This document discusses metabolic complications in childhood cancer survivors. More than 65% of survivors develop long-term complications such as insulin resistance and type 2 diabetes, increasing their risk of cardiac issues. Survivors treated with total body irradiation have a higher risk of insulin resistance and metabolic disorders. This is associated with increased systemic inflammation, specifically increased pro-inflammatory cytokines and T cells polarized towards producing Th1 responses. This immune activation occurs through a bystander effect of radiation on cells rather than direct irradiation and may be linked to unique epigenetic changes in survivors treated with radiation. These immune and epigenetic alterations could help monitor survivors' risk of metabolic diseases in the future.

2. Metabolic Complications in Childhood
Cancer Survivors
Inflammation and Infection Research – School of Medical Sciences
Eslami S, Cohn RJ, Johnston K, Barres R, Simar D
Dr David Simar,
Inflammation and Infection Research
School of medical Sciences, UNSW d.simar@unsw.edu.au

3. Childhood cancer in Australia
1 in 600 children diagnosed each year with cancer
Improved treatment  survival rate exceeding 85%
More than 65% of survivors develop long term complications,
including metabolic disorders (insulin resistance, T2D) that
contribute to the risk of life threatening cardiac complications.
Risk factors have been identified

4. Risk factors for insulin resistance in CCS
N=78 Odds ratio 95% CI p value
Age 1.08 0.99-1.18 0.07
Gender 1.58 0.51-4.91 0.43
Overweight (BMI>25kg/m2) 4.13 1.20-14.17 0.02*
Abdominal adiposity (W/H>0.5) 4.06 1.21-13.54 0.02*
Age at diagnosis 1.01 0.91-1.13 0.79
Treatment duration 1.07 0.81-1.43 0.62
Surgery 0.86 0.27-2.72 0.80
Acute Lymphoblastic Leukemia 0.80 0.25-2.59 0.71
HSCT (n=20) vs others (n=58) 3.65 1.10-12.04 0.03*
Total body irradiation 10.71 2.58-44.50 <0.01*
Abdominal irradiation 2.09 0.64-6.83 0.22
Irradiation to other areas 1.14 0.32-4.17 0.84
BMI: body mass index, W/H: waist to height ratio, HSCT: hematopoietic stem
cells transplant

5. Radiotherapy and insulin resistance in CCS
Total body irradiation
(N=14)
Non Irradiated
(N=27)
Age (yr) 24.6 (16-44) 22.8 (17-34)
Gender (M/F) 5/9 14/13
BMI (kg/m2) 23.9±6.8 25.6±5.8
Waist to height ratio 0.51±0.11 0.50±0.08
Triglycerides (mmol/l) 1.93±1.74* 0.96±0.46
Cholesterol (mmol/l) 5.28±0.97* 4.78±0.77
HDL-C (mmol/l) 1.28±0.41 1.58±0.72
LDL-C (mmol/l) 3.09±0.97 2.84±0.51
Insulin (mU/l) 9.24±8.02 5.62±4.61
Glucose (mmol/l) 5.87±3.40* 4.77±0.47
Insulin resistant (%) 7 (50%)* 2 (7.4%)
*: p<0.05, TBI vs. non irradiated, BMI: body mass index, HDL-C: high-density
lipoprotein cholesterol, insulin resistance: HOMA-IR score above 1.8.

6. Obesity and metabolic disorders
Visceral adipose tissue
Inflammation Van Gaal et al., Nature, 2006
Childhood Cancer Survivors treated with total body irradiation
are not characterised by impaired body composition:
Role of inflammation?
Dr David Simar 2014

7. Obesity and metabolic disorders
Lean  Obese
Osborne and Olefsky, Nat Med Rev, 2012
Pro-inflammatory cytokines in CCS?
Dr David Simar 2014

8. Radiotherapy and inflammation in CCS
CCS treated with
irradiation have
increased systemic
inflammation associated
with insulin resistance

9. Source of pro-inflammatory cytokines
Osborne and Olefsky, Nat Med Rev, 2012
Dr David Simar 2014

10. Radiotherapy and inflammation in CCS
CCS treated with total body irradiation
Are characterized by Tcell polarisation towards Th1
Dr David Simar 2014

