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Luongo C, Randazzo E, Iughetti L, DI Iorgi N, Loche S, Maghnie M, Valerio G, Delvecchio M. Cardiometabolic risk in childhood cancer survivors. Minerva Pediatr (Torino) 2021; 73:588-605. [PMID: 34309347 DOI: 10.23736/s2724-5276.21.06544-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Italian Cancer Registry Association has estimated that for the five-year period 2016-2020, in line with the previous five years, approximately 7,000 neoplasms have been diagnosed among children and 4,000 among adolescents. Leukemias, brain tumors and lymphomas together account for more than two-thirds of all pediatric cancers. Fortunately, the five-years survival rate has progressively improved reaching 80% thanks to the continuing improvement of therapeutic protocols but the vast majority of these cancer survivors will have at least one chronic health condition by 40 years of age. Long-term complications concern various organs and systems and have a multifactorial etiopathogenesis. Obesity, diabetes and metabolic syndrome represent chronic diseases that affect life expectancy. Cardiovascular risk partly linked to therapies and genetic susceptibility and partly linked to the presence of obesity, diabetes and metabolic syndrome predispose childhood cancer survivors to heart failure, coronary artery disease, valvular disease, arrhythmia. Hence the cardio- metabolic risk of childhood cancer survivors can have a significant impact on their lives, families, and on society at-large. It is therefore very important to know the risk factors that predispose to the development of cardio-metabolic pathologies in childhood cancer survivors, the possible primary and secondary prevention strategies, the methods of surveillance and the therapeutic approaches.
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Affiliation(s)
- Caterina Luongo
- Department of Woman, Child, General and Specialized Surgery, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Emioli Randazzo
- Department of Clinical and Experimental Medicine, Unit of Pediatric Endocrinology and Diabetes, University of Pisa, Pisa, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Natascia DI Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Sandro Loche
- Pediatric Endocrine Unit, Ospedale Pediatrico Microcitemico A Cao, Cagliari, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuliana Valerio
- Department of Movement Sciences and Wellbeing, University of Naples Parthenope, Naples, Italy
| | - Maurizio Delvecchio
- Metabolic Disorders and Genetic Unit, Giovanni XXIII Children Hospital, Bari, Italy -
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2
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Hanna S, Elshennawy S, El-Ayadi M, Abdelazeim F. Investigating fine motor deficits during maintenance therapy in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2020; 67:e28385. [PMID: 32400963 DOI: 10.1002/pbc.28385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/27/2020] [Accepted: 04/17/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Children diagnosed with acute lymphoblastic leukemia (ALL) in their early childhood are more susceptible to neuromuscular and musculoskeletal impairments. This cross-sectional study was designed to address different types of fine motor impairments in Egyptian children diagnosed with ALL. METHODS Fifty-four children treated for ALL in maintenance phase aged from four to seven years were compared with an age- and sex-matched control group. Fine motor performance was assessed using the total fine motor form of the Bruininks-Oseretsky Test of Motor Proficiency-second edition (BOT-2). Sex- and age-specific norms of BOT-2 were used to calculate scale and standard scores in both groups. RESULTS Children with ALL had significantly impaired fine motor skills in all subtests and composites of BOT-2 compared with the typically developing group (P < 0.00001). Cumulative doses of vincristine, methotrexate, and dexamethasone revealed no significant correlation with any BOT-2 measure. Males performed significantly better than females in all BOT-2 scores except for the fine motor integration subtest and the total fine motor control composite as no significant differences were observed. The protocol risk stratum, duration of maintenance treatment, and the age at assessment did not significantly affect the BOT-2 measures. CONCLUSION About 67% of children with ALL on maintenance treatment experienced fine motor difficulties. Periodic evaluation along the course of chemotherapy could identify specific impaired fine motor domains providing the base for a successful rehabilitation program.
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Affiliation(s)
- Silvia Hanna
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Shorouk Elshennawy
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Moatasem El-Ayadi
- Department of Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Faten Abdelazeim
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
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3
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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4
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Lupo PJ, Brown AL, Arroyo VM, Kamdar KY, Belmont JW, Scheurer ME, Leisenring WM, Gramatges MM, Okcu MF, Yasui Y, Oeffinger KC, Robison LL, Armstrong GT, Bhatia S. DNA methylation and obesity in survivors of pediatric acute lymphoblastic leukemia: A report from the Childhood Cancer Survivor Study. Genes Chromosomes Cancer 2018; 58:52-59. [PMID: 30382603 DOI: 10.1002/gcc.22701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 12/19/2022] Open
Abstract
Because survivors of pediatric acute lymphoblastic leukemia (ALL) are more likely to be obese than unaffected contemporaries, we compared DNA methylation profiles between normal-weight and obese survivors at adiposity-associated CpG sites previously-reported by epigenome-wide association studies (EWAS) of body mass index (BMI) in the general population. We selected 96 ALL survivors from the Childhood Cancer Survivor Study: 48 obese and 48 normal weight. The Illumina HumanMethylation450 BeadChip was used to compare DNA methylation at 211 loci identified in EWAS of BMI in the general population. Thirty-nine loci were associated (false discovery rate <0.05) with obesity among survivors who only received chemotherapy (n = 49). No loci were significantly associated with obesity among CRT-exposed survivors (n = 47). Our results suggest that previously identified BMI-DNA methylation loci are associated with obesity in ALL survivors who were spared CRT, while no loci were significantly associated with obesity in survivors who received CRT.
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Affiliation(s)
- Philip J Lupo
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Austin L Brown
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Vidal M Arroyo
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Kala Y Kamdar
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - John W Belmont
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | | | - Wendy M Leisenring
- Fred Hutchinson Cancer Research Center, Division of Public Health Sciences, Seattle, Washington
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Yutaka Yasui
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | | | - Leslie L Robison
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | - Gregory T Armstrong
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | - Smita Bhatia
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, Alabama
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5
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Follin C, Erfurth EM. Long-Term Effect of Cranial Radiotherapy on Pituitary-Hypothalamus Area in Childhood Acute Lymphoblastic Leukemia Survivors. Curr Treat Options Oncol 2017; 17:50. [PMID: 27476159 PMCID: PMC4967419 DOI: 10.1007/s11864-016-0426-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Survival rates of childhood cancer have improved markedly, and today more than 80 % of those diagnosed with a pediatric malignancy will become 5-year survivors. Nevertheless, survivors exposed to cranial radiotherapy (CRT) are at particularly high risk for long-term morbidity, such as endocrine insufficiencies, metabolic complications, and cardiovascular morbidity. Deficiencies of one or more anterior pituitary hormones have been described following therapeutic CRT for primary brain tumors, nasopharyngeal tumors, and following prophylactic CRT for childhood acute lymphoblastic leukemia (ALL). Studies have consistently shown a strong correlation between the total radiation dose and the development of pituitary deficits. Further, age at treatment and also time since treatment has strong implications on pituitary hormone deficiencies. There is evidence that the hypothalamus is more radiosensitive than the pituitary and is damaged by lower doses of CRT. With doses of CRT <50 Gy, the primary site of radiation damage is the hypothalamus and this usually causes isolated GH deficiency (GHD). Higher doses (>50 Gy) may produce direct anterior pituitary damage, which contributes to multiple pituitary deficiencies. The large group of ALL survivors treated with CRT in the 70–80-ties has now reached adulthood, and these survivors were treated mainly with 24 Gy, and the vast majority of these patients suffer from GHD. Further, after long-term follow-up, insufficiencies in prolactin (PRL) and thyroid stimulating hormone (TSH) have also been reported and a proportion of these patients were also adrenocoticotrophic hormone (ACTH) deficient. CRT to the hypothalamus causes neuroendocrine dysfunction, which means that the choice of GH test is crucial for the diagnosis of GHD.
