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Giertz M, Aarnivala H, Wilk Michelsen S, Björklund C, Englund A, Grönroos M, Hjalgrim LL, Huttunen P, Niinimäki T, Penno E, Pöyhönen T, Raittinen P, Ranta S, Svahn JE, Törnudd L, Niinimäki R, Harila A. Symptomatic osteonecrosis in children treated for Hodgkin lymphoma: A population-based study in Sweden, Finland, and Denmark. Pediatr Blood Cancer 2024:e31250. [PMID: 39140964 DOI: 10.1002/pbc.31250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Osteonecrosis (ON) is a potentially disabling skeletal complication of cancer treatment. Although symptomatic osteonecrosis (sON) is well-known in acute lymphoblastic leukemia (ALL), with an incidence around 6%, studies on sON in pediatric Hodgkin lymphoma (HL) are scarce. The aim of this study was to examine the incidence, risk factors, and outcome of sON in children treated for HL. PROCEDURE A total of 490 children under 18, diagnosed with HL between 2005 and 2019 in Sweden, Finland, and Denmark were eligible for the study. Data on patient characteristics, HL treatment, and development of sON were collected from patients' medical records. Magnetic resonance imaging scans were used to establish ON diagnosis and grade ON according to the Niinimäki grading system. RESULTS Cumulative 2-year incidence of sON among the 489 included patients was 5.5% (n = 30). The risk for developing sON was higher for those with older age (odds ratio [OR] 1.25, 95% confidence interval [CI]: 1.05-1.49, p < .010), female sex (OR 4.45, CI 1.87-10.58, p < .001), high total cumulative glucocorticoid (GC) doses (OR 1.76, 95% CI: 1.21-2.56, p = 0.003), and advanced HL (OR 2.19, 95% CI: 1.03-4.65, p = .042). Four (13.3%) patients underwent major surgical procedures and 13 (43.3%) had persistent symptoms due to ON at follow-up. CONCLUSIONS This study shows that sON is as common in pediatric HL as in pediatric ALL, with risk factors such as older age, female sex, high cumulative GC doses, and advanced HL. Future HL protocol development should aim to reduce the burden of ON by modifying GC treatment.
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Affiliation(s)
- Mia Giertz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Henri Aarnivala
- Department of Paediatrics, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Sascha Wilk Michelsen
- Department of Pediatric Hematology and Oncology, Department of Pediatric and Adolescence Medicine, Juliane Marie Centret, University Hospital Copenhagen, Copenhagen, Denmark
| | - Caroline Björklund
- Department of Pediatric Hematology and Oncology, Umeå University Hospital, Umeå, Sweden
| | - Annika Englund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Marika Grönroos
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Lisa Lyngsie Hjalgrim
- Department of Pediatric Hematology and Oncology, Department of Pediatric and Adolescence Medicine, Juliane Marie Centret, University Hospital Copenhagen, Copenhagen, Denmark
| | - Pasi Huttunen
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Tuukka Niinimäki
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Eva Penno
- Department of Surgical Sciences, Unit of Radiology, Uppsala University, Uppsala, Sweden
| | - Tuuli Pöyhönen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Päivi Raittinen
- Centre for Child Health Research, Tampere University and University Hospital, Tampere, Finland
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Johan E Svahn
- Department of Paediatric Oncology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lisa Törnudd
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Pediatrics, H.R.H Crown Princess Victoria's Children's and Youth Hospital, Linköping, Sweden
| | - Riitta Niinimäki
- Department of Paediatrics, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
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Aarnivala H, Giertz M, Michelsen SW, Björklund C, Englund A, Grönroos M, Hjalgrim LL, Huttunen P, Niinimäki T, Penno E, Pokka T, Pöyhönen T, Raittinen P, Ranta S, Svahn JE, Törnudd L, Harila A, Niinimäki R. Radiological follow-up of osteonecrosis lesions in children and adolescents with Hodgkin lymphoma. Br J Haematol 2024. [PMID: 39096138 DOI: 10.1111/bjh.19687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/22/2024] [Indexed: 08/04/2024]
Abstract
