Sagittal T2-weighted images demonstrating multilevel vertebral compression fractures
Sagittal T2-weighted images demonstrating multilevel vertebral compression fractures most severe at T6 and T11 with ~50% loss of vertebral body height. No bony retropulsion or evidence of cord compression. No marrow signal abnormality to suggest an acute fracture.

Endocrinologists are collaborating with radiologists and oncologists at Penn Medicine to perform metabolic bone biopsy and dual-energy x-ray absorptiometry (DXA) to assist in decision-making for the management of cancer patients.

As many as 70% of persons with advanced breast cancer or prostate cancer will have bone metastases as a complication of malignancy, as will between 15% and 30% of individuals with cancers of the lung, colon, stomach, bladder, uterus, rectum, thyroid or kidney. Metabolic bone biopsies are available only at very specialized medical centers, because their use requires extensive clinical training on the part of endocrinologists, as well as the presence of trained oncologic orthopedists to obtain bone specimens, and pathologists with the expertise to interpret them.

At the Penn Bone Center, as elsewhere, metabolic bone biopsies are used to guide therapy by determining bone turnover rate and qualitative defects in bone cells.1 It should be noted that metabolic bone biopsies are not used to interpret metastatic lesions.

A second investigative tool, DXA plays an instrumental role in the management of cancer patients as an assessment of bone mineral density, which can be depleted by both chemotherapy and radiotherapy. In these populations, DXA assessment can be used to alter these therapies. DXA is available at most Penn Radiology sites.

Case Study

In March 2015, Mr. Z, a 26-year-old man with no significant prior medical problems presented to a local emergency department complaining of severe back pain that began, he reported, after shoveling snow a few months before.

Mr. Z denied falls or accidents. His discomfort had worsened over time to the extent that he developed shortness of breath and was starting to hunch over in pain. He also reported a height loss of ~4 inches over the previous months. Imaging at this time reported a 15cm tumor in the liver and multiple fractures in the thoracic and lumbar spine (Figure 1).

A biopsy of the tumor yielded a diagnosis of hepatocellular carcinoma. Subsequently, Mr. Z underwent resection of the liver tumor, chemotherapy and extensive testing, including a comprehensive genetic profile assessment.

Mr. Z was then referred to Penn Endocrinology, where he was evaluated by Dr. Amna Khan in January 2016 for his spontaneous spinal fractures. Following a DXA, which found. dry low bone mineral density and a very low trabecular score consistent with osteoporosis, Mr. Z received a metabolic bone biopsy, which reported a low turnover state (see APPENDIX, pgs. 2-3 in the downloadable pdf).

Mr Z's regimen was then altered to include a medication that would increase bone turnover. He completed 2 years of this therapy with robust gains in bone density and skeletal quality, as demonstrated by improved trabecular bone score (see APPENDIX pgs 4-5 in the downloadable pdf) and without additional fractures. Today, more than five years after his original diagnosis, Mr. Z remains in the community and continues to pursue follow-up care.


Penn Endocrinology Perelman
Perelman Center for Advanced Medicine
3400 Civic Center Boulevard
West Pavilion, 4th Floor
Philadelphia, PA

Published on: April 26, 2021


1. de Bakker CMJ, Tseng W-J, Li Y, Zhao H, Liu XS. Clinical Evaluation of Bone Strength and Fracture Risk. Curr Osteoporos Rep 2017;15:32-42.


About The Penn Bone Center

The endocrinologists at Penn Bone Center are committed to assessment and treatment of patients with osteoporosis and metabolic bone disorders.

Penn Faculty Team

Carrie M. Burns, MD

Director, Diabetes in Pregnancy

Professor of Clinical Medicine

Amna Nabeel Khan, MD, FACE, CCD

Co-Director, Penn Bone Center

Associate Professor of Clinical Medicine

Kristen Noelle Kobaly, MD

Assistant Professor of Clinical Medicine

Christina M. Mitchell, MD

Associate Professor of Clinical Medicine

Mona Al Mukaddam, MD, MS

Director, Penn Bone Center

Associate Professor of Clinical Medicine

Associate Professor of Orthopaedic Surgery

Rahaf Sultan, MD

Assistant Professor of Clinical Medicine

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