INTRODUCTION PATIENTS AND METHODS. Pediatr Blood Cancer 2013;60:

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1 Pediatr Blood Cancer 2013;60: Long-Term Follow-Up of Pediatric Patients Receiving Total Body Irradiation Before Hematopoietic Stem Cell Transplantation and Post-Transplant Survival of >2 Years Annette Künkele, MD, 1 * Marianne Engelhard, MD, 2 Berthold P. Hauffa, MD, 3 Uwe Mellies, MD, 4 Carsten Müntjes, MD, 5 Claudia Hüer, MD, 1 Angelika Eggert, MD, 1 Johannes H. Schulte, MD, 1 and Bernhard Kremens, MD 1 Background. Total body irradiation (TBI) treatment eradicates malignant cells and suppresses the immune system before hematopoietic stem cell transplantation (HSCT). The radiation dose is limited by its toxicity to healthy organs. Many reports describe long-term sequelae from TBI in adults, but comparable data for pediatric patients are scarce. Procedures. We evaluated late effects of a cohort of survivors after at least 2 years from 106 children treated with TBI and HSCT between 1985 and Follow-up was available from 39 patients with a mean duration of 8.3 (range ) years. We examined cardiac, pulmonary and renal function, longitudinal growth, weight development, endocrinological parameters, and gastrointestinal problems. Results. Initial remission status and overall survival were significantly correlated. None of the 39 patients experienced cardiac dysfunction or changes in pulmonal function, but 5 exhibited renal impairment. Gastrointestinal problems were reported by 4 patients, and 10 patients had severe growth impairment. Altogether, our follow-up of pediatric patients who survived TBI-containing conditioning regimens for more than 2 years showed no cardiac morbidity or pulmonary aggravation, but mild renal sequelae and growth impairment. Conclusion. The adverse long-term effects of TBI in our cohort of children surviving at least 2 years after TBI and HSCT seem to be within a tolerable range. Future studies are required to investigate whether conditioning regimens lacking TBI result in a better ratio of benefits to overall side effects. Pediatr Blood Cancer 2013;60: # 2013 Wiley Periodicals, Inc. Key words: long-term sequelae; pediatric hematopoietic stem cell transplantation; total body irradiation INTRODUCTION Hematopoietic SCT (HSCT) is an effective therapy for many different diseases, including hematological malignancies, aplastic anemia, aggressive solid tumors and inherited metabolic disorders in childhood and adolescence [1,2]. The number of pediatric patients receiving HSCT is increasing since HLA-mismatched unrelated or related donors are also used. For certain indications radiation therapy is still part of many HSCT conditioning regimens, and improves overall survival (OS) especially in patients with acute lymphoblastic leukemia (ALL) [3,4]. Total body irradiation (TBI) administered before HSCT eradicates malignant cells and is immunosuppressive to prevent graft rejection. TBI is often combined with chemotherapy in conditioning regimens to exploit its independence from drug absorption, metabolism or transport across the blood brain barrier. Restricted cardiac, pulmonary or renal function and long-term endocrine sequelae are well-known long-term complications in adult patients receiving HSCT with TBI [5 8]. Cardiac complications, including heart failure or pancarditis, after TBI combined with high-dose cyclophosphamide or other intensive HSCT conditioning regimens have been well documented in adults, as are long-term infectious and noninfectious pulmonary sequelae of radiochemotherapy [9,10]. Less is known about long-term effects on cardiac and pulmonary function in children. Chronic renal impairment has also been attributed to delayed effects of radiochemotherapy used in HSCT conditioning regimens [11 13]. Recent data suggest that growing kidneys may be more vulnerable to HSCT conditioning regimens than adult kidneys [11,14]. Developing endocrine organs are highly sensitive to chemotherapy and irradiation [15]. Unfortunately, regimens avoiding irradiation are associated with higher rates of relapse and treatment failure, especially in lymphoid malignancies [4,16]. The increasing number of young long-term survivors after HSCT urgently advises to study the sequelae of TBIcontaining conditioning regimens in pediatric patients. We retrospectively studied a single center cohort of patients surviving 2 years or longer who had undergone hyperfractionated TBI C 2013 Wiley Periodicals, Inc. DOI /pbc Published online 24 July 2013 in Wiley Online Library (wileyonlinelibrary.com). (3 2 2 Gray) before HSCT. We analyzed gastrointestinal