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Rama TA, Henriques AF, Matito A, Jara-Acevedo M, Caldas C, Mayado A, Muñoz-González JI, Moreira A, Cavaleiro-Rufo J, García-Montero A, Órfão A, Sanchez-Muñoz L, Álvarez-Twose I. Bone and Cytokine Markers Associated With Bone Disease in Systemic Mastocytosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1536-1547. [PMID: 36801493 DOI: 10.1016/j.jaip.2023.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/05/2023] [Accepted: 02/03/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Mastocytosis encompasses a heterogeneous group of diseases characterized by tissue accumulation of clonal mast cells, which frequently includes bone involvement. Several cytokines have been shown to play a role in the pathogenesis of bone mass loss in systemic mastocytosis (SM), but their role in SM-associated osteosclerosis remains unknown. OBJECTIVE To investigate the potential association between cytokine and bone remodeling markers with bone disease in SM, aiming at identifying biomarker profiles associated with bone loss and/or osteosclerosis. METHODS A total of 120 adult patients with SM, divided into 3 age and sex-matched groups according to their bone status were studied: (1) healthy bone (n = 46), (2) significant bone loss (n = 47), and (3) diffuse bone sclerosis (n = 27). Plasma levels of cytokines and serum baseline tryptase and bone turnover marker levels were measured at diagnosis. RESULTS Bone loss was associated with significantly higher levels of serum baseline tryptase (P = .01), IFN-γ (P = .05), IL-1β (P = .05), and IL-6 (P = .05) versus those found in patients with healthy bone. In contrast, patients with diffuse bone sclerosis showed significantly higher levels of serum baseline tryptase (P < .001), C-terminal telopeptide (P < .001), amino-terminal propeptide of type I procollagen (P < .001), osteocalcin (P < .001), bone alkaline phosphatase (P < .001), osteopontin (P < .01), and the C-C Motif Chemokine Ligand 5/RANTES chemokine (P = .01), together with lower IFN-γ (P = .03) and RANK-ligand (P = .04) plasma levels versus healthy bone cases. CONCLUSIONS SM with bone mass loss is associated with a proinflammatory cytokine profile in plasma, whereas diffuse bone sclerosis shows increased serum/plasma levels of biomarkers related to bone formation and turnover, in association with an immunosuppressive cytokine secretion profile.
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Affiliation(s)
- Tiago Azenha Rama
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal; Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal.
| | - Ana Filipa Henriques
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) - Reference Center (CSUR) for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain
| | - Almudena Matito
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) - Reference Center (CSUR) for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain
| | - Maria Jara-Acevedo
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; DNA Sequencing Service (NUCLEUS), Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain
| | - Carolina Caldas
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; DNA Sequencing Service (NUCLEUS), Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain
| | - Andrea Mayado
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine, Cytometry Service (NUCLEUS) Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
| | - Javier I Muñoz-González
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine, Cytometry Service (NUCLEUS) Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
| | - André Moreira
- Serviço de Imunoalergologia, Centro Hospitalar Universitário São João, Porto, Portugal; Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - João Cavaleiro-Rufo
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Andrés García-Montero
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine, Cytometry Service (NUCLEUS) Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
| | - Alberto Órfão
- Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain; Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine, Cytometry Service (NUCLEUS) Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
| | - Laura Sanchez-Muñoz
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) - Reference Center (CSUR) for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain
| | - Iván Álvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast) - Reference Center (CSUR) for Mastocytosis, Hospital Virgen del Valle, Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Spanish Network on Mastocytosis (REMA), Toledo and Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain
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Tiryaki TO, Özkan SG, Erdem S, Aday AD, Hindilerden İY, Gelincik A, Baykal C, Yegen G, Doğan İÖ, Büyükbabani N, Nalçacı M, Yavuz AS. Comprehensive mastocytosis data analysis from a single center. BMC Cancer 2023; 23:82. [PMID: 36694141 PMCID: PMC9875486 DOI: 10.1186/s12885-022-10498-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/30/2022] [Indexed: 01/26/2023] Open
Abstract
Mastocytosis is a very rare disorder and is divided into three prognostically distinct variants by World Health Organization: Cutaneous mastocytosis (CM), systemic mastocytosis (SM), and mast cell sarcoma or localized mast cell (MC) tumors. The wide range of complaints may cause patients to consult various clinics, with resulting mis- or underdiagnosis. Therefore, cooperation between different subspecialties is of paramount importance. In this article, we have compiled 104 adult mastocytosis cases diagnosed and followed in our Hematology and other clinics. 86 (82.7%) of 104 patients had systemic mastocytosis. Osteoporosis, disease-related complications, and secondary malignancies are important topics in this group. We know that indolent form has great survival. But smoldering or aggressive mastocytosis has a poor prognosis. CM and indolent SM have a significantly better prognosis compared to aggressive SM (p < 0.001). We found that the presence of more than 25% of mast cells in the bone marrow, the presence of concomitant marrow dysplasia, and the presence of disease-related complications affect survival (p < 0.001). In addition to the WHO classification, the IPSM scoring system is indicative of the prognosis in this rare disease.
