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Jensenius KC, Ginnerup PB, Jeppe K, Cecilie L, Lycke K, Garm KL. Pelvic insufficiency fractures and bone pain after radiotherapy for anal cancer -Relation to pelvic bone dose volume parameters. Adv Radiat Oncol 2022; 8:101110. [DOI: 10.1016/j.adro.2022.101110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
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Haas S, Mikkelsen AH, Kronborg C, Oggesen BT, Faaborg PM, Serup-Hansen E, Spindler KLG, Christensen P. Management of late adverse effects after chemoradiation for anal cancer. Acta Oncol 2021; 60:1688-1701. [PMID: 34845967 DOI: 10.1080/0284186x.2021.1983208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects. MATERIALS AND METHODS Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations. SCIENTIFIC EVIDENCE Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available. CONCLUSION Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.
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Affiliation(s)
- Susanne Haas
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
| | | | - Camilla Kronborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Pia Moeller Faaborg
- Department of Surgery, Vejle Hospital, Danish Colorectal Cancer Centre South, Vejle, Denmark
| | | | | | - Peter Christensen
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
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Pendleton MM, Emerzian SR, Sadoughi S, Li A, Liu JW, Tang SY, O'Connell GD, Sibonga JD, Alwood JS, Keaveny TM. Relations Between Bone Quantity, Microarchitecture, and Collagen Cross-links on Mechanics Following In Vivo Irradiation in Mice. JBMR Plus 2021; 5:e10545. [PMID: 34761148 PMCID: PMC8567491 DOI: 10.1002/jbm4.10545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/20/2021] [Indexed: 01/22/2023] Open
Abstract
Humans are exposed to ionizing radiation via spaceflight or cancer radiotherapy, and exposure from radiotherapy is known to increase risk of skeletal fractures. Although irradiation can reduce trabecular bone mass, alter trabecular microarchitecture, and increase collagen cross‐linking, the relative contributions of these effects to any loss of mechanical integrity remain unclear. To provide insight, while addressing both the monotonic strength and cyclic‐loading fatigue life, we conducted total‐body, acute, gamma‐irradiation experiments on skeletally mature (17‐week‐old) C57BL/6J male mice (n = 84). Mice were administered doses of either 0 Gy (sham), 1 Gy (motivated by cumulative exposures from a Mars mission), or 5 Gy (motivated by clinical therapy regimens) with retrieval of the lumbar vertebrae at either a short‐term (11‐day) or long‐term (12‐week) time point after exposure. Micro‐computed tomography was used to assess trabecular and cortical quantity and architecture, biochemical composition assays were used to assess collagen quality, and mechanical testing was performed to evaluate vertebral compressive strength and fatigue life. At 11 days post‐exposure, 5 Gy irradiation significantly reduced trabecular mass (p < 0.001), altered microarchitecture (eg, connectivity density p < 0.001), and increased collagen cross‐links (p < 0.001). Despite these changes, vertebral strength (p = 0.745) and fatigue life (p = 0.332) remained unaltered. At 12 weeks after 5 Gy exposure, the trends in trabecular bone persisted; in addition, regardless of irradiation, cortical thickness (p < 0.01) and fatigue life (p < 0.01) decreased. These results demonstrate that the highly significant effects of 5 Gy total‐body irradiation on the trabecular bone morphology and collagen cross‐links did not translate into detectable effects on vertebral mechanics. The only mechanical deficits observed were associated with aging. Together, these vertebral results suggest that for spaceflight, irradiation alone will likely not alter failure properties, and for radiotherapy, more investigations that include post‐exposure time as a positive control and testing of both failure modalities are needed to determine the cause of increased fracture risk. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Megan M Pendleton
- Department of Mechanical Engineering University of California Berkeley CA USA
| | - Shannon R Emerzian
- Department of Mechanical Engineering University of California Berkeley CA USA
| | - Saghi Sadoughi
- Department of Mechanical Engineering University of California Berkeley CA USA
| | - Alfred Li
- Endocrine Research Unit University of California and Veteran Affairs Medical Center San Francisco CA USA
| | - Jennifer W Liu
- Department of Orthopaedic Surgery Washington University St. Louis MO USA
| | - Simon Y Tang
- Department of Orthopaedic Surgery Washington University St. Louis MO USA.,Department of Biomedical Engineering Washington University St. Louis MO USA.,Department of Mechanical Engineering and Materials Science Washington University St. Louis MO USA
| | - Grace D O'Connell
- Department of Mechanical Engineering University of California Berkeley CA USA.,Department of Orthopaedic Surgery University of California San Francisco CA USA
| | - Jean D Sibonga
