Vitamin D nutritional status and bone turnover markers in childhood acute lymphoblastic leukemia survivors: A PETALE study

Telomerase Inhibition in the Treatment of Leukemia: A Comprehensive Review

Leukemia, characterized by the uncontrolled proliferation and differentiation blockage of myeloid or lymphoid precursor cells, presents significant therapeutic challenges despite current treatment modalities like chemotherapy and stem cell transplantation. Pursuing novel therapeutic strategies that selectively target leukemic cells is critical for improving patient outcomes. Natural products offer a promising avenue for developing effective chemotherapy and preventive measures against leukemia, providing a rich source of biologically active compounds. Telomerase, a key enzyme involved in chromosome stabilization and mainly active in cancer cells, presents an attractive target for intervention. In this review article, we focus on the anti-leukemic potential of natural substances, emphasizing vitamins (such as A, D, and E) and polyphenols (including curcumin and indole-3-carbinol), which, in combination with telomerase inhibition, demonstrate reduced cytotoxicity compared to conventional chemotherapies. We discuss the role of human telomerase reverse transcriptase (hTERT), particularly its mRNA expression, as a potential therapeutic target, highlighting the promise of natural compounds in leukemia treatment and prevention.

Nutritional assessment and dietary intervention among survivors of childhood cancer: current landscape and a look to the future

Over 85% of childhood cancer patients become long-term survivors. Still, cancer and its therapies are associated with a myriad of long-term complications such that childhood cancer survivors (CCS) endure excess disease burden, morbidity, and mortality throughout their lifetimes. Existing literature suggests that CCS maintain poor dietary intake and nutritional status. Thus, as childhood cancer cure rates continue to improve, the role of diet and nutrition in mitigating many of the most common adverse long-term health outcomes among CCS has gained significant interest. Herein we present an in-depth review of existing scientific literature evaluating dietary intake and nutrition status among CCS and its impact on treatment-related health complications; as well as contemporary intervention strategies aimed at overcoming distinctive barriers and improving deleterious lifestyle behaviors in this heterogeneous, at-risk population. Patient-specific, clinical, and systemic factors act as barriers to the timely conduct of comprehensive dietary/nutritional assessments and provision of tailored, risk-based recommendations. This Mini Review discusses the current state of the science, persisting research gaps, and opportunities for advancement of assessment and intervention strategies to address the unique needs of CCS. Search Strategy: We searched PubMed for peer-reviewed articles with the search terms "pediatric cancer," "pediatric malignancy," "pediatric oncology," "childhood cancer," "survivorship," "cancer late effects," "long-term follow-up," "body mass index," "nutritional status," "malnutrition," "body weight," "body weight changes," "body composition," "obesity," "overweight ", "Mediterranean diet," "DASH diet," "processed foods," "micronutrients," "antioxidants," "vitamin D," "calcium," "selenium," "zinc," "metabolic syndrome," "heart disease," "cardiovascular disease," "cardiometabolic disease," "hypertension," "hyperlipidemia," "HDL," "LDL," and "small dense LDL" from January 1, 1995, to July 21, 2023. We also selected relevant articles from our personal files and from reference lists of identified papers. We prioritized publications after 2013; however, commonly cited and highly regarded (defined by high citation count and journal impact factor) older publications were also included. Randomized controlled trials, observational studies, retrospective studies, meta-analysis, editorials, and review articles were included, whereas conference abstracts and case reports were excluded. We only searched for articles published in English, or those translated into English.

Innovative strategies to predict and prevent the risk for malnutrition in child, adolescent, and young adult cancer survivors

Children, adolescents, and young adult cancer survivors (CAYAs) constitute a growing population requiring a customized approach to mitigate the incidence of severe complications throughout their lifetimes. During cancer treatment, CAYAs cancer survivors undergo significant disruptions in their nutritional status, elevating the risks of mortality, morbidity, and cardiovascular events. The assessment of nutritional status during cancer treatment involves anthropometric and dietary evaluations, emphasizing the necessity for regular assessments and the timely identification of risk factors. Proactive nutritional interventions, addressing both undernutrition and overnutrition, should be tailored to specific age groups and incorporate a family-centered approach. Despite encouraging interventions, a notable evidence gap persists. The goal of this review is to comprehensively examine the existing evidence on potential nutritional interventions for CAYAs cancer survivors. We explore the evidence so far collected on the nutritional intervention strategies elaborated for CAYAs cancer survivors that should target both undernutrition and overnutrition, being age-specific and involving a family-based approach. Furthermore, we suggest harnessing artificial intelligence (AI) to anticipate and prevent malnutrition in CAYAs cancer survivors, contributing to the identification of novel risk factors and promoting proactive, personalized healthcare.

