Transcript of May 28 – 30, 2015, Montréal, Québec AN UNDERAPPRECIATED CAUSE OF MORBIDITY Sian E. Iles MD...
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- May 28 30, 2015, Montral, Qubec AN UNDERAPPRECIATED CAUSE OF
MORBIDITY Sian E. Iles MD Associate Professor Dalhousie University
Halifax Nova Scotia Gina Di Primio MD Professor McMaster University
Hamilton, Ontario
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- Disclosure Statement: No Conflict of Interest May 28 30, 2015,
Montral, Qubec I do not have an affiliation, financial or
otherwise, with a pharmaceutical company, medical device or
communications organization. I have no conflicts of interest to
disclose ( i.e. no industry funding received or other commercial
relationships). I have no financial relationship or advisory role
with pharmaceutical or device-making companies, or CME provider. I
will not discuss or describe in my presentation at the meeting the
investigational or unlabeled ("off-label") use of a medical device,
product, or pharmaceutical that is classified by Health Canada as
investigational for the intended use.
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- Emphasis on clinical impact of fragility fractures CAROC: Joint
initiative of the Canadian Association of Radiologists and
Osteoporosis Canada www.osteoporosis.cawww.osteoporosis.ca
www.car.cawww.car.ca
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- AGE SEX BMD : Femoral neck T Score Clinical risk factors:
fragility fracture and steroid use
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- 2010 Guidelines 10-year Risk Assessment: CAROC Semiquantitative
method for estimating 10-year absolute risk of a major osteoporotic
fracture* in postmenopausal women and men over age 50 Stratified
into three zones (Low: 20%) Basal risk category is obtained from
age, sex, and T-score at the femoral neck Siminoski K, et al. Can
Assoc Radiol J 2005; 56(3):178-188. * Combined risk for fractures
of the proximal femur, vertebra [clinical], forearm, and proximal
humerus. Other fractures attributable to osteoporosis are not
reflected; total osteoporotic fracture burden is
underestimated
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- Chemotherapy induced menopause Gonadotropin-releasing hormone
(GnRH) suppression of gonadal function, Anti-estrogen and
antiandrogen therapies Glucocorticoids (used predominantly in
treatment of hematologic malignancies or as supportive agents in
solid tumors) Inadequate calcium intake Vitamin D deficiency
Inadequate exercise
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- Vertebral fractures are the most common osteoporotic fractures.
Existing vertebral fractures are a strong predictor of future
vertebral and other fractures. Risk of sustaining subsequent
fractures is grossly under-recognized
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- 2010 Guidelines Fracture is a Predictor of Future Fractures The
risk of experiencing another fracture in the year following a hip
fracture*: 5% 10% 1,2 The risk of experiencing another vertebral
fracture in the year following a vertebral fracture : 20% 3
Prevalent vertebral fractures also predict hip fracture* 4,5 40% of
Canadians who experience a fracture have a history of prior
fracture 6 1. Papaioannou A, et al. JOGC 2000; 22(8):591-597. 2.
Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893. 3. Lindsay
R, et al. JAMA 2001; 285:320-323. 4. Ismail AA, et al. Osteoporos
Int 2001; 12(2):85-90. 5. Melton LJ 3rd, et al. Osteoporos Int
1999; 10(3):214-21. 6. Hajcsar EE, et al. CMAJ 2000, 163:819-822. *
in men and women in postmenopausal women
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- 2010 Guidelines Post-fracture Care Gap: Comparison with Heart
Attack 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2.
Austin PC, et al. CMAJ 2008; 179(9):901-908.
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- In summary, all patients who begin cancer therapy that induces
early menopause, reduces sex steroids or interferes with their
action, or includes glucocorticoids should undergo assessment of
bone loss risk and subsequent risk for osteoporosis and fracture.
Risk for osteoporotic fractures can be considered a potential
toxicity for a wide array of cancer therapies.
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- Complications of bone metastases include pain, hypercalcemia,
nerve compression, and pathologic fractures, and significant
morbidity and mortality are associated with bone metastases.