- Biomedical Research and Environmental Sciences Division NASA Johnson Space Center Houston TX USA
| | - Joshua S Alwood
- Space Biosciences Division NASA Ames Research Center Moffett Field CA USA
| | - Tony M Keaveny
- Department of Mechanical Engineering University of California Berkeley CA USA.,Department of Bioengineering University of California Berkeley CA USA
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Almendros-Abellán VM, Castro-García M, Canales-Vázquez J, Berenguel-Herraiz P, Sabater S. Alterations in femoral neck strength following pelvic irradiation. A finite element analysis of simulated eccentric forces using bone density data derived from CT. Bone 2021; 145:115865. [PMID: 33513450 DOI: 10.1016/j.bone.2021.115865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Radiotherapy is known to produce long-term skeletal complications. We aim to evaluate the biomechanical effect on femoral neck bone from hypothetical eccentric loads on pre- and post-radiotherapy CT-images for patients treated for rectal cancer. MATERIAL AND METHODS Pre- and post-radiotherapy CT-images of rectal cancer from 10 patients were selected randomly. The cortical and trabecular bone was segmented by hand. The biomechanical simulations of 4 eccentric loads and one load aligned with the femoral neck axis were completed using finite element analysis (FEA) in both pre- and post-patient models. RESULTS A comparative statistical study was completed of pre- and post-radiotherapy patient models of stress and displacement factors. Significant differences were found in eccentric loads in both factors. Natural load has a significant difference in stress, but no differences were found for displacements. The absolute difference in eccentric load applied to the anterior area location on the same patient implies from 5.3% to 40.5% of the stress yield values reported in previous studies. CONCLUSIONS Loads applied to the anterior area of the femoral head must be considered in fracture simulations because the percentage of yield stress of pre- and post-irradiated bones shows a significant biomechanical change.
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Affiliation(s)
- Víctor M Almendros-Abellán
- D-ENERMAT, Instituto de Energías Renovables, University of Castilla-La Mancha, Paseo Investigación 1, Building 3, 02071 Albacete, Spain; CADE Engineered Technologies, Albacete, Spain
| | - Miguel Castro-García
- D-ENERMAT, Instituto de Energías Renovables, University of Castilla-La Mancha, Paseo Investigación 1, Building 3, 02071 Albacete, Spain
| | - Jesús Canales-Vázquez
- D-ENERMAT, Instituto de Energías Renovables, University of Castilla-La Mancha, Paseo Investigación 1, Building 3, 02071 Albacete, Spain
| | | | - Sebastià Sabater
- Dept. of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Spain.
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Wilson LJ, Newhauser WD. Generalized approach for radiotherapy treatment planning by optimizing projected health outcome: preliminary results for prostate radiotherapy patients. Phys Med Biol 2021; 66:065007. [PMID: 33545710 DOI: 10.1088/1361-6560/abe3cf] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Research in cancer care increasingly focuses on survivorship issues, e.g. managing disease- and treatment-related morbidity and mortality occurring during and after treatment. This necessitates innovative approaches that consider treatment side effects in addition to tumor cure. Current treatment-planning methods rely on constrained iterative optimization of dose distributions as a surrogate for health outcomes. The goal of this study was to develop a generally applicable method to directly optimize projected health outcomes. We developed an outcome-based objective function to guide selection of the number, angle, and relative fluence weight of photon and proton radiotherapy beams in a sample of ten prostate-cancer patients by optimizing the projected health outcome. We tested whether outcome-optimized radiotherapy (OORT) improved the projected longitudinal outcome compared to dose-optimized radiotherapy (DORT) first for a statistically significant majority of patients, then for each individual patient. We assessed whether the results were influenced by the selection of treatment modality, late-risk model, or host factors. The results of this study revealed that OORT was superior to DORT. Namely, OORT maintained or improved the projected health outcome of photon- and proton-therapy treatment plans for all ten patients compared to DORT. Furthermore, the results were qualitatively similar across three treatment modalities, six late-risk models, and 10 patients. The major finding of this work was that it is feasible to directly optimize the longitudinal (i.e. long- and short-term) health outcomes associated with the total (i.e. therapeutic and stray) absorbed dose in all of the tissues (i.e. healthy and diseased) in individual patients. This approach enables consideration of arbitrary treatment factors, host factors, health endpoints, and times of relevance to cancer survivorship. It also provides a simpler, more direct approach to realizing the full beneficial potential of cancer radiotherapy.