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.

Bone Turnover Markers in Children: From Laboratory Challenges to Clinical Interpretation

Bone turnover markers (BTMs) have been developed many years ago to study, in combination with imaging techniques, bone remodeling in adults. In children and adolescents, bone metabolism differs from adults since it implies both growth and bone remodeling, suggesting an age- and gender-dependent BTM concentration. Therefore, specific studies have evaluated BTMs in not only physiological but also pathological conditions. However, in pediatrics, the use of BTMs in clinical practice is still limited due to these many children-related specificities. This review will discuss about physiological levels of BTMs as well as their modifications under pathological conditions in children and adolescents. A focus is also given on analytical and clinical challenges that restrain BTM usefulness in pediatrics.

Osteoporosis in Childhood Cancer Survivors: Physiopathology, Prevention, Therapy and Future Perspectives

Simple Summary

Anti-cancer treatments induced an increase in the childhood cancer survival rate. However, they are responsible for several long-term side effects in childhood cancer survivors, including osteoporosis. Cancer itself, a sedentary lifestyle, and an unhealthy diet might adversely affect bone health. Early identification and adequate management of bone fragility in childhood cancer survivors could be useful to prevent osteoporosis onset and consequently fragility fractures.

Abstract

The improvement of chemotherapy, radiotherapy, and surgical interventions, together with hematopoietic stem cell transplantation, increased childhood cancer survival rate in the last decades, reaching 80% in Europe. Nevertheless, anti-cancer treatments are mainly responsible for the onset of long-term side effects in childhood cancer survivors (CCS), including alterations of the endocrine system function and activity. In particular, the most frequent dysfunction in CCS is a metabolic bone disorder characterized by low bone mineral density (BMD) with increased skeletal fragility. BMD loss is also a consequence of a sedentary lifestyle, malnutrition, and cancer itself could affect BMD, thus inducing osteopenia and osteoporosis. In this paper, we provide an overview of possible causes of bone impairment in CCS in order to propose management strategies for early identification and treatment of skeletal fragility in this population.

The Role of Nutrition in Primary and Secondary Prevention of Cardiovascular Damage in Childhood Cancer Survivors

Innovative therapeutic strategies in childhood cancer led to a significant reduction in cancer-related mortality. Cancer survivors are a growing fragile population, at risk of long-term side effects of cancer treatments, thus requiring customized clinical attention. Antineoplastic drugs have a wide toxicity profile that can limit their clinical usage and spoil patients’ life, even years after the end of treatment. The cardiovascular system is a well-known target of antineoplastic treatments, including anthracyclines, chest radiotherapy and new molecules, such as tyrosine kinase inhibitors. We investigated nutritional changes in children with cancer from the diagnosis to the end of treatment and dietary habits in cancer survivors. At diagnosis, children with cancer may present variable degrees of malnutrition, potentially affecting drug tolerability and prognosis. During cancer treatment, the usage of corticosteroids can lead to rapid weight gain, exposing children to overweight and obesity. Moreover, dietary habits and lifestyle often dramatically change in cancer survivors, who acquire sedentary behavior and weak adherence to dietary guidelines. Furthermore, we speculated on the role of nutrition in the primary prevention of cardiac damage, investigating the potential cardioprotective role of diet-derived compounds with antioxidative properties. Finally, we summarized practical advice to improve the dietary habits of cancer survivors and their families.

Broad application prospects of bone turnover markers in pediatrics

BACKGROUND

Bone turnover markers (BTMs) have been studied for application in clinical medicine. However, BTMs in children are challenging, and few studies explore these BTMs in children. The application of BTMs is complicated mainly due to pre-analytical factors, variable reference intervals of age- and sex-related BTMs for adolescents and children in different regions and laboratories. Therefore, laboratory testing of BTMs is critical for understanding pediatric bone development and metabolism, which provides additional information about bone development and diseases.

METHODS

Literature search was conducted using the MeSH term "child" combined with the terms that bone turnover markers such as "osteocalcin," "Procollagen type I N-terminal propeptide," "procollagen type I C-terminal propeptide," "osteocalcin," "N-terminal cross-linked telopeptide," and "C-terminal cross-linked telopeptide," Several databases including Web of Science, Google Scholar, and PubMed were searched to obtain the relevant studies.

