Obesity in patients with acute lymphoblastic leukemia in childhood

Prevalence of Undernutrition Among Children and Adolescents with Cancer Living in Sub-Saharan African Countries: A Systematic Review and Meta-analysis

Objective. To systematically review studies to provide the pooled estimate of undernutrition among children and adolescents with cancer living in sub-Saharan African countries. Methods. The review followed the recommendations outlined in the PRISMA statement. Online searches were performed on electronic databases such as PubMed, Scopus, Embase, and Hinari; gray literature sources: such as Google, Google Scholar, and university repositories were also searched. A random effect model was used to drive the pooled prevalence, and was reported at a 95% Confidence Interval (CI). Heterogeneity was assessed using subgroup analysis and univariable meta-regression. The effect of each study on the overall prevalence was assessed using leave-one-out sensitivity analysis. In all the models, statistical significance was set at P-value <.05. Result. A total of 623 articles were identified, and 21 articles were retrieved for the final analysis. The overall pooled prevalence of undernutrition was 41.34% (95% CI: 31.64%, 51.04%). The highest prevalence of undernutrition was observed from studies that used Arm Muscle Area (AMC) for age to assess undernutrition: 61.66% (95% CI: 47.59%, 75.72%). The protocol for this review has been registered at PROSPERO (CRD42024510052). Conclusion. The prevalence of undernutrition in sub-Saharan African countries was considerably high. Therefore, policy directions and cost-effective approaches that sustainably address undernutrition among pediatric patients with cancers are needed.

The Prevalence, Risk Factors and Cardiometabolic Complications of Obesity in Childhood Survivors of Acute Lymphoblastic Leukemia

Prevalence, risk factors and metabolic complications of overweight/obesity (OW/OB) are not well described in the childhood survivors of acute lymphoblastic leukemia (ALL). Longitudinal changes in body mass index-z score (BMIz) from diagnosis to the last follow-up visit after the end of treatment were evaluated in 73 children at first complete remission. Of them, 40 were tested for adipokine profiles at visit. The mean BMIz increased gradually from diagnosis (0.07 ± 1.68) to the end of dexamethasone containing reinduction therapy (0.70 ± 1.48, P:0.007), followed by a fall at the end of treatment (0.15 ± 1.24) and a rise again at visit (0.40 ± 1.23, P:0.007). OW/OB percentage of 15% at diagnosis, increased to 35% at visit (p < 0.05). Post-treatment OW/OB in survivors was related with being OW/OB at diagnosis (OR 5.4, 95% CI [0.94-31.7]; P = 0.02) and after dexamethasone containing reinduction therapy (OR 5.1, 95% CI [1.1-21.4]; P = 0.05), but not with age at diagnosis, gender, treatment intensity and cranial irradiation. Metabolic syndrome (MetS) was more prevalent in survivors (13%) than in Turkish children (2%). As compared with controls, survivors had higher leptin level (8.1 ± 8.6 vs 3.2 ± 2.2 ng/ml, P = 0.01) and leptin/adiponectin ratio (2.1 ± 3.5 vs 0.6 ± 0.5, P = 0.03). Leptin/adiponectin ratio was correlated with HOMA-IR (r: 0.57, P = 0.001). The prevalence of OW/OB and MetS are elevated in the childhood survivors of ALL. Post-treatment OW/OB in survivors is related with OW/OB at diagnosis and dexamethasone containing therapy. Elevated leptin level and leptin: adiponectin ratio may serve as an early sign of metabolic derangement increasing the risk for early cardiovascular disease.

Changes in the Concentrations of Proangiogenic Cytokines in Human Brain Glioma and Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) and glioma are some of the most common malignancies, with ALL most often affecting children and glioma affecting adult men. Proangiogenic cytokines and growth factors play an important role in the development of both of these tumors. Glioma is characterized by an extremely extensive network of blood vessels, which continues to expand mainly in the process of neoangiogenesis, the direct inducers of which are cytokines from the family of vascular endothelial growth factors, i.e., vascular endothelial growth factor (VEGF-A) and its receptor vascular endothelial growth factor receptor 2 (VEGF-R2), as well as a cytokine from the fibroblast growth factor family, fibroblast growth factor 2 (FGF-2 or bFGF). Growth factors are known primarily for their involvement in the progression and development of solid tumors, but there is evidence that local bone marrow angiogenesis and increased blood vessel density are also present in hematological malignancies, including leukemias. The aim of this study was to examine changes in the concentrations of VEGF-A, VEGF-R2, and FGF-2 (with a molecular weight of 17 kDa) in a group of patients divided into specific grades of malignancy (glioma) and a control group; changes of VEGF-A and FGF-2 concentrations in childhood acute lymphoblastic leukemia and a control group; and to determine correlations between the individual proteins as well as the influence of the patient's age, diet, and other conditions that may place the patient in the risk group. During the statistical analysis, significant differences in concentrations were found between the patient and control groups in samples from people with diagnosed glioma and from children with acute lymphoblastic leukemia, but in general, there are no significant differences in the concentrations of VEGF-A, VEGF-R2, and FGF-2 between different grades of glioma malignancy. Among individuals treated for glioma, there was no significant impact from the patient's gender and age, consumption of food from plastic packaging, frequency of eating vegetables and fruit, smoking of tobacco products, the intensity of physical exercise, or the general condition of the body (Karnofsky score) on the concentrations of the determined cytokines and receptor. The listed factors do not bring about an actual increase in the risk of developing brain glioma.

Pharmacotherapy for Cancer Treatment-Related Cardiac Dysfunction and Heart Failure in Childhood Cancer Survivors

The number of childhood cancer survivors is increasing rapidly. According to American Association for Cancer Research, there are more than 750,000 childhood cancer survivors in the United States and Europe. As the number of childhood cancer survivors increases, so does cancer treatment-related cardiac dysfunction (CTRCD), leading to heart failure (HF). It has been reported that childhood cancer survivors who received anthracyclines are 15 times more likely to have late cancer treatment-related HF and have a 5-fold higher risk of death from cardiovascular (CV) disease than the general population. CV disease is the leading cause of death in childhood cancer survivors. The increasing need to manage cancer survivor patients has led to the rapid creation and adaptation of cardio-oncology. Cardio-oncology is a multidisciplinary science that monitors, treats, and prevents CTRCD. Many guidelines and position statements have been published to help diagnose and manage CTRCD, including those from the American Society of Clinical Oncology, the European Society of Cardiology, the Canadian Cardiovascular Society, the European Society of Medical Oncology, the International Late Effects of Childhood Cancer Guideline Harmonization Group, and many others. However, there remains a gap in identifying high-risk patients likely to develop cardiomyopathy and HF in later life, thus reducing primary and secondary measures being instituted, and when to start treatment when there is echocardiographic evidence of left ventricular (LV) dysfunctions without symptoms of HF. There are no randomized controlled clinical trials for treatment for CTRCD leading to HF in childhood cancer survivors. The treatment of HF due to cancer treatment is similar to the guidelines for general HF. This review describes the latest pharmacologic therapy for preventing and treating LV dysfunction and HF in childhood cancer survivors based on expert consensus guidelines and extrapolating data from adult HF trials.

Metabolic/endocrine disorders in survivors of childhood-onset and cranial radiotherapy- treated ALL/NHL: a meta-analysis

BACKGROUND

Cranial radiotherapy (CRT) is recommended to high-risk pediatric patients with acute lymphoblastic leukemia or aggressive non-Hodgkin's lymphoma (ALL/NHL). However, effects of CRT treatment on the development of metabolic/endocrine disorders remain unclear. This meta-analysis aimed to identify metabolic and endocrine disturbances in survivors of childhood-onset and CRT-treated ALL/NHL.

