title: Insufficiency fractures after pelvic radiation therapy for uterine cervical cancer: an analysis of subjects in a prospective multi-institutional trial, and cooperative study of the Japan Radiation Oncology Group (JAROG) and Japanese Radiation Oncology Study Group (JROSG).
abstract: OBJECTIVE
  To investigate pelvic insufficiency fractures (IF) after definitive pelvic radiation therapy for early-stage uterine cervical cancer, by analyzing subjects of a prospective, multi-institutional study.
  
  
  METHODS
  Between September 2004 and July 2007, 59 eligible patients were analyzed. The median age was 73 years (range, 37-84 years). The International Federation of Gynecologic Oncology and Obstetrics stages were Ib1 in 35, IIa in 12, and IIb in 12 patients. Patients were treated with the constant method, which consisted of whole-pelvic external-beam radiation therapy of 50 Gy/25 fractions and high-dose-rate intracavitary brachytherapy of 24 Gy/4 fractions without chemotherapy. After radiation therapy the patients were evaluated by both pelvic CT and pelvic MRI at 3, 6, 12, 18, and 24 months. Diagnosis of IF was made when the patients had both CT and MRI findings, neither recurrent tumor lesions nor traumatic histories. The CT findings of IF were defined as fracture lines or sclerotic linear changes in the bones, and MRI findings of IF were defined as signal intensity changes in the bones, both on T1- and T2-weighted images.
  
  
  RESULTS
  The median follow-up was 24 months. The 2-year pelvic IF cumulative occurrence rate was 36.9% (21 patients). Using Common Terminology Criteria for Adverse Events version 3.0, grade 1, 2, and 3 IF were seen in 12 (21%), 6 (10%), and 3 patients (5%), respectively. Sixteen patients had multiple fractures, so IF were identified at 44 sites. The pelvic IF were frequently seen at the sacroileal joints (32 sites, 72%). Nine patients complained of pain. All patients' pains were palliated by rest or non-narcotic analgesic drugs. Higher age (>70 years) and low body weight (<50 kg) were thought to be risk factors for pelvic IF (P=.007 and P=.013, Cox hazard test).
  
  
  CONCLUSIONS
  Cervical cancer patients with higher age and low body weight may be at some risk for the development of pelvic IF after pelvic radiation therapy.
authors.affiliation: Department of Heavy Particle Therapy and Radiation Oncology, Saga University, Saga, Japan. tokumaru@cc.saga-u.ac.jp
authors.forename: Sunao
authors.initials: S
authors.lastname: Tokumaru
authors.forename: Takafumi
authors.initials: T
authors.lastname: Toita
authors.forename: Masahiko
authors.initials: M
authors.lastname: Oguchi
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Ohno
authors.forename: Shingo
authors.initials: S
authors.lastname: Kato
authors.forename: Yuzuru
authors.initials: Y
authors.lastname: Niibe
authors.forename: Tomoko
authors.initials: T
authors.lastname: Kazumoto
authors.forename: Takeshi
authors.initials: T
authors.lastname: Kodaira
authors.forename: Masaaki
authors.initials: M
authors.lastname: Kataoka
authors.forename: Naoto
authors.initials: N
authors.lastname: Shikama
authors.forename: Masahiro
authors.initials: M
authors.lastname: Kenjo
authors.forename: Chikako
authors.initials: C
authors.lastname: Yamauchi
authors.forename: Osamu
authors.initials: O
authors.lastname: Suzuki
authors.forename: Hideyuki
authors.initials: H
authors.lastname: Sakurai
authors.forename: Teruki
authors.initials: T
authors.lastname: Teshima
authors.forename: Yoshikazu
authors.initials: Y
authors.lastname: Kagami
authors.forename: Takashi
authors.initials: T
authors.lastname: Nakano
authors.forename: Masahiro
authors.initials: M
authors.lastname: Hiraoka
authors.forename: Norio
authors.initials: N
authors.lastname: Mitsuhashi
authors.forename: Sho
authors.initials: S
authors.lastname: Kudo
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001835:Body Weight; D001918:Brachytherapy / Q000009:adverse effects*; D019583:Dose Fractionation, Radiation; D005260:Female; D005500:Follow-Up Studies; D015775:Fractures, Stress / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D015994:Incidence; D007564:Japan; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed; D002583:Uterine Cervical Neoplasms / Q000473:pathology / Q000532:radiotherapy*