1
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Tinsley H, Gramatges M, Dreyer Z, Okcu MF, Shakeel O. Barriers to long-term follow-up in pediatric Hodgkin lymphoma survivors. Pediatr Blood Cancer 2024; 71:e30855. [PMID: 38200619 DOI: 10.1002/pbc.30855] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND/PURPOSE Pediatric Hodgkin lymphoma (HL) survivors have an increased risk of late effects following treatment. Barriers at the patient, provider, and payor level adversely affect adherence to long-term follow-up. METHODS We conducted a retrospective chart review of HL survivors diagnosed from 1999 to 2014 at Texas Children's Hospital. HL survivors were considered lost to follow-up if there were no documented visits to Texas Children's Cancer Center Long-Term Survivor (LTS) clinic for 2 or more years after their last LTS clinic visit. Univariate and multivariable logistic regression analyses were conducted to explore factors contributing to loss to follow-up. Reasons for not attending subsequent LTS visits were assessed by phone interviews in a subset of lost to follow-up patients. RESULTS There were 120 HL survivors who had at least one LTS clinic visit in this timeframe; 64 (53%) were classified as lost to follow-up, and of these, 23 (36%) were interviewed. Eleven (47%) indicated that the reason for failure to follow-up was lack of or inadequate insurance, and seven (30%) stated they were unaware of the importance of continued follow-up. Loss to follow-up was associated with lack of insurance, earlier diagnosis, and lack of comorbidities in univariate analyses. Only earlier year of diagnosis (odds ratio [OR] 0.84, 95% confidence interval [CI]: 0.7-0.9, p = .01) and lack of insurance (OR 22.2, 95% CI: 4-123, p < .001) were associated with loss to follow-up in multivariable analyses. CONCLUSIONS Insurance status and awareness of the need for long-term follow-up care are key factors associated with loss to follow-up in survivors of HL. Targeted education and low-cost options for survivorship care are potential strategies for improving adherence to long-term follow-up care in HL survivors.
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Affiliation(s)
| | - Maria Gramatges
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - ZoAnn Dreyer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - M Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Omar Shakeel
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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2
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de Blank PMK, Lange KR, Xing M, Mirzaei Salehabadi S, Srivastava D, Brinkman TM, Ness KK, Oeffinger KC, Neglia J, Krull KR, Nathan PC, Howell R, Turcotte LM, Leisenring W, Armstrong GT, Okcu MF, Bowers DC. Temporal changes in treatment and late mortality and morbidity in adult survivors of childhood glioma: a report from the Childhood Cancer Survivor Study. Nat Cancer 2024; 5:590-600. [PMID: 38429413 PMCID: PMC11058025 DOI: 10.1038/s43018-024-00733-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/19/2024] [Indexed: 03/03/2024]
Abstract
Pediatric glioma therapy has evolved to delay or eliminate radiation for low-grade tumors. This study examined these temporal changes in therapy with long-term outcomes in adult survivors of childhood glioma. Among 2,501 5-year survivors of glioma in the Childhood Cancer Survivor Study diagnosed 1970-1999, exposure to radiation decreased over time. Survivors from more recent eras were at lower risk of late mortality (≥5 years from diagnosis), severe/disabling/life-threatening chronic health conditions (CHCs) and subsequent neoplasms (SNs). Adjusting for treatment exposure (surgery only, chemotherapy, or any cranial radiation) attenuated this risk (for example, CHCs (1990s versus 1970s), relative risk (95% confidence interval), 0.63 (0.49-0.80) without adjustment versus 0.93 (0.72-1.20) with adjustment). Compared to surgery alone, radiation was associated with greater than four times the risk of late mortality, CHCs and SNs. Evolving therapy, particularly avoidance of cranial radiation, has improved late outcomes for childhood glioma survivors without increased risk for late recurrence.
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Affiliation(s)
- Peter M K de Blank
- The Cure Starts Now Brain Tumor Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Katharine R Lange
- Division of Pediatric Oncology, Hackensack Meridian Children's Health, Hackensack, NJ, USA
| | - Mengqi Xing
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Deokumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Tara M Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Joseph Neglia
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul C Nathan
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lucie M Turcotte
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Wendy Leisenring
- Cancer Prevention and Clinical Statistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - M Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Daniel C Bowers
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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3
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Timothy LD, Healy CM, Quintanilla NM, Montgomery N, Okcu MF. Nocardiosis in an infant with spindle cell rhabdomyosarcoma treated with mild immunosuppressive chemotherapy. Pediatr Blood Cancer 2024; 71:e30873. [PMID: 38259045 DOI: 10.1002/pbc.30873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024]
Affiliation(s)
- Leander D Timothy
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas, USA
| | - C Mary Healy
- Department of Infectious Diseases, Texas Children's Hospital, Houston, Texas, USA
| | - Norma M Quintanilla
- Department of Pathology and Immunology, Texas Children's Hospital, Houston, Texas, USA
| | - Nicole Montgomery
- Department of Orthopedics, Texas Children's Hospital, Houston, Texas, USA
| | - M Fatih Okcu
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas, USA
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4
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Raghubar KP, Heitzer AM, Malbari F, Gill J, Sillitoe RV, Merrill L, Escalante J, Okcu MF, Aldave G, Meoded A, Kralik S, Davis K, Ma M, Warren EAH, McCurdy MD, Weiner HL, Whitehead W, Scheurer ME, Rodriguez L, Daigle A, Chintagumpala M, Kahalley LS. Adaptive, behavioral, and emotional outcomes following postoperative pediatric cerebellar mutism syndrome in survivors treated for medulloblastoma. J Neurosurg Pediatr 2024:1-8. [PMID: 38552237 PMCID: PMC11010724 DOI: 10.3171/2024.1.peds23321] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/24/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Patients who experience postoperative pediatric cerebellar mutism syndrome (CMS) during treatment for medulloblastoma have long-term deficits in neurocognitive functioning; however, the consequences on functional or adaptive outcomes are unknown. The purpose of the present study was to compare adaptive, behavioral, and emotional functioning between survivors with and those without a history of CMS. METHODS The authors examined outcomes in 45 survivors (15 with CMS and 30 without CMS). Comprehensive neuropsychological evaluations, which included parent-report measures of adaptive, behavioral, and emotional functioning, were completed at a median of 2.90 years following craniospinal irradiation. RESULTS Adaptive functioning was significantly worse in the CMS group for practical and general adaptive skills compared with the group without CMS. Rates of impairment in practical, conceptual, and general adaptive skills in the CMS group exceeded expected rates in the general population. Despite having lower overall intellectual functioning, working memory, and processing speed, IQ and related cognitive processes were uncorrelated with adaptive outcomes in the CMS group. No significant group differences or increased rates of impairment were observed for behavioral and emotional outcomes. CONCLUSIONS Survivors with CMS, compared with those without CMS, are rated as having significant deficits in overall or general adaptive functioning, with specific weakness in practical skills several years posttreatment. Findings from this study demonstrate the high risk for ongoing functional deficits despite acute recovery from symptoms of CMS, highlighting the need for intervention to mitigate such risk.
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Affiliation(s)
- Kimberly P. Raghubar
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Andrew M. Heitzer
- Psychology Department, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Fatema Malbari
- Section of Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jason Gill
- Section of Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Roy V. Sillitoe
- Section of Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Livia Merrill
- Department of Psychology, University of Houston, Texas
| | - Johanna Escalante
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - M. Fatih Okcu
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Guillermo Aldave
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Avner Meoded
- Section of Neuroradiology, Department of Radiology, Baylor College of Medicine, Houston, Texas; and
| | - Stephen Kralik
- Section of Neuroradiology, Department of Radiology, Baylor College of Medicine, Houston, Texas; and
| | - Kimberly Davis
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Marina Ma
- Section of Physical Medicine and Rehabilitation, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Emily A. H. Warren
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Mark D. McCurdy
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Howard L. Weiner
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - William Whitehead
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael E. Scheurer
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Lisa Rodriguez
- Section of Physical Medicine and Rehabilitation, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Amy Daigle
- Section of Physical Medicine and Rehabilitation, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Murali Chintagumpala
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Lisa S. Kahalley
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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5
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Smith WT, Read J, Agarwal S, Tian G, Anum SJ, Choe M, Kurtz K, Tlais D, Shen X, Sarro J, Looney T, Porea T, Sauer H, Brackett J, Okcu MF, Chintagumpala M. Improving Time to Antibiotic Administration for Pediatric Oncology Patients With New-Onset Fever. JCO Oncol Pract 2024:OP2300314. [PMID: 38354362 DOI: 10.1200/op.23.00314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Time to antibiotic administration (TTA) in <60 minutes for children with neutropenic fever presenting to an emergency room is associated with reduced incidence of sepsis and intensive care admission. As such, TTA is used as a national quality metric for pediatric oncology patients. At our center, in 2020, 19% of the hospitalized patients with a new fever encounter were receiving antibiotics in <60 minutes, prompting a multidisciplinary approach to reach a goal of >90% in all pediatric patients with cancer with a new fever. METHODS A multidisciplinary team completed four Plan-Do-Study-Act cycles between March 2021 and September 2023. We implemented education initiatives, an updated handoff smartphrase guiding the on-call team, an antibiotic champion (AC) nursing role, a revised fever plan for handoff, a rapid-response team to address new fevers, and an algorithm for blood culture collection. Data were collected, analyzed, and reported biweekly with feedback sought for delays in TTA. RESULTS There was a total of 639 new fevers in 329 unique oncology patients. As of September 4, 2023, average TTA decreased from 89 minutes at baseline to 46.4 minutes for more than 12 months. The percentage of patients receiving first dose of antibiotic in <60 minutes also increased from 19% to 93.7%, which was sustained as well. The most effective interventions were creation of the AC role and streamlining the blood culture collection process. CONCLUSION This project demonstrates the importance of multidisciplinary involvement for providing optimal care. Specific implementation of targeted education, an AC role, and development of an algorithm streamlining the processes led to meaningful targeted improvements. Further analyses will explore the impact of these interventions on patient outcomes.
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Affiliation(s)
- Wesley T Smith
- Department of Pediatrics, Division of Hematology/Oncology, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Jay Read
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shreya Agarwal
- Department of Pediatrics, Division of Hematology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Gengwen Tian
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shaniqua J Anum
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Michelle Choe
- Clinical Research Division, Department of Pediatrics, Fred Hutchinson Cancer Center, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kristen Kurtz
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Dana Tlais
- Department of Oncology, Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Xiaofan Shen
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jill Sarro
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Thomas Looney
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy Porea
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Hannah Sauer
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Julienne Brackett
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Murali Chintagumpala
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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6
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Vuotto SC, Wang M, Okcu MF, Bowers DC, Ullrich NJ, Ness KK, Li C, Srivastava DK, Howell RM, Gibson TM, Leisenring WM, Oeffinger KC, Robison LL, Armstrong GT, Krull KR, Brinkman TM. Neurologic morbidity and functional independence in adult survivors of childhood cancer. Ann Clin Transl Neurol 2024; 11:291-301. [PMID: 38013658 PMCID: PMC10863908 DOI: 10.1002/acn3.51951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE To examine associations between neurologic late effects and attainment of independence in adult survivors of childhood cancer treated with central nervous system (CNS)-directed therapies. METHODS A total of 7881 survivors treated with cranial radiation therapy (n = 4051; CRT) and/or intrathecal methotrexate (n = 4193; IT MTX) ([CNS-treated]; median age [range] = 25.5 years [18-48]; time since diagnosis = 17.7 years [6.8-30.2]) and 8039 without CNS-directed therapy reported neurologic conditions including stroke, seizure, neurosensory deficits, focal neurologic dysfunction, and migraines/severe headaches. Functional independence was assessed using latent class analysis with multiple indicators (independent living, assistance with routine and personal care needs, ability to work/attend school, attainment of driver's license, marital/partner status). Multivariable regression models, adjusted for age, sex, race/ethnicity, and chronic health conditions, estimated odds ratios (OR) or relative risks (RR) for associations between neurologic morbidity, functional independence, and emotional distress. RESULTS Among CNS-treated survivors, three classes of independence were identified: (1) moderately independent, never married, and non-independent living (78.7%); (2) moderately independent, unable to drive (15.6%); and (3) non-independent (5.7%). In contrast to 50% of non-CNS-treated survivors and 60% of siblings, a fourth fully independent class of CNS-treated survivors was not identified. History of stroke (OR = 2.50, 95% CI: 1.70-3.68), seizure (OR = 9.70, 95% CI: 7.37-12.8), neurosensory deficits (OR = 2.67, 95% CI: 2.16-3.31), and focal neurologic dysfunction (OR = 3.05, 95% CI: 2.40-3.88) were associated with non-independence among CNS-treated survivors. Non-independence was associated with emotional distress symptoms. INTERPRETATION CNS-treated survivors do not attain full independence comparable to non-CNS-treated survivors or siblings. Interventions to promote independence may be beneficial for survivors with treatment-related neurological sequalae.
