Originally published as JCO Early Release 10.1200/JCO.2008.19.3508 on September 8 2009

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Risk of Fracture After Single Fraction Image-Guided Intensity-Modulated Radiation Therapy to Spinal Metastases

From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Orthopaedic Service and Departments of Surgery, Neurosurgery, Radiation Oncology, and Radiology, Memorial Sloan-Kettering Cancer Center, New York; and Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY.

Corresponding author: Eric Lis, MD, Department of Radiology – Neuroradiology Division, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; e-mail: lise{at}mskcc.org.

Purpose Single-fraction image-guided intensity-modulated radiation therapy (IG-IMRT) allows for tumoricidal treatment of traditionally radioresistant cancers while sparing critical adjacent structures. Risk of vertebral fracture after IG-IMRT for spinal metastases has not been defined.

Patients and Methods We evaluated 62 consecutive patients undergoing single fraction IG-IMRT at 71 sites for solid organ metastases. A neuroradiologist and three spine surgeons evaluated prospectively obtained magnetic resonance/computed tomography (CT) imaging studies for post-treatment fracture development and tumor recurrence.

Results Fracture progression was noted in 27 vertebrae (39%). Multivariate logistic regression analysis showed that CT appearance, lesion location, and percent vertebral body involvement independently predicted fracture progression. Lesions located between T10 and the sacrum were 4.6 times more likely to fracture than were lesions above T10 (95% CI, 1.1 to 19.7). Lytic lesions were 6.8 times more likely to fracture than were sclerotic and mixed lesions (95% CI, 1.4 to 33.3). As percent vertebral body involvement increased, odds of fracture also increased. Patients with fracture progression had significantly higher narcotic use, change in Karnofsky performance score, and a strong trend toward higher pain scores. Local tumor progression occurred in seven patients and contributed to one fracture. Obesity, posterior element involvement, bisphosphonate use, and local kyphosis did not confer increased risk.

Conclusion Vertebral fracture is common after single fraction IG-IMRT for metastatic spine lesions. Lytic disease involving more than 40% of the vertebral body and location at or below T10 confer a high risk of fracture, the presence of which yields significantly poorer clinical outcomes. These results may help clinicians identify high-risk patients who would benefit from prophylactic vertebro- or kyphoplasty.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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