Open Access Research article

Rib fracture after stereotactic radiotherapy for primary lung cancer: prevalence, degree of clinical symptoms, and risk factors

Atsushi Nambu12*, Hiroshi Onishi1, Shinichi Aoki1, Licht Tominaga1, Kengo Kuriyama1, Masayuki Araya1, Ryoh Saito1, Yoshiyasu Maehata1, Takafumi Komiyama3, Kan Marino4, Tsuyota Koshiishi1, Eiichi Sawada1 and Tsutomu Araki1

Author Affiliations

1 Department of Radiology, University of Yamanashi, Chuo City, Yamanashi Prefecture, Japan

2 Current institution: Department of Radiology, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kawasaki City, Kanagawa Prefecture, Japan

3 Department of Radiology, Kofu Municipal Hospital, Kofu City, Yamanashi Prefecture, Japan

4 Department of Radiology, Yamanashi Prefectural Central Hospital, Kofu City, Yamanashi Prefecture, Japan

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BMC Cancer 2013, 13:68  doi:10.1186/1471-2407-13-68

Published: 7 February 2013



As stereotactic body radiotherapy (SBRT) is a highly dose-dense radiotherapy, adverse events of neighboring normal tissues are a major concern. This study thus aimed to clarify the frequency and degree of clinical symptoms in patients with rib fractures after SBRT for primary lung cancer and to reveal risk factors for rib fracture. Appropriate α/β ratios for discriminating between fracture and non-fracture groups were also investigated.


Between November 2001 and April 2009, 177 patients who had undergone SBRT were evaluated for clinical symptoms and underwent follow-up thin-section computed tomography (CT). The time of rib fracture appearance was also assessed. Cox proportional hazard modeling was performed to identify risk factors for rib fracture, using independent variables of age, sex, maximum tumor diameter, radiotherapeutic method and tumor-chest wall distance. Dosimetric details were analyzed for 26 patients with and 22 randomly-sampled patients without rib fracture. Biologically effective dose (BED) was calculated with a range of α/β ratios (1–10 Gy). Receiver operating characteristics analysis was used to define the most appropriate α/β ratio.


Rib fracture was found on follow-up thin-section CT in 41 patients. The frequency of chest wall pain in patients with rib fracture was 34.1% (14/41), and was classified as Grade 1 or 2. Significant risk factors for rib fracture were smaller tumor-chest wall distance and female sex. Area under the curve was maximal for BED at an α/β ratio of 8 Gy.


Rib fracture is frequently seen on CT after SBRT for lung cancer. Small tumor-chest wall distance and female sex are risk factors for rib fracture. However, clinical symptoms are infrequent and generally mild. When using BED analysis, an α/β ratio of 8 Gy appears most effective for discriminating between fracture and non-fracture patients.

Stereotactic body radiotherapy; Lung cancer; Rib fracture; Chest wall injury