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Affiliation(s)
| | - Mingjuan Wang
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - M. Fatih Okcu
- Texas Children's Hospital, Baylor College of MedicineHoustonTexasUSA
| | | | - Nicole J. Ullrich
- Dana‐Farber/Boston Children's Cancer and Blood Disorders CenterBostonMassachusettsUSA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Chenghong Li
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Deo Kumar Srivastava
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | | | - Todd M. Gibson
- National Cancer InstituteDivision of Cancer Epidemiology & GeneticsBethesdaMarylandUSA
| | | | - Kevin C. Oeffinger
- Duke Univeristy School of MedicineDuke Cancer InstituteDurhamNorth CarolinaUSA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Kevin R. Krull
- Department of Psychology & Biobehavioral SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
- Department of Psychology & Biobehavioral SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
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7
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Hoyos-Martinez A, Scheurer ME, Allen-Rhoades W, Okcu MF, Horne VE. Leuprolide Protects Ovarian Reserve in Adolescents Undergoing Gonadotoxic Therapy. J Adolesc Young Adult Oncol 2023; 12:828-834. [PMID: 36976803 DOI: 10.1089/jayao.2022.0128] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Purpose: Treatment sequelae compromising reproductive health are highly prevalent in childhood cancer survivors, and a main determinant of health and quality of life. Follicular reserve determines ovarian function life span; thus, its preservation is important in the care of female survivors. Anti-Müllerian hormone (AMH) is a biomarker to measure functional ovarian reserve. We aimed to evaluate the effect of leuprolide during gonadotoxic therapy on pubertal females' post-treatment functional ovarian reserve using AMH levels. Methods: We conducted a single-center retrospective study including all pubertal females who had undergone gonadotoxic treatments between January 2010 and April 2020, and had an AMH level after completion of therapy. We used multivariable linear regressions to compare AMH-level beta coefficients in patients stratified by gonadotoxic risk, adjusting for leuprolide use. Results: Fifty-two females meeting study eligibility were included, of which 35 received leuprolide. The use of leuprolide was associated with higher post-treatment AMH levels in the lower gonadotoxic risk group (beta 2.74, 95% CI 0.97-4.51; p = 0.004). This association was lost in the higher gonadotoxic risk groups. Conclusions: Leuprolide may have a protective effect on the functional ovarian reserve. However, this is limited by increasing treatment gonadotoxicity. Larger, prospective studies are needed to elucidate the potential benefits of gonadotropin-releasing hormone agonist on preservation of ovarian reserve among children receiving gonadotoxic therapies, as cancer survivors.
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Affiliation(s)
- Alfonso Hoyos-Martinez
- Divisions of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Michael E Scheurer
- Divisions of Pediatric Oncology and Hematology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Wendy Allen-Rhoades
- Division of Pediatric Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Fatih Okcu
- Divisions of Pediatric Oncology and Hematology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Vincent E Horne
- Divisions of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Shakeel O, Aguilar S, Howell A, Ikwuezunma A, Taylor O, Okcu MF, Bista R, Hartley J, Eraña R, Bernini JC, Kahalley L, Scheurer M, Gramatges MM. Preferences for survivorship education and delivery among Latino and non-Latino childhood cancer survivors and caregivers. J Cancer Surviv 2023:10.1007/s11764-023-01485-z. [PMID: 37922072 PMCID: PMC11065964 DOI: 10.1007/s11764-023-01485-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE To assess survivor and parent perceptions of the long-term survivor visit and preferences regarding accessing health information, survivorship education, and support networks in rural and metropolitan regions of Texas. METHODS Leveraging the multi-institutional Survivorship and Access to Care for Latinos to Understand Disparities (SALUD) cohort, we administered a 26-item bilingual survey to adult survivors of childhood cancer and parents of younger survivors. Characteristics and responses were compared between survivors vs. parents and Latinos vs. non-Latinos using a t test or Fisher exact test. Odds ratios for the outcomes of interest were calculated with 95% confidence intervals. RESULTS We received 138 responses from 59 survivors and 79 parents of survivors treated at three Texas pediatric cancer hospitals/clinics. Parents were more likely than survivors to seek survivorship information from other survivors or parents of survivors (OR=6.32, 95% CI 1.78, 22.47), and non-Latinos preferred social media as an educational resource (OR=3.70, CI 1.58, 8.68). Survivors, particularly Latino survivors, preferred short videos as a mode of survivorship education delivery. Highest topic priorities for survivorship education were 'risk for second cancers' and 'diet, nutrition, and exercise.' All parents and survivors who rated survivor physical and mental health as 'fair' or 'poor' identified as Latino. CONCLUSIONS These results highlight differences in perceived health status between Latino and non-Latino survivors and support the development of adapted survivorship education content to address the specific needs of Latino survivors. Implications for Cancer Survivors Results of this study suggest a need for survivorship educational materials in multiple formats and that are tailored to the style, content, language preferences, and health literacy status of the target population.
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Affiliation(s)
- Omar Shakeel
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Shiley Aguilar
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Alicia Howell
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Ashley Ikwuezunma
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Olga Taylor
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Ranjan Bista
- Department of Pediatrics, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Jill Hartley
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
- Vannie Cook Children's Clinic, McAllen, TX, USA
| | - Rodrigo Eraña
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
- Vannie Cook Children's Clinic, McAllen, TX, USA
| | - Juan Carlos Bernini
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
- Vannie Cook Children's Clinic, McAllen, TX, USA
| | - Lisa Kahalley
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Michael Scheurer
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Maria Monica Gramatges
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA.
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9
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Aldave G, Okcu MF, Ruggieri L, Paulino AC, McGovern S, Whitehead W, Weiner HL, Chintagumpala M. The role of surgery in recurrent ependymomas. J Neurosurg Pediatr 2023; 32:584-589. [PMID: 37657117 DOI: 10.3171/2023.7.peds2373] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/11/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE The role of surgery in recurrent ependymomas and its contribution to the outcome are not well defined. While gross-total resection (GTR) has shown benefit in newly diagnosed patients with improvement in progression-free survival (PFS), its impact after recurrence is not known. Its role in distant relapses or multiple local recurrences is similarly less well understood. The objective of this study was to investigate whether GTR could prolong survival after recurrence. METHODS In this paper, the authors identified patients with ependymomas who underwent surgery at Texas Children's Hospital for recurrent ependymomas between December 2000 and December 2021. Surgical treatment was stratified as GTR, subtotal resection (STR), or a biopsy. Kaplan-Meier analysis was performed for PFS and overall survival (OS), and the log-rank test was used to assess statistical significance. The Cox regression model was used for multivariable analysis. RESULTS Forty children were identified with a first ependymoma recurrence and follow-up data were collected. The median age was 5.46 years (95% CI 4.52-6.39 years) with a mean follow-up of 3.92 years (95% CI 2.42-5.42 years). In 26 patients (65%), the original tumor was located in the infratentorial space. Twenty-nine patients (72.5%) presented with local recurrence. Within this group, the 5-year PFS rates for the GTR and STR groups were 40.1% and 26.8%, respectively. The 5- and 10-year OS rates were 58.3% and 50% in the GTR group and 51% and 16.7% in the STR group, respectively. Fifteen patients presented with a second recurrence. The 5-year PFS and OS rates in patients who had GTR after a second recurrence were 33% and 50%, respectively. CONCLUSIONS GTR of local recurrent ependymomas can result in long-term survival in first and second recurrences. Further and larger studies are necessary to elucidate the role of surgery in distal recurrences.
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Affiliation(s)
- Guillermo Aldave
- 1Department of Surgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston
| | - M Fatih Okcu
- 3Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston; and
| | - Lucia Ruggieri
- 1Department of Surgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston
| | - Arnold C Paulino
- 4Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan McGovern
- 4Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Whitehead
- 1Department of Surgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston
| | - Howard L Weiner
- 1Department of Surgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston
| | - Murali Chintagumpala
- 3Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston; and
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10
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Abu-Arja MH, Shatara MS, Okcu MF, McGovern SL, Su JM, Abdelbaki MS. The role of neoadjuvant chemotherapy in the management of metastatic central nervous system germinoma: A meta-analysis. Pediatr Blood Cancer 2023; 70:e30601. [PMID: 37501569 DOI: 10.1002/pbc.30601] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/20/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The role of neoadjuvant chemotherapy in treating patients with metastatic central nervous system (CNS) germinoma is controversial. METHODS We compared the relapse-free survival (RFS) of different treatment modalities by performing a meta-analysis using published data. We summarized all data using standard descriptive statistics. We used the Kaplan-Meier method to estimate RFS and their corresponding 95% confidence intervals (CIs). We used the log-rank test for the comparison of survival functions. RESULTS We identified 97 patients with a median age at presentation of 15 years (range: 7-38). Sites of metastasis were cerebrospinal fluid (CSF) disease only (n = 12), brain parenchyma (n = 18), spinal cord (n = 9), ventricular and CSF (n = 10), ventricular only (n = 31), and other (n = 17). The 3-year RFS among patients who received any form of radiotherapy was 89% (95% CI: 83-96) compared with 0% for patients who received a chemotherapy-only regimen (p = .001). Five-year RFS among patients who received craniospinal irradiation (CSI) was 92% (95% CI: 84-100) compared with 76.4% (95% CI: 63-90) in the non-CSI group (with or without neoadjuvant chemotherapy) (p = .014). Five-year RFS of patients who received CSI less than 24 Gy with neoadjuvant chemotherapy was 100% compared with 92% (95% CI: 83-100) CSI dose greater than or equal to 24 Gy alone (p = .3). CONCLUSIONS Our analysis does not support avoiding spinal irradiation among patients with radiographic metastatic CNS germinoma. Future studies are needed to confirm whether neoadjuvant chemotherapy will allow a reduction of irradiation dose without compromising survival.
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Affiliation(s)
- Mohammad H Abu-Arja
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Margaret S Shatara
- Division of Hematology and Oncology, St. Louis Children's Hospital, Washington University, School of Medicine in St. Louis, Washington University, St. Louis, Missouri, USA
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jack M Su
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed S Abdelbaki
- Division of Hematology and Oncology, St. Louis Children's Hospital, Washington University, School of Medicine in St. Louis, Washington University, St. Louis, Missouri, USA
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11
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Espinoza AF, Onwuka E, Hicks MJ, Masand P, Monson L, Okcu MF, Pinglay N, Vidimos A, Vasudevan SA. Dermatofibrosarcoma protuberans case report: Aggressive tumor in a preadolescent child. Journal of Pediatric Surgery Case Reports 2023. [DOI: 10.1016/j.epsc.2023.102612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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12
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McEvoy MT, Blessing MM, Fisher KE, Paulino AC, Nuchtern J, Chelius DC, Dimachkieh AL, Aldave G, Okcu MF. A novel case of malignant ossifying fibromyxoid tumor with a BCOR internal tandem duplication in a child. Pediatr Blood Cancer 2023; 70:e29972. [PMID: 36102745 DOI: 10.1002/pbc.29972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Matthew T McEvoy
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Melissa M Blessing
- Department of Pathology & Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kevin E Fisher
- Department of Pathology & Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Arnold C Paulino
- Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jed Nuchtern
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA.,Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amy L Dimachkieh
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Guillermo Aldave
- Division of Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - M Fatih Okcu
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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13
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McEvoy MT, Stuckert AJ, Castellanos MI, Gilbert MM, Pfeiffer T, Prudowsky Z, Rios X, Airewele G, Okcu MF, Powers JM. Management of nutritional iron deficiency anemia for young children in the emergency department. Pediatr Blood Cancer 2023; 70:e30181. [PMID: 36579803 DOI: 10.1002/pbc.30181] [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: 08/23/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Guidelines for young children with nutritional iron deficiency anemia (IDA) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. PROCEDURE Baseline data of the target population (n = 42; 60% male; median age 22.5 months, median hemoglobin 5.3 g/dl) identified variability across four key measures of clinical management: laboratory evaluation, therapy choice, therapy administration, and patient disposition. Literature review and consensus from pediatric hematology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From September 2020 to June 2021, we aimed to increase IDA management per the algorithm by ≥20% relative to baseline for the four key outcome measures using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider communication/documentation and balancing measures involving efficiency and therapy-related adverse events were assessed concurrently. RESULTS Thirty-five patients were evaluated among four PDSA cycles and shared similar characteristics as the baseline population. Improvements of ≥20% above baseline adherence levels or 100% adherence were achieved for all outcome measure across four PDSA cycles. Adherence to recommended laboratory evaluation improved from 43 (baseline) to 71%, therapy choice from 78 to 100%, therapy administration from 50 to 83%, and disposition from 85 to 100%. ED length of stay remained stable. CONCLUSIONS Implementation of a standardized algorithm for young children with nutritional IDA in the ED increased adherence to evidence-based patient care.
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Affiliation(s)
- Matthew T McEvoy
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Austin J Stuckert
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Maria I Castellanos
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,UCSF Benioff Children's Hospitals, Department of Pediatrics, San Francisco/Oakland, California, USA
| | - Megan M Gilbert
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas Pfeiffer
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,St. Louis Children's Hospital, Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zachary Prudowsky
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Xavier Rios
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Gladstone Airewele
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - M Fatih Okcu
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Jacquelyn M Powers
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
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14
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Aldave G, Okcu MF, Chintagumpala M, Ruggieri L, Minard CG, Malbari F, Mash LE, Paulino AC, McGovern S, Ramaswamy U, Whitehead W, Kahalley LS. Comparison of neurocognitive and quality-of-life outcomes in pediatric craniopharyngioma patients treated with partial resection and radiotherapy versus gross-total resection only. J Neurosurg Pediatr 2023; 31:453-462. [PMID: 36806176 DOI: 10.3171/2022.12.peds22367] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/22/2022] [Indexed: 02/19/2023]
Abstract
OBJECTIVE The optimal management of pediatric craniopharyngioma patients remains controversial, shifting from radical resection (gross-total resection [GTR]) to a more conservative approach with partial resection/biopsy followed by radiotherapy (PR+RT). To the authors' knowledge, no previous studies have compared neurocognitive and quality-of-life (QOL) outcomes between the two main treatments. In this study, the authors compared changes in intellectual, adaptive, and QOL scores in children treated for craniopharyngioma with GTR and those treated with PR+RT. METHODS Patients underwent annual neurocognitive and QOL evaluations for up to 10 years posttreatment, including the Full-Scale IQ, Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI). Child- and parent-reported QOL scores and adaptive behavior in different domains were assessed. General linear mixed models were used to examine change in scores over time by treatment group with adjustment for significant covariates. RESULTS Scores from 43 patients treated between 2009 and 2019 (21 GTR, 22 PR+RT) were examined. Within the PR+RT group, 9 patients had intensity-modulated RT and 13 had proton beam therapy. The treatment groups were similar in sex (44% male) and age (median 7.3 years). There were no significant differences in the trajectory of intellectual functioning or QOL scale scores between the two groups. However, patients who underwent GTR exhibited significant improvement over time in overall adaptive behavior (p = 0.04) and conceptual skills (p = 0.01), which was not observed in patients treated with PR+RT. CONCLUSIONS Long-term pediatric craniopharyngioma survivors treated with GTR and PR+RT have similar intellectual function and QOL. Larger studies are needed to explore small but clinically significant differences between the two groups.
