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Chan H, Savoie MB, Munir A, Moslehi J, Anwar M, Laffan A, Rowen T, Salmon R, Varma M, Van Loon K. Multi-Disciplinary Management in Rectal Cancer Survivorship: A Clinical Practice Review. J Gastrointest Cancer 2023; 54:1102-1115. [PMID: 36622517 PMCID: PMC10754749 DOI: 10.1007/s12029-022-00885-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 01/10/2023]
Abstract
Colorectal cancer (CRC) is the third most common cancer in the USA and worldwide. In the USA, nearly one-third of CRC cases are anatomically classified as rectal cancer. Over the past few decades, continued refinement of multimodality treatment and the introduction of new therapeutic agents have enhanced curative treatment rates and quality of life outcomes. As treatments improve and the incidence of young onset rectal cancer rises, the number of rectal cancer survivors grows each year. This trend highlights the growing importance of rectal cancer survivorship. Multimodality therapy with systemic chemotherapy, chemoradiation, and surgery can result in chronic toxicities in multiple organ systems, requiring a multi-disciplinary care model with services ranging from appropriate cancer surveillance to management of long-term toxicities and optimization of modifiable risk factors. Here, we review the evidence on these long-term toxicities and provide management considerations from consensus guidelines. Specific topics include bowel dysfunction from radiation and surgery, oxaliplatin-induced neuropathy, accelerated bone degeneration, the impact of fluoropyrimidines on long-term cardiovascular health, urinary incontinence, sexual dysfunction, and psychosocial distress. Additionally, we review modifiable risk factors to inform providers and rectal cancer survivors of various lifestyle and behavioral changes that can be made to improve their long-term health outcomes.
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Affiliation(s)
- Hilary Chan
- Department of Medicine, Division of Hematology and Oncology, University of California, San Francisco (UCSF), 550 16th Street, Floor 06, Room 6803, Box 3211, San Francisco, CA, 94158, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Marissa B Savoie
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Amir Munir
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Medicine, Division of Cardiology, UCSF, San Francisco, CA, USA
| | - Javid Moslehi
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Medicine, Division of Cardiology, UCSF, San Francisco, CA, USA
| | - Mekhail Anwar
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Radiation Oncology, UCSF, San Francisco, CA, USA
- Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, CA, USA
| | - Angela Laffan
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Tami Rowen
- Department of Obstetrics and Gynecology, UCSF, San Francisco, CA, USA
| | - Rebeca Salmon
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Madhulika Varma
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Section of Colorectal Surgery, Department of Surgery, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Katherine Van Loon
- Department of Medicine, Division of Hematology and Oncology, University of California, San Francisco (UCSF), 550 16th Street, Floor 06, Room 6803, Box 3211, San Francisco, CA, 94158, USA.
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
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Rijpma-Jacobs L, van der Vlies E, Meek DB, Bollen TL, Siersema PD, Weusten BLAM, Intven M, van Lelyveld N, Los M. Pelvic insufficiency fractures and pelvic bone metastases after neoadjuvant (chemo)radiotherapy for rectal cancer. Acta Oncol 2023; 62:1295-1300. [PMID: 37656773 DOI: 10.1080/0284186x.2023.2252168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/18/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Pelvic insufficiency fractures (PIFs) are a late complication of radiotherapy for pelvic malignancies. We evaluated the incidence, radiologic findings, clinical course, and outcome of PIFs in patients treated with neoadjuvant (chemo)radiotherapy ((C)RT) for rectal cancer. MATERIAL AND METHODS Data of patients diagnosed with rectal cancer from a large teaching hospital treated from 2002 to 2012 were extracted from the Dutch Cancer Registry. All hospital records were reviewed for the diagnosis of PIFs or pelvic bone metastases. An expert radiologist reassessed all imaging procedures of the lower back, abdomen, and pelvis. RESULTS A total of 513 rectal cancer patients were identified of whom 300 patients (58.5%) were treated with neoadjuvant (C)RT (long- vs. short-course radiotherapy: 91 patients [17.7%] vs. 209 [40.7%], respectively). Twelve PIFs were diagnosed initially according to hospital records and imaging reports of all 513 patients. These 12 patients were treated with neoadjuvant (C)RT. After reassessment of all pelvic imaging procedures done in this patient group (432 patients (84.2%)), 20 additional PIFs were detected in patients treated with neoadjuvant (C)RT, resulting in a 10.7% PIF rate in irradiated patients. One PIF was detected in the group of patients not treated with neoadjuvant (C)RT for rectal cancer. This patient had palliative radiotherapy for prostate cancer and is left out of the analysis. Median follow-up time of 32 PIF patients was 49 months. Median time between start of neoadjuvant (C)RT and diagnosis of PIF was 17 months (IQR 9-28). Overall median survival for patients with PIF was 63.5 months (IQR 44-120). CONCLUSION PIFs are a relatively common late complication of neoadjuvant (C)RT for rectal cancer but are often missed or misdiagnosed as pelvic bone metastases. The differentiation of PIFs from pelvic bone metastases is important because of a different treatment and disease outcome.
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Affiliation(s)
- Lotte Rijpma-Jacobs
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Ellen van der Vlies
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - David B Meek
- Department of Radiology, Treant Health Care Group, Hoogeveen, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niels van Lelyveld
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Vesa V, Jaana M, Ia K, Anu C, Heikki M, Raija R, Annika Å, Eetu H. Short-course preoperative radiotherapy increases pelvic fracture risk in rectal cancer. Clin Transl Radiat Oncol 2023; 42:100656. [PMID: 37457020 PMCID: PMC10339188 DOI: 10.1016/j.ctro.2023.100656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/10/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Pelvic insufficiency fractures (PIFs) are adverse events associated with chemoradiotherapy (CRT) administered preoperatively in rectal cancer, with incidences of 0-33.6% reported in the literature. Data on PIFs after 5 × 5 Gy fractionated short-course radiotherapy (SCRT) using highly conformal radiotherapy techniques such as volumetric modulated arc therapy (VMAT) is limited. Methods The Turku University Hospital colorectal cancer database was searched for patients operated on for stage I-III rectal cancer during the years 2014-2018. The hospital's routine follow-up includes a 2-year computed tomography (CT) scan, which was systemically re-evaluated to detect PIFs. Only radiotherapy delivered using VMAT and image-guided approaches was included. Baseline demographics, tumor data, and dose-volume data were collected to identify risk factors for PIFs. Results Median time to CT scan was 24 months. Among the 164 patients analyzed, the 2-year PIF incidence was 22.2% for SCRT (n = 12/54, OR 9.1 (CI95% 1.9-42.9), p = 0.004), 9.1% for CRT (n = 4/44, OR 3.2 (CI95% 0.6-18.3), p = 0.13) and 3.0% (n = 2/66, reference) for those operated on without radiotherapy. The PIF incidence was not explained by differences in dose-volume data in either the SCRT or CRT groups. Fracture risk was higher in women, up to 50% after SCRT. Conclusions Every fifth patient treated with SCRT and rectal surgery presented with a PIF. Critical bony structures to be avoided during radiotherapy contouring could not be identified. Clinicians, especially those involved with the follow-up of rectal cancer, should be aware of this potentially debilitating and surprisingly common adverse event.
