Received: 15 April 2020 Accepted: 31 August 2020

DOI: 10.1002/pbc.28709 Pediatric

Blood &
Cancer The American Society of
Pediatric Hematology/Oncology
SURVIVORSHIP: RESEARCH ARTICLE

Effects of treatments on gonadal function in long-term

survivors of pediatric hematologic malignancies: A cohort study

Francesco Felicetti1 Anna Castiglione2 Eleonora Biasin3 Nicoletta Fortunati1

Margherita Dionisi-Vici1 Patrizia Matarazzo4 Giovannino Ciccone2
Franca Fagioli3,5 Enrico Brignardello1

1
Transition Unit for Childhood Cancer
Survivors, “Città della Salute e della Scienza” Abstract
Hospital, Torino, Italy
Background: Potentially gonadotoxic protocols are currently used for the treatment
2
Unit of Clinical Epidemiology, “Città della
of childhood hematologic malignancies. This study aims to evaluate the prevalence
Salute e della Scienza di Torino” Hospital and
CPO Piemonte, Torino, Italy of gonadal dysfunction and the most important associated risk factors in a cohort of
3
DivisionofPaediatric Onco-Haematology, hematologic malignancy survivors.
Stem Cell Transplantation and Cellular
Therapy, “Città della Salute e della Scienza”
Procedure: We considered all patients referred to our long-term follow-up clinic for
Hospital, Torino, Italy childhood cancer survivors, between November 2001 and December 2017. Inclusion
4
DivisionofPaediatric Endocrinology, “Città criteria were: (a) previous diagnosis of hematologic malignancy; (b) age at hematologic
della Salute e della Scienza” Hospital, Torino,
Italy malignancy diagnosis < 18 years; (c) at least five years after the end of anticancer treat-
5
Department of Public Health and Paediatric ments; (d) at least one evaluation of gonadal function after the 18th birthday. Patients
Sciences, University of Turin, Torino, Italy diagnosed before January 1, 1990, were excluded.

Correspondence
Enrico Brignardello, Transition Unit for Child-
hood Cancer Survivors, A.O.U. Città della
Salute e della Scienza di Torino, Corso Bra-
mante 88-10126 Torino, Italy.
Email: ebrignardello@cittadellasalute.to.it
Results: Three hundred twenty-seven survivors (males = 196) were included. Iso-
lated spermatogenesis damage was found in 58/196 (29.6%) of males, whereas 18/196
(9.2%) had Leydig cell failure. In females, 35/131 (26.7%) experienced premature ovar-
ian insufficiency. In both sexes, abdominopelvic irradiation and hematopoietic stem
cell transplantation were strongly associated with the risk of gonadal dysfunction. For
every 1000 mg/m2 increase in cyclophosphamide-equivalent dose exposure, the risk of
spermatogenesis damage increased 1.52-fold and that of Leydig cell failure increased
1.34-fold, whereas the risk of premature ovarian insufficiency increased 1.80-fold.
About 30% of those males who developed Leydig cell failure did so more than five years
after the end of treatments.
Conclusions: Gonadal dysfunction is still a significant late effect of therapies for pedi-
atric hematologic malignancies. In males, the reevaluation of Leydig cell function may
be useful even several years after the exposure to gonadotoxic treatments.

KEYWORDS
cancer treatments, childhood cancer survivors, gonadal function, late effects

Abbreviations: ALL, acute lymphoblastic leukemia; AMH, anti-Müllerian hormone; AML, stimulating hormone; HMs, hematologic malignancies; HSCT, hematopoietic stem cell
acute myeloblastic leukemia; CCS, childhood cancer survivors; CED, transplantation; LCF, Leydig cell failure; LH, Luteinizing hormone; POI, premature ovarian
cyclophosphamide-equivalent dose; CT, chemotherapy; E2, 17beta-estradiol; FSH, follicular insufficiency; RT, radiotherapy; TBI, total body irradiation