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Affiliation(s)
- Guillermo Aldave
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - M Fatih Okcu
- 2Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Murali Chintagumpala
- 2Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Lucia Ruggieri
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Charles G Minard
- 3Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston
| | - Fatema Malbari
- 4Division of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Lisa E Mash
- 5Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston
| | - Arnold C Paulino
- 6Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston; and
| | - Susan McGovern
- 6Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston; and
| | - Uma Ramaswamy
- 7Department of Otorhinolaryngology, Division of Otorhinolaryngology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - William Whitehead
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Lisa S Kahalley
- 2Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston.,5Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston
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15
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Mash LE, Kahalley LS, Okcu MF, Grosshans DR, Paulino AC, Stancel H, Leon LD, Wilde E, Desai N, Chu ZD, Whitehead WE, Chintagumpala M, Raghubar KP. Superior verbal learning and memory in pediatric brain tumor survivors treated with proton versus photon radiotherapy. Neuropsychology 2023; 37:204-217. [PMID: 36480379 PMCID: PMC10544942 DOI: 10.1037/neu0000882] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Radiotherapy for pediatric brain tumor has been associated with late cognitive effects. Compared to conventional photon radiotherapy (XRT), proton radiotherapy (PRT) delivers lower doses of radiation to healthy brain tissue. PRT has been associated with improved long-term cognitive outcomes compared to XRT. However, there is limited research comparing the effects of XRT and PRT on verbal memory. METHOD Survivors of pediatric brain tumor treated with either XRT (n = 29) or PRT (n = 51) completed neuropsychological testing > 1 year following radiotherapy. Performance on neuropsychological measures was compared between treatment groups using analysis of covariance. Chi-squared tests of independence were used to compare the frequency of encoding, retrieval, and intact memory profiles between treatment groups. Associations between memory performance and other neurobehavioral measures were examined using Pearson correlation. RESULTS Overall, patients receiving PRT demonstrated superior verbal learning and recall compared to those treated with XRT. Encoding and retrieval deficits were more common in the XRT group than the PRT group, with encoding problems being most prevalent. The PRT group was more likely to engage in semantic clustering strategies, which predicted better encoding and retrieval. Encoding ability was associated with higher intellectual and adaptive functioning, and fewer parent-reported concerns about day-to-day attention and cognitive regulation. CONCLUSION Results suggest that PRT is associated with verbal memory sparing, driven by effective encoding and use of learning strategies. Future work may help to clarify underlying neural mechanisms associated with verbal memory decline, which will better inform treatment approaches. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Lisa E. Mash
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
| | - Lisa S. Kahalley
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital
| | - M. Fatih Okcu
- Department of Pediatrics, Division of Hematology Oncology, Baylor College of Medicine
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center
| | - Heather Stancel
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
| | - Luz De Leon
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
| | - Elisabeth Wilde
- Department of Neurology, University of Utah School of Medicine
| | - Nilesh Desai
- Department of Pediatrics, Division of Neuroradiology, Baylor College of Medicine
| | - Zili D. Chu
- Department of Pediatrics, Division of Neuroradiology, Baylor College of Medicine
| | | | - Murali Chintagumpala
- Department of Pediatrics, Division of Hematology Oncology, Baylor College of Medicine
| | - Kimberly P. Raghubar
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital
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16
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Abu-Arja M, Shatara M, Okcu MF, McGovern S, Su JM, Abdelbaki M. RADT-36. MANAGEMENT OF PATIENTS WITH METASTATIC CENTRAL NERVOUS SYSTEM (CNS) GERMINOMA; A LITERATURE REVIEW. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac209.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
BACKGROUND
No consensus exists on the optimal irradiation volume/dose for patients with metastatic CNS germinoma. We reviewed the literature for a potential association between different treatment modalities and survival.
METHODS
We searched PubMed for studies on patients with primary metastatic CNS germinoma including detailed survival outcome data. We used the Kaplan-Meier method to estimate event-free survival (EFS) rates and log-rank test for comparison among treatment modalities.
RESULTS
We identified 124 patients from 38 studies published between 1990 and 2021. The median age of presentation was 15 years (range: 1.5–47 years). Treatment modalities included: chemotherapy only (n = 5), radiotherapy only (n = 31), and radio-chemotherapy (n = 88). Radiotherapy modalities included: craniospinal irradiation (CSI) (n = 69), whole-brain irradiation (WBI) (n = 19), whole ventricular irradiation (WVI) (n=16), focal and spine irradiation (n = 5), focal irradiation only (n = 9), and not specified (n = 1). The median focal irradiation dose was 36.6 Gy (range:19.5-59.8 Gy). The median doses for CSI, WBI, and WVI were 24 Gy (range: 10.8-49 Gy). Eighteen patients relapsed, 111 were alive without disease, 2 were alive with disease, and 12 died of disease. The median follow-up time was 5 years in survivors. Four patients who received only chemotherapy relapsed. Five-year EFS rates were similar in patients who received chemo-radiotherapy and radiotherapy alone (89%, 95%CI 81-97%, vs 88%, 95%CI 74-100%, p = 0.6). Patients who were treated with CSI had a longer 5-year EFS compared to patients treated with other modalities (92%, 95%CI 84-100% vs 80%, 95%CI 64-94% p = 0.03). EFS was similar in patients treated with CSI whether they received ≥ 24 Gy or less.
CONCLUSION
CSI is required to achieve prolonged relapse-free survival (RFS). CSI dose of < 24 Gy may be sufficient to achieve sustained RFS. Future trials are needed to evaluate the potential role of neoadjuvant chemotherapy in reducing the dose/volume of irradiation in patients with metastatic CNS germinoma.
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Affiliation(s)
- Mohammad Abu-Arja
- Texas Children's Hospital - Baylor College of Medicine , Houston, TX , USA
| | | | - M Fatih Okcu
- Neuro-Oncology, Texas Children’s Hospital, Baylor College of Medicine , Houston, TX , USA
| | - Susan McGovern
- University of Texas MD Anderson Cancer Center , Houston, TX , USA
| | - Jack M Su
- Neuro-Oncology, Texas Children’s Hospital, Baylor College of Medicine , Houston, TX , USA
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17
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McCurdy MD, Raghubar KP, Christopher K, Okcu MF, Wilde E, Desai N, Chu ZD, Gragert M, Stancel H, Warren EH, Whitehead WE, Grosshans D, Paulino AC, Chintagumpala M, Kahalley LS. Predicting neurocognitive function in pediatric brain tumor early survivorship: The neurological predictor scale and the incremental validity of tumor size. Pediatr Blood Cancer 2022; 69:e29803. [PMID: 35709014 PMCID: PMC10265925 DOI: 10.1002/pbc.29803] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Neurological Predictor Scale (NPS) quantifies cumulative exposure to conventional treatment-related neurological risks but does not capture potential risks posed by tumors themselves. This study evaluated the predictive validity of the NPS, and the incremental value of tumor location and size, for neurocognitive outcomes in early survivorship following contemporary therapies for pediatric brain tumors. PROCEDURE Survivors (N = 69) diagnosed from 2010 to 2016 were administered age-appropriate versions of the Wechsler Intelligence Scales. Hierarchical multiple regressions examined the predictive and incremental validity of NPS score, tumor location, and tumor size. RESULTS Participants (51% female) aged 6-20 years (M = 13.22, SD = 4.09) completed neurocognitive evaluations 5.16 years (SD = 1.29) postdiagnosis. The NPS significantly predicted Full-Scale Intelligence Quotient (FSIQ; ΔR2 = .079), Verbal Comprehension Index (VCI; ΔR2 = 0.051), Perceptual Reasoning Index (PRI; ΔR2 = 0.065), and Processing Speed Index (PSI; ΔR2 = 0.049) performance after controlling for sex, age at diagnosis, and maternal education. Tumor size alone accounted for a significant amount of unique variance in FSIQ (ΔR2 = 0.065), PRI (ΔR2 = 0.076), and PSI (ΔR2 = 0.080), beyond that captured by the NPS and relevant covariates. Within the full model, the NPS remained a significant independent predictor of FSIQ (β = -0.249, P = 0.016), VCI (β = -0.223, P = 0.048), and PRI (β = -0.229, P = 0.037). CONCLUSIONS Tumor size emerged as an independent predictor of neurocognitive functioning and added incrementally to the predictive utility of the NPS. Pretreatment disease burden may provide one of the earliest markers of neurocognitive risk following contemporary treatments. With perpetual treatment advances, measures quantifying treatment-related risk may need to be updated and revalidated to maintain their clinical utility.
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Affiliation(s)
- Mark D. McCurdy
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Kimberly P. Raghubar
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Elisabeth Wilde
- Baylor College of Medicine, Houston, TX, US
- University of Utah, Salt Lake City, UT, US
| | - Nilesh Desai
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Zili D. Chu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Marsha Gragert
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Emily H. Warren
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - William E. Whitehead
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Lisa S. Kahalley
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
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18
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Malbari F, Gill J, Daigle A, Rodriguez LL, Raghubar KP, Davis KC, Scheurer M, Ma MM, Kralik SF, Meoded A, Okcu MF, Chintagumpala MM, Aldave G, Weiner HL, Kahalley LS. Cerebellar Mutism Syndrome in Pediatric Neuro-oncology: A Multidisciplinary Perspective and Call for Research Priorities. Pediatr Neurol 2022; 132:4-10. [PMID: 35598587 DOI: 10.1016/j.pediatrneurol.2022.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/14/2022] [Revised: 03/28/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Cerebellar mutism syndrome (CMS), also known as posterior fossa syndrome, occurs in a subset of children after posterior fossa tumor resection, most commonly medulloblastoma. Patients with this syndrome exhibit often transient, although protracted, symptoms of language impairment, emotional lability, cerebellar, and brainstem dysfunction. However, many patients experience persistent neurological deficits and lasting neurocognitive impairment. Historically, research and clinical care were hindered by inconsistent nomenclature, poorly defined diagnostic criteria, and uncertainty surrounding risk factors and etiology. Proposed diagnostic criteria include two major symptoms, language impairment and emotional lability, as proposed by the international Board of the Posterior Fossa Society in their consensus statement as well as other experts in this field. Risk factors most commonly associated with development of CMS include midline tumor location, diagnosis of medulloblastoma and specific tumor subtype, younger age at diagnosis, and preoperative language impairment. A proposed etiology of CMS includes disruption of the cerebellar outflow tracts, the cerebellar nuclei, and their efferent projections through the superior cerebellar peduncle. Treatment for CMS remains supportive. Herein, we present a comprehensive overview of CMS etiology, diagnosis, risk factors, clinical presentation, and clinical management. In addition, we identify essential multidisciplinary research priorities to advance diagnostics, prevention, and intervention efforts for patients with, or at risk for, development of CMS.
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Affiliation(s)
- Fatema Malbari
- Division of Neurology and Developmental Neurosciences, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Jason Gill
- Division of Neurology and Developmental Neurosciences, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Amy Daigle
- Division of Physical Medicine and Rehabilitation, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Lisa L Rodriguez
- Division of Physical Medicine and Rehabilitation, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kimberly P Raghubar
- Section of Psychology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kimberly C Davis
- Section of Psychology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Michael Scheurer
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Marina M Ma
- Division of Physical Medicine and Rehabilitation, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Stephen F Kralik
- Division of Radiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Avner Meoded
- Division of Radiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Murali M Chintagumpala
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Guillermo Aldave
- Division of Neurosurgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Howard L Weiner
- Division of Neurosurgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Lisa S Kahalley
- Section of Psychology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Lindsay H, Stuckert A, Chintagumpala M, Su J, Baxter P, Okcu MF, Malbari F, Rednam S, Reuther J, Fisher K, Scollon S, Plon S, Roy A, Parsons DW, Lin F. LGG-04. Clinical and molecular characterization of metastatic pediatric low grade gliomas. Neuro Oncol 2022. [PMCID: PMC9164636 DOI: 10.1093/neuonc/noac079.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND: Despite being the most common central nervous system tumor in children, ≤5% of pediatric low grade gliomas (pLGG) present with metastases. Due to their rarity, there is a paucity of clinical and molecular data in metastatic pLGGs. To address the need, we analyzed a cohort of 22 patients with pLGG followed at Texas Children’s Hospital who presented with metastatic disease. RESULTS: The predominant histology was pilocytic astrocytoma (16/22, 73%); average age at diagnosis was 4 years 11 months. The most common sites of primary disease were optic pathway/chiasm (7/22, 32%) and suprasellar (5/22, 23%). Metastatic disease was most commonly noted in the leptomeninges (12/22, 55%). 16/22 patients (73%) were treated with up-front medical therapy following tumor biopsy/resection, the majority with carboplatin-based therapy; the remaining 6 patients received only surgery up-front. Only 2/22 patients (9%) did not progress after their initial treatment with an average follow-up of 42 months. 14 patients (14/22, 64%) had continued disease progression after at least 2 therapeutic interventions; however, only 3 patients (3/22, 14%) eventually received craniospinal radiation. 10 patients (10/22, 45%) received treatment with an agent targeting the mitogen-activated protein kinase (MAPK) pathway. 20/22 patients (91%) were alive at last follow-up (average 72 months). 4/21 patients (19%) harbored a BRAF V600E mutation while 7/20 (35%) had a BRAF::KIAA1549 duplication/fusion. 8/20 patients (40%) were wildtype for both analyzed molecular alterations in BRAF. 8 patients had germline whole exome sequencing performed and all were negative for pathogenic/likely-pathogenic variants related to their clinical phenotype. Methylation analyses are pending on patients with available tumor tissue. CONCLUSION: In our cohort of patients with metastatic pLGG, most tumors progressed despite numerous therapeutic regimens, but the overall survival was >90%. 40% of patients were wild type for the 2 most common MAPK alterations seen in pLGG.
