Femoral and lumbar bone mineral densities (BMDs) were measured in 159 adults enrolled in the Leucémies de l'Enfant et de l'Adolescent program, a French prospective multicentric cohort of childhood leukemia survivors. BMDs were expressed as Z-scores, and multivariate linear regression analyses were used to construct association models with potential risk factors. Mean age at evaluation and follow-up was 23 and 14.7 years, respectively. In the whole cohort, mean femoral Z-score was −0.19 ± 0.08. Two factors were associated with lower femoral BMD transplantation (−0.49 ± 0.15 vs −0.04 ± 0.10 in the chemotherapy group; P = .006) and female sex (−0.34 ± 0.10 vs −0.03 ± 0.13; P = .03). Among patients who received a transplant, the only significant risk factor was hypogonadism (−0.88 ± 0.16 vs −0.10 ± 0.23; P = .04). A slight reduction in lumbar BMD (mean Z-score, −0.37 ± 0.08) was detected in the whole cohort without difference between the transplantation and chemotherapy groups. Among patients who received a transplant, younger age at transplantation was correlated with a low lumbar BMD (P = .03). We conclude that adults who had received only chemotherapy for childhood leukemia have a slight reduction in their lumbar BMD and a normal femoral BMD. Patients who received a transplant with gonadal deficiency have a reduced femoral BMD which might increase the fracture risk later in life.

During the past decades, the survival rates after childhood acute leukemia (AL) have improved substantially. Childhood AL is now a curable disease in 80% of patients with acute lymphoblastic leukemia (ALL) and in 50% of patients with acute myeloblastic leukemia (AML). Consequently, more emphasis is placed on the long-term side effects of this disease and its treatment.

Reduced bone mineral density (BMD) has been largely reported at diagnosis and during treatment of AL. Its cause is most probably multifactorial; the disease process itself, steroid therapy, intensive chemotherapy, lesion of endocrine organs that control bone accretion, immunosuppressive agents after HSCT, poor nutrition, and decreased physical activity may contribute to these abnormalities.1-4 

However, it is still controversial if survivors of childhood AL maintain low BMD after the end of treatment. The question is whether decreased bone mineralization during a period of illness will be restored or whether inappropriate bone mass will persist during adulthood. Some studies have already described long-term AL survivors with normal5-9  as well as reduced10-18  BMD. Most of those studies were limited by their low power because of limited sample size. They were also heterogeneous, reporting bone mass assessment performed before or after attainment of peak bone mass in both AL and other cancer survivors.19  Moreover, reports of BMD after childhood HSCT are rare and are limited to few patients.

In the study presented here, we aimed to determine in a group of 159 adults surviving childhood AL whether this disease and its therapy may have a lasting effect on bone density later in life and which (if any) AL-related factors, patient characteristics, or treatment modalities (HSCT especially) correlate with reduced BMD in this population.

Patients

This prospective study was designed to assess BMD in young adults included in the Leucémies de l'Enfant et de l'Adolescent program. This French multicentric program was created in 2003 to evaluate prospectively the long-term health status, quality of life, and socioeconomic status of childhood leukemia survivors who were treated from 1980 to now in 2 geographic areas (PACA-Corse and Lorraine). Details of the whole program have been previously described.20 

In 2007 and 2008, assessment of BMD by dual-energy x-ray absorptiometry (DXA) was systematically proposed to all adults with a new health status evaluation by the Leucémies de l'Enfant et de l'Adolescent program. Among 220 eligible patients, 159 (72.3%) underwent a DXA scan and are the subjects of this report. All patients have signed informed consent in accordance with the Declaration of Helsinki. This study was approved by the French National Clinical Research Program and the French National Cancer Institute.

BMD assessment

According to the 2007 International Society for Clinical Densitometry official positions for BMD reporting in women before menopause and in men younger than age 50,21  BMD was measured by DXA scan at the lumbar spine (LS; vertebrae L1 through L4) and at the left femoral neck (FN). The results were expressed as the number of SDs from normal values of sex-, age-, and ethnicity-matched controls (Z-score). A low BMD for age was defined as a Z-score of −2 or lower at 1 of the 2 sites.

Hormonal status

Growth hormone (GH) deficiency (GHD) was detected by measuring plasma levels of insulinlike growth factor I and GH peak response to ≥ 2 stimulation tests per patient. These tests were insulin tolerance tests, GH-releasing hormone infusion tests, or propranol-glucagon tests. GHD was diagnosed when peak GH levels after stimulation were inferior to 20 mUI/L (or 10 ng/mL). The tests were performed ≥ 6 months away from any antileukemic treatment. Evaluation was done only for patients with decreased height growth velocity.

Hypogonadism was defined by low testosterone (males) or estradiol (females) serum level and classified as hypergonadotrophic or hypogonadotrophic according to values of luteinizing hormone and follicle-stimulating hormone. Evaluation was done for patients who underwent stem cell transplantation or who had pubertal delay.

Evaluation of corticotherapy

For each patient, we collected the doses of prednisone and dexamethasone received as part of conventional therapy and during the posttransplantation period. With these data, the total dose of corticosteroid in equivalent of prednisone received by each patient was calculated with the use of the following formula: total dose of corticosteroids = dose of prednisone + (dose of dexamethasone × 6.67) in mg/m2 (Table 1).

Statistical methods

Statistical analysis was performed with SPSS Version 15.0 (SPSS Inc) and SAS Version 9.1 (SAS Institute). Qualitative data were expressed as counts and percentages, and quantitative variables were expressed as mean ± SEM. In the univariate analysis, χ2 and Fisher exact tests were used to compare qualitative variables, whereas quantitative variables were compared with the Student test, the Mann-Whitney test, or ANOVA.

The effect of patient, disease, and treatment-related variables on BMD Z-scores was evaluated in the whole population and also separately for patients who received HSCT (“HSCT group”) or not (“chemotherapy group”). Potential confounding factors were the following: sex, initial diagnosis (ALL or AML), age at diagnosis, follow-up duration, steroid therapy, and HSCT. Age at HSCT, type of graft, use of total body irradiation (TBI), steroid therapy after transplantation, and transplantation-related complications such as significant graft-versus-host disease (GVHD; ie, grade ≥ 2 acute GVHD or chronic extensive GVHD), hypogonadism, and GHD were evaluated only in the HSCT group. Conversely, CNS radiation was only evaluated in the chemotherapy group because only 2 patients who received a transplant also received CNS radiation. Multiple linear regression was used to construct association models of FN and LS BMD Z-scores (dependent variable) with the different explanatory variables listed earlier. Each model was given with its standardized β coefficient and significance of the association set as P < .05.

Eligible patients and comparison between participants and nonparticipants

Among 220 eligible patients, 159 (72.3%) underwent a DXA scan. To evaluate potential bias into the study cohort we compared patient, disease, and treatment-related characteristics among participants (n = 159) and nonparticipants (n = 61, who had not been evaluated by DXA scan at the time of the study). No statistically significant difference was observed between the 159 included patients and the 61 remaining patients for sex, type of leukemia, age at diagnosis, duration of follow-up, type of treatment (chemotherapy alone, chemotherapy and CNS irradiation, chemotherapy and HSCT), and treatment-related late endocrine complications.

When patients who only received a transplant were considered, participants and nonparticipants were not statistically different for age and disease status at transplantation (first complete remission vs more advanced), type of transplantation (allograft vs autograft, donor type), conditioning regimen (TBI or not), and occurrence of GVHD or late endocrine complications.

