Normal bone mineral density after treatment for childhood acute lymphoblastic leukemia diagnosed between 1991 and 1998

Every Move Counts to Improve Bone Health at Clinical Sites in Young Pediatric Cancer Survivors: The iBoneFIT Project

PURPOSE

We aimed to examine the associations of 24-h movement behaviors (moderate to vigorous physical activity [MVPA], light physical activity [LPA], sedentary behavior [SB], and sleep) with age-, sex-, and race-specific areal bone mineral density (aBMD) z -score parameters at clinical sites in young pediatric cancer survivors.

METHODS

This cross-sectional multicenter study was carried out within the iBoneFIT framework in which 116 young pediatric cancer survivors (12.1 ± 3.3 yr old; 42% female) were recruited. We obtained anthropometric and body composition data (i.e., body mass, stature, body mass index, and region-specific lean mass), time spent in movement behaviors over at least seven consecutive 24-h periods (wGT3x-BT accelerometer, ActiGraph), and aBMD z -score parameters (age-, sex-, and race-specific total at the body, total hip, femoral neck and lumbar spine). Survivors were classified according to somatic maturity (pre or peri/postpubertal depending on the estimated years from peak height velocity). The adjusted models' coefficients were used to predict the effect of reallocating time proportionally across behaviors on the outcomes.

RESULTS

In prepubertal young pediatric cancer survivors, reallocating time to MVPA from LPA, SB, and sleep was significantly associated with higher aBMD at total body ( B = 1.765, P = 0.005), total hip ( B = 1.709, P = 0.003), and lumbar spine ( B = 2.093, P = 0.001). In peri/postpubertal survivors, reallocating time to LPA from MVPA, SB, and sleep was significantly associated with higher aBMD at all sites ( B = 2.090 to 2.609, P = 0.003 to 0.038). Reallocating time to SB from MVPA or LPA was significantly associated with lower aBMD at most sites in prepubertal and peri/postpubertal survivors, respectively. Finally, reallocating time to sleep from MVPA, LPA, and SB was significantly associated with lower aBMD at total body ( B = -2.572, P = 0.036) and total hip ( B = -3.371, P = 0.015).

CONCLUSIONS

These findings suggest that every move counts and underline the benefits of increasing MVPA or LPA, when low MVPA levels are present, for bone regeneration after pediatric cancer treatment completion.

Transition of young adults with metabolic bone diseases to adult care

As more accurate diagnostic tools and targeted therapies become increasingly available for pediatric metabolic bone diseases, affected children have a better prognosis and significantly longer lifespan. With this potential for fulfilling lives as adults comes the need for dedicated transition and intentional care of these patients as adults. Much work has gone into improving the transitions of medically fragile children into adulthood, encompassing endocrinologic conditions like type 1 diabetes mellitus and congenital adrenal hyperplasia. However, there are gaps in the literature regarding similar guidance concerning metabolic bone conditions. This article intends to provide a brief review of research and guidelines for transitions of care more generally, followed by a more detailed treatment of bone disorders specifically. Considerations for such transitions include final adult height, fertility, fetal risk, heritability, and access to appropriately identified specialists. A nutrient-dense diet, optimal mobility, and adequate vitamin D stores are protective factors for these conditions. Primary bone disorders include hypophosphatasia, X-linked hypophosphatemic rickets, and osteogenesis imperfecta. Metabolic bone disease can also develop secondarily as a sequela of such diverse exposures as hypogonadism, a history of eating disorder, and cancer treatment. This article synthesizes research by experts of these specific disorders to describe what is known in this field of transition medicine for metabolic bone diseases as well as unanswered questions. The long-term objective is to develop and implement strategies for successful transitions for all patients affected by these various conditions.

Prevalence of low bone mineral density and risk of fractures in osteosarcoma and Ewing's sarcoma survivors: A scoping review

Background

The clinical outcomes of patients with pediatric cancer have significantly improved over the past few decades. However, the treatments are often highly intensive and can advertently pose a risk for developing various health conditions, including bone mass loss and fragility fractures. Since patients with bone malignancies, such as osteosarcoma (OS) and Ewing's sarcoma (ES), require musculoskeletal surgery as well as chemotherapy, OS/ES survivors are potentially at even greater risk of developing these musculoskeletal conditions than those with other types of cancer. However, these issues in OS/ES survivors are often overlooked by clinicians treating childhood cancers. Thus, this scoping review was designed and conducted to better understand the bone health conditions in OS/ES survivors.

