Single 4 Gy re-irradiation for painful bone metastasis following single fraction radiotherapy

Reirradiation of bone metastasis: A narrative review of the literature

Patients with bone metastasis are prevalent among those receiving palliative radiotherapy (RT), with approximately 20 % requiring reirradiation (reirradiation). The goal of bone reirradiation may be local control (oligoreoccurrence or oligoprogression of a previously treated lesion or in a previous treatment field) or symptomatic (threatening or painful progression). Published data on bone reirradiation indicate almost two-thirds of overall pain response. The primary organ at risk (especially for spine treatment) is the spinal cord. The risk of radiation myelitis is<1 % for cumulative doses of<50Gy. Intensity-modulated RT (IMRT) and stereotactic RT (SRT) appear to be safer than three-dimensional RT (3DRT), although randomized trials comparing these techniques in reirradiation are lacking. Reirradiation requires multidisciplinary assessment. Alternative treatments for bone metastases (surgery, interventional radiology, etc.) must be considered. Patients should have a performance status≤2, with at least a 1-month interval between treatments. The planning process involves reviewing previous RT plans, cautious dose adjustments, and precise target delineation and dose distribution to minimize toxicity. Cumulative dosimetry, patient consent, and vigilant post-treatment monitoring and dose reporting are crucial.

Re-irradiation for painful bone metastases using stereotactic body radiotherapy

PURPOSE

Stereotactic body radiotherapy (SBRT) is expected to achieve safe and effective re-irradiation for painful bone metastases. This study aimed to clarify the efficacy of re-irradiation using SBRT for painful bone metastases.

METHODS

Prospective database at our institution for the period between September 2013 and December 2017 were retrospectively reviewed for patients with: (1) painful bone metastases; (2) history of radiotherapy to the metastasis; and (3) SBRT performed as re-irradiation. Pain response, pain failure-free duration, analgesics medications, and adverse events were evaluated. Pain was evaluated using the Numerical Rating Pain Score, and pain response was evaluated based on International Consensus Pain Response Endpoints. Best response during follow-up was noted. Patients with complete or partial response were defined as showing pain response, and patients with pain progression were defined as showing pain failure. Adverse events were evaluated based on the RTOG/EORTC Late Radiation Morbidity Scoring Schema.

RESULTS

Sixty-six patients selected from our database showed: median age, 65 years (range, 33-82 years); ECOG performance status, 0-1/2/3/4, 51/10/3/2; lesion histopathology, rectal/lung/renal/thyroid/other cancer, 13/11/9/5/28; median previous irradiated dose, 30 Gy (range, 8-70.4 Gy); median interval from latest irradiation, 21 months (range, 4-192 months); prescribed dose for SBRT, 24 Gy in 2 fractions/30 Gy in 5 fractions/35 Gy in 5 fractions, 51/13/2. Median follow-up after SBRT was 10 months (range, 1-37 months). Fifty-seven patients achieved pain response (86%). The 1-year pain failure-free rate was 55%. Median pain failure-free duration was 13 months (range, 1-24 months). Grade 4 adverse events were observed in six patients (vertebral compression fracture, n = 5; radiation myelopathy, n = 1). No other toxicities of Grade 3 or greater were encountered.

CONCLUSIONS

Re-irradiation SBRT has potential to achieve good response and long-term pain control for painful bone metastases. Prospective analysis is necessary to confirm the safety and efficacy of SBRT as re-irradiation.

Comparative Evaluation of Two Hypofractionated Radiotherapy Regimens for Painful Bone Metastases

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.

Palliative Reirradiation for Painful Bone Metastases: Clinical Cases and Literature Review

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.

Epidural and intramedullary spinal metastasis: clinical features and role of fractionated radiotherapy

Metastases involving the spinal epidural space and cord parenchyma are major sources of neurological impairment and decreased quality of life in cancer patients. Herein we review the clinical manifestations, pathophysiology, importance of early diagnosis and initiation of treatment, and role of fractionated radiotherapy of these disorders.

