br Treatment and follow up recommendations for patients

Treatment and follow-up recommendations for patients receiving aromatase inhibitors
Conclusions and future directions It is evident that, in addition to BMD, clinical risk factors can greatly influence fracture risk. In addition to morbidity and mortality, fractures are associated with high healthcare costs and increased healthcare utilization for several months after fracture incidence [127–129]. In the European Union the economic burden of incident and prior fragility fractures was estimated at € 37 billion in 2010. Acute hip fracture costs in Europe were € 13,800 but varied widely from approximately €2000 in Bulgaria to about €25,000 in Denmark [130]. Additionally, vertebral and especially hip fractures are likely to result in prolonged disability and loss of independence, thereby leading to increased indirect costs. Improvements in assessing fracture risk can help identify patients who need pharmacologic intervention to improve bone health, thereby reducing fracture incidence. We have presented an evidence-based algorithm for assessing bone health in women with breast cancer and initiating antiresorptive therapy in postmenopausal women initiating AI therapy for early stage breast cancer as well as in other postmenopausal women not being considered for an AI treatment and in those receiving ovarian suppression therapies. Based on current evidence, six monthly denosumab or zoledronate for the duration of AI therapy is recommended for the prevention of AIBL in postmenopausal women receiving adjuvant AI therapy with zoledronate recommended when effects on disease recurrence are the priority and denosumab when fracture risk is the fructose 1 6 bisphosphatase concern. Long-term efficacy and safety data for other agents continue to mature, and should be taken into consideration as they become available.
Conflicts of interest
Introduction The technique of cryosurgery has been used to control local recurrence in a variety of benign and malignant bone tumors. Cryotherapy was initially instituted in seventeenth century originally by the Greeks, and adapted for dermatological use in 1850 for its anesthetic and vasoconstriction effects [1]. Since then, cryotherapy was put toward other uses in neurosurgery, gynecology, and eventually orthopaedics. The first reported use of cryosurgery for metastatic bone tumors was by Marcove who described an open system “direct pour” method using liquid nitrogen to aggressively fill the tumor cavity several times [2]. Repeated exposure of the curettaged area to extreme temperatures below 20°C created ice crystal formations that were later shown to produce osmotic disturbances and bone necrosis [3]. The initial study with cryotherapy by Marcove revealed a high complication rate (51%) that included fracture, skin necrosis, infection, and neuropraxia [4]. The use of curettage alone was shown to be associated with a high recurrence rate but minimized complications [5]. The high complication rate with cryotherapy led to other adjuvant modalities such as phenol, peroxide, and aggressive burring in the treatment of bone tumors. However, refinement and experience with the technique helped reduce complication rates over time [6]. Recent studies have revealed that cryosurgery could be a recommended treatment for benign-aggressive and malignant bone tumors with little bone loss or long standing functional complications [3,7].
Materials and methods We retrospectively reviewed charts in patients who had been treated with cryoablation between 1994 and 2015. Follow up varied with the tumor type or until complete healing was seen radiographically. 5 patients had three freeze/thaws 207 patients had two freeze thaws and 2 patients had cryoprobe treatment. Surgical technique using the freeze/thaw technique included initial extensive curettage of the lesion through a 1.5–3.5cm defect in the bone made with an 8mm drill and followed by increasing the size of the cortical defect with curettes. The tumor was excised using a combination of angled curettes and large bore Frazier tip suction under fluoroscopic guidance. A high speed burr was not used. Once the lesion was removed, warming the overlying tissue prior to pouring in the liquid nitrogen was performed. The liquid nitrogen was poured into the defect through a metal funnel under direct vision. If the liquid nitrogen began freezing the overlying tissue, warm saline would be judiciously applied to prevent freezing damage to the skin, subcutaneous tissue and in some cases the muscle. After the liquid nitrogen was poured into the defect, the limb would be manipulated to achieve maximum freeze throughout the defect. Once the intralesional ice ball thawed, a second and or third freeze thaw cycle would be repeated. If a portion of the defect could not be adequately frozen, additional freezing using a cryogun spray would be administered. The defect was then filled with either bone grafting, bone graft substitute, or polymethyl methacrylate (PMMA) cement to return mechanical support (Fig. 1). Tourniquet was used if the tumor surgery was distal to the proximal humerus and femur.