Clinical and biological markers of premature aging after autologous SCT in childhood cancer.

The aim of this study was to analyze the prevalence of frailty and physical health limitations among long-term survivors of high-risk neuroblastoma (HR NBL) and to investigate whether frail health is associated with variables of cardiovascular function, markers of inflammation and telomere length. A national study cohort of 19 (median age 22, range 16-30 years) long-term (>10 years) HR NBL survivors was studied and the findings were compared with 20 age- and sex-matched controls. Frailty was defined as ⩾3 of the following conditions: low muscle mass, low energy expenditure, slow running and weakness. The prevalence of frailty was significantly higher among the HR NBL survivors 9/19 (47%) than among the controls (0%). Thirteen (68%) of the survivors reported significant physical health limitations in vigorous activities, as opposed to none of the controls. The HR NBL survivors had significantly shorter telomere length and higher serum levels of high sensitivity C-reactive protein than did the controls. Frail health and poor physical functioning are prevalent among HR NBL survivors and suggest premature aging. Survivors with gonadal damage, very low fat mass percentage, low glycosylated hemoglobin A1c and increased common carotid artery intima-media thickness may be more prone to early aging after high dose therapy.

Adverse health events and late mortality after pediatric allogeneic hematopoietic SCT-two decades of longitudinal follow-up.

Treatment-related late toxicities after pediatric allogeneic hematopoietic SCT (allo-HSCT) are increasingly important as long-term survival has become an expected outcome for many transplanted children and adolescents. In a retrospective cohort study, we assessed long-term health outcomes in 204 allo-HSCT survivors transplanted in childhood or adolescence (<20 years) between 1978 through 2000 after a median follow-up time of 12 (range 4-28) years. Data on conditioning regimen, adverse health events (AE) and growth and hormonal substitutions (hormone replacement therapies (HRTs)) were obtained from medical records. AEs were graded retrospectively according to Common Terminology Criteria for Adverse Events v3.0. Late deaths (⩾48 months after allo-HSCT) were evaluated separately. Multivariate analysis demonstrated that chronic GVHD (P<0.000) and longer follow-up time (P<0.05) correlated with AEs, whereas CY-based conditioning was inversely correlated (P<0.002). TBI and longer follow-up duration predicted more severe AEs (P<0.001 and P<0.001, respectively). HRTs were more frequent after TBI. Diabetes type II, dyslipidemia and hypertension were detected in 9, 7 and 7% of the survivors, respectively. Late deaths (n=22) were most frequently due to pulmonary failure (n=7), followed by secondary malignancy (n=5). The occurrence of AEs after pediatric allo-HSCT is high and likely to increase during extended follow-up, particularly in patients who have received TBI.

Childhood cancer survival in Finland (1953-2010): a nation-wide population-based study.

Population based survival studies are critical in monitoring changes in anticancer therapy, evaluating effectiveness of new treatments as well as identifying possibilities for further improvement. The previous report on cancer survival in Finland covered patients diagnosed in 1953-1995. Data on survival in the European and Nordic pediatric populations have been published with follow-up ending in 2002. We describe population-based survival of childhood cancer patients (n = 8270, age 0-14 years) in Finland overall and by disease category with follow-up extending from 1953 to 2010 and focusing on the modern treatment era. Data were collected from the Finnish Cancer Registry. Age-standardised observed survival proportions (rates) were calculated using the actuarial (or life-table) method. Trends in observed survival rates were studied over six diagnostic periods: 1953-1960, 1961-1970, 1971-1980, 1981-1990, 1991-2000 and 2001-2010. The overall 5-year survival reached 82.1% (95% CI 80.0-84.2) in the most recent period. In most diagnostic categories, the biggest leap in survival was seen between 1961-1970 and 1981-1990, after which slight improvements occurred between 1981-1990 and 1991-2000, with no significant increase thereafter. In analyses by diagnostic group, positive trends in survival over the last three decades were seen for leukemia (p = 0.000), non-Hodgkin's lymphoma (p = 0.002) and CNS tumours (p = 0.02). Although survival of childhood cancer patients overall has significantly improved from 1953 to 2000, improvement thereafter has been marginal. Future treatment efforts should be directed at bone tumours, soft-tissue sarcoma, neuroblastoma and malignant brain tumours as well as high-risk leukemia.