The role of radiotherapy in bone metastases: A critical review of current literature

Radiotherapy is considered the treatment of choice for painful bone metastases. However, novel modalities of radiotherapy have emerged in the concept of oligometastasic disease. In addition, the increase of overall survival of patients with bone metastatic disease in the last decades due to systemic treatments has issued the silent topic of re-irradiation. The aim of this manuscript was to present a current thorough search of relevant literature. Originally, 6,087 articles revealed from PubMed database related to radiotherapy and bone metastases. The first objective was to identify prospective randomised phase III studies dealing with bone metastases and which treated primary with radiotherapy. Abstracts and non-English citations were excluded. Twenty-three phase III clinical trials, 17 prospective studies and eight meta-analysis/systemic reviews matching with these criteria, were identified. Eleven randomised studies were comparing single dose fraction to multi-fraction schedules of radiotherapy. The overall response rates and complete response rates were not significant between the two arms. Re-irradiations rates were significantly higher for the single dose fraction arms. Stereotactic radiotherapy showed excellent tumour control rates more than 80%. All trials showed the equivalence of either single or multi-fractionated radiotherapy for metastatic bone lesions. Stereotactic irradiation is feasible and safe for oligometastatic disease. However, it seems that the single fraction of 8 Gy is superior to 4 Gy, in terms of efficacy.

Clinical outcome of patients treated with re-irradiation for spine or pelvic bone metastasis: A multi-institutional analysis of 98 patients

The present study aimed to describe the clinical results of re-irradiation (Re-RT) for spine or pelvic bone metastasis at the same initial irradiated area. Between April 2010 and March 2014, cases involving 98 patients with spine or pelvic bone metastasis who had undergone Re-RT at five institutions were reviewed. The clinical outcomes following Re-RT were evaluated, including overall survival (OS) and severe adverse events. The median time interval from initial radiation therapy (RT) to Re-RT was 439 days (range, 23–4,993 days), and the median duration of patient follow-up was 256 days (range, 11–2,284 days). The median biological effective dose for the Re-RT was 150 Gy₂ (range, 17–240 Gy₂; α/β = 2). Severe late adverse events occurred in two patients who underwent three-dimensional conformal radiotherapy for lumbar spine or pelvic bone metastases, which may be associated with tumor progression. The median survival time following Re-RT was 255 days, and the actuarial OS rate at 1 year was 36%. The interval between initial RT and Re-RT, and their performance statuses (PS) were significant independent prognostic factors for OS rates in multivariate analysis. Re-RT for spine or pelvic bone metastases is a relatively acceptable option with low risk of anticipated severe adverse events, particularly for patients with good PS following a long disease-free interval.

Skeletal metastases from breast cancer: pathogenesis of bone tropism and treatment strategy

Breast cancer (BC) is the most common female cancer worldwide with approximately 10 % of new cases metastatic at diagnosis and 20-50 % of patients with early BC who will eventually develop metastatic disease. Bone is the most frequent site of colonisation and the development of skeletal metastases depends on a complex multistep process, from dissemination and survival of malignant cells into circulation to the actual homing and metastases formation inside bone. Disseminated tumor cells (DTCs) can be detected in bone marrow in approximately 30 % of BC patients, likely reflecting the presence of minimal residual disease that would eventually account for subsequent metastatic disease. Patients with bone marrow DTCs have poorer overall survival compared with patients without them. Although bone-only metastatic disease seems to have a rather indolent behavior compared to visceral disease, bone metastases can cause severe and debilitating effects, including pain, spinal cord compression, hypercalcemia and pathologic fractures. Delivering an appropriate treatment is therefore paramount and ideally it should require interdisciplinary care. Multiple options are currently available, from bisphosphonates to new drugs targeting RANK ligand and radiotherapy. In this review we describe the mechanisms underlying bone colonization and provide an update on existing systemic and locoregional treatments for bone metastases.

Bone health in breast cancer patients: a comprehensive statement by CECOG/SAKK Intergroup

Bone is the most common site of distant metastases in breast cancer that can cause severe and debilitating skeletal related events (SRE) including hypercalcemia of malignancy, pathologic fracture, spinal cord compression and the need for palliative radiation therapy or surgery to the bone. SRE are associated with substantial pain and morbidity leading to frequent hospitalization, impaired quality of life and poor prognosis. The past 25 years of research on the pathophysiology of bone metastases led to the development of highly effective treatment options to delay or prevent osseous metastases and SRE. Management of bone metastases has become an integral part of cancer treatment requiring expertise of multidisciplinary teams of medical and radiation oncologists, surgeons and radiologists in order to find an optimal treatment for each individual patient. A group of international breast cancer experts attended a Skeletal Care Academy Meeting in November 2012 in Istanbul and discussed current preventive measures and treatment options of SRE, which are summarized in this evidence-based consensus for qualified decision- making in clinical practice.

