Late Effects of the Musculoskeletal System
The musculoskeletal system of growing children and adolescents is vulnerable to the cytotoxic effects of cancer therapies, including surgery, chemotherapy, and radiation therapy. Documented late effects include the following:
- Bone and joint (abnormal bone and/or muscle growth) problems.
- Deformity and functional loss associated with amputation/limb-sparing surgery, joint contracture, osteoporosis/fractures, and osteonecrosis.
- Changes in body composition (obesity and loss of lean muscle mass).
While these late effects are discussed individually, it is important to remember that the components of the musculoskeletal system are interrelated. For example, hypoplasia to a muscle group can negatively affect the function of the long bones and the resultant dysfunction can subsequently lead to disuse and osteoporosis.
The major strength of the published literature documenting musculoskeletal late effects among children and adolescents treated for cancer is that most studies have clearly defined outcomes and exposures. However, many studies are observational and cross-sectional or retrospective in design. Single-institution studies are common, and for some outcomes, only small convenience cohorts have been described. Thus, it is possible that studies either excluded patients with the most severe musculoskeletal effects because of death or inability to participate in follow-up testing, or oversampled those with the most severe musculoskeletal late effects because these patients were accessible because they returned for complication-related follow-up. Additionally, some of the results reported in adult survivors of childhood cancer may not be relevant to patients currently being treated because the delivery of anticancer modalities, particularly radiation, has changed over the years in response to documented toxicities.[1,2]
Bone and Joint
Abnormal bone growth
Radiation to the head and brain
In an age- and dose-dependent fashion, radiation can inhibit normal bone and muscle maturation and development. Radiation to the head (e.g., cranial, orbital, infratemporal, or nasopharyngeal radiation therapy) can cause craniofacial abnormalities, particularly in children treated before age 5 years or with radiation doses of 20 Gy or more.[3-7] Soft tissue sarcomas such as orbital rhabdomyosarcoma and retinoblastoma are two of the more common cancer groups treated with these radiation fields. Often, in addition to the cosmetic impact of the craniofacial abnormalities, there can be related dental and sinus problems.
Cranial radiation therapy damages the hypothalamic-pituitary axis in an age- and dose-response fashion, and can result in growth hormone deficiency (GHD).[8,9] If untreated during the growing years, and sometimes, even with appropriate treatment, it leads to a substantially lower final height. Patients with a central nervous system tumor [8,10] or acute lymphoblastic leukemia (ALL) [11-13] treated with 18 Gy or more of cranial radiation therapy are at highest risk. Also, patients treated with total-body irradiation (TBI), particularly single-fraction TBI, are at risk of GHD.[14-17] In addition, if the spine is also irradiated (e.g., craniospinal radiation therapy for medulloblastoma or early ALL therapies in the 1960s), growth can be affected by two separate mechanisms—GHD and direct damage to the spine.
Radiation to the spine and long bones
- Short stature.
- Asymmetric growth (scoliosis/kyphosis).
- Limb-length discrepancy.
Orthovoltage radiation, commonly used before 1970, delivered high doses of radiation to bone and was commonly associated with subsequent abnormalities in bone growth. However, even with contemporary radiation therapy, if a solid tumor is located near an epiphysis or the spine, alterations in normal bone development can be difficult to avoid.
The effects of radiation administered to the spine on stature in survivors of Wilms tumor have been assessed.
- In the National Wilms Tumor Study (NWTS), studies 1 through 4, stature loss in 2,778 children was evaluated. Repeated height measurements were collected during long-term follow-up. The effects of radiation dosage, age at treatment, and chemotherapy on stature were analyzed using statistical models that accounted for the normal variation in height with gender and advancing age. Predictions from the model were validated by descriptive analysis of heights measured at ages 17 to 18 years for 205 patients. For those younger than 12 months at diagnosis who received more than 10 Gy, the estimated adult-height deficit was 7.7 cm when contrasted with the nonradiation group. For those who received 10 Gy, the estimated trunk shortening was 2.8 cm or less. Among those whose height measurements in the teenage years were available, patients who received more than 15 Gy of radiation therapy were 4 to 7 cm shorter on average than their nonirradiated counterparts, with a dose-response relationship evident. Chemotherapy did not confer additional risk.