Design

We conducted a literature search and included the studies that describe bone mineral density in association with bone health in OS/ES survivors for analysis. Data regarding patients' demographic, diagnosis, bone mineral density, laboratory examinations, and incidence of fractures were extracted and evaluated.

Results

We found that almost half of OS/ES survivors have bone mass deficit and that several factors (such as a frailer physique and younger age at diagnosis) are potentially associated with low bone mass in OS/ES survivors. On the other hand, due to a paucity of information currently available, we could not determine whether long-term OS/ES survivors would ultimately regain bone mass or be at a greater risk of fragility fractures.

Conclusions

This scoping review reveals a previously unappreciated knowledge gap in our understanding of bone health conditions in OS/ES survivors and raises awareness among clinicians and care providers of this condition that OS/ES patients may encounter after successful treatment.

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

Simple Summary

Anti-cancer treatments induced an increase in the childhood cancer survival rate. However, they are responsible for several long-term side effects in childhood cancer survivors, including osteoporosis. Cancer itself, a sedentary lifestyle, and an unhealthy diet might adversely affect bone health. Early identification and adequate management of bone fragility in childhood cancer survivors could be useful to prevent osteoporosis onset and consequently fragility fractures.

Abstract

The improvement of chemotherapy, radiotherapy, and surgical interventions, together with hematopoietic stem cell transplantation, increased childhood cancer survival rate in the last decades, reaching 80% in Europe. Nevertheless, anti-cancer treatments are mainly responsible for the onset of long-term side effects in childhood cancer survivors (CCS), including alterations of the endocrine system function and activity. In particular, the most frequent dysfunction in CCS is a metabolic bone disorder characterized by low bone mineral density (BMD) with increased skeletal fragility. BMD loss is also a consequence of a sedentary lifestyle, malnutrition, and cancer itself could affect BMD, thus inducing osteopenia and osteoporosis. In this paper, we provide an overview of possible causes of bone impairment in CCS in order to propose management strategies for early identification and treatment of skeletal fragility in this population.

Bone health in glucocorticoid-treated childhood acute lymphoblastic leukemia

Glucocorticoids (GCs) are widely used in the treatment of childhood acute lymphoblastic leukemia (ALL), but their long-term use is also associated with bone-related morbidities. Among others, growth deficit, decreased bone mineral density (BMD) and increased fracture rate are well-documented and severely impact quality of life. Unfortunately, no efficient treatment for the management of bone health impairment in patients and survivors is currently available. The overall goal of this review is to discuss the existing data on how GCs impair bone health in pediatric ALL and attempts made to minimize these side effects.

Vitamin D supplementation for children with cancer: A systematic review and consensus recommendations

Background

Prevalent vitamin D deficiency (VDD) and low bone mineral density (BMD) have led to vitamin D supplementation for children with cancer, regardless vitamin D status. However, it remains unsettled whether this enhances bone strength. We sought to address this issue by carrying out a systematic review of the literature.

Methods

We conducted a literature search using PubMed, Embase, and Cochrane databases. Studies including children up to 5 years after cancer therapy were assessed for the association between 25‐hydroxyvitamin D (25OHD) levels and BMD Z‐scores or fractures, and the effect of vitamin D supplementation on BMD or fractures. Evidence quality was assessed using the GRADE methodology.

Results

Nineteen studies (16 observational and 3 interventional, mainly involving children with hematologic malignancies) were included. One study which analyzed 25OHD as a threshold variable (≤10 ng/ml) found a significant association between 25OHD levels and BMD Z‐scores, while 25OHD as a continuous variable was not significantly associated with BMD Z‐scores in 14 observational studies. We found neither a significant association between lower 25OHD levels and fractures (2 studies), nor between vitamin D (and calcium) supplementation and BMD or fracture frequency (3 studies) (very low quality evidence).

Conclusion

There is a lack of evidence for an effect of vitamin D (and calcium) supplementation on BMD or fractures in children with cancer. Further research is needed; until then, we recommend dietary vitamin D/calcium intake in keeping with standard national guidelines, and periodic 25OHD monitoring to detect levels <20 ng/ml. Vitamin D/calcium supplementation is recommended in children with low levels, to maintain levels ≥20 ng/ml year‐long.

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.

Systematic review of the effects of bisphosphonates on bone density and fracture incidence in childhood acute lymphoblastic leukaemia

Skeletal fragility is a common complication of childhood acute lymphoblastic leukaemia (ALL) but the impact of bisphosphonate therapy on bone mass and fracture is unclear. We aim to conduct a systematic review to evaluate the effects of bisphosphonates on bone mineral density (BMD) and fracture incidence in children with ALL.

