Time-dependent alterations in growth and bone health parameters evaluated at different posttreatment periods in pediatric oncology patients

Bone mineral density surveillance for childhood, adolescent, and young adult cancer survivors: evidence-based recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Childhood, adolescent, and young adult cancer survivors are at increased risk of reduced bone mineral density. Clinical practice surveillance guidelines are important for timely diagnosis and treatment of these survivors, which could improve bone mineral density parameters and prevent fragility fractures. Discordances across current late effects guidelines necessitated international harmonisation of recommendations for bone mineral density surveillance. The International Late Effects of Childhood Cancer Guideline Harmonization Group therefore established a panel of 36 experts from ten countries, representing a range of relevant medical specialties. The evidence of risk factors for very low and low bone mineral density and fractures, surveillance modality, timing of bone mineral density surveillance, and treatment of very low and low bone mineral density were evaluated and critically appraised, and harmonised recommendations for childhood, adolescent, and young adult cancer survivors were formulated. We graded the recommendations based on the quality of evidence and balance between potential benefits and harms. Bone mineral density surveillance is recommended for survivors treated with cranial or craniospinal radiotherapy and is reasonable for survivors treated with total body irradiation. Due to insufficient evidence, no recommendation can be formulated for or against bone mineral density surveillance for survivors treated with corticosteroids. This surveillance decision should be made by the survivor and health-care provider together, after careful consideration of the potential harms and benefits and additional risk factors. We recommend to carry out bone mineral density surveillance using dual-energy x-ray absorptiometry at entry into long-term follow-up, and if normal (Z-score > -1), repeat when the survivor is aged 25 years. Between these measurements and thereafter, surveillance should be done as clinically indicated. These recommendations facilitate evidence-based care for childhood, adolescent, and young adult cancer survivors internationally.

MDCT evaluation of sternal development

BACKGROUND AND PURPOSE

Sternal ossification starts in utero, and continues throughout puberty in various patterns. In this study, our objective was to evaluate the correlation of ossification with age and to determine whether age can be predicted.

MATERIALS AND METHODS

Individuals younger than 30 years old without congenital anomalies, chronic disease, and history of long-term chemotherapy who had chest CT imaging with a slice thickness < 3 mm were retrospectively reviewed. Data of ossification centers, horizontal and vertical fusion were collected. Spearman correlation test and ROC analysis were performed to correlate age with fusion. Kruskal-Wallis test was used to perform gender wise comparisons. Sensitivity, specificity, positive predictive value and negative predictive value of cut-off points, estimated according to ROC analysis, were calculated.

RESULTS

Segmented ossification centers were more common in males, with significant difference in third and fourth mesosternal ossification centers (p < 0.05). Females had more vertical fusion at each level (p < 0.05). Spearman correlation test showed significant correlation between age and horizontal and vertical fusion for both genders. ROC analysis was performed and cut-off values were estimated. Sensitivity was very high (84.6-100%) but specificity was low (43.3-79.9%) for horizontal fusion. Sensitivity of vertical fusion (64.8-100%) was similar but specificity was higher (74.7-100%).

CONCLUSIONS

Horizontal and vertical fusions of sternal ossification centers correlate with age significantly. Vertical fusion might be a better indicator of age with higher sensitivity and specificity, while horizontal fusion has lower accuracy. Large-scale studies should be conducted to confirm our results.

Mobilization patterns of children on a hematology/oncology inpatient ward

BACKGROUND

Children being treated for cancer are admitted to the hospital for treatment of their disease or complications of therapy. Periods of bed rest during hospitalization can cause impairments detrimental to children with cancer who endure many side effects of therapy. Little is known about how these children mobilize while admitted to the hospital. The purpose of this study was to examine how children admitted to a hematology/oncology ward are mobilizing and analyze factors associated with delayed or infrequent mobility.

PROCEDURE

A retrospective chart review was conducted on 228 charts with data recorded on documented mobilization and referrals to physiotherapy. Primary outcome was related to mobility including timing, frequency, type, and nature of mobilization.

RESULTS

Almost half of children (43%) mobilized between 3 and 5 days per week, with median time to first mobilization being 2 days (interquartile range 1-3). Caregivers assisted with mobilization 91% of the time. Children isolated to their room and those reporting fever had a statistically significant decrease in the percent of admission days involving mobilization (mean difference 15 and 8%, respectively) than those not isolated and without fever. Children who were isolated also mobilized 1 day later (P = 0.016) than children who were not isolated. Percentage of time in isolation was positively correlated with timing (P = 0.04) and negatively correlated with frequency of mobilization (P < 0.001).

CONCLUSION

Most children admitted to the hospital for treatment of oncologic or hematologic conditions were noted to mobilize early, but frequency of mobilization could be improved. Periods of time in isolation appear to negatively affect mobilization.

Risk factors and surveillance for reduced bone mineral density in pediatric cancer survivors

BACKGROUND

Pediatric cancer survivors are at increased risk of developing low bone mineral density (BMD) due to cancer treatment. This study assessed the yield of screening for low BMD in pediatric-aged cancer survivors as per the Children's Oncology Group Long-Term Follow-Up (COG-LTFU) Guidelines, which recommend screening survivors who received steroids, methotrexate, or hematopoietic cell transplant (HCT).

METHODS

This is a retrospective cohort study of 475 pediatric blood cancer and noncentral nervous system solid tumor survivors screened for low BMD with dual-energy X-ray absorptiometry (DXA) as per the COG-LTFU Guidelines from 2003 to 2010. Risk factors for low BMD (DXA Z-score ≤-2) were evaluated by univariate and multivariate analysis.

RESULTS

The mean DXA Z-score was -0.1 for both whole body and lumbar spine measurements. Among at-risk survivors, 8.2% (39/475) had low BMD. Multivariate analysis of survivors with low BMD showed significant association with male gender (odds ratio [OR] 3.4, 95% confidence interval [CI], 1.3-9.0), exposure to total body irradiation (TBI), cranial, or craniospinal radiation (OR 5.2, 95% CI, 1.8-14.9), and gonadal dysfunction (OR 4.3, 95% CI, 1.4-13.0). Methotrexate exposure was not significantly associated with low BMD. Survivors receiving HCT had a reduced risk of low BMD (OR 0.2, 95% CI, 0.1-0.9).

CONCLUSION

The highest risk factors for low BMD were male gender, exposure to TBI, cranial, or craniospinal radiation, and gonadal dysfunction. Survivors receiving methotrexate or HCT therapy have the lowest risk for low BMD among those screened. Future studies should investigate risk of low BMD for survivors receiving HCT without radiation exposure.