Risk Factors for Sacral Insufficiency Fractures in Cervical Cancer After Whole Pelvic Radiation Therapy

Aim: To evaluate the incidence and risk factors of sacral insufficiency fractures (SIFs), particularly dose–volume histogram (DVH) parameters, in patients with cervical cancer after whole pelvic radiation therapy (WPRT). Patients and Methods: The medical records of 61 patients with cervical cancer who underwent WPRT were retrospectively reviewed. The cumulative incidence of SIF, as well as the risk factors that could affect its incidence were assessed. Results: Of the 61 patients, 11 (18%) were diagnosed with SIF, as revealed by computed tomography. Multivariate analysis revealed that abnormal body mass index (BMI) (more than 25 kg/m2 or below 18 kg/m2) and administration of five or more chemotherapy cycles were independently associated with SIF. A slight difference was observed in the D50% (the administered dose covering half of the sacrum) between patients with and those without SIF (p=0.052). Conclusion: Thus, the D50% of the sacrum should be particularly considered in patients with abnormal BMI and five or more cycles of chemotherapy.

[1]  S. Delorme,et al.  From radiation osteitis to osteoradionecrosis: incidence and MR morphology of radiation-induced sacral pathologies following pelvic radiotherapy , 2018, European Radiology.

[2]  E. M. Pedersen,et al.  Risk Factors for Pelvic Insufficiency Fractures in Locally Advanced Cervical Cancer Following Intensity Modulated Radiation Therapy. , 2017, International journal of radiation oncology, biology, physics.

[3]  K. Bohlke,et al.  Postoperative Radiation Therapy for Endometrial Cancer: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the American Society for Radiation Oncology Evidence-Based Guideline. , 2016, Journal of oncology practice / American Society of Clinical Oncology.

[4]  D. Matei,et al.  Postoperative Radiation Therapy for Endometrial Cancer: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the American Society for Radiation Oncology Evidence-Based Guideline. , 2015, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[5]  M. Serin,et al.  Bone complications after pelvic radiation therapy: Evaluation with MRI , 2014, Journal of medical imaging and radiation oncology.

[6]  M. Folkert,et al.  Pelvic insufficiency fractures in patients with cervical and endometrial cancer treated with postoperative pelvic radiation. , 2013, Gynecologic oncology.

[7]  D. Petereit,et al.  Severe late toxicities following concomitant chemoradiotherapy compared to radiotherapy alone in cervical cancer: an inter-era analysis. , 2012, International journal of radiation oncology, biology, physics.

[8]  Y. Yamada,et al.  Fractures of the sacrum after chemoradiation for rectal carcinoma: incidence, risk factors, and radiographic evaluation. , 2012, International journal of radiation oncology, biology, physics.

[9]  G. Steineck,et al.  Relative importance of hip and sacral pain among long-term gynecological cancer survivors treated with pelvic radiotherapy and their relationships to mean absorbed doses. , 2012, International journal of radiation oncology, biology, physics.

[10]  Shin-Hyung Park,et al.  Pelvic insufficiency fracture after radiotherapy in patients with cervical cancer in the era of PET/CT , 2011, Radiation oncology journal.

[11]  G. Alço,et al.  Insufficiency fractures after pelvic radiotherapy in patients with prostate cancer. , 2010, International journal of radiation oncology, biology, physics.

[12]  A. Sood,et al.  Pelvic fractures after radiotherapy for cervical cancer , 2010, Cancer.

[13]  C. Whitlow,et al.  Imaging and Treatment of Sacral Insufficiency Fractures , 2010, American Journal of Neuroradiology.

[14]  S. Choi,et al.  Pelvic bone complications after radiation therapy of uterine cervical cancer: evaluation with MRI. , 2008, AJR. American journal of roentgenology.

[15]  Ying Lu,et al.  MRI and CT of insufficiency fractures of the pelvis and the proximal femur. , 2008, AJR. American journal of roentgenology.

[16]  Jeong-Won Lee,et al.  Pelvic insufficiency fracture after pelvic radiotherapy for cervical cancer: analysis of risk factors. , 2007, International journal of radiation oncology, biology, physics.

[17]  H. Nishitani,et al.  Pelvic bone complications following radiation therapy of gynecologic malignancies: clinical evaluation of radiation-induced pelvic insufficiency fractures. , 2006, Gynecologic oncology.

[18]  Thomas M. Link,et al.  MR imaging of therapy-induced changes of bone marrow , 2006, European Radiology.

[19]  M. Jirásek,et al.  Symptomatic osteoradionecrosis of pelvic bones in patients with gynecological malignancies—result of a long‐term follow‐up , 2006, International journal of gynecological cancer : official journal of the International Gynecological Cancer Society.

[20]  R. Daffner.  Stress fractures: Current concepts , 1978, Skeletal Radiology.

[21]  N. Okamoto,et al.  Pelvic insufficiency fractures in postmenopausal woman with advanced cervical cancer treated by radiotherapy. , 2003, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[22]  D. Lim,et al.  Pelvic insufficiency fracture after pelvic irradiation in uterine cervix cancer. , 2002, Gynecologic oncology.

[23]  Paul Symonds,et al.  Survival and recurrence after concomitant chemotherapy and radiotherapy for cancer of the uterine cervix: a systematic review and meta-analysis , 2001, The Lancet.

[24]  J. W. van der Eijken,et al.  [Insufficiency fractures of the sacrum]. , 1999, Nederlands tijdschrift voor geneeskunde.

[25]  N. Howarth,et al.  Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof , 1997, Skeletal Radiology.

[26]  E. Rofstad,et al.  Incidence of radiation-induced insufficiency fractures of the female pelvis: evaluation with MR imaging. , 1996, AJR. American journal of roentgenology.

[27]  J. Pouchot,et al.  Sacral Insufficiency Fractures: An Easily Overlooked Cause of Back Pain in Elderly Women , 1996 .

[28]  K. Greven,et al.  Radiation Osteitis and Insufficiency Fractures After Pelvic Irradiation for Gynecologic Malignancies , 1994, American journal of clinical oncology.

[29]  S. Takahashi,et al.  Radiation-induced insufficiency fractures of the pelvis: evaluation with 99mTc-methylene diphosphonate scintigraphy. , 1992, AJR. American journal of roentgenology.

[30]  C. Golimbu,et al.  Radiation induced fractures of sacrum: CT diagnosis. , 1988, Journal of computer assisted tomography.

[31]  J. Neff,et al.  Pubic and sacral insufficiency fractures: clinical course and radiologic findings. , 1985, AJR. American journal of roentgenology.

[32]  H. Lourie.  Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. , 1982, JAMA.