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Affiliation(s)
| | | | | | - Jack Su
- Baylor College of Medicine , Houston, TX , USA
| | | | | | | | | | | | | | | | - Sharon Plon
- Baylor College of Medicine , Houston, TX , USA
| | | | | | - Frank Lin
- Baylor College of Medicine , Houston, TX , USA
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20
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de Blank PMK, Lange KR, Xing M, Salehabadi SM, Srivatava D, Brinkman TM, Ness KK, Oeffinger KC, Neglia J, Krull KR, Yasui Y, Nathan P, Howell R, Turcotte L, Leisenring W, Armstrong GT, Bowers DC, Okcu MF. LGG-15. Late mortality and morbidity of adult survivors of childhood glioma treated across three decades: a report from the Childhood Cancer Survivor Study. Neuro Oncol 2022. [PMCID: PMC9164667 DOI: 10.1093/neuonc/noac079.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE: Pediatric low-grade glioma therapy has evolved to delay or eliminate radiation. The impact of therapy changes on long-term outcomes remains unknown. METHODS: Cumulative incidence of late mortality (death >5 years from diagnosis), subsequent neoplasms (SNs), and chronic health conditions (CHCs, CTCAE grading criteria) were evaluated in the Childhood Cancer Survivor Study among 5-year survivors of glioma diagnosed 1970-1999. Outcomes were evaluated by diagnosis decade and by treatment exposures received ≤5 years following diagnosis (surgery-only, chemotherapy ± surgery, and cranial radiation ± surgery or chemotherapy). Relative risk (RRs) with 95%CIs estimated long-term outcomes using multivariable piecewise exponential models. RESULTS: Among 2,684 eligible survivors (age at diagnosis (median [range]), 7 years [0-20 years]; time from diagnosis, 24 years [5-48 years]), exposure to cranial radiation decreased [51% (1970s), 45% (1980s), 25% (1990s)] along with late tumor recurrence (>5 & ≤15 years from diagnosis) [9.8% (1970s), 8.8% (1980s), 5.0% (1990s)]. The 15-year cumulative incidence of late mortality was 10.3% (1970s), 6.5% (1980s), and 6.0% (1990s) (p<0.001, comparison of cumulative incidence curves). The 15-year cumulative incidence of grade 3-5 CHCs was 19.7% (1970s), 17.8% (1980s), and 14.2% (1990s) (p<0.0001). A reduction in SN incidence was not observed. In multivariable analyses excluding treatment exposure, later diagnosis (1990s vs. 1970s) was associated with lower risk of late mortality, grade 3-5 CHCs and SNs. Inclusion of treatment exposure in the model attenuated the effect of diagnosis decade. Radiation or chemotherapy exposure increased risk compared to surgery alone for late mortality (radiation RR 4.95, 95%CI 3.79-6.47; chemotherapy RR 2.88, 95%CI 1.85-4.48), CHCs (radiation RR 4.02, 95%CI 3.28-4.94; chemotherapy RR 1.66, 95%CI 1.13-2.45), and SNs (radiation RR 4.02, 95%CI 3.06-6.13, chemotherapy RR 2.08, 95%CI 1.03-4.23)). CONCLUSION: Late mortality and CHCs decreased in childhood glioma survivors diagnosed from 1970-1999 largely due to therapy changes, particularly avoidance of cranial radiation, without increased late recurrence.
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Affiliation(s)
- Peter M K de Blank
- University of Cincinnati Medical Center , Cincinnati, OH , USA
- Cincinnati Children's Hospital Medical Center , Cincinnati, OH , USA
| | | | - Mengqi Xing
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | | | | | | | - Kirsten K Ness
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | | | - Joseph Neglia
- University of Minnesota Medical School , Minneapolis, MN , USA
| | - Kevin R Krull
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | - Yutaka Yasui
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | - Paul Nathan
- The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Rebecca Howell
- University of Texas MD Anderson Cancer Center , Houston, TX , USA
| | - Lucie Turcotte
- University of Minnesota Medical School , Minneapolis, MN , USA
| | | | | | - Daniel C Bowers
- University of Texas Southwestern Medical Center , Dallas, TX , USA
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21
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Warren EA, Raghubar KP, Cirino PT, Child AE, Lupo PJ, Grosshans DR, Paulino AC, Okcu MF, Minard CG, Ris MD, Mahajan A, Viana A, Chintagumpala M, Kahalley LS. Cognitive predictors of social adjustment in pediatric brain tumor survivors treated with photon versus proton radiation therapy. Pediatr Blood Cancer 2022; 69:e29645. [PMID: 35285129 PMCID: PMC9208675 DOI: 10.1002/pbc.29645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/11/2021] [Revised: 01/13/2022] [Accepted: 02/15/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pediatric brain tumor survivors are at risk for poor social outcomes. It remains unknown whether cognitive sparing with proton radiotherapy (PRT) supports better social outcomes relative to photon radiotherapy (XRT). We hypothesized that survivors treated with PRT would outperform those treated with XRT on measures of cognitive and social outcomes. Further, we hypothesized that cognitive performance would predict survivor social outcomes. PROCEDURE Survivors who underwent PRT (n = 38) or XRT (n = 20) participated in a neurocognitive evaluation >1 year post radiotherapy. Group differences in cognitive and social functioning were assessed using analysis of covariance (ANCOVA). Regression analyses examined predictors of peer relations and social skills. RESULTS Age at evaluation, radiation dose, tumor diameter, and sex did not differ between groups (all p > .05). XRT participants were younger at diagnosis (XRT M = 5.0 years, PRT M = 7.6 years) and further out from radiotherapy (XRT M = 8.7 years, PRT M = 4.6 years). The XRT group performed worse than the PRT group on measures of processing speed (p = .01) and verbal memory (p < .01); however, social outcomes did not differ by radiation type. The proportion of survivors with impairment in peer relations and social skills exceeded expectation; χ2 (1) = 38.67, p < .001; χ2 (1) = 5.63, p < .05. Household poverty predicted peer relation difficulties (t = 2.18, p < .05), and verbal memory approached significance (t = -1.99, p = .05). Tumor diameter predicted social skills (t = -2.07, p < .05). CONCLUSIONS Regardless of radiation modality, survivors are at risk for social challenges. Deficits in verbal memory may place survivors at particular risk. Results support monitoring of cognitive and social functioning throughout survivorship, as well as consideration of sociodemographic risk factors.
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Affiliation(s)
- Emily A.H. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Paul T. Cirino
- Department of Psychology, University of Houston, Houston TX
| | - Amanda E. Child
- Department of Pediatrics, Division of Child and Adolescent Neurology, UT Health, Houston TX
| | - Philip J. Lupo
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Anita Mahajan
- Department of Radiation Oncology, The Mayo Clinic, Rochester MN
| | - Andres Viana
- Department of Psychology, University of Houston, Houston TX
| | - Murali Chintagumpala
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX,Correspondence To: Lisa S. Kahalley, Ph.D., Texas Children’s Hospital, 1102 Bates Ave., Suite 940, Houston, TX 77030-2399, US; Telephone: 832-822-4759; Fax: 832-825-1222; .
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22
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Russell HV, Chi YY, Okcu MF, Bernhardt MB, Rodriguez-Galindo C, Gupta AA, Hawkins DS. Rising drug cost impacts on cost-effectiveness of 2 chemotherapy regimens for intermediate-risk rhabdomyosarcoma: A report from the Children's Oncology Group. Cancer 2022; 128:317-325. [PMID: 34623638 PMCID: PMC8738099 DOI: 10.1002/cncr.33917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/24/2021] [Revised: 07/05/2021] [Accepted: 08/09/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND The Children's Oncology Group clinical trial for intermediate risk rhabdomyosarcoma randomized participants to a combination of vincristine, dactinomycin, and cyclophosphamide (VAC) alone or VAC alternating with vincristine plus irinotecan (VAC/VI). Clinical outcomes were similar, but toxicity profiles differed. This study estimates the cost differences between arms from the health care system's perspective. METHODS A decision-analytic model was used to estimate the incremental cost-effectiveness ratio (ICER) of VAC versus VAC/VI. Protocol-required or recommended medications and laboratory studies were included. Costs were obtained from national databases or supporting literature and inflated to 2019 US dollars. Demographic and outcome data were obtained from the clinical trial and directed chart reviews. Life-years (LY) were estimated from life-expectancy tables and discounted by 3% annually. Probabilistic sensitivity analyses and alternative clinical scenarios identified factors driving costs. RESULTS Mean direct medical costs of VAC and VAC/VI were $164,757 and $102,303, respectively. VAC was associated with an additional 0.97 LY and an ICER of $64,386/LY compared with VAC/VI. The ICER was sensitive to survival estimations and to alternative clinical scenarios including outpatient cyclophosphamide delivery (ICER $49,037/LY) or substitution of alternative hematopoietic growth factor schedules (ICER $73,191-$91,579/LY). Applying drug prices from 2012 decreased the total costs of VAC by 20% and VAC/VI by 15% because of changes in dactinomycin and pegfilgrastim prices. CONCLUSIONS Neither arm was clearly more cost-effective. Pharmaceutical pricing and location of treatment drove costs and may inform future treatment decisions. Rising pharmaceutical costs added $30,000 per patient, a finding important for future drug-pricing policy decisions. LAY SUMMARY Two chemotherapy regimens recently tested side-by-side for rhabdomyosarcoma had similar tumor outcomes, but different side effects. The health care costs of each regimen were compared; neither was clearly more cost-effective. However, the costs of each treatment changed dramatically with choices of supportive medicines and location of treatment. Costs of treatment rose by 15% to 20% because of rising US drug costs not associated with the clinical trial.
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Affiliation(s)
- Heidi V. Russell
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston Texas,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston Texas
| | - Yueh-Yun Chi
- Department of Pediatrics and Preventative Medicine, University of Southern California, Los Angeles, California
| | - M. Fatih Okcu
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston Texas
| | | | | | | | - Douglas S. Hawkins
- Seattle Children’s Hospital, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington
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23
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Mak DY, Laperriere N, Ramaswamy V, Bouffet E, Murray JC, McNall-Knapp RY, Bielamowicz K, Paulino AC, Zaky W, McGovern SL, Okcu MF, Tabori U, Dirks PB, Taylor MD, Tsang DS, Bavle A. 60: Re-Evaluating Surgery and Re-Irradiation for Locally Recurrent Pediatric Ependymoma – A Multi-Institutional Study. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Malbari F, Chintagumpala MM, Wood AC, Levy AS, Su JM, Okcu MF, Lin FY, Lindsay H, Rednam SP, Baxter PA, Paulino AC, Orzaiz GA, Whitehead WE, Dauser R, Supakul N, Kralik SF. Gadolinium is not necessary for surveillance MR imaging in children with chiasmatic-hypothalamic low-grade glioma. Pediatr Blood Cancer 2021; 68:e29178. [PMID: 34133064 DOI: 10.1002/pbc.29178] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with chiasmatic-hypothalamic low-grade glioma (CHLGG) have frequent MRIs with gadolinium-based contrast agents (GBCA) for disease monitoring. Cumulative gadolinium deposition in the brains of children is a potential concern. The purpose of this study is to evaluate whether MRI with GBCA is necessary for determining radiographic tumor progression in children with CHLGG. METHODS Children who were treated for progressive CHLGG from 2005 to 2019 at Texas Children's Cancer Center were identified. Pre- and post-contrast MRI sequences were separately reviewed by one neuroradiologist who was blinded to the clinical course. Three dimensional measurements and tumor characteristics were evaluated. Radiographic progression was defined as a 25% increase in size (product of two largest dimensions) compared with baseline or best response after initiation of therapy. RESULTS A total of 28 patients with progressive CHLGG were identified with a total of 683 MRIs with GBCA reviewed (mean 24 MRIs/patient; range, 11-43 MRIs). Radiographic progression was observed 92 times, 91 (99%) on noncontrast and 90 (98%) on contrast imaging. Sixty-seven progressions necessitating management changes were identified in all (100%) noncontrast sequences and 66 (99%) contrast sequences. Tumor growth > 2 mm in any dimension was identified in 184/187 (98%) noncontrast and 181/187 (97%) with contrast imaging. Metastatic tumors were better visualized on contrast imaging in 4/7 (57%). CONCLUSION MRI without GBCA effectively identifies patients with progressive disease. When imaging children with CHLGG, eliminating GBCA should be considered unless monitoring patients with metastatic disease.
