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Monostotic Fibrous Dysplasia of the Mandible in a 9-Year-Old Male Patient Treated with a Conservative Surgical Treatment: A Case Report and 15-Year Follow-Up. Case Rep Dent 2021; 2021:9963478. [PMID: 34007492 PMCID: PMC8110395 DOI: 10.1155/2021/9963478] [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: 03/10/2021] [Accepted: 04/27/2021] [Indexed: 11/17/2022] Open
Abstract
Fibrous dysplasia is a developmental disorder of the bone that originates from a genetic defect disturbing the osteogenesis leading to the replacement of normal bone with the excess proliferation of fibrous tissue. It can be associated with hyperpigmentation of the skin and endocrine disorders. Fibrous dysplasia can manifest in a monostotic form affecting one bone or in a polyostotic form involving several bones. Approximately 30% of monostotic forms are observed in the maxilla and the mandible. It frequently appears in the posterior region and is usually unilateral. It is found in teenagers and could become static after adulthood. Patients can present with swelling, facial asymmetry, pain, or numbness on the affected side. Treatment modalities vary between conservative surgical treatment, radical surgical approach, and medical treatment based on bisphosphonates. Here, we present a case of a monostotic form of fibrous dysplasia affecting the posterior left region of the mandible in a 9-year-old male complaining of gradually increased swelling on the left mandibular side of one-year duration. The diagnosis of fibrous dysplasia is established based on clinical, radiographical, and histopathological features. Conservative surgery is implemented with surgical shaving and reencountering of the bone excess to reduce the facial asymmetry. Recurrence is reported 10 years later and is also treated with a localized osteoplasty and remodeling of the bone contours. Five years later, the lesion remains stable. In conclusion, a conservative approach should be adopted as the first line of treatment for young patients suffering from monostotic fibrous dysplasia.
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Boyce AM, Collins MT. Fibrous Dysplasia/McCune-Albright Syndrome: A Rare, Mosaic Disease of Gα s Activation. Endocr Rev 2020; 41:5610851. [PMID: 31673695 PMCID: PMC7127130 DOI: 10.1210/endrev/bnz011] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022]
Abstract
Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare disorder of striking complexity. It arises from somatic, gain-of-function mutations in GNAS, leading to mosaic Gα s activation and inappropriate production of intracellular cyclic adenosine monophosphate (cAMP). The clinical phenotype is largely determined by the location and extent of affected tissues, and the pathophysiological effects of Gα s activation within these tissues. In bone, Gα s activation results in impaired differentiation of skeletal stem cells, leading to discrete skeletal lesions prone to fracture, deformity, and pain. Extraskeletal manifestations include a variable combination of hyperpigmented macules and hyperfunctioning endocrinopathies. Distinctive age-related changes in disease development has key effects on histologic, radiographic, and clinical features. FD/MAS thus presents along a uniquely broad clinical spectrum, and the resulting challenges in diagnosis and management can be difficult for clinicians. This review presents FD/MAS in the context of a mosaic disorder of Gα s activation, providing an intellectual framework within which to understand, evaluate, and treat this interesting disease. It includes a comprehensive summary of current understanding of FD/MAS pathogenesis, and a detailed discussion of clinical presentation and management. Critical areas of unmet need are highlighted, including discussion of key challenges and potential solutions to advance research and clinical care in FD/MAS.
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Affiliation(s)
- Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
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RANKL/RANK/OPG Pathway: A Mechanism Involved in Exercise-Induced Bone Remodeling. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6910312. [PMID: 32149122 PMCID: PMC7053481 DOI: 10.1155/2020/6910312] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 01/06/2020] [Indexed: 12/21/2022]
Abstract
Bones as an alive organ consist of about 70% mineral and 30% organic component. About 200 million people are suffering from osteopenia and osteoporosis around the world. There are multiple ways of protecting bone from endogenous and exogenous risk factors. Planned physical activity is another useful way for protecting bone health. It has been investigated that arranged exercise would effectively regulate bone metabolism. Until now, a number of systems have discovered how exercise could help bone health. Previous studies reported different mechanisms of the effect of exercise on bone health by modulation of bone remodeling. However, the regulation of RANKL/RANK/OPG pathway in exercise and physical performance as one of the most important remodeling systems is not considered comprehensive in previous evidence. Therefore, the aim of this review is to clarify exercise influence on bone modeling and remodeling, with a concentration on its role in regulating RANKL/RANK/OPG pathway.
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Tripathy SK, Swaroop S, Velagada S, Priyadarshini D, Das RR, Satpathy AK, Agrawal K. Response to Zoledronic Acid Infusion in Children With Fibrous Dysplasia. Front Pediatr 2020; 8:582316. [PMID: 33330278 PMCID: PMC7732464 DOI: 10.3389/fped.2020.582316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/02/2020] [Indexed: 02/05/2023] Open
Abstract
Objective: This retrospective study evaluated the outcome and safety of long-term treatment with zoledronic acid, in both polyostotic and mono-ostotic fibrous dysplasia (FD) of children. Methods: The case records of children and adolescents with symptomatic FD who received zoledronic acid (0.1 mg/kg IV infusion over 1 h) and have completed at least 2 years follow-up were analyzed. The relevant details were recorded in a predesigned chart. Clinical assessment [pain assessment by visual analog scale (VAS) and incidence of new fracture], radiological changes (cortical thickening, ossification, and decrease in the diameter of the osteolytic lesions) and biochemical parameters [alkaline phosphatase (ALP)] were used to evaluate the improvement. Results: The mean age of presentation was 9.1 years, with four males and six females. All patients had symptomatic FD in the lower limb with complaints of pain, tenderness, swelling, or deformity. Four children had associated pathological fracture. The radiological evaluation with bone scan revealed polyostotic involvement in eight patients and mono-ostotic involvement in two patients. Three patients had associated systemic features like café-au-lait spots or precocious puberty. The fracture united within 3 months and the radiological improvement was evident in the form of filling of the osteolytic defect. The pain score in six patients showed significant improvement (VAS < 3). The ALP level decreased to 544.12 ± 47.35 IU/L from an initial value of 895.75 ± 79.64 IU/L (p = 0.04) at 12 months. One patient had symptomatic hypocalcaemia after zoledronic acid infusion. Conclusion: The clinical and radiological response of zoledronic acid treatment in FD of children is promising. Further randomized control trials with a larger sample size are required to establish this drug as a first-line medical treatment in FD.
