The presence of disseminated tumour cells in the bone marrow is inversely related to circulating free DNA in plasma in breast cancer dormancy

BACKGROUND

The aim of this study was to gain insight into breast cancer dormancy by examining different measures of minimal residual disease (MRD) over time in relation to known prognostic factors.

METHODS

Sixty-four primary breast cancer patients on follow-up (a median of 8.3 years post surgery) who were disease free had sequential bone marrow aspirates and blood samples taken for the measurement of disseminated tumour cells (DTCs), circulating tumour cells (CTCs) by CellSearch and qPCR measurement of overlapping (96-bp and 291-bp) amplicons in circulating free DNA (cfDNA).

RESULTS

The presence of CTCs was correlated with the presence of DTCs measured by immunocytochemistry (P=0.01) but both were infrequently detected. Increasing cfDNA concentration correlated with ER, HER2 and triple-negative tumours and high tumour grade, and the 291-bp amplicon was inversely correlated with DTCs measured by CK19 qRT-PCR (P=0.047).

CONCLUSION

Our results show that breast cancer patients have evidence of MRD for many years after diagnosis despite there being no overt evidence of disease. The inverse relationship between bone marrow CK19 mRNA and the 291-bp amplicon in cfDNA suggests that an inverse relationship between a measure of cell viability in the bone marrow (DTCs) and cell death in the plasma occurs during the dormancy phase of breast cancer.

P4-12-13: A Multi-Center Randomized Controlled Double Blind Trial Assessing the Effect of Acupuncture in Reducing Musculoskeletal Symptoms in Breast Cancer Patients Taking Aromatase Inhibitors: First Interim Analysis

Background: Aromatase inhibitors (AIs) are recommended as first-line adjuvant hormonal therapy in postmenopausal women with hormone-receptor-positive breast cancer, as monotherapy or sequential therapy after tamoxifen. AI-associated musculoskeletal symptoms (AIMSS) occur in approximately 50% of women receiving AIs and in some may result in discontinuation of treatment. Symptom management is essential to ensure that breast cancer patients receive the full recommended duration of AI therapy. We conducted a randomized, placebo-controlled trial to evaluate the effect of acupuncture on AIMSS and report the first interim analysis.

Method: Postmenopausal women with early stage breast cancer, experiencing AIMSS, who had not had acupuncture in the year prior to the study, were eligible. Patients were randomized to 8 weekly acupuncture or sham acupuncture. Health assessment questionnaire disability index (HAQ-DI ranging 0–3.0) and pain visual analog scale (VAS ranging 0–100) were used to assess clinical musculoskeletal disorder severity at weeks 0, 4, 8, and 12 or 24. Change in HAQ-DI (ΔHAQ-DI) and VAS scores (ΔVAS) from baseline were compared between patients receiving acupuncture versus sham acupuncture using exact Wilcoxon rank sum test. Serum samples were collected for measurements of estrogens and beta endorphin concentrations and cytokine profile before and after the intervention to evaluate the etiology of AIMSS and the mechanism of acupuncture in treating AIMSS.

Results: Between May 2008 and June 2011, 48 patients were enrolled, 2 patients were not evaluable due to noncompliance to treatment and lost to follow up, 10 were still receiving treatment and therefore not evaluable. Thirty-six were evaluable, and were equally distributed between the real and sham acupuncture groups. Baseline characteristics were balanced between the two groups with regard to age, race, and body mass index (BMI) with the exception that baseline mean HAQ-DI was higher in the acupuncture group (0.9 vs 0.55, p=0.04). White/Black/Asian: 26/7/3, Median (range): age: 61 (45-82); BMI (kg/m2): 31.1 (22.9−59.6). At week 8, both groups showed a wide range of ΔHAQ-DI (ΔHAQ-DI =HAQ-DIweek8-HAQ-DIbaseline): from −1.38 to 0.5 in the acupuncture group versus from −1 to 0.12 in sham acupuncture group. There was no statistically significant difference in mean ΔHAQ-DI between the real and sham acupuncture groups (−0.33 vs −0.33, p=0.87). Eleven patients in each group (61%) reported decreased HAQ-DI scores, which correlated with improved function. There was no difference in mean ΔVAS between the real and sham acupuncture groups (−9.27 vs −13.82, p=0.67). No significant side effects were reported. Changes in other time points and in serum biomarkers will be presented at the meeting.