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Affiliation(s)
- Tarık Onur Tiryaki
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul University, Istanbul, Turkey.
| | - Sıdıka Gülkan Özkan
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul University, Istanbul, Turkey
| | - Simge Erdem
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul University, Istanbul, Turkey
| | - Aynur Dağlar Aday
- Faculty of Medicine, Department of Internal Medicine, Division of Medical Genetics, Istanbul University, Istanbul, Turkey
| | - İpek Yönal Hindilerden
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul University, Istanbul, Turkey
| | - Aslı Gelincik
- Faculty of Medicine, Department of Internal Medicine, Division of Allergy, Istanbul University, Istanbul, Turkey
| | - Can Baykal
- Faculty of Medicine, Department of Dermatology, Istanbul University, Istanbul, Turkey
| | - Gülçin Yegen
- Faculty of Medicine, Department of Pathology, Istanbul University, Istanbul, Turkey
| | - İbrahim Öner Doğan
- Faculty of Medicine, Department of Pathology, Istanbul University, Istanbul, Turkey
| | - Nesimi Büyükbabani
- Faculty of Medicine, Department of Pathology, Istanbul University, Istanbul, Turkey
| | - Meliha Nalçacı
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul University, Istanbul, Turkey
| | - Akif Selim Yavuz
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul University, Istanbul, Turkey
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Functional imaging with dual-energy computed tomography for supplementary non-invasive assessment of mast cell burden in systemic mastocytosis. Sci Rep 2022; 12:14228. [PMID: 35987779 PMCID: PMC9392758 DOI: 10.1038/s41598-022-18537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/16/2022] [Indexed: 11/08/2022] Open
Abstract
Systemic mastocytosis (SM) is characterized by multifocal accumulation of neoplastic mast cells (MCs), predominately affecting the bone marrow (BM). Imaging with computed tomography (CT) is used for assessment of bone mineral density and structure. However, the value of functional imaging with dual-energy CT (DECT) and the assessment of virtual-non-calcium attenuation values (VNCa-AV) for visualization of BM disease burden in SM has not yet been assessed. DECT of the axial skeleton was performed in 18 patients with SM (indolent SM [ISM], n = 6; smoldering SM [SSM]/advanced SM [AdvSM], n = 12) and 18 control subjects. VNCa-AV were obtained in 5 representative vertebraes per patient and correlated with laboratory, morphologic and molecular parameters. VNCa-AV strongly correlated with quantitative BM MC infiltration (r = 0.7, R2 = 0.49, P = 0.001) and serum tryptase levels (r = 0.7, R2 = 0.54, P < 0.001). Mean VNCa-AV were significantly higher in SSM/AdvSM as compared to ISM (− 9HU vs. − 54HU, P < 0.005) and controls (− 38HU, P < 0.005). Nine of 10 (90%) patients with a VNCa-AV > − 30HU and 7/7 (100%) patients with a VNCa-AV > − 10HU had SSM or AdVSM. BM VNCa-AV provide information about the MC burden of SM patients and correlate with SM subtypes. DECT may therefore serve as a supplementary tool for SM diagnosis, subclassification and monitoring in a one-stop-shop session.