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Rotman M, Hamdy NAT, Appelman-Dijkstra NM. Clinical and translational pharmacological aspects of the management of fibrous dysplasia of bone. Br J Clin Pharmacol 2018; 85:1169-1179. [PMID: 30471134 PMCID: PMC6533424 DOI: 10.1111/bcp.13820] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 11/08/2018] [Accepted: 11/10/2018] [Indexed: 12/11/2022] Open
Abstract
Fibrous dysplasia (FD) is a genetic, noninheritable rare bone disease caused by a postzygotic activating mutation of the α subunit of the stimulatory G‐protein causing increased abnormal bone formation leading to pain, deformity and fractures. To date, no cure has been identified for FD/McCune–Albright syndrome (MAS) and treatment is symptomatic and aimed at decreasing pain and/or local bone turnover. Various drugs have been used to achieve clinical improvement in FD/MAS patients including bisphosphonates and denosumab, however further translational studies are also warranted to address unresolved pathophysiological issues and explore novel pharmacological targets for the management of FD/MAS. In this article, we review literature on the medical treatment of FD/MAS, discuss the unresolved pathophysiological issues and explore novel pharmacological targets for the management of FD/MAS.
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Affiliation(s)
- Marlous Rotman
- Department of Medicine, Division of Endocrinology & Centre for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - Neveen Agnes Therese Hamdy
- Department of Medicine, Division of Endocrinology & Centre for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - Natasha M Appelman-Dijkstra
- Department of Medicine, Division of Endocrinology & Centre for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
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de Azambuja Carvalho PH, Torriani MA, Post LK, Chagas OL. Surgical Treatment of Fibroosseous Lesion in Young Patient with Reduced Mouth Opening. Craniomaxillofac Trauma Reconstr 2018; 11:314-319. [PMID: 30574276 PMCID: PMC6224290 DOI: 10.1055/s-0037-1608697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 07/27/2017] [Indexed: 10/18/2022] Open
Abstract
Fibrous dysplasia is a benign fibroosseous disorder that can affect the maxillary bones, causing aesthetic deformity and functional impairment. This article reports the case of a 13-year-old male patient at the time of diagnosis. The patient showed increased facial volume with relevant asymmetry, having reported the onset of the condition 12 months before. Upon examination, the patient presented an 8-mm mouth opening and an acute inflammatory process associated with tooth 37 pericoronal hood. Upon imaging exam, exuberant bone growth in the left mandibular ramus area of ground glass aspect was observed. After incisional biopsy, fibrous dysplasia was diagnosed and sequentially treated with osteoplasty and coronoid process removal. The patient evolved to a 43-mm mouth opening and favorable aesthetics without recurrence in a 3-year follow-up period. In this case, coronoidectomy and bone plasty proved to be effective, returning aesthetics and function. The patient is supposed to be followed up in the long term.
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Affiliation(s)
- Pedro Henrique de Azambuja Carvalho
- Department of Diagnosis and Oral and Maxillofacial Surgery, Faculdade de Odontologia Campus de Araraquara, Universidade Estadual Paulista Julio de Mesquita Filho, Araraquara, Brazil
| | - Marcos Antonio Torriani
- Department of Oral and Maxillofacial Surgery and Maxillofacial Prosthodontics, Faculty of Dentistry, Federal University of Pelotas, Pelotas, Brazil
| | - Letícia Kirst Post
- Department of Oral and Maxillofacial Surgery and Maxillofacial Prosthodontics, Faculty of Dentistry, Federal University of Pelotas, Pelotas, Brazil
| | - Otacílio Luiz Chagas
- Department of Oral and Maxillofacial Surgery and Maxillofacial Prosthodontics, Faculty of Dentistry, Federal University of Pelotas, Pelotas, Brazil
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Abstract
Fibrous dysplasia (FD) is a rare bony disorder in which normal bone is replaced by abnormal fibro-osseous tissue. It often involves the long bones, craniofacial bones, ribs, and pelvis. Approximately 30% of monostotic FD (MFD) lesions are found in the cranial or facial bones. In general, FD is found in teenagers, and it usually becomes static after adulthood. FD involves the maxilla almost two times more often than the mandible. It frequently appears in the posterior region of the jaw bone and is usually unilateral. Here, we present an unusual case of symptomatic MFD affecting the anterior region of the mandible in a 43-year-old female with the clinical, radiographical, and histopathological features. The clinical examination showed both the labial and lingual bone expansion in the anterior mandible. The radiographic examination revealed a lesion with both radiopaque and radiolucent features showing a “ground-glass” appearance. The diagnosis was obtained after confirmatory intrabony biopsy with the histopathological examination, and it was diagnosed with benign FD. The patient preferred regular follow-up of MFD after discussion. During the regular follow-up, MFD lesion showed no obvious signs of progression or malignancy features.
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Affiliation(s)
- Hsien-Yi Yang
- Department of Dentistry, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Bor-Cherng Su
- Department of Pathology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ming-Jay Hwang
- Department of Pathology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yi-Pang Lee
- Department of Dentistry, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Department of Health Administration, Tzu Chi University of Science and Technology, Hualien, Taiwan
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8
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Corsi A, Ippolito E, Robey PG, Riminucci M, Boyde A. Bisphosphonate-induced zebra lines in fibrous dysplasia of bone: histo-radiographic correlation in a case of McCune-Albright syndrome. Skeletal Radiol 2017; 46:1435-1439. [PMID: 28660402 PMCID: PMC5709201 DOI: 10.1007/s00256-017-2698-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/30/2017] [Accepted: 06/07/2017] [Indexed: 02/02/2023]
Abstract
Bisphosphonates (BPs) are currently used in the treatment of diverse bone diseases including fibrous dysplasia of bone (FD). In pediatric patients, a radiographic consequence of cyclical administration of BPs is the development of apo-, epi-, and meta-physeal sclerotic bands, otherwise known as zebra lines, which result from the temporary inhibition of osteoclastic activity at the time of drug treatment. We report here on a child with McCune-Albright syndrome (FD in addition to hyperfunctioning endocrinopathies and skin hyperpigmentation) treated with cyclical intravenous infusions of pamidronate in which conventional radiography, contact microradiography, histology, and backscattered electron image analysis demonstrated that zebra lines formed only where bone was normal, were arrested at the boundary between FD-unaffected and FD-affected bone where bone is sclerotic, and were absent within the undermineralized FD bone. Moreover, in spite of the treatment, the FD lesions continued to expand. This case report is unique because no previously published studies correlated the radiographic and the histologic features of BP-induced zebra lines in the metaphysis of an FD-affected long bone of the limbs.
