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Alcorn S, Cortés ÁA, Bradfield L, Brennan M, Dennis K, Diaz DA, Doung YC, Elmore S, Hertan L, Johnstone C, Jones J, Larrier N, Lo SS, Nguyen QN, Tseng YD, Yerramilli D, Zaky S, Balboni T. External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:377-397. [PMID: 38788923 DOI: 10.1016/j.prro.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases. METHODS The ASTRO convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systematic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed. RESULTS For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with nonspine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction (800 cGy/1 fx), 2000 cGy/5 fx, 2400 cGy/6 fx, or 3000 cGy/10 fx. Spinal cord or cauda equina compression in patients who are ineligible for surgery and receiving conventional RT are recommended 800 cGy/1 fx, 1600 cGy/2 fx, 2000 cGy/5 fx, or 3000 cGy/10 fx. Symptomatic bone metastases in selected patients with good performance status without surgery or neurologic symptoms/signs are conditionally recommended stereotactic body RT over conventional palliative RT. Spine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, 2400 cGy/6 fx, or 2000 cGy/8 fx; nonspine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, or 2400 cGy/6 fx. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision making is recommended. CONCLUSIONS Based on published data, the ASTRO task force's recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.
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Affiliation(s)
- Sara Alcorn
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota.
| | - Ángel Artal Cortés
- Department of Medical Oncology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | | | - Kristopher Dennis
- Division of Radiation Oncology, Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Dayssy A Diaz
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Shekinah Elmore
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Hertan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Candice Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua Jones
- Department of Radiation Oncology, Rochester Regional Health, Rochester, New York
| | - Nicole Larrier
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, Texas
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sandra Zaky
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
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Singh N, McClure EM, Akaike T, Park SY, Huynh ET, Goff PH, Nghiem P. The Evolving Treatment Landscape of Merkel Cell Carcinoma. Curr Treat Options Oncol 2023; 24:1231-1258. [PMID: 37403007 PMCID: PMC11260505 DOI: 10.1007/s11864-023-01118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/06/2023]
Abstract
OPINION STATEMENT Merkel cell carcinoma (MCC) has a high risk of recurrence and requires unique treatment relative to other skin cancers. The patient population is generally older, with comorbidities. Multidisciplinary and personalized care is therefore paramount, based on patient preferences regarding risks and benefits. Positron emission tomography and computed tomography (PET-CT) is the most sensitive staging modality and reveals clinically occult disease in ~ 16% of patients. Discovery of occult disease spread markedly alters management. Newly diagnosed, localized disease is often managed with sentinel lymph node biopsy (SLNB), local excision, primary wound closure, and post-operative radiation therapy (PORT). In contrast, metastatic disease is usually treated systemically with an immune checkpoint inhibitor (ICI). However, one or more of these approaches may not be indicated. Criteria for such exceptions and alternative approaches will be discussed. Because MCC recurs in 40% of patients and early detection/treatment of advanced disease is advantageous, close surveillance is recommended. Given that over 90% of initial recurrences arise within 3 years, surveillance frequency can be rapidly decreased after this high-risk period. Patient-specific assessment of risk is important because recurrence risk varies widely (15 to > 80%: Merkelcell.org/recur) depending on baseline patient characteristics and time since treatment. Blood-based surveillance tests are now available (Merkel cell polyomavirus (MCPyV) antibodies and circulating tumor DNA (ctDNA)) with excellent sensitivity that can spare patients from contrast dye, radioactivity, and travel to a cancer imaging facility. If recurrent disease is locoregional, management with surgery and/or RT is typically indicated. ICIs are now the first line for systemic/advanced MCC, with objective response rates (ORRs) exceeding 50%. Cytotoxic chemotherapy is sometimes used for debulking disease or in patients who cannot tolerate ICI. ICI-refractory disease is the major problem faced by this field. Fortunately, numerous promising therapies are on the horizon to address this clinical need.
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Affiliation(s)
- Neha Singh
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Erin M McClure
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Tomoko Akaike
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Song Y Park
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Emily T Huynh
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Peter H Goff
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Paul Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA.
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Tseng YD. Radiation Therapy for Painful Bone Metastases: Fractionation, Recalcification, and Symptom Control. Semin Radiat Oncol 2023; 33:139-147. [PMID: 36990631 DOI: 10.1016/j.semradonc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Bone is a common site for metastases, which may cause pain and other skeletal-related events (SRE) in patients with advanced cancer. Since the 1980s, prospective clinical trials have demonstrated the high efficacy of external beam radiotherapy (EBRT) for pain relief from focal, symptomatic lesions. In uncomplicated bone metastases, which include those without pathologic fracture, evidence of cord compression, or prior surgical intervention, improvement or complete pain relief with radiotherapy is as high as 60%, with no difference in efficacy when radiotherapy is delivered in a single or multiple fractions. The ability to treat with a single fraction makes EBRT an attractive therapy even for patients with poor performance status and/or life expectancy. Even in patients with complicated bone metastases (eg cord compression), several randomized trials have demonstrated similar rates of pain relief in addition to improved functional outcomes such as ambulation. In this review, we summarize the role of EBRT for alleviating painful bone metastases and explore its role for other endpoints including functional outcomes, recalcification, and prevention of SREs.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutch Cancer Center, Seattle, WA.
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Fabian A, Domschikowski J, Letsch A, Schmalz C, Freitag-Wolf S, Dunst J, Krug D. Use and Reporting of Patient-Reported Outcomes in Trials of Palliative Radiotherapy: A Systematic Review. JAMA Netw Open 2022; 5:e2231930. [PMID: 36136335 PMCID: PMC9500555 DOI: 10.1001/jamanetworkopen.2022.31930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Approximately 50% of all patients with cancer have an indication for radiotherapy, and approximately 50% of radiotherapy is delivered with palliative intent, with the aim of alleviating symptoms. Symptoms are best assessed by patient-reported outcomes (PROs), yet their reliable interpretation requires adequate reporting in publications. OBJECTIVE To investigate the use and reporting of PROs in clinical trials of palliative radiotherapy. EVIDENCE REVIEW This preregistered systematic review searched PubMed/Medline, EMBASE, and the Cochrane Center Register of Controlled Trials for clinical trials of palliative radiotherapy published from 1990 to 2020. Key eligibility criteria were palliative setting, palliative radiotherapy as treatment modality, and clinical trial design (per National Institutes of Health definition). Two authors independently assessed eligibility. Trial characteristics were extracted and standard of PRO reporting was assessed in adherence to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. The association of the year of publication with the use of PROs was assessed by logistic regression. Factors associated with higher CONSORT-PRO adherence were analyzed by multiple regression. This study is reported following the PRISMA guidelines. FINDINGS Among 7377 records screened, 225 published clinical trials representing 24 281 patients were eligible. Of these, 45 trials (20%) used a PRO as a primary end point and 71 trials (31%) used a PRO as a secondary end point. The most prevalent PRO measures were the Numeric Rating Scale/Visual Analogue Scale (38 trials), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire C30 (32 trials), and trial-specific unvalidated measures (25 trials). A more recent year of publication was significantly associated with a higher chance of PROs as a secondary end point (odds ratio [OR], 1.04 [95% CI, 1.00-1.07]; P = .03) but not as primary end point. Adherence to CONSORT-PRO was poor or moderate for most items. Mean (SD) adherence to the extension adherence score was 46.2% (19.6%) for trials with PROs as primary end point and 31.8% (19.8%) for trials with PROs as a secondary end point. PROs as a primary end point (regression coefficient, 9.755 [95% CI, 2.270-17.240]; P = .01), brachytherapy as radiotherapy modality (regression coefficient, 16.795 [95% CI, 5.840-27.751]; P = .003), and larger sample size (regression coefficient, 0.028 [95% CI, 0.006-0.049]; P = .01) were significantly associated with better PRO reporting per extension adherence score. CONCLUSIONS AND RELEVANCE In this systematic review of palliative radiotherapy trials, the use and reporting of PROs had room for improvement for future trials, preferably with PROs as a primary end point.
