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Patel CM, Wadas TJ, Shiozawa Y. Progress in Targeted Alpha-Particle-Emitting Radiopharmaceuticals as Treatments for Prostate Cancer Patients with Bone Metastases. Molecules 2021; 26:2162. [PMID: 33918705 PMCID: PMC8070008 DOI: 10.3390/molecules26082162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 02/03/2023] Open
Abstract
Bone metastasis remains a major cause of death in cancer patients, and current therapies for bone metastatic disease are mainly palliative. Bone metastases arise after cancer cells have colonized the bone and co-opted the normal bone remodeling process. In addition to bone-targeted therapies (e.g., bisphosphonate and denosumab), hormone therapy, chemotherapy, external beam radiation therapy, and surgical intervention, attempts have been made to use systemic radiotherapy as a means of delivering cytocidal radiation to every bone metastatic lesion. Initially, several bone-seeking beta-minus-particle-emitting radiopharmaceuticals were incorporated into the treatment for bone metastases, but they failed to extend the overall survival in patients. However, recent clinical trials indicate that radium-223 dichloride (223RaCl2), an alpha-particle-emitting radiopharmaceutical, improves the overall survival of prostate cancer patients with bone metastases. This success has renewed interest in targeted alpha-particle therapy development for visceral and bone metastasis. This review will discuss (i) the biology of bone metastasis, especially focusing on the vicious cycle of bone metastasis, (ii) how bone remodeling has been exploited to administer systemic radiotherapies, and (iii) targeted radiotherapy development and progress in the development of targeted alpha-particle therapy for the treatment of prostate cancer bone metastasis.
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Affiliation(s)
- Chirayu M. Patel
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA;
| | - Thaddeus J. Wadas
- Department of Radiology, University of Iowa, Iowa City, IA 52242, USA;
| | - Yusuke Shiozawa
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA;
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Tan HY, Yeong CH, Wong YH, McKenzie M, Kasbollah A, Md Shah MN, Perkins AC. Neutron-activated theranostic radionuclides for nuclear medicine. Nucl Med Biol 2020; 90-91:55-68. [PMID: 33039974 DOI: 10.1016/j.nucmedbio.2020.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022]
Abstract
Theranostics in nuclear medicine refers to personalized patient management that involves targeted therapy and diagnostic imaging using a single or combination of radionuclide (s). The radionuclides emit both alpha (α) or beta (β-) particles and gamma (γ) rays which possess therapeutic and diagnostic capabilities, respectively. However, the production of these radionuclides often faces difficulties due to high cost, complexity of preparation methods and that the products are often sourced far from the healthcare facilities, hence losing activity due to radioactive decay during transportation. Subject to the availability of a nuclear reactor within an accessible distance from healthcare facilities, neutron activation is the most practical and cost-effective route to produce radionuclides suitable for theranostic purposes. Holmium-166 (166Ho), Lutetium-177 (177Lu), Rhenium-186 (186Re), Rhenium-188 (188Re) and Samarium-153 (153Sm) are some of the most promising neutron-activated radionuclides that are currently in clinical practice and undergoing clinical research for theranostic applications. The aim of this paper is to review the physical characteristics, current clinical applications and future prospects of these neutron activated radionuclides in theranostics. The production, physical properties, validated clinical applications and clinical studies for each neutron-activated radionuclide suitable for theranostic use in nuclear medicine are reviewed in this paper.
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Affiliation(s)
- Hun Yee Tan
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor's University, 47500 Subang Jaya, Selangor, Malaysia
| | - Chai Hong Yeong
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, 47500 Subang Jaya, Selangor, Malaysia
| | - Yin How Wong
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, 47500 Subang Jaya, Selangor, Malaysia
| | - Molly McKenzie
- School of Life Sciences, University of Dundee, DD1 4HN, United Kingdom
| | - Azahari Kasbollah
- Medical Technology Division, Malaysian Nuclear Agency, Bangi, 43000 Kajang, Selangor, Malaysia
| | - Mohamad Nazri Md Shah
- Department of Biomedical Imaging, University of Malaya Medical Centre, 59100 Kuala Lumpur, Malaysia
| | - Alan Christopher Perkins
- Radiological Sciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom.
