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Beltran-Bless A, Murshed M, Zakikhani M, Kuchuk I, Bouganim N, Robertson S, Kekre N, Vandermeer L, Li J, Addison C, Rauch F, Clemons M, Kremer R. Histomorphometric and microarchitectural analysis of bone in metastatic breast cancer patients. Bone Rep 2021; 15:101145. [PMID: 34841014 PMCID: PMC8605385 DOI: 10.1016/j.bonr.2021.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/09/2021] [Accepted: 10/16/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite widespread use of repeated doses of potent bone-targeting agents (BTA) in oncology patients, relatively little is known about their in vivo effects on bone homeostasis, bone quality, and bone architecture. Traditionally bone quality has been assessed using a trans-iliac bone biopsy with a 7 mm "Bordier" core needle. We examined the feasibility of using a 2 mm "Jamshidi™" core needle as a more practical and less invasive technique. METHODS Patients with metastatic breast cancer on BTAs were divided according to the extent of bone metastases. They were given 2 courses of tetracycline labeling and then underwent a posterior trans-iliac trephine biopsy and bone marrow aspirate. Samples were analyzed for the extent of tumor invasion and parameters of bone turnover and bone formation by histomorphometry. RESULTS Twelve patients were accrued, 1 had no bone metastases, 3 had limited bone metastases (LSM) (<3 lesions) and 7 had extensive bone metastases (ESM) (>3 lesions). Most of the primary tumors were estrogen receptor (ER)/progesterone receptor (PR) positive. The procedure was well tolerated. The sample quality was sufficient to analyze bone trabecular structure and bone turnover by histomorphometry in 11 out of 12 patients. There was a good correlation between imaging data and morphometric analysis of tumor invasion. Patients with no evidence or minimal bone metastases had no evidence of tumor invasion. Most had suppressed bone turnover and no detectable bone formation when treated with BTA. In contrast, 6 out of 7 patients with extensive bone invasion by imaging and evidence of tumor cells in the marrow had intense osteoclastic activity as measured by the number of osteoclasts. Of these 7 patients with ESM, 6 were treated with BTA with 5 showing resistance to BTA as demonstrated by the high number of osteoclasts present. 3 of these 6 patients had active bone formation. Based on osteoblast activity and bone formation, 3 out of 6 patients with ESM responded to BTA compared to all 3 with LSM. Compared to untreated patients, all patients treated with BTA showed a trend towards suppression of bone formation, as measured by tetracycline labelling. There was also a trend towards a significant difference between ESM and LSM treated with BTA, highly suggestive of resistance although limited by the small sample size. DISCUSSION Our results indicate that trans-iliac bone biopsy using a 2 mm trephine shows excellent correlation between imaging assessment of tumor invasion and tumor burden by morphometric analysis of bone tissues. In addition, our approach provides additional mechanistic information on therapeutic response to BTA supporting the current clinical understanding that the majority of patients with extensive bone involvement eventually fail to suppress bone turnover (Petrut B, et al. 2008). This suggests that antiresorptive therapies become less effective as disease progresses.
