Impaired pubertal growth in acute lymphoblastic leukaemia

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.

Final height and body mass index in adult survivors of childhood acute lymphoblastic leukemia treated without cranial radiotherapy: a retrospective longitudinal multicenter Italian study

Background

Young adult survivors of childhood acute lymphoblastic leukemia (ALL) treated with protocols including cranial radiotherapy demonstrate a persistent weight gain and reduced final height. Published reports on the effects on growth of different oncologic therapies are conflicting and difficult to interpret because they combined children treated with both cranial irradiation and multi-agent chemotherapy. Our study investigated the effect of chemotherapy alone on body mass index (BMI) and on growth at the achievement of final height in a homogeneous cohort of Italian childhood ALL survivors.

Methods

We retrospectively studied 162 Caucasian patients treated on the Italian Association of Pediatric Hematology and Oncology protocols without radiotherapy between 1989 and 2000 at five Italian centers with 107 inclusions (58 males). Height- and BMI-standard deviation score (SDS) were collected at diagnosis of ALL, at the end of treatment and at the achievement of final height. Changes in height SDS and BMI SDS with time were analyzed using dependent sample Student's t-test.

Results

A significant reduction of height-SDS was documented during treatment in both genders. This reduction of height-SDS was not followed by an appropriate catch-up growth, despite the achievement of a mean final height within the normal range. At diagnosis females showed a lower mean BMI-SDS than males. During treatment, in the whole population, BMI-SDS increased significantly. After it, while males lost BMI-SDS, females showed its persistent increase.

Conclusions

Survivors of childhood ALL generally seemed to achieve a normal final height with a BMI within the normal range. These parameters appeared to be only minimally affected by chemotherapy. Nevertheless, height catch-up growth was not completed after chemotherapy in both genders and all patients experienced an increase of BMI-SDS during chemotherapy that only females seemed to conserve until the achievement of final height.

Endocrinopathies in survivors of childhood neoplasia

Advancements in cancer treatments have increased the number of survivors of childhood cancers. Endocrinopathies are common complications following cancer therapy and may occur decades later. The objective of the current review is to address the main endocrine abnormalities detected in childhood cancer survivors including disorders of the hypothalamic-pituitary axis, thyroid, puberty, gonads, bone, body composition, and glucose metabolism.

Timing of menarche among survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

BACKGROUND

The objective of this study was to determine risk factors associated with abnormal timing of menarche among survivors of childhood acute lymphoblastic leukemia (ALL).

PROCEDURE

Self-reported age of menarche was determined among 949 female ALL survivors participating in the Childhood Cancer Survivor Study (CCSS), a cohort of 5-year survivors of common pediatric cancers diagnosed from 1970 to 1986, and compared with 1,128 siblings.

RESULTS

The majority of survivors (92%) and siblings (97%) reported menarche between the ages of 10 and 16. Survivors treated with chemotherapy alone, including those exposed to alkylating agents, experienced menarche at a similar rate to siblings. However, compared to chemotherapy alone, cranial radiotherapy was associated with early menarche (age < 10; OR 6.2, 95% CI 2.1, 18.5) while craniospinal radiotherapy was associated with both early (OR 8.6, 95% CI 1.9, 38.6) and late (age > 16; OR 4.8, 95% CI 1.4, 16.7) menarche. There were no differences in effect between <20 and >/=20 Gy radiotherapy doses. In multivariable analysis, younger age at diagnosis was an independent risk factor for early menarche.

CONCLUSIONS

Few female childhood ALL survivors experienced menarche outside of the normal range. Alkylating agent exposure was not associated with abnormal timing. However, those exposed to cranial and craniospinal radiotherapy, especially at a young age, should be monitored closely for abnormal timing of menarche.

Decreased adult height in survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

OBJECTIVE

To determine risk factors associated with reduced adult height in survivors of childhood acute lymphoblastic leukemia (ALL).

STUDY DESIGN

This was a cross-sectional study. Attained adult height was determined among 2434 ALL survivors participating in the Childhood Cancer Survivor Study, a cohort of 5-year survivors of common pediatric cancers diagnosed from 1970 to 1986, and compared with 3009 siblings.

RESULTS

All survivor treatment exposure groups (chemotherapy alone, chemotherapy with cranial or craniospinal radiotherapy) had decreased adult height and an increased risk of adult short stature (height standard deviation score < -2) compared with siblings (P < .001). Compared with siblings, the risk of short stature for survivors treated with chemotherapy alone was elevated (OR, 3.4; 95% CI, 1.9, 6.0). Among survivors, significant risk factors for short stature included diagnosis of ALL before puberty, higher-dose cranial radiotherapy (> or = 20 Gy versus < 20 Gy), any radiotherapy to the spine, and female sex.

