Reactions 1680, p116 - 2 Dec 2017 Denosumab/pamidronic acid/zoledronic acid Atypical femoral fracture: 2 case reports Two women developed atypical femoral fractures (AFF) during treatment with denosumab, pamidronic acid and zoledronic acid (one woman) or zoledronic acid (one woman) [not all routes stated]. Patient 1: A 52-year-old woman, who had a history of breast cancer with bone metastasis, had been receiving bisphosphonate treatment with IV pamidronic acid 45mg monthly for 6 years and 10 months followed by IV zoledronic acid 4mg for 4.years and 4 months. Additionally, she received concurrent chemotherapy with goserelin, anastrozole, tamoxifen, letrozole, fulvestrant, capecitabine, trastuzumab and paclitaxel. Her bone metastasis progressed and spread to pelvis, vertebrae and femoral shafts. Subsequently, she underwent radiotherapy to vertebrae and pelvis. Thereafter, she started receiving treatment with denosumab 120mg monthly injections for two years and three months. However, following denosumab, pamidronic acid and zoledronic acid administration, she presented with right thigh pain without trauma. Thickening of the lateral subtrochanteric cortex was observed on the radiographs. Tomosynthesis showed a fracture line in the thickened cortex, which was not visible on the radiographs. Based on these results, she was diagnosed with incomplete AFF. Her denosumab was discontinued, and conservative management for incomplete AFF was initiated However, a month later, she fell down while in a standing position, and was admitted to the hospital. Upon admission, her radiographs showed a complete subtrochanteric transverse fracture on her right femur. The fracture extended through both cortices with a medial spike. She subsequently underwent surgical intra-medullary nail placement. One month later, she presented again with pain in her left thigh. Slight thickening of lateral subtrochanteric cortex was seen on the radiographs. Thereafter, the tomosynthesis did not show any fracture lines. However, due to persistent pain lasting for a month, an intra-medullary nail was placed, to avoid complete fracture. Her AFF was attributed to the use of bisphosphonates and denosumab. Patient 2: An 83-year-old woman, who had a history of breast cancer with bone metastasis. She was initiated on bisphosphonate therapy with IV injection zoledronic acid 4mg monthly. She was also receiving concurrent chemotherapy with tamoxifen, capecitabine, trastuzumab and fulvestrant. She had been receiving zoledronic acid treatment for 9 years, when she presented with mild pain in the left thigh without any trauma. Her radiographs showed thickening of lateral subtrochanteric cortex. Tomosynthesis showed a visible fracture line with thickened cortex. Based on the results, she was diagnosed with incomplete AFF and was started on conservative management. Her zoledronic acid was discontinued and low-intensity pulsed ultrasounds were initiated. However, three months later, she fell down while in a standing position, and was admitted to the hospital. Her radiographs upon admission showed a complete subtrochanteric transverse fracture in her left femur. The fracture through both cortices with a medial spike. She underwent a surgical intra-medullary nail placement. Her AFF was attributed to the use of zoledronic acid. Author comment: "We describe the cases of two women diagnosed with breast cancer who developed incomplete AFF associated with [bone-modifying agent] prescribed for bone metastases." "[A]typical femoral fracture (AFF) has emerged as a potential complication of bisphosphonates (BPs)." "[B]ecause of its molecular mechanisms and pharmacokinetics, denosumab can potentially cause AFFs similar to those observed with most BPs" Tateiwa D, et al. Atypical femoral fracture associated with bone-modifying agent for bone metastasis of breast cancer: A report of two cases. Journal of Orthopaedic Surgery 25: No. 3, Sep 2017. Available from: URL: http:// doi.org/10.1177/2309499017727916 - Japan 803285062 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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