Paget’s disease of bone: a review

Diaphyseal Tibial Osteosarcoma With Myiasis

Osteosarcoma is a tumour that can originate in any bone and is the most frequent malignant tumour of the skeleton. It typically develops close to the metaphyseal growth plates in the limbs' long bones. The three most prevalent places are the femur, tibia, and humerus. Additional locations include the pelvis, skull, and jaw. Diaphyseal osteosarcoma involves a smaller population and is highly uncommon. Conventional kinds of osteosarcoma, such as osteoblastic, chondroblastic, and fibroblastic types, as well as telangiectatic, multifocal, parosteal, and periosteal types, are some of the variations of the disease. The primary bone tumour (cancerous) is generated by the formation of immature bone and primarily affects adolescents. We present a case of a 45-year-old menopausal female with left tibial osteosarcoma of the proximal 1/3 diaphysis infected with maggots and complaints of left knee pain and tingling.

Premalignant Conditions of Bone

Development of malignancy is a multifactorial process, and there are multitude of conditions of bone that may predispose patients to malignancy. Etiologies of malignancy include benign osseous conditions, genetic predisposition, and extrinsic conditions. New-onset pain or growth in a previously stable lesion is that should concern for malignant change and should prompt a diagnostic workup for malignancy.

Epidemiology and Risk Factors of Osteosarcoma

Osteosarcoma is a rare tumor diagnosed at any age; however younger age is a common risk factor. In addition, multiple factors are believed to contribute to higher rates of osteosarcoma, particularly race and gender. Although diagnosed worldwide, osteosarcoma is found to be more prevalent in Africa with high numbers of cases reported in Nigeria, Uganda, and Sudan. Additionally, higher rates are detected in African Americans, suggesting a genetic predisposition linked to race. This review focuses on identifying high risk factors of osteosarcoma with an emphasis on sarcoma epidemiology and risk factors in African countries.

Skull Abnormalities in Cadavers in the Gross Anatomy Lab

Background

The skull encompasses and houses one of the most important organs in the body—the brain—and like all tissues in the body, it is comprised of living cells that are constantly remodeling as this maintains the strength and homeostasis of the bone. In the present study, abnormal bone growth patterns were observed and the possible causes of said findings were investigated in multiple cadaver skulls dissected during head and neck anatomy courses at Detroit Mercy Dental over the past year. There are many factors, both intrinsic and extrinsic, with differences in stimulation to the skull resulting in skull abnormalities. Materials and Methods. For this study, skull abnormalities were examined from 65 formalin-embalmed cadaver heads, obtained from the Gross Anatomy Laboratory at the University of Detroit Mercy School of Dentistry between the years 2016 and 2019. We have recorded the age, sex, and previous chief medical issues of all lab specimens used in the study. Skulls were later evaluated for possible indications of bone disease such as hypertosis frontalis interna (HFI) or Paget's disease.

Results

Among the sixty-five specimens provided to the Detroit Mercy Dental cadaver lab, 19 specimens (29%) were found to present with irregular, undulating, thickening of the frontal bone internal surface. The findings located on the skulls closely resembled the gross anatomic appearance of HFI or Paget's disease; however, a conclusive diagnosis of these skull abnormalities cannot be made without a pathologist biopsy and radiological examination. Twelve of the nineteen specimens that displayed possible bone disease, approximating 63% prevalence, were females; their ages ranged from 68 to 95 years old. Thus, seven of the nineteen specimens exhibiting features of skull abnormalities, approximating 36% prevalence, were males with ages ranging from 70 to 103 years old. In addition, five of these nineteen specimens collected (26% prevalence) had been diagnosed with neurological disorders, including Alzheimer's, dementia, depression, and Parkinson's disease. In the current study, the proportion of specimens exhibiting skull abnormalities was higher compared to the overall prevalence observed in previous studies.

