Insufficiency fractures in patients treated with pelvic radiotherapy and chemotherapy for uterine and cervical cancer

Effect of Patient Age on Total Hip Arthroplasty Outcomes in Patients Who Have Osteonecrosis of the Femoral Head Compared to Patients Who Have Hip Osteoarthritis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) affects both young and old patients. However, outcomes following total hip arthroplasty (THA) for these patients may vary with age. This study aimed to examine the effect of age on THA outcomes for non-traumatic ONFH patients, an area currently lacking research.

METHODS

Patients who had non-traumatic ONFH undergoing THA with at least 2 years of follow-up were identified using a database and divided into four groups by age. Then, 4 matched control groups of patients who had hip osteoarthritis (OA) were created. Multivariate logistic regression analyses were used to evaluate the rates of medical and surgical complications. Additionally, cohorts with a minimum 5-year follow-up were filtered to obtain further data on surgical outcomes. The study analyzed 85,462 non-traumatic ONFH and 80,120 hip OA patients undergoing THA.

RESULTS

Multiple medical complications in ONFH patients increased with age. Periprosthetic fracture within 2 years increased with age, while 90-day wound complications, 2-year periprosthetic joint infections, dislocations, and revisions decreased. The trends for complications continued at the 5-year follow-up. Compared to OA patients, those who had ONFH had higher risks of most complications, but this discrepancy decreased with age.

CONCLUSIONS

In ONFH patients undergoing THA, medical complications generally rise with age, while most surgical complications, including revisions, decrease. It is notable that ONFH patients experienced more complications than those who had OA, but this difference diminished with age.

Insights into pelvic insufficiency fracture following pelvic radiotherapy for cervical cancer: a comparative review

BACKGROUND

Radiotherapy (RT)-induced pelvic insufficiency fractures (PIF) are prevalent in patients with cervical cancer. Inconclusive studies on PIF after cervical irradiation create uncertainty. This review examined PIF after RT in cervical patients, including its pathobiology, likely locations of fractures, incidence, clinical symptoms, and predisposing factors. We further discussed study limitations and therapeutic possibilities of PIF.

METHODS

The following online resources were searched for relevant articles: Google Scholar and PubMed. The keywords 'pelvic insufficiency fractures', 'cervical carcinoma' and 'cervical cancer', as well as 'chemoradiotherapy', 'chemoradiation', and 'radiotherapy', were some of the terms that were used during the search.

RESULTS

Patients with PIF report pelvic pain after radiation treatment for cervical cancer; the incidence of PIF ranges from 1.7 to 45.2%. Evidence also supports that among all patients treated with pelvic radiation, those who experienced pelvic insufficiency fractures invariably had at least one sacral fracture, making it the most frequently fractured bone in the body. Menopausal status, weight, BMI, age, and treatments and diagnosis modalities can influence PIF during radiotherapy.

CONCLUSIONS

In conclusion, our comparative review of the literature highlights significant heterogeneity in various aspects of PIF following radiation for patients with cervical cancer. This diversity encompasses prevalence rates, associated risk factors, symptoms, severity, diagnosis methods, preventive interventions, and follow-up periods. Such diversity underscores the complexity of PIF in this population and emphasizes the critical need for further research to elucidate optimal management strategies and improve patient outcomes.

Symptomatic radiation-induced rib fractures after stereotactic body radiotherapy for early-stage non-small cell lung cancer

Background and purpose

The present study investigated the relationships between the risk of radiation-induced rib fractures (RIRF) and clinical and dosimetric factors in stereotactic body radiotherapy (SBRT) for early-stage non-small cell lung cancer (NSCLC). We also examined dosimetric parameters associated with symptomatic or asymptomatic RIRF and the dosimetric threshold for symptomatic RIRF.

Materials and methods

We reviewed 244 cases of early-stage NSCLC treated with SBRT. Gray's test and the Fine-Gray model were performed to examine the relationships between clinical and dosimetric factors and grade ≥ 2 (i.e., symptomatic) RIRF. The effects of each dose parameter on grade ≥ 1 and ≥ 2 RIRF were assessed with the Fine-Gray model. The t-test was used to compare each dose parameter between the grade 1 and grade ≥ 2 groups. Optimal thresholds were tested using receiver operating characteristic (ROC) curves.

