Skeletal Complications in Pediatric Oncology Patients1
Derek J. Roebuck, MB, BS, FRACR
1 From the Department of Diagnostic Radiology and Organ Imaging, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, New Territories, Hong Kong. Received October 27, 1997; revision requested April 7, 1998 and received August 26; accepted August 26. Address reprint requests to the author.
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Figure 1. Methotrexate osteopathy. Frontal radiograph shows dense metaphyseal bands (straight white arrows) with sharply outlined epiphyses (arrowhead). There are also metaphyseal "corner" fractures in the distal part of the femur (black arrow) and proximal part of the fibula (curved arrow). (Courtesy of Jack Lawson, MD, Yale University School of Medicine, New Haven, Conn.)
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Figure 2a. Ifosfamide rickets in an 11-year-old girl with Ewing sarcoma. (a) Frontal radiograph shows widening of the growth plates of the distal parts of the radius and ulna with mildly frayed metaphyses. (b) Frontal radiograph shows osteopenia of the tibia with an insufficiency fracture (arrow) and healing rickets.
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Figure 2b. Ifosfamide rickets in an 11-year-old girl with Ewing sarcoma. (a) Frontal radiograph shows widening of the growth plates of the distal parts of the radius and ulna with mildly frayed metaphyses. (b) Frontal radiograph shows osteopenia of the tibia with an insufficiency fracture (arrow) and healing rickets.
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Figure 3. Accelerated skeletal maturation in a 7-year-old girl with ovarian choriocarcinoma. Frontal radiograph shows bone maturation typically seen at 12-13 years of age.
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Figure 4a. Growth deformity and osteochondroma in a teenage girl who had undergone radiation therapy for Langerhans cell histiocytosis several years earlier. (a) Frontal radiograph shows marked deformity of the femoral head with reciprocal deformity of the acetabulum, which has a markedly sloping roof. (b) Frontal radiograph shows that a small osteochondroma has developed on the medial aspect of the femoral shaft.
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Figure 4b. Growth deformity and osteochondroma in a teenage girl who had undergone radiation therapy for Langerhans cell histiocytosis several years earlier. (a) Frontal radiograph shows marked deformity of the femoral head with reciprocal deformity of the acetabulum, which has a markedly sloping roof. (b) Frontal radiograph shows that a small osteochondroma has developed on the medial aspect of the femoral shaft.
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Figure 5a. Metaphyseal radiation changes in a 5-year-old girl who underwent treatment for Ewing sarcoma of the left scapula. (a) Frontal radiograph shows that 1 year after radiation therapy there is a sclerotic metaphyseal band in the proximal left humerus. (b) Frontal radiograph shows that 5 years after radiation therapy there is patchy metaphyseal sclerosis and areas of hyperlucency with mild fraying (arrow) and irregularity of the epiphysis.
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Figure 5b. Metaphyseal radiation changes in a 5-year-old girl who underwent treatment for Ewing sarcoma of the left scapula. (a) Frontal radiograph shows that 1 year after radiation therapy there is a sclerotic metaphyseal band in the proximal left humerus. (b) Frontal radiograph shows that 5 years after radiation therapy there is patchy metaphyseal sclerosis and areas of hyperlucency with mild fraying (arrow) and irregularity of the epiphysis.
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Figure 6. Growth deformity in a 22-year-old woman who as a child had received treatment for Wilms tumor with chemotherapy, radiation therapy, and left nephrectomy. Frontal radiograph obtained during excretory urography shows that the left ilium (arrows) is small owing to inclusion of the iliac crest in the radiation field. The lumbar vertebrae are flattened, and the end plates are slightly irregular. The right kidney shows compensatory hypertrophy.
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Figure 7. Ischemic necrosis of the femoral head in a teenage girl who underwent treatment for Hodgkin disease followed by bone marrow transplantation for myelodysplastic syndrome. Frontal radiograph of the right hip demonstrates a prominent subarticular radiolucent line (arrows) with mild sclerosis of the femoral head.
