Oncofertility: State of the art for young people with cancer

Professor W Hamish Wallace

Consultant Paediatric Oncologist,

Edinburgh

Scotland, UK

hamish.wallace@nhs.net

Swedish Society for Paediatric Oncologists, Stockholm 28 January 2015

Improved Five Year Survival (1966-2000)

Increasing numbers of five year UK survivors by current age

Skinner,  Wallace  &  Levitt  ,  Lancet  Oncology,  2006    

Risk assessment for Fertility preservation

•  Intrinsic factors –  Heath status of patient –  Consent (Patient/Parent) –  Assessment of ovarian reserve

•  Extrinsic factors –  Nature of predicted treatment

•  High/Medium/Low/Uncertain Risk

–  Time available –  Expertise available

Wallace WH, Critchley HOD & Anderson RA. JCO, 2012

Risk assessment for Fertility preservation

•  Intrinsic factors –  Heath status of patient –  Consent (Patient/Parent) –  Assessment of ovarian reserve

•  Extrinsic factors –  Nature of predicted treatment

•  High/Medium/Low/Uncertain Risk

–  Time available –  Expertise available

Wallace WH, Critchley HOD & Anderson RA. JCO, 2012

Infertility - Risk Factors

Ü  RT to HPA or a field that includes testes/ovaries

Ü  Busulphan

Ü  BCNU

Ü  CCNU

Ü  Cyclophosphamide

Ü  Ifosfamide

Ü  Melphalan

Ü  Mustine

Ü  Nitrogen mustard

Ü  Procarbazine

Ü  Thiotepa

Ü  Chlorambucil

Ü  Cytarabine

The pre-pubertal gonad is not protected

Radiation-induced ovarian damage

Human oocyte (Primordial follicle)

Ü LD50 < 2 Gy

Wallace, Thomson, Kelsey. (2003)

Hum Reprod.

Risk of infertility Low risk (<20%) Medium risk High risk (>80%)

ALL Wilms’ tumour Brain tumour Sx, RT < 24Gy Soft tissue sarcoma (stage1) Hodgkin’s Lymphoma HL(Low stage)

AML Osteosarcoma Ewing’s sarcoma STS: stage II/III Neuroblastoma NHL Brain tumour RT>24Gy HL (High Stage)

Total Body Irradiation Pelvic/testes RT Chemo pre BMT Metastatic Ewing's HL (Pelvic RT)

Wallace, Anderson, Irvine. Lancet Oncology 2005

Risk assessment for Fertility preservation

•  Intrinsic factors –  Heath status of patient –  Consent (Patient/Parent) –  Assessment of ovarian reserve

•  Extrinsic factors –  Nature of predicted treatment

•  High/Medium/Low/Uncertain Risk

–  Time available –  Expertise available

Wallace WH, Critchley HOD & Anderson RA. JCO, 2012

The Wallace-Kelsey Model (Five parameter asymmetric double-Gaussian cumulative curve)

Wallace &Kelsey (2010) PloS ONE ESHRE, Lille, 2012

Ovarian reserve: Conception to Menopause

Wallace &Kelsey (2010) PloS ONE

Ovarian reserve: Conception to Menopause

Anna

Bella

Wallace &Kelsey (2010) PloS ONE

Effective ovarian sterilizing doses of radiotherapy with increasing age

Prediction of Ovarian Reserve (AMH)

Ü  Anti Mullerian Hormone (AMH) is an important product of the adult ovary, produced by the granulosa cells of small growing follicles

Ü  AMH has little variation across and between menstrual cycles

Ü  AMH is the best currently available marker of the number of small-growing follicles in the ovary

Ü  But there was no validated reference model for AMH available

Anderson, Nelson, Wallace (2011) Maturitas

A validated model of serum anti-Mullerian hormone (AMH) from conception to

menopause

Kelsey et al. PLoS ONE 2011

Pre

Cycle

1

Cycle

2

Cycle

3

Cycle

4

Cycle

5

Cycle

60.0

0.5

1.0

1.5

2.0

2.5

**** *** ***

AMH

(ng/

ml)

AMH in childhood cancer

Pre End Recovery0

1

2

3

* **

AMH

(ng/

ml)

High risk

Pre End Recovery0

1

2

3 **

AMH

(ng/

ml)