Surgical treatment of neuroblastoma: twenty-three years of experience at a single institution.

PURPOSE: Neuroblastoma (NB) is treated with surgery, chemotherapy and radiotherapy. We assessed the effects of surgical resection on the outcome over a 23-year period at our institution. METHODS: 85 children were included with a median age at diagnosis of 2.0 (range 0.1-15) years. We assessed the correlation of the complete surgical resection (CR) rate, metastases, NMYC amplification (NMYCA) and chemotherapeutic response with the 5-year overall survival (OS). RESULTS: The INSS stage of NB was 1 in 11 (13 %) patients, 2 in 10 (11 %), 3 in 13 (17 %), 4 in 46 (53 %) and 4S in five patients (6 %). Fifty-two (61 %) patients had high-risk NB and 22 (26 %) had NMYCA. The resection was complete in 72 (85 %) patients, incomplete (ICR) in seven (8 %) and six (7 %) patients did not undergo surgery. Fifty-five patients were administered neoadjuvant and 61 were administered adjuvant chemotherapy (high-dose, n = 50). The OS (5 year) was 68 %: stage 1 (100 %), 2 (90 %), 3 (77 %), 4 (52 %), 4S (80 %) and high-risk NB (52 %). The OS in high-risk NB patients was correlated with a good chemotherapeutic response of the primary tumour, with a RR for mortality = 0.3 (95 % CI 0.1-0.7; p = 0.01), but not with the CR, which had an RR = 0.9 (95 % CI 0.3-2.4; p = 0.84). CONCLUSIONS: The OS in high-risk NB patients was related to a good histological chemotherapeutic response, but not with complete excision of the primary tumour.

Ovarian function after allogeneic hematopoietic stem cell transplantation in childhood and adolescence.

OBJECTIVE: The aim of the study was to evaluate long-term ovarian function after allogeneic hematopoietic stem cell transplantation (HSCT) in childhood and adolescence. SUBJECTS AND METHODS: Predictive factors for ovarian function were evaluated among 92 adult or pubertal female survivors transplanted at Huddinge and Helsinki University Hospital during 1978-2000, at a mean age of 9±4.3 years (range 1-19). At the time of the study a mean±s.d. of 13±5.5 years (range 6-27) had elapsed since the HSCT and the mean age of the participants was 22±6.3 years (range 9-41). RESULTS: Spontaneous puberty based on breast development occurred in 40 and menarche in 30 of the 70 girls who were prepubertal at transplantation. Six out of 20 girls who received HSCT after initiation of pubertal development recovered their ovarian function. Younger age at HSCT, conditioning without total body irradiation (TBI), and a non-leukemia diagnosis predicted the spontaneous menarche. The incidence of menarche was higher after fractioned vs single fraction TBI (P<0.05), cyclophosphamide (Cy) vs busulfan (Bu)-based conditioning (P<0.05), and among leukemia patients transplanted at first remission vs later remissions (P<0.01) and with no cranial irradiation (cranial radiotherapy, CRT) vs given CRT (14-24 Gy) (P<0.01). The majority of recipients conditioned with only Cy vs TBI (P<0.001) or vs Bu-based regimens (P<0.01) showed preserved ovarian function and required no estrogen replacement at their latest follow-up visit at a mean age of 23±6.3 years (range 15-41). Ten women became pregnant. CONCLUSIONS: Patients conditioned with TBI or Bu-based regimes are at high risk of ovarian failure. Intensive anti-leukemia therapy before HSCT including CRT especially among relapsed patients may further decrease the possibility of spontaneous menarche.