Studied cohort: clinical characteristics and treatment modalities

Between January 2007 and December 2008, 159 patients were studied (Table 1); 49.7% of the participants were males. The mean age at diagnosis was 8.33 ± 0.38 years, and the mean follow-up duration from diagnosis to DXA scan was 14.66 ± 0.44 years.

Table 1

Patients and treatment characteristics

All patients (n = 159)Chemotherapy group (n = 105)HSCT group (n = 54)P
Patient and disease related characteristics     
    Sex     
        Female, n (%) 80 (50.3) 57 (54.3) 23 (42.6) .18 
        Male, n (%) 79 (49.7) 48 (45.7) 31 (57.4)  
    Initial diagnosis     
        ALL, n (%) 130 (81.8) 96 (91.4) 34 (63) < .0001 
        AML, n (%) 29 (18.2) 9 (8.6) 20 (37)  
    Age at diagnosis, y, mean ± SEM 8.33 ± 0.38 8.03 ± 0.44 8.9 ± 0.72 .30 
    Age at HSCT, y, mean ± SEM   10.4 ± 0.74 NA 
    Relapse, n (%) 29(18.2) 4 (3.8) 25 (46.3) <.0001 
    Follow-up, y, mean ± SEM 14.66 ± 0.44 14.83 ± 0.54 14.34 ± 0.74 .60 
    Age at DXA scan, y, mean ± SEM 23.05 ± 0.38 22.99 ± 0.47 23.17 ± 0.66 .82 
Treatment modalities     
    Corticotherapy     
        Yes, n (%) 137 (86.2) 96 (91.4) 41 (75.9) .007 
        Prednisone, n (%) 137 (86.2) 96 (91.4) 41 (75.9) .007 
        Dexamethasone, n (%) 95 (59.7) 70 (66.7) 25 (46.3) .01 
    Mean ± SD total dose of steroids, mg/m2* 4534 ± 229 4488 ± 224 4622 ± 517 .81 
    Cranial radiation, n (%) 30 (18.9) 28 (26.7) 2 (3.7) <.0001 
    TBI, n (%)   38 (70.4) NA 
    Type of graft     
        Allograft, n (%)   36 (66.7) NA 
        Autograft, n (%)   18 (33.3)  
Posttransplantation steroid therapy     
        Yes, n (%)   23 (42.6) NA 
        Mean ± SD dose, mg/m2   444 ± 111 NA 
Treatment-related complications     
    GVH disease, n (%)   23 (42.6) NA 
        Acute GVHD, n (%)   20 (37.1)  
        Chronic GVHD, n (%)   13 (24.1)  
        Significant GVHD, n (%)   17 (31.5)  
        Treatment for GVHD, n (%)   19 (35.2)  
    Hypogonadism     
        Yes, n (%) 30 (18.9) 2 (1.9) 28 (51.9) <.0001 
        Compensated hypogonadism, n (%) 18 (11.3) 1 (0.9) 17 (31.5) <.999 
        Uncompensated hypogonadism, n (%) 12 (7.5) 1 (0.9) 11 (20.4)  
    GHD, n (%) 6 (3.8) 1 (1) 5 (9.3) .02 
All patients (n = 159)Chemotherapy group (n = 105)HSCT group (n = 54)P
Patient and disease related characteristics     
    Sex     
        Female, n (%) 80 (50.3) 57 (54.3) 23 (42.6) .18 
        Male, n (%) 79 (49.7) 48 (45.7) 31 (57.4)  
    Initial diagnosis     
        ALL, n (%) 130 (81.8) 96 (91.4) 34 (63) < .0001 
        AML, n (%) 29 (18.2) 9 (8.6) 20 (37)  
    Age at diagnosis, y, mean ± SEM 8.33 ± 0.38 8.03 ± 0.44 8.9 ± 0.72 .30 
    Age at HSCT, y, mean ± SEM   10.4 ± 0.74 NA 
    Relapse, n (%) 29(18.2) 4 (3.8) 25 (46.3) <.0001 
    Follow-up, y, mean ± SEM 14.66 ± 0.44 14.83 ± 0.54 14.34 ± 0.74 .60 
    Age at DXA scan, y, mean ± SEM 23.05 ± 0.38 22.99 ± 0.47 23.17 ± 0.66 .82 
Treatment modalities     
    Corticotherapy     
        Yes, n (%) 137 (86.2) 96 (91.4) 41 (75.9) .007 
        Prednisone, n (%) 137 (86.2) 96 (91.4) 41 (75.9) .007 
        Dexamethasone, n (%) 95 (59.7) 70 (66.7) 25 (46.3) .01 
    Mean ± SD total dose of steroids, mg/m2* 4534 ± 229 4488 ± 224 4622 ± 517 .81 
    Cranial radiation, n (%) 30 (18.9) 28 (26.7) 2 (3.7) <.0001 
    TBI, n (%)   38 (70.4) NA 
    Type of graft     
        Allograft, n (%)   36 (66.7) NA 
        Autograft, n (%)   18 (33.3)  
Posttransplantation steroid therapy     
        Yes, n (%)   23 (42.6) NA 
        Mean ± SD dose, mg/m2   444 ± 111 NA 
Treatment-related complications     
    GVH disease, n (%)   23 (42.6) NA 
        Acute GVHD, n (%)   20 (37.1)  
        Chronic GVHD, n (%)   13 (24.1)  
        Significant GVHD, n (%)   17 (31.5)  
        Treatment for GVHD, n (%)   19 (35.2)  
    Hypogonadism     
        Yes, n (%) 30 (18.9) 2 (1.9) 28 (51.9) <.0001 
        Compensated hypogonadism, n (%) 18 (11.3) 1 (0.9) 17 (31.5) <.999 
        Uncompensated hypogonadism, n (%) 12 (7.5) 1 (0.9) 11 (20.4)  
    GHD, n (%) 6 (3.8) 1 (1) 5 (9.3) .02 
*

Mean total dose of steroids is dose of prednisone + (dose of dexamethasone × 6.67) in mg/m2.

Significant GVHD indicates acute GVHD grades II, III, or IV or chronic extensive GVHD.

One hundred thirty patients (81.8%) were treated for ALL and 29 (18.2%) for AML. Twenty-nine patients (18.2%) had experienced relapse. They were treated according to various French multicentric protocols (ie, French Acute Lymphoblastic Leukaemia, European Organisation for Research and Treatment of Cancer, Leucemie Aigue Myeloblastique Enfant, ELAM), depending on the period of the treatment and the type of leukemia.22-25  Most of the patients had received corticosteroids (137 patients; 86.2%). Among them, all had received prednisone and 95 had received dexamethasone. The mean total dose of steroid, expressed in mg/m2, was 4534 ± 229 mg/m2. Fifty-four of our patients (34%) had received HSCT (HSCT group), whereas 105 patients (66%) had not (chemotherapy group).

In the chemotherapy group, 96 patients (91.4%) had received corticosteroids (mean total dose: 4488 ± 224 mg/m2). Twenty-eight patients (26.7%) had received a CNS irradiation, and 1 patient had received a testis irradiation on the basis of the underlying disease status and the protocol in use at the time of leukemia treatment. CNS irradiation dose was 18 Gy in 22 cases and 24 Gy in the 6 others.

