Pharmacological interventions for the prevention of insufficiency fractures and avascular necrosis associated with pelvic radiotherapy in adults

Blink, Qurrat U van den; Garcez, Kate; Henson, Caroline C; Davidson, Susan E; Higham, Claire

doi:10.1002/14651858.cd010604.pub2

Cited by 22 publications

(25 citation statements)

References 81 publications

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“…According to the results of the present study, 45.2% of patients with PIF were symptomatic. Treatment is generally conservative, with analgesic administration and rehabilitation ( 33 ). Early diagnosis and treatment may improve pain, immobilization and thus mortality ( 33 ).…”

Section: Discussionmentioning

confidence: 99%

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PET/MRI is useful for early detection of pelvic insufficiency fractures after radiotherapy for cervical cancer

et al. 2021

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Radiotherapy (RT) is used to manage cervical cancer, and pelvic insufficiency fracture (PIF) is known as a late complication of RT. The present study identified risk factors for PIF after radiotherapy for cervical cancer, and investigated its incidence rate. It also considered the usefulness of positron emission tomography/magnetic resonance imaging (PET/MRI) in PIF diagnosis. A total of 149 patients with cervical cancer who received definitive or adjuvant RT with/without concurrent chemotherapy between January 2013 and December 2018 were investigated in the present study and followed up for more than one month after RT at Kobe University Hospital. The median follow-up period was 32 months (range, 1-87 months), and the median age of all patients was 66 years (age range, 34-90 years). Computed tomography (CT), MRI, PET/CT or PET/MRI were used for image examination. Among the 149 patients, 31 (20.8%) developed PIF. The median age of these patients was 69 years (age range, 44-87 years). Univariate analysis using the log-rank test demonstrated that age (≥60 years) was significantly associated with PIF. The median maximum standardized uptake value of PIF sites on PET/CT was 4.32 (range, 3.04-4.81), and that on PET/MRI was 3.97 (range, 1.21-5.96) (P= 0.162). Notably, the detection time of PIF by PET/MRI was significantly earlier compared with PET/CT (P<0.05). The incidence of PIF after RT for cervical cancer was 20.8%, and age was significantly associated with risk factors for such fractures. Taken together, these results suggest that PET/MRI, which offers the advantage of decreased radiation exposure to the patient, is useful for diagnosing PIF and can detect it earlier than PET/CT imaging.

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Section: Discussionmentioning

confidence: 99%

“…Treatment is generally conservative, with analgesic administration and rehabilitation ( 33 ). Early diagnosis and treatment may improve pain, immobilization and thus mortality ( 33 ).…”

Section: Discussionmentioning

confidence: 99%

PET/MRI is useful for early detection of pelvic insufficiency fractures after radiotherapy for cervical cancer

et al. 2021

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“…Two studies have reported effects of bisphosphonates on stress fractures in special disease areas. One analysis found insuffi cient evidence for a positive effect on insuffi ciency fractures and avascular necrosis of the pelvis after pelvic radiotherapy for prostate cancer [28]. Another study, however, reported positive effects of bisphosphonates on stress fractures in patients suffering from Paget´s disease [29].…”

Section: Discussionmentioning

confidence: 99%

IV. Bisphosphonates promote healing of complicated stress fractures in the foot

Fink-Eriksen¹,

Ianssen²,

Husebye³

2021

Open J Orthop Rheumatol

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Delayed healing of stress fractures constitutes a signifi cant clinical problem causing pain and disability for the patients affected. The vast majority heal after immobilization of the extremity affected, but a certain small number of patients display delayed union despite standard treatment, resulting in prolonged disability and usually end up needing orthopedic procedures to get symptomatic relief. All stress fractures exhibit Bone Marrow Edema or Bone Marrow Lesions (BMLs) with and without fracture lines on MRI, and in cases of delayed union these lesions persist. Thus, it is conceivable that BML formation might contribute to non-union. Previous studies on transient osteoporosis and osteoarthritis have demonstrated that bisphosphonates can reduce BMLs. We therefore wanted to test, whether treatment with IV. Bisphosphonates could promote healing of such fractures. In this study we report our clinical experience and the results obtained after treating 8 patients exhibiting delayed healing an off label protocol using two Zoledronic acid infusions (given 3 months apart).Seven female and one male patient (aged 30-72) were enrolled. All had signs of non-union for more than 12 months (defi ned as continued pain, disability and persistent BMLs on MRI). Pain was monitored using VAS (1-10) and MRI was performed in six of the patients at baseline, 3, 6 and 12 months after the fi rst infusion. All patients received Ca (0.5-1 g Ca per day) and vitamin D supplementation (800-1000 IE per day).All patients experienced clinical healing with signifi cant reduction of pain at the fracture site and improvement of ambulation within 1-3 months after the fi rst infusion. 4 patients experienced further reducgtion of pain after the second infusion. At 6 months, ambulatory functions were completely restored in all patients and a highly signifi cant reduction of VAS scores from an average of 7.3 before treatment to 1.1 at 6 months and 0,9 at 12 months (P<0,0001) could be demonstrated. The alleviation of pain was accompanied by reduction or total resolution of BMLs on MRI. Except for 2 cases of fl u-like symptoms after the fi rst infusion, no adverse effects were recorded.In conclusion, In conclusion, 2 infusions of zoledronic acid (5 mg) given 3 months apart, may emerge as a possible treatment modality of stress fractures in the foot showing delayed union, and could potentially reduce the need for more extensive surgical intervention in such complicated cases. This small observational pilot study needs to be corroborated in a larger randomized, controlled trial.

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“…They concluded that radiation-induced bone loss is a consequence of osteoclastic bone resorption, which the bisphosphonate appeared to have the ability to counteract [ 83 ]. Conversely, the Cochrane Database reviewed two clinical trials examining the effect of bisphosphonate administration in men undergoing pelvis radiation for prostate cancer; insufficient evidence was found to show that bisphosphonate administration prevented radiation-induced bone complications [ 84 ]. Finally, denosumab has been theorized to have radioprotective effects as well, given its function to inhibit osteoclasts [ 18 ].…”

Section: Fracture Preventionmentioning

confidence: 99%

Postradiation Fractures after Combined Modality Treatment in Extremity Soft Tissue Sarcomas

Bartelstein

Yerramilli

Christ

et al. 2021

Sarcoma

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Soft tissue sarcoma (STS) of the extremities is typically treated with limb-sparing surgery and radiation therapy; with this treatment approach, high local control rates can be achieved. However, postradiation bone fractures, fractures occurring in the prior radiation field with minimal or no trauma, are a serious late complication that occurs in 2–22% of patients who receive surgery and radiation for STS. Multiple risk factors for sustaining a postradiation fracture exist, including high radiation dose, female sex, periosteal stripping, older age, femur location, and chemotherapy administration. The treatment of these pathological fractures can be difficult, with complications including delayed union, nonunion, and infection posing particular challenges. Here, we review the mechanisms, risk factors, and treatment challenges associated with postradiation fractures in STS patients.

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Pharmacological interventions for the prevention of insufficiency fractures and avascular necrosis associated with pelvic radiotherapy in adults

Cited by 22 publications

References 81 publications

PET/MRI is useful for early detection of pelvic insufficiency fractures after radiotherapy for cervical cancer

PET/MRI is useful for early detection of pelvic insufficiency fractures after radiotherapy for cervical cancer

IV. Bisphosphonates promote healing of complicated stress fractures in the foot

Postradiation Fractures after Combined Modality Treatment in Extremity Soft Tissue Sarcomas

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