Higher angiopoietin-2 and VEGF levels predict shorter EFS and increased non-relapse mortality after pediatric hematopoietic SCT.

The roles of angiogenesis and angiogenic factors after allogenic hematopoietic SCT (HSCT) and during acute GVHD (aGVHD) are not known. Studies on pediatric patients are extremely scarce. Levels of angiopoietin-2 (Ang2) and vascular endothelial growth factor (VEGF) were analyzed from blood samples of 67 consecutive patients. The levels were correlated with aGVHD grades, routine laboratory parameters and outcome. Pre-transplant Ang2 values correlated with the occurrence of intestinal aGVHD (P=0.009), whereas post-transplant measurements correlated with the severity of skin and liver aGVHD (P=0.03, P=0.04, respectively). Pre-transplant levels of VEGF were associated with the occurrence of skin aGVHD (P=0.04), whereas post-transplant levels correlated to the severity of intestinal aGVHD (P=0.04). High Ang2 levels were associated with shorter EFS (P=0.039) and increased non-relapse mortality (NRM) (P=0.009). In conclusion, higher Ang2 levels predict higher NRM and, with coexisting high VEGF, also shorter EFS after pediatric HSCT. Our results suggest that both pre- and post-transplant levels of Ang2 and VEGF seem to correlate to the clinical state of the patient. However, the pathophysiology of this connection needs further studies.

Integrated analysis of gene copy number, copy neutral LOH, and microRNA profiles in adult acute lymphoblastic leukemia.

We adopted an integrated analysis of gene copy number alterations (CNAs), copy number neutral loss of heterozygosity (CNN LOH), and microRNA (miRNA) profiling in 21 adult acute lymphoblastic leukemia (ALL) patients. This study revealed the most frequent CNAs to be at chromosomes 9p, 7, and 17 and recurrent CNN LOH at 5p, 9p, and Xq. As for the most differentially expressed miRNAs, they included 8 upregulated and 14 downregulated miRNAs, of which miR-148a at 7p15.2, miR-22 at 17p13.3, miR-223 at Xq12, as well as miR-101-2 at 9p24.1 exhibited recurrent CNAs or CNN LOH. miR-101-2 was recurrently downregulated, and although the related CNN LOH was detected only in BCR-ABL1 negative cases (2/14), deletions of miR-101-2 were observed solely in BCR-ABL1 positive cases (4/7). Finally, BCR-ABL1 positive cases, in contrast to negative ones, were characterized by slightly, but still significantly, higher expression levels of miR-29b.

Suboptimal long-term physical performance in children and young adults after pediatric allo-SCT.

We present a set of tests for physical performance used for annual prospective follow-up after a pediatric transplant. Of the 103 eligible patients transplanted at a mean age of 8.8 years, 94 were included. The results were divided into early, performed 1 (n=46) or 2 (n=12) years post transplant, and late tests (n=66), performed 4-16 (mean 6) years post transplant. A total of 30 patients had tests both at early and late time points (paired tests). The control subjects included 522 healthy age- and gender-matched schoolchildren. Using their test results, the s.d. score (SDS) was calculated for each patient and for each test individually. Both in the early and late tests, patients had the mean SDS for each test significantly lower (P<0.001) than controls, varying from -0.6 to -2.0 SDS. Specifically, tests measuring trunk muscles gave impaired results. In the group with paired tests, the results improved in four of six tests. In late tests, age at SCT, extensive chronic GVHD and being a sports club member correlated with the results. The potential beneficial effect of an exercise intervention program on impaired physical performance after pediatric SCT merits prospective studies.

Circulating dendritic cell subset levels after allogeneic stem cell transplantation in children correlate with time post transplant and severity of acute graft-versus-host disease.

