Bilateral avascular necrosis of the hips after chemoradiotherapy for cervical cancer

Clinical Outcomes Among Patients Treated With Stereotactic Body Radiation Therapy to Femur Metastases for Oligometastatic Disease Control or Reirradiation: Results From a Large Single-Institution Experience

Purpose

There are limited data regarding outcomes after stereotactic body radiation therapy (SBRT) for femur metastases, which was an exclusion criteria for the Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers (SABR-COMET) trial. We aimed to characterize clinical outcomes from a large single institution experience.

Methods and Materials

Forty-eight patients with 53 lesions were consecutively treated with femur SBRT from May 2017 to June 2022. The Kaplan-Meier method and Cox proportional hazard models were used to characterize time-to-event endpoints and associations between baseline factors and clinical outcomes, respectively. Local control and locoregional control were defined as the absence of tumor progression within the radiation treatment field or within the treated femur, respectively.

Results

Most patients had Eastern Cooperative Oncology Group performance status 0 to 1 (90%), prostate (52%) or breast/lung (17%) cancer, and 1 to 3 lesions (100%), including 29 proximal and 5 distal. Fifty-seven percent of the lesions were treated with concurrent systemic therapy. Median planning target volume was 49.1 cc (range, 6.6-387 cc). Planning target volume V100 (%) was 99% (range, 90-100). Fractionation included 18 to 20 Gy/1F, 27 to 30 Gy/3F, and 28.5-40 Gy/5F. Forty-two percent had Mirels score ≥7 and most (94%) did not have extraosseous extension. Acute toxicities included grade 1 fatigue (15%), pain flare (7.5%), nausea (3.8%), and decreased blood counts (1.9%). Late toxicities included fracture (1.9%) at 1.5 years and osteonecrosis (4%) from dose of 40 Gy in 5F and 30 Gy in 5F (after prior 30 Gy/10F). One patient (2%) required fixation postradiation for progressive pain. With median follow-up 19.4 months, 1- and 2-year rates of local control were 94% and 89%, locoregional control was 83% and 67%, progression-free survival were 56% and 25%, and overall survival were 91% and 73%. Fifty percent of local regional recurrence events occurred within 5 cm of gross tumor volume.

Conclusions

Femur SBRT for oligometastatic disease control in well-selected patients was associated with good outcomes with minimal rates of acute and late toxicity. Patterns of local regional recurrence warrant consideration of larger elective volume coverage. Additional prospective study is needed.

Osteoradionecrosis of the Hip, a Troublesome Complication of Radiation Therapy: Case Series and Systematic Review

Background

Osteoradionecrosis of the hip is a serious complication of radiotherapy that is easily overlooked by physicians and patients in the early stages. There are relatively few reports on this subject, so there is no clear scientific consensus for the pathogenesis, early diagnosis, and clinical treatment of hip osteoradionecrosis. In this paper, we report two cases of hip osteoradionecrosis and systematically review the related literature.

Case Presentation

We report two cases of hip osteoradionecrosis. One patient successfully underwent total hip arthroplasty in our hospital and recovered well postoperatively. Another patient although we offered a variety of surgical options for this patient, the patient was worried that the bone loss would lead to poor prosthesis fixation, resulting in prosthesis loosening and infection, and therefore ultimately refused surgical treatment.

Conclusion

With the development of radiological techniques, the incidence of hip osteoradionecrosis is decreasing year by year, but early diagnosis and rational treatment remain challenging. The effects of non-surgical treatment are limited. Early prevention, early detection, and early intervention are crucial to delay or prevent the emergence of more serious complications.

