Prevalence of Osteopathologies in Children and Adolescents After Diagnosis of Acute Lymphoblastic Leukemia

Adults with Phenylketonuria have suboptimal bone mineral density apart from vitamin D and calcium sufficiency

Introduction

Improvement of early diagnosis and treatment in patients with Phenylketonuria (PKU) allowed for healthy survival into adulthood of these patients, but non-neurological health impairments of unknown etiology emerged. One of these is impaired bone health that manifests in adolescence and adulthood, potentially depending not only on treatment adherence but also on additional lifestyle factors and nutrition.

Methods

Eighteen adults with PKU (18.3-51.6 years, ♀ n = 11) and 19 age- and gender-matched controls (18.3-54.9 years, ♀ n = 10) participated in the study. Bone metabolism-related parameters (BMRPs) in plasma, serum, and urine were analyzed. Dietary habits and lifestyle factors were obtained from questionnaires; a 6-min walk test and a dual X-ray absorptiometry measurement at two sites were performed. Phenylalanine (Phe) serum concentrations from the 5 years prior to study participation were collected from the patients' charts.

Results

Patients had reduced bone mineral density (BMD) T-score in hips (-0.67 ± 1.05) and lumbar spine (-0.71 ± 1.11, both p = 0.018). Most BMRPs in plasma, serum, and urine, as well as markers of oxidative stress did not differ from healthy controls. Whereas 89% of adults with PKU were vitamin D-sufficient, only 68% of controls reached vitamin D sufficiency. 25-Hydroxy vitamin D concentration was significantly higher in adults with PKU than that in controls [33.1 ng/mL (26.2-40.3) vs. 23.4 ng/mL (17.2-24.9); p < 0.001], whereas parathyroid hormone concentrations showed no difference [PKU: 27.6 pg/mL (19.6-42.8) vs. Co: 36.1 pg/mL (29.2-40.8); p = 0.089]. Neither Phe blood concentration nor dietary habits or lifestyle factors were associated with BMD in regression analysis.

Conclusion

Neither dietary habits nor lifestyle factors showed an association with BMD in this group of adults with PKU, whereas BMD was reduced.

High Parathyroid Hormone Rather than Low Vitamin D Is Associated with Reduced Event-Free Survival in Childhood Cancer

BACKGROUND

Vitamin D deficiency is linked to poor cancer outcomes but the impact of its consequence, elevated parathyroid hormone (PTH), remains understudied. PTH receptor activation influences cancer progression in vitro, yet the effect of elevated PTH on pediatric cancer survival is unexamined.

METHODS

This retrospective study examines associations between PTH, 25-OH vitamin D (25OHD), and event-free survival (EFS) and overall survival (OS) in patients with pediatric cancer. Laboratory data from 4,349 patients (0-18 years) at a tertiary pediatric cancer unit were analyzed for the highest PTH and lowest 25OHD levels at diagnosis and the following 5 years. Data on relapse, secondary malignancies, and mortality were stratified by PTH levels above/below the cohort median (47 pg/mL) and 25OHD levels ≤30 nmol/L. EFS and OS were analyzed and hazard ratios (HR) were calculated for the entire cohort and six cancer subgroups.

RESULTS

PTH and 25OHD values were available for 1,286 patients (731 male). Higher PTH associated with inferior EFS in primary malignant brain tumors [HR, 1.80 (1.19-2.72)], embryonal malignancies [HR, 2.20 (1.1-4.43)], and lymphatic malignancies [HR 1.98 (1.05-3.72)]. Vitamin D deficiency associated with inferior EFS in embryonal malignancies [HR 2.41 (1.24-4.68)]. In a multivariate Cox model, only higher PTH remained significant for inferior EFS.

CONCLUSIONS

Elevated PTH may indicate adverse outcomes in certain pediatric cancers.

IMPACT

This study identifies elevated parathyroid hormone as a potential marker for poor outcomes in patients with pediatric cancer, emphasizing the need for adequate vitamin D and calcium management.

