Avascular necrosis of bone in leukemia and osteonecrosis of jaw by bisphosphonates

Aseptic osteonecrosis, also known as avas- cular necrosis of bone or simply osteonecrosis (ON), is a disorder characterized by segmental death of 1 or more osseous sites due to a late toxicity of treatment for child- hood leukemia and lymphoma. The pathobiologic mechanism leading to ONJ has not been elucidated, and at present, there are no definitive guidelines for the management of care of patients with ONJ. Here, we report a case of ONJ in a patient treated for ALL and discuss the analogies with ONJ associated with bisphos- phonate treatment, another kind of bone necrosis occurring in hematologic patients, and treatment options. A 31-year-old man was admitted to the hospital because of mild fever with chills, anemia, and reduction in platelet count. Total-body computed tomography confirmed the presence of lymphadenopathy. Bone marrow aspira- tion, biopsy, and a chromosomal study permitted a diagno- sis of Philadelphia negative B-cell ALL. The patient underwent surgical debridement and osteot- omy to remove the necrotic segments of maxillary bone; and on day +35, the missing part of the maxillary bone was replaced with an obturator prosthesis. The pathogenesis of ON is still a matter of controversy. It is considered to be the result of multiple triggering factors, such as metabolic disorders; increased intraosseous pres- sure; and mechanical stress, leading to demineralization, death of trabecular bone, and collapse. In recent works we have shown the possibility that bisphosphonates could have a suppressive effect on angio- genesis through an action on circulating endothelial cells of patients with ONJ and on VEGF receptors. We believe that any of the treatments used in ON patients should have to be tried in ONJ patients. In the absence of any established therapy, a controlled experimental treatment plan could be put into place, espe- cially in disabled patients.