Spontaneous Rib Fractures After Breast Cancer Treatment Based on Bone Scans: Comparison Of Conventional Versus Hypofractionated Radiotherapy



      Spontaneous rib fractures (SRFs) are defined as fractures without apparent blunt force trauma. This study evaluated the incidence and risk factors of SRFs after treatment of patients with breast cancer based on bone scans. In addition, we analyzed radiation-associated SRFs and identified radiotherapy (RT) factors related to SRF.

      Patients and Methods

      We retrospectively reviewed 1265 patients with breast cancer who underwent surgery in 2015 at our institution, and were followed-up with at least 3 bone scans. Bone scans were conducted approximately every 12 months after breast cancer treatment. The endpoint was SRF detected by bone scan. In this study, 754 (60%) patients were treated with chemotherapy, 867 (69%) with RT, and 946 (75%) with anti-hormone therapy.


      The median follow-up duration was 37.5 months. A total of 209 (16.5%) patients experienced SRFs during follow-up. The incidence of SRFs increased sharply during the 3-year follow-up period after completion of treatment. In multivariate analyses, abnormal bone density, chemotherapy, and RT were significant risk factors for SRFs. In patients treated with RT (n = 867), 159 (18%) rib fractures occurred: 127 (80%) in the ipsilateral breast and 32 (20%) in the contralateral breast. Among the patients with ipsilateral SRFs who received tumor bed boost (n = 84), the SRF occurred inside the boost field in 80 (95%) cases. Multivariate analysis of RT subgroups showed that hypofractionated RT increased the rate of SRFs (P = .002).


