Treatment-related osteoporosis in men with prostate cancer

Intra-pituitary follicle-stimulating hormone signaling regulates hepatic lipid metabolism in mice

Inter-organ communication is a major hallmark of health and is often orchestrated by hormones released by the anterior pituitary gland. Pituitary gonadotropes secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to regulate gonadal function and control fertility. Whether FSH and LH also act on organs other than the gonads is debated. Here, we find that gonadotrope depletion in adult female mice triggers profound hypogonadism, obesity, glucose intolerance, fatty liver, and bone loss. The absence of sex steroids precipitates these phenotypes, with the notable exception of fatty liver, which results from ovary-independent actions of FSH. We uncover paracrine FSH action on pituitary corticotropes as a mechanism to restrain the production of corticosterone and prevent hepatic steatosis. Our data demonstrate that functional communication of two distinct hormone-secreting cell populations in the pituitary regulates hepatic lipid metabolism.

Drug Repurposing: A New Hope in Drug Discovery for Prostate Cancer

Prostate cancer (PCA), the most common cancer in men, accounted for 1.3 million new incidences in 2018. An increase in incidences is an issue of concern that should be addressed. Of all the reported prostate cancers, 85% were detected in stages III and IV, making them difficult to treat. Conventional drugs gradually lose their efficacy due to the developed resistance against them, thus requiring newer therapeutic agents to be used as monotherapy or combination. Recent research regarding treatment options has attained remarkable speed and development. Therefore, in this context, drug repurposing comes into the picture, which is defined as the "investigation of the off-patent, approved and marketed drugs for a novel therapeutic indication" which saves at least 30% of the time and cost, reducing the cost of treatment for patients, which usually runs high in cancer patients. The anticancer property of cardiac glycosides in cancers was tested in the early 1980s. The trend then shifts toward treating prostate cancer by repurposing other cardiovascular drugs. The current review mainly emphasizes the advantageous antiprostate cancer profile of conventional CVS drugs like cardiac glycosides, RAAS inhibitors, statins, heparin, and beta-blockers with underlying mechanisms.

The Relationship Between Bone and Reproductive Hormones Beyond Estrogens and Androgens

Reproductive hormones play a crucial role in the growth and maintenance of the mammalian skeleton. Indeed, the biological significance for this hormonal regulation of skeletal homeostasis is best illustrated by common clinical reproductive disorders, such as primary ovarian insufficiency, hypothalamic amenorrhea, congenital hypogonadotropic hypogonadism, and early menopause, which contribute to the clinical burden of low bone mineral density and increased risk for fragility fracture. Emerging evidence relating to traditional reproductive hormones and the recent discovery of newer reproductive neuropeptides and hormones has deepened our understanding of the interaction between bone and the reproductive system. In this review, we provide a contemporary summary of the literature examining the relationship between bone biology and reproductive signals that extend beyond estrogens and androgens, and include kisspeptin, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, prolactin, progesterone, inhibin, activin, and relaxin. A comprehensive and up-to-date review of the recent basic and clinical research advances is essential given the prevalence of clinical reproductive disorders, the emerging roles of upstream reproductive hormones in bone physiology, as well as the urgent need to develop novel safe and effective therapies for bone fragility in a rapidly aging population.

Raloxifene decreases cell viability and migratory potential in prostate cancer cells (LNCaP) with GPR30/GPER1 involvement

OBJECTIVES

This study evaluated raloxifene (ral) effects on LNCaP prostate tumour cells modulating the activity of GPER1/GPR30 receptors.

METHODS

LNCaP cells were submitted for 40/120 min and 12 h to the following treatments: C: RPMI + DMSO; R: RPMI + Ral; G: RPMI + Ral + G15 (GPER1 antagonist). Trypan blue staining measured cell viability. Migratory potential (12 h) was measured by transwell migration test in translucent inserts, which were then stained with DAPI and analysed under a fluorescence microscope for quantification. Cells from 40- and 120-min treatments were subjected to protein extraction to the study of AKT, pAKT, ERK, pERK, ERβ and SIRT1.

KEY FINDINGS

There is a reduction in cellular viability in R compared to C at all evaluated times, and an increased cell viability in G when compared to R; cell viability was similar in C and G in all times studied. The migration assay demonstrated a significant decrease in migration potential of tumour cells in R compared to C and G. Ral treatment reduced pERK expression and increased pAKT in the treated groups after 40 min, pointing out to an antiproliferative and apoptotic effect in the GPER1-controlled rapid-effect pathways.

CONCLUSIONS

Raloxifene was able to modulate GPER1 in LNCaP prostate tumour cells, decreasing cell viability and their migratory potential.

Prevalence and associated risk factors for osteoporosis in Korean men

Osteoporosis has become an important health concern even in men. We aimed to analyze its prevalence and associated factors in Korean men. Low socioeconomic status, unhealthy lifestyle, and chronic kidney disease increased the risk. High-risk men even at young age need to evaluate bone mineral density, and proper interventions should be reinforced.