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Affiliation(s)
- Fatema Malbari
- Department of Pediatrics, Division of Neurology and Developmental Neurosciences, Texas Children's Hospital, Houston, Texas
| | | | - Alexis C Wood
- USDA/ARS Children's Nutrition Research Center, Baylor College of Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Adam S Levy
- Department of Pediatrics, Division of Hematology Oncology and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, New York
| | - Jack M Su
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Frank Y Lin
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Holly Lindsay
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Surya P Rednam
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Patricia A Baxter
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Department of Radiation Oncology, Division of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Guillermo Aldave Orzaiz
- Department of Pediatrics, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Department of Pediatrics, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Robert Dauser
- Department of Pediatrics, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Nucharin Supakul
- Department of Clinical Radiology and Imaging Sciences, Indiana University Health, Indianapolis, Indiana
| | - Stephen F Kralik
- Department of Pediatrics, Division of Radiology, Texas Children's Hospital, Houston, Texas
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25
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Child AE, Warren EA, Grosshans DR, Paulino AC, Okcu MF, Ris MD, Mahajan A, Orobio J, Cirino PT, Minard CG, Viana AG, Bick J, Woods SP, Chintagumpala M, Kahalley LS. Long-term cognitive and academic outcomes among pediatric brain tumor survivors treated with proton versus photon radiotherapy. Pediatr Blood Cancer 2021; 68:e29125. [PMID: 34114294 PMCID: PMC8316321 DOI: 10.1002/pbc.29125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 03/08/2021] [Revised: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Proton radiotherapy (PRT) may be associated with less neurocognitive risk than photon RT (XRT) for pediatric brain tumor survivors. We compared neurocognitive and academic outcomes in long-term survivors treated with XRT versus PRT. METHODS Survivors underwent neurocognitive evaluation >1 year after craniospinal (CSI) or focal PRT or XRT. Groups were compared using separate one-way analyses of covariance for the CSI and focal groups. RESULTS PRT (n = 58) and XRT (n = 30) subgroups were similar on gender (66% male), age at RT (median = 6.5 years), age at follow-up (median = 14.6 years), and government assistance status (32%). PRT and XRT focal groups differed on follow-up interval, shunt history, and total RT dose (all p < .05), whereas PRT and XRT CSI groups differed on follow-up interval, baseline neurocognitive performance score, boost volume, and CSI dose (all p < .05). The PRT focal group outperformed the XRT focal group on inhibition/switching (p = .04). The PRT CSI group outperformed the XRT CSI group on inattention/impulsivity (both p < .05). Several clinical variables (i.e., RT dose, boost field, baseline performance) predicted neurocognitive outcomes (all p < .05). The PRT focal group performed comparably to population means on most neurocognitive measures, while both CSI groups performed below expectation on multiple measures. The XRT CSI group was most impaired. All groups fell below expectation on processing speed, fine motor, and academic fluency (most p < .01). CONCLUSIONS Findings suggest generally favorable neurocognitive and academic long-term outcomes following focal PRT. Impairment was greatest following CSI regardless of modality. Dosimetry and baseline characteristics are important determinants of outcome alone or in combination with modality.
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Affiliation(s)
- Amanda E. Child
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore MD
| | - Emily A. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Anita Mahajan
- Department of Radiation Oncology, The Mayo Clinic, Rochester MN
| | - Jessica Orobio
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas TX
| | | | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston TX
| | | | | | | | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston TX
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
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26
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Heitzer AM, Kahalley LS, Minard CG, Stafford C, Grosshans DR, Okcu MF, Raghubar KP, Gragert M, McCurdy M, Warren EH, Gomez J, Ris MD, Paulino AC, Chintagumpala M. Treatment age and neurocognitive outcomes following proton beam radiotherapy for pediatric low- and intermediate-grade gliomas. Pediatr Blood Cancer 2021; 68:e29096. [PMID: 34019329 PMCID: PMC9040342 DOI: 10.1002/pbc.29096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/11/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/11/2022]
Abstract
The relationship between age and neurocognitive functioning following proton beam radiotherapy (PRT) in low- and intermediate-grade gliomas (LIGG) has yet to be examined. Eighteen LIGG patients treated with PRT were prospectively enrolled and received annual neurocognitive evaluations of perceptual/verbal reasoning, working memory, and processing speed postradiotherapy. The median age at diagnosis was 8.2 years (range 1.0-14.7) and the median age at PRT was 9.9 years (range 4.2-17.0). Patients' neurocognitive performance did not change on any measure following PRT (p ≥ .142). We did not observe significant changes in cognitive function over time among a small group of LIGG patients treated with PRT.
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Affiliation(s)
- Andrew M. Heitzer
- Psychology Department, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Charles G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Claire Stafford
- Psychology Department, Macalester College, St. Paul, Minnesota
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston TX
| | - Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Marsha Gragert
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Mark McCurdy
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Emily H. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Jocelyn Gomez
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
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Buszek SM, Ludmir EB, Grosshans DR, McAleer MF, McGovern SL, Harrison DJ, Okcu MF, Chintagumpala MM, Mahajan A, Paulino AC. Disease Control and Patterns of Failure After Proton Beam Therapy for Rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2021; 109:718-725. [PMID: 33516439 DOI: 10.1016/j.ijrobp.2020.09.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 08/03/2020] [Accepted: 09/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Pediatric patients with rhabdomyosarcoma (RMS) are treated with multimodal therapy, often with radiation therapy (RT) as part of local therapy. We report on the efficacy and patterns of failure after proton beam therapy (PBT) for RMS. METHODS AND MATERIALS Between January 2006 and February 2017, patients with RMS were enrolled in a prospective institutional review board-approved registry protocol for pediatric patients undergoing PBT. Demographics, clinical characteristics, and treatment related outcomes were reviewed. RESULTS Ninety-four RMS patients were treated with a combination of chemotherapy (CT) and PBT. The majority of patients had head and neck (49%) and genitourinary (30%) primaries. Median tumor size was 4.1 cm (range, 1.0-16.5 cm); 33 patients (35%) had primary tumors >5 cm. Median cyclophosphamide equivalent dose was 14.4 g/m2 (range, 0-30.8 g/m2). Median time from CT initiation to RT initiation was 13 weeks (range, 1-58 weeks). With median follow-up of 4 years, 4-year overall survival (OS) was 71%, and 4-year progression-free survival (PFS) was 63%. Thirty patients (32%) experienced relapse (13% with local failure [LF]). Four-year local control (LC) was 85% overall; 4-year LC rates were 100% for low-risk, 85% for intermediate-risk, and 55% for high-risk patients (P = .02). Tumor size predicted LC (P = .007), with 7% versus 33% LF rate by tumor size (≤5 cm vs >5 cm). Delayed RT delivery (≥13 weeks from initiation of CT) predicted worse LC (P = .01). Increased tumor size predicted both inferior PFS (P = .02) and OS (P = .01). Delayed RT delivery predicted both inferior PFS (P = .04) and OS (P = .03). CONCLUSIONS PBT provides LC comparable to prior studies using photon RT. Inferior LC, PFS, and OS rates were observed for patients with larger tumors and those treated with delayed RT. This finding supports ongoing prospective efforts to dose-escalate treatment of tumors >5 cm; however, these data call into question the optimal timing of local therapy, particularly for patients treated with reduced-dose cyclophosphamide.
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Affiliation(s)
- Samantha M Buszek
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Douglas J Harrison
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Murali M Chintagumpala
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Paulino AC, Ludmir EB, Grosshans DR, Su JM, McGovern SL, Okcu MF, McAleer MF, Baxter PA, Mahajan A, Chintagumpala MM. Overall survival and secondary malignant neoplasms in children receiving passively scattered proton or photon craniospinal irradiation for medulloblastoma. Cancer 2021; 127:3865-3871. [PMID: 34254296 DOI: 10.1002/cncr.33783] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 04/17/2021] [Revised: 05/10/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Both intensity-modulated radiotherapy (RT) and passively scattered proton therapy have a risk of secondary malignant neoplasm (SMN) in children. To determine the influence of RT modality on the incidence of SMN after craniospinal irradiation (CSI), the authors compared the incidence of SMN in children who had medulloblastoma treated with either photon CSI plus an intensity-modulated RT boost (group I) or passively scattered proton CSI plus a boost (group II). METHODS From 1996 to 2014, 115 children with medulloblastoma (group I, n = 63; group II, n = 52) received CSI followed by a boost to the tumor bed. Most patients had standard-risk disease (63.5%). The median follow-up was 12.8 years for group I and 8.7 years for group II. RESULTS The 5-year and 10-year overall survival (OS) rates were 88.8% and 85.1%, respectively, for standard-risk patients and 63.1% and 57.3%, respectively, for high-risk patients, with no OS difference by RT modality (P = .81). Six SMNs were identified (4 in group I, 2 in group II). The 5-year and 10-year SMN incidence rates were 1.0% and 6.9%, respectively (0.0% and 8.0%, respectively, in group I; 2.2% and 4.9%, respectively, in group II; P = .74). Two SMNs occurred in the clinical target volume in the brain, 2 occurred in the exit dose region from the photon spinal field, 1 occurred in the entrance path of a proton beam, and 1 occurred outside the radiation field. There were no reported cases of secondary leukemia. CONCLUSIONS This analysis demonstrates no difference in OS or SMN incidence between patients in groups I and II 10 years after RT. LAY SUMMARY One hundred fifteen children with medulloblastoma received radiotherapy (RT) with either photon craniospinal irradiation (CSI) and an intensity-modulated RT boost (group I; n = 63) or passively scattered proton CSI and a boost (group II;, n = 52). The majority of children had standard-risk disease (63.5%). The 5-year and 10-year overall survival rates were 88.8% and 85.1% for standard-risk patients, respectively, and 63.1% and 57.3% for high-risk patients, respectively, with no difference in overall survival by RT group (P = .81). The 5-year and 10-year second malignant neoplasm incidence rates were 1.0% and 6.9%, respectively, with no difference in second malignant neoplasm incidence according to RT group (P = .74).
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack M Su
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia A Baxter
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Murali M Chintagumpala
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
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Milgrom SA, van Luijk P, Pino R, Ronckers CM, Kremer LC, Gidley PW, Grosshans DR, Laskar S, Okcu MF, Constine LS, Paulino AC. Salivary and Dental Complications in Childhood Cancer Survivors Treated With Radiation Therapy to the Head and Neck: A Pediatric Normal Tissue Effects in the Clinic (PENTEC) Comprehensive Review. Int J Radiat Oncol Biol Phys 2021:S0360-3016(21)00443-0. [PMID: 34074567 DOI: 10.1016/j.ijrobp.2021.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/14/2021] [Accepted: 04/21/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Radiation therapy (RT) to the head and neck (H&N) region is critical in the management of various pediatric malignancies; however, it may result in late toxicity. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on salivary dysfunction and dental abnormalities in survivors who received RT to the H&N region as children. MATERIALS & METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. RESULTS Of the 2,164 articles identified through a literature search, 40 were included in a qualitative synthesis and 3 were included in a quantitative synthesis. The dose-toxicity data regarding salivary function demonstrate that a mean parotid dose of 35 to 40 Gy is associated with a risk of acute and chronic grade ≥2 xerostomia of approximately 32% and 13% to 32%, respectively, in patients treated with chemo-radiation therapy. This risk increases with parotid dose; however, rates of xerostomia after lower dose exposure have not been reported. Dental developmental abnormalities are common after RT to the oral cavity. Risk factors include higher radiation dose to the developing teeth and younger age at RT. CONCLUSIONS This PENTEC task force considers adoption of salivary gland dose constraints from the adult experience to be a reasonable strategy until more data specific to children become available; thus, we recommend limiting the parotid mean dose to ≤26 Gy. The minimum toxic dose for dental developmental abnormalities is unknown, suggesting that the dose to the teeth should be kept as low as possible particularly in younger patients, with special effort to keep doses <20 Gy in patients <4 years old.
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Affiliation(s)
- Sarah A Milgrom
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ramiro Pino
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas
| | - Cecile M Ronckers
- Princess Máxima Centrum for Pediatric Oncology, Utrecht, Netherlands; Institute of Biostatistics and Registry Research, Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C Kremer
- Institute of Biostatistics and Registry Research, Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany; UMC Amsterdam, Location AMC, Department of Pediatrics, Amsterdam, Netherlands
| | - Paul W Gidley
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Siddhartha Laskar
- Department of Radiation Oncgqtology, Tata Memorial Hospital, Mumbai, India
| | - M Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
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Ravindra VM, Okcu MF, Ruggieri L, Frank TS, Paulino AC, McGovern SL, Horne VE, Dauser RC, Whitehead WE, Aldave G. Comparison of multimodal surgical and radiation treatment methods for pediatric craniopharyngioma: long-term analysis of progression-free survival and morbidity. J Neurosurg Pediatr 2021:1-8. [PMID: 34049281 DOI: 10.3171/2020.11.peds20803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/22/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors compared survival and multiple comorbidities in children diagnosed with craniopharyngioma who underwent gross-total resection (GTR) versus subtotal resection (STR) with radiation therapy (RT), either intensity-modulated radiation therapy (IMRT) or proton beam therapy (PBT). The authors hypothesized that there are differences between multimodal treatment methods with respect to morbidity and progression-free survival (PFS). METHODS The medical records of children diagnosed with craniopharyngioma and treated surgically between February 1997 and December 2018 at Texas Children's Hospital were reviewed. Surgical treatment was stratified as GTR or STR + RT. RT was further stratified as PBT or IMRT; PBT was stratified as STR + PBT versus cyst decompression (CD) + PBT. The authors used Kaplan-Meier analysis to compare PFS and overall survival, and chi-square analysis to compare rates for hypopituitarism, vision loss, and hypothalamic obesity (HyOb). RESULTS Sixty-three children were included in the analysis; 49% were female. The mean age was 8.16 years (95% CI 7.08-9.27). Twelve of 14 children in the IMRT cohort underwent CD. The 5-year PFS rates were as follows: 73% for GTR (n = 31), 54% for IMRT (n = 14), 100% for STR + PBT (n = 7), and 77% for CD + PBT (n = 11; p = 0.202). The overall survival rates were similar in all groups. Rates of hypopituitarism (96% GTR vs 75% IMRT vs 100% STR + PBT, 50% CD + PBT; p = 0.023) and diabetes insipidus (DI) (90% GTR vs 61% IMRT vs 85% STR + PBT, 20% CD + PBT; p = 0.004) were significantly higher in the GTR group. There was no significant difference in the HyOb or vision loss at the end of study follow-up among the different groups. Within the PBT group, 2 patients presented a progressive vasculopathy with subsequent strokes. One patient experienced a PBT-induced tumor. CONCLUSIONS GTR and CD + PBT presented similar rates of 5-year PFS. Hypopituitarism and DI rates were higher with GTR, but the rate of HyOb was similar among different treatment modalities. PBT may reduce the burden of hypopituitarism and DI, although radiation carries a risk of potential serious complications, including progressive vasculopathy and secondary malignancy. Further prospective study comparing neurocognitive outcomes is necessary.