problems, cardiac, pulmonary, nephrological, and endocrinological dysfunction. PATIENTS AND METHODS The study followed the tenets of the Declaration of Helsinki and was approved by the institutional review board of Children s University Hospital Essen. Data for retrospective evaluation were extracted from medical records of 106 consecutive pediatric patients treated in the University Hospital Essen with TBIcontaining HSCT conditioning regimens between January 1985 and December Of these 106 patients, 8 were excluded from the analysis due to use of other than 12 Gray (Gy). The remaining 98 patients included in the analysis all received 12 Gy over 3 days consisting of 2 Gy twice per day (3 2 2 Gy), and were being treated for different malignancies (Table I). TBI was conducted using a cobalt-60 source twice daily over 3 days, and lung exposure Additional Supporting Information may be found in the online version of this article at the publisher s web-site. 1 Department of Pediatric Hematology-Oncology, Pediatrics III, University Duisburg-Essen, Essen, Germany; 2 Department of Radiotherapy, University Hospital Essen, University Duisburg-Essen, Essen, Germany; 3 Department of Pediatric Endocrinology and Diabetology, Pediatrics II, University Duisburg-Essen, Essen, Germany; 4 Department of Pediatric Pulmonology, Pediatrics III, University Duisburg- Essen, Essen, Germany; 5 Department of Pediatric Cardiology, Pediatrics III, University Duisburg-Essen, Essen, Germany Conflict of interest: Nothing to declare. Correspondence to: Annette Künkele, Department of Pediatric Hematology-Oncology, University Children s Hospital Essen, Hufelandstraße 55, Essen, Germany. annette.kuenkele@uk-essen.de Received 10 October 2012; Accepted 24 June 2013

2 TBI in Pediatric Patients Before HSCT 1793 TABLE I. Diagnoses of Initial Patient Cohort Disease Patient number [n (%)] Mean of age at TBI [years (range)] Cytostatic drugs during conditioning ALL 78 (79.6) 9.1 ( ) Etoposide NHL 7 (7.1) 10.9 ( ) Etoposide, Cyclophosphamide AML 4 (4.1) 10.8 ( ) Cyclophosphamide NB 3 (3.1) 4.2 ( ) Vincristine, melphalan CML 2 (2.0) 10.2 ( ) Cyclophosphamide ES 1 (1.0) 3.7 (n/a) Melphalan JMML 1 (1.0) 1.8 (n/a) Cyclophosphamide OMF 1 (1.0) 11.7 (n/a) Cyclophosphamide B-LBL 1 (1.0) 4.9 (n/a) Etoposide NHL, non-hodgkin lymphoma; NB, neuroblastoma; ES, Ewing sarcoma; JMML, juvenile myelomonocytic leukemia; OMF, osteomyelofibrosis; B-LBL, precursor B-cell lymphoblastic lymphoma; n/a, not applicable. was reduced to 10 Gy. Patients with donors other than HLAidentical siblings received 3 10 mg/kg rabbit anti-thymocyte globulin. Graft-versus-host prophylaxis consisted of short course methotrexate and cyclosporin A. We developed a questionnaire to collect information about gastrointestinal problems. Cardiac function was measured using echocardiography (ie33 and Sonos 5500, Philips Healthcare, DA Best, the Netherlands), and dysfunction was defined as an echocardiographic shortening fraction (ESF) <30%. Pulmonary function was measured by spirometry on seated patients wearing a nose clip. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were measured with a JAEGER MasterScreen Body system (CareFusion, Hoechberg, Germany) and were used for calculation of 1% forced expiratory volume (FEV1%; FEV1% ¼ FEV1/FVC) [17,18]. Restrictive dysfunction was defined as <80% predicted FVC, obstructive dysfunction as <80% predicted FEV1% and bronchiolitis obliterans as <25% predicted mean expiratory flow 25 (MEF 25). Renal function was calculated using the Schwartz formula for glomerular filtration rate (GFR, ml/second per 1.73 m 2 ) ¼ k height (cm)/creatinine (mg/ dl), where k is an age-dependant factor (patient <1 year: k ¼ 0.45; patient >1 year: k ¼ 0.55). We defined chronic renal impairment as GFR <90 ml/second per 1.73 m 2 6 months after HSCT. Weight was measured using an electric scale (Modell 930, Seca, Hamburg, Germany). Standing height was measured to the nearest mm using a wall-mounted stadiometer (Ulmer Stadiometer, Busse Design and Engineering System GmbH, Elchingen, Germany). Conditional target height was calculated from the parents height according to Hermanussen and Cole [19]. Body mass index (BMI) for patients <18 years was converted into SD scores based on German reference data using the LMS method [20,21]. To assess the thyreotropic, corticotropic, somatotropic, and gonadal axis, we measured serum concentrations of TSH, thyroid hormones (T4, T3 as total or free hormones), adrenocorticotropic hormone (ACTH), cortisol, insulin-like growth factor I (IGF-I), insulin-like growth factor binding protein 3 (IGFBP-3), luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol in females and testosterone in males. IGF-I and IGFBP-3 serum concentrations were expressed as SD scores based on German reference data [22]. Statistical analyses were performed using SPSS Version 18 software, R statistical language and GraphPad Prism 5. Start of follow-up was the day of transplantation. Event-free survival (EFS) and OS were calculated from start of follow-up using Kaplan Meier analysis and the log-rank test. Results of functional tests performed before and after transplantation were compared using a paired t-test. The mean difference in SDS of height, BMI, IGF-1, and IGFBP-3 of the follow-up cohort was compared to the value of the population mean using a one-sample t-test. RESULTS According to our inclusion criteria, the charts of 98 children were reviewed (Table II). At the time of the study, 44 patients (44.9%) were deceased, 8 patients were lost to follow-up (8.2%) and 46 patients were alive (46.9%). Of the patients who were alive, 39 took part in the follow-up study (84.7%) wherein 18 patients were seen during routine outpatient exams. The remaining 21 patients were seen in outpatient exams following phone intervention (Fig. S1). The mean age of this follow-up cohort was 9.1 (range ) years at HSCT and 17.4 (range ) years at time of study. The mean time between HSCT and follow-up study was 8.3 (range ) years. At time of transplantation, all 98 patients were in complete remission (CR1: 50.0%, CR2: 31.6% and CR3: 18.4%). Relapse occurred in 29 patients (29.6%) in the initial cohort, whereas no data concerning relapse status were available for 6 patients (6.1%). Initial remission status and OS were correlated (P ¼ 0.041, Fig. 1A), with relapse occurring in 11 patients with CR1, 10 patients with CR2 and 8 patients with CR3. Almost two-thirds of the patients (63.6%) who died after HSCT died within the first 12 months from relapse (46.4%), septicemia and multiple organ failure (42.8%), post-transplant lymphoproliferative disorder (3.6%), gastrointestinal bleeding (3.6%), or graft-versus-host disease (GVHD, 3.6%; Fig. 1B). The OS of the initial cohort was 53.2% at 10 years. For patients surviving 2 or more years, the OS was 88.3%. Two patients died in remission from bronchiolitis obliterans and chronic GVHD, respectively, one patient died from relapsed disease and three patients died as a result of therapy-related toxicity after relapse. Of the initial and follow-up cohorts, 44 and 12 (30.8%) patients were pretreated with irradiation as part of primary cancer treatment (Table SI). Most of the patients were pretreated within 3 weeks prior to HSCT (Table SII). Prior irradiation had no influence on OS or relapse-free survival (data not shown). TABLE II. Summary of Patient Characteristics and SCT in the Initial and Follow-Up Patient Cohorts Patient characteristic Initial cohort [n (%)] Follow-up cohort [n (%)] Total number 98 (100.0) 39 (100.0) Male 54 (55.1) 25 (64.1) Female 44 (44.9) 14 (35.9) Autologous 4 (4.1) 0 (0.0) Allogenic 94 (95.9) 39 (100.0) BM 69 (70.4) 28 (71.8) PBSC 28 (28.6) 11 (28.2) Cord blood 1 (1.0) 0 (0.0) Age at HSCT (years) 9 ( ) 9.1 ( )

3 1794 Künkele et al. Fig. 1. Initial remission status and OS were significantly correlated (P ¼ 0.041) and almost two-thirds of the patients died within the first 12 months after HSCT. A: OS grouped by remission status (CR, complete remission) for the period of complete follow-up based on Kaplan Meier analysis including 96 patients who received TBI before HSCT. B: OS for the period of complete follow-up based on a Kaplan Meier analysis of 98 patients who received TBI before HSCT. TBI had no long-term impact on pulmonary, cardiac, renal, or gastrointestinal function. To detect obstructive or restrictive pulmonary dysfunction or signs of bronchiolitis obliterans, we compared values of FVC, FEV1%, and MEF25 before transplantation and at follow-up examination. Pre- and post-transplant results were: FVC 81.1% (46 113%) and 77.7% (45 96%), FEV1/FVC 88.8% (81 95%) and 84.5% (56 101%), MEF % (23 138%) and 70.5% (7 121%), respectively, and are depicted graphically in Figure 2. The differences between pre- and post-transplant values were not significant, and the time range between transplantation and follow-up examination ranged between 2.0 and 8.5 years. According to our definitions, 12/27 patients in the follow-up cohort had a restrictive component, 2/27 an obstructive component, 1/27 bronchiolitis obliterans and none of 28 had cardiac dysfunction. We calculated the GFR of 29 patients of our followup study to evaluate renal function and 5 had chronic renal impairment. Of