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Affiliation(s)
- Cecilia Follin
- Department of Endocrinology, Skåne University hospital and IKVL, Lund University, Lund, Sweden.
| | - Eva Marie Erfurth
- Department of Endocrinology, Skåne University hospital and IKVL, Lund University, Lund, Sweden
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6
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Chen AC, Okcu MF, Dreyer ZE, Kamdar KY, Sonabend RY, Suzawa HS, Jo E, Paulino AC. Comparison of height and weight after 12 vs. 18 Gy cranial radiation therapy in pediatric acute lymphoblastic leukemia (ALL) patients. Adv Radiat Oncol 2017; 2:228-234. [PMID: 28740936 PMCID: PMC5514256 DOI: 10.1016/j.adro.2017.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/24/2017] [Indexed: 11/04/2022] Open
Abstract
Purpose To compare the effect of 12 versus 18 Gy cranial radiation therapy (RT) on height and weight indices among pediatric patients with acute lymphoblastic leukemia (ALL). Methods and materials Records of children with ALL who were 2 to 14 years old at the time of RT and were treated at a single institution between 2000 and 2011 were reviewed. Patients' height, weight, and body mass index were converted into z-scores using the Centers for Disease Control growth charts to normalize the values to number of standard deviations from the mean. These values were measured at the pre-RT clinic visit and subsequent yearly intervals. The z-scores of the growth indices were fitted into a generalizing estimating equations model and analyzed by various clinical factors. Results A total of 48 patients met the study criteria, including 32 boys and 16 girls. The median age at the time of RT was 7 years (range, 2-14 years). Patients were separated into 2 dose groups: 12 Gy (n = 30) and 18 Gy (n = 18). Median follow-up was 4.9 years (range, 3.0-11.8 years) and 6.0 years (range, 3.1-10.5 years) and the median pre-RT height z-scores were −0.55 (range, −2.2 to 1.4) and −0.85 (range, −3.1 to 0.8) for the 2 groups, respectively (P = .65). Patients who received 18 Gy had a significant difference in change in height compared with those who received 12 Gy, who were able to maintain normal growth during the first 3 years of follow-up. This did not appear to be sex-specific, and there was no difference in change in weight or body mass index. Conclusions Compared with 18 Gy, patients with ALL who received 12 Gy of cranial RT had less height impairment in the first 3 years post-RT, but further prospective studies are needed.
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Affiliation(s)
- Albert C Chen
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Hematology/Oncology, Texas Children's Hospital, Houston, Texas
| | - ZoAnn E Dreyer
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Hematology/Oncology, Texas Children's Hospital, Houston, Texas
| | - Kala Y Kamdar
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Hematology/Oncology, Texas Children's Hospital, Houston, Texas
| | - Rona Y Sonabend
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Endocrinology, Texas Children's Hospital, Houston, Texas
| | - Hilary S Suzawa
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Hematology/Oncology, Texas Children's Hospital, Houston, Texas
| | - Eunji Jo
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
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7
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Collins L, Beaumont L, Cranston A, Savoie S, Nayiager T, Barr R. Anthropometry in Long-Term Survivors of Acute Lymphoblastic Leukemia in Childhood and Adolescence. J Adolesc Young Adult Oncol 2017; 6:294-298. [DOI: 10.1089/jayao.2016.0091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Laura Collins
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lesley Beaumont
- Department of Nuclear Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Amy Cranston
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Stefanie Savoie
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Trishana Nayiager
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ronald Barr
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
- Division of Hematology-Oncology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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8
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Abstract
This integrative literature review focuses on (1) the spectrum of cardiovascular late effects; (2) the factors that can influence the development of cardiovascular late effects; and (3) the role of the pediatric oncology nurse in minimizing the risks of cardiovascular late effects and associated disabilities in childhood cancer survivorship. The results showed that survivors who have been treated with radiation therapy, especially when the field includes the heart or the hypothalamic-pituitary axis (HPA), and specific chemotherapies are at increased risk for developing particular cardiovascular risk factors and/or cardiovascular disease. Younger age at diagnosis, longer time since treatment, and family history of early heart disease can further heighten the risks. The role of pediatric oncology nurses in the promotion of cardiovascular health for children with cancer across the illness trajectory is discussed.
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Affiliation(s)
- Dawn M Greving
- Hematology/Oncology Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA.
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9
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Prevalence and Predictors of Overweight and Obesity Among a Multiethnic Population of Pediatric Acute Lymphoblastic Leukemia Survivors: A Cross-Sectional Assessment. J Pediatr Hematol Oncol 2016; 38:429-36. [PMID: 26989911 PMCID: PMC4955650 DOI: 10.1097/mph.0000000000000555] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
As previous studies of obesity in survivors of pediatric acute lymphoblastic leukemia (ALL) have primarily been conducted among non-Hispanic white survivors or children treated on older protocols, our objective was to describe the prevalence and correlates of overweight status among an ethnically diverse population of pediatric ALL survivors, largely treated with more contemporary therapies. We evaluated the overweight/obesity status of pediatric ALL survivors (n=406) followed in the Texas Children's Cancer Center between 2004 and 2014. Survivors were classified as underweight, normal weight, overweight, or obese on the basis of their body mass index at their most current follow-up visit. Our results showed that Hispanic ethnicity (39% of the subjects) was associated with being overweight (adjusted odds ratio=1.88; 95% confidence interval, 1.13-3.14) or obese (adjusted odds ratio=2.84; 95% confidence interval, 1.59-5.06) at follow-up, even after adjusting for cranial radiotherapy (CRT) exposure. Body mass index z-score at diagnosis was also associated with overweight/obesity at follow-up. In addition, there was a statistically significant interaction between younger age at diagnosis and CRT, indicating that younger age at diagnosis was associated with obesity among patients who received CRT. These findings may help identify pediatric ALL patients that are at increased risk of being overweight or obese after treatment.
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10
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Mohapatra S, Bansal D, Bhalla AK, Verma Attri S, Sachdeva N, Trehan A, Marwaha RK. Is there an increased risk of metabolic syndrome among childhood acute lymphoblastic leukemia survivors? A developing country experience. Pediatr Hematol Oncol 2016; 33:136-49. [PMID: 26984439 DOI: 10.3109/08880018.2016.1152335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Data on metabolic syndrome (MS) in survivors of childhood acute lymphoblastic leukemia (ALL) from developing countries are lacking. The purpose of this single-center, uncontrolled, observational study was to assess the frequency of MS in our survivors. The survivors of ALL ≤15 years at diagnosis, who had completed therapy ≥2 years earlier, were enrolled. Anthropometric measurements (weight, height, waist circumference), biochemistry (glucose, insulin, triglycerides, high-density lipoprotein [HDL], thyroid function tests, C-reactive protein [CRP], magnesium), measurement of blood pressure, and Tanner staging were performed. MS was defined by International Diabetes Federation (IDF) and the National Cholesterol Education Program Third Adult Treatment Panel guidelines (NCEP ATP III) criteria, modified by Cook et al. (Arch Pediatr Adolesc Med. 2003;157:821-827) and Ford et al. (Diabetes Care. 2005;28:878-881). The median age of 76 survivors was 11.9 years (interquartile range [IQR]: 9.6-13.5). Twenty-four (32%) survivors were obese or overweight. The prevalence of insulin resistance (17%), hypertension (7%), hypertriglyceridemia (20%), and low HDL (37%) was comparable to the prevalence in children/adolescents in historical population-based studies from India. The prevalence of MS ranged from 1.3% to 5.2%, as per different defining criteria. Cranial radiotherapy, age at diagnosis, sex, or socioeconomic status were not risk factors for MS. The prevalence of MS in survivors of childhood ALL, at a median duration of 3 years from completion of chemotherapy, was comparable to the reference population. The prevalence of being obese or overweight was, however, greater than historical controls.
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Affiliation(s)
- Sonali Mohapatra
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Deepak Bansal
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - A K Bhalla
- b Growth and Anthropology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Savita Verma Attri
- c Biochemistry Unit, Department of Pediatrics, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Naresh Sachdeva
- d Department of Endocrinology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Amita Trehan
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - R K Marwaha
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
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11
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Growth in Children Treated for Acute Lymphoblastic Leukemia: Single Institution Report from North India. Indian J Hematol Blood Transfus 2016; 32:39-45. [PMID: 26855505 DOI: 10.1007/s12288-015-0513-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 02/03/2015] [Indexed: 10/24/2022] Open
Abstract
Survivors of childhood leukemia are at risk of impaired growth and short stature as adults due to intensive combination chemotherapy and radiation injury. This study was undertaken to evaluate anthropometry in children treated for acute lymphoblastic leukemia (ALL). Children treated for ALL and off treatment for a minimum period of 2 years were evaluated for height, weight and BMI. Z scores were calculated for height, weight and BMI: at induction, 6 months after starting treatment, at end of treatment and at 2 years after completion of therapy. Change in z scores were calculated and compared with CDC criteria and Agarwal standards for Indian children. Fifty two boys and 21 girls were analyzed. Height and weight z scores were seen to show a steep decrease during the initial intensive phase of therapy. The gain in height and weight continued to be slow during therapy and catch up occurred after cessation of therapy. On completion of therapy, patients were shorter, but not significantly so. Girls <9 years were significantly shorter. Weight remained on the lower side of normal. Change of z scores was statistically significant for weight at end of treatment (p = 0.032) and 2 years after completion of treatment (p = 0.00). BMI z score increased throughout the study period. Peak growth velocities were also late in the study subjects Anthropometric variables of height, weight and BMI are affected by ALL during therapy. Growth deceleration is maximum during the intensive phase of therapy. Catch up growth occurs but children remain smaller than their peers.