We examined the recovery of circulating monocytoid (Lin- CD11+ HLA-DR+) and plasmacytoid (Lin- CD123+ HLA-DR+) precursor (pre) dendritic cell (DC) subsets after allogeneic stem cell transplantation (SCT) in 39 children, using age-matched healthy children as controls. The frequencies of DCs in peripheral blood samples were determined by flow cytometry. The initial recovery of DC occurred simultaneously with myeloid engraftment. However, with time, DC subset values declined, being very low 40-50 days after SCT. Low monocytoid and plasmacytoid DC values were associated significantly with the development of severe acute graft-versus-host disease (aGVHD) (P=0.042 and 0.017, respectively). Plasmacytoid DC values were lower than in the age-matched controls for the entire follow-up period (range 102-2569 days), although, with time, values approached normal levels. Normal monocytoid DC numbers were observed within 300-400 days post SCT. The severity of chronic GVHD did not correlate with quantitative recovery of DC. We conclude that in pediatric SCT, initial recovery of DC production is concurrent with that of myelopoiesis, yet with time, DC subset values decline and low counts are associated with severe aGVHD. Monocytoid DC numbers approach normal levels within a year of SCT, but plasmacytoid DC counts recover very slowly.

Increased cell turnover, but no signs of increased T-cell infiltration or inflammatory cytokines in the duodenum of pediatric patients after allogeneic stem cell transplantation.

Intestinal immunopathology was studied after allogeneic stem cell transplantation (SCT) in a common clinical setup in 20 children with malignant (n=17) or nonmalignant diseases (n=3) receiving grafts from siblings (7) and unrelated donors (13). In all, 19 had total body irradiation. Duodenal biopsies at 6 and 12 weeks post transplant were evaluated by histology, immunohistochemistry, and ISEL for the detection of T-lymphocytes, inflammatory cytokines, proliferation, and apoptosis. The controls were 12 healthy children and three patients with proven intestinal graft-versus-host disease. An increased rate of apoptosis and proliferation with upregulated expression of HLA-DR antigen was detected up to 3 months post transplant in the SCT patients, even in those with a histologically normal small intestine. A low level of IFNgamma and TNFalpha was observed in the lamina propria. The initial low density of gammadelta-positive T cells had recovered to normal by the time of the second endoscopy at 12 weeks post transplant. We conclude that inflammatory activity and T cell infiltration detected by immunohistochemistry may not belong to the 'normal' recovery of the small intestine after SCT. Increased cell turnover in the intestinal crypts continues until 3 months after SCT, suggesting either an unexpectedly long-lasting effect of transplant-related toxicity or, preferably, an ongoing subclinical alloreactive process, also present in the patients without intestinal symptoms.

Dendritic cell subsets in childhood and in children with cancer: relation to age and disease prognosis.

Dendritic cells (DC) are a heterogeneous group of uniquely well-equipped bone marrow-derived antigen-presenting cells. They circulate in blood as precursor cells (preDC). In humans, two blood-borne subtypes of preDC can be distinguished by their differential expression of CD11c (CD11c+ preDC; monocytoid DC) and CD123 (CD123+ preDC; plasmacytoid DC). We studied the incidence of monocytoid and plasmacytoid DC in peripheral blood samples from 39 children of various ages (0.4-16.8 years) by flow cytometry, and found a significant negative correlation between the number of plasmacytoid DC and age (r = 0.421, P = 0.012). Monocytoid DC counts did not change significantly with age. Similarly, we analysed DC subsets in 19 children with cancer at the time of diagnosis prior to initiation of any myelosuppressive or antiproliferative treatment and compared the results with those obtained from gender- and age-matched control children. Patients with cancer had significantly less circulating monocytoid DC than controls (medians 13.2 versus 21.4 cells/ micro l, respectively, P = 0.042) at diagnosis, whereas absolute plasmacytoid DC counts did not differ significantly between the study groups. However, clinical outcome of the children with cancer (2.9-5 years follow-up after diagnosis) correlated with plasmacytoid DC count. Children with high plasmacytoid DC counts at diagnosis (above median) survived significantly worse (6/10 deceased) than those with low counts (1/9 deceased) (P = 0.034). Thus, circulating plasmacytoid DC counts are related to age during childhood, and development of cancer is associated with low number of monocytoid DC. A low circulating plasmacytoid DC count at diagnosis was a good prognostic sign.