Pediatr Blood Cancer. 2020;e28709. wileyonlinelibrary.com/journal/pbc © 2020 Wiley Periodicals LLC 1 of 10

https://doi.org/10.1002/pbc.28709
2 of 10
1 INTRODUCTION
Hematologic malignancies (HMs) account for about one half of pedi-
atric cancers,1 which are the second leading cause of mortality in chil-
dren in high-income countries. As for most other pediatric cancers,
the treatment of childhood HMs has dramatically improved in the past
few decades, largely as a result of improvements in risk stratification,
protocol design, and supportive care. The five-year survival rate is
currently approximately 60% for acute myeloblastic leukemia (AML)
and more than 90% for acute lymphoblastic leukemia (ALL),2 which
is the most common HM in children. Current treatment protocols are
intensive, typically involving multiple chemotherapeutic drugs and pos-
sibly including hematopoietic stem cell transplantation for high-risk
patients. Therefore, even if many pediatric HM patients can be cured,
treatments may cause substantial long-term morbidity. For this reason,
treatment-related complications and aftercare need to become a major
concern in this clinical context.3,4
Gonadal dysfunction is one of the most frequently observed late
effects of cancer therapies in childhood cancer survivors (CCS).5,6 In
both sexes, gonads serve two functions: secretion of sex hormones
and production of germ cells. Endocrine effects of gonadal damage
are more relevant in clinical terms, but fertility loss is a major psy-
chological concern for both male and female CCS. Thus, the concern
about gonadal dysfunction in CCS is justified by its effects on both the
patients’ physical and mental health.7,8
Gonadal function can be impaired by anticancer treatments, which
damage the hypothalamic-pituitary-gonadal axis.
Central hypogonadism is mainly due to ionizing radiation involv-
ing the hypothalamic-pituitary region. However, this condition rarely
occurs at lower doses of radiation because gonadotropic cells are quite
resistant to the radiation-induced damage.9
By contrast, both the testis10 and the ovary11 are highly sensitive to
toxic effects of radiotherapy (RT) and some chemotherapy (CT) agents
(mainly alkylating agents) currently employed to treat HMs.12–17
The gonadal toxicity of anticancer treatments is supported by clear
evidence, but we still have some gaps of knowledge in this field (e.g.,
very long-term deterioration of Leydig cell function). This study aims
to evaluate the prevalence of gonadal dysfunction and the most impor-
tant associated risk factors in a cohort of HMs enrolled in a surveillance
program at a specialized adult-focused long-term follow-up clinic.
2 MATERIALS AND METHODS
2.1 Patients
All patients referred to the Transition Unit for Childhood Cancer Sur-
vivors at the “Città della Salute e della Scienza” Hospital in Turin, Italy,
between November 2001 and December 2017, were considered for
the purpose of the study. This unit is a specialized follow-up clinic,
located in a tertiary cancer center, to which all CCS cured at the Pedi-
atric Oncology Department of the “Regina Margherita” Children’s Hos-
pital are transitioned when they become adults (5). During periodic
FELICETTI ET AL .
follow-up visits, all clinical information about cancer diagnosis, treat-
ments, relapses, late toxicities, etc., is recorded and updated.
Inclusion criteria were (a) previous diagnosis of HM (Tables 1 and 2
detailed the considered malignancies); (b) age at HM diagnosis < 18
years; (c) at least five years after the end of anticancer treatments;(d)
at least one evaluation of gonadal function after the 18th birthday. To
reduce possible selection bias of the cohort, patients whose HM was
diagnosed before January 1, 1990, were excluded from the study.
At every follow-up visit, patients were evaluated for signs and symp-
toms of gonadal dysfunction (i.e., secondary sexual characteristics, sex-
ual function as well as menstrual cycles in females).
The exposure to alkylating agents was expressed as
cyclophosphamide-equivalent dose (CED), calculated by the for-
mula proposed by Green et al.18
In males, follicle stimulating hormone (FSH), Luteinizing hormone
(LH), inhibin B, and total testosterone levels were evaluated at the time
of transition to our unit, and, if normal, subsequently reassessed every
three years. Male survivors at risk for infertility were also asked to pro-
vide a specimen for semen analysis. Due to the goal of our data collec-
tion and the reluctance of survivors to provide a semen specimen, in the
presence of FSH levels > 10 IU/L and inhibin B < 100 pg/mL, patients
were considered to have spermatogenesis damage.10
In the presence of symptoms and signs of testosterone deficiency,
consistently low serum total testosterone levels (< 300 ng/dL), and ele-
vated gonadotropin levels, male HMs were diagnosed to have Leydig
cell failure (LCF).19
In females, gonadal function was assessed measuring FSH, LH, and
17beta-estradiol (E2) levels, evaluated in early follicular phase (days 2
to 5) for women having menstrual cycles.20 In survivors having men-
strual cycle alterations or wishing to assess their potential for future
fertility, anti-Müllerian hormone (AMH) was also evaluated.
In females younger than 40 years, premature ovarian insufficiency
(POI) was defined as amenorrhea plus consistently low E2 levels and
elevated gonadotropin levels.20
Central hypogonadism was defined as low testosterone/E2 levels
with low or inappropriately normal levels of gonadotropins.21
2.2 Statistical analysis
Males and females were separately analyzed as two subcohorts. Demo-
graphic and clinical characteristics were summarized by absolute and
percent frequency, or median and percentiles, according to the pres-
ence of normal or impaired gonadal function (males with normal
gonadal function, males with spermatogenesis damage, and males with
LCF; females with normal gonadal function and females with POI).
In order to explore the effect of alkylating agents on gonadal dys-
function, in the male subcohort we performed a multinomial logistic
model and in the female subcohort a logistic model. In addition to
CED, we included age at diagnosis, era of treatment, and RT (none,
any RT except abdominopelvic, abdominopelvic RT) in both models. To
describe the onset of gonadal dysfunction during the long-term follow-
up, the cumulative incidence23 of LCF in males and POI in females was
TA B L E 1 Demographic and clinical characteristics of male HM survivors