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12
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Batra A, Patekar M, Bakhshi S. Short stature in retinoblastoma survivors: a cross-sectional study of 138 patients. Clin Transl Oncol 2015; 18:381-4. [PMID: 26286069 DOI: 10.1007/s12094-015-1380-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/05/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Short stature has been reported in pediatric cancer survivors. Data on retinoblastoma survivors are limited. We conducted a cross-sectional study to assess the height in retinoblastoma survivors. METHOD The recorded height was compared with median height for age and sex as per the Indian Academy of Pediatrics. Z-score less than -2 was considered short statured. RESULT Thirty percent of the survivors were short statured. The mean height was shorter than the mean 50th percentile height (119.7 ± 14.8 vs 128.7 ± 15 cm, p < 0.001). Previous chemotherapy showed a trend toward association (p = 0.09). CONCLUSION Short stature affects a significant number of retinoblastoma survivors.
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Affiliation(s)
- A Batra
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - M Patekar
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - S Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, 110029, India.
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13
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Zhang FF, Liu S, Chung M, Kelly MJ. Growth patterns during and after treatment in patients with pediatric ALL: A meta-analysis. Pediatr Blood Cancer 2015; 62:1452-60. [PMID: 25808413 PMCID: PMC4482769 DOI: 10.1002/pbc.25519] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Survivors of pediatric acute lymphoblastic leukemia (ALL) have a significantly higher body mass index (BMI) than their peers. Understanding the critical time periods in which patients with pediatric ALL are vulnerable to unhealthy weight gain will lay the groundwork for developing effectively timed interventions. PROCEDURE We determined the growth patterns of patients with pediatric ALL during and after treatment through the conduct of a systematic review and meta-analysis. A search of MEDLINE, Scopus, and Web of Science was performed from its inception through May 2014. Studies met the inclusion criteria if they included at least 10 patients of pediatric ALL, and longitudinally assessed BMI at diagnosis and at least one time point after diagnosis RESULTS Twenty-one studies met the inclusion criteria for the systematic review and 16 were included in meta-analysis. The mean increase in BMI z-score during treatment in 1,514 patients with pediatric ALL was 0.81 (95% CI: 0.25-1.38). Specifically, patients experienced substantial weight gain in early treatment (Δ = 0.41, 95% CI: -0.34, 1.17) and again during maintenance (Δ = 0.34, 95% CI:-0.22, 0.90). The mean increase in BMI z-score ranged between 0.52 and 0.89 beyond treatment completion. Subgroup analyses found unhealthy weight gain occurred regardless of patients' receipt of cranial radiation therapy, sex, and, weight status at diagnosis. CONCLUSIONS Patients with pediatric ALL experience unhealthy weight gain early in treatment, and increases in weight are maintained beyond treatment completion. Preventing early onset of obesity is a priority for improving the care and outcomes for patients with pediatric ALL.
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Affiliation(s)
- Fang Fang Zhang
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Shanshan Liu
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Mei Chung
- Nutrition/Infection Unit, Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Michael J. Kelly
- Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA
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14
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Nam GE, Kaul S, Wu YP, Nelson RE, Wright J, Fluchel MN, Hacking CC, Kirchhoff AC. A meta-analysis of body mass index of adolescent and adult survivors of pediatric acute lymphoblastic leukemia. J Cancer Surviv 2015; 9:412-21. [PMID: 25576213 DOI: 10.1007/s11764-014-0415-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/18/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE We conducted a meta-analysis of existing studies to examine body mass index (BMI) of adolescent and adult survivors of pediatric acute lymphoblastic leukemia (ALL) compared to individuals without cancer. METHODS Studies were identified and reviewed using specific inclusion criteria. The effect size was odds ratio (OR) of the prevalence of overweight/obese BMI (≥ 25 kg/m(2)) in ALL survivors versus comparison groups. Study data were coded and validated. Fixed-effects (FE) and random-effects (RE) estimates of the effect size were estimated. RESULTS A total of 9 studies met our inclusion criteria. Survivors were more likely to be overweight/obese compared to comparison groups (FE OR = 1.12, 95% CI 1.06-1.18 and RE OR = 1.28, 95% CI 1.07-1.53). When limited to studies from North American samples, female survivors were overweight/obese more often than the comparison groups (FE OR = 1.30, 95% CI 1.19-1.43). CONCLUSIONS Adolescent and adult survivors of pediatric ALL, especially female survivors, may be at a higher risk of being overweight/obese compared to individuals without cancer. However, few studies provided detailed information on patient and treatment factors (e.g., cranial radiation) that can impact BMI. Standardized reporting of study content is vital for providing robust information on the risk of developing late effects among cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS Adolescent and adult survivors of pediatric ALL require additional weight management resources such as targeted counseling for physical activity and dietician support both early in treatment and after the end of their therapy. Female survivors may need additional guidance to develop healthy eating practices and to participate in exercise programs.
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Affiliation(s)
- Gina E Nam
- Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Salt Lake City, UT, 84112, USA
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15
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Bruzzi P, Predieri B, Corrias A, Marsciani A, Street ME, Rossidivita A, Paolucci P, Iughetti L. Final height and body mass index in adult survivors of childhood acute lymphoblastic leukemia treated without cranial radiotherapy: a retrospective longitudinal multicenter Italian study. BMC Pediatr 2014; 14:236. [PMID: 25245636 PMCID: PMC4194356 DOI: 10.1186/1471-2431-14-236] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 09/10/2014] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena & Reggio Emilia, Via del Pozzo, 71, 41124 Modena, Italy.
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16
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Zhang FF, Kelly MJ, Saltzman E, Must A, Roberts SB, Parsons SK. Obesity in pediatric ALL survivors: a meta-analysis. Pediatrics 2014; 133:e704-15. [PMID: 24534408 PMCID: PMC3934345 DOI: 10.1542/peds.2013-3332] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Previous studies of survivors of pediatric acute lymphoblastic leukemia (ALL) have drawn heterogeneous conclusions regarding the prevalence of obesity and risk factors for developing obesity in pediatric ALL survivors. We sought to determine the prevalence of obesity in pediatric ALL survivors and examine risk factors for obesity through a systematic review and meta-analysis. METHODS A MEDLINE search was performed from its inception through 2013. Studies met the inclusion criteria if they (1) included at least 10 survivors of pediatric ALL; (2) assessed the prevalence or indicators of obesity; and (3) compared obesity among ALL survivors to a reference population or external control group. Extracted data included patient and treatment characteristics, study design, population used for comparison, and prevalence of obesity. RESULTS Forty-seven studies met the inclusion criteria. Despite significant heterogeneity among the studies (I(2) = 96%), the mean BMI z score in 1742 pediatric ALL survivors was 0.83 (95% confidence interval: 0.60-1.06), which corresponds to the 80th BMI percentile, indicating a significantly higher BMI in pediatric ALL survivors than the reference population. Subgroup analyses found a high prevalence of obesity in ALL survivors regardless of survivors' receipt of cranial irradiation, gender, or age at diagnosis. CONCLUSIONS Obesity is prevalent in pediatric ALL survivors and is independent of patient- and treatment-related characteristics. Clinicians need to screen for obesity and its associated health conditions early in survivorship.