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Affiliation(s)
- Väliaho Vesa
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Mäkitalo Jaana
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
- Department of Medical Physics, Turku University Hospital, Hämeentie 11, Turku 20521, Finland
| | - Kohonen Ia
- Medicity Research Laboratory, University of Turku, Tykistökatu 6A, Turku 20520, Finland
- Medical Imaging Centre of Southwest Finland, Turku University Hospital, Hämeentie 11, Turku 20521, Finland
| | - Carpelan Anu
- Department of Digestive Surgery, Turku University Hospital and University of Turku, Kiinamyllynkatu 4–8, Turku 20521, Finland
| | - Minn Heikki
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Ristamäki Raija
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Ålgars Annika
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Heervä Eetu
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
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Cattaneo S, Adriani M, Tonolini S, Oransky M, Galante C, Grava G, Milano G, Casiraghi A. FRAGILITY FRACTURES OF THE SACRUM: A SILENT EPIDEMIC. Orthop Rev (Pavia) 2022; 14:38572. [DOI: 10.52965/001c.38572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Fragility fractures of the sacrum (FFS) are caused by low-energy trauma in the elderly population. Due to the nuanced symptomatology, many FFS remains unrecognized and the prevalence is underestimated. The clinical presentation varies, typically presenting with weightbearing low back pain without even remembering of a previous trauma. Radiographs are usually insufficient for the diagnosis and second level imaging modalities are required. In particular, magnetic resonance demonstrated the highest diagnostic accuracy. Treatment should aim to guarantee early mobilization and weightbearing, efficient pain relief and early discharge from the hospital to a proper facility for rehabilitation. Conservative treatment is reserved to non-displaced fractures with an adequate pain relief within one week allowing early mobilization. Otherwise, surgical treatment must be preferred. Nowadays, minimally invasive techniques, such as ileo-sacral screws or trans-sacral bar osteosynthesis, are safe and effective procedures and have overcome open procedures. In more complex patterns, with complete dissociation between the pelvic ring and the ilio-lumbar spine, spino-pelvic fixation is the procedure of choice.
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Affiliation(s)
| | | | | | | | | | | | - Giuseppe Milano
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy; Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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D'Angelo T, Albrecht MH, Caudo D, Mazziotti S, Vogl TJ, Wichmann JL, Martin S, Yel I, Ascenti G, Koch V, Cicero G, Blandino A, Booz C. Virtual non-calcium dual-energy CT: clinical applications. Eur Radiol Exp 2021; 5:38. [PMID: 34476640 PMCID: PMC8413416 DOI: 10.1186/s41747-021-00228-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/11/2021] [Indexed: 12/15/2022] Open
Abstract
Dual-energy CT (DECT) has emerged into clinical routine as an imaging technique with unique postprocessing utilities that improve the evaluation of different body areas. The virtual non-calcium (VNCa) reconstruction algorithm has shown beneficial effects on the depiction of bone marrow pathologies such as bone marrow edema. Its main advantage is the ability to substantially increase the image contrast of structures that are usually covered with calcium mineral, such as calcified vessels or bone marrow, and to depict a large number of traumatic, inflammatory, infiltrative, and degenerative disorders affecting either the spine or the appendicular skeleton. Therefore, VNCa imaging represents another step forward for DECT to image conditions and disorders that usually require the use of more expensive and time-consuming techniques such as magnetic resonance imaging, positron emission tomography/CT, or bone scintigraphy. The aim of this review article is to explain the technical background of VNCa imaging, showcase its applicability in the different body regions, and provide an updated outlook on the clinical impact of this technique, which goes beyond the sole improvement in image quality.
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Affiliation(s)
- Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Moritz H Albrecht
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Danilo Caudo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Silvio Mazziotti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Thomas J Vogl
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Julian L Wichmann
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Simon Martin
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Giorgio Ascenti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Vitali Koch
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Giuseppe Cicero
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Alfredo Blandino
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Christian Booz
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Sabaliauskas V, Tiškevičius S. Diagnosing sacral insufficiency fractures after radiotherapy in women with cervical cancer: Report of three cases. Radiol Case Rep 2021; 16:2938-2944. [PMID: 34401030 PMCID: PMC8350190 DOI: 10.1016/j.radcr.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Diagnosing sacral insufficiency fractures (SIF) in oncology patients is a challenge to radiologists, and recognition of imaging features is essential in order to avoid misdiagnosis of bone metastases and prevent patients from inaccurate treatment. Clinical cases in order to better understand the essence of this pathology and to make diagnosis easier, we present three clinical cases of SIF in patients with cervical cancer. All patients received radiation therapy (external beam radiation and brachytherapy) and chemotherapy with cisplatin. Patients underwent pelvic MRI, CT, SPECT or SPECT/CT examinations. One patient underwent a FDG-PET/CT examination. Conclusions SPECT/CT should be included in the differential diagnostics when radiological features of pelvic bone pathology on CT or MRI are undetermined or SIF are suspected. SIF must always be considered in oncology patients with pelvic pain, especially in postmenopausal state and after radiation therapy. For patients with osteoporosis, bone density screening and precise review of the most common fracture sites are recommended.
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Vaishya R, Mittal P, Vaish A, Khosa R. Pubic Osteolysis in an Elderly Masquerading as Malignancy: A Case Report and Review of Literature. J Orthop Case Rep 2021; 11:18-22. [PMID: 34327158 PMCID: PMC8310627 DOI: 10.13107/jocr.2021.v11.i04.2134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: A rapidly progressive destructive lesion characterizes pubic osteolysis (PO) in the pubic bone due to an inadequate fracture healing response. It may be seen in pelvic insufficiency fractures (IF) secondary to radiation therapy (RT) of pelvic malignancies, occurring even in the absence of significant trauma. Such a radiological picture may distract the clinician towards a malignant etiology and may affect the management. Case Report: A 79- year- old female, known case of carcinoma of the urinary bladder, underwent contrast-enhanced computed tomography (CT) (CECT) of the abdomen and pelvis as a routine follow- up and was found to have an osteolytic lesion in the right pubic bone, suggesting a malignant pathology. CT- guided biopsy did not reveal any malignant or infective etiology. The patient showed recovery with conservative management. Conclusion: Osteolytic lesions of the pubic bone can often occur following radiation for pelvic malignancies. It occurs due to impaired fracture reparative response by a bone afflicted by radiation therapy RT. It can be managed effectively with conservative analgesics, bisphosphonates, calcium, and Vitamin D supplementation. The radiographic picture can imitate malignant or infective lesions and provoke invasive testing for confirmation. The clinicians need to be conscious of this clinical entity to initiate proper treatment and avoid unnecessary investigations.
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Affiliation(s)
- Raju Vaishya
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Parv Mittal
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Abhishek Vaish
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Robin Khosa
- Department of Radiation Oncology, Indraprastha Apollo Hospitals, New Delhi, India
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Radiation-Induced Insufficiency Fractures After Pelvic Irradiation for Gynecologic Malignancies: A Systematic Review. Int J Radiat Oncol Biol Phys 2020; 108:620-634. [DOI: 10.1016/j.ijrobp.2020.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/15/2022]
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Booz C, Nöske J, Albrecht MH, Lenga L, Martin SS, Bucher AM, Huizinga NA, Wichmann JL, Vogl TJ, Yel I. Diagnostic accuracy of color-coded virtual noncalcium dual-energy CT for the assessment of bone marrow edema in sacral insufficiency fracture in comparison to MRI. Eur J Radiol 2020; 129:109046. [DOI: 10.1016/j.ejrad.2020.109046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/11/2020] [Accepted: 04/30/2020] [Indexed: 12/30/2022]
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Li W, Zhang L, Li W, Zhang R. The Value of 99mTc-Methylene Diphosphonate Single-Photon Emission Computed Tomography/Computed Tomography in Detecting Atraumatic Costal Cartilage Fracture in Malignant Tumor Patients. Front Oncol 2020; 10:138. [PMID: 32195167 PMCID: PMC7062865 DOI: 10.3389/fonc.2020.00138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/27/2020] [Indexed: 11/13/2022] Open
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Savoie MB, Laffan A, Brickman C, Daniels B, Levin A, Rowen T, Smith J, Van Blarigan EL, Hope TA, Berry-Lawhorn JM, Anwar M, Van Loon K. A multi-disciplinary model of survivorship care following definitive chemoradiation for anal cancer. BMC Cancer 2019; 19:906. [PMID: 31510960 PMCID: PMC6737598 DOI: 10.1186/s12885-019-6053-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
Following definitive chemoradiation for anal squamous cell carcinoma (ASCC), patients face a variety of chronic issues including: bowel dysfunction, accelerated bone loss, sexual dysfunction, and psychosocial distress. The increasing incidence of this disease, high cure rates, and significant long-term sequelae warrant increased focus on optimal survivorship care following definitive chemoradiation. In order to establish our survivorship care model for ASCC patients, a multi-disciplinary team of experts performed a comprehensive literature review and summarized best practices for the multi-disciplinary management of this unique patient population. We reviewed principle domains of our survivorship approach: (1) management of chronic toxicities; (2) sexual health; (3) HIV management in affected patients; (4) psychosocial wellbeing; and (5) surveillance for disease recurrence and survivorship care delivery. We provide recommendations for the optimization of survivorship care for ASCC patients can through a multi-disciplinary approach that supports physical and psychological wellness.