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Affiliation(s)
- Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Justus Domschikowski
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anne Letsch
- Department of Haematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Juergen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
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Amini A, Shinde A, Wong J. Palliative Radiation for Cancer Pain Management. Cancer Treat Res 2021; 182:145-156. [PMID: 34542881 DOI: 10.1007/978-3-030-81526-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bone metastases are the most common cause of cancer-related pain. Radiation therapy (RT) is a very common and effective treatment to relieve pain. Conventionally fractionated RT typically consists of the following regimens: 8 Gy in a single treatment, 20 Gy in five fractions, 24 Gy in six fractions, or 30 Gy in ten fractions. All treatment regimens have similar rates of pain relief (range 50-80%), with single-fraction treatment often requiring retreatment. While many painful bony metastases can be managed with RT alone, some may be more complex, often requiring multidisciplinary management, including the need for surgical stabilization or augmentation prior to RT. There are multiple assessment tools including the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which allows clinicians to assess the proper course of treatment for these patients. For patients with good prognosis, oligometastatic disease, or those presenting with more radioresistant tumors, stereotactic body radiotherapy (SBRT) may be another option, which offers ablative doses of radiation delivered over several treatments. This chapter reviews the fundamentals of RT for palliation.
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Affiliation(s)
- Arya Amini
- Department of Radiation Oncology, City of Hope National Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
| | - Ashwin Shinde
- Department of Radiation Oncology, City of Hope National Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope National Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
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Li H, Zhang W, Zhang H, Xie Y, Sun C, Di C, Si J, Gan L, Yan J. Mitochondrial proteomics reveals the mechanism of spermatogenic cells apoptosis induced by carbon ion radiation in zebrafish. J Cell Physiol 2019; 234:22439-22449. [DOI: 10.1002/jcp.28808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 04/20/2019] [Accepted: 04/24/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Hongyan Li
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
- School of Nuclear Science and Technology University of Chinese Academy of Sciences Beijing China
| | - Weihong Zhang
- Department of Ultrasonography Gansu Wuwei Tumor Hospital Wuwei China
| | - Hong Zhang
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
- School of Nuclear Science and Technology University of Chinese Academy of Sciences Beijing China
- Department of Science and Technology Gansu Wuwei Tumor Hospital Wuwei China
| | - Yi Xie
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
| | - Chao Sun
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
| | - Cuixia Di
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
| | - Jing Si
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
| | - Lu Gan
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
| | - Junfang Yan
- Department of Radiation Medicine, Institute of Modern Physics Chinese Academy of Sciences Lanzhou China
- Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences Institute of Modern Physics Lanzhou China
- Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine Institute of Modern Physics, Chinese Academy of Sciences Lanzhou China
- School of Nuclear Science and Technology University of Chinese Academy of Sciences Beijing China
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Le Fèvre C, Antoni D, Thiéry A, Noël G. Radiothérapie des métastases osseuses : revue multi-approches de la littérature. Cancer Radiother 2018; 22:810-825. [DOI: 10.1016/j.canrad.2017.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/20/2017] [Accepted: 10/12/2017] [Indexed: 12/18/2022]
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Walker GV, Shirvani SM, Borghero Y, Callister MD, Chamberlain DD, Grade EJ, Khan MK, Kumar R, Richmond JG, Roberts TJ, Likhacheva AO. Palliation or Prolongation? The Impact of a Peer-Review Intervention on Shortening Radiotherapy Schedules for Bone Metastases. J Oncol Pract 2018; 14:e513-e516. [PMID: 30059272 DOI: 10.1200/jop.18.00042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Shorter fractionation radiation regimens for palliation of bone metastases result in lower financial and social costs for patients and their caregivers and have similar efficacy as longer fractionation schedules, although practice patterns in the United States show poor adoption. We investigated whether prospective peer review can increase use of shorter fractionation schedules. METHODS In June 2016, our practice mandated peer review of total dose and fractionation for all patients receiving palliative treatment during our weekly chart rounds. We used descriptive statistics and Fisher's exact test to compare lengths of treatment of uncomplicated bone metastases before and after implementation of the peer review process. RESULTS Between July 2015 and December 2016, a total of 242 palliative treatment courses were delivered, including 105 courses before the peer review intervention and 137 after the intervention. We observed greater adoption of shorter fractionation regimens after the intervention. The use of 8 Gy in one fraction increased from 2.8% to 13.9% of cases postadoption. Likewise, the use of 20 Gy in five fractions increased from 25.7% to 32.8%. The use of 30 Gy in 10 fractions decreased from 55.2% to 47.4% ( P = .002), and the use of ≥ 11 fractions decreased from 16.2% before the intervention to 5.8% after ( P = .006). CONCLUSION Prospective peer review of palliative regimens for bone metastases can lead to greater adoption of shorter palliative fractionation schedules in daily practice, in accordance with national guidelines. This simple intervention may therefore benefit patients and their caregivers as well as provide value to the health care system.
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Affiliation(s)
- Gary V Walker
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shervin M Shirvani
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yerko Borghero
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew D Callister
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel D Chamberlain
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emily J Grade
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mohamed K Khan
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey G Richmond
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Terence J Roberts
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anna O Likhacheva
- Banner MD Anderson Cancer Center, Gilbert, AZ; and The University of Texas MD Anderson Cancer Center, Houston, TX
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Cacicedo J, Gómez-Iturriaga A, Navarro A, Morillo V, Willisch P, Lopez-Guerra JL, Illescas A, Casquero F, Del Hoyo O, Ciervide R, Martinez-Indart L, Bilbao P, Rades D. Analysis of predictors of pain response in patients with bone metastasis undergoing palliative radiotherapy: Does age matter? J Med Imaging Radiat Oncol 2018; 62:578-584. [PMID: 29797486 DOI: 10.1111/1754-9485.12749] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/22/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To evaluate whether age is a predictor of pain response after radiotherapy for painful bone metastasis (BM). METHODS Between June 2010 and June 2014, 204 patients with BM undergoing palliative radiotherapy participated in a multicentre prospective study. Patients completed the Brief Pain Inventory (BPI) to rate the intensity pain (from 0 to 10) at baseline and 4 weeks after radiotherapy. To determine which variables predicted pain response and particularly whether age is a predictor, logistic regression analysis was used. Baseline variables considered were: age (≤65/66-75/>75 years), sex, Eastern Cooperative Oncology Group performance status (0-1/≥2), pretreatment pain score (≤4/5-7/≥8), radiotherapy (single/multiple fraction), primary tumour location, visceral metastases (yes/no), concomitant systemic chemotherapy and bisphosphonate use (yes/no). RESULTS Pain response was assessed in the 128 patients who completed BPI pretreatment and at 4 weeks after radiotherapy. According to univariate analysis, pain response was better in over 75-year-olds than younger patients: (OR, 3.2; 95% CI, 1.1-9.1; P = 0.031). Response was better in patients receiving multiple fractions rather than a single fraction of 8 Gy (OR, 2.8; 95% CI, 1.2-6.1; P = 0.01), and in patients with a pretreatment pain score ≥8 vs ≤7 (OR, 2.4; 95% CI, 1.1-5.0; P = 0.017). No other variables were significant. Multivariate analysis showed that treatment schedule (OR, 3.4; 95% CI 1.4-7.9; P = 0.004) and pre-radiotherapy pain score (OR, 2.8; 95% CI 1.3-6.3; P = 0.009) were the only independent predictors of pain response. CONCLUSION All patients with painful bone metastasis should be referred for palliative radiotherapy to relieve the pain regardless of age. Therefore, an older age should not be a reason to withhold palliative radiation treatment.