Conclusions: The majority of breast cancer patients experiencing AIMSS who participated in our study reported a reduced HAQ-DI score both from acupuncture and sham acupuncture. We did not observe significant differences between responses to real versus sham acupuncture after 8 weekly treatments. The study remains open to accrual to reach 50 evaluable patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-13.

Re-evaluating the efficacy of axillary ultrasound in the detection of nodal metastasis and its impact on clinical practice

4

Background: Recent reports have indicated a lack of overall survival benefit for axillary node dissection versus sentinel lymph node biopsy in early breast cancer. To study this further, we wished to assess the accuracy and effectiveness of ultrasound guided fine needle aspiration (FNA) cytology in detecting lymph node involvement in breast cancer patients, in order to refine and evaluate our current clinical pathways as newly diagnosed invasive breast cancer patients routinely undergo pre-surgical axillary ultrasound.

Methods: An FNA was taken from nodes of consecutive patients, which appeared abnormal on ultrasonography based on size, morphology, fatty hilum and cortical thickness measurements. Ultrasound and FNA cytological findings were correlated with histology following axillary node dissection. Of 260 cases, 123 (47.3%) had metastatic nodal involvement. Of these cases, only 66 (53.7%) were reported as positive on US findings.

Results: The overall positive predictive value (PPV) of ultrasound for detecting metastatic nodal involvement measured 0.82, and the negative predictive value (NPV) was 0.60. The sensitivity was 0.54, specificity measured 0.85 and the accuracy was 0.68. The ultrasound morphological nodal features with the greatest correlation with malignancy were absence of a fatty hilum (p=0.003) and an increased cortical thickness (p=0.03). Cases with a metastatic nodal burden density of a least 20% were also more likely to be detected as abnormal on axillary ultrasound. (p=0.009).

Conclusions: Axillary ultrasound has a low NPV and negative sonographic results do not exclude node metastases with sufficient sensitivity in most cases, to justify its routine clinical use.

[Table: see text]

Abstract S3-7: Kinome Screening for Regulators of Estrogen Receptor Identifies a Novel Kinase as a New Therapeutic Target in Breast Cancer

Background: Estrogen Receptor (ER) positive breast cancer is usually treated with hormone reduction or anti-estrogens. Still, only half the ER+ breast tumors respond to tamoxifen. Mutations in ER are rarely found; instead other mechanisms have been associated with resistance, namely phosphorylation of ERα. Since phosphorylation has been shown to be important for the stimulation of its transcriptional activity, focusing on the role of kinases and the influence of site specific phosphorylation in modulating activity may reveal fundamental insights and derive new druggable targets for exploitation in the clinic.

Materials and Methods: A systematic high-throughput RNAi screening using a large Human Kinase siRNA Library was carried out to identify novel kinases able to phosphorylate and/or modulate ERα activity; quantitative real-time RT-PCR analysis of pS2, PR and GREB1, three well characterized ERα-regulated genes, was performed after silencing each kinase individually. We then examined the effects of each newly identified kinase on various ERα features/functions including: i) ERα stability (Western blot), ii) ERα sub-cellular localization (confocal microscopy) and iii) ERα interactions with major components of the transcriptional machinery (co-immunoprecipitation). In addition, we examined the effects of these kinases on i) cell-cycle progression (FACS), ii) proliferation rate (MTT) and, iii) apoptosis levels (Annexin V, Caspase assays). We assessed clinical significance of our observations, by analyzing the expression of the novel kinases in BC tissue microarrays (TMAs, n=614) by immunohistochemistry.

Results: We have categorized the newly identified kinases in two groups depending on their effects on ERα transcriptional activity (30% up-regulation - 70% down-regulation). Among them, we discovered a novel receptor tyrosine kinase (RTK) whose role and/or involvement in ERα regulation has not been described thus far. We demonstrated that silencing of this kinase resulted in a great down-regulation (>70-80%) of all 3 ERα-regulated genes tested (pS2, GREB1, PGR). In addition, upon kinase-silencing, we observed a large decrease in ERα protein levels, suggesting an involvement of this kinase in ERαα stability. Moreover, silencing of this kinase resulted in a >50% decrease of breast cancer cells viability (P<0.001). Analysis of the BC TMAs, the kinase of interest was expressed in weak (27%), moderate (35%) and high levels (38%). High expression correlated significantly with high tumor grade (P<0.001) and predicted for worse BC specific overall survival (p=0.03).

