Radiation Osteitis Research Articles

Imaging assessment of spine infection.

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).

Novel MRI scoring system to assess osseous malignancy in patients with soft tissue sarcoma following radiotherapy.

11561 Background: Although radiotherapy is an important component of STS management, radiation induced changes such as radiation osteitis are commonly identified on magnetic resonance imaging (MRI). These imaging findings may be concerning for malignancy and sometimes require biopsy for investigation. This study proposes a novel MRI scoring system to assess osseous lesions and predict potential for malignancy based on MRI score in STS patients who received radiotherapy. Methods: The MRI score consisted of 3 parameters: morphology, signal intensity, and progression. Interobserver reliability between the total score of MRI examinations scored by two senior musculoskeletal radiologists were analyzed with Cohen’s kappa coefficient. Receiver operating curve (ROC) analysis was performed to determine a predictive MRI score for malignancy. Results: 156 MRI’s from 30 STS patients who received radiotherapy were retrospectively reviewed. Two (6.7%) patients developed regional osseous metastasis identified on MRI. The kappa coefficient of the scoring system was 0.785 demonstrating substantial interobserver agreement (p<0.001). ROC analysis demonstrated that the optimal cut-off value for malignant lesion on MRI was 5.5 (area under the curve 0.998 (95% CI 0.993-1.000) p<0.001). Conclusions: This novel MRI scoring system recommends lesions with a score of six and above to be biopsied to distinguish if malignancy is present. We believe this scoring system can be utilized by multidisciplinary care teams to guide clinical recommendations for patients with STS and MRI findings concerning for malignancy versus radiation induced changes.[Table: see text]

Radiation osteitis: incidence and clinical impact in the setting of radiation treatment for soft tissue sarcoma.

Radiotherapy is an important component of soft tissue sarcoma management. Radiation osteitis is a common radiographic finding identified in the setting of radiotherapy on magnetic resonance imaging (MRI). This study aims to identify the incidence of radiation osteitis in patients who received radiotherapy for soft tissue sarcoma and if a further workup, including a biopsy, was performed for concerning MRI findings. Medical records of patients with soft tissue sarcoma who received radiotherapy from 2008 to 2020 were retrospectively reviewed. Patients with at least one MRI of the sarcoma site following radiotherapy and information regarding radiotherapy treatments were included. MRIs of these patients were reviewed for the presence of radiation osteitis by two musculoskeletal radiologists. The clinical course of these patients including biopsy for concerning MRI findings, local recurrence, and metastasis was recorded. Thirty soft tissue sarcoma patients who received radiation for soft tissue sarcoma were included. Radiation osteitis was present in 18 patients. The time to osteitis present on MRI following radiotherapy completion was a median of 4.5 months. Biopsy for concerning MRI findings was performed in eight patients, five for local recurrence, and three for regional osseous metastasis. Three patients had confirmed osseous metastases. Although radiation osteitis is often a benign imaging finding, it can be difficult to discern these lesions from potentially malignant sites of disease. We recommend multidisciplinary management of soft tissue sarcoma at sarcoma centers to appropriately identify benign from malignant lesions and decide the necessity of a biopsy.

Acetabular fixation in total hip arthroplasty in the previously irradiated pelvis: a review of basic science and clinical outcomes.

Radiation therapy is a common primary, adjuvant, or palliative treatment for many intrapelvic tumors, including primary gastrointestinal, genitourinary, and hematopoietic tumors, as well as metastatic disease to bone. Radiation has well documented microbiologic and clinical effects on bone ranging from radiation osteitis to early degenerative changes of the hip joint and avascular necrosis of the femoral head. Conventional total hip arthroplasty methods have demonstrated high rates of failure in this population, with historical data describing aseptic loosening rates as high as 44-52%, as radiation have been shown to preferentially diminish osteoblast and osteocyte number and function and limit capacity for both cement interdigitation and biologic bony ingrowth. A review of the clinical literature suggests that patients with prior pelvic irradiation are at higher risk for both septic and aseptic loosening of acetabular components, as well as lower postoperative Harris Hip Score (HHS) when compared to historical controls. With limited evidence, trabecular metal shells with multi-screw fixation and cemented polyethene liners, as well as cemented cup-cage constructs both appear to be durable acetabular fixation options, though the indications for each remains elusive. Further prospective data are needed to better characterize this difficult clinical problem.