In the HSCT group the proportion of patients with AML (n = 20; 37%) and the percentage of patients who experienced relapse (n = 25; 46.3%) were higher. Forty-one patients who received a transplant (75.9%) had received corticosteroids (mean total dose: 4622 ± 517 mg/m2). Steroids were given as part of chemotherapy regimen in 34 patients and after transplantation in 23 patients. One patient had received a testis irradiation before HSCT and 2 others had received cranial irradiation. Mean age at transplantation was 10.4 ± 0.74 years and allograft accounted for 66.7% of the transplantations, distributed as follows: matched related donors (n = 25; 69.4%), matched unrelated donors (n = 4; 11.1%), mismatched related donors (n = 2; 5.6%), and cord blood (n = 5; 13.9%). Two patients had received 2 HSCTs because they had relapsed after the first one. TBI was used as part of the conditioning regimen in 38 of patients who received an allograft or autograft (70.4%) and was administered fractionated, usually as 2 Gy twice daily during 3 days for a total dose of 12 Gy with lung shielding at 8 Gy.

Among allograft recipients 23 (42.6%) had developed GVHD; 20 of them experienced an acute GVHD (16 of a grade ≥ 2) and 13 of them a chronic GVHD (only 1 in an extensive form). Nineteen patients who experienced GVHD required a treatment for it.

Hormonal status

Thirty patients (18.9%) had hypogonadism, all except 2 after HSCT, and 18 of them received hormonal replacement. Six patients (11.3%) had GHD, all except 1 after HSCT. Only 1 patient received GH replacement therapy.

Bone density measurements

The BMD values of the 2 regions, expressed in Z-scores, are shown in Table 2.

Table 2

BMD results at FN and LS

All patientsChemotherapy groupHSCT groupP
FN Z-score     
    Mean ± SEM −0.19 ± 0.08 −0.04 ± 0.10 −0.49 ± 0.15 .009 
    n ≤ 2DS (%) 5 (3.2) 2 (1.9) 3 (5.8) .33 
LS Z-score     
    Mean ± SEM −0.37 ± 0.08 −0.39 ± 0.11 −0.33 ± 0.13 .74 
    n ≤ 2DS (%) 6 (3.8) 5 (4.8) 1 (1.9) .66 
All patientsChemotherapy groupHSCT groupP
FN Z-score     
    Mean ± SEM −0.19 ± 0.08 −0.04 ± 0.10 −0.49 ± 0.15 .009 
    n ≤ 2DS (%) 5 (3.2) 2 (1.9) 3 (5.8) .33 
LS Z-score     
    Mean ± SEM −0.37 ± 0.08 −0.39 ± 0.11 −0.33 ± 0.13 .74 
    n ≤ 2DS (%) 6 (3.8) 5 (4.8) 1 (1.9) .66 

FN BMD.

FN BMD was slightly reduced compared with age- and sex-matched normal values in the overall study population (mean FN Z-score, −0.19 ± 0.08) with 5 patients (3.2%) having a low FN BMD for age (ie, Z-score ≤ −2DS). A transplantation history was significantly associated with a lower FN BMD in both univariate analysis (mean FN Z-score, −0.49 ± 0.15 for the HSCT group vs −0.04 ± 0.10 for the chemotherapy group; P = .009; Table 3) and multivariate analysis (P = .006; Table 4). Female sex was also a significant predictor of low FN BMD in multivariate analysis (P = .03l Table 4). We did not detect any influence of other variables such as initial diagnosis, age at diagnosis, follow-up duration, use of corticosteroids, type of steroid, and total steroid dose.

Table 3

Univariate analysis: FN BMD results

All patients
Chemotherapy group
HSCT group
Mean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable P
Patient and disease characteristics       
    Sex       
        Female −0.34 ± 0.10 .07 −0.13 ± 0.12 .28 −0.87 ± 0.14 .03 
        Male −0.03 ± 0.13  0.08 ± 0.16  −0.22 ± 0.23  
    Initial diagnosis       
        ALL −0.15 ± 0.09 .33 −0.02 ± 0.10 .71 −0.53 ± 0.19 .78 
        AML −0.36 ± 0.19  −0.18 ± 0.31  −0.44 ± 0.25  
    Age at diagnosis NA .53 NA .04 NA .09 
    Age at HSCT     NA .09 
    Follow-up NA .46 NA .30 NA .79 
Treatment modalities       
    Corticotherapy       
        No −0.39 ± 0.15 .33 −0.18 ± 0.31 .66 −0.54 ± 0.15 .87 
        Yes −0.16 ± 0.09  −0.02 ± 0.10  −0.48 ± 0.20  
    Dexamethasone       
        No −0.21 ± 0.13 .87 −0.01 ± 0.15 .88 −0.43 ± 0.22 .66 
        Yes −0.18 ± 0.11  −0.05 ± 0.13  −0.57 ± 0.19  
    HSCT       
        No −0.04 ± 0.10 .009     
        Yes −0.49 ± 0.15      
    TBI       
        No     −0.53 ± 0.18 .87 
        Yes     −0.48 ± 0.20  
    Type of graft       
        Allograft     −0.41 ± 0.21 .43 
        Autograft     −0.66 ± 0.20  
    Posttransplantation steroid therapy       
        No     −0.55 ± 0.14 .69 
        Yes     −0.41 ± 0.32  
Transplantation-related complications       
    Significant GVHD*       
        No     −0.37 ± 0.18 .22 
        Yes     −0.78 ± 0.25  
    Hypogonadism       
        No     −0.10 ± 0.23  
        Compensated     −0.59 ± 0.18 .004 
        Uncompensated     −1.37 ± 0.26  
    GHD       
        No     −0.45 ± 0.16 .27 
        Yes     −1.08 ± 0.42  
All patients
Chemotherapy group
HSCT group
Mean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable P
Patient and disease characteristics       
    Sex       
        Female −0.34 ± 0.10 .07 −0.13 ± 0.12 .28 −0.87 ± 0.14 .03 
        Male −0.03 ± 0.13  0.08 ± 0.16  −0.22 ± 0.23  
    Initial diagnosis       
        ALL −0.15 ± 0.09 .33 −0.02 ± 0.10 .71 −0.53 ± 0.19 .78 
        AML −0.36 ± 0.19  −0.18 ± 0.31  −0.44 ± 0.25  
    Age at diagnosis NA .53 NA .04 NA .09 
    Age at HSCT     NA .09 
    Follow-up NA .46 NA .30 NA .79 
Treatment modalities       
    Corticotherapy       
        No −0.39 ± 0.15 .33 −0.18 ± 0.31 .66 −0.54 ± 0.15 .87 
        Yes −0.16 ± 0.09  −0.02 ± 0.10  −0.48 ± 0.20  
    Dexamethasone       
        No −0.21 ± 0.13 .87 −0.01 ± 0.15 .88 −0.43 ± 0.22 .66 
        Yes −0.18 ± 0.11  −0.05 ± 0.13  −0.57 ± 0.19  
    HSCT       
        No −0.04 ± 0.10 .009     
        Yes −0.49 ± 0.15      
    TBI       
        No     −0.53 ± 0.18 .87 
        Yes     −0.48 ± 0.20  
    Type of graft       
        Allograft     −0.41 ± 0.21 .43 
        Autograft     −0.66 ± 0.20  
    Posttransplantation steroid therapy       
        No     −0.55 ± 0.14 .69 
        Yes     −0.41 ± 0.32  
Transplantation-related complications       
    Significant GVHD*       
        No     −0.37 ± 0.18 .22 
        Yes     −0.78 ± 0.25  
    Hypogonadism       
        No     −0.10 ± 0.23  
        Compensated     −0.59 ± 0.18 .004 
        Uncompensated     −1.37 ± 0.26  
    GHD       
        No     −0.45 ± 0.16 .27 
        Yes     −1.08 ± 0.42  
*

Significant GVHD indicates acute GVHD grades II, III, or IV or chronic extensive GVHD.

