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Chow E, Zeng L, Salvo N, Dennis K, Tsao M, Lutz S. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol) 2011; 24:112-24. [PMID: 22130630 DOI: 10.1016/j.clon.2011.11.004] [Citation(s) in RCA: 399] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 10/08/2011] [Accepted: 11/09/2011] [Indexed: 12/25/2022]
Abstract
AIMS To update previous meta-analyses of randomised palliative radiotherapy trials comparing single fractions versus multiple fractions. MATERIALS AND METHODS All published randomised controlled trials comparing single fraction versus multiple fraction schedules for the palliation of uncomplicated bone metastases were included in this analysis. Odds ratios and 95% confidence intervals were calculated for each trial. Forest plots were created using a random effects model and the Mantel-Haenszel statistic. RESULTS In total, 25 randomised controlled trials were identified. For intention-to-treat patients, the overall response rate was similar in patients receiving single fractions (1696 of 2818; 60%) and multiple fractions (1711 of 2799; 61%). Complete response rates were 620 of 2641 (23%) in the single fraction arm and 634 of 2622 (24%) in the multiple fraction arm. No significant difference was seen in overall or complete response rates. Pathological fracture did not favour either arm, but spinal cord compression trended towards favouring multiple fractions; however, neither was statistically significant (P = 0.72 and P = 0.13, respectively). Retreatment rates favoured patients in the multiple fraction arm, where the likelihood of requiring re-irradiation was 2.6-fold greater in the single fraction arm (95% confidence interval: 1.92-3.47; P < 0.00001). Repeated analyses excluding drop-out patients did not alter these findings. In general, no significant differences in acute toxicities were seen. CONCLUSION Overall and complete response rates were similar in both intention-to-treat and assessable patients. Single and multiple fraction regimens provided equal pain relief; however, significantly higher retreatment rates occurred in those receiving single fractions.
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Affiliation(s)
- E Chow
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Ontario, Canada.
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102
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103
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Venkitaraman R. Does one size fit all? Is there a standard radiation dose for malignant spinal cord compression? ACTA ACUST UNITED AC 2011; 9:127-8. [PMID: 21809515 DOI: 10.1016/j.suponc.2011.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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104
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Jennelle RLS, Vijayakumar V, Vijayakumar S. A Systematic and Evidence-Based Approach to the Management of Vertebral Metastasis. ISRN SURGERY 2011; 2011:719715. [PMID: 22084772 PMCID: PMC3200210 DOI: 10.5402/2011/719715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/21/2011] [Indexed: 11/23/2022]
Abstract
Diagnosis and management of vertebral metastasis requires a systematic approach to patient identification as well as selection of appropriate therapy. Rapid identification and prompt intervention in the treatment of malignant epidural spinal cord compression (MESCC) is key to maintaining quality of life. This paper provides a series of tools as well as guidance in selecting effective and evidence-based therapy individualized to the specific patient.
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Affiliation(s)
- Richard L. S. Jennelle
- Department of Radiation Oncology, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
| | - Vani Vijayakumar
- Department of Nuclear Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
| | - Srinivasan Vijayakumar
- Department of Radiation Oncology, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
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105
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The Optimal Dose Fractionation Schema for Malignant Extradural Spinal Cord Compression. ACTA ACUST UNITED AC 2011; 9:121-4. [DOI: 10.1016/j.suponc.2011.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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106
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Jones J, McMenamin E, Quon H. Treatment of metastatic epidural spinal cord compression: the Goldilocks principle. THE JOURNAL OF SUPPORTIVE ONCOLOGY 2011; 9:125-126. [PMID: 21809514 DOI: 10.1016/j.suponc.2011.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Joshua Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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107
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Abstract
Palliative radiotherapy has been prescribed since shortly after the discovery of the x-ray in the late 1800s, and it provides symptom relief that is successful, time-efficient, and cost-effective. Although palliative radiotherapy is worthwhile in a wide variety of clinical circumstances, there are situations where it is less worthwhile. We contrast the effective use of palliative radiotherapy with its ineffective use because of issues related to the patient, treatment, or health care system.
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108
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Maranzano E, Trippa F, Casale M, Anselmo P, Rossi R. Reirradiation of metastatic spinal cord compression: Definitive results of two randomized trials. Radiother Oncol 2011; 98:234-7. [DOI: 10.1016/j.radonc.2010.12.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 12/11/2010] [Accepted: 12/30/2010] [Indexed: 11/16/2022]
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109
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Lutz S, Lo SS, Chow E, Sahgal A, Hoskin P. Radiotherapy for metastatic bone disease: current standards and future prospectus. Expert Rev Anticancer Ther 2011; 10:683-95. [PMID: 20470001 DOI: 10.1586/era.10.32] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Changes in population dynamics will require increased end-of-life cancer care in the coming years. Palliative radiotherapy successfully relieves symptoms of advanced cancer, with the most common indication for its use being uncomplicated painful bone metastases. Single-fraction radiotherapy provides successful, time-efficient and cost-effective management of bone metastases. Newer technologies, such as stereotactic body radiotherapy, hold promise for some patients with spine metastases, although their niche has not been properly defined and their use outside of a protocol setting is inappropriate. Surgery should be considered for circumstances of completed or impending pathologic fracture, spinal instability, or spinal cord compression in patients who have adequate performance status and prognosis. Multiple sites of painful metastases may be treated with injectible radiopharmaceuticals or hemibody radiation. The future developments in palliative radiotherapy for bone metastases will mirror several forces affecting all of medicine, including resource allocation, the adoption of clinical guidelines and the integration of newer technologies.