METHODS

EMBASE, Medline and the Cochrane Library were thoroughly searched by two researchers. Inclusion criteria was any child under the age of 18 years with a diagnosis of ALL, who had received any bisphosphonate treatment and had serial measurements of bone density performed thereafter. All primary research studies of any study design, excluding case reports, were included.

RESULTS

Ten full text papers were identified with two exclusively meeting the inclusion criteria. Both studies administered bisphosphonates to children receiving maintenance chemotherapy for varying durations. Bone density was assessed at regular intervals by dual x-ray absorptiometry (DXA). The majority of participants had an improvement in bone density at the end of each study. However, no size adjustment of DXA data was performed. Limited information on fracture occurrence was provided by one study but did not include routine screening for vertebral fractures.

CONCLUSIONS

This systematic review identified that there is insufficient evidence to support routine use of prophylactic bisphosphonate therapy in childhood ALL for prevention of fracture and improvement of bone mass. Future well-designed clinical trials in those at highest risk of fractures in ALL are now needed.

Severity of reduced bone mineral density and risk of fractures in long-term survivors of childhood leukemia and lymphoma undergoing guideline-recommended surveillance for bone health

BACKGROUND

Survivors of childhood leukemia/lymphoma are at increased risk for reduced bone mineral density (BMD). The authors sought to determine the frequency of reduced BMD detected by off-therapy surveillance, factors associated with reduced BMD, and the association of reduced BMD with fractures.

METHODS

This cross-sectional study included childhood leukemia/lymphoma survivors attending 2 survivorship clinics who received guideline-recommended BMD surveillance ≥2 years post-therapy with dual-energy x-ray absorptiometry (from January 1, 2004 to August 31, 2016). Lumbar spine BMD z-scores were height-for-age-adjusted. Low and very low BMD were >1 SD and >2 SDs below norms, respectively. Treatment, chronic conditions, and fractures were abstracted from medical records. Logistic regression was used to examine the association of low BMD with patient/treatment factors and fractures.

RESULTS

In total, 542 patients (51.5% female) with a mean age of 15.5 years (range, 4.4-52.2 years) who were 6 years post-therapy (range, 2.0-35.1 years) were evaluated, including 116 who reported post-therapy fractures. Lumbar spine low BMD was identified in 17.2% of survivors, and very low BMD was identified in 3.5% of survivors, but frequencies varied considerably between subgroups; 10.8% of survivors aged 15 to 19 years at diagnosis had very low BMD. In multivariable analyses, older age at diagnosis, white race, and being underweight were significantly associated with low BMD. Survivors with low BMD had greater odds of nondigit fractures (odds ratio, 2.2; 95% CI, 1.3-3.7) and specifically long-bone fractures (odds ratio, 2.7; 95% CI, 1.5-4.7).

CONCLUSIONS

In this study of childhood leukemia/lymphoma survivors undergoing guideline-recommended dual-energy x-ray absorptiometry surveillance, patients who were older at diagnosis, white, and underweight were at the highest risk for lumbar spine low BMD. Low BMD was associated with a greater risk of fractures, emphasizing the clinical importance of surveillance.

Long-term effects on growth, development, and metabolism of ALL treatment in childhood

INTRODUCTION

One aim of the long-term care in survivors from acute lymphoblastic leukemia (ALL) during childhood is to avoid or limit complications caused by aggressive therapeutic strategies.

AREAS COVERED

ALL survivors are a heterogeneous group according to therapeutic protocols. In the last decades, cranial radiotherapy (cRT) has been largely replaced by intrathecal chemotherapy (CT) with a reduction of endocrine sequelae. Published studies are generally difficult to be interpreted because patients were treated according to different risk-adapted protocols and results are conflicting. We perform this review on endocrine long-term effects in childhood ALL survivors focusing on studies published in the last decades. Articles were selected using the following terms (Mesh terms): 'acute lymphoblastic leukemia' AND 'survivors' AND 'childhood' AND 'growth/puberty/fertility/obesity/metabolic syndrome/bone'.

EXPERT COMMENTARY

Most childhood ALL survivors treated with CT alone attain normal height and have adequate pubertal development. Despite recent protocols improvements, ALL survivors still develop long-term metabolic complications (overweight, obesity, and cardiovascular disease) especially the female gender and patients with an increased body mass index (BMI) at diagnosis. The aim of this review is to describe the state of the art on these topics. We should be able to anticipate, prevent, and treat endocrine long-term morbidities through a well-established follow-up strategy.