RESULTS

BTMs represent the combined effects of skeletal development, growth, and remodeling in children, which can be used in clinical pediatrics to assist in the diagnosis and prognosis of bone metabolic disorders.

CONCLUSION

BTMs are clearly helpful for diagnosis and monitoring of bone growth and development as well as bone metabolic disorders.

Relationships between Bone Turnover Markers and Factors Associated with Metabolic Syndrome in Prepubertal Girls and Boys

The associations between individual components of metabolic syndrome (MetS) and bone health in children are complex, and data on this topic are sparse and inconsistent. We assessed the relationship between bone turnover markers and markers of the processes underlying MetS (insulin resistance and inflammation) in a group of presumably healthy children aged 9–11 years: 89 (51 girls, 38 boys) presenting without any features of MetS and 26 (10 girls, 16 boys) with central obesity and two features of MetS. Concentrations of glucose, triglycerides (TG), HDL cholesterol (HDL-C), C-reactive protein (CRP), HbA1c, total 25-hydroxyvitamin D (25(OH)D), intact-P1NP (N-terminal propeptide of type I procollagen), CTX-1 (C-terminal telopeptide of type I collagen) were assayed and insulin resistance was assessed (HOMA-IR). BMI centile, waist circumference (WC) and blood pressure were measured. The presence of MetS in girls resulted in significantly lower concentrations of CTX-1 and a trend to lower CTX-1 in boys. The concentrations of bone formation marker i-P1NP were not affected. Among the features associated with MetS, HOMA-IR appeared as the best positive predictor of MetS in girls, whereas CRP was the best positive predictor in boys. A significant influence of HOMA-IR on the decrease in CTX-1 in girls was independent of BMI centile and WC, and the OR of having CTX-1 below the median was 2.8-fold higher/1SD increased in HOMA-IR (p = 0.003). A weak relationship between CTX-1 and CRP was demonstrated in girls (r = −0.233; p = 0.070). Although TG, as a MetS component, was the best significant predictor of MetS in both sexes, there were no correlations between bone markers and TG. We suggest that dyslipidemia is not associated with the levels of bone markers in prepubertal children whereas CRP is weakly related to bone resorption in girls. In prepubertal girls, insulin resistance exerts a dominant negative impact on bone resorption, independent of BMI centile and waist circumference.

Effect of fasting hyperglycemia and insulin resistance on bone turnover markers in children aged 9-11 years

AIM

Impaired regulation of glucose metabolism in childhood adversely affects bone health. We assessed the effect of fasting hyperglycemia and insulin resistance on bone turnover markers in prepubertal children with normal glycemia (<100 mg/dL) and fasting hyperglycemia (100-125 mg/dL).

METHODS

Glucose, hemoglobin A1c, IGF-I (insulin-like growth factor I), iP1NP (N-terminal propeptide of type I procollagen), CTX-1 (C-terminal telopeptide of type I collagen) and insulin were measured. Bone turnover index (BTI) and HOMA-IR (homeostasis model assessment) were calculated.

RESULTS

Bone resorption marker (CTX) levels were decreased by 26.5% in boys with hyperglycemia, though only 7% in girls. Hyperglycemia had no effect on the bone formation marker iP1NP. IGF-1, the best predictor of bone marker variance accounted for 25% of iP1NP and 5% of CTX variance. Girls presented significantly higher BTI indicating the predominance of bone formation over resorption. Insulin resistance significantly decreased CTX. In girls, HOMA-IR and IGF-1 predicted 15% of CTX variance.

CONSLUSIONS

Fasting hyperglycemia and insulin resistance in children impact bone turnover suppressing bone resorption. Hyperglycemia decreased resorption, particularly in boys, while suppression of resorption by insulin resistance was more pronounced in girls. We suggest that the progression of disturbances accompanying prediabetes, may interfere with bone modelling and be deleterious to bone quality in later life.

