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Hill-Kayser C, Yorke E, Jackson A, Gracia C, Ginsberg J, Keene K, Ronckers C, Metzger ML, Li Z, Constine LS, Hua CH. Effects of Radiation Therapy on the Female Reproductive Tract in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:588-609. [PMID: 37804257 DOI: 10.1016/j.ijrobp.2023.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE The PENTEC (Pediatric Normal Tissue Effects in the Clinic) task force aimed to quantify effects of radiation therapy (RT) dose to the female reproductive organs after treatment for childhood cancer. METHODS AND MATERIALS Relevant studies published 1970 to 2017 were identified systematically through PubMed, Medline, and Cochrane databases with additional articles before 2021 identified by the group. Two large studies reported sufficient data to allow modeling of acute ovarian failure (AOF; loss of function ≤5 year from diagnosis) and premature ovarian insufficiency (POI; loss of function at attained age <40 years) based on maximum dose to least affected ovary. Although normal tissue complication probability modeling was not feasible for the uterus due to limited data, the relationship between ultrasound-measured uterine volume and estimated amount of RT was plotted. Limited data regarding vaginal toxicity were available. RESULTS The risk of AOF increases with RT dose to least affected ovary, alkylating agent cumulative dose (cyclophosphamide equivalent dose [CED] in g/m2), age at RT, and stem cell transplantation: Two Gy to the least affected ovary resulted in AOF risk of 1% to 5% (CED = 0, risk increasing with age), 4% to 7% (CED = 10 g/m2, risk increasing with age), and 6% to 13% (CED = 30 g/m2, risk increasing with age). For patients aged 1 and 20 years at time of RT, AOF risk was ≥50% at doses of 24 Gy and 20 Gy with no alkylating chemotherapy, 22.5 Gy and 17 Gy with intermediate alkylator dose (10 g/m2), and 17 Gy and 13 Gy with high alkylator dose (30 g/m2). Risk of POI increases with survivor (attained) age (rather than age at time of RT), radiation dose to least affected ovary, and alkylator dose. Data review suggested that higher radiation doses to the uterus are associated with uterine toxicity, with uterine size considerably restricted after 12 Gy. Vaginal radiation in children is associated with high toxicity risk, although dose-volume data are not available for quantification. CONCLUSIONS Risk of AOF increases with age at RT, CED exposure, and RT dose; risk of POI likewise increases with RT dose, CED exposure, and survivor age. Both AOF and POI are expected to affect fertility and estrogen production. Data suggest that RT uterine dose >12 Gy may be associated with uterine size restriction. Adult literature suggests that maintaining vaginal dose <5 Gy may limit toxicity. Treatment of life-threatening malignancy remains a priority over reproductive preservation; however, when possible, radiation and surgical techniques should be considered to minimize dose to least affected ovary, uterus, and vagina. Survivors should receive endocrine and gynecologic support; those desiring pregnancy should be counseled early to maximize reproductive options.
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Affiliation(s)
- Christine Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania & Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Clarisa Gracia
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jill Ginsberg
- Department of Pediatrics, Division of Oncology, Perelman School of Medicine, University of Pennsylvania & Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kimberly Keene
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama
| | - Cecile Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Monika L Metzger
- Department of Pediatric Hematology & Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Zhenghong Li
- Department of Epidemiology & Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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Gazzo I, Massarotti C, Chiodi S, Spinelli S, Gualandi F, Passamonti U, Fulcheri E, Angelucci E, Cagnacci A. Pregnancy complications after allogeneic hematopoietic stem cells transplantation: Focus on the placenta. Placenta 2023; 132:27-31. [PMID: 36623416 DOI: 10.1016/j.placenta.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/02/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION hematopoietic stem cells transplantation (HSCT) is a treatment option for malignant and non-malignant haematological diseases. Because of the improved survival rates and the more widespread use of reproductive technologies in the last two decades, the number of patients who conceive is increasing while the pathogenesis of some obstetrical complications observed is not yet fully clarified. METHODS we present complete data about two pregnancies in women who had previously undergone HSTC, with conditioning regimen including total body irradiation. One pregnancy is spontaneous and one after oocytes donation. RESULTS In both pregnancies we observed relevant intrauterine growth retardation, attributable to a deficit in implantation and placentation. Ultrasound and histological data point to a defective placenta development, possibly sustained by uterine vessel damage caused by irradiation. A deeper understanding of factors influencing placentation post total body irradiation and HSCT, including the possible role of donor's sex and graft versus host disease, is pivotal to improve pregnancy outcomes in this specific population.