Re-irradiation for painful bone metastases - a systematic review

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.

'Who', 'when' and 'how' in re-irradiation of recurrent painful bone metastases

Re-irradiation of painful bony metastases is increasingly performed since patients are receiving better systemic treatments and having longer life expectancy, and may also be due to the increase use of initial single fraction radiotherapy. However, randomized control trial on the efficacy of re-irradiation is lacking. A recent meta-analysis concluded with a 58% response rate for pain relief by re-irradiation of symptomatic bone metastases. In this review, the effectiveness of re-irradiation in terms of clinical and economical aspects, and clinical questions on who, when, and how to re-irradiate would be discussed. A brief review of other treatment options and comparison with re-irradiation of bone metastases would be performed.

Retreatment with radiotherapy for symptomatic bone, brain or visceral metastases

BACKGROUND

The need for reirradiation in the metastatic disease appears when other modalities of treatment lose their efficacy. The aim of reirradiation in the metastatic disease is mainly palliative to control a particular symptom. However, this theoretical benefit must be confronted against the risk of an undesirable toxicity.

MATERIALS AND METHODS

Experience with reirradiation for symptomatic bone, brain or visceral metastases are reviewed. Twenty-two patients were found to have a second palliative radiotherapy on the same location. Locatión of metastases were visceral in 5 (23 %) patients, brain in 4 (18 %) patients, spine in 1 (4.5 %) patient and bone metastasis other than spine in 12 (54.5 %) patients. Median dose delivered in the first treatment was 30 Gy (range 20-30 Gy) and 20 Gy for the second treatment (range 6-32.4 Gy).

RESULTS

A good symptomatic response after first irradiation (complete response or disappearance of >50 % of symptoms) was reached in 21 (95.5 %) of the 22 patients analyzed. After second irradiation, 82 % (18 patients) achieved a good response, 3 (14 %) patients had a moderate response (relief of symptoms <50 %) whereas no response was observed in 1 (4 %) patient. Acute toxicity was limited to grade 1-2 proctitis in 2 and 3 patients after the first and second irradiation, respectively. No cases of late toxicity after the first or second irradiation were recorded.

CONCLUSION

A second treatment with palliative radiotherapy is feasible and well tolerated and offers the possibility of symptomatic relief in a high percentage of patients with symptomatic metastases.

A review of recently published radiotherapy treatment guidelines for bone metastases: Contrasts or convergence?

Bone metastases are a common manifestation of malignancy, and external beam radiotherapy (EBRT) effectively and safely palliates the pain caused by this clinical circumstance. The myriad of EBRT dosing schemes and complexities involved with coordinating radiotherapy with other interventions necessitated the need for bone metastases treatment guidelines. Here we compare and contrast the bone metastases radiotherapy treatment guidelines recently published by the American Society for Radiation Oncology (ASTRO) and the American College of Radiology (ACR). These evaluations acknowledge current controversies in treatment approaches, they evaluate the nuances of ASTRO and ACR task force decision-making regarding standard approaches to care, and they project the upcoming research results that may clarify approaches to palliative radiotherapy for bone metastases. The results of these two dedicated radiotherapy guidelines are compared to the brief mentions of radiotherapy for bone metastases in the National Comprehensive Cancer Network (NCCN) guidelines. Finally, the paper describes how treatment guidelines may influence patterns of care and reimbursement by their use as quality measures by groups such as the National Quality Forum (NQF).

Effectiveness of reirradiation for painful bone metastases: a systematic review and meta-analysis

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.

Radiation for bone metastases

PURPOSE OF REVIEW

To synopsize the current state-of-the-art for radiation and treatment of painful bone metastases with a focus on prostate cancer.