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Affiliation(s)
- Jon Cacicedo
- Department of Radiation Oncology, Hospital Universitario Cruces/Biocruces Health Research Institute, Barakaldo, Spain
| | - Alfonso Gómez-Iturriaga
- Department of Radiation Oncology, Hospital Universitario Cruces/Biocruces Health Research Institute, Barakaldo, Spain
| | - Arturo Navarro
- Department of Radiation Oncology, Hospital Duran i Reynals, Barcelona, Spain
| | - Virginia Morillo
- Department of Radiation Oncology, Hospital de Castellón, Castelló, Spain
| | | | | | - Ana Illescas
- Department of Radiation Oncology, Hospital Virgen Macarena, Sevilla, Spain
| | - Francisco Casquero
- Department of Radiation Oncology, Hospital Universitario Cruces/Biocruces Health Research Institute, Barakaldo, Spain
| | - Olga Del Hoyo
- Department of Radiation Oncology, Hospital Universitario Cruces/Biocruces Health Research Institute, Barakaldo, Spain
| | - Raquel Ciervide
- Department of Radiation Oncology, Hospital San Chinarro, Madrid, Spain
| | - Lorea Martinez-Indart
- Bioinformatics and Statistics Department, Hospital Universitario Cruces/Biocruces Heatlh Research Institute, Barakaldo, Spain
| | - Pedro Bilbao
- Department of Radiation Oncology, Hospital Universitario Cruces/Biocruces Health Research Institute, Barakaldo, Spain
| | - Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
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10
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Amichetti M, Orrù P, Madeddu A, Murtas R, Carau B, Farigu R, Carta S, Orrù S, Nagliati M, Lay G, Dessì M. Comparative Evaluation of Two Hypofractionated Radiotherapy Regimens for Painful Bone Metastases. TUMORI JOURNAL 2018; 90:91-5. [PMID: 15143979 DOI: 10.1177/030089160409000119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background In 75% of the patients with bone metastases (BM) pain is the dominant symptom. Radiotherapy (XRT) plays a major role in the palliation of pain in patients with BM. Several schedules of short and long fractionation XRT are used in clinical practice, with hypofractionated treatments being even more attractive for practical reasons. A considerable body of evidence supports the clinical use of short schedules and single-dose XRT. We retrospectively evaluated the efficacy of two short fractionated schedules of 8 Gy as a single dose and 20 Gy in 5 fractions in relieving pain in patients with multiple uncomplicated BM. Method From January to December 2001, 130 patients with 146 painful BM were treated with palliative localized XRT. There were 42 males and 88 females with a median age of 58 years (range 28–84). The commonest sites of treatment were the spine (59.6%) and pelvis (14.4%). The primary endpoint was clinically significant pain relief in the first six months of follow-up evaluated with the IAEA (International Atomic Energy Agency) pain measurement score measuring pain severity and pain frequency. Analgesic use was also recorded before and after treatment as drug frequency and drug severity. Patients with painful BM from any primary tumor site were irradiated. Treatment schedules consisted of a course of XRT with 4 Gy/fraction/day (total dose: 20 Gy/5 fractions) (group A, 59 lesions) or with a single dose of 8 Gy (group B, 87 lesions). Results There was no significant difference in complete response (CR) rates between treatment schedules: complete pain relief was achieved in 17/59 lesions (29%) in the fractionated group and in 29/87 lesions (33%) in the single-dose group. Also the overall response (complete + partial) was similar: 35/59 lesions (60%) in group A and 60/87 (69%) in group B. The minimum, maximum and median follow-up was 3, 23, and 9 months, respectively, for group A and 3, 20, and 11 months for group B. The actuarial median duration of pain relief was similar: 4.5 months in group A and 4 months in group B. No particular side effects were recorded in either group. Conclusions There were no differences between the two fractionation schedules used in our study with regard to pain relief and use of analgesics. Palliation of pain was obtained in approximately two thirds of patients with both schedules, providing further evidence of the similar efficacy between single and multiple fractions. With regard to pain response these data justify a recommendation for the use of a more simple and convenient 8 Gy single fraction for the palliation of uncomplicated BM.
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Affiliation(s)
- Maurizio Amichetti
- Department of Radiation Oncology, Regional Oncological Hospital A Businco, Cagliari, Italy.
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Tombolini V, Zurlo A, Montagna A, Notarianni E, Osti MF, Enrici RM, Pirolli C. Radiation Therapy of Spinal Metastases: Results with Different Fractionations. TUMORI JOURNAL 2018; 80:353-6. [PMID: 7839465 DOI: 10.1177/030089169408000508] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background Local radiotherapy plays an important role in the palliative treatment of all skeletal metastases, particularly those of the spine, with the purpose to obtain pain relief and prevent pathologic fractures or vertebral collapse. Methods From June 1991 to October 1993, 95 patients with a total of 103 sites of spinal metastases were treated at the Institute of Radiology of the University of Rome “La Sapienza”. Fractionations and total doses were divided as single fractions of 800 cGy, hypofractionated multiple fractions for a total dose of 20 Gy administered in 4-5 days, and conventional multiple fractions for a total dose of 30-40 Gy in 2-4 weeks. An evaluation of the efficacy of the different radiation treatments was performed with the use of a simplified descriptive pain scale. Results Seventy-three (70.9%) of 103 treatments were evaluables. An overall response rate of 82.2% was obtained: complete in 38.3% and partial in 43.8%, irrespective of total dose, fractionation and location of irradiated spinal metameres. The analysis of results did not show significant differences between the treatment courses. Conclusions We confirm that radiation therapy has a major role in the management of pain control and prevention of fractures in patients with spinal metastases. Hypofractionated and single fraction treatments showed equal efficacy compared to more prolonged therapy, with an advantage for the patient and the radiation therapy institution.
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Affiliation(s)
- V Tombolini
- Istituto di Radiologia, Università degli studi di Roma La Sapienza, Italy
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12
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Maranzano E, Latini P, Beneventi S, Marafioti L, Piro F, Perrucci E, Lupattelli M. Comparison of two Different Radiotherapy Schedules for Spinal Cord Compression in Prostate Cancer. TUMORI JOURNAL 2018; 84:472-7. [PMID: 9824999 DOI: 10.1177/030089169808400407] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background To assess the clinical outcome and toxicity of two different radiotherapy (RT) schedules for the management of metastatic spinal cord compression from prostate cancer, we performed a prospective analysis of 44 patients with the complication. Methods Two different RT schedules were adopted, a split-course regimen of 5 Gy x 3, 4 days rest, and then 3 Gy x 5, and a short-course regimen of 8 Gy, 7 days rest, and then 8 Gy. The split-course RT was adopted for all prostate cancer patients referred to our center between 1986 and 1992. Starting in 1993, the short-course RT was added for patients with a poor prognosis (i.e., paresis or paraplegia, low performance status, and/or short life expectation), whereas others still underwent the split-course regimen. So, 27 (61%) patients were treated with the split-course and the other 17 (39%) with the short-course regimen. Medium follow-up was 48 months (range, 6 to 123). Results Back pain total response rate was 82%. Effectiveness of RT on motor and bladder capacity was conditioned by pretreatment status of patients. All 20 (100%) walking cases maintained the function, whereas 11 of 24 (46%) with motor impairment regained the ability. The difference in response rate was statistically significant (P<0.001). All 36 (100%) patients, able to void at presentation preserved the capacity, whereas 3 of 8 (38%) with sphincter dysfunction no longer needed an indwelling catheter. Posttreatment neurologic status was the only factor found to affect survival. Median survival, 9 months for the whole group, was 10 and 2 months for posttreatment walking and nonwalking patients, respectively (10 vs 2 months, P<0.001). Neither presence of other metastases nor RT regimen used (split vs short-course) conditioned response rate, duration of response or survival. Acute or late, severe toxicity was never recorded. No patient complained of spinal cord morbidity. Conclusions Both split-course and short-course RT schedules were effective and without complications. Early diagnosis was the most important prognostic factor, but there was also recovery of function in about half of the patients unable to walk, and about one-third of patients with bladder dysfunction before treatment. Since length of the course of therapy is a factor with an important impact on the patient's quality of life, the short-course RT regimen adopted in the trial merits further investigation.
