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Title: Risk Factors for Pelvic Insufficiency Fractures in Locally Advanced Cervical Cancer Following Intensity Modulated Radiation Therapy

Abstract

Purpose: To investigate the incidence of and risk factors for pelvic insufficiency fracture (PIF) after definitive chemoradiation therapy for locally advanced cervical cancer (LACC). Methods and Materials: We analyzed 101 patients with LACC treated from 2008-2014. Patients received weekly cisplatin and underwent external beam radiation therapy with 45 Gy in 25 fractions (node-negative patients) or 50 Gy in 25 fractions with a simultaneous integrated boost of 60 Gy in 30 fractions (node-positive patients). Pulsed dose rate magnetic resonance imaging guided adaptive brachytherapy was given in addition. Follow-up magnetic resonance imaging was performed routinely at 3 and 12 months after the end of treatment or based on clinical indication. PIF was defined as a fracture line with or without sclerotic changes in the pelvic bones. D{sub 50%} and V{sub 55Gy} were calculated for the os sacrum and jointly for the os ileum and pubis. Patient- and treatment-related factors including dose were analyzed for correlation with PIF. Results: The median follow-up period was 25 months. The median age was 50 years. In 20 patients (20%), a median of 2 PIFs (range, 1-3 PIFs) were diagnosed; half were asymptomatic. The majority of the fractures were located in the sacrum (77%). Age was a significant risk factor (P<.001), and the incidence ofmore » PIF was 4% and 37% in patients aged ≤50 years and patients aged >50 years, respectively. Sacrum D{sub 50%} was a significant risk factor in patients aged >50 years (P=.04), whereas V{sub 55Gy} of the sacrum and V{sub 55Gy} of the pelvic bones were insignificant (P=.33 and P=.18, respectively). A dose-effect curve for sacrum D{sub 50%} in patients aged >50 years showed that reduction of sacrum D{sub 50%} from 40 Gy{sub EQD2} to 35 Gy{sub EQD2} reduces PIF risk from 45% to 22%. Conclusions: PIF is common after treatment of LACC and is mainly seen in patients aged >50 years. Our data indicate that PIFs are not related to lymph node boosts but rather to dose and volume associated with irradiation of the elective pelvic target. Reducing the prescribed elective dose from 50 to 45 Gy may reduce the risk of PIF considerably.« less

Authors:
 [1]; ;  [2];  [3]; ;  [1];  [1];  [4]
  1. Department of Oncology, Aarhus University Hospital, Aarhus (Denmark)
  2. Department of Radiotherapy, Aarhus University Hospital, Aarhus (Denmark)
  3. Department of Medical Physics, Aarhus University Hospital, Aarhus (Denmark)
  4. (Denmark)
Publication Date:
OSTI Identifier:
22649893
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 97; Journal Issue: 5; Other Information: Copyright (c) 2017 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BRACHYTHERAPY; CHEMOTHERAPY; DOSE RATES; ELDERLY PEOPLE; EXTERNAL BEAM RADIATION THERAPY; GY RANGE 10-100; LYMPH NODES; MAGNETIC RESONANCE; NEOPLASMS; NMR IMAGING; PATIENTS; RADIATION HAZARDS; SMALL INTESTINE

Citation Formats

Ramlov, Anne, E-mail: anraml@rm.dk, Pedersen, Erik Morre, Røhl, Lisbeth, Worm, Esben, Fokdal, Lars, Lindegaard, Jacob Chr., Tanderup, Kari, and Department of Medical Physics, Aarhus University Hospital, Aarhus. Risk Factors for Pelvic Insufficiency Fractures in Locally Advanced Cervical Cancer Following Intensity Modulated Radiation Therapy. United States: N. p., 2017. Web. doi:10.1016/J.IJROBP.2017.01.026.
Ramlov, Anne, E-mail: anraml@rm.dk, Pedersen, Erik Morre, Røhl, Lisbeth, Worm, Esben, Fokdal, Lars, Lindegaard, Jacob Chr., Tanderup, Kari, & Department of Medical Physics, Aarhus University Hospital, Aarhus. Risk Factors for Pelvic Insufficiency Fractures in Locally Advanced Cervical Cancer Following Intensity Modulated Radiation Therapy. United States. doi:10.1016/J.IJROBP.2017.01.026.
Ramlov, Anne, E-mail: anraml@rm.dk, Pedersen, Erik Morre, Røhl, Lisbeth, Worm, Esben, Fokdal, Lars, Lindegaard, Jacob Chr., Tanderup, Kari, and Department of Medical Physics, Aarhus University Hospital, Aarhus. Sat . "Risk Factors for Pelvic Insufficiency Fractures in Locally Advanced Cervical Cancer Following Intensity Modulated Radiation Therapy". United States. doi:10.1016/J.IJROBP.2017.01.026.
@article{osti_22649893,
title = {Risk Factors for Pelvic Insufficiency Fractures in Locally Advanced Cervical Cancer Following Intensity Modulated Radiation Therapy},
author = {Ramlov, Anne, E-mail: anraml@rm.dk and Pedersen, Erik Morre and Røhl, Lisbeth and Worm, Esben and Fokdal, Lars and Lindegaard, Jacob Chr. and Tanderup, Kari and Department of Medical Physics, Aarhus University Hospital, Aarhus},
abstractNote = {Purpose: To investigate the incidence of and risk factors for pelvic insufficiency fracture (PIF) after definitive chemoradiation therapy for locally advanced cervical cancer (LACC). Methods and Materials: We analyzed 101 patients with LACC treated from 2008-2014. Patients received weekly cisplatin and underwent external beam radiation therapy with 45 Gy in 25 fractions (node-negative patients) or 50 Gy in 25 fractions with a simultaneous integrated boost of 60 Gy in 30 fractions (node-positive patients). Pulsed dose rate magnetic resonance imaging guided adaptive brachytherapy was given in addition. Follow-up magnetic resonance imaging was performed routinely at 3 and 12 months after the end of treatment or based on clinical indication. PIF was defined as a fracture line with or without sclerotic changes in the pelvic bones. D{sub 50%} and V{sub 55Gy} were calculated for the os sacrum and jointly for the os ileum and pubis. Patient- and treatment-related factors including dose were analyzed for correlation with PIF. Results: The median follow-up period was 25 months. The median age was 50 years. In 20 patients (20%), a median of 2 PIFs (range, 1-3 PIFs) were diagnosed; half were asymptomatic. The majority of the fractures were located in the sacrum (77%). Age was a significant risk factor (P<.001), and the incidence of PIF was 4% and 37% in patients aged ≤50 years and patients aged >50 years, respectively. Sacrum D{sub 50%} was a significant risk factor in patients aged >50 years (P=.04), whereas V{sub 55Gy} of the sacrum and V{sub 55Gy} of the pelvic bones were insignificant (P=.33 and P=.18, respectively). A dose-effect curve for sacrum D{sub 50%} in patients aged >50 years showed that reduction of sacrum D{sub 50%} from 40 Gy{sub EQD2} to 35 Gy{sub EQD2} reduces PIF risk from 45% to 22%. Conclusions: PIF is common after treatment of LACC and is mainly seen in patients aged >50 years. Our data indicate that PIFs are not related to lymph node boosts but rather to dose and volume associated with irradiation of the elective pelvic target. Reducing the prescribed elective dose from 50 to 45 Gy may reduce the risk of PIF considerably.},
doi = {10.1016/J.IJROBP.2017.01.026},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 5,
volume = 97,
place = {United States},
year = {Sat Apr 01 00:00:00 EDT 2017},
month = {Sat Apr 01 00:00:00 EDT 2017}
}