Results

With a median follow-up period of 48 months, the 4-year cumulative incidence of grade ≥ 1 and grade ≥ 2 RIRF were 26.4 % and 8.0 %, respectively. Regarding clinical factors, only age was associated with the development of grade ≥ 2 RIRF (p = 0.024). Among dosimetric parameters, only V40Gy significantly differed between the grade 1 and grade ≥ 2 groups (p = 0.015). The ROC curve analysis of grade ≥ 2 RIRF showed that the optimal diagnostic thresholds for D3cc, D4cc, D5cc, and V40Gy were 45.86 Gy (area under the curve [AUC], 0.706), 39.02 Gy (AUC, 0.705), 41.62 Gy (AUC, 0.702), and 3.83 cc (AUC, 0.730), respectively. These results showed that V40Gy ≤ 3.83 cc was the best indicator of grade ≥ 2 RIRF. The 4-year incidence of grade ≥ 2 RIRF in the V40Gy ≤ 3.83 cc vs. > 3.83 cc groups was 1.8 % vs. 14.2 % (p = 0.001).

Conclusion

The present results recommend V40Gy ≤ 3.83 cc as the threshold for grade ≥ 2 RIRF in SBRT.

Opportunistic osteoporosis screening using routine computed tomography images to identify bone loss in gynecologic cancer survivors

Objective

Cancer treatment-induced bone loss is a known side effect of cancer therapy. Computed tomography (CT) bone mineral density screening is a novel tool for identifying bone loss. This study aims to use routine CT images to determine long-term bone mineral density changes and osteoporosis risk among women with gynecologic cancers.

Methods

Bone loss was evaluated in a retrospective cohort of women ≤65 years old with gynecologic cancer who underwent oophorectomy from January 2010 to December 2014. Opportunistic CT-based bone mineral density measurements (Hounsfield units, HU) were performed at baseline and intervals up to 5 years after cancer diagnosis. Osteoporosis risk was categorized by HU. Bivariate and multivariate analyses were performed to compare baseline to follow-up bone mineral density at 1, 3, and 5 years and to identify predictors of bone loss following diagnosis.

Results

A total of 185 patients (median age 53 years, range 23–65 years, 78.1% ovarian cancer) were included. Bone mineral density significantly decreased between baseline and 1 year (p<0.001), 3 years (p<0.001), and 5 years (p<0.001). Half with normal bone mineral density at baseline had risk for osteopenia or osteoporosis at 5 years. Four percent had osteoporosis risk at baseline compared with 1 year (7.4%), 3 years (15.7%), and 5 years (18.0%). Pre-treatment bone mineral density was a significant predictor at 1 and 5 years (1 year: p<0.01; 5 years: p<0.01). History of chemotherapy predicted bone loss at 1 year (p=0.03). More lifetime chemotherapy cycles were associated with increased risk of osteoporosis at 1 year (p=0.03) and 5 years (p=0.01).

Conclusions

Women with gynecologic cancers may experience accelerated cancer treatment-induced bone loss. Routine CT imaging is a convenient screening modality to identify those at highest risk for osteoporosis who warrant further evaluation with dual-energy X-ray absorptiometry. Routine bone mineral density assessments 1 year following oophorectomy for cancer treatment may be warranted in this population.

An injectable hydroxypropyl-β-cyclodextrin cross-linked gelatin-based hydrogel loaded bone mesenchymal stem cell for osteogenic and in vivo bone regeneration of femoral head necrosis

An injectable hydroxypropyl-β-cyclodextrin (HPβCD) cross-linking of gelatin (Gel) based hydrogel was embedded with BMSC in vivo bone regeneration of femoral head necrosis. This HPβCD-Gel hydrogel possesses quick gelation within 6 min; a high-water uptake resulted in faster biodegradation, high swelling, and a 3D porous network that strengthened its mechanical, surface, and morphological properties. The results indicated that BMSC showed high cell viability (>90%) during measurement; HPβCD-Gel hydrogels induced BMSC differentiation into osteocytes within 14 days more efficiently than the osteogenic medium. The HPβCD-Gel/BMSC hydrogels that were injected into the necrosis site of the femoral head in the vessels were measured for 2 weeks. In addition, the vessel density and mean vessel diameters increased in the next 2-8 weeks followed by increased new bone formation, according to the in vivo analysis. Overall, our findings show that this method is a promising strategy for improving femoral head necrosis bone regeneration.