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Affiliation(s)
- Marissa B Savoie
- School of Medicine, University of California, San Francisco, USA
| | - Angela Laffan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Cristina Brickman
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, USA
| | - Bevin Daniels
- Department of Physical Therapy, University of California, San Francisco, USA
| | - Anna Levin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Psycho-Oncology, University of California, San Francisco, USA
| | - Tami Rowen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | - James Smith
- Department of Urology, University of California, San Francisco, USA
| | - Erin L Van Blarigan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Urology, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - J Michael Berry-Lawhorn
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA
| | - Mekhail Anwar
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA.
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA.
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Kronborg CJ, Jørgensen JB, Petersen JB, Nyvang Jensen L, Iversen LH, Pedersen BG, Spindler KLG. Pelvic insufficiency fractures, dose volume parameters and plan optimization after radiotherapy for rectal cancer. Clin Transl Radiat Oncol 2019; 19:72-76. [PMID: 31646202 PMCID: PMC6804461 DOI: 10.1016/j.ctro.2019.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 12/13/2022] Open
Abstract
High rates of PIF are detected 3 years after VMAT based CRT for rectal cancer. Patients with PIFs received non-significantly higher V30 Gy to sacroiliac joints. 3 arc VMAT techniques can be optimized for bone. Proton beam therapy has the potential for further optimization for bone.
Pelvic insufficiency fractures (PIF) is a known but under-acknowledged late effect of pelvic radiotherapy. In rectal cancer, studies describing incidence of PIF and relation to dose volume relationships are lacking. The aim of this study was (i) to analyse dose volume histograms (DVH) from pelvic bones in patients with and without PIF, and (ii) to determine bone sparing capacity of 2 and 3 arc volumetric arc therapy (VMAT), intensity modulated radiotherapy (IMRT) and proton beam therapy (PBT), in rectal cancer patients treated with chemoradiotherapy (CRT). Material and methods Patients treated with CRT for primary rectal cancer underwent a 3-year pelvic MRI for identification of PIFs. Bone structures were retrospectively delineated, and DVHs were re-calculated. Comparative planning was done with 2 (original) and 3 arc VMAT, fixed field IMRT and PBT plans. Results 27 patients (18 men, mean age 64 years) were included and PIFs were identified in 9 (33%), most (n = 6) had multiple fracture sites. In general, patients with PIFs received higher doses to pelvic bones, and V30 Gy to the sacroiliac joint was non-significantly higher in patients with PIF 68.5% (60.1–69.3 IQR) vs. 56% (54.1–66.6 IQR), p = 0.064. Comparative planning showed that especially 3 arc VMAT and proton beam therapy could be optimized for bone. Conclusions Patients, treated with VMAT based CRT for rectal cancer, have high rates of PIFs after 3 years. Patients with PIFs tended to have received higher doses to sacroiliac joints. Comparative planning demonstrated most pronounced bone sparing capacity of 3 arc VMAT and with PBT having the potential to further lower doses. These results should be validated in larger and preferably prospective cohorts.
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Affiliation(s)
- Camilla J.S. Kronborg
- Department of Oncology Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
- Danish Centre for Particle Therapy, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
- Corresponding author at: Palle Juul Jensens Blvd. 99, 8200 Aarhus N, Denmark.
| | - Jesper B. Jørgensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Jørgen B.B. Petersen
- Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
- Danish Centre for Particle Therapy, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Lars Nyvang Jensen
- Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Lene H. Iversen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Karen-Lise G. Spindler
- Department of Oncology Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
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Hayar M, Durankuş NK, Altun GD, Koçak Z, Uzal MC, Saynak M. Investigation of differences of sacral and vertebral bone mineral densities before and after radiotherapy in patients with locally advanced rectal cancer. Cancer Radiother 2019; 23:408-415. [PMID: 31331841 DOI: 10.1016/j.canrad.2019.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Radiotherapy is a treatment method performed using ionizing radiation on cancer patients either alone or with surgery and/or chemotherapy. Although modern radiotherapy techniques provide a significant advantage in protecting healthy tissues, it is inevitable that normal tissues are also located in the areas targeted by radiations. In this study, we aimed to examine the bone mineral density changes in bone structures commonly included in the irradiated area such as, L5 vertebra, sacrum, and femur heads, in patients who have received pelvic radiotherapy; and the relationship between these changes with radiation dose. MATERIAL AND METHODS Patients included in the study had been previously diagnosed with rectal cancer, which were operated or not. Preoperative or postoperative pelvic radiotherapy was planned for all patients. In terms of convenience when comparing with future scans, all densitometry and CT scans were performed with the same devices. Fifteen patients were included in the study. In order to determine the dose of radiation each identified area had taken after radiotherapy, the sacrum, L5 vertebra, bilateral femoral heads, and L1 regions were contoured in the CT scans in which treatment planning was done. Sagittal cross-sectional images were taken advantage of while these regions were being contoured. RESULTS Bone mineral density was evaluated with CT and dual-energy X-ray absorptiometry before and after the treatment. The regions that have theoretically been exposed to irradiation, such as L5, sacrum, left to right femur were found to have significant difference in terms of bone density. According to CT evaluation, there was a significant decrease in bone intensity of L5, sacrum, left and right femurs. Dual-energy X-ray absorptiometry assessment revealed that the whole of the left femoral head, left femur neck and Ward's region were significantly affected by radiotherapy. However, there was no significant difference in the sacrum and L5 vertebra before and after radiotherapy. CONCLUSION More accurate results could be achieved if the same study was conducted on a larger patient population, with a longer follow-up period. When the reduction in bone density is at maximum or a cure is likely in a long-term period, bone mineral density could be determined by measurements performed at regular intervals.
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Affiliation(s)
- M Hayar
- Department of Radiation Oncology, Balıkesir State Hospital, Balıkesir, Turkey
| | - N K Durankuş
- Department of Radiation Oncology, Koc University Faculty of Medicine, Istanbul, Turkey.
| | - G D Altun
- Department of Nuclear Medicine, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Z Koçak
- Department of Radiation Oncology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - M C Uzal
- Department of Radiation Oncology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - M Saynak
- Department of Radiation Oncology, Trakya University Faculty of Medicine, Edirne, Turkey
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14
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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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15
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Zhong X, Li J, Zhang L, Lu B, Yin J, Chen Z, Zhang J, Tang R. Characterization of Insufficiency Fracture and Bone Metastasis After Radiotherapy in Patients With Cervical Cancer Detected by Bone Scan: Role of Magnetic Resonance Imaging. Front Oncol 2019; 9:183. [PMID: 30984616 PMCID: PMC6447664 DOI: 10.3389/fonc.2019.00183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/04/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Insufficiency fracture (IF) can show increased uptake on a bone scan (BS). IFs are often misinterpreted as bone metastases if the characteristic "Honda sign" (H-sign) is invisible. The purpose of the present study was to evaluate the utility of magnetic resonance imaging (MRI) alone for the characterization of IF and bone metastasis after radiotherapy in patients with cervical cancer detected by BS. Materials and Methods: Our study included 40 patients with cervical cancer after radiotherapy that showed pelvic emerging increased uptake on a BS during follow-up. Then further MRI examination was performed in all patients. Two radiologists independently reviewed the MR images, and the sensitivity, specificity and accuracy were calculated based on the mean scores. Diagnostic validity of the inter-observer was calculated by using kappa statistics. The gold standard was based on radiologic findings, clinical data and follow-up at least 12 months. Results: A total of 57 emerging bone lesions detected at BS were identified in the reference standard, including 43 IFs and 14 bone metastases. Only 20 patients showed a "H-sign" on the BS images. Using MRI analysis, all lesions detected by BS were found in MRI by both radiologists. On average, the sensitivity, specificity, and accuracy for distinguishing IFs from bone metastases were 95.3% (41/43), 92.8% (13/14), and 94.7% (54/57), respectively. The inter-observer variability was determined to be very good (kappa value = 0.962). Conclusions: MRI is a reliable diagnostic technique for the further characterization of emerging lesions detected by BS, MRI shows great diagnostic efficiency in the differentiation of IF and bone metastasis.
