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

Background: Magnetic resonance imaging (MRI) is the technique that demonstrated the highest sensitivity and specificity in the early diagnosis of osteonecrosis. It allows detecting initial typical signal intensity alterations of the bone marrow when other examinations showed nonspecific findings or even no alterations at all. The aim of this study is to assess the role of magnetic resonance imaging in detection and monitoring osteonecrotic lesions in pediatric patient with acute lymphoblastic leukemia after chemotherapy. Materials and Methods: This prospective study was performed on 30 pediatric patients ranged from 4 to 18 years with acute lymphoblastic leukemia on chemotherapy or after 3months from ending chemotherapy with symptoms suspicious for osteonecrosis (i.e., articular pain). All patients were explained about the procedure to be done. MRI study of whole lower limbs was done for all patients. Results: In the present study all patients were symptomatic. 24\30 patients (80%) had hip pain, 25\30 patients (83.3%) had knee pain and 8\30 patients (26.7%) had limping. We reported that knee pain was the most common complaint representing 83.3% of patients. 11\30 patients (36.7%) had no MRI findings. 19\30 patients (63.3%) had different positive findings; 4 patients (13.3%) had non -articular osteonecrosis (ON) only with no joint involvement (bone infarction), 2 patients (6.7%) had avascular necrosis of femoral head epiphysis without bone infarction and 13 patients (43.3%) had combined bone infarction and avascular necrosis with Joint involvement. Follow up by MRI was done for all patients (30 patients), 27 patients showed no change in MRI findings, one patient progressed from avascular necrosis of the femoral head epiphysis without deformity to avascular necrosis of the femoral head epiphysis with deformity. The other two patient showed regressive course. Conclusion: We concluded that MRI study is mandatory for early detection and monitoring of lower limb osteonecrosis in pediatric patients with acute lymphoblastic leukemia under or after chemotherapy. The radiologist and clinician must do MRI lower limbs routinely and follow up MRI after 4-6 months to first MRI due to some patients had regressive or progressive findings.

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Avascular Necrosis of Femoral Head in Childhood Acute Lymphoblastic Leukemia.

Blood ◽

10.1182/blood.v106.11.4544.4544 ◽

2005 ◽

Vol 106 (11) ◽

pp. 4544-4544

Author(s):

JingYan Tang

Keyword(s):

Risk Factors ◽

Acute Lymphoblastic Leukemia ◽

Femoral Head ◽

Mr Imaging ◽

Avascular Necrosis ◽

Solid Tumor ◽

Lymphoblastic Leukemia ◽

Hip Pain ◽

Childhood All ◽

Necrosis Of Femoral Head

Purpose This study was to determine the frequency of avascular necrosis of femoral head(AVNFH), clinical manifestation, following up results and risk factors in children with acute lymphoblastic leukemia (ALL) and non-Hodgkin lymphoma (NHL). Method Acute non-lymphoblastic leukemia and solid tumor as the background, to assess AVNFH in ALL and NHL between October 1998 and June 2003. Glucocorticoid was included in ALL and T-NHL therapy, but not in B-NHL and other diseases. The criteria of AVNFH is clinical hip pain and/or limp with avascular necrosis sign at MR imaging of the femoral head, but no sign of cancer relapse in clinical and laboratory checking. Results We treated ALL 164 cases, T-NHL 28, B-NHL 20, and solid tumor 126 between October 1998 and June 2003. Forty-three patients with ALL and T-NHL are older than 10 years, including 29 boys and 14 girls. Five cases were diagnosed as AVNFH through MR imaging, including 3 with ALL and 2 with T-NHL. No AVNFH happened in B-NHL and other groups. All of AVNFH are older than 14, average 15 years, and presented with hip pain and/or limping after 1 year glucocorticorid contained chemotherapy. It is 2.6%(5/192) in all ALL and T-NHL cases, but 11.6%(5/43) in the group of older than 10 years. Of those 5 patients, 4 girls and 1 boy. So in the group of older than 10 years girls with ALL and T-NHL, AVNFH happened as high as 28.5%(4/14). After medical interfering, 3 recovered, 2 remained slightly limping but no surgical replacement. Conclusion AVNFH incidence in childhood ALL and T-NHL under our therapy protocol is at least 2.6%. Girls, old than 10, with glucocorticoid contained chemotherapy, are the risk factors of AVNFH. Early detection and interfering may make most of them recover. So, regular MR imaging of the hips for girls who are older than 10 years with glucocorticoid contained chemotherapy longer than 1 year, is reasonable if financially tolerated. Clinical data of AVNFH in childhood ALL and T-NHL No sex disease chemo-time AVNFH predinision* status of cancer status of AVNFH * or equile to predinision 45mg/m2.d 1 F LR-ALL 42 months left 150 days CR stable, limp 2 M HR-ALL 12 months right 65 days CR stable, limp 3 F T-NHL 17 months right 90 days CR recover 4 F T-NHL 22 months both sides 105 days CR recover 5 F HR-ALL 42 months both sides 150 days CR recover