Discussion: As RTKs are considered the primary mediators of the signalling network that transmit extracellular signals into the cell, they represent the first ‘line’ of drug target development in cancer treatment. We propose that our newly identified kinase could be a successful and life-saving drug target for the progression of various types of cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S3-7.

DUSP16 is an epigenetically regulated determinant of JNK signalling in Burkitt's lymphoma

Background:

The mitogen-activated protein kinase (MAPK) phosphatases or dual specificity phosphatases (DUSPs) are a family of proteins that catalyse the inactivation of MAPK in eukaryotic cells. Little is known of the expression, regulation or function of the DUSPs in human neoplasia.

Methods:

We used RT–PCR and quantitative PCR (qPCR) to examine the expression of DUSP16 mRNA. The methylation in the DUSP16 CpG island was analysed using bisulphite sequencing and methylation-specific PCR. The activation of MAPK was determined using western blotting with phospho-specific antibodies for extra-cellular signal-related kinase (ERK), p38 and c-Jun N-terminal kinase (JNK). The proliferation of cell lines was assessed using the CellTiter 96 Aqueous One assay.

Results:

The expression of DUSP16, which inactivates MAPK, is subject to methylation-dependent transcriptional silencing in Burkitt's Lymphoma (BL) cell lines and in primary BL. The silencing is associated with aberrant methylation in the CpG island in the 5′ regulatory sequences of the gene blocking its constitutive expression. In contrast to BL, the CpG island of DUSP16 is unmethylated in other non-Hodgkin's lymphomas (NHLs) and epithelial malignancies. In BL cell lines, neither constitutive nor inducible ERK or p38 activity varied significantly with DUSP16 status. However, activation of JNK was increased in lines with DUSP16 methylation. Furthermore, methylation in the DUSP16 CpG island blocked transcriptional induction of DUSP16, thereby abrogating a normal physiological negative feedback loop that limits JNK activity, and conferred increased cellular sensitivity to agents, such as sorbitol and anthracycline chemotherapeutic agents that activate JNK.

Conclusion:

DUSP16 is a new epigenetically regulated determinant of JNK activation in BL.

The preferences and experiences of different bisphosphonate treatments in women with breast cancer

OBJECTIVE

The objective of this study was to examine women's experiences with oral and intravenous (i.v.) bisphosphonate therapy, the impact that treatment had on bone pain and Quality of Life (QoL), and their preferences if choice were available between oral and i.v. administration.

METHODS

This was a prospective study of women with metastatic breast cancer receiving either oral or i.v. bisphosphonate therapy. Semi-structured interview techniques and QoL questionnaires were employed. Participants in the study were interviewed three times, once in person and twice by telephone.

RESULTS

A total of 79 patients from eight UK hospitals participated in the study; 35 were receiving oral bisphosphonate medication and 44 i.v. treatments. Self-reported adherence to oral therapy was good although 21% had chosen not to take their drugs at some time. Most had adapted their lifestyle to accommodate oral therapy with 29/37(74%) completely satisfied. However 9/37(24%) expressed dissatisfaction with constraints especially the time required to stand upright after taking their tablets. By 6 months 23/25 (91%) of patients receiving (i.v.) therapies were generally satisfied with the frequency and 22/25 (88%) with the convenience especially if given concurrently with chemotherapy. Overall 25/54 (46%) patients reported improved bone pain scores on the validated FACT-BP scale from baseline to 6 months.

CONCLUSIONS

Both oral and i.v. therapies have disadvantages but were acceptable to most patients some of whom had reduced bone pain over time. More data regarding acceptability, adherence, and patients' preference for bisphosphonate therapies are required. Until randomised trials demonstrate superior efficacy for one mode of bisphosphonate therapy over another, we suggest offering patients a choice of bisphosphonate therapy.

The frequency and reasons for antiretroviral switching with specific antiretroviral associations: the SWITCH study

BACKGROUND

We investigated the reasons for switching antiretroviral regimens, an issue rarely addressed in cohort studies.

METHODS

An observed toxicity switch rate (OTSR) was calculated by Poisson regression using the number of days individuals received each individual antiretroviral drug.

