Pelvic Insufficiency Fractures Research Articles

Pelvic bone complications following radiation therapy of gynecologic malignancies: Clinical evaluation of radiation-induced pelvic insufficiency fractures

To investigate the incidence, clinical and imaging finding of insufficiency fractures (IF) of the female pelvis following radiation therapy. We reviewed the radiation oncology records of 158 patients with gynecologic malignancies who underwent external beam radiation therapy of the whole pelvis between April 1993 and March 2004. All patients underwent computed tomography (CT) scan every 6 months in follow-up after radiation therapy and magnetic resonance imaging (MRI) and radionuclide bone scan were added when the patients complained of a pelvic pain. Eighteen of 158 patients (11.4%) developed IF in the irradiated field with a median interval of 6 months (range 3-51) from the completion of external beam radiation therapy. The cumulative incidence of symptomatic IF at 5 years calculated with Kaplan-Meyer methods was 13%. Median age of the patients who developed IF was 70 years (range 48-88), and all of them were postmenopausal. IF occurred in the sacloiliac joints, upper limb of pubic bone, acetabulum, sacral body and 5th lumbar vertebra. Twelve of 18 patients had multiple lesions and 8 had symmetric longitudinal fracture lines parallel to the sacroiliac joints. Avoidance of weight bearing by bed rest and analgesics provided good pain relief in all patients, although symptoms lasted from 3 to 20 months. Radiation-induced pelvic IF following radiation therapy for gynecologic malignancies were frequently observed in the postmenopausal patients within 1 year after external beam radiation therapy. Symmetric fractures of the both sacroiliac joints were the characteristic pattern of pelvic IF. Knowledge of characteristic imaging pattern of IF is essential in order to rule out the bone metastasis. Therapy recommendations are conservative with analgesics.

Osteoporotic Compression Fracture of the Thoracolumbar Spine and Sacral Insufficiency Fracture: Incidence and Analysis of the Relationship according to the Clinical Factors

Purpose: To evaluate the incidence of sacral insufficiency fracture in osteoporotic patients with compression fracture of the thoracolumbar (T-L) spine on magnetic resonance image (MRI), and to analyze the correlation of variable clinical factors and the incidence of sacral insufficiency fracture. Materials and Methods: We retrospectively reviewed 160 patients (27 men, 133 women; age range of 50 to 89 years) who underwent spinal MRI and had compression fracture of the T-L spine. Compression fractures due to trauma or tumor were excluded. We evaluated the incidence of sacral insufficiency fracture according to the patients' age, sex, number of compression fractures, and the existence of bone marrow edema pattern of compression fracture. During the same period, we evaluated the incidence of spinal compression fracture in the patients of pelvic insufficiency fracture. Results: Out of the 160 patients who had compression fracture in the T-L spine, 17 (10.6％) had insufficiency fracture of the sacrum. Compression fracture occurred almost 5 times more frequently in women (27:133), but the incidence of sacral insufficiency fracture was 2/27 for men (7.4%) and 15/133 for women (11.3%), with no statistically significant difference (p = 0.80). According to age, the ratio of insufficiency fracture to compression fracture was 0% (0/23) in the 50's, 10.6% (7/66) in the 60's, 12.5% (7/56) in the 70's, and 20.0% (3/15) in the 80's. In respect of single and multiple compression fracture, the incidence of sacral insufficiency fracture was 8/65 for men (12.3%) and 9/95 for women (9.5%), showing no significant difference (p=0.37). In the patients with and without compression fracture with bone marrow edema, insufficiency fracture occurred in 5/76 (6.6%) and 12/84 (14.3%), respectively. On the other hand, of the 67 patients who had pelvic insufficiency fracture, 27 (40.3%) also had spinal compression fracture. Conclusion: About 10% of the patients with osteoporotic compression fracture in the T/L spine also had pelvic sacral insufficiency fracture, which was not uncommon. These findings suggest the need to consider the possibility of pelvic sacral insufficiency fracture in cases of T/L spinal MRI for patients with osteoporotic compression fracture.

