Chemotherapie-assoziierte Osteonekrosen im Kindes und Jugendalter

Zusammenfassung

Symptomatische Chemotherapie-assoziierte Osteonekrosen bei Kindern und Jugendlichen mit malignen Erkrankungen treten je nach Studiendesign mit einer Inzidenz von bis zu ca. zehn Prozent auf—schließt man die asymptomatischen Fälle ein, in bis zu 73 Prozent. Im Rahmen der multifaktoriellen Pathogenese gilt die Glukokortikoidgabe, insbesondere von Dexamethason, als ein gesicherter ursächlicher Faktor. Weitere Risikofaktoren sind ein höheres Patientenalter bei Diagnosestellung, weibliches Geschlecht, Adipositas und eine Knochenmarktransplantation im Rahmen der Therapie. Diskutiert werden zusätzlich genetische Faktoren. Ein Großteil der Patienten, bei denen in der Magnetresonanztomografie Osteonekrosen nachweisbar sind, bleibt asymptomatisch. Die Schmerzsymptomatik korreliert nicht regelhaft mit dem Ausmaß der Nekrose. Am häufigsten sind Hüftund Kniegelenke, meist auch beidseits, betroffen. Aktuell ist die Magnetresonanztomografie insbesondere das in Frühstadienüberlegene diagnostische Verfahren. Kausale Therapiekonzepte sind bislang nicht entwickelt. Konservative Therapieversuche bestehen je nach Symptomausprägung in Entlastung, Physiotherapie und Gabe von nichtsteroidalen Antirheumatika. Andere konservative Therapieansätze wie hyperbare Sauerstofftherapie (HBO), Iloprost und Bisphosphonatgabe sowie der Einsatz von Statinen sind bisher nur in wenigen klinischen Studien untersucht worden. Die operativen Methoden im Falle der Chemotherapie-assoziierten Osteonekrosen differieren nicht von denen anderer Ätiologie und werden beschwerde und stadienabhängig eingesetzt.

Summary

Depending on the design of the study, symptomatic chemotherapy-associated osteo necrosis in children and adolescents with malignant illnesses occur with an incidence of up to approximately 10 %, including the asymptomatic cases in up to 73 %. Within the scope of the multifactorial pathogenesis, medication with glucocorticoids, especially dexamethasone, is considered to be a verified cause. Further risk factors are a higher patient age on diagnosis, female gender, obesity and a bone marrow transplant as part of the therapy. Genetic factors are also being discussed. Most of the patients in whom osteonecrosis are detectable via magnetic resonance tomography remain asymptomatic. The pain symptoms do not correlate regularly with the extent of the necrosis. Hip and knee joints are most frequently affected, generally on both sides. At present magnetic resonance tomography is the superior diagnostic method, particularly in the early stages. No causal therapy concepts have been developed to date. Depending on the nature of the symptoms, conservative therapy options comprise relieving the extremities, physiotherapy and the use of non-steroidal anti-inflammatory drugs. Other conservative therapy approaches such as hyperbaric oxygen therapy (HOT), iloprost and bisphosphonate administration, as well as the use of statins, have been examined in so far just a few clinical studies. The operative methods for cases of chemotherapy-associated osteonecrosis do not differ from those of other aetiology and are deployed in line with the complaints and the severity of the disease.

Schlüsselwörter

Osteonekrose - Chemotherapie - Glukokortikoide

Keywords

Osteonecrosis - chemotherapy - glucocorticoid

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