Palliative Radiotherapy For Bone Metastases Research Articles

Patterns of Practice in Palliative Radiotherapy for Painful Bone Metastases: Impact of a Regional Rapid Access Clinic on Access to Care

External beam radiotherapy (RT) is commonly indicated for the palliation of symptomatic bone metastases, but there is evidence of underutilization of this treatment modality in palliative care for cancer populations. This study was conducted to investigate factors that influenced the use of palliative RT services at a regional comprehensive cancer center. A cohort of patients with radiographically confirmed bone metastases and first-time users of palliative RT between 2003 and 2005 was retrospectively reviewed from the time of initial diagnosis of bone metastases to death or last follow-up. Type of radiation treatment service provider used (rapid access or routine access) and patient-, tumor-, and treatment-related factors were analyzed for their influences on the number of treatment courses given over the duration of disease. A total of 887 patients received 1,354 courses of palliative RT for bone metastases at a median interval of 4.0 months between courses. Thirty-three percent of patients required more than one RT course. Increased age and travel distance reduced the likelihood and number of treatment courses, while service through a rapid access clinic was independently associated with an increase in subsequent use of palliative RT. A rapid access service model for palliative RT facilitated access to RT. Travel distance and other factors remained substantial barriers to use of palliative RT services. The pattern of practice suggests an unmet need for symptom control in patients with bone metastases.

56 DOSIMETRIC TREATMENT EVALUATION AND OPTIMIZED REPLANNING FOR IMRT OF CERVIX CANCER

Purpose: Palliative Radiotherapy (PRT) plays an important role in the relief of neurologic symptoms in patients with brain metastases; however, little is known about the use of PRT on a population level. The purpose of this study was to describe temporal trends in the use of PRT for brain metastases in Ontario. Methods: The Ontario Cancer Registry was used to gather information on all cancer deaths in Ontario between the years 1984-2004. The proportion of these cases receiving at least one course of PRT for bone metastases within the last two years of life was described over time and by disease site. Results: There were 435,055 cancer deaths in Ontario during the study period. Of these cases, 4.0% received at least one course of PRT for brain mets within the last two years of life. The rate of PRT varied significantly by primary site (e.g. lung8.7%, breast-6.4%, kidney-5.0%, prostate-0.6%) (p<0.001). Over time, the proportion of cases receiving PRT for brain mets increased from 2.1% to 5.0% (p<0.001). This increasing trend remained significant after taking into account primary site, age, sex, and time from diagnosis till death (p<0.001). The rate over time also varied by primary site (e.g. lung5.3% to 11.2%, breast3.7% to 8.8%, kidney2.2% to 6.0%, prostate0 to 0.9%) (p<0.001). Conclusion: The rate of PRT for brain metastases in Ontario has significantly increased over time. Explanations for these trends will be discussed.

Elderly Patients With Painful Bone Metastases Should be Offered Palliative Radiotherapy

To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients. The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed. No significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status. Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

Change in Urinary Markers of Osteoclast Activity Following Palliative Radiotherapy for Bone Metastases

Aims To examine the effect of radiotherapy for bone metastases on urinary markers of osteoclast activity. Materials and methods Patients with radiological evidence of bone metastases planned for palliative radiotherapy were eligible for the study. A urine specimen was collected before and 1 month after radiotherapy to assess levels of calcium, creatinine, magnesium, phosphate, N-telopeptide and pyridinoline. The Brief Pain Inventory was completed in person at baseline and by telephone follow-up at 1 month after radiotherapy. Patients were classified as responders (complete or partial pain response) or non-responders (stable or progressive pain) to radiotherapy based on the International Bone Metastases Consensus Criteria for end point measurements. Absolute values of urine markers were compared between responders and non-responders, or between responders and patients with progression. Results Our study population consisted of 74 men and 51 women. A single 8 Gy or 20 Gy in five daily fractions were commonly employed. At the 1 month follow-up, all Brief Pain Inventory functional interference scores showed a highly significant decrease from baseline ( P < 0.01). From our study population, 58 (64%) were classified as responders and 57 (46%) as non-responders to radiotherapy. We compared the urinary markers between the responders and the non-responders. There were no statistically significant differences between the two groups either in terms of baseline markers or in terms of month 1 follow-up markers. There was no significant change from baseline to the 1 month follow-up in responders or in non-responders to radiotherapy. Conclusion Baseline levels of urinary markers could not predict which patient would benefit from palliative radiotherapy.

