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Review
. 2011 May;196(5):1011-8.
doi: 10.2214/AJR.10.6073.

Osteonecrosis in children after therapy for malignancy

Affiliations
Review

Osteonecrosis in children after therapy for malignancy

Sue C Kaste et al. AJR Am J Roentgenol. 2011 May.

Abstract

Objective: Osteonecrosis in the growing population of childhood cancer survivors results from disease and treatment. Imagers must be knowledgeable about patient groups at risk for its development, patterns of involvement and potential implications. This review will focus on implications of this potentially life-altering toxicity.

Conclusion: Childhood cancer survivors are at increased risk for developing osteonecrosis. Because osteonecrosis is often asymptomatic until late in the process, imaging is critical for its detection and characterization when interventions may be most effective to ameliorate its progression.

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Figures

Fig. 1
Fig. 1. 9-year-old girl being treated for standard-risk acute lymphoblastic leukemia who underwent routine MR screening for osteonecrosis
A and B, Coronal unenhanced T1-weighted (A) and STIR (B) images of knees show very subtle geographic signal changes (arrows) in distal femoral and proximal tibial diametaphyses bilaterally. These signal changes are less well defined than those described in literature for osteonecrosis. C and D, MR images show that over course of 3 months, these changes evolved into typical geographic signal changes of osteonecrosis. E and F, Annual follow-up examinations (not shown) revealed progressive definition of these extensive lesions, with overall decrease in extent. Note rectangular foci of abnormal centrally located metaphyseal signal in proximal tibias (arrows), dark on T1-weighted image (E) and bright on STIR image (F). Over course of 3 years, these abnormalities narrowed transversely and elongated, coincident with longitudinal growth of patient. These findings represent cartilaginous ingrowths from arrested enchondral ossification.
Fig. 2
Fig. 2. Relapse of acute lymphoblastic leukemia in 14-year-old boy who underwent stem cell transplantation for acute lymphoblastic leukemia
A and B, MR images of hips obtained as part of pretransplantation assessment reveal no evidence of osteonecrosis or other abnormality of bones and soft tissues. C and D, MR images obtained 1 year after bone marrow transplantation reveal numerous foci of decreased signal on T1-weighted and increased signal on STIR sequences indicative of relapsed leukemia.
Fig. 3
Fig. 3. Nonspecific punctuate lesions that can be confused with tiny areas of osteonecrosis in 4-year-old boy
A and B, T1-weighted image (A) shows tiny foci of decreased signal (arrows, A) and STIR image (B) shows bright signal (arrows, B). These may be confused with tiny foci of osteonecrosis.
Fig. 4
Fig. 4. Mottled marrow pattern in 18-year-old man previously treated for acute lymphoblastic leukemia who underwent MRI for complaint of chronic knee pain
A and B, Coronal unenhanced T1-weighted (A) and STIR (B) images of knees show bilateral heterogeneous marrow signal (arrows) in distal femoral and proximal tibial metaphyses, which is mildly dark on T1-weighted and bright on STIR images. These changes became less apparent over course of 2 years (not shown). Also note area of nonspecific edema (arrowheads) in right lateral tibial epiphysis, which completely resolved over 2 years.
Fig. 5
Fig. 5. Nonspecific patchy edema in knees in 13-year-old boy who had completed treatment for leukemia and underwent MRI surveillance for development of osteonecrosis to evaluate knee pain
A and B, Coronal unenhanced T1-weighted (A) and STIR (B) images of knees show poorly defined decreased signal on T1-weighted and increased signal on STIR images, indicative of edema involving distal femoral and proximal tibial epiphyses and proximal left tibial epiphysis and metaphysis (arrows). These changes resolved at time of follow-up MRI 8 months later.
Fig. 6
Fig. 6. 15-year-old boy treated for acute lymphoblastic leukemia and asymmetric osteonecrosis of hips
A and B, Coronal unenhanced T1-weighted MR images of hips show small focus of osteonecrosis in right femoral head (arrow, A) and large (involving greater than 30% of articular surface) focus in left femoral head (arrowhead). C and D, Over course of 18 months, small lesion remained stable (arrow, C) but eventually healed (images not shown). Lesion of left femoral head (arrowhead) rapidly progressed to collapse.
Fig. 7
Fig. 7. Healing osteonecrosis of knees in 4-year-old girl undergoing treatment of acute lymphoblastic leukemia who was prospectively monitored annually for osteonecrosis of hips (normal throughout monitoring) and knees
A and B, Coronal unenhanced T1-weighted (A) and STIR (B) images of knees show small lesion of right distal femoral epiphysis (solid arrows), large lesion of distal right femoral diaphysis (arrowheads), and moderate-sized lesions of proximal tibial diametaphyses bilaterally (dotted arrows). C and D, Over course of 4 years, osteonecrotic lesions healed. Coronal unenhanced T1-weighted (C) and STIR (D) images of knees show no evidence of osteonecrosis.

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