Cortical Thinning and Structural Bone Changes in Non-Human Primates after Single-Fraction Whole-Chest Irradiation

Stereotactic body radiation therapy (SBRT) is associated with an increased risk of vertebral compression fracture. While bone is typically considered radiation resistant, fractures frequently occur within the first year of SBRT. The goal of this work was to determine if rapid deterioration of bone occurs in vertebrae after irradiation. Sixteen male rhesus macaque non-human primates (NHPs) were analyzed after whole-chest irradiation to a midplane dose of 10 Gy. Ages at the time of exposure varied from 45-134 months. Computed tomography (CT) scans were taken 2 months prior to irradiation and 2, 4, 6 and 8 months postirradiation for all animals. Bone mineral density (BMD) and cortical thickness were calculated longitudinally for thoracic (T) 9, lumbar (L) 2 and L4 vertebral bodies; gross morphology and histopathology were assessed per vertebra. Greater mortality (related to pulmonary toxicity) was noted in NHPs <50 months at time of exposure versus NHPs >50 months ( P = 0.03). Animals older than 50 months at time of exposure lost cortical thickness in T9 by 2 months postirradiation ( P = 0.0009), which persisted to 8 months. In contrast, no loss of cortical thickness was observed in vertebrae out-of-field (L2 and L4). Loss of BMD was observed by 4 months postirradiation for T9, and 6 months postirradiation for L2 and L4 ( P < 0.01). For NHPs younger than 50 months at time of exposure, both cortical thickness and BMD decreased in T9, L2 and L4 by 2 months postirradiation ( P < 0.05). Regions that exhibited the greatest degree of cortical thinning as determined from CT scans also exhibited increased porosity histologically. Rapid loss of cortical thickness was observed after high-dose chest irradiation in NHPs. Younger age at time of exposure was associated with increased pneumonitis-related mortality, as well as greater loss of both BMD and cortical thickness at both in- and out-of-field vertebrae. Older NHPs exhibited rapid loss of BMD and cortical thickness from in-field vertebrae, but only loss of BMD in out-of-field vertebrae. Bone is sensitive to high-dose radiation, and rapid loss of bone structure and density increases the risk of fractures.

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.

Screening and management of adverse endocrine outcomes in adult survivors of childhood and adolescent cancer

5 year survival for childhood and adolescent cancer in developed countries is now in excess of 80% and the number of survivors of cancer continues to increase worldwide. After completion of therapy, many of these survivors will face a lifelong risk of endocrine late effects. We summarise the available evidence related to the prevalence and risk factors for endocrine late effects among adult survivors of childhood and adolescent cancer. Present screening, surveillance, and treatment recommendations differ by country and region, so we also highlight the continued effort to harmonise the international guidelines for this population.

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.

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.

Longitudinal assessment of bone density and structure in childhood survivors of acute lymphoblastic leukemia without cranial radiation

PURPOSE

Children with acute lymphoblastic leukemia (ALL) are at risk for impaired bone accrual. This peripheral quantitative computed tomography study assessed changes in bone mineral density (BMD) and structure after completion of ALL treatment.

METHODS

Fifty ALL participants, ages 5-22 yr, were enrolled within 2 yr (median 0.8 yr) after completing ALL therapy. Tibia peripheral quantitative computed tomography scans were performed at enrollment and 12 months later. Age-, sex-, and race-specific Z-scores for trabecular BMD (TrabBMD), cortical BMD (CortBMD), and cortical area (CortArea) were generated based on more than 650 reference participants. Multivariable linear regression models examined determinants of changes in Z-scores.

RESULTS

At enrollment, mean TrabBMD (-1.03±1.34) and CortBMD (-0.84±1.05) Z-scores were low (both P<0.001) compared with reference participants. TrabBMD and CortBMD Z-scores increased to -0.58±1.41 and -0.51±0.91 over 1 yr, respectively (both P<0.001). Changes in cortical outcomes varied according to the interval since completion of therapy. Among those enrolled less than 6 months after therapy, CortArea Z-scores increased and CortBMD Z-scores decreased (both P<0.01). Among those enrolled 6 months or more after therapy, CortArea Z-scores did not change and CortBMD Z-scores increased (P<0.01). Changes in CortArea and CortBMD Z-scores were inversely associated (r=-0.32, P<0.001). Cumulative glucocorticoid exposure, leukemia risk status, and antimetabolite chemotherapy were not associated with outcomes.

