UroToday - In this study, we reported our experience with sacral insufficiency fractures (IF) in patients with prostate cancer who underwent pelvic radiotherapy as part of their definitive treatment. Insufficiency fractures are considered a rare complication of radiotherapy. IF has been described after irradiation for gynaecologic, anal, and rectal cancer. Data in prostate cancer patients is rare and limited to some case reports.

In our database we identified 8 cases with symptomatic IF. All of them presented with lower back pain after a median time of 20 months post radiotherapy. Three patients had their bone scans and were referred to our department for palliative radiotherapy, but CT and MR imaging revealed characteristic changes of IF in these patients with low PSA levels. The patients were managed conservatively with non steroid analgesics and bed rest, except one patient who needed opioids for pain relief.

The actual incidence of IF in patients with prostate cancer after pelvic radiotherapy is unknown. This could be related to follow-up policies for prostate cancer, as CT and MR scans are not used for routine follow-up unless there is disease progression or any symptomatic change. Investigators from Korea reported a 5-year cumulative incidence of IF and symptomatic IF of 19.7% and 11.1%, respectively, in a cohort of patients treated for cervical cancer and had routine CT, MR, or bone scans performed during their follow-up. Therefore, the 5-year actuarial incidence of 6.8% reported in this study might have underestimated the actual risk of IF in prostate cancer patients receiving pelvic radiotherapy.

A potential limitation of this retrospective study is that we did not have pretreatment bone mineral density (BMD) tests to evaluate the presence and severity of osteoporosis in this elderly cohort of patients. Androgen deprivation therapy (ADT) is well known to cause decreases in BMD and thus increasing the risk for fractures. Most of these fractures are hip or vertebral fractures, and sacral IF per se was not investigated. In our study we did not observe any fractures outside the radiation field despite the wide use of ADT, indicating radiation injury as the main cause of these fractures.

Improvement in the osseous environment in this elderly cohort of patients with an increased risk of bone loss may play a role to prevent IF. Therefore, clear identification of risk factors for osteoporosis in individual patients upfront, and use of biphosphonates, appropriate caicium and vitamin D intake, and lifestyle modification, as recommended to avoid ADT induced fractures may be of great importance.

In conclusion, our results indicate that prostate cancer patients treated with pelvic radiotherapy must be carefully assessed if pelvic pain appears. Although it is a rare complication, knowledge of pelvic IF is essential to rule out metastatic disease and prevent unnecessary treatment.

Şefik İğdem, MD, and Sait Okkan, MD as part of Beyond the Abstract on UroToday. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

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