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Affiliation(s)
- Alessandro Corsi
- Department of Molecular Medicine, Sapienza University, Policlinico Umberto I, Viale Regina 324, 00161, Rome, Italy.
| | - Ernesto Ippolito
- Department of Orthopaedic Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Pamela G Robey
- Skeletal Biology Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Mara Riminucci
- Department of Molecular Medicine, Sapienza University, Policlinico Umberto I, Viale Regina 324, 00161, Rome, Italy.
| | - Alan Boyde
- Dental Physical Sciences, Queen Mary University of London, London, E1 4NS, UK
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Wójcik S, Koszowski R, Drozdowska B, Śmieszek-Wilczewska J, Raczkowska-Siostrzonek A. Maxillary fibrous dysplasia associated with McCune-Albright syndrome. A case study. Open Med (Wars) 2017; 11:465-470. [PMID: 28352837 PMCID: PMC5329869 DOI: 10.1515/med-2016-0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 08/08/2016] [Indexed: 11/25/2022] Open
Abstract
McCune Albright syndrome (MCA) is a rare complication of genetic origin. The authors present a case study of a patient with MCA diagnosed with multifocal fibrous dysplasia in his limb and craniofacial bones. The symptoms of the disease in the patient’s facial and oral tissue and the treatment administered have been described.
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Affiliation(s)
- Sylwia Wójcik
- Chair of Dental Surgery, Department of Cranio-Maxillofacial Surgery and Oral Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Rafał Koszowski
- Chair of Dental Surgery, Department of Cranio-Maxillofacial Surgery and Oral Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Bogna Drozdowska
- Chair of Pathomorphology, Medical University of Silesia in Katowice, Poland
| | - Joanna Śmieszek-Wilczewska
- Chair of Dental Surgery, Department of Cranio-Maxillofacial Surgery and Oral Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Agnieszka Raczkowska-Siostrzonek
- Chair of Dental Surgery, Department of Cranio-Maxillofacial Surgery and Oral Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland
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Boyce AM, Kelly MH, Brillante BA, Kushner H, Wientroub S, Riminucci M, Bianco P, Robey PG, Collins MT. A randomized, double blind, placebo-controlled trial of alendronate treatment for fibrous dysplasia of bone. J Clin Endocrinol Metab 2014; 99:4133-40. [PMID: 25033066 PMCID: PMC4223439 DOI: 10.1210/jc.2014-1371] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Fibrous dysplasia (FD) is a rare skeletal disorder, resulting in deformity, fracture, functional impairment, and pain. Bisphosphonates have been advocated as a potential treatment. OBJECTIVE To determine the efficacy of alendronate for treatment of FD. DESIGN Two-year randomized, double-blind, placebo-controlled trial. SETTING Clinical research center. PATIENTS Forty subjects with polyostotic FD (24 adults, 16 children). Subjects were randomized and stratified by age. INTERVENTIONS Study drug was administered over a 24 month period in 6 month cycles (6 months on, 6 months off). Alendronate dosing was stratified: 40 mg daily for subjects >50 kg, 20 mg for 30-50 kg, 10 mg for 20-30 kg. MAIN OUTCOME MEASURES Primary endpoints were bone turnover markers, including serum osteocalcin, and urinary NTX-telopeptides. Secondary endpoints included areal bone mineral density (aBMD), pain, skeletal disease burden score, and functional parameters including the 9-min walk test and manual muscle testing. RESULTS Clinical data was collected on 35 subjects who completed the study. There was a decline in NTX-telopeptides in the alendronate group (P = .006), but no significant difference in osteocalcin between groups. The alendronate group had an increase in areal BMD in normal bone at the lumbar spine (P = .006), and in predetermined regions of FD (P < .001). There were no significant differences in pain scores, skeletal disease burden scores, or functional parameters between the groups. CONCLUSIONS Alendronate treatment led to a reduction in the bone resorption marker NTX-telopeptides, and improvement in aBMD, but no significant effect on serum osteocalcin, pain, or functional parameters.
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Affiliation(s)
- Alison M Boyce
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch (A.M.B., M.H.K., B.A.B., P.G.R., M.T.C.), National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892; Division of Endocrinology and Diabetes (A.M.B.), Children's National Health System, Washington, DC 20010; Bone Health Program, Division of Orthopaedics and Sports Medicine (A.M.B.), Children's National Health System, Washington, DC 20010; BioMedical Computer Research Institute (H.K.), Philadelphia, Pennsylvania 19115; Department of Pediatric Orthopedics (S.W.), Dana Children's Hospital, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel 64239; Department of Molecular Medicine (M.R., P.B.), La Sapienza Universita di Roma, Rome, Italy 00185
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Abstract
Osteogenesis and bone remodeling are complex biological processes that are essential for the formation of new bone tissue and its correct functioning. When the balance between bone resorption and formation is disrupted, bone diseases and disorders such as Paget's disease, fibrous dysplasia, osteoporosis and fragility fractures may result. Recent advances in bone cell biology have revealed new specific targets for the treatment of bone loss that are based on the inhibition of bone resorption by osteoclasts or the stimulation of bone formation by osteoblasts. Bisphosphonates, antiresorptive agents that reduce bone resorption, are usually recommended as first-line therapy in women with postmenopausal osteoporosis. Numerous studies have shown that bisphosphonates are able to significantly reduce the risk of femoral and vertebral fractures. Other antiresorptive agents indicated for the treatment of osteoporosis include selective estrogen receptor modulators, such as raloxifene. Denosumab, a human monoclonal antibody, is another antiresorptive agent that has been approved in Europe and the USA. This agent blocks the RANK/RANKL/OPG system, which is responsible for osteoclastic activation, thus reducing bone resorption. Other approved agents include bone anabolic agents, such as teriparatide, a recombinant parathyroid hormone that improves bone microarchitecture and strength, and strontium ranelate, considered to be a dual-action drug that acts by both osteoclastic inhibition and osteoblastic stimulation. Currently, anti-catabolic drugs that act through the Wnt-β catenin signaling pathway, serving as Dickkopf-related protein 1 inhibitors and sclerostin antagonists, are also in development. This concise review provides an overview of the drugs most commonly used for the control of osteogenesis in bone diseases.