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Affiliation(s)
- Fang Fang Zhang
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy and,Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Michael J. Kelly
- Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts;,Departments of Pediatrics
| | - Edward Saltzman
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Aviva Must
- Public Health and Community Medicine, and
| | - Susan B. Roberts
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Susan K. Parsons
- Departments of Pediatrics,,Medicine, Tufts University School of Medicine, Boston, Massachusetts; and,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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17
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Tan SY, Poh BK, Nadrah MH, Jannah NA, Rahman J, Ismail MN. Nutritional status and dietary intake of children with acute leukaemia during induction or consolidation chemotherapy. J Hum Nutr Diet 2013; 26 Suppl 1:23-33. [PMID: 23701375 DOI: 10.1111/jhn.12074] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The assessment of nutritional status among paediatric patients is important for the planning and execution of nutritional strategies that strive to optimise the quality of life and growth among sick children. The present study aimed to evaluate the nutritional status and dietary intake among children with acute leukaemia. METHODS This cross-sectional study included 53 paediatric patients aged 3-12 years old, who were diagnosed with either acute lymphoblastic leukaemia or acute myelogenous leukaemia and were undergoing chemotherapy treatments (induction or consolidation phase). Patients were matched for sex, age (±6 months) and ethnicity with healthy children as controls. Weight, height, body mass index, waist circumference, mid-upper arm circumference, triceps skinfold thickness, mid-upper arm muscle area and fat area were determined. Dietary intake was assessed using 3-day food records. RESULTS Anthropometric variables were generally higher among patients compared to controls, although the differences were not statistically significant (P > 0.05). The prevalence of overnutrition among patients according to body mass index-for-age, waist circumference-for-age, mid-upper arm circumference-for-age and triceps skinfold-for-age were 24.5%, 29.1%, 17.0% and 30.2%, respectively. Mean energy [5732 ± 1958 kJ (1370 ± 468 kcal) versus 6945 ± 1970 kJ (1660 ± 471 kcal), P < 0.01], protein (50.0 ± 19.7 g versus 62.3 ± 22.3 g, P < 0.01) and fat (43.6 ± 18.9 g versus 58.3 ± 16.7, P < 0.001) intakes of patients were significantly lower than controls. CONCLUSIONS The prevalence of being overweight and obesity in children with acute leukaemia was higher despite lower energy intake compared to controls. Studies assessing physical activity, the complex interaction and the effects of treatment drugs are warranted to better manage malnutrition among paediatric patients.
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Affiliation(s)
- S Y Tan
- Nutritional Sciences Programme, School of Healthcare Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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18
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van Waas M, Neggers S, te Winkel M, Beishuizen A, Pieters R, van den Heuvel-Eibrink M. Endocrine late sequelae in long-term survivors of childhood non-Hodgkin lymphoma. Ann Oncol 2012; 23:1626-32. [DOI: 10.1093/annonc/mdr511] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Iughetti L, Bruzzi P, Predieri B, Paolucci P. Obesity in patients with acute lymphoblastic leukemia in childhood. Ital J Pediatr 2012; 38:4. [PMID: 22284631 PMCID: PMC3295712 DOI: 10.1186/1824-7288-38-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 01/27/2012] [Indexed: 12/29/2022] Open
Abstract
Acute lymphoblastic leukemia is the most common malignancy in childhood. Continuous progress in risk-adapted treatment for childhood acute lymphoblastic leukemia has secured 5-year event-free survival rates of approximately 80% and 8-year survival rates approaching 90%. Almost 75% of survivors, however, have a chronic health condition negatively impacting on cardiovascular morbidity and mortality. Obesity can be considered one of the most important health chronic conditions in the general population, with an increasing incidence in patients treated for childhood cancers and especially in acute lymphoblastic leukemia survivors who are, at the same time, more at risk of experiencing precocious cardiovascular and metabolic co-morbidities. The hypothalamic-pituitary axis damage secondary to cancer therapies (cranial irradiation and chemotherapy) or to primary tumor together with lifestyle modifications and genetic factors could affect long-term outcomes. Nevertheless, the etiology of obesity in acute lymphoblastic leukemia is not yet fully understood. The present review has the aim of summarizing the published data and examining the most accepted mechanisms and main predisposing factors related to weight gain in this particular population.
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Affiliation(s)
- Lorenzo Iughetti
- Department of Paediatrics, University of Modena & Reggio Emilia, Modena, Italy.
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20
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Paulino AC, Jhaveri P, Dreyer Z, Teh BS, Okcu MF. Height impairment after lower dose cranial irradiation in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2011; 56:279-81. [PMID: 20830778 DOI: 10.1002/pbc.22781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/15/2010] [Indexed: 11/12/2022]
Abstract
PURPOSE The purpose of this study is to determine whether height measurements are affected by cranial radiation doses of 12-18 Gy. PATIENTS AND METHODS From 1997 to 2007, 23 children received cranial RT for T-cell or pre-B-cell acute lymphoblastic leukemia (ALL). Dose fractionation schemes included 18 Gy in 9 fractions (n = 8), 18 Gy in 10 fractions (n = 5), 12.6 Gy in 7 fractions (n = 6), and 12 Gy in 8 fractions (n = 4). These patients were matched and compared to a control group of 23 patients who had ALL but no cranial RT. Height z-scores at diagnosis and last follow-up were compared using the paired Student's t-test. Differences in z-scores according to host and treatment parameters were compared using the unpaired Student's t-test. Median follow-up for irradiated patients was 63.5 months while for unirradiated patients was 91 months. RESULTS The mean z-scores at initial diagnosis and last follow-up were 0.14 and -0.48 for patients receiving 12-12.6 Gy (P = 0.016), -0.16 and -0.89 for 18 Gy (P = 0.003), and 0.34 and 0.22 for no RT (P = 0.62). For children receiving RT, the mean difference in z-scores at initial diagnosis and last follow-up was -0.67 while for those not receiving RT, it was -0.10 (P = 0.043). CONCLUSION Children receiving 12-18 Gy cranial RT for ALL were found to have height impairment compared to those not receiving RT.
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, The Methodist Hospital, The Methodist Hospital Research Institute, Houston, Texas 77030, USA.
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21
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Abstract
BACKGROUND Nutritional status, as represented by body composition, is an important consideration in the treatment of pediatric cancer patients because it is linked to poor outcomes. Little is known about how a child's body composition responds to cancer and treatment. OBJECTIVES We aimed to compare the body composition of children undergoing treatment of cancer with that of healthy controls and to compare body composition between children with hematologic malignancies and children with solid tumors. DESIGN This cross-sectional study measured height, weight, body cell mass, fat-free mass, and fat mass in 48 children undergoing treatment of cancer and blood-related disorders and in age-matched healthy controls. RESULTS Patients with cancer had a significantly lower body cell mass index z score (body cell mass/height raised to the power of 2.5 for females and 3 for males) than did controls (P = 0.0001), and 45% of the patients with cancer were considered malnourished according to body cell mass. Subjects with cancer had a significantly higher percentage of body fat (P = 0.0001) and fat mass (P = 0.0001) than did controls; however, there was no significant difference in fat-free mass (P = 0.09). On the basis of percentage fat, 77% of subjects with cancer were considered obese. No difference in body composition was observed between cancer types. CONCLUSIONS This study showed that children undergoing treatment of all types of cancer have a significantly lower body cell mass and a significantly higher fat mass than do healthy controls. Nutritional support is suggested for all children undergoing treatment of cancer.
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Affiliation(s)
- Alexia J Murphy
- Discipline of Paediatrics, The University of Queensland Royal Children's Hospital, Queensland, Australia.
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22
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Abstract
The number of adult survivors of childhood cancer in the general population has increased. As reports on the prevalence of the metabolic syndrome in adult survivors of childhood cancer are scarce, we reviewed the available literature on the components of the metabolic syndrome in adult survivors of childhood cancer. Although there is a lack of studies estimating the prevalence of metabolic syndrome directly, especially prevalence of insulin resistance, obesity, and dyslipidemia is increased in certain groups. Therefore, adult survivors of childhood cancer are at increased risk of developing cerebrovascular and cardiovascular diseases. Accordingly, it is important to identify the predisposing factors of the metabolic syndrome in cohorts of survivors, to introduce medical interventions, and to subsequently decrease the risk of cerebrovascular and cardiovascular events.
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23
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Bechard LJ, Feldman HA, Gordon C, Gura K, Sonis A, Leung K, Venick R, Guinan EC, Duggan C. A multi-center, randomized, controlled trial of parenteral nutrition titrated to resting energy expenditure in children undergoing hematopoietic stem cell transplantation ("PNTREE"): rationale and design. Contemp Clin Trials 2010; 31:157-64. [PMID: 20004739 DOI: 10.1016/j.cct.2009.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 11/16/2009] [Accepted: 12/02/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Children undergoing hematopoietic stem cell transplantation (HSCT) frequently require prolonged courses of parenteral nutrition (PN) as a consequence of gastrointestinal dysfunction related to preparative chemotherapy and radiation. PN has been associated with shorter engraftment time and decreased mortality during HSCT, however, it is also linked with complications, including infections, liver disease, and metabolic disturbances. Some of these complications may be a result of providing PN in excess of nutrient requirements. We previously described significant reductions in resting energy expenditure (REE), as measured by indirect calorimetry, over the course of HSCT. We also documented a decline in mid-arm muscle area, suggesting depletion of muscle mass, while triceps skinfold, a marker of fat stores, was unchanged. These results suggested the need for further study of energy expenditure, body composition and nutritional intake in this group of high risk patients. DESIGN AND HYPOTHESIS We hypothesize that changes in body composition affect REE during HSCT, and that standard nutritional support may lead to overfeeding. We are performing a randomized controlled trial of parenteral nutrition among children undergoing allogeneic HSCT. Subjects are randomized to receive PN designed to provide 100% of measured REE, or standard PN, i.e., 140% of estimated energy expenditure. The primary outcome variable is change in percent body fat. Secondary outcomes include glycemic control and frequency of infections, changes in REE and body composition. CONCLUSION This study will provide unique and comprehensive nutritional data and its results will guide nutritional therapy for children undergoing HSCT and possibly other catabolic patients.
