoride, and calcitonin have been administered therapeutically, but the results were equivocal. Usually the disease remits by itself. Patient that has serious osteoporosis and high thyroid stimulating hormone level was diagnosed as IJO by eliminating secondary reasons. We report this case, whose symptoms were disappeared after parenteral pamidronat treatment, and he was reexamined owing to anemia and trombositopenia, and diagnosed as B-cell acute lymphoblastic leukemia, just to emphasis the importance of close follow-ups of IJO patients.

Cancer treatment-related bone disease

Bone health may be impaired in many patients being treated for cancer. Primary tumors that reside in or form metastases to bone can result in compromised skeletal integrity. It has also been increasingly recognized that patients undergoing therapies for treatment of cancer are at higher risk of bone loss. These include androgen-deprivation therapy for prostate cancer and aromatase inhibitor therapy for breast cancer, among others. Hypogonadism induced by many of these cancer treatments results in bone loss and increases the risk of osteoporosis and fractures. Progress has been made in identifying the role of oral and intravenous bisphosphonates to prevent bone loss in these patients. This review discusses bone loss associated with cancer treatments, with a focus on breast cancer, prostate cancer, and survivors of childhood malignancies.

Bone mineral density in young adult survivors of acute lymphoblastic leukemia

BACKGROUND

The purpose of the current study was to determine the prevalence of low bone mineral density (BMD) (ie, osteopenia) and identify factors associated with low BMD in young adult survivors of childhood acute lymphoblastic leukemia (ALL).

METHODS

Dual energy x-ray absorptiometry was used to evaluate BMD in 74 randomly selected, long-term childhood ALL survivors initially treated in Minneapolis/St. Paul, Minnesota. Growth hormone (GH)-releasing hormone-arginine stimulation testing was conducted to evaluate peak GH level, and insulin-like growth factor I (IGF-I) and other markers of endocrine functioning were also evaluated in relation to BMD.

RESULTS

The mean age at the time of interview was 30 years, and the mean time since diagnosis was 24 years. Low BMD (Z-score, < or = -1) was present in 24% of subjects, including 1 with osteoporosis. Low BMD was substantially more prevalent in men than in women and was strongly associated with short height. The mean height Z-score for those with low BMD was -1.44, compared with a height Z-score of -0.39 (P < .01) for those with normal BMD. GH insufficiency, low IGF-I Z-score, and current smoking were also suggestive risk factors for low BMD.

CONCLUSIONS

In this long-term follow-up study of childhood ALL survivors, low BMD was found to be more prevalent than expected based on population normative data, specifically in men. The health consequences of early-onset BMD problems in childhood ALL survivors need to be carefully monitored.

Bone mineral density deficits in survivors of childhood cancer: long-term follow-up guidelines and review of the literature

The development of curative therapy for most pediatric malignancies has produced a growing population of childhood cancer survivors who are at increased risk for a variety of health problems resulting from their cancer or its treatment. Because of the fact that many treatment-related sequelae may not become clinically apparent until the survivor attains maturity or begins to age, the ability of primary care providers to anticipate late effects of treatment is essential for providing timely interventions that prevent or correct these sequelae and their adverse effects on quality of life. Altered bone metabolism during treatment for childhood cancer may interfere with attainment of peak bone mass, potentially predisposing to premature onset of and more severe complications related to osteopenia and osteoporosis. Bone mineral deficits have been reported after treatment for a variety of pediatric malignancies and represent morbidity that can be reduced or prevented through lifestyle changes and attention to other common cancer-related sequelae such as hypogonadism. The Children's Oncology Group long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers provide risk-based surveillance recommendations that are based on expert opinion and review of the scientific literature for potential late effects of pediatric cancer therapy including osteopenia. This review summarizes the existing literature that has defined characteristics of cancer survivors at risk for bone mineral deficits and contributed to the surveillance and counseling recommendations outlined in the Children's Oncology group long-term follow-up guidelines.

Vitamin D status and bone biomarkers in childhood cancer

Early detection of abnormalities in bone turnover may be facilitated by assessing biomarkers of bone metabolism including vitamin D status. In many children with cancer, biomarkers of bone formation (osteocalcin, bone specific alkaline phosphatase and carboxy-(or N terminal) propeptide of type 1 procollagen) were observed to be suppressed, while bone resorption was elevated as measured by serum cross-linked (or C-terminal) telopeptide of type 1 collagen. Insulin-like growth factor 1, which stimulates bone formation, may be suppressed indirectly indicating a growth hormone insufficiency. Leptin may also play a role in bone remodeling as hyperleptinemia has been observed in association with acute lymphoblastic leukemia. Evaluation of bone status using such biomarkers is complicated by the lack of universally accepted reference values and the variation by age, gender, or pubertal status. Etiologic factors contributing to the observed skeletal morbidities include disease process, chemotherapy (drugs such as glucocorticoids and methotrexate) and radiotherapy. Other factors common to children with cancer, such as chronic inflammation, dietary changes and physical inactivity, must also be taken into account. The current evidence for abnormalities in biomarkers of vitamin D status and bone turnover will be the focus of this review of published studies.