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Parisi MS, Oliveri B. Long-term pamidronate treatment of polyostotic fibrous dysplasia of bone: A case series in young adults. Curr Ther Res Clin Exp 2014; 70:161-72. [PMID: 24683227 DOI: 10.1016/j.curtheres.2009.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2008] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Limited information is available about long-term pamidronate treatment in adults with fibrous dysplasia (FD) of bone. OBJECTIVE The aim of this case series was to report the clinical outcomes and the biochemical and densitometric findings in a group of young adult patients with polyostotic FD treated for ≥3 years with IV pamidronate. METHODS Pamidronate was administered every 6 months (60 mg/d for 3 days) for 2 years. Thereafter, treatment was individualized. Pamidronate was administered at shorter or longer intervals based on response. Bone pain, radiography, serum bone alkaline phosphatase (BALP) activity, and urinary C-terminal cross-linking telopep-tide of type I collagen (CTX-I) concentration were assessed for a mean of 7 years. Bone mineral density (BMD) of FD areas (FDas) and contralateral areas (CLas) were measured at baseline and at 12 and 24 months. Data were collected prospectively. RESULTS Seven patients (5 women, 2 men; mean [SD] age, 31.0 [7.2] years [range, 22-43 years]) were included in the study. Patients received IV pamidronate for a mean of 6.9 years (median, 7.1 years [range, 3.7-10.9 years]). Pamidronate was associated with a reduction in bone pain and a significant reduction in BALP in all patients at the end of follow-up (P < 0.02). The mean reduction from baseline in CTX-I concentration (measured in 3 patients) was 56%; this difference was not significant. Mean BMD values of FDas were significantly increased at 12 months (by 5.9%; P < 0.05) compared with baseline; but was not significantly increased at 24 months (7.3%), probably reflecting a higher dispersion of values due to individual responses to treatment. No significant changes were observed in CLa BMDs. Mean BMD of FDa had a numerically lower decrease of 15.3% compared with CLa at baseline; these decreases with pamidronate were 10.8% at 12 months (P = NS) and 9.3% at 24 months (P < 0.05). Refilling of osteolytic lesions was not observed. CONCLUSIONS These patients with FD of bone treated with IV pamidronate long term had improvement in bone pain and BMD. The effectiveness of individualized pamidronate administration in the long-term treatment of FD in adult patients should be investigated in blinded controlled trials.
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Affiliation(s)
- Muriel S Parisi
- Metabolic Bone Disease Section, University of Buenos Aires Hospital, Buenos Aires, Argentina
| | - Beatriz Oliveri
- Metabolic Bone Disease Section, University of Buenos Aires Hospital, Buenos Aires, Argentina
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13
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Gou W, Wang X, Peng J, Lu Q, Wang Y, Wang A, Guo Q, Gao X, Xu W, Lu S. Controlled delivery of zoledronate improved bone formation locally in vivo. PLoS One 2014; 9:e91317. [PMID: 24618585 PMCID: PMC3950209 DOI: 10.1371/journal.pone.0091317] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 02/10/2014] [Indexed: 12/18/2022] Open
Abstract
Bisphosphonates (BPs) have been widely used in clinical treatment of bone diseases with increased bone resorption because of their strong affinity for bone and their inhibition of bone resorption. Recently, there has been growing interest in their improvement of bone formation. However, the effect of local controlled delivery of BPs is unclear. We used polylactide acid-glycolic acid copolymer (PLGA) as a drug carrier to deliver various doses of the bisphosphonate zoledronate (Zol) into the distal femur of 8-week-old Sprague-Dawley rats. After 6 weeks, samples were harvested and analyzed by micro-CT and histology. The average bone mineral density and mineralized bone volume fraction were higher with medium- and high-dose PLGA-Zol (30 and 300 µg Zol, respectively) than control and low-dose Zol (3 µg PLGA-Zol; p<0.05). Local controlled delivery of Zol decreased the numbers of osteoclast and increased the numbers of osteoblast. Moreover, local controlled delivery of medium- and high-dose Zol accelerated the expression of bone-formation markers. PLGA used as a drug carrier for controlled delivery of Zol may promote local bone formation.
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Affiliation(s)
- Wenlong Gou
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Xin Wang
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Jiang Peng
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
- * E-mail:
| | - Qiang Lu
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Yu Wang
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Aiyuan Wang
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Quanyi Guo
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Xupeng Gao
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Wenjing Xu
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
| | - Shibi Lu
- Instistute of Orthopaedics, Chinese PLA General Hospital, Haidian District, Beijing, P.R. China
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14
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Boyce AM, Tosi LL, Paul SM. Bisphosphonate treatment for children with disabling conditions. PM R 2013; 6:427-36. [PMID: 24368091 DOI: 10.1016/j.pmrj.2013.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 10/11/2013] [Accepted: 10/22/2013] [Indexed: 01/09/2023]
Abstract
Fractures are a frequent source of morbidity in children with disabling conditions. The assessment of bone density in this population is challenging, because densitometry is influenced by dynamic forces affecting the growing skeleton and may be further confounded by positioning difficulties and surgical hardware. First-line treatment for pediatric osteoporosis involves conservative measures, including optimizing the management of underlying conditions, maintaining appropriate calcium and vitamin D intake, encouraging weight-bearing physical activity, and monitoring measurements of bone mineral density. Bisphosphonates are a class of medications that increase bone mineral density by inhibiting bone resorption. Although bisphosphonates are commonly prescribed for treatment of adult osteoporosis, their use in pediatric patients is controversial because of the lack of long-term safety and efficacy data.
