Cancer risk in children born after donor ART

STUDY QUESTION

Do children born after donor ART have an increased risk of developing childhood cancer in comparison to the general population?

SUMMARY ANSWER

This study showed no overall increased risk of childhood cancer in individuals born after donor ART.

WHAT IS KNOWN ALREADY

Most large population-based studies have shown no increase in overall childhood cancer incidence after non-donor ART; however, other studies have suggested small increased risks in specific cancer types, including haematological cancers. Cancer risk specifically in children born after donor ART has not been investigated to date.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study utilized record linkage to determine the outcome status of all children born in Great Britain (1992-2008) after donor ART. The cohort included 12 137 members who contributed 95 389 person-years of follow-up (average follow-up 7.86 years).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Records of all children born in Great Britain (England, Wales, Scotland) after all forms of donor ART (1992-2008) were linked to the UK National Registry of Childhood Tumours (NRCT) to determine the number who subsequently developed cancer by 15 years of age, by the end of 2008. Rates of overall and type specific cancer (selected a priori) were compared with age, sex and calendar year standardized population-based rates, stratifying for potential mediating/moderating factors including sex, age at diagnosis, birth weight, multiple births, maternal previous live births, assisted conception type and fresh/ cryopreserved cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

In our cohort of 12 137 children born after donor ART (52% male, 55% singleton births), no overall increased risk of cancer was identified. There were 12 cancers detected compared to 14.4 expected (standardized incidence ratio (SIR) 0.83; 95% CI 0.43-1.45; P = 0.50). A small, significant increased risk of hepatoblastoma was found, but the numbers and absolute risks were small (<5 cases observed; SIR 10.28; 95% CI 1.25-37.14; P < 0.05). This increased hepatoblastoma risk was associated with low birthweight.

LIMITATIONS REASONS FOR CAUTION

Although this study includes a large number of children born after donor ART, the rarity of specific diagnostic subgroups of childhood cancer results in few cases and therefore wide CIs for such outcomes. As this is an observational study, it is not possible to adjust for all potential confounders; we have instead used stratification to explore potential moderating and mediating factors, where data were available.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to investigate cancer risk in children born after donor ART. Although based on small numbers, results are reassuring for families and clinicians. The small but significant increased risk of hepatoblastoma detected was associated with low birthweight, a known risk factor for this tumour type. It should be emphasized that the absolute risks are very small. However, on-going investigation with a longer follow-up is needed.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by Cancer Research UK (C36038/A12535) and the National Institute for Health Research (405526) and supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. The work of the Childhood Cancer Research Group (CCRG) was supported by the charity CHILDREN with CANCER UK, the National Cancer Intelligence Network, the Scottish Government and the Department of Health for England and Wales. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Subsequent hospitalisation experience of 5-year survivors of childhood, adolescent, and young adult cancer in Scotland: a population based, retrospective cohort study

Background:

Survivors of childhood, adolescent, and young adult cancer are known to be at risk of late effects of their disease and its treatment. Most population-based studies of cancer survivors have reported on second primary cancers and mortality. The aim of this study was to research acute and psychiatric hospital admission rates and length of stay in 5-year survivors of cancer diagnosed before the age of 25 years.

Methods:

This was a population-based retrospective cohort study using linked national cancer registry, acute hospital discharge, psychiatric hospital, and mortality records. The study population consisted of 5229 individuals who were diagnosed with cancer before the age of 25 years between 1981 and 2003, and who survived at least 5 years after the date of diagnosis of their primary cancer. Indirect standardisation for age and sex was used to calculate standardised bed days and hospitalisation ratios (SBDR and SHR) for both acute and psychiatric hospital admissions, and absolute excess risks (AERs) compared with the general Scottish population.

Results:

Five-year survivors of cancer, diagnosed before the age of 25 years, are at increased risk of admission to acute hospitals (SHR 2.8; 95% confidence interval 2.7–2.9) and of spending more time in hospital (SBDR 3.7; 3.6–3.7). Corresponding AERs were 6.4 (6.0–6.6) admissions and 64.8 (64.4–66.9) bed days per 100 cancer survivors per year. In contrast, 5-year survivors were not at higher risk of admission to psychiatric hospital (SHR 0.9; 0.8–1.2), and they spent significantly less time as psychiatric in-patients (SBDR 0.4; 0.4–0.4) compared with the whole population.

Conclusion:

Using routinely collected linked records, our population-based study has demonstrated increased rates of hospitalisation in 5-year survivors of cancer diagnosed before the age of 25 years. Long-term clinical follow-up of survivors of cancer in this age group should focus on the prevention and treatment of the late effects of cancer in those patients at highest risk of hospitalisation.

Can intensity of long-term follow-up for survivors of childhood and teenage cancer be determined by therapy-based risk stratification?

OBJECTIVE

To determine the feasibility of therapy-based, risk-stratified follow-up guidelines for childhood and teenage cancer survivors by evaluating adverse health outcomes in a survivor cohort retrospectively assigned a risk category.

DESIGN

Retrospective cohort study.

SETTING

Tertiary level, single centre, paediatric cancer unit in South East Scotland.

PARTICIPANTS

All children and teenagers diagnosed with cancer (<19 years) between 1 January 1971 and 31 July 2004, who were alive more than 5 years from diagnosis formed the study cohort. Each survivor was retrospectively assigned a level of follow-up, based on their predicted risk of developing treatment-related late effects (LEs; levels 1, 2 and 3 for low, medium and high risk, respectively). Adverse health outcomes were determined from review of medical records and postal questionnaires. LEs were graded using the Common Terminology Criteria for Adverse Event, V.3.

RESULTS

607 5-year survivors were identified. Risk stratification identified 86 (14.2%), 271 (44.6%) and 250 (41.2%) as levels 1, 2 and 3 survivors, respectively. The prevalence of LEs for level 1 survivors was 11.6% with only one patient with grade 3 or above toxicity. 35.8% of level 2 survivors had an LE, of whom 9.3%, 58.8%, 18.5%, 10.3% and 3% had grades 1, 2, 3, 4 and 5 toxicity, respectively. 65.2% of level 3 survivors had LE, of whom 5.5% (n=9), 34.4% (n=56), 36.2% (n=59), 22.1% (n=36) and 1.8% (n=3) had grades 1, 2, 3, 4 and 5 toxicity, respectively.