CONCLUSIONS

Survivors of childhood ALL are at increased risk of adult short stature, including those treated with chemotherapy alone. Risk is highest for those treated with cranial and craniospinal radiotherapy at a young age.

Long-term effects of radiation therapy on cognitive and endocrine function in children with leukemia and brain tumors

BACKGROUND

As the number of long-term survivors of childhood cancer has grown, it has become increasingly clear that central nervous system therapy may have serious long-term effects on cognition and endocrine function. These complications have been studied most extensively in children with brain tumors and leukemia.

REVIEW SUMMARY

Children with acute lymphoblastic leukemia previously treated with cranial irradiation are at risk for cognitive decline. Chemotherapy-only regimens, which rely on high-dose frequently administered methotrexate, are also associated with producing cognitive dysfunction. Children irradiated for brain tumors are even more vulnerable. Risk factors include perioperative morbidity, young age, large-volume high-dose cranial irradiation, supra-tentorial location of tumor, moyamoya syndrome, and leukoencephalopathy. Cognitive decline is progressive over at least a decade. The most common radiation-induced endocrinopathies are hypothyroidism and growth hormone deficiency. Treatment effects on growth are multifactorial and include growth hormone deficiency,spinal shortening, precocious puberty, undetected hypothyroidism,and poor nutrition. Fifty percent to 80% of children treated with craniospinal radiation for brain tumors will experience growth failure. In hopes of reducing neurotoxicity, current treatments limit the dose and volume of radiation while adding chemotherapy. Results have not been uniformly positive, however, and may increase toxicity in some cases.

CONCLUSIONS

The standard of care in 2004 is that children who have been treated for brain tumors and leukemia should be monitored for cognitive and endocrine dysfunction. Until effective non-neurotoxic treatment is identified, long-term effects assessments are essential to maximize the quality of life of survivors of childhood cancer.

Reduction of adult height in childhood acute lymphoblastic leukemia survivors after prophylactic cranial irradiation

BACKGROUND

Impaired linear growth is a well-recognized complication in long-term childhood ALL survivors who received cranial irradiation. However, as many patients achieve a final height between the 5th and the 95th centile, the true incidence of linear growth impairment might be underestimated.

METHODS

Reduction of adult height (RAH) was estimated in adult childhood ALL survivors with and without cranial irradiation. RAH was calculated as the difference between target height (TH) and final height (FH). TH was calculated according to the formula TH = {[(height father + height mother +/- 12)/2] + 3}. RAH was assessed in 79 adult childhood ALL survivors in first complete remission who had received cranial irradiation 25 Gy (Group I, n = 53), 18 Gy (Group II, n = 10) or chemotherapy alone (controls, n = 16).

RESULTS

RAH was 8.6 +/- 8.2 cm in Group I (P = 0.001 vs. controls), 6.2 +/- 3.2 cm in Group II (P = 0.01 vs. controls), and 1.7 +/- 4.6 in controls (chemotherapy only). There was no significant difference between Group I and Group II. In Group I females had more RAH than males (P = 0.02). RAH was related to younger age at diagnosis (P = 0.001).

CONCLUSIONS

The deficit between target height and final height highlights the reduction of adult height in the majority of male and female childhood ALL survivors who had received prophylactic cranial irradiation, in particular in those who were diagnosed at a younger age. This reduction would have been masked if patients FH was only compared with standard methods. RAH might be a sensitive predictor for growth hormone deficiency as these results suggest that radiation-induced growth hormone deficiency in these patients is the rule rather than the exception.

Successful treatment without cranial radiotherapy of children receiving intensified chemotherapy for acute lymphoblastic leukaemia: results of the risk-stratified randomized central nervous system treatment trial MRC UKALL XI (ISRC TN 16757172)

Concern about late adverse effects of cranial radiotherapy (XRT) has led to alternative approaches to eliminate leukaemia from the central nervous system (CNS) in childhood acute lymphoblastic leukaemia (ALL). The Medical Research Council UKALL XI trial recruited 2090 children with ALL between 1990 and 1997. Median follow-up is 7 years 9 months; event-free survival (EFS) and overall survival were 63.1% and 84.6%, respectively, at 5 years and 59.8% and 79.4% at 10 years. The isolated CNS relapse rate was 7.0% at 10 years. Patients were randomized for CNS-directed therapy within white blood cell (WBC) groups. For WBC <50 x 10(9)/l, high-dose intravenous methotrexate (HDMTX) (6-8 g/m2) with intrathecal methotrexate (ITMTX) was compared with ITMTX alone, and was significantly better at preventing isolated and combined CNS relapse, but non-CNS relapses were similar. There was no significant difference in EFS at 10 years, 64.1% [95% confidence interval (CI) 60.4-67.8] with HDMTX plus ITMTX, and 63.0% (95% CI 59.5-66.5) with ITMTX alone. For WBC >/=50 x 10(9)/l, HDMTX with ITMTX was compared with XRT and a short course of ITMTX. CNS relapses were significantly fewer with XRT, but there was a non-significant increase in non-CNS relapses. EFS was not significantly different, being 55.2% (95% CI 47.8-62.6) at 10 years with XRT and 52.1% (95% CI 44.8-59.4) with HDMTX plus ITMTX.

