Bone fractures following external beam radiotherapy and limb-preservation surgery for lower extremity soft tissue sarcoma: relationship to irradiated bone length, volume, tumor location and dose.
OBJECTIVE
To examine the relationship between tumor location, bone dose, and irradiated bone length on the development of radiation-induced fractures for lower extremity soft tissue sarcoma (LE-STS) patients treated with limb-sparing surgery and radiotherapy (RT).


METHODS
Of 691 LE-STS patients treated from 1989 to 2005, 31 patients developed radiation-induced fractures. Analysis was limited to 21 fracture patients (24 fractures) who were matched based on tumor size and location, age, beam arrangement, and mean total cumulative RT dose to a random sample of 53 nonfracture patients and compared for fracture risk factors. Mean dose to bone, RT field size (FS), maximum dose to a 2-cc volume of bone, and volume of bone irradiated to >or=40 Gy (V40) were compared. Fracture site dose was determined by comparing radiographic images and surgical reports to fracture location on the dose distribution.


RESULTS
For fracture patients, mean dose to bone was 45 +/- 8 Gy (mean dose at fracture site 59 +/- 7 Gy), mean FS was 37 +/- 8 cm, maximum dose was 64 +/- 7 Gy, and V40 was 76 +/- 17%, compared with 37 +/- 11 Gy, 32 +/- 9 cm, 59 +/- 8 Gy, and 64 +/- 22% for nonfracture patients. Differences in mean, maximum dose, and V40 were statistically significant (p = 0.01, p = 0.02, p = 0.01). Leg fractures were more common above the knee joint.


CONCLUSIONS
The risk of radiation-induced fracture appears to be reduced if V40 <64%. Fracture incidence was lower when the mean dose to bone was <37 Gy or maximum dose anywhere along the length of bone was <59 Gy. There was a trend toward lower mean FS for nonfracture patients.
Dickie
Colleen I
CI
Princess Margaret Hospital, Toronto, ON, Canada. Colleen.euler@rmp.uhn.on.ca
Parent
Amy L
AL
Griffin
Anthony M
AM
Fung
Sharon
S
Chung
Peter W M
PW
Catton
Charles N
CN
Ferguson
Peter C
PC
Wunder
Jay S
JS
Bell
Robert S
RS
Sharpe
Michael B
MB
O'Sullivan
Brian
B
D005260:Female; D005264:Femoral Fractures / Q000209:etiology; D005360:Fibula; D050723:Fractures, Bone / Q000209:etiology*; D006801:Humans; D007869:Leg Injuries / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D011832:Radiation Injuries / Q000150:complications*; D011879:Radiotherapy Dosage; D018570:Risk Assessment; D016879:Salvage Therapy / Q000009:adverse effects; D012509:Sarcoma / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D012737:Sex Factors; D013978:Tibial Fractures / Q000209:etiology; D047368:Tumor Burden