Painful Osseous Metastases Research Articles

Does kV Image Guidance for Bone Metastases Improve Pain Control?

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.

Radiofrequency ablation versus stereotactic body radiotherapy for painful osseous metastases: A comparative correlation meta-analysis of pain relief.

e24156 Background: Osseous metastases (OMs), a common cause of cancer pain, are only partially palliated by analgesics. Stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA) are increasingly used, but the comparative effectiveness of SBRT vs. RFA for OMs has not been adequately evaluated. Herein we analyzed palliative benefits of SBRT and RFA in terms of pain relief from OMs. Methods: A systematic review was performed for all studies reporting palliative outcomes of SBRT (defined as five or fewer fractions of radiation) or RFA for palliation of OMs. Studies not reporting pain palliation were excluded. Random effects model determined the net Pearson correlation (R2) for post-SBRT and post-RFA pain reduction over time. The pooled correlation coefficient and 95% confidence interval were calculated using Fisher r-to- z transformation. Risk of bias was assessed using sunset plots; heterogeneity was assessed using I2 and meta-regression. Results: Seven full-text articles assessed a total of 1100 SBRT patients and 22 full-text articles assessed a total of 557 RFA patients. No studies directly compared SBRT to RFA. All included studies collected data on pain related to OM disease pre- and post-therapy. The scales used included the visual analog scale (2 SBRT, 15 RFA), brief pain inventory (4 SBRT, 4 RFA), numeric rating scale (0 SBRT, 2 RFA), QLQ-15 (1 SBRT, 0 RFA), or the memorial pain index card (0 SBRT, 1 RFA). Mean SBRT dose and fractions were 17.3 gy and 2.6. Median follow-up was 24 weeks for SBRT and 18 weeks for RFA, with median pain reduction of 59% (R2=0.83, 95%CI:0.80-0.87, I2=58.63%) and 64% (R2=0.52, 95%CI:0.41-0.62, I2=48.16%) respectively. Meta-regression by number of fractions and reporting metric fully accounted for heterogeneity in the SBRT and RFA data respectively. Sunset plots did not indicate significant publication bias. Conclusions: The published literature is predominately non-randomized, limiting the evidence level. Pain reduction and durability post-SBRT or post-RFA are comparable. Pre-SBRT or RFA therapies may obscure the full effect of either treatment modality. SBRT and RFA for painful OMs are associated with pain relief in a majority of patients, but the durability of this relief and the comparative efficacy of SBRT vs. RFA for this purpose has been inadequately reported in the literature. Future, combinatorial therapies as opposed to single-modality approaches may help to increase overall pain relief and durability as well as efficaciously palliating treatment-resistant patients.

Percutaneous Microwave Ablation and Cementoplasty: Clinical Utility in the Treatment of Painful Extraspinal Osseous Metastatic Disease and Myeloma.

OBJECTIVE. The purpose of this study was to review the efficacy and durability of pain control and local tumor control using microwave ablation and cementoplasty in treating extraspinal osseous tumors. Painful osseous metastases are a common cause of cancer-related morbidity. Percutaneous thermal ablation presents an attractive minimally invasive option in this vulnerable patient group. MATERIALS AND METHODS. A retrospective review included 65 patients (35 men, 30 women) with 77 tumors who underwent image-guided microwave ablation and cementoplasty at a tertiary referral academic center over 18 months. Procedural efficacy was determined with a visual analog scale before the procedure and 24 hours, 2-4 weeks, and 20-24 weeks after the procedure. Locoregional control was assessed at follow-up cross-sectional imaging. RESULTS. The 77 tumors were in the following locations: ilium, 38; acetabulum on supraacetabular region, 23; femur, five; humerus, four; shoulder, four; sternum, three. The tumors were 15 multiple myelomas and metastases from cancers of the following organs: colon, nine; lung, 15; breast, 12; thyroid, seven; prostate, three; and kidney, four. Complete, successful ablation of all 77 tumors was achieved. Mean ablation time was 6 minutes 15 seconds (SD, 12 seconds), and mean energy used was 5.49 (SD, 2.97) kJ. The mean visual analog scale scores were 6.32 (SD, 1.94) before the procedure, 1.01 (SD, 1.24) at 24 hours, 1.71 (SD, 1.31) at 2-4 weeks, and 2.01 (SD, 1.42) at 20-24 weeks. Follow-up imaging at 20-24 weeks showed no local progression in 42 of 65 patients (64.6%). Six patients died 24-52 weeks after the procedure. No procedure-related complications were reported. CONCLUSION. Microwave ablation is efficacious in alleviating pain due to osseous metastases. The modality has promise for locoregional control of metastases, particularly in the context of oligometastatic (limited disseminated) disease.