Dexamethasone for the Prophylaxis of Radiation-induced Pain Flare after Palliative Radiotherapy for Symptomatic Bone Metastases: a Phase II Study

Aims Pain flare occurs in over one-third of patients receiving palliative radiotherapy for bone metastases. A single dose of dexamethasone can decrease the incidence of pain flare during the first 2 days immediately after radiotherapy. We conducted a phase II prospective study to investigate the prophylactic role of prolonged dexamethasone. Materials and methods Patients with bone metastases treated with a single 8Gy were prescribed 8mg dexamethasone just before palliative radiotherapy and for 3 consecutive days after treatment. Worst pain score and analgesic consumption data were collected at baseline and daily for 10 days after treatment. Analgesic consumption was converted into a total daily oral morphine equivalent dose in the analysis. Pain flare was defined ( a priori) as a two-point increase in worst pain on an 11-point numeric rating scale compared with baseline with no decrease in analgesic intake, or a 25% increase in analgesic intake with no decrease in worst pain score. To distinguish pain flare from progressive disease, we required that the worst pain score and analgesic intake returned to baseline levels after the increase/flare. Results Forty-one patients were evaluable (32 men, nine women). Their median age was 67 years. The overall incidence of pain flare was 9/41 (22%) within 10 days after the completion of radiotherapy. Most (55%) of these pain flares occurred on day 5. Absence of pain flare was 34/41(83%) and 39/41 (95%) for days 1–5 and 6–10 after the completion of radiotherapy, respectively. Conclusion Dexamethasone is effective in the prophylaxis of radiotherapy-induced pain flare after palliative radiotherapy for bone metastases. Randomised studies are needed to confirm this finding.

Do Bone Metastases from Gastrointestinal Cancers Produce Similar Response Rates Following Radiotherapy When Compared to Bone Metastases from Other Primary Cancers?

Purpose There has been limited report investigating whether painful bone metastases from gastrointestinal (GI) cancers produce similar response rates to palliative radiation therapy (RT) when compared to bone metastases from other primary cancer sites. The present study evaluated the response rates of symptomatic bone metastases from GI cancers following palliative outpatient RT in the Rapid Response Radiotherapy Program (RRRP). Methods and Materials Sixty-nine patients with bone metastases from GI primaries who received palliative RT in the RRRP clinic from 1999-2006 were identified. Thirty-one of these patients were extracted from an RRRP database that employed the Edmonton Symptom Assessment Scale (ESAS) from 1999-2003. The remaining 38 patients were evaluated from an RRRP database that employed the Brief Pain Inventory (BPI) from 2003-2006. Eligibility criteria for encryption in the aforementioned RRRP databases and collected patient demographic information (age, gender, primary cancer site, and Karnofsky Performance Status) were identical. Response rates for this cohort of metastatic GI patients were then compared to 479 patients receiving palliative RT for bone metastases from other primary cancer sites. Pain scores, employing the ESAS and BPI, as well as analgesic consumption were collected at baseline and by telephone follow-up at 4, 8, and 12 weeks after RT for all patients. Complete response (CR), partial response (PR) and overall response (CR+PR) were evaluated according to International Consensus Endpoints. Results Assessment of the 69 patients with metastatic GI cancers revealed CR, PR, and CR+PR rates of 18%, 42%, and 61% at 4 weeks, 22%, 35%, and 57% at 8 weeks and 50%, 21%, and 71% at 12 weeks, respectively, for evaluable patients. The 479 evaluable patients with metastatic cancer from other primary cancer sites had CR, PR, and CR+PR rates of 25%, 27%, and 51% at 4 weeks, 26%, 22%, and 48% at 8 weeks, and 22%, 29%, and 51% at 12 weeks, respectively. There were no statistically significant differences in RT response rates for bone metastases from GI cancers versus the other primary cancer sites. Conclusion Bone metastases from GI cancers demonstrate similar response rates following palliative RT when compared to other primary cancer sites. Patients with symptomatic bone metastases from GI malignancies should be referred for palliative radiotherapy as readily as patients with osseous metastases from other primary cancer sites. Keywords Bone metastases, gastrointestinal cancers, palliative radiotherapy, response.

