Gamma Radiation-Induced Rib Necrosis and Stereotactic Radiosurgery Failure

Stereotactic radiosurgery, or SRS, uses focused beams of gamma radiation targeted to specific areas of the body and has been used for multiple forms of non-small cell lung cancer. In this article, the authors describe two incidental cases of osteonecrosis in patients who had previously undergone stereotactic radiosurgery with recurrence of tumor. While this is a known side effect of traditional radiation therapy, it has not been described in the context of stereotactic radiosurgery. Further, these lesions were immediately deep to a rib, which may have shielded the lesion, and led to SRS failure. Osteonecrosis of the rib is a rare clinical entity but has been found to occur with glucocorticoid use, bisphosphonates, radiation therapy, and radiofrequency ablation. In the authors' review of the literature on SRS for lung cancer and intrathoracic pathology, rib osteonecrosis was not described and has not been mentioned as a possible side effect. Patients who have undergone thoracic stereotactic radiotherapy may develop side effects of traditional radiotherapy. We identified two patients who developed rib osteonecrosis though that has not been previously described as an adverse effect of stereotactic radiotherapy. The patients described in this case did not have any radiographic evidence of disease on imaging, suggesting that further research is warranted on the diagnosis and management of this rare disease entity.