[Paget's disease of the bones: diagnosis and treatment]

Paget's disease of bone affects one or more bones and is characterized by increased bone turnover (remodelling) with hypertrophy and abnormal bone structure with diminished strength leading to deformity and fracture. The cause of the disease is not known, possibly is a slow virus infection. For diagnosis and follow-up the conventional bone markers, serum alkaline phosphatase and urine hydroxyproline, are still useful. Paget's disease cannot be cured, but it may be suppressed. Specific drug treatment aims at reducing the increased bone remodelling. New and potent biphosphonates enable early and more effective treatment of Paget's disease than in the past and better prevention of late complications of the disease.

Paget's disease of bone (osteitis deformans)

Paget's disease of bone is important in geriatric populations because it is the second most common bone disorder after osteoporosis. In older people, it may be responsible for chronic back pain and joint pain, skeletal deformities, hearing loss, and cranial nerve compression. Paget's disease can reduce both function and mobility in the older people. In addition to newer tests for assessing the activity of Paget's disease, effective therapy is available in the form of salmon calcitonin for nasal administration and new third generation bisphosphonates. Frequently, treatment can reverse the course of the disease. For these reasons, it is feasible for the physician to adopt an aggressive approach to diagnosis and treatment. The objective should be to relieve pain, improve mobility, and forestall debilitating complications. This review will focus on the manifestations and clinical management of Paget's disease. Two cases are presented that illustrate common management problems in older patients.

Paget's disease of bone

The highest incidence of Paget's disease is in the United Kingdom and is lower in other European countries. Worldwide the incidence appears to be decreasing. Some countries have observed a reduction in the severity at presentation, perhaps reflecting changes in migration of the UK population. Evidence of a genetic susceptibility to Paget's disease is accumulating, with chromosome 6 (the HLA locus) and 18q emerging as strong candidates. Use of molecular biology techniques has yielded evidence on the possible role of paramyxovirus infection in the etiology of Paget's disease. Altered measles virus nucleocapsid transcripts have been detected in bone marrow cell cultures and peripheral blood mononuclear cells from Paget's disease patients. Canine distemper virus may be the etiologic agent, and ownership of a mongrel dog or a dog not vaccinated against canine distemper virus is associated with an increased risk of Paget's disease. Familial Paget's disease is associated with more severe disease than is seen in sporadic cases. Quality of life may be reduced in patients with Paget's disease, and psychological problems are often present. New biochemical markers of resorption and formation appear to offer little advantage over urinary hydroxyproline and serum total alkaline phosphatase measurements in assessing Paget's disease activity or response to therapy. The best therapeutic responses are observed following treatment with the bisphosphonates, and oral etidronate is now being superseded by oral tiludronate, oral or intravenous alendronate, and clodronate or intravenous pamidronate.

Paget's disease of bone

Paget's disease of bone is a relatively common condition in the UK affecting up to 5% of the population over the age of 55 years with particularly high prevalence in the North West of England. The majority of those affected are asymptomatic. Its precise cause remains unknown, and until recently, choice of treatment of this sometimes painful and debilitating disease has been limited. In this article, we review various aspects of this disease, concentrating particularly on recent advances in our understanding of its aetiology and its treatment.

[Pathologic humeral fracture in secondary osteosarcoma of the humerus: a rare complication of osteodystrophia deformans Paget]

Pathological fracture in histologically proven post-Paget osteosarcoma of the humerus is a rare complication. Due to individual requests as well as age and comorbidity, a course of primary palliative treatment was chosen in the present case. Survival time after diagnosis was 9 months and the patient died of a tumor-independent disease. Even in combined treatment, consisting of surgery and (neo-)adjuvant radio-/chemotherapy, prognosis of osteosarcomas secondary to Paget's disease remains very disappointing. Therefore, in treatment of this highly lethal tumor the patient's individual requests and personal situation often require more consideration than in many other malignancies.

Paget's disease of bone: diagnosis and management

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[Osteomyelitis in the pagetic tibia]

Osteomyelitis developing in pagetic bone is a very rare event, of which only one instance has been reported to date, in a patient with mandibular disease. We have managed three patients with osteomyelitis of a pagetic tibia. The portal of entry was a skin lesion in all three cases. A Gram-negative organism was found in all three cases and was associated with the anaerobe Bacteroides melaninogenicus in one case. One of the patients was lost to follow up before eradication of the infection. Amputation was required in the other two after unsuccessful antimicrobial therapy for 23 and four years, respectively.