Endocrine sequelae of cancer therapy in childhood

New treatments for neoplastic diseases of childhood have significantly increased patients' long-term survival and the importance of recognizing and correcting late complications of medical therapy. In this review, we examine both central nervous system (CNS) and non-CNS-related endocrine morbidities associated with chemotherapy and radiation therapy of childhood cancer. These include effects on growth, puberty, fertility, thyroid and adrenal function which may present many years after the successful treatment of underlying disease.

Long-term outcome of treatment with protocols AL841, AL851, and ALHR88 in children with acute lymphoblastic leukemia: results obtained by the Kyushu-Yamaguchi Children's Cancer Study Group

We analyzed the long-term outcome and late effects of treatment in 187 patients with childhood acute lymphoblastic leukemia (ALL) diagnosed between 1984 and 1990. Overall survival and event-free survival rates were 68.2% +/- 3.7% and 63.2% +/- 3.6% at 15 years, respectively. Of 55 patients who relapsed after achieving the first complete remission (CR), only 17.4% were rescued by salvage therapy. The advantage of stem cell transplantation over chemotherapy was observed only in those patients with bone marrow relapse during therapy. The SD for score height in patients maintaining the first CR significantly decreased at the time of final follow-up compared with that at diagnosis: 0.059 to -0.800 (P < .0001). The decrease was remarkable in patients younger than 5 years at diagnosis. Other late effects included mild liver dysfunction in 18% and hepatitis C virus infection in 9%. Congestive heart failure was observed in only 2.9% of patients despite the high cumulative dose of daunorubicin (450 mg/m2). Although the survival rates of patients on our protocols were comparable to those of other study groups, some modification, including reduction in dose of cranial irradiation and/or anticancer drugs, should be considered to reduce late adverse effects in survivors of childhood ALL.

Adult height and age at menarche in childhood cancer survivors

The aim of this study was to assess the long-term effects of cancer treatments on adult height and age at menarche in survivors of various types of childhood cancer. 285 childhood cancer survivors (161 men and 124 women), at least 18 years old and having been off treatment for at least 5 years, were examined. The effects of cranial (CrRT) and craniospinal irradiation (CrSpRT), other treatments and age at diagnosis on adult height and age at menarche were investigated. Patients who did not receive CrRT or CrSpRT, reached normal adult heights. However, a significant reduction in adult height was observed in men and women treated with CrRT or CrSpRT, especially if the treatment was given at the age of 8 years or younger. In girls, CrRT resulted in a significantly earlier menarche, compared with the Dutch population. Chemotherapy, radiation dose and age at menarche did not affect adult height. The relative risk (RR) of attaining an adult height below the 3rd percentile (20% 49/244) of the study population) was 6 times increased (RR=6.4; 95% confidence interval (CI) 1.46-28.52) after CrSpRT, 4 times (RR=4.2; 95% CI 1.81-9.63) after Crth and 5 times (RR=51; 95% CI 2.23-11.59) when irradiation was administered at the age of 8 years or younger. CrRT and CrSpRT and age at treatment are the main determinants of short stature in male and female childhood cancer survivors.

The effect of chemotherapy on the growing skeleton

With the increasing use of high dose (poly)chemotherapy schedules in the treatment of childhood cancer it is particularly important to know the adverse effects of these treatments. Growth is a complex mechanism affected not only by chemotherapy but also by the malignancy itself as well as nutritional status, the use of corticosteroids and (cranial) radiation. In vitro and animal studies are often the most useful in determining the effect of a single chemotherapeutic agent on the growing skeleton. In vitro studies have shown doxorubicin, actinomycin D and cisplatin to have a direct effect on growth plate chondrocytes that in animals results in decreased growth and final height. Clinical studies with multiagent chemotherapy have demonstrated that antimetabolites decrease bone growth and final height. Childhood cancer survivors are at risk of a reduced bone mineral density, mainly due to methotrexate, ifosfamide and corticosteroids. This reduced bone mineral density persists into adult life and may increase bone fracture risk at an older age.