Subnormal androgen levels in young female bone marrow transplant recipients with ovarian dysfunction, chronic GVHD and receiving glucocorticoid therapy.

Ovarian function and sex hormone production with special focus on androgens (testosterone, androstenedione, dehydroepiandrosterone and its sulfate, DHEAS) was followed up during 1.5-20 (mean 9) years after bone marrow transplantation (BMT) in 24 female subjects aged 16-33 (mean 21) years at the last follow-up. All patients had received TBI and high-dose chemotherapy as the preparative regimen. A total of 24 female patients with conventionally treated pediatric hematologic malignancies served as controls. Four of 24 transplanted patients had spontaneous menstruation several years post transplantation, but in only one of them were serum FSH levels normal. Androgen levels of the BMT patients were lower than those of the conventionally treated patients. Subnormal testosterone levels were observed in 43% of BMT patients and subnormal DHEAS levels in 34% of BMT patients, the latter being a constant finding during glucocorticoid therapy for chronic GVHD (cGVHD). These results indicate that ovarian damage is a common late effect in patients transplanted at a young age, still having a seemingly normal pubertal development. Ovarian damage and cGVHD with glucocorticoid therapy are strongly associated with subnormal androgen levels. The clinical consequences of these changes and possible benefits of putative androgen replacement therapy remain to be elucidated.

Chediak-Higashi syndrome: four cases from Northern Finland.

UNLABELLED: Chediak-Higashi syndrome (CHS) is a rare multiorgan disease entity with autosomal recessive inheritance characterized by oculocutaneous albinism, bleeding tendency, recurrent bacterial infections and various neurological symptoms. Intracellular vesicle formation is deficient, resulting in giant granules in many cells, e.g. giant melanosomes in the melanocytes. Diagnosis has been based on morphological examination of peripheral blood and bone marrow, with giant granules seen in cells of the myeloid lineage and in lymphocytes. The ultimate diagnostic test is to look for a mutated LYST gene. Most patients develop an accelerated phase of the disease with deposition of lymphohistiocytes in the liver, spleen, lymph nodes and bone marrow, resulting in hepatosplenomegaly, bone marrow infiltration and haemophagocytosis. Peripheral blood neutropenia becomes more profound as anaemia and thrombocytopenia develop. Most patients succumb before the age of 10 years. Four patients with CHS are described, one of whom is a long-term survivor after successful allogeneic bone marrow transplantation, two succumbed during the accelerated phase and one is living with a chronic form of the disease. CONCLUSION: Allogeneic bone marrow transplantation from an HLA-matched sibling is the therapy of choice and should be performed early. If there is no matched family donor, an unrelated donor or a placental blood graft is a good alternative. The clinical picture of CHS is heterogeneous and therapeutic decisions need to be made on an individual basis.

Imminent allograft rejection prevented by donor lymphocyte transfusions: report of two pediatric cases.

Gradual allograft rejection after initial good engraftment may occur with simultaneous autologous reconstitution particularly in patients receiving nonmyeloablative conditioning. Careful post-transplant follow-up of the chimerism status can reveal these cases early on, when the immunological balance may still be shifted to the donor cells. We describe two children with nonmalignant diseases, in whom imminent rejection of their sibling allografts was prevented with donor lymphocyte transfusions (DLT). DLT dosing and timing need to be individually guided by monitoring of the chimerism status.

Restoration of ovarian function after chemotherapy for osteosarcoma.

