Osteonecrosis of the Shoulders in Pediatric Patients Treated for Leukemia or Lymphoma: Single-Institutional Experience

Abstract

Background: Osteonecrosis of the hips and knees is an often debilitating adverse event in children treated with glucocorticoids for leukemia and lymphoma but the impact of shoulder involvement has been understudied. Thus, we investigated the severity and functional impairment of shoulder osteonecrosis in a well-characterized population of pediatric patients treated for acute lymphoblastic leukemia or lymphoma.

Methods: We retrospectively reviewed orthopaedic clinic and physical therapy evaluations to determine range of motion (ROM), pain, and impact of magnetic resonance-defined osteonecrosis (ON) on activities of daily living. Adverse events were classified according to the National Cancer Institute's Common Terminology Criteria for Adverse Events version 4.03.

Results: We identified 35 patients (22 female), median age at cancer diagnosis 14.2 (range, 4.3 to 19) years; median age at ON diagnosis 16.7 (range, 5.5 to 28) years. Median time to last follow-up from diagnosis of primary malignancy was 6.4 (range, 0 to 12.7) years and from diagnosis of ON was 4.0 (range, 0 to 8.9) years. Twenty-two patients had magnetic resonance evidence of ON; 43 shoulders involved at least 30% of the articular surface of the capital humeral epiphyses.Common Terminology Criteria for Adverse Events mean scores for initial assessments of 55 shoulders (29 patients) showed moderate negative impact of ON on activity of daily living (1.94), decreased ROM limiting athletic activity (0.98), and mild to moderate levels of pain (1.38). Analysis of this group's most recent assessment showed improvement in pain and ON over time, with an average pain grade of 0.58 indicating no pain to mild pain, and 1.37 for ON grade, indicating asymptomatic to mildly symptomatic impact on activities of daily living. We also found minimal worsening average ROM grades (1.11).

Conclusions: Shoulder ON is an underappreciated adverse late effect of therapy in children treated for leukemia/lymphoma which can limit quality of life and functionality. In most cases, pain and disability can be improved with treatment.

Level of evidence: Level IV-case series.

Figure 1

18 year-old girl treated for acute lymphoblastic leukemia (ALL). Asymptomatic osteonecrosis of her hips and knees was identified 6 months into therapy by routine screening MR; involvement of her right elbow was diagnosed 8 years after diagnosis of leukemia. A. (right) and B. (left) Initial shoulder radiographs obtained 23 months after diagnosis of ALL show changes bilaterally of ON, worse on left (B) where a large subchondral crescent is apparent (arrows). Central sclerosis is seen in the right (A) humeral head (arrow). C. and D. Coronal non-contrast T1 and STIR (short tau inversion recovery) MR obtained 2 months later shoulder extensive bilateral changes of ON associated with joint effusions. Her CTCAE functional code (See Table 1) was 3-2-3. She underwent bilateral core decompressions 2 months following the imaging. One month post-operatively, her CTCAE functional code was 2-2-1 bilaterally. E. (right) and F. (left) Forty-one months after the core decompression, the patient’s functional score had deteriorated to 3-2-3. She underwent right-sided hemiarthroplasty 2 months later. Five months after the hemiarthroplasty, her functional scores were 1-1-0, bilaterally.

Figure 1

18 year-old girl treated for acute lymphoblastic leukemia (ALL). Asymptomatic osteonecrosis of her hips and knees was identified 6 months into therapy by routine screening MR; involvement of her right elbow was diagnosed 8 years after diagnosis of leukemia. A. (right) and B. (left) Initial shoulder radiographs obtained 23 months after diagnosis of ALL show changes bilaterally of ON, worse on left (B) where a large subchondral crescent is apparent (arrows). Central sclerosis is seen in the right (A) humeral head (arrow). C. and D. Coronal non-contrast T1 and STIR (short tau inversion recovery) MR obtained 2 months later shoulder extensive bilateral changes of ON associated with joint effusions. Her CTCAE functional code (See Table 1) was 3-2-3. She underwent bilateral core decompressions 2 months following the imaging. One month post-operatively, her CTCAE functional code was 2-2-1 bilaterally. E. (right) and F. (left) Forty-one months after the core decompression, the patient’s functional score had deteriorated to 3-2-3. She underwent right-sided hemiarthroplasty 2 months later. Five months after the hemiarthroplasty, her functional scores were 1-1-0, bilaterally.