PC-FACS

PC-FACS

Painful Boney Metastases

Boney metastasis may lead to terrible suffering from debilitating pain. The most likely malignancies that spread to bone are prostate, breast, and lung. Painful osseous metastases are typically associated with multiple episodes of breakthrough pain which may occur with activities of daily living, weight bearing, lifting, coughing, and sneezing. Almost half of these breakthrough pain episodes are rapid in onset and short in duration and 44% of episodes are unpredictable. Treatment strategies include: analgesic approaches with "triple opioid therapy", bisphosphonates, chemotherapeutic agents, hormonal therapy, interventional and surgical approaches, steroids, radiation (external beam radiation, radiopharmaceuticals), ablative techniques (radiofrequency ablation, cryoablation), and intrathecal analgesics.

Painful bone metastases - Can we do better?

The treatment of painful osseous metastases (POM) remains extremely challenging for the clinician. Richard Payne and Nora Janjan recognized how complex these patients are and as a result they recommended setting up specialized interdisciplinary cancer center bone metastasis clinics specific for patients with painful osseous metastases (1). Despite advances in the understanding of the pathophysiology of POM, new and improved analgesics/ analgesic techniques, and a greater appreciation of how to approach the evaluation and management of patients with POM, it appears that a significant proportion of patients with POM continue to suffer.

Painful boney metastases.

Treatments for painful osseous metastases may not only diminish pain, but also may improve quality of life and independence/mobility, and reduce skeletal morbidity, potential pathologic fractures, spinal cord compression, and other "skeletal-related events". Treatment strategies for painful osseous metastases include: Systemic analgesics, intrathecal analgesics, glucocorticoids, radiation (external beam radiation, radiopharmaceuticals), ablative techniques [radiofrequency ablation (RFA) and cryoablation], bisphosphonates, chemotherapeutic agents, inhibitors of RANKL-RANK interaction (e.g., denosumab), hormonal therapies, interventional techniques (e.g., kyphoplasty), and surgical approaches. The mechanisms underlying the development of bone metastases remain incompletely understood. A greater understanding of the pathophysiology of painful osseous metastases may lead to improved and more selective targeted analgesic therapy. Additionally, potential future therapeutic approaches to painful osseous metastases may revolutionize approaches to analgesia for this condition, leading to optimal outcomes with maximal pain relief and minimal adverse effects.

Effective use of strontium-89 in osseous metastases

Bone is one of the organs to which cancer metastasizes most frequently. However, it is not a vital organ, therefore, survival after the occurrence of osseous metastasis is relatively favorable. Improvements of medical treatment bring prolonged survival to patients with osseous metastases. But this makes us to recognize the importance of quality of life (QOL) due to several factors, including pain. It is important for oncologists to know how to deal with such painful osseous metastases, as pain relief may enable patients to live their remaining lives to the fullest. Strontium-89 (89Sr) has been used worldwide as in Japan, while being reported to have positive effects on pain relief and QOL improvement in patients with osseous metastases. This review paper is aimed to present not only the history, roles, and medical characters of 89Sr, but also new aspects, such as how to use bone turnover markers, which location of osseous metastases is suitable for effective use of 89Sr.

Value of percutaneous radiofrequency ablation with or without percutaneous vertebroplasty for pain relief and functional recovery in painful bone metastases

To evaluate the effectiveness of percutaneous radiofrequency (RF) ablation with or without percutaneous vertebroplasty (PV) on pain relief, functional recovery and local recurrence at 6months' follow-up (FU), in patients with painful osseous metastases. Thirty RF ablations were performed in 24 patients (mean age: 61years) with bone metastases. Half of the patients had an additional PV. The primary end point was pain relief evaluated by a visual analogue scale (VAS) before treatment, and at 1 and 6months' FU. Functional outcome was assessed according to the evolution of their ability to walk at 6months' FU. Imaging FU was available in 20 out of 24 patients with a mean delay of 4.7months. Reduction of pain was obtained at 6months FU in 81% of cases (15 out of 18). Mean pretreatment VAS was 6.4 (±2.7). Mean VAS was 1.9 (±2.4) at 1month FU, and 2.3 (±2.9) at 6months' FU. Pain was significantly reduced at 6months FU (mean VAS reduction = 4.1; P < 0.00001). Functional improvement was obtained in 74% of the cases. Major complications rate was 12.5 % (3 out of 24) with 2 skin burns, and 1 case of myelopathy. Local tumour recurrence or progression was recorded in 5 cases. Radiofrequency ablation is an effective technique in terms of pain relief and functional recovery for the treatment of bone metastases, which provides a relatively low rate of local recurrence.