Table 4

Multivariate analysis

LS
FN
β-coefficientPβ-coefficientP
All patients     
    Sex −0.01 .91 0.18 .03 
    Initial diagnosis 0.05 .78 0.14 .40 
    Age at diagnosis 0.06 .57 −0.005 .96 
    Follow-up 0.04 .69 0.06 .56 
    Corticotherapy 0.19 .23 0.14 .35 
    HSCT 0.05 .56 −0.24 .006 
Chemotherapy group     
    Sex −0.11 .3 0.12 .26 
    Initial diagnosis −0.06 .58 −0.04 .67 
    Age at diagnosis −0.09 .52 −0.18 .19 
    Follow-up 0.01 .94 0.01 .94 
    CNS radiation 0.001 .99 −0.06 .62 
HSCT group     
    Sex 0.13 .39 0.15 .31 
    Age at HSCT 0.38 .03 0.3 .07 
    Follow-up 0.11 .50 0.14 .39 
    TBI 0.23 .12 0.14 .31 
    Significant GVHD* −0.11 .41 −0.15 .25 
    Hypogonadism −0.17 .30 −0.32 .04 
LS
FN
β-coefficientPβ-coefficientP
All patients     
    Sex −0.01 .91 0.18 .03 
    Initial diagnosis 0.05 .78 0.14 .40 
    Age at diagnosis 0.06 .57 −0.005 .96 
    Follow-up 0.04 .69 0.06 .56 
    Corticotherapy 0.19 .23 0.14 .35 
    HSCT 0.05 .56 −0.24 .006 
Chemotherapy group     
    Sex −0.11 .3 0.12 .26 
    Initial diagnosis −0.06 .58 −0.04 .67 
    Age at diagnosis −0.09 .52 −0.18 .19 
    Follow-up 0.01 .94 0.01 .94 
    CNS radiation 0.001 .99 −0.06 .62 
HSCT group     
    Sex 0.13 .39 0.15 .31 
    Age at HSCT 0.38 .03 0.3 .07 
    Follow-up 0.11 .50 0.14 .39 
    TBI 0.23 .12 0.14 .31 
    Significant GVHD* −0.11 .41 −0.15 .25 
    Hypogonadism −0.17 .30 −0.32 .04 
*

Significant GVHD indicates acute GVHD grades II, III, or IV or chronic extensive GVHD.

In the chemotherapy group, FN BMD was normal (mean FN Z-score, −0.04 ± 0.10) with no increase in the incidence of low BMD for age (1.9%). None of the studied covariables (including CNS radiation) was found significant. A trend toward a lower FN BMD was observed among older patients at diagnosis (P = .04), but this difference did not remain significant anymore in the multivariate analysis (Table 4).

Patients in the HSCT group had a significantly reduced FN BMD (mean FN Z-score, −0.49 ± 0.15) compared with normal values and with patients who did not receive a transplant with a slight increase in patients with a low BMD for age (5.8%). In univariate analysis, female sex and gonadal deficiency were the 2 factors that influenced FN BMD (Table 3). Mean Z-score was −0.87 ± 0.14 for females and −0.22 ± 0.23 for males (P = .03). Mean Z-score was −0.88 ± 0.16 for hypogonadic patients compared with −0.10 ± 0.23 for the others (P = .02). The negative influence of gonadal deficiency was more important in case of uncompensed gonadal deficiency but was also present in patients receiving hormonal replacement at the time of the evaluation (mean FN Z-score, −1.37 ± 0.26 in patients with uncompensed gonadal deficiency vs −0.59 ± 0.18 in patients with hormone replacement vs −0.10 ± 0.23 in nonhypogonadic patients; P = .004).

We did not detect any influence of other variables such as type of graft, TBI, occurrence of GVHD after transplantation steroid therapy or GHD (Table 3). After multivariate analysis, gonadal deficiency was the only factor significantly associated with low FN BMD (P = .004; Table 4).

LS BMD.

LS BMD was reduced compared with age- and sex-matched normal values in the overall studied population (mean LS Z-score, −0.37 ± 0.08) with a slight increase in low BMD for age (3.8%). We did not find any influence of patient and disease characteristics, treatment modalities, and treatment-related complications on LS BMD in both univariate and multivariate analyses, taking into account the same factors as described earlier (Tables 4 and 5).

Table 5

Univariate analysis: LS BMD results

All patients
Chemotherapy group
HSCT group
Mean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable P
Patient and disease characteristics       
    Sex       
        Female −0.35 ± 0.11 .89 −0.28 ± 0.13 .26 −0.55 ± 0.19 .16 
        Male −0.38 ± 0.13  −0.51 ± 0.17  −0.17 ± 0.18  
    Initial diagnosis       
        ALL −0.32 ± 0.09 .27 −0.36 ± 0.11 .47 −0.20 ± 0.16 .24 
        AML −0.56 ± 0.22  −0.65 ± 0.52  −0.53 ± 0.24  
    Age at diagnosis NA .72 NA .34 NA .07 
    Age at HSCT     NA .02 
    Follow-up NA .93 NA .57 NA .49 
Treatment modalities       
    Corticotherapy       
        No −0.71 ± 0.24 .10 −0.65 ± 0.52 .47 −0.75 ± 0.24 .07 
        Yes −0.31 ± 0.09  −0.36 ± 0.11  −0.19 ± 0.15  
    Dexamethasone       
        No −0.44 ± 0.15 .45 −0.39 ± 0.23 .97 −0.50 ± 0.19 .16 
        Yes −0.31 ± 0.10  −0.38 ± 0.11  −0.12 ± 0.18  
    HSCT       
        No −0.39 ± 0.11 .74     
        Yes −0.33 ± 0.13      
    TBI       
        No     −0.40 ± 0.24 .23 
        Yes     −0.22 ± 0.16  
    Type of graft       
        Allograft     −0.36 ± 0.18 .71 
        Autograft     −0.26 ± 0.20  
    Posttransplantation steroid therapy       
        No     −0.55 ± 0.14 .69 
        Yes     −0.41 ± 0.32  
Transplantation-related complications       
    Significant GVHD*       
        No     −0.26 ± 0.17 .48 
        Yes     −0.47 ± 0.20  
    Hypogonadism       
        No     −0.16 ± 0.19  
        Compensated     −0.38 ± 0.25 .37 
        Uncompensated     −0.65 ± 0.27  
    GHD       
        No     −0.32 ± 0.14 .88 
        Yes     −0.40 ± 0.32  
All patients
Chemotherapy group
HSCT group
Mean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable PMean Z-score ± SEMUnivariable P
Patient and disease characteristics       
    Sex       
        Female −0.35 ± 0.11 .89 −0.28 ± 0.13 .26 −0.55 ± 0.19 .16 
        Male −0.38 ± 0.13  −0.51 ± 0.17  −0.17 ± 0.18  
    Initial diagnosis       
        ALL −0.32 ± 0.09 .27 −0.36 ± 0.11 .47 −0.20 ± 0.16 .24 
        AML −0.56 ± 0.22  −0.65 ± 0.52  −0.53 ± 0.24  
    Age at diagnosis NA .72 NA .34 NA .07 
    Age at HSCT     NA .02 
    Follow-up NA .93 NA .57 NA .49 
Treatment modalities       
    Corticotherapy       
        No −0.71 ± 0.24 .10 −0.65 ± 0.52 .47 −0.75 ± 0.24 .07 
        Yes −0.31 ± 0.09  −0.36 ± 0.11  −0.19 ± 0.15  
    Dexamethasone       
        No −0.44 ± 0.15 .45 −0.39 ± 0.23 .97 −0.50 ± 0.19 .16 
        Yes −0.31 ± 0.10  −0.38 ± 0.11  −0.12 ± 0.18  
    HSCT       
        No −0.39 ± 0.11 .74     
        Yes −0.33 ± 0.13      
    TBI       
        No     −0.40 ± 0.24 .23 
        Yes     −0.22 ± 0.16  
    Type of graft       
        Allograft     −0.36 ± 0.18 .71 
        Autograft     −0.26 ± 0.20  
    Posttransplantation steroid therapy       
        No     −0.55 ± 0.14 .69 
        Yes     −0.41 ± 0.32  
Transplantation-related complications       
    Significant GVHD*       
        No     −0.26 ± 0.17 .48 
        Yes     −0.47 ± 0.20  
    Hypogonadism       
        No     −0.16 ± 0.19  
        Compensated     −0.38 ± 0.25 .37 
        Uncompensated     −0.65 ± 0.27  
    GHD       
        No     −0.32 ± 0.14 .88 
        Yes     −0.40 ± 0.32  
*

Significant GVHD indicates acute GVHD grades II, III, or IV or chronic extensive GVHD.

