O-267 Uterine volume is dramatically decreased in Stem Cell Hematopoietic Transplantation childhood survivors whatever the conditioning regimen. A case-control MRI study in the L.E.A cohort

Study question

What is the impact of the type of myeloablative conditioning (MAC) regimen applied for hematopoietic stem cell transplantation (HSCT) on uterine volume of childhood leukemia survivors?

Summary answer

Uterine volume is significantly decreased after HSCT. Not only Total Body Irradiation (TBI), but also high-dose chemotherapy-based regimens containing alkylating agents induce uterine damage.

What is known already

Premature ovarian failure after HSCT is well known, as well as the uterine damage induced by TBI on uterine volume. A few studies have reported smaller uterus after HSCT in women treated with chemotherapy only. In these studies, uterus volume was assessed by a transabdominal and/or transvaginal ultrasonography, and primary diagnosis, age at treatment and chemotherapy regimen were heterogeneous. These preliminary results suggested that alkylating agents could induce uterine damage, as well as they induce fibrosis and vascular damage in ovarian stroma. The impact of chemotherapy on myometrium and uterus is still few investigated.

Study design, size, duration

A prospective multicentric national study was conducted between 2017, November and 2021, June in 16 University Teaching Hospitals that are following more than 4 500 childhood acute leukemia survivors enrolled in the L.E.A cohort. We included 88 adult women treated for a childhood acute leukemia with HSCT and who agreed a pelvic MRI assessment. Every case was matched 1:1 to control women who underwent MRI for benign ovarian cysts or benign pelvic pathology.

Participants/materials, setting, methods

Pelvic MRI scans were performed with a 1.5-T or 3T magnetic resonance scanner, including diffusion-weighted imaging sequences. Scans were centralized for a double-blinded lecture by two radiologists. The main outcome was the uterine volume. The secondary outcomes were uterine body-to-cervix ratio and apparent diffusion coefficient (ADC). Univariate and multivariate analyses have investigated the association of clinical and imaging variables with conditioning regimen and age at HSCT.

Main results and the role of chance

The mean age in HSCT group was 26.5 + 6.3 years. Mean age at HSCT was 9.1 + 0.3 years with a mean follow-up of 16.4 + 0.5 years. Among the 88 women included in HSCT group, two groups of conditioning regimens have been compared to the control group: a chemotherapy-only MAC regimen group with high dose of alkylating agents (n = 34) and one TBI-based regimen group (n = 52). Two MRI scans were not available. Among HSCT group, 75 women were considered as “normally impregnated” by estrogens, by hormone replacement therapy (HRT) for premature ovarian insufficiency (POI) or thanks to a residual ovarian function. Uterine volume was significantly decreased both after chemotherapy-only MAC regimen and after TBI, with respectively 45.3 + 5.6 and 19.6 + 1.9 mL Vs 79.7 + 3.3 mL in control population (p < 0.01). In chemotherapy-only MAC regimen group, uterine volume was dramatically decreased in POI women without HRT compared to those having a hormonal impregnation (15.2 + 2.6 Vs 49.3 + 6 mL, p < 0.05). In contrast, after TBI, uterine volume was similar in all women, with no positive effect of HRT on uterine volume (respectively 16.3 + 2.6 Vs 20.1 + 2.2 mL).

Limitations, reasons for caution

The number of pregnancies obtained spontaneously or after oocyte donation in our study population was too low to evaluate the obstetrical impact of uterine damage caused by non-TBI regimens.

Wider implications of the findings

Our results provide strong evidence that a MAC regimen containing high dose of alkylating agents could induce uterine damage. In these sub-group of women, HRT increases the volume of the uterus compared to non-treated women. After TBI, uterine volume is dramatically decreased, with no benefit of HRT on it.

Trial registration number

NCT 03583294

Urate-oxidase in the prevention and treatment of metabolic complications in patients with B-cell lymphoma and leukemia, treated in the Société Française d'Oncologie Pédiatrique LMB89 protocol

PURPOSE

To evaluate the frequency of metabolic complications and dialysis due to tumor lysis syndrome in patients with B-cell advanced-stage non-Hodgkin's lymphoma (NHL) and L3 leukemia at initiation of chemotherapy including the use of urate-oxidase.