Pelvic Insufficiency Fracture Related to Autosomal Dominant Polycystic Kidney Disease

We report the case of a patient with autosomal dominant polycystic kidney disease (ADPKD) and an insufficiency-type fracture of the pelvis. A 60-year-old Japanese woman was admitted because of pain in the right ischium and pubis that began suddenly with no precipitating cause. Computed tomography showed the bony pelvis to be compressed by enlarged dependent kidneys and an enlarged liver. We relieved compression on the pelvic bones by means of transarterial embolization (TAE) to the kidneys and liver after initiation of hemodialysis therapy. The fracture healed gradually after TAE, and the patient could walk 4 months later. In an iliac bone specimen obtained before TAE, cancellous bone was intact, but periosteal and endosteal surfaces of cortical bone showed marked resorption and were irregular. Normally, many ligaments are connected tightly to the periosteal surface, supporting the cortical bone. However, because of extensive surface resorption associated with pressure from enlarged kidneys, connections between ligaments and the periosteal surface presumably became fragile, promoting an insufficiency fracture from unapparent external forces. Thus, ADPKD is a potential cause of insufficiency fracture owing to abnormalities of cortical bone.

Pelvic Insufficiency Fractures Following Radiation Therapy for Gynecologic Malignancies

Pelvic Insufficiency Fractures Following Radiation Therapy for Gynecologic Malignancies

Pelvic insufficiency fractures following irradiation for cervical or endometrial cancer

Pelvic insufficiency fractures following irradiation for cervical or endometrial cancer

Pelvic insufficiency fractures following irradiation for cervical or endometrial cancer

Pelvic insufficiency fractures following irradiation for cervical or endometrial cancer

High-dose whole abdominal and pelvic irradiation for treatment of ovarian carcinoma: Long-term toxicity and outcomes

Purpose To evaluate the role of high-dose whole abdominal and pelvic irradiation (WART) in the treatment of epithelial ovarian carcinoma. Methods and materials A retrospective review was performed on 71 patients with Stage I–III ovarian carcinoma who were treated with WART using an open field technique after total abdominal hysterectomy and bilateral oophorectomy with or without omentectomy. Whole abdominal doses greater than typically recommended were used in a series of patients to enhance local control and to decrease abdominal recurrence. None of the patients had received chemotherapy before RT. Thirty-one patients received Alkeran or cyclophosphamide and two received cisplatin-based chemotherapy after WART. The median whole abdominal dose was 36 Gy (range 9–45.5), delivered in a median of 30 fractions (range 8–46). A pelvic boost was delivered using AP–PA fields during whole abdominal RT to a total midline pelvic dose of 200 cGy/d. The median pelvic dose was 51 Gy (range 16–59). The right lobe and a portion of the left lobe of the liver were shielded with custom blocks at a median dose of 25 Gy (range 9–41). The kidneys were shielded either AP–PA or PA from the first day of RT. The median dose to the kidneys was 19 Gy (range 4–30). Results The 5-year overall survival rate was 93%, 48%, and 29% for Stage I, II, and III patients, respectively. On multivariate analysis, stage and the extent of residual disease were independent prognostic factors. The 5- and 10-year overall survival rate for the 46 patients in the intermediate-risk group was 61% and 54%, respectively. For this group, a total abdominal dose of ≥36 Gy was associated with a longer overall survival independent of stage, grade, and the amount of residual disease. This was most likely due to a significant reduction in the incidence of abdominal recurrence in patients receiving >36 Gy to the whole abdomen (18% vs. 49%, p = 0.006). Multivariate analysis revealed that grade ( p = 0.023) and abdominal dose ( p = 0.018) were independent factors influencing the rate of abdominal recurrence. Pelvic recurrence was rare as a first site of failure (6%). Twenty-one percent ( n = 15) of the patients developed Grade 3 or 4 (Radiation Therapy Oncology Group [RTOG] criteria) chronic small or large bowel toxicity. Eleven percent of all patients had a small bowel obstruction requiring surgery. A whole abdominal dose >30 Gy and a pelvic dose >50 Gy were associated with a significant increase in small bowel obstruction ( p = 0.01) independent of other factors. Chronic Grade 3 or 4 (Common Toxicity Criteria) anemia, thrombocytopenia, and leukopenia were seen in 7%, 1%, and 4% of the patients, respectively. Transient liver enzyme elevation was common (62%). Two patients had Grade 3 (RTOG) hepatic toxicity. Grade 3 or 4 renal toxicity (RTOG) was observed in 4%, and 2 patients (3%) were diagnosed with pelvic insufficiency fractures that were managed conservatively. Conclusion Survival after RT for ovarian carcinoma rivals that achieved with systemic chemotherapy. The results of this study suggest a possible dose–control relationship between the whole abdominal dose and the risk of abdominal recurrence; however, a higher rate of small bowel obstruction was observed when greater abdominal doses and greater pelvic doses were combined. Careful attention to balancing toxicity and efficacy is imperative if RT is to have a future role in the treatment of this disease.