In the HSCT group, younger patients at HSCT have a greater LS BMD sequel than the others in univariate analysis (P = .02; Table 5), as well as in multivariate analysis, including the same covariates described earlier (P = .03; Table 4). Other factors studied did not influence LS BMD in univariate or multivariate analysis in both the HSCT and chemotherapy groups (Tables 4 and 5).

History of fractures

Only 6 fractures were reported: 4 in the HSCT group and 2 in the chemotherapy group. Patients with a history of fracture had a significantly lower FN BMD (FN Z-score, −1.26 ± 0.34 vs −0.10 ± 0.09; P = .008). No difference in LS BMD was identified (Table 6).

Table 6

BMD and history of fractures

Patients with fractures (n = 6)Patients without fractures (n = 153)P
FN Z-score    
    Mean ± SEM −1.26 ± 0.34 −0.10 ± 0.09 .008 
    n ≤ 2DS (%) 1 (16.7) 4 (2.8) .19 
LS Z-score    
    Mean ± SEM −0.48 ± 0.29 −0.35 ± 0.09 .77 
    n ≤ 2DS (%) 0 (0.0) 6 (4.2) < .999 
Patients with fractures (n = 6)Patients without fractures (n = 153)P
FN Z-score    
    Mean ± SEM −1.26 ± 0.34 −0.10 ± 0.09 .008 
    n ≤ 2DS (%) 1 (16.7) 4 (2.8) .19 
LS Z-score    
    Mean ± SEM −0.48 ± 0.29 −0.35 ± 0.09 .77 
    n ≤ 2DS (%) 0 (0.0) 6 (4.2) < .999 

Under healthy conditions, BMD increases dramatically during childhood and adolescence until peak bone mass is reached at the beginning of adulthood. Bone mass in young adults is an important determinant of long-term bone health, which correlates with the risk of involutional osteoporotic fractures.26-28  Our study shows that most survivors of childhood AL do not sustain significant long-term impairment of BMD. However, a subset of patients has lower than expected BMD for age, which may be related to specific aspects of their treatment and its consequences.

Chemotherapy group

Patients who did not receive a transplant have apparently normal FN BMD and a slight reduction of LS BMD. Unlike some prior studies, we were unable to detect any subgroup at risk for BMD involvement in this population.

Twenty years ago, Gilsanz et al29  used quantitative computed tomography (QCT) to determine BMD in 43 childhood ALL survivors and first reported decreased BMD and severe osteopenia exclusively in the 29 patients who received cranial irradiation. Later, many studies also implicated cranial irradiation as the main risk factor for decreased BMD in survivors of childhood AL.11-15  Indeed, cranial irradiation has a dose-dependent effect on the hypothalamic-pituitary axis and can induce GHD,10-12,17  which is known to impair bone accrual.30-33  Thus, Nussey et al33  found in a cohort of 39 ALL long-term survivors who had received CNS irradiation a reduced DXA BMD only in the 14 patients who had untreated GHD during the growth period. Our patients were all treated after the early 1980s, within the “modern era” of leukemia therapy. Therefore, they benefited from decreased dose and frequency of cranial irradiation: only 6 of our patients who received CNS irradiation received a 24-Gy dose, and all except 1 patient had normal GH function. This might explain the lack of effect of CNS irradiation on BMD as previously reported by Mandel et al6  who found normal DXA BMD in 106 patients with ALL who received cranial irradiation of 18 Gy after 1985.

Another potential cause of impaired bone mineralization after childhood AL might be prolonged corticosteroid treatment and high-dose methotrexate. Indeed, the negative effect of corticosteroids on bone metabolism is well known.34,35  Corticosteroids have been proposed to decrease the lifespan and the activity of osteoblasts and to increase bone resorption. Methotrexate osteopathy has also been largely reported in inflammatory diseases and in malignancies, but it usually is reverted spontaneously when methotrexate was stopped.13,35-37  Because our patients were treated according to different protocols, our study could not allow us to assess precisely the effect of each individual chemotherapy component on BMD. However, we did not detect a more pronounced BMD involvement in patients with ALL (who received steroids and methotrexate as a part of their treatment) compared with patients with AML in both univariate and multivariate analysis. Similarly, the use of steroids, whatever the type (prednisone only or associated with dexamethasone) did not influence BMD. This is in agreement with several studies in ALL long-term survivors which did not find any influence on BMD of dose4,6,9,12,17  and type7,9  (prednisone or dexamethasone) of steroid used.

At the spine, the detected slight reduction of BMD has no clear explanation. It might result from a particularly high sensibility of trabecular bone to metabolic factors (calcium and vitamin D deficiency especially) and from a direct effect of the disease itself. Indeed, the effect of various factors secreted by leukemic cells (osteoblast-inhibiting factor, parathyroid hormone-related peptide) on trabecular bone and the destruction of spongiosa caused by the leukemic infiltration and the repeated expansions of the bone marrow spaces have been reported in AL at diagnosis and during treatment.1,2,4 

HSCT group

HSCT is now an established therapy for several hematologic malignancies. As the cohort of surviving patients treated with HSCT grows, recognition of long-term transplantation-related complications increases. To our knowledge, the present study is the first one to report DXA measurements at the femur and the spine of > 50 adult patients treated with BMT for childhood AL. Although ∼ 25 studies have been published describing the features of bone loss consequent to HSCT in adulthood,38  reports on BMD after HSCT in childhood remain rare, limited by the small sizes of the studied cohorts and the heterogeneity of age at evaluation.39-43 

The previously published DXA BMD measurements in long-term survivors of childhood HSCT found a reduced BMD at different sites.43  Thus, Bhatia et al39  and Nysom et al40  reported a mean total body Z-score at −0.5 and −0.54 in 10 and 25 HSC transplant recipients at a mean of 3.3 and 7.5 years after HSCT, respectively. Similarly, Daniels et al41  found mean Z-scores ranging between −0.7 and −0.9 at FN, LS, and total body in 15 HSC transplant recipients 6.3 years after transplantation, and Kaste et al42  reported a mean LS Z-score at −0.89 with the use of QCT in 48 HSC transplant recipients 5 years after transplantation. In agreement with these data, we found reduced BMDs 14 years after transplantation. Moreover, as reported in adult cohorts, we found a more preferential femoral bone loss. Interestingly, the incidence of severe osteopenia was finally low with only 3 patients (5.8%) having a Z-score ≤ 2DS at the FN and 1 patients (1.9%) at the LS. Unfortunately, we do not have any information on bone density before transplantation or any serial measurement after transplantation to determine when the decrease in BMD occurred in the posttransplantation period. In adult reports, an early stage of rapid demineralization (within 6-12 months) at all skeletal sites but more pronounced at the femur is followed by an improvement in lumbar BMD, whereas bone loss at the FN persisted longer (48-120 months) and might be irreversible.38  The underlying mechanism responsible for these differences is unclear.