Primary Squamous Cell Carcinoma of the Lung With Bony Metastasis in a 13-year-old Boy

Primary bronchogenic carcinoma of the lung is extremely rare in children, particularly the squamous cell type. Only 6 cases have been reported in the literature. We are reporting a case of metastatic squamous cell carcinoma in a 13-year-old boy who presented with left shoulder pain secondary to bone metastasis. Given the lack of specific symptoms associated with such malignancies, many children are at risk of delayed diagnosis and, as a result, associated metastases. Diagnostic evaluation hinges on biopsy of suspected lesion and histopathologic evaluation. Treatment regimens are rather ill defined, though the mainstay is surgical resection of the lesion along with chemotherapy and palliative radiotherapy for bone metastasis.

Is Response to Radiotherapy in Patients Related to the Severity of Pretreatment Pain?

The primary objective of this study was to determine whether there is a relationship between the severity of pretreatment pain and response to palliative radiotherapy (RT) for painful bone metastases. The database for patients with bone metastases seen at the Rapid Response Radiotherapy Program at the Odette Cancer Center from 1999 to 2006 was analyzed. The proportion of patients with mild (scores 1-4), moderate (scores 5-6), or severe (scores 7-10) pain at baseline who experienced a complete response, partial response, stable response, or progressive response after palliative RT was determined according to International Bone Metastases Consensus definitions. During the 7-year study period 1,053 patients received palliative radiation for bone metastases. The median age was 68 years and the median Karnofsky performance status was 70. Of the patients, 53% had a complete or partial response at 1 month, 52% at 2 months, and 54% at 3 months post-RT. There was no significant difference in terms of the proportion of responders (patients with complete or partial response) and nonresponders in terms of painful bone metastases among patients presenting with mild, moderate, or severe pain. Patients with moderate pain should be referred for palliative RT.

Cardiac metastasis from renal cell carcinoma without inferior vena involvement: a review of the literature based on a case report. Two different patterns of spread?

We report the case of a 59-year-old man with advanced renal cell carcinoma (RCC), without inferior vena cava (IVC) involvement, treated with radical nephrectomy, palliative radiotherapy for bone metastasis, and medical therapy for bone and lung metastases. The patient died of cardiac arrest after evidence of massive malignant pericardial effusion. At autopsy, massive myocardial and pericardial neoplastic invasion was found. Heart involvement via the IVC is a well-known phenomenon during RCC progression, while in the absence of IVC involvement, clinically evident cardiac involvement is exceptional, with few cases reported in the worldwide literature. Analysis of prior reports and of the present case provides evidence on how the cardiac metastasis may have two distinct origins and clinical features. The first is hematogenous, via the IVC, even in the absence of renal vein involvement; it is generally circumscribed and has a good prognosis after surgery. The second is through the intrathoracic lymphatic system, in the presence of disseminated disease, especially pulmonary metastasis, and this type has a very poor prognosis.

Single versus Multiple Fractions of Palliative Radiotherapy for Bone Metastases: A Randomized Clinical Trial in Iranian Patients

