유방암 절제술 후 방사선치료를 시행한 환자의 골스캔에서 보이는 방사선 유발 늑골골절 = Radiation Induced Rib Fractures on Bone Scan after Breast Cancer Surgery and Radiation Therapy

국문 초록 (Abstract)

목적: 본 연구는 유방암절제술 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 섭취증가를 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. 28.6%, 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 15개(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: 유방암절제술 후 방사선치료를 시행한 환자의 골스캔에서 섭취 증가로 나타난 동측 늑골골절은 수술술식 및 방사선 치료 범위와 관련이 있으며, 방사선치료 후 1-2 년 사이에 가장 빈번하게 나타나며, 국소형으로 주로 한 개의 늑골에서 보인다. 이러한 소견들은 골스캔으로 유방암 환자의 골전이를 평가할 때 도움이 될 것으로 생각된다.

다국어 초록 (Multilingual 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 CT 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 CT, 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. (Nucl Med Mol Imaging 2009;43(4):287-293)

참고문헌 (Reference)

1 Sams A, "The effect of 2000 r of x-rays on the internal structure of the mouse tibia" 11 : 51-68, 1966

2 Bragg DG, "The clinical and radiographic aspects of radiation osteitis" 97 : 103-111, 1970

3 Overgaard M, "Spontaneous radiation-induced rib fractures in breast cancer patients treated with postmastectomy irradiation" 27 : 117-122, 1988

4 Kok G, "Spontaneous fractures of the femoral neck after the intensive irradiation of carcinoma of the uterus" 40 : 511-527, 1953

5 Kara G, "Solitary rib lesions in bone scans of patients with breast carcinoma" 24 : 887-892, 2003

6 Niitsu M, "Solitary hot spots in the ribs on bone scan: value of thin-section reformatted computed tomography to exclude radiography-negative fractures" 27 : 469-474, 2003

7 Connolly LP, "Rib stress fracture" 29 : 614-616, 2004

8 Goldhirsch A, "Relapse of breast cancer after adjuvant treatment in premenopausal and perimenopausal women: patterns and prognoses" 6 : 89-97, 1997

9 Phemister DB, "Radium necrosis of bone" 16 : 340-348, 1926

10 Bellon JR, "Radiation therapy for breast cancer" 20 : 239-257, 2006

11 Libshitz HI, "Radiation changes in bone" 29 : 15-37, 1994

12 Kulkarni MV, "Potential pitfalls of magnetic resonance imaging in the diagnosis of avascular necrosis" 28 : 1052-1054, 1987

13 Vandemergel X, "Periostitis and hypertrophic osteoarthropathy: etiologies and bone scan patterns in 115 cases" 15 : 375-380, 2004

14 Kamby K, "Pattern of dissemination and survival following isolated locoregional recurrence of breast cancer: a prospective study with more than 10 years of follow-up" 45 : 181-192, 1997

15 Fajardo LF, "Pathology of Radiation Injury" Masson 176-186, 1982

16 National Health Insurance Corporation, "National Health Insurance Statistical Yearbook" 9-17, 2005

17 Pierce SM, "Long-term radiation complications following conservative surgery and radiation therapy in patients with early stage breast cancer" 23 : 915-923, 1992

18 Ferguson DJ, "Late effects of adjuvant radiotherapy for breast cancer" 54 : 2319-2323, 1984

19 Maeseneer MD, "Helical CT of rib lesion: a pattern-based approach" 182 : 173-179, 2004

20 Gumerman LW, "Experimetal fracture healing:evaluation usuing radionuclide bone imageing" 19 : 1320-1323, 1978

21 Park HG, "Evaluation of the rib lesions by bone scanning" 17 : 63-69, 1983

22 Maffioli L, "Current role of bone scan with phosphonates in the follow-up of breast cancer" 31 (31): S143-S148, 2004

23 Chen HHW, "Clinical significance and outcome of of one or two rib lesions on bone scans in breast cancer patients without known metastases" 24 : 1167-1174, 2003

24 Gaze MN, "Bone scan hot spots in a patient with lung cancer: ischemic necrosis of bone mimicking metastatic carcinoma" 3 : 177-179, 1991

25 Hamaoka T, "Bone imaging in metastatic breast cancer" 22 : 2942-2953, 2004