CONCLUSION

TrabBMD was low after completion of ALL therapy and improved significantly. Early increases in cortical dimensions were associated with declines in CortBMD; however, participants further from ALL therapy demonstrated stable cortical dimensions and increases in CortBMD, potentially reflecting the time necessary to mineralize newly formed bone.

Fractures among long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

Although reductions in bone mineral density are well documented among children during treatment for cancer and among childhood cancer survivors, little is known about the long-term risk of fracture. The objective of this study was to ascertain the prevalence of and risk factors for fractures among individuals participating in the Childhood Cancer Survivor Study (CCSS).

METHODS

Analyses included 7414 ≥ 5-year survivors of childhood cancer diagnosed between 1970 and 1986 who completed the 2007 CCSS follow-up questionnaire and a comparison group of 2374 siblings. Generalized linear models stratified by sex were used to compare the prevalence of reported fractures between survivors and siblings.

RESULTS

The median ages at follow-up among survivors and siblings were 36.2 years (range, 21.2-58.8 years) and 38.1 years (range, 18.4-62.6 years), respectively, with a median 22.7 years of follow-up after cancer diagnosis for survivors. Approximately 35% of survivors and 39% of siblings reported ≥ 1 fracture during their lifetime. The prevalence of fractures was lower among survivors than among siblings, both in males (prevalence ratio, 0.87; 95% confidence interval, 0.81-0.94; P < .001) and females (prevalence ratio, 0.94; 95% confidence interval, 0.86-1.04; P = .22). In multivariable analyses, increasing age at follow-up, white race, methotrexate treatment, and balance difficulties were associated with increased prevalence of fractures among female survivors (P = .015). Among males, only smoking history and white race were associated with an increased prevalence of fracture (P < .001).

CONCLUSIONS

Findings from this study indicated that the prevalence of fractures among adult survivors did not increase compared with that of siblings. Additional studies of bone health among aging female cancer survivors may be warranted.

Modifiable risk factors associated with bone deficits in childhood cancer survivors

BACKGROUND

To determine the prevalence and severity of bone deficits in a cohort of childhood cancer survivors (CCS) compared to a healthy sibling control group, and the modifiable factors associated with bone deficits in CCS.

METHODS

Cross-sectional study of bone health in 319 CCS and 208 healthy sibling controls. Bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). Generalized estimating equations were used to compare measures between CCS and controls. Among CCS, multivariable logistic regression was used to evaluate odds ratios for BMD Z-score ≤ -1.

RESULTS

All subjects were younger than 18 years of age. Average time since treatment was 10.1 years (range 4.3 - 17.8 years). CCS were 3.3 times more likely to have whole body BMD Z-score ≤ -1 than controls (95% CI: 1.4-7.8; p = 0.007) and 1.7 times more likely to have lumbar spine BMD Z-score ≤ -1 than controls (95% CI: 1.0-2.7; p = 0.03). Among CCS, hypogonadism, lower lean body mass, higher daily television/computer screen time, lower physical activity, and higher inflammatory marker IL-6, increased the odds of having a BMD Z-score ≤ -1.

CONCLUSIONS

CCS, less than 18 years of age, have bone deficits compared to a healthy control group. Sedentary lifestyle and inflammation may play a role in bone deficits in CCS. Counseling CCS and their caretakers on decreasing television/computer screen time and increasing activity may improve bone 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.

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.

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.

Survivorship: childhood cancer survivors

Late effects of therapy for childhood cancer are frequent and serious. Fortunately, many late effects are also modifiable. Proactive and anticipatory risk-based care can reduce the frequency and severity of treatment-related morbidity. The primary care clinician should be an integral component in risk-based care of survivors. Continued communication between the "late effects" staff at the cancer center and the primary care clinician is essential for optimum care of this high-risk population.

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.

A randomized trial investigating an exercise program to prevent reduction of bone mineral density and impairment of motor performance during treatment for childhood acute lymphoblastic leukemia

BACKGROUND

Reduced bone mineral density (BMD), altered body composition, impaired motor performance and passive ankle dorsiflexion are side effects of acute lymphoblastic leukemia (ALL) treatment. We performed a randomized study investigating whether an exercise program could prevent these side effects.

PROCEDURE

At diagnosis we randomized 51 ALL patients (median age: 5.4 years) into a group receiving a 2-year exercise program or a control group receiving standard care. BMD of total body (BMD(TB)), lumbar spine (BMD(LS)) and body composition were measured using dual energy X-ray absorptiometry, motor performance with Bayley Scales of Infant Development or Movement-ABC, and passive ankle dorsiflexion with a goniometer. The investigator was blinded to the randomization.

