Avascular necrosis in older adolescents and adults with acute lymphoblastic leukemia treated with FRALLE protocols: a multicenter analysis of incidence, risk factors and morbidity.

Abstract

Paediatric-inspired acute lymphoblastic leukaemia (ALL) regimens have led to improved leukaemic outcomes in adults. However, avascular necrosis (AVN) has emerged as a debilitating orthopaedic complication. AVN is likely multifactorial, with corticosteroids and asparaginase therapy playing key roles in its pathogenesis. We assessed the incidence and potential risk factors for AVN, in older adolescent and adult patients with ALL treated with the FRALLE-93 protocol across three Australian tertiary centres. AVN occurred in 24% of 59 patients, primarily affecting hip and knee joints. Diagnosis occurred at a median of 11.7 months from commencement of chemotherapy. No association was identified between AVN risk and sex, age, BMI, smoking status and vitamin D level. The majority of patients required orthopaedic intervention (64%). Approximately two thirds had chronic pain or impaired mobility. AVN risk in adult patients with ALL receiving FRALLE protocols appears at least comparable to rates reported in paediatric cohorts.