Posterior reversible encephalopathy syndrome and other severe central nervous system adverse events in the NOPHO ALL2008 protocol : clinical and radiological findings, genetic risk factors and prognosis

Background: The advances in the therapeutic protocols for pediatric acute lymphoblastic leukemia (ALL) have led to a current survival rate of more than 90% in developed countries. Treatment periods are, however, long and marked by complications and toxicity that may challenge treatment outcomes and quality of life for patients. Central nervous system (CNS) toxicity is common during pediatric ALL treatment and may implicate treatment postponement as well as long-term adverse effects. The aim of this thesis was to map CNS toxicities in pediatric ALL in patients treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol. Methods: Patients aged 1 to 17.9 years at diagnosis of B-cell-precursor and T-cell ALL who were treated according to the NOPHO ALL2008 protocol between 2008 and 2015 were included. Detailed data on CNS toxicity were collected from the NOPHO ALL2008 registry with seven participating countries and a complementary questionnaire addressing phenotypical and work-up details. Genome-wide association studies (GWAS) and candidate single nucleotide polymorphism (SNP) analyses were performed. A validation study of significant findings from GWAS and candidate SNP analyses was made in an independent Australian cohort of pediatric ALL patients (n=797) including patients with diverse CNS toxicities (n=103) and methotrexate-related CNS-toxicity (n=48). The role of minimal CNS leukemia in CNS toxicity risk was further examined by detecting leukemic blasts in cerebrospinal fluid (CSF) by flow cytometric immunophenotyping (FCI) in addition to cytomorphological analysis (CM), which is the CSF examination method specified in the NOPHO ALL2008 protocol. Results: 1464 patients were included in the study of whom 52 (3.8%) had posterior reversible encephalopathy syndrome (PRES), and 135 (9.2%) had at least one form of CNS toxicity. Overall, 82/135 patients had at least one seizure episode (60.7%). PRES was the most common form of CNS toxicity in this cohort (38.5%). Older age, defined as each extra year of age and/or as patient group >10 years of age was a significant risk factor for PRES, seizures, and all CNS toxicities. T-cell immunophenotype was significant risk factor for PRES in univariate analysis and after adjustment for age. Leukemic blasts in CSF by CM were significantly related to PRES during induction and high-risk block treatment was related to PRES after induction. Minimal CNS leukemia, detected by FCI, was a significant risk factor for PRES, seizures, and all CNS toxicities in patients without CNS leukemia by CM in univariate analyses and for PRES and seizures after adjusting for induction therapy. Genome-wide association studies did not demonstrate any significant associations with CNS toxicities, but candidate SNP analyses showed that the ATXN1rs68082256 SNP, related to epilepsy, was associated with seizures in patients <10 years. ATXN1rs68082256 was replicated in the Australian cohort in the patient group with diverse CNS toxicities. At the last follow-up, 11.7% of survivors (12/103) who had displayed CNS toxicity were reported to have had an epilepsy diagnosis. Clinical suspicion of neurocognitive impairment was reported for 10.9% of survivors (12/110) with CNS toxicity at their last follow-up, but neuropsychiatric testing was performed in only two cases. Conclusion: Central nervous system toxicity was common during pediatric ALL treatment and PRES was the most common form of CNS toxicity in this cohort. Older patients had a greater risk of CNS toxicity as well as patients with minimal CNS leukemia. The role of ATXN1rs68082256 SNP in CNS toxicity warrants further studies. Epilepsy is rather common in ALL survivors, while the neurocognitive outcome warrants more systematic follow-up

Acute central nervous system toxicity during treatment of pediatric acute lymphoblastic leukemia : phenotypes, risk factors and genotypes