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Gehlen M, Schmidt N, Pfeifer M, Balasingam S, Schwarz-Eywill M, Maier A, Werner M, Siggelkow H. Osteoporosis Caused by Systemic Mastocytosis: Prevalence in a Cohort of 8392 Patients with Osteoporosis. Calcif Tissue Int 2021; 109:685-695. [PMID: 34223956 DOI: 10.1007/s00223-021-00887-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
Indolent systemic mastocytosis (ISM) is a group of heterogenous diseases characterized by abnormal accumulation of mast cells in at least one organ. ISM can be a cause of osteoporosis. The aim of this study is to determine the prevalence, and the prognosis of ISM in a cohort of patients with osteoporosis. In this monocentric and retrospective study, patients with osteoporosis who did not receive a bone biopsy (cohort 1) and patients that subsequently received a diagnostic bone biopsy for differential diagnosis (cohort 2) are compared with patients who are diagnosed with ISM (cohort 3). A total of 8392 patients are diagnosed with osteoporosis. Out of these patients 1374 underwent a diagnostic bone biopsy resulting in 43 patients with ISM. These figures indicate that ISM is diagnosed in 0.5% of patients with osteoporosis and in 3.1% (men 5.8%) of patients who underwent bone biopsies. Patients with ISM sustained significantly more vertebral fractures in comparison to patients in cohort 2 (4.4 ± 3.6 versus 2.4 ± 2.5 vertebral fractures, p < 0.001) and women were significantly younger compared to cohort 2 (57.3 ± 12 versus 63.6 ± 12 years, p < 0.05). Only 33% showed an involvement of the skin (urticaria pigmentosa). ISM is a rare cause of osteoporosis (0.5%). However, in a subgroup of rather young male patients with osteoporosis the prevalence is more than 5%. Thus, ISM should be considered in premenopausal women and men presenting with vertebral fractures even if urticaria pigmentosa is not present.
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Affiliation(s)
- Martin Gehlen
- Clinic "DER FÜRSTENHOF", Department of Rheumatology, Osteology and Orthopaedics, Am Hylligen Born 7, 31812, Bad Pyrmont, Germany.
| | - Niels Schmidt
- Clinic "DER FÜRSTENHOF", Department of Rheumatology, Osteology and Orthopaedics, Am Hylligen Born 7, 31812, Bad Pyrmont, Germany
| | - Michael Pfeifer
- Clinic "DER FÜRSTENHOF", Department of Rheumatology, Osteology and Orthopaedics, Am Hylligen Born 7, 31812, Bad Pyrmont, Germany
| | - Subathira Balasingam
- Clinic "DER FÜRSTENHOF", Department of Rheumatology, Osteology and Orthopaedics, Am Hylligen Born 7, 31812, Bad Pyrmont, Germany
| | - Michael Schwarz-Eywill
- Clinic "DER FÜRSTENHOF", Department of Rheumatology, Osteology and Orthopaedics, Am Hylligen Born 7, 31812, Bad Pyrmont, Germany
| | - Anna Maier
- Department of Rheumatology, Sankt Josef-Stift Sendenhorst, West Gate 7, 48324, Sendenhorst, Germany
| | - Mathias Werner
- Department of Pathology, Vivantes Klinikum Friedrichshain, Landsberger Allee 49, 10249, Berlin, Germany
| | - Heide Siggelkow
- Clinic of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
- MVZ Endokrinologikum Goettingen, Von-Siebold-Str. 3, 37075, Goettingen, Germany
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Zanotti R, Tanasi I, Crosera L, Bonifacio M, Schena D, Orsolini G, Mastropaolo F, Tebaldi M, Olivieri E, Bonadonna P. Systemic Mastocytosis: Multidisciplinary Approach. Mediterr J Hematol Infect Dis 2021; 13:e2021068. [PMID: 34804442 PMCID: PMC8577553 DOI: 10.4084/mjhid.2021.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/20/2021] [Indexed: 12/30/2022] Open
Abstract
Systemic mastocytosis (SM) is a heterogeneous group of diseases that affect almost exclusively adults and are defined by the proliferation and accumulation of clonal mast cells (MC) in various tissues. Disease subtypes range from indolent to rare aggressive forms. Although SM is classified as a rare disease, it is believed to be likely underdiagnosed. Major signs and symptoms mainly depend on MC activation and less frequent organ infiltration, typical of more aggressive variants. Diagnosis may be challenging, and symptoms can be aspecific and involve several organs. Therefore, it is advisable to refer patients to specialized centers, having sufficient knowledge of the disease, sensitive diagnostic procedures, offering a personalized and multidisciplinary diagnostic approach, including at least hematological, allergological, dermatological, and rheumatological evaluations. A precise and timely diagnosis is required for: a) adequate counseling of patients and their physicians; b) beginning of symptomatic treatment (anti-mediator therapy); c) prevention of severe manifestations of the disease (i.e., recurrent anaphylaxis, osteoporosis, and bone fractures); d) cytoreductive treatment of advanced SM variants. This review summarizes the disease's main manifestations and describes the ideal diagnostic approach for adult patients with suspected SM, giving physicians the main notions for correct patient diagnosis and management. This review also highlights the importance of a multidisciplinary approach in this very complex disease.