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Figure 8a. Ischemic necrosis of the femoral heads and bone infarcts in an 11-year-old girl with acute lymphoblastic leukemia as a second malignancy after head and neck rhabdomyosarcoma. (a) Frontal radiograph shows sclerosis, fragmentation, and slippage of the left femoral head and mild sclerosis and a subchondral area of hyperlucency on the right side. (b) Coronal T1-weighted MR image (repetition time msec/echo time msec = 519/16) shows loss of signal intensity in the left femoral head (arrows) due to ischemic necrosis. A band of decreased signal intensity appears in the right femoral capital epiphysis. Numerous bands of decreased signal intensity seen elsewhere in medullary bone are due to bone infarcts. (c) Frontal radiograph obtained 11 months later shows advanced changes of ischemic necrosis of the right femoral head and conspicuous bone infarcts in both proximal femora.
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Figure 8b. Ischemic necrosis of the femoral heads and bone infarcts in an 11-year-old girl with acute lymphoblastic leukemia as a second malignancy after head and neck rhabdomyosarcoma. (a) Frontal radiograph shows sclerosis, fragmentation, and slippage of the left femoral head and mild sclerosis and a subchondral area of hyperlucency on the right side. (b) Coronal T1-weighted MR image (repetition time msec/echo time msec = 519/16) shows loss of signal intensity in the left femoral head (arrows) due to ischemic necrosis. A band of decreased signal intensity appears in the right femoral capital epiphysis. Numerous bands of decreased signal intensity seen elsewhere in medullary bone are due to bone infarcts. (c) Frontal radiograph obtained 11 months later shows advanced changes of ischemic necrosis of the right femoral head and conspicuous bone infarcts in both proximal femora.
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Figure 8c. Ischemic necrosis of the femoral heads and bone infarcts in an 11-year-old girl with acute lymphoblastic leukemia as a second malignancy after head and neck rhabdomyosarcoma. (a) Frontal radiograph shows sclerosis, fragmentation, and slippage of the left femoral head and mild sclerosis and a subchondral area of hyperlucency on the right side. (b) Coronal T1-weighted MR image (repetition time msec/echo time msec = 519/16) shows loss of signal intensity in the left femoral head (arrows) due to ischemic necrosis. A band of decreased signal intensity appears in the right femoral capital epiphysis. Numerous bands of decreased signal intensity seen elsewhere in medullary bone are due to bone infarcts. (c) Frontal radiograph obtained 11 months later shows advanced changes of ischemic necrosis of the right femoral head and conspicuous bone infarcts in both proximal femora.
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Figure 9a. Ischemic necrosis and osteomyelitis in a 15-year-old girl who underwent bone marrow transplantation for acute lymphoblastic leukemia and in whom right knee symptoms developed. (a) Bone scintigram shows photopenia of both femoral heads, a finding consistent with ischemic necrosis. Scintigraphy demonstrated only nonspecific changes in both knees (not shown). (b) Technetium-99m-labeled white cell scintigram shows foci of activity in the distal right femur (arrow), which proved at surgery to be due to Streptococcus pneumoniae osteomyelitis. Diffuse periarticular activity is also seen, a finding consistent with synovitis.
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Figure 9b. Ischemic necrosis and osteomyelitis in a 15-year-old girl who underwent bone marrow transplantation for acute lymphoblastic leukemia and in whom right knee symptoms developed. (a) Bone scintigram shows photopenia of both femoral heads, a finding consistent with ischemic necrosis. Scintigraphy demonstrated only nonspecific changes in both knees (not shown). (b) Technetium-99m-labeled white cell scintigram shows foci of activity in the distal right femur (arrow), which proved at surgery to be due to Streptococcus pneumoniae osteomyelitis. Diffuse periarticular activity is also seen, a finding consistent with synovitis.