Bone loss after HSCT is a multifactorial disorder. There is consistent evidence that major risk factors include myeloablative conditioning regimens and their induced hormonal deficiencies, immunosuppressive therapy after HSCT, reduced mobility and sun exposure, reduced calcium intake, and secondary hyperparathyroidism. In addition, altered kidney, liver, and bowel functions (especially because of GVH disease) might result in reduced absorption and abnormal metabolism of calcium and vitamin D.38  Other potential mechanisms of bone loss after transplantation have been reported. Early decline in the production of growth factors and osteoclast activation by increased systemic or local cytokine production immediately after transplantation might play an important role in early demineralization, but the cytokine production and its influence on bone might decrease with time. Moreover, an alteration in the balance between the receptor activator of the NF-κB and osteoprotegerin have been reported in various conditions, including HSCT, but the exact contribution of impaired osteoprotegerin production in bone loss after HSCT remains far from clear.44-46  Finally, the HSCT procedure itself has been reported to cause severe and persistent quantitative and qualitative impairment of the osteoblastic precursors within the stromal stem cell compartment, suggesting that the inability to regenerate a normal osteogenic cell compartment may partly explain the reason for persistent bone damage after HSCT.36,46 

Sex hormones play a crucial role in the attainment of peak bone mass and in the maintenance of the bone mass in adulthood with estrogens inhibiting osteoclast activity and promoting osteoclast apoptosis and with androgens affecting directly osteoblast differentiation or at least acting on bone after being converted to estrogens by aromatization.32  Thus, gonadal failure secondary to the myeloablative conditioning regimen has been reported to be one of the main related factors of bone loss after HSCT in adult patients,44,45,47,48  as well as in 48 patients who received HSCT during childhood for various disorders.42  According to those previous report, gonadal deficiency was significantly associated with lower FN BMD in our HSCT group in univariate analysis (even more in case of uncompensated gonadal deficiency but also in patients receiving hormonal replacement at the time of the evaluation) and was the only factor significantly associated with low FN BMD after multivariate analysis.

TBI-related GHD is also a potential risk factor of bone loss after HSCT, as previously suggested by Nysom et al.40  In our study, there was a trend toward lower FN BMD in the patients who experienced GHD after transplantation, but this difference did not reach the threshold of significance, perhaps because of the very low sample size (4 patients).

In addition to the myeloablative conditioning regimen, immunosuppressive agents used after HSCT might also accelerate bone loss. Thus, several studies performed in adult patients have pointed out the relationship between severe GVH disease, its treatment (corticosteroids and cyclosporin A) and more severe bone loss.45-47,49  Indeed, in addition to the well-known negative effect of corticosteroids on bone, calcineurin inhibitors have been reported to induce accelerated cortical bone loss after solid-organ and BM transplantation with an involvement dependent on the duration of exposure. In our study, patients who experienced significant GVH disease (acute GVHD grade ≥ 2 or chronic extensive GVHD) seemed to have a lower FN BMD than the others, but this difference was not statistically significant. This lack of significance might be explained by the low incidence of chronic extensive GVHD in our cohort (only 1 patient).

In our HSCT group, children who were younger at the time of transplantation had a significant higher risk of low LS BMD during adulthood in both univariate (P = .02) and multivariate (P = .03) analyses. This finding is consistent with previous data of Bhatia et al39  who reported a decrease in total body Z-score assessed by DXA scan with decreasing age at transplantation in 10 childhood recipients of a BM transplant. However, this detected reduction of BMD might be related with a more impaired growth in patients who received a transplant at a younger age. Indeed, because DXA scanning is available worldwide, easily reproducible, and a low irradiant, it is recognized to be the standard method to evaluate BMD and to diagnose osteopenia or osteoporosis (according to the WHO criteria), and it has been used in most of the studies in AL survivors. However, its main limitation is that it provides a surfacic and not a volumetric measurement of bone mineral content. Therefore, DXA assessments of BMD do not take into account the thickness of the bone and might be influenced by skeletal size (height). For this reason, reduced bone size after HSCT might partly explain the lower BMD detected in our patients who received a transplant (especially in those who received a transplant at a younger age). QTC, which provides a volumetric assessment of BMD (and therefore avoids the influence of height on BMD measurements) and in addition differentiates trabecular from cortical bone, providing additional information about bone health, is therefore useful in children and has also been used in childhood AL survivors (who are at risk of short stature). Interestingly, the few QTC-based studies found a reduced BMD in high-dose radiated patients,17,29  GH-deficient patients,15  and patients who received a transplant42  identically to DXA-based studies, confirming that the results of these later (and our results) reflect a significant reduction in bone mass rather than misinterpretation because of the limitations imposed by radiologic techniques.

Finally, we reported bone loss after HSCT in both allo- and auto-HSC transplant recipients. In some previous studies, bone loss after allo-HSCT seemed to be greater than after autologous HSCT,47  probably because of a prolonged and greater cytokine release after transplantation and a more important use of immunosuppressive agents in the allogenic setting. The lack of statistical difference in BMD between our auto- and allo-HSC transplant recipients might be explained by the use of identical conditioning regimens in both types of transplantations and consequently by a same risk of gonadal failure.

In conclusion, 15 years after diagnosis, adult patients treated for childhood AL within the modern era of chemotherapy have a normal FN BMD associated with only a slight reduction in their mean LS BMD. Despite this reduction, no increase in the incidence of low BMD for age was detected at this site; therefore, this reduction might not have clinical consequence. However, our numbers remain too small to state this with confidence.

On the other hand, HSCT recipients with gonadal deficiency have a reduced mean FN Z-score with an increase in low BMD for age at this site (5.8%). However this detected reduction remains small, and its clinical significance is therefore uncertain. It is nevertheless interesting to note that, according to previous reports which showed that low bone density at the FN is the strongest predictor of hip fracture,50  lower FN Z-score is correlated to occurrence of fractures in our study (P = .008).

These findings underscore the importance of bone mass measurements in the HSCT survivors' routine long-term follow-up, as well as the benefit of the early diagnosis and prolonged treatment of medical conditions such as gonadal failure or GHD. Any secondary cause of osteoporosis should also be identified and treated: patients should avoid smoking, limit intake of caffeine and carbonate beverages, assure adequate dietary intake of calcium and vitamin D (ie, to achieve a serum 25-hydroxyvitamin D concentration of ≥ 20 ng/mL), and establish a weight-bearing exercise regimen. Further studies should be conducted to determine whether these interventions could prevent bone loss and reduce the fracture risk in these patients.

The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked “advertisement” in accordance with 18 USC section 1734.

The authors thank Isabelle Champenois for her helpful review of the manuscript.

This work was supported by the French National Clinical Research Program, the French National Cancer Institute, and the Paediatric Hematology PACA Network (RHEMAP).

Contribution: M.L.M. and G.M. designed the study, reviewed all medical records, analyzed data, and wrote the manuscript; P.A., M.-C.S., and J.B. participated in study design and in data analysis; V.B., M.P., C.G., A.C., N.S., P.C., P.B., and H.C. enrolled patients and revised the manuscript; V.V. performed statistical analysis; and B.P. contributed to data collection.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Marion Le Meignen, Service d'hémato-oncologie, Hôpital l'Archet II, 151 route de saint Antoine de Ginestière, 06202 Nice Cedex 3, France; e-mail: le-meignen-diop.m@pediatrie-chulenval-nice.fr.

