Randomized prospective clinical study of small, large and twice-a-day fraction radiotherapy for painful bone metastases

Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: an Australian and New Zealand practice survey and literature review

PURPOSE

To survey Australian and New Zealand (ANZ) radiation oncologists on their preferred fractionation regimens for pain due to bone metastases in the context of similar overseas surveys and the large body of evidence from randomized trials.

METHODS

Delegates to the October 1998 Royal ANZ College of Radiologists Annual Scientific Meeting were asked to state their fractionation for four hypothetical cases viz. local bone pain from metastatic breast, prostate and lung cancer and neuropathic (radicular) pain from metastatic lung cancer. In addition to demographic data, respondents were asked to select reasons for their choices and indicate what factors would influence a change in their recommended fractionation.

RESULTS

Twelve of 32 trainees and 41 of 82 specialists completed the survey, giving an overall response rate of 46%. There was decreasing use of shorter fractionation schedules from lung through prostate to breast cancer with, in particular, single fractions recommended by, respectively, 42, 28 and 15% of respondents for local bone pain (P=0.013). However, the presence of neuropathic pain from metastatic lung cancer led to lower use of single fractions (15%, P=0.0046). There were no statistically significant differences in preferred fractionation with respect to other variables assessed in this survey. The commonest reasons cited for fractionating were desire to minimize recurrent pain and the influence of training, with desire to minimize the risk of neurological progression and optimize tumour regression also important for neuropathic pain. By contrast, use of single fractions was most commonly based upon literature results and patient convenience. Changing from multiple to single fractions was most influenced by poor performance status, while the presence of neurological signs/symptoms had the reverse effect.

CONCLUSIONS

The findings from this ANZ survey largely reflect the results from other surveys performed in the UK, Europe, Canada and USA. Although debate continues in the literature, the continuing preference of radiation oncologists to fractionate for local bone pain is contrary to the 16 randomized trials published to date which give little support for a dose-response relationship above a single 6-8 Gy in this setting. This practice has significant implications for departmental workload, costs to the healthcare system and patient convenience. There is no objective evidence on the influence of fractionation for neuropathic bone pain in the literature at present, although an ANZ randomized trial addressing this problem is under way (TROG 96.05).

Differences in palliative radiotherapy for bone metastases within Western European countries

PURPOSE

To evaluate the differences in palliative radiotherapy for painful bone metastases amongst different Western European countries.

MATERIALS AND METHODS

A questionnaire was sent to 565 radiotherapy centres in 19 Western European countries, based on the 1997 ESTRO directory. In this questionnaire the current local palliative radiotherapy practice for bone metastases was assessed in terms of total dose, fractionation, treatment complexity (use of shielding blocks, frequency of isodose calculations, field set-up) and type of machine used. The differences were analyzed according to the country and to the type and size of radiotherapy centre.

RESULTS

A total of 205 centres (36%) returned the questionnaire, of which 198 could be further analyzed. The most frequently used antalgic fractionation schedule is 30 Gy in ten daily fractions of 3 Gy (50%), single fractions and conventional 2 Gy fractions being used in a minority of the centres (respectively, 11 and 9%). Most antalgic treatments are performed on a linear accelerator (67% of the centres uses linear accelerators) and 64% of the centres predominantly uses a two-field set-up. The majority of the centres uses shielding blocks and performs isodose calculations in less than 50% of the patients, (respectively, 88 and 81%). There is a correlation between the centre size and the palliative irradiation practice, the largest centres using more hypofractionation (chi(2): P=0.001; logit: P=0. 0003) and a less complex treatment set up as expressed by the use of isodose calculations (chi(2): P=0.027; logit: P=0.0161). There is also a tendency to use less shielding blocks (P=0.177). The same goes for university centres as compared with private centres: university centres use shorter fractionation schedules (chi(2): P=0. 008; logit: P=0.0094), less isodoses (chi(2): P=0.010; logit: P=0. 0115) and somewhat less shielding blocks (P=0.151). Amongst the analyzed countries different tendencies in fractionation (P=0.001) and treatment complexity are observed (use of isodoses: P=0.014, use of shielding blocks: P=0.001).