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Figure 10a. Osteomyelitis in an 8-year-old girl with relapsed acute lymphoblastic leukemia who presented with left hip symptoms. (a) Three-hour image from a technetium-99m-labeled white cell scan shows focal uptake in this region (arrow). (b) Short-inversion-time inversion recovery MR image (2,014/60; inversion time msec = 80) shows abnormally high signal intensity involving the greater trochanter and adjacent soft tissues as well as the intertrochanteric region (arrow), findings that are typical of osteomyelitis. Surgery revealed Pseudomonas infection.
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Figure 10b. Osteomyelitis in an 8-year-old girl with relapsed acute lymphoblastic leukemia who presented with left hip symptoms. (a) Three-hour image from a technetium-99m-labeled white cell scan shows focal uptake in this region (arrow). (b) Short-inversion-time inversion recovery MR image (2,014/60; inversion time msec = 80) shows abnormally high signal intensity involving the greater trochanter and adjacent soft tissues as well as the intertrochanteric region (arrow), findings that are typical of osteomyelitis. Surgery revealed Pseudomonas infection.
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Figures 11, 12. (11) Radiation-induced fatty marrow change in a 14-year-old girl who underwent
radiation therapy for thoracolumbar paravertebral neuroblastoma 9 years previously. Sagittal T1-weighted MR image
of the spine shows high signal intensity in the irradiated vertebral bodies with central areas of low signal intensity. (12) Reconversion to red marrow in a 15-year-old boy who underwent treatment for intracranial mixed
germ cell tumor with chemotherapy and a hematopoietic growth factor.
(a) Sagittal T1-weighted MR image of the lumbar spine shows normal conditions before therapy.
(b) MR image obtained after treatment shows
numerous rounded areas of decreased signal intensity that probably represent centers of regenerating hematopoietic
marrow. Tumor markers were not elevated.
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Figures 11, 12. (11) Radiation-induced fatty marrow change in a 14-year-old girl who underwent
radiation therapy for thoracolumbar paravertebral neuroblastoma 9 years previously. Sagittal T1-weighted MR image
of the spine shows high signal intensity in the irradiated vertebral bodies with central areas of low signal intensity. (12) Reconversion to red marrow in a 15-year-old boy who underwent treatment for intracranial mixed
germ cell tumor with chemotherapy and a hematopoietic growth factor.
(a) Sagittal T1-weighted MR image of the lumbar spine shows normal conditions before therapy.
(b) MR image obtained after treatment shows
numerous rounded areas of decreased signal intensity that probably represent centers of regenerating hematopoietic
marrow. Tumor markers were not elevated.
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Figures 11, 12. (11) Radiation-induced fatty marrow change in a 14-year-old girl who underwent
radiation therapy for thoracolumbar paravertebral neuroblastoma 9 years previously. Sagittal T1-weighted MR image
of the spine shows high signal intensity in the irradiated vertebral bodies with central areas of low signal intensity. (12) Reconversion to red marrow in a 15-year-old boy who underwent treatment for intracranial mixed
germ cell tumor with chemotherapy and a hematopoietic growth factor.
(a) Sagittal T1-weighted MR image of the lumbar spine shows normal conditions before therapy.
(b) MR image obtained after treatment shows
numerous rounded areas of decreased signal intensity that probably represent centers of regenerating hematopoietic
marrow. Tumor markers were not elevated.
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Figure 13a. Second malignant tumor in a 19-year-old woman who had undergone radiation therapy and chemotherapy for esthesioneuroblastoma several years earlier. (a) Frontal radiograph of the skull shows destruction of the right superior orbital margin (arrows) within the radiation field. (b) Coronal contrast-enhanced T1-weighted MR image shows a soft-tissue mass (arrow). Results of biopsy revealed malignant fibrous histiocytoma.
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Figure 13b. Second malignant tumor in a 19-year-old woman who had undergone radiation therapy and chemotherapy for esthesioneuroblastoma several years earlier. (a) Frontal radiograph of the skull shows destruction of the right superior orbital margin (arrows) within the radiation field. (b) Coronal contrast-enhanced T1-weighted MR image shows a soft-tissue mass (arrow). Results of biopsy revealed malignant fibrous histiocytoma.
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Copyright © 1999 by the Radiological Society of North America.