What Factors Are Associated With Local Metastatic Lesion Progression After Intramedullary Nail Stabilization?

What Factors Are Associated With Local Metastatic Lesion Progression After Intramedullary Nail Stabilization?

The evolution of bone marrow signal changes at the skull base in nasopharyngeal carcinoma patients treated with radiation therapy.

Clival infiltration is frequently seen in nasopharyngeal carcinoma (NPC) and the resultant bone marrow signal changes (BMSC) can persist even after complete tumor response to the radiation therapy (RT). The differentiation of those residual BMSC from recurrent/persistent disease may be challenging. We performed serial analysis of the clival BMSC after RT, to define an expected temporal evolution of those signal changes during the follow-up. Serial MRI studies of 50 NPC patients (with or without initial clival infiltration) who had undergone RT were retrospectively examined. Abnormal clival BMSC and contrast enhancement (CE) were evaluated on each follow-up scan. Duration of BMSC/CE was correlated with the degree of baseline clival involvement (BCID), RT dose, and primary mass volume (PMV). Clival BMSC persisted without any evidence of recurrence, for a mean of 66.5 (max. 137) months (with accompanying CE for up to 125months) in 26 patients with clival infiltration at diagnosis. Duration of BMSC and CE showed statistical correlations with PMW (p < 0.05), but not with RT dose or BCID. The rate of recurrence in clivus was 14%. New clival lesions that occurred within the first 12months after RT (in six patients) did not develop recurrence suggesting radiation osteitis (12%). After RT, residual clival medullary signal change/enhancement is seen in most NPC patients and can persist even years without recurrence.

Osteítis por radiación y fracturas por insuficiencia pélvica en paciente con adenocarcinoma de próstata tratado con radioterapia. Aspectos clínicos y radiográficos de la enfermedad.

Radiation osteitis is an anatomopathological term first coined by Ewing in 1926, refers to a radiation-induced inflammatory response in blood vessels, nerve tissue, and bone cells that can lead to fractures of the trabecular and cortical bone. Pelvic insufficiency fracture is a stress fracture over a weakened bone, seen in patients who have certain risk factors such as osteoporosis, connective tissue disease, use of corticosteroids, and especially in patients who have been treated with pelvic radiation therapy for rectal, anal, urogenital, and prostate tumors. We present the case of a 73-year-old patient with fractures due to pelvic failure treated four years before prostate adenocarcinoma with radiotherapy and hormone therapy. Clinical and radiographic diagnostic aspects are discussed.

EP-1693: Utility of Magnetic Resonance imaging in the diagnosis of Radiation osteitis in sarcoma patients

EP-1693: Utility of Magnetic Resonance imaging in the diagnosis of Radiation osteitis in sarcoma patients

From radiation osteitis to osteoradionecrosis: incidence and MR morphology of radiation-induced sacral pathologies following pelvic radiotherapy.

To investigate the incidence rate, time-to-onset and recovery, MRI morphology and occurrence of insufficiency fractures in radiation-induced changes in the sacrum following pelvic radiotherapy. 410 patients with pelvic malignancies treated with radiotherapy were reviewed. Follow-up was 1-124 months (mean 22 months). Serial MRI (average four studies/patient) were analysed using a new semi-quantitative score (Radiation-Induced Sacral Changes=RISC). A size category (I/II/III), a type category for MR signal morphologies (a/b/c) and sacral insufficiency fractures (+/-) were applied. Seventy-two patients (17.6 %) were found to have new pathological signal changes. Radiation osteitis was documented in 83.3 % (60/72, RISC stage a + b), and definite osteonecrosis (stage c) in 12 patients (16.7 %, 12/72). Thirty-one patients (43.1 %) had sacral insufficiency fractures. Initial bone marrow signal changes were found 1-35 months (median 4 months) after radiotherapy. The maximum manifestation of radiation-induced signal changes occurred after 1-35 months (mean 11 months). Fifty-six cases (77.8 %) showed a significant signal recovery within 16.5 months. Radiation-induced bone marrow changes appear with a high incidence at the sacrum with an early onset and frequent recovery. The majority presented a pattern of radiation osteitis, whereas osteoradionecrosis was proportionately rare. • Radiation-induced sacral bone marrow changes appear frequently (17.6 %) following pelvic radiotherapy. • Insufficiency fractures are common late effects (43 %). • Radiation osteitis develops early (4 mo), withrecovery between 16.5 and 39.5 months. • Definite radiological osteoradionecrosis is proportionately rare (3 %). • A 3-stage classification system simplifies and standardizes the morphological disease staging.