Osteopenia and cancer in children and adolescents: the fragility of success

The attainment of a satisfactory peak bone mass, which is accomplished largely by the end of adolescence, is the best protection against excessive bone mineral loss in late adulthood. Factors that influence this process include age, race, sex, body size, pubertal status, diet, physical activity, and other lifestyle elements. Cancer and its treatment in children and teenagers adversely impact bone mineralization. In particular, chemotherapy (especially glucocorticosteroids and methotrexate) and cranial irradiation (apparently by reducing growth hormone secretion and by causing hypogonadotropic hypogonadism) interfere with normal bone turnover. Resorption often exceeds formation, resulting in net bone mineral loss and providing a rational basis for the use of antiresorptive drugs. Such osteopenia may be symptomatic, with pain and abnormal gait, and increases the risk of fractures several fold. The disorder is compounded by reduced physical activity, so programs to reduce this deficit are of measurable benefit. All of those engaged in the care of children and adolescents with cancer have an opportunity to improve the bone health of these young people and to limit their risk of developing osteoporosis and fragility fractures in adult life.

Cancer-treatment-induced bone loss, part 1

PURPOSE

The pathophysiology, frequency, sequelae, diagnosis, and treatment of cancer-treatment-induced bone loss (CTIBL) are discussed.

SUMMARY

CTIBL is a long-term complication associated with cancer therapies that can directly or indirectly affect bone metabolism. Although CTIBL can occur in any patient receiving a cancer therapy known to cause bone loss, CTIBL is most common in patients with breast or prostate cancer who receive chemotherapy, hormone therapy, or surgical castration, as these can cause hypogonadism and induce bone loss. CTIBL causes bone fragility and an increased susceptibility to fractures; therefore, prevention, early diagnosis, and treatment of CTIBL are essential to decrease the risk of fracture. Bone loss occurs more rapidly and tends to be more severe in patients with CTIBL compared with those with normal age-related bone loss. Fractures of the hip, vertebra, and wrist are the fractures most commonly associated with bone loss. CTIBL is diagnosed by measuring bone mass using bone densitometry. Treatment of CTIBL consists of changing diet and lifestyle such as optimizing calcium and vitamin D intake, exercising, modifying behaviors known to increase the risk of CTIBL and pharmacologic therapy with hormone replacement therapy (HRT), selective estrogen-receptor modifiers (SERMs), calcitonin, or a bisphosphonate.

CONCLUSION

Early identification and treatment of CTIBL are essential to prevent fractures. Patients should be instructed to optimize calcium and vitamin D intake, exercise regularly, and modify lifestyle behaviors known to cause bone loss. Patients with CTIBL should be treated with an oral or i.v. bisphosphonate; SERMs or HRT may be an option in some patients if contraindications do not exist.

Bone metabolism markers predict increase in bone mass, height and sitting height during puberty depending on the VDR Fok1 genotype

OBJECTIVES

Longitudinal growth and bone mass accumulation are two important phenomena during puberty, resulting in attainment of peak bone mass (PBM) and final height. They are thought to be under strong genetic control, with the vitamin D receptor (VDR) gene being among the candidate genes. Bone metabolism markers are reported to be good predictors of longitudinal growth and bone mass increase. The purpose of this longitudinal study was to evaluate whether bone metabolism markers predict bone mass and height increase differently according to Fok1 VDR genotype throughout puberty in healthy adolescents.

PATIENTS AND MEASUREMENTS

At the start of the study 130 girls were aged 10.8 (range 8.5-12.8) years and 125 boys were aged 11.8 (range 9.4-14.6) years at the first visit. Markers of bone formation and bone resorption were measured at the first visit, as well as height and sitting height (SH), and bone mineral content (BMC) of the lumbar spine, femur, arm and total body. All measurements were repeated after 2 years.

RESULTS

A higher BMC of the femur, distal arm and total body was found in ff boys at the first visit, which was not related to higher levels of bone metabolism markers in this group. In girls, no differences between genotypes were seen in BMC (increase). However, concentrations of markers of bone formation [alkaline phosphatase (AP), bone-specific alkaline phosphatase (BAP), procollagen aminoterminal propeptide (PINP)] and bone resorption [type I carboxyterminal telopeptide (ICTP)] were higher in ff girls. Regression coefficients between bone metabolism markers and bone mass increase differed according to genotype and sex. A similar pattern was found for height and SH (increase), the latter as a representative of growth of the axial skeleton, mainly consisting of cancellous bone.

CONCLUSIONS

Our data suggest that the predicting capacities of bone metabolism markers on bone mass (increase), height and SH (increase) are genotype dependent. Their use as predictors of final height or PBM therefore remains questionable without knowing the genotype.

No difference between prednisolone and dexamethasone treatment in bone mineral density and growth in long term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Dexamethasone is known to have both more potent leukemic activity and is associated with a higher incidence of side effects than prednisolone. In this study, we compared the long-term effects of dexamethasone and prednisolone on bone mineral density (BMD), body composition and growth in long-term survivors of ALL in first complete remission.