The Tolerance and Therapeutic Efficacy of Rhenium-188 Hydroxyethylidene Diphosphonate in Advanced Cancer Patients with Painful Osseous Metastases

This study evaluated the tolerance and therapeutic efficacy of rhenium-188 hydroxyethylidene diphosphonate ((188)Re-HEDP) in patients with different types of advanced cancer suffering from bone pain caused by osseous metastases. Sixty-four patients received a single injection of escalating doses of (188)Re-HEDP with various dosages. Vital signs were observed before and after treatment for 8 weeks; adverse effects and rebound pain were recorded within 8 weeks after injection. Blood counts, biochemical parameters, and electrocardiogram were also measured over a period of 8 weeks. Clinical follow-up studies including the bone pain score and the Karnofsky performance score were performed. Pain response was scored by a four-point pain-rating scale as complete, marked, mild, and no response. No adverse effects or clinically significant changes in vital signs, electrocardiograms, and biochemical parameters in patients were observed, and there was no statistical change in alkaline phosphate levels in patients before or after treatment. The overall nadir of thrombopenia was at week 4, leucopoenia at week 3, and anemia at week 8. At week 8, the mean level of platelets and leukocytes returned to baseline levels. The pain score descended from 8.11 to 7.74 on the day of therapy, with a nadir of 4.89 at week 4, and up to 6.67 at week 8 after therapy (p < 0.05). The Karnofsky performance score continually increased from 74.81 before therapy to 82.31 at 8 weeks (p > 0.05 Pain palliation was reported by 73.33% of patients, with a mean duration of 6.85 weeks and a mean start time of 4.05 days. Of the specific tumor types, pain relief was achieved in 84.62% of patients with prostate cancer, 78.57% with breast cancer, 62.50% with lung cancer, and 55.56% with liver cancer. (188)Re-HEDP is a useful radiopharmaceutical agent for improving bone pain in patients with advanced cancer with painful bone metastases.

Management of Metastatic Bone Pain with Repeated Doses of Rhenium 186-HEDP in Patients Under Therapy with Zoledronic Acid: A Safe and Additively Effective Practice

The aim of this study was to compare pain response and hematologic toxicity between single and multiple therapies with (186)Re-HEDP under zoledronic acid in patients suffering from painful osseous metastases from prostate or breast cancer. Forty-five (45) patients received multiple therapies of (186)Re-HEDP (n = 77), under a stable regimen of analgesics and zoledronic acid, far off other therapeutic manipulations, and with no extraosseous disease progression. Hematologic status and pain indices were followed up regularly. Evaluable patients (n = 12), received 31 (186)Re-HEDP therapies. After the first treatment with (186)Re-HEDP, the mean percentile decrease for hemoglobin was 4.7%, for white blood cells was 21.4%, and for platelets was 12%. After multiple therapies, the respective declines were 7.0%, 16.0%, and 23.4%. With respect to baseline blood counts, only thrombocytes showed a tendency for greater decrease after repeated treatments, yet not of clinical significance. Favorable clinical response occurred after the first therapy in 10 of 12 patients (83.3%), after multiple doses in 15 of 19 (78.9%), and overall in 25 of 31 (80.6%) of (186)Re-HEDP therapies. Significant post-therapy improvement in pain indices was observed in all cases, regardless of the number of therapeutic doses. Retreatments with (186)Re-HEDP under zoledronic acid provide continuing effectiveness in metastatic bone pain and are safe enough, if an acceptable baseline hematologic status exists.