METHODS

Different online databases were searched using restricted search fields. Follow-up data and outcome measurements, including the prevalence of growth hormone (GH) deficiency, hypothyroidism, vitamin D deficiency, overweight/obesity, and hypogonadism were recorded. The height data was indicated by height-standard deviation score (height-SDS). Statistical estimates such as odds ratio (OR) and weighted standard mean difference (SMD) were compared between additional CRT treatment group and non-CRT treatment group. Study-to-study heterogeneity was calculated by calculating I-squared statistic, and fixed/random effect was applied to synthesize and analyze extracted data.

RESULTS

Fifteen studies were included (4269 patients in total). Adult height SDS was lower in CRT-treated patients (pooled SMD = -0.581, 95% CI: -0.649--0.512), and CRT-treated patients were likely to develop short stature (pooled OR = 2.289, 95% CI:1.674-3.130). Regardless of the study year, which potentially reflects the state-of-the-art CRT technique, the prevalence of short stature and GH deficiency was time-independent. Additionally, previous CRT can increase the risk of precocious puberty (pooled OR = 2.937, 95% CI: 1.281-6.736), hypothyroidism (pooled OR = 2.057, 95% CI:1.510-2.801), and hypogonadism (pooled OR = 3.098, 95% CI:2.521-3.807). However, the risk of being overweight/obese was similar between the patients with and without CRT (pooled OR = 1.278, 95% CI: 0.675-2.421).

CONCLUSION

Childhood-onset and CRT-treated ALL/NHL survivors are likely to have shorter height, precocious puberty, hypothyroidism, and hypogonadism.

PREMATURE MENOPAUSE AND OBESITY DUE TO OOCYTE LOSS IN FEMALE MICE CHRONICALLY EXPOSED TO LOW DOSE-RATE γ-RAYS

In previous reports, the authors showed a significant overall increase in neoplasms originating from the ovaries (2007) and increased body weights (2007, 2010) in female B6C3F1 mice chronically exposed to low dose-rate γ-rays at 20 mGy/day (total doses = 8 (2007) or 6 Gy (2010)), as well as significant increases in serum leptin, total cholesterol, adipose tissue deposits and liver lipid content (2010). The present study chronicles the progression of ovarian failure in relation to obesity and dyslipidemia in female B6C3F1 mice chronically exposed to low dose-rate of γ-rays from 9 to 43 weeks of age (total dose = 4.8 Gy). We monitored changes in body weights, estrus cycles, ovarian follicle counts, serum cholesterol and serum leptin. The number of mice with irregular estrus cycles and increased body weights (with increased fat deposits) significantly increased from 30-36 weeks of age. Depletion of oocytes in ovaries from irradiated mice at 30 weeks of age (accumulated dose = 3 Gy) was also observed. Findings suggest that obesity in female B6C3F1 mice continuously irradiated with low dose-rate of γ-rays at 20 mGy/day is a consequence of premature menopause due to radiation-induced oocyte depletion.

The triponderal mass index as a measure of adiposity in pediatric survivors of acute lymphoblastic leukemia: a cross-sectional study

Acute lymphoblastic leukemia (ALL) is the most common type of childhood cancer. Treatments of ALL predispose survivors to obesity, which increases the risk of cardiovascular disease and diabetes. The hallmark of obesity is excess fat mass, and adiposity is a superior predictor of cardiometabolic risk when compared to Body Mass Index (BMI), yet clinical measures of adiposity in children are lacking. The Tri-Ponderal Mass Index (TMI) (kg/m³) is a more accurate adiposity measure compared to BMI z-score in the general pediatric population. This cross-sectional study aimed to validate TMI as an adiposity measure against DEXA scan-derived adiposity, and to compare it to BMI z-score, in pediatric ALL survivors. This study was a retrospective chart review of pediatric ALL survivors diagnosed between 2004 and 2015 at McMaster Children’s Hospital, a tertiary pediatric center in Ontario, Canada. One hundred and thirteen patients (Female n = 55, 48.70%) were included, and adiposity was measured using DEXA scans. Exploratory partial correlations and linear regression analyses were adjusted for age, sex, ethnicity, and ALL risk status. Both TMI and BMI z-score correlated with the DEXA-measured fat mass percentage (FM%) (partial correlation TMI versus FM% r = 0.56; p value < 0.0001; BMI z-score versus FM% r = 0.55; p value < 0.0001). In regression analyses, the association of TMI was not inferior to BMI z-score in assessing adiposity (TMI versus FM% estimated unstandardized B 0.80, 95% CI 0.56, 1.02; p value < 0.0001; BMI z-score versus FM% (unstandardized B 0.37, 95% CI 0.26, 0.49; p value < 0.0001). The TMI is a useful clinical adiposity-specific measure in survivors of pediatric ALL.

Long-Term Effects of Pediatric Acute Lymphoblastic Leukemia Chemotherapy: Can Recent Findings Inform Old Strategies?

During the last few decades, pediatric acute lymphoblastic leukemia (ALL) cure rates have improved significantly with rates exceeding 90%. Parallel to this remarkable improvement, there has been mounting interest in the long-term health of the survivors. Consequently, modified treatment protocols have been developed and resulted in the reduction of many adverse long-term consequences. Nevertheless, these are still substantial concerns that warrant further mitigation efforts. In the current review, pediatric-ALL survivors' late adverse events, including secondary malignant neoplasms (SMNs), cardiac toxicity, neurotoxicity, bone toxicity, hepatic dysfunction, visual changes, obesity, impact on fertility, and neurocognitive effects have been evaluated. Throughout this review, we attempted to answer a fundamental question: can the recent molecular findings mitigate pediatric-ALL chemotherapy's long-term sequelae on adult survivors? For SMNs, few genetic predisposition factors have been identified including TP53 and POT1 variants. Other treatment-related risk factors have been identified such as anthracyclines' possible association with breast cancer in female survivors. Cardiotoxicity is another significant and common adverse event with some germline variants been found, albeit with conflicting evidence, to increase the risk of cardiac toxicity. For peripheral neurotoxicity, vincristine is the primary neurotoxic agent in ALL regimens. Some germline genetic variants were found to be associated with the vincristine neurotoxic effect's vulnerability. However, these were mainly detected with acute neuropathy. Moreover, the high steroid doses and prolonged use increase bone toxicity and obesity risk with some pharmacogenetic biomarkers were associated with increased steroid sensitivity. Therefore, the role of these biomarkers in tailoring steroid choice and dose is a promising research area. Future directions in pediatric ALL treatment should consider the various opportunities provided by genomic medicine. Understanding the molecular bases underlying toxicities will classify patients into risk groups and implement a closer follow-up to those at higher risk. Pharmacogenetic-guided dosing and selecting between alternative agents have proven their efficacy in the short-term management of childhood ALL. It is the right time to think about a similar approach for the life-long consequences on survivors.

Pharmacists' interventions on 2 years of drug monitoring in an oncology pediatric inpatient ward

BACKGROUND

In oncology, pharmacists contribute to safety and effectiveness of drug treatment, identifying, preventing and forwarding solutions to drug-related problems (DRPs). However, it is still necessary to elucidate the profile of drug-related problems in pediatric cancer treatment to contribute to guide clinical pharmacy activities.

METHODS

A retrospective cross-sectional study was conducted. Records on Excel® spreadsheets of 2 years of pharmaceutical assistance were analyzed regarding the prescriptions of chemotherapy for hospitalized patients aged 0-19 years. Data on age, sex, cancer diagnosis, protocol and drugs prescribed were collected. Causes and types of DRPs and pharmacists' interventions as their rate of acceptance were measured according to PCNE V 9.0.

