Vertebral Fractures [VF]

[pca2004]

New study from the Netherlands, below [1].

One would expect bone issues with ADT, since near-zero testosterone equates to near-zero estradiol.  When estradiol goes below 12 pg/mL (my limit, based on old non-PCa studies), bone loss can be rapid.

But this study looked at men who were about to start ADT:

"there is a high prevalence of vertebral fractures {VF} in a third of the men with PCa at the time of ADT initiation"

What isn't mentioned is testosterone [T] or estradiol [E2].  Men lose 1-2% of T each year, starting in their early 30s.  Men with lower T appear to have a greater risk of PCa.  It's not unusual to find T at diagnosis to be close to 350 ng/dL, the cut-off for hypogonadism.  Some men fall below 250 ng/dL and are effectively on ADT-Lite.

"In 115 men at ADT initiation, aged 73.3 ... years, osteoporosis was diagnosed in 4.3 %

... and osteopenia in 35.7 %.

... The mean 10-year fracture risk of major osteoporotic fracture was 4.4 % and of hip fracture 1.7 %, respectively.

 At least one VF was present in 32.2 % 

... and 33.9 % of men had osteoporosis and/or a VF assessed on spinal X-rays.

... In 10.4 % at least one new fracture-risk-associated metabolic bone disorder was diagnosed with laboratory testing."

-Patrick

[1]  pubmed.ncbi.nlm.nih.gov/365...

High prevalence of vertebral fractures at initiation of androgen deprivation therapy for prostate cancer

Marsha M van Oostwaard 1 2, Joop P van den Bergh 1 2, Yes van de Wouw 1, Maryska Janssen-Heijnen 3 4, Marc de Jong 5, Caroline E Wyers 1

Affiliations

1 Department of Internal Medicine, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, the Netherlands.

2 Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (Maastricht UMC+), P.O. Box 616, 6200 MD Maastricht, the Netherlands.

3 Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, the Netherlands.

4 Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.

5 Department of Urology, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, the Netherlands.

PMID: 36591574 PMCID: PMC9798166 DOI: 10.1016/j.jbo.2022.100465

Abstract

Purpose: Treatment of Prostate Cancer (PCa) with Androgen Deprivation Therapy (ADT) involves long-term consequences including bone loss and fractures. Our aim was to evaluate the calculated fracture risk and the prevalence of osteoporosis, vertebral fractures (VF) and sarcopenia in men with PCa at initiation of ADT, as ADT will increase fracture risk from that moment onward.

Methods: In this cross-sectional real-world study in men at ADT initiation, fracture risk factors including comorbidities, medication, and 10-year fracture risk (FRAX®) were assessed. Laboratory tests, dual-energy X-ray absorptiometry, and spinal X-rays were performed. Sarcopenia was defined according to EWGSOP2.

Results: In 115 men at ADT initiation, aged 73.3 (±7.6) years, osteoporosis was diagnosed in 4.3 % and osteopenia in 35.7 %. The mean 10-year fracture risk of major osteoporotic fracture was 4.4 % and of hip fracture 1.7 %, respectively. At least one VF was present in 32.2 % and 33.9 % of men had osteoporosis and/or a VF assessed on spinal X-rays. In 10.4 % at least one new fracture-risk-associated metabolic bone disorder was diagnosed with laboratory testing. Sarcopenia was diagnosed in only one patient.

Conclusions: Although the prevalence of osteoporosis, sarcopenia and 10-years fracture risk is low, there is a high prevalence of vertebral fractures in a third of the men with PCa at the time of ADT initiation. Besides a BMD measurement and fracture risk calculation using FRAX, a systematic vertebral fracture assessment should be considered in all men with PCa at initiation of ADT to provide a reliable baseline classification of VFs to improve identification of true incident VFs during ADT.

[MateoBeach]

This reaffirms my view that skeletal events including pathological fractures and severe bone pain from bone metastasis is in the future for most (90%) of men with advanced PC. It is in-the-cards from the time of first BCR after failure of primary curative-intent treatment. So it makes the most sense to me and start on a bone protective regimen long before bone mets become evident. And even before osteopenia is diagnosed on DEXA scan.

I started a regimen with oral weekly at alendronate at BCR, 13 years ago. When I had mild osteopenia diagnosed 5 years ago I moved up to Prolia treatment. Now, 15 years on in this journey, I still have no evidence of bone metastasis. (Though my spine is a mess with degenerative disc disease.)

I encourage others to consider being proactive in bone protection. If nothing else, at least low dose estradiol patch while on continuous long term ADT. Together with reasonable (lab monitored) Calcium and Vitamin D3 supplementation as indicated. And consider Prolia if one’s dentition is in good shape. Paul

[NPfisherman]

I had a DEXA scan and FRAX evaluation at the beginning of treatment. People need to do a f/u scan and evaluation every few years. So far, so good for me...

Fish

[Scout4answers]

Not sure if what I am

experiencing can be linked to PCa. What started out as leg cramps evolved into excruciating nerve pain similar to Sciatica but emanating from L5. I had such pain that I was awake all night for 3 nights in a row. I was unable to find any comfortable position Found relief in a Canabis product only made and sold in California, THC 100 Releaf capsules. They shut down the pain completely however All I want to do is sleep.

Any thoughts on the connection?

From todays MRI

CONCLUSION:

1. There is evidence of bilateral sacral alar fractures, which appear new relative to prior imaging. Patient does have a history of osteopenia diagnosed via DEXA scan on 10/28/2021. The possibility of the development of osteoporosis with insufficiency

fractures of the sacrum should be considered.

2. Multilevel disc disease and facet arthropathy throughout the lumbar spine, most pronounced at L4-5 where there is moderate central canal stenosis, severe bilateral subarticular stenosis and mild to moderate bilateral neural foraminal stenosis. Please

see the body of the report above for further specific details regarding degrees of stenoses at each individual lumbar level.