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Affiliation(s)
- Vijay M Ravindra
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
- 6Department of Neurosurgery, Naval Medical Center San Diego; and
- 7Division of Pediatric Neurosurgery, University of California, San Diego, California
| | - M Fatih Okcu
- 2Texas Children's Cancer Center, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Lucia Ruggieri
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Thomas S Frank
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | - Arnold C Paulino
- 4Department of Radiation Oncology, Texas Children's Hospital, Houston
| | - Susan L McGovern
- 4Department of Radiation Oncology, Texas Children's Hospital, Houston
| | - Vincent E Horne
- 5Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Robert C Dauser
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - William E Whitehead
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Guillermo Aldave
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
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31
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Hanania AN, Paulino AC, Ludmir EB, Shah VS, Su JM, McGovern SL, Baxter PA, McAleer MF, Grosshans DR, Okcu MF, Chintagumpala MM. Early radiotherapy preserves vision in sporadic optic pathway glioma. Cancer 2021; 127:2358-2367. [PMID: 33739455 DOI: 10.1002/cncr.33497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/12/2020] [Revised: 01/02/2021] [Accepted: 01/26/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Sporadic optic pathway/hypothalamic gliomas represent a unique entity within pediatric low-grade glioma. Despite favorable survival, location makes treatment difficult and local progression debilitating. This study is a longitudinal assessment of visual acuity (VA) among children treated within the last 2 decades. METHODS Clinical characteristics were abstracted for patients treated from 2000 to 2018 at Texas Children's Cancer Center in Houston. Ophthalmologic data taken at 3- to 6-month intervals were examined with age-appropriate VA metrics converted to the LogMAR (logarithm of the minimum angle of resolution) scale. Kaplan-Meier blindness-free survival (BFS) curves, calculated as time-to-bilateral functional blindness (LogMAR ≥0.8 in both eyes), were calculated for patients receiving early radiation therapy (RT; upfront or as first-line salvage treatment) or chemotherapy (CT) and evaluated using the log-rank test. RESULTS Thirty-eight patients with a median follow-up of 8.5 years (range, 2-17 years) were identified. Median age at diagnosis was 3 years (interquartile range, <1-6 years). Early RT was administered in 11 patients (29%). Twenty-seven patients (71%) were treated primarily with CT, initiated at a median age of 3.5 years (range, <1-11 years). Eight patients in the CT group did eventually require RT secondary to VA loss and following multiple lines of CT. Median age at RT for all patients was 11 years (range, 3-17 years). BFS rates were 81% at 5 years and 60% at 8 years for CT and 100% at 5 and 8 years for early RT (P = .017). CONCLUSIONS In a contemporary cohort, early RT, defined as initial or first-line salvage therapy, was found to have superior BFS for appropriately selected patients with sporadic optic pathway/hypothalamic gliomas. LAY SUMMARY Children with low-grade brain tumors of the optic pathway generally have excellent long-term survival; however, given the location of these tumors, there can commonly be threatened vision if the tumor grows. Although radiation is generally deferred in children on the basis of legitimate concerns regarding the effects on the developing brain, it may represent a vision-preserving therapy for well-selected older patients.
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Affiliation(s)
- Alexander N Hanania
- Department of Radiation Oncology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Veeral S Shah
- Department of Pediatric Ophthalmology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jack M Su
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia A Baxter
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
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Choe M, Smith V, Okcu MF, Wulff J, Gruner S, Huisman TAGM, Venkatramani R. Treatment of central giant cell granuloma in children with denosumab. Pediatr Blood Cancer 2021; 68:e28778. [PMID: 33089644 DOI: 10.1002/pbc.28778] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 09/14/2020] [Accepted: 10/09/2020] [Indexed: 11/09/2022]
Abstract
Central giant cell granuloma (CGCG) is a benign but locally aggressive intraosseous lesion of the mandible. Historically, it is treated by curettage or resection. Medical therapy is indicated when surgery is associated with increased morbidity or in adjuvant setting to decrease recurrence. Treatment of CGCG with denosumab, a receptor activator of nuclear factor kappa-beta (RANK) ligand inhibitor, is not well studied, especially in children. Here, we describe our experience with the use of denosumab in the treatment of six children with CGCG. All patients had a favorable response with manageable side effects, which suggests that denosumab is an effective treatment option without increased morbidity.
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Affiliation(s)
- Michelle Choe
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Valeria Smith
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jade Wulff
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephanie Gruner
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, Texas
| | - Rajkumar Venkatramani
- Cancer and Hematology Center, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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33
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Mak DY, Laperriere N, Ramaswamy V, Bouffet E, Murray JC, McNall-Knapp RY, Bielamowicz K, Paulino AC, Zaky W, McGovern SL, Okcu MF, Tabori U, Atwi D, Dirks PB, Taylor MD, Tsang DS, Bavle A. Reevaluating surgery and re-irradiation for locally recurrent pediatric ependymoma—a multi-institutional study. Neurooncol Adv 2021; 3:vdab158. [PMID: 34988448 PMCID: PMC8694210 DOI: 10.1093/noajnl/vdab158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The goal of this study was to evaluate extent of surgical resection, and timing and volume of re-irradiation, on survival for children with locally recurrent ependymoma. Methods Children with locally recurrent ependymoma treated with a second course of fractionated radiotherapy (RT2) from 6 North American cancer centers were reviewed. The index time was from the start of RT2 unless otherwise stated. Results Thirty-five patients were included in the study. The median doses for first radiation (RT1) and RT2 were 55.8 and 54 Gy, respectively. Median follow-up time was 5.6 years. Median overall survival (OS) for all patients from RT2 was 65 months. Gross total resection (GTR) was performed in 46% and 66% of patients prior to RT1 and RT2, respectively. GTR prior to RT2 was independently associated with improved progression-free survival (PFS) for all patients (HR 0.41, P = 0.04), with an OS benefit (HR 0.26, P = 0.03) for infratentorial tumors. Median PFS was superior with craniospinal irradiation (CSI) RT2 (not reached) compared to focal RT2 (56.9 months; log-rank P = 0.03). All distant failures (except one) occurred after focal RT2. Local failures after focal RT2 were predominantly in patients with less than GTR pre-RT2. Conclusions Patients with locally recurrent pediatric ependymoma should be considered for re-treatment with repeat maximal safe resection (ideally GTR) and CSI re-irradiation, with careful discussion of the potential side effects of these treatments.
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Affiliation(s)
- David Y Mak
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey C Murray
- Pediatric Hematology/Oncology, Cook Children’s Medical Center, Fort Worth, Texas, USA
| | - Rene Y McNall-Knapp
- Section of Pediatric Hematology/Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kevin Bielamowicz
- Section of Pediatric Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Wafik Zaky
- Division of Pediatrics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - M Fatih Okcu
- Section of Pediatric Hematology/Oncology, Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Doaa Atwi
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Peter B Dirks
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D Taylor
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abhishek Bavle
- Children’s Blood and Cancer Center, Dell Children’s Medical Center of Central Texas, Austin, Texas, USA
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34
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Kahalley L, Peterson R, Ris MD, Janzen L, Okcu MF, Grosshans D, Ramaswamy V, Paulino A, Hodgson D, Mahajan A, Tsang D, Laperriere N, Whitehead W, Dauser R, Taylor M, Conklin H, Bouffet E, Chintagumpala M, Mabbott D. QOL-01. LONGITUDINAL COMPARISON OF NEUROCOGNITIVE TRAJECTORIES IN PEDIATRIC MEDULLOBLASTOMA PATIENTS TREATED WITH PROTON VERSUS PHOTON RADIOTHERAPY. Neuro Oncol 2020. [PMCID: PMC7715279 DOI: 10.1093/neuonc/noaa222.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE By reducing dose to normal brain tissue, proton radiotherapy (PRT) may lessen neurocognitive risk traditionally associated with photon radiotherapy (XRT). We examined change in neurocognitive scores over time in pediatric medulloblastoma patients treated with PRT versus XRT. METHODS Neurocognitive scores from 79 patients (37 PRT, 42 XRT) were examined. Patients were treated between 2007–2018 on the same treatment protocols that differed only by craniospinal modality (PRT versus XRT). Change in scores over time since diagnosis were compared between groups. RESULTS Groups were similar on most demographic/clinical variables: sex (67.1% male), age at diagnosis (mean 8.6 years), CSI dose (median 23.4 Gy), length of follow-up (mean 4.3 years), and parental education (mean 14.3 years). Boost dose (p<0.001) and margin (p=0.001) differed between groups. Adjusting for covariates, the PRT group exhibited superior outcomes in global IQ, perceptual reasoning, and working memory versus the XRT group (all p<0.05). The XRT group exhibited significant decline in global IQ, working memory, and processing speed (all p<0.05). The PRT group exhibited stable scores in all domains except processing speed (p=0.003). Posterior fossa syndrome imparted risk independent of modality. CONCLUSION This is the first study comparing neurocognitive trajectories between pediatric patients treated for medulloblastoma with PRT versus XRT on comparable, contemporary protocols. PRT was associated with more favorable neurocognitive outcomes in most domains compared to XRT, although processing speed emerged as vulnerable in both groups. This is the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.
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Affiliation(s)
- Lisa Kahalley
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - M Douglas Ris
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Laura Janzen
- The Hospital for Sick Children, Toronto, ON, Canada
| | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - Vijay Ramaswamy
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | | | - David Hodgson
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Derek Tsang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - William Whitehead
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - Michael Taylor
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | | | - Eric Bouffet
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Donald Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
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Heitzer A, Kahalley L, Grosshans D, Okcu MF, Raghubar K, Gragert M, McCurdy M, Warren E, Ris MD, Paulino A, Chintagumpala M. RONC-12. TREATMENT AGE AND NEUROCOGNITIVE OUTCOMES FOLLOWING PROTON BEAM RADIOTHERAPY FOR PEDIATRIC LOW GRADE GLIOMA. Neuro Oncol 2020. [PMCID: PMC7715617 DOI: 10.1093/neuonc/noaa222.782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Younger age at radiotherapy increases cognitive risk for patients with pediatric low grade glioma (LGG). We examined the impact of age at treatment on cognitive trajectories in LGG patients treated with proton radiotherapy (PRT) compared to patients treated without radiotherapy (surgery only; SO). METHODS We examined cognitive scores of 48 LGG patients on a prospective, longitudinal study. General linear mixed models evaluated change in cognitive scores over time. RESULTS The sample included 16 patients treated with PRT and 32 with SO (median follow-up=3.1 years, range 0.9–6.1). Median age of PRT patients was 8.2 years at diagnosis (range 1.0–14.4) and 9.4 years at PRT (range 4.2–16.7). 13 PRT patients also received surgery: 53.8% biopsy, 30.8% subtotal resection, 15.4% gross total resection. Tumor sites included: 31.2% hypothalamic/suprasellar, 25.0% optic pathway, 18.8% temporal, 25.0% other. Median age of SO patients was 8.2 years at diagnosis (range 2.9–18.6). Surgical outcomes were: 75.0% gross total resection, 21.9% biopsy/other. There were no group differences in diagnosis age, tumor volume, or shunt history (all p>0.05). Both PRT and SO groups displayed stable cognitive functioning over time (all p>0.1). Slopes (i.e., change in scores over time) did not differ between groups (all p>0.1). Age at treatment was not associated with slope or performance at last follow-up in either group (all p>0.05). CONCLUSIONS We observed stable cognitive functioning, independent of age at treatment, following PRT for LGG. Outcomes were similar to patients receiving surgery only. Further examination in a larger sample is warranted.
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Affiliation(s)
- Andrew Heitzer
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Lisa Kahalley
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Kimberly Raghubar
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Marsha Gragert
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Mark McCurdy
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Emily Warren
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | | | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
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36
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Richard MA, Brown AL, Belmont JW, Scheurer ME, Arroyo VM, Foster KL, Kern KD, Hudson MM, Leisenring WM, Okcu MF, Sapkota Y, Yasui Y, Morton LM, Chanock SJ, Robison LL, Armstrong GT, Bhatia S, Oeffinger KC, Lupo PJ, Kamdar KY. Genetic variation in the body mass index of adult survivors of childhood acute lymphoblastic leukemia: A report from the Childhood Cancer Survivor Study and the St. Jude Lifetime Cohort. Cancer 2020; 127:310-318. [PMID: 33048379 DOI: 10.1002/cncr.33258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 04/13/2020] [Revised: 07/06/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment characteristics such as cranial radiation therapy (CRT) do not fully explain adiposity risk in childhood acute lymphoblastic leukemia (ALL) survivors. This study was aimed at characterizing genetic variation related to adult body mass index (BMI) among survivors of childhood ALL. METHODS Genetic associations of BMI among 1458 adult survivors of childhood ALL (median time from diagnosis, 20 years) were analyzed by multiple approaches. A 2-stage genome-wide association study in the Childhood Cancer Survivor Study (CCSS) and the St. Jude Lifetime Cohort Study (SJLIFE) was performed. BMI was a highly polygenic trait in the general population. Within the known loci, the BMI percent variance explained was estimated, and additive interactions (chi-square test) with CRT in the CCSS were evaluated. The role of DNA methylation in CRT interaction was further evaluated in a subsample of ALL survivors. RESULTS In a meta-analysis of the CCSS and SJLIFE, 2 novel loci associated with adult BMI among survivors of childhood ALL (LINC00856 rs575792008 and EMR1 rs62123082; PMeta < 5E-8) were identified. It was estimated that the more than 700 known loci explained 6.2% of the variation in adult BMI in childhood ALL survivors. Within the known loci, significant main effects for 23 loci and statistical interactions with CRT at 9 loci (P < 7.0E-5) were further identified. At 2 CRT-interacting loci, DNA methylation patterns may have differed by age. CONCLUSIONS Adult survivors of childhood ALL have genetic heritability for BMI similar to that observed in the general population. This study provides evidence that treatment with CRT can modify the effect of genetic variants on adult BMI in childhood ALL survivors.