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Affiliation(s)
- Roberta Zanotti
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Ilaria Tanasi
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Lara Crosera
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Massimiliano Bonifacio
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Donatella Schena
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Dermatology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Giovanni Orsolini
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Rheumatology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Francesca Mastropaolo
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Rheumatology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Morena Tebaldi
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Gastroenterology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Elisa Olivieri
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Patrizia Bonadonna
- Interdisciplinary Study Group for Mastocytosis (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
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Elsaiey A, Mahmoud HS, Jensen CT, Klimkowski S, Taher A, Chaudhry H, Morani AC, Wong VK, Salem UI, Palmquist SM, Elsayes KM. Mastocytosis-A Review of Disease Spectrum with Imaging Correlation. Cancers (Basel) 2021; 13:cancers13205102. [PMID: 34680251 PMCID: PMC8533777 DOI: 10.3390/cancers13205102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary In this review will discuss the clinical presentation, pathophysiology, and role of imaging in detection and extent estimation of the systemic involvement of the disease, in addition to demonstration of appearance on varying imaging modalities. Familiarity with the potential imaging findings associated with mastocytosis can aid in early disease diagnosis and classification and accordingly can lead directing further work up and better management. Abstract Mastocytosis is a rare disorder due to the abnormal proliferation of clonal mast cells. Mast cells exist in most tissues, mature in situ from hematopoietic stem cells and develop unique characteristics of local effector cells. Mastocytosis develops by activation mutation of the KIT surface receptor which is involved in the proliferation of a number of cell lines such as mast cells, germ cells, melanocytes, and hematopoietic cells. It manifests as two main categories: cutaneous mastocytosis and systemic mastocytosis. Imaging can play an important role in detection and characterization of the disease manifestation, not only by radiography and bone scans, but also magnetic resonance imaging and computed tomography, which can be more sensitive in the assessment of distinctive disease patterns. Radiologists should be aware of various appearances of this disease to better facilitate diagnosis and patient management. Accordingly, this review will discuss the clinical presentation, pathophysiology, and role of imaging in detection and extent estimation of the systemic involvement of the disease, in addition to demonstration of appearance on varying imaging modalities. Familiarity with the potential imaging findings associated with mastocytosis can aid in early disease diagnosis and classification and accordingly can lead directing further work up and better management.
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Affiliation(s)
| | - Hagar S. Mahmoud
- Department of Diagnostic Radiology, Yale New Haven Health at 1939 Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Corey T. Jensen
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
| | - Sergio Klimkowski
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
| | - Ahmed Taher
- Transitional Year Residency Program, Trinity Health Midatlantic, Nazareth Hospital, Philadelphia, PA 19152, USA;
| | - Humaira Chaudhry
- Department of Radiology, The State University of New Jersey, Piscataway, NJ 08854, USA;
| | - Ajaykumar C. Morani
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
| | - Vincenzo K. Wong
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
| | - Usama I. Salem
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
| | - Sarah M. Palmquist
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
| | - Khaled M. Elsayes
- MD Anderson Cancer Center, Department of Diagnostic Imaging, University of Texas, Houston, TX 77030, USA; (C.T.J.); (S.K.); (A.C.M.); (V.K.W.); (U.I.S.); (S.M.P.)