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Affiliation(s)
- E Maranzano
- Radiation Oncology Center, Policlinico Hospital of Perugia, Italy
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13
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Suzuki G, Yamazaki H, Aibe N, Masui K, Sasaki N, Tatekawa K, Shimizu D, Kimoto T, Nishimura T, Nakashima A, Yamada K. Palliative Reirradiation for Painful Bone Metastases: Clinical Cases and Literature Review. Kurume Med J 2018; 64:5-11. [PMID: 29249780 DOI: 10.2739/kurumemedj.ms6400004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Reirradiation to previously irradiated peripheral bone metastases for pain has been shown to be safe and effective, but no specific trial has been completed to define the indications for reirradiation of patients with recurrent symptoms of metastatic bone disease. Thus, we aimed to assess the effectiveness and prognostic factors of reirradiation for painful bone metastases. To do so, we reviewed the cases of 14 patients with painful bone metastases who had undergone reirradiation at our hospital. A favorable pain response after reirradiation was achieved in 50% (7/14) of the patients. An interval from initial radiotherapy >6 months was a significant prog nostic factor for pain response (p = 0.03). Performance status was correlated with pain response, with borderline significance (p = 0.06). No severe adverse events were reported. We conclude that reirradiation of painful bone metastases is effective in providing pain relief, especially for patients with a long interval from initial radiation and good performance status.
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Affiliation(s)
- Gen Suzuki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Koji Masui
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Naomi Sasaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kotoha Tatekawa
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Daisuke Shimizu
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takuya Kimoto
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takeshi Nishimura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Akihiro Nakashima
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kei Yamada
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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14
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SEOM Clinical Guideline for bone metastases from solid tumours (2016). Clin Transl Oncol 2016; 18:1243-1253. [PMID: 27896639 PMCID: PMC5138247 DOI: 10.1007/s12094-016-1590-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 12/25/2022]
Abstract
Bone metastases are common in many advanced solid tumours, being breast, prostate, thyroid, lung, and renal cancer the most prevalent. Bone metastases can produce skeletal-related events (SREs), defined as pathological fracture, spinal cord compression, need of bone irradiation or need of bone surgery, and hypercalcaemia. Patients with bone metastases experience pain, functional impairment and have a negative impact on their quality of life. Several imaging techniques are available for diagnosis of this disease. Bone-targeted therapies include zoledronic acid, a potent biphosfonate, and denosumab, an anti-RANKL monoclonal antibody. Both reduce the risk and/or delay the development of SREs in several types of tumours. Radium 233, an alpha-particle emitter, increases overall survival in patients with bone metastases from resistant castration prostate cancer. Multidisciplinary approach is essential and bone surgery and radiotherapy should be integrated in the treatment of bone metastases when necessary. This SEOM Guideline reviews bone metastases pathogenesis, clinical presentations, lab tests, imaging techniques for diagnosis and response assessment, bone-targeted agents, and local therapies, as radiation and surgery, and establishes recommendations for the management of patients with metastases to bone.
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15
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van der Velden JM, Verkooijen HM, Seravalli E, Hes J, Gerlich AS, Kasperts N, Eppinga WSC, Verlaan JJ, van Vulpen M. Comparing conVEntional RadioTherapy with stereotactIC body radiotherapy in patients with spinAL metastases: study protocol for an randomized controlled trial following the cohort multiple randomized controlled trial design. BMC Cancer 2016; 16:909. [PMID: 27871280 PMCID: PMC5117527 DOI: 10.1186/s12885-016-2947-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/10/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Standard radiotherapy is the treatment of first choice in patients with symptomatic spinal metastases, but is only moderately effective. Stereotactic body radiation therapy is increasingly used to treat spinal metastases, without randomized evidence of superiority over standard radiotherapy. The VERTICAL study aims to quantify the effect of stereotactic radiation therapy in patients with metastatic spinal disease. METHODS/DESIGN This study follows the 'cohort multiple Randomized Controlled Trial' design. The VERTICAL study is conducted within the PRESENT cohort. In PRESENT, all patients with bone metastases referred for radiation therapy are enrolled. For each patient, clinical and patient-reported outcomes are captured at baseline and at regular intervals during follow-up. In addition, patients give informed consent to be offered experimental interventions. Within PRESENT, 110 patients are identified as a sub cohort of eligible patients (i.e. patients with unirradiated painful, mechanically stable spinal metastases who are able to undergo stereotactic radiation therapy). After a protocol amendment, also patients with non-spinal bony metastases are eligible. From the sub cohort, a random selection of patients is offered stereotactic radiation therapy (n = 55), which patients may accept or refuse. Only patients accepting stereotactic radiation therapy sign informed consent for the VERTICAL trial. Non-selected patients (n = 55) receive standard radiotherapy, and are not aware of them serving as controls. Primary endpoint is pain response after three months. Data will be analyzed by intention to treat, complemented by instrumental variable analysis in case of substantial refusal of the stereotactic radiation therapy in the intervention arm. DISCUSSION This study is designed to quantify the treatment response after (stereotactic) radiation therapy in patients with symptomatic spinal metastases. This is the first randomized study in palliative care following the cohort multiple Randomized Controlled Trial design. This design addresses common difficulties associated with classic pragmatic randomized controlled trials, such as disappointment bias in patients allocated to the control arm, slow recruitment, and poor generalizability. TRIAL REGISTRATION The Netherlands Trials Register number NL49316.041.14. ClinicalTrials.gov registration number NCT02364115 . Date of trial registration February 1, 2015.
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Affiliation(s)
- Joanne M van der Velden
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Helena M Verkooijen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jochem Hes
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - A Sophie Gerlich
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Nicolien Kasperts
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Wietse S C Eppinga
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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16
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Robson T, Worthington J, McKeown SR, Hirst DG. Radiogenic Therapy: Novel Approaches for Enhancing Tumor Radiosensitivity. Technol Cancer Res Treat 2016; 4:343-61. [PMID: 16029055 DOI: 10.1177/153303460500400404] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Radiotherapy (RT) is a well established modality for treating many forms of cancer. However, despite many improvements in treatment planning and delivery, the total radiation dose is often too low for tumor cure, because of the risk of normal tissue damage. Gene therapy provides a new adjunctive strategy to enhance the effectiveness of RT, offering the potential for preferential killing of cancer cells and sparing of normal tissues. This specificity can be achieved at several levels including restricted vector delivery, transcriptional targeting and specificity of the transgene product. This review will focus on those gene therapy strategies that are currently being evaluated in combination with RT, including the use of radiation sensitive promoters to control the timing and location of gene expression specifically within tumors. Therapeutic transgenes chosen for their radiosensitizing properties will also be reviewed, these include: gene correction therapy, in which normal copies of genes responsible for radiation-induced apoptosis are transfected to compensate for the deletions or mutated variants in tumor cells (p53 is the most widely studied example). enzymes that synergize the radiation effect, by generation of a toxic species from endogenous precursors ( e.g., inducible nitric oxide synthase) or by activation of non toxic prodrugs to toxic species ( e.g., herpes simplex virus thymidine kinase/ganciclovir) within the target tissue. conditionally replicating oncolytic adenoviruses that synergize the radiation effect. membrane transport proteins ( e.g., sodium iodide symporter) to facilitate uptake of cytotoxic radionuclides. The evidence indicates that many of these approaches are successful for augmenting radiation induced tumor cell killing with clinical trials currently underway.