RECENT FINDINGS

Although external beam radiation has long been known to palliate painful bone metastatic disease for patients with prostate cancer, new studies continue to evolve in this area. Data from randomized studies over the past decade emphasize that palliation can be achieved with single-fraction radiation strategies. Despite these data, and various supportive national and international guidelines, single-fraction regimens are relatively underutilized in the USA as compared with other countries. In addition to external beam radiation, beta-emitting isotopes are also effective as systemic agents for the palliation of painful bone metastases. New alpha-emitters such as Alpharadin (radium-223) are under current development but remain unproven at this time and recent data indicate that this agent can prolong survival in patients with advanced prostate cancer.

SUMMARY

Radiation in various forms is highly effective for palliation of pain associated with bone metastases.

MR-guided high-intensity focused ultrasound for noninvasive cancer treatment

Magnetic resonance (MR)-high-intensity focused ultrasound (HIFU) is an innovative, noninvasive tumour ablation technique. MR imaging and focused ultrasound are combined allowing real-time anatomic guidance and temperature mapping during treatment. Recently, the volumetric ablation approach has been introduced in order to reduce treatment length and provide more homogeneous tumour ablation. After successful treatment of uterine fibroids, MR-HIFU is currently being investigated for the treatment of malignant tumours. Palliative treatment of painful bone metastases is already applied in clinical practice. Several issues need to be further investigated for successful cancer treatment with MR-HIFU, including patient selection criteria, definition of treatment margins and optimal transducer technology.

Radiotherapy for pain

Radiotherapy has been proven to be an effective treatment for the palliation of symptomatic bone metastases. Despite its widespread use and long history, there remains considerable debate over whether a single 8 Gy fraction or multiple fraction schemes are more effective at alleviating bone pain. Recent meta-analyses have shown equal efficacy between the different treatment regimens. One of the reasons supporting multiple fraction use is a lower re-irradiation rate. Recent research has explored many issues associated with retreatment, including timing, appropriate patient selection and concerns of toxicities. However, there are notable side-effects due to radiotherapy, perhaps one of the most significant being 'pain flare', which is a temporary increase in bone pain immediately after treatment. It has a reported incidence of up to 44% in patients. Despite possible side-effects like 'pain flare', radiotherapy can improve pain and also quality of life for patients. One of the quality of life tools that has become useful for assessing the effectiveness of palliative radiotherapy on physical, psychosocial and functional issues is the EORTC-QLQ-BM22. In addition to tracking quality of life changes in patients, analysing symptom clusters can be used to better understand the symptomatology of advanced cancer, and how radiotherapy can affect pain and other symptoms that cancer patients commonly experience.

Collimator angle influence on dose distribution optimization for vertebral metastases using volumetric modulated arc therapy

PURPOSE

The cylindrical symmetry of vertebrae favors the use of volumetric modulated are therapy in generating a dose "hole" on the center of the vertebrae limiting the dose to the spinal cord. The authors have evaluated if collimator angle is a significant parameter for dose distribution optimization in vertebral metastases.

METHODS

Three patients with one-three vertebrae involved were considered. Twenty-one differently optimized plans (nine single-arc and 12 double-arc plans) were performed, testing various collimator angle positions. Clinical target volume was defined as the whole vertebrae, excluding the spinal cord canal. The planning target volume (PTV) was defined as CTV+5 mm. Dose prescription was 5 x 4 Gy(2) with normalization to PTV mean dose. The dose at 1 cm(3) of spinal cord was limited to 11.5Gy.

RESULTS

The best plans in terms of target coverage and spinal cord sparing were achieved by two arcs and Arcl-80 degrees and Arc2-280 degrees collimator angles for all the cases considered (i.e., leaf travel parallel to the spinal cord primary orientation). If one arc is used, only 80 degrees reached the objectives.

CONCLUSIONS

This study demonstrated the role of collimation rotation for the vertebrae metastasis irradiation, with the leaf travel parallel to the spinal cord primary orientation to be better than other solutions. Thus, optimal choice of collimator angle increases the optimization freedom to shape a desired dose distribution.