Publisher Copyright: © 2022 Ferrata Storti Foundation Published under a CC BY-NC license.Central nervous system (CNS) toxicity is common at diagnosis and during treatment of pediatric acute lymphoblastic leukemia (ALL). We studied CNS toxicity in 1, 464 children aged 1.0-17.9 years, diagnosed with ALL and treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol. Genome-wide association studies, and a candidate single-nucleotide polymorphism (SNP; n=19) study were performed in 1, 166 patients. Findings were validated in an independent Australian cohort of children with ALL (n=797) in whom two phenotypes were evaluated: diverse CNS toxicities (n=103) and methotrexate-related CNS toxicity (n=48). In total, 135/1, 464 (9.2%) patients experienced CNS toxicity for a cumulative incidence of 8.7% (95% confidence interval: 7.31-10.20) at 12 months from diagnosis. Patients aged ≥10 years had a higher risk of CNS toxicity than had younger patients (16.3% vs. 7.4%; P<0.001). The most common CNS toxicities were posterior reversible encephalopathy syndrome (n=52, 43 with seizures), sinus venous thrombosis (n=28, 9 with seizures), and isolated seizures (n=16). The most significant SNP identified by the genome-wide association studies did not reach genomic significance (lowest P-value: 1.11x10-6), but several were annotated in genes regulating neuronal functions. In candidate SNP analysis, ATXN1 rs68082256, related to epilepsy, was associated with seizures in patients <10 years (P=0.01). ATXN1 rs68082256 was validated in the Australian cohort with diverse CNS toxicities (P=0.04). The role of ATXN1 as well as the novel SNP in neurotoxicity in pediatric ALL should be further explored.Peer reviewe

Pharmacogenetics of the Central Nervous System—Toxicity and Relapse Affecting the CNS in Pediatric Acute Lymphoblastic Leukemia

Despite improving cure rates in childhood acute lymphoblastic leukemia (ALL), therapeutic side effects and relapse are ongoing challenges. These can also affect the central nervous system (CNS). Our aim was to identify germline gene polymorphisms that influence the risk of CNS events. Sixty single nucleotide polymorphisms (SNPs) in 20 genes were genotyped in a Hungarian non-matched ALL cohort of 36 cases with chemotherapy related acute toxic encephalopathy (ATE) and 544 controls. Five significant SNPs were further analyzed in an extended Austrian-Czech-NOPHO cohort (n = 107 cases, n = 211 controls) but none of the associations could be validated. Overall populations including all nations’ matched cohorts for ATE (n = 426) with seizure subgroup (n = 133) and posterior reversible encephalopathy syndrome (PRES, n = 251) were analyzed, as well. We found that patients with ABCB1 rs1045642, rs1128503 or rs2032582 TT genotypes were more prone to have seizures but those with rs1045642 TT developed PRES less frequently. The same SNPs were also examined in relation to ALL relapse on a case-control matched cohort of 320 patients from all groups. Those with rs1128503 CC or rs2032582 GG genotypes showed higher incidence of CNS relapse. Our results suggest that blood-brain-barrier drug transporter gene-polymorphisms might have an inverse association with seizures and CNS relapse

