Pelvic insufficiency fractures after intensity modulated radiation therapy combined with chemotherapy for cervix carcinoma: Incidence and impact of bone mineral density

Agathe Duranson; Vincent Thevenet; Frédéric Guyon; Guillaume Babin; Coriolan Lebreton; Tiphaine Renaud; Anne-Lise Gaillard; Quentin Dupuy; Wafa Bouleftour; Nicolas Magne; Adeline Petit

doi:10.1016/j.ctro.2023.100650

Pelvic insufficiency fractures after intensity modulated radiation therapy combined with chemotherapy for cervix carcinoma: Incidence and impact of bone mineral density

Clin Transl Radiat Oncol. 2023 Jun 12:41:100650. doi: 10.1016/j.ctro.2023.100650. eCollection 2023 Jul.

Authors

Affiliations

¹ Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France.
² Department of Statistics, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France.
³ Department of Surgery, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France.
⁴ Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France.
⁵ Department of Diagnostic Radiology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France.
⁶ Department of Medical Physics, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France.
⁷ Department of Medical Oncology, North Hospital, University Hospital of Saint-Etienne, Saint-Etienne, France.
⁸ Cellular and Molecular Radiobiology Laboratory, Lyon-Sud Medical School, Unité Mixte de Recherche CNRS5822/IP2I, University of Lyon, Lyon, France.

Abstract

Background and purpose: The aim of this study was to evaluate the incidence and predictive factors of Pelvic Insufficiency Fractures (PIFs) occurring after Intensity Modulated Radiation Therapy (IMRT) combined with chemotherapy for locally advanced cervical cancer (CC).

Material and methods: Medical records of patients receiving radio-chemotherapy with IMRT between 2010 and 2020 for advanced CC were reviewed. PIFs were detected during follow-up on pelvic Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). The cumulative incidence rate of PIFs and its confidence interval were calculated at 2 and 5 years of follow-up. Pre-therapeutic Bone Mineral Density (BMD) (g/cm³) was evaluated on CT simulation for sacrum and the fourth lumbar (L4) vertebrae. Sacrum dosimetric parameters (V30Gy, V40Gy, D50%, Dmean) were analyzed.

Results: 136 patients were included. The median follow-up was 4.4 years. Median dose of D50% and V40Gy sacrum were 35.2 Gy (20.6-46.4) and 32.2% (7.2-73.4) respectively. The 2-year and 5-year cumulative incidence rates were 15.7% (95% CI: 9.88-22.71) and 22% (95% CI: 14.58-30.45) respectively. Median time interval between RT completion and PIFs' detection was 11.5 months (IQR: 7.4-22.3). Univariate analysis showed that older age (p < 0.01), postmenopausal status at baseline (p < 0.01), and lower sacral and spinal BMD at baseline (respectively p < 0.001 and p < 0.01) were significantly associated to all sites of PIFs, and lower sacral BMD with sacral fractures (p < 0.001).

Conclusion: Post-IMRT PIFs were detected in 18.4% of patients with locally advanced CC. Individual predisposing factors as older age, postmenopausal status, decreased bone density on the CT simulation were mainly predictive.

Keywords: Bone Mineral Density; Intensity Modulated Radiation Therapy; Locally advanced cervical cancer; Pelvic Insufficiency Fractures; Predictive factors.