High body mass index increases the risk for osteonecrosis in children with acute lymphoblastic leukemia.
OBJECTIVE
The aim of the study was to determine the incidence of and clinical risk factors for radiographic osteonecrosis (ON) in children treated for acute lymphoblastic leukemia (ALL) using the Nordic ALL protocols.


METHODS
Ninety-seven consecutive patients with childhood ALL were studied prospectively by magnetic resonance imaging (MRI) of the lower extremities at the end of the treatment.


RESULTS
Twenty-three (24%) of the 97 patients had ON. Seven of the patients (30%) were symptomatic, and three patients (13%) required surgical interventions. Multiple logistic regression analysis showed that high body mass index (BMI; P = .04), female sex (P = .01), older age at diagnosis (P < .001), and higher cumulative dexamethasone dose (P = .03) were independent risk factors for radiographic ON. The cumulative prednisone dose did not differ significantly between the patients with and without ON. The incidence of radiographic ON decreased significantly, from 36% to 7%, when the duration of dexamethasone exposure during the delayed-intensification phase was shortened from 3 to 4 weeks to 2 weeks with a taper (P = .001).


CONCLUSIONS
ON as determined by MRI was found to be a common complication in children and adolescents after treatment with the Nordic ALL protocols. Revision of the ALL protocols by shortening the single exposure to dexamethasone has diminished the risk for ON remarkably. High BMI was identified as a new significant risk factor for ON.
Niinimäki
Riitta A
RA
Department of Pediatrics, Oulu University Hospital, Oulu, Finland. rsalonen@paju.oulu.fi
Harila-Saari
Arja H
AH
Jartti
Airi E
AE
Seuri
Raija M
RM
Riikonen
Pekka V
PV
Pääkkö
Eija L
EL
Möttönen
Merja I
MI
Lanning
Marjatta
M
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000009:adverse effects* / Q000627:therapeutic use; D017677:Age Distribution; D000704:Analysis of Variance; D015992:Body Mass Index; D015984:Causality; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D003907:Dexamethasone / Q000009:adverse effects / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D005260:Female; D005387:Finland / Q000453:epidemiology; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D010020:Osteonecrosis / Q000139:chemically induced / Q000175:diagnosis / Q000453:epidemiology*; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D011237:Predictive Value of Tests; D011241:Prednisone / Q000009:adverse effects / Q000627:therapeutic use; D015995:Prevalence; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution
D000305:Adrenal Cortex Hormones; D003907:Dexamethasone; D011241:Prednisone