Conclusion

Possible causes of observed anatomical abnormalities in the skull of cadavers of a gross anatomy laboratory were investigated, and it was determined that hypertosis frontalis interna (HFI) may contribute to such abnormalities. This is a condition that affects bone growth in the frontal skull. Our numbers of skull abnormalities were higher than previous studies and might be due to the fact that HFI was predominately present as an incidental finding during imaging of postmenopausal females or observed postmortem in cadavers. In addition, Paget's disease or hormonal imbalances could also result in similar features, and thus cannot be ruled out as a plausible cause. Paget's disease causes the bone to deposit at a faster rate than normal, which will result in thick and brittle bone. Studies that will involve further examination of new cadavers for the presence of HFI is needed, either using biopsy specimens and/or radiological examination to explore possible causes for the abnormal bone growth in the frontal bone.

A microscopic evaluation of Paget's disease of bone from a Byzantine monastic crypt in Jordan

Paget's disease of bone (PDB) is a metabolic bone disease that has been present in human populations for over 2000 years, with the earliest cases reported in Western Europe. Now present globally, PDB is one of the most common metabolic bone diseases in modern populations. This study details possible PDB of an adult male (MNR-EN Skull 3) with abnormally thickened cranial bones (17 mm). The skull was recovered from commingled skeletal remains excavated from the Robebus crypt at the Byzantine monastery of Mount Nebo, Jordan (c. late 4-7^th C). Micro-CT imaging and histological sections of the bone samples revealed an abnormal pattern of bone remodeling, with atypical osteon formation, convoluted and enlarged trabeculae, and an overall pattern of highly vascularized bone. Polarized microscopy produced a mix of woven bone and lamellar bone, the mosaic pattern of atypical bone remodeling indicative of PDB. Coupled with the dense, thickened nature of the vault bones, these data suggest that the individual had PDB. To our knowledge, this represents the earliest evidence of PDB in the Middle East supported by micro-analysis, and adds to the emerging paleopathological literature involving commingled skeletal remains and the potential for identifying unique disease processes.

[Paget's disease of bone: Diagnostic and therapeutic updates]

Paget's disease of bone is the second most common metabolic bone disease after osteoporosis. Its pathogenesis is not yet clearly understood. Geographic distribution and epidemiological variations suggest a role of genetic and environmental factors in its pathophysiology. The frequency of the Paget's disease of bone increases with age. Its discovery can be fortuitous. Prognosis mainly depends on the occurrence of complications involving bones and joints, neurological, cardiovascular or metabolic systems. Treatment of symptomatic forms currently relies on bisphosphonates that have transformed its prognosis.

Management of Paget's Disease of the Calcaneum

The calcaneum is not the most common site for Paget's disease of bone, with only a few reports of monostotic involvement. We present 2 cases of Paget's disease of bone affecting the calcaneus, present an overview of the published data, and describe our management of these interesting cases.

Falsely Negative F-18 FDG PET of Osteosarcoma Arising In Paget Disease

We present the case of a large, painful pelvic bone tumor in a 53-year-old woman with severe Paget disease. Her presentation was complicated with bilateral total hip arthroplasty, history of spinal stenosis, and multiple lucent lesions in the spine and pelvis in severely affected pagetoid bone. This case features the rare but dreaded complication of osteosarcomatous transformation in Paget disease. A variety of imaging modalities including PET/CT were utilized in the evaluation of these lesions. The PET/CT findings were counter-intuitive with regard to the intense uptake of the underlying chronic disease process and the near-absence of uptake in the tumors. The histology of the pelvic mass is also intriguing, as it demonstrated a sarcoma with giant cell features. Conservative, non-operative management was chosen, due to the patient’s poor medical condition, so we may never know the nature of the spinal lesion in this case, but will discuss the differential diagnosis for a lytic spinal lesion in a patient with severe Paget disease complicated by osteosarcoma with giant cell features.

Diagnosis and management of Paget's disease of bone

OBJECTIVE

To conduct a literature review on the diagnosis and management of Paget's disease of bone.

MATERIALS AND METHODS

This scientific statement was generated by a request from the Brazilian Medical Association (AMB) to the Brazilian Society of Endocrinology and Metabolism (SBEM) as part of its Clinical Practice Guidelines program. Articles were identified by searching in PubMed and Cochrane databases as well as abstracts presented at the Endocrine Society, Brazilian Society for Endocrinology Annual Meetings and the American Society for Bone and Mineral Research Annual Meeting during the last 5 years. Grading quality of evidence and strength of recommendation were adapted from the first report of the Oxford Centre for Evidence-based Medicine. All grades of recommendation, including "D", are based on scientific evidence. The differences between A, B, C and D, are due exclusively to the methods employed in generating evidence.

