External Beam Irradiation in the Palliation of Bone Metastases: A Practice Analysis among Sicilian Departments of Radiation Oncology

The INTER-ROMA Project - a Survey among Italian Radiation Oncologists on Their Approach to the Treatment of Bone Metastases

Aims and background

Radiotherapy has an established palliative role for bone metastases but despite the large number of patients treated there is still controversy surrounding the optimal radiotherapy schedule to prescribe. The aim of this survey was to determine the decision patterns of Italian radiation oncologists in four different clinical cases of patients with bone metastases.

Methods and study design

During the latest national meeting of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to attending radiation oncologists. The cases were different with respect to the histology of the primary tumor, performance status, pain before and after analgesics, tumor site, and radiological characteristics of the metastatic lesions. For each clinical case the respondents were asked to give an indication for treatment; prescribe doses, volumes and treatment field arrangements; decide whether to prescribe prophylactic supportive therapy or not; and provide information about factors that particularly influenced prescription. Finally, a descriptive statistical analysis was performed.

Results

Three hundred questionnaires were distributed to radiation oncologists attending the congress. One hundred twenty-five questionnaires were returned but only 122 (40.6%) were adequately completed and considered for the analysis. Considerable differences were observed among radiation oncologists in prescribing and delivering radiotherapy for bone metastases. There was also a notable divergence from international guidelines, which will be discussed in this report.

Conclusions

Despite the results of clinical trials, Italian radiation oncologists differ considerably in their decisions on treatment doses and volumes. National guidelines are needed in order that patients can be treated uniformly and better data will become available for evidence-based palliative radiotherapy.

Oncological and functional results after surgical treatment of bone metastases at the proximal femur

Background

Metastatic lesions to the proximal femur occur frequently (about 10% of patients with cancer) and require surgical treatment. There are many surgical methods of treatment, however, use of the tumor modular endoprostheses seems to be particularly promising. The aim of study was to evaluate oncological and functional results of treatment in patients with proximal femur metastases. Oncological results were evaluated considering the survival of patients and the number of local recurrences. Functional results were assessed as pain intensity in VAS score and performance in Karnofsky and MSTS score.

Methods

Between 2010 and 2016, 122 patients with metastatic tumour to the proximal femur were treated in our hospital. Majority of the patients were women − 77 patients. The mean age was 67 years for women and 72 years for men. Pathological fracture was diagnosed in 98 cases. Metastatic bone tumors commonly develop from breast cancer – 48 and myeloma – 24. One hundred one patients underwent tumor resection and in 21 cases metastatic tumors was not resected. In 75 patients wide tumour resection and modular endoprosthetic replacement were prefomed. Twenty-one patients underwent standard or long stem hip endoprosthetic replacement. Intramedullary gamma nails were implanted in 20 cases and DHS plate in 6 cases. In 92 cases 3-4 weeks after surgery patients undergo external beam radiotherapy (8Gy).

Functional results were assessed as pain intensity in VAS score and performance in Karnofsky and MSTS score. Oncological results were evaluated considering the survival of patients and the number of local recurrences.

Results

The mean follow-up of patients was 27 months (min 4, max 51). Forty-five patients died before last visit in hospital. The mean survival after modular endoprosthetic replacement was 860 days and after bone fixations 360 days. We noticed 9 cases of local recurrences or progressions, 6 in patients who had no radiotherapy. Three patients after modular endoprosthesis replacement and 6 after bone fixations.

After surgery, all patients experienced improvement in the comfort of life resulting from reduction in pain. Mean VAS score before modular endoprosthetic replacement was 6.8 and after 3.4; before standard prothesoplasty 4.9 and after 2.8; and before and after bone fixation 6.9 -5.1. Mean MSTS score was respectively 6.4-19.8; 8.8-22.4 and 10.8-18.2.

In 6 patients after modular endoprosthesis replacement, delayed wound healing were observed. Infectious complications were not observed after fixation with nails and plates. In 3 cases, the fixation was failed. The systemic complications affected 12 patients.

Conclusions

Results of surgical treatment for metastases to the proximal femur are particularly good in patients after standard or modular endoprostheses replacement. The author considers this treatment method to be optimal in patients with good prognosis.