PET/MRI is useful for early detection of pelvic insufficiency fractures after radiotherapy for cervical cancer

Radiotherapy (RT) is used to manage cervical cancer, and pelvic insufficiency fracture (PIF) is known as a late complication of RT. The present study identified risk factors for PIF after radiotherapy for cervical cancer, and investigated its incidence rate. It also considered the usefulness of positron emission tomography/magnetic resonance imaging (PET/MRI) in PIF diagnosis. A total of 149 patients with cervical cancer who received definitive or adjuvant RT with/without concurrent chemotherapy between January 2013 and December 2018 were investigated in the present study and followed up for more than one month after RT at Kobe University Hospital. The median follow-up period was 32 months (range, 1-87 months), and the median age of all patients was 66 years (age range, 34-90 years). Computed tomography (CT), MRI, PET/CT or PET/MRI were used for image examination. Among the 149 patients, 31 (20.8%) developed PIF. The median age of these patients was 69 years (age range, 44-87 years). Univariate analysis using the log-rank test demonstrated that age (≥60 years) was significantly associated with PIF. The median maximum standardized uptake value of PIF sites on PET/CT was 4.32 (range, 3.04-4.81), and that on PET/MRI was 3.97 (range, 1.21-5.96) (P=0.162). Notably, the detection time of PIF by PET/MRI was significantly earlier compared with PET/CT (P<0.05). The incidence of PIF after RT for cervical cancer was 20.8%, and age was significantly associated with risk factors for such fractures. Taken together, these results suggest that PET/MRI, which offers the advantage of decreased radiation exposure to the patient, is useful for diagnosing PIF and can detect it earlier than PET/CT imaging.

Pelvic Insufficiency Fractures in Cervical Cancer After Radiation Therapy: A Meta-Analysis and Review

AIM

The aim of the study was to estimate the prevalence of pelvic insufficiency fractures (PIFs) after radiation therapy (RT) in patients with cervical cancer.

PATIENTS AND METHODS

A total of 3,633 patients from 15 cohort studies were included. Proportion meta-analysis was performed to estimate prevalence and subgroup analysis was performed according to imaging modalities for diagnosis of PIF. For continuous variables (age and length of follow-up), meta-regression analysis was performed.

RESULTS

Pooled prevalence estimate of PIF was 14% (95% CI=10-19). Incidence of PIF was higher in studies that used MRI as a diagnostic tool (17%, 95% CI=12-22) than non-MRI (8%, 95% CI=2-14). In meta-regression, we found a significant association of prevalence of PIF with age (p=0.021) but not with length of follow-up (p=0.118).

CONCLUSION

PIF after RT in patients with cervical cancer is not rare. Physicians need to pay attention to PIFs, especially in patients with high-risk factors for osteoporotic fracture.

Bone health and osteoporosis screening in gynecologic cancer survivors

Cancer treatment-induced bone loss is a known side effect of cancer therapy that increases the risk of osteoporosis and bone fracture. Women with gynecologic cancer are at increased risk of bone loss secondary to the combined effect of oophorectomy and adjuvant therapies. Data regarding bone loss in women with gynecologic cancers are overall lacking compared to other cancer populations. Consequently, guidelines for osteoporosis screening in women with cancer are largely based on data generated among non-gynecologic cancer survivors. This article reviews current available data of bone health in women with gynecologic cancer, summarizes best-available guidelines for screening for osteoporosis in women with cancer, and provides guidance for osteoporosis screening in women with gynecologic cancers based on best available evidence.

Pelvic Insufficiency Fractures After External Beam Radiation Therapy for Gynecologic Cancers: A Meta-analysis and Meta-regression of 3929 Patients

PURPOSE

To estimate the overall rate, symptomatic proportion, and most common sites of pelvic insufficiency fracture (PIF) after external beam radiation therapy for gynecologic cancers based on posttreatment computed tomography, magnetic resonance imaging, positron emission tomography, or bone scintigraphy.

METHODS AND MATERIALS

A systematic search of databases (PubMed and EMBASE) was performed (CRD42019125679). The pooled summary of overall PIF and the proportion of symptomatic cases were calculated using the random-effects model weighted by the inverse variance. A multivariate meta-regression was performed to evaluate potential sources of heterogeneity regarding PIF fractures.

RESULTS

Twenty-one studies met the inclusion criteria (total 3929 patients). Five hundred four patients developed PIF, translating to an overall rate of 14% (95% confidence interval, 10%-18%, based on 21 studies). Among these cases with PIF, the proportion of symptomatic patients was 61% (95% confidence interval, 52%-69%, based on 14 studies). The total number of PIFs was 704 (mean, 1.72 PIFs per each patient to develop PIF, based on 14 studies). More recent series (P = .0074) and the use of intensity modulated radiation therapy (P = .0299) were associated with lower fracture rates. The most common fracture sites were sacroiliac joint (39.7%), body of the sacrum (33.9%), pubis (13%), lumbar vertebra (7%), iliac bone (2.8%), acetabulum (2.1%), and femoral head/neck (1.5%). The median time to fracture was 7.1 to 19 months after radiation therapy.