RESULTS

Drug-related problems were identified for 84 patients, in 5.3% of analyzed prescriptions. Leukemias, patients aged 0-4 years and male sex were associated with higher rates of drug-related problems. The BFM 2009 protocol for acute lymphocytic leukemia treatment had the highest frequency of prescriptions with drug-related problems. Main drug-related problems were related to effectiveness (49.2%) and safety (33.2%), with most of them due to drug selection and dose. Rate of acceptance of interventions was 92.2% and 90.6% of drug-related problems were fully resolved. Mercaptopurine and filgrastim were the drugs most associated with drug-related problems. Oral antineoplastic agents represented 36% of the prescriptions with drug-related problems.

CONCLUSION

The high rate of acceptance of pharmacist interventions demonstrates the relevance of the pharmacist participation in the care of hospitalized pediatric patients undergoing chemotherapy. Pharmacists need to take attention to cases of necessity of drug prescription, intervening with other health professionals. Special attention to oral chemotherapy is required.

Eating behaviors and dietary quality in childhood acute lymphoblastic leukemia survivors

BACKGROUND

Childhood acute lymphoblastic leukemia (ALL) survivors' increased risk for adverse health outcomes could be mitigated through consuming a balanced diet. Nonetheless, >70% of adult survivors do not meet survivorship dietary recommendations. ALL treatment may amplify risk for restricted dietary preferences (picky eating) and poor self-regulation of food intake that could contribute to suboptimal diets in survivorship. This study aims to: (a) characterize differences in picky eating and self-regulation of food intake between survivors and peer controls; and (b) examine the associations between these eating behaviors and dietary quality in ALL survivors relative to peer controls.

METHODS

Participants were children (5-13 years) with (n = 32) and without (n = 32) a history of ALL and their caregivers. Children's dietary quality (Healthy Eating Index-2015) was calculated from 24-h dietary recalls. Caregivers completed the Child Eating Behavior Questionnaire-Food Fussiness subscale and the Child Self-Regulation in Eating Questionnaire.

RESULTS

Independent samples t-tests revealed survivors exhibited greater picky eating than peer controls but comparable self-regulation of food intake. Bootstrapped grouped multivariate regression results showed that for ALL survivors, greater picky eating was associated with worse dietary quality (controlling for age and self-regulation of food intake). For peer controls, worse self-regulation of food intake was associated with poorer dietary quality (controlling for picky eating and age).

CONCLUSIONS

Results provide preliminary support that different eating behaviors contribute to poor dietary quality in children with and without an ALL history. These findings suggest that interventions to improve ALL survivors' dietary quality may benefit targeting picky eating.

Rapid Weight Gain: An Unusual Presentation of Leukemia

Neurological manifestations of leukemia can be due to direct effects of the malignancy or due to the indirect effects of infection or therapy. An 11-year-old boy presented with recent-onset weight gain with papilledema and a history of tuberculosis contact. Neuroimaging and initial microscopic examination of the cerebrospinal fluid (CSF) did not aid in the diagnosis of central nervous system leukemia. He was started on antitubercular treatment yet deteriorated. Repeat CSF analysis when subjected to cytospin and flow cytometry confirmed the diagnosis of B cell acute lymphoblastic leukemia (ALL). Although there have been reports of relapsed ALL presenting as obesity, isolated rapid changes in weight at initial presentation are a very rare and unusual manifestation of ALL. To the best of our knowledge, this is the first such report.

Myosteatosis in adolescents and young adults treated for acute lymphoblastic leukemia

Myosteatosis refers to fat deposition within muscle and is linked to risk of cardiovascular disease and metabolic disorders. Though these comorbidities are common during and after therapy for acute lymphoblastic leukemia (ALL), little is known about tissue distribution, including myosteatosis, in this population. Using quantitative computed tomography, we assessed the impact of ALL therapy on bone, muscle, subcutaneous, and muscle-associated (MA) fat in 12 adolescents and young adults (AYA) treated for ALL as compared to a healthy control group without ALL (n = 116). AYA had a marked loss of muscle with a gain in MA fat between ALL diagnosis and end of induction. These changes persisted throughout intensive therapy. Lower bone and muscle and higher MA fat were also observed during and after treatment in comparison to controls. Altered lower extremity tissue distribution, specifically myosteatosis and sarcopenia, may contribute to functional declines and increased risk of metabolic disorders and cardiovascular diseases.

Effects of medium chain triglycerides on body fat distribution and adipocytokine levels in children with acute lymphoblastic leukemia under chemotherapy

Glucocorticoids used to treat acute lymphoblastic leukemia (ALL) are associated with cytotoxicity and obesity. The aim of the study was to investigate the effects of high-proportion medium chain triglyceride (MCT) on body fat distribution and levels of leptin and adiponectin during chemotherapy of children with ALL.New-onset ALL children treated at the Guangzhou Women and Children's Medical Center between March 2016 and March 2017 were enrolled. Children were divided into the MCT and control groups. For the MCT group, high-proportion MCT nutrition preparation was added to the diet, while no MCT was added for the control group. The MCT group was further divided into subgroups A and B based on the amount of supplement. Waist circumference, hip circumference, waist-to-hip ratio, bone marrow concentrations of leptin and adiponectin, and leptin-to-adiponectin ratio were measured before and on days 19 and 46 of chemotherapy. Body weight and body mass index (BMI) were measured on admission and discharge.Waist circumference in the control group increased by day 46 (P = .047), but did not change in the MCT group. The BMI of the children in the control group was higher than those in the MCT group on admission (P = .003), but not different at discharge. No significant differences in hip circumference, leptin levels, adiponectin levels, and body weight were observed between the 2 groups.This preliminary study suggests that short-term supplementation of high-proportion MCT nutrition preparation may help reduce the centripetal distribution of adipose induced by the application of glucocorticoids in children with ALL. This will have to be confirmed in future studies.

The role of adiponectin, LEPTIN, and ghrelin in the progress and prognosis of childhood acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Dysregulation of adipokine pathways is implicated in the carcinogenesis and ALL. The aim of this study is to present the most recent data available regarding the role of leptin, adiponectin and ghrelin in the pathogenesis and prognosis of ALL. The PubMed database was searched using 'Leptin', 'Adiponectin', 'Ghrelin', 'Cancer', 'Children' and 'Acute Lymphoblastic Leukemia' as keywords. The majority of the studies indicated that leptin levels are increased and adiponectin levels are decreased in ALL children at diagnosis, as well as in ALL survivors. Ghrelin levels were found to be lower at diagnosis and progressively increased during treatment. Further research is warranted, as the heterogeneity of the current studies, various treatment protocols and differences in sample sizes make it difficult to deduce solid conclusions regarding the role of adipokines in ALL.

Type 2 Diabetes Mellitus, the Metabolic Syndrome, and Its Components in Adult Survivors of Acute Lymphoblastic Leukemia and Hematopoietic Stem Cell Transplantations

PURPOSE OF REVIEW

A growing number of pediatric acute lymphoblastic leukemia (ALL) and hematopoietic stem cell transplantation (HSCT) survivors reach adulthood and face long-term health-related problems. We review risk factors and the prevalence of the metabolic syndrome (MetS), a cluster of obesity-related comorbidities, including abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, impaired glucose metabolism, and type 2 diabetes in ALL and HSCT survivors.