PURPOSE

Owing to an increase in the elderly population, osteoporosis and consequent fractures have become important health concerns even in men. We aimed to analyze the prevalence of osteoporosis in Korean men and identify risk factors associated with male osteoporosis.

METHODS

The study included 6104 men aged ≥ 30 years and who underwent dual-energy X-ray absorptiometry between 2008 and 2011 in Korean National Health and Nutrition Survey. Sociodemographic status, lifestyle factors, and body composition were measured. We defined osteoporosis according to the WHO criteria using a T score of - 2.5 or less in men aged ≥ 50 years and a Z score of - 2.0 or less in men aged < 50 years. We analyzed the prevalence of osteoporosis and conducted multivariate logistic regression to evaluate the associated risk factors.

RESULTS

Overall, 5.0% of all participants and 17.7% of participants aged ≥ 70 years had osteoporosis and showed rapid progression from the age of 60 years. Risk factors for osteoporosis in Korean men were old age, lower education status, lower household income, lack of physical activity, insufficient calcium intake, chronic kidney disease, underweight, insufficient nutrition, and sarcopenia. Additionally, young men aged 30-49 years with a history of cancer were at an increased risk of osteoporosis.

CONCLUSIONS

Low socioeconomic status, unhealthy lifestyle, insufficient nutrition, and chronic kidney disease increased the risk of osteoporosis in Korean men. Men who have the abovementioned risk factors even at a young age need to undergo bone mineral density evaluation, and proper interventions should be reinforced to prevent and manage osteoporosis.

Harnessing the potential of therapeutic agents to safeguard bone health in prostate cancer

Background

Patients with prostate cancer are at risk of impaired bone health. Prostate cancer has a propensity to metastasize to bone, after which patients are at risk of skeletal-related events (SREs). These complications are associated with increased mortality, substantial pain, and reduced quality of life. Patients are also at risk of bone loss due to androgen deprivation therapy (ADT), which can be compounded in elderly patients with reduced bone density. It is essential, therefore, that aspects of bone health and therapies able to prevent the occurrence of SREs are considered throughout the clinical course of prostate cancer.

Methods

We reviewed the literature regarding the molecular mechanisms underpinning bone lesion formation, the modes of action of therapies that prevent SREs, and the efficacy and safety of these therapies in patients with hormone-sensitive or castration-resistant prostate cancer (CRPC).

Results

Therapies such as denosumab (a RANKL inhibitor) and zoledronic acid (a bisphosphonate) were indicated for prevention of SREs. Radium-223 dichloride also has proven efficacy in delaying symptomatic SREs, as well as in improving overall survival through effects on bone metastases. Before development of bone metastases, low-dose denosumab may also be used for treatment of ADT-associated bone loss. Denosumab may also have the potential to delay bone metastases development in patients with CRPC, although this is not currently an approved indication. The safety profile of therapies to prevent SREs should be considered. This review consolidates the available evidence on use of denosumab and bisphosphonates in prostate cancer, differentiated by hormone-sensitive and castration-resistant disease.

Conclusions

There is convincing evidence to support the use of denosumab and bisphosphonates to maintain bone health in patients with prostate cancer. Clinicians should be mindful of the adverse event risk profile of these therapies.

In-vivo assessment of femoral bone strength using Finite Element Analysis (FEA) based on routine MDCT imaging: a preliminary study on patients with vertebral fractures

Purpose

To experimentally validate a non-linear finite element analysis (FEA) modeling approach assessing in-vitro fracture risk at the proximal femur and to transfer the method to standard in-vivo multi-detector computed tomography (MDCT) data of the hip aiming to predict additional hip fracture risk in subjects with and without osteoporosis associated vertebral fractures using bone mineral density (BMD) measurements as gold standard.

Methods

One fresh-frozen human femur specimen was mechanically tested and fractured simulating stance and clinically relevant fall loading configurations to the hip. After experimental in-vitro validation, the FEA simulation protocol was transferred to standard contrast-enhanced in-vivo MDCT images to calculate individual hip fracture risk each for 4 subjects with and without a history of osteoporotic vertebral fractures matched by age and gender. In addition, FEA based risk factor calculations were compared to manual femoral BMD measurements of all subjects.

Results

In-vitro simulations showed good correlation with the experimentally measured strains both in stance (R² = 0.963) and fall configuration (R² = 0.976). The simulated maximum stress overestimated the experimental failure load (4743 N) by 14.7% (5440 N) while the simulated maximum strain overestimated by 4.7% (4968 N). The simulated failed elements coincided precisely with the experimentally determined fracture locations. BMD measurements in subjects with a history of osteoporotic vertebral fractures did not differ significantly from subjects without fragility fractures (femoral head: p = 0.989; femoral neck: p = 0.366), but showed higher FEA based risk factors for additional incident hip fractures (p = 0.028).

