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Clin Oncol (R Coll Radiol). 2013 Apr;25(4):217-26. doi: 10.1016/j.clon.2012.11.004. Epub 2012 Dec 6.

Skeletal-related events and clinical outcomes in patients with bone metastases and normal levels of osteolysis: exploratory analyses.

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Penn State Cancer Center, Milton S. Hershey Medical Center, Pennsylvania State University, Division of Hematology/Oncology, Hershey, PA 17033, USA.



High levels of bone resorption markers (e.g. N-telopeptide of type I collagen; NTX) have been correlated with increased risks of skeletal-related events and death in patients with bone metastases from solid tumours. However, the disease course has not been well characterised in patients with bone metastases but normal NTX levels. Therefore, the aim of this study was to evaluate the patterns of skeletal morbidity in patients with normal NTX levels.


Exploratory analyses were carried out on patients with bone metastases from breast cancer, castration-resistant prostate cancer, non-small cell lung cancer or other solid tumours treated with zoledronic acid (ZOL) in phase III trials. The effects of covariates on the relative risk of death were estimated using the Cox proportional hazard model. The prognostic values of covariates were compared between patients with normal (<64 nmol/mmol creatinine) versus elevated (≥64 nmol/mmol creatinine) NTX levels.


Among patients with normal baseline NTX (n = 501), less than 10% developed elevated NTX levels before a skeletal-related event or death during ZOL treatment over 12 months. The prognostic factors identified in these analyses were mostly similar across NTX groups. However, some indicators of aggressive disease (e.g. visceral/cerebral metastases from breast cancer) were associated with poor clinical outcomes only in the normal NTX group.


Skeletal-related events were generally not preceded or followed by transition to elevated NTX in patients treated with ZOL. Elevated baseline NTX and aggressive extraskeletal disease were independently associated with reduced survival.

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