PROCEDURE

Ninety patients (51 male, 49 female; 8.6-38.5 year), treated with either a prednisolone containing protocol (n = 47; n = 19 also with CNS-irradiation) or a dexamethasone containing protocol (n = 43; no cranial irradiation) participated in this cross-sectional single center study. Mean follow-up was 12.7 years (2.0-29.7 years). BMD of lumbar spine and total body, and body composition were expressed as standard deviation scores (SDS) using dual energy X-ray absorptiometry. Bone mineral apparent density of the lumbar spine (BMAD) was calculated to correct for bone size.

RESULTS

There was no difference in height, height corrected for target height, BMD, or lean body mass between prednisolone and dexamethasone treated patients. Prednisolone treated patients had an increased percentage body fat (SDS +0.46; P < 0.05) and increased body mass index (SDS 0.88; P < 0.01) compared to normal. Dexamethasone treated patients had only an increased body mass index (SDS 0.52; P < 0.05). Height, total body BMD, and lean body mass were lower in patients treated with cranial irradiation as compared to non-irradiated patients, but differences in the latter two disappeared when corrected for height. BMAD was normal after CNS-irradiation.

CONCLUSIONS

Long term survivors of ALL treated with prednisolone or dexamethasone containing regimens do not differ in height, BMD, or body composition.

Evaluation of bone mineral density at different phases of therapy of childhood all

In the present study the authors evaluated the status of spinal bone mineral density (BMD) using dual-energy X-ray absorptiometry in a group of 31 children with acute lymphoblastic leukemia, treated by ALL-BFM protocols without irradiation, at different phases of their treatment. These patients were studied (1) within 2 months of diagnosis (group 1, n = 17, median time postdiagnosis 17 days), (2) during chemotherapy (group 2, n = 16, median time on treatment 22 months), and (3) shortly after completion of therapy (group 3, n = 10, median time postchemotherapy 13 months). Twelve patients underwent serial measurements in either of the groups they entered (6 patients of group 1 and 6 patients of group 2). The mean cumulative prednisone dose was 0.8, 4.3, and 5 g/m2 in groups 1, 2, and 3, respectively. A gradual decline of BMD from group 1 through group 3 was observed. The mean value of age- and sex-specific BMD z-score was -0.74 (+/-0.32) in group 1, -1.59 (+/-0.24) in group 2, and -2.03 (+/-0.27) in group 3; there was a statistically significant difference between groups 1 and 3 (p = .022). A BMD z-score < -2 was found in 3 (17%), 4 (25%), and 5 (50%) patients of groups 1, 2, and 3, respectively. In conclusion, a high incidence of reduced bone mass was observed during and shortly after treatment. These findings could have significant consequences in long-term survivors.

Secondary osteoporosis

Secondary osteoporosis occurs as a consequence of various lifestyle factors (eg, eating disorders, smoking, alcoholism), disease processes (eg, endocrinopathies, gastrointestinal tract disease, hepatobiliary disease), and treatment regimens that comprise corticosteroids or chemotherapeutic agents. Some of the disease entities underlying secondary osteoporosis may be clinically silent and identified only during evaluation for documented osteoporosis. The pathogenesis of osteoporosis in these settings is typically multifactorial. The loss of bone may be direct or indirect but ultimately is related to altered osteoblast or osteoclast function. Causes of secondary osteoporosis should especially be investigated in men at all ages and in premenopausal women with atraumatic fractures. In addition, patients with known risk factors should be evaluated. Early recognition and intervention are essential to prevent further loss of bone mass and to prevent fragility fractures.

Bone mineral density and serum bone turnover markers in survivors of childhood acute lymphoblastic leukemia: comparison of megadose methylprednisolone and conventional-dose prednisolone treatments

During recent decades, the survival rate after childhood acute lymphoblastic leukemia (ALL) has improved substantially; consequently, the long-term side effects of ALL and its treatment have gained attention, of which osteoporosis is one of the most important. The purpose of the present study was to compare the influence of different treatment protocols that include high-dose methylprednisolone (HDMP) versus conventional-dose prednisolone (CDP) for remission-induction therapy on bone mineral density (BMD) and serum bone turnover markers in survivors of childhood ALL after cessation of chemotherapy. Thirty-six boy and 23 girl survivors, treated for ALL, were cross-sectionally studied, at a mean age of 11.7 years (range 6-19). Group 1 (n = 30) received CDP therapy (prednisolone, 2 mg/kg/day, orally) and group 2 (n = 29) received HDMP therapy (prednol-L, 900-600 mg/m2, orally). All other therapies were similar in both groups. Cranial irradiation was added for high-risk patients as soon as possible after consolidation therapy. We found that mean lumbar spine BMD z score value was -1.75 (0.83) SDS in group 1 and -1.66 (1.21) SDS in group 2. There is no difference between both groups (P = 0.736). The mean BMD z scores of prepubertal and pubertal patients were not significantly different in both groups. Comparison of serum bone turnover parameters of the patients revealed no difference between the two groups. Stepwise regression analysis revealed that lumbar spine BMD z scores was predicted by height SDS and the time past since cessation of therapy, but not age at diagnosis, BMI SDS, cranial radiotherapy, and puberty. Our study results showed that HDMP treatment did not deteriorate the bone mass any more than CDP treatment. These results proved that high-dose steroid therapy over a short period of time in remission-induction treatment would not affect the bone mass any more adversely than would conventional doses approximately 3 years after cessation of chemotherapy.