Predictive implications of bone turnover markers after palliative treatment with 186Re-HEDP in hormone-refractory prostate cancer patients with painful osseous metastases

To prospectively evaluate the predictive value of various bone formation and resorption markers in patients with bone metastases from prostate cancer after palliative treatment with (186)Re-1,1-hydroxyethylidene diphosphonate ((186)Re-HEDP). Included in the study were 36 men with prostate cancer, suffering from painful osseous metastases and treated with (186)Re-HEDP. None had received any treatment that would have interfered with bone metabolism before (186)Re-HEDP treatment or throughout the follow-up period. For each patient, pretreatment and posttreatment serum levels of osteocalcin (OC), bone alkaline phosphatase (BALP), aminoterminal (PINP) and carboxyterminal (PICP) propeptides of type I collagen, amino-terminal (NTx) and carboxyterminal (CTx) telopeptides of type I collagen and their combinations were compared with the level and duration of pain response to radionuclide treatment. Pain response was correlated only with pretreatment NuTaux/PINP, PICP/PINP and NTx/CTx ratios and posttreatment decrease in baseline NTx and PICP values (p = 0.0025-0.035). According to multivariate and ROC analyses, the best marker-derived predictors of better and longer duration of response to (186)Re-HEDP treatment were a posttreatment decrease in NTx of > or = 20% (RR = 3.44, p = 0.0005) and a pretreatment NTx/PINP ratio of > or = 1.2 (RR = 3.04, p = 0.036) NTx, a potent collagenous marker of bone resorption, along with the novel NTx/PINP ratio provide useful cut-off values for identifying a group of patients suffering from painful osseous metastases from hormone-refractory prostatic carcinoma who do not respond to palliative treatment with (186)Re-HEDP. This information could help avoid an inefficient and expensive radionuclide treatment. Also, in the cohort of patients who will eventually undergo such treatment, the medium-term posttreatment changes in NTx offer valuable predictive information regarding long-term palliative response.

Multimodality treatment in hormone-refractory prostate cancer patients with bone metastases

Dear Sir, We agree with the interesting points made by Koutsikos et al. They confirm the feasibility of the combined use of bone-seeking radiopharmaceuticals and bisphosphonates and highlight the potential benefit of this combined treatment. We would like to stress the importance to study multimodality treatment strategies in well-designed clinical trials. These trials should evaluate the multidimensional character of pain, as well as survival, and they should incorporate imaging modalities for response stratification. Bone-seeking radiopharmaceuticals are indicated for the relief of bone pain in patients with multiple painful osteoblastic metastases. Several new approaches are being studied not only to improve treatment efficacy related to pain response but also to extend efficacy by improving overall survival. As a single treatment modality, treatment at short intervals has shown to be beneficial with regard to pain palliation and survival [1]. However, most progress has been made with combinations of treatment modalities, for example, bone-seeking radiopharmaceuticals and chemotherapy [2]. In a recent publication, we showed the feasibility of 153Sm-EDTMP combined with zoledronic acid in hormone-refractory prostate cancer patients [3]. The combination of these two phosphate-based pharmaceuticals does not lead to competition in uptake at the level of the calcified bone matrix, nor does it lead to unacceptable toxicity. As a phase I study, it was not designed to study efficacy. However, as an illustration of potentially increased efficacy, two patients showed a complete remission of pain and a remarkable decline in prostate-specific antigen levels over pretreatment values (−71% and −43%), and markers of bone metabolism (−65% and −90%) over a period of almost 6 months. These results suggest a clinical benefit. But, further research is needed to explore the possible benefit of bone-seeking radiopharmaceuticals in combination with bisphosphonates, preferably in phase II and phase III randomized controlled settings. In the past, our center performed a double-blind, placebo-controlled, randomized trial to study the efficacy of 186Re-HEDP compared to placebo [4]. Pain relief was assessed using an electronic diary containing questions reflecting the multidimensional character of pain. Daily pain assessment was mandatory because it fluctuated day by day. Besides a visual analog scale for pain and the assessment of daily activities, a medication index score was also registered. This complex method of evaluation showed a significant decrease of pain in the treated population. Besides this, the study illustrated the difficulty of pain response as an endpoint and the necessity of a well-designed method for pain evaluation. Although a survival benefit could not be detected in this study using 186Re-HEDP as a single modality treatment, survival should be studied in future trials focusing on the efficacy of bone-seeking radiopharmaceuticals in combination with bisphosphonates. Several clinicians have postulated the multimodality approach for the treatment of hormone-refractory prostate cancer patients with painful osseous metastases. Combinations of multiple single treatment modalities may lead to an improvement of clinical benefit beyond an additive effect alone. From all available single-agent modalities, docetaxel is currently the first choice because of its proven efficacy on patients’ survival [5]. Its toxicity is considerable, but responders show a clear benefit with regard to quality of life and survival. A combination of radiopharmaceuticals and chemotherapy might be an interesting therapeutical option. Besides the clinical benefit of each pharmaceutical separately, the radiation-sensitizing effect of chemotherapy may lead to synergy and a further improvement of clinical benefit. The combined use of chemotherapy as a radiosensitizer is well known in the field of external beam radiotherapy but must still be explored in the field of radionuclide therapy. Potential radiation modifiers may be docetaxel or other chemotherapeutics (such as platinum compounds or 5-FU). In hormone-refractory prostate cancer patients, continuous treatment with hormones and bisphosphonates in combination with periodical administrations of a bone-seeking radiopharmaceutical, modified by chemotherapy, may prove to be an effective regimen (Fig. 1). Such a regimen benefits from (1) the effects of repeated treatment with radiopharmaceuticals, bisphosphonates, and chemotherapy as single-agent modalities and (2) the radiation-sensitizing effects of chemotherapy. Different possible strategies should be studied in the future. Fig. 1 Proposed treatment regimen in hormone-refractory prostate cancer patients Last but not least, one of the greatest challenges in the field of nuclear oncology and oncology in general will be the selection of responders and nonresponders. Especially in hormone-refractory prostate cancer, a minority of treated patients show clinical benefit. It will prove to be beneficial to patients, as well as cost-effective, to recognize those who respond to the proposed treatment regimen. Molecular imaging may play a crucial role in identifying these subjects. In hormone-refractory prostate cancer patients, several tracers are being developed and studied for positron emission tomography imaging [6]. Stratification of patients and the development of new treatment strategies will lead to improvement of efficacy with improved overall survival.

