Analgesia for patients with advanced disease: 2

Comparative Therapeutic Efficacy of 153Sm-EDTMP and 177Lu-EDTMP for Bone Pain Palliation in Patients with Skeletal Metastases: Patients' Pain Score Analysis and Personalized Dosimetry

Introduction

The aim of the present study was to compare the therapeutic efficacy of ¹⁵³Sm-EDTMP and ¹⁷⁷Lu-EDTMP in pain palliation in cancer patients with skeletal metastases.

Materials and methods

Thirty patients (25 M:5 F, mean age: 66.0 ± 14.7 years) of breast/prostate cancer with documented skeletal metastases were recruited prospectively. Twenty patients were considered randomly for treatment with ¹⁵³Sm-EDTMP and with ¹⁷⁷Lu-EDTMP in 10 patients, respectively. Using fixed dose of 37.0 MBq/kg body weight of each, the mean administered doses of ¹⁵³Sm-EDTMP and ¹⁷⁷Lu-EDTMP were 2,155.2 ± 419.6 MBq (1,347–2,857) and 1,935.1 ± 559.4 MBq (1,073–2,627), respectively. Anterior and posterior whole body images were acquired at different time points following radioactivity administration. The first data set of pre-void images (acquired at 0.5 h) representing the total activity of either of ¹⁵³Sm-EDTMP or ¹⁷⁷Lu-EDTMP was considered as reference images. All the serial images were used for patients’ dosimetry analysis by using organ level internal dosimetry assessment algorithm. Reduction in pain scoring was assessed clinically over 8 weeks by using appropriate WHO criteria and correlated with the absorbed dose to the metastatic sites.

Results

A total of 86 metastatic lesions clearly visualized on post-therapy serial images (matching on bone scans) were evaluated for absorbed dose calculations. Both ¹⁵³Sm-EDTMP and ¹⁷⁷Lu-EDTMP delivered similar absorbed dose to the metastatic sites, i.e., 6.22 ± 4.21 and 6.92 ± 3.92 mSv/MBq, respectively. The mean absorbed doses to various other organs were found to be comparable and within the safe limits. A complete response (CR) for each radionuclide was evaluated as 80.0%. No significant alternation in blood parameters and no untoward reaction were observed. However, a mild to severe toxicity was observed in two patients (1 each with ¹⁵³Sm-EDTMP and ¹⁷⁷Lu-EDTMP). Kaplan–Meier survival analysis demonstrated that 27/30 patients had pain-free survival (CR) up to the observational period of 8 weeks. However, no statistically significant correlation could be established between the pain scoring and absorbed dose to metastatic sites.

Conclusion

Both the radionuclides thus offer an effective and comparable therapeutic efficacy for bone pain palliation at an affordable cost and can be used interchangeably as per the availability.

Intravenous Ketamine for Rapid Opioid Dose Reduction, Reversal of Opioid-Induced Neurotoxicity, and Pain Control in Terminal Care: Case Report and Literature Review

OBJECTIVE

We report a case of opioid-induced neurotoxicity (OIN) in an actively dying hospice patient, its reversal and improved analgesia that followed opioid dosage reduction made possible after addition of IV ketamine. We briefly review the diagnosis and treatment of OIN.

SETTING

OIN, particularly when associated with high dose opioid therapy in palliative care, may pose difficult diagnostic and treatment challenges. Few publications from end-of-life settings provide systematic approaches to management of OIN.

PATIENTS

We describe a case of OIN in a hospice patient receiving medical care at home while actively dying.

INTERVENTION

Addition of IV ketamine and reduction of the patient's high-dose opioid regimen.

RESULTS

The patient's pain was controlled within 24 hours of initiation of IV ketamine while the total opioid dose was reduced. His symptoms of OIN (delirium, tremor, myoclonus, and hallucinations) also rapidly subsided.

CONCLUSION

OIN should be considered as an etiology of CNS dysfunction occurring with prolonged, high-dose opioid therapy. This case highlights the opioid-sparing and analgesic properties of low-dose ketamine, allowing reversal of OIN in the home hospice setting.

Bisphosphonate treatment of aggressive primary, recurrent and metastatic Giant Cell Tumour of Bone

Background

Giant cell tumour of bone (GCTB) is an expansile osteolytic tumour which contains numerous osteoclast-like giant cells. GCTB frequently recurs and can produce metastatic lesions in the lungs. Bisphosphonates are anti-resorptive drugs which act mainly on osteoclasts.

Method

In this study, we have examined clinical and radiological outcomes of treatment with aminobisphosphonates on 25 cases of aggressive primary, recurrent and metastatic GCTB derived from four European centres. We also analysed in vitro the inhibitory effect of zoledronic acid on osteoclasts isolated from GCTBs.

Results

Treatment protocols differed with several different aminobisphosphonates being employed, but stabilisation of disease was achieved in most of these cases which were refractory to conventional treatment. Most inoperable sacral/pelvic tumours did not increase in size and no further recurrence was seen in GCTBs that had repeatedly recurred in bone and soft tissues. Lung metastases did not increase in size or number following treatment. Zoledronic acid markedly inhibited lacunar resorption by GCTB-derived osteoclasts in vitro.

Conclusion

Our findings suggest that bisphosphonates may be useful in controlling disease progression in GCTB and that these agents directly inhibit GCTB - derived osteoclast resorption. These studies highlight the need for the establishment of standardised protocols to assess the efficacy of bisphosphonate treatment of GCTB.

A guide to cancer pain management

Most, if not all, cancer patients require care from community teams at some stage during their disease trajectory. For many of these patients, community nurses and General Practitioners are the main point of contact. Pain is reported by between 55-95% of patients with advanced or terminal disease. Optimal pain control positively impacts on the physical, emotional and functional well-being of the patient. Despite the existence of guidelines (WHO, 1996) (SIGN, 2000) and a wealth of literature on cancer pain management, half of all patients in Western countries still do not receive adequate pain relief. This article looks at the reasons behind this and provides community nurses with an overview of up-to-date information on pain pathophysiology and management, so that the control of cancer pain can be optimized in the community.