Dose-Fractionation Schedules for Radiotherapy of Bone Metastases

BACKGROUND: Bone metastases are common in breast cancer patients. Radiotherapy is safe and effective. This review aimes to contribute to the definition of the appropriate radiation regimens for different endpoints. MATERIAL AND METHODS: Information was compiled by searching PubMed and MEDLINE databases including early-release publications. When possible, primary sources were quoted. Full articles were obtained. References were checked for additional material when appropriate. RESULTS: Randomized trials and meta-analyses demonstrated that single-fraction radiotherapy with 1 × 8 Gy is as effective for pain relief as multi-fraction regimens such as 5 × 4 Gy or 10 × 3 Gy. Re-irradiation for recurrent pain is required more often after single-fraction radiotherapy. Re-irradiation with another single fraction is safe and effective. Multi-fraction long-course radiotherapy such as 10 × 3 Gy leads to better re-calcification and better local control of metastatic spinal cord compression (MSCC). Because both re-calcification and MSCC recurrences occur only several months after radiotherapy, long-course radiotherapy is particularly appropriate for patients with a favorable survival prognosis. CONCLUSIONS: For uncomplicated painful bone metastases, single-fraction radiotherapy with 1 × 8 Gy may be considered the standard regimen. If re-calcification is a major goal, longer-course radiotherapy (i.e. 10 × 3 Gy) should be used. For MSCC, 10 × 3 Gy is preferable for patients with a favorable survival prognosis.

An Expedited Palliative Radiation Protocol for Lytic or Proliferative Lesions of Appendicular Bone in Dogs

Fifty-eight dogs with lytic or proliferative bone lesions were treated with a radiation protocol of two 8-Gy fractions over 2 consecutive days. The protocol was well tolerated, with no increase in early or late effects over previously published protocols. Forty-three (91%) of 47 dogs responded positively to radiation, with a median time of 2 days to onset of pain relief. Median duration of pain relief was 67 days (range 12 to 503 days; mean 99±16 days). Median survival time for all dogs was 136 days (mean 179±18 days). Distal radial location was a positive prognostic indicator for survival (P=0.005).

Patients with a favourable prognosis are equally palliated with single and multiple fraction radiotherapy: results on survival in the Dutch Bone Metastasis Study

BACKGROUND AND PURPOSE

In the prospectively, randomized Dutch Bone Metastasis Study on the effect of a single fraction of 8 Gy versus 24 Gy in six fractions on painful bone metastases, 28% of the patients survived for more than 1 year. Purpose of the present study was to analyze the palliative effect of radiotherapy in long-term surviving patients, and to identify prognostic factors for survival.

MATERIAL AND METHODS

Response rates were compared in all patients surviving>52 weeks. The Cox proportional hazards model stratified by primary tumour was used for multivariate (MV) analyses of prognostic factors for survival.

RESULTS

In 320 patients surviving>52 weeks, responses were 87% after 8 Gy and 85% after 24 Gy (P=0.54). Duration of response and progression rates were similar. For all primary tumours, prognostic factors for survival were a good Karnofsky Performance Score, no visceral metastases, and non-opioid analgesics intake (all factors, MV P<0.001).

CONCLUSIONS

Single fraction radiotherapy should be the standard dose schedule for all patients with painful bone metastases, including patients with an expected favourable survival. General prognosticators as the Karnofsky Performance Score and metastatic tumour load are useful in predicting survival.

Radiotherapy fractionation for the palliation of uncomplicated painful bone metastases - an evidence-based practice guideline

BACKGROUND

This practice guideline was developed to provide recommendations to clinicians in Ontario on the preferred standard radiotherapy fractionation schedule for the treatment of painful bone metastases.

METHODS

A systematic review and meta-analysis was performed and published elsewhere. The Supportive Care Guidelines Group, a multidisciplinary guideline development panel, formulated clinical recommendations based on their interpretation of the evidence. In addition to evidence from clinical trials, the panel also considered patient convenience and ease of administration of palliative radiotherapy. External review of the draft report by Ontario practitioners was obtained through a mailed survey, and final approval was obtained from the Practice Guidelines Coordinating Committee.

RESULTS

Meta-analysis did not detect a significant difference in complete or overall pain relief between single treatment and multifraction palliative radiotherapy for bone metastases. Fifty-nine Ontario practitioners responded to the mailed survey (return rate 62%). Forty-two percent also returned written comments. Eighty-three percent of respondents agreed with the interpretation of the evidence and 75% agreed that the report should be approved as a practice guideline. Minor revisions were made based on feedback from the external reviewers and the Practice Guidelines Coordinating Committee. The Practice Guidelines Coordinating Committee approved the final practice guideline report.

