Half-body irradiation for pain relief

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.

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.

Third-body irradiation as an effective palliative treatment for painful multiple bone metastases resistant to chemo- or hormonal treatment

Fifty-three patients had 54 third-body areas irradiated for breast and prostate bone metastases using the third-body irradiation technique during a period of 6 years. These patients were previously treated with chemotherapy, hormonal therapy and limited field irradiation. Seventy percent responded completely and 24% partially. This modality is safe and effective for pain relief.

Half body irradiation for the palliation of bone metastases

Half body irradiation using single large doses of photons has been reported as an effective modality for the palliation of symptoms due to widespread metastatic bone malignancy. Over a 7 year period (1982-1988) sixteen patients with disseminated malignancy were given half body irradiation at Auckland Hospital. Treatment consisted of a single dose of radiation of between 5 and 8 Gray. Either 6 or 8 MV photon beams were used. Twelve patients received treatment to the lower half body, three patients to the upper half body and one patient to both upper and lower half body. Significant pain relief occurred in fifteen patients and two patients experienced improvement with hypercalcaemia. All patients tolerated the treatment well and toxicity was minimal.

Palliative hemiskeletal irradiation for widespread metastatic prostate cancer: a comparison of single dose and fractionated regimens

Between 1986 and 1987 patients with hormone refractory metastatic adenocarcinoma of the prostate were treated with hemiskeletal irradiation. One group of 15 patients was treated with a fractionated regimen of 2500-3000 cGy in 9 to 10 fractions. A second group of 14 patients received a single dose of 600 cGy or 800 cGy depending upon whether the upper or lower hemiskeleton was irradiated. Both groups were similar with respect to their initial Karnofsky performance status and extent of disease. With the exception of one patient in the single dose group, all patients treated achieved complete or partial relief shortly after completion of their respective courses of therapy. Of the patients treated with single dose therapy, 10 of 14 (71%) ultimately needed retreatment in the region initially irradiated because of recurrent bone pain or spinal cord compression. In contrast, only 2 of 15 (13%) of the patients receiving the fractionated treatment course needed retreatment (p = .001). Although the median survival of both groups from the time of initial treatments was similar (10 and 11 months), the median duration for palliation was greater for those patients receiving the fractionated regimen as compared with single dose therapy (8.5 months vs 2.8 months). The incidence of treatment related toxicity was similar for both groups. We conclude that fractionated hemiskeletal radiation is a more effective means of palliation when compared to single dose therapy.

Palliative irradiation of bone metastases

Painful bone metastases is a common feature in patients with advanced cancer. The application of radiotherapy is often used as palliative treatment. A review of available data from the literature reveals that irrespective of the primary diagnosis palliation is achieved in 70-100% of cases. The biological basis of pain and the effects of radiotherapy is discussed. Treatment schedules for patients with single-bone lesions are reviewed. It is concluded that single-shot treatment in doses ranging from 5 to 8 Gy is as effective as multi-fractionated treatment. In addition, the possible role of radiotherapy in relation to patients with multiple lesions, and the use of combined surgery and radiotherapy in patients with impending and manifest fractures are discussed. It is concluded that the literature does not allow a definitive conclusion concerning an optimal use of radiotherapy.

Radiotherapy in the treatment of multiple myeloma

Fifty-nine patients with multiple myeloma referred for treatment of painful bony lesions received irradiation to 95 local areas, and 16 of the 59 were irradiated using hemibody techniques. Pain relief was obtained in practically all of the irradiated regions. Most local areas were treated to doses of 3000 cGy in 10 to 15 fractions. Patients with generalized pain due to multiple site involvement were treated with single dose hemibody irradiation, to doses of 600 cGy to the upper hemibody, and of 800 cGy to the lower hemibody. This treatment was well tolerated and side effects minimal. Median survival from diagnosis was 30 months and the survival at 1, 3, and 5 years was 80%, 42%, and 12% respectively. Key articles on radiation therapy of multiple myeloma are reviewed and discussed. Since all patients eventually relapse after chemotherapy, the role of radiotherapy using present techniques should be fully evaluated and considered as an alternative in the primary treatment of multiple myeloma.

Bone metastases: pathogenesis, treatment, and rationale for use of resorption inhibitors

Tumors in bone are usually metastatic, with breast, prostate, and lung tumors accounting for more than 80 percent of clinically manifest lesions. Untreated, such metastases can produce the symptoms that most concern cancer patients--pain, pathologic fractures, and paralysis through epidural cord compression. Recent advances in the understanding of the metastatic cascade and the regulation of bone formation and resorption provide unique therapeutic approaches for prevention and treatment of these lesions. This article reviews the prevalence, distribution, diagnosis, and treatment of metastatic cancer in the skeleton, as well as the processes involved in the development of such metastases, the local mediators responsible for some of the destructive changes in bone, and their pathologic results. In addition to considering some of the conventional therapeutic approaches, a rationale for the use of bone resorption inhibitors, such as the diphosphonates (bisphosphonates), is presented for the prevention and amelioration of the pathologic consequences of skeletal metastases.

Once-a-week lower hemibody irradiation (HBI) for metastatic cancers

Hemibody irradiation (HBI) of 8 Gy has been shown to produce pain relief in widespread metastatic disease. The major problems occurred with high dose (over 6 Gy) to the upper hemibody. Because 8 Gy lower HBI was well tolerated, we decided to study the efficacy and tolerance of even higher radiation doses given to the lower hemibody. Nineteen patients with widespread metastatic cancers in the lower hemibody were treated from 1982 to 1984 with 16 Gy (8 Gy one week apart) to the lower hemibody (from top of iliac crest to knee joint) after premedication with an antiemetic. All the patients tolerated this high dose, lower HBI well, except for two patients who had slight nausea and vomiting, and one patient who had moist reaction in the perineum. There was no significant bone marrow depression. All patients had improvement in performance status and had prompt pain relief, ten (53%) with complete pain relief and nine (47%) with partial pain relief. The median duration of pain relief was 5 months. Ten of the 15 patients who died were pain-free at the time of death. The four patients still living are free of pain. The median survival was 7 months, and five patients survived 1 year. High dose (8 Gy X 2 spaced one week apart), lower HBI produces prolonged, prompt and effective palliation of pain with minimal morbidity and is well tolerated. It probably does not prolong survival. Because it requires only two treatments spaced one week apart, it is a very convenient and cost effective regimen for the sick and elderly patient.

Hemibody irradiation in multiple myeloma

Eighteen patients with multiple myeloma were treated by hemibody irradiation using large single fractions, usually to a dose of 10 Gy (lower half) and 7.5 Gy (upper half). All except one patient had previously been treated by multiple courses of conventional chemotherapy with melphalan and prednisone, and were considered to be resistant to further chemotherapy. In most cases, local field irradiation had also been given for symptomatic bone pain. Of the 13 patients who had symptoms at the start of hemibody irradiation, 11 improved sufficiently for their analgesia requirement to be reduced. In eight patients, there was a significant fall in circulating immunoglobulin but no patient with Bence-Jones proteinuria had complete resolution of this biochemical abnormality. Although thrombocytopenia and neutropenia were common, only two patients required platelet transfusion and the treatment was in general extremely well tolerated. Survival following hemibody irradiation was similar to the survival reported from the use of "second-line" chemotherapy and we feel that hemibody irradiation is a more acceptable alternative for most patients.