Avascular necrosis of bone--a complication of aggressive therapy for acute lymphoblastic leukemia

Avascular necrosis of the femoral head in patients treated for leukaemia. Assessment of the need for a diagnostic protocol

OBJECTIVE

To evaluate the incidence of avascular necrosis of the hip in leukaemia patients treated in our hospital with high doses of corticosteroids in order to evaluate the necessity for an early detection protocol.

MATERIAL AND METHODS

Observational-descriptive and retrospective study from 2005 to 2016 of 253 patients diagnosed with paediatric leukaemia. Patients with musculoskeletal pathology were identified and patients with avascular necrosis were analysed.

RESULTS

A total of 26 patients (10%) had musculoskeletal symptoms. Three patients with avascular necrosis (1.2%) were analysed. One girl, 7 years old, was treated conservatively with traction - suspension and discharge. Two boys, an 11 and a 15.4 year-old,who developed graft-versus-host disease secondary to bone marrow transplantation, and whose treatment included high doses of corticosteroids, developed avascular necrosis of the hip. One was treated with bisphosphonates and forage and the other ended up with a total hip arthroplasty.

DISCUSSION

The occurrence of musculoskeletal symptoms during the treatment of leukaemia is different according to the bibliographic series (0.43 -12.6%). Some authors observe an increased risk in female patients between the ages of 10 and 17. A retrospective study reveals that there is a delay of 3.9 months in the diagnosis of CAP since the onset of pain. Other authors relate NAV to loading joints, age and high doses of corticosteroids.

CONCLUSION

Based on the low incidence of avascular necrosis of the hip in our 14-year-old population treated for leukaemia, the creation of diagnostic protocols seems not to be necessary. However, close monitoring of patients with potential risk factors recognized in the literature, is advisable.

Collar Osteophytes Mimicking Osteonecrosis in Planar Bone Scintigraphy and Usefulness of SPECT/CT Images

The use of prednisolone is one major risk factor for osteonecrosis in patients with systemic lupus erythematosus. Bone scintigraphy can be a diagnostic tool for early diagnosis. We present a case who had collar osteophytes at the bilateral femoral heads, which mimicked osteonecrosis in the planar bone scintigram. An SPECT/CT scan avoided this pitfall and increased the diagnostic accuracy for osteonecrosis.

High-Dose Corticosteroid Use and Risk of Hip Osteonecrosis: Meta-Analysis and Systematic Literature Review

The effect of varying corticosteroid regimens on hip osteonecrosis incidence remains unclear. We performed a meta-analysis and systematic literature review to determine osteonecrosis occurrences in patients taking corticosteroids at varying mean and cumulative doses and treatment durations, and whether medical diagnoses affected osteonecrosis incidence. Fifty-seven studies (23,561 patients) were reviewed. Regression analysis determined significance between corticosteroid usage and osteonecrosis incidence. Osteonecrosis incidence was 6.7% with corticosteroid treatment of >2 g (prednisone-equivalent). Systemic lupus erythematosus patients had positive correlations between dose and osteonecrosis incidence. Each 10 mg/d increase was associated with a 3.6% increase in osteonecrosis rate, and >20 mg/d resulted in a higher osteonecrosis incidence. Clinicians must be wary of osteonecrosis in patients on high corticosteroid regimens, particularly in systematic lupus erythematosus.

Avascular necrosis of the femoral head in children with acute lymphoblastic leukemia: a 4- to 9-year follow-up study

Avascular necrosis of the femoral head is usually seen in children aged 1.5 to 10 years, reaching a peak incidence between the ages of 4 and 9. Avascular necrosis of the femoral head is a known complication of corticosteroid therapy in acute lymphoblastic leukemia. There are few reports in the literature regarding the natural history of this condition, and there is no consensus on its management. This study examined the natural history of avascular necrosis of the femoral head in children with leukemia. From 1993 to 2006, a total of 865 children with acute lymphoblastic leukemia were admitted to the hematology-oncology ward of a children's hospital. The diagnosis of acute lymphoblastic leukemia was established by bone marrow aspiration. Based on clinical and radiographic findings, avascular necrosis of the femoral head was found in 7 patients; these patients underwent follow-up for 4 to 9 years. Avascular necrosis of the femoral head was clinically symptomatic in all of the children, and they had advanced radiographic collapse of the femoral head. However, the head of the femur was not at risk in any patient based on clinical and radiographic findings. Patients received supportive treatment such as abduction brace and physiotherapy. After 4 to 9 years of follow-up, clinical and radiographic results were satisfactory. Provided that the head of the femur is not at risk, avascular necrosis of the femoral head in children with acute lymphoblastic leukemia may be successfully managed with nonoperative care.

