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  • br Introduction Patients with advanced breast


    Introduction Patients with advanced breast, prostate, lung and colo-rectal cancer frequently develop bone metastases (BMs). These lesions may be asymptomatic or may cause pain, pathologic fractures, malignant hypercalcemia, epidural spinal cord compression and/or shorten survival [1]. The underlying pathophysiology of BMs involves reciprocal interactions between tumor cells and the bone micro-environment that lead to the disruption of the balanced physiological activity between osteoblasts and osteoclasts. Loss of this critical balance results in a spectrum of osteolytic to osteoblastic bone lesions [2]. Computed tomography (CT) provides accurate morphological images of bone, allowing visualization of cortical and trabecular bone, tumor margins and dimensions [2]. Anatomical extension of lesions is depicted on CT studies as well as the presence of sclerosis in the context of lytic lesions [3]. Whole-body CT scans are diffusely used to detect osteolytic, mixed or osteoblastic bone lesions in the staging, follow-up and re-staging studies of oncological patients. CT scans are also considered crucial in the assessment of the bone response to therapy [2,4,5]. In osteolytic bone metastases, indeed, an increase of density is considered an indicator of response to therapy [2]. As potent inhibitors of osteoclast function, biphosphonates are being incorporated into the management of metastatic bone disease [6], with beneficial effects on skeletal complications [7,9], bone pain [9], quality of life [7–9], particularly in advanced breast cancer [7,10], multiple myeloma [8,11], and more recently in lung, prostate and kidney cancer [12,13]. Zoledronic buy strontium chloride (ZA) is a potent third generation nitrogen-containing biphosphonate, which has been widely used in the treatment of Paget\'s disease of bone [14], hypercalcemia [15], multiple myeloma [16], breast cancer BMs [16], prostate cancer BMs [17], lung cancer BMs [18] and osteolytic BMs [19,20]. In patients with BMs, decrease of bone density is the consequence of several factors, not only of pathologic mechanisms at bone metastatic sites, but also of the normal ageing process, of concurrent postmenopausal or drug-related osteoporosis, or of androgen-deprivation therapy in men with prostate cancer [21]. In multicenter randomized controlled trials, once yearly injection of 5mg of ZA has been demonstrated to significantly reduce the risk of vertebral and hip fractures in postmenopausal women [22] and the risk of recurrence of clinical fractures in men and women with a recent hip fracture [23]. Sclerosis of bone metastases has been documented by CT imaging after ZA treatment in studies [24–26] conducted on patients at an advanced stage of cancer. However, the CT changes of the normal bone after ZA treatment in oncological patients has not yet been established.
    Materials and methods
    Discussion Biphosphonates are known to reduce the incidence of skeletal complications in patients with BMs and delay the onset of SREs and the progression of skeletal disease. ZA is a third generation bisphosphonate binary fission has been shown to be more effective than other biphosphonates [27] and significantly reduces skeletal related complications compared with placebo in patients with BMs [28]. This study shows increase of bone density at the level of the normal trabecular bone in oncologic patients. In non-oncologic postmenopausal osteoporotic patients, once yearly injections of ZA (5mg/year vs. much higher doses in oncology) significantly increase bone mineral density (BMD) of the trabecular compartment at the spine, femoral neck, trochanter and hip, when compared with placebo, as measured by both dual-energy X-ray absorptiometry (DXA) and quantitative computed analysis (QCT) [29]. Density measures of the cortical bone did not yield, in respect to a trend toward a density increase, a significant change up to 24 months: still, these results may be explained by a different effect of ZA on the cortical bone in comparison to that on the trabecular bone or by HU measurements at a saturation level in the cortical compartment, so that slight increases could not be detected. These results, thus, confirm previous reports of a slight but not significant increase of cortical density after ZA treatment [29].