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Affiliation(s)
- Xi Zhong
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jiansheng Li
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Linqi Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Binggui Lu
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jinxue Yin
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Zhijun Chen
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jian Zhang
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Rijie Tang
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
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16
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Simard J, Kamath S, Kircher S. Survivorship Guidance for Patients with Colorectal Cancer. Curr Treat Options Oncol 2019; 20:38. [DOI: 10.1007/s11864-019-0635-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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17
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Jørgensen JB, Bondeven P, Iversen LH, Laurberg S, Pedersen BG. Pelvic insufficiency fractures frequently occur following preoperative chemo-radiotherapy for rectal cancer - a nationwide MRI study. Colorectal Dis 2018; 20:873-880. [PMID: 29673038 DOI: 10.1111/codi.14224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/19/2018] [Indexed: 12/12/2022]
Abstract
AIM The aim of this prospective case-control study was to evaluate the rate of pelvic insufficiency fractures (PIFs) in Denmark using MRI at the 3-year follow-up. All patients had rectal cancer and had undergone surgery with or without preoperative chemo-radiotherapy (CRT). METHOD Patients registered with primary rectal cancer in the Danish Colorectal Cancer Group database, who underwent rectal cancer resection from April 2011 through August 2012, were invited to participate in a national MRI study aiming to detect local recurrence and evaluate quality of the surgical treatment. Pelvic MRI including bone-specific sequences 3 years after treatment was obtained. The primary outcome was the rate of PIFs; secondary outcome was risk factors of PIFs evaluated in multivariate analysis. RESULTS During the study period, 890 patients underwent rectal cancer surgery. Of these, 403 patients were included in the MRI study and had a 3-year follow-up MRI. PIFs were detected in 49 (12.2%; 95% CI 9.0-15.4) patients by MRI. PIFs were detected in 39 patients (33.6%; 95% CI 24.9-42.3) treated with preoperative CRT compared to 10 (3.5%; 95% CI 1.3-5.6) non-irradiated patients (P < 0.001). In a multivariate analysis female gender (OR = 3.52; 95% CI 1.7-7.5), age above 65 years (OR = 3.20; 95% CI 1.5-6.9) and preoperative CRT (OR = 14.20; 95% CI 6.1-33.1) were significant risk factors for PIFs. CONCLUSION Preoperative CRT in the treatment of rectal cancer was associated with a 14-fold higher risk of PIFs after 3 years, whereas female gender and age above 65 years each tripled the risk of PIFs.
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Affiliation(s)
- J B Jørgensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - P Bondeven
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - L H Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - B G Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
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18
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Bostel T, Nicolay NH, Welzel T, Bruckner T, Mattke M, Akbaba S, Sprave T, Debus J, Uhl M. Sacral insufficiency fractures after high-dose carbon-ion based radiotherapy of sacral chordomas. Radiat Oncol 2018; 13:154. [PMID: 30139357 PMCID: PMC6108137 DOI: 10.1186/s13014-018-1095-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/08/2018] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to analyse the frequency and clinical relevance of sacral insufficiency fractures (SIFs) after high-dose carbon-ion based irradiation of sacral chordomas. Methods A total of 56 patients were included in this retrospective study. Twenty one patients (37%) were treated with definitive radiotherapy (RT), and 35 patients (63%) received postoperative RT using carbon ions, either in combination with photons or as single-modality treatment (median radiation dose 66 Gy RBE, range 60–74 Gy). Follow-up examinations including MRI of the pelvis were performed at 3-monthly intervals in the first year and consecutively at 6-monthly intervals. Median follow-up was 35.5 months (range 2–83). Results SIFs were diagnosed in 29 patients (52%) after a median follow-up of 11 months (range 1–62 months). Most sacral fractures (79%) occurred within 2 years after RT. For the overall study population, the fracture-free survival probability amounted to values of 0.68 (95% CI, 0.53–0.79) after 1 year, 0.46 (95% CI, 0.31–0.60) after 2 years, and 0.31 (95% CI, 0.16–0.47) after 5 years. Statistical analysis showed no significant difference regarding the fracture rates between patients who received an operation and postoperative RT and patients treated with definitive RT. About one third of the patients with SIFs (34%; 10 of 29 patients) had associated clinical symptoms, most notably pain. All patients with symptomatic fractures required strong analgesics and often intensive pain management. Conclusions Sacral fractures after high-dose carbon ion-based RT of sacral chordomas were shown to be a considerable radiogenic late effect, affecting about half of the treated patients. However, only one third of these fractures were clinically symptomatic requiring regular medical care and pain therapy. Further hazard factor analysis in the future with larger patient numbers will possibly enable the identification of high-risk patients for developing SIFs with the ultimate goal to prevent symptomatic fractures.
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Affiliation(s)
- Tilman Bostel
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld, 280, Heidelberg, Germany. .,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany.
| | - Nils Henrik Nicolay
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld, 280, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
| | - Thomas Bruckner
- Department of Medical Biometry, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Mattke
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
| | - Sati Akbaba
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld, 280, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Research in Radiation Oncology, Im Neuenheimer Feld, 280, Heidelberg, Germany
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19
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van den Blink QU, Garcez K, Henson CC, Davidson SE, Higham CE. Pharmacological interventions for the prevention of insufficiency fractures and avascular necrosis associated with pelvic radiotherapy in adults. Cochrane Database Syst Rev 2018; 4:CD010604. [PMID: 29683475 PMCID: PMC6494432 DOI: 10.1002/14651858.cd010604.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pelvic radiotherapy is a treatment delivered to an estimated 150,000 to 300,000 people annually across high-income countries. Fractures due to normal stresses on weakened bone due to radiotherapy are termed insufficiency fractures. Pelvic radiotherapy-related interruption of the blood supply to the hip is termed avascular necrosis and is another recognised complication. The reported incidences of insufficiency fractures are 2.7% to 89% and risk of developing avascular necrosis is 0.5%. These complications lead to significant morbidity in terms of pain, immobility and consequently risk of infections, pressure sores and mortality. OBJECTIVES To assess the effects of pharmacological interventions for preventing insufficiency fractures and avascular necrosis in adults over 18 years of age undergoing pelvic radiotherapy. SEARCH METHODS We performed electronic literature searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and DARE to 19 April 2017. We also searched trial registries. Further relevant studies were identified through handsearching of citation lists of included studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or non RCTs with concurrent comparison groups including quasi-RCTs, cluster RCTs, prospective cohort studies and case series of 30 or more participants were screened. We included studies assessing the effect of pharmacological interventions in adults over 18 years of age undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded studies involving radiotherapy for bone metastases. We assessed use of pharmacological interventions at any stage before or during pelvic radiotherapy. Interventions included calcium or vitamin D (or both) supplementation, bisphosphonates, selective oestrogen receptor modulators, hormone replacement therapy (oestrogen or testosterone), denosumab and calcitonin. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. Data were to be pooled using the random-effects model if study comparisons were similar, otherwise results were to be reported narratively. MAIN RESULTS We included two RCTs (1167 participants). The first RCT compared zoledronic acid with placebo in 96 men undergoing pelvic radiotherapy for non-metastatic prostate cancer.The second RCT had four treatment arms, two of which evaluated zoledronic acid plus adjuvant androgen suppression compared with androgen suppression only in 1071 men undergoing pelvic radiotherapy for non-metastatic prostate cancer.Both studies were at a moderate to high risk of bias and all evidence was judged to be of very low certainty.The studies provided no evidence on the primary outcomes of the review and provided limited data in relation to secondary outcomes, such that meta-analyses were not possible. Both studies focused on interventions to improve bone health in relation to androgen deprivation rather than radiation-related insufficiency fractures and avascular necrosis. Few fractures were described in each study and those described were not specific to insufficiency fractures secondary to radiotherapy. Both studies reported that zoledronic acid in addition to androgen deprivation and pelvic radiotherapy led to improvements in BMD; however, the changes in BMD were measured and reported differently. There was no available evidence regarding adverse effects. AUTHORS' CONCLUSIONS The evidence relating to interventions to prevent insufficiency fractures and avascular necrosis associated with pelvic radiotherapy in adults is of very low certainty. This review highlights the need for prospective clinical trials using interventions prior to and during radiotherapy to prevent radiation-related bone morbidity, insufficiency fractures and avascular necrosis. Future trials could involve prospective assessment of bone health including BMD and bone turnover markers prior to pelvic radiotherapy. The interventions for investigation could begin as radiotherapy commences and remain ongoing for 12 to 24 months. Bone turnover markers and BMD could be used as surrogate markers for bone health in addition to radiographic imaging to report on presence of insufficiency fractures and development of avascular necrosis. Clinical assessments and patient reported outcomes would help to identify any associated adverse effects of treatment and quality of life outcomes.