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Affiliation(s)
- Lori J Bechard
- Children's Hospital, Boston, 300 Longwood Avenue, Boston, MA 02115, United States
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24
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Duro D, Bechard LJ, Feldman HA, Klykov A, O'Leary A, Guinan EC, Duggan C. Weekly measurements accurately represent trends in resting energy expenditure in children undergoing hematopoietic stem cell transplantation. JPEN J Parenter Enteral Nutr 2008; 32:427-32. [PMID: 18596314 DOI: 10.1177/0148607108319804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Resting energy expenditure (REE) measurements are optimal for accurate assessment of energy requirements and precise provision of parenteral nutrients. We previously observed significant reduction in REE during a 4-week period in children undergoing hematopoietic stem cell transplantation (HSCT). The goal of this study was to determine if weekly REE measurements could accurately represent changes in REE in the peritransplant period compared with a more frequent standard of daily measurements. METHODS Data are presented from a previously described cohort of 37 children undergoing HSCT. We performed weekly indirect calorimetry on 25 patients; of those 25, we performed daily measurements on a convenience sample of 5 children. The time course of REE was analyzed in each sample by repeated measures regression. RESULTS The REE trend of the 20 weekly participants was similar to that of the 5 daily participants, reaching about 80% of predicted REE at 4 weeks posttransplant, with an average decline of 3.4% per week during 4 weeks. CONCLUSION The results suggest that weekly REE measurements accurately characterize REE changes 4 weeks after HSCT compared with daily measurements. Characterization of these trends using weekly measurements may help guide clinical and nutrition care of these patients.
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Affiliation(s)
- Debora Duro
- Children's Hospital Boston, Boston, MA 02115, USA
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25
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Abstract
Leptin has been hypothesized to play a role in the development of obesity in leukemia survivors, particularly those who have received cranial radiotherapy. This cross-sectional study evaluated the relationship between leptin levels and body mass index (BMI) in a sample of 26 acute lymphocytic leukemia survivors of both sexes, treated with and without cranial irradiation, aged 7.6 to 17 years, at a mean 3.4+/-2.0 years off treatment. There were significantly more males among the irradiated group (P<0.001), even though no differences were encountered in pubertal stage (P=1.000), BMI standard deviation score (mean+/-SD) (0.68+/-1.00 vs. 1.19+/-0.78; P=0.164), or leptin concentrations (17.01+/-17.04 vs. 23.3+/-13.4; P=0.309). Nonetheless, there was a positive correlation between the natural logarithm of leptin and BMI standard deviation score [t(22)=2.348, P=0.028], however, no differences were recorded among irradiated and nonirradiated patients [F(2,22)=0.384, P=0.685]. When this relationship was compared between sexes, a significant difference was encountered [F(2,22)=4.907, P=0.017], with males having the strongest association (R(2)males=65.5%, R(2)females=34.7%). Leptin is a reliable adiposity index as it strongly correlates with BMI. Overall, the current data suggest that cranial irradiation did not play a role upon this relationship; however, sex differences influenced positively this correlation.
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26
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Bechard LJ, Guinan EC, Feldman HA, Tang V, Duggan C. Prognostic factors in the resumption of oral dietary intake after allogeneic hematopoietic stem cell transplantation (HSCT) in children. JPEN J Parenter Enteral Nutr 2007; 31:295-301. [PMID: 17595438 PMCID: PMC4743033 DOI: 10.1177/0148607107031004295] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) is a common supportive care therapy in patients undergoing hematopoietic stem cell transplantation (HSCT). Inadequate oral dietary intake may necessitate prolonged courses of PN, which have been associated with metabolic, infectious, and hepatobiliary complications. The objective of this study was to identify demographic, clinical, and nutrition factors associated with the resumption of oral dietary intake following HSCT. METHODS This was an observational cohort study of 37 children undergoing allogeneic HSCT. Repeated-measures regression analysis was performed to identify factors associated with the resumption and macronutrient composition of oral nutrient intake after HSCT. RESULTS Mean oral dietary intake during the first 2 weeks after HSCT was <280 kcal/d. At all times, oral carbohydrate intake was high, ranging from 58% to 74% of oral energy. Age, time since transplant, degree of oral mucositis, and severity of graft-vs-host disease (GVHD) were all significantly correlated with the resumption of oral energy intake, as well as oral intake of carbohydrates. Oral protein and fat intake were also associated with elapsed time since HSCT, severity of mucositis, and GVHD. Factors not associated with oral dietary intake included gender, pre-HSCT nutrition status, diagnosis, type of donor, and infections. CONCLUSIONS Children undergoing HSCT exhibit a marked reduction in oral dietary intake and a preference for a diet high in carbohydrates. Careful attention should be directed to the oral dietary intake and nutrient requirements of children during HSCT, especially in younger patients and those who experience severe mucositis or GVHD.
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Affiliation(s)
- Lori J. Bechard
- Children’s Hospital Boston, Boston, Massachusetts
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Eva C. Guinan
- Children’s Hospital Boston, Boston, Massachusetts
- Dana Farber Cancer Institute, Boston, Massachusetts
| | | | - Vivian Tang
- Children’s Hospital Boston, Boston, Massachusetts
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Chow EJ, Friedman DL, Yasui Y, Whitton JA, Stovall M, Robison LL, Sklar CA. Decreased adult height in survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study. J Pediatr 2007; 150:370-5, 375.e1. [PMID: 17382112 PMCID: PMC2766352 DOI: 10.1016/j.jpeds.2006.11.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 08/19/2006] [Accepted: 11/09/2006] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Eric J Chow
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.
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Papadia C, Naves LA, Costa SSS, Vaz JAR, Domingues L, Casulari LA. Incidence of obesity does not appear to be increased after treatment of acute lymphoblastic leukemia in Brazilian children: role of leptin, insulin, and IGF-1. HORMONE RESEARCH 2007; 68:164-70. [PMID: 17356293 DOI: 10.1159/000100781] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 01/18/2007] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS It has been reported that children treated for acute lymphoblastic leukemia (ALL) in developed countries show an increased risk of overweight and obesity in adolescence and adulthood. However, the majority of patients who came to our observation in Brazil have low or normal body weight and only one of them was obese. Therefore, we have decided to assess some biochemical parameters possibly related to the intermediate metabolism and body composition in these patients. METHODS Two groups of subjects were studied: 27 survivors of childhood ALL (14.0 +/- 4.2 years old; post-treatment interval 8.6 +/- 3.9 years) (ALL group) and 17 healthy subjects (12.8 +/- 4 years old) (control group) selected on the basis of their kinship with the patients. RESULTS 14/27 patients of the ALL group and 4/17 of the control group had leptin levels higher than the normal range for age and sex (p < 0.05). The leptin level was significantly higher in the ALL group (15.5 +/- 1.8 ng/ml) than in the control group (10.7 +/- 2 ng/ml) (p < 0.05). When adjusted by sex, BMI z-score, and age, the level of leptin in patients of the ALL group was 8.5 higher than in subjects of the control group (p = 0.006). Leptin/insulin correlation in the ALL group was 0.08 and in the control group it was +0.585 (p < 0.05). CONCLUSION The data indicate the presence of alterations in the homeostatic regulatory mechanisms controlling body weight in Brazilian patients treated for ALL in childhood, still, it did not lead to obesity in the absence of favorable environmental conditions.
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Affiliation(s)
- Carla Papadia
- Department of Endocrinology, University of Brasília, Brasília, Brazil
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29
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Kim GH, Kook H, Baek HJ, Han DK, Song ES, Jo YK, Choi IS, Kim YO, Kim CJ, Woo YJ, Yang SJ, Hwang TJ. Comparison of growth and neuropsychological function after treatment for hematologic and oncologic diseases in monozygotic twins. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.2.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Gi Hwan Kim
- Department of Pediatrics, St. Carollos Hospital, Suncheon, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Hee Jo Baek
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Dong Kyun Han
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Eun Song Song
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Young Kook Jo
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Ic Sun Choi
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Young Ok Kim
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Chan Jong Kim
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Young Jong Woo
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Soo Jin Yang
- Department of Psychiatry, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
| | - Tai Ju Hwang
- Department of Pediatrics, Chonnam National University Hwasun Hospital Chonnam National University Medical School, Hwasun, Korea
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30
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Abstract
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.
