Pathologic femur fractures after limb-sparing treatment of soft-tissue sarcomas

Blaes, Anne; Lindgren, Bruce R.; Mulrooney, Daniel A.; Willson, Lauren; Cho, L. Chinsoo

doi:10.1007/s11764-010-0144-8

Cited by 26 publications

(37 citation statements)

References 18 publications

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“…The overall rate of radiation-associated bone fracture in soft tissue sarcoma (STS) of the extremity is about 4-6%. [1][2][3] Most of these fractures occur in patients with lower extremity lesions, particularly the thigh. 4 Even within the thigh, there is a higher rate of fracture in anterior compartment tumors compared to medial or posterior compartments.…”

Section: Introductionmentioning

confidence: 99%

Femoral Fracture in Primary Soft-Tissue Sarcoma of the Thigh and Groin Treated with Intensity-Modulated Radiation Therapy: Observed versus Expected Risk

et al. 2019

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Purpose.-To compare the observed risk of femoral fracture in primary soft-tissue sarcoma (STS) of the thigh/groin treated with IMRT to expected risk calculated using the Princess Margaret Hospital (PMH) nomogram. Methods.-Expected femoral fracture risk was calculated using the PMH nomogram. Cumulative risk of fracture was estimated using Kaplan-Meier statistics. Prognostic factors were assessed with univariate and multivariate analysis using Cox's stepwise regression. Results.-Between February 2002 and December 2010, 92 consecutive eligible patients were assessed. Median follow-up was 73 months (106 months in surviving patients). IMRT was delivered preoperatively (50 Gy) in 13 (14%) patients, and postoperatively in 79 (86%) patients (median dose of 63 Gy, range 59.4-66.6 Gy). The observed crude risk of fractures was 6.5% compared to 25.6% expected risk from the nomogram; the cumulative risk of fracture using IMRT at 5 years was 6.7% (95% CI 2.8-16.0%). The median time to fracture was 23 months (range 6.9-88.6). Significant predictors of fracture on univariate analysis were age ≥ 60 years (p = 0.03), tumor location in the anterior thigh (p = 0.008), and periosteal stripping to > 20 cm (p < 0.0001). On multivariate analysis, age ≥ 60 years and periosteal stripping > 20 cm retained significance (p = 0.04 and p = 0.009, respectively). Conclusions.-In this study, the cumulative risk of femur fracture in patients treated with IMRT (6.7%) is less than the expected risk using the PMH nomogram (25.6%). Established predictors of femur fracture such as gender, tumor size, and dose of RT seem to have less impact on fracture risk when using IMRT.

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Section: Introductionmentioning

confidence: 99%

Femoral Fracture in Primary Soft-Tissue Sarcoma of the Thigh and Groin Treated with Intensity-Modulated Radiation Therapy: Observed versus Expected Risk

et al. 2019

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“…When the tumor lies adjacent to bone, some of the periosteum may be removed (stripped) in order to ensure adequate surgical margins. This combination of surgery and radiation greatly improves local control of these tumors,20–22 but several clinical studies have identified PS as a significant risk factor for post‐radiation pathologic fracture following surgery for extremity STS 20, 21, 23. In patients treated for STS of the thigh, PS is associated with an 18‐ to 20‐fold increase in the risk of pathologic femoral fracture, with the incidence of fracture at 5 years ranging from 29% to 32% 20, 21.…”

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confidence: 99%

Effects of extensive circumferential periosteal stripping on the microstructure and mechanical properties of the murine femoral cortex

Mercurio

Motta

Green

et al. 2011

Journal Orthopaedic Research

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Extensive periosteal stripping (PS) is a risk factor for post-radiation pathologic fracture following surgery for extremity soft tissue tumors. The purpose of this study was to determine the effects of PS on bone structure and mechanical properties. Thirty-one skeletally mature mice underwent PS, with circumferential removal of periosteum from an 8-mm segment of the mid-diaphysis of the left femur. Thirty-one control mice underwent sham surgery in which the femur was isolated without manipulation of the periosteum. At 2, 6, 12, or 26 weeks following surgery, the left femora were examined by micro-CT to quantify cortical thickness (CtTh), cross-sectional area (CSA), bone volume (BV), and polar moment of inertia (PMI). Three-point mechanical bend testing was performed and peak load, stiffness, and energy to failure were determined. PS resulted in significantly decreased CtTh, CSA, BV, and PMI at all time points. Peak load, stiffness, and energy to failure were significantly reduced at 2, 6, and 12 weeks. There were no significant differences in mechanical properties at 26 weeks. In this mouse model, extensive circumferential PS resulted in sustained changes in bone structure that were still evident after 6 months, accompanied by reductions in bone strength that persisted for at least 3 months. ß

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“…In report by Blaes et al, post treatment pathologic fracture among soft-tissue sarcoma patients was identified to increase with time with overall incidence reported at 9% at 10 years 9 . In a study of gynecologic cancer patientes treated with radiation to the pelvis, the fracture incidence within the radiation field was 11% at 5 years and 15% at 10 years 3 .…”

Section: Discussionmentioning

confidence: 96%

Spatial and Temporal Fracture Pattern in Breast and Gynecologic Cancer Survivors

Song

Arentsen

Wilcox³

et al. 2015

J. Cancer

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Objective(s): To assess skeletal wide fracture location and time of fracture after cancer treatmentStudy Design: One hundred thirty-nine women diagnosed with breast or gynecologic cancer between 2003 and 2012 that subsequently had a radiologic diagnosis of fracture were identified retrospectively using electronic medical records. Results were compared with skeletal fracture pattern previously reported for a general population.Results: Skeletal fractures in cancer patients occur throughout the entire skeleton similar to general population. The most common sites were vertebrae (16%), feet and toes (15%), ribs (12%), hands and fingers (10%), and pelvis (8%). Fracture incidence was observed starting within the first year of survivorship, and continued to after five years. The median time from cancer diagnosis to fracture varied by age (p<0.01), from a high of 3.2 years for ages 50-59 to a low of 1.2 years for patients older than 70.Conclusion: The pattern of skeletal fracture is similar between cancer survivor and general population. Contrary to general assumption, survivors can experience skeletal fracture early after cancer treatment, especially at an older age. Thus, cancer survivorship care should include assessment of early time points with improved management of cancer treatment related bone injury.

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Pathologic femur fractures after limb-sparing treatment of soft-tissue sarcomas

Abstract: Survivors of soft tissue sarcomas of the femur may be at risk for the development of femur fractures and warrant close observation.

Cited by 26 publications

References 18 publications

Femoral Fracture in Primary Soft-Tissue Sarcoma of the Thigh and Groin Treated with Intensity-Modulated Radiation Therapy: Observed versus Expected Risk

Femoral Fracture in Primary Soft-Tissue Sarcoma of the Thigh and Groin Treated with Intensity-Modulated Radiation Therapy: Observed versus Expected Risk

Effects of extensive circumferential periosteal stripping on the microstructure and mechanical properties of the murine femoral cortex

Spatial and Temporal Fracture Pattern in Breast and Gynecologic Cancer Survivors

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