Osteonecrosis (ON) is a common complication of glucocorticoid-based Hodgkin lymphoma (HL) treatment, but the natural evolution and prognosis of ON lesions remain poorly understood. We describe the radiological evolution of ON lesions identified in a Nordic population-based cohort of paediatric HL patients. Magnetic resonance images of suspected ON lesions were centrally reviewed to confirm ON diagnosis and grade the ON lesions according to the Niinimäki classification. The study included 202 ON lesions in 46 patients, of which 77 were joint lesions. Follow-up images were available for 146/202 lesions, with a mean follow-up time of 28 months. During follow-up, 71% of the lesions remained stable, 26% improved or resolved, and 3% progressed. A higher ON grade at diagnosis was associated with a lower likelihood of spontaneous resolution. The likelihood for resolution of ON decreased by 50% for each year of added patient age, when adjusted for sex, ON location, and symptoms. Hip ON showed less spontaneous improvement compared with other joints, and the risk for surgery was 13-fold in hip ON. Grades 3-4 joint ON has the potential to either progress or resolve, warranting follow-up in patients with severe symptoms. Research on secondary prevention should be directed at grade 3-4 joint ON.
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Affiliation(s)
- Henri Aarnivala
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Mia Giertz
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sascha Wilk Michelsen
- Department of Pediatric and Adolescence Medicine, Clinic for Pediatric Oncology and Hematology, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Caroline Björklund
- Department of Pediatric Hematology and Oncology, Umeå University Hospital, Umeå, Sweden
| | - Annika Englund
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Marika Grönroos
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Lisa Lyngsie Hjalgrim
- Department of Pediatric and Adolescence Medicine, Clinic for Pediatric Oncology and Hematology, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pasi Huttunen
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Tuukka Niinimäki
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Eva Penno
- Department of Diagnostic Radiology, Uppsala University Hospital, Uppsala, Sweden
| | - Tytti Pokka
- Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Tuuli Pöyhönen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Päivi Raittinen
- Centre for Child Health Research, Tampere University and University Hospital, Tampere, Finland
| | - Susanna Ranta
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan E Svahn
- Department of Pediatric Oncology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lisa Törnudd
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Riitta Niinimäki
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
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Rokkanen R, Aarnivala H, Pokka T, Niinimäki R. Chemotherapy-related toxicities follow a typical pattern in children treated for acute lymphoblastic leukaemia. Acta Paediatr 2024; 113:1103-1111. [PMID: 38178211 DOI: 10.1111/apa.17092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
AIM Acute lymphoblastic leukaemia (ALL) therapy has been associated with a significant burden of toxicities. The aim of this study was to describe the full spectrum of toxic effects associated with childhood ALL. METHODS Toxicity-related data were collected from the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL-2008 toxicity registry, in which data on 19 clinically relevant toxicities were registered during ALL treatment, and from patient medical records. All patients treated according to the NOPHO ALL-2008 protocol in Oulu University Hospital between 2008 and 2020 were included in the study. RESULTS The cohort consisted of 73 patients, 38 of whom were male. Mean age at diagnosis was 6.6 ± 4.2 (range 1.4-16.0) years. All but one of the patients developed at least one treatment-related toxicity and more than half had multiple toxicities. Female sex and older age were associated with a higher tendency towards toxicity. The most common toxicity was vincristine-induced peripheral neuropathy, which was observed in 70 patients. Most toxicities were moderate or severe, but even mild toxicities often affected leukaemia treatment. CONCLUSION Moderate and severe treatment-related toxicities are common, and most toxicities occur in a typical pattern in relation to the treatment phases.