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Affiliation(s)
- Alison M Boyce
- Division of Endocrinology and Diabetes, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010; and Bone Health Program, Division of Orthopaedics and Sports Medicine, Children's National Medical Center, Washington, DC(∗).
| | - Laura L Tosi
- Bone Health Program, Division of Orthopaedics and Sports Medicine, Children's National Medical Center, Washington, DC(†)
| | - Scott M Paul
- Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, National Institutes of Health, Bethesda, MD(‡)
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Gaski G, Hansen D, Willis LM, Bos GD, Kean JR. Intramedullary rod fixation of fibrous dysplasia without use of bisphosphonates. J Child Orthop 2013; 7:277-83. [PMID: 24432087 PMCID: PMC3799931 DOI: 10.1007/s11832-013-0522-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 08/12/2013] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Controversy exists regarding approach to treatment of pediatric patients with fibrous dysplasia. METHODS We retrospectively reviewed medical records of seven patients who were treated at our institution for fibrous dysplasia by intramedullary rod fixation without bisphosphonate supplementation. RESULTS Seven patients with a total of ten fibrous dysplasia lesion sites surgically treated by intramedullary rod fixation were included. Of these ten lesion sites, eight demonstrated pathologic fracture at the time of fixation. Complete fracture healing was observed in all eight sites, with no incidence of recurrent pathologic fractures examined radiographically. There were no major infections or neurologic deficits, and lesions appeared to stabilize. CONCLUSIONS In this series, intramedullary rod fixation proved to be successful in treatment of acute pathologic fracture and incompletely healed fibrous dysplasia lesions. We observed partial resolution of fibrous dysplasia lesions at all ten sites without significant long-term complications. Following treatment, there were no refractures. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Greg Gaski
- Nationwide Children’s Hospital, 700 Children’s Drive, A2630, Columbus, OH 43205-2696 USA
| | - Dane Hansen
- Nationwide Children’s Hospital, 700 Children’s Drive, A2630, Columbus, OH 43205-2696 USA
| | - Leisel M. Willis
- Nationwide Children’s Hospital, 700 Children’s Drive, A2630, Columbus, OH 43205-2696 USA
| | - Gary D. Bos
- Kittitas Valley Orthopedics, Ellensburg, WA USA
| | - John R. Kean
- Nationwide Children’s Hospital, 700 Children’s Drive, A2630, Columbus, OH 43205-2696 USA ,Department of Orthopaedics, The Ohio State University, Columbus, OH USA
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Sreeramalu SK, Sumalatha GB, Dodawad RR, Prabhu JP. Fibrodysplasia of maxilla: A difficult airway. Indian J Anaesth 2013; 57:300-2. [PMID: 23983294 PMCID: PMC3748690 DOI: 10.4103/0019-5049.115569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sunitha Kuruvadi Sreeramalu
- Department of Anaesthesiology, Vydehi Institute of Medical Sciences and Research, Whitefield, Bangalore, Karnataka, India
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Lamplot JD, Denduluri S, Qin J, Li R, Liu X, Zhang H, Chen X, Wang N, Pratt A, Shui W, Luo X, Nan G, Deng ZL, Luo J, Haydon RC, He TC, Luu HH. The Current and Future Therapies for Human Osteosarcoma. CURRENT CANCER THERAPY REVIEWS 2013; 9:55-77. [PMID: 26834515 PMCID: PMC4730918 DOI: 10.2174/1573394711309010006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Osteosarcoma (OS) is the most common non-hematologic malignant tumor of bone in adults and children. As sarcomas are more common in adolescents and young adults than most other forms of cancer, there are a significant number of years of life lost secondary to these malignancies. OS is associated with a poor prognosis secondary to a high grade at presentation, resistance to chemotherapy and a propensity to metastasize to the lungs. Current OS management involves both chemotherapy and surgery. The incorporation of cytotoxic chemotherapy into therapeutic regimens escalated cure rates from <20% to current levels of 65-75%. Furthermore, limb-salvage surgery is now offered to the majority of OS patients. Despite advances in chemotherapy and surgical techniques over the past three decades, there has been stagnation in patient survival outcome improvement, especially in patients with metastatic OS. Thus, there is a critical need to identify novel and directed therapy for OS. Several Phase I trials for sarcoma therapies currently ongoing or recently completed have shown objective responses in OS. Novel drug delivery mechanisms are currently under phase II and III clinical trials. Furthermore, there is an abundance of preclinical research which holds great promise in the development of future OS-directed therapeutics. Our continuously improving knowledge of the molecular and cell-signaling pathways involved in OS will translate into more effective therapies for OS and ultimately improved patient survival. The present review will provide an overview of current therapies, ongoing clinical trials and therapeutic targets under investigation for OS.
