1
|
Pelvic insufficiency fractures in patients with cervical and endometrial cancer treated with postoperative pelvic radiation. Gynecol Oncol 2013; 128:540-3. [DOI: 10.1016/j.ygyno.2012.12.021] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 11/15/2012] [Accepted: 12/12/2012] [Indexed: 11/17/2022]
|
2
|
Girish G, Finlay K, Fessell D, Pai D, Dong Q, Jamadar D. Imaging review of skeletal tumors of the pelvis malignant tumors and tumor mimics. ScientificWorldJournal 2012; 2012:240281. [PMID: 22593667 PMCID: PMC3349129 DOI: 10.1100/2012/240281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 11/30/2011] [Indexed: 11/18/2022] Open
Abstract
Malignant lesions of the pelvis are not uncommon and need to be differentiated from benign lesions and tumor mimics. Appearances are sometimes nonspecific leading to consideration of a broad differential diagnosis. Clinical history, anatomic location, and imaging characterization can help narrow the differential diagnosis. The focus of this paper is to demonstrate the imaging features and the role of plain films, computed tomography, and magnetic resonance imaging for detecting and characterizing malignant osseous pelvic lesions and their common mimics.
Collapse
Affiliation(s)
- Gandikota Girish
- Department of Radiology, University of MI, 1500 E. Medical Center Drive, TC-2910, Ann Arbor, MI 48109-0326, USA.
| | | | | | | | | | | |
Collapse
|
3
|
Radiological features of superomedial iliac insufficiency fractures: a possible mimicker of metastatic disease. Skeletal Radiol 2009; 38:43-9. [PMID: 18682929 DOI: 10.1007/s00256-008-0555-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 06/19/2008] [Accepted: 06/20/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Pelvic insufficiency fractures are common in elderly patients. Because both osteoporosis and metastatic disease occur in similar patient populations, insufficiency fractures may be mistaken for metastatic foci. Although the ilium is not an uncommon location for metastases, insufficiency fractures rarely involve the ilium. The radiological features of insufficiency fractures adjacent to the sacroiliac joint (superomedial ilium) have not been well described. We describe the computed tomography (CT), magnetic resonance (MR), and positron emission tomography (PET) imaging findings of these rare fractures. MATERIALS AND METHODS Six patients (five female, one male; mean age 66 years, age range 47-83 years) with iliac insufficiency fractures adjacent to the sacroiliac joint were identified following retrospective review of a clinical database. Imaging studies, including CT (n = 4), MR (n = 3), and PET (n = 2) were reviewed by two radiologists. Tissue biopsy result was available in one patient. RESULTS CT demonstrated subtle fracture lucency (n = 2) or linear sclerosis (n = 3) adjacent to the sacroiliac joint; MR marrow changes adjacent to the sacroiliac joint demonstrated a low T1, high T2 signal intensity line (n = 2), or a low T1 and low T2 signal intensity line (n = 1). Fractures were fluorodeoxyglucose avid (n = 2) with average SUV(max) 2.2. Iliac fractures were bilateral in three patients; additional pelvic insufficiency fractures were present in one patient. In one patient, CT-guided biopsy showed no evidence of malignancy. CONCLUSION Recognition of the radiological characteristics of iliac insufficiency fractures is important in order to distinguish them from malignancy. The presence of additional pelvic fractures in characteristic locations in the setting of osteoporosis may help to confirm the diagnosis.