Dictated by (CST): Malik, Amaar, DO on 1/03/2023 at 1:51 PM

Finalized by (CST): Malik, Amaar, DO on 1/03/2023 at 2:05 PM

Narrative

PROCEDURE: MRI SPINE LUMBAR (W+WO) (CPT=72158)

LOCATION: Edward

COMPARISON: EDWARD , MR, MRI PROSTATE (W+WO)(CPT=72197), 4/20/2022, 12:23 PM. North Naperville, XR, XR HIP W OR WO PELVIS 2 OR 3 VIEWS, RIGHT (CPT=73502), 12/15/2022, 5:04 PM.

INDICATIONS: Low back pain radiating to right lower extremity with weakness.

TECHNIQUE: Multiplanar T1 and T2 weighted images including fat suppression sequences. Images acquired in sagittal and axial planes. Intravenous gadolinium was administered followed by multiplanar post-infusion T1 weighted sequences.

PATIENT STATED HISTORY:(As transcribed by Technologist) Patient complains of lower back pain and right lower extremity weakness.

CONTRAST USED: 17 mL of Dotarem

FINDINGS:

LUMBAR DISC LEVELS

L1-L2: No significant disc disease noted. Mild bilateral facet arthropathy and ligamentum flavum thickening. No evidence of stenosis.

L2-L3: Mild disc desiccation and bilateral facet arthropathy. There is a small right posterolateral disc protrusion into the right subarticular zone measuring 6 mm in the AP dimension, best seen on sagittal T2 image 14 of series 5. There is secondary

mild to moderate right subarticular stenosis. No central canal or neural foraminal stenosis.

L3-L4: Mild disc desiccation with mild disc height loss and mild broad-based disc bulge. Mild to moderate bilateral facet arthropathy and ligamentum flavum thickening. There is mild central canal stenosis, moderate to severe bilateral subarticular

stenosis and mild to moderate bilateral neural foraminal stenosis.

L4-L5: There is mild to moderate disc desiccation with disc height loss and broad-based disc bulge. Moderate bilateral facet arthropathy with hypertrophy and ligamentum flavum thickening. There is moderate central canal stenosis, severe bilateral

subarticular stenosis and mild to moderate bilateral neural foraminal stenosis.

L5-S1: Moderate disc desiccation with disc height loss and broad-based disc bulge. Moderate bilateral facet arthropathy with ligamentum flavum thickening. No significant central canal stenosis. There is moderate bilateral subarticular neural

foraminal stenosis.

PARASPINAL AREA: Normal with no visible mass.

BONES: There are bilateral sacral alar fractures with surrounding bone marrow edema and surrounding enhancement. Mild to moderate multilevel facet arthropathy throughout the lumbar spine. No lytic, blastic or destructive osseous changes are noted. No

evidence of lumbar spondylolysis.

Pain Dr. who ordered MRI is going to inject Cortisone to releave pain. Any thoughts?

[Seasid in reply to Scout4answers]

Is your pain doctor a neurologist?

I am just asking as my MO professor Antony Joshua said to me that he is a prostate doctor...

[cujoe]

Patrick - Since I've never been on long-term T-lowering ADT and regularly do activities, like running & resistance exercises, I've never been overly concerned about bone density. However in researching a new plant derived supplement, I came across the following paper that might be of interest to those on ADT. While it is a Mighty Mouse study, it might also provide some suggested avenues for improved bone health and exercise directives for those who are sugically castrated:

Combined Effects of Exercise and Phytoanabolic Extracts in Castrated Male and Female Mice - Nutrients, 2021 Apr 2;13(4):1177

Abstract

Dry extracts from the Eurasian plants, Ajuga turkestanica, Eurycoma longifolia, and Urtica dioica have been used as anabolic supplements, despite the limited scientific data on these effects. To assess their actions on early sarcopenia signs, male and female castrated mice were supplemented with lyophilized extracts of the three plants, isolated or in association (named TLU), and submitted to resistance exercise. Ovariectomy (OVX) led to body weight increase and non-high-density cholesterol (HDL) cholesterol elevation, which had been restored by exercise plus U. dioica extract, or by exercise and TLU, respectively. Orchiectomy (ORX) caused skeletal muscle weight loss, accompanied by increased adiposity, being the latter parameter reduced by exercise plus E. longifolia or U. dioica extracts. General physical activity was improved by exercise plus herbal extracts in either OVX or ORX animals. Exercise combined with TLU improved resistance to fatigue in OVX animals, though A. turkestanica enhanced the grip strength in ORX mice. E. longifolia or TLU also reduced the ladder climbing time in ORX mice. Resistance exercise plus herbal extracts partly altered gastrocnemius fiber size frequencies in OVX or ORX mice. We provide novel data that tested ergogenic extracts, when combined with resistance exercise, improved early sarcopenia alterations in castrated male and female mice.

ncbi.nlm.nih.gov/pmc/articl...

Hope your New Year is off to a fine start, esp. with the arrival of warmer weather.

BS/SW, Ciao - cujoe

[Hidden]

I was in the hypogonadism cohort when diagnosed at age 66 and I am fighting stooped posture. Have a kyphotic curve that I am trying to keep from getting worse. I haven't been on ADT for 5 years. I think my chances of getting prescribed T is slim to none. I had a bone density scan not too long ago and it was fine. I've been doing gym workouts for many years which include some heavy lifting. There's one I do on a machine where I sit and lean back to lift the weight. I'm wondering if I am pushing it too far sometimes but no pain and it feels good to have a strong core. I hope I never hear a crunch sound while using that machine. 😮