Endocrine late effects of cancer treatment

Endocrinopathies are significant consequences of the treatment of childhood cancers. The risk of developing these adverse events is related to the underlying disease and its treatment with cytotoxic agents and radiation therapy. This article reviews hypothalamic-pituitary, thyroid, and gonadal dysfunction, as well as osteopenia-osteoporosis and obesity.

Adolescent survivors: a secondary analysis of a clinical trial targeting behavior change

BACKGROUND

The late effects of radiation and chemotherapy increase childhood cancer survivors' risk of chronic health problems. Survivors' behavior is important in modifying this risk, yet adolescent and young adult survivors fail to engage in important health-promoting behaviors and frequently practice high-risk behaviors. This secondary analysis re-evaluated a multi-component behavior-change intervention that had previously demonstrated no impact in adolescent survivors of childhood cancer.

PROCEDURE

The parent trial compared 132 adolescent survivors in the intervention arm with 135 in the standard-care arm at baseline and at 1 year for disease and treatment knowledge, perception of late effects risk, and the frequency of health-risk and health-protective behaviors (combined as a single summative measure). In contrast, the secondary analysis examined each of the 14 behaviors separately. Additionally, an analysis of covariance (ANCOVA) was conducted to examine the change in health behaviors while statistically controlling for age, gender, and the wide variation in baseline behaviors.

RESULTS

Knowledge (P = 0.038), breast self-examination (BSE) (P < or = 0.0001) and testicular self-examination (P = 0.004) increased, as did perceptions about the need to change behavior (P = 0.004) and the effort needed to stay healthy (P < or = 0.0001). In the treatment group, junk food consumption decreased (P = 0.052) and smoking abstinence was maintained (P = 0.088). Significant interactions between gender and treatment group were demonstrated.

CONCLUSIONS

Health-risk and health-protective behaviors cannot be effectively combined in a one-dimensional measure. Gender and age influence the impact of interventions targeting health behavior in survivors. Future trials should include observation of the patient-clinician encounter, more complex sampling methods, and pre-trial knowledge of the distribution of the study behaviors.

Improvement in bone mineral density and body composition in survivors of childhood acute lymphoblastic leukemia: a 1-year prospective study

OBJECTIVES

Abnormalities in bone mineral density (BMD), body composition, and bone metabolism have been reported in children who were treated for acute lymphoblastic leukemia (ALL) during and after completion of therapy. However, these studies are cross-sectional, and no longitudinal data are available in a large group of patients after completion of therapy. In the present study, 1-year longitudinal changes in BMD, body composition, and bone metabolism were evaluated in children with ALL during the first 3 years after completion of therapy without cranial irradiation.

METHODS

BMD of total body (TB; g/cm(2)), areal and apparent volumetric lumbar spine (L2-L4), lean body mass, and percentage of body fat were measured by dual-energy x-ray absorptiometry in 37 children (median age: 7.9 years; range: 4.7-20.6 years) who were treated for ALL at a median age of 3.3 years (range: 1.1-16.6 years), after a median time of 2.2 years after the completion of treatment, and after a 1-year follow-up period. Two control subjects (n = 74) who were matched for gender, age, and pubertal stage were also longitudinally investigated for body composition for 1 year. Usual serum biochemical markers of calcium metabolism and bone turnover were measured in patients during the study period.

RESULTS

A slight decrease in TB BMD was found after a median time of 2.2 years after the completion of therapy for ALL in childhood. Patients showed a significantly lower median TB BMD when evaluated <1.5 years as compared with those at >or=1.5 years since completion of therapy. At the time of first evaluation, the percentage of body fat mass was significantly higher and patients were physically less active than their matched control subjects. Although, as expected, during the 1 year of follow-up both groups showed an annual increment in their BMD measurements, a significantly higher increase in TB BMD was observed in patients in comparison with control subjects. During this same period, the increase in the percentage of body fat mass was slightly lower in ALL patients as compared with control subjects. At the end of the follow-up year, BMD, body-composition parameters, and physical activity of ALL patients were similar to those observed in matched control subjects. Serum biochemical markers of bone turnover were normal at both evaluations.

CONCLUSIONS

A significant increase in TB BMD and a tendency to a lesser increase in percentage of body fat mass were observed during the study period in ALL patients as compared with chronological age-, gender-, and pubertal stage-matched control subjects. These findings suggest a positive effect of long-term completion therapy and increase in physical activity on BMD, body composition, and bone metabolism in patients who have been treated for ALL.

Evaluation of bone metabolism in children with acute lymphoblastic leukemia after induction chemotherapy treatment

Osteopenia and osteoporosis are currently receiving particular attention as late effects of therapy in survivors of childhood acute lymphoblastic leukemia (ALL). The aim of this study was to evaluate abnormalities in bone mass and mineral homeostasis in children with ALL after induction therapy (during consolidation treatment). Lumbar spine (L2-L4) bone mineral density (BMD, g/cm(2)) was measured by dual energy X-ray absorptiometry in 20 children with ALL, a median of 25.9 months postdiagnosis and results were expressed as z-scores relative to healthy Caucasian children (controls). Serum levels of intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), calcium, phosphate, and magnesium were also analyzed. In addition, the body mass indexes (kg/cm(2)) of patients and controls were calculated. Results were compared with those of 40 healthy controls. Among the 20 children with ALL (12 boys and 8 girls), 12 presented z-scores < 1 SD (normal) and 8 were osteopenic (z-score between 1 and 2.5 SD). In addition, children with ALL had reduced lumbar BMDs (z-score -0.817) in comparison to healthy controls (z-score -0.353) (p = .04). Moreover, alkaline phosphatase and intact parathyroid hormone values were significantly increased compared to controls values. The data demonstrate that bone metabolism in children with ALL during consolidation therapy is disturbed, resulting in a reduced BMD and z-score with respect to healthy controls. Since a reduced BMD predisposes to osteopenia and osteoporosis, specific attention and therapeutic interventions should be considered.