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Affiliation(s)
- Qurrat U van den Blink
- The Christie NHS Foundation TrustRadiotherapy‐related ResearchWilmslow RoadManchesterGreater ManchesterUKM20 4BX
| | - Kate Garcez
- The Christie NHS Foundation TrustClinical OncologyWilmslow RoadManchesterUKM20 4BX
| | - Caroline C Henson
- University Hospital of South Manchester NHS Foundation Trust, Wythenshawe HospitalGastroenterologySouthmoor RoadWythenshaweManchesterLancashireUKM23 9LT
| | - Susan E Davidson
- The Christie NHS Foundation TrustClinical OncologyWilmslow RoadManchesterUKM20 4BX
| | - Claire E Higham
- The Christie NHS Foundation TrustEndocrinologyWilmslow RoadManchesterGreater ManchesterUKM20 4BX
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20
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Geh I, Gollins S, Renehan A, Scholefield J, Goh V, Prezzi D, Moran B, Bower M, Alfa-Wali M, Adams R. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Anal Cancer. Colorectal Dis 2017; 19 Suppl 1:82-97. [PMID: 28632308 DOI: 10.1111/codi.13709] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
| | | | - Andrew Renehan
- University of Manchester and Christie Hospital, Manchester, UK
| | - John Scholefield
- University of Nottingham and Queens Medical Centre, Nottingham, UK
| | - Vicky Goh
- King's College and Guy's & St Thomas' Hospital, London, UK
| | | | - Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - Mark Bower
- Imperial College and Chelsea & Westminster Hospital, London, UK
| | | | - Richard Adams
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
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21
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Moreno CC, Sullivan PS, Kalb BT, Tipton RG, Hanley KZ, Kitajima HD, Dixon WT, Votaw JR, Oshinski JN, Mittal PK. Magnetic resonance imaging of rectal cancer: staging and restaging evaluation. ACTA ACUST UNITED AC 2016; 40:2613-29. [PMID: 25759246 DOI: 10.1007/s00261-015-0394-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Magnetic resonance imaging is used to non-invasively stage and restage rectal adenocarcinomas. Accurate staging is important as the depth of tumor extension and the presence or absence of lymph node metastases determines if an individual will undergo preoperative neoadjuvant chemoradiation. Accurate description of tumor location is important for presurgical planning. The relationship of the tumor to the anal sphincter in addition to the depth of local invasion determines the surgical approach used for resection. High-resolution T2-weighted imaging is the primary sequence used for initial staging. The addition of diffusion-weighted imaging improves accuracy in the assessment of treatment response on restaging scans. Approximately 10%-30% of individuals will experience a complete pathologic response following chemoradiation with no residual viable tumor found in the resected specimen at histopathologic assessment. In some centers, individuals with no residual tumor visible on restaging MR who are thought to be at high operative risk are monitored with serial imaging and a "watch and wait" approach in lieu of resection. Normal rectal anatomy, MR technique utilized for staging and restaging scans, and TMN staging are reviewed. An overview of surgical techniques used for resection including newer, minimally invasive endoluminal techniques is included.
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Affiliation(s)
- Courtney C Moreno
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA.
| | - Patrick S Sullivan
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Bobby T Kalb
- Department of Medical Imaging, The University of Arizona School of Medicine, Tucson, AZ, 85724, USA
| | - Russell G Tipton
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Krisztina Z Hanley
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Hiroumi D Kitajima
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - W Thomas Dixon
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - John R Votaw
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - John N Oshinski
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Pardeep K Mittal
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
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22
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Lutz MP, Zalcberg JR, Glynne-Jones R, Ruers T, Ducreux M, Arnold D, Aust D, Brown G, Bujko K, Cunningham C, Evrard S, Folprecht G, Gerard JP, Habr-Gama A, Haustermans K, Holm T, Kuhlmann KF, Lordick F, Mentha G, Moehler M, Nagtegaal ID, Pigazzi A, Pucciarelli S, Roth A, Rutten H, Schmoll HJ, Sorbye H, Van Cutsem E, Weitz J, Otto F. Second St. Gallen European Organisation for Research and Treatment of Cancer Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of rectal cancer. Eur J Cancer 2016; 63:11-24. [PMID: 27254838 DOI: 10.1016/j.ejca.2016.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/10/2016] [Accepted: 04/17/2016] [Indexed: 01/12/2023]
Abstract
Primary treatment of rectal cancer was the focus of the second St. Gallen European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Conference. In the context of the conference, a multidisciplinary international expert panel discussed and voted on controversial issues which could not be easily answered using published evidence. Main topics included optimal pretherapeutic imaging, indication and type of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report the key recommendations and summarise the related evidence. The treatment strategy for localised rectal cancer varies from local excision in early tumours to neoadjuvant radiochemotherapy (RCT) in combination with extended surgery in locally advanced disease. Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended magnetic resonance imaging (MRI) or MRI + endoscopic ultrasonography (EUS) as mandatory staging modalities, except for early T1 cancers with an option for local excision, where EUS in addition to MRI was considered to be most important because of its superior near-field resolution. Primary surgery with total mesorectal excision was recommended by most panellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were considered for multimodal treatment. The consensus panel recommended long-course RCT over short-course radiotherapy for most clinical situations where neoadjuvant treatment is indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable tumours and synchronous liver metastases, most panel members did not see an indication to start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection approach in resectable metastases, which both allow optimal systemic therapy for the metastatic disease. In general, proper patient selection and discussion in an experienced multidisciplinary team was considered as crucial component of care.
