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


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Qurrat Mehmood1, Marianne Beardwood2, Ric Swindell1, Lisa Barraclough1, Jacqueline Livsey1, Susan Davidson1
1The Christie NHS Foundation Trust, Manchester, UK, 2Royal Bolton Hospital, Bolton, UK

Background

Insufficiency fractures are a recognised consequence of radiotherapy in gynaecological malignancy though the literature is limited with reported incidence ranging from 1.7% to 89%. We aimed to determine the incidence and possible risk factors for insufficiency fractures in patients receiving radical pelvic radiotherapy for uterine and cervical cancer.

Method

A casenote review was undertaken of patients receiving radical pelvic radiotherapy at the Christie Hospital between December 2006- August2009. Chemotherapy, steroid use, radiotherapy and bone abnormalities were recorded. Insufficiency fractures were identified from reported radiographs, CT and MRI images. Chi-squared and Mann-Whitney tests were performed to determine associations between insufficiency fractures and use of chemotherapy, steroids and age.

Results

285 patients were treated with radical pelvic radiotherapy including 137 patients (48.1%) for uterine cancer and 148 (51.9%) for cervical cancer. Median age was 61.6 years (range 23.7-86.7). 143 patients (50.1%) received chemotherapy, given neo-adjuvantly (3 patients), adjuvantly (39 patients) and concurrently (101 patients). 68 patients (23.8%) had bone abnormalities of which 33 (11.6%) had pelvic insufficiency fractures. Sites commonly affected the sacrum (30 patients), vertebrae (27 patients), pelvis (26 patients) and acetabulum (10 patients). 12 patients had multiple fractures and 3 patients (1%) had developed femoral head avascular necrosis. Median age of patients with bone abnormalities was 59.7 years (range 26.5-85.2) vs 61.8 years (range 23.7-86.7) in patients with none. No significant association was found between age and bone abnormalities (p=0.059). Significantly higher incidence of bone abnormalities were seen in cervical cancer compared to uterine cancer patients (p=0.011). Use of chemotherapy was significantly associated with bone abnormalities (X2=29.4 1df p<0.00005).

Conclusion

These data suggest a higher risk of insufficiency fractures in patients treated with radical pelvic radiotherapy when chemotherapy also forms a part of the treatment regime. Further research is required to establish ways to effectively identify, reduce and prevent this long-term morbidity.