title: Bony morbidity in children treated for acute lymphoblastic leukemia.
abstract: OBJECTIVE
  Corticosteroids are widely used in the treatment of acute lymphoblastic leukemia (ALL). To determine the frequency of corticosteroid-associated bony morbidity in children with ALL, we retrospectively evaluated the incidence of fractures and osteonecrosis (ON) on two consecutive pediatric ALL protocols.
  
  
  METHODS
  One hundred seventy-six consecutive children were treated for ALL between 1987 and 1995 at the Dana-Farber Cancer Institute and Children's Hospital. Prednisone was used as the corticosteroid during postremission therapy from 1987 to 1991, and dexamethasone was used from 1991 to 1995. Medical records for all patients were reviewed to assess the occurrence of fractures and ON.
  
  
  RESULTS
  With a median follow-up of 7.6 years, the 5-year cumulative incidence (CI) +/- SE of any bony morbidity for the 176 patients was 30% +/- 4%, with a 5-year CI of fractures of 28% +/- 3% and of ON of 7% +/- 2%. With multivariate analysis, independent predictors of bony morbidity included age 9 to 18 years at diagnosis (P <.01), male sex (P <.01), and treatment with dexamethasone (P =.01). Dexamethasone was associated with a higher risk of fractures (5-year CI, 36% +/- 5% v 20% +/- 4% with prednisone; P =.04), but not ON (P =.40). The 5-year event-free survival for the 176 patients was 79% +/- 3%.
  
  
  CONCLUSIONS
  Children treated for ALL had a high incidence of fractures and ON. Older children, boys, and patients receiving dexamethasone were at increased risk for the development of bony morbidity. Future studies should attempt to minimize corticosteroid-associated bony morbidity without compromising clinical efficacy.
authors.affiliation: Department of Pediatrics, Massachusetts General Hospital, USA.
authors.forename: A J
authors.initials: AJ
authors.lastname: Strauss
authors.forename: J T
authors.initials: JT
authors.lastname: Su
authors.forename: V M
authors.initials: VM
authors.lastname: Dalton
authors.forename: R D
authors.initials: RD
authors.lastname: Gelber
authors.forename: S E
authors.initials: SE
authors.lastname: Sallan
authors.forename: L B
authors.initials: LB
authors.lastname: Silverman
mesh_terms: D000293:Adolescent; D000704:Analysis of Variance; D018931:Antineoplastic Agents, Hormonal / Q000009:adverse effects*; D001900:Boston / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003907:Dexamethasone / Q000009:adverse effects*; D018572:Disease-Free Survival; D005260:Female; D005598:Fractures, Spontaneous / Q000139:chemically induced* / Q000453:epidemiology; D005938:Glucocorticoids / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010020:Osteonecrosis / Q000139:chemically induced* / Q000453:epidemiology; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy* / Q000401:mortality; D011241:Prednisone / Q000009:adverse effects*; D011379:Prognosis; D012044:Regression Analysis; D012189:Retrospective Studies
chemical_list: D018931:Antineoplastic Agents, Hormonal; D005938:Glucocorticoids; D003907:Dexamethasone; D011241:Prednisone