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Review
. 2024 Aug 14;16(8):e66839.
doi: 10.7759/cureus.66839. eCollection 2024 Aug.

A Comprehensive Narrative Review of the Impact of Pelvic Radiotherapy on Pelvic Bone Health: Pathophysiology, Early Diagnosis, and Prevention Strategies

Mohamed Elgendy  1 , Alvin Billey  2 , Asra Saleem  3 , Bushra Zeeshan  4 , Gayanthi Dissanayake  5 , Meaza Zergaw  6 , Marcellina Nwosu  3
Affiliations
Review

A Comprehensive Narrative Review of the Impact of Pelvic Radiotherapy on Pelvic Bone Health: Pathophysiology, Early Diagnosis, and Prevention Strategies

Mohamed Elgendy et al. Cureus. .

Abstract

Radiotherapy is a commonly used modality in pelvic malignancies such as prostate, gastrointestinal, or gynecological, either as a primary treatment or an adjuvant post-surgery. Despite its positive impact on the prognosis of these patients, it was found in several studies that it contributes to insufficiency fractures in different sites of the pelvis, more commonly in the sacral ala. This is particularly true for elderly patients. There are several hypotheses on how radiotherapy affects bone health, as it destroys the bone matrix and causes obliterative vasculitis. Several imaging techniques, particularly magnetic resonance imaging (MRI), help detect the radiotherapy-induced fracture and distinguish it from metastases. Some modalities, such as intensity-modulated radiotherapy (IMRT) and brachytherapy, have decreased fracture risk by escaping the adjacent structures to the targeted organ. Pharmacological interventions such as amifostine and desferrioxamine are promising in terms of bone protection, which necessitates further studies to confirm their mechanism of action.

Keywords: bone density; insufficiency fractures; intensity-modulated radiotherapy; pelvic malignancy; pelvic radiotherapy.

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Conflict of interest statement

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. A pie chart that illustrates the 2.1% fracture risk in patients who received irradiation at a total dose of less than 50.4 GY.
Data according to Oh et al.'s study (2008) [26]
Figure 2
Figure 2. A pie chart illustrates that those patients who underwent irradiation at a total dose >/= 50.4 GY had a fracture risk of 21.7%.
Data according to Oh et al.'s study (2008) [26]
Figure 3
Figure 3. A diagram that illustrates the common sites of radiation-induced insufficiency fractures in the pelvis, along with the incidence of each fracture.
The data are based on a study by Abe et al. (2013) [29]
Figure 4
Figure 4. A graph that illustrates the common sites of radiation-induced insufficiency fractures in the pelvis, along with the incidence of each fracture.
The data are based on a study by Abe et al. (2013) [29]
Figure 5
Figure 5. MRI pelvis showing a fracture of the right acetabulum (red arrow) after radiotherapy for prostate cancer. The examination was performed on October 27, 2023, in the radiology department at Bolton NHS Trust, UK.
Figure 6
Figure 6. MRI showing a non-displaced fracture of the left sacral ala (red arrow) after radiotherapy to the rectum for rectal cancer. The examination was performed on October 3, 2022, in the radiology department at Bolton NHS Trust, UK.
See this image and copyright information in PMC

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