Results of the treatment of bone metastases with modular prosthetic replacement--analysis of 67 patients

Background

Surgical treatment of long-bone metastases requires a comprehensive approach. The indications for surgery are based on the patient’s general condition, type and stage of cancer, and survival time expectancy. Tumor modular endoprostheses have been increasingly used. Surgery should provide pain relief and improve the quality of life.

Methods

Between 2010 and 2013, 67 patients with malignant metastases were surgically treated with resection prostheses. We performed a retrospective analysis of the indications for the surgery, its course, the type of the prostheses used, and the implantation techniques applied. We evaluated the most important clinical parameters influencing the postoperative quality of life of the patients.

Results

Breast, prostate, and lung cancers are the most common primary tumors that metastasize to bones. The most common site of the lesions is the proximal femur; sporadically, they do occur in bones distal to the knee and elbow. After the surgery, all the patients could walk, most of them without crutches. The pain, rated on a VAS scale, decreased significantly, and the Karnofsky score improved. We observed that joint mobility and the strength of the muscles in the limbs allowed for normal functioning. Postoperative complications including infections and local tumor recurrences were rarely observed.

Conclusions

The use of modular prostheses is an adequate method of treatment in patients with bone metastases. A radical resection of the tumor, which prevents local recurrences and loosening of implants, gives good outcomes. Reduced joint mobility resulting from muscle attachment cutting is well tolerated and concerns mainly patients that underwent operations on the humerus.

International patterns of practice in radiotherapy for bone metastases: A review of the literature

PURPOSE

Radiation therapy is the standard treatment for symptomatic bone metastases. Several randomized control trials and meta-analyses have concluded a similar efficacy in pain relief when comparing single versus multiple fraction regimes. However, there continues to be reluctance to conform to published guidelines that recommend a single treatment for the palliation of painful bone metastases. The purpose of this literature review is to summarize international patterns of practice, and to determine if guidelines recommending single fraction treatment have been implemented in clinical care.

METHODS

A literature search was conducted in Ovid Medline, Embase, and Cochrane Central. Search words included, 'bone metastases', 'radiation therapy', 'radiotherapy', 'patterns of practice', and 'dose fractionation'. Both prospective and retrospective studies that investigated the prescription of radiotherapy to bone metastases using actual patient databases were included. Articles were excluded if they investigated hypothetical scenarios.

RESULTS

Six hundred and thirteen results were generated from the literature search. Twenty-six articles met the inclusion criteria. Of these, 11 were Canadian, 8 were European, 6 were American, and 1 was Australian. The use of single fraction radiotherapy (SFRT) ranged from 3% to 75%, but was generally lower in American studies. Choice of fractionation depended on a variety of factors, including patient age, prognosis, site of irradiation, and physician experience.

CONCLUSION

Despite the publication of robust randomized control trials, meta-analyses, and clinical practice guidelines recommending the use of a single treatment to palliate uncomplicated bone metastasis, SFRT is internationally underutilized.

Review of international patterns of practice for the treatment of painful bone metastases with palliative radiotherapy from 1993 to 2013

BACKGROUND AND PURPOSE

Numerous randomized controlled trials and meta-analyses have affirmed that single and multiple fractions of radiotherapy provide equally efficacious outcomes in the palliation of painful, uncomplicated bone metastases (UBM). We aim to determine geographic, temporal and ancillary factors that influence the global patterns of practice in this setting.

MATERIALS AND METHODS

A literature search was conducted on Ovid MEDLINE and EMBASE. Studies were included if they disclosed prescription patterns of single fraction radiotherapy, either through hypothetical cases or actual patient data. Weighted analysis of variance was conducted for binary predictors while weighted linear regression analysis was performed for continuous parameters.

RESULTS

Nine hypothetical case studies and thirteen actual patterns of practice articles were included from 301 search results. Radiation oncologists prescribed dose fractionations ranging from 3Gy×1 to 2Gy×30, with a median of 3Gy×10, for the palliation of UBM. Actual data demonstrated a weak, non-significant, negative linear relationship between the use of single fraction radiotherapy and the year of treatment. Geographical location of treatment was a key predictor of prescription patterns.

CONCLUSION

In the last twenty years, there was an overall global reluctance to practice evidence-based medicine by employing single fractions for UBM.