- Correspondence:
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Low risk of contrast media-induced hypersensitivity reactions in all subtypes of systemic mastocytosis. Ann Allergy Asthma Immunol 2021; 128:314-318. [PMID: 34637924 DOI: 10.1016/j.anai.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/27/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with systemic mastocytosis (SM) are at increased risk of hypersensitivity reactions (HRs). Although Hymenoptera venoms are the predominant triggers, cases of contrast media-induced HR (CMIHR) have also been reported and prophylactic premedication is often performed. However, data from larger series are limited and differences between indolent and advanced SM have not yet been investigated. OBJECTIVE To determine the incidence and severity of CMIHR in all subtypes of SM. METHODS We analyzed 162 adult patients with SM (indolent systemic mastocytosis [ISM], n = 65; advanced systemic mastocytosis [advSM], n = 97). First, the cumulative incidence of CMIHR was retrospectively assessed in the patient's history. Second, at our institution, patients underwent 332 contrast media (CM)-enhanced imaging including 80 computed tomography (CT) scans with iodine-based contrast agent and 252 magnetic resonance imaging (MRI) with a gadolinium-based contrast agent, and tolerance was assessed. RESULTS Previous CMIHRs to CT (vomiting, n = 1, erythema, n = 1, cardiovascular shock, n = 1), and MRI (dyspnea, n = 1, cardiovascular shock, n = 1) had been reported by 4 out of 162 (2.5%) patients (ISM, n = 3; advSM, n = 1). In contrast, during or after 332 CM-enhanced CT or MRI examinations at our institution, no CMIHRs were reported. Premedication was solely given to 3 patients before CT scans, including 1 with previous CMIHR, who tolerated the imaging well. CONCLUSION We conclude that: (1) there is a substantial discrepancy between the perception and prevalence of HRs to CM in SM; (2) reactions are scarce in ISM and even rarer in advSM; and (3) in SM patients without previous history of CM hypersensitivity, prophylactic premedication before CM-enhanced CT or MRI is dispensable.
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Systemic Mastocytosis: Radiological Point of View. Mediterr J Hematol Infect Dis 2021; 13:e2021056. [PMID: 34527208 PMCID: PMC8425380 DOI: 10.4084/mjhid.2021.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/10/2021] [Indexed: 12/27/2022] Open
Abstract
Radiological diagnosis of systemic mastocytosis (SM) can be hard to establish. This difficulty is mainly due to the variable radiological features involving many organ systems (e.g., respiratory, cardiovascular, lympho-reticular, digestive systems, and most commonly skin), and above all, to the broad spectrum of skeletal findings. Skeletal involvement is the most common and prominent imaging feature in patients with SM and represents a prognostic factor as it may entail an aggressive course of the disease. Diagnosis, largely established by histological evaluation of a bone marrow trephine biopsy, supplemented by imaging modalities such as radiography, CT, and magnetic resonance imaging, requires a team approach between the hematologist, radiologist, and pathologist. The general radiologist needs to be familiar with the imaging findings because they may be the first to suggest the correct diagnosis. The primary purpose of this review article was to equip clinicians with pertinent radiological semiotics by presenting relevant radiological features that assist early diagnosis and selection of an effective treatment.
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Paccou J, Javier RM, Henry-Desailly I, Ternynck C, Nottez A, Legroux-Gérot I, Robin F, Fardellone P, Lespessailles E, Roux C, Guggenbuhl P, Kolta S, Cortet B. The French multicentre elevated bone mass study: prevalence and causes. Osteoporos Int 2021; 32:1763-1775. [PMID: 33655400 DOI: 10.1007/s00198-021-05898-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
UNLABELLED The purpose of this multicentric study was to evaluate the prevalence and causes of Elevated Bone Mass (EBM) in patients who underwent DXA scanning over a 10-year period. The prevalence of EBM was 1 in 100. The main causes of EBM were degenerative spine disorders and renal osteodystrophy. INTRODUCTION Reports of elevated bone mass (EBM) on routine dual energy X-Ray absorptiometry (DXA) scanning are not infrequent. However, epidemiological studies of EBM are few and definition thresholds are variable. The purpose of this French multicentric study was to evaluate the prevalence and causes of EBM in adult patients who underwent DXA scanning over a 10-year period. METHODS This multicentric, retrospective study was conducted in six French regional bone centres. DXA databases were initially searched for individuals with a bone mineral density (BMD) Z-score ≥ +4 at any site in the lumbar spine or hip from April 1st, 2008 to April 30st, 2018. RESULTS In all, 72,225 patients with at least one DXA scan were identified. Of these, 909 (322 men and 587 women) had a Z-score ≥ + 4, i.e. a prevalence of 1.26% [1.18-1.34%]. The DXA scan reports and imagery and medical records of the 909 EBM patients were reviewed and 936 causes were found. In 42 patients (4%), no cause could be determined due to unavailability of data. Artefactual causes of EBM were found in 752 patients (80%), in whom the predominant cause was degenerative disease of the spine (613 patients, 65%). Acquired causes of focal EBM-including Paget's disease (n = 7)-were found in 12 patients (1%), and acquired causes of generalized EBM-including renal osteodystrophy (n = 32), haematological disorders (n = 20) and hypoparathyroidism (n = 15)-in 84 patients (9%). Other causes were rare hereditary diseases and unknown EBM in 19 (2%) and 27 (3%) cases respectively. CONCLUSIONS The prevalence of EBM was approximately 1 in 100. These findings suggest that degenerative disease of the spine is the main cause of EBM, but that acquired or hereditary diseases are also causal factors.