Sexually dimorphic and radiation dose dependent effect of cranial irradiation on body mass index

OBJECTIVES

To investigate the relation between cranial irradiation received during treatment for childhood leukaemia and obesity at final height.

DESIGN

Retrospective cross sectional study.

SETTING

Paediatric oncology centres at Great Ormond Street Hospital for Children and the Royal Marsden Hospital.

SUBJECTS

Survivors of childhood leukaemia who received cranial irradiation, were in continuous first remission, and had reached final height. An unirradiated group of patients from the United Kingdom acute lymphoblastic leukaemia XI trial was also included; these patients were in continuous first remission and had been followed for at least four years from diagnosis.

MAIN OUTCOME MEASURES

Body mass index standard deviation score (BMI z score) at final height for irradiated patients and at most recent follow up for unirradiated patients. Regression analysis was used to examine the effect on BMI z score of sex, age at diagnosis, and the dose of radiation received.

RESULTS

For cranially irradiated patients, an increase in the BMI z score at final height was associated with female sex and lower radiation dose, but not with age at diagnosis. Severe obesity, defined as a BMI z score of > 3 at final height, was only present in girls who received 18-20 Gy irradiation and had a prevalence of 8%. Both male and female unirradiated patients had raised BMI z scores at latest follow up and there was no association with age at diagnosis.

CONCLUSIONS

These data are further evidence for a sexually dimorphic and dose dependent effect of radiation on the human brain.

Insulin-like growth factor-I (IGF-I) and IGF-binding protein-3 (IGFBP-3) concentrations compared to stimulated growth hormone (GH) in the evaluation of children treated for malignancy

OBJECTIVE

The aim of this investigation was to evaluate the utility of IGF-I and IGFBP-3 determinations in screening for GH deficiency (GHD) in children previously submitted to treatment for childhood malignancy.

PATIENTS AND METHODS

We compared the GH responses to two pharmacological tests (arginine and levo-dopa) with the IGF-I and IGFBP-3 levels in 48 patients (29 boys) who had undergone bone marrow transplantation (BMT) (36 patients) or treatment for a solid cranial tumor (12 patients).

RESULTS

22 patients (45.8%) showed GHD (i.e. GH peak < 8 ng/ml in both tests), and only three (13.6%) of the GHD patients had concomitant low IGF-I levels (i.e. -2 SD below the normal mean) and only one (4.5%) an abnormal IGFBP-3 value (i.e. -2 SD below the normal mean). Among the 26 children with normal GH secretion, 21 (80.8%) also showed normal IGF-I and IGFBP-3 levels, three (11.5%) had a concomitant low IGF-I value and two (7.7%) a concomitant low IGFBP-3 value. A significant correlation was found between GH secretion and age at diagnosis (r = 0.26, P < 0.05), and between IGF-I and IGFBP-3 (r = 0.52, P < 0.0001), but not between GH and IGF-I or IGFBP-3. Comparing the growth pattern of these patients from diagnosis to the first year after therapy or BMT, we found that while individual height changes did not correlate with the GH peak, a significant correlation was found between height SDS decrease and IGF-I (r = 0.31, P < 0.05) or IGFBP-3 SDS (r = 0.37, P < 0.01).

CONCLUSION

Our results indicate that the cut-off of -2 SD for IGF-I and IGFBP-3 was insensitive in screening for GHD. A normal value did not exclude a subnormal GH response to provocative tests and therefore although IGF-I and IGFBP-3 levels may be indicators of the growth pattern, they cannot be used alone as a tool for identifying GHD children after treatment for childhood malignancy.

Endocrine complications of bone marrow transplantation in children

Eighty-seven patients had a bone marrow transplantation (BMT) at our institution between 1980 and 1992. We wished to study the endocrine complications that accompany this procedure as long-term survival is now much more common. Forty-three patients were retrospectively available for review and their records were examined for evidence of thyroid, pubertal, and growth complications. Fifteen per cent of the patients showed evidence of thyroid involvement. Pubertal delay or gonadal damage was almost universal in pubertal-aged girls treated with busulfan/cyclophosphamide. Gonadal involvement was more frequent in girls than in boys (70% vs. 47%). Sixty per cent of children were shorter or grew at a slower rate. Sixty-five per cent of the children presented with one or more endocrine complications. These are the combined effects of different treatment regimens (chemotherapy, radiotherapy, combined therapy). It is essential to know the natural history of these patients in order to offer proper guidance and treatment as survival rates are increasing.

Height and weight pattern up to 20 years after treatment for acute lymphoblastic leukaemia

OBJECTIVE

To assess height and body mass index standard deviation scores up to 20 years after treatment for acute lymphoblastic leukaemia (ALL).