Collapse
|
4
|
Oh D, Huh SJ, Nam H, Park W, Han Y, Lim DH, Ahn YC, Lee JW, Kim BG, Bae DS, Lee JH. Pelvic Insufficiency Fracture After Pelvic Radiotherapy for Cervical Cancer: Analysis of Risk Factors. Int J Radiat Oncol Biol Phys 2008; 70:1183-8. [DOI: 10.1016/j.ijrobp.2007.08.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2007] [Revised: 08/02/2007] [Accepted: 08/04/2007] [Indexed: 12/31/2022]
|
5
|
Ikushima H, Osaki K, Furutani S, Yamashita K, Kishida Y, Kudoh T, Nishitani H. Pelvic bone complications following radiation therapy of gynecologic malignancies: clinical evaluation of radiation-induced pelvic insufficiency fractures. Gynecol Oncol 2006; 103:1100-4. [PMID: 16919711 DOI: 10.1016/j.ygyno.2006.06.038] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2006] [Accepted: 06/21/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the incidence, clinical and imaging finding of insufficiency fractures (IF) of the female pelvis following radiation therapy. METHODS We reviewed the radiation oncology records of 158 patients with gynecologic malignancies who underwent external beam radiation therapy of the whole pelvis between April 1993 and March 2004. All patients underwent computed tomography (CT) scan every 6 months in follow-up after radiation therapy and magnetic resonance imaging (MRI) and radionuclide bone scan were added when the patients complained of a pelvic pain. RESULTS Eighteen of 158 patients (11.4%) developed IF in the irradiated field with a median interval of 6 months (range 3-51) from the completion of external beam radiation therapy. The cumulative incidence of symptomatic IF at 5 years calculated with Kaplan-Meyer methods was 13%. Median age of the patients who developed IF was 70 years (range 48-88), and all of them were postmenopausal. IF occurred in the sacloiliac joints, upper limb of pubic bone, acetabulum, sacral body and 5th lumbar vertebra. Twelve of 18 patients had multiple lesions and 8 had symmetric longitudinal fracture lines parallel to the sacroiliac joints. Avoidance of weight bearing by bed rest and analgesics provided good pain relief in all patients, although symptoms lasted from 3 to 20 months. CONCLUSIONS Radiation-induced pelvic IF following radiation therapy for gynecologic malignancies were frequently observed in the postmenopausal patients within 1 year after external beam radiation therapy. Symmetric fractures of the both sacroiliac joints were the characteristic pattern of pelvic IF. Knowledge of characteristic imaging pattern of IF is essential in order to rule out the bone metastasis. Therapy recommendations are conservative with analgesics.
Collapse
Affiliation(s)
- Hitoshi Ikushima
- Department of Radiology, Tokushima University School of Medicine, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan.
| | | | | | | | | | | | | |
Collapse
|
6
|
Feltl D, Vosmik M, Jirásek M, Stáhalová V, Kubes J. Symptomatic osteoradionecrosis of pelvic bones in patients with gynecological malignancies-result of a long-term follow-up. Int J Gynecol Cancer 2006; 16:478-83. [PMID: 16681714 DOI: 10.1111/j.1525-1438.2006.00540.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to assess the incidence and risk factors of pelvic fractures as a result of radiation therapy in women with gynecological cancer. We retrospectively reviewed 3530 female patients treated at our institute between 1980 and 1998 with megavoltage radiation with or without brachytherapy for cancer in the pelvic area. Eligible were patients with vulvar, vaginal, cervical, endometrial, and fallopian tube cancer. Median follow-up was 88 months (range 0-240). Emphasis was put on treatment-related and patient-related risk factors. Of the eligible 3155 patients, 15 developed symptomatic bone fracture caused by osteoradionecrosis, which makes an overall incidence of 0.44% The diagnosis was based on anamnesis, clinical course, and X-ray or computed tomography images. Median time of onset was 44 months (range 6-197). All patients had pain as the first symptom. The only independent predictive factor for developing osteoradionecrosis seemed to be preexistent osteoporosis. Other risk factors that are related to osteoporosis include higher age, postmenopausal status, or steroid treatment. We did not find any significant treatment-related predictive factor for pelvic osteoradionecrosis. Patients with osteoporosis are probably at the highest risk for developing osteoradionecrotic fractures after pelvic radiotherapy. More studies are needed to find out other endogenous predictive factors.