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Spine and Non-spine Bone Metastases - Current Controversies and Future Direction. Clin Oncol (R Coll Radiol) 2020; 32:728-744. [PMID: 32747153 DOI: 10.1016/j.clon.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Bone is a common site of metastases in advanced cancers. The main symptom is pain, which increases morbidity and reduces quality of life. The treatment of bone metastases needs a multidisciplinary approach, with the main aim of relieving pain and improving quality of life. Apart from systemic anticancer therapy (hormonal therapy, chemotherapy or immunotherapy), there are several therapeutic options available to achieve palliation, including analgesics, surgery, local radiotherapy, bone-seeking radioisotopes and bone-modifying agents. Long-term use of non-steroidal analgesics and opiates is associated with significant side-effects, and tachyphylaxis. Radiotherapy is effective mainly in localised disease sites. Bone-targeting radionuclides are useful in patients with multiple metastatic lesions. Bone-modifying agents are beneficial in reducing skeletal-related events. This overview focuses on the role of surgery, including minimally invasive treatments, conventional radiotherapy in spinal and non-spinal bone metastases, bone-targeting radionuclides and bone-modifying agents in achieving palliation. We present the clinical data and their associated toxicity. Recent advances are also discussed.
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Appraisement of 186/188Re-HEDP, a new compositional radiopharmaceutical. J Radioanal Nucl Chem 2019. [DOI: 10.1007/s10967-019-06816-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sierko E, Hempel D, Zuzda K, Wojtukiewicz MZ. Personalized Radiation Therapy in Cancer Pain Management. Cancers (Basel) 2019; 11:cancers11030390. [PMID: 30893954 PMCID: PMC6468391 DOI: 10.3390/cancers11030390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/05/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022] Open
Abstract
The majority of advanced cancer patients suffer from pain, which severely deteriorates their quality of life. Apart from analgesics, bisphosphonates, and invasive methods of analgesic treatment (e.g., intraspinal and epidural analgesics or neurolytic blockades), radiation therapy plays an important role in pain alleviation. It is delivered to a growing primary tumour, lymph nodes, or distant metastatic sites, producing pain of various intensity. Currently, different regiments of radiation therapy methods and techniques and various radiation dose fractionations are incorporated into the clinical practice. These include palliative radiation therapy, conventional external beam radiation therapy, as well as modern techniques of intensity modulated radiation therapy, volumetrically modulated arch therapy, stereotactic radiosurgery or stereotactic body radiation therapy, and brachytherapy or radionuclide treatment (e.g., radium-223, strontium-89 for multiple painful osseous metastases). The review describes the possibilities and effectiveness of individual patient-tailored conventional and innovative radiation therapy approaches aiming at pain relief in cancer patients.
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Affiliation(s)
- Ewa Sierko
- Department of Oncology, Medical University of Bialystok, 15-027 Białystok, Poland.
- Department of Radiation Therapy, Comprehensive Cancer Center of Białystok, 15-027 Bialystok, Poland.
| | - Dominika Hempel
- Department of Oncology, Medical University of Bialystok, 15-027 Białystok, Poland.
- Department of Radiation Therapy, Comprehensive Cancer Center of Białystok, 15-027 Bialystok, Poland.
| | - Konrad Zuzda
- Student Scientific Association Affiliated with Department of Oncology, Medical University of Bialystok, 15-027 Bialystok, Poland.
| | - Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, 15-027 Białystok, Poland.
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Choi JY. Treatment of Bone Metastasis with Bone-Targeting Radiopharmaceuticals. Nucl Med Mol Imaging 2018; 52:200-207. [PMID: 29942398 PMCID: PMC5995773 DOI: 10.1007/s13139-017-0509-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/16/2017] [Accepted: 12/13/2017] [Indexed: 12/18/2022] Open
Abstract
Bone is a common metastatic site of cancer. Bone metastasis reduces life expectancy and results in serious symptoms and complications such as bone pain, pathological fractures, and spinal cord compression, decreasing quality of life by restricting sleep and mobility. Treatment for bone metastasis includes drugs (pure analgesics, hormones, cytotoxic chemotherapy, and bisphosphonates, among others), external radiation therapy, surgery, and radionuclide therapy using bone-targeting radiopharmaceuticals. Particulate radiation with α- or β-rays is used as a bone-targeting radiopharmaceutical in radionuclide therapy. β-Emitters have lower energy and a longer range than α-emitters and have less tumoricidal activity and deliver more radiation to adjacent normal tissue. Therefore, the main therapeutic effect of bone-targeting β-emitters such as 89Sr-dichloride is bone pain palliation rather than enhanced survival. In contrast, α-emitters such as 223Ra-dichloride have high energy and a short range, resulting in greater tumoricidal activity and less radiation damage to adjacent normal tissue. Treatment with bone-targeting α-emitters can improve survival and decrease bone pain. This review focuses on the principles and clinical utility of several clinically available bone-targeting radiopharmaceuticals in metastatic bone disease.