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Affiliation(s)
- Robert E Goldsby
- Division of Pediatric Hematology/Oncology, University of California, San Francisco, USA.
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Oğuz A, Pinarli FG, Karadeniz C, Bideci A, Ozkan S. Late effects of treatment on growth in childhood non-Hodgkin's lymphoma. Leuk Lymphoma 2006; 47:1283-9. [PMID: 16923558 DOI: 10.1080/10428190500467776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Growth impairment is one of the most important late sequelae in childhood malignancies. In the last few years, the contribution of cytotoxic agents to growth retardation has been a subject of investigation. The aim of this study was to evaluate the growth impairment in children treated for non-Hodgkin's lymphoma (NHL). The study group comprised 41 children (eight girls, 33 boys) treated for NHL with three different chemotherapy protocols. All patients were in remission at the last visit. The control group consisted of 41 healthy age- and sex-matched children. All patients' standing heights and body weights were measured regularly from the time of diagnosis. Growth parameters were measured both at the time of diagnosis and at the end of treatment (median treatment time: 6 months). Height and weight velocities were calculated at 6 month intervals after the diagnosis until the last visit. The mean height SDS of the patients was -0.66 +/- 1.42 at the diagnosis and 0.29 +/- 1.21 at the last visit. Height SDS of the patients showed a significant improvement at the end of the 2nd year after the diagnosis (p = 0.005) and at the last visit (p = 0.022) (median follow-up time: 48 months after diagnosis). The height velocity SDS increase at the end of the 2nd year was particularly remarkable in short-term protocols such as BFM-90 B-NHL. The sitting height, the sitting height/height ratio and serum insulin-like growth factor-I (IGF-I) levels were found to be lower in the patients than those of control group at the last visit. One can conclude that chemotherapy might cause a reduction in growth velocity during treatment. The cumulative dosages of anti-neoplastic agents and serum IGF-I levels could have been implied in the pathogenesis of growth retardation.
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Affiliation(s)
- Aynur Oğuz
- Department of Pediatric Oncology, Gazi University Medical Faculty, Ankara, Turkey
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Abstract
Today's obesity pandemic began in the United States, spread to Western Europe and other developed regions, and is emerging in developing countries. Its influences on outcomes of childhood cancer are unknown. A recent Children's Oncology Group symposium considered epidemiology of obesity, pharmacology of chemotherapy and outcomes in obese adults with cancer, excess mortality in obese pediatric patients with acute myeloid leukemia (AML), and complications in obese survivors. The salient points are summarized herein. Body mass index (BMI) is the accepted index of weight for height and age. In the US, obesity prevalence (BMI > 95th centile) is increasing in all pediatric age groups and accelerating fastest among black and Hispanic adolescents. Pharmacologic investigations are few and limited: half-life, volume of distribution, and clearance in obese patients vary between drugs. Obese adults with solid tumors generally experience less toxicity, suggesting underdosing. For patients undergoing bone marrow transplantation, obese adults generally experience greater toxicity. In pediatric acute myeloblastic leukemia, obese patients have greater treatment-related mortality (TRM), similar toxicity and relapse rates, and inferior survival compared with patients who are not obese. An excess of female survivors of childhood leukemia who received cranial irradiation are obese. Ongoing treatment effects of childhood cancer may predispose to a sedentary lifestyle. These findings call for measures to prevent obesity, retrospective and prospective studies of chemotherapy pharmacology of analyzed according to BMI and outcomes, additional studies of the obesity impact on outcomes in pediatric cancer, and promotion of a healthy lifestyle among survivors.
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Affiliation(s)
- Paul C Rogers
- Children's and Women's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
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33
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Jarfelt M, Lannering B, Bosaeus I, Johannsson G, Bjarnason R. Body composition in young adult survivors of childhood acute lymphoblastic leukaemia. Eur J Endocrinol 2005; 153:81-9. [PMID: 15994749 DOI: 10.1530/eje.1.01931] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Obesity is frequently reported in patients treated for childhood leukaemia. Obesity, particularly abdominal obesity, is one of the main characteristics of the metabolic syndrome and a risk factor for cardiovascular disease and non-insulin-dependent diabetes mellitus (NIDDM). DESIGN All patients treated for acute lymphoblastic leukaemia (ALL) before the onset of puberty in the region of western Sweden, between 1973 and 1985, and in first remission, were included. 35 out of 47 patients aged 20-32 years participated. 19 patients had received cranial radiotherapy, and the median follow-up time was 20 years. The focus of this report was to study body composition and signs of the metabolic syndrome and correlate the findings to spontaneous growth hormone (GH) secretion. METHODS Body composition was assessed using dual-energy X-ray absorbtiometry (DEXA). We analyzed serum concentrations of insulin, glucose, leptin and lipids. RESULTS No patient was obese according to World Health Organization criteria (body mass index, BMI > or = 30 kg/m2) but one-third were overweight (BMI 25-29.9 kg/m2). The maximal GH peak during 24 h (GHmax) was correlated to percentage of total body fat (r = -0.42; P = 0.017), trunk fat (r = -0.5; P = 0.005) and fat-free mass (r = 0.42; P = 0.017). GHmax was also correlated to s-triglycerides (r = -0.54; P = 0.001), low-density lipoprotein-cholesterol (r = -0.382; P = 0.024) and high-density lipoprotein-cholesterol (r = 0.45; P = 0.007). CONCLUSIONS We found little effect on BMI but an increased percentage of total body fat, especially trunk fat, and a tendency for an unfavourable lipid profile in adult survivors of childhood leukaemia. These findings were related to low endogenous GH secretion due to cranial irradiation.
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Affiliation(s)
- M Jarfelt
- Department of Pediatrics, Division of Haematology and Oncology, Göteborg Paediatric Growth Research Center, University of Göteborg, Göteborg, Sweden.
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Ness KK, Oakes JM, Punyko JA, Baker KS, Gurney JG. Prevalence of the metabolic syndrome in relation to self-reported cancer history. Ann Epidemiol 2005; 15:202-6. [PMID: 15723765 DOI: 10.1016/j.annepidem.2004.07.092] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2004] [Accepted: 07/22/2004] [Indexed: 12/20/2022]
Abstract
PURPOSE To estimate the prevalence of metabolic syndrome in persons with a history of cancer from a population-based sample of adults, and compare that prevalence to persons without a history of cancer. METHODS Data from the Third National Health and Nutrition Examination Survey were analyzed to compare prevalence and prevalence differences of the metabolic syndrome, as defined by Adult Treatment Panel III criteria, between 486 persons with a reported history of cancer and 12,526 persons with no reported history of cancer. RESULTS The prevalence of metabolic syndrome was 258/1000 persons for those with a cancer history and 184/1000 persons among those without, resulting in a prevalence difference of 74/1000 persons (95% CI, 38-110). Prevalence differences varied substantially by age at interview. The prevalence difference was highest among those aged 40 to 49 years (112/1000 persons) and 50 to 59 years (73/1000 persons), while those in younger (18-39 years) and older (: 60 years) age groups had a moderately higher prevalence among those without a cancer history. CONCLUSION These results add to the emerging concern that metabolic syndrome and associated risks for cardiovascular disease and type 2 diabetes may be an adverse late effect of cancer and/or its treatment.