Collapse
Affiliation(s)
- D Feltl
- Department of Radiotherapy and Oncology, 3rd Faculty of Medicine, Charles University Prague, University Hospital Královské Vinohrady, Prague, Czech Republic.
| | | | | | | | | |
Collapse
|
7
|
|
8
|
Ogino I, Okamoto N, Ono Y, Kitamura T, Nakayama H. Pelvic insufficiency fractures in postmenopausal woman with advanced cervical cancer treated by radiotherapy. Radiother Oncol 2003; 68:61-7. [PMID: 12885453 DOI: 10.1016/s0167-8140(03)00128-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To assess the predisposing factors and clinical characteristics of pelvic insufficiency fractures (PIF) in postmenopausal women with pelvic irradiation. MATERIAL AND METHODS A total 335 postmenopausal patients with cervical cancer of the intact uterus treated with radiation therapy between 1983 and 1998 were reviewed. Total external dose was delivered between 45 and 50.4 Gy with parallel opposed anteroposterior portals. Total brachytherapy dose at point A was delivered between 10 and 36 Gy. PIF were diagnosed by bone scintigraphy and confirmed by computed tomography. The cumulative incidence of symptomatic PIF was estimated by actuarial methods. Potential risk factors (age, weight, type II diabetes, delivery, menopause, total external dose, total brachytherapy dose) were assessed. RESULTS Fifty-seven (17.0%) of 335 patients were diagnosed as having PIF. Forty-seven patients were symptomatic and ten were asymptomatic. Parameters carrying a significant association with PIF were body weight 49 kg or below (P=0.044) in stepwise logistic regression analysis. The cumulative incidence of symptomatic PIF at 5 years was 17.9% calculated by the Kaplan-Meier method. A body weight of 49 kg or below and more than three deliveries were identified as having a significant effect on symptomatic PIF in univariate analysis (P=0.021, P=0.003, log-rank test) and Cox life table regression analysis (P=0.038, P=0.013). Five patients required narcotic agents and eight patients required hospital admission. CONCLUSIONS We should consider reducing the dose contribution to the sacrum and sacroilac joints, without underdosing the tumor, especially in postmenopausal women with many deliveries or low body weight.
Collapse
Affiliation(s)
- Ichiro Ogino
- Department of Radiology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Yokohama, Japan
| | | | | | | | | |
Collapse
|
9
|
Diel J, Ortiz O, Losada RA, Price DB, Hayt MW, Katz DS. The sacrum: pathologic spectrum, multimodality imaging, and subspecialty approach. Radiographics 2001; 21:83-104. [PMID: 11158646 DOI: 10.1148/radiographics.21.1.g01ja0883] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The sacrum is a structure that is imaged by both general and subspecialty radiologists. A wide variety of disease processes can involve the sacrum either focally or as part of a systemic process. Plain radiographs, although limited in evaluation of the sacrum, should be carefully examined when abnormalities of the sacrum are suspected. Cross-sectional imaging, particularly computed tomography and magnetic resonance (MR) imaging, plays a crucial role in identification, localization, and characterization of sacral lesions. Congenital lesions of the sacrum, including sacral agenesis and meningocele, are optimally imaged with MR. The most common sacral neoplasm is metastatic disease. Primary neoplasms of the sacrum, which include giant cell tumor, chordoma, and teratoma, are infrequent. Infection of the sacrum or sacroiliac joint is most often due to contiguous spread from a suppurative focus. A wide variety of arthritic disorders such as ankylosing spondylitis and osteoarthritis can involve the sacroiliac joints as part of a localized or systemic process. Sacral fractures related to acute trauma or repetitive stress are difficult to diagnose and treat. Knowledge of these abnormalities and familiarity with the imaging of these processes will allow radiologists of all subspecialties to contribute to the diagnosis and management of sacral disorders.
Collapse
Affiliation(s)
- J Diel
- Department of Radiology, Winthrop University Hospital, 259 First St, Mineola, NY 11501, USA
| | | | | | | | | | | |
Collapse
|
10
|
Leeds NE, Kumar AJ, Zhou XJ, McKinnon GC. Magnetic resonance imaging of benign spinal lesions simulating metastasis: role of diffusion-weighted imaging. Top Magn Reson Imaging 2000; 11:224-34. [PMID: 11133064 DOI: 10.1097/00002142-200008000-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In an attempt to avoid unnecessary therapy, this article demonstrates benign vertebral body lesions that mimic metastatic disease in cancer patients with back pain. The magnetic resonance imaging features that aid in differential diagnosis are demonstrated. In addition, the value of diffusion-weighted spinal imaging to further aid in distinguishing benign from malignant disease is described.
