Atypical Femoral Fractures (AFF) from Bone Remodeling Agents in Patients with Cancer

Abstract

Anti-resorptive drugs like bisphosphonates (BP) and denosumab are widely used for prevention and treatment of skeletal diseases, such as osteoporosis and bone metastases and mainly work through the prevention of osteoclast-mediated bones resorption. BP can lead to atypical femoral fractures (AFF) that is a rare, easily misdiagnosed treatment-related complication with great impact on the quality of life of patients. We present a concise review of the literature on BP related AFF based on the cases of 3 breast cancer patients that reflect the diagnostic pitfall of this rare entity. In conclusion, breast cancer patients very often are exposed to BP use and are at risk of developing AFF.Bisphosphonate therapy is one of the principal methods of treatment for skeletal diseases, such as osteoporosis and bone metastases. These anti-resorptive drugs, including alendronate and zoledronate, work to hinder bone loss and thereby the occurrence of classic fractures through the prevention of osteoclast-mediated bone resorption. Bisphosphonate (BP) use can lead to adverse effects, including osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFF) (1).Breast cancer patients with bone metastases receive BPs to prevent skeletal complications, and often undergo radiation therapy (RT) or surgery to treat such complications (2). An accurate diagnosis of treatment-related side-effects 6439

A Simple Clinical Instrument to Predict the Survival Probability of Breast Cancer Patients Receiving Radiotherapy for Bone Metastases

“…During recent years, several studies have been carried out to improve the outcomes of patients with metastatic breast cancer (20)(21)(22)(23)(24). For patients with breast cancer who require irradiation for bone metastases, a variety of dose-fractionation regimens are available (1).…”

The limitations of today’s clinical guidance: Atypical femoral fracture and long-term bone-modifying agents in the oncology setting

“…29 Standard imaging modalities such as magnetic resonance imaging or computed tomography can visualize beaking, bone heterogeneity, the fracture line, and associated bone marrow edema. 10 Although less specific, radionuclide bone scans may detect hyperemia suggestive of AFF. Limited evidence suggests that novel imaging technologies such as tomosynthesis (which is able to visualize fracture healing at lower radiation doses) may be superior to radiographs for the diagnosis and management of AFF.…”

“…[6][7][8][9] Consistently, imaging suggests an accumulation of injury in the bone cortex over long periods of time. 10 In the absence of BMAs, stress fractures heal as endogenous upregulation of RANKL mediates osteoclast resorption at the site of damage and replacement with osteoblasts. When repair is defective, the microscopic cracks coalesce and precipitate an AFF.…”