Percutaneous radiofrequency ablation of painful osseous metastases: A multicenter trial: American College of Radiology Imaging Network 6661

9101 Background: Radiofrequency Ablation (RFA) can destroy tissue in a defined area. Single institutions have reported that RFA can reduce pain from bone metastases. To confirm this, the American College of Radiology Imaging Network (ACRIN) completed a multicenter study of RFA for bone metastases. Methods: Eligible patients had bone pain in one dominant site: tumor size &lt; 8 cm, and location &gt; 1 cm from the spinal cord or cauda equina. RFA was performed under CT guidance. The Memorial Pain Assessment Card was used prior to RFA and repeated daily for two weeks, and at 1 and 3 months after RFA. AEs were recorded in addition to four different pain assessment measures: pain relief, patient mood, pain intensity, and pain severity. Results: Fifty-six patients had RFA at 9 centers. Metastatic sites were pelvis (24), chest wall (19), thoracolumbar spine (8), and extremities (5). Six out of 56 patients experienced at least one adverse event of grade 3 or higher, yielding an AE rate of 10.7% (95%CI is 2.6% to18.8%). AEs attributed directly to RFA were nerve injury in 2 patients. Of the 56 participants, 43 completed the 1 month follow-up and 33 completed the 3 month follow-up. At the time of this analysis, assuming that missing data were missing at random and after adjusting for all covariates, RFA showed significant effect in reducing pain at 1 and 3 month follow-up for all 4 pain assessment measures. The average increase in pain relief from pre-RFA to 1 month follow-up is 26.4 (P&lt;0.0001) and the increase from pre-RFA to 3 month follow-up is 17.2 (P=0.003). The average increase in mood from pre-RFA to 1 month follow-up is 21.5 (P&lt;0.0001) and the increase from pre-RFA to 3 month follow-up is 16.3 (P=0.001). The average decrease in pain intensity from pre-RFA to 1 month follow-up is 25.9 (P&lt;0.0001) and the decrease from pre-RFA to 3 month follow-up is 13.0 (P=0.02). The odds of being in lower pain severity at 1 month follow-up is 12.6 (P&lt;.0001) times higher than that at pre-RFA, and the odds at 3 month follow-up is 7.1 (P&lt;0.0001) times higher than that at pre- RFA. Conclusions: This cooperative group trial confirms that RFA can safely palliate pain due to bone metastases. ACRIN receives funding from the National Cancer Institute through the grants U01 CA079778 and U01 CA080098. No significant financial relationships to disclose.

