Pediatric Neurology 50 (2014) e3ee4
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Letters to the Editor
Stroke in Children With Cancer: The Tip of the Iceberg? We read with great interest the article by Noje et al.1 in which they analyzed the incidence and characteristics of stroke in children with cancer. Among a population of 1411 children with cancer, during a 10-year period registry, 15 children had stroke, corresponding to an overall prevalence of 1%. A slightly increased prevalence of stroke in children with brain tumors was documented (1.3%). The occurrence of stroke in children with brain tumors is potentiated by cranial radiation therapy.2 We are currently following a cohort of 103 adult survivors of childhood primary central nervous system tumors in our neurooncology clinic.3 They all underwent radiotherapy during childhood as part of their treatment protocol. Of these patients, two had stroke, grossly corresponding to a prevalence of 1.9%. This finding is consistent with the results presented by Noje et al.1 The two stroke cases occurred at the age of 4 yearsd19 months after tumor treatment in one patientd and at the age of 25 yearsd20 years after tumor treatment in the other patient. In both patients, we identified additional silent cerebrovascular lesions (cavernomas and microbleeds). In our cohort, the overall prevalence of late cerebrovascular complications such as microbleeds, cavernomas, stroke, superficial siderosis, and moyamoya syndrome identified by magnetic resonance imaging was 34.0%. These complications appeared any time during the follow-up period (median of 18.7 years after radiation therapy). In the case series presented by Noje et al.,1 most patients had stroke a median of 5 months of cancer diagnosis, and the majority died. The article clearly showed that the burden of stroke should be carefully accessed, including prevention and treatment strategies in this specific population. We agree with the authors in that stroke after cancer diagnosis probably involves many different mechanisms, most of which remain to be elucidated. Furthermore, we think that stroke during the first months after cancer diagnosis may only be the tip of the iceberg. Patients surviving the first years after cancer diagnosis are at an increased risk of several cerebrovascular complications that may overlap and become more evident if we consider a longer follow-up period. References 1 Noje C, Cohen K, Jordan LC. Hemorrhagic and ischemic stroke in children with cancer. Pediatr Neurol. 2013;49:237e242. 2 Campen CJ, Kranick SM, Kasner SE, et al. Cranial irradiation increases risk of stroke in pediatric brain tumor survivors. Stroke. 2012;43:3035e3040.
0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
3 Passos J, Nzwalo H, Marques J, Azevedo A, Nunes S, Salgado D. Late cerebrovascular complications of radiation therapy for pediatric primary central nervous system tumors. J Neurol Sci. 2013;333(Suppl 1): e238ee239.
João Passos, MD Department of Neurology Instituto Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal E-mail address: [email protected] Hipólito Nzwalo, MD Department of Neurology Centro Hospitalar do Algarve Algarve, Portugal Joana Marques, MD Ana Azevedo, MD Department of Neurology Instituto Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal Sofia Nunes, MD Department of Pediatric Neuro-Oncology Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal Duarte Salgado, MD Departments of Neurology and Pediatric Neuro-Oncology Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal Instituto Português de Oncologia de Lisboa Francisco Gentil Rua Professor Lima Basto Lisbon, Portugal
http://dx.doi.org/10.1016/j.pediatrneurol.2013.10.010
Response to Passos et al: We appreciate the letter from Drs. Passos, Nzwalo, and colleagues1 as well as their interest in our article, “Hemorrhagic and Ischemic Stroke in Children with Cancer.” They report important data on the long term rate of stroke and cerebrovascular disease in adult survivors of childhood primary central nervous system tumors followed in their neuro-oncology clinic at Centro Hospitalar do Algarve in Lisbon, Portugal. We applaud their efforts to carefully follow their patients longitudinally and assess for nonovert lesions
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Letters to the Editor
Stroke in Children With Cancer: The Tip of the Iceberg? We read with great interest the article by Noje et al.1 in which they analyzed the incidence and characteristics of stroke in children with cancer. Among a population of 1411 children with cancer, during a 10-year period registry, 15 children had stroke, corresponding to an overall prevalence of 1%. A slightly increased prevalence of stroke in children with brain tumors was documented (1.3%). The occurrence of stroke in children with brain tumors is potentiated by cranial radiation therapy.2 We are currently following a cohort of 103 adult survivors of childhood primary central nervous system tumors in our neurooncology clinic.3 They all underwent radiotherapy during childhood as part of their treatment protocol. Of these patients, two had stroke, grossly corresponding to a prevalence of 1.9%. This finding is consistent with the results presented by Noje et al.1 The two stroke cases occurred at the age of 4 yearsd19 months after tumor treatment in one patientd and at the age of 25 yearsd20 years after tumor treatment in the other patient. In both patients, we identified additional silent cerebrovascular lesions (cavernomas and microbleeds). In our cohort, the overall prevalence of late cerebrovascular complications such as microbleeds, cavernomas, stroke, superficial siderosis, and moyamoya syndrome identified by magnetic resonance imaging was 34.0%. These complications appeared any time during the follow-up period (median of 18.7 years after radiation therapy). In the case series presented by Noje et al.,1 most patients had stroke a median of 5 months of cancer diagnosis, and the majority died. The article clearly showed that the burden of stroke should be carefully accessed, including prevention and treatment strategies in this specific population. We agree with the authors in that stroke after cancer diagnosis probably involves many different mechanisms, most of which remain to be elucidated. Furthermore, we think that stroke during the first months after cancer diagnosis may only be the tip of the iceberg. Patients surviving the first years after cancer diagnosis are at an increased risk of several cerebrovascular complications that may overlap and become more evident if we consider a longer follow-up period. References 1 Noje C, Cohen K, Jordan LC. Hemorrhagic and ischemic stroke in children with cancer. Pediatr Neurol. 2013;49:237e242. 2 Campen CJ, Kranick SM, Kasner SE, et al. Cranial irradiation increases risk of stroke in pediatric brain tumor survivors. Stroke. 2012;43:3035e3040.
0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
3 Passos J, Nzwalo H, Marques J, Azevedo A, Nunes S, Salgado D. Late cerebrovascular complications of radiation therapy for pediatric primary central nervous system tumors. J Neurol Sci. 2013;333(Suppl 1): e238ee239.
João Passos, MD Department of Neurology Instituto Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal E-mail address: [email protected] Hipólito Nzwalo, MD Department of Neurology Centro Hospitalar do Algarve Algarve, Portugal Joana Marques, MD Ana Azevedo, MD Department of Neurology Instituto Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal Sofia Nunes, MD Department of Pediatric Neuro-Oncology Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal Duarte Salgado, MD Departments of Neurology and Pediatric Neuro-Oncology Português de Oncologia de Lisboa Francisco Gentil Lisbon, Portugal Instituto Português de Oncologia de Lisboa Francisco Gentil Rua Professor Lima Basto Lisbon, Portugal
http://dx.doi.org/10.1016/j.pediatrneurol.2013.10.010
Response to Passos et al: We appreciate the letter from Drs. Passos, Nzwalo, and colleagues1 as well as their interest in our article, “Hemorrhagic and Ischemic Stroke in Children with Cancer.” They report important data on the long term rate of stroke and cerebrovascular disease in adult survivors of childhood primary central nervous system tumors followed in their neuro-oncology clinic at Centro Hospitalar do Algarve in Lisbon, Portugal. We applaud their efforts to carefully follow their patients longitudinally and assess for nonovert lesions