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Affiliation(s)
- T Robson
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
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17
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Vergleich unterschiedlicher Fraktionsdosen bei der Einzeitbestrahlung schmerzhafter Knochenmetastasen. Strahlenther Onkol 2015; 191:817-8. [DOI: 10.1007/s00066-015-0876-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Thureau S, Leysalle A, Faivre JC, Lagrange JL. [Radiotherapy of bone metastases: Which fractionations?]. Cancer Radiother 2015; 19:437-41. [PMID: 26321686 DOI: 10.1016/j.canrad.2015.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 06/23/2015] [Accepted: 06/29/2015] [Indexed: 12/12/2022]
Abstract
First-line palliative radiotherapy for painful bone metastases is an effective treatment whatever its fractionation (single or multiple fractions). It is also indicated after failure or insufficient effect of a first irradiation, or the appearance of new painful site. Other indications are spinal cord compression, either as an adjuvant to surgery or as sole treatment, and after surgery for long bone metastases. The development of high precision techniques (stereotactic conditions) widens the possibility of re-irradiation when tolerance doses to normal tissues have already been delivered. Local control and possibly overall survival could be improved in oligometastatic patients.
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Affiliation(s)
- S Thureau
- Quantif-Litis EA 4108, département de radiothérapie et de physique médicale, département de médecine nucléaire, centre Henri-Becquerel, 76038 Rouen, France.
| | - A Leysalle
- Département de radiothérapie, centre Antoine-Lacassagne, 33, avenue Valombrose, 06100 Nice, France
| | - J-C Faivre
- Département de radiothérapie, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandœuvre-lès-Nancy, France
| | - J-L Lagrange
- Service de radiothérapie, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Upec, avenue du Général-de-Gaulle, 94010 Créteil cedex, France
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19
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Rose JN, Crook JM. The role of radiation therapy in the treatment of metastatic castrate-resistant prostate cancer. Ther Adv Urol 2015; 7:135-45. [PMID: 26161144 DOI: 10.1177/1756287215576647] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In the setting of castrate-resistant prostate cancer, patients present with a variety of symptoms, including bone metastases, spinal cord compression and advanced pelvic disease. Fortunately, a variety of radiotherapeutic options exist for palliation. This article focuses on these options, including both external beam radiotherapy and radiopharmaceuticals.
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Affiliation(s)
- Jim N Rose
- Department of Radiation Oncology, British Columbia Cancer Agency, Cancer Centre for the Southern Interior, Kelowna, BC, Canada
| | - Juanita M Crook
- Department of Radiation Oncology, Cancer Centre for the Southern Interior, 399 Royal Avenue, Kelowna, BC, Canada V1Y 5L3
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20
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Hoskin P, Rojas A, Fidarova E, Jalali R, Mena Merino A, Poitevin A, Oucrif S, Abdelwahab S, Kochbati L, Plieskiene A, Casas F, Stojanovic S, Schneider G, Jeremic B. IAEA randomised trial of optimal single dose radiotherapy in the treatment of painful bone metastases. Radiother Oncol 2015; 116:10-4. [DOI: 10.1016/j.radonc.2015.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/12/2015] [Accepted: 05/16/2015] [Indexed: 12/25/2022]
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21
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Kapoor A, Singhal MK, Kumar N, Kalwar A, Bagri PK, Narayan S, Nirban RK, Kumar HS. Analysis of patterns of palliative radiotherapy in north west India: a regional cancer center experience. Indian J Palliat Care 2015; 21:168-73. [PMID: 26009670 PMCID: PMC4441178 DOI: 10.4103/0973-1075.156482] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Palliative radiotherapy (PRT) is the eventual requirement in 30-50% of all cancer patients. PRT is primarily aimed to relieve pain and prevent/treat collapse or fracture in case of bone metastasis, to reduce edema in patients with cranial metastasis, and to control distressing symptoms of rapid primary growth. An audit of PRT planned in a busy cancer center can help in the characterization of the requirements of the patients and the formulation of institutional policies. Materials and Methods: In total, 516 patients who received PRT in our regional cancer center from January 2012 to December 2012 and whose complete records were available for analysis were selected for this retrospective study. Medical records and radiotherapy files were analyzed to obtain data such as sociodemographic parameters, prescription of PRT, and follow up. Descriptive statistics were evaluated in terms of frequencies and percentages to allow comparisons. Results: Of the 516 patients, 73% patients were male; the median age of the patients receiving PRT was 62 years (range 13-83 years). About 48% (n = 248) patients received PRT at the primary site while rest (52%) were given PRT at the metastatic site. The most common indication of PRT was pain (56.8% cases), followed by cytostatic PRT (19.8%) and raised ICT (12.4%). The median dose prescribed was 30 Gy (range 8-36 Gy) delivered in 1-12 fractions over the duration of 1-18 days. The overall response rate was about 43% at 2 weeks of completion of PRT; the median follow-up of the patients was 154 days (range 9-256 days). The long-term symptom relief at median follow up was 8%. Conclusions: Good clinical judgment and expertise is required in prescribing correct fractionation schedule to achieve effective symptom palliation with lowest possible cost and inconvenience to the patients and relatives. Hypofractionated radiotherapy is a feasible treatment option in patients with advanced incurable disease to achieve effective palliation.
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Affiliation(s)
- Akhil Kapoor
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Mukesh Kumar Singhal
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | | | - Ashok Kalwar
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Puneet Kumar Bagri
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Satya Narayan
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Raj Kumar Nirban
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Harvindra Singh Kumar
- Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India
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22
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Iyer JG, Parvathaneni U, Gooley T, Miller NJ, Markowitz E, Blom A, Lewis CW, Doumani RF, Parvathaneni K, Anderson A, Bestick A, Liao J, Kane G, Bhatia S, Paulson K, Nghiem P. Single-fraction radiation therapy in patients with metastatic Merkel cell carcinoma. Cancer Med 2015; 4:1161-70. [PMID: 25908228 PMCID: PMC4559027 DOI: 10.1002/cam4.458] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/27/2015] [Accepted: 03/08/2015] [Indexed: 12/20/2022] Open
Abstract
Merkel cell carcinoma (MCC) is an aggressive, polyomavirus-associated cancer with limited therapeutic options for metastatic disease. Cytotoxic chemotherapy is associated with high response rates, but responses are seldom durable and toxicity is considerable. Here, we report our experience with palliative single-fraction radiotherapy (SFRT) in patients with metastatic MCC. We conducted retrospective analyses of safety and efficacy outcomes in patients that received SFRT (8 Gy) to MCC metastases between 2010 and 2013. Twenty-six patients were treated with SFRT to 93 MCC tumors located in diverse sites that included skin, lymph nodes, and visceral organs. Objective responses were observed in 94% of the measurable irradiated tumors (86/92). Complete responses were observed in 45% of tumors (including bulky tumors up to 16 cm). “In field” lesion control was durable with no progression in 77% (69/89) of treated tumors during median follow-up of 277 days among 16 living patients. Clinically significant toxicity was seen in only two patients who had transient side effects. An exploratory analysis suggested a higher rate of in-field progression in patients with an immunosuppressive comorbidity or prior recent chemotherapy versus those without (30% and 9%, respectively; P = 0.03). Use of SFRT in palliating MCC patients was associated with an excellent in field control rate and durable responses at treated sites, and with minimal toxicity. SFRT may represent a convenient and appealing alternative to systemic chemotherapy for palliation, for which most patients with oligometastatic MCC are eligible. SFRT may also synergize with emerging systemic immune stimulants by lowering tumor burden and enhancing presentation of viral/tumor antigens.