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Avascular Necrosis of Bone in Acute Lymphoblastic Leukemia

Journal of Pediatric Hematology/Oncology ◽

10.1097/00043426-198722000-00006 ◽

1987 ◽

Vol 9 (2) ◽

pp. 143-145 ◽

Cited By ~ 6

Author(s):

Neelam Giri ◽

C. N. Nair ◽

S. K. Pai ◽

P. A. Kurkure ◽

R. Gopal ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Avascular Necrosis ◽

Lymphoblastic Leukemia ◽

Avascular Necrosis Of Bone

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Avascular Necrosis(AVN) and Surgical Intervention In Pediatric Acute Lymphoblastic Leukemia(ALL): A Retrospective Cohort Analysis From The Pediatric Health Information Systems (PHIS)

Blood ◽

10.1182/blood.v122.21.1689.1689 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1689-1689

Author(s):

Mallorie B Heneghan ◽

Susan R. Rheingold ◽

Yimei Li ◽

Alix E. Seif ◽

Yuan-Shung Huang ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Health Information ◽

Avascular Necrosis ◽

Administrative Data ◽

Surgical Intervention ◽

Lymphoblastic Leukemia ◽

Administrative Database ◽

Complication Rates ◽

Pediatric Health ◽

Surgical Interventions

Abstract Cure rates for acute lymphoblastic leukemia (ALL) have improved dramatically, but the incidence of avascular necrosis (AVN) has increased over the past decade. No national administrative data on the incidence of AVN or surgical therapies for AVN exist. We sought to define the incidence of AVN and AVN surgical interventions after treatment for ALL in a national administrative data set. The Pediatric Health Information System (PHIS) is an administrative database including ICD-9 discharge diagnosis, procedure codes, and billing data for daily resource utilization from 43 free standing pediatric hospitals in the US. This study identified patients with an associated ICD-9 code for AVN (733.4X) in a cohort previously established by our group to have newly diagnosed ALL. Between January 1999 and September 2011 242(2.25%), of the 10,729 patients in the ALL cohort had at least one admission with AVN with a mean time of 1.6 years from first ALL treatment until a hospital admission with an associated AVN diagnosis. Table 1 compares demographic and treatment characteristics between ALL patients with and without AVN diagnosis. Age 10-18.99 years and prednisone exposure during ALL induction were associated with increased incidence of AVN. Dexamethasone exposure was associated with a decreased incidence of AVN. AVN diagnosis was associated with a statistically significant increase in mortality. The rate of surgical intervention was 13.7%. The type and location of surgical intervention are reported in Table 2.Table 1Demographicsn (%)ALL Patients w/o AVN (n=10,487)ALL Patients with AVN (n=242)PAge<.0001M <1 year295(2.8)0(0.0) 1 to <10 years7,515(71.7)65(26.9) 10 to <19 years2,557(24.4)169(69.8) ≥ 19 years120(1.1)8(3.3)Sex0.2009 Male5,893(56.2)126(52.1) Female4,594(43.8)116(47.9)Race0.1219 White7,927(75.6)193(79.8) Black774(7.4)17(7.0) Asian321(3.1)5(2.1) Native American121(1.2)6(2.5) Other1,019(9.7)14(5.8) Missing325(3.1)7(2.9)Region0.0527 Midwest2,742(26.2)63(26.0) Northeast1,042(9.9)19(7.9) South3,478(33.2)67(27.7) West3,225(30.8)93(38.4)Medication use during induction*Prednisone4,252(40.6)152(62.8)<.0001Pegasparaginase6,540(62.4)150(62.0)0.9041Dexamethasone6,378(60.8)104(43.0)<.0001Concurrent Dex & Pred600(5.7)17(7.0)0.3892Death649(6.2)27(11.2)0.0017** Induction is defined as 60-day period from ALL admissionTable 2Surgical Interventions during first AVN admissionDescriptionPatient countExcision of lesion or tissue of femur10Bone graft of femur9Arthroscopy of knee5Total hip replacement4Arthrotomy of knee3Excision or destruction of lesion of hip joint3Wedge osteotomy of femur2Excision of lesion or tissue of tibia and fibula2Excision of other bone for graft2Bone graft of tibia and fibula2Arthrotomy of hip2Repair of knee2Partial hip replacement2Excision of elbow joint2Excision of lesion or tissue of humerus1Excision of femur for graft1Partial ostectomy of femur1Bone graft of humerus1Arthrotomy of elbow1Arthrotomy of other specified site1Arthroscopy of hip1Excision or destruction of lesion of elbow joint1Excision or destruction of lesion of knee joint1Excision or destruction of lesion of ankle joint1 To our knowledge, this is the first report using a national administrative database to determine the incidence of AVN in ALL. As expected, age was associated with AVN risk. The association of increased in-hospital mortality was unexpected and warrants further study. Surgical interventions typically involved lower extremity procedures. Work is ongoing to define the rates of subsequent surgical procedures and complication rates. These data demonstrate the feasibility of using administrative data to study surgical interventions for patients with AVN. Disclosures: Rheingold: Novartis: Research Funding.

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