(P131) The Role of Radiation Therapy in the Management of Neurogenic Heterotopic Ossification

OncologyOncology Vol 28 No 1S
Volume 28
Issue 1S

Patients who sustain brain and spinal cord injuries are at risk for developing neurogenic heterotopic ossification (NHO), the formation of bone in extraskeletal soft tissue. The purpose of this study was to review the experience and to report the outcome of eight consecutively irradiated joints in four patients with NHO.

Elizabeth C. Ester, MD, Ian S. Gallaher, MD, Daniel A. Jones, MD, Joseph G. Lynch, CMD; Department of Radiation Oncology, Minneapolis Veterans Affairs Medical Center; Department of Radiation Oncology, University of Minnesota Medical Center

Background: Patients who sustain brain and spinal cord injuries are at risk for developing neurogenic heterotopic ossification (NHO), the formation of bone in extraskeletal soft tissue. The pathogenesis of NHO is unclear but may be a combination of local inflammation, prostaglandins, and growth factors stimulating the differentiation of soft tissue mesenchymal progenitor cells into osteoblasts. NHO most commonly affects the hip and elbow joints and ranges from asymptomatic to clinically significant restriction in range of motion resulting in functional deficits. Prevention and management of NHO includes pharmacologic interventions, surgical resection, and radiation therapy (RT). Radiation for NHO is controversial, and the effectiveness of a single 700-cGy fraction, as used in heterotopic ossification (HO) prophylaxis, has been questioned. The purpose of this study was to review the experience and to report the outcome of eight consecutively irradiated joints in four patients with NHO at the Minneapolis Veterans Affairs Medical Center between July and September 2013.

Materials and Methods: The management of eight consecutively treated joints in patients with clinically significant NHO was reviewed. One patient had an anoxic brain injury, and the remaining patients had thoracic spinal cord injury (SCI) ranging from T4–T8. Patients were irradiated with 800 cGy in a single fraction to the area of visible ossification. Patients were followed with physical examination and imaging to determine efficacy of therapy. Toxicity was evaluated and reported according to Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0).

Results: Sites irradiated included six hips and two elbows. The mean age was 34 years, and median follow-up was 11 weeks. Three hip joints were treated with surgical resection followed by RT and indomethacin at 25 mg tid for 6 weeks. One hip joint, previously treated with surgical resection and RT, had NHO recurrence within 2 months of therapy and was retreated. Radiation was delivered between 24 and 60 hours of surgery. All three patients with treated hip joints achieved improvement in joint range of motion and functionality. Three hip joints and two elbow joints were treated with RT and etidronate without surgical resection. All joints initially demonstrated improvement in range of motion after RT. One patient subsequently experienced progression, clinically and radiographically, 2 months following treatment. Overall treatment efficacy was 87.5%. Acute toxicity was minimal and limited to grade 2 dermatitis in a single patient.

Conclusion: While this cohort of patients is small, outcomes suggest that a single fraction of 800 cGy, in addition to pharmacologic prophylaxis, may be a reasonable regimen to study in patients with NHO. Follow-up is short, and long-term efficacy and toxicity are unknown. The risk of secondary malignancy is small, as reported by others.

Articles in this issue

(P113) Age and Marital Status Are Associated With Choice of Mastectomy in Patients Eligible for Breast Conservation Therapy
(P112) Single-Institution Experience With Intrabeam IORT for Treatment of Early-Stage Breast Cancer
(P110) Breast Cancer Before Age 40: Current Patterns in Clinical Presentation and Local Management
(P111) Accelerated Partial-Breast Irradiation With Multicatheter High-Dose-Rate Brachytherapy: Feasibility and Results in a Private Practice Cohort
(P115) Breast Cancer Laterality Does Not Influence Overall Survival in a Large Modern Cohort: Implications for Radiation-Related Cardiac Mortality
(P117) Anatomical Variations and Radiation Technique for Breast Cancer
(P116) Bilateral Immediate DIEP Reconstruction and Postmastectomy Radiotherapy: Experience at a Tertiary Care Institution
(P118) Metadherin Overexpression Is Associated With Improved Locoregional Control After Mastectomy
(P119) Effect of Economic Environment on Use of Postlumpectomy Radiation Therapy for Stage I Breast Cancer
(P120) Immediate Versus Delayed Reconstruction After Mastectomy in the United States Medicare Breast Cancer Patient
(P121) Trend in Age and Racial Disparities in the Receipt of Postlumpectomy Radiation Therapy for Stage I Breast Cancer: 2004–2009
(P122) Streamlining Referring Physicians Orders With ‘Reflex Testing’ Significantly Decreases Time to Resolution for Abnormal Screening Mammograms
(P123) National Trends in the Local Management of Early-Stage Paget Disease of the Breast
(P124) Effect of Inhomogeneity on Cardiac and Lung Dose in Partial-Breast Irradiation Using HDR Brachytherapy
(P125) Breast Cancer Outcomes With Anthracycline-Based Chemotherapy for Residual Disease Burden After Full-Dose Neoadjuvant Chemotherapy and Surgery Followed by Radiation Treatment
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