RESULTS

Of 3333 individuals receiving HAART, a total of 14% of regimens were switched, the majority occurring after 6 months of therapy. Toxicity was the major reason for switching (61%) and there were no major statistically significant differences in OTSR between the protease inhibitor (OTSR 26.4, 95% CI 18.3-37) and non-nucleoside reverse transcriptase inhibitor (OTSR 22.2, 95% CI 13.6-34.4) based regimes. For individual antiretrovirals, stavudine and zidovudine had significantly higher "switch" scores than all other drugs.

CONCLUSIONS

There were no differences between the major HAART classes in OTSR. We suggest that newer antiretrovirals will require differentiation in terms of longer-term toxicity, as this is the major reason for switching.

Changes in [18F]Fluorothymidine Pharmacokinetics Following Capecitabine Treatment in Human Breast Cancer Detected by Positron Emission Tomography

Background: Pre-clinical models used by our group have demonstrated that thymidylate synthase (TS) inhibition leads to redistribution of the nucleoside transporter, ENT1, to the cell membrane and hence increases the tissue uptake of [18F]fluorothymidine (FLT).Methods: In this study we assessed, for the first time, the altered pharmacokinetics of FLT in patients following TS inhibition. We analyzed 10 lesions from 6 breast cancer patients by positron emission tomography (PET) before and after treatment with capecitabine.Results: Whereas drug treatment did not alter tumor delivery pharmacokinetic variables or blood flow, tumor FLT retention variables increased with drug treatment in all but one patient. The baseline average standardized uptake value (SUV) at 60 min, rate constant for the net irreversible transfer of radiotracer from plasma to tumor (Ki) and unit impulse response function (IRF) at 60 min were 11.11 x 10-5 m2/ml, 4.38 x 10-2 ml plasma/min/ml tissue and 4.93 x 10-2 /min, respectively. At 1 h after capecitabine, the SUV was 13.55 x 10-5 m2/ml (p=0.004), Ki 7.40 x 10-2 ml plasma/min/ml tissue (p=0.004) and IRF 7.40 x 10-2 /min (p= 0.002).Conclusion: FLT pharmacokinetics did not change in normal tissues suggesting that the effect was largely restricted to tumor (p=0.55). In summary, we have identified FLT-PET retention parameters that could be used in future early clinical studies to measure the pharmacodynamics of TS inhibitors, as well as for identifying patients who are unlikely to benefit from TS inhibition.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5003.

DNA methylation status of Smurf2 promoter in patients with multiple myeloma

e19537

Background: Multiple myeloma (MM) is an incurable interleukin (IL)-6 dependent plasma-cell malignancy. Transforming growth factor-β (TGF-β) is the major inducer of IL-6 secretion by bone marrow stromal cells. The signaling responses to TGF-b are mediated by the Smad proteins. The Smurf2 gene (Smad ubiqitiniation regulatory factor 2) encodes a Smad-specific E3 ubiquitin ligase and targets Smad2 and Smad3 for proteasome-dependent degradation. Methods: Bone marrow samples from individuals with MM were obtained at diagnosis and in 5 cases at disease progression as well. Genomic DNA was isolated and bisulphite modification was performed using commercially available kits. The methylation-specific polymerase chain reaction was employed to study the methylation status of the CpG island. Logistic regression analysis was used to measure the association between gene methylation and the development of advanced disease (DS≥ II), extramedullary disease, bone disease, anemia (Hb 10 mg/dl), serum albumin and beta 2 microglobulin levels. Results: We analysed the methylation of Smurf2 in 45 cases of MM (24 male, 21 female, mean age 66.4 years). No sample from the control population was found methylated. The Smurf2 gene promoter was found to be methylated in 11/45 MM patients (24%). Interesting trends were noted where patients with methylated Smurf2 promoter had an increased risk of death (HR = 1.3; p = 0.68), anemia (OR=2.1, p=0.2) and advanced stage (OR=1.3, p=0.6) and a reduced risk of extramedullary disease (OR= 0.2, p=0.2). No association was found between Smurf2 methylation status and bone lytic lesions, serum albumin levels or beta-2 microglobulin levels. Conclusions: Interesting associations between Smurf2 methylation and some relevant clinical parameters in patients with MM were suggested by the data. These findings warrant further evaluation in a larger sample of patients in order to enhance our statistical power and better define the prognostic and clinical value of Smurf2 methylation in MM.

No significant financial relationships to disclose.

