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

Abstract

Avascular necrosis of bone is a well-described complication of cancer chemotherapy containing corticosteroids and has been observed in lymphomas and acute lymphoblastic leukemia (ALL). This study reports the case of a young male patient in whom avascular necrosis of right femur head was the presenting feature of acute lymphoblastic leukemia. The temporal association in this instance implicates a pathophysiologic relationship between the development of ALL and necrosis.

Early presentation of osteonecrosis in acute lymphoblastic leukemia: Two children from the Nordic and Baltic cohort

“…Leukostasis, thrombocytosis, and bone marrow hypercellular infiltration have been proposed to induce early ON development. In combination with changes in bone homeostasis during puberty, these changes caused by leukemia could create a state of ischemia in the bone that could induce ON.…”

“…Musculoskeletal symptoms, frequently present at ALL diagnosis, are mostly caused by lymphoblastic bone marrow infiltration, spinal compression fractures, and osteopenia and not by ON. Only one adult patient has been reported with the diagnosis of ON before ALL diagnosis, while all reported pediatric cases have been diagnosed during therapy. To further shed light to the pathogenesis of ALL‐related ON, we describe two children with symptoms and radiologically verified ON already at ALL diagnosis before cancer therapy.…”

Avascular Necrosis of Femoral Head as the Initial Manifestation of CML

“…Children treated for malignancy are at risk for AVN; factors implicated include metabolic factors, local factors affecting blood supply, increased intraosseous pressure, mechanical factors, and inhibition of angiogenesis by glucocorticoids and interferon [4-6, 9, 16]. AVN is a frequent complication of corticosteroid therapy in the treatment of lymphomas and acute leukemias and estimated to occur in 1-10% of patients [6].…”

Bilateral avascular necrosis of the femoral head following treatment of Ewing’s sarcoma

“…In contrast to some centers, our standard approach is to use simple non-rigid positioning aids as part of a strategy that tries to achieve comfort in combination with fast delivery and frequent imaging. We have previously published data on spine stability for patients undergoing lung SBRT, reporting that 92% of translational displacements were 1 mm (with SD in all three directions 0.4-0.6 mm) based on stereoscopic X-rays of the spine taken before and after volumetric modulated arc therapy (VMAT) delivery [6]. We use the same positioning strategy for the majority of SBRT treatments in the spine and bony pelvis.…”

“…Association between AVN of the femoral head and neoplasms has been described for hematological malignancies both as a presenting symptom of acute leukemia [6,7] and as a complication for treatment of Hodgkin's lymphoma [8]. For solid tumors sparse and casuistic reports of AVN following treatment of testicular cancer [9] and high-dose chemotherapy with autologous stem cell support for ovarian cancer have been published [10].…”