CONCLUSION

For adult patients with single or multiple radiographically confirmed bone metastases of any histology corresponding to painful areas in previously non-irradiated areas without pathologic fractures or spinal cord/cauda equine compression, we conclude that: Where the treatment objective is pain relief, a single 8 Gy treatment, prescribed to the appropriate target volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases. Several factors frequently considered in clinical practice when applying this evidence such as the effect of primary histology, anatomical site of treatment, risk of pathological fracture, soft tissue disease and cord compression, use of antiemetics, and the role of retreatment are discussed as qualifying statements.Our systematic review and meta-analysis provided high quality evidence for the key recommendation in this clinical practice guideline. Qualifying statements addressing factors that should be considered when applying this recommendation in clinical practice facilitate its clinical application. The rigorous development and approval process result in a final document that is strongly endorsed by practitioners as a practice guideline.

Single fraction radiotherapy is efficacious: a further analysis of the Dutch Bone Metastasis Study controlling for the influence of retreatment

PURPOSE

The Dutch Bone Metastasis Study on the effect on painful bone metastases of 8 Gy single fraction (SF) vs. 24 Gy in multiple fractions (MF) showed 24% retreatment after SF vs. 6% after MF (p < 0.001). The purpose of the present study was to evaluate factors influencing retreatment and its effect on response.

METHODS AND MATERIALS

The database on all randomized patients was reanalyzed with separately calculated responses to initial treatment and retreatment.

RESULTS

Response to initial treatment was 71% after SF vs. 73% after MF (p = 0.84). Retreatment raised response to 75% for SF; MF remained unaltered (p = 0.54). The response status after initial treatment did not predict occurrence of retreatment: 35% SF vs. 8% MF nonresponders and 22% SF vs. 10% MF patients with progressive pain were retreated. Logistic regression analyses showed the randomization arm and the pain score before retreatment to significantly predict retreatment (p < 0.001). Retreatment for nonresponders was successful in 66% SF vs. 33% MF patients (p = 0.13). Retreatment for progression was successful in 70% SF vs. 57% MF patients (p = 0.24).

CONCLUSIONS

With or without the effect of retreatment, SF and MF radiotherapy provided equal palliation for painful bone metastases. Irrespective of response to initial treatment, physicians were more willing to retreat after a single fraction. Overall, retreatment was effective in 63% of retreated patients.

Palliative radiotherapy for patients with bone metastases: survey of primary care physicians

Three hundred Canadian primary care physicians were surveyed to determine their perceived barriers to the accessibility of palliative bone radiotherapy and their perceptions regarding treatment efficacy. The response rate was 61%. Factors perceived to hinder accessibility were identified, and the physicians recognized they were not comfortable with their radiotherapy knowledge.

International consensus on palliative radiotherapy endpoints for future clinical trials in bone metastases

PURPOSE

To reach a consensus on a set of optimal endpoint measurements for future external beam radiotherapy trials in bone metastases.

METHODS

An International Bone Metastases Consensus Working Party invited principal investigators and individuals with a recognized interest in bone metastases to participate in the two surveys and a panel meeting on their preference of choice of optimal endpoints.

RESULTS

Consensus has been reached on the following: (a) eligibility criteria for future trials; (b) pain and analgesic assessments; (c) radiation techniques; (d) follow-up and timing of assessments; (e) parameters at follow-up; (f) endpoints; (g) re-irradiation; and (h) statistical analysis.

CONCLUSIONS

Based on the available literature and the clinical experience of the working party members, an acceptable set of endpoints has been agreed upon for future clinical trials to promote consistency in reporting. It is intended that the consensus will be re-examined every 5 years. Areas of further research were identified.

Clinical results of retreatment of vertebral bone metastases by stereotactic conformal radiotherapy and intensity-modulated radiotherapy

PURPOSE

Reirradiation of spinal tumors is limited by the tolerance of the spinal cord. We evaluated local control, pain relief, neurologic improvement, side effects, and survival rates after fractionated conformal radiotherapy (FCRT) and intensity-modulated RT (IMRT) of recurrent spinal metastases.