[11C]Choline-PET imaging of breast cancer

1110

Background: Molecular imaging techniques are increasingly being used in cancer diagnosis, staging, and assessment of response to treatment. This study sought to evaluate, for the first time, [11C]choline-PET in patients with breast cancer. The potential of [11C]choline-PET for differentiating tumours from normal tissue, correlation with molecular markers, determine its normal variability range, and finally the effect of trastuzumab on [11C]choline uptake in patients with breast cancer was investigated. Methods: 21 patients with newly diagnosed and recurrent breast cancer AJCC stage II-IV were enrolled in the study, all of whom had a baseline dynamic [11C]choline-PET scan with arterial sampling. 14 patients had 2 [11C]choline-PET scans to examine reproducibility, and 7 had a scan after trastuzumab. Analysis of [11C]choline uptake was measured using SUV, Ki (irreversible retention), and IRF@60min (retention using spectral analysis). Results: Breast tumour lesions were visualised by [11C]choline PET in all patients. The difference in tumour and non-tumour uptake were significant for SUV, Ki, and IRF@60 min (Wilcoxon p < 0.0001 for all parameters). [11C]choline uptake was reproducible in breast tumour lesions (r2 = 0.945 for SUV, 0.894 for Ki, and 0.799 for IRF60). The metabolism analysis of arterial plasma samples in 19 patients showed that [11C]choline decreased rapidly post-injection such that at 60 mins the mean radioactivity in arterial plasma due to choline was 15.15 ± 2.16%.Early responses to trastuzumab were determined to be significant in 5 lesions which corresponded with 3 clinical responses. Conclusions: [11C]choline-PET is a promising imaging modality in breast cancer, and could play an important role for determining response to novel treatment strategies in vivo.

No significant financial relationships to disclose.

Peritoneal disease in breast cancer: A specific entity with an extremely poor prognosis

e12023

Background: We are observing increasing numbers of patients with advanced breast cancer and peritoneal metastases. There are few published data regarding the prognosis, clinical characteristics, and management of such individuals. Methods: The electronic imaging database at Charing Cross Hospital was searched for the terms ’breast,’ ’cancer or tumor,’ ’peritoneal,’ and ’ascites’ from 2000–2008. Those with confirmed peritoneal disease from breast cancer, as described on ultrasound or staging CT reports with a clinico-pathologic confirmed diagnosis, were included in the study. Results: A total of 1,628 scans were screened and initially 168 patients were identified. A subsequent total of 44 individuals (2.7% of the metastatic cohort) were included in this study, as having breast cancer with peritoneal secondaries. Of these, the majority (77%) had invasive ductal carcinomas (IDC). While the median survival from the diagnosis of metastatic breast cancer measured 20.5 months (range 0.1 -125 months), the median survival of patients with peritoneal disease was 1.56 months (range 0.2 - 27 months). Conclusions: Our data shows that the median survival of patients with peritoneal breast cancer metastasis is surprisingly poor, with only a minority surviving more than six months. A specific association with invasive lobular carcinoma (ILC) was not observed. The dismal outcome of these individuals despite further active therapy merits their inclusion into trials of new treatments.

No significant financial relationships to disclose.

Methylation reversal in high-grade B lymphoma cell lines and novel epigenetic changes conserved between immunocompetent and HIV-positive hosts

8585

Background: Methylation-dependent transcriptional silencing is an important mechanism of tumour suppressor gene inactivation in neoplasia, including lymphoma. Methods: Pharmacological “unmasking” of transcriptionally silenced genes in B lymphoma cell lines was achieved using 5' deazacytidine ± Trichostatin A and subsequent analysis of mRNA levels on micro-array. Candidate genes thus identified, were further analysed by qPCR, methylation-specific PCR (MSP) and bisulphite sequencing in B lymphoma cell lines and by MSP in clinical samples from sporadic (immunocompetent) (18 cases) and HIV-infected patients (14 cases). Samples in both patient groups were diffuse large B cell lymphoma (DLBCL) and Burkitt's lymphoma (BL). Additionally, we analysed 8 cases of marginal zone lymphoma (MZL) from the immunocompetent group. Results: We report the identification of 13 novel genes, not previously described in the literature, which are subject to methylation-dependent transcriptional silencing in high-grade lymphoma and whose expression can be reactivated by demethylating agents. The novel genes encode proteins involved in diverse functional classes and include pro-apoptotic members of the p53 pathway (Scotin), transcriptional regulators (Baz2B) and regulators of telomerase (Smrf2). The frequency of methylation in individual genes varied from approximately 10% to 75% in specific lymphoma subtypes, but was in general similar in high grade lymphomas in immunocompetent and HIV-infected hosts. Conclusions: Using pharmacological reversal of methylation, we have identified a number of genes, not previously implicated in human neoplasia, which are subject to transcriptional silencing in high-grade B lymphomas. The similar frequencies of methylation, observed in immunocompetent and HIV positive patients implies that the genes are fundamental in suppression of lymphomagenesis. Detection of methylated DNA of one or more of these genes may have utility as biomarkers of clinical outcome in each patient group.