1
Halton
 
JM
Atkinson
 
SA
Fraher
 
L
, et al. 
Altered mineral metabolism and bone mass in children during treatment for acute lymphoblastic leukemia.
J Bone Miner Res
1996
, vol. 
11
 
11
(pg. 
1774
-
1783
)
2
Henderson
 
RC
Madsen
 
CD
Davis
 
C
Gold
 
SH
Longitudinal evaluation of bone mineral density in children receiving chemotherapy.
J Pediatr Hematol Oncol
1998
, vol. 
20
 
4
(pg. 
322
-
326
)
3
Arikosky
 
P
Komulainen
 
J
Riikonen
 
P
Voutilainen
 
R
Knip
 
M
Kröger
 
H
Alterations in bone turnover and impaired development of bone mineral density in newly diagnosed children with cancer: a 1-year prospective study.
J Clin Endocrinol Metab
1999
, vol. 
84
 
9
(pg. 
3174
-
3181
)
4
Van der Sluis
 
JM
van den Heuvel-Eibrink
 
MM
Hählen
 
K
Krenning
 
EP
de Muinck Keizer-Schrama
 
SM
Altered bone mineral density and body composition and increased fracture risk in childhood acute lymphoblastic leukemia.
J Pediatr
2002
, vol. 
141
 
2
(pg. 
204
-
210
)
5
Lequin
 
MH
van de Sluis
 
IM
Van Rijn
 
RR
, et al. 
Bone mineral assessment with tibial ultrasonometry and dual-energy X-ray absorptiometry in long-term survivors of acute lymphoblastic leukemia in childhood.
J Clin Densitom
2002
, vol. 
5
 
2
(pg. 
167
-
173
)
6
Mandel
 
K
Atkinson
 
S
Barr
 
RD
Pencharz
 
P
Skeletal morbidity in childhood acute lymphoblastic leukemia.
J Clin Oncol
2004
, vol. 
22
 
7
(pg. 
1215
-
1221
)
7
Van Beek
 
RD
de Muinck Keizer-Schrama
 
SM
Hakvoort-Kammel
 
FG
, et al. 
No difference between prednisolone and dexamethasone treatment in bone mineral density and growth in long term survivors of childhood acute lymphoblastic leukemia.
Pediatr Blood Cancer
2006
, vol. 
46
 
1
(pg. 
88
-
93
)
8
van der Sluis
 
IM
van den Heuvel-Eibrink
 
MM
Hählen
 
K
Krenning
 
EP
de Muinck Keizer-Schrama
 
SM
Bone mineral density, body composition, and height in long-term survivors of acute lymphoblastic leukemia in childhood.
Med Pediatr Oncol
2000
, vol. 
35
 
4
(pg. 
415
-
420
)
9
Kadan-Lottick
 
N
Marshall
 
JA
Baron
 
AE
Krebs
 
NF
Hambidge
 
KM
Albano
 
E
Normal bone mineral density after treatment for childhood acute lymphoblastic leukemia diagnosed between 1991 and 1998.
J Pediatr
2001
, vol. 
138
 
6
(pg. 
898
-
904
)
10
Henderson
 
RC
Madsen
 
CD
Davis
 
C
Gold
 
SH
Bone density in survivors of childhood malignancies.
J Pediatr Hematol Oncol
1996
, vol. 
18
 
4
(pg. 
367
-
371
)
11
Nysom
 
K
Holm
 
K
Michaelsen
 
KF
Hertz
 
H
Muller
 
J
Molgaard
 
C
Bone mass after treatment for acute lymphoblastic leukemia in childhood.
J Clin Oncol
1998
, vol. 
16
 
12
(pg. 
3752
-
3760
)
12
Hesseling
 
PB
Hough
 
SF
Nel
 
ED
Van Riet
 
FA
Beneke
 
T
Wessels
 
G
Bone mineral density in long-term survivors of childhood cancer.
Int J Cancer Suppl
1998
, vol. 
11
 (pg. 
44
-
47
)
13
Arikosky
 
P
Komulainen
 
J
Voutilainen
 
R
, et al. 
Reduced bone mineral density in long-term survivors of childhood acute lymphoblastic leukemia.
J Pediatr Hematol Oncol
1998
, vol. 
20
 
3
(pg. 
234
-
240
)
14
Hoorweg-Nijman
 
JJ
Kardos
 
G
Roos
 
JC
, et al. 
Bone mineral density and markers of bone turnover in young adult survivors of childhood lymphoblastic leukaemia.
Clin Endocrinol (Oxf)
1999
, vol. 
50
 
2
(pg. 
237
-
244
)
15
Brennan
 
BMD
Rahim
 
A
Adams
 
JA
Eden
 
OB
Shalet
 
SM
Reduced bone mineral density in young adults following cure of acute lymphoblastic leukemia in childhood.
Br J Cancer
1999
, vol. 
79
 
11–12
(pg. 
1859
-
1863
)
16
Warner
 
JT
Evans
 
WD
Webb
 
DK
Bell
 
W
Gregory
 
JW
Relative osteopenia after treatment for acute lymphoblastic leukemia.
Pediatr Res
1999
, vol. 
45
 
4 Pt 1
(pg. 
544
-
551
)
17
Kaste
 
SC
Jones Wallace
 
D
Rose
 
SR
, et al. 
Bone mineral decrements in survivors of childhood acute lymphoblastic leukemia: frequency of occurrence and risk factors for their development.
Leukemia
2001
, vol. 
15
 
5
(pg. 
728
-
734
)
18
Tillmann
 
V
Darlington
 
AS
Eiser
 
C
Bishop
 
NJ
Davies
 
HA
Male sex and low physical activity are associated with reduced spine bone mineral density in survivors of childhood acute lymphoblastic leukemia.
J Bone Miner Res
2002
, vol. 
17
 
6
(pg. 
1073
-
1080
)
19
Wasilewski-Masker
 
K
Kaste
 
SC
Hudson
 
MM
Esiashvili
 
N
Mattano
 
LA
Meacham
 
LR
Bone mineral density deficits in survivors of childhood cancer: long-term follow-up guidelines and review of the literature.
Pediatrics
2008
, vol. 
121
 
3
(pg. 
e705
-
e713
)
20
Michel
 
G
Bordigoni
 
P
Simeoni
 
MC
, et al. 
Health status and quality of life in long-term survivors of childhood leukaemia: the impact of haematopoietic stem cell transplantation.
Bone Marrow Transplant
2007
, vol. 
40
 
9
(pg. 
897
-
904
)
21
Lewiecki
 
EM
Gordon
 
CM
Baim
 
S
, et al. 
International Society for Clinical Densitometry 2007 official adult and pediatric positions.
Bone
2008
, vol. 
43
 
6
(pg. 
1115
-
1121
)
22
Schaison
 
G
Sommelet
 
D
Bancillon
 
A
, et al. 
Treatment of acute lymphoblastic leukemia French protocol Fralle 83-87.
Leukemia
1992
, vol. 
6
 
Suppl 2
(pg. 
148
-
152
)
23
Perel
 
Y
Auvrignon
 
A
Leblanc
 
T
, et al. 
Treatment of childhood acute myeloblastic leukemia: dose intensification improves outcome and maintenance therapy is of no benefit–multicenter studies of the French LAME (Leucemie Aigue Myeloblastique Enfant) Cooperative Group.
Leukemia
2005
, vol. 
19
 