Skeletal status in survivors of acute lymphoblastic leukemia assessed by quantitative ultrasound at the hand phalanges: a longitudinal study

The skeletal growth in a course of acute lymphoblastic leukemia (ALL) may be affected, and the aim of the longitudinal study was to assess the skeletal status in survivors of (ALL). The studied population consisted of 38 subjects (17 female and 21 male) measured at the age of 13.9 +/- 3.8 years (5.7 +/- 2.9 years after completion of the therapy, 11.0 +/- 14.4 years after diagnosis) and 2 years earlier; compared with 1402 controls (628 female and 774 male). Patients and controls did not differ significantly in regard to age, height or weight. Skeletal status was assessed by quantitative ultrasound (US) measurements at the hand phalanges using the DBM Sonic 1200, which measures amplitude-dependent speed-of-sound, Ad-SoS (m/s). rms CV% was 0.43%. Mean baseline Ad-SoS value in patients was 1990 +/- 76 m/s and, at second measurement, 2045 +/- 86 m/s (p < 0.000001). In 31 patients, Ad-SoS increased and, in one patient, decreased more than the value of the least significant change. In controls, mean Ad-SoS values were 1973 +/- 64 m/s (baseline) and 2016 +/- 86 m/s (follow-up) and did not differ significantly vs. baseline values in patients. At second measurement, Ad-SoS in controls was significantly lower than in patients (p < 0.05). In five patients with low baseline Ad-SoS values, bone mineral density (BMD) at the spine using DPX-L was estimated; baseline mean BMD was 0.95 +/- 0.11 g/cm2, Z-score was 1.25 +/- 0.97 and, at second measurement, 1.16 +/- 0.07 g/cm2, Z-score was 0.23 +/- 0.43. A significant increase in BMD (p < 0.01) and Z-score (p < 0.05) was noted. In patients, Ad-SoS correlated significantly with age, period after completion of the therapy, body size and Tanner stages (r ranged from 0.43 to 0.83, p ranged from 0.0001 to 0.05). It can be concluded that skeletal status assessed by quantitative US at the hand phalanges in survivors of ALL improved significantly over the period of observation.

Skeletal morbidity in childhood acute lymphoblastic leukemia

PURPOSE

Treatment for acute lymphoblastic leukemia (ALL) in childhood results in a reduction in bone mineral density (BMD). Whether there is a recovery of this lost bone mass in survivors of ALL is not known. We sought to determine if changes in BMD are common long-term sequelae in children with ALL.

METHODS

Bone mineral densitometry of the lumbar spine and femoral neck was performed on 106 patients. The results were compared with those of age-matched normal controls. The effect of treatment was examined in those with low BMD compared with the remainder of the study group.

RESULTS

When data were tested with respect to age, sex, and age and sex, no difference was observed in BMD between survivors of childhood ALL and controls. In the subgroup of patients with low BMD, the difference was not related to age, age at diagnosis, or years since diagnosis. Low BMD of the spine was not explained by radiotherapy (RT), methotrexate (MTX) dose, or corticosteroid dose. Low BMD of the femur was not explained by RT. However, those with low femoral BMD were more likely to have received high-dose MTX or higher-dose corticosteroids compared with the remainder of the group.

CONCLUSION

It appears that survivors of childhood ALL as a whole recover normal BMD. However, those patients who received a total MTX dose of greater than 40000 mg/m(2) or a total corticosteroid dose of greater than 9000 mg/m(2) may not recover normal BMD and therefore should be screened for decreased BMD of the femoral neck.

The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

The current study characterized the self-reported cancer screening practices of adult survivors of childhood cancer.

METHODS

A cohort of 9434 long-term survivors of childhood cancer and a comparison group of 2667 siblings completed a 289-item survey that included items regarding cancer-screening practices.

RESULTS

Overall, 27.3% of female respondents reported performing breast self-examination (BSE) regularly, 78.2% reported undergoing a Papanicolaou smear within the previous 3 years, 62.4% underwent a clinical breast examination (CBE) within the last year, and 20.9% had gotten a mammogram at least once in their lifetime. Approximately 17.4% of male respondents reported performing regular testicular self-examination (TSE). Women age > or =30 years who had been exposed to chest or mantle radiation therapy were more likely to report undergoing CBE (odds ratio [OR], 1.59; 95% confidence interval [95% CI], 1.32-1.92) and mammography (OR, 1.92; 95% CI, 1.47-2.56). Compared with the sibling comparison group, survivors demonstrated an increased likelihood of performing TSE (OR, 1.52; 95% CI, 1.22-1.85) or BSE (OR, 1.30; 95% CI, 1.10-1.52), of having undergone a CBE within the last year (OR, 1.18; 95% CI, 1.02-1.35), and of ever having undergone a mammogram (OR, 1.82; 95% CI, 1.52-2.17).