Normal gonadal function (N = 120) Spermatogenesis damage (N = 58) Leydig cell failure (N = 18) Total (N = 196)
No. % No. % No. % No. %
FELICETTI ET AL .

Age at the first cancer diagnosis (years)

0-4 21 17.50 8 13.79 8 44.44 37 18.88
5-9 35 29.17 15 25.86 5 27.78 55 28.06
≥ 10 64 53.33 35 60.34 5 27.78 104 53.06
Median age at last follow-up 24.27 [21.47-29.12] 26.35 [22.44-30.20] 26.99 [23.75-31.17] 24.57 [21.84-29.39]
[25th percentile-75th
percentile]
Median age at gonadal 19.9 [18.34-22.83] 20.86 [17.47-24.60] 24.35 [21.31-29.02]
dysfunction [25th
percentile-75th percentile]
Era of the first cancer diagnosis (years)
1990-1999 53 44.17 30 51.72 11 61.11 94 47.96
2000-2012 67 55.83 28 48.28 7 38.89 102 52.04
Cancer type
ALL 56 46.67 23 39.66 10 55.56 89 45.41
Hodgkin lymphoma 29 24.17 25 43.10 1 5.56 55 28.06
Non-Hodgkin lymphoma 29 24.17 3 5.17 0 0.00 32 16.33
AML and myelodysplastic 6 5.00 7 12.07 7 38.89 20 10.20
syndrome
Radiotherapy
Any RT 36 30.00 49 84.48 18 100.00 103 52.55
Abdominopelvic RT 6 5.00 15 25.86 11 61.11 32 16.33
TBI 0 0.00 11 18.97 10 55.56 21 10.71
Cranial RT 11 9.17 1 1.72 1 5.56 13 6.63
Chemotherapy
Any chemotherapy 120 100.00 58 100.00 18 100.00 196 100.00
Alkylating agents 110 91.67 57 98.28 18 100.00 185 94.39
2
Cyclophosphamide-equivalent dose (mg/m )
0-4000 88 73.33 13 22.41 3 16.67 104 53.06
4000-8000 30 25.00 29 50.00 12 66.67 71 36.22
> 8000 2 1.67 16 27.59 3 16.67 21 10.71
HSCT 2 1.67 31 53.45 17 94.44 50 25.51

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloblastic leukemia; HSCT, hematopoietic stem cell transplantation; RT, radiotherapy; TBI, total body irradiation.
3 of 10
 4 of 10