Low Serum 25-hydroxyvitamin D Level Does Not Adversely Affect Bone Turnover in Prepubertal Children

Both vitamin D and insulin-like growth factor 1 (IGF-1) play essential roles in bone metabolism and may interact during prepubertal bone accrual. We investigated the association of low serum 25-hydroxyvitamin D (25(OH)D) (<20 ng/mL) with the circulating bone turnover markers, when compared to their interaction with IGF-1. Subjects and Methods: Serum 25(OH)D, IGF-I, P1NP (N-terminal propeptide of type I procollagen), and CTX-1 (C-terminal telopeptide of type I collagen) were measured, and the bone turnover index (BTI) was calculated in 128 healthy children, aged 9–11 years. Results: Mean 25(OH)D concentration was 21.9 ± 4.9 ng/mL, but in 30.5% of participants it was <20 ng/mL (<50 nmol/L). We observed a trend for higher P1NP (p < 0.05) and IGF-1 (p = 0.08), towards lower 25(OH)D in tertiles. Levels of P1NP in the lowest 25(OH)D tertile (<20 ng/mL) were the highest, while CTX and BTI remained unchanged. Additionally, 25(OH)D negatively correlated with IGF-1, while the correlation with P1NP was not significant. A strong positive correlation of IGF-1 with P1NP and BTI but weak with CTX was observed. Low 25(OH)D (<20 ng/mL) explained 15% of the IGF-1 variance and 6% of the P1NP variance. Conclusions: Low levels of 25(OH)D do not unfavorably alter bone turnover. It seems that serum 25(OH)D level may not be an adequate predictor of bone turnover in children.

Genetic polymorphism of vitamin D receptors and plasminogen activator inhibitor-1 and osteonecrosis risk in childhood acute lymphoblastic leukemia

BACKGROUND

Osteonecrosis (ON) is one of the major therapy-related complications in childhood acute lymphoblastic leukemia (ALL). The purpose of the current study is to assess the frequency of ON in children with ALL and to detect whether polymorphisms in vitamin D receptor gene (VDR) and plasminogen activator inhibitor-1 (PAI-1) gene can affect the risk of ON.

PATIENTS AND METHODS

Nighty-six ALL children were enrolled. Serum 25-hydroxyvitamin D 25(OH)D levels were performed in addition to the detection of polymorphisms in PAI-1and VDR genes by polymerase chain reaction.

RESULTS

Ten out of 96 patients had ON (four males and six females aged above 10 years) and had an insufficient level of 25(OH)D. Fifty-two percent of patients had PAI-1 GG genotype while 48% had PAI-1 GA genotype. PAI-1 polymorphism was detected in 60% of all ON cases. The frequencies of VDR genotypes were CT (56.3%), CC (39.6%), and TT (4.2%). Osteonecrosis was found in eight patients with CC genotype and in two patients with CT genotype.

CONCLUSION

Osteonecrosis can develop early during the therapy of ALL. Older age and insufficient level of 25(OH)D were considered important risk factor for the development of osteonecrosis. PAT-1 and VDR gene polymorphism may be a genetic risk factor in its pathogenesis.

Bone health and hyperglycemia in pediatric populations

The impact of prediabetes and diabetes on skeletal health in the context of increased risk of fragility fractures in adults has been studied recently. However, the prevalence of diabetes, overweight, and obesity have also increased in younger subjects. Current data concerning bone metabolism based on assessment of markers for bone turnover and of bone quality in diabetes patients in diverse age groups appears to be inconsistent. This review synthesizes the current data on the assessment of bone turnover based on the use of circulating bone markers recommended by international organizations; the effects of age, gender, and other factors on the interpretation of the data; and the effects of type 1 and type 2 diabetes as well as hyperglycemia on bone quality and turnover with particular emphasis on the pediatric population. Early intervention in the pediatric population is necessary to prevent the progression of metabolic disturbances that accompany prediabetes and diabetes in the context of common low vitamin D status that may interfere with bone growth.

Is there a relationship between vitamin D nutritional status and metabolic syndrome in childhood acute lymphoblastic leukemia survivors? A PETALE study

BACKGROUND

Treatment of childhood acute lymphoblastic leukemia (cALL) has reached unprecedented success leading to survival rates reaching 90%. This is regrettably linked to increased risk of developing long-term health-related sequels into early adulthood.

OBJECTIVE

This study aims at assessing the relationship between the vitamin D status and metabolic biomarkers in PETALE, a well-characterized cohort of cALL survivors.

RESULTS

We demonstrate that 15.9% of the study participants exhibited 3 or more metabolic syndrome (MetS) risk factors. We also show a direct relationship between s25OHD₃ and plasma HDL-Cholesterol concentrations in female but not male participants.

CONCLUSION

Our data, from a metabolically well-described cohort, support a modest role for vitamin D in lipid metabolism in childhood leukemia survivors. The major outcome of this study is the strong association between HDL-Cholesterol concentration and s25OHD₃ only in female subjects, thereby conveying vitamin D a gender-specific cardio-protective effect. cALL survivors represent a population at higher risk for secondary diseases. For this reason thorough nutritional evaluation, including vitamin D should be part of the regular follow-up.