Radiopharmaceuticals for Palliation of Painful Osseous Metastases

Bone pain secondary to metastases may develop in more than half of patients with metastatic cancer. The treatment of metastatic osseous pain usually begins with oral analgesics following the WHO-ladder followed by external beam radiotherapy, ablative nerve blocks and implantable devices. Despite aggressive interventions, pain control seems challenging in this population. Treatment strategies including bisphosphonates, mitoxantrone and hormonal therapy have recently come into light. In some cases of osseous metastasis, radiopharmaceuticals may prove to be beneficial as an additional non-invasive therapy. This discussion will review different radiopharmaceutical agents available today including Strontium-89 chloride, Phosphorus-32 orthophosphate and Samarium-153 lexidronam and their clinical considerations.

Radiopharmaceuticals for palliation of painful osseous metastases.

Bone metastases represent the most common etiology of pain for patients with advanced cancer In the United States, the most common treatment for pain caused by bone metastases in late-stage cancer cases is external beam radiotherapy in conjunction with opioids. An alternative or adjuvant to external radiotherapy is intravenous radiopharmaceutical treatment. This review explores the pros and cons of different radiopharmaceutical options, their advantages over traditional external beam radiotherapy, and the conditions for optimal efficacy.

The use of zoledronic acid in painful osseous metastases due to prostate cancer

The use of zoledronic acid in painful osseous metastases due to prostate cancer

22. Current status of systematic radiopharmaceuticals for the treatment of painful metastatic bonr disease

Intractable bone pain secondary to bone metastasis from prostate or breast cancer, or other malignancies is a major problem in the management of the oncological patient. Treatment often includes the use of analgesic drug therapy; however, radiation therapy, hormonal therapy, chemotherapy, and surgery may also be needed. Advances in systemic radionuclide therapy have increased the number of treatment options available for patients with painful osseous metastases. This treatment modality offers three major advantages i.) by addressing all sites of involvement; and ii) by limiting irradiation of normal tissues due to selective absorption into bone which results in an improved therapeutic ratio. Patients with a positive bone scan are eligible for treatment, and indications and contraindications for use are well defined. Large, prospectively randomized clinical trials have established the efficacy of samarium-153 EDTMP and strontium-89 Cl as a first-line therapy. When these agents are used, pain relief often occurs rapidly and lasts several weeks to months with responses seen in 60–80% of patients, depending on the extent and stage of the disease. With the introduction of modern bone-seeking radiopharmaceuticals as Sm-153 EDTMP toxicity is rare and restricted to reversible myelosuppression. In summary, evidenced based literature suggests that these radiopharmaceuticals can significantly reduce pain and analgesic requirements, improve quality of life, reduce lifetime radiotherapy requirements and management costs, and may even slow the progression of painful metastatic lesions. Retreatment is safe and effective.

Systemic bone-seeking radionuclides for palliation of painful osseous metastases: current concepts.

Bone metastases require multidisciplinary treatment, the primary goal of which is to relieve pain and improve quality of life. Among the options available, bone-seeking radioisotopes are attractive because they can treat several symptomatic metastases simultaneously. This therapy may have antitumor efficacy in addition to analgesic properties. Although the ultimate place of systemic radionuclides in the treatment of bone metastases has not been firmly established, some patients clearly benefit from these modalities.

Palliative treatment for pain in osseous metastasized prostatic carcinoma with osteotropic rhenium-186 hydroxyethylidene diphosphonate (HEDP)

Systemic administration of strontium-89 is an important option for pain relief in advanced prostate carcinoma with multiple osseous metastases. Recently, rhenium-186-HEDP was introduced as a new substance which has important advantages (shorter physical half-life, scintigraphic imaging, dose distribution). The myelosuppressive effect can be estimated more accurately in advance, so that adverse effects can be reduced and the treatment can be repeated after a shorter period of time and more often. Our study comprises 15 treatments with rhenium-186-HEDP in advanced prostate cancer patients using the 1.4- to 2-fold standard dose. The response rate, estimated as reduction in pain and increase in patient mobility, was 87% with no major myelosuppressive effects. The mean duration of pain relief was 4-6 weeks. All four patients with repeated therapy were also responding to the second treatment. Radionuclide therapy for painful osseous metastases with rhenium-186-HEDP appears to be an effective and, even at higher doses, safe procedure.