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Affiliation(s)
- Lydia J Wilson
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA 70803-4001, United States of America
| | - Wayne D Newhauser
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA 70803-4001, United States of America.,Mary Bird Perkins Cancer Center, 4950 Essen Lane, Baton Rouge, LA 70809, United States of America
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Mir R, Dragan AD, Mistry HB, Tsang YM, Padhani AR, Hoskin P. Sacral Insufficiency Fracture Following Pelvic Radiotherapy in Gynaecological Malignancies: Development of a Predictive Model. Clin Oncol (R Coll Radiol) 2020; 33:e101-e109. [PMID: 33127236 DOI: 10.1016/j.clon.2020.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/27/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022]
Abstract
AIMS To investigate the time-to-event and the evolution of sacral insufficiency fractures in gynaecological patients receiving pelvic external beam radiotherapy (EBRT) in relation to dosimetric and imaging parameters across a spectrum of radiotherapy delivery techniques, and to develop a predictive model with a clinical nomogram to identify those at risk of sacral insufficiency fracture. MATERIALS AND METHODS Patients who received radical or adjuvant pelvic EBRT for gynaecological malignancy between 2014 and 2019 were identified. The data collected were: demographics and clinical details; radiotherapy planning data: dose, fractionation, technique (fixed-field intensity-modulated radiotherapy, adaptive arc, and non-adaptive arc), 60 Gy simultaneous integrated boost. Each plan was examined to determine the sacral dose in 5%/Gy3 increments. Follow-up magnetic resonance scans were reviewed for insufficiency fractures, defined as linear low T1-weighted signal intensity with a high short-T1 inversion recovery (STIR) signal. The site of insufficiency fracture was recreated on the planning computed tomography, the dose to insufficiency fracture contours was recorded and insufficiency fractures were determined as healed with resolution of high STIR signal. Univariable analysis was conducted of the clinical variables. The area under the receiver operator characteristic curve and odds ratio of the risk prediction model with 95% confidence interval are reported with a nomogram for use in clinical practice. RESULTS 115 patients were identified; the median imaging follow-up was 12 months (2-47). 37.4% developed sacral insufficiency fractures; 93.0% were detected within 12 months of EBRT. At the final radiological follow-up, 83.7% of insufficiency fractures remained active. The radiotherapy delivery technique was not associated with insufficiency fracture after adjusting for patient age (P = 0.115). The location of the 60 Gy simultaneous integrated boost planning target volume did not impact upon the site of insufficiency fracture or the dose received by the insufficiency fracture sites. Age and V40Gy3 are predictors for insufficiency fracture and form the clinical risk model (receiver operator characteristic 0.72). CONCLUSIONS Age and V40Gy3 predict sacral insufficiency fractures; future work should focus on optimising radiotherapy planning with adoption of a bone-sparing planning approach for those patients at high risk of insufficiency fracture.
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Affiliation(s)
- R Mir
- Mount Vernon Cancer Centre, Northwood, UK; National Radiotherapy Trials Quality Assurance (RTTQA) Group, UK
| | - A D Dragan
- Paul Strickland Scanner Centre, Northwood, UK
| | - H B Mistry
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Division of Pharmacy, University of Manchester, Manchester, UK
| | - Y M Tsang
- Mount Vernon Cancer Centre, Northwood, UK
| | - A R Padhani
- Paul Strickland Scanner Centre, Northwood, UK
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, UK; National Radiotherapy Trials Quality Assurance (RTTQA) Group, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK.