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Affiliation(s)
- J Paccou
- Rheumatology Unit, MABlab ULR 4490, Lille University Hospital, CHRU Lille, rue Emile Laine, 59037, Lille, France.
| | - R-M Javier
- Rheumatology Unit, Strasbourg University Hospital, Strasbourg, France
| | - I Henry-Desailly
- Rheumatology Unit, Picardie-Jules Verne University, Amiens Teaching Hospital, Amiens, France
| | - C Ternynck
- Lille University Hospital, CHRU Lille, ULR 2694-METRICS, F-59037, Lille, France
| | - A Nottez
- Rheumatology Unit, Lille University Hospital, CHRU Lille, 59037, Lille, France
| | - I Legroux-Gérot
- Rheumatology Unit, MABlab ULR 4490, Lille University Hospital, CHRU Lille, rue Emile Laine, 59037, Lille, France
| | - F Robin
- Rheumatology Unit, CHU de Rennes, Univ Rennes, INSERM, INRA, Institut NUMECAN (Nutrition Metabolisms and Cancer), UMR 1241, F-35000, Rennes, France
| | - P Fardellone
- Rheumatology Unit, Picardie-Jules Verne University, Amiens Teaching Hospital, Amiens, France
| | - E Lespessailles
- Rheumatology Unit, Regional Hospital of Orleans, EA 4708-I3MTO, University of Orleans, Orleans, France
| | - C Roux
- Rheumatology Unit, INSERM U1153 APHP Centre, Université de Paris, Paris, France
| | - P Guggenbuhl
- Rheumatology Unit, CHU de Rennes, Univ Rennes, INSERM, INRA, Institut NUMECAN (Nutrition Metabolisms and Cancer), UMR 1241, F-35000, Rennes, France
| | - S Kolta
- Rheumatology Unit, INSERM U1153 APHP Centre, Université de Paris, Paris, France
| | - B Cortet
- Rheumatology Unit, MABlab ULR 4490, Lille University Hospital, CHRU Lille, rue Emile Laine, 59037, Lille, France
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10
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Zanotti R, Tanasi I, Bernardelli A, Orsolini G, Bonadonna P. Bone Marrow Mastocytosis: A Diagnostic Challenge. J Clin Med 2021; 10:jcm10071420. [PMID: 33915965 PMCID: PMC8037514 DOI: 10.3390/jcm10071420] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 12/12/2022] Open
Abstract
Bone marrow mastocytosis (BMM) represents a provisional, indolent subvariant of systemic mastocytosis (SM). Utilizing WHO criteria, BMM requires bone marrow (BM) involvement and the absence of mastocytosis skin lesions. BMM is characterized by male sex prevalence, a slight increase of serum tryptase levels, low BM mast cells (MC) burden, and an indolent clinical course. BMM shows a strong correlation with severe anaphylaxis, mainly due to an IgE-mediated allergy to bee or wasp venom and, less frequently, to unexplained (idiopathic) anaphylaxis. Furthermore, BMM is often associated with osteoporosis which could be the only presenting symptom of the disease. BMM is an undervalued disease as serum tryptase levels are not routinely measured in the presence of unexplained osteoporosis or anaphylaxis. Moreover, BMM patients are often symptom-free except for severe allergic reactions. These factors, along with typical low BM MCs infiltration, may contribute to physicians overlooking BMM diagnosis, especially in medical centers that lack appropriately sensitive diagnostic techniques. This review highlights the need for a correct diagnostic pathway to diagnose BMM in patients with suspected symptoms but lacking typical skin lesions, even in the case of normal serum tryptase levels. Early diagnosis may prevent potential life-threatening anaphylaxis or severe skeletal complications.