CONCLUSIONS

The results of the current study demonstrate that the cancer screening practices among survivors of childhood cancer are below optimal levels. Primary care physicians who include childhood cancer survivors among their patients could benefit these individuals by informing them about future cancer risks and recommending appropriate evidence-based screening.

Bone density in survivors of childhood cancer

Advances in combination chemotherapy, radiation therapy, surgery, and bone marrow transplantation have resulted in markedly improved survival rates for many children with cancer. Advancements in therapy, however, have led to new concerns, namely long-term consequences of effective treatments. Young adult and adult survivors of childhood cancer are at risk for a number of disorders related to therapy. Specifically, the young adult who has survived cancer, attendant treatments, and their complications is at risk for factors that can lead to suboptimal acquisition of peak bone mass. These factors include chronic illness, nutritional deficiencies, limited physical activity, and treatment with glucocorticoids, multiagent chemotherapy, and radiation. The long-term adverse effects of these therapies on endocrine systems, especially sex steroid and growth hormone deficiencies, are additional risk factors for some patients. After a brief review of the processes associated with acquisition of peak bone mass in the young adult, this article examines the impact of cancer and cancer therapy on bone mineral density in survivors of childhood cancer.

Health care of young adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

We wanted to determine the type of outpatient medical care reported by young adult survivors of childhood cancer and to examine factors associated with limited medical care.

METHODS

We analyzed data from 9,434 adult childhood cancer survivors enrolled in a retrospective cohort study who completed a baseline questionnaire. They had a mean age of 26.8 years (range 18 to 48 years), 47% were female, 12% were minorities, and 16% were uninsured. Four self-reported outcome measures were used to determine outpatient medical care in a 2-year period: general contact with the health care system, general physical examination, cancer-related medical visit, and medical visit at a cancer center.

RESULTS

Eighty-seven percent reported general medical contact, 71.4% a general physical examination, 41.9% a cancer-related visit, and 19.2%, a visit at a cancer center. Factors associated with not reporting a general physical examination, a cancer-related visit, or a cancer center visit included no health insurance (odds ratio [OR] = 2.34; 95% confidence interval [CI], 1.97-2.77), male sex (OR = 1.65; 95% CI, 1.44-1.88), lack of concern for future health (OR = 1.57; 95% CI, 1.36-1.82), and age 30 years or older in comparison with those 18 to 29 years (OR = 1.56; 95% CI, 1.35-1.81). The likelihood of reporting a cancer-related visit or a general physical examination decreased significantly as the survivor aged or the time from cancer diagnosis increased. This trend was also significant for those treated with therapies associated with substantial risk for cardiovascular disease or breast cancer.

CONCLUSIONS

Primary care physicians provide health care for most of this growing high-risk population. To optimize risk-based care, it is critical that cancer centers and primary care physicians develop methods to communicate effectively and longitudinally.

Online exclusive: a model of health behavior to guide studies of childhood cancer survivors

PURPOSE/OBJECTIVES

To describe the Interaction Model of Client Health Behavior (IMCHB) and its application to health promotion in childhood cancer survivors.

DATA SOURCES

Periodical literature about cancer survivors, health behavior models, and the IMCHB.

DATA SYNTHESIS

Childhood cancer survivors are at risk for various late complications of treatment. The primary goal of intervention is the modification of health-related behavior. Conceptual models that extend beyond health beliefs are needed to guide explanatory and intervention studies in this group.

CONCLUSIONS

The IMCHB identifies background, cognitive, affective, motivational, and contextual variables that explain health-related behaviors. The model defines the interactive and collective contributions of a survivor, family, and provider to adherence to protocols, reduction of risk behavior, and promotion of health-protective behavior.

IMPLICATIONS FOR NURSING

This model may identify new determinants of health-related behavior that can be targeted by specific inter- or intrapersonal interventions to protect the health of childhood cancer survivors and reduce their risk of late sequelae.

Skeletal status in survivors of childhood acute lymphoblastic leukemia assessed by quantitative ultrasound: a pilot cross-sectional study