Chemotherapy-associated osteonecrosis in cancer patients with solid tumours: a systematic review

Non-traumatic osteonecrosis of bone is recognized as a potential complication in solid-tumour cancer patients receiving treatment with cytotoxic chemotherapy. This review summarizes recent reports of osteonecrosis associated with chemotherapy in cancer patients, and describes the possible underlying pathophysiology and options available for its diagnosis, prevention and treatment. Fifty-four reported cases of non-traumatic osteonecrosis in adult patients with solid tumours receiving chemotherapy were identified by searching for reports in the medical literature. Osteonecrosis was observed most commonly in men receiving chemotherapy for testicular cancer. Osteonecrosis was also seen in patients receiving chemotherapy for breast, ovarian, small-cell lung cancer and osteosarcoma. Most patients had received corticosteroids, had femoral head involvement and had delayed onset of osteonecrosis. It appears that patients at higher risk for osteonecrosis with chemotherapy are identifiable. As the long-term survival of patients with solid tumours receiving chemotherapy increases, the prevalence of treatment-related osteonecrosis may also increase. Patients should be informed that osteonecrosis is a potential complication of cancer treatment. Measures to reduce risk should be taken, and patients should be monitored for early symptoms. Routine screening for chemotherapy-associated osteonecrosis is not recommended; however, a high index of clinical suspicion in patients at risk may allow for early intervention and preservation of the joints.

Long-term survival and late toxicity after chemoradiotherapy for cervical cancer--the Addenbrooke's experience

AIM

To evaluate the long term cause-specific survival and late toxicity of chemoradiotherapy for carcinoma of the cervix treated outside research settings.

MATERIALS AND METHODS

Between May 1999 and April 2003, 74 patients with carcinoma of the cervix were treated with radical radiotherapy given concurrently with weekly cisplatin chemotherapy. Three patients died during treatment, leaving 71 patients available for analysis of long-term survival and late toxicity of treatment. In total, 56 patients (78.9%) received chemoradiotherapy as primary radical treatment. Ten patients (14.1%) received chemoradiotherapy as adjuvant treatment after radical surgery. The remaining five patients (7.0%) received chemoradiotherapy as salvage treatment for pelvic recurrences after previous surgery. Forty-seven (66.2%) patients had squamous cell carcinomas, whereas 24 (33.8%) patients had adenocarcinomas.

RESULTS

The median follow-up for surviving patients was 64 months. The actuarial 5-year cause-specific survival for the 66 patients undergoing primary treatment (chemoradiotherapy+/-surgery) was 54.6%. The cause-specific survival by International Federation of Gynecology and Obstetrics (FIGO) disease stage was 58.3% for stage I disease, 69.9% for stage II disease and 20.8% for stage III disease. The actuarial 5-year pelvic control rate for the same group of patients was 73.3% overall (stage I=79.2%, stage II=89.0%, stage III=33.3%). Four of the five patients treated for recurrent disease are alive and well with a median follow-up of 70 months. Of the 66 patients undergoing primary treatment, seven (10.6%) had persistent disease after chemoradiotherapy. Of the 22 patients (33.3%) who relapsed >6 months after treatment, eight (36.4%) relapsed within the pelvis alone, 12 (54.5%) had metastatic disease alone, whereas two (9.1%) had both local and distant relapse. The overall rates of pelvic and distant relapse were 25.8 and 21.2%, respectively. Eight of 23 patients (34.8%) with adenocarcinomas developed metastatic disease compared with only six of 43 patients (14.0%) with squamous cell tumours. Thirteen patients (18.3%) had at least one complication that was classified as grade 3 or 4. Six patients (8.5%) had grade 3 or 4 urinary complications, five (7.0%) had grade 3 or 4 bowel complications and six (8.5%) had grade 3 or 4 complications affecting other organs. Five patients had grade 3 or 4 complications affecting more than one organ. The actuarial rate for grade 3 or 4 urinary complications was 14.5%, 9.4% for grade 3 or 4 bowel complications and 11.4% for grade 3 or 4 complications affecting other organs. The overall actuarial risk for grade 3 or 4 long-term morbidity in the study group was 28.2%. There were no significant correlations between the incidence of serious late toxicity and disease stage, field arrangement, treatment volumes or postoperative radiotherapy.

CONCLUSIONS

Our study has shown that the addition of chemotherapy to radiotherapy for cervical cancer probably improves the survival of patients treated outside research settings, but the benefit may not be as large as that obtained in clinical trials and the risk of serious late toxicity is increased. Further developments to improve survival and local control and to minimise toxicity are therefore necessary.