AIM: To evaluate ovarian function after modern intensive multi-agent chemotherapy for osteosarcoma given during childhood or adolescence. METHODS: After discontinuation of treatment, 10 female osteosarcoma survivors were followed up for 1.5-14 (median 4.6) years. Their age at diagnosis was a median of 12.9 (range 6-15) years and at the last follow up 18.6 (range 16-22). The main follow up included recording of their pubertal and menstrual status and of sex hormone determinations. RESULTS: Prior to diagnosis, 5/10 had had their menarche, and one had it while on therapy. At discontinuation of chemotherapy, ovarian function had severely deteriorated; none of the girls experienced regular menstrual cycles. However, during follow up, significant restoration of ovarian function was evident. At the last follow up, 9/10 patients were menstruating spontaneously. During follow up, four patients, three of whom had received high doses of alkylating agents, presented with clear hypergonadotrophism with high FSH levels (14.4-132 IU/l). Three of these four patients initiated menstruation after their gonadotrophin levels normalised. CONCLUSIONS: The modern multi-agent chemotherapy applied for osteosarcoma impairs ovarian function. Normalisation of ovarian function is common, even in cases with severe hypergonadotrophic hypogonadism, but may only occur after several years off chemotherapy. Regular assessment of ovarian function and cautious use of hormone replacement therapy are important in patients with chemotherapy induced gonadal damage.

Expression of myeloid-specific genes in childhood acute lymphoblastic leukemia - a cDNA array study.

Several specific cytogenetic changes are known to be associated with childhood acute lymphoblastic leukemia (ALL), and many of them are important prognostic factors for the disease. Little is known, however, about the changes in gene expression in ALL. Recently, the development of cDNA array technology has enabled the study of expression of hundreds to thousands of genes in a single experiment. We used the cDNA array method to study the gene expression profiles of 17 children with precursor-B ALL. Normal B cells from adenoids were used as reference material. We discuss the 25 genes that were most over-expressed compared to the reference. These included four genes that are normally expressed only in the myeloid lineages of the hematopoietic cells: RNASE2, GCSFR, PRTN3 and CLC. We also detected over-expression of S100A12, expressed in nerve cells but also in myeloid cells. In addition to the myeloid-specific genes, other over-expressed genes included AML1, LCP2 and FGF6. In conclusion, our study revealed novel information about gene expression in childhood ALL. The data obtained may contribute to further studies of the pathogenesis and prognosis of childhood ALL.

Neutrophil regeneration precedes healing of tissue destruction, as indicated by serum C-reactive protein, in children with cancer recovering from neutropenic fever.

AIM: To evaluate the relationship between absolute neutrophil count and C-reactive protein (CRP) in the recovery phase of neutropenic fever among paediatric patients with cancer. METHODS: A total of 102 paediatric oncology patients with 177 episodes of fever and neutropenia was studied prospectively in a two-centre setting. Antimicrobial therapy was discontinued 9 d (mean) post-initiation with a mean absolute neutrophil count of 1.8 x 10(9) l(-1) and CRP of 32 mg l(-1). RESULTS: The mean level of CRP below 20 mg l(-1) was reached on day 12. The level of CRP peaked on the day following the commencement of antimicrobial therapy. Throughout the episodes of fever and neutropenia higher levels of CRP were associated with a lower absolute neutrophil count. Following defervescence the pace of marrow recovery as evidenced by an increasing absolute neutrophil count to > 0.2 and > 0.5 x 10(9) l(-1) was more rapid than the normalization of serum CRP. There was a 2-3 d lag period between absolute neutrophil count exceeding the level of 200 x 10(6) l(-1) and the return of CRP to a baseline level. All episodes were treated successfully and there were no fatalities. CONCLUSION: Among patients recovering from neutropenia and fever the signs of marrow recovery remain the key criterion in evaluating the safety of discontinuing antimicrobial therapy, with serum CRP remaining more of an indicator of ongoing tissue repair.