Steroid induced osteonecrosis: An analysis of steroid dosing risk

Osteonecrosis is a serious condition involving bone destruction that frequently requires surgical treatment to rebuild the joint. While there is an abundance of literature documenting corticosteroid related osteonecrosis, there is no consensus as to the relative risk of osteonecrosis after administration of steroids via parenteral, oral, topical, inhaled and other routes. This risk is an important prognostic indicator because identification and conservative intervention can potentially reduce morbidity associated with aggressive surgical treatment of osteonecrosis. This paper provides insight into establishing guidelines related to the risk of developing osteonecrosis as a result of corticosteroid use. Case studies, retrospective studies and prospective studies in humans on different corticosteroids and varied dosages were assessed. Most cases of osteonecrosis are secondary to systemically administered corticosteroids and/or high dose daily therapy, particularly in patients with underlying comorbidities including connective tissue diseases, hyperlipidemia, or previous trauma. Previous case reports of osteonecrosis related to inhaled or topical use of steroids are complicated by the fact that in the great majority of cases, the patients are also treated with systemic steroids prior to the development of osteonecrosis. Based on the literature, a set of recommendations regarding the risk of osteonecrosis in patients on steroids was formulated.

Avascular necrosis of the femoral head as the first manifestation of acute lymphoblastic leukemia

Avascular necrosis of bone is a well-described complication of cancer chemotherapy containing corticosteroids and has been observed in lymphomas and acute lymphoblastic leukemia (ALL). This study reports the case of a young male patient in whom avascular necrosis of right femur head was the presenting feature of acute lymphoblastic leukemia. The temporal association in this instance implicates a pathophysiologic relationship between the development of ALL and necrosis.

Bisphosphonate-associated osteonecrosis of the jaw: what do we currently know? A survey of knowledge given in the recent literature

Increasing application of bisphosphonates for therapy of osteopathies has led to reports of the severe associated adverse effects of osteonecrosis of the jaw (ONJ). We reviewed recent literature to assess several aspects of bisphosphonate-associated ONJ, and to provide healthcare professionals with an overview of treatment and preventive options. Literature databases were searched using keywords. Information of 54 articles were discussed and completed by additional literature. High-risk factors were application of nitrogen-containing bisphosphonates, teeth extractions, and ill-fitting dentures. Treatment included non-surgical options and radical surgery. Success and failure were described for all treatment options; further studies investigating long-term recovery and recurrence are warranted. Paying attention to effective prevention of ONJ before, during, and after treatment is essential.

Bisphosphonate-associated osteomyelitis of the jaw: guidelines for practicing clinicians

OBJECTIVE

To evaluate the literature and discuss the risk factors, mechanisms, pathophysiologic aspects, and recommended management of bisphosphonate-associated osteomyelitis of the jaw (BAOMJ).

METHODS

More than 350 published articles, case reports mentioning BAOMJ, and independent histology slides from BAOMJ lesions were reviewed critically. The most pertinent publications are cited and discussed.

RESULTS

The incidence of BAOMJ increases after extraction of teeth, dentoalveolar surgical procedures, or recent oral trauma leading to exposed maxillary or mandibular bone. Contributory factors include poor oral hygiene, oral infections, periodontal disease; recent or ongoing corticosteroid administration or chemotherapy; compromised immune status; diabetes or vascular insufficiency; old age; chronic diseases; and malignancies. On average, 1 of every 100,000 patients treated with bisphosphonates orally for osteoporosis or Paget disease of bone may develop BAOMJ-like lesions. Patients with cancer often receive bisphosphonate doses 10 times or higher, and also more frequently, than those used in patients with osteoporosis or Paget disease of bone. Therefore, greater frequency of administration of bisphosphonates, higher dosages, and prolonged use (that is, for more than 2 years) are likely to be factors triggering BAOMJ.