CONCLUSION

We present a scientific statement on Paget's disease of bone providing the level of evidence and the degree of recommendation regarding causes, clinical presentation as well as surgical and medical treatment.

Time-trends on incidence and survival in a nationwide and unselected cohort of patients with skeletal osteosarcoma

Background

This study describes time-trends on epidemiology, subtypes and histopathological entities of osteosarcoma (OS) in a nationwide and unselected cohort of OS patients in Norway between 1975 and 2009. Few nationwide studies are published, and we still have particularly limited knowledge regarding patients not included in clinical trials comprising about half of the OS population.

Method

Histologically verified skeletal OS for all subgroups were included, resulting in 473 eligible cases from a total of 702 evaluated patients. To ensure completeness, the present cohort was based on all cases reported to the Norwegian Cancer Registry, complemented with data from all Norwegian hospitals involved in sarcoma management. Survival analyses were performed with overall and sarcoma-specific survival as endpoints.

Results

Mean annual age-standard incidence amounted to about 3.8 per million in male and 2.8 per million in female with no clear time-trends. The male to female ratio was 1.4. Peak incidence was observed in the second decade for both genders. Conventional OS comprised 71.2% of all cases, while low grade OS represented 10.4% and telangiectatic OS only 1.3%. The most common primary site of OS was femur and tibia, respectively. The axial to appendicular ratio increased with the age. The overall 10-year survival did increase from about 30% during the late 1970s to around 50% 20 years later, with no subsequent improvement during the last two decades. Axial tumours, age above 40 years and overt metastatic disease at time of diagnosis were all negative prognostic factors.

Conclusion

No improvement in the overall survival for OS since the 1990s was documented. The survival rates are still poor for elderly people, patients with axial disease and in the primary metastatic setting. The average incidence rate of skeletal OS in Norway was in line with international figures.

Benign osseous and articular abnormalities of the pelvis: a review of CT imaging findings

Computed tomography (CT) has become the standard of care for evaluation and follow-up for a wide range of abdominal and pelvic pathology. Many incidental osseous and articular abnormalities of the pelvis are detected on these studies, most of which have a benign etiology. However, most of these studies are interpreted by nonmusculoskeletal radiologists, who may not be familiar with the CT appearances of these benign musculoskeletal abnormalities. Uncertainty often leads to mischaracterization or unnecessary follow-up, resulting in increased health care costs and patient anxiety. This article reviews the CT appearance of the benign musculoskeletal entities that occur in pelvis.

Syringomyelia associated with Paget disease of the skull

A 38-year-old man presented with a rare case of syringomyelia associated with Paget disease of the skull. Syringosubarachnoid (SS) shunting was performed. We speculate that deformation of the skull secondary to Paget disease caused narrowing of the foramen magnum with progressive impairment of the cerebrospinal fluid circulation, which led to syringomyelia and neurological symptoms. SS shunting is safe, effective, and technically simple, so may be a useful initial treatment for syringomyelia associated with Paget disease of the skull.

Paget's Disease. A Case Report

Paget's disease (PD) is a common focal progressive osteometabolic disorder characterised by a disturbance in bone modelling and remodelling, because of an increase in osteoblastic and osteoclastic activity. It is a condition of unknown aetiology affecting approximately 3% of the population over 40 years of age and, approximately 10% of those over the age of 85 years. It is most common in Northern Europe and Australia and is rare in Asia and Africa. We describe the case of a 71-year-old man diagnosed with PD confined to the sacrum. After laboratory test, an imaging study with radiography, scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI) was performed disclosing findings compatible with Paget's disease in middle pathologic phase. The diagnosis was confirmed at biopsy. The structural modification of the sacrum with spongiosa rarefaction, thickening of bone and intact bone cortical, confirmed by CT, are tipical of an intermediate phase of PD. This was also supported by signal MRI changes showing substitution of the red by the fat medulla, visualized by FS sequences. Once the treatment for the bone disease was established, the patient no longer complained of pain. Special attention should be paid to male and elderly patients with pain in the lumbar spine because of the potential risk cancer development (21). The radiologist must be attentive to the possible presentations and complications of PD, even in uncommon sites, trying whenever possible to correlate the radiological features with the patient's clinical symptoms.