these five patients, serum creatinine concentrations were slightly elevated in two patients. Four patients reported gastrointestinal problems, including sensitive stomach (n ¼ 1), chronic stomach ache (n ¼ 1) or loss of appetite (n ¼ 2). No patient reported chronic diarrhea or constipation. Our follow-up did not detect significant pulmonary or cardiac changes, renal impairment or severe gastrointestinal problems after TBI. TBI influenced growth, but not BMI, thyroid function or serum adrenocorticotropic hormone or cortisol concentrations. Average height of the 39 patients in our follow-up cohort was significantly less than that of a reference population (P < 0.001, Tables III and SIII). Growth was severely impaired in 10 patients (SD scores less than 2), who had a median age of 6.5 (range ) years at HSCT. Further, 3 of these 10 patients received irradiation as part of their primary cancer treatment. Although the conditional target height was within the reference range ( ), its distribution was slightly shifted towards the lower end. The SD score for BMI was less than 2 in one patient, but the mean BMI for the follow-up cohort did not differ from that in a standard population (P ¼ 0.053), although we saw a trend towards lower values. The SD scores for IGF-I serum concentrations were significantly lower than in a reference population (P ¼ 0.01), while the SD scores for IGFBP-3 did not differ (P ¼ 0.84). TSH, ft3 and ft4 serum concentrations were normal in the majority of the follow-up cohort patients (median TSH ¼ 2.3 mu/l, range mu/l, median ft4 ¼ 13.2 pmol/l, range pmol/l), except one thyroid function test in the hypothyroid range for two patients (ft4 ¼ 8.5 and 10.0 pmol/l). Laboratory results suggested mild hyperthyroidism in five patients (Table IV). However, all patients were euthyroid at clinical examination, and none received thyroid-specific therapy. Fig. 2. Pulmonary function was not affected by TBI-containing conditioning regimens. Values for forced vital capacity (FVC) (A), 1% forced expiratory volume (FEV1%) (B), and mean expiratory flow 25 (MEF25) (C) were assessed pre- and post-transplantation, and did not vary significantly.

4 TBI in Pediatric Patients Before HSCT 1795 TABLE III. Endocrinological Analyses in Follow-Up Cohort as SD Scores Parameter Male patients Height 0.86 ( ) cth 0.33 ( ) BMI 0.14 ( ) IGF-I 0.72 ( ) IGFBP ( ) SD score Female patients 1.63 ( ) 0.23 ( ) 0.88 ( ) 0.89 ( ) 0.23 ( ) Total patients 1.13 ( ) 0.30 ( ) 0.43 ( ) 0.79 ( ) 0.05 ( ) We further analyzed the values for TSH and ft4 before HSCTwith a median for TSH of 1.3 (range ) mu/l and for ft4 of 13.9 (range ) pmol/l. All patients had normal circulating levels of adrenocorticotropic hormone, and only one patient had a serum cortisol below the reference range. We found no association between age and hormonal deficits. Taken together, we detected no significant influence of TBI on the laboratory values of the thyrotropic or corticotropic axis. However, TBI significantly affected growth and the somatotropic axis, with growth being severely impaired in 10 patients. Altogether 19 patients of our follow-up cohort were 16 years or older during the follow-up examination (female n ¼ 6, male n ¼ 13). Half of the female patients agreed to the measurement of LH, FSH and estradiol and all of them had values within the normal range (n ¼ 3, follow-up: 2.1, 4.7, and 9 years, age at followup 18.7, 23.1, and 16.2 years). We further obtained hormonal data (gonadotropins, testosterone) from 7 male patients and 42% (n ¼ 3) had values within the normal range. For the other patients we found two patients with decreased testosterone concentrations, two with elevated levels of FSH and one with a known Leydig cell insufficiency. But whereas none of the girls had received prior irradiation, three of the seven males had been pretreated with prophylactic central nervous system (CNS) and testis irradiation. In this very small cohort, we could not detect an influence of TBI on the gonadotropic axis of our female patients but we could not exclude it for our male patients. All together only one patient received a substitution therapy with sex steroids due to a known TABLE IV. Endocrinological Analyses in Follow-Up Cohort in Relation to Reference Ranges Parameter Below reference range [n (%)] Within reference range [n (%)] Above reference range [n (%)] TSH 0 (0.0) 26 (83.9) 5 (16.1) ft3 0 (0.0) 18 (81.8) 4 (18.2) ft4 2 (6.7) 27 (90.0) 1 (3.3) ACTH 0 (0.0) 22 (100.0) 0 (0.0) Cortisol 1 (3.8) 25 (96.2) 0 (0.0) GFR 5 (17.2) 24 (82.8) Leydig cell insufficiency. There were no reported pregnancies or miscarriages. None