Lymphoblastic lymphoma following prenatal exposure to phenytoin

Danish Population Based Study of Familial Epilepsy and Childhood Cancer

Objective

Results from studies investigating the association between maternal or child epilepsy, use of anticonvulsants in pregnancy, and childhood cancer are inconsistent and at times contradictory.

Methods

Linking Danish national databases, we obtained epilepsy and childhood cancer diagnoses, and anticonvulsant use data. We estimated adjusted odds ratios of all or specific childhood cancers in relation to maternal or child epilepsy and anticonvulsant therapies using conditional logistic regression.

Results

Maternal epilepsy was positively associated with all childhood cancers in offspring, specifically, with acute lymphoblastic leukemia (Odds Ratio (OR) = 1.68, 95% Confidence Interval (CI) = 1.16, 2.43) and Wilms tumor (OR = 2.13, 95%CI = 0.97, 4.68). When considering maternal ever (lifetime) ingestion of anticonvulsants, a positive association was found with all cancers (OR = 1.15, 95%CI = 1.01, 1.31), and central nervous system tumors (OR = 1.32, 95%CI = 1.03, 1.69) as well as neuroblastoma (OR = 2.05, 95%CI = 1.29, 3.28) among offspring. Maternal anticonvulsant use before or during the index pregnancy was related to CNS tumors in offspring (OR = 1.78, 95%CI = 0.99, 3.21), however the confidence interval included the null.

Significance

Maternal use of certain anticonvulsant medications may be a risk factor for cancer in offspring. Medical providers may need to consider what type of treatments to prescribe to pregnant mothers with epilepsy.

Association between antiepileptic drugs and hepatocellular carcinoma in patients with epilepsy: a population-based case-control study

BACKGROUND

This study explored whether antiepileptic drugs (AEDs) use increases the risk of hepatocellular carcinoma (HCC).

METHODS

We conducted a case-control study using data from the National Health Insurance system of Taiwan. The case group comprised 1,454 epilepsy patients with newly diagnosed HCC, and the control group comprised 1,448 epilepsy patients without HCC. Both groups had similar distributions of sex and age, and follow-up duration. Possible associations with the AEDs in Taiwan were examined.

RESULTS

After adjusted for AEDs (phenobarbital and primidone, clonazepam, clorazepate and diazepam, and other AEDs), and for the comorbidities of diabetes, chronic liver disease and cirrhosis, hepatitis B and C virus infection, and alcoholism, the odds ratio (OR) of HCC was 1.22 (95% confidence interval [CI]: 1.01-1.47) for the group of phenytoin users compared with nonphenytoin users. An annual means of 61-120, 121-180, and >180 of defined daily doses (DDDs) of phenytoin (OR: 4.07, 95% CI: 2.03-8.18; OR: 7.51, 95% CI: 3.03-18.7, and OR: 14.6, 95% CI: 7.88-26.9, respectively) were significantly correlated with the risk of HCC but not with a DDD of ≤60. Compared with nonphenytoin users, HCC patients who had used phenytoin within 1 year of HCC diagnosis were at a greatest risk of HCC (adjusted OR: 2.29, 95% CI: 1.71-3.08), followed by who had used phenytoin within 2 years of diagnosis (adjusted OR: 1.92, 95% CI: 1.44-2.56).

CONCLUSION

The results indicate that high dose of phenytoin was associated with a statistically significant increased OR for HCC, which was not demonstrated for low-dose phenytoin.

Transplacental carcinogenesis with dibenzo[def,p]chrysene (DBC): timing of maternal exposures determines target tissue response in offspring

Dibenzo[def,p]chrysene (DBC) is a transplacental carcinogen in mice (15mg/kg; gestation day (GD) 17). To mimic residual exposure throughout pregnancy, dams received four smaller doses of DBC (3.75mg/kg) on GD 5, 9, 13 and 17. This regimen alleviated the previously established carcinogenic responses in the thymus, lung, and liver. However, there was a marked increase in ovarian tumors (females) and hyperplastic testes (males). [(14)C]-DBC (GD 17) dosing revealed transplacental distribution to fetal tissues at 10-fold lower concentrations than in paired maternal tissue and residual [(14)C] 3weeks post-dose. This study highlights the importance of developmental stage in susceptibility to environmental carcinogens.

