Abstract
The deleterious effects of X-rays on bone have been recognised for almost a century and continue to be seen today because of improved survival in patients treated for malignancy with radiotherapy with or without other treatments. In this pictorial review we present the imaging features of radiation damage to bone highlighting the differences seen in the immature skeleton and post-skeletal fusion. In the former, damage is greatest to the physis resulting in growth disturbances. In the mature skeleton there is a spectrum of changes from mild osteopenia, through disordered attempts at healing with varying degrees of sclerosis, radionecrosis which may lead to acute fractures following minimal trauma and insufficiency fractures both with refractory healing to the dreaded complication of sarcomatous transformation. The imaging appearances are illustrated and the features that help distinguish malignant change from other complications stressed.
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References
British Medical Journal (1896) 1:997–998
Hawks HD (1896) The physiologic effects of the Roentgen rays. Elect Eng 22:276
Kolle FS (1897) The effect of X-rays on the hair. Elect Eng 23:267
Walsh D (1897) Deep tissue traumatism from Roentgen ray exposure. BMJ 2:272–273
Frieben A (1902) Cancroid des Handruckens nach Langdauernder Einwurkung von Rontgenstrahlen. Fortschr Rontgenstr 6:106–112
Hall-Edwards J (1908) The effects upon bone due to prolonged exposure to the X-ray. Arch Roentgen Ray 13:44
Maitland HS, Humphries RE (1929) Osteogenic sarcoma in dial pointers using luminous paint. Arch Pathol 7:406
Beck A (1922) Zur Frage des Rontgensarcoms, Zugleich ein Beitrag zur Patholgenese des Sarcoms. Munchen Med Wschr 69:623–625
Berrington de Gonzàlez A, Darby S (2004) Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet 363:345–51
Penman D (2004) Medical X-rays cause thousands of cancers. NewScientist.com news service
Dalinka MK, Haygood TM (2002) Radiation changes. In: Resnick D (ed) Diagnosis of bone and joint disorders. Philadelphia, Saunders, 5th edn, pp 3393–3422
Rubin P, Andrews JR, Swarm JR, Gump H (1959) Radiation induced dysplasia of bone. Am J Roentgenol 82:206–216
Probert JC, Parker BR (1975) The effects of radiation therapy on bone growth. Radiology 114:155–162
Howland WJ, Loeffler RK, Starchman DE, Johnson RB (1975) Post-irradiation atrophic changes of bone and related complications. Radiology 117:677–685
Ergun H, Howland WJ (1980) Postradiation atrophy of mature bone. Crit Rev Diagn Imaging 12:225–243
Perthes G (1903) Ueber den Einfluss der Röentgenstrahlen auf Epitheliale Gewebe, Insbesondere auf des Carcinom. Arch Clin Chir 71:955
Hueck H, Speiss W (1929) Zur Frage der Wachstumsstörungen bei Röntgenbestrahlten Knochen und Gelenktuberkulosen. Strahlentherapie 32:322
Desjardins AU (1930) Osteogenic tumor: growth injury of bone and muscular atrophy following therapeutic irradiation. Radiology 14:296–308
Bisgard JD, Hunt HB (1936) Influence of roentgen rays and radium on epiphyseal growth in long bones. Radiology 26:56–64
Dawson WB (1968) Growth impairment following radiotherapy in childhood. Clin Radiol 19:241–256
Dalinka MK, Mazzeo VP (1985) Complications of radiation therapy. Crit Rev Diagn Imaging 23:235–267
De Smet AA, Kuhns LR, Fayos JV, Holt JF (1976) Effect of radiation therapy on growing long bones. Am J Roentgenol 127:935–939
Libshitz HI, Edeikin BS (1981) Radiotherapy changes of the pediatric hip. Am J Roentgenol 137:585–588
Eifel PJ, Donaldson SS, Thomas PRM (1995) Response of growing bone to irradiation: a proposed late effects scoring system. Int J Radiat Oncol Biol Phys 31:1301–1307
Silverman C, Thomas P, McAlister W, Walder S, Whiteside L (1981) Slipped capital femoral epiphysis in irradiated children: Dose volume and age relationships. Int J Radiat Oncol Biol Phys 7:1357–1363
Edeikin BS, Libshitz HJ, Cohen MA (1982) Slipped proximal humeral epiphysis: a complication of radiotherapy to the shoulder in children. Skelet Radiol 9:123–125
Rutherford H, Todd GD (1974) Complications of radiation therapy: growing bone. Semin Roentgenol 9:15–27
