Avascular necrosis of bone following intensified steroid therapy for acute lymphoblastic leukaemia and high-grade malignant lymphoma.
Five out of nine adults (55%) with lymphoblastic disease developed severe avascular necrosis of bone (AVN) when treated with a Berlin-Frankfurt-Munster (BFM) ALL protocol similar to the current joint MRC-ECOG ALL trial (UKALL XII). The principal purpose of these intensified regimens is to improve long-term disease-free survival without necessarily increasing toxicity and secondary morbidity. The presentation of all five was non-specific bone pain occurring after the re-intensification block of chemotherapy containing high doses of dexamethasone. Three types of diagnostic imaging were performed and magnetic resonance imaging (MRI) proved superior in demonstrating AVN and showed it at an earlier stage than plain radiographs or isotopic scans. We believe that the dose of corticosteroids was the major factor in the development of AVN. The five men in our series all remain in first remission with a median disease-free survival of 3.5 years (range 2-8 years) but with varying degrees of disability due to AVN. Clinicians involved in UKALL XII and similar trials should be aware of this debilitating and potentially crippling complication when using high-dose steroid-containing regimens, perform MRI scan early and modify treatment if necessary.
Department of Haematology, Derriford Hospital, Plymouth.
D
D
Chan-Lam
A G
AG
Prentice
J A
JA
Copplestone
M
M
Weston
M
M
Williams
C W
CW
Hutton
D000293:Adolescent; D000328:Adult; D003907:Dexamethasone / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000473:pathology; D008228:Lymphoma, Non-Hodgkin / Q000188:drug therapy*; D008279:Magnetic Resonance Imaging; D008297:Male; D010020:Osteonecrosis / Q000139:chemically induced* / Q000175:diagnosis / Q000000981:diagnostic imaging; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy*; D011239:Prednisolone / Q000009:adverse effects; D011859:Radiography
D003907:Dexamethasone; D011239:Prednisolone