Femur fracture classification in women with a history of breast cancer

Distribution of Femoral Metastases; Potential Role for Extended FDG PET/CT Scanning

This study investigates the distribution of femoral metastases in cancer patients, specifically addressing the incidence of distal femoral metastases. PET/CT examinations routinely extend only to mid-thigh level, precluding detection of distal metastases. We found a total of 208 femoral metastases in 112 patients. 30% had distal femoral metastases in addition to other areas of involvement. 7% of patients with femoral metastases had only distal femur disease. 6 patients had distal pathologic fractures. Exclusion of the distal femur during PET/CT may result in a missed or delayed diagnosis that could contribute to the development of a pathologic fracture with increased morbidity.

Neck of femur fracture: Previous history of malignancy is not an indication to send femoral head for routine histology

BACKGROUND

Neck of femur fractures is the most common fractures associated with low-velocity injury in the elderly. Some patients may require further histological examination of the femoral head due clinical suspicion of malignance as a cause of fracture.

OBJECTIVES

To review whether standard screening question(s) could be used to identify patients that require histological examinations following neck of femur fracture.

STUDY DESIGN AND METHODS

Femoral heads sent for histological examination over a period of 5 years were identified from hospital database. All patients presenting acutely with neck of femur fracture above the age of 70 were included, and their case notes were retrospectively reviewed. Reason for histopathological examination were categorised into three screening questions: (Q1) clinical suspicion based on history alone, i.e. neck of femur fracture with no clear history of fall or trauma or preceding hip pain, (Q2) radiological evidence of suspicious abnormality on admission radiographs, (Q3) previous history of malignancy or concurrent malignancy or (Q4) combination of above.

RESULTS

In total, 119 samples of femoral head were sent and 18 patients had a positive histology. The sensitivity and specificity of these questions individually showed very poor correlation to positive histology with lowest for (Q3) previous history of malignancy (0.39 and 0.51, respectively). However, combining Q1 and Q2 the sensitivity is improved to 1.0 (95% CI 1.0-1.0) and specificity to 0.35 (95% CI 0.25-0.44) with a positive predictive value of 0.21 (95% CI 0.13-0.30) and negative predictive value of 1.00 (95% CI 1.00-1.00).

CONCLUSION

History of previous malignancy poorly correlates with positive histology. Routine request based on these screening criteria is not cost-effective in patient management.

LEVEL OF EVIDENCE

Prognostic level III.

Tamoxifen use correlates with increased risk of hip fractures in older women with breast cancer: A case-control study in Taiwan

AIM

This study aimed to evaluate the association between tamoxifen use and hip fractures in older women with breast cancer in Taiwan.

METHODS

We carried out a retrospective nationwide case-control study using the database of the Taiwan National Health Insurance Program. A total of 762 female patients with breast cancer aged ≥65 years newly diagnosed with hip fractures from 2000 to 2011 were identified for inclusion in the study. Additionally, 7620 female patients with breast cancer aged ≥65 years without hip fractures were randomly selected as controls. Patients were defined as having used tamoxifen if they had an existing prescription for tamoxifen before the index date. Patients were defined as having never used tamoxifen if they had never been given a prescription for tamoxifen before the index date. We used an unconditional logistic regression model to calculate the odds ratio and 95% confidence interval for the association between tamoxifen use and risk of hip fractures.

RESULTS

After adjustment for confounding variables, compared with patients who did not use tamoxifen, the adjusted odds ratio of hip fracture was 2.29 for those who had used tamoxifen (95% confidence interval 1.92, 2.72). Furthermore, adjusted odds ratios were 2.74 (95% confidence interval 2.19, 3.42) among patients with a cumulative duration of tamoxifen use of >3 years.

CONCLUSION

Tamoxifen use is associated with increased risk of hip fractures among older women with breast cancer in Taiwan. Geriatr Gerontol Int 2019; 19: 56-60.

Bone health history in breast cancer patients on aromatase inhibitors

A cross-sectional study was performed to assess bone health history among aromatase inhibitor (AI) users before breast cancer (BC) diagnosis, which may impact fracture risk after AI therapy and choice of initial hormonal therapy. A total of 2,157 invasive BC patients initially treated with an AI were identified from a prospective cohort study at Kaiser Permanente Northern California (KPNC). Data on demographic and lifestyle factors were obtained from in-person interviews, and bone health history and clinical data from KPNC clinical databases. The prevalence of osteoporosis and fractures in postmenopausal AI users was assessed, compared with 325 postmenopausal TAM users. The associations of bone health history with demographic and lifestyle factors in AI users were also examined. Among all initial AI users, 11.2% had a prior history of osteoporosis, 16.3% had a prior history of any fracture, and 4.6% had a prior history of major fracture. Postmenopausal women who were taking TAM as their initial hormonal therapy had significantly higher prevalence of prior osteoporosis than postmenopausal AI users (21.5% vs. 11.8%, p<0.0001). Among initial AI users, the associations of history of osteoporosis and fracture in BC patients with demographic and lifestyle factors were, in general, consistent with those known in healthy older women. This study is one of the first to characterize AI users and risk factors for bone morbidity before BC diagnosis. In the future, this study will examine lifestyle, molecular, and genetic risk factors for AI-induced fractures.