CONCLUSION

These data suggest that beside work-load and clinical evidence, country-related factors such as tradition and habits, past teaching, the national organization of health care and reimbursement criteria may influence the local practice.

Fractionation and outcomes with palliative radiation therapy

A dose-response relationship can be established for local control of a variety of malignancies treated with radiation, yet palliation of symptoms oftentimes does not have a clear dose-response relationship. It is important that palliation be achieved with as efficient a fractionation schedule as possible in patients with limited life expectancy and with as few side effects as possible. This article reviews the literature addressing optimal schedules of radiation for palliation based on prognostic factors.

A role for radiotherapy in neuropathic bone pain: preliminary response rates from a prospective trial (Trans-tasman radiation oncology group, TROG 96.05)

PURPOSE

Radiotherapy (RT) has a proven role in palliation of pain from bone metastases with numerous randomized trials obtaining response rates (RRs) of typically 70-80% regardless of the fractionation employed. However RT for neuropathic bone pain (NBP), i.e., pain with a radiating cutaneous component due to compression/irritation of nerves by tumor has not previously been studied, and its role is thus uncertain.

METHODS AND MATERIALS

In February 1996, the Trans-Tasman Radiation Oncology Group (TROG) initiated a multicenter randomized trial comparing a single 8 Gy fraction with 20 Gy in 5 fractions for NBP with an accrual target of 270. Formal interim analyses were planned at 90 and 180 patients. The 90th patient was accrued in June 1998, and data from the first interim analysis with both arms combined form the basis of this report.

RESULTS

Forty-four patients were randomized to a single 8 Gy, 46 to 20 Gy in 5 fractions. The commonest primary sites were prostate (34%), lung (28%) and breast (10%). Median age was 68 years (range 37-89). The index site was spine (86%), rib (13%), base of skull (1%). On an intention-to-treat basis, the overall RR was 53/90 = 59% (95% CI = 48-69%), with 27% achieving a complete response and 32% a partial response. The overall RR for eligible patients was 49/81 = 60% (95% CI = 49-71%) with 27% and 33% achieving complete and partial responses respectively. Estimated median time to treatment failure was 3.2 months (95% CI = 2.1-5.1 months), with estimated median survival of 5.1 months (95% CI = 4.2-7.2 months). To date, six spinal cord/cauda equina compressions and four new or progressive pathological fractures have been detected at the index site after randomization, although one cord compression occurred before radiotherapy was planned to commence. In February 1999, the Independent Data Monitoring Committee strongly recommended continuation of the trial.

CONCLUSION

Although these results are preliminary, it seems clear that there is indeed a role for RT in the treatment of NBP. Analysis of outcome by treatment arm awaits completion of the randomized trial.

Radiotherapy for the palliation of painful bone metastases

BACKGROUND

Radiotherapy is used commonly to provide pain relief for painful bone metastases, and there is a perception that of the three-quarters of patients who achieve pain relief, half of these stay free from pain. However, the precise contribution from radiotherapy may be unclear because of difficulties in assessing the numbers of people achieving relief, the extent of relief and its duration, and the influence of other contemporaneous interventions, such as analgesics.

OBJECTIVES

To assess pain relief from: 1. localised bone metastases achieved by radiotherapy, comparing the efficacy of different fractionation schedules 2. more generalised metastatic disease achieved by radiotherapy or radioisotopes.

SEARCH STRATEGY

Studies were identified by searching Medline (1966 to August 1998), Embase (1980 to 1998), the Cochrane Library (1998 Issue 3) and the Oxford Pain Relief Database (1950 to 1994).

SELECTION CRITERIA

The inclusion criteria used were: full journal publication, patients with pain due to bone metastases, and random allocation to a radiotherapeutic intervention (either external irradiation or administration of radioisotopes).