Medium/low risk

22 girls age 0.3-15yr 17 prepubertal

Brougham et al 2012 JCE&M

AMH in 3 girls with cancer

0 50 100 150 2000.0

1.0

2.0

3.0

Age 2.4; rhabdomyosarcoma 0 25 50 75

0.0

0.2

0.4

0.6

0.8

1.0

Weeks

AMH

(ng/

ml) Age 1.2; neuroblastoma

0 50 100 1500.0

0.5

1.0

1.5

2.0

Weeks

Age 14.6: Hodgkin’s lymphoma

Brougham et al 2012 JCE&M

Summary

Ü  AMH is detectable before puberty

Ü  AMH falls rapidly during cancer treatment in both pre-pubertal and pubertal girls

Ü  AMH levels recover in those patients at low/medium risk of gonadotoxicity

Ü  AMH fails to recover in those at high risk. This could be indicative of future reproductive impairment

Brougham et al 2012 JCE&M

Pretreatment anti-Müllerian hormone predicts for loss of ovarian function after chemotherapy for early breast cancer.

Anderson and Cameron 2011 JCE&M Anderson et al 2013 Eur J Cancer

sensitivity 98.2% specificity 80.0% for correct classification of amenorrhoea n=75

Fertility preservation options: established and experimental

FERTILITY RISK ASSESSMENT(Includes Intrinsic and Extrinsic factors)

Pre-pubertal

Testis

biopsy

Pubertal

Able to produce a suitable

semen sample

Post-pubertal

Testis Tissue

Cryopreservation

Experimental Established

Sperm

Cryopreservation

Ovarian Tissue

Cryopreservation

Embryo

Cryo

Pre-pubertal

FEMALEMALE

PatientAssessment

Intervention

Storage

NO

Testis biopsy/

Gamete extraction

YES

Post-pubertal

Ovarian

stimulation

Partner/

Donor

sperm

Oocyte

Cryo

Ovarian biopsy

Key features of the 3 options for fertility preservation for women

Ü  Embryo cryopreservation Ü  Established but require time and a partner

Ü  Oocyte cryopreservation Ü  Established but require time and hormone

stimulation (success rate per oocyte low)

Ü  Ovarian tissue cryopreservation Ü  Minimal delay Ü  No lower age limit Ü  Surgical procedure Ü  Allows for future developments

Ovarian  tissue  cryopreservation:  World-­‐wide  experience  

*  At  least  39  pregnancies  worldwide  after  othotopic  reimplantation  of  frozen–thawed    ovarian  cortex  *  Success  rate  is  unclear  as  the  denominator  is  unknown  *  No  pregnancies  reported  following  the  reimplantation  of  ovarian  tissue  harvested  pre-­‐pubertally    *  Young  children  are  potentially  ideal  candidates  

Donnez, J. & Dolmans, M.‐M. Nat. Rev. Endocrinol. 9, 735–749 (2013)

8  

5   3  

3   3  

8   2  1  

Children  born  from  transplanta7on  of  frozen/thawed  ovarian  7ssue  

All  Normal  Babies  weight  and  dura7on    

   Orthotopic  >>  heterotopic    

All  except  for  one  is  a  result  of  a  slow-­‐freezing  protocol  

 

An  es7mated    excess  of  150    transplanta7ons  have  been  performed    

   

1   3   1  1  

Cryopreservation: European experience

Ü  Three centres ( Denmark, Spain and Belgium)

Ü  60 cases of orthotopic reimplantation.

Ü  Of these women, 11 (21%) became pregnant

Ü  Six have delivered 12 healthy babies.

Ü  Restoration of ovarian activity was observed in 93% of the patients between 3.5 months and 6.5 months after grafting

Ü  The mean duration of ovarian function after trans- plantation is ~4–5 years but can persist for up to 7 years.

Donnez, J. et al. Fertil. Steril. 99, 1503–1513 (2013).

Reduc7on  in  FSH  and  LH  following  transplanta7on  of    frozen/thawed  ovarian  7ssue  in  Danish  pa7ents  

       

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

100  

0   4   8   12   16   20   24   28   32  

IU/L  

Weeks  a5er  transplanta;on  

FSH   LH  

Edinburgh  experience    in  children  (<  18  yrs)  

1996-­‐2012    

Ovarian  Cryopreservation  &  Ovarian  Function  

Cryopreservation  of  ovarian  cortical  tissue  –  Edinburgh  criteria  

Selection  criteria  (1995,  modified  2000)  Ü Age  <  35  years  Ü No  previous  chemotherapy/radiotherapy  if  age  >15  years  