SUBJECTS AND METHODS

Height and body mass index standard deviation scores were measured in 33 patients (14 boys and 19 girls) with childhood ALL at diagnosis, after the end of treatment, at final height, and at follow up 10-20 years (median, 16.2) after diagnosis. Eleven patients were treated with chemotherapy only and 22 patients were treated with chemotherapy and cranial irradiation.

RESULTS

In the chemotherapy only group, height standard deviation scores were the same at follow up as at diagnosis, but there was a significant decrease in height standard deviation scores during treatment. Mean body mass index standard deviation scores increased steadily from the start of treatment until final height and continued to increase from final height until follow up. In the cranially irradiated group, mean height standard deviation scores decreased steadily from the start of treatment until follow up. Mean body mass index standard deviation scores increased continuously from the start of treatment until final height and from final height until follow up.

CONCLUSION

Chemotherapy combined with cranial irradiation and chemotherapy alone might be persisting risk factors for obesity even after final/height has been attained in patients treated for childhood ALL. Chemotherapy is a risk factor for reduced final height only when administered in combination with cranial irradiation. These problems need to be recognised and dealt with at follow up examination.

Growth and endocrinological disorders up to 21 years after treatment for acute lymphoblastic leukemia in childhood

BACKGROUND

Our aim was to evaluate endocrinological status 10-21 years after treatment for childhood acute lymphoblastic leukemia (ALL) with chemotherapy (C) and cranial irradiation (C + I) or only C, and to correlate the endocrine data with growth parameters.

PROCEDURE

Of 30 patients (15 females and 15 males), 18 were treated with C + I and 12 were treated with C only. Height standard deviation score (HSDS) and body mass index standard deviation score (BMISDS) before treatment, at end of treatment, and at follow-up were calculated from height and weight registered from the charts. At follow-up examinations, provocative growth hormone (GH) tests (clonidine and insulin tolerance test) and an ACTH test were performed. Furthermore, blood samples for hormonal analysis, IGF-I, IGFBP-3, GHBP, and leptin were drawn.

RESULTS

Eleven patients (9 treated with C + I and 2 treated with C) showed insufficient response to GH tests. Two patients had hypogonadism. HSDS and IGF-I were significantly lower and GHBP significantly higher in GH-deficient patients compared to the group with normal GH secretion at follow-up. BMISDS steadily increased from start of treatment until follow-up, independent of GH status at follow-up. BMISDS at follow-up was positively correlated with serum leptin (P < 0.001), and serum leptin was significantly higher in the cranial irradiated group as compared to the nonirradiated group.

CONCLUSIONS

GH deficiency is frequently found at long-term follow-up in patients treated for childhood ALL. Other hormonal deficiencies are rare. HSDS at long-term follow-up is dependent on GH secretory status. Long-term endocrinological follow-up examinations in patients treated for childhood ALL are recommended, as hormonal replacement therapy may be indicated.

Menarche in a cohort of 188 long-term survivors of acute lymphoblastic leukemia

OBJECTIVE

As more children survive acute lymphoblastic leukemia (ALL), questions are raised regarding how the disease and its therapy affect their pubertal development.

STUDY DESIGN

The National Institute of Child Health and Human Development-National Cancer Institute-Children's Cancer Group Leukemia Follow-Up Study used a historical cohort design to investigate menarche in 188 ALL survivors who were premanarchal at diagnosis, aged at least 18 years, at least 2 years after diagnosis, alive, and in remission. Female siblings of ALL survivors (n = 218) served as control subjects.

RESULTS

Menarche occurred within the normal age range in 92% of survivors and 96% of the control subjects (p = 0.09). Early menarche occurred in four survivors (2%) and three control subjects (1%). Delayed, absent, or medically induced menarche was reported by 12 survivors (6%) and six control subjects (3%). Compared with the control subjects, survivors of ALL who received 1800 cGy cranial radiation before the age of 8 years had significantly earlier menarche, relative hazard (RH) of 2.2 (95% confidence interval: 1.4, 3.4 [p = 0.0003]). Survivors receiving 2400 cGy of craniospinal radiation with or without abdominal radiation had significantly later menarche than the control subjects, RH 0.4 (95% confidence interval: 0.3, 0.7 [p = 0.0002]).

CONCLUSIONS

In this large cohort of ALL survivors, the risk of disordered menarche was low. However, younger subjects receiving 1800 cGy cranial radiation and those receiving 2400 cGy below the diaphragm required careful monitoring.