[Paget's disease with an exclusively maxillary location. A case report]

The authors illustrate a case report of Paget's disease in an exclusively cranio-facial localisation. Paget's disease is a dystrophy of an osteo-condensing type. Excess bone remodelling activity, due primarily to hyperclastic hyperactivity, leads to accelerated resorption and excess tissue formation. This marked alteration of the metabolism causes the hypertrophy of the bones involved, with zones of greater density and increased vascularisation. Its clinical manifestations include morphological deformations and painful symptoms in the areas affected. Complications may include pathological fractures, medullary or radicular compression, heart failure (rare), sarcomatous transformation (approximately 1% of cases). The case reported here describes a 70-year-old who was admitted to the out-patient clinic of the Odontostomatological Division of the Ospedale Mauriziano in Turin for a dental check up. The patient had had 6 teeth removed during the past 2 weeks in a private clinic. At the time of the control a mucous crater was present, also involving the underlying bone, at the level of the extracted 2.6 tooth. The patient had kept the teeth which had been removed some of which showed that the roots were surrounded by alveolar bone. A dental panoramic x-ray and cranial x-ray were performed using 3 projections and showed the remodelling of the cranial theca and upper jaw. The suspicion of Paget's disease was confirmed by hematochemical tests, bone scintigraphy with calcium phosphate and by the histologic examination of the alveolar bone fragments adhering to the root surface of the extracted teeth.(ABSTRACT TRUNCATED AT 250 WORDS)

Paget's disease of bone

In this review, recent studies on the etiology and pathogenesis of Paget's disease, with particular attention to the apparent familial clustering of cases and the possibility of a causal role for viral infection, are discussed. The role of biochemical markers of bone turnover is explored, as well as the value of imaging in confirming the diagnosis, monitoring the effects of therapy, and assessing complications. The bisphosphonates are widely used in the treatment of Paget's disease; experience with newer, more potent second- and third-generation bisphosphonates, as well as potential future roles for calcitonin, are described. Studies on some of the orthopedic effects of Paget's disease are also presented.

Paget's disease of bone and fibrous dysplasia

This review discusses recent studies of the etiology and epidemiology of Paget's disease of bone, as well as studies of its complications and associations. Medical and surgical treatments are reviewed; agents used in the medical treatment of Paget's disease include pamidronate and other bisphosphonates, gallium nitrate, and plicamycin, among others. The article concludes with a review of various investigations of fibrous dysplasia.

Osteosarcoma: then and now. A fifty year review at Royal Prince Alfred Hospital

The purpose of this study is to review survival, treatment methods and criteria for diagnosis of osteosarcoma at Royal Prince Alfred Hospital during two periods in the last 50 years. The records of 22 patients diagnosed with osteosarcoma and nine with osteosarcoma in Paget's disease (from 1939 to 1950) were reviewed. All but one had died within three years. One patient survived six years. The second series was taken from 1983 to 1990. Forty-nine patients, including three with Paget's sarcoma, were studied. Probability of survival was estimated by actuarial analysis using Kaplan-Meier curves. Overall survival was estimated at 45%. Those patients who were free of metastatic disease at the conclusion of their treatment were estimated to have a probability of survival of 85%.

Spinal manifestations of Paget's disease

This paper reviews the syndromes which affect the spinal column as a result of Paget's disease. These are back pain, spinal canal stenosis, paraplegia or paraparesis, sarcomatous transformation, intradiscal invasion, and extramedullary haemopoesis.

[Current aspects of Paget's bone disease]

The clinical and laboratory signs, as well as the imaging and course of Paget's disease of bone, are now well known. This chronic and usually benign disease is characterized by excessive remodelling of bone tissue, associated with an increase, sometimes considerable, of osteoclast resorption and osteoblast formation activities. Studies conducted during the last two decades were aimed at determining more precisely some aspects of the disease, notably: its epidemiological aspect and in particular its geographical distribution; its aetiological aspect using data obtained from electron microscopy, immunocytology and hydridization in situ, which has led to the hypothesis of a viral origin, and finally its therapeutic aspect with the recent introduction of truly effective treatments such as calcitonin and biphosphonates.