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Affiliation(s)
- Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, 06351 Seoul, Republic of Korea
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Denis-Bacelar AM, Chittenden SJ, Dearnaley DP, Divoli A, O'Sullivan JM, McCready VR, Johnson B, Du Y, Flux GD. Phase I/II trials of 186Re-HEDP in metastatic castration-resistant prostate cancer: post-hoc analysis of the impact of administered activity and dosimetry on survival. Eur J Nucl Med Mol Imaging 2017; 44:620-629. [PMID: 27770145 PMCID: PMC5323472 DOI: 10.1007/s00259-016-3543-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/30/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE To investigate the role of patient-specific dosimetry as a predictive marker of survival and as a potential tool for individualised molecular radiotherapy treatment planning of bone metastases from castration-resistant prostate cancer, and to assess whether higher administered levels of activity are associated with a survival benefit. METHODS Clinical data from 57 patients who received 2.5-5.1 GBq of 186Re-HEDP as part of NIH-funded phase I/II clinical trials were analysed. Whole-body and SPECT-based absorbed doses to the whole body and bone lesions were calculated for 22 patients receiving 5 GBq. The patient mean absorbed dose was defined as the mean of all bone lesion-absorbed doses in any given patient. Kaplan-Meier curves, log-rank tests, Cox's proportional hazards model and Pearson's correlation coefficients were used for overall survival (OS) and correlation analyses. RESULTS A statistically significantly longer OS was associated with administered activities above 3.5 GBq in the 57 patients (20.1 vs 7.1 months, hazard ratio: 0.39, 95 % CI: 0.10-0.58, P = 0.002). A total of 379 bone lesions were identified in 22 patients. The mean of the patient mean absorbed dose was 19 (±6) Gy and the mean of the whole-body absorbed dose was 0.33 (±0.11) Gy for the 22 patients. The patient mean absorbed dose (r = 0.65, P = 0.001) and the whole-body absorbed dose (r = 0.63, P = 0.002) showed a positive correlation with disease volume. Significant differences in OS were observed for the univariate group analyses according to disease volume as measured from SPECT imaging of 186Re-HEDP (P = 0.03) and patient mean absorbed dose (P = 0.01), whilst only the disease volume remained significant in a multivariable analysis (P = 0.004). CONCLUSION This study demonstrated that higher administered activities led to prolonged survival and that for a fixed administered activity, the whole-body and patient mean absorbed doses correlated with the extent of disease, which, in turn, correlated with survival. This study shows the importance of patient stratification to establish absorbed dose-response correlations and indicates the potential to individualise treatment of bone metastases with radiopharmaceuticals according to patient-specific imaging and dosimetry.
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Affiliation(s)
- Ana M Denis-Bacelar
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK.