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- Clinically important differentiation for treatment and
prognosis Multimodality assessment often necessary Important to
remember possibility of osteoporosis complications Recommend
appropriate investigation and treatment according to Osteoporosis
Canada Guidelines Thoracolumbar Spine Anatomy and Pathology -
Midlumbar Vertebra Pathological Fracture of a Midlumbar Vertebra
Written by Wolfgang Rauschning, MD Wolfgang Rauschning, MD
http://www.pathguy.com/lectures/bones.htm Benign fracture
Pathologic fracture Renal cell Ca
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- Patient is automatically at high risk for future fracture and
treatment with a first line osteoporosis medication is
indicated
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- Known lung primary with bone mets Bone scan for back pain
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- New fracture
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- Typical appearance of benign fragility fracture on bone scan is
horizontal end plate uptake Fracture may be very subtle on cross
sectional or other imaging SPECT/CT superior if good quality
CT
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- 64 yo male No obvious posterior bony protrusion but there does
appear to be a paravertebral hematoma suggesting that the fracture
is recent. Unfortunately the bone density is not accurately
assessed by plain film and this study would suggest a reasonable
bone density and therefore the concern for metastatic disease
cannot be excluded. IMPRESSION: Grade 3 wedge compression of T12
would appear to be recent based on the paraspinal line suggesting a
hematoma.
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- Fracture at T 12 with retropulsion of fragments Clinically and
radiologically assumed to be related to lymphoma
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- Convex Posterior contour Epidural extension Complete marrow
involvement of the vertebra
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- Fracture T 12 Degenerative Change L4 L5 Uptake at T9 CT normal
in area of bone scan
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- No FDG uptake at T9
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- New compression fractures KEY FEATURES Superior end plate Low
signal band Background marrow not replaced (but may be edematous)
Sequential @ T11 & T12
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- Complete metabolic response T 12 also negative
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- Abnormal signal posterior L2 Compression fracture T9 with
abnormal signal Compression fracture L3
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- No metabolic activity L2 or L3 End plate only at T9
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- Pathologic and osteoporotic fractures may coexist Recognition
of fragility fracture and recommendation of appropriate management
may get lost in complicated cases Fragility fractures presenting as
pain may mimic recurrent disease Multimodality imaging may be
necessary to clarify findings When original tumour is FDG avid PET
CT may be helpful
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- Linear band like lines Usually Multiple # sequential Superior
end plate NORMAL signal of marrow around the fx & other non
collapsed vertebral bodies (VB) Partially preserved signal w/in
affected VB Retro-pulsion of posterior bone fragment
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- T1T2 FS Look for # elsewhere
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- T1 Replacement Multiple focal lesions or Diffuse involvement of
NON collapsed vertebral bodies (VB) Involvement of posterior arch
& pedicle Convex posterior contour (scalloping) (beware
superior end plate kyphosis) Muscle edema Sharp margins between
normal & abnormal Involvement of inferior end plate
(metaphyseal equivalent)
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- FRACTURE LINES ARE NOT ALL BENIGN Non horizontal & Inferior
end plate T1T2 GAD
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- Osteoporosis & Cancer is common in the elderly They may
co-exist or be sequelae of treatment Vertebral fractures are the
most common fracture in osteoporosis Fracture complication is
common & Implication on management is significant THEREFORE
IMPORTANT to RECOGNIZE HOW to Differentiate Benign from Malignant
dz What is available to make the diagnosis Recommend assessment and
treatment of osteoporosis when fragility fractures detected
according to guidelines from Osteoporosis Canada and CAR
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- Osteoporosis is a complication of cancer treatment Patients
with cancer have multiple risk factors for osteoporosis Vertebral
fractures most common fracture in osteoporosis Important to
differentiate osteoporotic compression fracture from pathologic
fracture secondary to metastatic disease Recommend assessment and
treatment of osteoporosis when fragility fractures detected
according to guidelines from Osteoporosis Canada and CAR
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