CONCLUSIONS

Therapy-based risk stratification of survivors can predict which patients are at significant risk of developing moderate-to-severe LEs and require high-intensity long-term follow-up. Our findings will need confirmation in a prospective cohort study that has the power to adjust for all potentially confounding variables.

Ovarian cryopreservation: experimental or established and a cure for the menopause?

Long-term (>7 years) duration of function of ovarian cortical tissue grafts in three patients who have had several successful pregnancies is encouraging and requires us to carefully examine the risk benefit analysis of this technique for our future patients. However, the success rate for ovarian cryopreservation is unclear as the denominator (the number of women in whom frozen-thawed ovarian tissue has been re-implanted) is unknown. There still remain many unknowns and much more research is required before ovarian transplantation can be considered standard practice. The ability of ovarian cryopreservation to preserve fertility for some young survivors of cancer is proven, but the indications for which patients should be offered this exciting new technology are not yet established.

How do chemotherapeutic agents damage the ovary?

BACKGROUND

Chemotherapy treatment in premenopausal women is associated with an increased risk of premature ovarian failure (POF) but the exact mechanism through which this occurs is uncertain. In this review we examine the current evidence for the direct action of chemotherapeutic agents on the ovary and discuss possible molecular pathways through which follicle loss may occur.

METHODS

A systemic search of the databases, PubMed and Google Scholar, was made for all English language articles through to 2011 in each subject area discussed.

RESULTS

POF results from the loss of primordial follicles but this is not necessarily a direct effect of the chemotherapeutic agents. Instead, the disappearance of primordial follicles could be due to an increased rate of growth initiation to replace damaged developing follicles. Likewise, the loss of oocytes need not necessarily be a direct result of damage: evidence suggests that chemotherapy drugs can also induce oocyte death indirectly via damage to somatic cells. Specific molecular mechanisms and likely ovarian targets are discussed for some of the anti-cancer drugs most commonly used to treat premenopausal women. Finally, we consider current and prospective methods of preserving fertility.

CONCLUSIONS

It is likely that different chemotherapeutic drugs act through a range of mechanisms and on different target cells. More research into the cellular mechanisms underpinning chemotherapy-induced follicle loss could lead to the generation of treatments specifically designed to prevent POF.

ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context

This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.

Pathobiology and prevention of cancer chemotherapy-induced bone growth arrest, bone loss, and osteonecrosis

Cancer chemotherapy has been recognized as one severe risk factor that influences bone growth and bone mass accumulation during childhood and adolescence. This article reviews on the importance of this clinical issue, current understanding of the underlying mechanisms for the skeletal defects and potential preventative strategies. Both clinical and basic studies that appeared from 1990 to 2010 were reviewed for bone defects (growth arrest, bone loss, osteonecrosis, and/or fractures) caused by paediatric cancer chemotherapy. As chemotherapy has become more intensive and achieved greater success in treating paediatric malignancies, skeletal complications such as bone growth arrest, low bone mass, osteonecrosis, and fractures during and/or after chemotherapy have become a problem for some cancer patients and survivors particularly those that have received high dose glucocorticoids and methotrexate. While chemotherapy-induced skeletal defects are likely multi-factorial, recent studies suggest that different chemotherapeutic agents can directly impair the activity of the growth plate and metaphysis (the two major components of the bone growth unit) through different mechanisms, and can alter bone modeling/remodeling processes via their actions on bone formation cells (osteoblasts), bone resorption cells (osteoclasts) and bone "maintenance" cells (osteocytes). Intensive use of multi-agent chemotherapy can cause growth arrest, low bone mass, fractures, and/or osteonecrosis in some paediatric patients. While there are currently no specific strategies for protecting bone growth during childhood cancer chemotherapy, regular BMD monitoring and exercise are have been recommended, and possible adjuvant treatments could include calcium/vitamin D, antioxidants, bisphosphonates, resveratrol, and/or folinic acid.

Analysis of residual chemicals on filtering facepiece respirators after decontamination

The N95 filtering facepiece respirator (FFR) is commonly used to protect individuals from infectious aerosols. Health care experts predict a shortage of N95 FFRs if a severe pandemic occurs, and an option that has been suggested for mitigating such an FFR shortage is to decontaminate and reuse the devices. Before the effectiveness of this strategy can be established, many parameters affecting respiratory protection must be measured: biocidal efficacy of the decontamination treatment, filtration performance, pressure drop, fit, and toxicity to the end user post treatment. This research effort measured the amount of residual chemicals created or deposited on six models of FFRs following treatment by each of 7 simple decontamination technologies. Measured amounts of decontaminants retained by the FFRs treated with chemical disinfectants were small enough that exposure to wearers will be below the permissible exposure limit (PEL). Toxic by-products were also evaluated, and two suspected toxins were detected after ethylene oxide treatment of FFR rubber straps. The results provide encouragement to efforts promoting the evolution of effective strategies for decontamination and reuse of FFRs.

Twentieth-century survival from osteosarcoma in childhood. Trends from 1933 to 2004

We have reviewed the data from our regional Bone Tumour Registry on patients with osteosarcoma diagnosed between 1933 and 2004 in order to investigate the relationship between survival and changes in treatment. There were 184 patients with non-metastatic appendicular osteosarcoma diagnosed at the age of 18 or under. Survival was calculated using Kaplan-Meier curves, and multivariate analysis was performed using the Cox regression proportional hazards model. The five-year survival improved from 21% between 1933 and 1959, to 62% between 1990 and 1999. During this time, a multi-disciplinary organisation was gradually developed to manage treatment. The most significant variable affecting outcome was the date of diagnosis, with trends in improved survival mirroring the introduction of increasingly effective chemotherapy. Our experience suggests that the guidelines of the National Institute for Clinical Excellence on the minimum throughput of centres for treatment should be enforced flexibly in those that can demonstrate that their historical and contemporary results are comparable to those published nationally and internationally.

Outcome of children with nodular lymphocyte predominant Hodgkin lymphoma - a Children's Cancer and Leukaemia Group report

This report describes the clinical outcomes and follow-up records of 42 children with nodular lymphocyte predominant Hodgkin lymphoma (LPHL) treated on United Kingdom Children's Cancer Study Group (UKCCSG) HD1 (1982-1992) and HD2 protocols (1992-2000). The clinical records of 42 children with LPHL treated between 1982 and 2000 were reviewed retrospectively. All 42 had histology reviewed centrally and confirmed as LPHL by an expert panel. In both trials, only patients with stage IA disease had the option of being treated with either involved field radiation alone or combination chemotherapy consisting of chlorambucil, vinblastine, procarbazine and prednisolone (ChlVPP). Patients with all other stages were treated with ChlVPP chemotherapy. Thirty-five patients (83%) presented with early stage disease (Stages I & II). All 42 patients achieved a complete remission (CR). Six children relapsed after primary therapy. The 5- and 10-year relapse-free survival rates were 87% and 82% respectively. Forty-one are currently alive in CR. In conclusion, children with low-stage LPHL treated between 1982 and 2000 according to the UK strategy for classical Hodgkin lymphoma (HL) had an excellent prognosis. There have been no second malignancies or transformations to B-cell non-Hodgkin lymphoma.