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Rasmusson E, Nilsson P, Kjellén E, Gunnlaugsson A. Long-Term Risk of Hip Complications After Radiation Therapy for Prostate Cancer: A Dose-Response Study. Adv Radiat Oncol 2020; 6:100571. [PMID: 33665484 PMCID: PMC7897764 DOI: 10.1016/j.adro.2020.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/28/2020] [Accepted: 09/19/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose The aim of the present study was to analyze the long-term incidence of hip complications after external beam radiation therapy compared with age-matched controls from the general population. We also investigated whether there were any dose-response associations. Methods and materials A total of 349 patients with prostate cancer treated to curative dose with external beam radiation therapy between 1997 and 2002 were included in the study. Physical and fractionation-corrected dose-volume descriptors were derived for the femoral heads, pubic bone, and sacrum. Information on skeletal events was collected for the patients and 1661 matched controls through the Prostate Cancer database Sweden. Uni- and multivariable Cox proportional hazard regressions were used to analyze the time to event. Results Data from 346 patients were available for analysis. The median mean physical dose and corresponding equivalent 2-Gy/fraction dose (EQD2) to the femoral heads were 35.5 Gy and 28.7 Gy, respectively. The median follow-up time was 16.0 years. During the follow up, 12 hip fractures occurred. Hip osteoarthritis was diagnosed in 36 cases, with 29 cases leading to replacement surgery. No increased risk of hip fractures was found. Hip osteoarthritis was the only event for which a statistically significant difference was found between the irradiated cohort and the controls (cause-specific hazard ratio: 1.56; 95% confidence interval, 1.07-2.26; P = .02). The cumulative incidence of osteoarthritis at 10 years was 8.1% and 4.9% in the irradiated cohort and the controls, respectively. A significant relationship between osteoarthritis and the volume of the femoral head receiving ≥40 Gy (ie, EQD2) was found. Conclusions In this study of 346 patients treated with conventional radiation therapy, we found no increased risk of hip fracture but an increased risk of clinically relevant osteoarthritis at long-term follow up. Our results indicate a dose-response relationship between osteoarthritis and the volume of the femoral head receiving an EQD2 dose of ≥40 Gy.
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Affiliation(s)
- Elisabeth Rasmusson
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden.,Lund University, Faculty of Medicine, Department of Clinical Sciences, Lund, Oncology and Pathology, Lund, Sweden
| | - Per Nilsson
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden.,Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Radiation Physics, Lund, Sweden
| | - Elisabeth Kjellén
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden.,Lund University, Faculty of Medicine, Department of Clinical Sciences, Lund, Oncology and Pathology, Lund, Sweden
| | - Adalsteinn Gunnlaugsson
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden.,Lund University, Faculty of Medicine, Department of Clinical Sciences, Lund, Oncology and Pathology, Lund, Sweden
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Farris MK, Helis CA, Hughes RT, LeCompte MC, Borg AM, Nieto K, Munley MT, Willey JS. Bench to Bedside: Animal Models of Radiation Induced Musculoskeletal Toxicity. Cancers (Basel) 2020; 12:cancers12020427. [PMID: 32059447 PMCID: PMC7073177 DOI: 10.3390/cancers12020427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 12/29/2022] Open
Abstract
Ionizing radiation is a critical aspect of current cancer therapy. While classically mature bone was thought to be relatively radio-resistant, more recent data have shown this to not be the case. Radiation therapy (RT)-induced bone loss leading to fracture is a source of substantial morbidity. The mechanisms of RT likely involve multiple pathways, including changes in angiogenesis and bone vasculature, osteoblast damage/suppression, and increased osteoclast activity. The majority of bone loss appears to occur rapidly after exposure to ionizing RT, with significant changes in cortical thickness being detectable on computed tomography (CT) within three to four months. Additionally, there is a dose–response relationship. Cortical thinning is especially notable in areas of bone that receive >40 gray (Gy). Methods to mitigate toxicity due to RT-induced bone loss is an area of active investigation. There is an accruing clinical trial investigating the use of risderonate, a bisphosphonate, to prevent rib bone loss in patients undergoing lung stereotactic body radiation therapy (SBRT). Additionally, several other promising therapeutic/preventative approaches are being explored in preclinical studies, including parathyroid hormone (PTH), amifostine, and mechanical loading of irradiated bones.