of our patients developed a cataract or secondary malignancy within this follow-up period. Further, none were on immunosuppressive treatment at the time of our follow-up study. DISCUSSION TBI is an important part of the conditioning regimen for many patients undergoing HSCT by exerting cytotoxic effects on malignant cells and potent immunosuppressive effects that aid in successful engraftment. In adults, high-dose myeloablative regimens without TBI offer no obvious advantages for reducing toxicity or improving control rates over TBI-containing high-dose regimens, and have been shown to be inferior in some studies [23 25]. Especially for ALL, the most common malignant disease in childhood, the efficacy of TBI as part of the conditioning regimen is well known, and the number of children undergoing and surviving HSCT is currently increasing. A controlled randomized comparison of conditioning regimens containing TBI or not in childhood ALL is still missing. Therefore, determining the incidence and severity of long-term sequelae caused by TBI is important. We retrospectively analyzed the outcomes and long-term complications in a cohort of children who underwent TBI as part of their conditioning regimen before HSCT. Our report comprises one of the largest groups of pediatric patients uniformly treated with TBI before HSCT. The long mean follow-up time of 8 years in our study allowed evaluation of continuing disease control and occurrence of long-term sequelae concerning cataract, secondary malignancy, organ toxicity, and quality of life issues. We could show that none of our patients developed a cataract or a secondary malignancy, admitting that the risk of second malignancy does not level off after any possible observation time. Furthermore, our TBI conditioning regimen before HSCT led to a 10-year OS of 53.3% (initial cohort) and 88.3% (survival 2 years after HSCT), depending upon the initial remission status. Many studies included only patients who had survived 2 years after HSCT, and report 10-year OS rates of 63% [26] and 69% [27]. Additionally, retrospective studies comparing the efficiency of busulfan/cyclophosphamide to TBI/cyclophosphamide in pediatric patients with ALL suggest that the TBI-based regimen had better outcomes than ones based on chemotherapy [28 30]. Comparisons between treatment regimens remain difficult due to lack of randomized studies. None of our follow-up patients experienced complications of cardiac or pulmonary toxicity but 11% of them suffered from gastrointestinal and 17% from renal toxicity. Although most cases of cardiac toxicity occurred within a few months of HSCT, it is well documented that late cardiotoxicity may occur in survivors of childhood cancers [31]. None of our patients exhibited cardiac dysfunction during follow-up. Two other studies also observed no serious or fatal acute cardiac toxicity [32,33]. In other reports, major cardiotoxicity following HSCT occurred in 6% and 9% of patients, respectively [34,35]. Differences in cardiac toxicity between studies could be due to variability in the HSCT patient age, pre-transplant screening, pre-transplant drugs used and length of follow-up. TBI did not influence any of the three parameters examined for pulmonary dysfunction before and after HSCT. The restrictive component identified in some patients of the follow-up cohort may be the result of fatigue, lack of motivation

5 1796 Künkele et al. and/or poor cooperation due to the underlying disease. Socie et al. [26] reported a 7-year cumulative incidence of late pulmonary disease of 6% in adult acute myeloid leukemia patients and 15% in adult chronic myeloid leukemia patients, but no differences between conditioning regimens with or without TBI. Only two of the patients in our study had slightly elevated serum creatinine levels, but 17.2% had chronic renal impairment. Guinan et al. [11] reported that 7 of 21 children with ALL developed renal impairment after Auto-SCT. The high incidence was attributed to the combination of intensive chemotherapy and TBI (12 14 Gy over 3 4 days) in the conditioning regimen. TBI also appeared to be an important risk factor for developing chronic renal impairment in a study by Frisk et al. [5], but these results must be taken with caution, since the groups with or without TBI also differed in other important factors that may have influenced outcome. Few reports address gastrointestinal longterm complications in pediatric HSCT patients, but problems associated with radiation, including pancreatitis, nausea, diarrhea, or abdominal pain [36,37], did not occur in our patients. Only 11% of our