Ü Mild,  non  gonadotoxic  chemotherapy  if  <  15  years  Ü A  realistic  chance  of  surviving  five  years  Ü A  high  risk  of  ovarian  failure  Ü Informed  consent  (parent  and  where  possible  patient)  

Ü Negative  HIV  and  Hepatitis  serology  Ü No  existing  children  

The normative validated model of ovarian volume throughout life

Kelsey TW, Dodwell SK, Wilkinson AG, Greve T, Andersen CY, et al. (2013) Ovarian Volume throughout Life: A Validated Normative Model. PLoS ONE 8(9): e71465. doi:10.1371/journal.pone.0071465

15 year, population-based analysis of criteria for ovarian cryopreservation

Female cancer patientsage <18 at diagnosis

01/01/1996 - 30/6/2012n = 410

Offered cryopreservationn = 34

Tissue cryopreservedn = 20

Proceduredeclinedn = 13

Procedureunsuccessful

n = 1

Deceased

n = 1

Not offered cryopreservationn = 376

Deceasedn = 81

Deceased

= cryopreservation offered.= reasons for not having tissue cryopreserved.= patients in study eligible for ovarian function evaluation.

n = 1

n = 4

Poorcommunication

n = 1

Uterinefactorn = 1

Parentalchoicen = 2

Too unwell

n = 9

<12 years oldn = 91

<12 years oldn = 1

Deceasedn = 3

<12 years oldn = 2

Lost to follow-upn = 1

<12 years old

n = 14 n = 6 n = 141

On COCP

n = 1

Still ontreatment

n = 4

On COCP

n = 17

Insufficientinformation on

follow-upn = 42

Walllace WH et al. 2014 Lancet Oncology

Do the ‘Offered’ group have a higher prevalence of POI?

Not offered

Offered

Cumulative  incidence  of  POI  

Walllace…..and Anderson 2014 Lancet Oncology

15-year probability 35% [95% CI 10–53] vs 1% [0–2] p<0.0001 Hazard ratio 56.8 [95% CI 6.2–521.6] at 10 years

Conclusion  

• Ovarian  cryopreservation  was  offered  to  9%  of  our  patients,  and  performed  in  5%  

• The  procedure  was  safe  and  without  complications  • No  patients  have  asked  for  re-­‐implantation  of  their  tissue  –  to  date    

• All  patients  who  have  thus  far  developed  premature  ovarian  insufficiency  were  identified  except  one  patient  

• The  Edinburgh  Selection  Criteria  have  proved  to  be  helpful  in  selecting  those  patients  at  highest  risk  of  POI  

Wallace WH…..and Anderson 2014 Lancet Oncology

 Reimplantation?

Ü It  is  important  to  be  aware  that  reimplantation  of  ovarian  cortical  tissue  is  a  separate  procedure  at  a  time  distant  from  the  treatment  of  the  original  cancer  

Ü Consent  for  harvesting  ovarian  tissue  from  children  often  will  have  been  obtained  from  their  parents  

Ü Informed  consent  for  reimplantation  can  be  obtained  from  the  patients  at  a  much  later  date  when  they  are  competent  to  assess  the  complex  issues  themselves.  

Ewings sarcoma localised T 7 Vertebrae (Age 12) – unexpected contamination of ovarian biopsy

CD99  

Re-­‐implantation  or  IVG  and  maturation?  

Ü Contamination  of  the  cryopreserved  tissue  with  malignant  cells,  particularly  in  haematological  malignant  disease  –  shown  in  a  rodent  lymphoma  model  –  to  cause  recrudescence  of  the  original  disease  

Ü Oocyte  maturation  in  vitro,  followed  by  IVF,  would  eliminate  this  risk  

Antral development from in vitro grown human primordial follicles within 10 days

Telfer et al., 2008: A two step serum free culture system supports development of human oocytes from primordial follicles in the presence of activin. Human Reproduction 23: 1151-1158

Telfer et al. (2008) Human Reproduction

The Uterus

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

2.2

2.4

0   2   4   6   8   10   12   14   16   18   20   22   24   26   28   30   32   34   36   38   40  

Uterine Volume (cm3log- adjusted)

Age (years)

Observed Uterine Volume Predicted Uterine Volume 95% Conf Lim for Model 95% Prediction Limit

Normative model for uterine volume from birth to 40 years. The r2 is 0.859.