DATA COLLECTION AND ANALYSIS

The number of patients achieving complete pain relief and at least 50% at one month were compared with an assumed natural history of 1 in 100 patients achieving pain relief without treatment to obtain the number-needed-to-treat (NNT). Summed pain relief or pain intensity difference over four to six hours was extracted, converted into dichotomous information yielding the number of patients with at least 50% pain relief, and used to calculate the relative benefit and the NNT for one patient to achieve at least 50% pain relief.

MAIN RESULTS

Twenty trials reported on 43 different radiotherapy fractionation schedules and eight studies of radioisotopes. Radiotherapy produced complete pain relief at one month in 395/1580 (25%) patients, and at least 50% relief in 788/1933 (41%) patients at some time during the trials. There were no differences in the proportions of patients achieving these outcomes between single or multiple fraction schedules. The number-needed-to-treat (NNT) to achieve complete relief at one month (compared with an assumed natural history of 1 in 100 patients whose pain resolved without treatment) was 4.2 (95% CI 3.7-4.7). No pooled estimates of speed of onset of relief, or of its duration, could be obtained. In the largest trial (759 patients) 52% of those who had complete relief had achieved it within four weeks, and the median duration of complete relief was 12 weeks. For more generalised disease, radioisotopes produced similar analgesic results to external irradiation. Adverse effect reporting was poor. There were no obvious differences between the various fractionation schedules in the incidence of nausea and vomiting, diarrhoea or pathological fractures.

REVIEWER'S CONCLUSIONS

Radiotherapy is clearly effective at reducing pain from painful bone metastases. There was no evidence of any difference in efficacy between different fractionation schedules, nor indeed of a dose-response with total dose of radiation. For treatment of generalised bone pain both hemibody irradiation and radioisotopes can reduce the number of painful new sites.

External beam radiotherapy for painful osseous metastases: pooled data dose response analysis

PURPOSE

Although the effectiveness of external beam irradiation in palliation of pain from osseous metastases is well established, the optimal fractionation schedule has not been determined. Clinical studies to date have failed to demonstrate an advantage for higher doses. To further address this issue, we conducted a pooled dose response analysis using data from published Phase III clinical trials.

METHODS AND MATERIALS

Complete response (CR) was used as an endpoint because it was felt to be least susceptible to inconsistencies in assessment.The biological effective dose (BED) was calculated for each schedule using the linear-quadratic model and an alpha/beta of 10. Using SAS version 6.12, the data were fitted using a weighted linear regression, a logistic model, and the spline technique. Finally, BED was categorized, and odds ratios for each level were calculated.

RESULTS

CR was assessed early and late in 383 and 1,007 patients, respectively. Linear regression on the early-response data yielded a poor fit and a nonsignificant dose coefficient. With the late-response data, there was an excellent fit (R-square = 0.842) and a highly significant dose coefficient (p = 0.0002). Fitting early CR to a logistic model, we could not establish a significant dose response relationship. However, with the late-response data there was an excellent fit and the dose coefficient was significantly different from zero (0.017 +/- 0.00524; p = 0.0012). Application of the spline technique or removal of an outlier resulted in an improved fit (p = 0.048 and p = 0.0001, respectively). Using BED of < 14.4 Gy as a reference level, the odds ratios for late CR were 2.29-3.32 (BED of 19.5-51.4 Gy, respectively).

CONCLUSION

Our results demonstrate a clear dose-response for pain relief. Further testing of high intensity regiments is warranted.

Local and systemic radiation for palliation of metastatic disease

Many radiotherapeutic treatment options are available for the palliation of patients with metastatic prostate cancer. These include local field radiotherapy to symptomatic sites of metastasis and the use of radioisotope therapy either alone or in combination with local field radiotherapy. To date, the majority of patients treated with radioisotope therapy have been treated with 89Sr. Other agents, such as 153Sm-EDTMP are available now, also. Combined radioisotope therapy, cytotoxic chemotherapy, and biphosphonates hold great promise.