RECENT FINDINGS

Components of the MetS are already detected during the first year of ALL maintenance therapy and significantly worsen over time. The prevalence of MetS increases at a faster rate in this setting than in the general population. Factors found to be of the greatest potential risk to the development of the MetS are central obesity, increased BMI, irradiation therapy, older age, poor diet, and low level of physical activity. The early onset of MetS and its components among ALL and HSCT survivors calls for early and continuous screening to identify those at risk and to implement preventive measures.

Overweight in childhood cancer patients at diagnosis and throughout therapy: A multicentre cohort study

BACKGROUND

Childhood cancer patients (CCP) have been reported to be at increased risk of becoming overweight during treatment. We assessed prevalence of overweight in CCP at diagnosis and at the end of treatment, determined risk factors, and identified weight change during treatment by type of cancer.

METHODS

In a multicentre cohort study, we collected height and weight measurements of CCP at diagnosis and repeatedly during treatment. We calculated age- and sex-adjusted BMI Z-scores using references of the International Obesity Taskforce for children. Risk factors were described by multivariable linear regression, and weight change during treatment by multilevel segmented linear regression.

RESULTS

The study included 327 CCP with a median age of 7 years (IQR 3-12) at diagnosis (55% boys), who had been diagnosed with acute lymphoblastic leukaemia (ALL, 29%), lymphoma (16%), central nervous system (CNS) tumours (13%), sarcoma (18%), and other types of cancer (24%). At diagnosis, 27 CCP (8%) were overweight. This increased to 43 (13%) at end of treatment, on average 0.7 years after diagnosis. Being a boy (p = 0.005) and having been diagnosed with ALL or lymphoma (p < 0.001) were risk factors for weight gain during treatment. During the first half of treatment, BMI Z-scores increased in ALL (regression slope β = 0.4, 95% CI 0.1-0.7) and lymphoma (β = 1.5, 95% CI 0.2-2.9) patients, whereas for patients with CNS tumours (β = -1.4, 95% CI -2.7 to -0.2), sarcoma (β = -1.4, 95% CI -2.0 to -0.7), or other types of cancer (β = -0.3, 95% CI -1.5-0.9) BMI Z-scores tended to drop initially. During the second half of treatment BMI Z-scores of all patients tended to increase. Exploratory analyses showed that BMI Z-scores of younger ALL patients (<7 years at diagnosis) increased during induction (β = 3.8, 95% CI 0.5-7.0). The inverse was seen for older ALL patients (≥7 years at diagnosis), in whom BMI Z-scores tended to decrease during induction (β = -1.5, -5.1-2.2), both groups tended to increase afterwards.

CONCLUSION

CCP diagnosed with ALL or lymphoma are at increased risk of weight gain during treatment, and might particularly benefit from early lifestyle interventions.

Cardiovascular Risk Factors after Childhood Cancer Treatment Are Independent of the FTO Gene Polymorphism?

The study objective was to assess the prevalence of cardiovascular disease risk factors in patients treated for childhood cancer (N = 101) and to determine the involvement of clinical (cancer type and therapy) and/or genetic (FTO gene rs9939609 polymorphism) factors. Anthropometric features, laboratory findings, and standardized osteodensitometric indices (fat and lean mass) were considered. Overweight/obesity was found in 17.82% of the patients; however, central adiposity was found in as many as 42.5%. At least one abnormality in lipid metabolism was observed in 35.6%. Densitometry revealed elevated levels of fat mass in 44.55% of the patients. None of the parameters studied were associated with the FTO gene polymorphism. Standardized waist circumference was significantly higher in patients treated for leukemia than those treated for solid tumors (p = 0.04). Our findings indicate a high rate of central adiposity among childhood cancer survivors, especially leukemia patients. The prevalence of risk factors of cardiovascular disease after anticancer therapy is not FTO gene polymorphism-dependent.

Association of dietary patterns with overweight risk and all-cause mortality in children with cancer

BACKGROUND/OBJECTIVES

This study aimed to investigate the association of dietary patterns with overweight risk and all-cause mortality in pediatric cancer patients.

SUBJECTS/METHODS

Prospective cohort study was undertaken; 83 cancer patients admitted to the pediatric cancer ward at a university hospital in Seoul were included and followed for obesity and death over 24 months. Food consumption data were collected from patients using validated meal order sheets for breakfast, lunch, and dinner at the pediatric cancer ward over 3 days. Using principal component analysis, three dietary patterns were derived from 29 food groups.

RESULTS

Eighteen deaths occurred among the patient cohort during the follow-up period. The “spicy & fried meat and fish” dietary pattern was positively associated with overweight risk at both baseline [odds ratio (OR) = 4.396, 95% confidence interval (CI) = 1.111-17.385, P for trend = 0.023] and after 6 months (OR = 4.088, 95% CI = 1.122-14.896, P for trend = 0.025) as well as all-cause mortality (hazard ratios = 5.124, 95% CI = 1.080-24.320, P for trend = 0.042), when comparing the highest and lowest tertiles after adjusting for covariates. The “fish, egg, meat, and fruits & vegetables” dietary pattern was associated with lower overweight risk after 24 months (OR = 0.157, 95% CI = 0.046-0.982, P for trend = 0.084).

CONCLUSION

The results imply that dietary patterns might be associated with weight gain and premature death among pediatric cancer patients.

Genomic determinants of long-term cardiometabolic complications in childhood acute lymphoblastic leukemia survivors

BACKGROUND

While cure rates for childhood acute lymphoblastic leukemia (cALL) now exceed 80%, over 60% of survivors will face treatment-related long-term sequelae, including cardiometabolic complications such as obesity, insulin resistance, dyslipidemia and hypertension. Although genetic susceptibility contributes to the development of these problems, there are very few studies that have so far addressed this issue in a cALL survivorship context.

METHODS

In this study, we aimed at evaluating the associations between common and rare genetic variants and long-term cardiometabolic complications in survivors of cALL. We examined the cardiometabolic profile and performed whole-exome sequencing in 209 cALL survivors from the PETALE cohort. Variants associated with cardiometabolic outcomes were identified using PLINK (common) or SKAT (common and rare) and a logistic regression was used to evaluate their impact in multivariate models.

RESULTS

Our results showed that rare and common variants in the BAD and FCRL3 genes were associated (p<0.05) with an extreme cardiometabolic phenotype (3 or more cardiometabolic risk factors). Common variants in OGFOD3 and APOB as well as rare and common BAD variants were significantly (p<0.05) associated with dyslipidemia. Common BAD and SERPINA6 variants were associated (p<0.05) with obesity and insulin resistance, respectively.

CONCLUSIONS

In summary, we identified genetic susceptibility loci as contributing factors to the development of late treatment-related cardiometabolic complications in cALL survivors. These biomarkers could be used as early detection strategies to identify susceptible individuals and implement appropriate measures and follow-up to prevent the development of risk factors in this high-risk population.

Pubertal height gain is inversely related to peak BMI in childhood

BACKGROUND

Childhood BMI may influence subsequent growth in height as well as the timing of puberty. The aim of the present study was to investigate associations between BMI in childhood and subsequent height gain/pubertal growth.

METHODS

Longitudinal growth data were used (GrowUp₁₉₉₀Gothenburg cohort, n = 1,901). The QEPS growth-model was used to characterize height gain in relation to the highest BMI_SDS value between 3.5 and 8 y of age. Children were defined as overweight/obese (OwOb) or normal weight/underweight (NwUw), using the 2012 International Obesity Task Force criteria.

RESULTS

A negative association between childhood BMI_SDS and pubertal height gain was observed. Already at birth, OwOb children were heavier than NwUw children, and had a greater height velocity during childhood. Onset of puberty was 3.5/3.0 mo earlier in OwOb girls/boys, and they had 2.3/3.1 cm less pubertal height gain from the QEPS-models specific P-function than NwUw children. Adult height was not related to childhood BMI.