- The effect of radiation on the development of scoliosis has also been re-evaluated. In a group of 42 children treated for Wilms tumor from 1968 to 1994, scoliosis was seen in 18 patients, with only one patient needing orthopedic intervention. Median time to development of scoliosis was 102 months (range, 16–146 months). A clear dose-response relationship was seen; children treated with lower dosages (<24 Gy) of radiation had a significantly lower incidence of scoliosis than those who received more than 24 Gy of radiation. There was also a suggestion that the incidence was lower in patients who received 10 to 12 Gy, the dosages currently used for Wilms tumor, although the sample size was small.
Maximal peak bone mass is an important factor influencing the risk of osteoporosis and fracture associated with aging. Treatment-related factors that affect bone mineral loss include the following:
- Chemotherapy. Methotrexate has a cytotoxic effect on osteoblasts, resulting in a reduction of bone volume and formation of new bone.[26,27] This effect may be exacerbated by the chronic use of corticosteroids, another class of agents routinely used in the treatment of hematological malignancies and in supportive care for a variety of pediatric cancers.
- Radiation therapy. Radiation-related endocrinopathies, such as GHD or hypogonadism, may contribute to ongoing bone mineral loss.[28,29]
- Suboptimal nutrition and physical inactivity may further predispose to deficits in bone mineral accretion.
Most of our knowledge about cancer and treatment effects on bone mineralization has been derived from studies of children with ALL.[26,30] In this group, the leukemic process, and possibly vitamin D deficiency, may play a role in the alterations in bone metabolism and bone mass observed at diagnosis. Antileukemic therapy causes further bone mineral density loss, which has been reported to normalize over time [33,34] or to persist for many years after completion of therapy.[35,36] Clinical factors predicting higher risk of low bone mineral density include treatment with high cumulative doses of methotrexate (>40 g/m2), high cumulative doses of corticosteroids (>9 g/m2), cranial radiation, and use of more potent glucocorticoids like dexamethasone.[35,37-39]
Clinical assessment of bone mineral density in adults treated for childhood ALL indicates that most bone mineral deficits normalize over time after discontinuing osteotoxic therapy. Very low bone mineral density was relatively uncommon in a cohort of 845 adult survivors of childhood ALL evaluated at a median age of 31 years, with only 5.7% and 23.8% demonstrating bone mineral density z-scores consistent with osteoporosis and osteopenia, respectively. Cranial radiation dose of 24 Gy or greater, but not cumulative methotrexate or prednisone equivalent doses, was associated with a twofold elevated risk of bone mineral density z-scores of -1 or lower. In a subset of 400 survivors with longitudinal bone mineral density evaluations, bone mineral density z-scores tended to improve from adolescence to young adulthood.
Bone mineral density deficits that are likely multifactorial in etiology have been reported in allogeneic hematopoietic cell transplant recipients conditioned with TBI.[40,41] French investigators observed a significant risk for lower femoral bone mineral density among adult survivors of childhood leukemia treated with hematopoietic stem cell transplantation (HSCT) who had gonadal deficiency. Hormonal therapy has been shown to enhance bone mineral density of adolescent girls diagnosed with hypogonadism after HSCT.[Level of evidence: 3iiiC]
Despite disease- and treatment-related risks of bone mineral density deficits, the prevalence of self-reported fractures among Childhood Cancer Survivor Study (CCSS) participants was lower than that reported by sibling controls. Predictors of increased prevalence of fracture by multivariable analyses included the following:
- Among female survivors, increasing age at follow-up, white race, methotrexate treatment, and balance difficulties.
- Among male survivors, smoking history and white race.
Osteonecrosis (also known as aseptic or avascular necrosis) is a rare, but well-recognized skeletal complication observed predominantly in survivors of pediatric hematological malignancies treated with corticosteroids.[47-49] The prevalence of osteonecrosis has varied from 1% to 22% based on the study population, treatment protocol, method of evaluation, and time from treatment.[49-55] The condition is characterized by death of one or more segments of bone that most often affects weight-bearing joints, especially the hips and knees. Longitudinal cohort studies have identified a spectrum of clinical manifestations of osteonecrosis, ranging from asymptomatic, spontaneously-resolving imaging changes to painful progressive articular collapse requiring joint replacement.[56,57] Symptomatic osteonecrosis characterized by pain, joint swelling, and reduced mobility typically presents during the first 2 years of therapy, particularly in patients with ALL. These symptoms may improve over time, persist, or progress in the years after completion of therapy. In one series, 60% of patients continued to have symptoms at a median follow-up of 4.9 years after diagnosis of osteonecrosis. Surgical procedures, including core decompression, osteotomy and joint replacements, are sometimes performed in those with persistently severe symptoms.
