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Case History

image A 41-year old woman had a diagnosis of an oestrogen receptor (ER) positive, HER-2 negative breast cancer 12 years previously. She underwent a wide local excision and axillary node clearance for a 25 mm, grade 3 cancer with 11/16 axillary nodes involved. Following surgery she received adjuvant chemotherapy, radiotherapy and endocrine treatment with goserelin and exemestane for 5 years. Her baseline bone mineral density (BMD) scan was normal.

After 5 years, goserelin and exemestane were stopped and she was found to be biochemically post-menopausal. She was commenced on letrozole to complete a further 5 years of adjuvant treatment in view of her poor prognostic features at presentation. Her surveillance BMD scan at 8 years demonstrated osteopenia, with a T score of −1.8 in the lumbar spine. She was started on an oral bisphosphonate until she completed letrozole; her BMD scan after 10 years of adjuvant endocrine therapy was normal.

One year later she presented with liver and bone metastatic disease. She was commenced on capecitabine chemotherapy and zoledronic acid (4 mg IV every 3 months, after initial loading with 4 mg every 4 weeks for 9 doses). She had a good response to treatment on follow-up imaging.

After 11 months of treatment she fell off a curb as her leg ‘gave way’. She was admitted to A+E. She reported a 4 week history of right hip pain.

On examination she had a shortened, externally rotated right leg with associated thigh swelling.

Her routine bloods including Ca 15-3 were unremarkable.

Plain radiographs demonstrated a transverse subtrochanteric fracture of her right femur. There were no lytic or sclerotic lesions. The radiographer commented that there was bilateral beaking of the subtrochanteric cortices. She had restaging with a CT and bone scan which demonstrated stable disease and no new bone lesions.

This presentation was consistent with a bisphosphonate-related stress fracture of her right femur. She had an intra-medullary nail fixation. Her bisphosphonates were discontinued. She had radiographic changes in the asymptomatic contralateral femur; these were managed by minimal weight-bearing and MRI surveillance until resolution of bone oedema in keeping with a healed stress fracture. Should she develop pain she will be referred for an orthopaedic review to consider a prophylactic femoral nail to prevent fracture.

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What factors affect bone health in the management of early breast cancer?

Bone health of breast cancer patients can be impacted negatively by anti-oestrogen drugs, chemo-therapy, steroids and positively by adjuvant bisphosphonates. This patient, at age 35, was found to be biochemically post-menopausal following 5 years of ...

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