Conclusion

FEA simulations were successfully validated by elastic and destructive in-vitro experiments. In the subsequent in-vivo analyses, MDCT based FEA based risk factor differences for additional hip fractures were not mirrored by according BMD measurements. Our data suggests, that MDCT derived FEA models may assess bone strength more accurately than BMD measurements alone, providing a valuable in-vivo fracture risk assessment tool.

[Corticotherapy in castration-resistant prostate cancer]

INTRODUCTION

Corticosteroids are commonly used in the treatment of prostate cancer resistant to castration (PCRC), partly due to the inhibitory effects on adrenal androgen production acting as a pituitary suppressant.

METHODS

A literature search was conducted in PubMed/MEDLINE database using the following key words: prostate cancer; castration resistance; metastasis; corticotherapy.

RESULTS

Corticosteroids exert direct anti-tumoral activities mediated by the glucocorticoids receptor and involving cellular/tissue functions as growth, apoptosis, inflammation, metastasis, differentiation and angiogenesis. As a pain relieving agents, corticosteroids significantly relieve PCRC clinical symptoms, especially those due to bone metastasis. In the comparative arm of phase II-III trials, corticosteroids administered daily produce a PSA decline. Among the adverse effects due to corticosteroids, bone loss and cardiovascular risk should be carefully monitored. In association with abiraterone acetate, corticosteroids increase overall survival in PCRC patients, and reduce the mineralocorticoid side effects of abiraterone.

CONCLUSION

Corticosteroids in monotherapy for PCRC have a limited efficacy. In association with abiraterone acetate it reduces the mineralocorticoid toxicity and enhances the androgenic suppression.

Modulators of estrogen receptor inhibit proliferation and migration of prostate cancer cells

In the initial stages, human prostate cancer (PC) is an androgen-sensitive disease, which can be pharmacologically controlled by androgen blockade. This therapy often induces selection of androgen-independent PC cells with increased invasiveness. We recently demonstrated, both in cells and mice, that a testosterone metabolite locally synthetized in prostate, the 5α-androstane-3β, 17β-diol (3β-Adiol), inhibits PC cell proliferation, migration and invasion, acting as an anti-proliferative/anti-metastatic agent. 3β-Adiol is unable to bind androgen receptor (AR), but exerts its protection against PC by specifically interacting with estrogen receptor beta (ERβ). Because of its potential retro-conversion to androgenic steroids, 3β-Adiol cannot be used "in vivo", thus, the aims of this study were to investigate the capability of four ligands of ERβ (raloxifen, tamoxifen, genistein and curcumin) to counteract PC progression by mimicking the 3β-Adiol activity. Our results demonstrated that raloxifen, tamoxifen, genistein and curcumin decreased DU145 and PC3 cell proliferation in a dose-dependent manner; in addition, all four compounds significantly decreased the detachment of cells seeded on laminin or fibronectin. Moreover, raloxifen, tamoxifen, genistein and curcumin-treated DU145 and PC3 cells showed a significant decrease in cell migration. Notably, all these effects were reversed by the anti-estrogen, ICI 182,780, suggesting that their actions are mediated by the estrogenic pathway, via the ERβ, the only isoform present in these PCs. In conclusion, these data demonstrate that by selectively activating the ERβ, raloxifen, tamoxifen, genistein and curcumin inhibit human PC cells proliferation and migration favoring cell adesion. These synthetic and natural modulators of ER action may exert a potent protective activity against the progression of PC even in its androgen-independent status.

[The non-hormonal treatment of metastatic prostate cancer]

AIM

To describe drugs used in the non-hormonal treatment of metastatic prostate cancer.

MATERIAL

Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned.

RESULTS

The metabolic radiotherapy although under-used for this indication, kept a place at the beginning of the disease. Radium-223 chloride seems to have to occupy an important place in the coming years. The chemotherapy, the only recourse until very recently in the castration-resistant prostate cancer, must redefine its place partially. The denosumab provide an interesting alternative to bisphosphonates.

CONCLUSION

The non-hormonal treatment of the metastatic disease of the prostate cancer is changing rapidly with the emergence of new molecules. Urologist must know perfectly these new drugs.

Bone mineral density measurements of the proximal femur from routine contrast-enhanced MDCT data sets correlate with dual-energy X-ray absorptiometry

OBJECTIVES

To evaluate the utility of femoral bone mineral density (BMD) measurements in routine contrast-enhanced multi-detector computed tomography (ceMDCT) using dual-energy X-ray absorptiometry (DXA) as the reference standard.

METHODS

Forty-one patients (33 women, 8 men) underwent DXA measurement of the proximal femur. Subsequently, transverse sections of routine ceMDCT of these patients were used to measure BMD of the femoral head and femoral neck. The MDCT-to-DXA conversion equations for BMD and T-score were calculated using linear regression analysis. The conversion equations were applied to the MDCT data sets of 382 patients (120 women, 262 men) of whom 74 had osteoporotic fractures.