CONCLUSIONS

The incidence of PIF after radiation therapy for gynecologic cancers is high (14%), with the majority affecting the sacral bone or joint (73.6%), although this risk appears to be lower with intensity modulated radiation therapy. Posttreatment bone surveillance is warranted in this population because nearly 40% of patients were asymptomatic at the time of PIF diagnosis.

Increased risk of pelvic fracture after radiotherapy in rectal cancer survivors: A propensity matched study

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.

Epidemiology of osteonecrosis among older adults in Sweden

This study estimated the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults. Osteonecrosis was approximately 10 times more common than in previous studies. The strongest risk factors were dialysis, hip fracture, osteomyelitis, and organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

INTRODUCTION

The aim of this study was to estimate the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults and in a large number of risk groups in that cohort.

METHODS

In this retrospective cohort study, we included everyone who was aged 50 years or older and who was living in Sweden on 31 December 2005. We used Swedish national databases to collect data about prescription medication use, diagnosed medical conditions, and performed medical and surgical procedures. The study outcome was diagnosis of primary or secondary osteonecrosis at any skeletal site. The strength of risk factors was assessed using age- and sex-standardized incidence ratios (SIRs).

RESULTS

The study cohort comprised 3,338,463 adults. The 10-year risk of osteonecrosis was 0.4% (n = 13,425), and the incidence rate was 4.7 cases/10000 person-years (95% confidence interval [CI], 4.6 to 4.7 cases). The strongest risk factors for osteonecrosis were hip fracture (SIR, 7.98; 95% CI, 7.69-8.27), solid organ transplantation (SIR, 7.14; 95% CI, 5.59-8.99), dialysis (SIR, 6.65; 95% CI, 5.62-7.81), and osteomyelitis (SIR, 6.43; 95% CI, 5.70-7.23). A history of hip fracture was present in 21.7% of cases of osteonecrosis, but osteomyelitis, dialysis, and solid organ transplantation were present in only 0.5 to 2% of cases.

CONCLUSIONS

Osteonecrosis was approximately 10 times more common than a small number of previous population-based studies have suggested. The strongest risk factors for osteonecrosis were dialysis, hip fracture, osteomyelitis, and solid organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

Pharmacological interventions for the prevention of insufficiency fractures and avascular necrosis associated with pelvic radiotherapy in adults

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.

[Normal tissue tolerance to external beam radiation therapy: Bone marrow and cortical bone structures]

In patients undergoing external radiation therapy, bone marrow and cortical bone structures are all often neglected as organs at risk. Still, from increased febrile neutropenia risk in patients undergoing chemoradiation for a pelvic tumour to increased risk of vertebral fracture when undergoing hypofractioned stereotactic radiotherapy of a spinal metastasis, adverse effects are frequent and sometimes serious. This literature review first defines the rules for contouring these structures, then the dose constraints currently recommended. This article focuses first on conventional irradiation or intensity modulation radiotherapy considering classical fractionation. Secondly, it focuses on stereotactic radiotherapy. The considered organs will be haematopoietic structures, and bone cortical structures. Current recommendations are summarised in a table.

Walking Disability in Patients with Pelvic Insufficiency Fracture after Radiotherapy for Uterine Cervical Cancer

Objective

Radiotherapy is an essential component of curative or palliative therapy for patients with uterine cervical cancer. Although advances in radiotherapy have led to longer survival, survivors may consequently be at risk of pelvic insufficiency fracture (PIF). We retrospectively reviewed medical records and clinical outcomes to assess the impact of PIF on walking disability.

Methods

Between January 2002 and December 2009, 145 uterine cancer patients treated with radiotherapy in our hospital were reviewed. Among these, 15 patients (10.3%) were diagnosed with PIF. The types of fractures were identified according to the AO/OTA classification system. Medical records were examined to establish the time to first diagnosis of PIF, the type of fracture, and clinical outcomes. Disability was assessed using Barthel index mobility scores.

Results

The median time to PIF detection was 16 months. Of the 15 patients with PIF, 14 had type B fractures (7 cases of B2 and 7 cases of B3) and 1 had a type C fracture. Among 11 patients with pelvic pain, 6 achieved pain control but 5 patients with bilateral lesions in the posterior arch or lateral compression of the sacrum developed pain that finally resulted in walking disability and a lower performance status.

Conclusions

PIF causes severe motor disturbance in patients with unstable fracture types. Routine imaging checkups were useful during the 5 years after completion of radiotherapy; in nine patients the fracture progressed for longer than 1 year. In cancer rehabilitation for PIF patients, continuous assessment is essential for predicting walking disability.