D. Chanlam et al., AVASCULAR NECROSIS OF BONE FOLLOWING INTENSIFIED STEROID-THERAPY FOR ACUTE LYMPHOBLASTIC-LEUKEMIA AND HIGH-GRADE MALIGNANT-LYMPHOMA, British Journal of Haematology, 86(1), 1994, pp. 227-230
Five out of nine adults (55%) with lymphoblastic disease developed sev
ere avascular necrosis of bone (AVN) when treated with a Berlin-Frankf
urt-Munster (BFM) ALL protocol similar to the current joint MRC-ECOG A
LL trial (UKALL XII). The principal purpose of these intensified regim
ens is to improve long-term disease-free survival without necessarily
increasing toxicity and secondary morbidity. The presentation of all f
ive was non-specific bone pain occurring after the re-intensification
block of chemotherapy containing high doses of dexamethasone. Three ty
pes of diagnostic imaging were performed and magnetic resonance imagin
g (MRI) proved superior in demonstrating AVN and showed it at an earli
er stage than plain radiographs or isotopic scans. We believe that the
dose of corticosteroids was the major factor in the development of AV
N. The five men in our series all remain in first remission with a med
ian disease-free survival of 3.5 years (range 2-8 years) but with vary
ing degrees of disability due to AVN. Clinicians involved in UKALL XII
and similar trials should be aware of this debilitating and potential
ly crippling complication when using high-dose steroid-containing regi
mens, perform MRI scan early and modify treatment if necessary.