Nuclear Medicine and Molecular Imaging

The Korean Society of Nuclear Medicine (대한핵의학회)
권호 표지

Radiation Induced Rib Fractures on Bone Scan after Breast Cancer Surgery and Radiation Therapy

유방암 절제술 후 방사선치료를 시행한 환자의 골스캔에서 보이는 방사전 유발 늑골골절

  • Kim, Hae-Won (Departments of Nuclear Medicine, Keimyung University, School of Medicine) ;
  • Won, Kyoung-Sook (Departments of Nuclear Medicine, Keimyung University, School of Medicine) ;
  • Zeon, Seok-Kil (Departments of Nuclear Medicine, Keimyung University, School of Medicine) ;
  • Kim, Jin-Hee (Department of Radiation Oncology, Keimyung University, School of Medicine)
  • 김해원 (계명대학교 동산의료원 핵의학과) ;
  • 원경숙 (계명대학교 동산의료원 핵의학과) ;
  • 전석길 (계명대학교 동산의료원 핵의학과) ;
  • 김진희 (계명대학교 동산의료원 방사선종양학과)
  • Published : 2009.08.30
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: This study is to evaluate rib fractures on bone scan in breast cancer patients treated with breast cancer surgery and radiation therapy and to evaluate its relation with radiation therapy and operation modality. Materials and Methods: Two hundred seventy cases that underwent serial bone scan after breast cancer surgery and radiation therapy were enrolled. Bone scan and chest a findings of rib fracture were analyzed. Results: The rib uptake was seen in 74 of 270 cases (27.4%) on bone scan and 50 cases (18.5%) were confirmed to have rib fracture by chest CT. The rate of modified radical mastectomy in patients with rib fracture was significantly higher than that in patients without rib fracture (66.0% vs. 27.0%, p = 0.000). The rate of additional radiation therapy to axillar or supraclavicular regions in patients with rib fracture was significantly higher than that in patients without rib fracture (62.0% vs. 28.6%, p =0.000). Rib fracture was seen most frequently at 1-2 years after radiation therapy (51.9%) and single rib fracture was seen most frequently (55.2%). Of total 106 rib fractures, focal rib uptake was seen in 94 ribs (88.7%) and diffuse rib uptake was seen in 12 ribs (11.3%). On one year follow-up bone scan, complete resolution of rib uptake was seen in 15 ribs (14.2%). On chest a, the rate of fracture line in ribs with intense uptake was significantly higher than that in ribs with mild or moderate uptake (p = 0.000). The rate of presence of fracture line in ribs with focal uptake was significantly higher than that in ribs with diffuse uptake (p = 0.001). Conclusion: Rib fracture in breast cancer patients after radiation therapy was related to radiation portal and operation modality. It should be interpreted carefully as a differential diagnosis of bone metastasis.

목적: 본 연구는 유방암절제 술 후 방사선 치료를 받은 환자에서 발생한 늑골골절의 골스캔 소견을 분석하고 방사선 치료와의 상관관계를 알아보고자 하였다. 대상 및 방법: 유방암으로 수술 후 방사선 치료를 받고 추적 골스캔을 시행받은 270예를 대상으로 골스캔을 분석하였다. 골스캔에서 늑골의 섭취증가가 관찰 된 경우 흉부CT를 통해 늑골골절을 확인하였다. 늑골골절은 각 예의 총 방사선 조사량, 방사선 치료범위 방사선 치료 당시 연령, 수술술식, 방사선 치료 후 늑골골절이 나타난 기간, 늑골골절의 개수, 위치, 골스캔에서의 섭취증가 정도, 유형과 변화양상을 분석하였다. 결과: 방사선 치료 후 추적관찰 중 시행된 골스캔 검사에서 방사선 치료를 시행한 쪽의 늑골에 비정상적인 섭취 증가를 보인 예는 총 270예 중 74예(27.4%)였으며, 이 중 흉부CT에서 늑골골절로 확인된 예는 50예(18.5%)였다. 늑골골절이 발생한 군이 그렇지 않은 군에 비해 변형유방전절제술을 시행한 경우가 유의하게 높았고(66.0% vs. 27.0%, p=0.000), 늑골골절이 발생한 군이 그렇지 않은 군에 비해 액와림프절이나 쇄골상림프절 부위에 추가로 방사선치료를 한 경우가 유의하게 높았다(62.0% vs. 28.5%, p=0.000). 늑골골절이 발생한 50예 중 총 106개의 늑골골절이 확인되었고, 단일 늑골골절이 24예(48.0%)에서 발생해 가장 많았다. 방사선 치료 후 골스캔에서 늑골골절이 나타나기까지의 기간은 1년에서 2년 사이가 55개(51.9%)로 가장 많았다. 섭취증가의 유형은 국소형(88.7%)이 확산형(11.3%)보다 많이 나타났고, 1년 후 추적 골스캔에서 섭취증가 정도의 변화는 완전히 사라진 것이 IS개(14.2%)였다. 골스캔의 소견과 흉부CT를 비교하여 늑골의 섭취증가가 강할수록 흉부CT에서 늑골의 골절선이 더 많이 보이는 것으로 나타났으며(p=0.000), 섭취증가가 국소형일 때가 확산형일 때 보다 늑골의 골절선이 유의하게 많이 나타났다(p=0.001). 결론: 유방암절제 술 후 방사선치료를 시행한 환자의 골스캔에서 섭취 증가로 나타난 동측 늑골골절은 수술술식 및 방사선 치료 범위와 관련이 있으며, 방사선치료 후 1-2년 사이에 가장 빈번하게 나타나며, 국소형 으로 주로 한개의 늑골에서 보인다. 이러한 소견들은 골스캔으로 유방암 환자의 골전이를 평가할 때 도움이 될 것으로 생각된다.

