成年人急性白血病治疗相关骨坏死十例分析

Ten cases of treatment-related osteonecrosis in adults with acute leukemia

目的 分析与成年人急性白血病治疗相关的骨坏死的病因及影像学表现.方法 回顾2010年9月至2013年2月发生骨坏死的成年人急性白血病10例临床资料,所有患者均行磁共振成像（MRI）检查确诊.结果 10例患者中,4例为急性淋巴细胞白血病（ALL）,均行含大剂量激素的化疗,其中2例行造血干细胞移植（HSCT）,1例出现移植物抗宿主病（GVHD）并行激素治疗;6例为急性髓系白血病（AML）,所行化疗方案均不含激素,5例患者行HSCT,术后4例出现GVHD并行激素治疗;2例从未接受激素治疗,1例AML-M3患者曾接受4个疗程全反式维甲酸治疗.骨坏死确诊的时间距白血病确诊平均时间为25.1个月.病变多发9例,局部单发1例,受累部位包括股骨、胫骨、髌骨、髂骨、腰椎.X线片检查均为阴性表现;CT检查可见阳性表现,表现为不规则骨质密度减低区伴边缘环状骨质硬化;所有病灶均有典型MRI表现.结论 骨坏死是白血病治疗后影响患者生存质量的重要并发症,大剂量激素化疗、HSCT后GVHD的激素治疗、化疗药物的细胞毒性、AML-M3患者全反式维甲酸治疗等均可导致骨坏死的发生.MRI是发现骨坏死最有效的方法,X线片敏感性较差,CT可发现中晚期骨坏死病变,但其表现与非白血病患者骨坏死表现略有不同.

Objective To study the imaging features and possible aetiology of osteonecrosis in adults with acute leukemia.Methods Ten adult patients with acute leukemia for osteonecrosis were reviewed retrospectively.All the lesions were confirmed with MRI.Results Four patients with ALL had accepted chemotherapy contained corticosteroids,two of them were performed HSCT,and one patient suffered GVHD.Six patients with AML had accepted chemotherapy without steroids,five of them were performed HSCT,and four patients suffered GVHD.One patient with AML-M3 had accepted chemotherapy including four courses of ATRA.The mean time between diagnosis of osteonecrosis and leukemia was 25.1 months.Nine cases had multiple lesions,one case had single lesion.The lesions involved femurs,tibias,patellas,iliums,and lumbars.Plain radiographs in six patients can not detect any lesion.Circinal reaction ossification could be detected in CT images of four cases.All the cases had typical feature in MRI.Conclusions In adult leukemia patients,osteonecrosis is a complication after chemotherapy or HSCT.Steroids in chemotherapy protocols or treatment for GVHD,ATRA for APML,chemotherapy-induced direct cytotoxic effect or leukemia itself can be the possible risk factor.For the diagnosis,MRI is the most effective way,and CT features of osteonecrosis in leukemia patients are different from those in non-leukemia patients. Keywords