Gonadal dysfunction due to cis-platinum

Gonadal function was studied in 15 patients 12 pubertal or postpubertal, and three prepubertal, who had been treated during childhood for nonmetastatic osteosarcoma of the long bones by chemotherapy regimens that included cis-platinum and adriamycin. Of seven postpubertal female patients assessed (mean age at diagnosis 16.5 years), three were amenorrhoeic and showed evidence of ovarian damage with raised gonadotrophin levels and a low serum oestradiol concentration. One patient who had regular periods had a raised luteal-phase follicle-stimulating hormone (FSH) concentration suggestive of gonadal dysfunction. Severe oligospermia or reduced testicular volumes in the presence of raised gonadotrophin levels were observed in three of the five pubertal males (mean age at diagnosis 13.25 years). A reliable assessment of gonadal function was not possible in three male patients who remained prepubertal at the time of study. The median total dose of cis-platinum received by those patients with gonadal damage (median dose, 490 mg) was significantly higher than in those patients with normal gonadal function (median dose, 300 mg) (P = 0.01). In the boys the damage to the testes was primarily directed at the germinal epithelium. Leydig cell function was intact and the males progressed spontaneously through puberty. In the girls, unlike the boys, there was evidence of reversibility of gonadal damage with time. This is the first study to show gonadal dysfunction due to cis-platinum and adriamycin therapy in childhood.

Technical aspects of the Naval Dosimetry Center quality assurance programme

The purpose of this paper is to describe the technical aspects of the Naval Dosimetry Center (NDC) quality programme. The Navy has been formally monitoring personnel for occupational exposure to ionising radiation since at least 1946. The current system, the DT-702/PD, is the Harshaw 8840 holder and 8841 card. New card and holder checks are performed to verify that the correct LiF elements and holder filters are in the correct location and are of the correct composition. Element correction coefficient (ECC) magnitude and repeatability are also verified. Several quality assurance parameters are checked by a specially designed shipping machine. Calibration cards are used to calibrate each reader and quality control cards are inserted throughout a group of field cards to verify reader operation during the read process. The success of the programme is measured by annual proficiency tests administered by the National Voluntary Laboratory Accreditation Programme and Pacific Northwest National Laboratories.

Comparative genomic hybridization and pathological findings in atypical teratoid/rhabdoid tumour of the central nervous system

The atypical teratoid/rhabdoid tumour (AT/RT) is an uncommon tumour of the central nervous system in children, characterized by the presence of a rhabdoid cell component associated with variable combinations of primitive neuroectodermal tumour, mesenchymal and epithelial differentiation. Immunohistochemistry reveals a complex pattern of antigen expression and cytogenetic studies have demonstrated losses from chromosome 22. We have performed comparative genomic hybridization (CGH) on paraffin-embedded material from three cases of AT/RT. Two cases showed losses from chromosome 22 associated with other chromosome imbalances including losses from 1p in both cases. The third case demonstrated a loss from 8p as the sole abnormality. While monosomy or deletion from chromosome 22 is a useful diagnostic marker for AT/RT, it is not present in all cases. The variation in cytogenetic patterns reported for this tumour type raises the possibility that different genetic pathways may underlie this tumour phenotype and warrants the further definition of the cytogenetic spectrum for this rare tumour.

Hypothalamic-pituitary-ovarian dysfunction after prepubertal chemotherapy and cranial irradiation for acute leukaemia

BACKGROUND

We assessed adult hypothalamic-pituitary-ovarian function following treatment with chemotherapy and cranial irradiation for childhood acute lymphoblastic leukaemia.

METHODS

The patients (n = 12) had median age at diagnosis of 4.7 years, and at assessment of 20.8 years. They collected a daily urine sample over two to five consecutive menstrual cycles (total of 41 cycles) for analysis of LH and steroid excretion. Blood sampling and ovarian ultrasound examination was performed in the early follicular phase. Sixteen healthy women with regular menstrual cycles were recruited as controls.

RESULTS

Urinary LH excretion was significantly lower in patients throughout the cycle, particularly during the LH surge (P < 0.0001). The length of the luteal phase was significantly shorter in patients than in normal controls (12.2 +/- 0.3 versus 13.6 +/- 0.4 days, P = 0.01) with a high prevalence of short (< or =11 days) luteal phases (15/39 cycles). Luteal phase pregnanediol excretion was slightly but not significantly lower. Follicular and luteal phase excretion of oestrone was lower in patients than in controls (P = 0.01). Early follicular phase plasma oestradiol was also lower in the patient group (P = 0.032) although LH, FSH, inhibin A and B concentrations were similar.

CONCLUSIONS

These data indicate that treatment for childhood leukaemia results in subtle ovulatory disorder in some patients, probably related to cranial irradiation. Follow-up of these women is required to detect any effect on reproductive potential.

Premature adiposity rebound in children treated for acute lymphoblastic leukemia

The adiposity rebound (AR), when body mass index begins to increase after its nadir in childhood, is a critical period for the regulation of energy balance and adult obesity risk. The aim of the present study was to test whether children treated for acute lymphoblastic leukemia (ALL) experience premature AR. This might, in part, explain their tendency to develop obesity. Timing of AR was assessed by visual inspection of body mass index plots in 68 patients treated for ALL in first remission. This sample comprised all eligible patients treated in Scotland between 1991 and 1998, age 30 months or less at the time of diagnosis. Timing of AR in patients was compared against a cohort of 889 healthy British children studied during the 1990s using the same method. AR occurred significantly earlier in the patients treated for ALL (chi(2) test, P < 0.001). The AR had occurred in 43% (29 of 68) of the patients and 4% (40 of 889) of the comparison group by age 37 months. At 49 months AR had occurred in 81% (55 of 68) of the patients and 21% (190 of 889) of the comparison group. Treatment of ALL is associated with a significantly advanced AR. This might, in part, explain the extremely high prevalence of obesity in long-term survivors. Clinical management should focus on minimizing excess weight gain during therapy to reduce long-term obesity risk.