Kelsey et al. unpublished

30

25

20

15

10

5

0 2 4 6 8 10 12 14

Uterine volume and age at irradiation (TBI)

Bath et al. BJOG (1999) Age at Irradiation (years)

Uterine function after cancer treatment

Ü  No reports of uterine damage due to chemotherapy

Ü  Radiotherapy: Ü  Uterine damage, manifest by impaired growth and

blood flow. Ü  Uterine volume correlates with age at irradiation. Ü  Exposure of the pelvis to radiation is associated with

an increased risk of miscarriage, mid-trimester pregnancy loss, PPH, pre-term birth and low birth weight.

Vitruvian man

Leonardo da Vinci 1490

Sertoli Cell

Hormone levels and semen concentration in relation to the number of MOPP cycles in male long-term survivors of childhood Hodgkin’s.

van Beek R D et al. Hum. Reprod. 2007;22:3215-3222

Radia7on-­‐induced  tes7cular  damage  

Germinal epithelium

>1.2Gy azoospermia

Radia7on-­‐induced  tes7cular  damage  

Leydig cell function

Ü  Dose received by testis P <0.05

Ü  Time Interval after radiotherapy P <0.05

Ü  Age at treatment NS

Li, Kelsey, Wallace (unpublished data)

FERTILITY RISK ASSESSMENT(Includes Intrinsic and Extrinsic factors)

Pre-pubertal

Testis

biopsy

Pubertal

Able to produce a suitable

semen sample

Post-pubertal

Testis Tissue

Cryopreservation

Experimental Established

Sperm

Cryopreservation

Ovarian Tissue

Cryopreservation

Embryo

Cryo

Pre-pubertal

FEMALEMALE

PatientAssessment

Intervention

Storage

NO

Testis biopsy/

Gamete extraction

YES

Post-pubertal

Ovarian

stimulation

Partner/

Donor

sperm

Oocyte

Cryo

Ovarian biopsy

Males:  Fer7lity  preserva7on  

Ü  Young  men  who  can  produce  semen  should  have  the  opportunity  of  sperm  banking  before  treatment  begins  

Ü  Sperm  retrieval    should  be  considered  if  the  chances  of  infer7lity  are  high  and  the  testes  are  >10mls  Ü  Storage  of  gametes  is  governed  by  the  HFE  act  1990  Ü  WriWen  informed  consent  from  a  competent  male  is  required  

Ü  There  is  currently  no  established    op7on  to  preserve  fer7lity  in  the  pre-­‐pubertal  boy….  

Isolated  human  sperm  cells  (1500x)  Albert  Tousson  –  Nikon  Small  world  

Cryopreservation of pre-pubertal testis tissue prior to cancer treatment

Ü  Boys undergoing cancer treatment with >80% risk of infertility

Ü  Biopsy to be taken with routine procedure

Ü  Storage by Tissue Services according to ‘mature’ or ‘immature’ protocol

Ü  Small piece of tissue to be used for research

Ethical Approval Granted – September 2013

Human Testis Xenografting

Ü  Provide  fertility  counseling  to  all  young  patients  with  cancer  

Ü  Cryopreserve  ovarian  and  pre-­‐pubertal  testicular  tissue  from  the  right  (high  risk)  patients  

Ü  Define  the  success  rate  of  the  procedures  

Ü  Develop  IVG/M  as  a  safe  alternative  to  re-­‐implantation  through  basic  research  

Challenges  

Acknowledgements  

• Richard  Anderson  • David  T  Baird  • Tom  Kelsey  • Evelyn  Telfer  • Marie  McLaughlan  • Alice  Grove  Smith  • Lucy  Li  • Phoebe  Wright  • Sarah  Dodwell  

• Rod  Mitchell  • Louise  Bath  • Chris  Kelnar  • Angela  Edgar  • Mark  Brougham  • Fraser  Munro  • Merrill  McHoney  

 

Ü  [1] R. Skinner, W. H. Wallace, G. A. Levitt, and U. K. C. s. C. S. G. L. E. Group, "Long-term follow-up of people who have survived cancer during childhood," Lancet Oncol, vol. 7, pp. 489-98, Jun 2006.

Ü  [2] W. H. Wallace, R. A. Anderson, and D. S. Irvine, "Fertility preservation for young patients with cancer: who is at risk and what can be offered?," Lancet Oncol, vol. 6, pp. 209-18, Apr 2005.