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Key Words
- BM, Bone met
- BPs, Bisphosphonates
- BTAs, Bone targeting agents
- Bone biopsy
- Bone microarchitecture
- Bone turnover
- Bone-targeted agents
- Breast cancer
- CK, Cytokeratin staining
- CM, Collagen material
- DEXA, Dual-energy X-ray absorptiometry
- ER, Estrogen receptor
- ESM, Extensive skeletal metastases
- HE, Haematoxylin and Eosin
- HER2, Human Epidermal growth factor Receptor 2
- Histomorphometry
- IDC, Invasive ductal carcinoma
- IHC, Immunohistochemistry staining
- LSM, Limited skeletal metastases
- MB, Mineralized bone
- OB, Osteoblasts
- OC, Osteoclasts
- OS, Osteoid surface
- PAM, Pamidronate
- PFA/PBS, Paraformaldehyde/phosphate buffer solution
- PR, Progesterone receptor
- QCT, Quantitative CT
- SREs, Skeletal related events
- TRAP, Tartrate-resistant acid phosphatase staining
- VKVG, von Kossa and van Gieson
- Zol, Zoledronic acid
- astasis AI, Aromatase inhibitors
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Affiliation(s)
- A. Beltran-Bless
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, Canada
| | - M. Murshed
- Department of Medicine, Faculty of Dentistry, Shriners Hospital for Children, McGill University, Montreal, Canada
| | - M. Zakikhani
- Department of Medicine, Research Institute of the McGill University Health Center, Montreal, Canada
| | - I. Kuchuk
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, Canada
| | - N. Bouganim
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, Canada
| | - S. Robertson
- Department of Pathology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - N. Kekre
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, Canada
| | - L. Vandermeer
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, Canada
| | - J. Li
- Department of Medicine, Research Institute of the McGill University Health Center, Montreal, Canada
| | - C.L. Addison
- Centre for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, Canada
| | - F. Rauch
- Department of Pediatric Surgery, McGill University Health Center, Montreal, Canada
| | - M. Clemons
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, Canada
- Centre for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, Canada
| | - R. Kremer
- Department of Medicine, Research Institute of the McGill University Health Center, Montreal, Canada
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Ibrahim MF, Hilton J, Addison C, Robertson S, Werier J, Mazzarello S, Vandermeer L, Jacobs C, Clemons M. Strategies for obtaining bone biopsy specimens from breast cancer patients - Past experience and future directions. J Bone Oncol 2016; 5:180-184. [PMID: 28008380 PMCID: PMC5154702 DOI: 10.1016/j.jbo.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/04/2016] [Accepted: 07/05/2016] [Indexed: 01/07/2023] Open
Abstract
Background Cancer and its treatment can have multiple effects on the bone. Despite the widespread use of in vivo and in vitro models, it is still necessary to understand these effects in humans. Obtaining human bone biopsies is technically challenging and in this article we review the experiences from the Ottawa Bone Oncology Program. Methods A series of bone biopsy studies in breast cancer patients with and without bone metastasis have been performed. We reviewed the results of these studies and present them in a descriptive manner. We discuss lessons learned from each project and how they have affected future directions for research. Results Since 2009, 5 studies have been performed accruing 97 breast cancer patients. Study endpoints have ranged from comparing the yield of malignant cells from CT-guided versus standard iliac crest biopsies, to studies assessing the feasibility of micro-CT analysis on Jedhadi trephines to evaluate bisphosphonate effects on bone micro-architecture. More recently, we have assessed the feasibility of performing repeat bone biopsies in the same patient as well as evaluating the practicality of obtaining bone tissue at the time of orthopaedic surgery. Conclusion Human bone tissue is an important biological resource. Our experience suggests that obtaining bone biopsies is feasible and can yield adequate amount of tumour cells for many studies. However, these remain technically challenging specimens to obtain and given the rapid advances in cancer therapeutics and the use of potent adjuvant bone-targeted agents, more centres need to be involved in these types of studies.
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Affiliation(s)
- Mohammed F.K. Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Christina Addison
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Susan Robertson
- Division of Anatomical Pathology, Eastern Ontario Regional Laboratory Association, Ottawa, Ontario, Canada
| | - Joel Werier
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sasha Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Carmel Jacobs
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
- Corresponding author at: Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, Canada.Division of Medical Oncology, The Ottawa Hospital Cancer Centre501 Smyth RoadOttawaCanada
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Jacobs C, Amir E, Paterson A, Zhu X, Clemons M. Are adjuvant bisphosphonates now standard of care of women with early stage breast cancer? A debate from the Canadian Bone and the Oncologist New Updates meeting. J Bone Oncol 2015; 4:54-8. [PMID: 26579489 DOI: 10.1016/j.jbo.2015.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/14/2015] [Indexed: 01/07/2023] Open
Abstract
The 9th Bone and the Oncologist New Updates conference was held in Ottawa, Canada during 2014. This annual meeting focuses on innovative research into the mechanisms and consequences of treatment-induced and metastatic bone disease. Given the recent presentation of the Oxford overview's “Effects of bisphosphonate treatment on recurrence and cause-specific mortality in women with early breast cancer: A meta-analysis of individual patient data from randomized trials” at the San Antonio Breast Cancer Symposium, a debate as to the pro's and con's of adjuvant bisphosphonate use in early stage breast cancer was undertaken. As bisphosphonate treatment in post-menopausal women appeared to demonstrate a similar magnitude of benefit to that of other commonly used adjuvant strategies the debate assessed whether or not there was sufficient data to incorporate adjuvant bisphosphonates into standard practice and if so, in which patient populations.