Factors that increase the risk of osteonecrosis include the following:
- Exposure to corticosteroids, and possibly methotrexate and concurrent asparaginase. The most important treatment factor associated with the development of osteonecrosis is prolonged exposure to corticosteroids, which is typical in regimens used for ALL, non-Hodgkin lymphoma, and HSCT.[52,55,59,60] Osteonecrosis risk may be related to type of corticosteroid, with some studies in patients with ALL indicating increased risk with the use of dexamethasone compared with prednisone. Corticosteroid dosing schedule also appears to impact the risk of developing osteonecrosis. In the Children’s Oncology Group (COG) 1961 trial for newly diagnosed high-risk ALL, patients were randomly assigned to receive either continuous (daily) dexamethasone or an alternate-week schedule of dexamethasone during the delayed intensification phase; the alternate-week schedule was associated with a lower incidence of osteonecrosis. In addition to corticosteroids, exposure to methotrexate and concurrent asparaginase may contribute to the development of osteonecrosis.
- Age at time of diagnosis or transplant. Several studies have demonstrated that age at diagnosis (or at time of transplant) is a significant independent predictor of osteonecrosis.[49,50,59,55,58,61] Osteonecrosis is significantly more common in older children and adolescents than in younger children. In the COG-1961 trial for high-risk ALL, the 5-year cumulative incidence of symptomatic osteonecrosis was 1.0% for patients aged 1 to 9 years, 9.9% for patients aged 10 to 15 years, and 20% for patients aged 16 to 21 years (P < .0001).
- Race. Osteonecrosis also occurs more frequently in whites than in blacks.[60,63]
- Genetic factors. Genetic factors influencing antifolate and glucocorticoid metabolism have also been linked to excess risk of osteonecrosis among survivors. St. Jude Children's Research Hospital investigators observed an almost sixfold (odds ratio, 5.6; 95% confidence interval, 2.7–11.3) risk of osteonecrosis among survivors with polymorphism of the ACP1 gene, which regulates lipid levels and osteoblast differentiation.
Studies evaluating the influence of gender on the risk of osteonecrosis have yielded conflicting results, with some suggesting a higher incidence in females [56,58,63] that has not been confirmed by others.[48,56]
Approximately 5% of children undergoing myeloablative stem cell transplantation will develop osteochondroma, a benign bone tumor that most commonly presents in the metaphyseal regions of long bones. Osteochondroma generally occurs as a single lesion, however multiple lesions may develop in the context of hereditary multiple osteochondromatosis. A large Italian study reported a 6.1% cumulative risk of developing osteochondroma at 15 years posttransplant, with increased risk associated with younger age at transplant (≤3 years) and use of TBI. Growth hormone therapy may influence the onset and pace of growth of osteochondromas.[17,66]
Because malignant degeneration of these lesions is exceptionally rare, clinical rather than radiological follow-up is most appropriate. Surgical resection is only necessary when the lesion interferes with joint alignment and movement.
Amputation and limb-sparing surgery
Amputation and limb-sparing surgery prevent local recurrence of bone tumors by removal of all gross and microscopic disease. If optimally executed, both procedures accomplish an en bloc excision of tumor with a margin of normal uninvolved tissue. The type of surgical procedure, the primary tumor site, and the age of the patient affect the risk of postsurgical complications. Complications in survivors treated with amputation include prosthetic fit problems, chronic pain in the residual limb, phantom limb pain, and bone overgrowth.[69,70] While limb-sparing surgeries may offer a more aesthetically pleasing outcome, complications have been reported more frequently in survivors who underwent these procedures than in those treated with amputation. Complications after limb-sparing surgery include non-union, pathologic fracture, aseptic loosening, limb-length discrepancy, endoprosthetic fracture, and limited joint range of motion.[69,71] Occasionally, refractory complications develop after limb-sparing surgery and require amputation.[72,73]
A number of studies have compared functional outcomes after amputation and limb-sparing surgery, but results have been limited by inconsistent methods of functional assessment and small cohort sizes. Overall, data suggest that limb-sparing surgery results in better function than amputation, but differences are relatively modest.[69,73] Similarly, long-term quality of life outcomes among survivors undergoing amputation and limb sparing procedures have not differed substantially. A longitudinal analysis of health status among extremity sarcoma survivors in the CCSS indicates an association between lower extremity amputation and increasing activity limitations with age, and an association between upper extremity amputation and lower educational attainment.