RESULTS

Body fat increased equally during treatment in both groups. One year after cessation of therapy more rapid decline of excessive body fat was observed in the intervention group than in the controls (P = 0.01). Lean body mass, BMD(TB) and BMD(LS) of both groups decreased equally during treatment and increased equally thereafter. Both groups showed a similar decrease in passive ankle dorsiflexion and motor performance during treatment. Adherence to the intervention program varied considerably. Adherence to intervention: 11% of children exercised daily, 37% > once a week, 16% once weekly, 36% < once a week.

CONCLUSIONS

The exercise program was not more beneficial than standard care in preventing reduction in BMD, motor performance and passive ankle dorsiflexion than standard care, most likely due to unsatisfactory compliance. Increased BMI and body fat in the intervention group normalized faster after cessation of chemotherapy.

The complexity of symptoms and problems experienced in children with cancer: a review of the literature

To adequately help children with cancer, care providers need to understand the complexity of symptoms and problems associated with the illness that children are experiencing, which can enable them to better tailor patient care individually to each child. In this integrative literature review, we identified the types of symptoms and problems that children with cancer can experience during treatment and rehabilitation; the terms/expressions they use to describe their symptoms and problems; how children's symptoms and problems vary during the course of their illness; and how they vary and co-vary with age, gender or race. Of the 1175 titles identified, 110 articles met the inclusion criteria and were included in the review. Seventy-eight were research-based. A total of 219 distinct symptoms or problems were identified in the literature either as the main problem or a symptom of the main problem. There is significant evidence that children and adolescents experience numerous and complex symptoms, and problems during and after treatment for cancer. Children use many different expressions to talk about their symptom experiences. However, few articles looked at how children's symptoms and problems varied during the course of their illness or the variations in symptom severity and degree of bother, or examined the relationship between children's symptom experience and age, gender, or race. Most instruments that were used to measure symptoms were interviewer-administered questionnaires, often adaptations from adult versions, and in younger children, symptoms were often obtained from adult informants. The insights gained from this review can be helpful to researchers and clinicians who wish to better understand how symptoms and problems are experienced from the children's own perspective. However, more research is needed: to better understand differences in symptom experiences among different age groups; to identify differences among children from distinct cultural, ethnic, or socio-economic backgrounds; to clarify how symptoms and problems interfere with daily life; and to refine assessment methods that allow even younger children to communicate their symptom experiences in an age-adjusted manner.

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.

Dual-energy X-ray aborptiometry assessment in children and adolescents with diseases that may affect the skeleton: the 2007 ISCD Pediatric Official Positions

The Task Force focusing on the use of dual energy X-ray absorptiometry (DXA) in children and adolescents with diseases that may affect the skeleton reviewed over 300 articles to establish the basis for the Official Positions. A significant number of studies used DXA-based outcome measures to assess the effects of specific interventions and charted the natural history of incremental changes in bone size and mass in specific disease states in children. However, the utility of DXA in clinical practice has not been evaluated systematically, in large part due to the lack of a workable definition for childhood osteoporosis. Thus, in combination with the Official Positions addressing the diagnosis of osteoporosis in children, and the reporting of DXA results in children, this document presents clear guidelines from which clinicians and researchers alike can work. This report delineates a set of disorders in which it is appropriate to use DXA as part of the comprehensive assessment of skeletal health in children and adolescents, and provides guidance concerning the initiation of assessment and the frequency of monitoring. Importantly, this document also highlights significant gaps in our knowledge, emphasizing areas for future research.

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.

Effect of 1,25(OH)2-vitamin D on bone mass in children with acute lymphoblastic leukemia

BACKGROUND

Calcitriol deficit has been described in patients with acute lymphoblast leukemia (ALL). The aim of this randomized case-control trial is to investigate the effectiveness of calcitriol administration during the first year of treatment to protect bone mass. Sixteen children recently diagnosed with ALL, aged 1.7 to 11.5 years, average 5.5, completed the study. Anthropometrical measurements, food intake record, physical activity, and bone pain were registered. Dual energy x-ray absorptiometry was performed at the completion of remission induction chemotherapy (after 1 mo) to measure bone mineral density (BMD) at hip, lumbar spine and whole body, and total bone mineral content and 1 year after. Half of them were randomly assigned to receive calcitriol during 1 year.

STATISTICAL

Kruskal-Wallis, Wilcoxon, Mann-Whitney, and Spearman.

