A cortical thickness and radiation dose mapping approach identifies early thinning of ribs after stereotactic body radiation therapy

Okoukoni, Catherine; Lynch, Sarah K.; McTyre, E.; Randolph, David M.; Weaver, Ashley A.; Blackstock, A. William; Lally, Brian E.; Munley, Michael T.; Willey, Jeffrey S.

doi:10.1016/j.radonc.2016.03.023

Cited by 18 publications

(23 citation statements)

References 28 publications

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“…In a pooled analysis of patients undergoing SABR with 2 different types of treatment machine (LINAC and Cyberknife®), 10% risk level for grade 2 or higher chest wall complication for D 2cc was 43.0 Gy in 4 fractions [29]. A recent study by Okoukoni et al reported early cortical thinning of ribs after SABR in regions of receiving ≥10 Gy and suggested that rib thinning would contribute to the occurrence of rib fractures [30]. In our study, various parameters were associated with RIRF but D 4.6cc and V 160 were most predictive.…”

Section: Discussionmentioning

confidence: 99%

Predictors of chest wall toxicity after stereotactic ablative radiotherapy using real-time tumor tracking for lung tumors

2017

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BackgroundTo evaluate the incidence of chest wall toxicity after lung stereotactic ablative radiotherapy (SABR) and identify risk factors for the development of rib fracture.MethodsThirty-nine patients with 49 lesions underwent SABR for primary or metastatic lung tumors using Cyberknife® with tumor tracking systems. Patient characteristics, treatment factors and variables obtained from dose-volume histograms (DVHs) were analyzed to find the association with chest wall toxicity. Four-dimensional (4D) dose calculations were done to investigate the effect of respiratory motion on dose to the ribs.ResultsAfter follow-up of median 26.7 months (range: 8.4 – 80.0), 8 patients (20.5%) experienced rib fractures and among these patients, three (37.5%) had chest wall pain at 2–3 months after SABR. Median time to rib fracture was 13.4 months (range: 8.0 – 38.5) and the 2-year actuarial risk of rib fracture was 12.2%. Dose to the 4.6 cc of the ribs (D4.6cc) and rib volume received 160 Gy or more (V160) were significant predictor for rib fracture. No significant differences between three-dimensional (3D) and 4D dose calculations were found.ConclusionsParameters from DVH are useful in predicting the risk of chest wall toxicity after SABR for lung tumors. Efforts should be made to reduce the risk of the rib fracture after lung SABR.

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Section: Discussionmentioning

confidence: 99%

Predictors of chest wall toxicity after stereotactic ablative radiotherapy using real-time tumor tracking for lung tumors

2017

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“…CBM has been previously applied to ribs for tracking bone thickness reductions after cancer therapy (Okoukoni et al. ), but it has not yet been used to report rib cortical bone thickness distributions from individuals or across populations.…”

Section: Introductionmentioning

confidence: 99%

“…The Cortical Bone Mapping (CBM) methodology allows for accurate measurements of these important geometric factors from CT imaging (Treece et al 2010;Treece & Gee, 2015;Holcombe et al 2018). CBM has been previously applied to ribs for tracking bone thickness reductions after cancer therapy (Okoukoni et al 2016), but it has not yet been used to report rib cortical bone thickness distributions from individuals or across populations.…”

