Growth and development of children born to patients after cancer therapy

Testicular tissue cryopreservation: 8 years of experience from a coordinated network of academic centers

STUDY QUESTION

Is it feasible to disseminate testicular tissue cryopreservation with a standardized protocol through a coordinated network of centers and provide centralized processing/freezing for centers that do not have those capabilities?

SUMMARY ANSWER

Centralized processing and freezing of testicular tissue from multiple sites is feasible and accelerates recruitment, providing the statistical power to make inferences that may inform fertility preservation practice.

WHAT IS KNOWN ALREADY

Several centers in the USA and abroad are preserving testicular biopsies for patients who cannot preserve sperm in anticipation that cell- or tissue-based therapies can be used in the future to generate sperm and offspring.

STUDY DESIGN, SIZE, DURATION

Testicular tissue samples from 189 patients were cryopreserved between January 2011 and November 2018. Medical diagnosis, previous chemotherapy exposure, tissue weight, and presence of germ cells were recorded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Human testicular tissue samples were obtained from patients undergoing treatments likely to cause infertility. Twenty five percent of the patient's tissue was donated to research and 75% was stored for patient's future use. The tissue was weighed, and research tissue was fixed for histological analysis with Periodic acid-Schiff hematoxylin staining and/or immunofluorescence staining for DEAD-box helicase 4, and/or undifferentiated embryonic cell transcription factor 1.

MAIN RESULTS AND THE ROLE OF CHANCE

The average age of fertility preservation patients was 7.9 (SD = 5) years and ranged from 5 months to 34 years. The average amount of tissue collected was 411.3 (SD = 837.3) mg and ranged from 14.4 mg-6880.2 mg. Malignancies (n = 118) were the most common indication for testicular tissue freezing, followed by blood disorders (n = 45) and other conditions (n = 26). Thirty nine percent (n = 74) of patients had initiated their chemotherapy prior to undergoing testicular biopsy. Of the 189 patients recruited to date, 137 have been analyzed for the presence of germ cells and germ cells were confirmed in 132.

LIMITATIONS, REASONS FOR CAUTION

This is a descriptive study of testicular tissues obtained from patients who were at risk of infertility. The function of spermatogonia in those biopsies could not be tested by transplantation due limited sample size.

WIDER IMPLICATIONS OF THE FINDINGS

Patients and/or guardians are willing to pursue an experimental fertility preservation procedure when no alternatives are available. Our coordinated network of centers found that many patients request fertility preservation after initiating gonadotoxic therapies. This study demonstrates that undifferentiated stem and progenitor spermatogonia may be recovered from the testicular tissues of patients who are in the early stages of their treatment and have not yet received an ablative dose of therapy. The function of those spermatogonia was not tested.

STUDY FUNDING/COMPETING INTEREST(S)

Support for the research was from the Eunice Kennedy Shriver National Institute for Child Health and Human Development grants HD061289 and HD092084, the Scaife Foundation, the Richard King Mellon Foundation, the Departments of Ob/Gyn & Reproductive Sciences and Urology of the University of Pittsburgh Medical Center, United States-Israel Binational Science Foundation (BSF), and the Kahn Foundation. The authors declare that they do not have competing financial interests.

Acute lymphoblastic leukemia in pregnancy: a case report with literature review

The management of acute lymphoblastic leukemia (ALL) during pregnancy requires treatment with high-dose chemotherapy that can pose risks to both the mother and fetus. Special consideration to chemotherapy regimen and its doses and to fetal gestational age at the time of chemotherapy administration should be taken in order to limit fetal exposure while still providing optimal therapy to the mother. Here we describe a 22-year-old patient who was diagnosed at 26 weeks gestation with ALL and was treated in the third trimester with HyperCVAD (cytoxan, vincristine, adriamycin, dexamethasone) combination chemotherapy giving birth via Caesarean section to a healthy baby girl 4 weeks after induction chemotherapy.

Hematological malignancies and pregnancy: a final report of 84 children who received chemotherapy in utero

To evaluate the risk of acute and late side effects in children whose mothers received chemotherapy during pregnancy for hematological malignancies, we performed an analysis of 84 children with a long-term follow-up. The 84 children in our study were born to mothers with hematological malignancies (29 acute leukemia, 26 Hodgkin's disease, and 29 malignant lymphoma) who received chemotherapy during pregnancy, including 38 during the first trimester. These children were examined for physical health; growth; development; and hematological, cytogenetic, neurological, psychological, and learning disorders. The occurrence of cancer or acute leukemia in these children was also considered. Some of these patients have become parents, and their children were also considered in this analysis. In all of the children studied, including the 12 second-generation children, the birth weight was normal; learning and educational performance were normal; and no congenital, neurological, or psychological abnormalities were observed. With a median follow-up of 18.7 years (range, 6-29 years), no cancer or acute leukemia has been observed. These results confirm our previous reports, suggesting that if a pregnant patient has an aggressive hematological malignancy, chemotherapy at full doses can be safely administered, even during the first trimester, if cure of the hematological malignancy is considered reasonable.