METHODS AND MATERIALS

Eighteen patients with 19 radiologic manifestations were retreated for recurrent spinal metastases using FCRT (n = 5) or IMRT (n = 14). All patients had previously undergone conventional RT (median dose 38 Gy). The indication for reirradiation was tumor progression associated with pain (n = 16) or neurologic symptoms (n = 12). The median time to recurrence was 17.7 months. The median total dose for reirradiation was 39.6 Gy.

RESULTS

The overall local control rate was 94.7% after a median follow-up of 12.3 months. Of 16 patients with pain, 13 experienced significant relief after reirradiation. Neurologic improvement was obtained in 5 of 12 patients. Tumor size remained unchanged in 84.2%. A partial response was seen in 2 of 19 patients. One patient had local tumor progression 9.5 months after reirradiation. Six patients received chemotherapy after reirradiation because of progressive distant metastases. Twelve patients died 10.5 months median after reirradiation. No clinically significant late toxicity was seen after FCRT or IMRT.

CONCLUSION

These data demonstrate that FCRT and IMRT are effective and safe in recurrent spinal tumors and can be offered to patients to achieve local control, as well as pain relief.

Palliative radiotherapy in the treatment of skeletal metastases

Two-third of patients with metastatic cancer suffer from pain. Pain originating from skeletal metastases is the most common form of cancer pain. Bone pain, often exacerbated by pressure or movement, limits the patient's autonomy and social life. Pathological fracture and spinal cord compression are additional complications caused by bone metastases. Radiotherapy is effective in treating bone pain not adequately controlled by analgesics. Seventy percent of patients benefit from radiotherapy. Single and multifraction regimens are equally effective in relieving pain. Retreatment is needed somewhat more often following single fraction therapy. Most patients benefit from retreatment irrespectively of previous fractionation schedule. Hemibody irradiation and radioisotopes, e.g., strontium-89 and samarium-153 are used in treating scattered painful bone metastases. Radiotherapy is used for preventing pathological fracture by treating osteolytic lesions especially in the weight-bearing bones such as the spinal column and long bones. Radiotherapy is the treatment of choice in spinal cord compression, which is the most serious complication caused by bone secondaries. Radiotherapy provides efficient, well-tolerated and cost-effective palliative care.

Second single 4 Gy reirradiation for painful bone metastasis

To investigate the efficacy of the second 4 Gy given as a single fraction radiotherapy (RT) for patients with painful bone metastasis who had already twice received single fraction RT (4, 6, or 8 Gy plus 4 Gy), a total of 25 patients were assessed before and after re-irradiation. The patients included 19 responders and 6 nonresponders to two prior single fraction RT, the latter one being 4 Gy. The overall response rate was 80%, with both complete response (CR) and partial response (PR) being 40%. No difference was found between the previous responders and previous nonresponders regarding both CR (P = 0.70) and overall response rate (P = 0.35). Response duration was longer in the previous responders (P = 0.0041), but the time to pain relief was similar between the two treatment groups. No acute or late high-grade toxicity was observed during this study and no pathological fractures or spinal cord compressions were seen. In this small and highly selected series of patients, the third single fraction RT of 4 Gy was effective and not toxic in the treatment of painful bone metastasis.

Single fraction external beam radiation therapy in the treatment of localized metastatic bone pain. A review

Bone metastases are a frequent complication of cancer, and frequently cause pain. Indications for radiotherapy for bone metastases include pain, risk for pathologic fracture, and neurological complications arising from spinal cord compression, nerve root pain or cranial nerve involvement. There are numerous fractionation patterns of external beam radiation therapy for painful bone metastasis, both fractionated schedules and single fraction regimens. All prospective randomized trials that evaluated differences in the outcomes associated with various fractionated regimens versus single fraction regimens unequivocally showed that single fraction regimens (mostly 8 Gy) are at least equal with various fractionated regimens. The single fraction regimens have an additional advantage of being more convenient to both patients and hospitals. However, there are still numerous questions that are left unanswered in these trials, such as the "optimal" single fraction that should be used, the possibility for retreatment, and prognostic factors that may help identify those patients more likely to respond to a single fraction radiation therapy in the treatment of painful bone metastasis.