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Sullivan LK, Livingston EW, Lau AG, Rao-Dayton S, Bateman TA. A Mouse Model for Skeletal Structure and Function Changes Caused by Radiation Therapy and Estrogen Deficiency. Calcif Tissue Int 2020; 106:180-193. [PMID: 31583426 DOI: 10.1007/s00223-019-00617-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/18/2019] [Indexed: 12/23/2022]
Abstract
Radiation therapy and estrogen deficiency can damage healthy bone and lead to an increased fracture risk. The goal of this study is to develop a mouse model for radiation therapy using a fractionated biologically equivalent dose for cervical cancer treatment in both pre- and postmenopausal women. Thirty-two female C57BL/6 mice 13 weeks of age were divided into four groups: Sham + non-irradiated (SHAM + NR), Sham + irradiated (SHAM + IRR), ovariectomy + non-irradiated (OVX + NR) and ovariectomy + irradiated (OVX + IRR). The irradiated mice received a 6 Gy dose of X-rays to the hindlimbs at Day 2, Day 4 and Day 7 (18 Gy total). Tissues were collected at Day 35. DEXA, microCT analysis and FEA were used to quantify structural and functional changes at the proximal tibia, midshaft femur, proximal femur and L1 vertebra. There was a significant (p < 0.05) decline in proximal tibia trabecular BV/TV from (1) IRR compared to NR mice within Sham (- 46%) and OVX (- 41%); (2) OVX versus Sham within NR mice (- 36%) and IRR mice (- 30%). With homogenous material properties applied to the proximal tibia mesh using FEA, there was (1) an increase in whole bone (trabecular + cortical) structural stiffness from IRR compared to NR mice within Sham (+ 10%) and OVX (+ 15%); (2) a decrease in stiffness from OVX versus Sham within NR mice (- 18%) and IRR mice (- 14%). Fractionated irradiation and ovariectomy both had a negative effect on skeletal microarchitecture. Ovariectomy had a systemic effect, while skeletal radiation damage was largely specific to trabecular bone within the X-ray field.
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Affiliation(s)
- Lindsay K Sullivan
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, USA.
| | - Eric W Livingston
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, USA
| | - Anthony G Lau
- Department of Biomedical Engineering, The College of New Jersey, Ewing, USA
| | - Sheila Rao-Dayton
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, USA
| | - Ted A Bateman
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, USA
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, USA
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Sapienza LG, Salcedo MP, Ning MS, Jhingran A, Klopp AH, Calsavara VF, Schmeler KM, Leite Gomes MJ, de Freitas Carvalho E, Baiocchi G. Pelvic Insufficiency Fractures After External Beam Radiation Therapy for Gynecologic Cancers: A Meta-analysis and Meta-regression of 3929 Patients. Int J Radiat Oncol Biol Phys 2019; 106:475-484. [PMID: 31580930 DOI: 10.1016/j.ijrobp.2019.09.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE To estimate the overall rate, symptomatic proportion, and most common sites of pelvic insufficiency fracture (PIF) after external beam radiation therapy for gynecologic cancers based on posttreatment computed tomography, magnetic resonance imaging, positron emission tomography, or bone scintigraphy. METHODS AND MATERIALS A systematic search of databases (PubMed and EMBASE) was performed (CRD42019125679). The pooled summary of overall PIF and the proportion of symptomatic cases were calculated using the random-effects model weighted by the inverse variance. A multivariate meta-regression was performed to evaluate potential sources of heterogeneity regarding PIF fractures. RESULTS Twenty-one studies met the inclusion criteria (total 3929 patients). Five hundred four patients developed PIF, translating to an overall rate of 14% (95% confidence interval, 10%-18%, based on 21 studies). Among these cases with PIF, the proportion of symptomatic patients was 61% (95% confidence interval, 52%-69%, based on 14 studies). The total number of PIFs was 704 (mean, 1.72 PIFs per each patient to develop PIF, based on 14 studies). More recent series (P = .0074) and the use of intensity modulated radiation therapy (P = .0299) were associated with lower fracture rates. The most common fracture sites were sacroiliac joint (39.7%), body of the sacrum (33.9%), pubis (13%), lumbar vertebra (7%), iliac bone (2.8%), acetabulum (2.1%), and femoral head/neck (1.5%). The median time to fracture was 7.1 to 19 months after radiation therapy. CONCLUSIONS The incidence of PIF after radiation therapy for gynecologic cancers is high (14%), with the majority affecting the sacral bone or joint (73.6%), although this risk appears to be lower with intensity modulated radiation therapy. Posttreatment bone surveillance is warranted in this population because nearly 40% of patients were asymptomatic at the time of PIF diagnosis.