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Affiliation(s)
- Irene Gazzo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Dept.), University of Genoa, Genova, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Claudia Massarotti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Dept.), University of Genoa, Genova, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | - Sandra Chiodi
- UO Hematology and Cell Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Simonetta Spinelli
- UO Hematology and Cell Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Gualandi
- UO Hematology and Cell Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Ezio Fulcheri
- Fetal-Perinatal Pathology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, Università di Genova, Genoa, Italy
| | - Emanuele Angelucci
- UO Hematology and Cell Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Angelo Cagnacci
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Dept.), University of Genoa, Genova, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Courbiere B, Drikes B, Grob A, Hamidou Z, Saultier P, Bertrand Y, Gandemer V, Plantaz D, Plat G, Poirée M, Ducassou S, Pochon C, Dalle JH, Thouvenin S, Paillard C, Kanold J, Sirvent A, Rousset-Jablonski C, Duros S, Gueniffey A, Cohade C, Boukaidi S, Frantz S, Agopiantz M, Poirot C, Genod A, Pirrello O, Gremeau AS, Bringer-Deutsch S, Auquier P, Michel G. The uterine volume is dramatically decreased after hematopoietic stem cell transplantation during childhood regardless of the conditioning regimen. Fertil Steril 2023; 119:663-672. [PMID: 36627013 DOI: 10.1016/j.fertnstert.2022.12.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To study the impact of hematopoietic stem cell transplantation (HSCT) on the uterine volume of childhood acute leukemia (AL) survivor depending on age at HSCT and the type of myeloablative conditioning regimen. SETTING Thirteen French University Teaching Hospitals. DESIGN Prospective cohort study. PATIENT(S) Eighty-eight women who underwent HSCT during childhood or adolescence for AL compared to a control group. INTERVENTION(S) A multicentric prospective national study compared the uterine volume in a cohort of childhood AL survivor adult women treated with HSCT, matched 1:1 to control women. Pelvic magnetic resonance imaging scans included diffusion-weighted imaging sequences. Scans were centralized for a double-blinded reading by 2 radiologists. MAIN OUTCOME MEASURE(S) Uterine volume, uterine body-to-cervix ratio, and apparent diffusion coefficient. RESULT(S) The mean age at HSCT was 9.1 ± 0.3 years with a mean follow-up duration of 16.4 ± 0.5 years. The cohort of 88 HSCT survivor women was composed of 2 subgroups depending on the myeloablative conditioning regimen received: an alkylating agent-based regimen group (n = 34) and a total body irradiation (TBI)-based regimen group (n = 54). Among the 88 women, 77 were considered as having a "correct hormonal balance" with estrogens supplied by hormone replacement therapy (HRT) for premature ovarian insufficiency (POI) or because of a residual ovarian function. In the control group (n = 88), the mean uterine volume was 79.7 ± 3.3 mL. The uterine volume significantly decreased in all HSCT survivor women. After the alkylating agent-based regimen, the uterine volume was 45.3 ± 5.6 mL, corresponding to a significant volume reduction of 43.1% (28.8-57.4%) compared with that of the control group. After TBI, the uterine volume was 19.6 ± 1.9 mL, corresponding to a significant volume reduction of 75.3% (70.5%-80.2%) compared with that of the control group. After the alkylating agent-based regimen, the uterine volume dramatically decreased in women with POI without HRT compared with that in those with a correct hormonal balance (15.2 ± 2.6 vs. 49.3 ± 6 mL). In contrast, after TBI, the uterine volume was similar in all women, with no positive effect of hormonal impregnation on the uterine volume (16.3 ± 2.6 vs. 20.1 ± 2.2 mL, respectively). CONCLUSION(S) The uterine volume was diminished after HSCT, regardless of the conditioning regimen. The physiopathology needs to be further investigated: specific impact of a high dose of an alkylating agent; impact of hormone deprivation around puberty; poor compliance to HRT; or different myometrial impact of HRT compared with endogenous ovarian estrogens? CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov/NCT03583294 (enrollment of the first subject, November 11, 2017; enrollment of the last subject, June 25, 2021).