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Affiliation(s)
- Kirsten K Ness
- Division of Epidemiology and Clinical Research, Department of Pediatrics, School of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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35
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Jarfelt M, Bjarnason R, Lannering B. Young adult survivors of childhood acute lymphoblastic leukemia: spontaneous GH secretion in relation to CNS radiation. Pediatr Blood Cancer 2004; 42:582-8. [PMID: 15127412 DOI: 10.1002/pbc.20020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Young adults who are long-term survivors of acute lymphoblastic leukaemia (ALL) in early childhood usually do well and do not have to go to regular medical checkups. Many of these survivors did receive prophylactic cranial radiotherapy during their oncological treatment. The effect of cranial irradiation on the hypothalamus is considered to be progressive. Therefore, late effects, such as reduced growth hormone (GH) secretion, may remain undetected until adulthood. PROCEDURE Records from all patients treated for ALL before the onset of puberty in the region of West Sweden, between 1 January 1973 and 31 December 1985 were included, provided they were in first remission with a minimum follow-up time of 15 years, and a minimum age of 20. These criteria were met by 47 young adults aged 20-32 years, of whom 35 agreed to participate. We studied spontaneous GH secretion over 24 hr, IGF-I and IGFBP-3, final height and BMI. The patients had been treated according to three consecutive Swedish childhood leukaemia group protocols. The median follow-up time was 20 years, and 19 of the patients had been treated with cranial irradiation (CRT+), 16 had not (CRT-). RESULTS CRT+ patients had significantly lower maximal peaks of GH than CRT- patients. Fifty percent of the CRT+ patients had a GH(max) below the cut-off level (3.3 microg/l), for GH treatment. CRT- patients all had GH(max) levels considered within the normal range. Final height of all the patients, except one CRT+ women, was in the range of expected midparental height, the median loss in final height in the CRT+ patients was 0.8 standard deviation (SD). No patient in this study was obese by definition (BMI <30 kg/m(2)). IGF-I and IGFBP-3 concentrations did not correlate to variations in spontaneous GH secretion in these patients. CONCLUSIONS In spite of the little effect on final height, we found impaired spontaneous GH secretion in 79% of young adults 20-32 years of age, and GH deficiency (GHD) in 47% after low-dose cranial irradiation in early childhood. The consequences of this low-GH secretion need to be investigated.
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Affiliation(s)
- M Jarfelt
- Department of Pediatrics, Division of Hematology and Oncology, Sahlgrenska Academy of Göteborg University, Göteborg, Sweden.
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36
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Dalton VK, Rue M, Silverman LB, Gelber RD, Asselin BL, Barr RD, Clavell LA, Hurwitz CA, Moghrabi A, Samson Y, Schorin M, Tarbell NJ, Sallan SE, Cohen LE. Height and weight in children treated for acute lymphoblastic leukemia: relationship to CNS treatment. J Clin Oncol 2003; 21:2953-60. [PMID: 12885815 DOI: 10.1200/jco.2003.03.068] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We evaluated the long-term effects of treatment on height and weight in children with acute lymphoblastic leukemia (ALL) treated with one of the following three different CNS therapies: intrathecal therapy alone, intrathecal therapy with conventional cranial radiation, or intrathecal therapy with twice-daily radiation. PATIENTS AND METHODS Between 1987 and 1995, 618 children treated on two consecutive Dana-Farber Cancer Institute Consortium protocols for ALL were measured for height and weight at diagnosis, and approximately every 6 months thereafter. Patient height, weight, and body mass index (BMI) were converted to z scores for age and sex using the 2000 Centers for Disease Control and Prevention growth charts for the United States. RESULTS Children younger than 13 years at diagnosis had a statistically significant decrease in their height z scores and an increase in their BMI z scores, regardless of whether they had received cranial radiation. Young age at diagnosis and increased chemotherapy intensity were major risk factors. Unexpectedly, there was no significant difference in long-term height between children who received radiation and those who did not. CONCLUSION Final height is compromised in survivors of ALL. The detrimental effects on height occur during therapy without the ability for long-term catch-up growth. Although patients became overweight for height, this seemed to be a result of relative height loss with normal weight gain rather than accelerated weight gain. The type of CNS treatment received did not affect changes in height, weight, or BMI.
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Duggan C, Bechard L, Donovan K, Vangel M, O'Leary A, Holmes C, Lehmann L, Guinan E. Changes in resting energy expenditure among children undergoing allogeneic stem cell transplantation. Am J Clin Nutr 2003; 78:104-9. [PMID: 12816778 DOI: 10.1093/ajcn/78.1.104] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Because of the effects of chemotherapy and radiotherapy, patients undergoing stem cell transplantation (SCT) are commonly provided nutritional support with parenteral nutrition. The energy and nutrient needs of these patients have not been well studied. OBJECTIVE The objective was to measure resting energy expenditure (REE), dietary intake, and biochemical and anthropometric changes in children before and after allogeneic SCT. DESIGN This was a prospective cohort study of 37 children aged 9.1 +/- 6.4 y ( +/- SD) undergoing SCT who were enrolled in an open-label trial of a unique supportive care intervention that included the routine use of oral leucovorin, vitamin E, and ursodeoxycholic acid. Parenteral nutrition was provided to match 100% of measured or estimated REE. REE was measured weekly via indirect calorimetry. RESULTS Baseline REE was 95% of the predicted age- and sex-matched norms and was significantly correlated with midarm muscle area (r = 0.82, P < 0.001). REE fell to a nadir of approximately 80% of the predicted levels by week 3 after SCT, with a gradual increase in weeks 4 and 5. Arm anthropometric measurements showed no change in triceps skinfold thickness but significant declines in midarm muscle area after SCT. Serum vitamin E remained in the normal range. CONCLUSIONS Children undergoing SCT show significant declines in REE after transplantation. These changes may be due to alterations in lean body mass. Standard nutritional regimens may lead to overfeeding.
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Affiliation(s)
- Christopher Duggan
- Clinical Nutrition Service, Division of GI/Nutrition, Children's Hospital, Boston, MA 02115, USA.
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Nysom K, Holm K, Michaelsen KF, Hertz H, Müller J, Mølgaard C. Degree of fatness after treatment of malignant lymphoma in childhood. MEDICAL AND PEDIATRIC ONCOLOGY 2003; 40:239-43. [PMID: 12555252 DOI: 10.1002/mpo.10260] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Sex hormone deficiency or growth hormone deficiency may cause excess fatness after treatment for childhood malignant lymphoma. Previous studies of the body composition after treatment for childhood cancer included few survivors of malignant lymphoma who were not analysed separately. PROCEDURE We measured the whole-body percent fat by dual energy X-ray absorptiometry (DXA) and the body-mass index (weight/height(2) (kg/m(2)), BMI) in survivors of childhood Hodgkin disease (n = 23) or non-Hodgkin lymphoma (n = 21) a median of 11 years after diagnosis (range 2-25). Results were compared with local data on 463 healthy controls. RESULTS Adjusted for sex and age, the mean BMI did not differ from that of local controls, but the mean whole-body percent fat was significantly increased (0.8 SD above predicted, P = 0.0001). Sixteen of 44 participants had a percent fat above the 90 percentile of the reference values, which indicates excess fatness. Adjusted for sex and age, percent fat was significantly higher in persons treated for non-Hodgkin lymphoma. Controlled for this, the whole-body percent fat was not significantly related to sex, age at diagnosis, length of follow-up, sex hormone therapy at follow-up or the cumulative dose of corticosteroids or doxorubicin. CONCLUSIONS Eleven years after diagnosis of childhood Hodgkin disease or non-Hodgkin lymphoma, the whole-body percent fat was increased whereas the BMI was like that of the controls. This indicates a reduced lean body mass.
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Affiliation(s)
- Karsten Nysom
- Section of Paediatric Haematology and Oncology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark
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39
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Abstract
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.
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Affiliation(s)
- Scott C Howard
- Department of Hematology-Oncology, University of Tennessee Health Science Center, Memphis, TN, USA.
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40
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Affiliation(s)
- T Mushtaq
- Dept of Integrative Biology, Roslin Institute, Edinburgh, UK
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41
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Gleeson HK, Darzy K, Shalet SM. Late endocrine, metabolic and skeletal sequelae following treatment of childhood cancer. Best Pract Res Clin Endocrinol Metab 2002; 16:335-48. [PMID: 12064896 DOI: 10.1053/beem.2002.0201] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
With an ever increasing adult population of childhood cancer survivors there is a need to focus on the late effects of cancer therapy. It is essential that, after discharge from the paediatric oncologists, the patients are not lost from the health system but are under continued surveillance with access to the appropriate physicians. Endocrine and metabolic consequences may affect a patient's life both soon after cancer treatment and also for many years in the future. In this review we consider the following potential problems: growth hormone deficiency and replacement in adulthood, cardiovascular risk factors, osteopaenia, thyroid and parathyroid dysfunction.
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Affiliation(s)
- Helena K Gleeson
- Department of Endocrinology, Christie Hospital, Wilmslow Road, Manchester, Withington, M20 4BX, UK
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42
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Abstract
Because of the increasing population of childhood cancer survivors, there is a need to focus on the late effects of cancer therapy. After discharge by their pediatric oncologists, it is essential that patients are not lost to the health system but rather are under continued surveillance with access to the appropriate physicians. Endocrine and metabolic consequences may impact the life of the patient both soon after cancer treatment and for many years in the future. The purpose of this article is to explore the current literature in the following areas: growth hormone (GH) deficiency, gonadotropin-releasing hormone (GnRH) analogues with GH therapy in childhood, safety of GH replacement, cardiovascular risk factors, osteopenia, thyroid problems, and gonadal damage resulting in infertility.