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Affiliation(s)
- Lucas Gomes Sapienza
- Department of Internal Medicine, Michigan State University College of Human Medicine, Ascension Providence Hospital, Southfield, Michigan.
| | - Mila Pontremoli Salcedo
- Department of Obstetrics and Gynecology, Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Brazil
| | - Matthew Stephen Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Kathleen M Schmeler
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Maria José Leite Gomes
- Department of Radiation Oncology, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Glauco Baiocchi
- Department of Gynecologic Oncology, A.C. Camargo Cancer Center, São Paulo, Brazil
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Kang YM, Chao TF, Wang TH, Hu YW. Increased risk of pelvic fracture after radiotherapy in rectal cancer survivors: A propensity matched study. Cancer Med 2019; 8:3639-3647. [PMID: 31104362 PMCID: PMC6639197 DOI: 10.1002/cam4.2030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 12/12/2022] Open
Abstract
To determine whether radiotherapy (RT) can increase pelvic fracture risk in rectal cancer survivors. Rectal cancer patients who underwent curative surgery between 1996 and 2011 in Taiwan were retrospectively studied using the National Health Insurance Research Database (NHIRD) of Taiwan. ICD‐9 Codes 808, 805.4‐805.7, 806.4‐806.7, and 820 (including pelvic, sacrum, lumbar, and femoral neck fracture) were defined as pelvic fracture. Propensity scores for RT, age, and sex were used to perform one‐to‐one matches between the RT and non‐RT group. Risks of pelvic and arm fractures were compared by multivariable Cox regression. Of the 32 689 patients, 7807 (23.9%) received RT, and 1616 suffered from a pelvic fracture (incidence rate: 1.17/100 person‐years). The median time to pelvic fracture was 2.47 years. After matching, 6952 patients each in the RT and non‐RT groups were analyzed. RT was associated with an increased risk of pelvic fractures in the multivariable Cox model (hazard ratio (HR): 1.246, 95% confidence interval (CI): 1.037‐1.495, P = 0.019) but not with arm fractures (HR: 1.013, 95% CI: 0.814‐1.259, P = 0.911). Subgroup analyses revealed that RT was associated with a higher pelvic fracture rate in women (HR: 1.431, 95% CI: 1.117‐1.834) but not in men, and the interaction between sex and RT was significant (P = 0.03). The HR of pelvic fracture increased 2‐4 years after RT (HR: 1.707, 95% CI: 1.150‐2.534, P = 0.008). An increased risk of pelvic fracture is noted in rectal cancer survivors, especially women, who receive RT.