| | - Sarah J Chittenden
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Antigoni Divoli
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Joe M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
| | - V Ralph McCready
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Bernadette Johnson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Yong Du
- Department of Nuclear Medicine and PET/CT, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Glenn D Flux
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
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Jong JMVDD, Oprea-Lager DE, Hooft L, de Klerk JM, Bloemendal HJ, Verheul HM, Hoekstra OS, van den Eertwegh AJ. Radiopharmaceuticals for Palliation of Bone Pain in Patients with Castration-resistant Prostate Cancer Metastatic to Bone: A Systematic Review. Eur Urol 2016; 70:416-26. [DOI: 10.1016/j.eururo.2015.09.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/04/2015] [Indexed: 11/28/2022]
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Fujita T, Ohue M, Fujii Y, Miyauchi A, Takagi Y. Comparison of the analgesic effects of bisphosphonates: etidronate, alendronate and risedronate by electroalgometry utilizing the fall of skin impedance. J Bone Miner Metab 2009; 27:234-9. [PMID: 19214375 DOI: 10.1007/s00774-009-0035-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 07/11/2008] [Indexed: 01/23/2023]
Abstract
Analgesic effects of etidronate, alendronate and risedronate were compared in patients with osteoporosis and/or osteoarthritis by measuring the fall of skin impedance along with conventional subjective pain-estimation by visual rating scale (VRS). One hundred ninety-nine postmenopausal women consulting the Osteoporosis and Osteoarthritis Clinic of Katsuragi Hospital complaining of back and/or knee pain were randomly divided into four groups; Group A (49 subjects) given 5 mg/day alendronate, Group E (50 subjects) 200 mg/day etidronate, Group R (50 subjects) 2.5 mg/day risedronate and Group P no bisphosphonate. None of the four groups showed significant deviation from others as to age and parameters of bone metabolism. Proportions of subjects with osteoporosis was 18-40%. Those with osteoarthritis of the spine and knee, higher than Grade II according to the Nathan and Lawrence-Kellgren scale, respectively, was 45 and 61%, respectively, without a significant difference among the four groups. Significant positive correlation was found between the fall of skin impedance and pain expressed in VRS. Attenuation of exercise-induced fall of skin impedance and also subjective pain expressed in VRS was greatest in Group E with a highly significant difference from Groups A (P = 0.0002 and P < 0.0001), R (P < 0.0001 and P = 0.0014) and P (P < 0.0001 and P < 0.0001). Neither A nor R showed significant difference from P as to the fall of skin impedance. Among the three bisphosphonates tested, etidronate appeared to be outstanding in analgesic effects.
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Affiliation(s)
- Takuo Fujita
- Katsuragi Hospital, 250 Makami-cho, Kishiwada, Osaka 596-0842, Japan.
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Lam MGEH, de Klerk JMH, van Rijk PP. 186Re-HEDP for Metastatic Bone Pain in Breast Cancer Patients. Breast Cancer 2008. [DOI: 10.1007/978-3-540-36781-9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dolezal J, Vizda J, Odrazka K. Prospective Evaluation of Samarium-153-EDTMP Radionuclide Treatment for Bone Metastases in Patients with Hormone-Refractory Prostate Cancer. Urol Int 2007; 78:50-7. [PMID: 17192733 DOI: 10.1159/000096935] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Accepted: 05/05/2006] [Indexed: 11/19/2022]
Abstract
PURPOSE Bone is a common site of metastatic disease and the most frequent site of metastatic spread in patients with prostate cancer. Most patients with bone metastases complain of bone pains. This pain may be alleviated or eliminated by administration of radiotherapy at the site of metastases. Currently, two forms of radiotherapy administration exist: external-beam irradiation or intravenous administration of bone-seeking therapeutic radiopharmacon such as samarium-153-ethylene-diamino-tetramethylene-phosphonate (EDTMP). This radiopharmacon produces beta-particles and concentrates in the areas of enhanced osteoblastic activity. The aim of this study was to assess the efficacy of (153)Sm-EDTMP therapy. MATERIALS AND METHODS 32 men (aged 50-83, mean 70 years) with bone disseminated hormone-refractory prostate cancer and bone pain received (153)Sm-EDTMP. Mean applied dosage was 40 MBq/kg of the patient's body weight. Karnofsky performance status, pain score (numerical rating scale), analgesic score (WHO) and blood count were evaluated before, and 1 and 3 months after the treatment. RESULTS Significant pain relief was observed in 44 and 38% of patients, mild relief in 31 and 34% and no effect in 25 and 28% of patients, 1 and 3 months after administration, respectively. Pain palliation was accompanied by an improvement in mobility and a decrease in necessary dosage of analgesics. Mild and transient bone marrow suppression was observed as a side effect of (153)Sm-EDTMP treatment. None of the patients showed hematological toxicity grade 4, and only 2 showed grade 3 (NCI CTC). The majority of the patients had hematological toxicity grade 1 or 2. CONCLUSION After (153)Sm-EDTMP administration, bone pain palliation was observed in 72% of patients for 3 months. Hematological toxicity after (153)Sm-EDTMP treatment was mild and transient.