TA B L E 2 Demographic and clinical characteristics of female HM survivors

Females with normal ovarian function Females with premature ovarian

(N = 96) insufficiency (N = 35) Total (N = 131)
No. % No. % No. %
Age at the first cancer diagnosis (years)
0-4 23 23.96 7 20.00 30 22.90
5-9 17 17.71 8 22.86 25 19.08
≥10 56 58.33 20 57.14 76 58.02
Median age at last follow-up [25th percentile-75th percentile] 25.11 [21.46-28.44] 23.70 [21.54-27.87] 24.68 [21.47-28.27]
Median age at gonadal dysfunction [25th percentile-75th 15.19 [14.39-15.19]
percentile]
Era of the first cancer diagnosis (years)
1990-1999 38 39.58 11 31.43 49 37.40
2000-2012 58 60.42 24 68.57 82 62.60
Cancer type
ALL 48 50.00 17 48.57 65 49.62
Hodgkin lymphoma 31 32.29 2 5.71 33 25.19
Non-Hodgkin lymphoma 7 7.29 1 2.86 8 6.11
AML and myelodysplastic syndrome 10 10.42 15 42.86 25 19.08
Radiotherapy
Any RT 38 39.58 28 80.00 66 50.38
Abdominopelvic RT 7 7.29 14 40.00 21 16.03
TBI 1 1.04 14 40.00 15 11.45
Cranial RT 5 5.21 0 0.00 5 3.82
Chemotherapy
Any chemotherapy 96 100.00 35 100.00 131 100.00
Alkylating agents 88 91.67 35 100.00 123 93.89
2
Cyclophosphamide-equivalent dose (mg/m )
0-4000 59 61.46 0 0.00 59 45.04
4000-8000 36 37.50 22 62.86 58 44.27
> 8000 1 1.04 13 37.14 14 10.69
HSCT 6 6.25 34 97.14 40 30.53