CONCLUSION

The association of bisphosphonate therapy with BAOMJ is rare in noncancer patients and is likely to be a class effect that may occur with use of any bisphosphonate. Whether patients with cancer require such a high frequency of intravenously administered bisphosphonates needs to be investigated. Following established guidelines can decrease the risks of BAOMJ in vulnerable patients. Rather than necrotic bone, current evidence supports an infectious and perhaps immunologic underlying cause for BAOMJ. The estimated incidence of BAOMJ among noncancer patients receiving bisphosphonates is about 0.001%, whereas among patients with cancer receiving intravenous bisphosphonate therapy the incidence is between 0.5% and 4%, depending on the dose, frequency, and duration of therapy (on average, approximately 2%). Nevertheless, the benefits of bisphosphonates far outweigh the risks.

Avascular necrosis--an antineoplastic-treatment-related toxicity: the experiences of two institutions

Avascular necrosis (avn) is a complication of treatment for malignancies in children and adolescents. The authors present a two-center retrospective of experiences with avn in children treated for acute lymphoblastic leukaemia or non-Hodgkin lymphoma (8 from 191 patients with newly diagnosed disease in total of 19 sites). The median age at diagnosis was 16.6 years. Avn was observed in 4.1% of the group, higher among males than females (7/1), both during and after therapy. Early diagnosis of the process has enabled 7 patients to avoid surgical intervention. The increased incidence of avn, the multimodal character of symptoms, but unknown late consequences of avn showed that prospective studies of early recognition and proper therapy are needed.

Bisphosphonates and osteonecrosis of the jaw: cause and effect or a post hoc fallacy?

BACKGROUND

An increasing amount of reports are being published suggesting a relationship between the use of bisphosphonates (BPs) and the development of osteonecrosis of the jaw (ONJ). We reviewed the currently available evidence and explore the potential mechanisms of action based on the known effects of the concerned BP.

DESIGN

The MEDLine, Current Contents and Science Citation Index Expanded databases were queried and the results augmented by analyzing cited references and recent congress proceedings.

RESULTS

22 papers were included detailing 225 patients, all based on retrospective chart review without control groups. The prevalence of ONJ was estimated at 1.5%. The involved BPs were pamidronate, zoledronic acid, alendronate and risedronate, all potent nitrogen-containing agents. The most common symptom was pain (81.7%), although 12.2% of cases were asymptomatic. In 69.3% of patients ONJ was preceded by a dental extraction. At the time of diagnosis, 74.5% of patients were receiving chemotherapy and in 38.2% of cases corticosteroids were administered. Although various conservative and surgical treatment modalities were reported, residual sites of ONJ persisted in 72.5% of cases.

CONCLUSION

Although not enough evidence is available to prove a causal link, it seems that under specific circumstances local defenses can become overwhelmed resulting in ONJ.

Avascular Osteonecrosis After Allogeneic Hematopoietic Stem-Cell Transplantation: Diagnosis and Gender Matter

BACKGROUND

Avascular osteonecrosis (AVN) is a serious complication of allogeneic stem-cell transplantation (SCT). Acute and chronic graft-versus-host disease and its treatment with steroids are identified as main risk factors. In a single-center, prospective cohort study of patients undergoing allogeneic SCT for chronic myeloid leukemia (CML), acute myeloid leukemia, myelodysplastic syndrome, and acute lymphatic leukemia, we determined the incidence of hip AVN necessitating total arthroplasty (severe adverse event) and performed risk factor analysis.

METHODS

A total of 255 patients were followed for an observation period of at least 4 years. Thirteen potential risk factors including age, recipient and donor gender, underlying disease and disease stage, conditioning therapy, human leukocyte antigen match, acute or chronic graft-versus-host disease, and immunosuppressive medication were tested in univariate and multifactorial nominal logistic and Cox proportional hazard analyses.