|Predisposing Therapy||Musculoskeletal Effects||Health Screening|
|CT = computed tomography; DXA = dual-energy x-ray absorptiometry; GVHD = graft-versus-host disease; HSCT = hematopoietic stem cell transplantation.|
|Radiation impacting musculoskeletal system||Hypoplasia; fibrosis; reduced/uneven growth (scoliosis, kyphosis); limb length discrepancy||Exam: bones and soft tissues in radiation fields|
|Radiation impacting head and neck||Craniofacial abnormalities||History: psychosocial assessment, with attention to: educational and/or vocational progress, depression, anxiety, posttraumatic stress, social withdrawal|
|Head and neck exam|
|Radiation impacting musculoskeletal system||Radiation-induced fracture||Exam of affected bone|
|Methotrexate; corticosteroids (dexamethasone, prednisone); radiation impacting skeletal structures; HSCT||Reduced bone mineral density||Bone mineral density test (DXA or quantitative CT)|
|Corticosteroids (dexamethasone, prednisone)||Osteonecrosis||History: joint pain, swelling, immobility, limited range of motion|
|Radiation with impact to oral cavity||Osteoradionecrosis||History/oral exam: impaired or delayed healing after dental work, persistent jaw pain or swelling, trismus|
|Amputation||Amputation-related complications (impaired cosmesis, functional/activity limitations, residual limb integrity, chronic pain, increased energy expenditure)||History: pain, functional/activity limitations|
|Exam: residual limb integrity|
|Limb-sparing surgery||Limb-sparing surgical complications (functional/activity limitations, fibrosis, contractures, chronic infection, chronic pain, limb length discrepancy, increased energy expenditure, prosthetic malfunction [loosening, non-union, fracture])||History: pain, functional/activity limitations|
|Exam: residual limb integrity|
|Radiograph of affected limb|
|HSCT with any history of chronic GVHD||Joint contracture||Musculoskeletal exam|
Refer to the Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers for musculoskeletal system late effects information, including risk factors, evaluation, and health counseling.
- Green DM: 11th International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer. Forward. Pediatr Blood Cancer 58 (1): 111, 2012. [PUBMED Abstract]
- Hudson MM, Neglia JP, Woods WG, et al.: Lessons from the past: opportunities to improve childhood cancer survivor care through outcomes investigations of historical therapeutic approaches for pediatric hematological malignancies. Pediatr Blood Cancer 58 (3): 334-43, 2012. [PUBMED Abstract]
- Estilo CL, Huryn JM, Kraus DH, et al.: Effects of therapy on dentofacial development in long-term survivors of head and neck rhabdomyosarcoma: the memorial sloan-kettering cancer center experience. J Pediatr Hematol Oncol 25 (3): 215-22, 2003. [PUBMED Abstract]
- Gevorgyan A, La Scala GC, Neligan PC, et al.: Radiation-induced craniofacial bone growth disturbances. J Craniofac Surg 18 (5): 1001-7, 2007. [PUBMED Abstract]
- Karsila-Tenovuo S, Jahnukainen K, Peltomäki T, et al.: Disturbances in craniofacial morphology in children treated for solid tumors. Oral Oncol 37 (7): 586-92, 2001. [PUBMED Abstract]
- Paulino AC, Simon JH, Zhen W, et al.: Long-term effects in children treated with radiotherapy for head and neck rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 48 (5): 1489-95, 2000. [PUBMED Abstract]
- Choi SY, Kim MS, Yoo S, et al.: Long term follow-up results of external beam radiotherapy as primary treatment for retinoblastoma. J Korean Med Sci 25 (4): 546-51, 2010. [PUBMED Abstract]