Isolation and biological activity of active ingredients of natural products

This thesis focuses on the study of the chemical composition and biological activity of five native taxa Sideritis: two taxa S. raeseri Boiss & Heldr ssp. raeseri were collected in Syrrako of Ioannina and in Kellari of Melissourgi, two taxa S. scardica Griseb were collected in Vourino in Rhodian of Kozani and in Krystallopigi of Florina, one taxon S. perfoliata L. ssp perfoliata was collected in Koryfi of Trikala. A comparative approach between Sideritis taxa and a commercial Ceylon green Tea (C. sinensis), known for its use in a wide range of research and its many biological activities) has been performed.In particular, extractions were performed with three solvents of different polarity (methanol, water, hexane). Dry extracts:•were tested for their percent yield of solid extraction for each plant species,•were tested for their content in total flavonoids and total phenolics as well as for their antioxidant activity with the DPPH test and were compared with the antioxidant activity of the standard compounds Quercetin, Vitamin C and Troxol,•were qualitatively and quantitatively determinated with standard compounds (eight phenolic acids, nine flavonoids, phenylethanoid glycoside verbascoside, two monoterpenoids and two triterpenoids) using ultra high pressure liquid chromatography coupled to high resolution and precision mass spectrometry and UHPLC / LTQ- Orbitrap XL,•were tested for their biological activity.The results were found to be similar among Sideritis taxa, while there were differences between them and C. Sinensis. In particular, Sideritis taxa exhibited the highest content in total flavonoids in highly polar solvents (methanol, water). In contrast to C. sinensis the highest content of total flavonoids was found in the solvent hexane. Finally, we compared the results (IC50) of the extracts with those of the standard compounds and all the methanolic and aqueous extracts were characterized by moderate antioxidant activity, except of the C. sinensis methanol extract, which had a strong antioxidant effect, and all hexane extracts were characterized by a weak antioxidant activity. We obtained similar quantitative and qualitative results for the Sideritis taxa while different ones for C. Sinensis. Finally, the biological activity was tested in vitro against four cell lines and was compared to cis-Diamminadichloroplatinum (cis-platin). Cell lines were: HeLa, A549, LS174 and the MRC5 series. Τhe results were compared to cis-DDP, which showed the highest cytotoxic activity. Interestingly, the S. perfoliata L. ssp.perfoliata extract exhibited the highest activity against the three cancer cell lines among all the extracts, including that of C. Sinensis, with a selective activity for the normal cell line. Finally, the results for the activity of the methanolic and aqueous extracts of the other two Sideritis taxon in the HeLa cell cancer cell line were also of interest.Η παρούσα διδακτορική διατριβή περιλαμβάνει τη μελέτη της χημικής σύστασης και βιολογικής δράσης πέντε αυτοφυών taxa Sideritis: δύο taxa S. raeseri Boiss & Heldr ssp. raeseri που συλλέχθηκαν στο Συρράκο Ιωαννίνων και το Κελλάρι Μελλισουργών Άρτας, δύο taxa S. scardica Griseb που συλλέχθηκαν στο Βούρινο -Ροδιανής Κοζάνης και την Κρυσταλοπηγή Φλώρινας, ένα taxon S. perfoliata L. ssp perfoliata που συλλέχθηκε στην Κορυφή Τρικάλων. Γίνεται συγκριτική προσέγγιση μεταξύ των taxa Siderits, καθώς και με ένα εμπορικό σκεύασμα πράσινου τσαγιού (C. sinensis, γνωστό για το μεγάλο εύρος ερευνών και την πληθώρα δράσεών του), τσάι Κεϋλάνης. Ειδικότερα, πραγματοποιήθηκαν εκχυλίσεις με τρεις διαλύτες διαφορετικής πολικότητας (μεθανόλη, νερό και εξάνιο). Στα ξηρά εκχυλίσματα:•έγινε έλεγχος ως προς την απόδοση επί τοις εκατό της εκχύλισης σε στερεό για κάθε φυτικό είδος,•έγινε έλεγχος ως προς την περιεκτικότητα σε ολικά φλαβονοειδή και ολικά φαινολικά, καθώς και ως προς την αντιοξειδωτική δράση με τη μέθοδο του DPPH˙ και σύγκριση με την αντιοξειδωτική δράση των πρότυπων ουσιών Quercetin, Vitamin C και Troxol,•έγινε ποιοτικός και ποσοτικός προσδιορισμός με τη χρήση πρότυπων ουσιών με υγρή χρωματογραφία συζευγμένη με φασματομετρία μάζας υψηλής διακριτικής ικανότητας και ακρίβειας UHPLC/LTQ-Orbitrap XL•έγινε έλεγχος ως προς την βιολογική δράση σε καρκινικές κυτταρικές σειρές και σύγκριση με φυσιολογικά κύτταρα.Τα αποτελέσματα βρέθηκαν παρόμοια μεταξύ των taxa Sideritis, ενώ παρατηρήθηκαν διαφορές μεταξύ αυτών και του C. Sinensis. Συγκεκριμένα, τα taxa Sideritis παρουσίασαν τη μεγαλύτερη περιεκτικότητα σε ολικά φλαβονοειδή σε υψηλής πολικότητας διαλύτες (μεθανόλη, νερό). Αντίθετα στο C. sinensis η μεγαλύτερη περιεκτικότητα σε ολικά φλαβονοειδή βρέθηκε στο διαλύτη εξάνιο. Τέλος, συγκρίνοντας τα αποτελέσματα IC50 που βρέθηκαν για τα εκχυλίσματα με αυτά των πρότυπων ουσιών, όλα τα μεθανολικά και υδατικά εκχυλίσματα χαρακτηρίζονται ως μέτριας αντιοξειδωτικής δράσης, με εξαίρεση το μεθανολικό εκχύλισμα του C. Sinensis που εμφάνισε ισχυρή αντιοξειδωτική δράση, όλα δε τα εξανικά εκχυλίσματα χαρακτηρίζονται ασθενούς αντιοξειδωτικής δράσης. Κατά τον ποιοτικό και ποσοτικό προσδιορισμό, προέκυψαν παρόμοια αποτελέσματα για τα taxa Sideritis και διαφορετικά για το C. Sinensis. Για τις ουσίες που βρέθηκαν εκατέρωθεν (taxa Sideritis & C. Sinensis) τα επίπεδα συγκέντρωσης στο C. Sinensis είναι πολλαπλάσια των taxa Sideritis.Τέλος, ελέγχθηκε η κυτταροτοξικότητα in vitro, έναντι τεσσάρων κυτταρικών σειρών και συγκρίθηκε με το cis-Diamminadichloroplatinum (cis-platin). Οι κυτταρικές σειρές είναι: HeLa, Α549, LS174 και η σειρά MRC5. Τα αποτελέσματα συγκρινόμενα με cis-DDP υπολείπονται της κυτταροτοξικής δράσης τους. Όμως, θα μπορούσαν να αξιολογηθούν ως ενδιαφέροντα τα αποτελέσματα του εξανικού εκχυλίσματος του S. perfoliata L. ssp.perfoliata, το οποίο παρουσίασε τη μεγαλύτερη δραστικότητα έναντι και των τριών καρκινικών σειρών ακόμα, και από αυτή του C. Sinensis, ενώ εμφάνισε επιλεκτική δραστικότητα για τη φυσιολογική κυτταρική σειρά. Ενδιαφέρον παρουσίασαν τα αποτελέσματα για τη δραστικότητα των μεθανολικών και υδατικών εκχυλισμάτων των άλλων δυο taxon Sideritis στην καρκινική σειρά κυττάρων, HeLa