Radical chest wall resection and hyperfractionated accelerated radiotherapy for radiation-associated angiosarcoma of the breast: A safe and effective treatment strategy.

Radiation-associated angiosarcomas (RAS) of the breast are vascular tumors arising in a previous radiation field for primary breast cancer. They occur rarely but confer a high probability of local recurrence (LR) and poor prognosis. A wide range of treatment strategies exists due to limited evidence, and although resection is the definitive treatment, LR rates remain high. It has been suggested hyperfractionated accelerated radiotherapy (HART) has the potential to prevent LR. The sarcoma group at the Juravinski Cancer Centre (JCC) reports our experience of nine patients treated with radical resection and adjuvant HART. This is one of the largest reported cohorts we are aware of to receive this treatment. The JCC pathologic data base was reviewed between the year 2006-2015 for patients with RAS. Patients who received radical surgery and immediate HART were eligible. Patients underwent radical chest wall resection and en bloc mastectomy. Radiotherapy was then delivered to 4500 cGy in 45 fractions three times daily using parallel opposed photon beams and electron patching, or volumetric modulated arc therapy. Primary outcome was recurrence-free survival in months, and records were reviewed for descriptive reports of toxicity. We compared our results to other institutions experience with surgery alone or other adjuvant therapies. Median follow-up was 19 months (range 3-41 months). One of nine patients developed LR and developed metastasis, one died of other causes, and seven are alive with no recurrent disease. There were seven reports of mild skin toxicity during treatment. One patient developed chronic wound healing complications which eventually resolved and one patient developed asymptomatic radiation osteitis of a rib. On the basis of our experience at the JCC, we recommend treatment with radical chest wall resection and adjuvant HART to prevent recurrence in RAS patients. As demonstrated in our patients, the large normal tissue volume irradiated is tolerable with in combination with small fraction sizes, and no major toxicities were seen. Further investigation into adjuvant therapy regimens and prospective studies are required to reach consensus on optimal treatment for this disease.

CORR(®) Tumor Board: Sacral Insufficiency Fractures are Common After High-dose Radiation for Sacral Chordomas Treated With or Without Surgery.

Beth Israel Deaconess Medical Center and Boston Children’s Hospital Preventing these fractures is important, since we know from our patients and other research [13] that the morbidity of sacral insufficiency fractures is tremendous. The fractures in combination with radiation osteitis are painful and limit patients’ abilities to mobilize, care for themselves, work, and other daily living activities. They are difficult to treat and slow to heal [13]. Patients may be cured of their tumors, but have lasting effects from the treatment on their quality of life. These tumors are rare, but further prospective multiinstitutional collaborative efforts [6, 9] can demonstrate the exact morbidity in this specific population. Given that these fractures are relevant clinically, what can we do to prevent them? Other work by some of the same investigators [10] has shown that high-dose radiation, in addition to en bloc resection, leads to the highest rates of local control in chordomas. Therefore, the argument could be made that radiation cannot be withheld to best improve local tumor control. Antiresorptive therapy, such as use of bisphosphonates, might offer some A Note from the Editor-in-Chief: We are pleased to present our newest column, CORR Tumor Board. This column provides multidisciplinary perspective on the themes raised in selected CORR tumor papers. In this column, we will discuss the implications of the highlighted article from the varied disciplines of the Tumor Board members: Orthopaedic surgery, pathology, and radiology. This month’s column discusses ‘‘Sacral Insufficiency Fractures are Common After High-dose Radiation for Sacral Chordomas Treated With or Without Surgery’’ by Osler and colleagues available at: DOI: 10.1007/s11999-0154566-5. The authors certify that they, or any members of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Tumor Board column refers to the article available at DOI: 10.1007/s11999-0154566-5.