- Sklar CA, Constine LS: Chronic neuroendocrinological sequelae of radiation therapy. Int J Radiat Oncol Biol Phys 31 (5): 1113-21, 1995. [PUBMED Abstract]
- Brownstein CM, Mertens AC, Mitby PA, et al.: Factors that affect final height and change in height standard deviation scores in survivors of childhood cancer treated with growth hormone: a report from the childhood cancer survivor study. J Clin Endocrinol Metab 89 (9): 4422-7, 2004. [PUBMED Abstract]
- Packer RJ, Boyett JM, Janss AJ, et al.: Growth hormone replacement therapy in children with medulloblastoma: use and effect on tumor control. J Clin Oncol 19 (2): 480-7, 2001. [PUBMED Abstract]
- Chow EJ, Friedman DL, Yasui Y, et al.: Decreased adult height in survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study. J Pediatr 150 (4): 370-5, 375.e1, 2007. [PUBMED Abstract]
- Sklar C, Mertens A, Walter A, et al.: Final height after treatment for childhood acute lymphoblastic leukemia: comparison of no cranial irradiation with 1800 and 2400 centigrays of cranial irradiation. J Pediatr 123 (1): 59-64, 1993. [PUBMED Abstract]
- Bongers ME, Francken AB, Rouwé C, et al.: Reduction of adult height in childhood acute lymphoblastic leukemia survivors after prophylactic cranial irradiation. Pediatr Blood Cancer 45 (2): 139-43, 2005. [PUBMED Abstract]
- Huma Z, Boulad F, Black P, et al.: Growth in children after bone marrow transplantation for acute leukemia. Blood 86 (2): 819-24, 1995. [PUBMED Abstract]
- Leung W, Ahn H, Rose SR, et al.: A prospective cohort study of late sequelae of pediatric allogeneic hematopoietic stem cell transplantation. Medicine (Baltimore) 86 (4): 215-24, 2007. [PUBMED Abstract]
- Sanders JE: Growth and development after hematopoietic cell transplant in children. Bone Marrow Transplant 41 (2): 223-7, 2008. [PUBMED Abstract]
- Sanders JE, Guthrie KA, Hoffmeister PA, et al.: Final adult height of patients who received hematopoietic cell transplantation in childhood. Blood 105 (3): 1348-54, 2005. [PUBMED Abstract]
- Fletcher BD: Effects of pediatric cancer therapy on the musculoskeletal system. Pediatr Radiol 27 (8): 623-36, 1997. [PUBMED Abstract]
- Hogeboom CJ, Grosser SC, Guthrie KA, et al.: Stature loss following treatment for Wilms tumor. Med Pediatr Oncol 36 (2): 295-304, 2001. [PUBMED Abstract]
- Merchant TE, Nguyen L, Nguyen D, et al.: Differential attenuation of clavicle growth after asymmetric mantle radiotherapy. Int J Radiat Oncol Biol Phys 59 (2): 556-61, 2004. [PUBMED Abstract]
- Willman KY, Cox RS, Donaldson SS: Radiation induced height impairment in pediatric Hodgkin's disease. Int J Radiat Oncol Biol Phys 28 (1): 85-92, 1994. [PUBMED Abstract]
- Wallace WH, Shalet SM, Morris-Jones PH, et al.: Effect of abdominal irradiation on growth in boys treated for a Wilms' tumor. Med Pediatr Oncol 18 (6): 441-6, 1990. [PUBMED Abstract]
- Silber JH, Littman PS, Meadows AT: Stature loss following skeletal irradiation for childhood cancer. J Clin Oncol 8 (2): 304-12, 1990. [PUBMED Abstract]
- Hartley KA, Li C, Laningham FH, et al.: Vertebral body growth after craniospinal irradiation. Int J Radiat Oncol Biol Phys 70 (5): 1343-9, 2008. [PUBMED Abstract]
- Paulino AC, Wen BC, Brown CK, et al.: Late effects in children treated with radiation therapy for Wilms' tumor. Int J Radiat Oncol Biol Phys 46 (5): 1239-46, 2000. [PUBMED Abstract]
- Wasilewski-Masker K, Kaste SC, Hudson MM, et al.: Bone mineral density deficits in survivors of childhood cancer: long-term follow-up guidelines and review of the literature. Pediatrics 121 (3): e705-13, 2008. [PUBMED Abstract]