CONCLUSION

We found that pubertal height gain was inversely related to peak BMI in childhood. Higher childhood BMI_SDS was associated with more growth before onset of puberty, earlier puberty, and less pubertal height gain, resulting in similar adult heights for OwOb and NwUw children.

Adipokines, insulin resistance, and adiposity as a predictors of metabolic syndrome in child survivors of lymphoma and acute lymphoblastic leukemia of a developing country

BACKGROUND

There is a growing body of evidence indicating that pediatric survivors of cancer are at a greater risk of developing metabolic syndrome. This study evaluated some probable predictors of metabolic syndrome (MS), such as leptin and adiponectin concentrations, the leptin/adiponectin ratio, insulin resistance, and adiposity, in a sample of child survivors of lymphoma and leukemia in Mexico City.

METHODS

Fifty two children (leukemia n = 26, lymphoma n = 26), who were within the first 5 years after cessation of therapy, were considered as eligible to participate in the study. Testing included fasting insulin, glucose, adipokines and lipids; body fat mass was measured by DXA. The MS components were analyzed according to tertiles of adipokines, insulin resistance, and adiposity. Comparisons between continuous variables were performed according to the data distribution. The MS components were analyzed according to tertiles of adipokines, insulin resistance, and adiposity. With the purpose of assessing the risk of a present MS diagnosis, odds ratios (OR) with a 95% confidence interval (95% IC) were obtained using logistic regression analysis according to the various metabolic markers.

RESULTS

The median children age was 12.1 years, and the interval time from the completion of therapy to study enrollment was 4 years. Among the MS components, the prevalence of HDL-C low was most common (42%), followed by central obesity (29%). The HOMA-IR (OR 9.0, 95% CI 2.0; 41.1), body fat (OR 5.5, 95% CI 1.6; 19.3), leptin level (OR 5.7, 95% CI 1.6; 20.2) and leptin/adiponectin ratio (OR 9.4, 95% CI 2.0; 49.8) in the highest tertile, were predictive factors of developing MS; whereas the lowest tertile of adiponectin was associated with a protective effect but not significant.

CONCLUSIONS

Biomarkers such as HOMA-IR, leptin and leptin/adiponectin are associated with each of the components of the MS and with a heightened risk of suffering MS among children survivors of cancer. Given the close relationship between MS with risk of developing type 2 diabetes and cardiovascular disease, it is imperative to implement prevention measures in this population and especially in developing countries where these pathologies have become the leading cause of death.

Non-alcoholic fatty liver disease is associated with early left ventricular dysfunction in childhood acute lymphoblastic leukaemia survivors

BACKGROUND

Childhood acute lymphoblastic leukaemia (ALL) survivors have an increased risk of metabolic and cardiovascular disease. We aimed to assess the presence of non-alcoholic fatty liver disease (NAFLD) in childhood ALL and if it is associated with early cardiovascular dysfunction.

METHODS

In total, 53 childhood ALL survivors and 34 controls underwent auxological evaluation, biochemical assay, liver, heart and vascular ultrasound study.

RESULTS

NAFLD was more frequent in ALL patients than in controls (39.6% vs 11.7%, P < 0.01). Patients with NAFLD were more obese and insulin resistant than patients without NAFLD. Flow-mediated dilatation and interventricular septum were lower in the ALL group than those in the control group (P < 0.001 for both). The patients with NAFLD showed lower left ventricular ejection fraction than those without NAFLD (P = 0.011). In ALL survivors, BMI-SDS and subcutaneous fat were the strongest predictors of NAFLD, whereas preperitoneal adipose tissue and C-reactive protein were the strongest predictors of left ventricular ejection fraction.

CONCLUSIONS

Childhood ALL survivors had higher prevalence of NAFLD than healthy controls, which is associated with early left ventricular impairment. In the case of fatty liver, a comprehensive heart evaluation is mandatory. We strongly recommend to prevent visceral adiposity in ALL survivors, to search for metabolic syndrome or its components and to reinforce the need of intervention on diet and lifestyle during the follow-up of these patients.

Endothelial dysfunction and cardiovascular risk factors in childhood acute lymphoblastic leukemia survivors

BACKGROUND

Childhood acute lymphoblastic leukemia (ALL) survivors have increased risk of obesity, metabolic alterations and cardiovascular disease (CVD). Vascular endothelial function has been studied in adult cancers. Limited data exist regarding CVD risk factors among childhood ALL survivors. We aimed to assess endothelial function, metabolic and cardiovascular risk factors in young survivors of childhood ALL.

METHODS

Auxological parameters, blood pressure, glucose, lipid profile, hemostatic markers (total adiponectin and high-molecular-weight subfraction, endothelin-1, von Willebrand factor antigen, thrombin-antithrombin complex, D-dimers, fibrinogen), high sensitive C-reactive protein and ultrasound parameters of endothelial function (flow-mediated dilation-FMD, common carotid intima-media thickness-C-IMT, and antero-posterior diameter of infra-renal abdominal aorta-APAO) were assessed in 52 ALL survivors and 34 sex and age-matched controls.

RESULTS

ALL patients and controls were not statistically different as regards body mass index and waist circumference. Blood pressure, glucose, total and LDL-cholesterol, triglycerides, high sensitive C-reactive protein were statistically higher in ALL than in controls, while HDL-cholesterol was lower in ALL than in controls. Patients showed statistically lower high-molecular-weight adiponectin and thrombin-antithrombin complex (p=0.003 and p<0.001, respectively) and higher vonWillebrand factor antigen (p=0.002) than controls. FMD was lower in patients than in controls (p<0.001). Biomarkers of endothelial function, systolic blood pressure and waist circumference were correlated to FMD.

CONCLUSIONS

ALL survivors showed derangement of endothelial function, which likely occurs during chemotherapy and lasts till follow up. They showed metabolic alterations even though obesity was not documented. Endothelial vascular parameters should be evaluated earlier during follow-up to detect preclinical onset of CVD.

Association of energy intake and expenditure with obesity: A cross-sectional study of 150 pediatric patients following treatment for leukemia

Increased obesity in leukemia survivors has been attributed to chemotherapy and radiation. Data on total energy intake (TEI) and total energy expenditure (TEE) are lacking in obese childhood leukemia patients after completion of therapy from India. We conducted a cross-sectional study in pediatric acute leukemia patients after completion of therapy wherein energy intake was assessed by 24-hour recall method. TEE was calculated using Harris-Benedict equation, by assessing the physical activity level using Physical Activity Questionnaire for children and basal metabolic rate by World Health Organization equation. Indian Academy of Pediatrics 2015 guidelines for BMI were used for defining overweight and obesity. Nutritional status was assessed in 150 leukemia patients after completion of therapy. Twenty-five percent of leukemia patients after completion of therapy were overweight and obese versus 11% of healthy controls (p = 0.042). The mean ratio of TEI/required energy intake (REI), TEE/required energy expenditure (REE), and (TEI:REI)/(TEE:REE) were significantly higher in overweight and obese group versus nonobese survivors (p < 0.001, p = 0.091, p < 0.001, respectively). Multivariate analysis showed higher income (HR-2.3, p = 0.04), increased TEI/REI (HR-4, p = 0.049) and higher (TEI:REI)/(TEE:REE) (HR-3.1, p = 0.039) to be significant factors predicting obesity. Obesity in leukemia patients after completion of therapy is associated with increased energy intake, causing imbalance between energy intake and TEE in these patients.