Description of bone health in adolescents and young persons with Klinefelter syndrome - results from a pilot study

BACKGROUND

In adults with Klinefelter syndrome (KS), impaired bone health with reduced bone mineral density (BMD) has been described even in the presence of testosterone replacement therapy. The aim of the present study was to characterize bone health in young patients with KS.

PATIENTS AND METHODS

20 participants aged 16.10 ± 4.28 years with KS (7 with testosterone replacement therapy) were included in the KliBONE study (DRKS 00024870). Medical history, clinical, radiographic and biochemical parameters of bone health and metabolism were obtained. Radiographic bone health index (BHI) was assessed via automated digital X-ray radiogrammetry of the left hand or via dual energy X-ray absorptiometry (DXA) of the lumbar spine and left femur in participants ≥ 16 years. Peripheral blood mononuclear cells were differentiated into osteoclasts and quantified in 7 participants and 7 healthy controls.

RESULTS

Mean BHI SDS was - 1.42 ± 1.22 and mean BMD z-score at the lumbar vertebrae (L1-4) was - 0.92 ± 1.00. 25-OH-vitamin D levels < 20 ng/ml were detected in 8/20. Other parameters of bone metabolism (bone-specific alkaline phosphatase, PTH, ß-crosslaps and osteocalcin) were within age-appropriate reference ranges. Serum leptin SDS was elevated (mean 2.15 ± 1.19). The number of osteoclasts in participants with KS did not differ from that of controls.

CONCLUSION

BHI SDS and BMD z-scores were lower than expected in young individuals with KS despite age-appropriate bone turnover markers and no apparent pathology in osteoclast differentiation. The cause of the early-onset bone phenotype requires further investigation.

Exercise and QUality Diet after Leukemia: A Randomized Weight Loss Trial among Adult Survivors of Childhood Leukemia in the Childhood Cancer Survivor Study

BACKGROUND

Obesity is prevalent in childhood cancer survivors and interacts with cancer treatments to potentiate risk for cardiovascular (CV) death. We tested a remote weight-loss intervention trial that was effective among adults with CV risk factors in a cohort of adult survivors of childhood acute lymphoblastic leukemia (ALL) with overweight/obesity.

METHODS

In this phase III efficacy trial, survivors of ALL enrolled in the Childhood Cancer Survivor Study with a body mass index ≥25 kg/m2 were randomized to a remotely delivered weight-loss intervention versus self-directed weight loss, stratified by history of cranial radiotherapy. The primary endpoint was the difference in weight loss at 24 months in an intent-to-treat analysis. Analyses were performed using linear mixed-effects models.

RESULTS

Among 358 survivors (59% female; median attained age: 37 years; IQR: 33-43 years), the baseline mean (SD) weight was 98.6 kg (24.0) for the intervention group (n = 181) and 94.9 kg (20.3) for controls (n = 177). Adherence to the intervention was poor; 15% of individuals in the intervention group completed 24/30 planned coaching calls. Weight at 24 months was available for 274 (77%) participants. After controlling for cranial radiotherapy, sex, race/ethnicity, and age, the mean (SE) change in weight from baseline to 24 months was -0.4 kg (0.8) for the intervention group and 0.2 kg (0.6) for control participants (P = 0.59).

CONCLUSIONS

A remote weight-loss intervention that was successful among adults with CV conditions did not result in significant weight loss among adult survivors of childhood ALL.

IMPACT

Future interventions in this population must be tailored to the unique needs of survivors to encourage engagement and adherence. See related In the Spotlight, p. 1147.

Analysis of factors affecting the clinical efficacy and quality of life in the treatment of pediatric acute lymphoblastic leukemia

Objective

To analyze the factors affecting the long-term clinical efficacy and quality of life in the treatment of pediatric acute lymphoblastic leukemia (ALL).