No significant financial relationships to disclose.

Serum molecular signatures of weight change during early breast cancer chemotherapy

e11534

Background: Weight gain in women receiving chemotherapy following breast cancer diagnosis has negative implications on quality of life and those who gain weight during treatment appear to be at higher risk of disease recurrence. The mechanism(s) implicated in chemotherapy associated weight gain are poorly understood. Methods: To investigate this further, we assessed the metabolic, cytokine and appetite related peptide alterations before and during adjuvant FEC chemotherapy for early breast cancer in post-menopausal women, and correlated these with body mass measurements. Specifically, we performed global metabolic profiling (metabonomics/ metabolomics) using 1H nuclear magnetic resonance spectroscopy of sequential sera, examined ghrelin immunoreactivity, performed radioimmunoassays for glucagon like peptide-1 (GLP-1) and peptide YY (PYY) and electro-chemiluminescent cytokine analyses (tumor necrosis factor-α and interleukin-6; TNF-α, IL-6) on the sequential samples. Results: In those who gained ≥ 1.5kg (on average ∼5% of initial body weight), several metabolite levels were positively associated with weight change, in particular lactate which was 55% greater in patients with increased body weight during chemotherapy compared to those with stable weight during chemotherapy (p<0.01; the pre-specified primary end-point). A significant inverse relationship was also observed between levels of TNF-α and weight change group (ρ 0.476, p<0.05). Baseline lactate, alanine and body fat were all prognostic for weight gain (ROC AUC >0.77, p<0.05). No significant associations were observed between any other parameter and weight gain, nor any parameter and tumor burden, including cytokine and appetite peptide alterations. Conclusions: Metabonomics identifies pathways perturbed during early chemotherapy for breast cancer, and establishes a positive association between serum lactate, body fat, TNF-α and substantive weight changes during chemotherapy. Interventions that target these processes may be clinically useful in breast cancer.

No significant financial relationships to disclose.

The efficacy of percutaneous vertebroplasty for palliation of pain in vertebral metastases associated with solid malignancies

e20670

Background: Painful vertebral metastases are a debilitating and common complication of a number of solid malignancies. Percutaneous vertebroplasty appears beneficial for patients with acute compression fractures of multiple aetiologies including myeloma, and osteoporosis. There are few reports on its use in the setting of metastatic solid malignancy. Methods: We identified all individuals who had undergone percutaneous vertebroplasty at our institution since 2004 and focused on those with metastatic solid malignancies. Their clinical characteristics and outcomes were investigated. Results: From 136 cases that underwent percutaneous vertebroplasties, 19 were performed mainly in breast, prostate, lung, and renal cancers. Of these 19 cases, ten patients (53%) were treated for solitary lesions, 3 (16%) were injected at two levels and the remaining 6 cases (31%) underwent cement injection at three levels. The majority of patients (84%) reported short (within 48 hours) and longer term symptomatic improvements. At a median follow up of one year, 6 patients have died. Conclusions: This study illustrates that percutaneous vertebroplasty can be a safe and beneficial palliative procedure for patients with pain related to metastatic vertebral disease. Up to three vertebral levels maybe injected at one sitting with good results. Its use can be successfully combined with other treatment modalities (radiotherapy and chemotherapy). For optimal results its use before radiotherapy has been recommended. Although it does not improve the survival outcome, palliation is a reasonable goal when life expectancy is short. Cost benefits from this procedure will come from reduced analgesic requirements and avoided complications of long-term bed rest, with significant potential savings from reduced in-patient admissions for pain control, home care costs, community nursing, and out-of ours access to clinical services.

No significant financial relationships to disclose.