Hearing loss in Paget's disease: a temporal bone histopathology study

BACKGROUND

Hearing loss in Paget's disease of bone (PDB) is typically mixed and bilateral. Although different mechanisms have been proposed, the pathophysiology of hearing impairment remains unclear.

OBJECTIVE

The purpose of this study is to describe the histopathologic findings of temporal bones in patients with PDB and elucidate possible pathologic mechanisms related to hearing impairment.

METHODS

This is an archival human temporal bone study of 8 subjects diagnosed with Paget's disease from the temporal bone collection of the UCL Ear Institute.

RESULTS

A fractured stapes footplate was observed in 1 temporal bone and stapes footplate fixation in 2 other specimens. Obliteration of Cotugno's canal by extensive bone remodeling was observed in 78% of temporal bones. An intracochlear vestibular schwannoma was observed in 1 specimen (previously reported in the literature). Other findings include microfissures and microfractures of the otic capsule, bleeding in the scalae, strial atrophy, and cystic lesions in the spiral ligament.

CONCLUSION

This study is the first to report a fractured stapes footplate, as a causative lesion of conductive hearing loss in PDB. Extensive bone remodeling around Cotugno canal also was a frequent finding, not reported before in the literature. We hypothesize that sensorineural hearing loss in patients with PDB of the temporal bone may, in some cases, be attributed to obliteration of Cotugno's canal by remodeling pagetoid bone, thus obstructing the venous drainage of the cochlea, with a subsequent effect on the function of stria vascularis and spiral ligament. This seems to be consistent with experimental studies in animals.

Radiological features of Paget disease of bone associated with VCP myopathy

OBJECTIVE

Mutations in the Valosin-containing protein (VCP) gene cause a unique disorder characterized by classic Paget disease of bone (PDB), inclusion body myopathy, and frontotemporal dementia (IBMPFD). Our objective was to analyze the radiographic features of PDB associated with VCP mutations since there is a dearth of literature on the PDB component of VCP disease.

MATERIALS AND METHODS

Radiographic bone surveys were examined in 23 individuals with VCP mutation and compared with their unaffected relatives. Laboratory testing relevant for VCP disease was performed in all individuals.

RESULTS

Of the 17 affected individuals with clinical manifestations of VCP disease, 16 of whom had myopathy, radiographic analysis revealed classic PDB in 11 individuals (65%). The mean age of diagnosis for myopathy was 43.8 years and for PDB was 38.1 years of age. Radiological evidence of PDB was seen in one individual (16%) amongst six clinically asymptomatic VCP mutation carriers. Alkaline phosphatase was a useful marker for diagnosing PDB in VCP disease.

CONCLUSIONS

Radiographic findings of classic PDB are seen in 52% of individuals carrying VCP mutations at a significantly younger age than conventional PDB. Screening for PDB is warranted in at-risk individuals because of the benefit of early treatment with the new powerful bisphosphonates that hold the potential for prevention of disease.

Paget’s disease: clinical update

Paget’s disease is a chronic disorder of bone remodeling, characterized by an abnormal increase of osteoclast and, hence, osteoblast activity. The imbalance of bone turnover results in the formation of unhealthy and fragile bone. It also leads to impairment of adjacent joints and to a risk of various complications. Current research focuses on the elucidation of the etiologic role viral infection and predisposing genetic factors. Paget’s disease is commonly discovered by chance; its suspicion is raised either by high level of alkaline phosphatase or by the X-ray of the pathological bone. Bisphosphonates have proven to be effective in controlling disease activity because they inhibit osteoclast function. Their use is recommended when bone-derived serum alkaline phosphatase is high and/or when disease localizations are highly suspected for the development of complications. Orv. Hetil., 2011, 152, 1337–1346.