Risk factors for excess weight gain in children treated for acute lymphoblastic leukaemia

OBJECTIVE

To test whether excess weight gain in patients treated for childhood acute lymphoblastic leukaemia (ALL) was predictable using patient characteristics at diagnosis.

DESIGN AND SUBJECTS

Longitudinal study of changes in body mass index (BMI) in all 98 patients treated in Scotland on treatment protocol MRC UKALL-XI who had reached at least 3y post-diagnosis in first remission.

MEASUREMENTS

The influence of the following variables on changes in BMI, expressed as a standard deviation score (SDS), was tested using variable selection techniques and classification and regression trees: BMI SDS at diagnosis; age at diagnosis; gender; socioeconomic status; treatment.

RESULTS

Prevalence of obesity (BMI SDS>2.0) was <2% at diagnosis, but increased to 16% at 3y. Gain in BMI SDS was significantly inversely influenced by BMI SDS at diagnosis (P<0.01) and age at diagnosis (P<0.01).

CONCLUSION

Obesity is common in ALL by the end of therapy, and is more likely in children who are younger and thinner at diagnosis. Excess weight gain was not readily predictable from routinely collected information available at diagnosis and so all children treated for ALL should be considered 'at risk' of excess weight gain and the target of obesity prevention.

Bone turnover and growth during and after continuing chemotherapy in children with acute lymphoblastic leukemia

Children treated for acute lymphoblastic leukemia may develop reduced bone mineral density during treatment, but there is little information on the mechanisms involved. In a prospective, longitudinal study on 15 children with ALL, we undertook serial measurements of markers of bone and collagen turnover, insulin-like growth factor (IGF)-I and its binding proteins (IGFBPs)-3 and -2 during the second year of continuing chemotherapy. In eight patients we also measured lower leg length by knemometry. Height SD scores, lower leg length velocity, IGF-I, and markers of bone collagen turnover did not differ significantly from healthy children. However, bone alkaline phosphatase, a marker of the differentiated osteoblast, was lower (mean SD score, -0.64; p < 0.0001), whereas procollagen type III N-terminal propeptide (P3NP, a marker of soft tissue collagen turnover; mean SD score, +0.93, p < 0.05), IGFBP-3 (mean SD score, +0.76; p < 0.01), and IGFBP-2 (mean SD score, +1.24, p = 0.01) were all higher than in healthy children. IGFBP-3 decreased during episodes of afebrile neutropenia (p < 0.05). Within 3 mo after completion of treatment, bone ALP increased in all eight patients, but collagen markers showed little change. IGFBP-2 returned to normal posttreatment, but P3NP and IGFBP-3 remained significantly elevated compared with healthy children (mean SD scores, +1.51 and +1.36, respectively; p < 0.01). We conclude that continuing chemotherapy was associated with normal growth and bone collagen turnover but enhanced soft tissue collagen turnover. Bone bone alkaline phosphatase was low throughout treatment, which suggests impaired osteoblast differentiation resulting from a direct effect of chemotherapy on bone. Although the effect was reversible, the long-term implications for bone health in survivors remain uncertain.

Human bone cell hyperpolarization response to cyclical mechanical strain is mediated by an interleukin-1beta autocrine/paracrine loop

Mechanical stimuli imparted by stretch, pressure, tension, fluid flow, and shear stress result in a variety of biochemical responses important in bone (re)modeling. The molecules involved in the recognition and transduction of mechanical stimuli that lead to modulation of bone cell function are not yet fully characterized. Cyclical pressure-induced strain (PIS) induces a rapid change in membrane potential of human bone cells (HBC) because of opening of membrane ion channels. This response is mediated via integrins and requires tyrosine kinase activity and an intact actin cytoskeleton. We have used this electrophysiological response to further study the signaling events occurring early after mechanical stimulation of HBC. Stimulation of HBC at 0.33 Hz PIS, but not 0.104 Hz PIS, results in the production of a transferable factor that induces membrane hyperpolarization of unstimulated HBC. The production of this factor is inhibited by antibodies to beta1-integrin. Interleukin-1beta (IL-1beta and prostaglandin E2 (PGE2) were identified as candidate molecules for the transferable factor as both were shown to induce HBC hyperpolarization by opening of small conductance calcium-activated potassium channels, the means by which 0.33 Hz PIS causes HBC hyperpolarization. Antibodies to IL-1beta, but not other cytokines studied, inhibit the hyperpolarization response of HBC to 0.33 Hz PIS. Comparison of the signaling pathways required for 0.33 Hz PIS and IL-1beta-induced membrane hyperpolarization shows that both involve the phospholipase C/inositol triphosphate pathway, protein kinase C (PKC), and prostaglandin synthesis. Unlike 0.33 Hz PIS-induced membrane hyperpolarization, IL-1beta-induced hyperpolarization does not require tyrosine kinase activity or an intact actin cytoskeleton. These studies suggest that 0.33 Hz PIS of HBC induces a rapid, integrin-mediated, release of IL-1beta with a subsequent autocrine/paracrine loop resulting in membrane hyperpolarization. IL-1beta production in response to mechanical stimuli is potentially of importance in regulation of bone (re)modeling.

Subfertility following treatment for childhood cancer

The majority of children with cancer can now expect to be cured. Recent advances in assisted reproduction have focused attention on the long-term fertility outcome for these survivors. This article summarizes the current state of our knowledge about who is at risk of subfertility after childhood cancer and discusses possibilities of fertility preservation that are currently being researched.

Obesity in leukemia survivors: the familial contribution

A high prevalence of obesity in survivors of acute lymphoblastic leukemia (ALL) has been described, but genetic and social influence in obesity has not been analyzed in this group of patients. The authors studied a population of 33 long-term (25 females, 8 males) in first remission who had reached their final height. All patients received cranial irradiation as part of their central nervous system (CNS)-directed therapy and no patient received growth hormone. The body mass index (BMI: weight/height2) of patients and their biological parents was calculated and submitted to statistical analysis. Obesity was defined as BMI greater than the 85th centile. No excessive obesity was found among the males at final height. Fifty-six percent of the females were obese. In this group of 14 obese female survivors 59% had obese mother, but only 14% had obese fathers. The results indicate a significant maternal predisposition to obesity.