Seizures during treatment of childhood acute lymphoblastic leukemia: A population-based cohort study

Background Seizures are common in children with acute lymphoblastic leukemia (ALL). As ALL survival rates are improving, the challenge to minimize treatment related side effects and late sequelae rises. Here, we studied the frequency, timing, etiology and risk factors of seizures in ALL patients. Methods The study included children aged 1–17.9 years at diagnosis of B-cell-precursor and T cell ALL who were treated according to the Nordic Society of Pediatric Haematology and Oncology (NOPHO) ALL2008 protocol between 2008 and 2015. Detailed patient data were acquired from the NOPHO ALL2008 registry and by review of medical records. Results Seizures occurred in 81/1464 (5.5%) patients. The cumulative incidence of seizures at one months was 1.7% (95% CI: 1.2–2.5) and at one year 5.3% (95% CI 4.2–6.5%). Patients aged 10–17.9 years, those with T cell immunophenotype, CNS involvement, or high-risk induction with dexamethasone had higher risk for seizures in univariable analyses. Only age remained a risk factor in multivariable analyses (the cumulative incidence of seizures for patients 10–17.9 years old at one year was 9.0% (95% CI: 6.2–12.9)). Of the 81 patients with seizures, 43 had posterior reversible encephalopathy syndrome (PRES), 15 had isolated seizures, nine had sinus venous thrombosis (SVT), three had stroke-like syndrome, and 11 had other neurotoxicities. Epilepsy diagnosis was reported in totally 11 ALL survivors at last follow up. Conclusion Seizures are relatively common in ALL patients and occur most often in patients with PRES, SVT, or as an isolated symptom. Older children have higher risk of seizures.Peer reviewe

Does minimal central nervous system involvement in childhood acute lymphoblastic leukemia increase the risk for central nervous system toxicity?

Central nervous system (CNS) involvement in childhood acute lymphoblastic leukemia (ALL) implicates enhanced intrathecal chemotherapy, which is related to CNS toxicity. Whether CNS involvement alone contributes to CNS toxicity remains unclear. We studied the occurrence of all CNS toxicities, seizures, and posterior reversible encephalopathy syndrome (PRES) in children with ALL without enhanced intrathecal chemotherapy with CNS involvement (n = 64) or without CNS involvement (n = 256) by flow cytometry. CNS involvement increased the risk for all CNS toxicities, seizures, and PRES in univariate analysis and, after adjusting for induction therapy, for seizures (hazard ratio [HR] = 3.33; 95% confidence interval [CI]: 1.26-8.82; p = 0.016) and PRES (HR = 4.85; 95% CI: 1.71-13.75; p = 0.003)

Does minimal central nervous system involvement in childhood acute lymphoblastic leukemia increase the risk for central nervous system toxicity?

