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Women with early, estrogen receptor-positive breast cancer are treated with adjuvant endocrine therapy, using aromatase inhibitors or selective estradiol receptor modulators such as tamoxifen, to deprive breast tissue from the deleterious effects of estradiol action, hence improving long-term prognosis. Aromatase inhibitors and, in premenopausal women, tamoxifen accelerate bone loss and increase fracture risk. Therefore, all women commencing endocrine therapy need a targeted work-up to assess the baseline fracture risk, and monitoring of bone health during endocrine therapy should be individualized based on this baseline risk. While high-level evidence specific to early breast cancer is lacking, non-pharmacologic measures to maintain optimal bone health such as weight-bearing exercise and calcium and vitamin D sufficiency should be implemented in all women. Antiresorptive treatment should be initiated in all women with preexisting fragility fractures (including vertebral morphometric fractures) and should be considered in women with areal bone mineral density (BMD) T-scores < -2.0 (or Z-scores in women aged <50 years) or those experiencing rapid bone loss (≥5% per year), taking into consideration the baseline BMD and other risk factors for fracture. Further clinical trial evidence is required to provide definitive guidance regarding criteria to initiate antiresorptive treatment, choice of agents, and duration of treatment, taking into account potential oncologic benefits of antiresorptive therapy on breast cancer-related outcomes.

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A 74-year-old man presented to the Andrology Clinic for management of potential complications of androgen deprivation therapy for prostate cancer. He had a rising prostate-specific antigen with a concurrent rise in alkaline phosphatase and bone remodeling markers. This was despite treatment with a radical prostatectomy, androgen deprivation, and anti-resorptive therapy. A follow-up dual-energy X-ray absorptiometry scan revealed a marked increase in his bone mineral density at both the lumbar spine and femoral neck. This increase, especially in the context of rising bone remodeling markers, was unlikely due to the effect of anti-resorptive therapy alone. Subsequent whole-body bone scintigraphy demonstrated a "superscan" phenomenon which is characterized by uniform and avid tracer retention throughout the skeleton, in this case due to widespread skeletal metastasis, so that the usual physiological uptake in the kidneys is no longer observed and can be misinterpreted as a "normal" scan if the absence of the kidneys is not recognized. This case highlights the importance of considering diffuse metastatic disease when there is a rapid increase in bone mineral density, even in individuals treated with anti-resorptive therapy.

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We report that a postmenopausal woman with osteoporosis developed bilateral incomplete atypical femoral fractures (AFFs) after seven years of bisphosphonate therapy. Cessation of the bisphosphonate and treatment with teriparatide was associated with near complete radiological resolution of the AFFs. After 12 months without treatment, denosumab was commenced to prevent structural deterioration. Six months later she developed recurrent bilateral AFFs. This case highlights the management dilemma in patients with ongoing bone loss but prone to stress fractures associated with antiresorptive therapy. Stopping the antiresorptive is recommended but structural decay will recur predisposing to fragility fractures. If the antiresorptive is continued, bone material composition will be further compromised predisposing to atypical fractures. Teriparatide may assist healing of stress fractures and improvement in bone matrix composition. Later antiresosrptive therapy to preserve bone microstructure may compromise material composition.

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We describe clinical and immunofluorescence findings of a patient with Brunsting-Perry-type cicatricial pemphigoid. Direct immunofluorescence showed tissue-fixed basement membrane zone antibodies similar to those characteristic of bullous pemphigoid. Circulating antibodies to the basement membrane zone were not found. Brunsting-Perry-type cicatricial pemphigoid probably represents a clinical variation midway in the cicatricial pemphigoid-bullous pemphigoid spectrum of disease. Management with intralesional corticosteroids was successful in controlling the skin lesions.

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This report calls attention to a bizarre, almost pathognomonic, cutaneous feature of lightning injury. It has been variously described as "lightning prints," "arborescent" burns, or "feathering," and has long been neglected in the dermatologic literature. Its recognition may be lifesaving in the unaccompanied comatose patient and is important because even delayed resuscitation of lightning victims can be very successful.

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