title: Influence of Musculoskeletal Manifestations as the Only Presenting Symptom in B-Cell Acute Lymphoblastic Leukemia.
abstract: To evaluate the clinical and prognostic impact of musculoskeletal manifestations as the only initial presenting symptom in childhood acute lymphoblastic leukemia (ALL).
  
  
  
  We retrospectively reviewed 158 children with precursor B-cell type ALL who were followed up for >2 years. The patients were assigned to the groups musculoskeletal manifestations (n = 24) or nonmusculoskeletal manifestations (n = 134) based on initial presenting symptom. The symptom duration (regarding any initial presenting symptom) and the leukemic symptom duration (regarding symptoms of systemic manifestation, such as fever, bleeding, or pallor) were assessed, along with other clinical characteristics.
  
  
  
  The musculoskeletal manifestations group exhibited a longer symptom duration than the nonmusculoskeletal manifestations group (43 days vs 22 days, P = .006), but overall survival did not significantly differ between the groups. Multivariate analysis indicated that a longer symptom duration did not affect prognosis but that a longer leukemic symptom duration was associated with a poorer prognosis (hazard ratio, 7.720; P = .048).
  
  
  
  Musculoskeletal manifestations are associated significantly with diagnostic delay, but this delay does not affect the prognosis. Diagnostic delay after the onset of leukemic symptoms, however, does appear to affect the prognosis. Intensive evaluations for hematologic malignancies may be unnecessary in children who complain of limb pain without any definite cause, unless they also present with accompanying leukemic symptoms.
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Seungcheol
authors.initials: S
authors.lastname: Kang
authors.affiliation: Department of Pediatrics, Division of Pediatric Hematology/Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Ho Joon
authors.initials: HJ
authors.lastname: Im
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Kunhyung
authors.initials: K
authors.lastname: Bae
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address: sspark@amc.seoul.kr.
authors.forename: Soo-Sung
authors.initials: SS
authors.lastname: Park
mesh_terms: D000293:Adolescent; D000367:Age Factors; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D057210:Delayed Diagnosis; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D009140:Musculoskeletal Diseases / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality*; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D018709:Statistics, Nonparametric; D016019:Survival Analysis
keywords: children; limb pain; overall survival; symptom duration