Growth and neuroendocrine dysfunction following therapy for childhood cancer

Poor linear growth and short adult stature are common complications following successful treatment of childhood cancer. Although several factors contribute to the impaired growth of these patients, growth potential is most reduced following radiotherapy to the head or spine. Younger age at treatment and female sex seem to be significant and independent risk factors for short adult height. Early diagnosis and timely therapy of the endocrine sequelae of cancer treatment (i.e., GH deficiency, hypothyroidism, and precocious puberty) ensure that these individuals will reach their optimum growth potential. For patients exposed to high-dose radiotherapy (> 35-40 Gy) to the region of the hypothalamus and pituitary gland, a variety of neuroendocrine abnormalities in addition to GH deficiency and early sexual development may occur, including deficiencies of LH/FSH, TSH, and ACTH as well as hypersecretion of prolactin. Because these problems may develop many years after irradiation, patients at risk for neuroendocrine disturbances require long-term endocrine follow-up.

Adult height after cranial irradiation with 24 Gy: factors and markers of height loss

The decrease in adult height of children who have been given cranial irradiation (24 Gy) for acute lymphoblastic leukaemia is attributed to chemotherapy, growth hormone (GH) deficiency and early puberty. This study evaluates the factors involved in the height loss between irradiation and adult height and its markers in 43 patients irradiated at 5.8 +/- 0.4 (SEM) years. The mean height loss was 0.9 +/- 0.2 SD in the children with a normal GH peak (n = 11), 1.7 +/- 0.2 SD in those with a low GH peak and untreated (n = 15) and 0.6 +/- 0.2 SD in those treated with GH (n = 17). The adult height was significantly lower than target height in all three groups. The height loss correlated negatively with the GH peak (p < 0.02) and with the age at onset of puberty (p < 0.05) in the first two groups with spontaneous growth, but not with the chemotherapy regimen or its duration, or the plasma insulin-like growth factor I (IGFI) and its GH-dependent binding protein (BP-3). Early puberty (onset at 8-10 years) occurred in 6 girls from the first two groups. At the first evaluation, 5.6 +/- 0.4 years after irradiation, the GH peak values after arginine-insulin stimulation correlated with the age at irradiation (p < 0.03), taking into account the time since irradiation. The plasma IGFI and BP-3 values were correlated with each other, but not with the GH peak. In conclusion, this study demonstrates the impact of GH deficiency and GH replacement therapy on adult height in children given cranial irradiation for leukaemia. They therefore should be evaluated for their GH secretion 1-2 years after the end of chemotherapy. GH therapy is indicated for those with low GH peak and decreased growth rate or no increase in growth rate despite puberty.

Clinical characteristics and factors affecting growth in long-term survivors of cancer

We evaluated clinical characteristics and growth in 51 (24 males) long-term survivors of childhood cancer (median follow up 12.7 years). Patients were shorter, had a higher proportion of body fat and higher systolic blood pressure than their controls. The change in relative height during treatment was -0.83 standard deviation score (S.D.S.) in patients with cranial irradiation and -0.32 S.D.S. in patients without cranial irradiation; the figures after treatment were -0.56 and 0.20 S.D.S., respectively. Half (r2 = 0.50) of the variation in growth retardation during therapy could be explained by the cumulative doses of 6-mercaptopurine (6-MP) and vincristine and relative height at diagnosis. Cranial irradiation, increased relative height at diagnosis and young age at diagnosis were significant predictors of growth failure over the total observation period, explaining 43% of the variation. We conclude that long-term survivors of childhood cancer have impaired linear growth, increased body fat mass and elevated systolic blood pressure. Young children who are tall for their age at diagnosis and treated with cranial irradiation have the highest risk of impaired growth after the diagnosis. High doses of 6-MP seem to contribute significantly to growth retardation during therapy.

Growth, puberty and obesity after treatment for leukaemia

Final height, body proportions, pubertal growth and body mass index were studied retrospectively in 142 survivors of acute lymphoblastic leukaemia (ALL). Treatment consisted of combination chemotherapy and cranial irradiation (18 or 24 Gy). Significant standing height loss and disproportion, with a relatively short back, was seen in both radiation dose groups. Girls were more severely affected than boys. Pubertal growth was adversely affected, with a reduction in peak height velocity in both sexes. Puberty occurred early in girls but at the normal time in boys. Nearly half the group were obese at final height, with no significant difference in incidence between the sexes. The relative roles of cranial irradiation and chemotherapy in the disturbance of growth, puberty and body composition observed in survivors of childhood ALL remain unclear. The aetiology is almost certainly multifactorial, with radiation-induced growth hormone insufficiency, early puberty, steroids and chemotherapy all having a role.