RESULTS

A correlation coefficient of r = 0.84 (P < 0.05) was calculated for BMD(MDCT) values of the femoral head and DXA T-scores of the total proximal femur using the conversion equation T-score = 0.021 × BMD(MDCT) - 5.90. The correlation coefficient for the femoral neck was r = 0.79 (P < 0.05) with the conversion equation T-score = 0.016 × BMD(MDCT) - 4.28. Accordingly, converted T-scores for the femoral neck in patients with versus those without osteoporotic fractures were significantly different (female, -1.83 versus -1.47; male, -1.86 versus -1.47; P < 0.05).

CONCLUSION

BMD measurements of the proximal femur were computed in routine contrast-enhanced MDCT and converted to DXA T-scores, which adequately differentiated patients with and without osteoporotic fractures.

Converted lumbar BMD values derived from sagittal reformations of contrast-enhanced MDCT predict incidental osteoporotic vertebral fractures

We obtained baseline and follow-up bone mineral density (BMD) values of the lumbar spine from sagittal reformations of routine abdominal contrast-enhanced multidetector computed tomography (MDCT) using a reference phantom and assessed their performance in differentiating patients with no, existing, and incidental osteoporotic fractures of the spine. A MDCT-to-QCT (quantitative computed tomography) conversion equation for lumbar BMD measurements was developed by using 15 postmenopausal women (63 ± 12 years), who underwent standard lumbar QCT (L1-L3) and afterward routine abdominal contrast-enhanced MDCT. Sagittal reformations were used for corresponding lumbar BMD measurements. The MDCT-to-QCT conversion equation was applied to baseline and follow-up routine abdominal contrast-enhanced MDCT scans of 149 postmenopausal women (63 ± 10 years). Their vertebral fracture status (no, existing, or incidental osteoporotic fracture) was assessed in the sagittal reformations. A correlation coefficient of r = 0.914 (p < 0.001) was calculated for the BMD values of MDCT and standard QCT with the conversion equation BMD(QCT) = 0.695 × BMD(MDCT) - 7.9 mg/mL. Mean follow-up time of the 149 patients was 20 ± 12 months. Fifteen patients (10.1 %) had an existing osteoporotic vertebral fracture at baseline. Incidental osteoporotic vertebral fractures were diagnosed in 13 patients (8.7 %). Patients with existing and incidental fractures showed significantly (p < 0.05) lower converted BMD values (averaged over L1-L3) than patients without fracture at baseline and at follow-up. In this longitudinal study, BMD values of the lumbar spine derived from sagittal reformations of routine abdominal contrast-enhanced MDCT predicted incidental osteoporotic vertebral fractures.

Bone-modifying agents in the treatment of bone metastases in patients with advanced genitourinary malignancies: a focus on zoledronic acid

Many patients with advanced genitourinary malignancies develop bone metastases, which can lead to potentially debilitating skeletal complications. Moreover, age-related bone loss and cancer treatments such as hormonal therapy for prostate cancer can weaken bone, placing patients at risk for osteoporotic fractures in addition to skeletal-related events (SREs) from bone metastases. Zoledronic acid, a bisphosphonate, is approved worldwide to reduce the risk of SREs in patients with bone metastases from solid tumors or bone lesions from multiple myeloma. Zoledronic acid, although underutilized in genitourinary malignancies, has long been the mainstay of treatment in patients with bone metastases, and can also help preserve bone during anticancer therapy. Recently, denosumab, a monoclonal antibody directed against the receptor activator of nuclear factor kappa-B ligand, was approved in the United States and the European Union for reducing the risk of SREs in patients with bone metastases from solid tumors. Denosumab (at a lower dose) is also approved in the European Union and the United States to treat androgen deprivation-induced bone loss in men with prostate cancer. In addition, preclinical rationale and emerging clinical data suggest that bone-modifying agents may be able to delay disease progression in genitourinary cancers, just as newly developed anticancer treatments have produced reductions in SREs, possibly by indirect effects on the disease course. This review article summarizes current data and ongoing studies to preserve bone health in patients with advanced genitourinary cancers.

Hypogonadism in the aging male diagnosis, potential benefits, and risks of testosterone replacement therapy

Hypogonadism in older men is a syndrome characterized by low serum testosterone levels and clinical symptoms often seen in hypogonadal men of younger age. These symptoms include decreased libido, erectile dysfunction, decreased vitality, decreased muscle mass, increased adiposity, depressed mood, osteopenia, and osteoporosis. Hypogonadism is a common disorder in aging men with a significant percentage of men over 60 years of age having serum testosterone levels below the lower limits of young male adults. There are a variety of testosterone formulations available for treatment of hypogonadism. Data from many small studies indicate that testosterone therapy offers several potential benefits to older hypogonadal men. A large multicenter NIH supported double blind, placebo controlled study is ongoing, and this study should greatly enhance the information available on efficacy and side effects of treatment. While safety data is available across many age groups, there are still unresolved concerns associated with testosterone therapy. We have reviewed the diagnostic methods as well as benefits and risks of testosterone replacement therapy for hypogonadism in aging men.