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloblastic leukemia; HSCT, hematopoietic stem cell transplantation; RT, radiotherapy; TBI, total body irradiation.
FELICETTI ET AL .
FELICETTI ET AL .
FIGURE 1 Selection process of the cohort
calculated using as time the age at which gonadal dysfunction was diag-
nosed or, in the absence of alterations, the age at the last evaluation of
the gonadal function. In Figure 2, we reported the cumulative incidence
from the age of 18 years (age at which usually the transition more often
occurs).
3 RESULTS
Figure 1 describes the selection process of our cohort. A total of 327
CCS (M:F = 196:131) were included in the study (54.5% of the original
population). The difference in the distribution of age, cancer diagnosis,
F I G U R E 2 Incidence of primary hypogonadism
during long-term follow-up
5 of 10
and residence place between the original population and our cohort are
reported in Supporting Information Tables S1 and S2.
Demographic and clinical characteristics, according to the gonadal
function, are detailed for males in Table 1 and for females in
Table 2.
At the latest available follow-up visit, 38.8% of male (76/196) and
26.7% of female (35/131) HM survivors demonstrated gonadal dys-
function. In males, spermatogenesis damage with normal testosterone
production was found in 58 out of 196 patients (29.6%), whereas 18
(9.2%) were diagnosed with LCF.
Twenty-six of 35 females experienced POI early, such as during, or
immediately following the completion of cancer treatments, whereas
6 of 10
nine developed POI in the years that followed the completion of cancer
treatments but prior to age 40.
No HM survivor had central hypogonadism.
All male HM survivors affected by LCF had received RT, mostly
focused on abdominopelvic fields (Table 1).The majority of HM sur-
vivors treated with hematopoietic stem cell transplantation (males—
96.0%, 48/50; females—85.0%, 34/40) had gonadal dysfunction
(Tables 1 and 2). All but one of the 36 transplanted survivors who
received total body irradiation (TBI) as part of the conditioning regimen
showed gonadal dysfunction.
Gonadal dysfunction was most common after AML (both in males
and in females), whereas survivors of lymphomas (Hodgkin as well as
non-Hodgkin lymphomas) showed a lower prevalence of POI or LCF.
In the male subcohort, the risk of gonadal dysfunction was strongly
associated with RT. The risk of spermatogenesis damage was increased
among all HM survivors exposed to RT, especially those who received
treatment to abdominopelvic fields (ORany RT = 5.98, 95% CI, 2.31-
15.45 and ORabdominopelvic RT = 13.30, 95% CI 3.73-47.41; Table 3). We
could not estimate the RT effect on the risk of LCF because all patients
with LCF had been exposed to RT.
Similarly, the exposure to abdominopelvic RT increased the risk of
POI (OR = 7.85, 95% CI 2.02-30.47; Table 4).
We observed a significant effect of CED in both males and females:
a greater exposure to alkylating agents was associated with a higher
risk of spermatogenesis damage (ORCED (per 1000 mg/mg2) = 1.52, 95% CI,
1.28-1.81; Table 3), LCF (ORCED(per 1000 mg/mg2) = 1.34, 95% CI, 1.03-
174; Table 3) or POI (ORCED(per 1000 mg/mg2) = 1.80,95% CI, 1.34-2.41;
Table 4).
Era of cancer diagnosis had no influence on the risk of spermatoge-
nesis damage, LCF, or POI (Tables 3 and 4).
Figure 2 describes the incidence of LCF and POI during long-term
follow-up. At the age of 24 years, the cumulative incidence of LCF was
6.9% (95% CI, 3.9-11.9) while that of POI was 26.2% (95% CI, 19.3-
35.0). Among males, nine had LCF after the age of 18 years, and five
of them developed this condition more than five years after the end of
anticancer treatment. At the most recent evaluation of gonadal func-
tion before the onset of LCF, all nine of these HM survivors showed
increased levels of LH (> 10 UI/L), normal testosterone production, and
no clinical symptoms. At the latest available evaluation, an additional
13 male HM survivors showed this gonadal hormone condition of com-
pensated LCF (i.e., elevated LH with normal testosterone levels).
AMH levels were evaluated in about one half (n = 58) of the
female HM survivors included in this study. In 26 of them, AMH levels
were < 1 ng/mL; 13 of them had POI, whereas the other 13 had nor-
mal menstrual cycles and E2 levels. All female HM survivors with AMH
levels > 1 ng/mL also had a normal gonadal function.
4 DISCUSSION
Our data, based on a single-center cohort, confirm that impairment of
gonadal function still represents a relevant complication after treat-
ments for pediatric HMs.
FELICETTI ET AL .
We did not observe any case of central hypogonadism. This result
is not surprising as the radiation dose given to the brain when treating
HMs is usually lower than 18 Gy, and the gonadotropin-secreting pitu-
itary cells are quite resistant to the damaging effects of RT.6 Moreover,
we excluded from the study all patients treated before 1990, when pro-
phylactic cranial RT was routinely performed.
Impairment in sex hormone production was much more common in
female than in male HM survivors, but about 30% of males had sper-
matogenesis damage. This reflects anatomical and physiological differ-
ences between testis and ovary.
In females, the loss of fertility is always associated with the loss of
sex hormone production, due to the close association between germ
cells and endocrine cells in the ovary. RT and CT decrease the ovarian
reserve, thus predisposing female CCS to POI. The extent of ovarian
damage is dependent on the radiation dose received by the ovaries12
and on the cumulative dose of alkylating agents.13 Female CCS may
exhibit normal ovarian function (i.e., they are fertile and show normal
hormone levels) until the onset of hypogonadism. The patient’s age at
the time of treatment influences the risk of hypogonadism, because the
number of primordial follicles at the time of treatment defines the “fer-
tility window,” progressively smaller doses of CT and RT being required
to produce ovarian failure with increasing age.14 For this reason, about
one quarter of our female HM survivors did not have acute ovarian fail-
ure, but experienced POI during the subsequent follow-up.
In the testis, endocrine and reproductive functions are anatomi-
cally and functionally more distinct than in the ovary. The intersti-
tial Leydig cell–containing compartment of the testis, with its produc-
tion of testosterone, is much more resistant to the damage induced
by RT15 and CT16 than the seminiferous tubules. Hence, after gonado-
toxic treatments, male CCS may become oligospermic or azoospermic,
but testosterone production is usually unaffected.16 Among anticancer
agents, RT and alkylating drugs are the most potent azoospermia-
inducing therapies. Azoospermia may be transient or permanent,
depending on whether or not anticancer therapies damage spermato-
gonial stem cells.17 Higher doses of CT and RT can damage Leydig cells,
thereby causing testosterone secretion deficiency.15,16
Despite the heterogeneity of the cohorts evaluated in different
studies, the prevalence of spermatogenesis damage and LCF observed
in our cohort was similar to those reported in literature data.24–26
In females, we found a 26.2% cumulative incidence of POI, which
is higher than that recently observed in a wide cohort of CCS.27 This
discrepancy is probably due to the high exposure to alkylating agents
and gonadal RT that characterized HM survivors, consistent with the
results reported by Overbeek et al. in their systematic review.28
Allogeneic hematopoietic stem cell transplantation (HSCT) was
almost always associated with gonadal dysfunction, in males as well as
in females. This is due to the conditioning regimens for HSCT, which
are based on highly gonadotoxic treatments (i.e., high dose alkylat-
ing agents and/or TBI). For this reason, AML (which required HSCT in
about 80% of affected patients) is the HM most commonly associated
with LCF or POI.
TBI was found to be particularly harmful to the gonads. This
result agrees with previous reports showing a very high prevalence of
 FELICETTI ET AL .