El-Mahdi AM, Marks R, Thornton WN, Constable WC (1974) Sequelae of pelvic irradiation in infancy. Radiology 110:165–166
Bluemke DA, Fishmann EK, Scott WW (1994) Skeletal complications of radiation therapy. Radiographics 14:111–121
Yue NC, Benson ML (1996) The hourglass facial deformity as a consequence of orbital irradiation for bilateral retinoblastoma. Pediatr Radiol 26:421–423
Kaste SC, Hopkins KP, Jenkins JJ (1994) Abnormal odontogenesis in children treated with radiation and chemotherapy. Am J Roentgenol 162:1407–1411
Neuhauser EBD, Wittenborg MH, Berman CZ, Cohen J (1952) Irradiation effects of roentgen therapy on the growing spine. Radiology 59:637–650
Mayfield JK, Riseborough EJ, Jaffe N, Nehme M (1981) Spinal deformity in children treated for neuroblastoma. J Bone Joint Surg Am 63:183–193
Heaston D, Libshitz H, Chan R (1979) Skeletal effects of megavoltage irradiation in survivors of Wilm's tumour. Am J Roentgenol 133:389–395
Ewing J (1926) Radiation osteitis. Acta Radiol 6:399–412
Casamassima F, Ruggiero C, Caramella D, Tinacci E, Villari N, Ruggerio M (1989) Haematopoietic bone marrow recovery after radiation therapy: MRI evaluation. Blood 73:1677–1681
Stevens SK, Moore SG, Kaplan ID (1990) Early and late bone-marrow changes after irradiation: MR evaluation. Am J Roentgenol 154:745–750
Sugimura H, Kisanuki A, Tamura S, Kihara Y, Watanabe K, Sumiyoshi A (1994) Magnetic resonance imaging of bone marrow changes after irradiation. Invest Radiology 29:35–41
Cavenagh EC, Weinburger E, Shaw DWW, White KS, Geyer R (1995) Haematopoietic marrow regeneration in paediatric patients undergoing spinal irradiation: MR depiction. Am J Neuroradiol 16:461–467
Camp JD, Moreton RD (1945) Radiation necrosis of the calvarium: report of 5 cases. Radiology 213–219
Overgaard M (1988) Spontaneous radiation-induced rib fractures in breast cancer patients treated with post-mastectomy irradiation. Acta Oncol 27:117–122
Dalinka MK, Edeiken J, Finkelstein JB (1974) Complications of radiation therapy: adult bone. Semin Roentgenol 9:29–40
Paul LW, Pohle EA (1942) Radiation osteitis of the ribs. Radiology 38:543–549
Bragg DG, Shidnia H, Chu FCH, Higinbotham NL (1970) The clinical and radiographic aspects of radiation osteitis. Radiology 97:103–111
Rubin P, Probhasawat D (1961) Characteristic bone lesions in post irradiated carcinoma of the cervix: metastases versus osteonecrosis. Radiology 76:703–707
Yoshioka H, Nakano T, Kandatsu S, Koga M, Itai Y, Tsujii H (2000) MR imaging of radiation osteitis in the sacroiliac joints. Magn Reson Imag 18:117–124
Fu AL, Greven KM, Maruyama Y (1994) Radiation osteitis and insufficiency fractures after pelvic irradiation for gynaecological malignancies. Am J Clin Oncol 17:248–254
Bliss P, Parsons CA, Blake PR (1996) Incidence and possible aetiological factors in the development of pelvic insufficiency fractures following radical radiotherapy. Br J Radiol 69:548–554
Mumber MP, Greven KM, Haygood TM (1997) Pelvic insufficiency fractures associated with radiation atrophy: clinical recognition and diagnostic evaluation. Skelet Radiol 26:94–99
Moreno A, Clemente J, Crespo C (1999) Pelvic insufficiency fractures in patients with pelvic irradiation. Int J Radiat Oncol Biol Phys 44:61–66
Blomlie V, Rofstat EK, Talle K, Sundfor K, Winderen M, Lein HH (1996) Incidence of radiation-induced insufficiency fractures of the female pelvis: evaluation with MR imaging. Am J Roentgenol 167:1205–1210
Mammone JF, Schweitzer ME (1995) MRI of occult sacral insufficiency fractures following radiotherapy. Skelet Radiol 24:101–104
Bonfiglio M (1953) The pathology of fractures of the femoral neck following irradiation. Am J Roentgenol 70:449–459
McCrorie W (1950) Fractures of the femoral neck following pelvic irradiation. Br J Radiol 23:587–592
Epps HR, Brinker MR, O'Connor DP (2004) Bilateral femoral neck fractures after pelvic irradiation. Am J Orthop 33:457–460
Cole ARC, Darte JMM (1963) Osteochondromata following irradiation in children. Pediatrics 32:285–288
Murphy FD, Blount WP (1962) Cartilaginous exostoses following irradiation. J Bone Joint Surg (Am) 44:628–668