Denosumab and changes in bone turnover markers during androgen deprivation therapy for prostate cancer

Androgen deprivation therapy (ADT) for prostate cancer increases fracture risk, decreases bone mineral density, and increases bone turnover markers (BTMs) including serum type 1 C-telopeptide (sCTX), tartrate-resistant alkaline phosphatase 5b (TRAP-5b), and procollagen-1 N-terminal telopeptide (P1NP). In a prespecified exploratory analysis of a phase 3, multicenter, double-blind study, we evaluated the effects of denosumab (60 mg subcutaneously every 6 months for 3 years) versus placebo (1468 patients, 734 in each group) on BTM values. BTMs were measured at baseline, month 1, and predose at months 6, 12, 24, and 36 in the overall population. BTMs at month 1 are also reported for subgroups based on age (<  70 years versus ≥  70 years), prior duration of ADT (≤  6 months versus > 6 months), and baseline BTM (≤  median versus >  median BTM values). Treatment with denosumab provided a rapid and sustained decrease of BTM values compared with placebo. The median change in sCTX levels at month 1 was -90% in the denosumab group and -3% in the placebo group (p  <  0.0001). The median change in TRAP-5b levels at month 1 was -55% in the denosumab group and -3% in the placebo group (p <  0.0001). The maximal median change in P1NP was -64% in the denosumab group and -11% in the placebo group, (p  <  0.0001). Significantly greater decreases in BTM for denosumab were also seen in subgroup analyses based on age, prior ADT treatment, and baseline BTM values. Suppression of bone turnover markers was consistent with marked increases in bone mineral density reported previously.

Raloxifene induces cell death and inhibits proliferation through multiple signaling pathways in prostate cancer cells expressing different levels of estrogen receptor α and β

Raloxifene (RAL), a selective estrogen receptor (ER) modulator (SERM) seems to induce apoptosis in both androgen-dependent and -independent prostate cell (PC) lines via activation of ERβ and an antagonistic effect on ERα. In this study, we evaluated the effects of RAL on epithelial PC growth using the two following in vitro models: the androgen-dependent cell line EPN which expressed both ERs; and a stabilized epithelial cell line derived from a prostate cancer specimen (CPEC), which expressed low levels of ERβ and lacked ERα. In EPN cells, there was an increase in the pre-G1 apoptotic peak and a reduction in the S phase of the cell cycle with G0/G1 arrest after E2 or RAL treatment; bcl-2 mRNA and Bcl-2 protein levels were significantly reduced, while activated caspase-3 and Par-4 levels increased significantly after either E2 or RAL treatment; in addition, c-myc transcript was inhibited after 10(-6)  M RAL treatment. A dose-dependent increase of metallothionein II gene RNA level was also induced by RAL in EPN. In CPEC, there was only a weak apoptotic peak associated with caspase-3 activation and Par-4 increase after either E2 or RAL treatment; while c-myc transcript level increased. RAL induced a rapid but transient phosphorylation of ERK 1/2 in EPN cells but generated a sustained effect in CPEC. These findings suggest that RAL effects on PC growth control in vitro are cell-specific, depending on ERβ or ERβ/ERα relative expression levels. Moreover, this study demonstrated that RAL affected both transcriptional regulation and non-genomic signals, which resulted in the modulation of multiple signaling pathways of apoptosis and of cell cycle progression.

Improving progression-free and overall survival in patients with cancer: a potential role for bisphosphonates

INTRODUCTION

Bisphosphonates are a well-established therapy for patients with multiple myeloma or bone metastases from advanced cancers and are used routinely to delay the onset and reduce the risk of skeletal-related events. Emerging evidence indicates that they also may provide additional anticancer benefits. These developments warrant reappraisal of their role in patients with cancer and reevaluation of optimal therapeutic regimens.

AREAS COVERED

This article reviews the evidence of the anticancer activity of bisphosphonates in patients with solid tumors or multiple myeloma. The underlying mechanisms of the anticancer activity of bisphosphonates are elucidated from preclinical and translational data that show that bisphosphonates suppress tumor growth and survival, inhibit tumor-mediated angiogenesis, or stimulate host anticancer immune response. These data also provide insights into the potential for therapeutic combinations. Preclinical and clinical data relating to the anticancer effects of bisphosphonates are reviewed by cancer type.

EXPERT OPINION

Future trials of bisphosphonates in cancer patients will explore the underlying mechanism of the anticancer benefit in greater detail and attempt to examine critically the potential clinical benefit in individual cancer types in early/advanced disease.

BMD measurements of the spine derived from sagittal reformations of contrast-enhanced MDCT without dedicated software

PURPOSE

To assess QCT equivalent BMD of the lumbar spine in sagittal reformations of routine abdominal contrast-enhanced MDCT with simple PACS measurement tools and to apply this method to MDCT datasets for differentiating patients with and without osteoporotic vertebral fractures.