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Affiliation(s)
- Joseph D. Lamplot
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Sahitya Denduluri
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Jiaqiang Qin
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- Stem Cell Biology and Therapy Laboratory of the Key Laboratory for Pediatrics co-designated by Chinese Ministry of Education, The Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Ruidong Li
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Xing Liu
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- Stem Cell Biology and Therapy Laboratory of the Key Laboratory for Pediatrics co-designated by Chinese Ministry of Education, The Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Hongyu Zhang
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Xiang Chen
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- Department of Orthopaedic Surgery, The Affiliated Tangdu Hospital of the Fourth Military Medical University, Xi’an 710032, China
| | - Ning Wang
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- Department of Oncology, the Affiliated Southwest Hospital of the Third Military Medical University, Chongqing 400038, China
| | - Abdullah Pratt
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Wei Shui
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Xiaoji Luo
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Guoxin Nan
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- Stem Cell Biology and Therapy Laboratory of the Key Laboratory for Pediatrics co-designated by Chinese Ministry of Education, The Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Zhong-Liang Deng
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Jinyong Luo
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Rex C Haydon
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Tong-Chuan He
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
- Stem Cell Biology and Therapy Laboratory of the Key Laboratory for Pediatrics co-designated by Chinese Ministry of Education, The Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- The Affiliated Hospitals and the Key Laboratory of Diagnostic Medicine designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing 400016, China
| | - Hue H. Luu
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
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Chapurlat RD, Gensburger D, Jimenez-Andrade JM, Ghilardi JR, Kelly M, Mantyh P. Pathophysiology and medical treatment of pain in fibrous dysplasia of bone. Orphanet J Rare Dis 2012; 7 Suppl 1:S3. [PMID: 22640953 PMCID: PMC3359957 DOI: 10.1186/1750-1172-7-s1-s3] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
One of the most common complications of fibrous dysplasia of bone (FD) is bone pain. Usual pain killers are often of inadequate efficacy to control this bone pain. The mechanism of bone pain in FD remains uncertain, but by analogy with bone tumors one may consider that ectopic sprouting and formation of neuroma-like structures by sensory and sympathetic nerve fibers also occur in the dysplastic skeleton. Bone pain has been reported in up to 81% of adults and 49% of children. It affects predominantly the lower limbs and the spine. The degree of pain is highly variable and adults reports more pain than children. Bisphosphonates have been shown to reduce bone pain in uncontrolled studies. Their influence on bone strength remains unknown. In a randomized trial testing alendronate, bone pain was not significantly improved. Another trial assessing the effect of risedronate is ongoing. Possible future therapies include tocilizumab, denosumab and drugs targeting nerve growth factor and its receptor TrkA.
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Affiliation(s)
- Roland D Chapurlat
- INSERM UMR 1033, Université de Lyon, Hospices Civils de Lyon, Hôpital E Herriot, 69437 Lyon, France
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Maruotti N, Corrado A, Neve A, Cantatore FP. Bisphosphonates: effects on osteoblast. Eur J Clin Pharmacol 2012; 68:1013-8. [PMID: 22318756 DOI: 10.1007/s00228-012-1216-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 01/10/2012] [Indexed: 01/06/2023]
Abstract
PURPOSE Bisphosphonates are synthetic analogues of pyrophosphate usually used in treating bone disorders such as osteoporosis, Paget's disease, fibrous dysplasia, hypercalcemia of malignancy, and inflammation-related bone loss. Though therapeutic effects of bisphosphonates depend primarily on their inhibitory effect on osteoclasts, increasing attention is being given to other effector cells, such as osteoblasts. This review focuses on the presumed effect of bisphosphonates on osteoblasts. METHODS A review of the literature was conducted to evaluate the pharmacodynamic effects of bisphosphonates including inhibition of osteoclasts and apoptosis of osteocytes and osteoblasts as well as their potential stimulatory effects on the proliferation of osteoblasts. RESULTS Studies have demonstrated that bisphosphonates may stimulate proliferation of osteoblasts and inhibit apoptosis of osteocytes and osteoblasts. CONCLUSION Considering that osteoblasts may be involved in bone disorders, such as osteoporosis, osteopetrosis, osteogenesis imperfecta, and Paget's disease, and that bisphosphonates may stimulate proliferation of osteoblasts and inhibit apoptosis of osteocytes and osteoblasts, it is conceivable that a role for bisphosphonates exists in these diseases beyond merely the osteoclast influence.
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Affiliation(s)
- Nicola Maruotti
- Department of Rheumatology, University of Foggia Medical School, Foggia, Italy
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20
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Meyers PA, Healey JH, Chou AJ, Wexler LH, Merola PR, Morris CD, Laquaglia MP, Kellick MG, Abramson SJ, Gorlick R. Addition of pamidronate to chemotherapy for the treatment of osteosarcoma. Cancer 2010; 117:1736-44. [PMID: 21472721 DOI: 10.1002/cncr.25744] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 08/05/2010] [Accepted: 09/20/2010] [Indexed: 11/06/2022]
Abstract
BACKGROUND This study evaluated the safety and feasibility of the addition of pamidronate to chemotherapy for treatment of osteosarcoma. METHODS The authors treated 40 patients with osteosarcoma with cisplatin, doxorubicin, and methotrexate with the addition of pamidronate 2 mg/kg/dose (max dose 90 mg) monthly for 12 doses. Survival, event-free survival (EFS), and durability of orthopedic reconstruction were evaluated. RESULTS For patients with localized disease, event-free survival (EFS) at 5 years was 72% and overall survival 93%. For patients with metastatic disease, EFS at 5 years was 45% and overall survival 64%. Toxicity was similar to patients treated with chemotherapy alone. Thirteen of 14 uncemented implants demonstrated successful osteointegration. Among allograft reconstructions, there were 2 graft failures, 4 delayed unions, and 6 successful grafts. Overall, 5 of 33 reconstructions failed. There were no stress fractures or growth disturbances. CONCLUSIONS Pamidronate can be safely incorporated with chemotherapy for the treatment of osteosarcoma. It does not impair the efficacy of chemotherapy. Pamidronate may improve the durability of limb reconstruction.
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Affiliation(s)
- Paul A Meyers
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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21
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Kelly MH, Brillante B, Collins MT. Pain in fibrous dysplasia of bone: age-related changes and the anatomical distribution of skeletal lesions. Osteoporos Int 2008; 19:57-63. [PMID: 17622477 DOI: 10.1007/s00198-007-0425-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 05/10/2007] [Indexed: 01/01/2023]
Abstract
UNLABELLED To determine the prevalence, distribution, age-related changes and treatment of pain in fibrous dysplasia, we studied 78 children and adults. Pain was common, more prevalent and intense in adults, sometimes requiring narcotic analgesia. It was often untreated, especially in children, and surprisingly severity did not correlate with skeletal disease burden. INTRODUCTION Pain is common in fibrous dysplasia (FD), but relatively unstudied. We studied a well-characterized population of patients with a spectrum of disease. METHODS Thirty-five children (16 male, 19 female, mean age 11.4 (range 5-18)) and 43 adults (15 male, 28 female, 23-62 yrs, mean age 40.3 (range 23-62)) were studied. Bone scans were used to identify the location and extent of disease. The Brief Pain Inventory was used to determine severity. RESULTS Pain at sites of FD was common, reported by 67% of the population, but more prevalent and severe in the adult group than the children (81% and 49%, respectively p < 0.005, severity 4.1/10, and 2.8/10, respectively, p < 0.01). Surprisingly, there was no correlation between pain severity and skeletal disease burden. Children were more likely than adults to be untreated for pain (44% vs. 26%). CONCLUSIONS Pain, which was sometimes severe, was common in subjects with FD. It was often un- or under-treated, especially in children. The prevalence and severity of pain was greater in the adult group, but unrelated to the burden of FD.
