Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia.
Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia.
Pract Radiat Oncol. 2019 May;9(3):e338-e346. doi: 10.1016/j.prro.2019.01.012. Epub 2019 Feb 4.
Chest wall (CW) pain and rib fractures are frequently diagnosed after stereotactic body radiation therapy (SBRT) for malignant lung tumors. We hypothesize that multiple risk factors, including bone mineral density (BMD), are associated with CW toxicity, and that CW pain and rib fractures often evolve into chronic clinical problems.
A total of 118 lung tumors treated with SBRT in 100 patients with a minimum follow-up period of 2 years were retrospectively analyzed. The incidence, clinical course, and related demographic, clinical, and dosimetric factors of CW pain and rib fractures were analyzed. In addition, BMD was assessed, and the radiographic appearance of radiation-induced rib fractures and their healing process were characterized.
The median follow-up was 49 months (range, 24-106 months). CW pain developed in 33 of 118 treatments (28%) after, on average, 12.5 months (range, 0-50 months), and was more common in women (P = .04). The mean duration of CW pain was 25 months (range, 2-63 months), and 36% of patients never had resolution of CW pain. A total of 34 of 118 treatments (29%) resulted in rib fractures at a mean time of 22 months (range, 3-46 months); rib fractures were more common in women, African Americans, upper/middle lobe tumors, and patients with lower BMD (P < .05). The mean duration of rib fractures was 25 months (range, 5-41 months), and only 16 rib fractures (47%) healed. Shorter CW planning target volume distance resulted in a higher risk for both rib fractures and CW pain (P = .01). Sixty-seven percent of fractures developed surrounding soft tissue fibrosis, and 62% (21 of 34 fractures) heterotopic ossification. Diabetes, body mass index, and steroid use were not associated with CW pain or rib fracture.
Several factors were associated with a higher risk of SBRT-related CW toxicity. Optimal CW sparing (eg, volumetric modulated arc therapy, lower dose per fraction) should be considered in this patient group without compromising tumor control. SBRT-induced rib fractures commonly heal abnormally and result in potential chronic CW pain.
胸部（CW）疼痛和肋骨骨折在立体定向体部放射治疗（SBRT）治疗恶性肺肿瘤后经常被诊断出来。我们假设包括骨密度（BMD）在内的多种危险因素与 CW 毒性有关，并且 CW 疼痛和肋骨骨折通常会发展成慢性临床问题。
对 100 例接受 SBRT 治疗的 118 个肺肿瘤进行回顾性分析，所有患者的随访时间均至少为 2 年。分析了 CW 疼痛和肋骨骨折的发生率、临床过程以及相关的人口统计学、临床和剂量学因素。此外，评估了 BMD，并对放射性诱导的肋骨骨折的影像学表现及其愈合过程进行了特征描述。
中位随访时间为 49 个月（范围，24-106 个月）。在平均 12.5 个月（范围，0-50 个月）后，118 例治疗中有 33 例（28%）出现 CW 疼痛，女性更常见（P=0.04）。CW 疼痛的平均持续时间为 25 个月（范围，2-63 个月），36%的患者 CW 疼痛从未缓解。在 118 例治疗中有 34 例（29%）发生肋骨骨折，平均时间为 22 个月（范围，3-46 个月）；女性、非裔美国人、上/中叶肿瘤和 BMD 较低的患者肋骨骨折更常见（P<.05）。肋骨骨折的平均持续时间为 25 个月（范围，5-41 个月），只有 16 例（47%）肋骨骨折愈合。CW 计划靶区距离较短与肋骨骨折和 CW 疼痛的风险较高相关（P=0.01）。67%的骨折周围出现软组织纤维化，62%（34 例骨折中的 21 例）出现异位骨化。糖尿病、体重指数和类固醇的使用与 CW 疼痛或肋骨骨折无关。
有几个因素与 SBRT 相关的 CW 毒性风险较高相关。在不影响肿瘤控制的情况下，应考虑对该患者群体进行最佳的 CW 保护（例如，容积调制弧形治疗，降低分割剂量）。SBRT 诱导的肋骨骨折通常愈合异常，并导致潜在的慢性 CW 疼痛。