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Jacobs C, Ng T, Ong M, Clemons M. Long-term benefits versus side-effects from bone-targeted therapies for cancer patients: minimizing risk while maximizing benefits. Curr Opin Support Palliat Care 2014; 8:420-8. [DOI: 10.1097/spc.0000000000000084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Jacobs C, Simos D, Addison C, Ibrahim M, Clemons M. Pharmacotherapy of bone metastases in breast cancer patients – an update. Expert Opin Pharmacother 2014; 15:1109-18. [DOI: 10.1517/14656566.2014.903925] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Zhu X, Amir E, Singh G, Clemons M, Addison C. Bone-targeted therapy for metastatic breast cancer-Where do we go from here? A commentary from the BONUS 8 meeting. J Bone Oncol 2014; 3:1-4. [PMID: 26909291 PMCID: PMC4723414 DOI: 10.1016/j.jbo.2014.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 12/24/2022] Open
Abstract
The annual Bone and The Oncologist New Updates (BONUS 8) conference focuses on the current understanding and dilemmas in the treatment and prevention of bone metastasis in cancer, as well as novel research on bone homeostasis and cancer-induced bone loss. We present commentaries from experts for their own take on where they feel the field of bone-targeted therapies for metastatic breast cancer is moving, or needs to move, if we are to make further progress.
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Affiliation(s)
- Xiaofu Zhu
- Division of Medical Oncology, Ottawa Hospital and Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Eitan Amir
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Hospital, Toronto, Canada
| | - Gurmit Singh
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Mark Clemons
- Division of Medical Oncology, Ottawa Hospital and Faculty of Medicine, University of Ottawa, Ottawa, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Christina Addison
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Simos D, Addison CL, Kuchuk I, Hutton B, Mazzarello S, Clemons M. Bone-Targeted Agents for the Management of Breast Cancer Patients with Bone Metastases. J Clin Med 2013; 2:67-88. [PMID: 26237063 PMCID: PMC4470229 DOI: 10.3390/jcm2030067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/25/2013] [Accepted: 07/29/2013] [Indexed: 01/12/2023] Open
Abstract
Despite advances in adjuvant therapy for breast cancer, bone remains the most common site of recurrence. The goal of therapy for these patients is palliative and focused on maximizing the duration and quality of their life, while concurrently minimizing any disease or treatment-related complications. Bone metastases predispose patients to reduced survival, pain, impaired quality of life and the development of skeletal-related events. With an increased understanding of the pathophysiology of bone metastasis, effective treatments for their management have evolved and are now in widespread clinical use. This article will discuss the pathogenesis of bone metastases and review the key clinical evidence for the efficacy and safety of currently available systemic bone-targeted therapies in breast cancer patients with an emphasis on bisphosphonates and the receptor activator of nuclear factor kappa B ligand (RANKL) inhibitors. We will also discuss novel strategies and therapies currently in development.
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Affiliation(s)
- Demetrios Simos
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa Hospital Research Institute, Box 900, 501 Smyth Road, Ottawa, Ontario K1H8L6, Canada.
| | - Christina L Addison
- Centre for Cancer Therapeutics, The Ottawa Hospital Research Institute, Departments of Medicine & Biochemistry Microbiology & Immunology, University of Ottawa, Box 926, 501 Smyth Road, Ottawa, Ontario K1H8L6, Canada.
| | - Iryna Kuchuk
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa Hospital Research Institute, Box 900, 501 Smyth Road, Ottawa, Ontario K1H8L6, Canada.
| | - Brian Hutton
- Centre for Practice Changing Research & Ottawa Hospital Research Institute, Box 201, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.
| | - Sasha Mazzarello
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa Hospital Research Institute, Box 900, 501 Smyth Road, Ottawa, Ontario K1H8L6, Canada.
| | - Mark Clemons
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa Hospital Research Institute, Box 900, 501 Smyth Road, Ottawa, Ontario K1H8L6, Canada.
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