Intensive treatment in acute lymphoblastic leukemia (ALL) with the use of multimodality therapies, including radiotherapy, corticosteroids and cytotoxic agents, may lead to disturbances in bone metabolism. The aim of this study was to determine the degree of possible changes in bone status in survivors of ALL. The studied population consisted of 54 subjects aged 13.0 +/- 3.3 years (31 girls and 23 boys). The mean age at diagnosis was 5.5 +/- 3.5 years, age at the completion of therapy was 8.4 +/- 3.5 years, and the period of follow-up was 4.6 +/- 3.4 years. Patients were divided into three subgroups (low-, moderate- and high-risk) according to the presence of risk factors of ALL and compared with 1020 healthy subjects (508 girls and 512 boys). Patients and controls did not differ significantly in regard to age, height, or weight. Bone status was assessed by quantitative ultrasound (US) at right (dominant) hand phalanges using DBM Sonic 1200 (IGEA, Carpi, Italy) that measures amplitude-dependent speed of sound (Ad-SoS, m/s). Root mean square (RMS)_CV% was 0.43%. Mean Ad-SoS values were 2018 +/- 73 m/s in patients and 2003 +/- 80 m/s in controls and did not differ significantly. Ad-SoS tended to be lower in moderate- and high-risk patients, but differences were not significant. Ad-SoS correlated significantly with age in patients (r value ranged from 0.63 to 0.77, p < 0.01) and controls (r value ranged from 0.79 to 0.84, p < 0.0001). In multiple forward regression analysis, the following equation was obtained: Ad-SoS (m/s) = 1878 (m/s) + 11.4 x age at the study (y) + 4.0 x period after therapy completion (y) - 9.5 x duration of the therapy (y). It can be concluded that bone status assessed by quantitative US at the hand phalanges in survivors of acute lymphoblastic leukemia 4.6 years after completion of the therapy is not affected in comparison to healthy controls.

Male sex and low physical activity are associated with reduced spine bone mineral density in survivors of childhood acute lymphoblastic leukemia

Survivors of acute lymphoblastic leukemia (ALL) are at risk of osteoporosis and obesity. We studied bone mineral density (BMD), percent of fat mass (%FM), and activity levels in survivors of ALL treated without radiotherapy. Lumbar and total areal BMD (g/cm2) and %FM were measured in 28 survivors (aged 5.7-14.7 years) of childhood ALL by dual-energy X-ray absorptiometry (DXA) scan (GE Lunar, Prodigy) an average of 5 years after completion of chemotherapy (UK Medical Research Council randomized trial protocol XI [UKALL XI]). One boy fractured his arm during treatment. Apparent volumetric lumbar BMD (BMD(vol); g/cm3) was calculated and %FM was adjusted for sex and age (%FM(adj)). Physical activity was measured by accelerometer and questionnaire. The results were compared with 28 sex- and age-matched healthy controls. Total body and lumbar areal BMD (g/cm2) were not different between the ALL group and the control group. However, mean lumbar BMD(vol) in survivors of ALL was significantly lower than in controls (0.303 +/- 0.036 g/cm3 vs. 0.323 +/- 0.03 g/cm3; p < 0.01), which mostly was caused by the difference in boys (0.287 +/- 0.032 g/cm3 vs. 0.312 +/- 0.027 g/cm3; p < 0.05). Weekly activity score by questionnaire was significantly lower in the ALL group than in the control group (geometric mean 50 vs. geometric mean 74; p < 0.05). Male gender, low activity levels and an intravenous (iv) high dose of methotrexate were associated with low lumbar BMD(vol). Patients who received an iv high dose of methotrexate (n = 18) had significantly higher %FM(adj) than those with intrathecal methotrexate only (n = 10; 141 +/- 70% vs. 98 +/- 37%;p < 0.05). In conclusion, male survivors of childhood ALL have reduced lumbar BMD(vol), whereas no such difference was seen in girls. Overall, survivors of ALL were physically less active than their healthy controls and lower activity correlated with lower lumbar BMD(vol) and higher %FM(adj).

Spinal irradiation impairs the osteo-anabolic effects of low-dose GH replacement in adults with childhood-onset GH deficiency

BACKGROUND AND OBJECTIVE

Both adult- and childhood-onset GH-deficient adults are prone to osteopenia. Studies of GH replacement have, for the most part, demonstrated increases in bone mineral density (BMD). Previous studies have, however, used GH doses in excess of those currently used in low-dose titration regimens aimed at normalizing the serum IGF-I level. Furthermore, the effect of GH on the lumbar spine that has been irradiated during treatment of childhood cancer is unknown.

PATIENTS

Thirty-two adult patients with childhood-onset GH deficiency were subdivided according to whether or not they had received spinal irradiation in childhood. The cohort in whom the spine had not been irradiated was comprised of 17 patients (seven male, 10 female), median age 29.8 years (range 20.6--40.8), the median age at primary pathological diagnosis being 9 years (range 4--16). The cohort who received spinal irradiation was composed of 15 patients (seven male, eight female), median age 22.9 years (range 16.5--40.3), with a median age at craniospinal irradiation of 9 years (range 2--16).

MEASUREMENTS

At baseline, BMD was assessed at the lumbar spine and femoral neck by DXA, and at the ultradistal and distal radius by SXA. The patients were then commenced on GH replacement, titrating the dose at 4--6-weekly intervals to normalize the serum IGF-I level. BMD scans were reassessed following at least 1 year of GH replacement therapy. The mean duration of GH therapy was 1.68 plus minus 0.52 years.

RESULTS

BMD was significantly reduced, compared to the reference data, at all four sites measured in both the spinally irradiated and unirradiated groups. No significant difference was observed between the subgroups with respect to lumbar spine BMD (P = 0.64). In the cohort who did not receive spinal irradiation, an increase in BMD of 3.5% above baseline was observed at the lumbar spine (P = 0.018), 13/17 patients showing a positive increment in lumbar spine BMD. No significant changes in BMD were observed at any other site within this cohort, or at any site in the patients who received spinal irradiation. A significantly greater change in lumbar spine BMD was observed in the unirradiated spine cohort compared with the spinally irradiated cohort (P = 0.018). No differences in response were demonstrated at the other sites studied between the two subgroups.