Collapse
Affiliation(s)
- N E Leeds
- Division of Neuroradiology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | | | | | | |
Collapse
|
11
|
Tai P, Hammond A, Dyk JV, Stitt L, Tonita J, Coad T, Radwan J. Pelvic fractures following irradiation of endometrial and vaginal cancers-a case series and review of literature. Radiother Oncol 2000; 56:23-8. [PMID: 10869751 DOI: 10.1016/s0167-8140(00)00178-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To review the induction of pelvic fractures as a result of radiation therapy and to assess their management. MATERIALS AND METHODS The charts of patients with endometrial and vaginal cancers irradiated between 1991 and 1995 were reviewed. All patients were treated with megavoltage machines, energy ranging from cobalt to 25 MV photons. RESULTS We treated 336 patients, with a median follow-up duration of 28.9 months (range 0-73.3). Sixteen patients had symptomatic pelvic fractures. The 5-year actuarial incidence of symptomatic pelvic fracture was 2.1%. All patients had pain as the first symptom. The median time of onset was 11 months (range 4-46). Imaging studies of 37.5% (6/16) were initially interpreted to be recurrent malignancy. All patients were managed conservatively and nine patients showed radiological evidence of healing over a median time of 13 months (range 2-34). Six patients had specific drug treatment including provera, premarin, calcium supplements, or pamidronate. Of these, five healed. For the ten patients who did not have any specific treatment, only four showed signs of healing at the time of last follow-up. There was a trend toward earlier healing with specific drug treatment (P=0.11). CONCLUSIONS Fractures can easily be mistaken for metastatic lesions (37.5% in this series) which might be treated with further irradiation. Although not statistically significant, there was a trend towards early healing with drug therapy. More studies are required to generate quantitative data for dose-response relationships and to evaluate the effect of drug therapy on the healing of such fractures.
Collapse
Affiliation(s)
- P Tai
- Department of Radiation Oncology, Allan Blair Cancer Center, 4101 Dewdney Ave., SK S4T 7T1, Regina, Canada
| | | | | | | | | | | | | |
Collapse
|
12
|
Yoshioka H, Nakano T, Kandatsu S, Koga M, Itai Y, Tsujii H. MR imaging of radiation osteitis in the sacroiliac joints. Magn Reson Imaging 2000; 18:125-8. [PMID: 10722971 DOI: 10.1016/s0730-725x(99)00129-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to analyze magnetic resonance (MR) images of radiation osteitis of sacroiliac joints, retrospectively. Seven patients with radiation osteitis, which was diagnosed by pelvic plain radiographs and CT images, underwent MRI. T(1)-weighted spin echo images and T(2)-weighted fast spin echo images were obtained in all patients. Four patients were examined after gadolinium injection. Major signal changes of radiation osteitis were distributed on the iliac side. T(1)-weighted images showed diffuse low intensity both in sacral and iliac sides. T(2)-weighted images showed very low intensity adjacent to sacroiliac joints, but mixed intensity was illustrated apart from joints, and high intensity in the peripheral areas. Radiation osteitis showed slight to mild, but irregular enhancement in four patients after gadolinium administration. MRI can illustrate abnormal bone change distribution and is useful for diagnosing this entity by characteristic intensity patterns on T(1)-weighted images with and without gadolinium and T(2)-weighted image. However, the diagnosis of accompanied insufficiency fractures in the area of radiation osteitis is occasionally difficult with conventional MRI.