Bone metastasis: review and critical analysis of random allocation trials of local field treatment

PURPOSE

Compare and contrast reports of random allocation clinical trials of local field radiation therapy of metastases to bone to determine the techniques producing the best results (frequency, magnitude, and duration of benefit), and relate these to the goals of complete relief of pain and prevention of disability for the remaining life of the patient.

METHODS AND MATERIALS

Review all published reports of random allocation clinical trials, and perform a systematic analysis of the processes and outcomes of the several trial reports.

RESULTS

All trials were performed on selected populations of patients with symptomatic metastases and most studies included widely diverse groups with regard to: (a) site of primary tumor, (b) location, extent, size, and nature of metastases, (c) duration of survival after treatment All trial reports lack sufficient detail for full and complete analysis. Much collected information is not now available for reanalysis and many important data sets were apparently never collected. Several of the variations in patient and tumor characteristics were found to be much more important than treatment dose in the outcome results. Treatment planning and delivery techniques were unsophisticated and probably resulted in a systematic delivery of less than the assigned dose to some metastases. In general the use and benefit of retreatment was greater in those patients who initially received lower doses but the basis and dose of retreatment was not documented. Follow-up of patients was varied with a large proportion of surviving patients lost to follow-up in several studies. The greatest difference in the reports is the method of calculation of results. The applicability of Kaplan-Meier actuarial analysis, censoring the lost and dead patients, as used in studies with loss to follow-up of a large number of patients is questionable. The censoring involved is "informative" (the processes of loss relate to the outcome) and not acceptable since it results in artificial elevation of the frequency of response. Overall, higher dose fractionated treatment regimens produced a better frequency, magnitude, and duration of response than lower dose single-fraction regimens. Relapse after initial response was frequent. The "median duration of relief" was much shorter than the "median duration of survival" post-treatment. Thus the "net pain relief" is far less than the goal of pain relief for the total duration of life after treatment.

CONCLUSIONS

The pain relief obtained in all studies is poor and our care practices need to be improved. Many patients never achieved complete relief and for most who did, the duration of relief was much less than their period of survival after treatment. Higher dose, fractionated treatments produced a greater frequency, magnitude, and duration of response with an improved "net pain relief." Additional trials with selection of comparable cases, good definition of extent of disease, exemplary treatment, and complete follow-up are required.

Radiotherapy for bone metastases: a critical appraisal of outcome measures

Pain from bone metastases is a common problem in patients with advanced cancer, and radiotherapy plays an important role in its palliation. Single fraction treatments are often prescribed, but there is no clear consensus on this issue and clinical practice shows significant variability. This situation is unsatisfactory for all patients--the patient, the clinician, and the health care administrator. Randomized trials may use poor outcome measures and this contributes to practice variability. The credibility of outcome studies is often reduced due to poor study design, small sample sizes, and the use of endpoints that are both unreliable and unsuitable. The endpoints used have been narrowly defined, the patient's perspective has generally been overlooked, and quality of life has only once been used as an endpoint. A review of the current literature suggests that instruments specific to bone metastases are required. These must be based on patient experience, and rely on self-report. In addition, there is a need to understand the relative priority that patients attribute to treatment outcomes. The use of better instruments and methodologies in future trials will enhance the credibility of results and reduce practice variations.

Pain relief and quality of life following radiotherapy for bone metastases: a randomised trial of two fractionation schedules

BACKGROUND

The optimum dose and fractionation schedule for the palliative irradiation of painful bone metastases is controversial.

PURPOSE

To compare the efficacy, side-effects and effect on quality of life of two commonly used radiotherapy schedules in the management of painful bone metastases.

MATERIALS AND METHODS

In a prospective trial, 280 patients were randomised to receive either a single 10 Gy treatment or a course of 22.5 Gy in five daily fractions for the relief of localised metastatic bone pain.

RESULTS

Response rates have been calculated from 240 assessable treated sites of pain. The overall response rates were 83.7% (single treatment) and 89.2% (five fractions). The complete response rates were 38.8% (single treatment) and 42.3% (five fractions). The median duration of pain control was 13.5 weeks (single treatment) and 14.0 weeks (five fractions). None of these differences was statistically significant. There were no differences between the groups in the effect of treatment on a variety of quality of life parameters.