CONCLUSIONS

We have demonstrated an increase in lumbar spine BMD with long-term (mean 1.78 +/- 0.55 years) GH therapy in adults with childhood-onset GH deficiency, who have not received spinal irradiation, when GH was administered by a titration regimen aimed at normalizing the serum IGF-I level. No improvements were observed at the femoral neck, ultradistal or distal radius. Patients who had received spinal irradiation during childhood did not present with a reduction in spinal BMD in excess of that observed in the nonirradiated cohort. The spinally irradiated group were, however, resistant to the osteo-anabolic effects of GH, which we propose reflects the capacity of radiation-induced damage to suppress the skeletal response.

Severe osteopenia in a young boy with Kostmann's congenital neutropenia treated with granulocyte colony-stimulating factor: suggested therapeutic approach

Kostmann's syndrome is a congenital disorder that causes an impairment of myeloid differentiation in the bone marrow characterized by severe neutropenia, which can be treated with recombinant human granulocyte colony-stimulating factor (G-CSF). We present the case of a 13-year-old boy with Kostmann's syndrome who was treated with recombinant human G-CSF from age 3.5 years. His growth and development was normal, although complicated by intermittent infections. Bone mineral density (BMD) measurement revealed severe osteopenia at the spine and hips (lumbar spine BMD 0.486 g/cm(2); Z score -3.6), and he was referred to the Endocrine Service. Relevant laboratory evaluation showed a pretreatment ionized calcium level at the upper limit of normal (1.28 mmol/L; range: 1.13-1.32 mmol/L), suppressed intact parathyroid hormone (iPTH) level (12 pg/mL; range: 10-65 pg/mL), and a low 1,25-dihydroxy vitamin D level (21 pg/mL; range: 24-65 pg/mL). He had evidence of increased bone turnover evidenced by elevated urinary deoxypyridinoline (DPD) cross-links (46.9 nmol/mmol creatinine; range: 2-34 nmol/mmol creatinine) and a simultaneous increase in markers of bone formation with elevated osteocalcin level (200 ng/mL; normal: 20-80 ng/mL) and alkaline phosphatase level (236 IU/mL; normal: 38-126 IU/mL). Because of clinical concern for his skeletal health, bisphosphonate therapy with intravenous pamidronate was initiated. One month after treatment, the iPTH and DPD cross-links were in the normal range (54 pg/mL and 17.7 nmol/mmol creatinine, respectively) and the 1,25-dihydroxy vitamin D level was elevated (111 pg/mL). Four months after treatment, there was a striking increase in BMD at the lumbar spine (+30.86%), femoral necks (left, +20.02%; right, +17.98%), and total hips (left, +18.40%; right, +15.94%). Seven months after bisphosphonate therapy, his biochemical parameters showed a return toward pretreatment levels with increasing urinary DPD cross-links (28.7 nmol/mmol creatinine) and decreasing iPTH (26 pg/mL). However, the BMD continued to increase (8 months posttreatment), but the magnitude of the increment was attenuated (lumbar-spine, +4.8%; left total hip, +1.2% and right total hip +2.4%), relative to BMD at 4 months. Eight months after the initial treatment, his iPTH was suppressed at 14 pg/mL and he again received pamidronate (at a lower dose); 3 months later, he had an additional increase in BMD (lumbar spine +7.4%, left total hip +3.9%, right total hip +2.7%), relative to the previous study. We hypothesize that prolonged administration of G-CSF as treatment for Kostmann's syndrome is associated with increased bone resorption, mediated by osteoclast activation and leading to bone loss. In children, the resulting osteopenia can be successfully managed with antisreorptive bisphosphonate therapy with significant improvement in bone density. Measurements of biochemical parameters of bone turnover can be used to monitor the magnitude and duration of the therapeutic response and the need for BMD reassessment and, perhaps, retreatment.

Osteoporosis in survivors of acute lymphoblastic leukemia

Osteoporosis is currently receiving increasing attention as an important late effect in survivors of childhood cancer and its treatment because of their quality of life and its negative effect on the survivors' ability to perform developmentally appropriate activities. Survivors of childhood cancer are especially vulnerable because they are affected during childhood and adolescence, a time when peak bone mass should be achieved. This paper reviews decreased bone density in acute lymphoblastic leukemia (ALL), which is the most common childhood cancer and has a cure rate approaching 80%. Osteopenia/osteoporosis has been observed in all phases of the disease: at diagnosis, during treatment, and throughout the post-treatment period for as long as 20 years. Among the findings that have been described are musculoskeletal pain, disturbed gait, fractures, kyphosis, lordosis, and growth failure. Risk factors not specifically related to ALL include smoking, ingestion of carbonated beverages, and family history of "brittle bone" or fractures. Patients should be counseled in regard to diet, exercise, smoking cessation, and avoidance of carbonated beverages. There are a number of options for specific drug therapy; however, the administration of bisphosponates to children and adolescents must be approached with caution. Research is needed to determine how extensive the problem is and how to best prevent and treat the osteopenia/osteoporosis associated with ALL.