Plasma exchange as successful treatment of thrombotic thrombocytopenic purpura post autologous bone marrow transplant in a child

We describe the case of a small child with stage IV neuroblastoma who developed thrombotic thromobocytopenic purpura (TTP) post autologous bone marrow transplant. Pneumococcal sepsis may have been the cause, a previously unreported association in transplant-associated TTP. Despite the child's size (10 kg) and the severity of the disease early intensive treatment with whole blood exchange and subsequently plasma exchange with cryosupernatant proved to be rapidly effective, in contrast to previous reports on its ineffectiveness in this setting.

Ovarian and uterine characteristics after total body irradiation in childhood and adolescence: response to sex steroid replacement

OBJECTIVE

To study the effect of total body irradiation (14.4 Gray) in childhood and adolescence on ovarian and uterine characteristics, and to investigate the response to physiological sex steroid serum concentrations.

DESIGN

All long term post-pubertal female survivors of total body irradiation who had been treated in paediatric centres in Scotland were identified. Their ovarian and uterine characteristics were studied.

SETTING

Recruitment was from follow up oncology clinics.

SAMPLE

Nine women were identified, eight of whom were assessed and five progressed to detailed investigation. A control population of 12 women treated for acute leukaemia, but not treated with total body irradiation, and five healthy women with no history of childhood malignancy were recruited as controls.

METHODS

Ovarian function was determined by measurement of serum gonadotrophins and sex steroids. Uterine response to physiological sex steroid replacement was investigated in women with ovarian failure, and to endogenous sex steroid production in women with ovarian function by ultrasound scan. The physiological sex steroid replacement was achieved with transdermal oestradiol patches and self administered vaginal progesterone pessaries.

MAIN OUTCOME MEASURES

Determination of ovarian function and uterine response to physiological sex steroid serum concentrations.

RESULTS

Six of eight women treated with total body irradiation had ovarian failure; preservation of function was seen in two girls treated pre-pubertally who had biochemical evidence of incipient ovarian failure. Four women with ovarian failure had reduced uterine volume, undetectable blood supply and absent endometrium at baseline assessment; after three months of physiological sex steroid replacement treatment uterine blood supply and endometrial response were not significantly different from controls; uterine volume improved but remained significantly smaller than controls and correlated with age at total body irradiation.

CONCLUSIONS

Ovarian failure after total body irradiation is common and risk relates to age at treatment. Physiological sex steroid replacement improved uterine measures and these women may benefit from assisted reproductive technology.

Totally implantable central venous access devices for paediatric oncology patients

BACKGROUND

Totally implantable central venous access devices (ports) have been available for over 10 years but have not achieved widespread use in paediatric oncology patients. We reviewed our experience with these devices over 9 years to assess their safety and acceptability.

PROCEDURE

We conducted a retrospective review of insertion technique and reasons for removal of all ports placed in paediatric oncology patients in this hospital between 1989 and 1996, with follow-up until 1998. Acceptability of both ports and external catheters was assessed by a questionnaire in a subgroup of families attending the oncology clinic.

RESULTS

One hundred forty-nine ports were inserted during the study period. The median catheter life was 399 days (4-1,406), with a total of 69,342 catheter days. Sixty-nine percent of ports were removed electively at the end of treatment; 8% required removal because of infection and 5% because of blockage. No ports were accidentally dislodged or damaged. Children experienced significantly less restriction of activity with a port compared to an external catheter and greatly preferred the cosmetic appearance. The need for needle insertion to access the port was not seen as a disadvantage by most families.

CONCLUSIONS

Ports can provide satisfactory central venous access for the majority of paediatric oncology patients, with a low risk of line-related complications and a high degree of acceptability to children and their parents.

Congenital hemihypertrophy and epithelioid haemangioendothelioma in a 10-year-old boy: a case report

Epithelioid haemangioendothelioma has not been previously described in a patient with congenital hemihypertrophy and diabetes mellitus. Hepatic nodules were incidentally discovered on a routine US examination searching for known associated abnormalities. Pulmonary nodules were present on chest X-ray and CT of the lungs. The diagnosis was confirmed by open biopsy of a hepatic nodule. Despite significant disease progression the patient remains symptom free.

Effects of a third intensification block of chemotherapy on bone and collagen turnover, insulin-like growth factor I, its binding proteins and short-term growth in children with acute lymphoblastic leukaemia

Children with acute lymphoblastic leukaemia (ALL) have reduced bone turnover caused by the disease itself and early intensive chemotherapy, but the effects of later chemotherapy using different drug combinations are uncertain. We report here a longitudinal study on 9 children with ALL randomised to receive an additional third intensification block of chemotherapy, compared with 9 children receiving continuing chemotherapy over the same period. During third intensification, bone alkaline phosphatase, procollagen type I C-terminal propeptide, the carboxyterminal propeptide of type I collagen, procollagen type III N-terminal propeptide and lower leg length all decreased in response to dexamethasone, then returned to (but not beyond) baseline levels after dexamethasone was stopped and other drugs started. These changes were unrelated to circulating insulin-like growth factor (IGF)-I, IGF binding protein (IGFBP)-3 or IGFBP-2. In all children, bone alkaline phosphatase remained below the population mean throughout. We conclude that dexamethasone decreased bone and soft tissue turnover, probably through direct effects on target tissues. The postdexamethasone phase of third intensification and continuing chemotherapy had no major deleterious effect on collagen turnover, but there was evidence of continuing suboptimal bone mineralisation.

With advances in medical imaging can the radiologist reliably diagnose Wilms' tumours?

AIM

To evaluate whether radiologists can accurately differentiate Wilms' tumours from other paediatric abdominal masses with renal involvement using modern imaging methods alone.

METHODS

From February 1993 to June 1997, 23 patients presented to the Paediatric Oncology Service at The Royal Hospital for Sick Children, Edinburgh with an intra-abdominal mass which had renal involvement. Nine patients had Wilms' tumours, 12 had neuroblastomas, one patient had xanthogranulomatous pyelonephritis and there was a single case of a mesoblastic nephroma. In each case, two radiologists retrospectively reviewed the initial imaging examinations and independently reached a radiological diagnosis.