Methods

This is a retrospective study. One hundred children with ALL were collected before June, 2018 at The First Affiliated Hospital of Yangtze University and followed up for five years. Not only were their five-years survival rates analyzed, but univariate and multivariate analyses were also performed for factors that might affect their five-year survival rates. The MOS 36-Item Short Form of Health Survey (SF-36) was utilized to investigate the surviving children after five years in order to analyze the factors that may affect the quality of life of the children.

Results

The five-years survival rate of one hundred children with ALL after treatment was 91.00% (91/100). Univariate and multivariate Logistic regression analyses were performed on the factors that may affect the long-term efficacy of pediatric ALL. The results showed that white blood cell count at first diagnosis, prednisone response test, treatment compliance and recurrence were independent risk factors for the long-term efficacy of pediatric ALL(p<0.05). The SF-36 survey of 91 surviving children after five years showed that prednisone response test and treatment compliance were independent risk factors affecting the quality of life of pediatric ALL(p<0.05).

Conclusion

In the initial diagnosis of pediatric ALL, sufficient attention and control should be given to the factors that may affect the long-term clinical efficacy and quality of life, and appropriate treatment plans should be adopted. Meanwhile, the treatment compliance of children should be improved during treatment to improve the survival rate and quality of life of pediatric ALL.

Vitamin D Deficiency in Childhood Cancer Survivors: Results from Southern Thailand

There is limited information on vitamin D deficiency among childhood cancer survivors (CSS), especially in tropical countries. The aims of this study are to determine the prevalence and risk factors for vitamin D deficiency in CCSs. This study was conducted at the long-term follow-up clinic for CCSs at Prince of Songkla University, Songkhla, Thailand. All CCSs who were followed up between January 2021 and March 2022 were enrolled. Demographic data, dietary dairy intake, average weekly duration of outdoor activities, total 25-hydroxyvitamin D [25(OH)D] levels, parathyroid hormone levels, and blood chemistry were collected. A total of 206 CCSs with a mean age at follow-up of 10.8 ± 4.7 years were included. The prevalence of vitamin D deficiency was 35.9%. Female gender (odds ratio (OR): 2.11, 95% CI: 1.08-4.13), obesity (OR: 2.01, 95% CI: 1.00-4.04), lack of outdoor activities (OR: 4.14, 95% CI: 2.08-8.21), and lower dietary dairy intake (OR: 0.59, 95% CI: 0.44-0.80) were independent risk factors for vitamin D deficiency. Vitamin D deficiency was common in CCSs and associated with female gender, obesity, lack of outdoor activities, and lower dietary dairy intake. Regular 25(OH)D screening should be established in long-term care to identify those who require vitamin D supplements.

Cardiorespiratory fitness in adolescents and young adults with Klinefelter syndrome - a pilot study

BACKGROUND

Klinefelter syndrome (KS) may be associated with a wide spectrum of phenotypic changes including endocrine, metabolic, cognitive, psychiatric and cardiorespiratory pathologies in adults. However, in adolescence the clinical phenotype of KS is not well described, especially regarding physical fitness. The present study reports on cardiorespiratory function in adolescents and young adults with KS.

METHODS

Adolescents and young adults with KS were recruited in a cross-sectional pilot study. Biochemical parameters of fitness including hormonal status, a body impedance analysis, the grip strength, the amount of physical activity at home for 5 days via trackbands and anamnestic parameters were assessed. In addition, participants underwent an incremental symptom-limited cardiopulmonary exercise test (CPET) on a bicycle ergometer.

RESULTS

Nineteen participants with KS aged 15.90 ± 4.12 years (range: 9.00 - 25.00) participated in the study. Pubertal status was Tanner 1 (n = 2), Tanner 2 - 4 (n = 7) and Tanner 5 (n = 10). Seven participants received testosterone replacement therapy. Mean BMI z-score was 0.45 ± 1.36 and mean fat mass was 22.93% ± 9.09. Grip strength was age-appropriate or above normal. 18 participants underwent CPET with subnormal results for maximum heart rate (z-score -2.84 ± 2.04); maximum workload (Watt_max; z score -1.28 ± 1.15) and maximum oxygen uptake per minute (z- score -2.25 ± 2.46). Eight participants (42.1%) met the criteria for chronotropic insufficiency (CI). Data from track-bands showed sedentary behavior for 81.15% ± 6.72 of the wear time.