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Affiliation(s)
- Melissa A Richard
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Austin L Brown
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - John W Belmont
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Michael E Scheurer
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Vidal M Arroyo
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Kayla L Foster
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Kathleen D Kern
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - M Fatih Okcu
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Yadav Sapkota
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Lindsay M Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Stephen J Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Philip J Lupo
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
| | - Kala Y Kamdar
- Section of Hematology/Oncology, Department of Pediatrics, Texas Children's Cancer Center and Baylor College of Medicine, Houston, Texas
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Kahalley LS, Douglas Ris M, Mahajan A, Fatih Okcu M, Chintagumpala M, Paulino AC, Whitehead WE, Minard CG, Stancel HH, Orobio J, Xue JJ, Warren EA, Grosshans DR. Prospective, longitudinal comparison of neurocognitive change in pediatric brain tumor patients treated with proton radiotherapy versus surgery only. Neuro Oncol 2020; 21:809-818. [PMID: 30753584 DOI: 10.1093/neuonc/noz041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Proton radiotherapy (PRT) reduces the volume of normal tissue receiving radiation dose, which may lead to better neurocognitive outcomes. We examined change in neurocognitive scores over time in pediatric brain tumor patients treated with proton craniospinal irradiation (CSI), proton focal RT, or surgery only. METHODS Patients received annual neurocognitive evaluations for up to 6 years. We examined Full Scale IQ (FSIQ), Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI) scores. General linear mixed models examined change in scores over time by treatment group, adjusting for significant covariates. RESULTS Scores from 93 patients treated between 2012 and 2017 (22 proton CSI, 31 proton focal, and 40 surgery only) were examined. Treatment groups were similar on gender (51.6% male), age at treatment (median = 9.7 y), and length of follow-up (median = 2.9 y). The surgery only group had proportionately more gliomas (P < 0.001), and the proton CSI group had more infratentorial tumors (P = 0.001) and higher total RT dose (P = 0.004). The proton focal and surgery only groups exhibited stable neurocognitive scores over time across all indexes (all P > 0.05). In the proton CSI group, WMI, PSI, and FSIQ scores declined significantly (P = 0.036, 0.004, and 0.017, respectively), while VCI and PRI scores were stable (all P > 0.05). CONCLUSIONS Focal PRT was associated with stable neurocognitive functioning into survivorship. Outcomes were similar whether patients received focal PRT or no radiotherapy, even in neurocognitive domains known to be particularly radiosensitive. Proton CSI emerged as a neurocognitive risk factor, consistent with photon outcomes research.
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Affiliation(s)
- Lisa S Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - M Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneosta
| | - M Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William E Whitehead
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Heather H Stancel
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Judy J Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas.,Rice University
| | - Emily A Warren
- University of Houston, Department of Psychology, Houston, Texas
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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38
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de Blank P, Li N, Fisher MJ, Ullrich NJ, Bhatia S, Yasui Y, Sklar CA, Leisenring W, Howell R, Oeffinger K, Hardy K, Okcu MF, Gibson TM, Robison LL, Armstrong GT, Krull KR. Late morbidity and mortality in adult survivors of childhood glioma with neurofibromatosis type 1: report from the Childhood Cancer Survivor Study. Genet Med 2020; 22:1794-1802. [PMID: 32572180 PMCID: PMC7606750 DOI: 10.1038/s41436-020-0873-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 04/08/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Neurofibromatosis type 1 (NF1) is associated with tumor predisposition and non-malignant health conditions. Whether survivors of childhood cancer with NF1 are at increased risk for poor long-term health outcomes is unknown. Methods 147 5+ year survivors of childhood glioma with NF1 from the Childhood Cancer Survivor Study were compared to 2 629 non-NF1 glioma survivors and 5 051 siblings for late mortality, chronic health conditions, psychosocial, neurocognitive, and socioeconomic outcomes. Results Survivors with NF1 (age at diagnosis: 6.8±4.8 years) had greater cumulative incidence of late mortality 30 years after diagnosis (46.3%[95% confidence interval: 23.9%−62.2%]) compared to non-NF1 survivors (18.0%[16.1%−20.0%]) and siblings (0.9%[0.6%−1.2%]), largely due to subsequent neoplasms. Compared to survivors without NF1, those with NF1 had more severe/life-threatening chronic conditions at cohort entry (46.3%[38.1%−54.4%] vs. 30.8%[29.1%−32.6%]), but similar rates of new conditions during follow-up (Rate Ratio: 1.26 [0.90–1.77]). Survivors with NF1 were more likely to report psychosocial impairments, neurocognitive deficits, and socioeconomic difficulties compared to survivors without NF1. Conclusion Late mortality among glioma survivors with NF1 is twice that of other survivors, due largely to subsequent malignancies. Screening, prevention and early intervention for chronic health conditions, psychosocial and neurocognitive deficits may reduce long-term morbidity in this vulnerable population.
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Affiliation(s)
- Peter de Blank
- University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Nan Li
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Michael J Fisher
- University of Pennsylvania Perlman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicole J Ullrich
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yutaka Yasui
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Wendy Leisenring
- Cancer Prevention and Clinical Statistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - M Fatih Okcu
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Todd M Gibson
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin R Krull
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
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39
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Kahalley LS, Peterson R, Ris MD, Janzen L, Okcu MF, Grosshans DR, Ramaswamy V, Paulino AC, Hodgson D, Mahajan A, Tsang DS, Laperriere N, Whitehead WE, Dauser RC, Taylor MD, Bouffet E, Chintagumpala M, Mabbott D. Reply to S.A. Milgrom et al. J Clin Oncol 2020; 38:2212-2213. [PMID: 32374644 DOI: 10.1200/jco.20.00344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lisa S Kahalley
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Rachel Peterson
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - M Douglas Ris
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Laura Janzen
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - M Fatih Okcu
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - David R Grosshans
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Arnold C Paulino
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - David Hodgson
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Anita Mahajan
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Derek S Tsang
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Normand Laperriere
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - William E Whitehead
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Robert C Dauser
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Michael D Taylor
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Eric Bouffet
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Murali Chintagumpala
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
| | - Donald Mabbott
- Lisa S. Kahalley, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Rachel Peterson, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Douglas Ris, PhD, Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, TX; Laura Janzen, PhD, Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; M. Fatih Okcu, MPH, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; David R. Grosshans, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Vijay Ramaswamy, MD, PhD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Arnold C. Paulino, MD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; David Hodgson, MPH, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Anita Mahajan, MD, Department of Radiation Oncology, The Mayo Clinic, Rochester, MN; Derek S. Tsang, MSc, MD and Normand Laperriere, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; WilliamE. Whitehead, MPH, MD and Robert C.Dauser, MD, Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Houston, TX; Michael D. Taylor, MD, PhD, Division of Neurosurgery, The Hospital for Sick Children, and Department of Surgery, The University of Toronto, Toronto, Ontario, Canada; Eric Bouffet, MD, Division of Haematology/Oncology, The Hospital for Sick Children, and Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada; Murali Chintagumpala, MD, Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX; and Donald Mabbott, PhD, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, and Department of Psychology, The University of Toronto, Toronto, Ontario, Canada
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Roth AK, Ris MD, Orobio J, Xue J, Mahajan A, Paulino AC, Grosshans D, Okcu MF, Chintagumpala M, Kahalley L. Cognitive mediators of adaptive functioning outcomes in survivors of pediatric brain tumors treated with proton radiotherapy. Pediatr Blood Cancer 2020; 67:e28064. [PMID: 31736188 PMCID: PMC7433211 DOI: 10.1002/pbc.28064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/29/2019] [Revised: 09/10/2019] [Accepted: 10/12/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranial radiotherapy (RT) is associated with risk for cognitive and adaptive dysfunction. Proton RT (PRT) is a technique hypothesized to spare cognition by reducing exposure to nontarget brain tissue. However, little is known regarding functional outcomes in survivors of pediatric brain tumor (BT) treated with PRT. The present study examined the relationship between cognitive and adaptive outcomes in pediatric BT survivors post-PRT. METHODS Survivors treated with either focal (n = 33) or craniospinal irradiation (CSI; n = 37) PRT completed neurocognitive evaluations approximately 5 years post-treatment. Results of intelligence testing and ratings of adaptive functioning are reported. Mediation models examined the relationship among radiation field, cognition, and adaptive functioning. RESULTS The PRT CSI group demonstrated worse cognitive outcomes than the PRT Focal group across each cognitive index (Cohen's d = 0.56-0.70). Parent ratings of adaptive functioning were also worse in the PRT CSI group than the PRT Focal group (Global Adaptive Composite, d = 0.53; conceptual skills, d = 0.67). Cognitive performance fully mediated the relationship between radiation field and adaptive outcomes, while controlling for group differences in tumor histology and RT dose. CONCLUSIONS Focal PRT survivors demonstrated generally positive outcomes with weaknesses in processing speed and aspects of adaptive functioning. CSI exposure was associated with more consistently poor cognitive and adaptive outcomes. The increased risk for adaptive dysfunction in the PRT CSI group appeared due to the effects of CSI on cognition. Efforts to reduce the volume of tissue exposure to RT remain important.
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Affiliation(s)
- Alexandra K. Roth
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Judy Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | | | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Lisa Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
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Heitzer AM, Raghubar K, Ris MD, Minard CG, Gragert MN, Stancel HH, Orobio J, Xue J, Whitehead W, Okcu MF, Chintagumpala M, Kahalley LS. Neuropsychological functioning following surgery for pediatric low-grade glioma: a prospective longitudinal study. J Neurosurg Pediatr 2019; 25:1-9. [PMID: 31812134 PMCID: PMC9040333 DOI: 10.3171/2019.9.peds19357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High survival rates have led to an increased emphasis on the functional outcomes of children diagnosed with low-grade glioma. Most outcomes research has focused on risks associated with radiotherapy, but less is known about neuropsychological risks for patients treated with surgery alone. Here, the authors sought to examine the neuropsychological trajectories of children diagnosed with a low-grade glioma and monitored up to 6 years postsurgery. Secondarily, they explored demographic and clinical predictors of neuropsychological performance. METHODS The neuropsychological functioning of 32 patients (median age at diagnosis 10.0 years) was prospectively assessed annually for up to 6 years after surgery (median days from surgery at baseline = 72). Tumor location was predominately supratentorial (65.6%). A combination of performance-based and parent-reported measures was used to assess intelligence, memory, executive functioning, and fine motor control in all patients. RESULTS Binomial tests at the postoperative baseline revealed that the proportion of children falling below the average range (< 16th percentile) was significantly higher than the rate expected among healthy peers on measures of verbal memory, processing speed, executive functioning, and fine motor control (p < 0.05). Even so, linear mixed models indicated that neuropsychological functioning at the postoperative baseline did not significantly change over time for up to 6 years after surgery across all domains. A larger tumor size was associated with a slower reaction time (p < 0.01). A supratentorial tumor location and history of seizures were associated with more parent-reported executive difficulties (p < 0.01). CONCLUSIONS While radiotherapy is a known risk factor for neuropsychological deficits in pediatric brain tumor patients, findings in this study indicate that children treated for low-grade glioma with surgery alone (without radiotherapy or chemotherapy) remain susceptible to difficulties with memory, executive functioning, and motor functioning that persist over time. Over half of the children in the study sample required school support services to address neuropsychological weaknesses. Although low-grade glioma is often conceptualized as a benign tumor, children treated for this lesion require ongoing monitoring and intervention to address neuropsychological weaknesses resulting from the tumor itself as well as the surgery.
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Affiliation(s)
- Andrew M Heitzer
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
| | - Kimberly Raghubar
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
| | - M Douglas Ris
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
| | - Charles G Minard
- 2Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Marsha N Gragert
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
| | - Heather H Stancel
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
| | - Jessica Orobio
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
| | - Judy Xue
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
- 3Rice University, Houston, Texas
| | - William Whitehead
- 5Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine; and
| | - M Fatih Okcu
- 4Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine
| | - Murali Chintagumpala
- 4Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine
| | - Lisa S Kahalley
- 1Department of Pediatrics, Section of Psychology, Baylor College of Medicine
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Kahalley LS, Peterson R, Ris MD, Janzen L, Okcu MF, Grosshans DR, Ramaswamy V, Paulino AC, Hodgson D, Mahajan A, Tsang DS, Laperriere N, Whitehead WE, Dauser RC, Taylor MD, Conklin HM, Chintagumpala M, Bouffet E, Mabbott D. Superior Intellectual Outcomes After Proton Radiotherapy Compared With Photon Radiotherapy for Pediatric Medulloblastoma. J Clin Oncol 2019; 38:454-461. [PMID: 31774710 DOI: 10.1200/jco.19.01706] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Proton radiotherapy (PRT) may lessen the neuropsychological risk traditionally associated with cranial radiotherapy for the treatment of pediatric brain tumors by reducing the dose to normal tissue compared with that of photon radiotherapy (XRT). We examined the change in intellectual scores over time in patients with pediatric medulloblastoma treated with craniospinal PRT versus XRT. METHODS Intelligence test scores were obtained for a sample of pediatric patients treated between 2007 and 2018 on the same medulloblastoma protocols that differed only in radiotherapy modality (PRT v XRT). Growth curve analyses compared change in scores over time since diagnosis between groups. RESULTS Longitudinal intelligence data from 79 patients (37 PRT, 42 XRT) were examined. Groups were similar on most demographic/clinical variables, including sex (67.1% male), age at diagnosis (mean, 8.6 years), craniospinal irradiation dose (median, 23.4 Gy), length of follow-up (mean, 4.3 years), and parental education (mean, 14.3 years). Boost dose (P < .001) and boost margin (P = .001) differed between groups. Adjusting for covariates, the PRT group exhibited superior long-term outcomes in global intelligence quotient (IQ), perceptual reasoning, and working memory compared with the XRT group (all P < .05). The XRT group exhibited a significant decline in global IQ, working memory, and processing speed (all P < .05). The PRT group exhibited stable scores over time in all domains with the exception of processing speed (P = .003). CONCLUSION To our knowledge, this is the first study to compare intellectual trajectories between pediatric patients treated for medulloblastoma with PRT versus those treated with XRT on comparable, contemporary protocols. PRT was associated with more favorable intellectual outcomes in most domains compared with XRT, although processing speed emerged as a vulnerable domain for both groups. This study provides the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.