Glia: silent partners in energy homeostasis and obesity pathogenesis

Body weight stability requires homeostatic regulation to balance energy intake and energy expenditure. Research on this system and how it is affected by obesity has largely focused on the role of hypothalamic neurons as integrators of information about long-term fuel storage, short-term nutrient availability and metabolic demand. Recent studies have uncovered glial cells as additional contributors to energy balance regulation and obesity pathogenesis. Beginning with early work on leptin signalling in astrocytes, this area of research rapidly emerged after the discovery of hypothalamic inflammation and gliosis in obese rodents and humans. Current studies have revealed the involvement of a wide variety of glial cell types in the modulation of neuronal activity, regulation of hormone and nutrient availability, and participation in the physiological regulation of feeding behaviour. In addition, one glial type, microglia, has recently been implicated in susceptibility to diet-induced obesity. Together, these exciting new findings deepen our understanding of energy homeostasis regulation and raise the possibility of identifying novel mechanisms that contribute to the pathogenesis of obesity.

Development of Metabolic Syndrome Associated to Cancer Therapy: Review

Long-term childhood cancer survivors are at great risk of developing late adverse effects after treatment, such as, reduced growth, obesity, decreased fertility, high blood pressure, cardiovascular diseases, impaired glucose, another form of cancer, among others organ dysfunctions, some of them are part of the metabolic syndrome. Metabolic syndrome and cancer connection is still not entirely understood, but there are some notions about it. Metabolic alterations produced during childhood cancer are more likely determined by treatments like radiotherapy, chemotherapy, glucocorticoids therapy, and surgery. Cancer treatment is associated to vascular alterations, hormone deficiencies, changes in insulin sensitivity, lipid metabolism, and inflammatory mediators. Obesity has been considered a crucial component in metabolic syndrome; obesity risk factors during childhood cancer include cranial radiation, female gender, and exposure to glucocorticoids such as dexamethasone. In addition, local radiotherapy or surgery may cause endocrine deficiencies, depends on the directly damage of endocrine organs. Patients who received some types of cancer treatment should be evaluated periodically to early diagnostic metabolic disorders associated to antineoplastic therapy.

Space radiation exposure persistently increased leptin and IGF1 in serum and activated leptin-IGF1 signaling axis in mouse intestine

Travel into outer space is fraught with risk of exposure to energetic heavy ion radiation such as ⁵⁶Fe ions, which due to its high linear energy transfer (high-LET) characteristics deposits higher energy per unit volume of tissue traversed and thus more damaging to cells relative to low-LET radiation such as γ rays. However, estimates of human health risk from energetic heavy ion exposure are hampered due to lack of tissue specific in vivo molecular data. We investigated long-term effects of ⁵⁶Fe radiation on adipokines and insulin-like growth factor 1 (IGF1) signaling axis in mouse intestine and colon. Six- to eight-week-old C57BL/6J mice were exposed to 1.6 Gy of ⁵⁶Fe ions. Serum and tissues were collected up to twelve months post-irradiation. Serum was analyzed for leptin, adiponectin, IGF1, and IGF binding protein 3. Receptor expressions and downstream signaling pathway alterations were studied in tissues. Irradiation increased leptin and IGF1 levels in serum, and IGF1R and leptin receptor expression in tissues. When considered along with upregulated Jak2/Stat3 pathways and cell proliferation, our data supports the notion that space radiation exposure is a risk to endocrine alterations with implications for chronic pathophysiologic changes in gastrointestinal tract.

A New Role for Glia in Leptin Action and Energy Balance

Chemo- or radiotherapy against dividing cells in the brain can promote obesity. Djogo et al. (2016) suggest that the loss of NG2 glia and diminished leptin action in the median eminence underlie this response, likely due to the loss of dendrites originating in the adjacent arcuate nucleus.

Adult NG2-Glia Are Required for Median Eminence-Mediated Leptin Sensing and Body Weight Control

While leptin is a well-known regulator of body fat mass, it remains unclear how circulating leptin is sensed centrally to maintain energy homeostasis. Here we show that genetic and pharmacological ablation of adult NG2-glia (also known as oligodendrocyte precursors), but not microglia, leads to primary leptin resistance and obesity in mice. We reveal that NG2-glia contact the dendritic processes of arcuate nucleus leptin receptor (LepR) neurons in the median eminence (ME) and that these processes degenerate upon NG2-glia elimination, which explains the consequential attenuation of these neurons' molecular and electrical responses to leptin. Our data therefore indicate that LepR dendrites in the ME represent the principal conduits of leptin's anorexigenic action and that NG2-glia are essential for their maintenance. Given that ME-directed X-irradiation confirmed the pharmacological and genetically mediated ablation effects on body weight, our findings provide a rationale for the known obesity risk associated with cranial radiation therapy.

Radiation-Induced Growth Retardation and Microstructural and Metabolite Abnormalities in the Hippocampus

Cranial radiotherapy (CRT) increases survival in pediatric brain-tumor patients but can cause deleterious effects. This study evaluates the acute and long-term impact of CRT delivered during childhood/adolescence on the brain and body using a rodent model. Rats received CRT, either 4 Gy fractions × 5 d (fractionated) or a cumulative dose of 20 Gy (single dose) at 28 d of age. Animals were euthanized 1 d, 5 d, or 3.5 mo after CRT. The 3.5 mo group was imaged prior to euthanasia. At 3.5 mo, we observed significant growth retardation in irradiated animals, versus controls, and the effects of single dose on brain and body weights were more severe than fractionated. Acutely single dose significantly reduced body weight but increased brain weight, whereas fractionation significantly reduced brain but not body weights, versus controls. CRT suppressed cell proliferation in the hippocampal subgranular zone acutely. Fractional anisotropy (FA) in the fimbria was significantly lower in the single dose versus controls. Hippocampal metabolite levels were significantly altered in the single dose animals, reflecting a heightened state of inflammation that was absent in the fractionated. Our findings indicate that despite the differences in severity between the doses they both demonstrated an effect on cell proliferation and growth retardation, important factors in pediatric CRT.

Metabolic Health in Childhood Cancer Survivors: A Longitudinal Study in a Long-Term Follow-Up Clinic

PURPOSE

Childhood cancer survivors (CCS) are at increased risk of metabolic dysfunction as a late effect of cancer treatment. However, pediatric metabolic syndrome (MetS) lacks a unified definition, limiting the diagnosis of MetS in CCS. This study evaluated individual metabolic health risk factors and potential areas for intervention in this at-risk population.

METHODS

This single center, retrospective observational longitudinal study evaluated the metabolic health of all CCS attending an oncology long-term follow-up clinic at a university hospital in Sydney, Australia (January 2012-August 2014). Participants were 276 CCS (52.2% male; mean age 18.0 years; range 6.8-37.9 years), at least 5 years disease free with a broad spectrum of oncological diagnoses. Primary metabolic health risk factors included raised body mass index, hypertension, and hypertransaminasemia. Participants treated with cranial radiotherapy (n = 47; 17.0% of cohort) had additional biochemical variables analyzed: fasting glucose/insulin, HDL/LDL cholesterol, and triglycerides.

RESULTS

Hypertension was common (19.0%), with male sex (p < 0.01) and being aged 18 years or above (p < 0.01) identified as risk factors. Cranial irradiation was a risk factor for overweight/obesity (47.8% in cranial radiotherapy-treated participants vs. 30.4%; p = 0.02). Hypertransaminasemia was more prevalent among participants treated with radiotherapy (15.6% vs. 7.3%; p = 0.03), and overweight/obese participants (17.6% vs. 8.2%; p = 0.04).