CONCLUSIONS

It is concluded that a single 10 Gy treatment is as effective as a course of 22.5 Gy in five fractions in the management of painful bone metastases.

Radiotherapy for palliation of symptoms in incurable cancer

Approximately one half of prescribed radiotherapy is given for palliation of symptoms due to incurable cancer. Distressing symptoms including pain, bleeding, and obstruction can often be relieved with minimal toxic effects. Painful osseous metastasis is common in oncologic practice. Ninety percent of patients with symptomatic bone metastases obtain some pain relief with a lowdose, brief course of palliative radiotherapy. One half of the responding patients may experience complete pain relief. A single dose of 800 cGy in the setting of painful bone metastasis may provide pain control comparable to more protracted treatment at a higher dose of radiation. Patients with lytic disease in weight-bearing bones, particularly in the presence of cortical destruction, should be considered for prophylactic surgical stabilization of their condition. Routinely a brief, fractionated course of radiotherapy is given postoperatively. Pain due to multiple bone metastases uncontrolled by analgesics can be managed with single doses of halfbody irradiation. Doses of 600 cGy delivered to the upper half-body (above the umbilicus) and 800 cGy to the lower half-body (from the umbilicus to the middle of the femur) will provide some pain relief in 73% of patients. Half-body techniques have been investigated as prophylactic treatment, as a complement to local-field irradiation, and as fractionated rather than singledose therapy. Although intravenous administration of strontium 89 has been associated with myelosuppression, this treatment has been shown (a) to relieve pain due to bone metastasis and (b) to delay development of new painful sites. Recent data from phase III trials demonstrated that bisphosphonates have a role in reducing skeletal morbidity due to bone metastasis. Bone pain was reduced, and the incidence of pathologic fracture and the need for future radiotherapy was decreased. Radiotherapy relieves clinical symptoms in 70% to 90% of patients with brain metastases. Brief treatment schedules (e.g., 2000 cGy in five fractions over 1 week) are as effective as more prolonged therapy. Patients with solitary brain metastasis and no extracranial disease or controlled extracranial disease should be considered for surgical resection, because phase III data indicate enhanced survival with such an approach. Whole-brain radiotherapy is routinely administered postoperatively. A phase III study is examining the impact of accelerated fractionated doses of radiotherapy (two treatments per day) on survival of patients with brain metastases. Stereotaxic radiosurgical treatment is becoming increasingly available and permits delivery of radiation to metastatic intracranial tumor with minimal exposure of normal surrounding brain This treatment is most commonly used at the time of a solitary recurrence of disease in patients who previously received whole-brain radiotherapy. A role for this modality in newly diagnosed brain metastases remains to be defined. Chest symptoms are common in patients with locally advanced lung cancer and are effectively palliated with one 1000 cGy or two 850 cGy one fraction doses of radiation to the thoracic inlet and mediastinum. Chest pain and hemoptysis are more effectively palliated than cough and dyspnea. In patients with stage III cancer there is no compelling evidence that radiotherapy confers a survival advantage, and it may be reasonable to administer thoracic radiotherapy only when the patient has significant symptoms and the goal is to achieve control of these symptoms. Approximately 75% of the cases of superior vena cava syndrome are due to lung cancer, and small-cell lung cancer is the most common histologic type. A histologic diagnosis should be obtained before treatment is started, because detection of lymphoma or small-cell carcinoma would necessitate systemic therapy. Eighty percent of the patients with vena cava syndrome due to malignant disease achieve symptom relief with a brief, fractionated, palliative course of rad

Rapid course radiation therapy vs. more standard treatment: a randomized trial for bone metastases

PURPOSE

In a prospective randomized trial we examined whether radiotherapy of painful bone metastases can be shortened using larger single doses without impairing effectivity.