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Affiliation(s)
- Yu-Mei Kang
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ti-Hao Wang
- Department of Radiation Oncology, China Medical University Hospital, Taipei, Taiwan
| | - Yu-Wen Hu
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Beavers KM, Walkup MP, Weaver AA, Lenchik L, Kritchevsky SB, Nicklas BJ, Ambrosius WT, Stitzel JD, Register TC, Shapses SA, Marsh AP, Rejeski WJ. Effect of Exercise Modality During Weight Loss on Bone Health in Older Adults With Obesity and Cardiovascular Disease or Metabolic Syndrome: A Randomized Controlled Trial. J Bone Miner Res 2018; 33:2140-2149. [PMID: 30088288 PMCID: PMC6545884 DOI: 10.1002/jbmr.3555] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/21/2018] [Accepted: 07/07/2018] [Indexed: 01/08/2023]
Abstract
The objective of this study was to determine the ability of either aerobic or resistance training to counter weight-loss-associated bone loss in older adults. There were 187 older adults (67 years, 70% women, 64% white) with obesity (BMI = 34.5 ± 3.7 kg/m2 ) and cardiovascular disease and/or metabolic syndrome who were randomized to participate in an 18-month, community-based trial, with a follow-up assessment at 30 months. Intervention arms included: weight loss alone (WL; 7% to 10% baseline weight), WL plus aerobic training (WL + AT), and WL plus resistance training (WL + RT), as well as DXA-acquired total hip, femoral neck, and lumbar spine areal bone mineral density (aBMD), and trabecular bone score (TBS). Biomarkers of bone turnover (procollagen type 1 N-terminal propeptide, C-terminal telopeptide of type 1 collagen) were measured at baseline, 6, 18, and 30 (aBMD and TBS only) months. CT-acquired hip and spine volumetric BMD (vBMD), cortical thickness, and bone strength were measured in a subset at baseline (n = 55) and 18 months. Total hip aBMD was reduced by 2% in all groups at 18 months, with a primary analysis showing no significant treatment effects for any DXA, biomarker, or CT outcome. After adjustment for WL and follow-up at 30 months, secondary analyses revealed that total hip [-0.018 (-0.023 to -0.012) g/cm2 versus -0.025 (-0.031 to -0.019) g/cm2 ; p = 0.05] and femoral neck [-0.01 (-0.009 to 0.008) g/cm2 versus -0.011 (-0.020 to -0.002) g/cm2 ; p = 0.06] aBMD estimates were modestly attenuated in the WL + RT group compared with the WL group. Additionally, lumbar spine aBMD was increased in the WL [0.015 (0.007 to 0.024) g/cm2 ] and the WL + RT [0.009 (0.000 to 0.017) g/cm2 ] groups compared with the WL + AT [-0.003 (-0.012 to 0.005)g/cm2 ] group; both p ≤ 0.01. Community-based exercise does not prevent bone loss during active WL in older adults; however, adding RT may help minimize long-term hip bone loss. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Kristen M Beavers
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA
| | - Michael P Walkup
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ashley A Weaver
- Department of Bioengineering, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen B Kritchevsky
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Barbara J Nicklas
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Walter T Ambrosius
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joel D Stitzel
- Department of Bioengineering, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Thomas C Register
- Department of Pathology-Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Sue A Shapses
- Department of Nutrition, Rutgers University, New Brunswick, NJ, USA
| | - Anthony P Marsh
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA
| | - W Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA
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Abstract
PURPOSE OF REVIEW Cortical bone mapping (CBM) is a technique for measuring localised skeletal changes from computed tomography (CT) images. It can provide measurements with accuracy surpassing the underlying imaging resolution. CBM can detect changes in several properties of the cortex, with no prior assumptions about the likely location of said changes. This paper summarises the theory behind CBM, discusses its strengths and limitations, and reviews some studies in which it has been applied. RECENT FINDINGS CBM has revealed associations between fracture risk and cortical properties in specific regions of the proximal femur which present feasible therapeutic targets. Analyses of several pharmaceutical and exercise interventions quantify effects that are distinct both in location and in the nature of the micro-architectural changes. CBM has illuminated age-related changes in the proximal femur and has recently been applied to other bones, as well as to the assessment of cartilage. The CBM processing pipeline is designed primarily for large cohort studies. Its main impact thus far has not been in the realm of clinical practice, but rather to improve our fundamental understanding of localised bone structure and changes.