MATERIALS AND METHODS

Eight postmenopausal women (65±5 years) underwent standard QCT to assess BMD of L1-L3. Afterwards routine abdominal contrast-enhanced MDCT images of these women were obtained and apparent BMD of L1-L3 was measured using the sagittal reformations. The MDCT-to-QCT conversion equation for BMD was calculated with linear regression analysis. The conversion equation was applied to vertebral BMD datasets (L1-L3) of 75 postmenopausal women (66±4 years). Seventeen of the 75 patients had osteoporotic vertebral fractures.

RESULTS

BMD values of contrast-enhanced MDCT were on average 56 mg/ml higher than those of standard QCT. A correlation coefficient of r=0.94 (p<0.05) was calculated for the BMD values of MDCT and standard QCT with the conversion equation BMDQCT=0.69×BMDMDCT-11 mg/ml. Accordingly converted BMD values of patients with vertebral fractures were significantly lower than those of patients without vertebral fractures (69 mg/ml vs. 85 mg/ml; p<0.05). Using ROC analysis to differentiate patients with and without vertebral fractures, AUC=0.72 was obtained for converted BMD values (p<0.05). Short- and long-term reproducibility errors for BMD measurements in the sagittal reformations amounted 2.09% and 7.70%, respectively.

CONCLUSION

BMD measurements of the spine could be computed in sagittal reformations of routine abdominal contrast-enhanced MDCT with minimal technical and time effort. Using the conversion equation, the acquired BMD data could differentiate patients with and without osteoporotic vertebral fractures.

Disruption of androgen and estrogen receptor activity in prostate cancer by a novel dietary diterpene carnosol: implications for chemoprevention

Emerging data are suggesting that estrogens, in addition to androgens, may also be contributing to the development of prostate cancer (PCa). In view of this notion, agents that target estrogens, in addition to androgens, may be a novel approach for PCa chemoprevention and treatment. Thus, the identification and development of nontoxic dietary agents capable of disrupting androgen receptor (AR) in addition to estrogen receptor (ER) could be extremely useful in the management of PCa. Through molecular modeling, we found that carnosol, a dietary diterpene, fits within the ligand-binding domain of both AR and ER-alpha. Using a time-resolved fluorescence resonance energy transfer assay, we found that carnosol interacts with both AR and ER-alpha and additional experiments confirmed that it functions as a receptor antagonist with no agonist effects. LNCaP, 22Rv1, and MCF7 cells treated with carnosol (20-40 mumol/L) showed decreased protein expression of AR and ER-alpha. Oral administration of carnosol at 30 mg/kg 5 days weekly for 28 days to 22Rv1 PCa xenografted mice suppressed tumor growth by 36% (P = 0.028) and was associated with a decrease in serum prostate-specific antigen by 26% (P = 0.0042). These properties make carnosol unique to any known antiandrogen or antiestrogen investigated thus far for the simultaneous disruption of AR and ER-alpha. We suggest that carnosol may be developed or chemically modified through more rigorous structure-activity relationship studies for a new class of investigational agents-a dual AR/ER modulator.

Older men's knowledge of osteoporosis and the prevalence of risk factors

It has been estimated that up to 45% of men in the United States have low bone density. Yet, only a few studies have examined men's knowledge of bone health and disease. Men's knowledge of sex-specific issues related to osteoporosis is especially not well understood. We surveyed 1535 community-dwelling men with a mean age of 79 yr. The assessed risk factors included a current diagnosis of low bone mass, positive history for fracture, recent level of physical activity, and current medications with the potential to affect bone health. Knowledge about male risk factors for osteoporosis was also assessed, including the effects of advancing age, frame size, fracture risk, calcium and Vitamin D supplementation, low testosterone level, and treatment for prostate cancer. Within this sample, only 11% of the men reported a current diagnosis of low bone mass, whereas 11% reported a prior hip fracture. Only 5% of the sample reported taking some type of Food and Drug Administration-approved medication for osteoporosis. In the aggregate, the participating men answered only 39% of the 6 male osteoporosis-knowledge questions correctly. It is imperative that bone health promotion campaigns that have educated many women effectively now expand their focus to advance the bone health of men also.

Clinical efficacy and safety of zoledronic acid in prostate and breast cancer

The anti-estrogen treatment for hormone-sensitive breast cancer and the androgen deprivation therapy for prostate cancer can lead to the development of osteoporosis and bone fractures. Metastases associated with prostate and breast cancer can also occur in bone. Bisphosphonates are used in these types of bone dysfunction. Zoledronic acid is the most potent bisphosphonate. In osteoporosis, zoledronic acid inhibits bone reabsorption and increases bone mineral density for at least a year after intravenous administration. The efficacy and safety of zoledronic acid in osteoporosis secondary to hormone-sensitive cancers (prostate and breast), and in the bone metastases associated with these cancers are reviewed.

Good clinical endpoints with denosumab in osteoporosis and cancer

BACKGROUND

Bone loss associated with low oestrogen levels in postmenopausal women, and with androgen deprivation therapy in men with hormone-sensitive prostate cancer, result in an increased incidence of fractures. Denosumab has been shown to increase bone mineral density in these two conditions.