11. Radiotherapy and inflammation in CCS
Rest
Stimulated
Rest
Stimulated
60
40
20
0
p-p38 MFI in CD4+ cells
p = 0.02
* *
TBI Non-IRR
pS6K1 MFI in C D4+ cels p = 0.04
0
Rest
Stimulated
Rest
Stimulated60
40
20
30
20
10
* *
TBI Non-IR
Rest
Stimulated
Rest
Stimulated
Rest
Stimulated
Rest
Stimulated
80
60
40
20
300
200
100
0
pAkt Ser473 MFI in CD4+ cells
* *
TBI Non-IRR
0
p-JNK MFI in CD4+ cells
TBI Non-IRR
Rest
Stimulated
Rest
Stimulated
6000
4000
2000
300
200
100
0
pS6K1 MFI in CD4+ cells
p = 0.04
* *
TBI Non-IRR
p38/JNK
ERK
TBI
Non-IRR
PMA
Rest
PMA
Rest
* : significant difference between rest and stimulated condition

12. Activation of p38 and mTORC1 signaling in T cells in response to radiation:
a direct or indirect effect?
Jurkat cells exposed to radiation
Tcell signaling in CCS
100
75
50
25
1000
750
500
250
Direct irradiation does not directly impact on the activation
of the intracellular signaling pathways
responsible for Th1 polarisation in T cells
0
1day 14days 28days
p-p38 MFI in Jurkat cells
0Gy 1Gy 3Gy 6Gy
0
1day 14days 28days
pS6K1 MFI in Jurkat cells
0Gy 1Gy 3Gy 6Gy
Dr David Simar 2014

13. RPMI 0Gy 1Gy 3Gy 6Gy
40
30
20
10
0
p-p38 MFI in CD4+ cells
p = 0.04
p < 0.01 p < 0.01
p < 0.01
RPMI 0Gy 1Gy 3Gy 6Gy
100
80
60
40
20
0
pS6K1 MFI in CD4+ cells
p = 0.05
p = 0.01 p < 0.01
T cells signaling in CCS
Activation of p38 and mTORC1 signaling in T cells in response to radiation:
a direct or indirect effect?
T cells exposed to conditioned media from irradiated adipocytes
Activation of those 2 signaling pathways
is achieved through a bystander but not a direct effect
How to explain the long-term memory effect?
Dr David Simar 2014

14. Mechanisms for long-term memory of irradiation?
Epigenetic modifications:
heritable gene alterations without changes to DNA sequence
CH3 CH3
CH3
TRANSCRIPTION
MACHINERY
x
GENE EXPRESSION
MEMORY
3- Small RNA expression
1- HISTONE modification
2- DNA methylation
Metabolic disorders associated with epigenetic changes
Barres et al, Cell Metab, 2009
Simar et al., Metabolism, 2014
Changes in DNA methylation in response to irradiation
Kalinish et al., Radiat Res, 1989
Dr David Simar 2014

15. TBI non-IRR
15
10
5
0
MeC5 Lymphocytes (MFI)
p > 0.05
TBI non-IRR
15
10
5
0
MeC5 CD4 cells (MFI)
p = 0.05
TBI non-IRR
60
40
20
0
MeC5 Monocytes (MFI)
p > 0.05
TBI non-IRR
15
10
5
0
MeC5 CD8 cells (MFI)
p = 0.07
IRR non-IRR
8
6
4
2
0
MeC5 B cells (MFI)
p > 0 .05
Epigenetic changes in PBMCs in CCS
T cells from childhood cancer survivors treated with radiation
characterised by unique epigenetic signature
Role in long-term memory of treatment?
Dr David Simar 2014

16. Metabolic complications in childhood cancer survivors
CCS: - increased risk of metabolic diseases
- irradiation is a major risk factor
Neville et al., J Clin Endo Metab, 2006
Survivors treated with total body irradiation:
- increased insulin resistance
- increased levels of pro-inflammatory cytokines
Systemic inflammation in CCS:
- increased T cells polarised activation towards Th1
- increased intracellular signaling due to a bystander effect
- linked to unique epigenetic signature
Immune alterations in childhood cancer survivors:
to monitor and facilitate early detection of survivors at risk
Dr David Simar 2014

17. UNSW
IIR: Dr Saghar Eslami
SCH: APr Richard J Cohn, Karen Johnston
Adult Cancer Program: Dr Luc Hesson, Dr Jia Liu
Novo Nordisk Foundation
Centre for Basic Metabolic Research
AProf Romain Barres, Vibe Nylander,
Dr Soetkin Verstyhe, Ida Donkin, Dr Anna Fossum
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