Spontaneous humerus fracture and osteoporosis: an unusual initial presentation of acute lymphoblastic leukemia

The Association of Oral Vitamin D and Calcium Supplementation With Bone Mineral Density in Pediatric Acute Lymphoblastic Leukemia Patients

AIM

To investigate the association of calcium (Ca) and vitamin D (vit D) supplementation with bone mineral density (BMD) in pediatric acute lymphoblastic leukemia (ALL).

MATERIALS AND METHODS

Group I (n=11): de novo ALL patients aged 1 to 18 years. Group II (n=46): pediatric ALL survivors in first complete remission and ALL patients on maintenance chemotherapy. We stratified group II into 3 subgroups according to the postdiagnosis period (group IIa: 8 to 24 mo, group IIb: 24 to 48 mo, group IIc: >48 mo). Group III (n=22): healthy siblings of group II. Daily oral vit D3 and Ca carbonate was given only to group I. In group I, BMD was measured at diagnosis and after completion of intensive chemotherapy (TP1 and TP2).

RESULTS

A significant increase in Ca (P=0.024) and 25-OH vit D (P=0.01), and a decrease in magnesium (P=0.023) were detected at TP2 compared with TP1 in group I. Mean plasma levels of 25-OH vit D were <20 ng/mL in all the groups. Total body (P=0.005), total body less head (P=0.005), and L1 to L4 BMD Z scores (P=0.025) decreased significantly at TP2 compared with TP1. The lowest BMD scores were found at 8 to 24 months after diagnosis in unsupplemented patients. A gradual increase in BMD Z scores was shown, with the highest scores in group IIc.

CONCLUSION

Vit D and Ca supplementation in pediatric ALL patients during intensive chemotherapy may not prevent bone mineral loss. BMD scores of pediatric ALL patients described by other studies, as a major decrease in the first 2 years and gradual increase afterward, was also observed in our patients.

Childhood acute lymphoblastic leukemia (ALL) presenting with severe osteolysis: a model to study leukemia-bone interactions and potential targeted therapeutics

Interference with the molecular mechanisms that generate tumor supportive niches in the bone microenvironment is a rational approach to inhibit the growth of hematological malignancies. However, the advancement of knowledge in this area has been slowed down by the lack of in vitro models to facilitate the screening of potential candidate agents. The rare cases of acute lymphoblastic leukemia (ALL) in children presenting with extensive bone involvement may represent an exaggerated form of some aspects of the normal tumor-bone interactions. Thus, these cases can provide insight into processes that are otherwise challenging to uncover. The authors describe the case of a 6-year-old child who presented with severe osteopenia that resolved at the time of leukemic remission. Compared to control sera, serum taken at disease presentation contained increased levels of a group of osteolytic cytokines and was effective in activating preosteoclast cells in culture. Based on these findings, the authors describe an experimental model to identify agents that would interfere with leukemia mediated osteolytic process.

Severe osteoporosis and high level TSH in a child before the diagnosis of acute lymphoblastic leukemia

Osteoporosis in children is rare and mostly secondary to such conditions as prolonged immobilization, malabsorption syndromes, corticosteroid excess, osteogenesis imperfecta, celiac disease, Turner syndrome, and malignancy. Idiopathic juvenile osteoporosis (IJO) is a very rare condition of primary bone demineralization that presents in childhood. IJO, a disease of unknown etiology, manifests typically by pain, bone deformities, and fractures. Diagnosis of IJO was made by excluding other common causes of osteoporosis in this age. Bisphosphonates, calcitriol, fluoride, and calcitonin have been administered therapeutically, but the results were equivocal. Usually the disease remits by itself. Patient that has serious osteoporosis and high thyroid stimulating hormone level was diagnosed as IJO by eliminating secondary reasons. We report this case, whose symptoms were disappeared after parenteral pamidronat treatment, and he was reexamined owing to anemia and trombositopenia, and diagnosed as B-cell acute lymphoblastic leukemia, just to emphasis the importance of close follow-ups of IJO patients.

Late effects in long-term survivors after treatment for childhood acute leukemia

BACKGROUND

This is a report of late effects in childhood cancer survivors seen in the follow-up clinic of a single institution.

MATERIALS AND METHODS

There were 324 acute leukemia survivors in the database of the Long Term Follow Up Clinic of Children's National Medical Center from January 1, 1997, through June 30, 2005.

RESULTS

Of the 324 acute leukemia survivors, 228 were white, 48 black, 20 Hispanic, and 12 other. Their follow-up time was 0 to 25 years (mean 5.3 years). One or more adverse events occurred in 74.1% of the 324 survivors. Defective physical growth was most commonly reported, followed by disturbed neurocognitive function, emotional difficulties, cardiac abnormalities, hypertension, osteoporosis/osteopenia, fractures, and second neoplasms. More black and Hispanic children had acute myeloid leukemia, relapses, cardiac problems, and hypertension than white and other subjects.

CONCLUSION

Childhood cancer survivors require lifelong monitoring, with prompt identification and treatment of adverse late effects.