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Affiliation(s)
- Jayasri G Iyer
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | | | - Ted Gooley
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Natalie J Miller
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Elan Markowitz
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Astrid Blom
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Christopher W Lewis
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Ryan F Doumani
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Kaushik Parvathaneni
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Austin Anderson
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Amy Bestick
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Jay Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Gabrielle Kane
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Shailender Bhatia
- Fred Hutchinson Cancer Research Center, Seattle, Washington.,Seattle Cancer Care Alliance, Seattle, Washington.,Department of Medicine/Oncology, University of Washington, Seattle, Washington
| | - Kelly Paulson
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington
| | - Paul Nghiem
- Department of Medicine/Dermatology, University of Washington, Seattle, Washington.,Fred Hutchinson Cancer Research Center, Seattle, Washington.,Seattle Cancer Care Alliance, Seattle, Washington
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23
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Radiothérapie des métastases osseuses : indications actuelles et nouvelles perspectives. ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2492-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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McQuay HJ, Collins SL, Carroll D, Moore RA, Derry S. WITHDRAWN: Radiotherapy for the palliation of painful bone metastases. Cochrane Database Syst Rev 2013; 2013:CD001793. [PMID: 24271498 PMCID: PMC6564087 DOI: 10.1002/14651858.cd001793.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This review is out of date and has been withdrawn. The content of the review may be of historical interest to readers. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Henry J McQuay
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)West Wing (Level 6)John Radcliffe HospitalOxfordOxfordshireUKOX3 9DU
| | - Sally L Collins
- University of OxfordNuffield Department of Obstetrics and GynaecologyThe Fetal Medicine Unit, Level 6, Women's CentreJohn Radcliffe HospitalOxfordOxfordshireUKOX3 9DU
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26
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Thavarajah N, Zhang L, Wong K, Bedard G, Wong E, Tsao M, Danjoux C, Barnes E, Sahgal A, Dennis K, Holden L, Lauzon N, Chow E. Patterns of practice in the prescription of palliative radiotherapy for the treatment of bone metastases at the Rapid Response Radiotherapy Program between 2005 and 2012. ACTA ACUST UNITED AC 2013; 20:e396-405. [PMID: 24155637 DOI: 10.3747/co.20.1457] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE We examined whether patterns of practice in the prescription of palliative radiation therapy for bone metastases had changed over time in the Rapid Response Radiotherapy Program (rrrp). METHODS After reviewing data from August 1, 2005, to April 30, 2012, we analyzed patient demographics, diseases, organizational factors, and possible reasons for the prescription of various radiotherapy fractionation schedules. The chi-square test was used to detect differences in proportions between unordered categorical variables. Univariate logistic regression analysis and the simple Fisher exact test were also used to determine the factors most significant to choice of dose-fractionation schedule. RESULTS During the study period, 2549 courses of radiation therapy were prescribed. In 65% of cases, a single fraction of radiation therapy was prescribed, and in 35% of cases, multiple fractions were prescribed. A single fraction of radiation therapy was more frequently prescribed when patients were older, had a prior history of radiation, or had a prostate primary, and when the radiation oncologist had qualified before 1990. CONCLUSIONS For patients with bone metastasis, a single fraction of radiation therapy was prescribed with significantly greater frequency.
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Affiliation(s)
- N Thavarajah
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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Wong E, Hoskin P, Bedard G, Poon M, Zeng L, Lam H, Vulpe H, Tsao M, Pulenzas N, Chow E. Re-irradiation for painful bone metastases - a systematic review. Radiother Oncol 2013; 110:61-70. [PMID: 24094630 DOI: 10.1016/j.radonc.2013.09.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/06/2013] [Accepted: 09/08/2013] [Indexed: 12/25/2022]
Abstract
The purpose of this review was to determine the efficacy of re-irradiation in patients with bone metastases. A literature search was conducted in Ovid Medline, OldMedline, Embase, Embase Classic, and Cochrane Central Register of Controlled Trials using relevant subject headings and keywords such as bone metastases, radiotherapy and palliative care. The resulting articles were sorted for inclusion for palliative external beam radiation retreatment response rate data. The literature search produced 2164 references and 15 articles were included in the final selection. Complete, partial and overall response rates were calculated to be 20%, 50% and 68%, respectively. Information on treatment toxicities was scarce. The efficacy of re-irradiation is comparable to initial radiation treatment. However, aspects of re-irradiation treatment including dose fractionation, related adverse events and toxicities require further corroboration.
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Affiliation(s)
- Erin Wong
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Peter Hoskin
- Mount Vernon Hospital Cancer Centre, Middlesex, United Kingdom
| | - Gillian Bedard
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Michael Poon
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Liang Zeng
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Henry Lam
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Horia Vulpe
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - May Tsao
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Natalie Pulenzas
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada.
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Palliative radiotherapy for bone metastases: assessment of factors influencing dose-fractionation schedules at a UK cancer centre. JOURNAL OF RADIOTHERAPY IN PRACTICE 2013. [DOI: 10.1017/s1460396912000295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractContextMeta-analyses demonstrate single-fraction radiotherapy to be as effective as multi-fraction treatment in palliating painful bone metastases, although surveys suggest reluctance in prescribing single fractions.AimsAssess the factors influencing the choice of dose-fractionation regimen in an unselected population; examine retreatment rates and subsequent skeletal events.MethodsData were extracted from case notes for 120 patients treated in 2000 and 2006 in a single centre serving a defined population; analysis used χ2 and Fisher's exact statistical tests.ResultsAn 8 Gy fraction was the commonest regimen prescribed (single-fraction delivery rate 53·6%). Tumour site was a significant factor in choice of dose-fractionation schedule. Patients with metastatic breast carcinoma were significantly less likely to receive single-fraction treatment compared with those with metastatic lung carcinoma (year 2000: p = 0·038, 2006: p = 0·001). There was a significantly higher retreatment rate following single-fraction compared with multi-fraction treatment (11% versus 3%). There were two subsequent neural axis compressions and four pathological fractures.ConclusionsSingle-fraction treatment is the commonest regimen but multiple fractions are still frequently delivered. Better prognosis groups appear more likely to receive multi-fraction treatment, possibly to avoid the need for retreatment. Subsequent skeletal events are rare but carry high morbidity when they occur.
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Nieder C, Pawinski A, Dalhaug A. Continuous controversy about radiation oncologists' choice of treatment regimens for bone metastases: should we blame doctors, cancer-related features, or design of previous clinical studies? Radiat Oncol 2013; 8:85. [PMID: 23574944 PMCID: PMC3643865 DOI: 10.1186/1748-717x-8-85] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 04/07/2013] [Indexed: 12/25/2022] Open
Abstract
Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases. Routine use of single fraction treatment might or might not be the preferred institutional approach. It is not entirely clear why inter-physician and inter-institution differences continue to persist despite numerous randomized trials, meta-analyses and guidelines, which recommend against more costly and inconvenient multi-fraction regimens delivering total doses of 30 Gy or more in a large number of clinical scenarios. In the present mini-review we discuss the questions of whether doctors are ignoring evidence-based medicine or whether we need additional studies targeting specifically those patient populations where recent surveys identified inconsistent treatment recommendations, e.g. because of challenging disease extent. We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, 8092, Norway.
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Dennis K, Makhani L, Zeng L, Lam H, Chow E. Single fraction conventional external beam radiation therapy for bone metastases: A systematic review of randomised controlled trials. Radiother Oncol 2013; 106:5-14. [DOI: 10.1016/j.radonc.2012.12.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 12/10/2012] [Accepted: 12/10/2012] [Indexed: 12/25/2022]
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Cutler CS, Hennkens HM, Sisay N, Huclier-Markai S, Jurisson SS. Radiometals for Combined Imaging and Therapy. Chem Rev 2012. [DOI: 10.1021/cr3003104] [Citation(s) in RCA: 281] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Cathy S. Cutler
- University of Missouri Research Reactor Center, Columbia, Missouri 65211, United
States
| | - Heather M. Hennkens
- University of Missouri Research Reactor Center, Columbia, Missouri 65211, United
States
| | - Nebiat Sisay
- University of Missouri Research Reactor Center, Columbia, Missouri 65211, United
States
- Department of Chemistry, University of Missouri, Columbia, Missouri 65211, United
States
| | - Sandrine Huclier-Markai
- Laboratoire Subatech,
UMR 6457, Ecole des Mines de Nantes/Université de Nantes/CNRS-IN2P3, 4 Rue A. Kastler, BP 20722, F-44307
Nantes Cedex 3, France
| | - Silvia S. Jurisson
- Department of Chemistry, University of Missouri, Columbia, Missouri 65211, United
States
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Ferreira S, Dormehl I, Botelho MF. Radiopharmaceuticals for bone metastasis therapy and beyond: a voyage from the past to the present and a look to the future. Cancer Biother Radiopharm 2012; 27:535-51. [PMID: 23075374 DOI: 10.1089/cbr.2012.1258] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Bone cancer can be divided into primary and secondary (metastatic) bone cancer. Osteosarcoma is the most common type of primary bone cancer, but still is a rare cancer. The development of bone metastases is a common event for the cancer patient and the main cause of treatment failure and death, being chronic pain syndrome the most important complication. There are currently several therapeutic modalities for the treatment of metastatic bone disease, including radiation therapy. Treatment with radionuclides (β- and α-particle emitters and Auger electron cascades) is a safe and effective tool of medicine. There is a great deal of interest in diphosphonic acids in nuclear medicine as ligands for radiometals in bone-seeking diagnostic and therapeutic agents. Several radiopharmaceuticals have been designed with the phosphonates as ligands. A recent approach to develop an effective radiopharmaceutical for therapy of bone cancer was the design of a water-soluble polymer that would exploit the disrupted vasculature in tumors according to the enhanced permeability and retention effect. To enhance the effect of radionuclide therapy on the cancer cells, new strategies have recently been investigated, such as the combined radionuclide and chemotherapy, high-dose radionuclide therapy, and repeated radionuclide therapy.