Hyperfractionated Accelerated Reirradiation in Patients With Radiation Associated Secondary Angiosarcoma of the Breast: A Report of Local Control and Toxicity Using a Postoperative Radiation Therapy Approach

Hyperfractionated Accelerated Reirradiation in Patients With Radiation Associated Secondary Angiosarcoma of the Breast: A Report of Local Control and Toxicity Using a Postoperative Radiation Therapy Approach

Bone Complications After Pelvic Radiation Therapy: Evaluation With MRI

Introduction The purpose of this study was to assess the incidence, distribution and MRI characteristics of pelvic bone complications after radiation therapy. Methods The medical charts of 345 patients who received pelvic radiation therapy were retrospectively reviewed. A total of 122 patients, 99 women and 23 men, with a mean age of 57 (range 32–87 years) were included in this study. The MR images were retrospectively reviewed by two radiologists. Results Fatty replacement of bone marrow was seen in all patients. Pelvic bone complications and focal red marrow changes were identified in a total of 38 patients (31.1%). Pelvic insufficiency fracture was diagnosed in 17 patients (13.9%, with a total of 64 lesions) and radiation osteitis was diagnosed in 5 patients (4.1%, with a total of 13 lesions). Avascular necrosis of the femoral head was detected in one patient (0.8%). Focal red bone marrow changes were seen in 15 patients (12.3%). The median time from the end of radiotherapy to the diagnosis of pelvic bone complications or changes was 25 months (range 2–45 months). The 1-, 2-, and 3-year cumulative incidences were 22%, 41% and 49%, respectively. The distribution of insufficiency fractures was as follows: sacral ala, sacral body, ilium, acetabulum, pubis and lumbar spinal vertebra. The distribution of radiation osteitis was as follows: sacral ala, ilium and pubis. Conclusion Radiation-induced pelvic bone complications are not uncommon, and knowledge of characteristic imaging patterns is essential in order to rule out bone metastases and to avoid inaccurate or excessive treatment.

Bone complications after pelvic radiation therapy: Evaluation with MRI

The purpose of this study was to assess the incidence, distribution and MRI characteristics of pelvic bone complications after radiation therapy. The medical charts of 345 patients who received pelvic radiation therapy were retrospectively reviewed. A total of 122 patients, 99 women and 23 men, with a mean age of 57 (range 32-87 years) were included in this study. The MR images were retrospectively reviewed by two radiologists. Fatty replacement of bone marrow was seen in all patients. Pelvic bone complications and focal red marrow changes were identified in a total of 38 patients (31.1%). Pelvic insufficiency fracture was diagnosed in 17 patients (13.9%, with a total of 64 lesions) and radiation osteitis was diagnosed in 5 patients (4.1%, with a total of 13 lesions). Avascular necrosis of the femoral head was detected in one patient (0.8%). Focal red bone marrow changes were seen in 15 patients (12.3%). The median time from the end of radiotherapy to the diagnosis of pelvic bone complications or changes was 25 months (range 2-45 months). The 1-, 2-, and 3-year cumulative incidences were 22%, 41% and 49%, respectively. The distribution of insufficiency fractures was as follows: sacral ala, sacral body, ilium, acetabulum, pubis and lumbar spinal vertebra. The distribution of radiation osteitis was as follows: sacral ala, ilium and pubis. Radiation-induced pelvic bone complications are not uncommon, and knowledge of characteristic imaging patterns is essential in order to rule out bone metastases and to avoid inaccurate or excessive treatment.