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Affiliation(s)
- Graham Treece
- Department of Engineering, University of Cambridge, Cambridge, CB2 1PZ, UK.
| | - Andrew Gee
- Department of Engineering, University of Cambridge, Cambridge, CB2 1PZ, UK
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Farris M, McTyre ER, Okoukoni C, Dugan G, Johnson BJ, Blackstock AW, Munley MT, Bourland JD, Cline JM, Willey JS. Cortical Thinning and Structural Bone Changes in Non-Human Primates after Single-Fraction Whole-Chest Irradiation. Radiat Res 2018; 190:63-71. [PMID: 29738279 PMCID: PMC6036641 DOI: 10.1667/rr15007.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Stereotactic body radiation therapy (SBRT) is associated with an increased risk of vertebral compression fracture. While bone is typically considered radiation resistant, fractures frequently occur within the first year of SBRT. The goal of this work was to determine if rapid deterioration of bone occurs in vertebrae after irradiation. Sixteen male rhesus macaque non-human primates (NHPs) were analyzed after whole-chest irradiation to a midplane dose of 10 Gy. Ages at the time of exposure varied from 45-134 months. Computed tomography (CT) scans were taken 2 months prior to irradiation and 2, 4, 6 and 8 months postirradiation for all animals. Bone mineral density (BMD) and cortical thickness were calculated longitudinally for thoracic (T) 9, lumbar (L) 2 and L4 vertebral bodies; gross morphology and histopathology were assessed per vertebra. Greater mortality (related to pulmonary toxicity) was noted in NHPs <50 months at time of exposure versus NHPs >50 months ( P = 0.03). Animals older than 50 months at time of exposure lost cortical thickness in T9 by 2 months postirradiation ( P = 0.0009), which persisted to 8 months. In contrast, no loss of cortical thickness was observed in vertebrae out-of-field (L2 and L4). Loss of BMD was observed by 4 months postirradiation for T9, and 6 months postirradiation for L2 and L4 ( P < 0.01). For NHPs younger than 50 months at time of exposure, both cortical thickness and BMD decreased in T9, L2 and L4 by 2 months postirradiation ( P < 0.05). Regions that exhibited the greatest degree of cortical thinning as determined from CT scans also exhibited increased porosity histologically. Rapid loss of cortical thickness was observed after high-dose chest irradiation in NHPs. Younger age at time of exposure was associated with increased pneumonitis-related mortality, as well as greater loss of both BMD and cortical thickness at both in- and out-of-field vertebrae. Older NHPs exhibited rapid loss of BMD and cortical thickness from in-field vertebrae, but only loss of BMD in out-of-field vertebrae. Bone is sensitive to high-dose radiation, and rapid loss of bone structure and density increases the risk of fractures.
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Affiliation(s)
| | | | | | - Greg Dugan
- c Pathology/Section on Comparative Medicine
| | - Brendan J Johnson
- e Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
| | | | - Michael T Munley
- Departments of a Radiation Oncology
- b Biomedical Engineering
- d Physics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - J Daniel Bourland
- Departments of a Radiation Oncology
- d Physics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Schernberg A, Hennequin C. [Normal tissue tolerance to external beam radiation therapy: Bone marrow and cortical bone structures]. Cancer Radiother 2017; 21:619-625. [PMID: 28774489 DOI: 10.1016/j.canrad.2017.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022]
Abstract
In patients undergoing external radiation therapy, bone marrow and cortical bone structures are all often neglected as organs at risk. Still, from increased febrile neutropenia risk in patients undergoing chemoradiation for a pelvic tumour to increased risk of vertebral fracture when undergoing hypofractioned stereotactic radiotherapy of a spinal metastasis, adverse effects are frequent and sometimes serious. This literature review first defines the rules for contouring these structures, then the dose constraints currently recommended. This article focuses first on conventional irradiation or intensity modulation radiotherapy considering classical fractionation. Secondly, it focuses on stereotactic radiotherapy. The considered organs will be haematopoietic structures, and bone cortical structures. Current recommendations are summarised in a table.
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Affiliation(s)
- A Schernberg
- Service de radiothérapie, hôpital Tenon, hôpitaux universitaires Est parisien, 4, rue de la Chine, 75020 Paris, France.
| | - C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75475 Paris, France
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