Low turnover bone disease in Egyptian children with acute leukemia

The aim of this work was to study bone turnover markers, calcium homeostasis and bone mineral density (BMD) in children with acute leukemia at diagnosis, after induction chemotherapy, and during maintenance therapy to delineate abnormalities present. After evaluation of L2-L4 BMD using dual-energy X-ray absorptiometry in patients with acute myeloid and lymphoid leukemia at presentation and after treatment, the results were compared to 352 healthy age- and sex-matched Egyptian controls. Calcium homeostasis parameters and bone turnover biochemical markers (serum osteocalcin and urinary deoxypyridinoline) were also assayed and the results were compared to 12 healthy age- and sex-matched controls. Osteopenia was observed at diagnosis and during treatment in patients with acute leukemia. At diagnosis osteopenia was observed in 27 patients (62.8%): 10 (23.3%) had non severe osteopenia and 17 (39.5%) had severe osteopenia. This low BMD persisted in those who were followed up. Parathyroid hormone (PTH) (pg/ml) levels demonstrated non significant differences between children with acute leukemia at different stages of therapy and controls, while, 25 (OH) D3 (ng/ml) was significantly lower in acute leukemia patients at different stages of therapy compared to controls (p<0.001). Osteocalcin (ng/ml) is significantly lower in patients at different stages of the disease compared to controls (p<0.001) but there was no significant difference between patients at different stages of therapy. Deoxy-pyridoline cross links showed non-significant difference between the different types of acute leukemia and with controls. Osteopenia is a significant problem in children with acute leukemia at presentation and after chemotherapy. Osteopenia in acute leukemia appears to be of the low turnover type (decreased osteoblastic activity and decreased bone mineralization).

Evaluation of bone metabolism in children with acute lymphoblastic leukemia after induction chemotherapy treatment

Osteopenia and osteoporosis are currently receiving particular attention as late effects of therapy in survivors of childhood acute lymphoblastic leukemia (ALL). The aim of this study was to evaluate abnormalities in bone mass and mineral homeostasis in children with ALL after induction therapy (during consolidation treatment). Lumbar spine (L2-L4) bone mineral density (BMD, g/cm(2)) was measured by dual energy X-ray absorptiometry in 20 children with ALL, a median of 25.9 months postdiagnosis and results were expressed as z-scores relative to healthy Caucasian children (controls). Serum levels of intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), calcium, phosphate, and magnesium were also analyzed. In addition, the body mass indexes (kg/cm(2)) of patients and controls were calculated. Results were compared with those of 40 healthy controls. Among the 20 children with ALL (12 boys and 8 girls), 12 presented z-scores < 1 SD (normal) and 8 were osteopenic (z-score between 1 and 2.5 SD). In addition, children with ALL had reduced lumbar BMDs (z-score -0.817) in comparison to healthy controls (z-score -0.353) (p = .04). Moreover, alkaline phosphatase and intact parathyroid hormone values were significantly increased compared to controls values. The data demonstrate that bone metabolism in children with ALL during consolidation therapy is disturbed, resulting in a reduced BMD and z-score with respect to healthy controls. Since a reduced BMD predisposes to osteopenia and osteoporosis, specific attention and therapeutic interventions should be considered.

Endocrine complications in pediatric patients with acute lymphoblastic leukemia

Endocrine complications of therapy for acute lymphoblastic leukemia (ALL) are common and are potentially debilitating both during and after therapy. Growth velocity slows during therapy for ALL, especially during the first year; however, children who do not receive cranial irradiation usually reach normal adult height. While growth hormone deficiency generally occurs in patients who have received 24Gy of cranial irradiation, it may also develop in those treated with lower doses (18Gy) of cranial radiation or with only high-dose methotrexate. Obesity commonly occurs during therapy and persists after completion of therapy. Osteopenia can occur early during therapy for ALL and can persist for many years. Adrenal insufficiency should be suspected in any child who has recently received glucocorticoid therapy, and stress doses of steroid should be administered in the event of metabolic stress. Screening of urine is useful for early detection of hyperglycemia during therapy with glucocorticoids and L-asparaginase. The syndrome of inappropriate secretion of anti-diuretic hormone is usually associated with vincristine therapy and may be aggravated by concurrent use of azole antifungals. Finally, patients who have received 18 or 24Gy of cranial irradiation may have clinical or subclinical deficiencies of thyroid hormones.

Osteoporosis in survivors of acute lymphoblastic leukemia

Osteoporosis is currently receiving increasing attention as an important late effect in survivors of childhood cancer and its treatment because of their quality of life and its negative effect on the survivors' ability to perform developmentally appropriate activities. Survivors of childhood cancer are especially vulnerable because they are affected during childhood and adolescence, a time when peak bone mass should be achieved. This paper reviews decreased bone density in acute lymphoblastic leukemia (ALL), which is the most common childhood cancer and has a cure rate approaching 80%. Osteopenia/osteoporosis has been observed in all phases of the disease: at diagnosis, during treatment, and throughout the post-treatment period for as long as 20 years. Among the findings that have been described are musculoskeletal pain, disturbed gait, fractures, kyphosis, lordosis, and growth failure. Risk factors not specifically related to ALL include smoking, ingestion of carbonated beverages, and family history of "brittle bone" or fractures. Patients should be counseled in regard to diet, exercise, smoking cessation, and avoidance of carbonated beverages. There are a number of options for specific drug therapy; however, the administration of bisphosponates to children and adolescents must be approached with caution. Research is needed to determine how extensive the problem is and how to best prevent and treat the osteopenia/osteoporosis associated with ALL.