METHODS AND MATERIALS

One hundred patients with painful bone metastases having no prior surgical intervention or treatment with x-ray therapy and had a median follow-up of 12 months were analyzed. The primary tumor was located in the breast in 43%, in the lung in 24%, and in the prostate in 14%. The most frequent sites of metastases were the pelvis (31%), the vertebral column (30%), and the ribs (20%). Further percentages of sites were: lower extremity 11%, upper extremity 6%, and skull 2%. Fifty-one patients received a short course radiotherapy with a total dose of 20 Gy in 1 week (daily dose 4 Gy), and 49 patients received 30 Gy in 3 weeks (daily dose 2 Gy).

RESULTS

There were no significant differences in frequency, duration of pain relief, improvement of mobility, recalcification, frequency of pathologic fractures nor survival. There was a light trend favoring 30 Gy in frequency of pain relief and recalcification. Survival was mostly influenced by primary tumor site, Karnofsky performance status, and possibly by the response to radiotherapy (pain relief).

CONCLUSIONS

Because of the very short life expectancy of patients with metastatic bone disease, we now use 20 Gy in 1 week as our standard to reduce hospital stay.

Fractionated half-body irradiation for pain palliation in widely metastatic cancers: comparison with single dose

PURPOSE

To explore fractionated half-body irradiation (HBI) for pain palliation and determine if it is more efficient and effective than single dose HBI.

METHODS AND MATERIALS

During the last 13 years, 75 out of 115 HBIs (64%) at the University of Maryland Medical Center were given for palliation of various widely metastatic cancers (28% prostate, 25% breast, 12% lung). The HBI fields were 28% upper, 25% mid, and 47% lower; three patients had both upper and lower HBI. An initial performance status (PS) 3&4 with a life expectancy < 3 months was found in 50% of patients. The HBI techniques used on consecutive patients were: single dose (SD) in 54% with escalating doses of 4-10 Gy; split-course (SC) in 12% with two 4 Gy single doses separated by 2 weeks; and daily fractionated (DF) in 34% with five fractions of 3 Gy each. There were 68 of 75 HBI (91%) given for pain control purposes.

RESULTS

The percent total (complete) pain relief was SD-73(32), SC-50(13), and DF-96(49). Time to maximum and (complete) relief was: SD 5 days each and DF HBI 7(11) days. Pain-free survival (PFS) was short but so was overall survival (OS). PFS was SD-5, SC-4.5, and DF-19 weeks. The percent of the remaining patient's life spent pain free without retreatment (NPR) was SD-38, SC-34, and DF-68. Differences in pain relief, PFS, OS, and NPR were significant and carried over primary tumor types; prostate, breast, and surprisingly GI were very responsive (90, 84, and 83%, respectively). On multivariate analysis only the PS and degree of relief were independent variables. Despite lack of premedication in DF-HBI, toxic reactions were identical to SD-HBI with premedication. No Grade 4 toxicities occurred. Grade 3 toxicities were 4%. Retreatment was 3% in SD and 13% in fractionated HBI; these differences were not significant.

CONCLUSION

HBI is still the most effective and efficient way to palliate pain from widely disseminated cancer. Fractionating HBI eliminates need for the premedication and close patient monitoring required for SD-HBI. It also allows for an increase in total dose which can produce better responses in pain relief, duration of relief, PFS, OS, and quality of life.

Skeletal metastases

This synthesis of the literature on radiotherapy for skeletal metastases is based on 171 scientific articles, including 13 randomized studies, 24 prospective studies, and 79 retrospective studies. These studies involve 13054 patients. Radiotherapy has been well documented as a method for alleviating pain, but the mechanisms underlying this effect are largely unknown. When used for pain palliation, radiotherapy achieves freedom from pain, or substantial alleviation of pain in nearly all cases, with few side effects. Half-body irradiation is effective in treating multiple metastatic sites and should be considered for use more frequently. However, this increases the requirements on equipment, dosimetry, and hospital beds. Systemic radiotherapy with radionuclides may be indicated for generalized skeletal pain. The role of radiotherapy in preventing or healing fractures is not fully evaluated. Optimum dose levels and fractionation schedules have not been established. Early radiotherapy for spinal cord compression may prevent symptoms from worsening, but the effects on existing paralysis are modest.