CONCLUSION

A substantial impairment of cardiopulmonary function can be detected in this group of boys to young adults with KS, including chronotropic insufficiency in 40%. The track-band data suggest a predominantly sedentary lifestyle, despite normal muscular strength as assessed via grip strength. Future studies need to investigate the cardiorespiratory system and its adaption to physical stress in a larger cohort and in more detail. It is feasible that the observed impairments contribute to the avoidance of sports in individuals with KS and may contribute to the development of obesity and the unfavorable metabolic phenotype.

Prevalence of osteopathologies in a single center cohort of survivors of childhood primary brain tumor

Background

Childhood primary brain tumors (CPBT) are the second largest group of childhood malignancies and associated with a high risk for endocrine late effects.

Objective

To assess endocrine late effects and their relevance for the development of osteopathologies in survivors.

Methods

This single center cross sectional study investigated data from 102 CPBT survivors with a mean age of 13.0 years and a mean age at diagnosis of 8.7 years. Clinical, biochemical, radiographic, and anamnestic data regarding endocrine and bone health were obtained at study visits. In addition, data regarding tumor stage and therapy was obtained by chart review. An expert opinion was applied to define presence of osteopathologies.

Results

Impaired bone health, defined by at least one pathological screening parameter, was present in 65% of patients. 27.5% were found to have overt osteopathologies per expert opinion. 37.8% displayed a severe vitamin D deficiency (25-OH vitamin D < 10 ng/ml) and 11% a secondary hyperparathyroidism. Patients with osteopathologies had lower 25-OH vitamin D levels compared to patients without osteopathologies. Multiple endocrine late effects were present: diabetes insipidus in 10.8%, aberrant pubertal development in 13.7%, central hypocortisolism in 14.9%, thyroid dysfunction in 23.8% and growth hormone deficiency in 21.8%. A total of 31.3% of survivors displayed any endocrinopathy. Tumors located near hypothalamic structures and patients who received irradiation had a higher likelihood of endocrine morbidity.

Conclusion

This study indicates that endocrine deficiencies are common in pediatric survivors of CPBTs. Osteopathologies are present in this cohort. A prominent effect of hormonal deficiencies on bone health was not detected, possibly because patients were sufficiently treate for their endocrine conditions or indicating resilience of the childhood bone remodeling process. Vitamin D deficiency is frequent and should be treated as recommended.

The Role of Nutritional Status, Gastrointestinal Peptides, and Endocannabinoids in the Prognosis and Treatment of Children with Cancer

Neoplastic diseases in children are the second most frequent cause of death among the young. It is estimated that 400,000 children worldwide will be diagnosed with cancer each year. The nutritional status at diagnosis is a prognostic indicator and influences the treatment tolerance. Both malnutrition and obesity increase the risk of mortality and complications during treatment. It is necessary to constantly search for new factors that impair the nutritional status. The endocannabinoid system (ECS) is a signaling system whose best-known function is regulating energy balance and food intake, but it also plays a role in pain control, embryogenesis, neurogenesis, learning, and the regulation of lipid and glucose metabolism. Its action is multidirectional, and its role is being discovered in an increasing number of diseases. In adults, cannabinoids have been shown to have anti-cancer properties against breast and pancreatic cancer, melanoma, lymphoma, and brain tumors. Data on the importance of both the endocannabinoid system and synthetic cannabinoids are lacking in children with cancer. This review highlights the role of nutritional status in the oncological treatment process, and describes the role of ECS and gastrointestinal peptides in regulating appetite. We also point to the need for research to evaluate the role of the endocannabinoid system in children with cancer, together with a prospective assessment of nutritional status during oncological treatment.