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Affiliation(s)
- Blandine Courbiere
- Department of Gynecology-Obstetric and Reproductive Medicine, AP-HM, Hôpital La Conception/Aix-Marseille Université, IMBE, CNRS, IRD, Avignon Université, Marseille, France.
| | - Benjamin Drikes
- Department of Radiology, University Teaching Hospital Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Anaïs Grob
- Department of Radiology, University Teaching Hospital Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Zeinab Hamidou
- CEReS Research Unit EA 3279 and Department of Public Health, Hôpital de la Timone, Marseille, France
| | - Paul Saultier
- Department of Pediatric Hematology, Immunology and Oncology, AP-HM, La Timone Children's Hospital, Marseille, France; Aix Marseille Univ, INSERM, INRAe, C2VN, Marseille, France
| | - Yves Bertrand
- Department of Pediatric Hematology and Oncology, University Hospital of Lyon, Lyon, France
| | - Virginie Gandemer
- Department of Pediatric Hematology and Oncology, University Hospital of Rennes, Rennes, France
| | - Dominique Plantaz
- Department of Pediatric Hematology-Oncology, University Hospital of Grenoble, Grenoble, France
| | - Geneviève Plat
- Department of Pediatric Hematology and Oncology, University Hospital of Toulouse, Toulouse, France
| | - Maryline Poirée
- Department of Pediatric Hematology and Oncology, University Hospital L'Archet, Nice, France
| | - Stéphane Ducassou
- Department of Pediatric Hematology and Oncology, University Hospital of Bordeaux, Bordeaux, France
| | - Cécile Pochon
- Department of Pediatric Hematology and Oncology, Children's Hospital of Brabois, Vandoeuvre-Les-Nancy, France
| | - Jean-Hugues Dalle
- Department of Hematology and immunology, Hôpital Robert-Debré, GHU APHP-Nord Université de Paris-Cité, Paris, France
| | - Sandrine Thouvenin
- Department of Pediatric Onco-hematology, CHU de Saint-Etienne, Saint-Etienne, France
| | - Catherine Paillard
- Department of Pediatric Hematology-Oncology, University Hospital, Strasbourg, France
| | - Justyna Kanold
- Department of Pediatric Hematology and Oncology, CIC Inserm 501, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne Sirvent
- Department of Pediatric Onco-Hematology, University Hospital of Montpellier, Montpellier, France
| | - Christine Rousset-Jablonski
- Département de Chirurgie Oncologique, Centre Léon Bérard, Lyon, France, and Hospices Civils de Lyon, Département de Gynécologie-Obstétrique, Groupe Hospitalier Sud, Pierre Benite Cedex, France; INSERM U1290 RESHAPE RESearch in HealthcAre PErformance, Université Lyon 1, Lyon, France
| | - Solène Duros
- Département de Gynécologie-Obstétrique et Reproduction Humaine, CHU Rennes, Rennes, France
| | - Aurore Gueniffey
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), La Tronche, France
| | - Clementine Cohade
- Department of Reproductive Medicine, Toulouse University Hospital, Toulouse, France
| | - Samir Boukaidi
- Department of Obstetrics and Gynecology and Reproductive Medicine, CHU de Nice, Archet 2 Hospital, Nice, France
| | - Sandrine Frantz
- Service de Chirurgie Gynécologique et Médecine de la reproduction, Centre Aliénor d'Aquitaine, CHU de Bordeaux, place Amélie-Raba-Léon, Bordeaux cedex, France
| | - Mikael Agopiantz
- Department of Reproductive Medicine, CHRU de Nancy, Université de Lorraine, Nancy, France INSERM U1256, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Catherine Poirot
- Department of Hematology, AYA Unit, Saint Louis Hospital, Paris, France, Médecine Sorbonne Université, Site Pitié Salpêtrière, Paris, France, and Department of Reproductive Biology, Cochin Hospital AP-HP, Paris, France
| | - Anne Genod
- Service de Gynécologie-Obstétrique, Université Jean-Monnet, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - Olivier Pirrello
- Assisted Reproductive Technique Unit, CMCO, University Hospital of Strasbourg, Schiltigheim, France
| | - Anne-Sophie Gremeau
- Department of Gynecologic Surgery and IVF, Clermont-Ferrand, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Sophie Bringer-Deutsch
- Service de Gynécologie-Obstétrique et Médecine de la reproduction, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - Pascal Auquier
- CEReS Research Unit EA 3279 and Department of Public Health, Hôpital de la Timone, Marseille, France
| | - Gérard Michel
- CEReS Research Unit EA 3279 and Department of Public Health, Hôpital de la Timone, Marseille, France; Department of Pediatric Hematology, Immunology and Oncology, AP-HM, La Timone Children's Hospital, Marseille, France