Figure 1

18 year-old girl treated for acute lymphoblastic leukemia (ALL). Asymptomatic osteonecrosis of her hips and knees was identified 6 months into therapy by routine screening MR; involvement of her right elbow was diagnosed 8 years after diagnosis of leukemia. A. (right) and B. (left) Initial shoulder radiographs obtained 23 months after diagnosis of ALL show changes bilaterally of ON, worse on left (B) where a large subchondral crescent is apparent (arrows). Central sclerosis is seen in the right (A) humeral head (arrow). C. and D. Coronal non-contrast T1 and STIR (short tau inversion recovery) MR obtained 2 months later shoulder extensive bilateral changes of ON associated with joint effusions. Her CTCAE functional code (See Table 1) was 3-2-3. She underwent bilateral core decompressions 2 months following the imaging. One month post-operatively, her CTCAE functional code was 2-2-1 bilaterally. E. (right) and F. (left) Forty-one months after the core decompression, the patient’s functional score had deteriorated to 3-2-3. She underwent right-sided hemiarthroplasty 2 months later. Five months after the hemiarthroplasty, her functional scores were 1-1-0, bilaterally.

Figure 1

18 year-old girl treated for acute lymphoblastic leukemia (ALL). Asymptomatic osteonecrosis of her hips and knees was identified 6 months into therapy by routine screening MR; involvement of her right elbow was diagnosed 8 years after diagnosis of leukemia. A. (right) and B. (left) Initial shoulder radiographs obtained 23 months after diagnosis of ALL show changes bilaterally of ON, worse on left (B) where a large subchondral crescent is apparent (arrows). Central sclerosis is seen in the right (A) humeral head (arrow). C. and D. Coronal non-contrast T1 and STIR (short tau inversion recovery) MR obtained 2 months later shoulder extensive bilateral changes of ON associated with joint effusions. Her CTCAE functional code (See Table 1) was 3-2-3. She underwent bilateral core decompressions 2 months following the imaging. One month post-operatively, her CTCAE functional code was 2-2-1 bilaterally. E. (right) and F. (left) Forty-one months after the core decompression, the patient’s functional score had deteriorated to 3-2-3. She underwent right-sided hemiarthroplasty 2 months later. Five months after the hemiarthroplasty, her functional scores were 1-1-0, bilaterally.

Figure 1

18 year-old girl treated for acute lymphoblastic leukemia (ALL). Asymptomatic osteonecrosis of her hips and knees was identified 6 months into therapy by routine screening MR; involvement of her right elbow was diagnosed 8 years after diagnosis of leukemia. A. (right) and B. (left) Initial shoulder radiographs obtained 23 months after diagnosis of ALL show changes bilaterally of ON, worse on left (B) where a large subchondral crescent is apparent (arrows). Central sclerosis is seen in the right (A) humeral head (arrow). C. and D. Coronal non-contrast T1 and STIR (short tau inversion recovery) MR obtained 2 months later shoulder extensive bilateral changes of ON associated with joint effusions. Her CTCAE functional code (See Table 1) was 3-2-3. She underwent bilateral core decompressions 2 months following the imaging. One month post-operatively, her CTCAE functional code was 2-2-1 bilaterally. E. (right) and F. (left) Forty-one months after the core decompression, the patient’s functional score had deteriorated to 3-2-3. She underwent right-sided hemiarthroplasty 2 months later. Five months after the hemiarthroplasty, her functional scores were 1-1-0, bilaterally.

Figure 1

18 year-old girl treated for acute lymphoblastic leukemia (ALL). Asymptomatic osteonecrosis of her hips and knees was identified 6 months into therapy by routine screening MR; involvement of her right elbow was diagnosed 8 years after diagnosis of leukemia. A. (right) and B. (left) Initial shoulder radiographs obtained 23 months after diagnosis of ALL show changes bilaterally of ON, worse on left (B) where a large subchondral crescent is apparent (arrows). Central sclerosis is seen in the right (A) humeral head (arrow). C. and D. Coronal non-contrast T1 and STIR (short tau inversion recovery) MR obtained 2 months later shoulder extensive bilateral changes of ON associated with joint effusions. Her CTCAE functional code (See Table 1) was 3-2-3. She underwent bilateral core decompressions 2 months following the imaging. One month post-operatively, her CTCAE functional code was 2-2-1 bilaterally. E. (right) and F. (left) Forty-one months after the core decompression, the patient’s functional score had deteriorated to 3-2-3. She underwent right-sided hemiarthroplasty 2 months later. Five months after the hemiarthroplasty, her functional scores were 1-1-0, bilaterally.