Keywords

References

  1. National Health Insurance Corporation. National Health Insurance Statistical Yearbook ;2005. p. 9-17
  2. Goldhirsch A, Gelber RD, Castiglione M. Relapse of breast cancer after adjuvant treatment in premenopausal and perimenopausal women: patterns and prognoses. J Clin Oncol 1997;6:89-97
  3. Kamby K, Senegelov L. Pattern of dissemination and survival following isolated locoregional recurrence of breast cancer: a prospective study with more than 10 years of follow-up. Breast Cancer Res Treat 1997;45:181-92 https://doi.org/10.1023/A:1005845100512
  4. Maffioli L, Florimonte L, Pagani L, Butti I. Roca I. Current role of bone scan with phosphonatcs in the follow-up of breast cancer. Eur J Nncl Med Mol Imaging 2004;31(Suppl 1):S143-8. https://doi.org/10.1007/s00259-004-1537-6
  5. Hamaoka T, Madewell JE, Podoloff DA. Hortobagyi GN, Ueno NT. Bone imaging in metastatic breast cancer. J Clin Oncol 2004;22:2942-53 https://doi.org/10.1200/JCO.2004.08.181
  6. Ferguson DJ, Sutton HG, Dawson PJ. Late effects of adjuvant radiotherapy for breast cancer. Cancer 1984;54: 2319-23 https://doi.org/10.1002/1097-0142(19841201)54:11<2319::AID-CNCR2820541102>3.0.CO;2-C
  7. Libshitz HI. Radiation changes in bone. Semi Roentgenol 1994;29:15-37 https://doi.org/10.1016/S0037-198X(05)80069-0
  8. Bragg DG, Shidnia H, Chu FCH, Higinbotham NL. The clinical and radiographic aspects of radiation osteitis. Radiology 1970;97:103-11 https://doi.org/10.1148/97.1.103
  9. Pierce SM, Recht A, Lingos TI, Abner A, Vicini F, Silver B, et al. Long-term radiation complications following conservative surgery and radiation therapy in patients with early stage breast cancer. Int J Radiation Oncology Bioi Phys 1992;23:915-23 https://doi.org/10.1016/0360-3016(92)90895-O
  10. Overgaard M. Spontaneous radiation-induced rib fractures in breast cancer patients treated with postmastectomy irradiation. Acta Ocol 1988;27:117-22 https://doi.org/10.3109/02841868809090331
  11. Bellon JR, Katz A, Taghian A. Radiation therapy for breast cancer. Hematol Oncol Clin N Am 2006;20:239-57 https://doi.org/10.1016/j.hoc.2006.01.014
  12. Phemister DB. Radium necrosis of bone. Am J Roentgenol 1926;16:340-8
  13. Sams A. The effect of 2000 r of x-rays on the internal structure of the mouse tibia. Int J Radiat Biol Relat Stud Phys Chem Med 1966;11:51-68 https://doi.org/10.1080/09553006614550791
  14. Kok G. Spontaneous fractures of the femoral neck after the intensive irradiation of carcinoma of the uterus. Acta Radiol 1953:40;511-27 https://doi.org/10.3109/00016925309177060
  15. Fajardo LF. Pathology of Radiation Injury. New York: Masson; 1982. p. 176-86
  16. Gumerman LW, Fogel SR, Goodman MA. Experimetal fracture healing:evaluation usuing radionuclide bone imageing. J Mel Med 1978;19:1320-3
  17. Maeseneer MD, Mey JD, Lenchik L, Hendrik E, Osteaux M. Helical CT of rib lesion: a pattern-based approach. Am J Roentgenol 2004;182:173-9 https://doi.org/10.2214/ajr.182.1.1820173
  18. Kara G, Bozkurt MF, Ozcan PP, Caner B. Solitary rib lesions in bone scans of patients with breast carcinoma. Nucl Med Commun 2003;24:887-92 https://doi.org/10.1097/00006231-200308000-00007
  19. Park HG, Lee DS, Lee MC, Cho BY, Koh CS. Evaluation of the rib lesions by bone scanning. Nucl Med Mol Imaging 1983;17:63-9
  20. Niitsu M, Takeda T. Solitary hot spots in the ribs on bone scan: value of thin-section reformatted computed tomography to exclude radiography-negative fractures. J Comput Assist Tomorg 2003;27:469-74 https://doi.org/10.1097/00004728-200307000-00002
  21. Kulkarni MV, Tarr RR, Kim EE, McArdle CB, Partain CL. Potential pitfalls of magnetic resonance imaging in the diagnosis of avascular necrosis. J Nucl Med 1987;28:1052-4
  22. Gaze MN, Neville E, Rooke HW. Bone scan hot spots in a patient with lung cancer: ischemic necrosis of bone mimicking metastatic carcinoma. Clin Oncol 1991;3:177-9 https://doi.org/10.1016/S0936-6555(05)80843-X
  23. Chen HHW, Su WC, GUO HR, Lee BF, Su WR, Wu PS, et al. Clinical significance and outcome of of one or two rib lesions on bone scans in breast cancer patients without known metastases. Nucl Med Commun 2003;24:1167-74 https://doi.org/10.1097/00006231-200311000-00007
  24. Connolly LP, Connolly SA Rib stress fracture. Clin Nucl Med 2004;29:614-6 https://doi.org/10.1097/00003072-200410000-00002
  25. Vandemergel X. Blocklet D, Decaux G. Periostitis and hypertrophic osteoarthropathy: etiologies and bone scan patterns in 115 cases. Eur J Intern Med 2004;15:375-80 https://doi.org/10.1016/j.ejim.2004.04.017