Libshitz HI, Cohen MA (1982) Radiation-induced Osteochondromas. Radiology 142:643–647
Rajah R, Tinkler SA, Conway WF (1975) General case of the day. Radiographics 15:1510–1512
Mitchell MJ, Logan PM (1998) Radiation-induced changes in bone. Radiographics 18:1125–1136
Perez CA, Vietti T, Ackerman LV, Eagleton J, Powers WE (1967) Tumors of the sympathetic nervous system in children: an appraisal of treatment and results. Radiology 88:750–760
Mahboubi S, Dormans JP, D'Angio G (1997) Malignant degeneration of radiation-induced osteochondroma. Skelet Radiol 26:195–198
Paulino AC, Wen BC, Brown CK, Tannous R, Mayr NA, Zehn WK, Weidner GJ, Hussey DH (2000) Late effects in children treated with radiation therapy for Wilm's tumoor. Int J Radiat Oncol Biol Phys 46:1239–1246
Taitz J, Cohn RJ, White L, Russell SJ, Vowels MR (2004) Osteochondroma after total body irradiation: an age related complication. Pediatr Blood Cancer 42:225–229
Cohen J, D'Angio GJ (1962) Unusual bone tumors after roentgen therapy of children. Am J Roentgenol 86:502–512
Patel SR (2000) Radiation-induced sarcoma. Curr Treatm Opt Oncol 1:258–261
Sheppard DG, Libshitz HI (2001) Post-radiation sarcomas: a review of the clinical and imaging features in 63 cases. Clin Radiol 56:22–29
Weatherby RP, Dahlin DC, Irvins JC (1981) Postradiation sarcoma of bone: review of 78 Mayo Clinic Cases. Mayo Clin Proc 56:294–306
Kim JH, Chu FCH, Woodard HQ, Melamed MR, Huvos A, Cantin J (1978) Radiation induced soft tissue and bone sarcoma. Radiology 129:501–508
Smith J (1987) Postradiation sarcoma of bone and soft tissues. Skelet Radiol 16:524–532
Halperin EC, Greenberg MS, Suite HD (1984) Sarcoma of bone and soft tissue following treatment of Hodgkin's disease. Cancer 53:232–236
Huvos AG, Woodard HQ, Cahan WG (1985) Postradiation osteogenic sarcoma of bone and soft tissues. Cancer 55:1244–1255
Kuttesch JF, Wexler LH, Marcus RB (1996) Second malignancies after Ewing's sarcoma: radiation dose-dependency of secondary sarcomas. J Clin Oncol 14:2818–2825
Cahan WG, Woodard HQ, Higinbotham NL, Stewart FW, Coley BL (1948) Sarcoma arising in irradiated bone. Cancer 1:3–29
Arlen M, Higginbotham NL, Huvos AG (1971) Radiation-induced sarcoma of bone. Cancer 28:1087–1099
Wiklund TA, Blomqvist CP, Raty J, Elomaa I, Rissanen P, Miettinen M (1991) Postirradiation sarcoma: analysis of a nationwide cancer registry material. Cancer 68:524–531
Vázquez E, Castellote A, Piqueras J, Ortuño P, Sánchez-Toledo J, Nogués PO, Lucaya J (2003) Second malignancies in pediatric patients: imaging findings and differential diagnosis. Radiographics 23:1155–1172
Roebuck DJ (1999) Skeletal complications in pediatric oncology patients. Radiographics 19:873–885
Lorigan JG, Libshitz HI, Peuchot M (1989) Radiation-induced sarcoma of bone: CT findings in 19 cases. Am J Roentgenol 153:791–794
Koenig TR, Wolff D, Mettler FA, Wagner LK (2001) Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. Am J Roentgenol 177:3–11
Koenig TR, Mettler FA, Wagner LK (2001) Skin injuries from fluoroscopically guided procedures: part 2, review of 73 cases and recommendations for minimising dose delivery to patients. Am J Roentgenol 177:13–20
Berlin L (2001) Malpractice issues in radiology. Radiation induced skin injuries and fluoroscopy. Am J Roentgenol 177:21–25
Geijer H, Persliden J (2004) Radiation exposure and patient experience during percutaneous coronary intervention using radial and femoral artery access. Eur Radiol 14:1674–1680
Imanishi Y, Fukui A, Niimi H, Nozaki S, Ishizuka K, Tabata H, Furuya K, Uzura M, Takahama H, Hashizume S, Arima S, Nakajima Y (2005) Radiation-induced temporary hair loss as a radiation damage only occurring in patients who had the combination of MDCT and DSA. Eur Radiol 15:41–46
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Williams, H.J., Davies, A.M. The effect of X-rays on bone: a pictorial review. Eur Radiol 16, 619–633 (2006). https://doi.org/10.1007/s00330-005-0010-7
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DOI: https://doi.org/10.1007/s00330-005-0010-7