Pelvic insufficiency fractures after radiation therapy for pelvic cancer in female patients: an updated meta-analysis of 11,272 patients
Abstract
BACKGROUND: Pelvic insufficiency fractures (PIFs) are a debilitating complication of pelvic radiotherapy (RT) for pelvic cancer in female patients, which could lead to a sharp decline in patients’ quality of life. A 2019 meta-analysis by Lucas Gomes Sapienza reported a PIF rate of 14%, but advancements in RT techniques (IMRT, VMAT, C-ion RT) and new published studies necessitate an updated analysis. This study aimed to re-evaluate PIF incidence, fracture location, and associated factors using recent high-quality evidence. METHODS: A systematic search of PubMed, Web of Science and Cochrane Library (1980–April 2025) with cohort studies for gynecologic/anal/rectal cancers, pelvic insufficiency fractures. Data on PIF incidence, location, and RT methods were extracted. Random-effects models were used to address expected high heterogeneity. Subgroup analyses were explored in detail. RESULTS: The pooled PIF incidence was 17% (95% CI: 15–20%), higher than the prior 14% estimate. Sacral bone/sacroiliac joint involvement dominated (71%), followed by pubic bone (11.6%). Subgroup analyses revealed higher PIF rates with definitive RT (25%) vs. adjuvant RT (6%). Modern RT techniques (IMRT: 8%, 3D-CRT: 11%) reduced PIF risk vs. historical methods (AP/PA: 22%, 4-field: 18%). However, VMAT and C-ion RT showed elevated rates (30%), likely due to higher doses (≥ 55 Gy). Regional difference indicates Europe (23%) > Asia (20%) > USA (9%). MRI detected more PIFs (19%) than other modalities (14%).…
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