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Affiliation(s)
- Lisa S Kahalley
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | | | - M Douglas Ris
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Laura Janzen
- The Hospital for Sick Children, Toronto, ON, Canada
| | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | | | - Vijay Ramaswamy
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | | | - David Hodgson
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Derek S Tsang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - William E Whitehead
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Robert C Dauser
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Michael D Taylor
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | | | | | - Eric Bouffet
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | - Donald Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
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Buszek SM, Ludmir EB, Grosshans DR, McAleer MF, McGovern SL, Harrison DJ, Okcu MF, Chintagumpala MM, Mahajan A, Paulino AC. Patterns of failure and toxicity profile following proton beam therapy for pediatric bladder and prostate rhabdomyosarcoma. Pediatr Blood Cancer 2019; 66:e27952. [PMID: 31397065 DOI: 10.1002/pbc.27952] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 05/13/2019] [Revised: 06/19/2019] [Accepted: 07/18/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE/OBJECTIVE(S) Bladder and prostate are unfavorable sites for rhabdomyosarcoma (B/P-RMS), and represent a challenging location for radiotherapy. MATERIALS/METHODS Nineteen patients with B/P-RMS were enrolled on a prospective registry protocol (2008-2017) and treated with chemotherapy, proton beam therapy (PBT), and surgical resection (n = 8; 42%). Emphasis was given to treatment technique, disease-related outcomes, and toxicity associated with PBT. RESULTS The majority of patients had bladder RMS (74%) of embryonal histology (95%), Group III (68%), and intermediate-risk disease by Children's Oncology Group (COG) risk stratification (89%). Seven patients (37%) had primary tumors >5 cm in size. All patients were treated according to COG protocols. With a median follow-up of 66.2 months, 5-year overall survival (OS) and progression-free survival (PFS) were 76%. Four patients (21%) experienced disease relapse, all presenting with local failure. The 5-year local control (LC) rate was 76%. Tumor size predicted LC, with 5-year LC for patients with >5 cm tumors being 43% versus 100% for those with ≤5 cm tumors (P = .006). Univariate analysis demonstrated an effect of tumor size on OS (tumor >5 cm, hazard ratio [HR] 17.7, P = .049) and PFS (HR 17.7, P = .049). Acute grade 2 toxicity was observed in two patients (11%, transient proctitis). Late grade 2+ toxicity was observed in three patients (16%; n = 1 grade 2 skeletal deformity; n = 3 transient grade 2 urinary incontinence; one patient experienced both). CONCLUSIONS PBT for B/P-RMS affords promising disease-related outcomes with an acceptable toxicity profile. Higher local failure rates were observed for larger tumors, supporting dose-escalation components of ongoing RMS clinical trials.
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Affiliation(s)
- Samantha M Buszek
- Department of Radiation Oncology, Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Department of Radiation Oncology, Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary F McAleer
- Department of Radiation Oncology, Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Douglas J Harrison
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Murali M Chintagumpala
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arnold C Paulino
- Department of Radiation Oncology, Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
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Raghubar KP, Orobio J, Ris MD, Heitzer AM, Roth A, Brown AL, Okcu MF, Chintagumpala M, Grosshans DR, Paulino AC, Mahajan A, Kahalley LS. Adaptive functioning in pediatric brain tumor survivors: An examination of ethnicity and socioeconomic status. Pediatr Blood Cancer 2019; 66:e27800. [PMID: 31134755 PMCID: PMC6730637 DOI: 10.1002/pbc.27800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 02/17/2019] [Revised: 04/11/2019] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Survivors of pediatric brain tumor are at risk for adaptive difficulties. The present study examined adaptive functioning in a multiethnic sample of survivors accounting for socioeconomic status, and whether demographic, diagnostic, and/or treatment-related variables predict adaptive outcomes. METHOD Participants included a multiethnic sample of survivors (58 Caucasian, 34 Hispanic, and 22 other non-Caucasian; M age = 14.05 years, SD = 4.33) who were approximately seven years post-treatment. Parents rated adaptive functioning and provided demographic information. Diagnostic and treatment-related information was abstracted from the electronic medical record. RESULTS Parent ratings of adaptive functioning were similar across Caucasian, Hispanic, and other non-Caucasian survivors covarying for family income and primary caregiver education, both of which served as proxies for socioeconomic status. All ethnic groups were rated lower than the normative mean in overall adaptive functioning as well as the specific domains of conceptual, social, and practical skills. Demographic, diagnostic, and treatment-related variables were differentially associated with adaptive functioning in survivors of pediatric brain tumor, though socioeconomic status emerged as a strong significant predictor of adaptive functioning domains. CONCLUSIONS Adaptive outcomes do not differ as a function of ethnicity after accounting for primary caregiver education and family income. Racial and ethnic minorities may be at increased risk for poorer outcomes given their overrepresentation at lower income levels. Assessing demographic and treatment-related variables early on may be helpful in identifying children likely to develop adaptive difficulties.
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Affiliation(s)
- Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Andrew M. Heitzer
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Alexandra Roth
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Austin L. Brown
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Anita Mahajan
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
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45
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Treviño M, Breitmeyer BG, Ris MD, Fletcher JM, Kamdar K, Okcu MF, Parke EM, Raghubar KP. Interactions between visual working memory and visual attention among survivors of pediatric acute lymphoblastic leukemia (ALL) and their healthy peers. J Clin Exp Neuropsychol 2019; 41:974-986. [PMID: 31327287 DOI: 10.1080/13803395.2019.1643453] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: There is increasing concern for adverse cognitive late effects among survivors of pediatric acute lymphoblastic leukemia (ALL) given the widespread impact they have on academic achievement, particularly working memory and attention. We assessed performance among survivors and their healthy peers on a dual task paradigm measuring visual working memory (VWM) and visual attention independently and the dynamic relationship between the two. Assessing specific subsets within cognitive domains allows for understanding the distinct nature of cognitive impairments. Method: Participants were 34 survivors of ALL who have been off-treatment and disease free for 7.5 years; and 20 healthy controls, all between the ages of 10 and 18 years. We utilized behavioral single- and dual-task paradigms. In the dual tasks, participants maintained several items in VWM while performing a visual attention task (Eriksen Flanker Task) that required processing of a target stimulus while inhibiting the processing of distractor stimuli. The single tasks involved performing only the VWM task or only the visual attention task. Results: Results revealed survivors of ALL performed significantly worse than their healthy peers on the single visual attention task but not the single VWM task. Of particular interest, group differences were obtained on the dual VWM and visual attention tasks, such that the VWM and attention tasks reciprocally interfered with each other only among survivors and not their healthy peers. Conclusions: Our results highlight a core deficit in visual attention that is exacerbated by VWM demands among survivors of ALL. The implementation of tasks from cognitive neuroscience paradigms may be sensitive to cognitive impairments experienced by cancer survivors. Assessment and intervention practices among survivors of pediatric ALL are discussed.
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Affiliation(s)
- Melissa Treviño
- Department of Psychology, University of Houston , Houston , TX , USA
| | - Bruno G Breitmeyer
- Department of Psychology, University of Houston , Houston , TX , USA.,Center for Neuro-engineering & Cognitive Science, University of Houston , Houston , TX , USA
| | - M Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine , Houston , TX , USA
| | - Jack M Fletcher
- Department of Psychology, University of Houston , Houston , TX , USA
| | - Kala Kamdar
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine , Houston , TX , USA
| | - M Fatih Okcu
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine , Houston , TX , USA
| | - Elyse M Parke
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine , Houston , TX , USA
| | - Kimberly P Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine , Houston , TX , USA
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46
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Ludmir EB, Grosshans DR, McAleer MF, McGovern SL, Harrison DJ, Okcu MF, Chintagumpala MM, Mahajan A, Paulino AC. Patterns of failure following proton beam therapy for head and neck rhabdomyosarcoma. Radiother Oncol 2019; 134:143-150. [PMID: 31005208 DOI: 10.1016/j.radonc.2019.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 01/02/2019] [Revised: 01/30/2019] [Accepted: 02/03/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Pediatric patients with rhabdomyosarcoma (RMS) of the head and neck (H&N) are treated with multimodal therapy, often with radiotherapy (RT) as definitive local therapy. We report on the patterns of failure following proton beam therapy (PBT) for H&N RMS. METHODS Forty-six H&N RMS patients were enrolled on a prospective registry protocol between 2006 and 2015. All were treated with a combination of chemotherapy (ChT) and PBT. Most patients (25 patients, 54%) had parameningeal tumors, of which 11 (24%) had intracranial extension (ICE). Thirteen patients (28%) had primary tumors greater than 5 cm. Median total cyclophosphamide (CPM) equivalent dose was 13.2 g/m2 (range 0-16.8 g/m2). Median RT dose was 50.4 Gy(RBE) (range 36 Gy[RBE]-50.8 Gy[RBE]). RESULTS With median follow-up of 3.9 years, five-year overall survival was 76%, and five-year progression-free survival was 57%. Seventeen patients (37%) experienced relapse, including 7 with local failure (LF). Five-year local control (LC) was 84%. Tumor size greater than 5 cm predicted increased risk of LF (hazard ratio [HR] 6.49, p = 0.03), as did the presence of ICE at diagnosis (HR 5.21, p = 0.03). Six relapses occurred in patients with ICE; all included a component of central nervous system relapse, with leptomeningeal disease and/or LF with an intracranial component. Delayed RT delivery after week 4 of ChT predicted increased risk of relapse for ICE patients (HR 10.49, p = 0.006). CONCLUSIONS PBT confers excellent LC, and a favorable late toxicity profile as compared with prior photon RT data. Our observations support ongoing trial efforts to dose-escalate RT for patients with larger tumors. However, these data raise concerns regarding excess failures among patients with ICE.
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Affiliation(s)
- Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Mary Frances McAleer
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Susan L McGovern
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Douglas J Harrison
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, United States
| | - Murali M Chintagumpala
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States.
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47
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Arroyo VM, Lupo PJ, Scheurer ME, Rednam SP, Murray J, Okcu MF, Chintagumpala MM, Brown AL. Pilot study of DNA methylation-derived neutrophil-to-lymphocyte ratio and survival in pediatric medulloblastoma. Cancer Epidemiol 2019; 59:71-74. [PMID: 30703618 DOI: 10.1016/j.canep.2019.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/07/2019] [Accepted: 01/15/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Methylation-derived neutrophil-to-lymphocyte ratio (mdNLR) has been identified as a potential prognostic biomarker of outcomes in various cancers. We evaluated the prognostic value of blood-derived mdNLR within a retrospective cohort of pediatric medulloblastoma patients. MATERIALS AND METHODS DNA methylation was measured in archival peripheral blood samples collected on 56 pediatric medulloblastoma patients. Hazard ratios (HR) and 95% confidence intervals (CI) for the association between mdNLR and survival were evaluated using Cox proportional hazard models. RESULTS Compared to patients who were alive at last follow-up (n = 43), the mean mdNLR value was slightly higher in deceased patients (n = 13) (12.3 vs. 5.2,P = 0.163). Elevated log-transformed mdNLR was suggestively associated with an increased likelihood of death in unadjusted models (HR=1.43, 95%CI: 0.92-2.22) and significantly associated with mortality in adjusted models (HR=1.61, 95%CI: 1.01-2.58). DISCUSSION Future work is warranted to investigate the relationship between mdNLR outcomes in specific pediatric medulloblastoma molecular subgroups.
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Affiliation(s)
- Vidal M Arroyo
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Philip J Lupo
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA; Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Michael E Scheurer
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA; Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Surya P Rednam
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA; Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | | | - M Fatih Okcu
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA; Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Murali M Chintagumpala
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA; Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Austin L Brown
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA; Texas Children's Cancer and Hematology Centers, Houston, TX, USA.
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48
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Lupo PJ, Brown AL, Arroyo VM, Kamdar KY, Belmont JW, Scheurer ME, Leisenring WM, Gramatges MM, Okcu MF, Yasui Y, Oeffinger KC, Robison LL, Armstrong GT, Bhatia S. DNA methylation and obesity in survivors of pediatric acute lymphoblastic leukemia: A report from the Childhood Cancer Survivor Study. Genes Chromosomes Cancer 2018; 58:52-59. [PMID: 30382603 DOI: 10.1002/gcc.22701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 12/19/2022] Open
Abstract
Because survivors of pediatric acute lymphoblastic leukemia (ALL) are more likely to be obese than unaffected contemporaries, we compared DNA methylation profiles between normal-weight and obese survivors at adiposity-associated CpG sites previously-reported by epigenome-wide association studies (EWAS) of body mass index (BMI) in the general population. We selected 96 ALL survivors from the Childhood Cancer Survivor Study: 48 obese and 48 normal weight. The Illumina HumanMethylation450 BeadChip was used to compare DNA methylation at 211 loci identified in EWAS of BMI in the general population. Thirty-nine loci were associated (false discovery rate <0.05) with obesity among survivors who only received chemotherapy (n = 49). No loci were significantly associated with obesity among CRT-exposed survivors (n = 47). Our results suggest that previously identified BMI-DNA methylation loci are associated with obesity in ALL survivors who were spared CRT, while no loci were significantly associated with obesity in survivors who received CRT.
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Affiliation(s)
- Philip J Lupo
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Austin L Brown
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Vidal M Arroyo
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Kala Y Kamdar
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - John W Belmont
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | | | - Wendy M Leisenring
- Fred Hutchinson Cancer Research Center, Division of Public Health Sciences, Seattle, Washington
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Yutaka Yasui
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | | | - Leslie L Robison
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | - Gregory T Armstrong
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | - Smita Bhatia
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, Alabama
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49
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Ludmir EB, Paulino AC, Grosshans DR, McAleer MF, McGovern SL, Huh WW, Okcu MF, Harrell LM, Mahajan A. Patterns of Failure With Proton Therapy for Head and Neck Rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.01.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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50
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Ludmir EB, Paulino AC, Grosshans DR, McAleer MF, McGovern SL, Huh WW, Okcu MF, Harrell LM, Mahajan A. Timing of Radiation Therapy for Parameningeal Rhabdomyosarcoma With Intracranial Extension. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.01.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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