12
(pg. 
2082
-
2089
)
24
Oudot
 
C
Auclerc
 
MF
Levy
 
V
, et al. 
Prognostic factors for leukemic induction failure in children with acute lymphoblastic leukemia and outcome after salvage therapy: the FRALLE 93 study.
J Clin Oncol
2008
, vol. 
26
 
9
(pg. 
1496
-
1503
)
25
Uyttebroeck
 
A
Suciu
 
S
Laureys
 
G
, et al. 
Treatment of childhood T-cell lymphoblastic lymphoma according to the strategy for acute lymphoblastic leukaemia, without radiotherapy: long term results of the EORTC CLG 58881 trial.
Eur J Cancer
2008
, vol. 
44
 
6
(pg. 
840
-
846
)
26
Johnston
 
CC
Slemenda
 
CW
Determinants of peak bone mass.
Osteoporis Int
1993
, vol. 
3
 
Suppl 1
(pg. 
54
-
55
)
27
Sabatier
 
JP
Guaydier-Souquières
 
G
Laroche
 
D
, et al. 
Bone mineral acquisition during adolescence and early adulthood: a study in 574 healthy females 10-24 years of age.
Osteoporos Int
1996
, vol. 
6
 
1
(pg. 
141
-
148
)
28
Osteoporosis prevention, diagnosis, and therapy.
NIH Consens Statement Online
2000
, vol. 
17
 
1
(pg. 
1
-
36
)
29
Gilsanz
 
V
Carlson
 
ME
Roe
 
TF
Ortega
 
JA
Osteoporosis after cranial irradiation for acute lymphoblastic leukemia.
J Pediatr
1990
, vol. 
117
 
2 Pt 1
(pg. 
238
-
244
)
30
Kaufman
 
JM
Taelman
 
P
Vermeulen
 
A
Vandeweghe
 
M
Bone mineral status in Growth-hormone deficient males with isolated and multiple pituitary deficiencies of childhood onset.
J Clin Endocrinol Metab
1992
, vol. 
74
 
1
(pg. 
118
-
123
)
31
Hyer
 
SL
Rodin
 
DA
Tobias
 
JH
Leyper
 
A
Nussey
 
SS
Growth hormone deficiency during puberty reduces adult bone mineral density.
Arch Dis Child
1992
, vol. 
67
 
12
(pg. 
1472
-
1474
)
32
Holmes
 
SJ
Shalet
 
SM
Role of growth hormone and sex steroids in achieving and maintaining normal bone mass.
Horm Res
1996
, vol. 
45
 
1–2
(pg. 
86
-
93
)
33
Nussey
 
SS
Hyer
 
SL
Brada
 
M
Leiper
 
AD
Pazianas
 
M
Bone mineralization after treatment of growth hormone deficiency in survivors of childhood malignancy.
Acta Pediatr Suppl
1994
, vol. 
399
 (pg. 
9
-
14
)
34
Canalis
 
E
Mazziotti
 
G
Giustina
 
A
Bilezikian
 
JP
Glucocorticoid-induced osteoporosis: pathophysiology and therapy,
Osteop Int
2007
, vol. 
18
 
10
(pg. 
1319
-
1328
)
35
Mazziotti
 
G
Canalis
 
E
Giustina
 
A
Drug-induced osteoporosis: mechanisms and clinical implications.
Am J Med
2010
, vol. 
123
 
10
(pg. 
877
-
884
)
36
Ragab
 
AH
Fresh
 
RS
Vietti
 
TJ
Osteoporotic fractures secondary to methotrexate therapy of acute leukemia in remission.
Cancer
1970
, vol. 
25
 
3
(pg. 
580
-
585
)
37
Stanisavljevic
 
S
Babcock
 
AL
Fractures in children treated with methotrexate for leukemia.
Clin Orthop Relat Res
1977
125
(pg. 
139
-
144
)
38
Tauchmanovà
 
L
Colao
 
A
Lombardi
 
G
Rotoli
 
B
Selleri
 
C
Bone loss and its management in long-term survivors from allogeneic stem cell transplantation.
J Clin Endocrinol Metab
2007
, vol. 
92
 
12
(pg. 
4536
-
4545
)
39
Bhatia
 
S
Ramsay
 
NKC
Weisdorf
 
D
Griffiths
 
H
Robison
 
LL
Bone mineral density in patients undergoing bone marrow transplantation for myeloid malignancies.
Bone Marrow Transplant
1998
, vol. 
22
 
1
(pg. 
87
-
90
)
40
Nysom
 
K
Holm
 
K
Fleischer Michaelsen
 
K
, et al. 
Bone mass after allogenic BMT for childhood leukemia or lymphoma.
Bone Marrow Transplant
2000
, vol. 
25
 
2
(pg. 
191
-
196
)
41
Daniels
 
MW
Wilson
 
DM
Paguntalan
 
HG
, et al. 
Bone mineral density in pediatric transplant recipients.
Transplantation
2003
, vol. 
76
 
4
(pg. 
673
-
678
)
42
Kaste
 
SC
Shidler
 
TJ
Tong
 
X
, et al. 
Bone mineral density and osteonecrosis in survivors of childhood allogenic bone marrow transplantation.
Bone Marrow Transplant
2004
, vol. 
33
 
4
(pg. 
435
-
441
)
43
McClune
 
BL
Polgreen
 
LE
Burmeister
 
LA
, et al. 
Screening, prevention and management of osteoporosis and bone loss in adult and pediatric hematopoietic cell transplant recipients.
Bone Marrow Transplant
2011
, vol. 
46
 
1
(pg. 
1
-
9
)
44
Tauchmanova
 
L
Serio
 
B
Del Puente
 
A
, et al. 
Long-lasting bone damage detected by dual energy X-ray absorbtiometry, phalangeal osteosonogrammetry and in vitro growth of marrow stroma cells after allogenic stem cell transplantation.
J Clin Endocrinol Metab
2002
, vol. 
87
 
11
(pg. 
5058
-
5065
)
45
Kananen
 
K
Volin
 
L
Tahtela
 
R
Laitenen
 
K
Ruutu
 
T
Valimaki
 
MJ
Recovery of bone mass and normalization of bone turnover in long-term survivors of allogenic bone marrow transplantation.
Bone Marrow Transplant
2002
, vol. 
29
 
1
(pg. 
33
-
39
)
46
Schulte
 
CMS
Beelen
 
DW
Bone loss following hematopoietic stem cell transplantation, a long term follow-up.
Blood
2004
, vol. 
103
 
10
(pg. 
3635
-
3643
)
47
Ebeling
 
PR
Thomas
 
DM
Erbas
 
B
Hopper
 
JL
Szer
 
J
Grigg
 
AP
Mechanisms of bone loss following allogeneic and autologous hemopoietic stem cell transplantation.
J Bone Miner Res
1999
, vol. 
14
 
3
(pg. 
342
-
350
)
48
Valimaki
 
MJ
Kinnunen
 
K
Volin
 
L
, et al. 
A prospective study of bone loss and turnover after allogenic bone marrow transplantation: effect of calcium supplementation with or without calcitonin.
Bone Marrow Transplant
1999
, vol. 
23
 
4
(pg. 
355
-
361
)
49
Stern
 
JM
Sullivan
 
KM
Ott
 
SM
Seidel
 
K
, et al. 
Bone density loss after allogeneic stem cell transplantation: a prospective study.
Biol Blood Marrow Transplant
2001
, vol. 
7
 
5
(pg. 
257
-
264
)
50
Cummings
 
SR
Black
 
DM
Nevitt
 
MC
, et al. 
Bone density at various sites for prediction of hip fractures. The study of Osteoporotic Fractures Research Group.
Lancet
1993
, vol. 
341
 
8837
(pg. 
72
-
75
)