CONCLUSION

Metabolic health risk factors comprising MetS are common in CCS, placing this population at risk of premature adverse cardiovascular consequences. Proactive surveillance and targeted interventions are required to minimize these metabolic complications, and a unified definition for pediatric MetS would improve identification and monitoring.

Metabolic syndrome in childhood leukemia survivors: a meta-analysis

A significant number of long-term complications have been described in childhood leukemia survivors. In particular, these patients may present features of metabolic syndrome (MetS), and therefore increased risk for cardiovascular diseases. The aim of this meta-analysis is to evaluate the prevalence and the risk of MetS in survivors of childhood leukemia. Two authors independently performed a systematic literature search in PubMed and EMBASE to March 2014, reviewed and selected articles, based on pre-determined selection criteria. Twelve articles, comprising 2,337 participants (1,462 cases and 875 controls), were included in the meta-analysis. Only three of them were case-control studies eligible for the meta-analysis. The childhood leukemia survivors showed an increased risk of MetS as compared to healthy controls (OR = 4.36; 95 % CI 1.19-16.22). The risk was significantly increased only in patients treated with chemotherapy and radiotherapy (OR = 7.79; 95 % CI 1.27-47.77), and not in patients treated with only chemotherapy (OR = 2.35; 95 % CI 0.40-13.78). Childhood leukemia survivors, in particular if treated also with radiotherapy, are prone to develop MetS more than healthy controls. Monitoring of MetS components in these patients is necessary to avoid cardiovascular consequences later in life.

[Life style and occupational factors and prevention of second primary cancers after childhood and adolescent cancer: Current state of knowledge]

CONTEXT

Survival of children, adolescents and young adults treated for cancer increased with improved treatments. But there is still an increased risk of second primary cancer (SPC) in the long term compared to the population of the same age, especially related to treatments. A reflection on the follow-up of this population and the prevention of SPC is an important issue.

OBJECTIVES

To perform a synthesis of the available literature on SCP risk factors, related risk behaviors, occupational exposures and prevention strategies.

METHODS

Literature search on PubMed from the following equation: "cancer [Tiab] AND young adult [Tiab] or teen [Tiab] or childhood [Tiab] AND prevention [Tiab] AND survivors [Mesh term]".

RESULTS

Twenty-seven articles were included in this synthesis. Children, adolescents and young adults have similar risk behaviors than those of their peers regarding tobacco, diet and sun exposure; however, they have lower physical activity. There are few studies on prevention strategies focused on this population. Results of available studies remain inconclusive. No publication was found in relation to occupational exposure and risk of second cancer.

CONCLUSIONS

Children, adolescents and young adults treated for cancer are a population at risk and require long-term follow-up and the implementation of effective prevention strategies tailored to this population.

The association between glucocorticoid therapy and BMI z-score changes in children with acute lymphoblastic leukemia

PURPOSE

Few studies have addressed the common issue of weight gain in children with acute lymphoblastic leukemia (ALL) during early phases of treatment, and even fewer have used the appropriate measure for weight fluctuation in children, BMI-for-age z-scores (BAZs). The purpose of this study is thus to measure the extent of the weight gain in BAZ during the 150 first days of treatment and to identify factors associated with the weight gain. Furthermore, we wish to raise the question of whether changes in treatment protocols automatically should be followed by an evaluation of the nutritional guidelines.

METHOD

In this retrospective study, the medical records of 51 children with ALL treated with the NOPHO ALL 2008 protocol at Copenhagen University Hospital were assessed. Patient characteristics were extracted, and height, weight, and age during the first 150 days of treatment were converted to BAZ.

RESULTS

During 150 days of treatment, the proportion of overweight/obese patients increased significantly from 9.8 to 33.3 %. The mean change in BAZ (∆BAZ) was +1 standard deviation (0.02 ± 1.16 vs. 1.12 ± 1.44; p < 0.001) and BAZ increased significantly during periods with glucocorticoid (GC) treatment but not in periods without GC. ΔBAZ was larger in boys compared to girls, and ΔBAZ was higher in patients who were under/normal weight at diagnosis, compared to patients who were overweight/obese (1.26 ± 1.29 vs. -0.04 ± 0.41; p = 0.032).

CONCLUSION

BAZ increased significantly in children with ALL during the initial treatment with the NOPHO ALL 2008 protocol. This is likely associated with the GC administration and influenced by gender and initial BAZ.

A meta-analysis of body mass index of adolescent and adult survivors of pediatric acute lymphoblastic leukemia

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.

Association of Serum Leptin Level with Obesity in Children with Acute Lymphoblastic Leukemia

BACKGROUND

Obesity is a medical problem in survivors of childhood acute lymphoblastic leukemia. Obesity is associated with many complications, so it is important to investigate the respective etiology. Leptin is a protein synthesized in the fatty tissue and is effective in the control of obesity. Survey of leptin in acute lymphoblastic leukemia (ALL) survivors could be helpful in controlling obesity.

MATERIALS AND METHODS

In this prospective study, 53 pediatric patients diagnosed with ALL between 2006 and 2012 from Southern Iran, were enrolled. We examined body mass index (BMI) status and performed laboratory measuring tests including triglyceride, cholesterol, fasting blood sugar, leptin at diagnosis time and then every 6 months and in the last visit.

RESULTS

Participants consisted of 35 male and 18 female patients. At the time of diagnosis, 5.66% were overweight or obese, whereas at the end of treatment, approximately 13 patients (24.53%) were overweight or obese. The median and interquartile range (IQR) for blood leptin level were significantly higher for obese patients than other patients (885, 1120 vs. 246, 494 pg/ml), (P=0.030). The median and IQR were also significantly higher in females than in males (861, 969 vs. 204, 267 pg/ml), (P=0.006).

CONCLUSION

Obesity is a complication of ALL treatment. It is associated with elevated blood leptin level. Hypothalamus leptin resistance in obese patients should be considered. In each visit, clinicians should weight and their patient's BMI take into account.

The negative impact of being underweight and weight loss on survival of children with acute lymphoblastic leukemia

Body mass index and change in body mass index during treatment may influence treatment outcome of pediatric patients with acute lymphoblastic leukemia. However, previous studies in pediatric acute lymphoblastic leukemia reported contradictory results. We prospectively collected data on body composition from a cohort of newly diagnosed Dutch pediatric patients with acute lymphoblastic leukemia (n=762, age 2-17 years). Patients were treated from 1997-2004 and the median follow-up was 9 years (range, 0-10). Body mass index at diagnosis was expressed as age- and gender-matched standard deviation scores and on the basis of these scores the patients were categorized as being underweight, of normal weight or overweight. Multivariate analyses showed that patients who were underweight (8%) had a higher risk of relapse [hazard ratio: 1.88, 95% confidence interval (1.13-3.13)], but similar overall survival and event-free survival as patients who had a normal weight or who were overweight. Patients with loss of body mass index during the first 32 weeks of treatment had a similar risk of relapse and event-free survival, but decreased overall survival [hazard ratio: 2.10, 95% confidence interval (1.14-3.87)] compared to patients without a loss of body mass index. In addition, dual X-ray absorptiometry scans were performed in a nested, single-center cohort. Data from these scans revealed that a loss of body mass consisted mainly of a loss of lean body mass, while there was a gain in the percentage of fat. In conclusion, being underweight at diagnosis is a risk factor for relapse, and a decrease in body mass index early during treatment is associated with decreased survival. In addition, loss of body mass during treatment seems to consist mainly of a loss of lean body mass. This study was approved by the Medical Ethical Committee in 1996 (trial number NTR460/SNWLK-ALL-9).