A study of children, fathered by men treated for testicular cancer, conceived before, during, and after chemotherapy

One hundred fifty children of 113 fathers with testicular tumour treated from 1979 on the National Institute of Oncology, Budapest, were studied. Three groups were formed on the basis of the time of conception; 69 children were born before the illness of the fathers, 40 during the 12 pretreatment months, and 41 during or after combined chemotherapy. One hundred fifty control children underwent tonsillectomy/appendectomy, but were otherwise healthy. They were matched according to age, sex, and place of inhabitance with index children. Family anamnesis, perinatal, and gestational data were listed; thereafter, physical, laboratory, immunological, and, if required, radiological examinations were made. No difference was detectable in the somatic and psychiatric status of the three groups, and development was well balanced, corresponding to age. Protocols of the combined chemotherapy applied, and the incidence of anomalies, abnormalities, malignancies, and other diseases was recorded. Incidence was similar in all three groups. Incidence of congenital malformations was not increased in children conceived before and after therapy; however, a complex congenital abnormality, an atrial septal defect with horseshoe kidney, occurred in one young girl, conceived after the end of her father's treatment. The interval between conception and the end of therapy was established in the case of children conceived either during or after therapy. This was shorter in the case of healthy children; the number of healthy children conceived during cytostatic treatment was also remarkable. Further detailed analysis of data and individual evaluation of case reports are recommended.

Growth and development of children of mothers treated with chemotherapy during pregnancy: current status of 43 children

To evaluate the potential teratogenicity of modern cancer treatment, 43 children born to mothers with hematological malignancies (18 with non-Hodgkin lymphoma, 14 Hodgkin disease, seven acute leukemia, and four with chronic granulocytic leukemia) who received chemotherapy during some portion of their pregnancy, including 19 of these 43 who received chemotherapy during the first trimester, were examined for physical health, growth, and development. Immunological, hematological, and cytogenetic status also were evaluated. The children's ages ranged from 3 to 19 years. The children had a careful history and physical examination to detect any abnormal symptoms or signs and the mother's previous chemotherapy was carefully documented. In all of the children studied, physical, neurological, psychological, hematological, immune function, and cytogenetics were normal. These results suggest that chemotherapy can be administered during pregnancy, even during the first trimester, because it is not hazardous to the fetus; nevertheless, this study is inadequate in size to exclude the possibility of teratogenesis, and more reports are necessary to define the best treatment from cancer during pregnancy.

Reversibility of the effects of chronic paternal exposure to cyclophosphamide on pregnancy outcome in rats

Low-dose chronic treatment of the male rat with the antitumor drug cyclophosphamide causes a time- and dose-dependent increase in pre- and post-implantation loss in the untreated females to which he is mated. The objective of the present study was to determine whether such effects are reversed, and if so at what time after cessation of drug treatment. Adult male Sprague-Dawley rats were gavage fed daily, 6 times per week for 9 weeks, with saline (control) or with 1 of 3 doses of cyclophosphamide, 1.4, 3.4 or 5.1 mg/kg/day. After the 9 weeks of treatment and at 2-week intervals thereafter, each male was mated with 2 females in proestrus. The females were caesarian sectioned 20 days later and pregnancy outcome assessed. After 9 weeks of drug treatment, pre-implantation loss increased more than 3-fold from 6% in the control group to 21% in the 5.1 mg/kg/day cyclophosphamide treatment group. Post-implantation loss increased in a dose dependent fashion from 5% in the control group to 74% in the 5.1 mg/kg/day cyclosphosphamide treatment group. Pre-implantation loss rapidly decreased upon cessation of treatment with cyclophosphamide: within 2 weeks it had returned to within the control range. Within just 2 weeks after termination of drug treatment in the 5.1 mg/kg/day cyclophosphamide treatment group, post-implantation loss decreased by half to 44%; it had decreased to 11% by 4 weeks and then was maintained at 4-6% thereafter. In the 3.4 mg/kg/day cyclophosphamide treatment group, post-implantation loss returned to the control range by 4 weeks. Thus, the effects of paternally administered cyclophosphamide on progeny outcome are reversible. The timing of reversal suggests that the effects on pre-implantation loss are due to a drug effect on spermatozoa either in the epididymis or near the time of spermiation while those on post-implantation loss are due to an additional effect on spermatids in the seminiferous tubules.