- Davies JH, Evans BA, Jenney ME, et al.: Skeletal morbidity in childhood acute lymphoblastic leukaemia. Clin Endocrinol (Oxf) 63 (1): 1-9, 2005. [PUBMED Abstract]
- van der Sluis IM, Boot AM, Hop WC, et al.: Long-term effects of growth hormone therapy on bone mineral density, body composition, and serum lipid levels in growth hormone deficient children: a 6-year follow-up study. Horm Res 58 (5): 207-14, 2002. [PUBMED Abstract]
- van der Sluis IM, van den Heuvel-Eibrink MM, Hählen K, et al.: Bone mineral density, body composition, and height in long-term survivors of acute lymphoblastic leukemia in childhood. Med Pediatr Oncol 35 (4): 415-20, 2000. [PUBMED Abstract]
- Oeffinger KC, Hudson MM, Landier W: Survivorship: childhood cancer survivors. Prim Care 36 (4): 743-80, 2009. [PUBMED Abstract]
- van der Sluis IM, van den Heuvel-Eibrink MM, Hählen K, et al.: Altered bone mineral density and body composition, and increased fracture risk in childhood acute lymphoblastic leukemia. J Pediatr 141 (2): 204-10, 2002. [PUBMED Abstract]
- Arikoski P, Komulainen J, Riikonen P, et al.: Reduced bone density at completion of chemotherapy for a malignancy. Arch Dis Child 80 (2): 143-8, 1999. [PUBMED Abstract]
- Brennan BM, Mughal Z, Roberts SA, et al.: Bone mineral density in childhood survivors of acute lymphoblastic leukemia treated without cranial irradiation. J Clin Endocrinol Metab 90 (2): 689-94, 2005. [PUBMED Abstract]
- Kadan-Lottick N, Marshall JA, Barón AE, et al.: Normal bone mineral density after treatment for childhood acute lymphoblastic leukemia diagnosed between 1991 and 1998. J Pediatr 138 (6): 898-904, 2001. [PUBMED Abstract]
- Kaste SC, Jones-Wallace D, Rose SR, et al.: Bone mineral decrements in survivors of childhood acute lymphoblastic leukemia: frequency of occurrence and risk factors for their development. Leukemia 15 (5): 728-34, 2001. [PUBMED Abstract]
- Warner JT, Evans WD, Webb DK, et al.: Relative osteopenia after treatment for acute lymphoblastic leukemia. Pediatr Res 45 (4 Pt 1): 544-51, 1999. [PUBMED Abstract]
- Mandel K, Atkinson S, Barr RD, et al.: Skeletal morbidity in childhood acute lymphoblastic leukemia. J Clin Oncol 22 (7): 1215-21, 2004. [PUBMED Abstract]
- Holzer G, Krepler P, Koschat MA, et al.: Bone mineral density in long-term survivors of highly malignant osteosarcoma. J Bone Joint Surg Br 85 (2): 231-7, 2003. [PUBMED Abstract]
- Gurney JG, Kaste SC, Liu W, et al.: Bone mineral density among long-term survivors of childhood acute lymphoblastic leukemia: results from the St. Jude Lifetime Cohort Study. Pediatr Blood Cancer 61 (7): 1270-6, 2014. [PUBMED Abstract]
- Benmiloud S, Steffens M, Beauloye V, et al.: Long-term effects on bone mineral density of different therapeutic schemes for acute lymphoblastic leukemia or non-Hodgkin lymphoma during childhood. Horm Res Paediatr 74 (4): 241-50, 2010. [PUBMED Abstract]
- McClune BL, Polgreen LE, Burmeister LA, et al.: Screening, prevention and management of osteoporosis and bone loss in adult and pediatric hematopoietic cell transplant recipients. Bone Marrow Transplant 46 (1): 1-9, 2011. [PUBMED Abstract]
- Le Meignen M, Auquier P, Barlogis V, et al.: Bone mineral density in adult survivors of childhood acute leukemia: impact of hematopoietic stem cell transplantation and other treatment modalities. Blood 118 (6): 1481-9, 2011. [PUBMED Abstract]