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Affiliation(s)
- Roberta Zanotti
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Correspondence:
| | - Ilaria Tanasi
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Andrea Bernardelli
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Giovanni Orsolini
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Reumathology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy
| | - Patrizia Bonadonna
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Allergy Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy
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11
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Ulivieri FM, Rinaudo L, Piodi LP, Barbieri V, Marotta G, Sciumè M, Grifoni FI, Cesana BM. Usefulness of Dual X-ray Absorptiometry-Derived Bone Geometry and Structural Indexes in Mastocytosis. Calcif Tissue Int 2020; 107:551-558. [PMID: 32839841 DOI: 10.1007/s00223-020-00749-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/11/2020] [Indexed: 12/20/2022]
Abstract
Reduced bone mass with or without fragility fractures is a common feature of mastocytosis, particularly in adult males. However, bone mineral density does not account for all the fragility fractures, being a part of them attributable to impairment in bone quality. Aim of this study is to assess the usefulness of DXA-derived geometry and structural indexes in the assessment of bone status in mastocytosis. Ninety-six consecutive patients (46 women and 50 men) affected by cutaneous (CM) or systemic (SM) mastocytosis were studied. Mean age (± SD) was 53.3 ± 14.23. Spine lateral X-rays for Genant's scale, DXA for lumbar (L) and femoral (F) bone mineral density (BMD), bone strain index (BSI), lumbar trabecular bone score (TBS), and hip structural analysis (HSA) were performed. Among the laboratory variables, data of serum tryptase were reported. Tryptase was higher in SM (p = 0.035), inversely correlated with LBMD (r = - 0.232; p = 0.022) and TBS (r = - 0.280; p = 0.005), and directly with L-BSI (r = 0.276; p = 0.006). L-BSI remained statistically significant (p = 0.006; adjusted R2 = 0.101) together with mastocytosis (SM or CM: p = 0.034) in the multivariate regression model with tryptase as dependent variable, being LBMD and TBS not statistically significant (p = 0.887, and p = 0.245, respectively). Tryptase increased about 22 units for each unit increase of L-BSI and about 18 units for SM against CM. L-BSI was lower (p = 0.012), while FN-BSI and FT-BSI were higher in women (p < 0.001) than in men. HSA indexes were significantly higher in men, particularly with SM. SM is a risk factor for reduced bone mass, texture and strength. Since mean L-BSI and Z-modulus of all the femoral sites are statistically higher in men than in female, it could be argued that men have a better femoral bone resistance to bending forces than women, but a worse lumbar bone resistance to compressive loads. DXA indexes of bone quality are useful in mastocytosis' bone assessment and its clinical management.
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Affiliation(s)
- Fabio Massimo Ulivieri
- U.O. Medicina Nucleare, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milano, Italy.
- U.O. Endocrinologia, Università Vita-Salute San Raffaele, via Olgettina 58, 20132, Milano, Italy.
| | - Luca Rinaudo
- TECHNOLOGIC Srl, Lungo Dora Voghera, 34/36, 10153, Torino, Italy
| | | | - Valentina Barbieri
- Scuola Di Specializzazione in Medicina Fisica e Riabilitativa, Università Degli Studi Di Milano, Via Festa del Perdono, 7, 20122, Milano, Italy
| | - Giorgio Marotta
- U.O. Medicina Nucleare, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milano, Italy
| | - Mariarita Sciumè
- U.O. Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milano, Italy
| | - Federica Irene Grifoni
- U.O. Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milano, Italy
| | - Bruno Mario Cesana
- Unità Di Statistica Medica, Biometria e, Bioinformatica "Giulio A. Maccacaro", Dipartimento Di Scienze Cliniche E Salute Della Comunità, Università Degli Studi Di Milano, Via Vanzetti, 5, 20100, Milano, Italy
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12
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Leone A, Criscuolo M, Gullì C, Petrosino A, Carlo Bianco N, Colosimo C. Systemic mastocytosis revisited with an emphasis on skeletal manifestations. Radiol Med 2020; 126:585-598. [PMID: 33242205 DOI: 10.1007/s11547-020-01306-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/15/2020] [Indexed: 12/12/2022]
Abstract
Systemic mastocytosis (SM) is a rare form of mastocytosis that can affect various organ systems. Bone involvement is the most common and prominent imaging feature in patients with SM regardless of the subtype. Furthermore, bone involvement is a prognostic factor as it may entail an aggressive course of the disease. Diagnosis is established by bone marrow biopsy complemented by imaging modalities such as radiography, CT, and magnetic resonance (MR) imaging. The radiographic and CT appearances are that of sclerotic, lytic, or mixed patterns with focal or diffuse distribution, involving primarily the axial skeleton and the ends of the long bones. Bone marrow infiltration is best recognized on MR imaging. Osteoporosis is common in SM; thus, a bone mineral density measurement at lumbar spine and proximal femur by dual-energy X-ray absorptiometry should be obtained. Imaging plays a huge part in the diagnostic process; when skeletal imaging findings are carefully interpreted and correlated with clinical features, they can lead to the suspicion of SM. The primary aims of this review article were to focus on the role of imaging in detection and characterization of skeletal patterns of SM and to discuss relevant clinical features that could facilitate prompt and correct diagnosis.
