Clinical Orthopaedics and Related Research®

, Volume 470, Issue 10, pp 2874–2885 | Cite as

Osteoporosis in Children and Young Adults: A Late Effect After Chemotherapy for Bone Sarcoma

  • Ulrike Michaela Pirker-Frühauf
  • Jörg Friesenbichler
  • Ernst-Christian Urban
  • Barbara Obermayer-Pietsch
  • Andreas LeithnerEmail author
Clinical Research



Premature bone loss after childhood chemotherapy may be underestimated in patients with bone sarcoma. Methotrexate (MTX), a standard agent in osteosarcoma protocols, reportedly reduces bone mineral density (BMD). The literature, however, has reported cases of BMD reduction in patients with Ewing's sarcoma treated without MTX. Thus, it is unclear whether osteoporosis after chemotherapy relates to MTX or to other factors.


We therefore asked whether (1) young patients with a bone sarcoma had BMD reduction, (2) patients treated with MTX had lower BMD, and (3) other factors (eg, lactose intolerance or vitamin D deficiency) posed additional risks for low BMD.


We retrospectively reviewed 43 patients with malignancies who had dual-energy x-ray absorptiometry (DEXA) (lumbar, femoral); 18 with Ewing's sarcoma (mean age, 26 ± 8 years), and 25 with an osteosarcoma (mean age, 27 ± 10 years). The mean time since diagnosis was 8 ± 4 years in the group with Ewing’s sarcoma and 7 ± 5 years in the group with osteosarcoma. At last followup we determined BMD (computing z-scores), fracture rate, and lifestyle, and performed serum analysis.


BMD reduction was present in 58% of patients (37% had a z-score between −1 and −2 SD, 21% had a z-score less than −2 SD) in at least one measured site. Seven of the 43 patients (16%) had nontrauma or tumor-associated fractures after chemotherapy. Findings were similar in the Ewing and osteosarcoma subgroups. We found vitamin D deficiency in 38 patients (88%) and borderline elevated bone metabolism; lactose intolerance was present in 16 patients (37%).


Doctors should be aware of the possibility of major bone loss after chemotherapy with a risk of pathologic fracture. Vitamin D deficiency, calcium malnutrition, and lactose intolerance may potentiate the negative effects of chemotherapy, and should be considered in long-term patient management.

Level of Evidence

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.


Bone Mineral Density Osteoporosis Osteosarcoma Lower Bone Mineral Density Lactose Intolerance 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Franz Quehenberger PhD, Institute of Medical Informatics, Statistics and Documentation, for statistical analysis, and Thomas Lovse MD, Karin Novotny, and Andreas Frings for their assistance.


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Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Ulrike Michaela Pirker-Frühauf
    • 1
  • Jörg Friesenbichler
    • 1
  • Ernst-Christian Urban
    • 2
  • Barbara Obermayer-Pietsch
    • 3
  • Andreas Leithner
    • 1
    Email author
  1. 1.Department of Orthopaedic SurgeryMedical University of GrazGrazAustria
  2. 2.Division of Paediatric Haemato-Oncology, Department of PaediatricsMedical University of GrazGrazAustria
  3. 3.Division of Endocrinology and Metabolism, Department of Internal MedicineMedical University of GrazGrazAustria

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