0-7-21 radiation therapy for the palliation of advanced cancer in dogs

The 0-7-21 radiation therapy protocol was investigated as a palliative treatment in dogs with advanced malignancies. Twenty-four dogs with a variety of tumor types were irradiated using 800 cGy fractions given on days 0, 7, and 21. Twenty-three dogs were evaluated. Palliative response was assessed using a quality of life instrument developed for veterinary use. This pain score was based on owner response to questions regarding analgesic requirement, activity level, appetite, and degree of lameness in the affected dogs. Seventeen (74%) of the 23 dogs experienced complete pain relief, and 3 (13%) obtained partial relief. Of the 17 dogs that achieved a complete response, pain recurred in 8 at a median time of 70 days. Six dogs were alive and free of pain up to 557 days after irradiation. The 0-7-21 protocol was well tolerated; pain relief occurred quickly, and acute radiation reactions were negligible.

Radiotherapy for Bone Pain

Painful bone metastases are a common problem for cancer patients. Although current evidence supports the use of a single fraction of radiotherapy as the treatment of choice, many radiotherapists, for a variety of reasons, continue to use fractionated regimens. Over one six month period 105 patients received external beam irradiation for painful bone metastases at the Royal London Hospital (RLH). Thirty-one per cent of the patients were aged 70 or over. The treatment of 97 of these patients was assessed. They had a total of 280 sites treated over the course of their disease. Fifty-nine per cent of sites treated received a fractionated course of radiotherapy. Site significantly influenced fractionation. Overall response rates of 82% were achieved. Fractionation did not appear to influence this. Ten patients received large field irradiation. Fifteen patients had five or more sites irradiated, of whom only one received hemibody irradiation.

Radiotherapy for painful bone metastases

Bone metastases are a frequent cause of morbidity in patients with malignant disease. Pain is the commonest symptom; it can be treated successfully in the majority of patients by local external beam irradiation. Controversy exists over which regimen should be used, with a single dose necessitating only one treatment visit to the radiotherapy department, or a fractionated course requiring several visits. Many radiotherapists continue to use fractionated regimens despite the current evidence that single fractions are as effective. Many reasons exist for this, including departmental policy and training, fears of recurrence, problems with retreatment of previously treated areas, fears of increased early and late morbidity, and attempts at promoting recalcification. The majority of these reasons are theoretical and have yet to be substantiated. In many patients, symptomatic bone metastases are widespread, and hemibody irradiation, although more toxic, should be considered in order to avoid the need for repeated courses of local treatment.

The role of radiotherapy in palliative care

Radiotherapy is an indispensable modality in the palliation of cancer. All palliative care programs should be acquainted with its indications and have a close working relationship with a radiation oncology department. The technical aspects of the subject may be intimidating to many staff and patients, and departments need to improve their outreach and education. The main indications are: pain relief (particularly bone pain), control of hemorrhage, fungation and ulceration, dyspnea, blockage of hollow viscera, and the shrinkage of any tumors causing problems by virtue of space occupancy. In addition, it has an important role in the palliation of three oncological emergencies: superior vena caval obstruction, spinal cord compression, and raised intracranial pressure due to cerebral metastases. More pragmatic fractionation schedules are being developed that are compatible with good results in terms of palliative end points, giving shorter courses with fewer hospital attendances for patient and family comfort and convenience. More clinical research and evaluation of palliative radiotherapy are required.

Osseous metastases from hepatocellular carcinoma: embolization for pain control

Transcatheter arterial embolization for osseous metastasis of hepatocellular carcinoma (HCC) was performed in 7 patients. The embolization therapy was used in patients in whom the feeding artery could be catheterized. All tumors were accompanied by abundant neovascularity and tumor stain. Embolization was successfully performed in 5 patients, all of whom became symptom free within a week. The only complication was local pain which was controlled by nonnarcotic pain medication. Embolization may be a useful treatment method for osseous metastasis of HCC.