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Rozen G, Rogers P, Chander S, Anderson R, McNally O, Umstad M, Winship A, Hutt K, Teh WT, Dobrotwir A, Hart R, Ledger W, Stern K. Clinical summary guide: reproduction in women with previous abdominopelvic radiotherapy or total body irradiation. Hum Reprod Open 2020; 2020:hoaa045. [PMID: 33134561 PMCID: PMC7585646 DOI: 10.1093/hropen/hoaa045] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/13/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What is the evidence to guide the management of women who wish to conceive following abdominopelvic radiotherapy (AP RT) or total body irradiation (TBI)? SUMMARY ANSWER Pregnancy is possible, even following higher doses of post-pubertal uterine radiation exposure; however, it is associated with adverse reproductive sequelae and pregnancies must be managed in a high-risk obstetric unit. WHAT IS KNOWN ALREADY In addition to primary ovarian insufficiency, female survivors who are treated with AP RT and TBI are at risk of damage to the uterus. This may impact on its function and manifest as adverse reproductive sequelae. STUDY DESIGN SIZE DURATION A review of the literature was carried out and a multidisciplinary working group provided expert opinion regarding assessment of the uterus and obstetric management. PARTICIPANTS/MATERIALS SETTING METHODS Reproductive outcomes for postpubertal women with uterine radiation exposure in the form of AP RT or TBI were reviewed. This included Pubmed listed peer-reviewed publications from 1990 to 2019, and limited to English language.. MAIN RESULTS AND THE ROLE OF CHANCE The prepubertal uterus is much more vulnerable to the effects of radiation than after puberty. Almost all available information about the impact of radiation on the uterus comes from studies of radiation exposure during childhood or adolescence.An uncomplicated pregnancy is possible, even with doses as high as 54 Gy. Therefore, tumour treatment doses alone cannot at present be used to accurately predict uterine damage. LIMITATIONS REASONS FOR CAUTION Much of the data cannot be readily extrapolated to adult women who have had uterine radiation and the publications concerning adult women treated with AP RT are largely limited to case reports. WIDER IMPLICATIONS OF THE FINDINGS This analysis offers clinical guidance and assists with patient counselling. It is important to include patients who have undergone AP RT or TBI in prospective studies to provide further evidence regarding uterine function, pregnancy outcomes and correlation of imaging with clinical outcomes. STUDY FUNDING/COMPETING INTERESTS This study received no funding and there are no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- G Rozen
- Reproductive Services, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne and Gynaecology Research Centre, Parkville, VIC, Australia.,Melbourne IVF, East Melbourne, VIC, Australia
| | - P Rogers
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne and Gynaecology Research Centre, Parkville, VIC, Australia
| | - S Chander
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - R Anderson
- University of Edinburgh, MRC Centre for Reproductive Health Queens Medical Research Institute, Edinburgh, UK
| | - O McNally
- Royal Women's Hospital, Gynae-Oncology Unit, Parkville, VIC, Australia
| | - M Umstad
- Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne School of BioSciences, Melbourne, VIC, Australia
| | - A Winship
- Development and Stem Cells Program, Monash University Monash Biomedicine Discovery Institute, Clayton, VIC, Australia.,Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC, Australia
| | - K Hutt
- Development and Stem Cells Program, Monash University Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
| | - W T Teh
- Reproductive Services, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne and Gynaecology Research Centre, Parkville, VIC, Australia.,Melbourne IVF, East Melbourne, VIC, Australia
| | - A Dobrotwir
- Royal Women's Hospital, Radiology, Parkville, VIC, Australia
| | - R Hart
- University of Western Australia, School of Womens and Infants Health University of Western Australia King Edward Memorial Hospital Subiaco, Perth, WA, Australia
| | - W Ledger
- University of New South Wales, School of Womens and Childrens Health Level 1, Royal Hospital for Women, Sydney, NSW, Australia
| | - K Stern
- Reproductive Services, Royal Women's Hospital, Parkville, VIC, Australia.,Melbourne IVF, East Melbourne, VIC, Australia
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Abstract