Best Practices for Conducting Observational Research to Assess the Relation between Nutrition and Bone: An International Working Group Summary

Diet is a modifiable factor that can affect bone strength and integrity, and the risk of fractures. Currently, a hierarchy of scientific evidence contributes to our understanding of the role of diet on bone health and fracture risk. The strength of evidence is generally based on the type of study conducted, the quality of the methodology employed, the rigor and integrity of the data collected and analysis plan, and the transparency and completeness of the results. Randomized controlled trials (RCTs) are considered to be the gold standard from a clinical research paradigm, but there is a dearth of high-quality diet-related intervention trials with bone as the primary outcome, forcing the use of observational research to inform research and clinical practices. However, for observational research to be of the most utility, standardization and optimization of the study design, accurate and reliable measurement of key variables, and appropriate data analysis and data reporting are paramount. Although there have been recommendations made in relation to RCTs in the field of nutrition, no clear rubric exists for best practices in conducting observational research with regard to nutrition and bone health. Therefore, the purpose of this paper is to describe the best practices and considerations for designing, conducting, analyzing, interpreting, and reporting observational research specifically for understanding the role of nutrition in bone health, amassed by a global panel of scientific experts with strengths in bone, nutrition epidemiology, physical activity, public health, clinical and translational trials, and observational study methods. The global panel of scientific experts represents the leadership and selected participants from the 10th annual International Symposium for the Nutritional Aspects of Osteoporosis. The topics selected and best practices presented reflect expert opinion and areas of scientific expertise of the authors rather than a systematic or comprehensive literature review or professional reporting guidelines.

Psychological risk in long-term survivors of childhood acute lymphoblastic leukemia and its association with functional health status: A PETALE cohort study

BACKGROUND

Recent research has suggested that long-term pediatric cancer survivors were at risk of important physical and psychological morbidities. To date, we do not know to what extent functional health status contributes to psychological risk and which domains are most important. The aim of this study was to systematically explore which functional domain could explain anxiety, depression, and distress symptoms.

PROCEDURE

We used data available for 105 adolescents and 182 adults successfully treated for childhood acute lymphoblastic leukemia at two Canadian sites part of the PETALE cohort. Participants were ≥5 years postdiagnosis, aged 22 ± 6 years, 52% female, and 49% acute lymphoblastic leukemia high-risk status. The contribution of health functional status (15D/16D questionnaires) to self-reported anxiety, depression, and distress (Beck scales and distress thermometer) was evaluated using adjusted logistic regression models.

RESULTS

Prevalence rates found for mild-severe anxiety, depression, and distress were 14%, 21%, and 30% among adolescents and 27%, 20%, and 19% among adults. Frequent health domains associated with psychological risk were sleeping and breathing in adolescents, and vitality/fatigue, discomfort/symptoms, mental function, and sleeping in adults. Mental function was systematically associated with psychological risk across age groups (median OR = 10.00, 95% CI 3.01-33.71). Exploratory mediation bootstrapping analyses suggested that the effect on psychological risk of overall health status and mental function problems was partly explained by social/work/school functioning.

CONCLUSION

The results identified important functional health domains that could be targeted for interventions preventing psychological risk: vitality/fatigue, discomfort/symptoms, sleeping, and mental function issues. Health domains probably affect mood partly by limiting social/work/school functioning.

Data for the measurement of serum vitamin D metabolites in childhood acute lymphoblastic leukemia survivors

This article describes data related to a companion research paper entitled “Vitamin D nutritional status and bone turnover biomarkers in childhood acute lymphoblastic leukemia (cALL) survivors.” (Delvin et al., submitted for publication) [1]. Various methods for the measurement of serum 25OHD₃, the accepted biomarker for assessing vitamin D nutritional status, have been described (Le Goff et al., 2015; Jensen et al., 2016) [2], [3]. This article describes a novel mass spectrometry-QTOF method for the quantification of circulating 25OHD₃, 3-epi-25OHD₃ and 24,25(OH)₂D₃. It provides the description of the extraction, chromatography and mass spectrometry protocols, a sample of mass spectra obtained from standards and extracted serum, and a comparison with another HPLC-MS/MS (Jensen et al., 2016) [3] method for the measurement of serum concentrations of 25OHD₃.