- Kodama M, Komura H, Shimizu S, et al.: Efficacy of hormone therapy for osteoporosis in adolescent girls after hematopoietic stem cell transplantation: a longitudinal study. Fertil Steril 95 (2): 731-5, 2011. [PUBMED Abstract]
- Wilson CL, Dilley K, Ness KK, et al.: Fractures among long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Cancer 118 (23): 5920-8, 2012. [PUBMED Abstract]
- Paulino AC: Late effects of radiotherapy for pediatric extremity sarcomas. Int J Radiat Oncol Biol Phys 60 (1): 265-74, 2004. [PUBMED Abstract]
- Wagner LM, Neel MD, Pappo AS, et al.: Fractures in pediatric Ewing sarcoma. J Pediatr Hematol Oncol 23 (9): 568-71, 2001. [PUBMED Abstract]
- Sala A, Mattano LA Jr, Barr RD: Osteonecrosis in children and adolescents with cancer - an adverse effect of systemic therapy. Eur J Cancer 43 (4): 683-9, 2007. [PUBMED Abstract]
- Elmantaser M, Stewart G, Young D, et al.: Skeletal morbidity in children receiving chemotherapy for acute lymphoblastic leukaemia. Arch Dis Child 95 (10): 805-9, 2010. [PUBMED Abstract]
- Mattano LA Jr, Devidas M, Nachman JB, et al.: Effect of alternate-week versus continuous dexamethasone scheduling on the risk of osteonecrosis in paediatric patients with acute lymphoblastic leukaemia: results from the CCG-1961 randomised cohort trial. Lancet Oncol 13 (9): 906-15, 2012. [PUBMED Abstract]
- Bürger B, Beier R, Zimmermann M, et al.: Osteonecrosis: a treatment related toxicity in childhood acute lymphoblastic leukemia (ALL)--experiences from trial ALL-BFM 95. Pediatr Blood Cancer 44 (3): 220-5, 2005. [PUBMED Abstract]
- Karimova EJ, Rai SN, Howard SC, et al.: Femoral head osteonecrosis in pediatric and young adult patients with leukemia or lymphoma. J Clin Oncol 25 (12): 1525-31, 2007. [PUBMED Abstract]
- Karimova EJ, Wozniak A, Wu J, et al.: How does osteonecrosis about the knee progress in young patients with leukemia?: a 2- to 7-year study. Clin Orthop Relat Res 468 (9): 2454-9, 2010. [PUBMED Abstract]
- Campbell S, Sun CL, Kurian S, et al.: Predictors of avascular necrosis of bone in long-term survivors of hematopoietic cell transplantation. Cancer 115 (18): 4127-35, 2009. [PUBMED Abstract]
- Kawedia JD, Kaste SC, Pei D, et al.: Pharmacokinetic, pharmacodynamic, and pharmacogenetic determinants of osteonecrosis in children with acute lymphoblastic leukemia. Blood 117 (8): 2340-7; quiz 2556, 2011. [PUBMED Abstract]
- Girard P, Auquier P, Barlogis V, et al.: Symptomatic osteonecrosis in childhood leukemia survivors: prevalence, risk factors and impact on quality of life in adulthood. Haematologica 98 (7): 1089-97, 2013. [PUBMED Abstract]
- Aricò M, Boccalatte MF, Silvestri D, et al.: Osteonecrosis: An emerging complication of intensive chemotherapy for childhood acute lymphoblastic leukemia. Haematologica 88 (7): 747-53, 2003. [PUBMED Abstract]
- Ribeiro RC, Fletcher BD, Kennedy W, et al.: Magnetic resonance imaging detection of avascular necrosis of the bone in children receiving intensive prednisone therapy for acute lymphoblastic leukemia or non-Hodgkin lymphoma. Leukemia 15 (6): 891-7, 2001. [PUBMED Abstract]
- te Winkel ML, Pieters R, Hop WC, et al.: Prospective study on incidence, risk factors, and long-term outcome of osteonecrosis in pediatric acute lymphoblastic leukemia. J Clin Oncol 29 (31): 4143-50, 2011. [PUBMED Abstract]
- Faraci M, Calevo MG, Lanino E, et al.: Osteonecrosis after allogeneic stem cell transplantation in childhood. A case-control study in Italy. Haematologica 91 (8): 1096-9, 2006. [PUBMED Abstract]