PURPOSE OF REVIEW Iatrogenic ovarian damage can occur after chemotherapy, radiotherapy and surgery for cancer as well as for non-malignant conditions. This review describes the effects of such treatment on antimullerian hormone (AMH) and the implications of the fall in AMH in relation to ovarian function and fertility, especially in the era of improved fertility preservation strategies. RECENT FINDINGS The risk of gonadotoxicity differs between chemotherapy regimens. There is growing evidence that pretreatment AMH has prognostic significance for the degree of fall in AMH after treatment, the reversibility of ovarian damage and risk of premature ovarian insufficiency. The accuracy of prediction increases when age is coupled with AMH. The adverse effect of removal of endometriomas is increasingly clear, and AMH pre and post surgery useful is assessing the degree of damage to the ovary. The implications of low AMH after such treatment on natural fertility and reproductive lifespan are less clear. Apart from treatment effects, there are other coexisting conditions that can affect AMH which needs to be taken into consideration during interpretation of AMH before and after treatment. SUMMARY A fall in AMH in women after gonadotoxic treatment has been consistently described, with variable recovery, the accurate interpretation and clinical application of post-treatment AMH level on reproductive lifespan and fertility prediction needs to be studied in future larger prospective studies with longer follow-up.
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Affiliation(s)
- Queenie Ho Yan Wong
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong
| | - Richard A. Anderson
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
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Oktem O, Kim SS, Selek U, Schatmann G, Urman B. Ovarian and Uterine Functions in Female Survivors of Childhood Cancers. Oncologist 2017; 23:214-224. [PMID: 29158370 DOI: 10.1634/theoncologist.2017-0201] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/21/2017] [Indexed: 01/27/2023] Open
Abstract
Adult survivors of childhood cancers are more prone to developing poor reproductive and obstetrical outcomes than their siblings and the general population as a result of previous exposure to chemotherapy and radiation during childhood. Chemotherapy drugs exert cytotoxic effects systemically and therefore can damage the ovaries, leading to infertility, premature ovarian failure, and, to a lesser extent, spontaneous abortions. They have very limited or no deleterious effects on the uterus that can be recognized clinically. By contrast, radiation is detrimental to both the ovaries and the uterus, thereby causing a greater magnitude of adverse effects on the female reproductive function. These include infertility, premature ovarian failure, miscarriage, fetal growth restrictions, perinatal deaths, preterm births, delivery of small-for-gestational-age infants, preeclampsia, and abnormal placentation. Regrettably, the majority of these adverse outcomes arise from radiation-induced uterine injury and are reported at higher incidence in the adult survivors of childhood cancers who were exposed to uterine radiation during childhood in the form of pelvic, spinal, or total-body irradiation. Recent findings of long-term follow-up studies evaluating reproductive performance of female survivors provided some reassurance to female cancer survivors by documenting that pregnancy and live birth rates were not significantly compromised in survivors, including those who had been treated with alkylating agents and had not received pelvic, cranial, and total-body irradiation. We aimed in this narrative review article to provide an update on the impact of chemotherapy and radiation on the ovarian and uterine function in female survivors of childhood cancer. IMPLICATIONS FOR PRACTICE Adult survivors of childhood cancers are more prone to developing a number of poor reproductive and obstetrical outcomes than their siblings and the general population as a result of previous exposure to chemotherapy and radiation during childhood. The impact of radiation therapy on the female genital system is greater than chemotherapy regimens because radiation is detrimental to both the uterus and the ovaries, whereas toxic effects of chemotherapy drugs are confined to the ovaries. Therefore, radiation-induced uterine damage accounts for most poor obstetrical outcomes in the survivors. These include infertility, miscarriages, stillbirths, fetal growth restrictions, preeclampsia, and preterm deliveries.