RESULTS

Both groups had similar anthropometric measurements and bone densitometric variables increments. Spine BMD significantly increased in calcitriol supplemented children with lower baseline BMD (r=-0.78 and P<0.05).

CONCLUSIONS

One-year calcitriol administered to recently diagnosed ALL children did not show impact on bone mass. Greater increment in lumbar spine bone mass was observed in patients who received calcitriol and had lower baseline BMD.

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.

Incidence of skeletal complications during treatment of childhood acute lymphoblastic leukemia: comparison of fracture risk with the General Practice Research Database

BACKGROUND

Skeletal complications during or after treatment of acute lymphoblastic leukemia (ALL) have been frequently reported and can cause substantial morbidity, yet their incidence is not well established. The present study assessed the incidence of fractures, osteonecrosis (ON), and bone pain during ALL treatment and compared the fracture incidence with age- and sex-specific reference data from the UK General Practice Research Database (GPRD).

PROCEDURE

Medical records of 122 ALL patients diagnosed at our institution from 1992 to 2004 were reviewed for information on fractures, ON, bone pain, and their anatomical location, risk group, phase of antileukemic therapy, and time since diagnosis. Evaluation of skeletal complications was followed up until July 2005 or the patient's death. Thirteen children were excluded as they were transferred to other institutions shortly after diagnosis.

RESULTS

Skeletal complications occurred at a 5-year incidence of 32.7%. The 5-year incidence of fractures, ON, and isolated bone pain was 13.5%, 12.1%, and 12.3%, respectively. The relative rate of fractures adjusted for age and sex was 2.03 (95% confidence interval 1.15-3.57) compared to the GPRD, with greatest rates in children <5 years. Thirty ON occurred in 10 patients with a 15 times greater incidence in children >10 years than in those <5 years. Nearly all skeletal complications occurred during maintenance therapy at a median of 14.92 months (range 0.0-53.8) after diagnosis and in weight-bearing bones.

CONCLUSIONS

The doubled fracture rate and the high incidence of skeletal complications during the first years after diagnosis suggest the developing skeleton is very vulnerable in this period. Adolescents develop more ON whereas younger children may be more prone to fractures. Serious "immediate effects" of chemotherapy on bone appear of great concern and should entail preventative studies in this group of patients.

Advances in the diagnosis and treatment of osteoporosis

Although severely low bone density is relatively rare in the pediatric population, it can be a significant problem in many patients with chronic illness. As peak bone formation occurs during adolescence, it is crucial that pediatricians and other care providers for this patient population recognize the significance of attainment of adequate bone. Dietary intake of vitamin D and calcium should be optimized, and correction of underlying causes of poor bone density should occur whenever possible. Assessment of bone density is difficult, as each technology available has problems, and none of the technologies are well-associated with fracture risk in pediatric patients. Once diagnosis of severely low bone density is established, treatment options are limited and poorly studied. The benefits of bisphosphonate therapy appear to outweigh the risks in patients with low bone density and frequent fragility fractures, and it appears that most improvement with bisphosphonates occurs within the first 2 to 4 years. Evidence, however, is emerging that once off therapy, bone turnover remains decreased for at least several years. During that time, improvements in bone density are decreased. Many questions remain regarding duration of therapy with bisphosphonate therapy and the long-term effects on the children who receive this medication. Anabolic therapies may become important in the future, but there is currently extremely limited information regarding their use in pediatrics.

Surviving childhood cancer: the impact on life

With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.

Bone mineral density and bone metabolism in children treated for bone sarcomas

In adolescent bone sarcoma patients, bone mass acquisition is potentially compromised at a time in which it should be at a maximum. To evaluate the problem we measured bone mineral density (BMD) and serum markers of bone formation and resorption in a series of pediatric patients with bone tumors. BMD was measured by dual-energy x-ray absorptiometry, at clinical remission, for lumbar spine and the neck of the femur in 38 osteosarcoma and 25 Ewing's sarcoma patients. Mean age was 20.65 and 19.13 y respectively. Serum markers of bone metabolism were: OC, PICP, ICTP, 25-OH vit D and 1,25-(OH)(2) vit D, IGF-I, IGFBP-3 and intact PTH. Serum was sampled throughout anti-tumoral treatments and follow-up. We analyzed 85 samples from 59 osteosarcoma patients and 54 samples from 36 Ewing's sarcoma patients. Patients had decreased lumbar and femoral BMD. The decrease was more pronounced in pubertal patients compared with those who had completed pubertal development at the time of disease diagnosis. Multivariate analysis indicated that sex, age, weight and BMI were significant in lumbar BMD depletion. Weight and BMI were significant in femoral BMD depletion. Serum markers of bone formation (PICP and OC) and resorption (ICTP) were, throughout, lower than reference values. Significant alterations in other markers were also observed. Up to a third of osteosarcoma and Ewing's sarcoma patients in clinical remission had some degree of BMD deficit. The corresponding increased risk of pathologic bone fractures constitutes a reduction in future quality of life.