TA B L E 3 Crude and adjusted effects on gonadal dysfunction in male HM survivors

Crude effects Adjusted effects

Spermatogenesis damage Leydig cell failure Spermatogenesis damage Leydig cell failure
Age at the first cancer
diagnosis (years) OR 95% CI P value OR 95% CI P value OR 95% CI P value OR 95% CI P value
0-4 1.00 . . 1.00 . . 1.00 . . 1.00 . .
5-9 1.12 [0.41-3.10] 0.820 0.38 [0.11-1.30] 0.121 1.09 [0.29-4.18] 0.896 0.24 [0.04-1.41] 0.114
≥10 1.44 [0.58-3.58] 0.437 0.21 [0.06-0.70] 0.011 1.11 [0.32-3.84] 0.865 0.13 [0.02-0.70] 0.018
Radiotherapy
None 1.00 . 1.00 .
a a
Any RT (except 10.58 [4.55-24.62] <0.001 NE 5.98 [2.31-15.45] <0.001 NE
abdominopelvic)
a a
Abdominopelvic RT 23.32 [7.24-75.14] <0.001 NE 13.30 [3.73-47.41] <0.001 NE
Era of the first cancer diagnosis (years)
1990-1999 1.00 . . 1.00 . . 1.00 . . 1.00 . .
2000-2012 0.74 [0.39-1.38] 0.344 0.50 [0.18-1.39] 0.185 0.48 [0.20-1.17] 0.109 0.43 [0.11-1.69] 0.226
Cyclophosphamide- 1.73 [1.46-2.05] <0.001 1.62 [1.32-1.99] <0.001 1.52 [1.28-1.81] <0.001 1.34 [1.03-1.74] 0.032
equivalent
b
dose

Abbreviation: RT, radiotherapy.

a
NE, not estimable (all patients exposed to RT).
b
For each 1000 mg/m2 increase.
7 of 10
 8 of 10 FELICETTI ET AL .

gonadal failure after exposure to TBI, in both males and females.29–33

The gonadal toxicity of ionizing radiation is confirmed by the effects of
abdominopelvic RT, that caused gonadal dysfunction in two thirds of
females and in over 80% of male survivors, about one half of the latter
showing both spermatogenesis damage and LCF.

<0.001
P value

0.698

0.950
0.054

0.799
0.003
We observed a significant association between CED and the risk of
spermatogenesis damage, LCF, and POI. However, consistent with prior
reports,18 our data did not demonstrate a CED that was associated
with no risk of gonadal dysfunction. Indeed, we observed gonadal dys-
function after exposure to less than 4000 mg/m2 CED as well as normal

[2.02-30.47]
gonadal function in patients who received more than 8000 mg/m2 CED,
[0.15-3.64]
[0.06-1.02]

[0.35-3.08]

[0.22-3.19]

[1.34-2.41]
in both males and females.
95% CI

The risk to develop gonadal dysfunction was similar in recently

treated patients and in those who were treated earlier.
The age at cancer diagnosis was not a risk factor for POI or sper-
matogenesis damage. With the limitation of the small number of obser-
Adjusted effect

vations, sex hormone production seems to be more preserved when

anticancer treatments have been performed at an older age (> 10
years). Some studies reported an increased risk of POI in females
0.73
1.00

