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A 66-year-old woman presents to her family physician with an emergency department radiograph report showing a transverse fracture of the posterior right 11th rib. She states that the rib pain started a few days ago and, when rolling over in bed from her back to her side the previous night, she heard a crack and felt a sharp pain in her right rib cage, precipitating the visit to the emergency department. The patient has a history of long-standing osteopenia (for which she is undergoing treatment with alendronate) and asynchronous bilateral breast cancer, which last occurred in the right breast 16 years ago. On physical examination, this patient has point tenderness over the posterior-lateral portion of the lower ribs on the right side.
Is this patient likely to have metastatic breast cancer?
A review of this patient's history for the last diagnosis of breast cancer showed that she had a grade 2 tumour (2.4 cm) with four axillary lymph nodes positive for metastases (stage IIB). Because local or distant recurrences will develop in up to 70% of patients with node-positive breast cancer1 and bone is the most common site for metastases,2 it is reasonable to suspect that the rib pain may be due to metastatic disease. A population-based retrospective cohort study of fracture risk involving 608 women with a history of breast cancer showed that about 30% of the reported rib fractures were due to metastatic lesions.3
What other possible causes for the rib fracture should be ruled in or out?
In addition to a history of breast cancer, this patient also has long-standing osteopenia (diagnosed at age 46 yr). A long-term (median followup time = 13.9 yr), population-based study involving 699 randomly selected adults reported that almost 40% of the 67 episodes of rib fracture in older adults were "spontaneous" or nontraumatic.4 Long-term use of bisphosphonates, e.g., alendronate...