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Affiliation(s)
| | - John R Zalcberg
- Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, The Alfred Centre, Melbourne, Australia
| | - Rob Glynne-Jones
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Theo Ruers
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michel Ducreux
- Gustave Roussy, Université Paris-Saclay, Département de Médecine, Villejuif, France
| | - Dirk Arnold
- CUF Hospitals, Oncology Center, Lisbon, Portugal
| | - Daniela Aust
- Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Gina Brown
- Department of Diagnostic Imaging, The Royal Marsden NHS Foundation Trust, London, UK
| | - Krzysztof Bujko
- The Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | | | - Serge Evrard
- Institut Bergonié, Université de Bordeaux, Bordeaux, France
| | | | | | | | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Belgium
| | - Torbjörn Holm
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Florian Lordick
- University Cancer Center Leipzig (UCCL), University Medicine Leipzig, Germany
| | | | - Markus Moehler
- I. Med. Klinik und Poliklinik, Johannes Gutenberg Universität Mainz, Mainz, Germany
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, CA, USA
| | | | | | - Harm Rutten
- Catharina Hospital Eindhoven, Eindhoven and GROW: School of Oncology and Developmental Biology, University Maastricht, Maastricht, The Netherlands
| | - Hans-Joachim Schmoll
- Department of Oncology/Haematology, Martin-Luther-University Halle, Halle (Saale), Germany
| | - Halfdan Sorbye
- Department of Oncology, Haukeland University Hospital, University of Bergen, Norway; Department of Clinical Science, Haukeland University Hospital, University of Bergen, Norway
| | - Eric Van Cutsem
- Digestive Oncology, University Hospitals Gasthuisberg/Leuven, Leuven, Belgium
| | - Jürgen Weitz
- Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Florian Otto
- Tumor- und Brustzentrum ZeTuP, St. Gallen, Switzerland
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Sacral Insufficiency Fractures are Common After High-dose Radiation for Sacral Chordomas Treated With or Without Surgery. Clin Orthop Relat Res 2016; 474:766-72. [PMID: 26400251 PMCID: PMC4746193 DOI: 10.1007/s11999-015-4566-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 09/16/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgery with high-dose radiation and high-dose radiation alone for sacral chordomas have shown promising local control rates. However, we have noted frequent sacral insufficiency fractures and perceived this rate to be higher than previously reported. QUESTIONS/PURPOSES We wished (1) to characterize the incidence of sacral insufficiency fractures in patients with chordomas of the sacrum who received high-dose radiation, and (2) to determine whether patients treated with surgery plus high-dose radiation or high-dose radiation alone are more likely to experience a sacral fracture, and to compare time to fracture in these groups. METHODS Sixty-two patients who received high-dose radiation for sacral chordomas with (n = 44) or without surgical resection (n = 18) between 1992 and 2013 were included in this retrospective study. At our institution, sacral chordomas generally are treated by preoperative radiotherapy, followed by en bloc resection, and postoperative radiotherapy. Radiation alone, with an intent to cure, is offered to patients who otherwise are not good surgical candidates or patients who elect radiotherapy based on tumor location and the anticipated morbidity after surgery (such as sexual, bowel, or bladder dysfunction). MRI and CT scans were evaluated for evidence of sacral insufficiency fractures. Complete followup was available at a minimum of 2 years (or until fracture or death) for all 18 patients who underwent radiation alone, whereas 14% (six of 44 patients) in the surgery plus radiation group (9% [three of 33] after high sacrectomy and 27% [three of 11] after low sacrectomy) were lost to followup before 2 years. RESULTS Sacral insufficiency fractures occurred in 29 of the 62 patients (47%). A total of 25 of 33 patients (76%) with high sacrectomy had fractures develop compared with zero of 11 (0%) after low sacrectomy, and four of the 18 patients (22%) who had high-dose radiation alone (p < 0.001). The fracture rate was greater in the high sacrectomy group than in the low sacrectomy group (p < 0.001) and the radiation only group (p < 0.001). There was no difference with the numbers evaluated in fracture probability between patients in the low-sacrectomy group and those treated with radiation alone (p = 0.112). The fracture-free survival probability was 0.99 for the low sacrectomy group at all times as there were no insufficiency fractures in this group; the 1-year fracture-free survival probability was 0.53 (95% CI, 0.35-0.69) after high sacrectomy, 0.83 (95% CI, 0.57-0.94) after radiation alone; the 2-year fracture-free survival probability was 0.36 (95% CI, 0.19-0.52) after high sacrectomy and 0.77 (95% CI, 0.50-0.91) after radiation alone; and the 5-year fracture-free survival probability was 0.14 (95% CI, 0.04-0.30) after high sacrectomy and 0.77 (95% CI, 0.50-0.91) after radiation alone. CONCLUSIONS Acknowledging the limitations of potential differences in baseline and followup among treatment groups in our study, we found that almost ½ of our patients experienced an insufficiency fracture. We found that the fracture rate was greater in the surgery group compared with the radiation alone group and that high sacrectomy accounted for all fractures in the surgery group. These findings can be used to inform patients and also support the need for further research to elucidate the influence of high-dose radiation on bone quality. LEVEL OF EVIDENCE Level III, therapeutic study.
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Bone Health and Pelvic Radiotherapy. Clin Oncol (R Coll Radiol) 2015; 27:668-78. [DOI: 10.1016/j.clon.2015.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 07/19/2015] [Indexed: 12/26/2022]
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Wagner D, Ossendorf C, Gruszka D, Hofmann A, Rommens PM. Fragility fractures of the sacrum: how to identify and when to treat surgically? Eur J Trauma Emerg Surg 2015; 41:349-62. [PMID: 26038048 PMCID: PMC4523697 DOI: 10.1007/s00068-015-0530-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/07/2015] [Indexed: 12/29/2022]
Abstract
The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.
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Affiliation(s)
- D Wagner
- Department of Orthopaedics and Traumatology, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany,
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Oh D, Huh SJ. Insufficiency fracture after radiation therapy. Radiat Oncol J 2014; 32:213-20. [PMID: 25568849 PMCID: PMC4282995 DOI: 10.3857/roj.2014.32.4.213] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/04/2014] [Accepted: 12/09/2014] [Indexed: 12/25/2022] Open
Abstract
Insufficiency fracture occurs when normal or physiological stress applied to weakened bone with demineralization and decreased elastic resistance. Recently, many studies reported the development of IF after radiation therapy (RT) in gynecological cancer, prostate cancer, anal cancer and rectal cancer. The RT-induced insufficiency fracture is a common complication during the follow-up using modern imaging studies. The clinical suspicion and knowledge the characteristic imaging patterns of insufficiency fracture is essential to differentiate it from metastatic bone lesions, because it sometimes cause severe pain, and it may be confused with bone metastasis.
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Affiliation(s)
- Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
The limitation of the traditional method of stratifying patients with rectal cancer for prognosis using magnetic resonance imaging (MRI) and computerised tomography (CT)-TNM staging-is that cT3 tumors comprise the vast majority of rectal cancers. There is a wide variability in outcomes for cT3. Despite this observation, many still advocate routine short course preoperative radiotherapy (SCPRT) or chemoradiation (CRT) for all patients staged as cT3N0 regardless of tumour location, proximity to other structures or extent, despite the fact that advances in imaging with MRI now offer the ability to predict potential outcomes in terms of the risk of local and metastatic recurrence for the individual. Preoperative CRT is designed to reduce local recurrence. The majority of local recurrences historically reflected inadequate quality of the mesorectal resection. Currently, optimal quality-controlled surgery in terms of total mesorectal excision (TME) in the trial setting can be associated with much lower local recurrence rates of less than 10 % whether patients receive radiotherapy or not. Because of the high risk of metastatic disease in selected patients, integrating more active chemotherapy is now attractive. Chemoradiotherapy (CRT) achieves shrinkage and sometimes eradication of tumour-i.e. a pathological complete response (pCR), and reduces local recurrence, but has no impact on overall survival. CRT also increases surgical morbidity and impacts on anorectal, urinary and sexual function with an increased risk of second malignancies. Hence, the predominant aims of CRT have been to shrink/downstage a tumour to allow an R0 resection to be performed, or to increase the chances of performing sphincter-sparing surgery. However, it remains unclear why shrinkage/downstaging is meaningful to a patient unless the tumour is initially borderline resectable or unresectable (i.e. the CRM is threatened) or the aim is to perform a lesser operation (i.e. sphincter-sparing or local excision) or for organ-sparing, i.e. to avoid surgery altogether. If it is important to shrink the cancer-ie there is a predicted threat to the CRM, then CRT is currently the treatment of choice. If the cancer is resectable and the aim is simply to lower the risk of local recurrence and preoperative CRT does not impact on survival, can CRT be omitted in selected cases? The answer is yes-with the proviso that we are using good quality MRI and the surgeon is performing good quality TME surgery within the mesorectal plane.
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Affiliation(s)
- Rob Glynne-Jones
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Rickmansworth Road, Northwood, London, Middlesex, HA6 2RN, UK,
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Sacral insufficiency fracture after pelvic radiotherapy: A diagnostic challenge for a radiologist. Medicina (B Aires) 2014; 50:249-54. [DOI: 10.1016/j.medici.2014.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 09/13/2014] [Indexed: 11/20/2022] Open
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Thiagarajan A, Pan L, Zatcky J, Krol G, Boland PJ, Yamada Y. Insufficiency fractures of the sacrum following stereotactic body radiotherapy for sacral tumors. JOURNAL OF RADIOSURGERY AND SBRT 2014; 3:59-65. [PMID: 29296386 PMCID: PMC5725331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 02/17/2013] [Indexed: 06/07/2023]
Abstract
INTRODUCTION There is little data on sacral insufficiency fracture(SIF) incidence following pelvic radiotherapy, with existing studies based on conventional fractionation. Stereotactic body radiotherapy (SBRT), characterized by dose escalation with hypofractionation, may pose even greater risks to sacral integrity. This study aims to define SIF incidence and risk factors following SBRT. METHODS Records of 43 consecutive patients who underwent sacral SBRT from September 2005-May 2009 were reviewed. Baseline patient information (age, gender, menopausal status, body mass index, use of bone-thinning agents, presence of osteoporosis), tumor characteristics (histology, lesion appearance and extent) and treatment parameters (dose/fractionation, prior radiation/surgery) were documented. Primary end-point was development of new fractures or progression of pre-existing fractures. Secondary end-points included pain scores, analgesic use, functional ability, and local tumor control. RESULTS Median follow-up was 17months. Common histologies included sarcoma, renal cell, and prostate carcinoma; 47% of lesions were lytic, 37% sclerotic and the remainder mixed. Doses ranged from 18-24Gy/1fraction to 30Gy/5fractions with 45% receiving single fractions.14% had prior radiation (median dose: 30Gy/10fractions).Five patients developed SIF. In four, fractures occurred in the context of controlled local disease. Median time to SIF was 8.2months. Symptoms varied from minimal pain requiring no intervention to severe pain impacting on function. Two patients underwent sacroplasty due to intractable pain, with both obtaining good analgesia. Low event numbers precluded meaningful univariate/multivariate analyses. One-year local tumor control rates were excellent (91.7%). CONCLUSION In this study, actuarial SIF incidence at one year was 8.2%, suggesting that SIF risk from sacral SBRT is low. However, larger prospective studies with longer follow-up are needed. In addition, novel therapies such as sacroplasty need further study to determine safety, efficacy and indications for use.