Mortality and functional outcomes of pelvic insufficiency fractures in older patients

Objective. – To evaluate 1-year mortality and functional outcomes after pelvic insufficiency fractures in older patients. Patients and methods. – Retrospective review of medical records of patients 65 years of age or older admitted to our geriatrics department for pelvic fracture related to bone insufficiency over a 10-year period (1990-1999). For each patient, we recorded the circumstances of the fracture, time to diagnosis and imaging studies needed for diagnosis, functional status, place of residence before and after the fracture, general health status, treatment, short-term outcome, complications if any, length of hospital stay, and 1-year outcome. Results. – Sixty patients (54 women and 6 men) with a mean age of 83 ± 7.1 years had 49 pubic rami fractures, 16 sacral fractures, and three acetabular fractures. The sacral fractures were usually found only by radionuclide bone scanning, so that time to diagnosis was longer. A history of fracture or risk factor for fracture was found in 45% of the patients. One patient died during the hospital stay. No thromboembolic events were recorded. Twenty-four patients experienced other intercurrent events (urinary retention, lower respiratory tract infection, or urinary tract infection). Mean hospital length of stay was 45 ± 28 d overall and was longer in the subset of patients who were not fully self-sufficient before the fracture. At discharge, 50% of patients had not recovered their former level of self-sufficiency and 25% had to be institutionalized. The 1-year mortality rate was 14.3%. Pelvic insufficiency fractures are common in older patients. Although they are rarely life threatening, they deserve special attention as a source of functional disability.

Pelvic insufficiency fractures in postmenopausal woman with advanced cervical cancer treated by radiotherapy.

To assess the predisposing factors and clinical characteristics of pelvic insufficiency fractures (PIF) in postmenopausal women with pelvic irradiation. A total 335 postmenopausal patients with cervical cancer of the intact uterus treated with radiation therapy between 1983 and 1998 were reviewed. Total external dose was delivered between 45 and 50.4 Gy with parallel opposed anteroposterior portals. Total brachytherapy dose at point A was delivered between 10 and 36 Gy. PIF were diagnosed by bone scintigraphy and confirmed by computed tomography. The cumulative incidence of symptomatic PIF was estimated by actuarial methods. Potential risk factors (age, weight, type II diabetes, delivery, menopause, total external dose, total brachytherapy dose) were assessed. Fifty-seven (17.0%) of 335 patients were diagnosed as having PIF. Forty-seven patients were symptomatic and ten were asymptomatic. Parameters carrying a significant association with PIF were body weight 49 kg or below (P=0.044) in stepwise logistic regression analysis. The cumulative incidence of symptomatic PIF at 5 years was 17.9% calculated by the Kaplan-Meier method. A body weight of 49 kg or below and more than three deliveries were identified as having a significant effect on symptomatic PIF in univariate analysis (P=0.021, P=0.003, log-rank test) and Cox life table regression analysis (P=0.038, P=0.013). Five patients required narcotic agents and eight patients required hospital admission. We should consider reducing the dose contribution to the sacrum and sacroilac joints, without underdosing the tumor, especially in postmenopausal women with many deliveries or low body weight.

67 disc Pentoxifylline in the treatment of radiation related pelvic insufficiency fractures of bone: a case report

67 disc Pentoxifylline in the treatment of radiation related pelvic insufficiency fractures of bone: a case report

Six cases of pelvic insufficiency fracture

Six cases of pelvic insufficiency fracture

Pelvic insufficiency fracture after pelvic irradiation in uterine cervix cancer.