Survival and management considerations in postirradiation osteosarcoma and Paget's osteosarcoma

Postirradiation and Paget's osteosarcomas are high-grade malignancies. The five-year survival was only 10% in recent experience at the author's institution. Progressive pain is an important clinical feature in both conditions. Careful roentgenographic studies demonstrate cortical destruction and a soft-tissue mass in virtually all patients. Metastasis was present in 25% of both groups of patients at presentation. In contrast to previous series, more than 80% of the patients with postirradiation osteosarcoma had had irradiation for malignant entities and more than 70% had been treated with modern radiotherapy regimens (cobalt-60 or linear accelerator). Twice as many patients with postirradiation osteosarcoma were evaluated and treated in the 1980s than in the previous decade. The initial indication for irradiation often was carcinoma of the breast, uterus, or cervix, or lymphoma. Two-thirds of the patients had progressive disease that was not controllable within six months after diagnosis. Early detection may be the only effective means of improving survival with postirradiation or Paget's osteosarcoma. These patients require lifelong follow-up evaluations.

Radiation and pagetic osteogenic sarcomas

Radiation and pagetic osteogenic sarcomas should be distinguished from classical osteogenic sarcoma. Both occur in older patients with significantly greater comorbidity. Roentgenographically, radiation osteogenic sarcoma is typically sclerotic, whereas pagetic osteogenic sarcoma is lytic and associated with pathologic fracture. Radical resections give the best result, local control, and survival. Chemotherapy has not proven effective to date. Improvements in tumor imaging and more intensive chemotherapy regimens may permit limb-sparing surgery. Overall results remain poor, with approximately 15% five-year survival in each condition.

Paget's disease and fibrous dysplasia

Many papers were published on both Paget's disease and fibrous dysplasia during the past year. In Paget's disease, evidence for a generalized, probably viral disorder of the skeleton has been adduced, although focal radiologic features dominate the clinical picture. Unusual clinical manifestations were highlighted in several clinical reports. A search for biochemical abnormalities other than increased serum alkaline phosphatase and urinary hydroxyproline levels yielded evidence for secondary hyperparathyroidism in many cases, and also, a confusing array of abnormalities in vitamin D metabolite levels. The application of newer imaging techniques such as computed tomography, MR imaging, bone marrow scintigraphy, and thermography was reported. The year's reports particularly highlighted new forms of effective therapy, including intranasal calcitonin, second- and third-generation bisphosphonates, and gallium nitrate. Finally, the feasibility of joint replacement in arthritic joints secondary to Paget's disease was again documented. Fibrous dysplasia continued to be an enigmatic disorder with no new insights as to etiology. Reports of unusual clinical features, imaging characteristics, bony distribution, and an array of endocrine linkages were prominent. A highlight of the year's reports was the discovery of an increased female sex steroid receptor number of dysplastic cells, and the possibility that sex steroids linked to their receptors may be responsible for the bony overgrowth. Concern was again expressed as to the possibility of malignant transformation of dysplastic lesions and the possible contribution of radiotherapy treatment to sarcoma development.

Advances in the management of Paget's disease of bone

The advent of potent new bisphosphonates (diphosphonates) now makes it possible to restore and maintain normal bone turnover in many patients with Paget's disease of bone (osteitis deformans). This has necessitated a reappraisal of the indications for treatment, the ways in which disease activity and response are assessed, as well as the place of existing therapies. Measurements of urinary hydroxyproline and serum alkaline phosphatase remain the most useful markers of disease activity. Pyridinium crosslinks may prove to be more specific than hydroxyproline in the assessment of bone resorption but osteocalcin has been disappointing in monitoring the effect of treatment on bone formation. Etidronic acid (disodium etidronate), the first bisphosphonate introduced for clinical use, is a potent inhibitor of osteoclastic bone resorption but its potential is limited by the development of defective mineralisation with high dosage (10 to 20 mg/kg/day). The newer bisphosphonates, clodronic acid (clodronate) and pamidronic acid (pamidronate, APD), are free from this problem and appear able to control a wide range of disease activity. A small number of patients appear resistant to the agents but the underlying mechanism is unclear. The efficacy and safety of these bisphosphonates makes it likely that the threshold for treating asymptomatic patients will fall in the hope of preventing long term complications. These developments will lead to a reappraisal of the role of calcitonin which can now be administered by both the parenteral and intranasal routes. One focus of interest will be on the quality of the bone laid down during treatment. Meticulous radiographic studies have shown that calcitonin improves bone architecture and this may have particular relevance to the treatment of lytic disease. The relative merits of the different forms of therapy for Paget's disease need further evaluation, particularly with respect to the identification of specific advantages of individual drugs.