Serum homocysteine, folate and vitamin B12 in patients with Paget's disease of bone: the effect of zoledronic acid

High serum homocysteine (HCY) and indirectly deficiency of folate and/or vitamin B(12) stimulate bone resorption and adversely affect collagen cross-linking. The aim of this study was the evaluation of serum levels of HCY, folate and vitamin B(12) in patients with Paget's disease of bone (PDB) and the effect of zoledronic acid (ZOL) on their serum levels. Nine consecutive patients with polyostotic PDB (median age 66 years) received a single 5-mg ZOL infusion. Blood samples for HCY, folate, vitamin B(12), 25-hydroxyvitamin D (25-OH-D), total serum alkaline phosphatase (TSAP), bone-specific serum alkaline phosphatase (BSAP) and C-terminal cross-linking telopeptide of type I collagen (CTX) were obtained at baseline and 3, 6 and 12 months after ZOL infusion. Twelve age-, gender- and BMI-matched healthy individuals were recruited for the control group at baseline assessment. Patients with PDB had significantly higher serum HCY (p = 0.028), folate (p < 0.001) and bone markers [TSAP (p < 0.001), BSAP (p < 0.001) and CTX (p < 0.001)] compared with the control group at baseline. In the pagetic group, serum HCY significantly decreased 3 months after ZOL infusion and remained essentially unchanged up to the end of the study (p = 0.005). Serum vitamin B(12) and folate remained unaffected throughout the study. Our data suggest that serum HCY levels are increased in patients with PDB. A single ZOL infusion results in a decrease in HCY levels that might represent another mechanism for the reduction of the activity of PDB achieved by ZOL.

Dual-energy X-ray absorptiometry and quantitative ultrasound in patients with Paget's disease of bone before and after treatment with zoledronic acid: association with serum bone markers and Dickkopf-1

The main aim of this study was to determine the effect of zoledronic acid (ZOL) on parameters of dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) in unaffected bones of patients with Paget's disease of bone (PDB). The secondary aim was the association of bone markers and Dickkopf (DKK)-1 with parameters of DXA and QUS. Ten consecutive patients with polyostotic PDB (median age: 63 yr) received a single 5-mg ZOL infusion. The patients were subjected to calcaneal QUS and DXA of both lumbar spine (LS) and femoral neck (FN). Blood samples for serum bone markers and DKK-1 were serially obtained for 12 mo. There was a significant increase in LS (p=0.005) and FN bone mineral density (BMD) (p=0.021) 12 mo after ZOL infusion. QUS parameters remained unaffected throughout the study. A significant correlation between broadband ultrasound attenuation and DKK-1 (p<0.001) and between speed of sound and DKK-1 (p=0.033) at baseline was found, which remained significant after adjustment for gender, age, and body mass index. Our data suggest that a single ZOL infusion significantly increases nonpagetic BMD 12 mo after treatment but has no effect on QUS parameters or DKK-1. Significant correlations were observed between QUS parameters and DKK-1 at baseline.

Paget's disease of bone: emphasis on treatment with zoledronic acid

The treatment of Paget's disease of bone (PDB) aims at suppression of abnormal bone turnover and bisphosphonates (BPs) are currently the drugs of choice. Zoledronic acid, a third-generation nitrogen-containing BPs, is the newest BP approved for PDB and is administered by a single intravenous infusion. In vitro zoledronic acid has higher binding affinity for hydroxyapatite and is a stronger inhibitor of farnesyl pyrophosphate synthase compared with other BPs. In vivo zoledronic acid improves symptoms, normalizes bone turnover markers and scintigraphic imaging in the majority of patients, and maintains remission of PDB longer than other BPs. This review summarizes available data on the pathogenesis, epidemiology, clinical manifestation, biochemical assessment and management of PDB, giving special attention to the treatment of PDB with zoledronic acid, based on current evidence.

International osteosarcoma incidence patterns in children and adolescents, middle ages and elderly persons

Osteosarcoma incidence rates in the United States peak in adolescence and in the elderly. The international patterns of osteosarcoma incidence in children have been described, whereas those for young, middle age or elderly adults have not. Using the Cancer Incidence in Five Continents, International Agency for Cancer Research database we compared incidence rates for children and adolescents (age 0-24 years), the middle age group (25-59 years) and elderly (>or=60 years) persons by world regions and individual countries. Overall, worldwide osteosarcoma incidence rates were quite similar in the younger age groups. The greatest variation in incidence rates was observed in the elderly.