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Affiliation(s)
- Ozgur Oktem
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
- Assisted Reproduction Unit, Fertility Preservation Program, American Hospital Women's Health Center, Istanbul, Turkey
| | - Samuel S Kim
- Department of Obstetrics and Gynecology, School of Medicine, Kansas University, Kansas City, Kansas, USA
| | - Ugur Selek
- Department of Radiation Oncology, Koc University School of Medicine and MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, Comprehensive Cancer Care Program, American Hospital, Istanbul, Turkey
| | - Glenn Schatmann
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Medical College of Cornell University, New York, New York, USA
| | - Bulent Urman
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
- Assisted Reproduction Unit, Fertility Preservation Program, American Hospital Women's Health Center, Istanbul, Turkey
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Abstract
INTRODUCTION Disorders of sex development (DSD) is a congenital condition in which the development of chromosomal, gonadal or genital sex is atypical. Majority of patients present clinical characteristics of primary amenorrhea, absent secondary sex characters, and abnormal hormone level. A female appearance patient with primary amenorrhea and 46 XY karyotype seems to be solid evidences to diagnose Y-chromosome-related DSD diseases, while it is not necessarily the accurate diagnosis. We report the case of an 18-year-old girl with primary amenorrhea and 46 XY karyotype misdiagnosed as Y-chromosome-related DSD. CLINICAL FINDINGS The patient has normal female reproductive organs and a disrupted pubertal development after the treatment for acute myeloid leukemia (AML). We consider that her gonads were probably functional and later impaired after AML. The clinical manifestations were not consistent with DSD. With doubts, we found that she received bone marrow transplantation (BMT) from her brother and adjuvant chemotherapy 6 years ago. Her karyotype changed from normal female to a karyotype of donor (her brother) origin after BMT.Adjuvant chemotherapy for AML may impair her ovarian function and finally bring about disrupted puberty or primary ovarian insufficiency (POI). INTERVENTIONS We provided close follow-up. OUTCOMES During the second visit, the patient had her menarche lasting 4 days without any medication. CONCLUSION The present case serves as a reminder that a correct diagnosis depends on the comprehensive collection of present and past medical history, complete physical examination, and careful evaluation of related adjuvant tests. Do not presumptively judge a test and mislead reasoning. In addition, ovarian function protection should be considered for young girls having chemotherapy.
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Affiliation(s)
| | - Qinjie Tian
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Correspondence: Qinjie Tian, Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, China (e-mail: )
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Abstract
Purpose of review To provide an update on the latest clinical applications of serum antimüllerian hormone (AMH) testing with practical approaches to mitigate the impact of significant variability in AMH results. Recent findings Recent studies continue to demonstrate that AMH is the best single serum test for ovarian response management with, at most, a weak-to-moderate age-independent association with live-birth rate and time to conception. Data confirm serum AMH levels improve menopause prediction, monitoring of ovarian damage, and identification of women at risk for several ovary-related disorders such as polycystic ovary syndrome and premature or primary ovarian insufficiency. However, it is now recognized that serum AMH results can have dramatic variability due to common, biologic fluctuations within some individuals, use of hormonal contraceptives or other medications, certain surgical procedures, specimen treatment, assay changes, and laboratory calibration differences. Practical guidelines are provided to minimize the impact of variability in AMH results and maximize the accuracy of clinical decision-making. Summary AMH is an ovarian biomarker of central importance which improves the clinical management of women's health. However, with the simultaneous rapid expansion of AMH clinical applications and recognition of variability in AMH results, consensus regarding the clinical cutpoints is increasingly difficult. Therefore, a careful approach to AMH measurement and interpretation in clinical care is essential.