Radiation osteitis after radiotherapy of soft tissue sarcomas

Radiation osteitis after radiotherapy of soft tissue sarcomas

Management of Temporal Bone Osteoradionecrosis: Surgical and Adjunctive Therapies

Management of Temporal Bone Osteoradionecrosis: Surgical and Adjunctive Therapies

Radiation Induced Sarcomas of the Head and Neck Following Radiotherapy for Nasopharyngeal Carcinoma

AIM: To report the radiological findings of radiation induced sarcomas (RIS) in the head and neck following radiotherapy for nasopharyngeal carcinoma.MATERIALS AND METHODS: The clinical notes and radiological studies (MRn=3, CT n=4) of four patients were reviewed retrospectively.RESULTS: RIS developed 5 to 10 years following radiotherapy. Two patients had tumours arising from the alveolar process of the maxilla, one from the nasal cavity, and one patient had a tumour at two sites, involving the external auditory canal and the uvula. Three of the four patients had large tumours at diagnosis with a 3.5–6cm predominately homogeneous soft tissue mass, complete destruction of bone and extensive local invasion. One was small and localized to the nasal turbinate. Radiation osteitis was identified in two of the four (50%) patients.CONCLUSION: The site of RIS following radiotherapy for NPC is variable but is invariably within the high dose zone of the radiotherapy. These sarcomas tend to present late with a large soft tissue mass. Radiation osteitis is not a constant feature. As surgery provides the only chance of cure, imaging has an important role in the pre-operative mapping of the extent of tumour. King, A. D. et al. (2000).Clinical Radiology55 , 684–689.

MR imaging of radiation osteitis in the sacroiliac joints

The purpose of this study was to analyze magnetic resonance (MR) images of radiation osteitis of sacroiliac joints, retrospectively. Seven patients with radiation osteitis, which was diagnosed by pelvic plain radiographs and CT images, underwent MRI. T 1-weighted spin echo images and T 2-weighted fast spin echo images were obtained in all patients. Four patients were examined after gadolinium injection. Major signal changes of radiation osteitis were distributed on the iliac side. T 1-weighted images showed diffuse low intensity both in sacral and iliac sides. T 2-weighted images showed very low intensity adjacent to sacroiliac joints, but mixed intensity was illustrated apart from joints, and high intensity in the peripheral areas. Radiation osteitis showed slight to mild, but irregular enhancement in four patients after gadolinium administration. MRI can illustrate abnormal bone change distribution and is useful for diagnosing this entity by characteristic intensity patterns on T 1-weighted images with and without gadolinium and T 2-weighted image. However, the diagnosis of accompanied insufficiency fractures in the area of radiation osteitis is occasionally difficult with conventional MRI.

Imaging features of radiation-induced changes in the abdomen.

After external-beam radiation therapy, radiation-induced changes may be observed in abdominal and pelvic organs at imaging. In the liver, an area of low attenuation corresponding to the radiation port (or an area of hyperattenuation if the underlying liver tissue shows fatty change) can be seen at computed tomography (CT) performed within 3-6 months after therapy. Later, the liver may be fibrotic and contracted. In the stomach, small intestine, and colon, wall thickening and edema are early manifestations. Ulcers may also be observed. Long-term complications include strictures and fistulas. After irradiation of the kidneys, altered attenuation of the renal parenchyma may be seen at CT. Ureteral strictures, typically involving the distal ureter, may be observed after pelvic irradiation. The bladder may be small and contracted with a thickened wall after radiation exposure. Fistulas between the bladder and other pelvic organs sometimes occur. Typical musculoskeletal changes include growth abnormalities in skeletally immature patients, fatty replacement of bone marrow, and radiation osteitis. Radiation-induced neoplasms are also recognized after therapy.

Total hip replacement in irradiated hips. A retrospective study of 71 cases

We retrospectively reviewed 56 patients (71 hips) treated by total replacement for severe disability after pelvic irradiation. Symptoms were associated with various radiological lesions due to irradiation, including atraumatic femoral-neck fracture, osteonecrosis of the femoral head or of the acetabulum, and radiation osteitis of the whole pelvis. From 1970 to 1982 we used standard cemented components in 49 hips and had a high rate of acetabular loosening (52%) at a mean follow-up of 69 months. This was probably due to the mechanical insufficiency of irradiated periacetabular bone. From 1983 to 1990 we routinely used acetabular reinforcement rings. The rate of aseptic acetabular loosening in 22 hips at a mean follow-up of 40 months was 19%, but there were two septic loosenings emphasising the risk of infection in these patients. When total replacement is required for an irradiated hip, we recommend reinforcement of the acetabulum using a metallic ring, but there is still an increased risk of infection and in difficult cases such as severe acetabular destruction or soft-tissue or vascular injuries, a Girdlestone procedure may be indicated.