Collapse
Affiliation(s)
- H Yoshioka
- Department of Radiology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan.
| | | | | | | | | | | |
Collapse
|
13
|
Wall JE, Kaste SC, Greenwald CA, Jenkins JJ, Douglass EC, Pratt CB. Fractures in children treated with radiotherapy for soft tissue sarcoma. Orthopedics 1996; 19:657-64. [PMID: 8856775 DOI: 10.3928/0147-7447-19960801-09] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is a clear association between multimodal therapy for bone tumors and the development of skeletal complications; however, this has not been addressed in children with soft tissue sarcomas. We reviewed records of the 70 children treated for soft tissue sarcoma of the lower extremity at St. Jude Children's Research Hospital between 1962 and 1991. Of the 12 patients who received radiation after surgical excision of their tumors, three subsequently developed fractures. Two of the three had also received chemotherapy. Our findings indicate that, although the risk of fracture after therapy for soft tissue sarcoma may be multifactorial, radiation may play a significant role. Minimizing the size of surgical incisions, improving radiotherapy techniques, maximizing chemotherapy, and emphasizing physical therapy and appropriate follow up can all serve to decrease long-term toxicities. Such optimal use of therapy could subsequently reduce side effects, such as osteoporosis and muscle and bone atrophy, that predispose patients to fractures.
Collapse
Affiliation(s)
- J E Wall
- Department of Hematology/Oncology, St. Jude Children's Research Hospital, Memphis, Tenn, USA
| | | | | | | | | | | |
Collapse
|
14
|
Henry AP, Lachmann E, Tunkel RS, Nagler W. Pelvic insufficiency fractures after irradiation: diagnosis, management, and rehabilitation. Arch Phys Med Rehabil 1996; 77:414-6. [PMID: 8607769 DOI: 10.1016/s0003-9993(96)90094-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Insufficiency fractures of the pelvis are commonly overlooked as causes of severe hip and low back pain. Predisposing factors include postmenopausal osteoporosis, corticosteroids, and local irradiation. Differential diagnosis includes metastatic disease to bone. We present the case of a 65-year-old woman who had a two-month history of low back pain and left groin pain. Her medical history included osteoporosis and endometrial cancer that was treated with radiation therapy to the pelvis 1 year prior to presentation. Despite bed rest, analgesics, and therapeutic modalities, her pain remained intractable and prevented ambulation. Plain radiographs showed no fracture. Computed tomography (CT) and magnetic resonance imaging showed fractures of the pelvis but were suggestive of malignancy. CT-guided bone biopsy was consistent with radiation osteonecrosis. After diagnosis and continued therapy, the patient progressed to ambulation with moderate discomfort. Failure to diagnose insufficiency fractures could lead to further pelvic irradiation, compromising already weakened bones and causing prolonged disability.
Collapse
Affiliation(s)
- A P Henry
- Department of Rehabilitation Medicine, New York Hospital-Cornell Medical Center, New York, NY, USA
| | | | | | | |
Collapse
|
15
|
Stäbler A, Beck R, Bartl R, Schmidt D, Reiser M. Vacuum phenomena in insufficiency fractures of the sacrum. Skeletal Radiol 1995; 24:31-5. [PMID: 7709249 DOI: 10.1007/bf02425944] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Insufficiency fractures of the sacrum are found in women who have undergone radiation therapy to the lower abdomen as well as those suffering from osteoporosis of postmenopausal, steroid-induced, or primary biliary cirrhosis-related origin. Increased uptake in bone scintigraphy and osteolytic changes in these fractures can be misinterpreted as bone metastases, leading to unnecessary biopsies and other procedures in the ensuing search for non-existent primary tumor. PATIENTS In eight female patients averaging 69.4 years of age, insufficiency fracture of the sacrum was diagnosed by computed tomography (CT) and bone scintigraphy. Three underwent a total of five MRI examinations. Malignancy was excluded by histology in two patients and follow-up of at least 6 months in the remainder. Retrospective analysis of CT scans of 13 patients with metastases in the sacrum revealed no vacuum phenomena. RESULTS In seven of eight patients with insufficiency fracture of the sacrum, vacuum phenomena were shown on CT examination. The gas was localized centrally within the ventral part of the fracture in three patients; gas was located in ten adjacent sacro-iliac joints of six patients. CONCLUSIONS The vacuum phenomenon may be an incidental finding in osteoarthritis of the sacro-iliac joint, but it has not been previously recognized in IFS. The presence of intra-articular vacuum phenomena in the sacro-iliac joints in combination with a sacral fracture and vacuum phenomena located within the sacral fracture supports a diagnosis of insufficiency fracture or may indeed be the clue by which this diagnosis is established.
