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Pelvic Bone Complications After Radiation Therapy of Uterine Cervical Cancer: Evaluation with MRI

Jong Won Kwon1, Seung Jae Huh2, Young Cheol Yoon1, Sang-Hee Choi1, Jee Young Jung1, Dongryul Oh2 and Bong Keun Choe3

1 Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
2 Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Gu, Seoul 135-710, Korea.
3 Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, Korea.


Figure 1
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  		Fig. 1A —Radiation therapy planning images and dose distribution. Representative digitally reconstructed image shows anteroposterior irradiation field for 61-year-old woman with stage IIB uterine cervical cancer according to FIGO (International Federation of Gynecology and Obstetrics) criteria. Radiation field shaped with multileaf collimators includes tumor (red), clinical target volume (turquoise), regional lymph nodes (pink), and small bowel (blue).

 

Figure 2
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  		Fig. 1B —Radiation therapy planning images and dose distribution. Transverse plane image of 61-year-old woman treated with four fields shows dose distribution: 97% of prescribed dose (brown) encompasses clinical target (light blue). Sacrum and iliac bones are partially included in radiation fields.

 

Figure 3
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  		Fig. 2 —Graph shows overall prevalence of pelvic insufficiency fractures after pelvic radiation therapy for uterine cervical cancer; 5-year cumulative prevalence was 45.2%.

 

Figure 4
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  		Fig. 3 —Schematic shows distribution of insufficiency fractures in our study population. Some patients had multiple fractures.

 

Figure 5
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  		Fig. 4A —Insufficiency fractures—bilateral sacral alae, sacral body, and L5 vertebra—in 68-year-old woman who had undergone radiation therapy for carcinoma of uterine cervix 20 months earlier. Axial T1-weighted image (TR/TE, 450/10; 1.5-T unit) shows hypointense bands of reactive bone marrow change bilaterally in sacral alae and linear low-signal lines in medial portion of left iliac bone (arrows).

 

Figure 6
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  		Fig. 4B —Insufficiency fractures—bilateral sacral alae, sacral body, and L5 vertebra—in 68-year-old woman who had undergone radiation therapy for carcinoma of uterine cervix 20 months earlier. Axial T2-weighted image (4,333/98) shows linear fracture lines bilaterally in sacral alae and medial portion of left iliac bone (arrows) corresponding to findings shown in T1-weighted image (A).

 

Figure 7
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  		Fig. 4C —Insufficiency fractures—bilateral sacral alae, sacral body, and L5 vertebra—in 68-year-old woman who had undergone radiation therapy for carcinoma of uterine cervix 20 months earlier. Sagittal T2-weighted image shows linear fracture lines in L5 vertebral body and sacral body at level of S1 (arrows). L5 vertebral body is collapsed.

 

Figure 8
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  		Fig. 5A —Subchondral insufficiency fracture in left femoral head in 82-year-old woman who had undergone radiation therapy 2 months earlier. Axial T1-weighted image (TR/TE, 583/10; 1.5-T unit) shows low signal intensity of reactive bone marrow change associated with insufficiency fracture in left femoral head (arrow).

 

Figure 9
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  		Fig. 5B —Subchondral insufficiency fracture in left femoral head in 82-year-old woman who had undergone radiation therapy 2 months earlier. Axial T2-weighted image (3,733/96) shows hypointense fracture line (arrow) within hyperintense reactive bone marrow change.

 

Figure 10
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  		Fig. 6A —Insufficiency fractures bilaterally in acetabula and avascular necrosis of left femoral head in 69-year-old woman who had undergone radiation therapy 19 months earlier. Axial T1-weighted image (TR/TE, 633/10, 1.5-T unit) shows hypointense lines of fractures in roof of acetabulum bilaterally in iliac bones (arrows).

 

Figure 11
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  		Fig. 6B —Insufficiency fractures bilaterally in acetabula and avascular necrosis of left femoral head in 69-year-old woman who had undergone radiation therapy 19 months earlier. Coronal T2-weighted image (3,000/102) shows low-signal lines of fractures in roof of acetabulum (arrows) that correspond to findings shown in A. Geographic hypointense signal is seen in left femoral head with mild flattening (arrowheads) suggestive of avascular necrosis.

 

Figure 12
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  		Fig. 7A —Osteolysis in symphysis pubis in 65-year-old woman who had undergone radiotherapy 7 years earlier. Axial T2-weighted image (TR/TE, 4,800/102; 1.5-T unit) obtained before radiation treatment shows only osteoarthritic change in symphysis pubis.

 

Figure 13
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  		Fig. 7B —Osteolysis in symphysis pubis in 65-year-old woman who had undergone radiotherapy 7 years earlier. Axial T2-weighted image (4,333/84) obtained 7 years after radiation therapy shows widening of symphysis pubis (arrow). High signal for fluid is seen within joint, which is suggestive of osteolysis.

 

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