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Affiliation(s)
- J Dolezal
- Department of Nuclear Medicine, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
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Finlay IG, Mason MD, Shelley M. Radioisotopes for the palliation of metastatic bone cancer: a systematic review. Lancet Oncol 2005; 6:392-400. [PMID: 15925817 DOI: 10.1016/s1470-2045(05)70206-0] [Citation(s) in RCA: 207] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Strontium-89 and samarium-153 are radioisotopes that are approved in the USA and Europe for the palliation of pain from metastatic bone cancer, whereas rhenium-186 and rhenium-188 are investigational. Radioisotopes are effective in providing pain relief with response rates of between 40% and 95%. Pain relief starts 1-4 weeks after the initiation of treatment, continues for up to 18 months, and is associated with a reduction in analgesic use in many patients. Thrombocytopenia and neutropenia are the most common toxic effects, but they are generally mild and reversible. Repeat doses are effective in providing pain relief in many patients. The effectiveness of radioisotopes can be greater when they are combined with chemotherapeutic agents such as cisplatin. Some studies with 89Sr and 153Sm indicate a reduction of hot spots on bone scans in up to 70% of patients, and suggest a possible tumoricidal action. Further studies are needed to address the questions of which isotope to use, what dose and schedule to use, and which patients will respond.
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Affiliation(s)
- Ilora G Finlay
- Department of Palliative Medicine, Velindre NHS Trust, Velindre Hospital, Whitchurch, Cardiff, Wales, UK
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Bauman G, Charette M, Reid R, Sathya J. Radiopharmaceuticals for the palliation of painful bone metastases—a systematic review. Radiother Oncol 2005; 75:258-70. [PMID: 16299924 DOI: 10.1016/j.radonc.2005.03.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE The purpose was to develop a systematic review that would address the following question: what is the role of radiopharmaceuticals in the palliation of metastatic bone pain in adults with uncomplicated, multifocal painful bone metastases whose pain is not controlled with conventional analgesic regimens? The outcomes of interest are pain response, analgesic consumption, overall survival, adverse effects and quality of life. MATERIALS AND METHODS A systematic review of the English published literature was undertaken to provide evidence relevant to the above outcomes. RESULTS Six randomized phase III trials, two randomized phase II trials and one randomized crossover trial of strontium-89 were reviewed. A randomized phase III trial comparing strontium-89 plus cisplatin with strontium-89 plus placebo reported a significantly higher proportion of patients experiencing pain relief for a significantly longer duration with strontium-89 plus cisplatin. A randomized phase III trial comparing adjuvant strontium-89 with placebo following radiotherapy reported a higher proportion of pain-free patients with strontium-89. Patients who received strontium-89 also experienced fewer new sites of bone pain. A second, but underpowered study failed to confirm these results. In one randomized trial of strontium-89 versus radiotherapy (hemibody or local), patients treated with strontium-89 developed fewer new sites of pain. In a second trial comparing strontium-89 versus local radiotherapy, median overall survival was improved with radiotherapy, while pain response and time-to-progression were similar in the two groups. One randomized phase III trial reported no difference in pain relief between strontium-89 and placebo. Three randomized phase III trials and two randomized phase II trials investigating samarium-153 were reviewed. In a randomized phase III trial of three different doses of samarium-153, the pain responses were similar for all three doses. In a randomized phase III trial of two different doses of samarium-153 versus placebo, the complete pain response rate was significantly higher with the higher dose of samarium-153 compared with placebo. In a randomized phase III trial comparing samarium-153 with placebo, significant differences favouring samarium-153 were reported for pain and opiate use. In addition, one randomized phase III trial, two randomized phase II trials, one randomized crossover trial and 13 phase II or phase I trials of rhenium, one phase I trial of tin-117 m and one phase II trial of phosphorus-32 were reviewed. The majority of patients treated in trials of radiopharmaceuticals where histology was specified had metastatic breast cancer (approximately 5-10% of patients reported), metastatic hormone-refractory prostate cancer (80-90% of patients reported) or metastatic lung cancer (5-10% of patients reported). Information on histologic subtype was not available for a significant proportion of patients treated on trials (30-40% of patients reported). CONCLUSIONS Use of single-agent radiopharmaceuticals (strontium-89 and samarium-153) should be considered as a possible option for the palliation of multiple sites of bone pain from metastatic cancer where pain control with conventional analgesic regimens is unsatisfactory and where activity on a bone scan of the painful lesions is demonstrated. Ongoing clinical research should seek to establish the benefit of newer radiopharmaceuticals and radiopharmaceuticals in combination with other systemic therapies.
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