OBJECTIVES/METHODS

The objective of this evaluation is to review the clinical trials that have studied clinical endpoints in these conditions.

RESULTS

FREEDOM (Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months) was an International Phase III clinical trial that measured the clinical endpoints with denosumab in postmenopausal women with osteoporosis. At 36 months, new vertebral fractures had occurred in 7.2% of subjects in the placebo group and this was lowered to 2.3% of subjects treated with denosumab. HALT (Denosumab Hormone Ablation Bone Loss Trial) studied the clinical endpoints in men with non-metastatic prostate cancer receiving androgen-deprivation therapy. The incidence of vertebral fractures was significantly lower in the denosumab group (1.5%) than in the placebo group (3.9%). The incidence of adverse effects with denosumab in both clinical trials was low.

CONCLUSIONS

Denosumab reduces the incidence of fractures in postmenopausal women with osteoporosis and in men with non-metastatic prostate cancer receiving androgen-deprivation therapy. Denosumab is well tolerated.

Can dutasteride delay or prevent the progression of prostate cancer in patients with biochemical failure after radical therapy? Rationale and design of the Avodart after Radical Therapy for Prostate Cancer Study

OBJECTIVE

To describe the Avodart after Radical Therapy for prostate cancer Study (ARTS), investigating the use of dutasteride (a dual 5alpha-reductase inhibitor that suppresses intraprostatic dihydrotestosterone, reduces tumour volume and improves other markers of tumour regression in prostate cancer) to prevent or delay disease progression in patients with biochemical recurrence after therapy with curative intent.

PATIENTS AND METHODS

An increasing serum prostate-specific antigen (PSA) level after radical prostatectomy (RP) or radiotherapy (RT) is indicative of recurrent prostate cancer and typically pre-dates clinically detectable metastatic disease by several years. ARTS is an ongoing European multicentre trial in which patients are stratified by previous therapy (RP with or without salvage RT vs primary RT) and randomized to double-blind treatment with dutasteride 0.5 mg or placebo once daily for 2 years. Eligible patients will have a PSA doubling time (DT) of 3-24 months. Biochemical recurrence is defined as three increases in PSA level from the nadir, with each increase > or =4 weeks apart and each PSA level > or =0.2 ng/mL, and a final PSA level of > or =0.4 ng/mL (after RP) or > or =2 ng/mL (after primary RT). Study endpoints include time to PSA doubling, time to disease progression, treatment response (PSA decrease or an increase of < or =15% from baseline), changes in PSA and PSADT, and changes in anxiety (Memorial Anxiety Scale for Prostate Cancer). CONCLUSIONS ARTS: will be the first study to evaluate the effects of dutasteride on PSADT, disease progression and treatment response in patients with biochemical failure after RP or RT, and should help to elucidate the potential role of dual 5alpha-reductase inhibition in prostate cancer.

Cancer therapy and osteoporosis: approach to evaluation and management

The incidences of osteoporosis and cancer increase with age, and these two diagnoses are often made in the same individual. Both increasing age and hypogonadism associated with aging, as well as cancer therapies, can lead to loss of bone mass and increased risk for fragility fractures. Advancing age carries an association with increased incidence of cancers. Thus, cancer and its therapies may predispose an individual to osteoporosis and its associated morbidity and mortality. Prevention of bone loss and its consequent fractures is critical in the care of aging patients. This article reviews the mechanisms of bone metabolism and the principles of management of bone health in the older population with a history of cancer.

Vertebral Fracture Assessment: the 2007 ISCD Official Positions

Vertebral fracture assessment (VFA) is an established, low radiation method for detection of prevalent vertebral fractures. Vertebral fractures are usually not recognized clinically at the time of their occurrence, but their presence indicates a substantial risk for subsequent fractures independent of bone mineral density. Significant evidence supporting VFA use for many post-menopausal women and older men has accumulated since the last ISCD Official Position Statement on VFA was published. The International Society for Clinical Densitometry considered the following issues at the 2007 Position Development Conference: (1) What are appropriate indications for Vertebral Fracture Assessment; (2) What is the most appropriate method of vertebral fracture detection with VFA; (3) What is the sensitivity and specificity for detection of vertebral fractures with this method; (4) When should additional spine imaging be performed following a VFA; and (5) What are the reporting obligations for those interpreting VFA images?

Some musculo-skeletal sequelae in cancer survivors

This paper deals with some of the musculo-skeletal complication that can occur after cancer treatment. In particular, we focus on Cancer Treatment Induced Bone Loss (CTIBL) and the musculo-skeletal complications that can occur in patients treated for extremity sarcoma. In addition we discuss peripheral neuropathy, musculo-skeletal pain and briefly mention some of the complications related to radiotherapy. CTIBL is mostly studied in breast cancer and prostate cancer survivors. The cause in these groups is mainly due to treatment induced hypogonadism. Other causes of CTIBL are indirect or direct cause of chemotherapy, physical inactivity and inadequate intake of vitamin D and calcium. Treatment of CTIBL consists of diet and lifestyle changes and pharmacological intervention. Extremity bone sarcomas constitute a special group since they often experience mutilating surgery and heavy combination chemotherapy. The treatment results in worse function than the normal population and the amputated usually have lower physical functioning than patients treated with limb sparing surgery (LSS). However, most studies fail to show differences in quality of life between the amputated and LSS. Most of the studies performed on musculo-skeletal sequelae have been done on survivors of childhood cancer, breast cancer or prostate cancer. More studies among the other cancer groups are needed to reveal the extent and prevalence of these complications.