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Affiliation(s)
- Sara Ferreira
- Biophysics Unit, Institute of Biomedical Research in Light and Image, Faculty of Medicine, University of Coimbra, Portugal.
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Ashford RU, Benjamin L, Pendlebury S, Stalley PD. The modern surgical and non-surgical management of appendicular skeletal metastases. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.mporth.2012.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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A randomized, dose-response, multicenter phase II study of radium-223 chloride for the palliation of painful bone metastases in patients with castration-resistant prostate cancer. Eur J Cancer 2012; 48:678-86. [PMID: 22341993 DOI: 10.1016/j.ejca.2011.12.023] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 12/16/2011] [Accepted: 12/20/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate the dose-response relationship and pain-relieving effect of radium-223, a highly bone-targeted alpha-pharmaceutical. METHODS One hundred patients with castration-resistant prostate cancer (CRPC) and painful bone metastases were randomized to a single intravenous dose of 5, 25, 50 or 100 k Bq/kg radium-223. The primary end-point was pain index (visual analogue scale [VAS] and analgesic use), also used to classify patients as responders or non-responders. RESULTS A significant dose response for pain index was seen at week 2 (P = .035). At week 8 there were 40%, 63%, 56% and 71% pain responders (reduced pain and stable analgesic consumption) in the 5, 25, 50 and 100 k Bq/kg groups, respectively. On the daily VAS, at week 8, pain decreased by a mean of -30, -31, -27 and -28 mm, respectively (P = .008, P = .0005, P = .002, and P < . 0001) in these responders (post-hoc analysis). There was also a significant improvement in the brief pain inventory functional index for all dose-groups (P = .04, .01, .002 and .02, Wilcoxon signed rank test). Furthermore, a decrease in bone alkaline phosphatase in the highest dose-group was demonstrated (P = .0067). All doses were safe and well tolerated. CONCLUSION Pain response was seen in up to 71% of the patients with a dose response observed 2 weeks after administration. The highly tolerable side-effect profile of radium-223 previously reported was confirmed.
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Huisman M, van den Bosch MAAJ, Wijlemans JW, van Vulpen M, van der Linden YM, Verkooijen HM. Effectiveness of reirradiation for painful bone metastases: a systematic review and meta-analysis. Int J Radiat Oncol Biol Phys 2012; 84:8-14. [PMID: 22300568 DOI: 10.1016/j.ijrobp.2011.10.080] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/14/2011] [Accepted: 10/28/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE Reirradiation of painful bone metastases in nonresponders or patients with recurrent pain after initial response is performed in up to 42% of patients initially treated with radiotherapy. Literature on the effect of reirradiation for pain control in those patients is scarce. In this systematic review and meta-analysis, we quantify the effectiveness of reirradiation for achieving pain control in patients with painful bone metastases. METHODS AND MATERIALS A free text search was performed to identify eligible studies using the MEDLINE, EMBASE, and the Cochrane Collaboration library electronic databases. After study selection and quality assessment, a pooled estimate was calculated for overall pain response for reirradiation of metastatic bone pain. RESULTS Our literature search identified 707 titles, of which 10 articles were selected for systematic review and seven entered the meta-analysis. Overall study quality was mediocre. Of the 2,694 patients initially treated for metastatic bone pain, 527 (20%) patients underwent reirradiation. Overall, a pain response after reirradiation was achieved in 58% of patients (pooled overall response rate 0.58, 95% confidence interval = 0.49-0.67). There was a substantial between-study heterogeneity (I² = 63.3%, p = 0.01) because of clinical and methodological differences between studies. CONCLUSIONS Reirradiation of painful bone metastases is effective in terms of pain relief for a small majority of patients; approximately 40% of patients do not benefit from reirradiation. Although the validity of results is limited, this meta-analysis provides a comprehensive overview and the most quantitative estimate of reirradiation effectiveness to date.
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Affiliation(s)
- Merel Huisman
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.
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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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38
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Radiation Therapy in the Management of Cancer Pain. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00034-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Sutton DS, Kong W, Ding K, Mackillop WJ. The use of palliative radiotherapy for bone metastasis. Radiother Oncol 2010; 97:548-53. [DOI: 10.1016/j.radonc.2010.09.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 09/20/2010] [Accepted: 09/20/2010] [Indexed: 11/28/2022]
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International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys 2009; 75:1501-10. [PMID: 19464820 DOI: 10.1016/j.ijrobp.2008.12.084] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 12/20/2008] [Accepted: 12/29/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE Multiple randomized controlled trials have demonstrated the equivalence of multifraction and single-fraction (SF) radiotherapy for the palliation of painful bone metastases (BM). However, according to previous surveys, SF schedules remain underused. The objectives of this study were to determine the current patterns of practice internationally and to investigate the factors influencing this practice. METHODS AND MATERIALS The members of three global radiation oncology professional organizations (American Society for Radiology Oncology [ASTRO], Canadian Association of Radiation Oncology [CARO], Royal Australian and New Zealand College of Radiologists) completed an Internet-based survey. The respondents described what radiotherapy dose fractionation they would recommend for 5 hypothetical cases describing patients with single or multiple painful BMs from breast, lung, or prostate cancer. Radiation oncologists rated the importance of patient, tumor, institution, and treatment factors, and descriptive statistics were compiled. The chi-square test was used for categorical variables and the Student t test for continuous variables. Logistic regression analysis identified predictors of the use of SF radiotherapy. RESULTS A total of 962 respondents, three-quarters ASTRO members, described 101 different dose schedules in common use (range, 3 Gy/1 fraction to 60 Gy/20 fractions). The median dose overall was 30 Gy/10 fractions. SF schedules were used the least often by ASTRO members practicing in the United States and most often by CARO members. Case, membership affiliation, country of training, location of practice, and practice type were independently predictive of the use of SF. The principal factors considered when prescribing were prognosis, risk of spinal cord compression, and performance status. CONCLUSION Despite abundant evidence, most radiation oncologists continue to prescribe multifraction schedules for patients who fit the eligibility criteria of previous randomized controlled trials. Our results have confirmed a delay in the incorporation of evidence into practice for palliative radiotherapy for painful bone metastases.
