Skeletal characteristics and clinical course
| Patient | Treatment and clinical course | Dual energy X-ray absorptiometry (DXA) T-scoresa | Additional imaging | Bone resorption and formation markers/biochemical indices | Inflammatory markers | Biopsy data |
|---|---|---|---|---|---|---|
| 1 | Intravenous zoledronic acid infusionsNED; progressive back pain requiring kyphoplasty | T-scores:Lumbar spine, −2.1Left femoral neck, − 1.2Left total hip, −0.4Right femoral neck, − 1.7Right total hip, − 0.8 | MRI: Multilevel compression fractures of T12-L5 vertebral bodies; bilateral posterolateral rib fractures; multiple nondisplaced pelvic fractures superimposed on underlying osteopenia. | CTX: 1038 pg/mL (↑)bsALP: 11.6 μg/LCa: 9.5 mg/dL25OHD: 48 ng/mL | CRP: 1.0 mg/dL (↑)ESR 12 mm/h | Transiliac bone biopsy:Reduced cortical and trabecular thickness; no osteoblastic activity; increased eroded surface and osteoclastic resorptive activity. |
| 2 | Denosumab q6moProgressive metastatic disease requiring hospice care; now deceased | T-scores:Left femoral neck, − 1.5Left total hip, 0.1 | VFA: Multiple wedge deformities 16.8% in T6, 13.6% in T7, 11.2% in T8, 18% in T9, 4.1% in T10, 6.9% in T12, 13.2% in L1.CT chest 1/17: New compression deformity of the superior endplates of T2-T5 vertebral bodies | CTX: 537 pg/mLbsALP: 13.1 μg/LCa: 8.9. mg/dL25OHD: 37 ng/mL | N/A | N/A |
| 3 | Conservative management with calcium and vitamin D optimizationNED, pain free | T-scores:L-spine, − 0.9Left femoral neck, − 1.8Left total hip, − 1.2 | CT scan: T12 compression fracture with evolving compression deformity at T11; biconcave deformities of lumbar vertebrae | CTX: 335 pg/mLbsALP: 8.7 μg/LCa: 9.4. mg/dL25OHD: 18 ng/mL (↓) | N/A | N/A |
| 4 | Systemic oral steroidsAdalimumabNED; improved inflammatory arthritis but progressive left shoulder pain and lack of mobility; no additional resorptive lesions | T-scores:L-spine, − 1.0Left femoral neck, − 1.2Left total hip, 0.21/3 radius, − 1.9 | MRI shoulder: Severe erosive changes of the glenohumeral articulation | CTX: 589 pg/mL (↑)bsALP: 18 μg/L (↑)Ca: 9.4. mg/dL25OHD: 52 ng/mL | CRP: 2.7 mg/dL (↑)ESR: 69 mm/h (↑) | No evidence of melanoma (S100, HMB-45 and melan-A stains negative). Trabecular bone with bone marrow fibrosis and a scattered, mixed inflammatory cell infiltration. |
| 5 | Systemic oral steroidsProgressive, metastatic disease; limited response to steroids, currently in hospice | N/A | Hand X-ray: Loss of ossific densities related to the capitate and also hamate, loss of cortical outline of the capitate and hamate | CTX: 877 pg/mL (↑)bsALP: 24 μg/L (↑)Ca: 8.8 mg/dL25OHD: 51.8 | CRP: 13.5 mg/L (↑)ESR: 31 mm/h (↑) | N/A |
| 6 | NSAIDs, Intraarticular corticosteroidsProgressive, metastatic disease; good rheumatologic response to steroids, currently on carboplatin pemetrexed and bevacizumab | T-scores:L- spine, 0.8Left femoral neck, 0. 0Left total hip, 0.8 | MRI clavicle: Acromioclavicular joint arthrosis with disproportionate bone marrow edema affecting the distal, no visible fracture | CTX: 681 pg/mL (↑)bsALP: 17 μg/L (↑)Ca: 8.8 mg/dL25OHD: 22 ng/mL (↓) | CRP: 2.0 mg/dL (↑)ESR: 32 mm/h (↑) | N/A |
aT-score criteria by DXA: > − 1, normal bone density; − 1 to − 2.4, osteopenia; < − 2.5, osteoporosis
(L-spine) Lumbar spine, (N/A) Not applicable, (NED) No evidence of disease, (CT) computed tomography, (MRI) magnetic resonance imaging, (VFA) Vertebral Fracture Assessment
Biochemical parameters, normative levels: C-telopeptides (CTX) < 10–584 pg/mL; bone-specific alkaline phosphatase (bsALP) 7.6–14.9 μg/L; calcium (Ca) 8.4–10.5 mg/dL; 25-hydroxy vitamin D (25OHD); C reactive protein (CRP) < 0.5 mg/dL; erythrocyte sedimentation rate (ESR) 1–20 mm/h