Intellectual performance after presymptomatic cranial radiotherapy for leukaemia: effects of age and sex

Cognitive outcome, as measured by verbal and performance IQs, was compared in 35 girls and 47 boys who were in first remission for acute lymphoblastic leukaemia. All children had received presymptomatic cranial radiotherapy and intrathecal methotrexate. The mean age at diagnosis was 4.2 years and the mean elapsed time from initial diagnosis to intellectual assessment was 7.1 years. Results showed that children irradiated before the age of 4 years were impaired in certain aspects of non-verbal ability, as well as in measures of short term memory and attention, calculated by factor scores derived from selected subtests of the IQ test. Subtests requiring verbal and non-verbal reasoning showed the greatest impairment after early diagnosis and treatment. In addition girls were selectively impaired in verbal IQ and other aspects of verbal ability, with the degree of impairment exacerbated by early treatment. No relationship was found between degree of impairment and either time since treatment or number of methotrexate injections. It is concluded that early age at irradiation increases the risk of impaired intellectual outcome, particularly in girls.

Normal final height after treatment for acute lymphoblastic leukemia without irradiation

In order to evaluate the influence of chemotherapy on linear growth, 28 children treated for acute lymphoblastic leukemia without irradiation were evaluated before, during and after the end of therapy. Median age at diagnosis was 4.4 years (range 2.2-12.7 years) and treatment was discontinued after a median period of 3.1 years (3.0-5.2 years). We observed a significant decrease in height SDS (p = 0.006) from diagnosis to the end of chemotherapy, followed by catch-up in height SDS from the end of chemotherapy to final observation. Catch-up growth took place mainly within the first 2 years after cessation of therapy. In 22 patients final height was reached. Final height was normal (median height SDS -0.035) and even significantly higher than mid-parental height SDS (p = 0.012). In those patients who attained adult stature, the sitting height to standing height ratio was also normal. In conclusion, in children treated for acute lymphoblastic leukemia, chemotherapy exerted a negative influence on growth, but catch-up occurred within 2 years after cessation of therapy, resulting in normal final height and body proportions.

Longitudinal growth and final height in long-term survivors of childhood leukaemia

Survival of children with acute lymphoblastic leukaemia (ALL) has increased considerably in recent years and data on the spontaneous growth and final height of these children are conflicting. Therefore, we analysed the longitudinal growth and final height in 52 survivors (33 females, 19 males) of childhood ALL. These children were diagnosed and treated in a single institution, all remained in first remission and were submitted to cranial irradiation with either 2400 or 1800 cGy. None of the patients received testicular or spinal irradiation. Median age at diagnosis was 4.2 (range 1.3-9.6) years in the first group (2400 cGy) and 3.9 (0.8-10.5) years in the second (1800 cGy). Standing height was measured at diagnosis, at the end of treatment (median 3.1 years after diagnosis), 6, 12, 24 months after the end of treatment, and finally at the completion of growth. In girls a significant decrease of mean height standard deviation score (SDS) during treatment and a catch up in growth after the end of therapy was followed by a second period of reduced growth. Mean final height SDS was significantly lower than the value at diagnosis in both groups of girls, but only in males treated with 2400 cGy. Mean overall loss in height SDS from diagnosis to final height was higher in females (-1.24) than in males (-0.40) (P = 0.009). Females < or = 4 years of age at diagnosis showed a higher loss in final height than females > 4 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Disproportionate short stature after cranial irradiation and combination chemotherapy for leukaemia

The effect of combination chemotherapy and cranial irradiation on final height and body proportions was retrospectively examined in a cohort of 142 children treated for acute lymphoblastic leukaemia (ALL). Eighty four children (48 girls, 36 boys) received 24 Gy cranial irradiation and 58 (35 girls, 23 boys) 18 Gy. None had received testicular or spinal irradiation. A significant reduction in standing height SD score from diagnosis to final height was seen in all groups. Of the 109 children in whom sitting height measurements were available, 88 (81%) had relatively shorter backs than legs and in 25 (23%) this disproportion was of a marked degree. After mathematical correction for sitting height loss there was no longer a significant reduction in standing height SD score at final height in all except the 24 Gy group of girls. These data suggest that disproportion is a common finding after treatment for ALL and that, at least in some children, much if not all of the height loss seen is due to a reduction in sitting height. Possible explanations for this disproportion include a disturbance of puberty or an effect of chemotherapy on spinal growth, or both.

