Skeletal manifestations of acute leukemia in childhood

Paleo-oncology in the Dakhleh Oasis, Egypt: Case studies and a paleoepidemiological perspective

This article describes six cases of cancer from the Dakhleh Oasis, Egypt. A mummy had a confirmed 'primary' diagnosis of adenocarcinoma of the rectum. The remaining diagnoses were based on the distribution and types of skeletal lesions in conjunction with age, sex, and/or the molecular phylogeny of the Human Papillomavirus (HPV). HPV is a confirmed cause of cancer of the uterine cervix (UC) and testes (TC) and it evolved in Africa long before Homo sapiens emerged. Today these cancers are common in young adult females and males, a fact which was pivotal in respectively including them in the differential diagnosis of UC and TC. The remaining diagnoses were acute lymphocytic leukemia in a 3-5 year old child and an older female with metastatic carcinoma. Due to problems of determining specific diagnoses and their prevalence in 'paleo' populations, we opted for a lifetime cancer risk statistic (LTCR). The LTCR in ancient Dakhleh was ∼5/1000 (6/1087). In modern Western societies the LTCR cancer approaches 50% (500/1000). Thus the LTCR in today's western societies is 100 times greater than in ancient Dakhleh. These cases demonstrate that oncogenes and their environmental cofactors were present in antiquity, but were significantly less pervasive than today.

Musculoskeletal problems in pediatric acute leukemia

Acute leukemia (AL) in children can mimic several orthopedic pathologies at presentation, with a variable delay in the correct diagnosis. This is a major problem, which may result in fractures, loss of mobility, and deformity, with resultant adverse effects on quality of life. Here, we studied the clinical and radiological musculoskeletal manifestations in children with AL. We reviewed 328 children [208 boys (62%), median age 7.2 years] with acute lymphoblastic (279, 85%) or myeloid (49, 15%) leukemia, treated between January 1982 and December 2003 by the Paediatric Oncology Service, Second University of Naples. The group was further divided into two groups: group 1 included 255 patients (78%, 163 boys) without skeletal morbidity at diagnosis, and group 2 included 73 patients (22%, 41 boys) with musculoskeletal symptoms. This group was further subdivided into group 2A (56 patients), which included children with symptoms related to the appendicular skeleton, and group 2B (17 patients), which included children with symptoms related to the axial skeleton. Moreover, we also reported the long-term complications of therapy, such as osteonecrosis of the weight-bearing joints. In group 2A, 44 children presented only pain, seven septic arthritis-type symptoms, and five osteomyelitis-type symptoms. Joint compression was in the tibia-tarsus (21 patients), knee (16), coxofemoral (12), and elbow (seven). In group 2B, 11 patients presented with vertebral collapses. The remaining six patients complained of localized pain in the lumbar-sacral area, with limited flexor and extensor muscle capacity. Fifty-five (75.3%) patients showed radiographic abnormalities: osteoporosis in 22 patients (40%), pathological fractures in 11 (20%), osteolysis in 10 (18.1%), osteosclerosis in five (9%), periosteal reactions in four (7.2%), and metaphyseal bands in three (5.4%). Four (1.2%) patients in total showed avascular necrosis (4.3% when only high-risk patients were considered). At presentation, 22% of our children had at least one musculoskeletal manifestation and 75.3% showed one radiographic change. Our study highlights the importance of including AL in the differential diagnosis of musculoskeletal manifestations. Four cases of avascular necrosis confirm the need for regular check-ups, both orthopedic and nonorthopedic, particularly in adolescent girls, to prevent permanent disability.

Musculoskeletal manifestations in pediatric acute leukemia

BACKGROUND

In children, acute leukemia (AL) at presentation can mimic several orthopaedic pathologies, so that a variable delay of the correct diagnosis is often reported.

METHODS

To define more clearly the clinical and radiological musculoskeletal manifestations of leukemia in children, 122 affected children referred from 1984 to 1999 to our Pediatric Onco-Hematologic Clinic were retrospectively reviewed. Average age at diagnosis was 6.6 years (from 7 months to 17 years). Seventy-three (60%) were boys and adolescent boys, 49 (40%) were girls and adolescent girls. One hundred two (83.6%) had acute lymphoblastic leukemia, 20 (16.4%) had acute myeloid leukemia. The mean follow-up was 8.2 years for the 104 survivors and 2.5 years for the 18 nonsurvivors. The chi2 test was used to perform the statistical analyses.

RESULTS

At presentation, complaints related to the musculoskeletal system were frequent (38.3%), including pain (34.4%), functional impairment (22.9%), limping (12.3%), swelling (10.6%), and joint effusion (5.7%). At presentation, 40.2% of children had at least 1 radiographic abnormality. In order, they were osteolysis (13.1%), metaphyseal bands (9.8%), osteopenia (9%), osteosclerosis (7.4%), permeative pattern (5.7%), pathological fractures (5.7%), periosteal reactions (4.1%), and mixed lysis-sclerosis lesions (2.5%). Different from previous reports, late radiographic lesions were uncommon (5.7%), probably because of milder newer medication protocols. They included avascular necrosis (3.3%), vertebral collapses (1.6%), and osteolysis (0.8%).

CONCLUSIONS

Both clinical and radiological changes had various and no uniform localization. Poor correlation was found between symptoms and radiological lesions. Survival rates in children with AL were 95.8% at 1 year, 89.6% at 3 years, 85.8% at 5 years, and 83.4% at 10 and at 13 years. Radiographic abnormalities (P = 0.400), type of leukemia (P = 0.291), sex (P = 0.245), and white blood cell count at presentation (P = 0.877) were not prognostic factors. The presence of multiple bone lesions did not affect the survival rate (P=0.632). As early diagnosis significantly decreases morbidity and mortality of AL, the orthopaedist should suspect AL in any child with unexplained persistent skeletal pain or radiographic alterations. Accurate history, general physical examination, and complete blood cell count tests should address the suspicion, which is confirmed by a peripheral and/or iliac crest bone marrow biopsy.

Radiologic investigation of rheumatic diseases

This article reviews the current use of the wide variety of imaging modalities now available, presenting the imaging features of common and important causes of acute and chronic rheumatic disorders including juvenile idiopathic arthritis, spondyloarthropathies/enthesitis-related arthritis, sepsis, autoimmune diseases, vasculitis, and osteoporosis.

Recognition of leukemia in skeletal remains: report and comparison of two cases

Recognition of disease in the archeologic record is facilitated by characterization of the skeletal impact of documented (in life) disease. The present study describes the osteological manifestations of leukemia as identified in the skeletons of two individuals diagnosed during life: a 3-year-old black girl with acute lymphocytic leukemia and a 60-year-old white male with acute myelogenous leukemia in the Hamann-Todd collection. Contrasting with the lack of specificity of radiologic findings, macroscopic skeletal changes appear sufficiently specific to allow distinguishing leukemia from other forms of cancer. While leukemia appears confidently diagnosable, distinguishing among the varieties (e.g., myelogenous and lymphocytic) does not appear possible at this time. Skeletal findings in leukemia are presented in tabular form to facilitate their application to future diagnosis of the disease in the archaeological record.

Differentiation of systemic juvenile rheumatoid arthritis from acute leukemia near the onset of disease

Many children with acute leukemia have musculoskeletal complaints and non-specific hematologic abnormalities. A total of 10 children with acute leukemia and 10 with systemic juvenile rheumatoid arthritis were compared to delineate which early features could differentiate these diagnoses. Attention to evolving hematologic abnormalities and musculoskeletal findings may expedite diagnosis of these diseases.