medwireNews: Limb bone pain is frequently reported among pediatric cancer patients with articular symptoms and could be used to distinguish cancer from juvenile idiopathic arthritis (JIA), suggest results of the ONCOREUM study.
“The results of this study highlight the clinical manifestations that are most valuable to suspect a malignancy in children who present with musculoskeletal complaints,” explain Adele Civino (Ospedale Vito Fazzi, Lecce, Italy) and fellow researchers.
They found that a quarter of 1277 cancer patients aged below 16 years of age had musculoskeletal symptoms. These were most common among patients with malignant bone tumors (80%), followed by those with Langerhans histiocytosis (47%), leukemia (32%), soft-tissue sarcomas (24%), and neuroblastoma (19%).
Lisette van Suijlekom-Smit (Erasmus MC Sophia Children’s Hospital, Rotterdam, the Netherlands) emphasizes in an accompanying comment that “[a]lthough haematological malignancies are particularly known for presenting with symptoms mimicking juvenile idiopathic arthritis, this study reveals that several other malignancies can do so as well.”
She added: “[K]nowledge of the broad variety of malignancies that present with musculoskeletal symptoms, as well as insight into the clinical differences between, and specific aspects of, juvenile idiopathic arthritis categories is of great importance.”
The researchers analyzed data pertaining to 1957 children from 47 Italian hemato-oncology or rheumatology centers, including 1277 with cancer (64% hematologic and 36% solid malignancies) and 680 with JIA (65% oligoarthritis).
Joint pain (61%) was the most frequently recorded musculoskeletal symptom among cancer patients, followed by limb bone pain (35%), limp (32%), arthritis (32%), arthralgia (31%), back pain (26%), and refusal to walk (21%).
Civino et al point out that for 5% and 12% of patients with hematologic and solid malignancies, respectively, musculoskeletal symptoms were the only presenting symptom. Meanwhile, a corresponding 83% and 44% of hematologic and solid tumor patients who had musculoskeletal symptoms also presented with at least one systemic manifestation, of which fever (48% in total), fatigue (35%), and pallor (26%) were the most frequent.
More than a third (35%) of patients with musculoskeletal symptoms had arthropathy, with the hip (43%) and knees (39%) being the most affected joints. This was more common among patients with hematologic than solid tumors (19 vs 11%), among those with lymphoid versus myeloid leukemia (26 vs 8%), and in patients with precursor B-cell acute lymphoblastic leukemia rather than T-cell leukemia (29 vs 5%).
The researchers performed multivariable analyses in order to identify factors that could distinguish between cancer and JIA among patients with arthropathy. They demonstrated that limb bone pain was a significant 87.80-fold more likely to be associated with cancer than juvenile idiopathic arthritis. Other factors strongly associated included weight loss, thrombocytopenia, monoarticular involvement, hip involvement, and male sex, with odds ratios of 59.88, 12.67, 11.30, 3.30, and 2.40, respectively.
van Suijlekom-Smit says that these symptoms “are helpful and could be considered as potential red flags for cancer diagnoses.”
As expected, stiffness, joint swelling, and involvement of the small hand joints more strongly correlated with juvenile idiopathic arthritis.
Civino and team write in The Lancet Rheumatology: “Altogether, the results of our analysis increase the knowledge of musculoskeletal manifestations of childhood cancer and help to define the optimal diagnostic algorithm for children who present with unexplained joint involvement.”
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Lancet Rheumatol 2021; doi:10.1016/S2665-9913(21)00086-2
Lancet Rheumatol 2021; doi:10.1016/S2665-9913(21)00120-X