0.25

1.04

1.00
0.84
7.85
1.80
OR

treated at an older age, probably due to the physiological decline in fol-

licle pool.25 Conversely, in male patients the currently available liter-
ature seems to exclude a role of age at treatments in predicting sper-
matogenesis damage or LCF.34
In male HM survivors, the prevalence of testosterone deficiency
increased over time and was preceded by increased LH plasma levels.
<0.001
<0.001
P value

Although the occurrence of new events over time is not surprising for
0.474
0.724

0.395

0.010
Crude and adjusted effects on premature ovarian insufficiency in female HM survivors

female patients, because ovarian failure typically occurs years after the
end of anticancer treatments, the finding that LCF occurred after the
age of 25 years and more than five years after the end of anticancer
treatment in about 25% of affected males is intriguing and suggests a
late deterioration of Leydig cell activity.
[5.00-54.98]
[1.37-10.24]
[0.47-5.10]
[0.44-3.15]

[0.63-3.25]

[1.31-1.98]

Our study has some limitations. First, some eligible patients were
95% CI

lost before or at the time of the transition from pediatric oncology to

our unit, and others refused to be followed for a long time after child-
hood cancer. This selection could affect the prevalence of gonadal dys-
Crude effect

function; however, it is hard to hypothesize the direction of bias. On

the other hand, the selection process should not influence the inter-
16.57
1.00
1.55
1.17

1.00
1.43

1.00
3.74

1.61
OR

nal comparisons and then the estimated effect of the risk factors. The
significant difference in residence distribution between HM survivors
included in the study and those lost to follow-up was expected and
likely due to costs and difficulties in transportation for patients living
abroad or in an Italian region other than Piedmont. The differences
in distribution of age and cancer diagnosis could also cause some bias
Age at the first cancer diagnosis (years)

Era of the first cancer diagnosis (years)

when estimating the prevalence of gonadal dysfunctions.

Cyclophosphamide-equivalent dose
Any RT (except abdominopelvic)

Secondly, it was impossible to categorize patients on the basis

For each 1000 mg/m2 increase.
Abbreviation: RT, radiotherapy.

of pubertal status at the time of anticancer treatments, preventing

potentially interesting pathophysiological interpretation of our results.
Abdominopelvic RT

Moreover, in male HM survivors, the evaluation of spermatogenesis

on the basis of FSH and inhibin B levels provides only indirect infor-
1990-1999
2000-2012
Radiotherapy

mation about the fertility potential. Indeed, these parameters certainly

TA B L E 4

have a correlation with semen quality, but they demonstrated a subop-

None
≥10
0-4
5-9

timal ability to predict fertility (in particular, low specificity and positive
predictive value).35,36 Finally, semen analysis was performed only on a
a
FELICETTI ET AL .
small percentage of male patients, hampering highly specific diagnosis
of the spermatogenesis damage and definition of the severity of sperm
alterations.
Our results show nevertheless that POI, LCF, and spermatogenesis
damage are significant late effects of therapies currently used to treat
HMs. As a consequence, prior to initiation of treatment, information
about the risk of gonadal damage and the offer of options for fertil-
ity preservation are still mandatory in HM patients. Moreover, these
results indicate the usefulness of reassessing Leydig cell function even
several years after the exposure to gonadotoxic treatments, and also
show the value of LH to predict subsequent LCF.
ACKNOWLEDGMENTS
The authors would like to acknowledge the U.G.I. Onlus for the ongoing
support to their clinical and research activities.
CONFLICTS OF INTEREST
The authors declare that they do not have any competing interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Enrico Brignardello https://orcid.org/0000-0003-4734-8429
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SUPPORTING INFORMATION
Additional supporting information may be found online in the Support-
ing Information section at the end of the article.
How to cite this article: Felicetti F, Castiglione A ,Biasin E,
et al. Effects of treatments on gonadal function in long-term
survivors of pediatric hematologic malignancies: A cohort
study. Pediatr Blood Cancer. 2020;e28709.
https://doi.org/10.1002/pbc.28709