Does kV Image Guidance for Bone Metastases Improve Pain Control?

Ahmet S Tunceroglu,Shou-En Lu,Bruce G Haffty,Bin Gui,Julian Sison,Sharad Goyal,Sung Kim,Salma K Jabbour,Rahul Parikh

doi:10.3389/fonc.2021.627282

Abstract

Purpose/ObjectivesDespite its widespread availability, the use of kilovoltage (kV) image guidance is often related to factors such as perceived adequacy of clinical patient setup and individual practice patterns. We sought to determine whether kV image guidance in the treatment of painful bone metastases would improve therapeutic efficacy.Materials/MethodsUnder an Institutional Review Board approved protocol, hospital records of 164 patients having received radiation therapy to 257 individual painful osseous metastases were retrospectively reviewed. Marginal logistic regression analyses using the generalized estimating equation (GEE) approach were used to investigate potential associations between pain reduction and several patient, disease, and treatment related variables. Correlation of kV image guidance with pain reduction was analyzed by univariate and multivariate GEE logistic regression analysis.ResultsMedian time to pain reduction was 3 days (range 0~109 days) from the start of radiation therapy. Pain reduction ≥ 50% was noted in 196 (77%) metastatic lesions with 136 (53%) demonstrating complete pain relief. Patients with metastatic lesions from non-small cell lung cancer experienced less pain relief (p = 0.007). Disease extension outside of bone was a negative predictor for pain reduction (p = 0.02). On univariate and multivariate logistic regression, kV image guidance demonstrated a statistically significant correlation with improved pain control in cases involving treatment of the lower extremities (p = 0.03) and those with fewer treatment fractions (p = 0.01), particularly in the setting of extra-osseous disease extension (p = 0.003).ConclusionsKilovoltage image guidance in the treatment of painful bone metastases may offer greater pain control through improved patient setup, particularly for patients with tumors of the lower extremities, extraosseous disease extension, and fewer treatment fractions.

Highlights

While long-term cure is the optimal outcome of radiation therapy (RT), many cancer patients will relapse and present with metastatic disease while others will be discovered to harbor widespread metastases at the initial presentation
Of the initial 255 patients identified, 91 were excluded from the study, resulting in a final cohort of 164 patients treated for 257 osseous metastases
We report the findings of our analysis, which did detect a correlation between improved pain relief and kV imaging

Summary

Introduction

While long-term cure is the optimal outcome of radiation therapy (RT), many cancer patients will relapse and present with metastatic disease while others will be discovered to harbor widespread metastases at the initial presentation. The incidence of bone metastases have increased, believed to result largely from improved overall patient survival owing to improved cancer treatments [1, 2]. Of the 1,806,590 cases of cancer estimated for 2020 in the United States, over 40% will be of cancers that commonly metastasize to the bone including breast, prostate, lung, and kidney [3]. Bone is the third most common site of metastatic disease [2]. Among patients with breast and prostate cancers, the bulk of the disease at the time of death typically will be in bone [4]. Among patients with non-small cell lung cancer, Kuchuk et al reported bone metastases at diagnosis in 20-40% of patients [7]

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Conclusion