Section: Introductionmentioning

confidence: 99%

Regional maps of rib cortical bone thickness and cross‐sectional geometry

et al. 2019

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Here we present detailed regional bone thickness and cross‐sectional measurements from full adult ribs using high resolution CT scans processed with a cortical bone mapping technique. Sixth ribs from 33 subjects ranging from 24 to 99 years of age were used to produce average cortical bone thickness maps and to provide average ± 1SD corridors for expected cross‐section properties (cross‐sectional areas and inertial moments) as a function of rib length. Results obtained from CT data were validated at specific rib locations using direct measurements from cut sections. Individual thickness measurements from CT had an accuracy (mean error) and precision (SD error) of −0.013 ± 0.167 mm (R2 coefficient of determination of 0.84). CT‐based measurement errors for rib cross‐sectional geometry were −0.1 ± 13.1% (cortical bone cross‐sectional area) and 4.7 ± 1.8% (total cross‐sectional area). Rib cortical bone thickness maps show the expected regional variation across a typical rib's surface. The local mid‐rib maxima in cortical thickness along the pleural rib aspect ranged from range 0.9 to 2.6 mm across the study population with an average map maximum of 1.4 mm. Along the cutaneous aspect, rib cortical bone thickness ranged from 0.7 to 1.9 mm with an average map thickness of 0.9 mm. Average cross‐sectional properties show a steady reduction in total cortical bone area from 10% along the rib's length through to the sternal end, whereas overall cross‐sectional area remains relatively constant along the majority of the rib's length before rising steeply towards the sternal end. On average, male ribs contained more cortical bone within a given cross‐section than was seen for female ribs. Importantly, however, this difference was driven by male ribs having larger overall cross‐sectional areas, rather than by sex differences in the bone thickness observed at specific local cortex sites. The cortical bone thickness results here can be used directly to improve the accuracy of current human body and rib models. Furthermore, the measurement corridors obtained from adult subjects across a wide age range can be used to validate future measurements from more widely available image sources such as clinical CT where gold standard reference measures (e.g. such as direct measurements obtained from cut sections) are otherwise unobtainable.

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“…Micro-CT also improves upon the evaluation of trabecular volume/number and cortical thickness, but is limited to small regions of interest. A novel three-dimensional (3D) cortical mapping algorithm was developed that could easily be scalable to larger CT scans, multiple bones simultaneously, and provide both quantitative and qualitative information on RT-induced bone changes [4,61,62].…”

Section: Development Of a Methods For Measuring Rt-induced Bone Toxicitymentioning

confidence: 99%

“…Stereotactic body radiation therapy (SBRT), for example, when used in the treatment of lung tumors near the chest wall, unavoidably delivers high doses of radiation to the ribs or vertebrae, and it can predispose patients to significant risks of radiation-induced rib fractures (RIRF), vertebral fractures, and chest wall pain (CWP) [4][5][6]. These toxicities have been correlated with the dose received by the chest wall.…”

Section: Introductionmentioning

confidence: 99%

Bench to Bedside: Animal Models of Radiation Induced Musculoskeletal Toxicity

Farris

Helis

Hughes

et al. 2020

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Ionizing radiation is a critical aspect of current cancer therapy. While classically mature bone was thought to be relatively radio-resistant, more recent data have shown this to not be the case. Radiation therapy (RT)-induced bone loss leading to fracture is a source of substantial morbidity. The mechanisms of RT likely involve multiple pathways, including changes in angiogenesis and bone vasculature, osteoblast damage/suppression, and increased osteoclast activity. The majority of bone loss appears to occur rapidly after exposure to ionizing RT, with significant changes in cortical thickness being detectable on computed tomography (CT) within three to four months. Additionally, there is a dose–response relationship. Cortical thinning is especially notable in areas of bone that receive >40 gray (Gy). Methods to mitigate toxicity due to RT-induced bone loss is an area of active investigation. There is an accruing clinical trial investigating the use of risderonate, a bisphosphonate, to prevent rib bone loss in patients undergoing lung stereotactic body radiation therapy (SBRT). Additionally, several other promising therapeutic/preventative approaches are being explored in preclinical studies, including parathyroid hormone (PTH), amifostine, and mechanical loading of irradiated bones.

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A cortical thickness and radiation dose mapping approach identifies early thinning of ribs after stereotactic body radiation therapy

Cited by 18 publications

References 28 publications

Predictors of chest wall toxicity after stereotactic ablative radiotherapy using real-time tumor tracking for lung tumors

Predictors of chest wall toxicity after stereotactic ablative radiotherapy using real-time tumor tracking for lung tumors

Regional maps of rib cortical bone thickness and cross‐sectional geometry

Bench to Bedside: Animal Models of Radiation Induced Musculoskeletal Toxicity

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