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Janjan N, Lutz ST, Bedwinek JM, Hartsell WF, Ng A, Pieters RS, Ratanatharathorn V, Silberstein EB, Taub RJ, Yasko AW, Rettenmaier A. Therapeutic Guidelines for the Treatment of Bone Metastasis: A Report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology. J Palliat Med 2009; 12:417-26. [DOI: 10.1089/jpm.2009.9633] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nora Janjan
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Andrea Ng
- Harvard University, Boston, Massachusetts
| | | | | | | | - Robert J. Taub
- Cedars Sinai Hospice Program, American Society of Clinical Oncology, Los Angeles, California
| | - Alan W. Yasko
- MED-Orthopedic Surgery, American Academy of Orthopaedic Surgeons, Chicago, Illinois
| | - Andrew Rettenmaier
- Department of Economics and the Private Enterprise Research Center, Texas A&M University, College Station, Texas
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Sande TA, Ruenes R, Lund JA, Bruland OS, Hornslien K, Bremnes R, Kaasa S. Long-term follow-up of cancer patients receiving radiotherapy for bone metastases: results from a randomised multicentre trial. Radiother Oncol 2009; 91:261-6. [PMID: 19307034 DOI: 10.1016/j.radonc.2009.02.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 02/05/2009] [Accepted: 02/15/2009] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to compare the need for re-irradiation, rates of pathological fractures, and spinal cord compressions in patients randomised to single-fraction radiotherapy (8 Gy x 1) or multiple-fraction therapy (3 Gy x 10) and with a long-term follow-up. The underlying hypothesis was that single-fraction and multiple-fraction regimens are equally effective. MATERIAL AND METHODS The present study reports on the Norwegian sub sample of an international large prospective-randomised multicentre study. One hundred and eighty patients with painful skeletal metastases in four Norwegian hospitals were randomised to receive single-fraction (8 Gy x 1) or multiple-fraction (3 Gy x 10) radiotherapy. RESULTS Patients in the single-fraction arm received significantly more re-irradiations as compared to the multiple-fraction arm (27% versus 9%, p=0.002). There were no significant differences in the rate of pathological fractures (5% versus 5%, p=1.00) or spinal cord compressions (1% versus 4%, p=0.37) between the two treatment groups. CONCLUSION The present study indicates no difference between radiotherapy with 8 Gy x 1 and 3 Gy x 10 for the majority of patients with painful bone metastases, also in a long-term perspective. Importantly, the patients in this study were followed up until death, and the trial showed no disadvantage for 8 Gy x 1 compared to 3 Gy x 10. Despite the fact that single-fraction treatment will imply an approximately 2.5-fold greater need for re-irradiation, single-fraction treatment is considered more convenient for the patients and more cost-effective for the radiotherapy departments.
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Affiliation(s)
- Tonje Anette Sande
- Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway
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A dosimetric comparison of different treatment plans of palliative spinal bone irradiation: analysis of dose coverage with respect to ICRU 50 Report. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2009; 28:2. [PMID: 19128500 PMCID: PMC2636764 DOI: 10.1186/1756-9966-28-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 01/07/2009] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study aimed to analyze three-dimensional (3D) dosimetric data of conventional two-dimensional (2D) palliative spinal bone irradiation using different reference points and treatment plans with respect to the International Commission on Radiation Units and Measurements (ICRU) Report 50. METHODS Forty-five simulation CT scans of 39 patients previously treated for thoraco-lumbar spinal bone metastases were used. Three different treatment plans were created: (1) single posterior field plans using the ICRU reference points (ICRUrps); (2) single posterior field plans using the International Bone Metastasis Consensus Working Party reference points (IBMCrps); (3) two opposed anterior-posterior (AP-PA) field plans using the ICRUrps. The intended dose range for planning target volume (PTV) was 90% to 110% of the prescribed dose for AP-PA field plans. Cumulative dose-volume histograms were generated for each plan, and minimum, maximum and mean doses to the PTV, medulla spinalis, esophagus and intestines were analyzed. RESULTS The mean percentages of minimum, maximum and mean PTV doses +/- standard deviation were, respectively, 91 +/- 1.3%, 108.8 +/- 1.3% and 99.7 +/- 1.3% in AP-PA field plans; 77.3 +/- 2.6%, 122.2 +/- 4.3% and 99.8 +/- 2.6% in ICRUrp single field plans; and 83.7 +/- 3.3%, 133.9 +/- 7.1% and 108.8 +/- 3.3% in IBMCrp single field plans. Minimum doses of both single field plans were significantly lower (p < 0.001) while maximum doses were significantly higher (p < 0.001) than AP-PA field plans. Minimum, maximum and mean doses were higher in IBMCrp single field plans than in ICRUrp single field plans (p < 0.001). The mean medulla spinalis doses were lower in AP-PA field plans than single posterior field plans (p < 0.001). Maximum doses for medulla spinalis were higher than 120% of the prescribed dose in 22 of 45 (49%) IBMCrp single field plans. Mean esophagus and intestinal doses were higher (p < 0.001) in AP-PA field plans than single field plans, however, less than 95% of the prescribed dose. CONCLUSION In palliative spinal bone irradiation, 2D conventional single posterior field radiotherapy did not accomplish the ICRU Report 50 recommendations for PTV dose distribution, while the AP-PA field plans did achieve the intended dose ranges with a homogenous distribution and reasonable doses to the medulla spinalis, esophagus and intestines.
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Pradier O, Bouchekoua M, Albargach N, Muller M, Malhaire JP. Radiothérapie des métastases osseuses : quel est le meilleur schéma de radiothérapie ? Cancer Radiother 2008; 12:837-41. [DOI: 10.1016/j.canrad.2008.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 06/05/2008] [Indexed: 11/27/2022]
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Ratanatharathorn V, Peñagarícano JA. Management of Bone Metastases. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Randomised study of single dose (8 Gy vs. 6 Gy) of analgesic radiotherapy plus zoledronic acid in patients with bone metastases. Clin Transl Oncol 2008; 10:281-7. [PMID: 18490245 DOI: 10.1007/s12094-008-0198-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess the effectiveness of a single dose of radio therapy (8 Gy vs. 6 Gy) plus zoledronic acid in cancer patients with bone metastases in treating pain; quality of life, time to onset of skeletal events and functional status. MATERIAL AND METHODS A total of 139 patients from 22 Spanish hospitals were randomly assigned to: Group A, administered a single dose of 8 Gy+zoledronic acid (4 mg iv, in 15-min infusions), and Group B, administered a single dose of 6 Gy+zoledronic acid (4 mg iv, in 15-min infusions). The main variable was pain, which was assessed with the Visual Analogue Pain Scale (VAS) in supine, seated and standing positions. RESULTS There was a total of 118 patients for intention to treat (n=67 in Group A and n=51 in Group B). The most frequent primary neoplasms were the lung (29.66%), prostate (22.03%) and breast (21.19%). Sixty patients were analysed per protocol, n=34 in group A and n=26 in group B. Improvements were observed in the VAS scores for pain in all three positions. The mean time to onset of the event was greater (p=0.0211) in Group A than in Group B (122 vs. 81.62 days). Functional status improved in Group A, and quality of life improved in both groups. CONCLUSION The two groups achieved similar levels of pain control in supine, seated and standing positions. Quality of life also improved in both groups. However, the higher dose (8 Gy dose) in combination with zoledronic acid is associated with a longer period without skeletal events.
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50
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Gieger T, Rassnick K, Siegel S, Proulx D, Bergman P, Anderson C, LaDue T, Smith A, Northrup N, Roberts R. Palliation of clinical signs in 48 dogs with nasal carcinomas treated with coarse-fraction radiation therapy. J Am Anim Hosp Assoc 2008; 44:116-23. [PMID: 18451069 DOI: 10.5326/0440116] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Data from 48 dogs with nasal carcinomas treated with palliative radiation therapy (PRT) were retrospectively reviewed. Factors potentially influencing resolution of clinical signs and survival after PRT were evaluated. Clinical signs completely resolved in 66% of dogs for a median of 120 days. The overall median survival time was 146 days. Duration of response to PRT was shorter in dogs that had clinical signs for <90 days before PRT. Survival times were shorter in dogs that had partial or no resolution of clinical signs after PRT than in dogs that had complete resolution of clinical signs.
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Affiliation(s)
- Tracy Gieger
- Department of Clinical Sciences, Cornell University Hospital for Animals, CPC Box 31, Tower Road, Ithaca, New York 14853, USA
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