      Most of the rib fractures that occurred after treatment were spontaneous. Hypofractionated RT increased the risk of ipsilateral rib fractures in RT-treated patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wick J.Y.
        Spontaneous fracture: multiple causes.
        Consult Pharm. 2009; 24 (105-8, 110-2): 100-102
        • Coleman R.
        • Body J.J.
        • Aapro M.
        • Hadji P.
        • Herrstedt J.
        ESMO Guidelines Working Group. Bone health in cancer patients: ESMO Clinical Practice Guidelines.
        Ann Oncol. 2014; 25: iii124-iii137
        • Body J.-J.
        Increased fracture rate in women with breast cancer: a review of the hidden risk.
        BMC Cancer. 2011; 11: 384
        • Robinson P.J.
        • Bell R.J.
        • Zecena Morales C.S.
        • Fradkin P.
        • Davis S.R.
        Minimal-trauma fracture in women with breast cancer surviving for at least 5 years from diagnosis.
        Osteoporos Int. 2015; 26: 795-800
        • Lester J.
        • Coleman R.
        Bone loss and the aromatase inhibitors.
        Br J Cancer. 2005; 93: S16-S22
        • Harris S.R.
        Differentiating the causes of spontaneous rib fracture after breast cancer.
        Clin Breast Cancer. 2016; 16: 431-436
        • Wright A.A.
        • Hegedus E.J.
        • Lenchik L.
        • Kuhn K.J.
        • Santiago L.
        • Smoliga J.M.
        Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures: a systematic review with evidence-based recommendations for clinical practice.
        Am J Sports Med. 2016; 44: 255-263
        • Meléndez J.C.
        • McCrank E.
        Anxiety-related reactions associated with magnetic resonance imaging examinations.
        JAMA. 1993; 270: 745-747
        • Smith J.B.
        • Buchanan S.G.
        • Shuler D.F.
        A comparison of imaging modalities for the diagnosis of osteomyelitis.
        Marshall J Med. 2016; 2: 1044
        • National Comprehesive Cancer Network
        Breast cancer (Version 2.2020).
        (Available at:)
        • Haviland J.S.
        • Owen J.R.
        • Dewar J.A.
        • et al. START Trialists’ Group
        The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials.
        Lancet Oncol. 2013; 14: 1086-1094
        • Schmidt N.
        • Jacob L.
        • Coleman R.
        • Kostev K.
        • Hadji P.
        The impact of treatment compliance on fracture risk in women with breast cancer treated with aromatase inhibitors in the United Kingdom.
        Breast Cancer Res Treat. 2016; 155: 151-157
        • Wuermser L.A.
        • Achenbach S.J.
        • Amin S.
        • Khosla S.
        • Melton 3rd, L.J.
        What accounts for rib fractures in older adults?.
        J Osteoporos. 2011; 2011: 457591
        • Glaser D.L.
        • Kaplan F.S.
        Osteoporosis. Definition and clinical presentation.
        Spine (Phila Pa 1976). 1997; 22: 12S-16S
        • Rizzoli R.
        • Body J.J.
        • Brandi M.L.
        • et al. International Osteoporosis Foundation Committee of Scientific Advisors Working Group on Cancer-Induced Bone Disease
        Cancer-associated bone disease.
        Osteoporos Int. 2013; 24: 2929-2953
        • Kalder M.
        • Hadji P.
        Breast cancer and osteoporosis - management of cancer treatment-induced bone loss in postmenopausal women with breast cancer.
        Breast Care (Basel). 2014; 9: 312-317
        • Greep N.C.
        • Giuliano A.E.
        • Hansen N.M.
        • Taketani T.
        • Wang H.-J.
        • Singer F.R.
        The effects of adjuvant chemotherapy on bone density in postmenopausal women with early breast cancer.
        Am J Med. 2003; 114: 653-659
        • Shapiro C.L.
        • Manola J.
        • Leboff M.
        Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss in women with early-stage breast cancer.
        J Clin Oncol. 2001; 19: 3306-3311
        • Powles T.J.
        • Hickish T.
        • Kanis J.A.
        • Tidy A.
        • Ashley S.
        Effect of tamoxifen on bone mineral density measured by dual-energy x-ray absorptiometry in healthy premenopausal and postmenopausal women.
        J Clin Oncol. 1996; 14: 78-84
        • Rachner T.D.
        • Coleman R.
        • Hadji P.
        • Hofbauer L.C.
        Bone health during endocrine therapy for cancer.
        Lancet Diabetes Endocrinol. 2018; 6: 901-910
        • Mincey B.A.
        • Duh M.S.
        • Thomas S.K.
        • et al.
        Risk of cancer treatment-associated bone loss and fractures among women with breast cancer receiving aromatase inhibitors.
        Clin Breast Cancer. 2006; 7: 127-132
        • Kim H.W.
        • Won K.S.
        • Zeon S.K.
        • Kim J.H.
        Radiation induced rib fractures on bone scan after breast cancer surgery and radiation therapy.
        Nucl Med Mol Imaging. 2009; 43: 287-293
        • Pitkänen M.A.
        • Hopewell J.W.
        Functional changes in the vascularity of the irradiated rat femur. Implications for late effects.
        Acta Radiol Oncol. 1983; 22: 253-256
        • Pacheco R.
        • Stock H.
        Effects of radiation on bone.
        Curr Osteoporos Rep. 2013; 11: 299-304
        • Pierce S.M.
        • Recht A.
        • Lingos T.I.
        • et al.
        Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer.
        Int J Radiat Oncol Biol Phys. 1992; 23: 915-923
        • Aoki M.
        • Sato M.
        • Hirose K.
        • et al.
        Radiation-induced rib fracture after stereotactic body radiotherapy with a total dose of 54-56 Gy given in 9-7 fractions for patients with peripheral lung tumor: impact of maximum dose and fraction size.
        Radiat Oncol. 2015; 10: 99
        • Asai K.
        • Shioyama Y.
        • Nakamura K.
        • et al.
        Radiation-induced rib fractures after hypofractionated stereotactic body radiation therapy: risk factors and dose-volume relationship.
        Int J Radiat Oncol Biol Phys. 2012; 84: 768-773
        • Overgaard M.
        Spontaneous radiation-induced rib fractures in breast cancer patients treated with postmastectomy irradiation. A clinical radiobiological analysis of the influence of fraction size and dose-response relationships on late bone damage.
        Acta Oncol. 1988; 27: 117-122
        • Li Q.
        • Chen Z.
        • Zhao Y.
        • et al.
        Risk of metastasis among rib abnormalities on bone scans in breast cancer patients.
        Sci Rep. 2015; 5: 9587