Cerebral irradiation causes blunted pubertal growth in girls treated for acute leukemia

The improved treatment of childhood leukemia is a major achievement. The late effects of the treatment need further investigation. Growth inhibition has been demonstrated in earlier studies. Growth and the timing of puberty were studied in 179 girls who had been treated for acute lymphoblastic leukemia (ALL) in Denmark, Finland, Norway, and Sweden. The patients were divided into two groups according to mode of CNS prophylaxis: with or without cerebral irradiation. Longitudinal analysis of 103 patients showed no difference in prepubertal growth in irradiated and nonirradiated girls. Growth during puberty was normal in girls without irradiation and below normal in irradiated girls. There was no difference in growth between girls after 24 Gy or 20 Gy of cerebral irradiation. Irradiated girls had a final height which was one SD less than expected before puberty and menarche occurred one year earlier than in the nonirradiated girls. Prophylactic cerebral irradiation is the most important factor for subnormal growth after treatment for ALL. There is no short-term influence on growth but the effects of irradiation become apparent several years after therapy when girls enter puberty somewhat early and have a subnormal pubertal growth. Growth and growth hormone (GH) levels should be evaluated several years after CNS irradiation, and treatment with GH and/or luteinizing hormone releasing hormone (LHRH) analogues may be considered.

Final attained height in patients successfully treated for childhood acute lymphoblastic leukemia

We evaluated final adult height in 109 patients treated for childhood acute lymphoblastic leukemia on two multiarm Pediatric Oncology Group protocols between 1974 and 1981. Fifty-one patients received 2400 cGy cranial irradiation (XRT), and 58 patients received no XRT. All patients had no central nervous system involvement at diagnosis, achieved and maintained a complete response, entered puberty spontaneously, and had achieved final height. Height data were converted to standardized deviation scores. Mean age at diagnosis was 7.8 +/- 4.2 years. Distribution of heights at diagnosis was similar to that of the U.S. population. Relative to gender-specific heights for the population, female subjects in this study had lower attained heights than male subjects (p = 0.03). There was a monotonic trend of patients treated at an earlier age to have a reduction in final height (p = 0.057). Cranial irradiation was strongly associated with final height (mean standardized deviation score with XRT = -1.04 and without XRT = -0.14; p < 0.001). Final height was not associated with age at diagnosis, prognostic risk group, or Pediatric Oncology Group protocol. By multivariate analysis, only XRT and XRT x age were significantly associated with final height (p < 0.001 and p = 0.002, respectively). There was no significant gender effect. We conclude that XRT is significantly associated with reduced final adult height after treatment for childhood acute lymphoblastic leukemia. For survivors, therapy devoid of XRT does not appear to affect final height.

Growth and growth hormone in children during and after therapy for acute lymphoblastic leukaemia

Growth impairment and growth hormone (GH) deficiency have been reported in children treated for acute lymphoblastic leukaemia (ALL). We have studied growth and GH secretion in a group of 50 patients, affected by ALL, during a 2- to 5-year period after diagnosis, and in 12 "long-term-survivors". We observed a significant decrease in growth velocity during the 1st year (in particular during the first 6 months) of therapy and a catch-up growth after the end of therapy. "Long-term survivors" did not exhibit a significant reduction of height standard deviation score (SDS), as compared to height SDS at diagnosis. None of the patients showed GH deficiency. Our data indicate that chemotherapy significantly affects growth of patients treated for ALL, whereas radiotherapy-at the doses used in this study-does not induce GH deficiency, at least not within 9 years after diagnosis.

Final height after treatment for childhood acute lymphoblastic leukemia: comparison of no cranial irradiation with 1800 and 2400 centigrays of cranial irradiation

We analyzed growth and final heights in 127 patients (68 female patients) treated for childhood acute lymphoblastic leukemia. Central nervous system prophylaxis included either no cranial radiation therapy (CRT) (n = 38), irradiation with 1800 centigrays (cGy) (n = 36), or irradiation with 2400 cGy (n = 53). None of the patients received spinal irradiation. Mean (+/- SEM) age at diagnosis was 6.4 +/- 0.25 years, mean height standard deviation score (SDS) at diagnosis was 0.28 +/- 0.12, and mean age at final height was 18.26 +/- 0.19 years. The change in height SDS between diagnosis and achievement of final height was significant for all treatment groups: -0.49 +/- 0.14, no CRT; -0.65 +/- 0.15, 1800 cGy; and -1.38 +/- 0.16, 2400 cGy. Irradiated patients had a greater loss in height SDS compared with the nonirradiated patients (p < 0.01), and those treated with 2400 cGy CRT had a greater decrease in final height SDS than the patients treated with 1800 cGy (p < 0.01). Both younger age and female sex were significantly associated with a greater decrease in height SDS in the patients treated with CRT; girls < or = 4 years of age at diagnosis had a mean loss in height SDS that was more than twice that observed for others treated with the same dose of CRT. Thus, although modern regimens for acute lymphoblastic leukemia (no CRT or 1800 cGy CRT) appear overall to have only a modest impact on final height, patients, especially girls, treated with 1800 cGy CRT at a young age remain at risk for clinically significant growth failure.