Bone mineral density decrements and children diagnosed with cancer

This integrative literature review is focused on (1) the prevalence of bone mineral density (BMD) decrements in children treated for acute lymphoblastic leukemia (ALL), and when these decrements are observed; (2) the risk factors associated with the development of decreased BMD and resultant complications in children treated for ALL; (3) the role, if any, that corticosteroids play in decreasing BMD in children treated for ALL; (4) interventions that can potentially manage bone loss in people treated for ALL during childhood or adolescence. The results showed that people who have been diagnosed with ALL can have decrements in BMD. The etiology of BMD decrements can be attributed to multiple factors including genetic endowment, lifestyle behaviors, the leukemia disease process, and treatment exposures especially to corticosteroids and cranial radiotherapy. Male gender, age greater than 10 years, and physical inactivity are associated with BMD decrements in ALL survivors. The role of pediatric oncology nurses in the management of bone disease in children with cancer across the illness trajectory is discussed.

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.

Low turnover bone disease in Egyptian children with acute leukemia

The aim of this work was to study bone turnover markers, calcium homeostasis and bone mineral density (BMD) in children with acute leukemia at diagnosis, after induction chemotherapy, and during maintenance therapy to delineate abnormalities present. After evaluation of L2-L4 BMD using dual-energy X-ray absorptiometry in patients with acute myeloid and lymphoid leukemia at presentation and after treatment, the results were compared to 352 healthy age- and sex-matched Egyptian controls. Calcium homeostasis parameters and bone turnover biochemical markers (serum osteocalcin and urinary deoxypyridinoline) were also assayed and the results were compared to 12 healthy age- and sex-matched controls. Osteopenia was observed at diagnosis and during treatment in patients with acute leukemia. At diagnosis osteopenia was observed in 27 patients (62.8%): 10 (23.3%) had non severe osteopenia and 17 (39.5%) had severe osteopenia. This low BMD persisted in those who were followed up. Parathyroid hormone (PTH) (pg/ml) levels demonstrated non significant differences between children with acute leukemia at different stages of therapy and controls, while, 25 (OH) D3 (ng/ml) was significantly lower in acute leukemia patients at different stages of therapy compared to controls (p<0.001). Osteocalcin (ng/ml) is significantly lower in patients at different stages of the disease compared to controls (p<0.001) but there was no significant difference between patients at different stages of therapy. Deoxy-pyridoline cross links showed non-significant difference between the different types of acute leukemia and with controls. Osteopenia is a significant problem in children with acute leukemia at presentation and after chemotherapy. Osteopenia in acute leukemia appears to be of the low turnover type (decreased osteoblastic activity and decreased bone mineralization).

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.

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.

Endocrine complications in pediatric patients with acute lymphoblastic leukemia

Endocrine complications of therapy for acute lymphoblastic leukemia (ALL) are common and are potentially debilitating both during and after therapy. Growth velocity slows during therapy for ALL, especially during the first year; however, children who do not receive cranial irradiation usually reach normal adult height. While growth hormone deficiency generally occurs in patients who have received 24Gy of cranial irradiation, it may also develop in those treated with lower doses (18Gy) of cranial radiation or with only high-dose methotrexate. Obesity commonly occurs during therapy and persists after completion of therapy. Osteopenia can occur early during therapy for ALL and can persist for many years. Adrenal insufficiency should be suspected in any child who has recently received glucocorticoid therapy, and stress doses of steroid should be administered in the event of metabolic stress. Screening of urine is useful for early detection of hyperglycemia during therapy with glucocorticoids and L-asparaginase. The syndrome of inappropriate secretion of anti-diuretic hormone is usually associated with vincristine therapy and may be aggravated by concurrent use of azole antifungals. Finally, patients who have received 18 or 24Gy of cranial irradiation may have clinical or subclinical deficiencies of thyroid hormones.

Late effects of childhood cancer therapy

This study reviews the common long-term sequalae of childhood cancer and its therapy. It discusses the clinical and research challenges posed by such late effects. The authors address related topics of late effects research and clinical care, methodological issues, barriers and directions for the future.