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

Background

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

Methods

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

Results

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

Conclusions

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

Thyroid nodule in an eighteen-year-old man as the first presentation of acute lymphoblastic leukemia

INTRODUCTION

Acute lymphoblastic leukemia (ALL) is the most common malignancy of childhood. Patients with ALL commonly present with easy bruising and infections due to medullary involvement. The extra medullary involvements of ALL manifests as hepatosplenomegaly, lymphadenopathy, and testicular enlargement. Among extramedullary manifestations of the ALL, thyroid involvement is rare. Herein, we reported a case of ALL that manifested as a thyroid nodule.

CASE PRESENTATION

An 18-year-old young man with a thyroid nodule presented without any other symptom or sign. The excisional biopsy of the nodule was planned by the surgeon. After two months of lost to follow-up, the patient returned with a complaint of continuous bleeding after a tooth extraction. Peripheral blood smear (PBS) study and bone marrow aspiration proposed ALL and the flow cytometry confirmed the diagnosis. The R-Hyper-CVAD induction chemotherapeutic regimen (rituximab in combination with cyclophosphamide, vincristine, doxorubicin, and dexamethasone) was used for treatment. Interestingly, thyroid sonography and Tc(99m) scan showed resolution of the thyroid nodule after chemotherapy.

DISCUSSION

In this patient, poor interdisciplinary communication and the rarity of this manifestation led to a delayed diagnosis. Therefore, we insist on more careful clinical examinations, reassessment of unusual FNA reports, and closer communication between clinicians and pathologists in such cases. This approach would lead to accurate and earlier diagnosis and would prevent unnecessary interventions.

Chemotherapy alone or HSCT after reduced-intensity conditioning for patients with malignant hematologic diseases are not associated to metabolic syndrome: a cross-sectional observational study

The relationship between treatment for hematologic malignancies and risk of developing metabolic syndrome (MS) is controversial; in addition, metabolic changes following hematopoietic stem cell transplantation (HSCT) is an area of growing interest. We documented the presence of MS in patients with hematological malignancies treated with chemotherapy and HSCT. Nutritional status, anthropometrics, and pertinent laboratory parameters were used to evaluate the presence of MS using the Adult Treatment Panel (ATP III) criteria. In the study, 115 patients were included. Using ATP III criteria, MS was identified in 42 (44.7%) patients treated only with chemotherapy and in 8 (33.3%) patients with an HSCT. There was an important but not significant difference in the mean fasting glucose, which was higher in the chemotherapy group (108.32 ± 54.28 vs. 94.48 ± 18.25, P = 0.300). Mean values of biochemical markers and blood pressure were not different between the groups. An increase in central obesity in men with hematological diseases in comparison to the rest of the population was also found (46.7% vs 32.4%). There was no difference in the prevalence of MS between patients with hematologic malignancies receiving an HSCT and those treated with chemotherapy alone.

Fit4Life: a weight loss intervention for children who have survived childhood leukemia

BACKGROUND

Children surviving acute lymphoblastic leukemia (ALL) are at increased risk for overweight and obesity over that of the general population. Whether a generic or tailored approach to weight management is needed for cancer survivors has yet to be tested.

PROCEDURE

Thirty-eight youth 8-18 years with BMI ≥ 85% who had survived ALL were recruited for a randomized clinical trial evaluating a weight management intervention (WMI) tailored for childhood ALL survivors (Fit4Life). Fit4Life recipients received a 4-month web, phone, and text message-delivered WMI tailored for cancer survivorship. Controls received a general WMI delivered via phone and mail. Assessments were performed at baseline and 4 months. Outcome data were analyzed according to assigned treatment condition over time.

RESULTS

Most (80%, (70%, 100%) [median (IQR)]) of the assigned curriculum was received by Fit4Life participants as compared to 50% (40%, 65%) among controls. Fit4Life recipients ≥ 14 years demonstrated less weight gain (P = 0.05) and increased moderate-to-vigorous physical activity (P < 0.01) while all Fit4Life recipients reported reduced negative mood (P < 0.05) over time as compared to control counterparts.

CONCLUSIONS

We demonstrated acceptable feasibility of a WMI tailored for overweight and obese children surviving ALL utilizing a multimodal technology approach. Improved weight, weight-related behavior, and psychological outcomes were demonstrated among Fit4Life intervention as compared to youth receiving a generic WMI. Data from this pilot trial may be used to design a larger trial to determine whether youth of all ages also can derive a benefit from a cancer survivor-tailored WMI and whether short-term outcomes translate into improved long-term outcomes for childhood ALL survivors.

Eating behavior and BMI in adolescent survivors of brain tumor and acute lymphoblastic leukemia

OBJECTIVES

Elevated body mass index (BMI) has been reported in pediatric cancer survivors. It is unclear whether this is related to altered energy intake (via disordered eating), decreased energy expenditure (via limited exercise), or treatment-related direct/indirect changes. The aims of this study are to describe the occurrence of overweight and obesity, exercise frequency, and the extent of disordered eating patterns in this sample of survivors, and to examine relationships among BMI, eating patterns, exercise frequency, and demographic and disease and treatment-related variables to identify those survivors most at risk for overweight/obesity.

METHODS

This cross-sectional study recruited 98 cancer survivors (50 acute lymphoblastic leukemia [ALL], 48 brain tumor [BT]), aged 12 to 17 years and ≥12 months posttreatment from a large pediatric oncology hospital. Survivors completed health behavior measures assessing disordered eating patterns and physical activity. Clinical variables were obtained through medical record review. Univariate analyses were conducted to make comparisons on health behaviors by diagnosis, gender, treatment history, and BMI category.

RESULTS

Fifty-two percent of ALL survivors and 41.7% of BT survivors were classified as overweight/obese. Overweight/obesity status was associated with higher cognitive restraint (odds ratio = 1.0; 95% confidence interval = 1.0-1.1). Only 12% of ALL survivors and 8.3% of BT survivors met Centers for Disease Control and Prevention guidelines for physical activity. Males reported more physical activity, t(96) = 2.2, P < .05.

CONCLUSIONS

Overweight/obese survivors may attempt to purposefully restrict their food intake and rely less on physiological cues to regulate consumption. Survivors should be screened at follow-up for weight-related concerns.

Gene expression of WWOX, FHIT and p73 in acute lymphoblastic leukemia

The aim of the present study was to analyze the expression of WW-domain oxidoreductase (WWOX), fragile histidine triad (FHIT) and p73 in acute lymphoblastic leukemia (ALL). Samples from 122 ALL patients and 35 non-ALL control patients were collected in this study. RT-PCR was performed to detect the mRNA expression of WWOX, FHIT and p73. The methylation status of the WWOX promoter region, FHIT promoter region and the first exon region of p73 were also analyzed using the methylation-specific PCR method. The mRNA expression of WWOX, FHIT and p73 was significantly lower in the ALL samples compared with the controls (48.2, 42.9 and 55.4%, respectively). By contrast, the methylation frequency of WWOX, FHIT and p73 was significantly higher in the ALL samples compared with the controls (44.6, 46.4 and 37.5%, respectively). The mRNA expression of these three genes was inversely correlated with the methylation frequency in the ALL samples (correlation coefficients, −0.661, −0.685 and −0.536 for WWOX, FHIT and p73, respectively). Moreover, the mRNA expression of WWOX was positively correlated with that of FHIT and p73 (correlation coefficients, 0.569 and 0.556, respectively). However, the methylation status of WWOX had no correlation with that of FHIT or p73. It was concluded that the high methylation status of WWOX, FHIT and p73 may lead to the inactivation of expression and the silencing of these genes, promoting the occurrence and development of ALL. The determination of the mRNA expression and methylation status of WWOX, FHIT and p73 may aid in the development of treatment approaches for ALL.