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Affiliation(s)
- M H Kelly
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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22
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Leet AI, Collins MT. Current approach to fibrous dysplasia of bone and McCune-Albright syndrome. J Child Orthop 2007; 1:3-17. [PMID: 19308500 PMCID: PMC2656698 DOI: 10.1007/s11832-007-0006-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 12/22/2006] [Indexed: 02/07/2023] Open
Abstract
Fibrous dysplasia (FD) of bone is an uncommon disease caused by sporadic, congenital mutations in the cAMP regulating protein, G(s)alpha. It is an example of somatic mosaicism in which a wide spectrum of disease is possible. Widespread skeletal involvement is often associated with varying combinations of café-au-lait skin spots, and/or endocrine dysfunction (precocious puberty, renal phosphate wasting, hyperthyroidism, and/or growth hormone excess). Unrecognized and untreated endocrine dysfunction can exacerbate the skeletal disease. The diagnosis is usually established on clinical grounds on the basis of physical examination and typical radiographic appearance. Occasionally, gene testing of affected tissue may be helpful. The skeletal sites involved with disease are established at an early age, and the complications of fracture deformity are most pronounced in childhood. Bone pain in the absence of a fracture is more common in adults, but can also be present in children. Treatment with bisphosphonates is usually effective at relieving pain, but probably has no effect on the natural history of the disease. Scoliosis, which was previously thought to be an uncommon occurrence, has been shown to be common and progressive, and as such, warrants investigation and, when necessary, surgical treatment. The surgical management of FD remains challenging. Timing and technique remain controversial, but some consensus exists in that grafting materials (of any type) usually fail and should not be a central aspect of the surgical approach. Intramedullary devices are in general superior to side plates and screws. In extremely widespread disease with very early fracture and deformity, no surgical approach will affect final functional outcome. Efforts should be made for the initiation of international collaborative studies to better define optimal surgical approaches to the treatment of this challenging disease.
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Affiliation(s)
- Arabella I. Leet
- />Division of Pediatric Orthopedics, Johns Hopkins University, Baltimore, MD USA
| | - Michael T. Collins
- />Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services, Bethesda, MD USA
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23
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Al-Mayouf SM, Madi SM, Bin-Abbas BS. Cyclic intravenous pamidronate treatment in children with nodulosis, arthropathy and osteolysis syndrome. Ann Rheum Dis 2006; 65:1672-3. [PMID: 17105860 PMCID: PMC1798483 DOI: 10.1136/ard.2005.035725] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Bone mass increases progressively during childhood, but mainly during adolescence when approximately 40% of total bone mass is accumulated. Peak bone mass is reached in late adolescence, and is a well recognised risk factor for osteoporosis later in life. Thus, increasing peak bone mass can prevent osteoporosis. The critical interpretation of bone mass measurements is a crucial factor for the diagnosis of osteopenia/osteoporosis in children and adolescents. To date, there are insufficient data to formally define osteopenia/osteoporosis in this patient group, and the guidelines used for adult patients are not applicable. In males and females aged <20 years the terminology 'low bone density for chronologic age' may be used if the Z-score is less than -2. For children and adolescents, this terminology is more appropriate than osteopenia/osteoporosis. Moreover, the T-score should not be used in children and adolescents. Many disorders, by various mechanisms, may affect the acquisition of bone mass during childhood and adolescence. Indeed, the number of disorders that have been identified as affecting bone mass in this age group is increasing as a consequence of the wide use of bone mass measurements. The increased survival of children and adolescents with chronic diseases or malignancies, as well as the use of some treatment regimens has resulted in an increase in the incidence of reduced bone mass in this age group. Experience in treating the various disorders associated with osteoporosis in childhood is limited at present. The first approach to osteoporosis management in children and adolescents should be aimed at treating the underlying disease. The use of bisphosphonates in children and adolescents with osteoporosis is increasing and their positive effect in improving bone mineral density is encouraging. Osteoporosis prevention is a key factor and it should begin in childhood. Pediatricians should have a fundamental role in the prevention of osteoporosis, suggesting strategies to achieve an optimal peak bone mass.
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Acott PD, Wong JA, Lang BA, Crocker JFS. Pamidronate treatment of pediatric fracture patients on chronic steroid therapy. Pediatr Nephrol 2005; 20:368-73. [PMID: 15690187 DOI: 10.1007/s00467-004-1790-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 11/08/2004] [Accepted: 11/09/2004] [Indexed: 10/25/2022]
Abstract
Pediatric nephrology and rheumatology patients with steroid-induced osteopenia are at risk of skeletal fracture. Bisphosphonate therapy has not been routinely advocated as a primary or secondary intervention for steroid-associated fractures in this population. This case control study evaluates the role of pamidronate therapy as a secondary fracture intervention. Children with symptomatic pathological fractures of the axial spine or ribs were treated with pamidronate 1 mg/kg/dose (n=17) IV at 60-day intervals for 1 yr (n=15) or 2 yr (n=2). Bone mineral density of L1-L4 (BMD) was assessed prior to treatment and at six-month intervals, and compared to 17 disease-age-gender-steroid dose-matched control patients. Alkaline phosphatase, calcium, phosphate, PTH, renal biochemistry, and 24-hr urine collections for CrCl, N-telopeptide/creatinine ratio, phosphate excretion, and calcium excretion were obtained every two months in the pamidronate population. Pamidronate caused a first exposure transient flu-like illness lasting <24 h in three patients and one patient had a new pathological fracture. No adverse events of hypocalcemia, allergic reaction or thrombophlebitis were noted. All patients reported improvement of skeletal pain. Despite ongoing steroid treatment, pamidronate significantly increased L1-L4 BMD Z-scores (mean+/-SE) relative to baseline (pamidronate vs control: 0-6 months: 0.27+/-0.14 vs -0.82+/-0.31; 0-12 months: 0.63+/-0.17 vs -0.46+/-0.27; 0-18 months: 0.55+/-0.32 vs 0.17+/-0.27; 0-24 months: 0.15+/-0.21 vs -0.23+/-0.22; 0-30 or 36 months: 0.77+/-0.71 vs -0.68+/-0.25) with repeated measures ANOVA assessment (F=11.27, p=0.0057). This study supports the safety and efficacy of pamidronate in steroid-induced fractures in pediatric nephrology and rheumatology patients.