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Affiliation(s)
- Anuradha Thiagarajan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
- Department of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610, Singapore
| | - Larry Pan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
| | - Joan Zatcky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
| | - George Krol
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
| | - Patrick J Boland
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
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Kim YI, Kang HG, Kim SK, Kim JH, Kim HS. Clinical outcome prediction of percutaneous cementoplasty for metastatic bone tumor using 18F-FDG PET-CT. Ann Nucl Med 2013; 27:916-23. [DOI: 10.1007/s12149-013-0771-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/09/2013] [Indexed: 01/09/2023]
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Abstract
Neoadjuvant treatment in terms of preoperative radiotherapy reduces local recurrence in rectal cancer, but this improvement has little if any impact on overall survival. Currently performed optimal quality-controlled total mesorectal excision (TME) surgery for patients in the trial setting can be associated with very low local recurrence rates of less than 10% whether the patients receive radiotherapy or not. Hence metastatic disease is now the predominant issue. The concept of neoadjuvant chemotherapy (NACT) is a potentially attractive additional or alternative strategy to radiotherapy to deal with metastases. However, randomised phase III trials, evaluating the addition of oxaliplatin at low doses plus preoperative fluoropyrimidine-based chemoradiotherapy (CRT), have in the main failed to show a significant improvement on early pathological response, with the exception of the German CAO/ARO/AIO-04 study. The integration of biologically targeted agents into preoperative CRT has also not fulfilled expectations. The addition of cetuximab appears to achieve relatively low rates of pathological complete responses, and the addition of bevacizumab has raised concerns for excess surgical morbidity. As an alternative to concurrent chemoradiation (which delivers only 5-6 weeks of chemotherapy), potential options include an induction component of 6-12 weeks of NACT prior to radiotherapy or chemoradiation, or the addition of chemotherapy after short-course preoperative radiotherapy (SCPRT) or chemoradiation (defined as consolidation chemotherapy) which utilises the "dead space" of the interval between the end of chemoradiation and surgery, or delivering chemotherapy alone without any radiotherapy.
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Affiliation(s)
- Rob Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Northwood, United Kingdom
| | - Ian Chau
- Royal Marsden Hospital, Department of Medicine, Sutton, United Kingdom
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Mehmood QU, Garcez K, Henson CC, Davidson SE, Higham CE. Pharmacological interventions for the prevention of insufficiency fractures and avascular necrosis associated with pelvic radiotherapy in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Qurrat U Mehmood
- Christie NHS Foundation Trust; Radiotherapy-related Research; Wilmslow Road Manchester Greater Manchester UK M20 4BX
| | - Kate Garcez
- Christie Hospital NHS Foundation Trust; Clinical Oncology; Wilmslow Road Manchester UK M20 4BX
| | - Caroline C Henson
- Royal Bolton Hospital; Gastroenterology; Minerva Rd Farnworth Bolton Lancashire UK BL4 0JR
| | - Susan E Davidson
- Christie Hospital NHS Foundation Trust; Clinical Oncology; Wilmslow Road Manchester UK M20 4BX
| | - Claire E Higham
- Christie Hospital NHS Foundation Trust; Endocrinology; Wilmslow Road Manchester Greater Manchester UK M20 4BX
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Kim HJ, Boland PJ, Meredith DS, Lis E, Zhang Z, Shi W, Yamada YJ, Goodman KA. Fractures of the sacrum after chemoradiation for rectal carcinoma: incidence, risk factors, and radiographic evaluation. Int J Radiat Oncol Biol Phys 2012; 84:694-9. [PMID: 22867889 DOI: 10.1016/j.ijrobp.2012.01.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 01/05/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE Sacral insufficiency fractures after adjuvant radiation for rectal carcinoma can present similarly to recurrent disease. As a complication associated with pelvic radiation, it is important to be aware of the incidence and risk factors associated with sacral fractures in the clinical assessment of these patients. METHODS AND MATERIALS Between 1998 and 2007, a total of 582 patients with locally advanced rectal carcinoma received adjuvant chemoradiation and surgical excision. Of these, 492 patients had imaging studies available for review. Hospital records and imaging studies from all 492 patients were retrospectively evaluated to identify risk factors associated with developing a sacral insufficiency fracture. RESULTS With a median follow-up time of 3.5 years, the incidence of sacral fractures was 7.1% (35/492). The 4-year sacral fracture free rate was 0.91. Univariate analysis showed that increasing age (≥60 vs. <60 years), female sex, and history of osteoporosis were significantly associated with shorter time to sacral fracture (P=.01, P=.004, P=.001, respectively). There was no significant difference in the time to sacral fracture for patients based on stage, radiotherapy dose, or chemotherapy regimen. Multivariate analysis showed increasing age (≥60 vs. <60 years, hazard ratio [HR] = 2.50, 95% confidence interval [CI] = 1.22-5.13, P=.01), female sex (HR = 2.64, CI = 1.29-5.38, P=.008), and history of osteoporosis (HR = 3.23, CI = 1.23-8.50, P=.02) were independent risk factors associated with sacral fracture. CONCLUSIONS Sacral insufficiency fractures after pelvic radiation for rectal carcinoma occur more commonly than previously described. Independent risk factors associated with fracture were osteoporosis, female sex, and age greater than 60 years.
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Affiliation(s)
- Han Jo Kim
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
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Glynne-Jones R. Neoadjuvant treatment in rectal cancer: do we always need radiotherapy-or can we risk assess locally advanced rectal cancer better? Recent Results Cancer Res 2012; 196:21-36. [PMID: 23129364 DOI: 10.1007/978-3-642-31629-6_2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
There is good quality evidence that preoperative radiotherapy reduces local recurrence but there is little impact on overall survival. This is not completely unexpected as radiotherapy is a localised treatment and local control may not prevent systemic failure. Optimal quality-controlled surgery for patients with operable rectal cancer in the trial setting can be associated with local recurrence rates of less than 10 % whether patients receive radiotherapy or not (Quirke et al. 2009). However, despite the reassuring results of randomised trials, concerns remain that radiotherapy increases surgical morbidity (Horisberger et al. 2008; Stelzmueller et al. 2009; Swellengrebel et al. 2011), which can compromise the delivery of postoperative adjuvant chemotherapy. There are also significant late effects from pelvic radiotherapy (Peeters et al. 2005; Lange et al. 2007) and a risk of second malignancies (Birgisson et al. 2005; van Gijn et al. 2011). If preoperative radiotherapy does not impact on survival, can it be omitted in selected cases? The answer is yes-with the proviso that we are using good quality magnetic resonance imaging and good quality TME surgery within the mesorectal plane and the predicted risk of subsequent metastatic disease justifies its use. In this case, the concept of neoadjuvant chemotherapy (NACT) is a potentially attractive alternative strategy which might have less early and long-term side effects compared to preoperative radiotherapy-particularly where the MRI predicts a high risk of metastatic disease in the context of a modest risk of local recurrence. This chapter discusses a more precise method of risk categorisation for locally advanced rectal cancer, and discusses possible options for neoadjuvant chemotherapy (NACT).
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Affiliation(s)
- Rob Glynne-Jones
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK.
