title: Radiation-induced rib fractures after hypofractionated stereotactic body radiation therapy: risk factors and dose-volume relationship.
abstract: OBJECTIVE
  The purpose of this study was to clarify the incidence, the clinical risk factors, and the dose-volume relationship of radiation-induced rib fracture (RIRF) after hypofractionated stereotactic body radiation therapy (SBRT).
  
  
  METHODS
  One hundred sixteen patients treated with SBRT for primary or metastatic lung cancer at our institution, with at least 6 months of follow-up and no previous overlapping radiation exposure, were included in this study. To determine the clinical risk factors associated with RIRF, correlations between the incidence of RIRF and the variables, including age, sex, diagnosis, gross tumor volume diameter, rib-tumor distance, and use of steroid administration, were analyzed. Dose-volume histogram analysis was also conducted. Regarding the maximum dose, V10, V20, V30, and V40 of the rib, and the incidences of RIRF were compared between the two groups divided by the cutoff value determined by the receiver operating characteristic curves.
  
  
  RESULTS
  One hundred sixteen patients and 374 ribs met the inclusion criteria. Among the 116 patients, 28 patients (46 ribs) experienced RIRF. The estimated incidence of rib fracture was 37.7% at 3 years. Limited distance from the rib to the tumor (<2.0 cm) was the only significant risk factor for RIRF (p = 0.0001). Among the dosimetric parameters used for receiver operating characteristic analysis, the maximum dose showed the highest area under the curve. The 3-year estimated risk of RIRF and the determined cutoff value were 45.8% vs. 1.4% (maximum dose, ≥42.4 Gy or less), 51.6% vs. 2.0% (V40, ≥0.29 cm(3) or less), 45.8% vs. 2.2% (V30, ≥1.35 cm(3) or less), 42.0% vs. 8.5% (V20, ≥3.62 cm(3) or less), or 25.9% vs. 10.5% (V10, ≥5.03 cm(3) or less).
  
  
  CONCLUSIONS
  The incidence of RIRF after hypofractionated SBRT is relatively high. The maximum dose and high-dose volume are strongly correlated with RIRF.
authors.affiliation: Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Kaori
authors.initials: K
authors.lastname: Asai
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Shioyama
authors.forename: Katsumasa
authors.initials: K
authors.lastname: Nakamura
authors.forename: Tomonari
authors.initials: T
authors.lastname: Sasaki
authors.forename: Saiji
authors.initials: S
authors.lastname: Ohga
authors.forename: Takeshi
authors.initials: T
authors.lastname: Nonoshita
authors.forename: Tadamasa
authors.initials: T
authors.lastname: Yoshitake
authors.forename: Kayoko
authors.initials: K
authors.lastname: Ohnishi
authors.forename: Kotaro
authors.initials: K
authors.lastname: Terashima
authors.forename: Keiji
authors.initials: K
authors.lastname: Matsumoto
authors.forename: Hideki
authors.initials: H
authors.lastname: Hirata
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Honda
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000601:surgery*; D019583:Dose Fractionation, Radiation; D004307:Dose-Response Relationship, Radiation; D005260:Female; D006801:Humans; D015994:Incidence; D008175:Lung Neoplasms / Q000473:pathology / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D016634:Radiosurgery / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D012253:Rib Fractures / Q000453:epidemiology / Q000209:etiology*; D012307:Risk Factors; D012737:Sex Factors; D013256:Steroids / Q000008:administration & dosage / Q000009:adverse effects; D047368:Tumor Burden
chemical_list: D013256:Steroids