- Relling MV, Yang W, Das S, et al.: Pharmacogenetic risk factors for osteonecrosis of the hip among children with leukemia. J Clin Oncol 22 (19): 3930-6, 2004. [PUBMED Abstract]
- Vrooman LM, Stevenson KE, Supko JG, et al.: Postinduction dexamethasone and individualized dosing of Escherichia Coli L-asparaginase each improve outcome of children and adolescents with newly diagnosed acute lymphoblastic leukemia: results from a randomized study--Dana-Farber Cancer Institute ALL Consortium Protocol 00-01. J Clin Oncol 31 (9): 1202-10, 2013. [PUBMED Abstract]
- Yang L, Panetta JC, Cai X, et al.: Asparaginase may influence dexamethasone pharmacokinetics in acute lymphoblastic leukemia. J Clin Oncol 26 (12): 1932-9, 2008. [PUBMED Abstract]
- Mattano LA Jr, Sather HN, Trigg ME, et al.: Osteonecrosis as a complication of treating acute lymphoblastic leukemia in children: a report from the Children's Cancer Group. J Clin Oncol 18 (18): 3262-72, 2000. [PUBMED Abstract]
- Bovée JV: Multiple osteochondromas. Orphanet J Rare Dis 3: 3, 2008. [PUBMED Abstract]
- Faraci M, Bagnasco F, Corti P, et al.: Osteochondroma after hematopoietic stem cell transplantation in childhood. An Italian study on behalf of the AIEOP-HSCT group. Biol Blood Marrow Transplant 15 (10): 1271-6, 2009. [PUBMED Abstract]
- Bordigoni P, Turello R, Clement L, et al.: Osteochondroma after pediatric hematopoietic stem cell transplantation: report of eight cases. Bone Marrow Transplant 29 (7): 611-4, 2002. [PUBMED Abstract]
- Taitz J, Cohn RJ, White L, et al.: Osteochondroma after total body irradiation: an age-related complication. Pediatr Blood Cancer 42 (3): 225-9, 2004. [PUBMED Abstract]
- King EA, Hanauer DA, Choi SW, et al.: Osteochondromas after radiation for pediatric malignancies: a role for expanded counseling for skeletal side effects. J Pediatr Orthop 34 (3): 331-5, 2014 Apr-May. [PUBMED Abstract]
- Nagarajan R, Neglia JP, Clohisy DR, et al.: Limb salvage and amputation in survivors of pediatric lower-extremity bone tumors: what are the long-term implications? J Clin Oncol 20 (22): 4493-501, 2002. [PUBMED Abstract]
- Aulivola B, Hile CN, Hamdan AD, et al.: Major lower extremity amputation: outcome of a modern series. Arch Surg 139 (4): 395-9; discussion 399, 2004. [PUBMED Abstract]
- Kaste SC, Neel MN, Rao BN, et al.: Complications of limb-sparing procedures using endoprosthetic replacements about the knee for pediatric skeletal sarcomas. Pediatr Radiol 31 (2): 62-71, 2001. [PUBMED Abstract]
- Eiser C, Darlington AS, Stride CB, et al.: Quality of life implications as a consequence of surgery: limb salvage, primary and secondary amputation. Sarcoma 5 (4): 189-95, 2001. [PUBMED Abstract]
- Renard AJ, Veth RP, Schreuder HW, et al.: Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol 73 (4): 198-205, 2000. [PUBMED Abstract]
- Marina N, Hudson MM, Jones KE, et al.: Changes in health status among aging survivors of pediatric upper and lower extremity sarcoma: a report from the childhood cancer survivor study. Arch Phys Med Rehabil 94 (6): 1062-73, 2013. [PUBMED Abstract]
- Antin JH: Clinical practice. Long-term care after hematopoietic-cell transplantation in adults. N Engl J Med 347 (1): 36-42, 2002. [PUBMED Abstract]
- Beredjiklian PK, Drummond DS, Dormans JP, et al.: Orthopaedic manifestations of chronic graft-versus-host disease. J Pediatr Orthop 18 (5): 572-5, 1998 Sep-Oct. [PUBMED Abstract]
- Inamoto Y, Storer BE, Petersdorf EW, et al.: Incidence, risk factors, and outcomes of sclerosis in patients with chronic graft-versus-host disease. Blood 121 (25): 5098-103, 2013. [PUBMED Abstract]