TITLE:
Pelvic Insufficiency Fractures after Chemoradiation for Gynecologic Malignancies: A Review of Seven Cases
AUTHORS:
Emeline M. Aviki, Sophie M. Cowan, Laura Young, Marcela G. Del Carmen, Whitfield B. Growdon, Anthony H. Russell, Annekathryn Goodman
KEYWORDS:
Pelvic Insufficiency Fracture; Vulva Cancer; Cervical Cancer; Radiation; Chemotherapy; Diagnostic Imaging; Fracture Screening; Fracture Prophylaxis
JOURNAL NAME:
International Journal of Clinical Medicine,
Vol.4 No.12A,
December
30,
2013
ABSTRACT:
Background: Radiation-induced
pelvic insufficiency fracture (PIF) is an important complication associated
with pelvic radiation therapy (RT) for patients with gynecologic malignancies.
Despite known risk factors and recent reports describing the incidence on the order of 30 percent,
there has been a dearth of translational research or consensus statements to
guide clinical management. Objective: The aim of this study is to describe seven cases of PIF diagnosed and managed
at the Massachusetts General Hospital during a 5-year period and to perform a
focused review of the literature to inform several clinical questions that
remain unanswered. A secondary aim of this study is to highlight the need for
additional research related to screening, prophylaxis, diagnostics, and
treatment of PIF in patients with gynecologic malignancy. Methods: In the current retrospective review, we report 10 cases of
PIF diagnosed over a 5-year period in 7 patients with vulvar (4), vaginal (2), and cervical (1) cancer following chemoradiation
therapy at a single institution. Data were collected from the medical records by
a single investigator and all diagnostic imaging was reviewed by a single
radiologist to confirm the presence or absence of PIF. Results: All 7 patients were post-menopausal and received
concurrent chemoradiation, 3 were over the age of 65 years old (42.8%), 3 had
BMI kg/m2 (42.8%), 2 had a history of osteoporosis (28.6%), and 1 had a history of
hormone replacement therapy use (14.3%). No patients underwent standard
screening for PIF and no patients were started on prophylaxis prior to
diagnosis. The plain film was the most common initial imaging performed while MRI was
the most common overall study used to diagnose PIF. Median time to the development of fracture was 16 months
(range 4-114) with femoral neck fracture being
the most common (40%) and sacral fractures trailing close behind (30%). 7 of 10
fractures were initially managed expectantly with 1 ultimately failing expectant
management and requiring surgical intervention. 4 of 10 fractures required
surgical intervention. All patients had resolution of symptoms by 12 months
after diagnosis. Conclusion: Radiation-induced PIF remains an important complication associated with pelvic
RT. Significant risk factors have been identified and studies have compared
various diagnostic imaging modalities. Future studies are needed to compare
screening algorithms and evaluate the comparative effectiveness of prophylactic pharmacotherapies.
Future studies are also needed to determine the cost-effectiveness of PET/CT
versus MRI and compare the morbidity associated with expectant management
versus surgical intervention in patients with symptomatic fractures.