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. 2022;8(2):109-116.

Characterization of rib fracture development following liver directed stereotactic body radiation therapy

Camille Hardy-Abeloos  1   2 , Eric J Lehrer  1 , Anthony D Nehlsen  1 , Kunal K Sindhu  1 , Jared P Rowley  1 , Rendi Sheu  1 , Kenneth E Rosenzweig  1 , Michael Buckstein  1
Affiliations

Characterization of rib fracture development following liver directed stereotactic body radiation therapy

Camille Hardy-Abeloos et al. J Radiosurg SBRT. 2022.

Abstract

Purpose: Rib fractures are a well-described complication following thoracic stereotactic body radiation therapy (SBRT). However, there are limited data in the setting of liver-directed SBRT.

Methods: Patients who underwent liver SBRT from 2014 to 2019 were analyzed. Logistic regression models were used to identify the demographic, clinical, and dosimetric factors associated with the development of rib fractures.

Results: Three hundred and forty-three consecutive patients were reviewed with median follow-up of 9.3 months (interquartile range [IQR]: 4.7-17.4 months); 81% of patients had primary liver tumors and 19% had liver metastases. Twenty-one patients (6.2%) developed rib fractures with a median time to diagnosis of 7 months following SBRT (IQR: 5-19 months). Of those patients, 11 experienced concomitant chest wall pain, while 10 patients had an incidental finding of a rib fracture on imaging. On univariate analysis, female gender (odds ratio [OR]: 2.29; p = 0.05), V30 Gy (OR: 1.02; p < 0.001), V40 Gy (OR: 1.08; p < 0.001), maximum chest wall dose (OR: 1.1; p < 0.001), and chest wall D30 cm3 (OR: 1.09; p < 0.001) were associated with an increased probability of developing a rib fracture. On multivariate analysis, maximum chest wall dose (OR: 1.1; p < 0.001) was associated with developing a rib fracture. Receipt of more than one course of SBRT (p = 0.34), left versus right sided lesion (p = 0.69), osteoporosis (p = 0.54), age (p = 0.82), and PTV volume (p = 0.55) were not significant.

Conclusions: Rib fractures following liver SBRT were observed in 6.2% of patients with the majority being asymptomatic. To mitigate this risk, clinicians should minimize dose delivery to the chest wall. Female patients may be at increased risk.

Keywords: Hepatocellular carcinoma; liver metastases; radiation oncology.

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Figures

Figure 1
Figure 1
Patient with post-SBRT Rib Fracture. (Left Pane) Simulation CT scan with overlaid isodoses (100% isodose line = yellow) (Right Pane) CT scan taken in follow-up approximately 27 months after treatment with a fracture in the right posterior 10th rib (yellow arrow). The patient is a 55 year old female with a history of metastatic squamous cell carcinoma of the anus. Imaging demonstrated two lesions consistent with metastatic disease in segments II and VI. She was treated to a dose of 48 Gy in 3 fractions to each site. Approximately 27 months later she developed pain in the right lower posterior chest wall and was diagnosed with a rib fracture.
Figure 2
Figure 2
Cumulative Incidence of Rib Fracture. Cumulative incidence plot of development of rib fractures and competing risk of death after undergoing liver directed SBRT. The cumulative incidence of rib fractures was 5.9% at 2-years post SBRT
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