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Sklavos MM, Stratton P, Giri N, Alter BP, Savage SA, Pinto LA. Reduced serum levels of anti-Müllerian hormone in females with inherited bone marrow failure syndromes. J Clin Endocrinol Metab 2015; 100:E197-203. [PMID: 25405500 PMCID: PMC4318906 DOI: 10.1210/jc.2014-2838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Previously, reduced levels of anti-Müllerian hormone (AMH), a circulating marker of ovarian reserve, were found in females with Fanconi anemia (FA). FA, dyskeratosis congenita (DC), and Diamond-Blackfan anemia (DBA) are inherited bone marrow failure syndromes (IBMFS) associated with high risks of bone marrow failure, leukemia, and solid tumors. OBJECTIVE The objective of the study was to assess AMH levels in females with DC or DBA. DESIGN AND SETTING This observational study used the National Cancer Institute's inherited bone marrow failure syndrome cohort at the National Institutes of Health Clinical Center. PARTICIPANTS The study included females with DC, unaffected female relatives of patients with DC, females with DBA, unaffected female relatives of patients with DBA, and unrelated healthy female volunteers younger than 41 years of age. MAIN OUTCOME MEASURE Serum AMH levels were measured. RESULTS Females with DC had significantly lower levels of AMH (median 0.55 ng/mL) compared with unaffected relatives (median 2.28 ng/mL, P = .004) or unrelated healthy volunteers (median 2.69 ng/mL, P = .005). Females with DBA showed a nonsignificant trend for lower levels of AMH (median 0.89 ng/mL) compared with unaffected relatives (median 1.71 ng/mL, P = .21) or unrelated healthy volunteers (P = .11). Patients with DC and DBA had significantly higher levels of AMH (P = .013, P = .003) compared with FA (median 0.05 ng/mL). CONCLUSIONS Our findings suggest that women with IBMFS have lower levels of AMH than unaffected women. This AMH deficiency could be a primary ovarian defect or a consequence of the pathophysiology of the syndromes. Additional studies of AMH and ovarian function in women with IBMFS are warranted to better understand the underlying biology.
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Affiliation(s)
- Martha M Sklavos
- Human Papillomavirus Immunology Laboratory (M.M.S., L.A.P.), Leidos Biomedical Research, Incorporated, Frederick National Laboratory for Cancer Research, Frederick, Maryland 21702; Program in Reproductive and Adult Endocrinology (P.S.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Clinical Genetics Branch (N.G., B.P.A., S.A.S.), Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland 20852
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Wei C, Albanese A. Endocrine Disorders in Childhood Cancer Survivors Treated with Haemopoietic Stem Cell Transplantation. Children (Basel) 2014; 1:48-62. [PMID: 27417467 PMCID: PMC4939518 DOI: 10.3390/children1010048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 12/25/2022]
Abstract
The increasing number of haemopoietic stem cell transplantations (HSCT) taking place worldwide has offered a cure to many high risk childhood malignancies with an otherwise very poor prognosis. However, HSCT is associated with an increased risk of morbidity and premature death, and patients who have survived the acute complications continue to face lifelong health sequelae as a result of the treatment. Endocrine dysfunction is well described in childhood HSCT survivors treated for malignancies. The endocrine system is highly susceptible to damage from the conditioning therapy, such as, alkylating agents and total body irradiation, which is given prior stem cell infusion. Although not immediately life-threatening, the impact of these abnormalities on the long term health and quality of life in these patients may be considerable. The prevalence, risk factors, clinical approaches to investigations and treatments, as well as the implications of ongoing surveillance of endocrine disorders in childhood HSCT survivors, are discussed in this review.
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Affiliation(s)
- Christina Wei
- St Georges Hospital, St Georges Health Care NHS Trust, Tooting, London SW17 0QT, UK.
| | - Assunta Albanese
- St Georges Hospital, St Georges Health Care NHS Trust, Tooting, London SW17 0QT, UK.
- Royal Marsden Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK.
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