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Affiliation(s)
- Antonio Leone
- Department of Radiological and Hematological Sciences Fondazione, Policlinico Universitario A. Gemelli, IRCCS Università Cattolica del Sacro Cuore, Largo A. Gemelli, 100168, Rome, Italy.
| | - Marianna Criscuolo
- Department of Radiological and Hematological Sciences Fondazione, Policlinico Universitario A. Gemelli, IRCCS Università Cattolica del Sacro Cuore, Largo A. Gemelli, 100168, Rome, Italy
| | - Consolato Gullì
- Department of Radiological and Hematological Sciences Fondazione, Policlinico Universitario A. Gemelli, IRCCS Università Cattolica del Sacro Cuore, Largo A. Gemelli, 100168, Rome, Italy
| | - Antonella Petrosino
- Department of Radiological and Hematological Sciences Fondazione, Policlinico Universitario A. Gemelli, IRCCS Università Cattolica del Sacro Cuore, Largo A. Gemelli, 100168, Rome, Italy
| | - Nicola Carlo Bianco
- Department of Radiological and Hematological Sciences Fondazione, Policlinico Universitario A. Gemelli, IRCCS Università Cattolica del Sacro Cuore, Largo A. Gemelli, 100168, Rome, Italy
| | - Cesare Colosimo
- Department of Radiological and Hematological Sciences Fondazione, Policlinico Universitario A. Gemelli, IRCCS Università Cattolica del Sacro Cuore, Largo A. Gemelli, 100168, Rome, Italy
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13
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Onnes MC, van Doormaal JJ, van der Veer E, Versluijs JB, Arends S, Oude Elberink HNG. Fracture Risk Reduction by Bisphosphonates in Mastocytosis? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3557-3564. [PMID: 32673882 DOI: 10.1016/j.jaip.2020.06.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fragility fractures (FFxs) and osteoporosis are frequent manifestations of indolent systemic mastocytosis (ISM). So far, the effect of antiosteoporotic therapy on FFxs has scarcely been investigated. OBJECTIVE This study evaluates the long-term effect of bisphosphonate treatment on FFxs, bone mineral density (BMD), and bone resorption in patients with ISM in daily clinical practice. METHODS Patients with ISM who received bisphosphonates because of osteoporosis and/or FFxs were retrospectively analyzed (n = 58). Fractures were recorded by vertebral fracture assessment, X-rays of the thoracolumbar spine, medical records, and a questionnaire. Five-year analysis (n = 30) was made by comparing observed 5-year FFx risk with MastFx-predicted FFx risk for patients with ISM not treated with antiosteoporotic drugs and analyzing 5-year change in BMD and serum collagen C telopeptide (sCTx) Z-scores. RESULTS During the median follow-up of 7.3 years, 14 of 58 patients suffered 40 FFxs. Five- and 10-year FFx-free survival were 81.9% (standard error [SE], 5.5%) and 67.0% (SE, 7.7%), respectively. FFx risk was significantly higher in patients with previous vertebral FFxs (P = .004), lower femoral BMD at baseline (P = .042), and history of anaphylaxis (P = .028). No 5-year FFx risk reduction could be proven, possibly due to the small sample size. The lumbar BMD Z-score significantly increased from median (interquartile range [IQR]) -2.20 (-2.80 to -1.50) to -1.50 (-2.30 to -0.60) (P < .001, n = 27). The sCTx Z-score decreased from median 0.71 (IQR, -0.59 to 2.39) to -0.95 (-1.30 to -0.16) (P = .008, n = 15). CONCLUSION Bisphosphonates significantly increase BMD and decrease sCTx in patients with ISM. However, FFxs still frequently occur. Especially patients with previous FFxs remain at high risk of new FFxs.
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Affiliation(s)
- Merel C Onnes
- Department of Allergology, University Medical Center Groningen, University of Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | - Jasper J van Doormaal
- Department of Allergology, University Medical Center Groningen, University of Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | - Eveline van der Veer
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joris B Versluijs
- Department of Allergology, University Medical Center Groningen, University of Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | - Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hanneke N G Oude Elberink
- Department of Allergology, University Medical Center Groningen, University of Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands.
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