Effect of polyunsaturated fatty acids on diphenyl hydantoin-induced genetic damage in vitro and in vivo

Phenytoin sodium/diphenyl hydantoin (DPH) is used by a major segment of epileptics and neuro surgery patients with head injury to prevent seizures. DPH is a known mutagen, carcinogen, and teratogen. Essential fatty acids (EFAs) are critical for various tissues and were reported to act as anti-mutagenic agents. In the present study we assessed the effect of five EFAs on DPH-induced genetic damage both in vitro and in vivo. DPH induced significant genetic damage. Of all the EFAs (linoleic acid, alpha-linolenic acid, gamma-linolenic acid, arachidonic acid, dihomo-gamma-linolenic acid, and eicosapentaenoic acid) studied, all except eicosapentaenoic acid showed significant decrease in DPH induced genetic damage as assessed by micronucleus (MN) test. However, gamma-linolenic acid (GLA) was found to be the most effective in reducing the number of MN containing lymphocytes both in vitro and in vivo to control values. EFAs when tested alone produced insignificant increase in the amount of genetic damage but when tested in combination with DPH the number of micronuclei containing lymphocytes was reduced; but the DNA ladder pattern, an indication of DNA damage, was increased. This apparently paradoxical action of EFAs, especially of GLA, suggests that, in all probability, fatty acids induce apoptosis of cells that harbor significant DNA damage. Based on these results we suggest that GLA functions as a unique endogenous molecule that protects cells from accumulating genetic damage.

In utero Exposure of Mice to Dibenzo[a,l]Pyrene Produces Lymphoma in the Offspring: Role of the Aryl Hydrocarbon Receptor

Lymphoma and leukemia are the most common cancers in children and young adults; in utero carcinogen exposure may contribute to the etiology of these cancers. A polycyclic aromatic hydrocarbon (PAH), dibenzo[a,l]pyrene (DBP), was given to pregnant mice (15 mg/kg body weight, gavage) on gestation day 17. Significant mortalities in offspring, beginning at 12 weeks of age, were observed due to an aggressive T-cell lymphoblastic lymphoma. Lymphocytes invaded numerous tissues. All mice surviving 10 months, exposed in utero to DBP, exhibited lung tumors; some mice also had liver tumors. To assess the role of the aryl hydrocarbon receptor (AHR) in DBP transplacental cancer, B6129SF1/J (AHR(b-1/d), responsive) mice were crossed with strain 129S1/SvIm (AHR(d/d), nonresponsive) to determine the effect of maternal and fetal AHR status on carcinogenesis. Offspring born to nonresponsive mothers had greater susceptibility to lymphoma, irrespective of offspring phenotype. However, when the mother was responsive, an AHR-responsive phenotype in offspring increased mortality by 2-fold. In DBP-induced lymphomas, no evidence was found for TP53, beta-catenin, or Ki-ras mutations but lung adenomas of mice surviving to 10 months of age had mutations in Ki-ras codons 12 and 13. Lung adenomas exhibited a 50% decrease and a 35-fold increase in expression of Rb and p19/ARF mRNA, respectively. This is the first demonstration that transplacental exposure to an environmental PAH can induce a highly aggressive lymphoma in mice and raises the possibility that PAH exposures to pregnant women could contribute to similar cancers in children and young adults.

Retro-peritoneal cystic lymphangioma in association with fetal hydantoin syndrome

Antiepileptic drugs are known to be teratogenic. Use of phenytoin during pregnancy can cause various congenital malformations leading to 'fetal hydantoin syndrome'. One such case reported is unique in the sense that it occurred with retroperitoneal cystic lymphangioma, itself a rare condition. Such an association is not described elsewhere.