Once-yearly zoledronic acid in the prevention of osteoporotic bone fractures in postmenopausal women

Zoledronic acid is a nitrogen-containing, third-generation bisphosphonate that has recently been approved for the treatment of postmenopausal osteoporosis as an annual intravenous infusion. Zoledronic acid is an antiresorptive agent which has a high affinity for mineralized bone and especially for sites of high bone turnover. Zoledronic acid is excreted by the kidney without further metabolism. Zoledronic acid administered as a 5 mg intravenous infusion annually increases bone mineral density in the lumbar spine and femoral neck by 6.7% and 5.1% respectively and reduces the incidence of new vertebral and hip fractures by 70% and 41% respectively in postmenopausal women with osteoporosis. Most common side effects are post-dose fever, flu-like symptoms, myalgia, arthralgia, and headache which usually occur in the first 3 days after infusion and are self-limited. Rare adverse effects include renal dysfunction, hypocalcemia, atrial fibrillation, and osteonecrosis of the jaw.

A prospective, multicenter, open-label trial of zoledronic acid in patients with hormone refractory prostate cancer

PURPOSE

The short-term safety and efficacy of zoledronic acid for the treatment of skeletal metastasis was evaluated in patients with hormone-refractory prostate cancer.

PATIENTS AND METHODS

A total of 19 hormone-refractory prostate cancer patients with bone metastases were enrolled. All patients received up to six infusions of zoledronic acid (4 mg, given intravenously over 15 minutes, every 3-4 weeks). Safety was assessed by monitoring adverse events and serum creatinine levels. Efficacy was assessed by monitoring skeletal-related events, brief pain inventory score, quality of life score, type of pain medication, and analgesic score. Mean age of patients was 67.3 years (46-86 years), mean time from diagnosis of bone metastases was 27.6 months (0-117 months), and mean time from diagnosis of hormone-refractory disease was 7.5 months (0-26 months).

RESULTS

There was no clinically significant change in serum creatinine levels. Eleven adverse events (musculoskeletal disorders and systemic disorders) in 8 patients were classed as having a possible relationship to study drug. Fifteen patients completed six courses of zoledronic acid infusion. There were no significant changes in the brief pain inventory composite scores, quality of life questionnaire scores or analgesic score. No new skeletal-related events developed during the treatment period.

CONCLUSION

Zoledronic acid administered in this study as a 15-minute infusion demonstrated an acceptable and well-known safety profile in patients with refractory prostate cancer with bone metastases. However, prospective placebo- controlled clinical trials are required to elucidate the efficacy of zoledronic acid.

Testosterone therapy in the aging male

The decline, with aging, in serum concentrations of biologically active forms of testosterone in men is an indisputable fact and some men will eventually develop symptoms of late-onset hypogonadism (LOH) with its clinical consequences. LOH reduces quality of life and may pose important risk factors for frailty, changes in body composition, cardiovascular disease, sexual dysfunction and osteoporosis. Testosterone supplementation in cases of LOH will restore serum testosterone levels into the physiologic range; will restore metabolic parameters to the eugonadal state, increase muscle mass, strength, and function; maintaine or improve BMD reducing fracture risk; will improve neuropsychological function (cognition and mood); libido and sexual functioning; and enhance quality of life. The ultimate goals, however, are to maintain or regain a high quality of life, to reduce disability, to compress major illnesses into a narrow age range and to add life to years. To achieve these goals men must also adjust their lifestyle to optimize dietary habits, as well as to exercise and to abstain from smoking life-long. Monitoring these patients is a shared responsibility that cannot be taken lightly. The physician must emphasize to the patient the need for periodic evaluations and the patient must agree to comply with these requirements. The physician's evaluation should include an assessment of the clinical response and monitoring must be tailored to the indications and individual needs of the patient.

Prävention der Osteoporose – wichtig für den Urologen?

Osteoporosis is a systemic disease of the bones with increasing incidence in the elderly. Over the age of 50 years bone mineral density continuously decreases resulting in osteoporotic fracture. Osteoporosis is positively correlated with late-onset hypogonadism and increases under androgen deprivation therapy. The evaluation of osteoporosis should be done in cooperation with an endocrinologist. Measurement of bone mineral density is recommended before starting androgen deprivation therapy. Patients with fracture and/or decreased bone mineral density 2.5 or more standard deviations below normal peak bone mass of young men should be treated. The appropriate treatment is calcium and vitamin D substitution combined with oral or i.v. administration of bisphosphonates.