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Affiliation(s)
- H K Gleeson
- Department of Endocrinology, Christie Hospital, Wilmslow Road, Withington, Manchester M20 4BX, UK
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Nysom K, Holm K, Michaelsen KF, Hertz H, Jacobsen N, Müller J, Mølgaard C. Degree of fatness after allogeneic BMT for childhood leukaemia or lymphoma. Bone Marrow Transplant 2001; 27:817-20. [PMID: 11477438 DOI: 10.1038/sj.bmt.1703012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2000] [Accepted: 02/13/2001] [Indexed: 11/09/2022]
Abstract
Excess fatness is frequent after childhood ALL treated without BMT. We measured the whole-body percent fat by dual-energy X-ray absorptiometry and the body-mass index (weight/height(2) (kg/m(2)), BMI) in 25 survivors of childhood leukaemia or lymphoma (21 with ALL) who had received TBI and allogeneic BMT a median of 8 years ago (range 4-13). Adjusted for sex and age, the mean BMI was slightly but significantly reduced (0.4 s.d. below predicted) and the whole-body percent fat was significantly increased compared with healthy controls (1.1 s.d. above predicted). Eleven of 25 patients had a percent fat above the 90 percentile of the reference values, which indicates excess fatness. Adjusted for sex and age, a higher percent fat was related to additional cranial irradiation. Controlled for this, the whole-body percent fat seemed to be unrelated to age at BMT, length of follow-up, and previous chemotherapy. Compared with untransplanted ALL survivors treated with cranial irradiation, BMT survivors had significantly reduced BMI but similar whole body percent fat. BMI was a poor measure of body fatness in these patients. In conclusion, survivors of BMT for childhood leukaemia or lymphoma are adipose and slightly underweight and consequently have a substantially reduced lean body mass.
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Affiliation(s)
- K Nysom
- Section of Paediatric Haematology and Oncology, The Juliane Marie Centre, Rigshospitalet, Denmark
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44
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Sklar CA, Mertens AC, Walter A, Mitchell D, Nesbit ME, O'Leary M, Hutchinson R, Meadows AT, Robison LL. Changes in body mass index and prevalence of overweight in survivors of childhood acute lymphoblastic leukemia: role of cranial irradiation. MEDICAL AND PEDIATRIC ONCOLOGY 2000; 35:91-5. [PMID: 10918229 DOI: 10.1002/1096-911x(200008)35:2<91::aid-mpo1>3.0.co;2-g] [Citation(s) in RCA: 177] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The risk factors responsible for an increased prevalence of obesity or overweight in survivors of acute lymphoblastic leukemia (ALL) remain controversial. We evaluated changes in body mass index (BMI) in a cohort of ALL survivors, all of whom have been followed until completion of linear growth. PROCEDURE BMI (weight/height(2)) was used as an index of adiposity and was calculated at diagnosis, at the end of treatment, and at attainment of final height in a cohort of 126 (59 males) survivors of ALL. BMI was adjusted for age and sex by computing a BMI standard deviation score (SDS) or z score. The spectrum of therapies used included intrathecal chemotherapy given alone (n = 38) or combined with cranial irradiation (CRT; 18 Gy, n = 35; 24 Gy, n = 53) and exposure to prednisone at a low dose (<3.5 gm, n = 49), medium dose (3.5-9.4 gm, n = 46), or high dose (>9.4 gm, n = 30). RESULTS Overall, mean +/- SEM BMI-SDS increased significantly between diagnosis (-0.18 +/- 0.08) and the end of therapy (0.41 +/- 0.09, P < 0.01), with no significant change thereafter. For patients without CRT, mean BMI-SDS remained unchanged, whereas, for those so treated, mean BMI-SDS increased significantly between diagnosis and the completion of therapy (P < 0.001). The change in mean BMI-SDS was greater in the 24 Gy group vs. the 18 Gy CRT sample (P < 0.005). In a multivariate logistic regression model, CRT was an independent predictor of being overweight (BMI >/=85 percentile) at attainment of final height [odds ratio = 1.6 (95% confidence interval 1.0-23. 1)]. The percentage of subjects who were overweight at attainment of final height was 10.5%, 40%, and 38% for subjects treated with no CRT, 18 Gy CRT, or 24 Gy CRT, respectively (P < 0.01). CONCLUSIONS Children with ALL given CRT develop increases in their BMI-SDS early on and during treatment and remain at significant risk for becoming overweight as young adults, a development that may increase their already heightened risk for various adverse health outcomes.
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Affiliation(s)
- C A Sklar
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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45
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Shaw MP, Bath LE, Duff J, Kelnar CJ, Wallace WH. Obesity in leukemia survivors: the familial contribution. Pediatr Hematol Oncol 2000; 17:231-7. [PMID: 10779989 DOI: 10.1080/088800100276406] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A high prevalence of obesity in survivors of acute lymphoblastic leukemia (ALL) has been described, but genetic and social influence in obesity has not been analyzed in this group of patients. The authors studied a population of 33 long-term (25 females, 8 males) in first remission who had reached their final height. All patients received cranial irradiation as part of their central nervous system (CNS)-directed therapy and no patient received growth hormone. The body mass index (BMI: weight/height2) of patients and their biological parents was calculated and submitted to statistical analysis. Obesity was defined as BMI greater than the 85th centile. No excessive obesity was found among the males at final height. Fifty-six percent of the females were obese. In this group of 14 obese female survivors 59% had obese mother, but only 14% had obese fathers. The results indicate a significant maternal predisposition to obesity.
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Affiliation(s)
- M P Shaw
- Department of Paediatric Oncology, Royal Hospital for Sick Children, Edinburgh, UK
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46
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Abstract
As the overall long-term event-free survival rate in children with acute lymphoblastic leukemia approaches 80%, emphasis is being placed on risk-directed therapy so that patients are neither overtreated nor undertreated. It has become apparent that a risk assignment system based on primary genetic abnormalities is inadequate by itself. For example, leukemias with the MLL-AF4 or BCR-ABL fusion gene are, in fact, heterogeneous diseases. Many require allogeneic hematopoietic stem-cell transplantation; some, if the patient is of favorable age and has a low presenting leukocyte count, can be cured with chemotherapy alone. Measurement of early responses to therapy and extent of minimal residual disease can greatly improve the accuracy of risk assessment. Consideration of the variable effects of therapy on the prognostic significance of specific genetic abnormalities is also important. Therefore, TEL-AML1 fusion confers a favorable prognosis in some protocols of chemotherapy but not in others. Studies to identify genetic polymorphisms with pharmacokinetic and pharmacodynamic significance promise to guide further refinement of treatment strategies. This will allow maximization of anticancer effects without induction of unacceptable toxicity in individual patients.
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Affiliation(s)
- C H Pui
- Department of Hematology/Oncology and Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-2794, USA
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47
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Nysom K, Holm K, Michaelsen KF, Hertz H, Müller J, Mølgaard C. Degree of fatness after treatment for acute lymphoblastic leukemia in childhood. J Clin Endocrinol Metab 1999; 84:4591-6. [PMID: 10599724 DOI: 10.1210/jcem.84.12.6205] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Excessive fatness is considered a frequent late complication of treatment for childhood acute lymphoblastic leukemia. Most previous studies, however, were based on body mass index (BMI) rather than more direct fat mass measurements. We studied 95 survivors of childhood acute lymphoblastic leukemia a median of 11 yr (range, 3-23 yr) after diagnosis. BMI values at diagnosis, at cessation of therapy, yearly thereafter for up to 10 yr, and at follow-up were compared with French reference values. Whole body percent fat was measured at follow-up by dual energy x-ray absorptiometry and compared with data from 463 local controls. Adjusted for sex and age, the mean BMI increased significantly during therapy and remained largely unchanged thereafter. At follow-up, BMI did not differ significantly between patients and local controls. On the other hand, the whole body percent fat was significantly increased (mean observed/predicted value, 21.8/19.0%; P < 0.0002). Twenty-five patients (26%) had a percent fat above the 90th percentile of the reference values, which indicates excessive fatness. Adjusted for sex and age, a higher percent fat was related to cranial irradiation or GH insufficiency, but not to sex, the cumulative doses of anthracyclines or corticosteroids, or the type of corticosteroid used. BMI was a poor measure of body fatness.
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Affiliation(s)
- K Nysom
- Section of Pediatric Hematology and Oncology, The Juliane Marie Center, Rigshospitalet, Copenhagen, Denmark. ]
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