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Affiliation(s)
- Stephen Lutz
- Blanchard Valley Regional Cancer Center, 15990 Medical Drive South, Findlay, OH 45840, USA.
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110
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Abstract
Radiotherapy alone is the most common treatment for metastatic epidural spinal cord compression (MESCC). Decompressive surgery followed by radiotherapy is generally indicated only in 10-15% of MESCC cases. Chemotherapy has an unclear role and may be considered for selected patients with hematological or germ-cell malignancies. If radiotherapy alone is given, it is important to select the appropriate regimen. Similar functional outcomes can be achieved with short-course radiotherapy regimens and longer-course radiotherapy regimens. Longer-course radiotherapy is associated with better local control of MESCC than short-course radiotherapy. Patients with a more favorable survival prognosis (expected survival of ≥6 months) should receive longer-course radiotherapy, as they may live long enough to develop a recurrence of MESCC. Patients with an expected survival of <6 months should be considered for short-course radiotherapy. A recurrence of MESCC in the previously irradiated region after short-course radiotherapy may be treated with another short-course of radiotherapy. After primary administration of longer-course radiotherapy, decompressive surgery should be performed if indicated. Alternatively, re-irradiation can be performed using high-precision techniques to reduce the cumulative dose received by the spinal cord. Larger prospective trials are required to better define the appropriate treatment for the individual patient.
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111
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Rades D, Freundt K, Meyners T, Bajrovic A, Basic H, Karstens JH, Adamietz IA, Wildfang I, Rudat V, Schild SE, Dunst J. Dose escalation for metastatic spinal cord compression in patients with relatively radioresistant tumors. Int J Radiat Oncol Biol Phys 2010; 80:1492-7. [PMID: 20579816 DOI: 10.1016/j.ijrobp.2010.04.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Revised: 03/05/2010] [Accepted: 04/16/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE Radiotherapy alone is the most common treatment for metastatic spinal cord compression (MSCC) from relatively radioresistant tumors such as renal cell carcinoma, colorectal cancer, and malignant melanoma. However, the results of the "standard" regimen 30 Gy/10 fractions need to be improved with respect to functional outcome. This study investigated whether a dose escalation beyond 30 Gy can improve treatment outcomes. METHODS AND MATERIALS A total of 91 patients receiving 30 Gy/10 fractions were retrospectively compared to 115 patients receiving higher doses (37.5 Gy/15 fractions, 40 Gy/20 fractions) for motor function and local control of MSCC. Ten further potential prognostic factors were evaluated: age, gender, tumor type, performance status, number of involved vertebrae, visceral or other bone metastases, interval from tumor diagnosis to radiotherapy, pretreatment ambulatory status, and time developing motor deficits before radiotherapy. RESULTS Motor function improved in 18% of patients after 30 Gy and in 22% after higher doses (p = 0.81). On multivariate analysis, functional outcome was associated with visceral metastases (p = 0.030), interval from tumor diagnosis to radiotherapy (p = 0.010), and time developing motor deficits (p < 0.001). The 1-year local control rates were 76% after 30 Gy and 80% after higher doses, respectively (p = 0.64). On multivariate analysis, local control was significantly associated with visceral metastases (p = 0.029) and number of involved vertebrae (p = 0.043). CONCLUSIONS Given the limitations of a retrospective study, escalation of the radiation dose beyond 30 Gy/10 fractions did not significantly improve motor function and local control of MSCC in patients with relatively radioresistant tumors.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lubeck, Germany.