RESULTS

The radiologists were concordant and reached the correct diagnosis in 20/23 cases (87%), unsure of the diagnosis in one case (4.3 %) and discordant in two cases (8.7 %). Radiologists should be aware that a mesoblastic nephroma can have identical imaging features to a Wilms' tumour. In most cases, ultrasound and a chest X-ray were sufficient to reach the correct diagnosis although computed tomography (CT) and magnetic resonance imaging were superior for demonstrating the relationship of the mass to the great vessels, retroperitoneum and spinal canal. Inferior vena cava invasion was strongly predictive of a Wilms' tumour. Displacement of the great vessels, extension of the mass across the mid-line, renal displacement and tumour calcification on CT were more suggestive of a neuroblastoma although these features were also seen in a significant number of patients with Wilms' tumours. Encasement of vessels by tumour, a paravertebral mass and spinal canal invasion were highly predictive of neuroblastoma.

CONCLUSION

In this study, radiologists were accurate at diagnosing Wilms' tumours using modern imaging methods, however, care should be taken in children who are less than 1 year of age as a mesoblastic nephroma may have identical imaging characteristics.

Short-term changes in lower leg length in children treated for acute lymphoblastic leukaemia

The lower leg length velocity (LLLV) of 14 children with a median age of 4.5 yr who were undergoing chemotherapy (CT) for acute lymphoblastic leukaemia (ALL) was studied for a median duration of 56 weeks (range 14-112). Nine children were studied over the first 6 months, six over the first year, four over the full 2-year course and nine children over the 3 months before and after the end of CT. Over the first month of CT, during induction, median LLLV was 0 mm/wk (P5, P95: -1.6, 0.11); during the fourth month of CT, at the end of CNS-directed therapy, there was a significant rise to 0.38 mm/wk (P5, P95: -0.04, 0.81; p = 0.01, WSR). In the children measured following the end of CT, median LLLV rose from 0.46 mm/wk (P5, P95: -0.02, 0.79) in month 23 to 0.84 mm/wk (P5, P95: 0.72, 1.12) (p = 0.03). There was a positive relationship between neutrophil count and LLLV during continuation chemotherapy (r = 0.4, p = 0.0002); median LLLV was 0.2 mm/ wk (P5, P95: -0.15, 0.5) when the neutrophil count was less than 1 x 10(9)/l and 0.65 mm/wk (P5, P95: 0.1, 1.0) (p = 0.01) when the count was above 1 x 10(9)/l. No significant differences in LLLV were observed between children randomised to different UKALLXI regimens. Intensive chemotherapy for ALL adversely affects lower leg growth. Growth was subnormal during the first few weeks of chemotherapy, but was comparable to healthy children during CNS directed and continuation therapy. There was a significant relationship between growth velocity and neutrophil count during continuation chemotherapy. On discontinuation of chemotherapy there was a further acceleration in lower leg length velocity to supranormal levels ("catch-up" growth).

Effects of intensive chemotherapy on bone and collagen turnover and the growth hormone axis in children with acute lymphoblastic leukemia

To investigate the effects of disease and intensive chemotherapy on bone turnover and growth in children with acute lymphoblastic leukemia (ALL), a longitudinal prospective study was carried out in 22 children, aged 1.2-13.5 yr, enrolled in the Medical Research Council-funded randomized trial of childhood ALL treatment in the UK. We measured lower leg length and markers of bone formation [bone alkaline phosphatase (ALP) and procollagen type I C-terminal propeptide (PICP)], bone resorption [pyridinoline, deoxypyridinoline, and carboxyl-terminal telopeptide of type I collagen (ICTP)], soft tissue turnover [procollagen type III N-terminal propeptide (P3NP)], and the GH axis [IGF-I, IGF-binding protein-3 (IGFBP-3), IGFBP-2, and urinary GH] at 1- to 4-week intervals from diagnosis to week 27 of treatment. In addition, GH-binding protein was measured at diagnosis. At diagnosis, mean SD scores were: bone ALP, -1.84; PICP -1.77; pyridinoline, -1.42; deoxypyridinoline, -1.66; ICTP, -0.42; P3NP, +1.45; GH, +24.4; IGF-I, -1.70; IGFBP-3, -0.88; IGFBP-2, +2.42; and GH-binding protein, -0.69. Bone ALP, PICP, and IGFBP-3 were all correlated (P < or = 0.03). During induction and intensification, there was shrinkage of the lower leg, with decreases in PICP, pyridinoline, ICTP, and P3NP (P < 0.05), whereas IGF-I and IGFBP-3 increased (P < 0.05). After prednisolone was discontinued, bone ALP and collagen markers increased markedly (P < 0.01), but there was no significant change in IGF-I and IGFBP-3. In 12 children who received high dose i.v. methotrexate, postglucocorticoid increases in bone ALP and PICP were less, whereas those in ICTP and P3NP were greater, compared to levels in children who did not receive methotrexate (P < 0.05). We conclude that ALL itself caused GH resistance and low bone turnover. During early intensive chemotherapy, further suppression of osteoblast proliferation and osteoclast activity occurred, not mediated through the systemic GH axis, probably by the direct action of prednisolone on bone. The postglucocorticoid increase in bone turnover was also independent of the GH axis and was modulated by high dose i.v. methotrexate, which depressed osteoblast recovery and enhanced osteoclast activity.

A morbidity study of former pentachlorophenol-production workers

Pentachlorophenol (PCP) is a pesticide that was once widely used for wood preservation. Commercial PCP contained impurities including higher chlorinated dibenzo-p-dioxins (CDDs) and chlorinated dibenzofurans (CDFs). We investigated the effects of occupational exposure to PCP and its CDD and CDF contaminants on the skin, liver, porphyrin metabolism, and central and peripheral nervous systems. In 1986 we conducted a medical survey of 366 workers who had been engaged in the production of PCP at a single plant between 1938 and 1978. The referent group consisted of 303 workers from the same plant who were not exposed to these or related compounds. Exposure was determined from computerized personnel records. The medical survey included an administered questionnaire, medical record review, physical examination by dermatologists, internists, and neurologists, and analysis of 24-hr urine for quantitative porphyrins among other tests. In this paper we present the results of analyses of the general health, chloracne, and porphyrin metabolism end points. The general health status of PCP workers was similar to unexposed workers, but 17.8% of PCP workers had evidence of current or past chloracne. PCP workers with chloracne had significantly higher mean urinary excretion of coproporphyrins (117. 0 vs. 90.6 microg/24 hr) than unexposed workers after controlling for potential confounders. Workers with chloracne who had worked with both PCP and polychlorinated biphenyls had significantly higher mean urinary excretions of hepta-, penta-, and coproporphyrins than unexposed workers. We conclude that occupational exposure to PCP is associated with chloracne and biochemical abnormalities which may persist years after exposure.

