Recent perspectives on the association between osteonecrosis and bone mineral density decline in childhood acute lymphoblasticleukemia

The attention to treatment related toxicity has increased since the survival of children with acute lymphoblastic leukemia (ALL)
has improved significantly over the past few decades. Intensive ALL treatment schedules including corticosteroids and
asparaginase have been shown to give rise to skeletal abnormalities such as osteonecrosis and low bone mineral density (BMD),
which may lead to debilitating sequelae in survivors. Although osteonecrosis and low BMD are different entities with suggested
separate pathophysiological mechanisms, recent studies indicate that osteonecrosis is associated with accelerated BMD decline.
Common underlying mechanisms for osteonecrosis and BMD decline are considered, such as an enhanced sensitivity to
corticosteroids in children who suffer from both osteonecrosis and low BMD. In addition, restriction of weight-bearing activities,
which is generally advised in patients with osteonecrosis, could aggravate BMD decline. This induces a clinical dilemma, since
bone stimulation is important to maintain BMD but alternative interventions for osteonecrosis are limited. Furthermore, this recent
finding of accelerated BMD decline in children with osteonecrosis emphasizes the need to develop effective preventive measures
for osteonecrosis, which may include targeting BMD decline.