patients reported sensitive stomach, stomach aches, or loss of appetite, and none reported chronic diarrhea or constipation. Altogether, we could show that TBI in children did not cause pulmonary or cardiac dysfunction, but did cause gastrointestinal problems in 11% and renal impairment in less than 20% of our patients. The results of our study show that children and adolescents who underwent TBI before HSCT developed growth impairment while maintaining normal weight, with no impairment on the thyreotropic and corticotropic axis. Ten of the 39 patients developed moderate to severe short stature. Circulating levels of the growth hormone-dependent IGF-I was shifted towards the lower end of the reference range in all patients. This is even more impressive considering that the conditional target height of our patients was within the reference range. TBI can impair longitudinal growth by various mechanisms, such as growth hormone deficiency and by inducing disproportionate growth [38 40]. At the time of HSCT, 9 of the 10 patients who showed severe growth impairment had not yet entered puberty, which might have played a role in growth impairment [41,42]. Three of the nine patients received additional irradiation as part of their primary cancer treatment. It is unknown whether the additional irradiation may have contributed to growth impairment as well. Compared to childhood ALL survivors treated with conventional chemotherapy, in those treated with TBI an increased risk for metabolic problems, including central adiposity, insulin resistance and metabolic syndrome was described [43]. Additionally, hypothyroidism is a well-known complication of TBIcontaining regimens [15]. All of our patients were clinically euthyroid, with only 6.7% having one thyroid function test in the hypothyroid range. None received thyroid-specific treatment. Other studies have reported 10 28% overall incidence of primary hypothyroidism after fractionated TBI [44 46]. However, irradiation of the thyroid gland is not the only risk factor [47]. Abnormalities of thyroid function, including severe primary hypothyroidism, occurred after HSCT in 10.8% of children with immunodeficiency who received chemotherapy conditioning without TBI [48]. Five of our 27 patients had laboratory results suggestive of hyperthyroidism, which was more than expected and stands in contrast to the previous studies on hypothyroidism after TBI and HSCT. None of the patients were clinically hyperthyroid. We conclude that children and adolescents who undergo TBI and HSCT should be considered to be at minimal risk for thyroid dysfunction and at high risk for growth impairment. Because patients should have completed puberty to evaluate the effects of TBI on pubertal development properly we analyzed the data from our patients who were 16 years or older during the followup examination. This caused small patient numbers. Also, some of our patients received prophylactic irradiation of testis and CNS prior to TBI and HSCT. These facts lead to caution in interpreting our data concerning fertility after TBI. Since the prognosis for normal gonadal function in survivors of childhood leukemia treated with chemotherapy alone is good, impairment of fertility in survivors of HSCT and TBI is likely to be the result of irradiation or of the additive effect of high-dose chemotherapy used in preconditioning regimens [49]. In our study, none of the female patients had values outside the normal range but so far none of them has entered the family-planning stage. Therefore, we cannot exclude an influence of TBI on the future fertility. This is also true for the male patients. No one of them has tried to father children yet. The elevated serum FSH levels in three of them are suggesting impairment of reproductive gonadal function. One patient needs replacement therapy with sex steroids due to Leydig cell insufficiency. Sanders [50] observed in a group of 463 male TBI patients testicular recovery in 17% (normal serum levels of LH, FSH, and testosterone), and 5 of these patients had fathered one or more children. Many years of continuous follow-up are required to accurately determine the fertility outcome. Therefore programs for the long-term follow-up of gonadal function in adolescent patients after childhood TBI, and strategies to preserve fertility into adult life are needed. Our follow-up study of pediatric patients who survived 2 years or more after TBI-identified sequelae of growth impairment, thyroid and gonadal dysfunction, but no significant effects on weight, cardiac, pulmonary, or renal function. 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