Pelvic insufficiency fractures (IF) are well known but uncommon and are frequently misinterpreted sequelae. The clinical features were investigated. Four hundred sixty-three patients, who were treated between 1994 and 2000 for uterine cervix cancer, were clinically examined. All patients had been treated with 10 or 15 MV photons, with 50.4-55.8 Gy in 28 fractions with adjuvant intent (n = 235) in addition to high-dose-rate brachytherapy 24 Gy in 6 fractions for curative treatment (n = 228). The median follow-up was 38 months. Eight patients (8/463, 1.7%) developed pelvic IF 7-19 months (median, 12 months) after the treatment. Among these, seven patients (7/228, 3.1%) were treated with curative intent and one (1/235, 0.4%) was treated with adjuvant intent. All patients were postmenopausal and complained of moderate to severe pelvic pain, which resolved after 1-11 months with conservative therapy in all patients. Two of these patients also had radiation proctitis. In women who present with pelvic pain after radiotherapy for cervical cancer, bony destruction and fractures may be indicative of a late radiation effect rather than osseous metastasis. IF are more common in the curative treatment group than in the postoperative adjuvant group.

High dose whole abdominal and pelvic irradiation for treatment of ovarian carcinoma: long-term toxicity and outcomes

High dose whole abdominal and pelvic irradiation for treatment of ovarian carcinoma: long-term toxicity and outcomes

Osteoradionecrosis after radiotherapy for gynecologic tumors

Insufficiency fractures of the pelvis are a well known but rare and frequently misinterpreted radiation sequela. The clinical features and possible risk factors were investigated. 71 of living 82 patients, who were treated 1986-1994 for gynecologic tumors were clinically examined. 47 patients underwent also bone scan, CT of the pelvis and 13 patients had osteodensitometry. All patients had been treated with adjuvant (n = 29) or curative intent (n = 18) by d.v. fields with 18-MV photons, with 46 Gy in 23 fractions plus brachytherapy (15-39 Gy). Median follow-up was 36 months. Seven patients developed pelvic insufficiency fractures 11 months (median, minimum 2 months) after treatment. All patients complained of moderate to severe pelvic pain, which resolved after 5-28 months without specific therapy in five of seven patients. At first examination all but one bone scan showed extremely increased uptake in the os sacrum and/or iliosacral joints, correlating CT scans demonstrated small fractures and bony destruction. Four of the asymptomatic 40 patients with complete radiologic examinations had medium uptake in bone scan (CT normal). Three of four examined patients with insufficiency fractures and seven of nine patients without insufficiency fractures had osteoporosis. In women who present with pelvic pain after radiotherapy for gynecologic tumors bony destruction and fractures may be indicative of a late radiation effect rather than osseous metastasis, even after early onset of symptoms.

Pelvic insufficiency fractures in patients with pelvic irradiation

Background: Insufficiency fractures (IF) occur as a result of normal physiological stress on bones with deficient elastic resistance. Pelvic insufficiency fractures are a complication of osteoporosis due to postmenopausal status, high dose of corticosteroids, or local irradiation. They are important because differential diagnosis includes pelvic bone metastases. Diagnosis is based on both clinical manifestations and radiographic and scintigraphic findings. Methods and Materials: We examined eight patients with pelvic cancer who had previously undergone external beam radiation therapy as part of their treatment. In the follow-up, they developed insufficiency fractures, and no factor other than pelvic irradiation was present. Diagnosis was confirmed by radionuclide bone scan followed by conventional radiography and computed tomography (CT) scan. Results: The average onset of symptoms was 13.7 months after radiation therapy was completed. The initial symptom in all cases was pain. In all of the patients, the bone scan showed abnormalities. One to four increased uptake foci were observed, in the sacroiliac joint in all cases, and in the pubis in three cases. The initial diagnosis was bone metastases in five patients. CT scan showed fractures in all of the patients, in sacrum and pubis, both endostic and cortical. Treatment, consisting of nonsteroidal anti-inflammatory drugs and rest, led to symptomatic relief in all cases. Conclusion: Knowledge of pelvic insufficiency fractures is essential in order to rule out metastasic disease, and thus avoid inaccurate treatment. Although radionuclide bone scan is useful in early detection of pelvic IF, definitive diagnosis is provided by CT scan.

Pelvic insufficiency fracture with diastasis of the pubic symphysis after irradiation

A 61-year-old woman was seen with diastasis of the symphysis pubis and insufficiency fractures of the wings of both ilia after irradiation for carcinoma of the cervix. The characteristics and treatment of these fractures are discussed.