RESULTS

Severe adverse events occurred in eight patients (4-year cumulative incidence rate 6.1%). Univariate and multifactorial analysis revealed a diagnosis other than CML and steroid intake as main risk factors (chi model 31.6, P=0.0005; chi diagnosis 11, P=0.001; chi steroid 6.8, P=0.009). The demonstrably strong influence of diagnosis was steroid independent (steroid intake in CML comparable to non-CML). We repeated the analysis in 103 patients without CML (70 with acute myeloid leukemia, 13 with myelodysplastic syndrome, and 20 with acute lymphatic leukemia), excluding 152 patients with CML. Univariate and multifactorial analyses revealed female gender (of both recipient and donor) as risk factors for AVN in addition to steroids. Relative AVN risk for female compared with male donor transplantation was 8.7 (P=0.01); relative AVN risk for female compared with male recipient transplantation was 4.3 (P=0.047).

CONCLUSIONS

Diagnosis and gender are steroid-independent risk factors for severe hip AVN after allogeneic SCT.

Pathogenesis and natural history of osteonecrosis

BACKGROUND AND OBJECTIVES

Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment.

METHODS

A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited.

RESULTS

Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one.

CONCLUSIONS

Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis.

RELEVANCE

A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options.

Avascular necrosis of the femoral head following heart transplant in a child

A case of avascular necrosis of the femoral head following heart transplantation in a 2-year-old child has been followed to skeletal maturity. Avascular necrosis is a well-known complication following steroid use in childhood. There are no reported cases of avascular necrosis following heart transplant in childhood. Similar cases should be reported.

Osteonecrosis of the maxilla as a complication to chemotherapy: a case report

Numerous oral complications have been documented as a consequence of chemotherapy for the treatment of cancer. One not so well documented consequence of this treatment is avascular necrosis or osteonecrosis of the underlying bone. In this case report, osteonecrosis of the maxilla in a 48-year-old female patient who was treated for acute myelogenous leukemia is presented. The patient had successfully completed both induction and consolidation chemotherapy without steroid administration. Possible causes and difficulties in diagnosis were reviewed.

Long term survivors of childhood leukemia

Changes in therapy, primarily intensification, for childhood leukemias have significantly improved cure rates during the past 30 years. The increasing number of survivors has led to a heightened appreciation of the late complications of treatment caused by both radiation and chemotherapy. Important late effects include decreased growth, poor school performance, altered cardiac function, infertility, and second malignant neoplasms. The long term outcome of children and adolescents suffering from the most recently recognized acute complication of treatment, avascular necrosis of weight-bearing bones, is still not known. These, and all patients treated on clinical trials, should be followed throughout their lives. Many of the complications of treatment are often not realized until years after the completion of therapy; some have been found to be related to dose intensity, emphasizing the importance of clinical trials that examine reduction of therapy for diseases with excellent cure rates. A successful example of this strategy is the elimination or reduction of radiation dose for the prevention of central nervous system acute lymphocytic leukemia. This has resulted in fewer long term central nervous system complications without a decrease in survival rates. As knowledge of late effects increases, design of future trials will need to focus on striking a balance between cure and long term toxicity.

Avascular necrosis of head of femur in a patient with acute promyelocytic leukemia

Avascular necrosis (AVN) of head of the femur is associated with various pathological conditions and treatment modalities. We present a case of acute promyelocytic leukemia who was treated with all-transretinoic acid (ATRA), daunomycin, cytarabine and a short course of dexamethasone. He developed AVN of bone after 2 years of treatment. Whether this is related to ATRA is dealt with in the discussion.

Acute lymphoblastic leukemia in children

As the overall long-term event-free survival rate in children with acute lymphoblastic leukemia approaches 80%, emphasis is being placed on risk-directed therapy so that patients are neither overtreated nor undertreated. It has become apparent that a risk assignment system based on primary genetic abnormalities is inadequate by itself. For example, leukemias with the MLL-AF4 or BCR-ABL fusion gene are, in fact, heterogeneous diseases. Many require allogeneic hematopoietic stem-cell transplantation; some, if the patient is of favorable age and has a low presenting leukocyte count, can be cured with chemotherapy alone. Measurement of early responses to therapy and extent of minimal residual disease can greatly improve the accuracy of risk assessment. Consideration of the variable effects of therapy on the prognostic significance of specific genetic abnormalities is also important. Therefore, TEL-AML1 fusion confers a favorable prognosis in some protocols of chemotherapy but not in others. Studies to identify genetic polymorphisms with pharmacokinetic and pharmacodynamic significance promise to guide further refinement of treatment strategies. This will allow maximization of anticancer effects without induction of unacceptable toxicity in individual patients.