Post-chemotherapy cognitive impairment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and Keywords: Chemotherapy-induced cognitive dysfunction; Chemo brain; Chemo fog; Chemobrain; PCCI

Overview

Post-chemotherapy cognitive impairment (also known as chemotherapy-induced cognitive dysfunction) is defined as the cognitive impairment that can result from chemotherapy treatment. Post-chemotherapy cognitive impairment was first discovered and described in 1980.[1] Post-chemotherapy cognitive impairment is characterized by changes in memory, fluency, and other cognitive abilities that impeded their ability to function as they had pre-chemotherapy. Approximately 20-30% of patients that undergo chemotherapy experience some level of post-chemotherapy cognitive impairment. The exact pathogenesis of post-chemotherapy cognitive impairment is not fully understood.[1] However, the underlying mechanisms of the disease are believed to be caused by direct neurotoxicity. Genes involved the development of post-chemotherapy cognitive impairment, include: COMT nucleotide polymorphism, Apolipoprotein E gene, and BDNF gene mutations. Post-chemotherapy cognitive impairment is more commonly observed among middle aged and elderly patients. The median age at diagnosis ranges between 40-70 years old. There are no specific imaging findings associated with post-chemotherapy cognitive impairment. However, in some cases MRI may detect accurate measurement of therapy-induced changes in gray and white matter volumes. Recent studies suggest further investigation on the underlying mechanisms of cognitive impairment.[2]

Historical Perspective

  • Post-chemotherapy cognitive impairment was first discovered and described in 1980.[1]

Classification

  • There is no classification system for post-chemotherapy cognitive impairment.[1]

Pathophysiology

  • The pathogenesis of post-chemotherapy cognitive impairment is not fully understood.[1]
  • However, the underlying pathophysiology is believed to be caused by direct neurotoxicity.
  • Genes involved the development of post-chemotherapy cognitive impairment, include:[1]
  • COMT nucleotide polymorphism
  • Apolipoprotein E
  • BDNF gene
  • On gross pathology, characteristic findings of post-chemotherapy cognitive impairment, include:[1]
  • No remarkable findings
  • On microscopic histopathological analysis, characteristic findings of post-chemotherapy cognitive impairment, may include:
  • Smaller tumor size
  • Reduced cellularity
  • Extensive cytoplasmic vacuolization causing tumor cells to resemble histiocytes
  • Tumor necrosis
  • Atrophy and marked nuclear atypia

Causes

  • Common causes of post-chemotherapy cognitive impairment, include:[3]

Differentiating Post-Chemotherapy Cognitive Impairment from Other Diseases

  • Post-chemotherapy cognitive impairment must be differentiated from other diseases that cause cognitive impairment (such as, lack of attention, orientation to time and space), such as:[1]

Epidemiology and Demographics

  • Post-chemotherapy cognitive impairment is rare.
  • Approximately 20-30% of patients that undergo chemotherapy experience some level of post-chemotherapy cognitive impairment.
  • The prevalence of post-chemotherapy cognitive impairment remains unknown.[1]

Age

  • Post-chemotherapy cognitive impairment is more commonly observed among patients aged 40-70 years old.
  • Post-chemotherapy cognitive impairment is more commonly observed among middle aged adults and elderly patients.

Gender

  • Females are slightly more commonly affected with post-chemotherapy cognitive impairment than males.[2]

Race

  • There is no racial predilection for post-chemotherapy cognitive impairment.[2]

Risk Factors

  • The most common risk factor in the development of post-chemotherapy cognitive impairment are number of cycles of chemotherapy.[3]

Natural History, Complications and Prognosis

  • The majority of patients with post-chemotherapy cognitive impairment are initially symptomatic.[1]
  • Early clinical features, include:
  • Lack of attention
  • Memory loss
  • Problems to recall
  • Lack of orientation
  • If left untreated, patients with post-chemotherapy cognitive impairment may progress to develop severe cognitive impairment.
  • Common complications of post-chemotherapy cognitive impairment, include:[3]
  • Prognosis will generally good, and symptoms of post-chemotherapy cognitive impairment typically disappear in about four years.

Diagnosis

Symptoms

  • Post-chemotherapy cognitive impairment is usually symptomatic at diagnosis
  • Symptoms of post-chemotherapy cognitive impairment may include the following:[1]
  • Memory loss
  • Lack of attention
  • Difficult language fluency
  • Poor calculation and recall
  • Loss of appetite
  • Irritability or constant mood swings
  • Hopelessness
  • A directed history should be obtained to ascertain:
  • Aggravating factors, such as:

Physical Examination

  • Patients with post-chemotherapy cognitive impairment usually appear malnourished and pale.
  • Physical examination shows no remarkable findings for patients with post-chemotherapy cognitive impairment.[3]

Laboratory Findings

  • There are no specific laboratory findings associated with post-chemotherapy cognitive impairment.[1]
  • In some cases, elevated levels of apolipoprotein (APOE) allele may be seen in patients with post-chemotherapy cognitive impairment

Imaging Findings

  • There are no imaging findings associated with post-chemotherapy cognitive impairment.
  • In some cases, MRI may detect accurate measurement of therapy-induced changes in gray and white matter volumes.

Treatment

Medical Therapy

  • There is no treatment for post-chemotherapy cognitive impairment; the mainstay of therapy is supportive care.
  • Common medical therapies for the treatment of post-chemotherapy cognitive impairment, include:[3]

Surgery

  • Surgery is not recommended for patients with post-chemotherapy cognitive impairment.[1]

Prevention

  • There are no primary preventive measures available for post-chemotherapy cognitive impairment.[1]
  • Once diagnosed and successfully treated, patients with post-chemotherapy cognitive impairment are followed-up every visit.
  • Follow-up testing includes cognitive function assessments (such as, mini–mental state examination)

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, Morrow GR (2011). "An update on cancer- and chemotherapy-related cognitive dysfunction: current status". Semin. Oncol. 38 (3): 431–8. PMC 3120018Freely accessible. PMID 21600374. doi:10.1053/j.seminoncol.2011.03.014. 
  2. 2.0 2.1 2.2 Post-chemotherapy cognitive impairment. Wikipedia. https://en.wikipedia.org/wiki/Post-chemotherapy_cognitive_impairment Accessed on May 18, 2016

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