A pedunculated intraluminal foregut reduplication cyst of the proximal esophagus

A 66-year-old woman with a 3-month history of progressive dysphagia underwent transoral excision of a pedunculated cyst arising in the proximal esophagus. Histologic examination confirmed a pedunculated intraluminal foregut reduplication cyst. She remains well 1 year after excision with no recurrence of dysphagia.

Reduction mammaplasty using the inferior pedicle technique

A retrospective study of 350 reduction mammaplasties by the inferior pedicle technique performed over a 3-year period allows a critical evaluation of postoperative complications and patient satisfaction. The procedure can be done in a timely manner on an outpatient basis and is applicable to breasts of different shapes and sizes. The rate of postoperative complications (5%) was comparable with previous studies. Patient satisfaction was high (98%), with near-total relief of preoperative symptoms. Concern about the resultant scars was low (2%) when the incisions followed the natural contour of the breast.

Cytogenetics of an atypical Spitz nevus metastatic to a single lymph node

Clinicopathologic details of an atypical Spitz nevus are reported. A metastasis to a single ipsilateral lymph node is documented. Cytogenetic analysis of the metastatic lesion revealed a clonal chromosomal abnormality, add(6)(q12-13), previously noted in cases of malignant melanoma.

An anthropometric study of children during intensive chemotherapy for acute lymphoblastic leukaemia

In order to study the short-to medium-term effects of cytotoxic chemotherapy (CT) for acute lymphoblastic leukaemia (ALL) on growth in prepubertal children, a prospective study of weight (Wt), height (Ht), sitting height (SH) and body mass index (BMI) was performed in 31 children receiving intensive CT for ALL. Two pubertal children, 1 child with Down's syndrome and 3 children who had cranial irradiation were excluded from the analysis. Monthly measurements were presented as change in standard deviation scores from baseline (delta SDS). The median age at diagnosis was 4.4 years (range, 1.1-14). The median duration of study per subject was 18 months (3-24). The median delta SDS-Ht reached a nadir of -0.35 at 6 months after the start of CT (p = 0.001, Wilcoxon signed rank test); the median delta SDS-SH was -0.55 at 3 months (p = 0.02); the median delta SDS-Wt and delta SDS-BMI increased at 2 months to 0.15 (p = 0.03) and 0.5 (p = 0.002), respectively. The median delta SDS-BMI was also elevated at 10 months (0.75, p = 0.01) reflecting the relative delay in recovery of Ht-SDS in comparison to Wt-SDS. The median SH:Ht ratio, a measure of disproportion, was reduced at 3 months (delta SH:Ht ratio, -0.01, p = 0.009). No significant changes in Ht-SDS, BMI-SDS or SH:Ht from baseline were evident at the end of the CT. Cytotoxic CT for ALL in childhood has a significant adverse effect on growth, but there is some evidence for recovery before the end of CT.

Stage IV malignant intrapericardial germ cell tumor: a case report

The mediastinum is a common site for germ cell tumors. We describe an unusual case in an 18-month-old girl who presented with respiratory distress and cardiomegaly. An echocardiogram revealed a large pericardial effusion and a mass adjacent to the heart. She underwent detailed investigation and at open exploration was found to have a wholly intrapericardial malignant yolk sac tumor. Staging investigations revealed a bony metastasis. The serum marker alpha-fetoprotein was elevated. She was treated with chemotherapy and is in remission 1 year after completion of treatment. We review the methods of diagnosis and follow-up of children with these tumors.

Effect of low dose oxandrolone and testosterone treatment on the pituitary-testicular and GH axes in boys with constitutional delay of growth and puberty

OBJECTIVE

To investigate the effect of low dose oxandrolone and testosterone on the pituitary-testicular and GH-IGF-I axes.

DESIGN

Prospective double-blind placebo-controlled trial.

PATIENTS

Sixteen boys with constitutional delay of growth and puberty (CDGP) with testicular volumes 4-6 ml were randomized to 3 months treatment: Group 1 (n = 5), daily placebo: Group 2 (n = 5), 2.5 mg oxandrolone daily or Group 3 (n = 6), 50 mg testosterone monthly intramuscular injections with assessment (growth, pubertal development and overnight hormone profiles) at 0, 3, 6 and 12 months.

MAIN OUTCOME MEASURES

LH and GH profiles (15-minute samples) were analysed by peak detection (Pulsar), Fourier transformation and autocorrelation. Testosterone levels were measured hourly and insulin, SHBG, IGF-I, and IGFBP-3 levels at 0800 h. Statistical analysis was by multivariate analysis of variance for repeated measures.

RESULTS

LH and testosterone parameters increased significantly with time in all 16 (LH AUC, P < 0.001; peak amplitude, P = 0.02; number of peaks, P = 0.02; testosterone AUC, P = 0.02; morning testosterone, P = 0.002). In Group 2, however, LH and testosterone parameters decreased at 3 months followed by a rebound increase at 6 and 12 months. SHBG levels were markedly reduced at 3 months (P = 0.006) and a wider range of dominant GH frequencies was present although GH AUC was not increased until 6 months, with an increase in GH pulse frequency but not amplitude. IGF-I levels were increased at both 3 and 12 months. In Group 3, pituitary-testicular suppression was not apparent, but GH levels increased with an increase in GH amplitude at 3 and 12 months.

CONCLUSION

Oxandrolone transiently suppressed the pituitary-testicular axis and altered GH pulsatility. Testosterone increased GH via amplitude modulation.

Short-term changes in urinary growth hormone excretion and lower leg length in healthy children

To investigate any association between changes in lower leg length (LLL) and urinary growth hormone (uGH) excretion, 4 prepubertal children supplied daily 12-hour overnight urine samples and had daily knemometry performed for 4 weeks. The mean daily and weekly LLL velocity (LLLV) of the group was (0.08 mm/day (95% CI 0.01-0.18) and 0.52 mm/week (range 0.38-0.78), respectively. The mean uGH excretion was 8.9 ng/l (CI 3.7-13.3), and the mean intrasubject coefficient of variation of uGH was 55% (range 32-93). The tallest subject who also had the highest LLLV excreted the least amount of uGH (mean 3.7 ng/l, CI 2.9-4.5). No temporal relationship was evident between daily uGH excretion and LLLV. There was no evidence of any association between amount of uGH excreted and LLLV. There remains some doubt on the usefulness of uGH measurement as the sole predictor of normal GH production.