PATIENTS AND METHODS

Retrospective review of the clinical records of 410 patients with stage III and IV B-cell NHL and L3 leukemia treated in France and prospectively registered in the LMB89 protocol.

RESULTS

During the first week of chemotherapy, only 34 of 410 patients recorded metabolic problems that included hypocalcemia (< 70 mg/dl) in 24 patients, hyperphosphatemia (> 6.5 mg/dl) in 28 and elevation of creatinine > or = 2 SD in 16. Six patients underwent dialysis for life-threatening problems and a seventh as a preventive measure. In the other 27 cases, metabolic problems were successfully resolved using urate-oxidase in combination with alkaline hyperhydration. Among the 410 patients, one case of hemolysis was reported and there was no severe allergic reaction to urate-oxidase.

CONCLUSIONS

Only 1.7% of patients in our study receiving urate-oxidase during their induction chemotherapy needed renal dialysis. Urate-oxidase was well tolerated, and used as prophylaxis and/or treatment of hyperuricemia and tumor lysis syndrome consistently gave a lower rate of renal and metabolic complications than in other series of similar patients.

[(P)FAPA syndrome: value of cimetidine]

The (P)FAPA syndrome (periodic fever, adenitidis, pharyngitis, aphthous stomatitis) was described in 1987. The etiology of this periodic syndrome remains unknown. We report three new cases.

CASE REPORTS

Three girls, aged from 23 months to eight years, developed (P)FAPA. The other causes of periodic fevers were eliminated and the various treatments (antibiotics, antipyretics, nonsteroidal anti-inflammatory agents) proved ineffective. The repetition of the periodic bouts resulted in depressive disorders, absenteeism from school and a drop in weight in the youngest patient. Two of them suffered a sinusal involvement (chronic sinusitis, polyp) and had an increase in the level of immunoglobulin A. In all three cases, cimetidine at a dose of 20 mg/kg/d was well tolerated and resulted in a disappearance of the periodic fevers.

CONCLUSION

Cimetidine, as an immunomodulating agent, appears to be beneficial in the in-depth treatment of (P)FAPA syndrome.

Astrocytomas and choroid plexus tumors in two families with identical p53 germline mutations

Germline p53 mutations carry an increased risk of development of breast cancer, soft tissue and osteosarcomas, brain tumors, leukemia and adrenocortical carcinomas. Cerebral neoplasms are usually of astrocytic lineage and occur in 40% of affected families. This report presents clinical, neuropathological and molecular genetic data from 2 families in France with an identical p53 germline mutation in codon 248 (CGG->TGG; Arg->Trp) and a clustering of CNS tumors. The youngest patient in each family developed a malignant choroid plexus tumor while several young adults of both kindred succumbed to low-grade astrocytoma, anaplastic astrocytoma or glioblastoma. The only non-neural neoplasm was an adrenocortical carcinoma in a boy aged 4 years who developed an anaplastic choroid plexus papilloma 2 years later. Of 2 previously reported inherited choroid plexus tumors, 1 occurred in a family which also carried a germline mutation in codon 248. It remains to be shown whether this unusual pattern of CNS tumors is due to an organ-specific effect of this particular p53 mutation or whether it reflects the genetic background of the affected families.

Second thyroid neoplasms after prophylactic cranial irradiation for acute lymphoblastic leukemia

An understanding of the pathogenesis of second cancers may help in their prevention. We report on two children who were treated for acute lymphoblastic leukemia (ALL), with an exclusively cranial prophylactic irradiation (18 Gy) and who presented with a thyroid carcinoma (TC) 12 and 13 years later. From a thorough review of the literature of TC after ALL and of radiation-induced TC, a strong case can be made that these tumors are caused by late effects of scattered radiation. The risk is at its highest in small children. After cranial irradiation, patients require clinical monitoring of the thyroid and cervical area for nodules, continued indefinitely. We suggest that, in most cases, an alternative form of neuromeningeal prophylaxis should be offered in small children with ALL.