Collapse
Affiliation(s)
- A Stäbler
- Institute of Diagnostic Radiology, Klinikum Grosshadern, Ludwig Maximilian University, Munich, Germany
| | | | | | | | | |
Collapse
|
16
|
Peh WC, Khong PL, Sham JS, Ho WY, Yeung HW. Sacral and pubic insufficiency fractures after irradiation of gynaecological malignancies. Clin Oncol (R Coll Radiol) 1995; 7:117-22. [PMID: 7619761 DOI: 10.1016/s0936-6555(05)80814-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The association between radiotherapy and insufficiency fractures of the pelvis has not been well documented. Fractures were detected over a 2-year period in eight postmenopausal women who had previously undergone irradiation for gynaecological malignancies. Six of these patients also had local soft tissue complications, such as rectal bleeding and haematuria, in addition to severe low back, buttock or groin pain, caused by the fractures. Plain radiographs were unhelpful in the detection of sacral insufficiency fractures, but showed the pubic fractures in five patients. Diagnoses of insufficiency fractures were made on bone scintigraphic demonstration of the typical 'H' shaped sacral pattern, or the combination of the partial 'H' pattern together with public uptake. Computed tomography was useful for confirmation of insufficiency fractures in doubtful cases. Recognition of insufficiency fractures helps to avoid the pitfalls of misdiagnosing tumour recurrence or bony metastases.
Collapse
Affiliation(s)
- W C Peh
- Department of Diagnostic Radiology, University of Hong Kong, Queen Mary Hospital
| | | | | | | | | |
Collapse
|
17
|
Affiliation(s)
- H I Libshitz
- Diagnostic Radiology Department, University of Texas M.D. Anderson Cancer Center, Houston 77030
| |
Collapse
|
18
|
Abstract
Twenty-five post-menopausal women with one or more insufficiency fractures of the pelvic ring are reported. In 80% of cases the fractures were multiple and a total of 79 insufficiency fractures was identified. Twelve iliac insufficiency fractures were present in 11 patients located at one of three sites: above and parallel to the acetabular roof ("supra-acetabular"), extending diagonally across the iliac ala from the greater sciatic notch ("oblique iliac"), and adjacent to the sacro-iliac joint ("superomedial iliac"). The plain radiographic appearances of these iliac fractures were typically subtle with ill defined medullary sclerosis, due to trabecular compression, the cardinal sign. Scintigraphy revealed the fractures as foci of increased activity which, in the presence of multiple pelvic insufficiency fractures, may be mistaken for metastatic disease. Computed tomography can be helpful in confirming the presence of suspected fractures, revealing further occult fractures and also excluding the likelihood of malignancy.
Collapse
Affiliation(s)
- A M Davies
- Department of Radiology, Royal Orthopaedic Hospital, Birmingham, UK
| | | |
Collapse
|
19
|
Lundin B, Björkholm E, Lundell M, Jacobsson H. Insufficiency fractures of the sacrum after radiotherapy for gynaecological malignancy. Acta Oncol 1990; 29:211-5. [PMID: 2334574 DOI: 10.3109/02841869009126547] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An entity is described which is characterized by low back pain and increased radionuclide uptake in the sacrum at bone scintigraphy in postmenopausal women having received radiotherapy towards the pelvis because of gynaecological malignancy. The findings stimulate bone metastases, but are in all likelihood caused by insufficiency fractures of the sacrum promoted by bone weakness induced by postmenopausal osteoporosis and radiotherapy combined. The increased radionuclide activity has a characteristic appearance which in the fully developed fracture acquires the shape of an 'H'. In plain radiography, changes are absent or subtle. The proper complementary examination is CT, in which the fractures can be visualized and malignant changes excluded. Awareness of this benign entity is important to avoid overdiagnosis of bone metastases.
Collapse
Affiliation(s)
- B Lundin
- Department of Diagnostic Radiology, Radiumhemmet Karolinska Hospital, Stockholm, Sweden
| | | | | | | |
Collapse
|