Spindle cell carcinoma of the tongue in a long-term survivor of childhood acute lymphoblastic leukemia

A 25-year-old male previously treated (age 9 years) for acute lymphoblastic leukemia developed a spindle cell carcinoma of the tongue. Possible causes for the development of his second malignancy are discussed. A combination of scatter from cranial irradiation, poor oral hygiene, alcohol consumption, and cigarette smoking is likely to be contributory. Genetic predisposition can never be fully excluded.

Late effects of antineoplastic therapy in childhood on growth and endocrine function

The major challenge for this generation of children's cancer specialists is to sustain the significant improvement in survival rates, while at the same time minimising treatment-induced late adverse effects. The available evidence suggests that, following first line treatment of acute lymphoblastic leukaemia (ALL), current treatment regimens used in the UK are unlikely to cause sterilisation in either gender. For men who are treated for Hodgkin's disease with 6 or more courses of antineoplastic therapy, azoospermia is the rule. Childhood studies have clearly indicated that the prepubertal testis is not protected from antineoplastic therapy that is potentially sterilising. The interpretation of tests of ovarian function in women treated for cancer in childhood is difficult, but there is increasing evidence of ovarian dysfunction in children treated for Hodgkin's disease. Reassuringly there is no evidence of an increased risk of miscarriage following antineoplastic therapy or an increased number of abnormalities in the offspring. The growth patterns and requirement for growth hormone replacement therapy in children treated for ALL are still unclear. There is good evidence that the intensity and duration of combination cytotoxic antineoplastic therapy received by children with ALL influences the pattern of growth, and that adjuvant antineoplastic therapy for children treated for a brain tumour is an important factor in final height achieved. A child who has been treated for cancer should not be discharged from follow-up. Late effects may have significant implications in later life, and an understanding of these effects is essential to enable balanced decisions to be made regarding the benefits and risks of currently available agents.

Primary malignant melanoma of the esophagus

Primary malignant melanoma of the esophagus, first recognized as a primary tumor by de la Pava et al. in 1963, is rare. It usually presents as an aggressive polypoidal darkly colored or non-pigmented tumor in the mid to lower esophagus which may be diagnosed preoperatively by the use of immunohistochemical stains such as HMB-45 (melanoma specific antigen). The treatment of choice is surgical resection however the overall prognosis is poor with only 4 per cent of patients surviving 5 years.

The relationship between short-term changes in weight and lower leg length in children and young adults

As the knemometer is increasingly being used to study changes in lower leg length in conditions associated with weight changes it is important to clearly delineate the relationship between these two variables. Lower leg length and weight were measured in 26 children and nine adults including one pregnant woman. There was a weak but positive relationship between lower leg length and weight fluctuation in children. Daily fluctuations in weight as well as lower leg length were higher in women than men; median lower leg length fluctuation: women, 0.16 mm (P5-0, P95-0.7); men, 0.1 mm (P5-0, P95-0.48) p approximately 0.02, Wilcoxon signed-rank test. Median weight fluctuation: women 0.15 kg (P5-0, P95-0.54); men, 0.1 kg (P5-0, P95-0.5) p = 0.94 (Wilcoxon signed-rank test). Sustained weight gain in pregnancy led to a reduction in lower leg length followed by an increase which was coincident with the appearance of dependent oedema. Lower leg length changes are likely to be positively related to changes in weight when the latter are only modest in magnitude. However, greater sustained increases in weight are likely to have an opposite effect on lower leg length due to direct compression of the lower leg. Due consideration of weight is essential in longitudinal studies of lower leg length changes, especially in conditions which are associated with significant changes in weight.

Biochemical markers of bone turnover

Three studies to evaluate procollagen type I C-terminal propeptide, type I collagen cross-linked telopeptide and bone alkaline phosphatase (BALP) in the assessment of bone turnover and growth in children are presented. (1) In 50 short normal children treated with placebo or growth hormone, delta BALP after 3 months of treatment was highly correlated with height velocity response after 1 year (r = 0.67, p < 0.0001). (2) In 12 children with acute lymphoblastic leukaemia, marked changes in collagen peptides, BALP, and lower leg length velocity were seen during the first 6 months of chemotherapy. Suppression occurred during induction and the two intensification phases, with catch-up during the intervening phase (paired t-tests, p < 0.001). (3) Fourteen babies (birthweight < 1,500 g) treated with high-dose dexamethasone for bronchopulmonary dysplasia were compared with 25 non-steroid-treated babies < 1,500 g. Both collagen peptides decreased rapidly and dramatically (mean decreases 41-68%) after dexamethasone was started, accompanied by weight loss and lower leg shrinkage and followed by recovery during steroid weaning.

Degree of activation of the pituitary-testicular axis in early pubertal boys with constitutional delay of growth and puberty determines the growth response to treatment with testosterone or oxandrolone

Early pubertal boys (testicular volume, 4-6 mL) with constitutionally delayed growth and puberty were randomized to 3 months of treatment after a baseline 12-h overnight hormone profile: group 1 (n = 5), daily placebo; group 2 (n = 5), 2.5 mg oxandrolone daily; or group 3 (n = 6), 50-mg testosterone monthly im injections. LH and GH profiles (15-min samples) were analyzed by peak detection (Pulsar), Fourier transformation, and autocorrelation. FSH and testosterone levels were measured hourly, and insulin, sex hormone-binding globulin, insulin-like growth factor-I, and insulin-like growth factor-binding protein-3 levels were determined at 0800 h. Multiple regression was used to analyze the response to treatment (growth) with respect to baseline features. Endocrine variability was marked. Profiles ranged from unreactive to well established LH pulsatility and adult testosterone levels. The areas under the curve (AUC) for LH, FSH, and testosterone ranged 10-fold (4.4-46.3 IU/L.h), 8-fold (7.9-63.4 IU/L.h), and 45-fold (3.6-161.7 nmol/L.h), respectively. The growth response was individually varied, but significantly increased 0-6 months in the active treatment groups. Age, testicular volume, and LH AUC interacted significantly (r2 = 0.95; P < 0.05). Allowance for these produced a highly significant treatment effect (P = 0.006). Age, testicular volume, LH AUC, and testosterone AUC, but not treatment, significantly increased growth by 0-12 months (r2 = 0.88; P < 0.05). We demonstrate a spectrum of activation of the reproductive axis despite tight clinical staging. This, and not GH status at treatment commencement, influenced the growth response.