MR imaging of supra-acetabular insufficiency fractures.

Diagnosis of insufficiency fractures in the pelvis is difficult, especially in patients with prior malignancy, irradiation, steroid therapy or osteoporosis. This report shows the MR imaging appearance of supra-acetabular insufficiency fractures and how they can be differentiated from metastatic disease. Twelve patients (four men, eight women, average age 72.8 years) at risk for pelvic insufficiency fractures and who had pelvic or hip pain were studied with MR imaging. Indications were possible recurrent tumor or previous radiation to the pelvis (7 patients); osteoporosis from steroid use in rheumatoid arthritis (two patients); to exclude osteonecrosis of the hip (two patients); or to rule out a hip fracture (one patient). A characteristic linear region of low signal intensity on both T1- and T2-weighted sequences was found in the supra-acetabular region paralleling the superior acetabulum in a curvilinear are in 92% (11/12) of cases, and oblique in origin in 8% (1/11). Diffuse bands of high signal on T2-weighted images indicated surrounding edema. In two cases, MR findings obviated biopsy. One patient underwent a biopsy prior to the imaging studies being reviewed. All patients were treated conservatively and did well. Attention to insufficiency fractures has previously focused on characteristic locations in the sacrum and pubic bones. Supra-acetabular insufficiency fractures also occur and are difficult to diagnose without a high degree of suspicion. MR imaging is a useful tool for diagnosing supra-acetabular insufficiency fractures. The characteristic MR imaging appearance of these fractures can preclude additional diagnostic studies and therapy in most instances.

Pelvic insufficiency fractures after irradiation: Diagnosis, management, and rehabilitation

Insufficiency fractures of the pelvis are commonly overlooked as causes of severe hip and low back pain. Predisposing factors include postmenopausal osteoporosis, corticosteroids, and local irradiation. Differential diagnosis includes metastatic disease to bone. We present the case of a 65-year-old woman who had a 2-month history of low back pain and left groin pain. Her medical history included osteoporosis and endometrial cancer that was treated with radiation therapy to the pelvis 1 year prior to presentation. Despite bed res, analgesics, and therapeutic modalities, her pain remained intractable and prevented ambulation. Plain radiographys showed no fracture. Computed tomography (CT) and magnetic resonance imaging showed fractures of the pelvis but were suggestive of malignancy. CT-guided bone biopsy was consistent with radiation osteonecrosis. After diagnosis and continued therapy, the patient progressed to ambulation with moderate discomfort. Failure to diagnose insufficiency fractures could lead to further pelvic irradiation, compromising already weekend bones and causing prolonged disability.

Imaging of pelvic insufficiency fractures.

Insufficiency fractures of the pelvis are being increasingly recognized as a major cause of low back pain in elderly women with osteoporosis. Fractures in the sacrum are difficult to diagnose, as plain radiographic findings are either unhelpful or misleading. Bone scintigraphy is very sensitive for the detection of fractures in the sacrum, with demonstration of the H-shaped (or butterfly) sacral pattern or the combination of concomitant sacral and parasymphyseal uptake being considered as characteristic of insufficiency fractures. Computed tomography (CT) is helpful for confirming the presence of fractures in cases with atypical scintigraphic patterns, particularly in those with a known primary malignant neoplasm. CT is especially useful in the further evaluation of parasymphyseal and pubic rami lesions. The majority of patients respond well to periods of enforced bed rest and administration of analgesics. Recognition of the spectrum of imaging findings for this entity should lead to its correct identification and the institution of appropriate treatment.

Pelvic insufficiency fractures after irradiation: Diagnosis, management and rehabilitation: Allison P. Henry, MD (New York Hospital-Cornell Medical Center, New York, NY); Elisabeth A. Lachmann, MD; Richard S. Tunkel, MD; Alicia S. Ferraro-Herrera, MD; Willibald Nagler, MD

Pelvic insufficiency fractures after irradiation: Diagnosis, management and rehabilitation: Allison P. Henry, MD (New York Hospital-Cornell Medical Center, New York, NY); Elisabeth A. Lachmann, MD; Richard S. Tunkel, MD; Alicia S. Ferraro-Herrera, MD; Willibald Nagler, MD