Ü  [3] W. H. Wallace, H. O. Critchley, and R. A. Anderson, "Optimizing reproductive outcome in children and young people with cancer," J Clin Oncol, vol. 30, pp. 3-5, Jan 1 2012.

Ü  [4] W. H. Wallace and T. W. Kelsey, "Human ovarian reserve from conception to the menopause," PLoS One, vol. 5, p. e8772, 2010.

Ü  [5] W. H. Wallace, A. B. Thomson, and T. W. Kelsey, "The radiosensitivity of the human oocyte," Hum Reprod, vol. 18, pp. 117-21, Jan 2003.

Ü  [6] R. A. Anderson, S. M. Nelson, and W. H. Wallace, "Measuring anti-Mullerian hormone for the assessment of ovarian reserve: when and for whom is it indicated?," Maturitas, vol. 71, pp. 28-33, Jan 2012.

References  

Ü  [7] R. A. Anderson and D. A. Cameron, "Pretreatment serum anti-mullerian hormone predicts long-term ovarian function and bone mass after chemotherapy for early breast cancer," J Clin Endocrinol Metab, vol. 96, pp. 1336-43, May 2011.

Ü  [8] R. A. Anderson, M. Rosendahl, T. W. Kelsey, and D. A. Cameron, "Pretreatment anti-Mullerian hormone predicts for loss of ovarian function after chemotherapy for early breast cancer," Eur J Cancer, vol. 49, pp. 3404-11, Nov 2013.

Ü  [9] M. F. Brougham, P. M. Crofton, E. J. Johnson, N. Evans, R. A. Anderson, and W. H. Wallace, "Anti-Mullerian hormone is a marker of gonadotoxicity in pre- and postpubertal girls treated for cancer: a prospective study," J Clin Endocrinol Metab, vol. 97, pp. 2059-67, Jun 2012.

Ü  [10] J. Donnez and M. M. Dolmans, "Fertility preservation in women," Nat Rev Endocrinol, vol. 9, pp. 735-49, Dec 2013.

Ü  [11] T. W. Kelsey, P. Wright, S. M. Nelson, R. A. Anderson, and W. H. Wallace, "A validated model of serum anti-mullerian hormone from conception to menopause," PLoS One, vol. 6, p. e22024, 2011.

Ü  [12] J. Donnez, M. M. Dolmans, A. Pellicer, C. Diaz-Garcia, M. Sanchez Serrano, K. T. Schmidt, et al., "Restoration of ovarian activity and pregnancy after transplantation of cryopreserved ovarian tissue: a review of 60 cases of reimplantation," Fertil Steril, vol. 99, pp. 1503-13, May 2013.

References  

Ü  [13] T. W. Kelsey, S. K. Dodwell, A. G. Wilkinson, T. Greve, C. Y. Andersen, R. A. Anderson, et al., "Ovarian volume throughout life: a validated normative model," PLoS One, vol. 8, p. e71465, 2013.

Ü  [14] W. H. Wallace, A. G. Smith, T. W. Kelsey, A. E. Edgar, and R. A. Anderson, "Fertility preservation for girls and young women with cancer: population-based validation of criteria for ovarian tissue cryopreservation," Lancet Oncol, vol. 15, pp. 1129-36, Sep 2014.

Ü  [15] E. E. Telfer, M. McLaughlin, C. Ding, and K. J. Thong, "A two-step serum-free culture system supports development of human oocytes from primordial follicles in the presence of activin," Hum Reprod, vol. 23, pp. 1151-8, May 2008.

Ü  [16] R. D. van Beek, M. Smit, M. M. van den Heuvel-Eibrink, F. H. de Jong, F. G. Hakvoort-Cammel, C. van den Bos, et al., "Inhibin B is superior to FSH as a serum marker for spermatogenesis in men treated for Hodgkin's lymphoma with chemotherapy during childhood," Hum Reprod, vol. 22, pp. 3215-22, Dec 2007.

Ü  [17] R A Anderson, R T Mitchell, T W Kelsey, N Spears, E E Telfer, W H B Wallace; “Cancer treatment and gonadal function: experimental and established strategies for fertility preservation in children and young adults”,The Lancet Diabetes and Endocrinology, 2015.

Ü  [18] W. H. Wallace, T. W. Kelsey, and R. A. Anderson, "Ovarian cryopreservation: experimental or established and a cure for the menopause?," Reprod Biomed Online, vol. 25, pp. 93-5, Aug 2012.

References  

Thank You