Abstract Central nervous system (CNS) involvement in childhood acute lymphoblastic leukemia (ALL) implicates enhanced intrathecal chemotherapy, which is related to CNS toxicity. Whether CNS involvement alone contributes to CNS toxicity remains unclear. We studied the occurrence of all CNS toxicities, seizures, and posterior reversible encephalopathy syndrome (PRES) in children with ALL without enhanced intrathecal chemotherapy with CNS involvement (n = 64) or without CNS involvement (n = 256) by flow cytometry. CNS involvement increased the risk for all CNS toxicities, seizures, and PRES in univariate analysis and, after adjusting for induction therapy, for seizures (hazard ratio [HR] = 3.33; 95% confidence interval [CI]: 1.26–8.82; p = 0.016) and PRES (HR = 4.85; 95% CI: 1.71–13.75; p = 0.003)

Acute central nervous system toxicity during treatment of pediatric acute lymphoblastic leukemia : phenotypes, risk factors and genotypes

Publisher Copyright: © 2022 Ferrata Storti Foundation Published under a CC BY-NC license.Central nervous system (CNS) toxicity is common at diagnosis and during treatment of pediatric acute lymphoblastic leukemia (ALL). We studied CNS toxicity in 1, 464 children aged 1.0-17.9 years, diagnosed with ALL and treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol. Genome-wide association studies, and a candidate single-nucleotide polymorphism (SNP; n=19) study were performed in 1, 166 patients. Findings were validated in an independent Australian cohort of children with ALL (n=797) in whom two phenotypes were evaluated: diverse CNS toxicities (n=103) and methotrexate-related CNS toxicity (n=48). In total, 135/1, 464 (9.2%) patients experienced CNS toxicity for a cumulative incidence of 8.7% (95% confidence interval: 7.31-10.20) at 12 months from diagnosis. Patients aged ≥10 years had a higher risk of CNS toxicity than had younger patients (16.3% vs. 7.4%; P<0.001). The most common CNS toxicities were posterior reversible encephalopathy syndrome (n=52, 43 with seizures), sinus venous thrombosis (n=28, 9 with seizures), and isolated seizures (n=16). The most significant SNP identified by the genome-wide association studies did not reach genomic significance (lowest P-value: 1.11x10-6), but several were annotated in genes regulating neuronal functions. In candidate SNP analysis, ATXN1 rs68082256, related to epilepsy, was associated with seizures in patients <10 years (P=0.01). ATXN1 rs68082256 was validated in the Australian cohort with diverse CNS toxicities (P=0.04). The role of ATXN1 as well as the novel SNP in neurotoxicity in pediatric ALL should be further explored.Peer reviewe

Acute central nervous system toxicity during treatment of pediatric acute lymphoblastic leukemia : phenotypes, risk factors and genotypes

Central nervous system (CNS) toxicity is common at diagnosis and during treatment of pediatric acute lymphoblastic leukemia (ALL). We studied CNS toxicity in 1,464 children aged 1.0-17.9 years, diagnosed with ALL and treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol. Genome-wide association studies, and a candidate single-nucleotide polymorphism (SNP; n=19) study were performed in 1,166 patients. Findings were validated in an independent Australian cohort of children with ALL (n=797) in whom two phenotypes were evaluated: diverse CNS toxicities (n=103) and methotrexate-related CNS toxicity (n=48). In total, 135/1,464 (9.2%) patients experienced CNS toxicity for a cumulative incidence of 8.7% (95% confidence interval: 7.31-10.20) at 12 months from diagnosis. Patients aged &gt;= 10 years had a higher risk of CNS toxicity than had younger patients (16.3% vs. 7.4%; P &lt; 0.001). The most common CNS toxicities were posterior reversible encephalopathy syndrome (n=52, 43 with seizures), sinus venous thrombosis (n=28, 9 with seizures), and isolated seizures (n=16). The most significant SNP identified by the genome-wide association studies did not reach genomic significance (lowest P-value: 1.11x10(-6)), but several were annotated in genes regulating neuronal functions. In candidate SNP analysis, ATXN1 rs68082256, related to epilepsy, was associated with seizures in patients &lt; 10 years (P=0.01). ATXN1 rs68082256 was validated in the Australian cohort with diverse CNS toxicities (P=0.04). The role of ATXN1 as well as the novel SNP in neurotoxicity in pediatric ALL should be further explored