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112
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Harel R, Angelov L. Spine metastases: current treatments and future directions. Eur J Cancer 2010; 46:2696-707. [PMID: 20627705 DOI: 10.1016/j.ejca.2010.04.025] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 04/08/2010] [Accepted: 04/28/2010] [Indexed: 11/17/2022]
Abstract
Spinal metastases are the most frequently encountered spinal tumour and can affect up to 50% of cancer patients. Both the incidence and prevalence of metastases are thought to be rising due to better detection and treatment options of the systemic malignancy resulting in increased patient survival. Further, the development and access to newer imaging modalities have resulted in easier screening and diagnosis of spine metastases. Current evidence suggests that pain, neurological symptoms and quality of life are all improved if patients with spine metastases are treated early and aggressively. However, selection of the appropriate therapy depends on several factors including primary histology, extent of the systemic disease, existing co-morbidities, prior treatment modalities, patient age and performance status, predicted life expectancy and available resources. This article reviews the currently available therapeutic options for spinal metastases including conventional external beam radiation therapy, open surgical decompression and stabilisation, vertebral augmentation and other minimally invasive surgery (MIS) options, stereotactic spine radiosurgery, bisphosphonates, systemic radioisotopes and chemotherapy. An algorithm for the management of spine metastases is also proposed. It outlines a multidisciplinary and integrated approach to these patients and it is hoped that this along with future advances and research will result in improved patient care and outcomes.
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Affiliation(s)
- Ran Harel
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, OH 44195, USA
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113
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Rades D, Lange M, Veninga T, Stalpers LJA, Bajrovic A, Adamietz IA, Rudat V, Schild SE. Final results of a prospective study comparing the local control of short-course and long-course radiotherapy for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys 2010; 79:524-30. [PMID: 20452136 DOI: 10.1016/j.ijrobp.2009.10.073] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 10/27/2009] [Accepted: 10/30/2009] [Indexed: 11/19/2022]
Abstract
PURPOSE Many patients with metastatic spinal cord compression (MSCC) live long enough to develop a recurrence in the irradiated spinal area. This is the first prospective study that has compared local control of different radiotherapy schedules for MSCC. METHODS AND MATERIALS A total of 265 patients treated with radiotherapy alone were included in this prospective nonrandomized study. The primary goal was to compare local control from short-course (1 × 8 Gy/5 × 4 Gy, n = 131) and long-course radiotherapy (10 × 3 Gy/15 × 2.5 Gy/20 × 2 Gy, n = 134). Secondary end points were motor function and survival. The analysis of local control (no MSCC recurrence in the irradiated spinal area) included the 224 patients with improvement or no change of motor deficits during radiotherapy. Eleven additional factors were evaluated for outcomes. RESULTS One-year local control was 61% after short-course and 81% after long-course radiotherapy (p = 0.005). On multivariate analysis (MVA), improved local control was associated with long-course radiotherapy (p = 0.018). Motor function improved in 37% after short-course and 39% after long-course radiotherapy (p = 0.95). Improved motor function was associated with better performance status (p = 0.015), favorable tumor type (p = 0.034), and slower development of motor deficits (p < 0.001). One-year survival rates were 23% after short-course and 30% after long-course radiotherapy (p = 0.28). On MVA, improved survival was associated with better performance status (p < 0.001), no visceral metastases (p < 0.001), involvement of only one to three vertebrae (p = 0.040), ambulatory status (p = 0.038), and bisphosphonate administration after radiotherapy (p < 0.001). CONCLUSIONS Long-course radiotherapy was associated with better local control, similar functional outcome, and similar survival compared to short-course radiotherapy. Patients with a relatively favorable expected survival should receive long-course radiotherapy.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lubeck, Germany.
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114
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Rades D. E18. CNS metastasis: The role of radiotherapy for brain metastasis and metastatic spinal cord compression. EJC Suppl 2010. [DOI: 10.1016/s1359-6349(10)70022-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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115
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Prewett S, Venkitaraman R. Metastatic spinal cord compression: review of the evidence for a radiotherapy dose fractionation schedule. Clin Oncol (R Coll Radiol) 2010; 22:222-30. [PMID: 20138487 DOI: 10.1016/j.clon.2010.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 12/10/2009] [Accepted: 01/05/2010] [Indexed: 12/17/2022]
Abstract
Metastatic spinal cord compression is a frequent medical emergency, and the most common treatment offered is radiotherapy. The routine treatment prescription for spinal cord compression in the UK is 20 Gy in five daily fractions delivered over 1 week. Here, we evaluate the evidence base for the radiotherapy dose for spinal cord compression. Evidence from the four prospective studies conducted so far and retrospective studies does not support a uniform dose of 20 Gy for all patients with spinal cord compression. Available evidence suggests that the radiotherapy dose should be tailored to the individual patient, depending on the subtype of the tumour, the extent of metastatic disease and expected survival. A risk stratification for the optimum dose prescription for patients with spinal cord compression is recommended.
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Affiliation(s)
- S Prewett
- Department of Oncology, Ipswich Hospital NHS Trust, Ipswich, UK
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Kuijper IT, Dahele M, Senan S, Verbakel WF. Volumetric modulated arc therapy versus conventional intensity modulated radiation therapy for stereotactic spine radiotherapy: A planning study and early clinical data. Radiother Oncol 2010; 94:224-8. [DOI: 10.1016/j.radonc.2009.12.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 12/22/2009] [Accepted: 12/22/2009] [Indexed: 11/16/2022]
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