Osteonecrosis as a complication of treating acute lymphoblastic leukemia in children: A report from the children's cancer group

Purpose: To determine the incidence, risk factors, and morbidity for osteon ecrosis (ON) in children with acute lymphoblastic leukemia (ALL) treated wi th intensive chemotherapy including multiple, prolonged courses of corticos teroid. Patients and Methods: The occurrence of symptomatic ON was investigated ret rospectively in 1,409 children ages 1 to 20 years old receiving therapy for high-risk ALL on Children's Cancer Group (CCG) protocol CCG-1882. Results: ON was diagnosed in 111 patients (9.3% +/- 0.9%, 3-year life-table incidence). The incidence was higher for older children (greater than or e qual to 10 years: 14.2% +/- 1.3% v < 10 years: 0.9% +/- 0.4%; P < .0001), e specially females 10 to 15 years old and males 16 to 20 years old (19.2% +/ - 2.3% and 20.7% +/- 4.7%, respectively). In patients 10 to 20 years old, t he incidence of ON was higher for females versus males (17.4% +/- 2.1% v 11 .7% +/- 1.6%, respectively; P = .03) and for patients randomized to receive two 21-day dexamethasone courses versus one course (23.2% +/- 4.8% v 16.4% +/- 4.3%, respectively; P = .27). Among ethnic groups, whites herd the hig hest incidence and blacks the lowest, with other groups intermediate (16.7% +/- 1.4% v 3.3% +/- 2.3% v 6.7% +/- 2.2%, respectively; P = .003). There w as no difference in event-free survival in patients with or without ON. ON wets diagnosed within 3 years of starting ALL therapy in all but one patien t, involved weight-bearing joint(s) in 94% of patients, and was multifocal in 74% of patients. Symptoms of pain and/or immobility were chronic in 84% of patients, with 24% having undergone an orthopedic procedure and an addit ional 15% considered candidates far surgery in the future. Conclusion: Children ages 10 to 20 years who receive intensive ALL therapy, including multiple courses of corticosteroid, are at significant risk for developing ON. (C) 2000 by American Society of Clinical Oncology.