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Affiliation(s)
- Roosa Rokkanen
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Henri Aarnivala
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Paediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Tytti Pokka
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Riitta Niinimäki
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Paediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
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Ha AS, Chang EY, Bartolotta RJ, Bucknor MD, Chen KC, Ellis HB, Flug J, Leschied JR, Ross AB, Sharma A, Thomas JM, Beaman FD. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol 2022; 19:S409-S416. [PMID: 36436966 DOI: 10.1016/j.jacr.2022.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington.
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Roger J Bartolotta
- Division Chief, Musculoskeletal Imaging, Weill Cornell Medical College, New York, New York
| | - Matthew D Bucknor
- Associate Chair, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Karen C Chen
- Musculoskeletal Radiology Section Chief, VA San Diego Healthcare System, San Diego, California
| | - Henry B Ellis
- Medical Director, Clinical Research, Texas Scottish Rite Hospital for Children, Dallas, Texas; American Academy of Orthopaedic Surgeons; Board of Directors, Pediatric Research in Sports Medicine; Board of Directors, Texas Orthopaedic Association; Council of Delegates, Texas Representative, AAOS
| | - Jonathan Flug
- Committee Chair, Radiology Quality Oversight, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jessica R Leschied
- Committee on Emergency Radiology-GSER, Henry Ford Health System, Detroit, Michigan
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Akash Sharma
- Chair, Research Committee, Radiology and Chair, PET-MRI Workgroup, Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | - Jonelle M Thomas
- Vice-Chair, Clinical Affairs and Director, Radiology Informatics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Utriainen P, Niinimäki TT, Huurre AJ, Vepsäläinen KL, Mäkitie OM, Niinimäki RA. Bisphosphonate treatment in children with acute lymphoblastic leukemia and osteonecrosis - radiological and clinical findings in a national cohort. Acta Oncol 2021; 60:1140-1145. [PMID: 34309491 DOI: 10.1080/0284186x.2021.1950928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Osteonecrosis (ON) is a recognized complication of childhood ALL, but its optimal management remains unestablished. This study evaluated the effect of bisphosphonate (BP) treatment on the evolution of ON lesions in childhood ALL.Material and Methods: We included a national cohort of ALL patients diagnosed with symptomatic ON before 18 years of age and treated with BPs (N = 10; five males). Patients were followed both clinically and with serial MRIs. ON lesions were graded according to the Niinimäki classification.Results: The 10 patients had a total of 55 ON lesions. The median age was 13.3 years at ALL diagnosis and 14.8 years at ON diagnosis. Four patients had received HSCT before the ON diagnosis. BPs used were pamidronate (N = 7), alendronate (N = 2) and ibandronate (N = 1). The duration of BP treatment varied between 4 months and 4 years. In 4/10 patients, BP treatment was given during the chemotherapy. BPs were well-tolerated, with no severe complications or changes in kidney function. At the end of follow up 13/55 (24%) ON lesions were completely healed both clinically and radiographically; all these lesions were originally graded 3 or less. In contrast, ON lesions originally classified as grade 5 (joint destruction; N = 4) remained at grade 5. All grade 5 hip joint lesions needed surgical treatment. During BP treatment, the pain was relieved in 7/10 patients. At the end of follow-up, none of the patients reported severe or frequent pain.Conclusion: BP treatment was safe and seemed effective in relieving ON-induced pain in childhood ALL. After articular collapse (grade 5) lesions did not improve with BP treatment. Randomized controlled studies are needed to further elucidate the role of BPs in childhood ALL-associated ON.
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Affiliation(s)
- Pauliina Utriainen
- Children’s Hospital and Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Anu J. Huurre
- Department of Pediatric and Adolescent Medicine, Turku University Hospital, FICAN-West, Turku University, Turku, Finland
| | - Kaisa L. Vepsäläinen
- Department of Pediatrics, Kuopio University Hospital, University of Kuopio, Kuopio, Finland
| | - Outi M. Mäkitie
- Children’s Hospital and Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Riitta A. Niinimäki
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
- PEDEGO Unit, University of Oulu, Finland
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