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Affiliation(s)
- Philip D Acott
- Department of Pediatrics, Dalhousie University, 5850 University Avenue, Halifax, Nova Scotia, B3J 3G9, Canada.
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26
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Bryowsky JJ, Bugnitz MC, Hak EB. Pamidronate Treatment for Hypercalcemia in an Infant Receiving Parenteral Nutrition. Pharmacotherapy 2004; 24:939-44. [PMID: 15303458 DOI: 10.1592/phco.24.9.939.36103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 17-day-old infant who was delivered 8 weeks premature underwent small bowel resection for necrotizing enterocolitis. During treatment with continuous infusions of furosemide and hydrocortisone, his total calcium concentration had increased. The calcium dose in his parenteral nutrition solution was decreased and then finally withheld. At 7 weeks of age and after 10 days of calcium-free parenteral nutrition, pamidronate 3 mg (1.1 mg/kg) in 60 ml of normal saline was infused over 6 hours. The infant's total serum calcium concentration decreased, but then 6 days later it had increased again; pamidronate 2 mg (0.7 mg/kg) in 40 ml of normal saline over 4 hours was administered. The patient demonstrated no signs or symptoms of adverse reactions to pamidronate. His serum calcium concentration returned to normal, and calcium-containing parenteral nutrition was tolerated. The use of pamidronate for treatment of hypercalcemia and chronic conditions that affect normal bone growth is increasing in children. Clinical trials in pediatric patients are necessary to determine how best to use bisphosphonates in this patient population.
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Affiliation(s)
- Jason J Bryowsky
- Department of Pharmacy, College of Pharmacy, University of Tennessee Health Science Center Memphis, Tennessee 38163, USA
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27
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Duke JL, Jones DP, Frizzell NK, Chesney RW, Hak EB. Pamidronate in a girl with chronic renal insufficiency dependent on parenteral nutrition. Pediatr Nephrol 2003; 18:714-7. [PMID: 12750976 DOI: 10.1007/s00467-003-1162-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2002] [Revised: 03/06/2003] [Accepted: 03/07/2003] [Indexed: 10/25/2022]
Abstract
A 10-year-old 40-kg African-American female with megacystis microcolon hypoperistalsis syndrome maintained on total parenteral nutrition (TPN), with a history of metabolic bone disease and renal insufficiency, was admitted with a Candida parapsilosis central venous line infection. During her 280-day hospital stay, she had multiple episodes of bacteremia and recurrent candidemia. Furthermore, she developed pathological fractures and hip displacement with osteomyelitis due to Enterobacter. Hypercalcemia and a history of nephrocalcinosis had prevented appropriate dosing of calcium prior to and during the first months of her hospital stay. Pamidronate and chlorothiazide were added to her regimen. The urinary calcium to creatinine ratio and ionized calcium decreased. The pamidronate dose was increased to 60 mg once a week and was well tolerated. Daily calcium was added to her TPN solution and was increased to 10 mEq/day by the time of discharge. We conclude that relatively large doses of pamidronate may be required in certain cases of refractory hypercalcemia and are well tolerated in children.
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Affiliation(s)
- Janet L Duke
- Department of Pharmacy, The Center for Pediatric Pharmacokinetics and Therapeutics, Pediatric Pharmacology Research Unit, University of Tennessee Health Science Center, Tennessee, USA
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Batch JA, Couper JJ, Rodda C, Cowell CT, Zacharin M. Use of bisphosphonate therapy for osteoporosis in childhood and adolescence. J Paediatr Child Health 2003; 39:88-92. [PMID: 12603794 DOI: 10.1046/j.1440-1754.2003.00083.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Congenital and acquired forms of osteoporosis in childhood and adolescence can result in morbidity from fracture and pain in childhood, and place an individual at significant risk for problems in adult life. A range of therapies exist for the prevention and treatment of osteoporosis, including optimization of daily calcium intake, adequate vitamin D status, weight-bearing exercise, treatment with sex steroids where delayed puberty is a problem and, more recently, use of bisphosphonate therapy. Intravenous pamidronate therapy (a bisphosphonate) has been shown to reduce fractures and improve bone density in children with osteogenesis imperfecta, and might prove to be of benefit in other osteoporotic conditions in childhood. However, a number of issues regarding the optimal use of bisphosphonate therapy in children and adolescents remain to be resolved, including total annual dose and frequency and duration of administration. Bisphosphonate therapy should, therefore, be used only in the context of a well-run clinical programme with specialist knowledge in the management of osteopenic disorders in childhood.
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Affiliation(s)
- J A Batch
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Brisbane, Queensland, Australia.
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Di Candia S, Weber G, Mora S, de Pellegrin M, Chiumello G. Early fractures and occult hyperthyroidism: McCune-Albright syndrome? Horm Res Paediatr 2002; 56:58-62. [PMID: 11815729 DOI: 10.1159/000048091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
McCune-Albright syndrome (MAS) is a sporadic disease characterized by fibrous bone dysplasia, café-au-lait spots and hyperfunctional endocrinopathies. We report a 2.5-year-old child with MAS with an early and nonclassic onset. He was admitted to our attention for frequent fractures without clinical signs of endocrinopathies, found to have asymptomatic, nonautoimmune hyperthyroidism. The diagnosis of MAS was based on RX and MR imaging associated with hyperthyroidism. It is not clear if there was a correlation between the severity of bone disease and the presence of thyroid disorder. At the moment no standard treatment exists for bone fibrous dysplasia and hyperthyroidism in children before the age of 6 years.
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Affiliation(s)
- S Di Candia
- Department of Pediatrics, Scientific Institute H.S. Raffaele, University of Milan, Italy
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