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Park SH, Kim JC, Lee JE, Park IK. Pelvic insufficiency fracture after radiotherapy in patients with cervical cancer in the era of PET/CT. Radiat Oncol J 2011; 29:269-76. [PMID: 22984680 PMCID: PMC3429912 DOI: 10.3857/roj.2011.29.4.269] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 11/16/2011] [Accepted: 11/16/2011] [Indexed: 11/03/2022] Open
Abstract
PURPOSE To determine the incidence, risk factors, and clinical characteristics of pelvic insufficiency fracture (PIF) in patients with cervical cancer. MATERIALS AND METHODS Between July 2004 and August 2009, 235 patients with non-metastatic cervical cancer were treated with definitive chemoradiation or postoperative radiotherapy. Among 235 patients, 117 (49.8%) underwent the first positron emission tomography/computed tomography (PET/CT) within 1 year after radiotherapy. The median radiation dose was 55 Gy (range, 45 to 60 Gy). Medical charts and imaging studies, including PET/CT, magnetic resonance imaging (MRI), CT, bone scintigraphy were reviewed to evaluate the patients with PIF. RESULTS Among 235 patients, 16 developed PIF. The 5-year detection rate of PIF was 9.5%. The 5-year detection rate of PIF in patients who underwent the first PET/CT within a year was 15.6%. The median time to development of PIF was 12.5 months (range, 5 to 30 months). The sites of fracture included 12 sacroiliac joints, 3 pubic rami, 3 iliac bones, and 1 femoral neck. Eleven of 16 patients having PIF complained of hip pain requiring medications. One patient required hospitalization for pain control. The significant risk factors of PIF were old age, body mass index less than 23, bone mineral density less than -3.5 SD, and the first PET/CT within a year after radiotherapy. Radiation dose and concurrent chemotherapy had no impact on PIF rate. CONCLUSION PIFs were not rare after pelvic radiotherapy in cervical cancer patients in the era of PET/CT. Timely diagnosis and management of PIF can improve quality of life in patients with cervical cancer, in addition to reducing unnecessary medical expenses.
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Affiliation(s)
- Shin-Hyung Park
- Department of Radiation Oncology, Kyungpook National University School of Medicine, Daegu, Korea
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Glynne-Jones R, Kronfli M. Locally advanced rectal cancer: a comparison of management strategies. Drugs 2011; 71:1153-77. [PMID: 21711061 DOI: 10.2165/11591330-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Traditionally, there has been a high local recurrence rate in rectal cancer and 10-40% of patients require a permanent stoma. Both short-course preoperative radiotherapy (SCPRT) and long-course preoperative chemoradiation (CRT) are used to reduce the risk of local recurrence and enable a curative resection. Total mesorectal excision has reduced the rate of local recurrence (even without radiotherapy) to below 10%, but has highlighted a high risk of metastatic disease in 30-40% of patients. Current trials suggest that in resectable cancers, where the preoperative magnetic resonance imaging (MRI) suggests the circumferential resection margin (CRM) is not potentially involved, then SCPRT and CRT are equivalent in terms of outcomes such as local recurrence, disease-free survival (DFS) and overall survival (OS). For patients with more advanced disease, where the CRM is breached or threatened according to the MRI, the integration of more active chemotherapy and biological agents into chemoradiation is an attractive strategy because of the high risk of metastases. However, in none of the trials published in the last decade has chemoradiation impacted on DFS or OS. We examine the strategies of neoadjuvant, concurrent, consolidation (after chemoradiation and before surgery) and postoperative adjuvant chemotherapy with cytotoxic agents, and the integration of biological agents for future potential strategies of treatment. We also compare the trials and compare the different strategies of long-course preoperative radiotherapy and SCPRT; the intensification of preoperative radiation and chemoradiation with dose escalation of external beam radiotherapy, using brachytherapy, intra-operative radiotherapy, hyperfractionation, and various available techniques such as intensity-modulated radiotherapy. We recommend examining dose escalation of radiotherapy to the primary tumour where MRI predicts a threatened CRM. Of the potential treatment strategies involving cytotoxic agents, such as neoadjuvant, concurrent, consolidation and postoperative adjuvant chemotherapy, the most promising would appear to be consolidation chemotherapy following chemoradiation in locally advanced disease, and neoadjuvant chemotherapy in MRI-selected patients who do not require radiation. Improvement in the quality of surgery is also an important future goal.
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Affiliation(s)
- Robert Glynne-Jones
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK.
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Michalecki Ł, Gabryś D, Kulik R, Wydmański J, Trela K. Radiotherapy induced hip joint avascular necrosis-Two cases report. Rep Pract Oncol Radiother 2011; 16:198-201. [PMID: 24376980 PMCID: PMC3863280 DOI: 10.1016/j.rpor.2011.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 03/23/2011] [Accepted: 04/29/2011] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Avascular necrosis (AVN) refers to the death of osteocytes and osteoblasts. Sites such as the femoral head, the head of the humerus and the mandibula with restricted access to local blood supply are particularly vulnerable to osteonecrosis. A COMBINATION OF SEVERAL FACTORS IS RESPONSIBLE FOR ISCHAEMIA AND IS ASSOCIATED WITH AVN: corticosteroids, alcohol abuse, Cushing's syndrome, SLE, systemic vasculitis, RA, scleroderma, haemoglobinopathies, radiotherapy. Management is based on proper diagnosis and treatment - conservative, pharmacological or surgical. Radiotherapy has become an integral part of the therapeutic programme of cancer patients. However, early and late after-effects of irradiation still constitute a significant issue in clinical practice. AIM The aim of this report is to present two cases of acetabular protrusion and femoral head deformities after a therapeutic pelvic irradiation and draw physicians' attention to that clinical problem which continues to be underestimated. MATERIALS AND METHODS This report documents two cases of acetabular protrusion and femoral head deformities after a therapeutic pelvic radiation. RESULTS Avascular necrosis (AVN) constitutes a severe and challenging long-term complication in radiation oncology. CONCLUSION It is necessary to take into account bone structures among organ at risk (OAR) involved in irradiation fields. The detailed analysis of the dose distribution and the use of collimators allow to decrease the total dose to OAR. An adequate management, early diagnosis and prompt, proper treatment may protect patients from long-term morbidities.
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Affiliation(s)
- Łukasz Michalecki
- Department Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-100 Gliwice, Poland
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Fiorino C, Valdagni R, Rancati T, Sanguineti G. Dose–volume effects for normal tissues in external radiotherapy: Pelvis. Radiother Oncol 2009; 93:153-67. [DOI: 10.1016/j.radonc.2009.08.004] [Citation(s) in RCA: 225] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 08/11/2009] [Accepted: 08/11/2009] [Indexed: 02/07/2023]
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Insufficiency fractures after pelvic radiotherapy in patients with prostate cancer. Int J Radiat Oncol Biol Phys 2009; 77:818-23. [PMID: 19879066 DOI: 10.1016/j.ijrobp.2009.05.059] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 05/25/2009] [Accepted: 05/29/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE To assess the incidence, predisposing factors, and clinical characteristics of insufficiency fractures (IF) in patients with prostate cancer, who received pelvic radiotherapy as part of their definitive treatment. METHODS AND MATERIALS The charts of 134 prostate cancer patients, who were treated with pelvic radiotherapy between 1998 and 2007 were retrospectively reviewed. IF was diagnosed by bone scan and/or CT and/or MRI. The cumulative incidence of symptomatic IF was estimated by actuarial methods. RESULTS Eight patients were identified with symptomatic IF after a median follow-up period of 68 months (range, 12-116 months). The 5-year cumulative incidence of symptomatic IF was 6.8%. All patients presented with lower back pain. Insufficiency fracture developed at a median time of 20 months after the end of radiotherapy and was managed conservatively without any need for hospitalization. Three patients were thought to have metastatic disease because of increased uptake in their bone scans. However, subsequent CT and MR imaging revealed characteristic changes of IF, avoiding any further intervention. No predisposing factors for development of IF could be identified. CONCLUSIONS Pelvic IF is a rare complication of pelvic radiotherapy in prostate cancer. Knowledge of pelvic IF is essential to rule out metastatic disease and prevent unnecessary treatment, especially in a patient cohort with high-risk features for distant spread.
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