Despite high-level evidence in the literature, the use of single-fraction radiotherapy (rt) for management of painful bone metastases is not widely practiced in the world, as highlighted in several practice-pattern surveys. Fractionation of palliative rt for bone metastases has not been addressed in Iran, where the most common clinical practice is the use of 30 Gy in 10 fractions. Thus, we decided to perform a randomized clinical trial to compare responses in our patients with those reported in the international literature. Adult patients with multiple painful uncomplicated bone metastases were randomized to 8 Gy in a single fraction or 30 Gy in 10 fractions. Pain was graded by the patients on a scale of 1 to 4 just before and again 1 month after the end of rt. Palliative response was defined as "complete" (pain reduction of 2 grades or more), "partial" (pain reduction of 1 grade or more, but less than 2 grades), and "no response" (pain reduction of less than 1 grade). We randomized 70 patients in this trial (63% women; mean age: 51.6 years). Sites of treatment included spine (n = 27), sacrum or pelvis (n = 25), extremities (n = 14), ribs (n = 3), and sternum (n = 1). Patients graded their pain before rt in a range from 1.8 to 4.0 (mean: 3.2). All patients finished their scheduled course of rt without incident. Unfortunately, 5 patients died less than 1 month after the end of rt, and 7 did not return for any follow-up and could not be contacted. As a result, only 58 patients (31 who received multiple fractions, and 27 who received a single fraction) were available for evaluation of pain 1 month after treatment. At that time, pain was graded in a range from 1.0 to 4.0 (mean: 2.0). The reduction in pain grade ranged from -0.8 to 2.6 (mean: 1.1). We observed 8 (14%) complete responses, 33 (57%) partial responses, and 17 (29%) no responses, for an overall response rate of 71%. The number of responders was 21 (78%) among those who received a single fraction and 20 (65%) among those who received multiple fractions (p > 0.1). The mean reduction in pain was 1.1 in both groups. The 10-fraction group contained a higher number of complete responders (11 of 31 as compared with 6 of 27 in the 1-fraction group)-a result that was not statistically significant. The mean reduction in pain was 1.4 in patients 50 years of age or younger and 0.9 in patients more than 50 years of age (p = 0.01). Of the 8 complete responses, 7 (87.5%) were seen in the patients 50 years of age or younger, and the mean age of patients with a complete response (38.7 years) was significantly lower than that of patients with a partial response or no response (53.7 years, p = 0.017). By logistic regression, patient sex, primary tumour, rt site, and type of treatment (single-fraction vs. multifraction) did not have any significant effect on pain reduction. The only factor with a significant effect was age (p = 0.002). Our trial showed no significant difference in pain relief after palliative radiotherapy with 1 or 10 fractions in Iranian patients. The overall response rate was 71%, similar to results in the international literature. Younger patients responded better.

P72. Dexamethasone for the prophylaxis of radiation-induced pain flare following palliative radiotherapy for bone metastases: A phase II study

P72. Dexamethasone for the prophylaxis of radiation-induced pain flare following palliative radiotherapy for bone metastases: A phase II study

Semiautomatic vertebrae visualization, detection, and identification for online palliative radiotherapy of bone metastases of the spinea)

A treatment process which integrates simulation, planning, and delivery in one single session of < or =30 min on a treatment unit capable of cone-beam CT imaging (CBCT) is under development in our institution for palliation of spinal metastases. The objective of this work is to develop and validate a semiautomatic vertebra detection and identification algorithm to streamline the target definition process and improve the consistency of online planning on cone-beam CT data sets while the patient is on the treatment couch. Key issues pertaining to this work are the limited field of view and image quality of CBCT, the inter- and intrapatient variation of vertebra morphology, and the spine curvature. An initial library of ten patient CBCT data sets was used to derive the vertebra detection and identification method and set the parameters used by the algorithm. In this method, sagittal and coronal "curved" digitally reconstructed radiographs (cDRRs) are first created by projecting a subvolume of the CBCT data orthogonally to the centerline of a cylinder model positioned manually. The detection of the vertebra centers is then performed on the cDRRs based on an edge detection algorithm. The identification of the vertebrae by name is based on the detection of one or more of four different reference anatomical landmarks on cDRRs. The validation of the vertebra detection and identification algorithm was performed on a library of 27 patient CBCT data sets with an average detection success rate of 92.8% and 89.9% for sagittal and coronal cDRRs, respectively, for three different users. The entire process including manual steps and user approval was performed on average in 3.23-3.45 min (n=37, three users), with only 0.14 min for the automatic detection and identification of the vertebrae. The semiautomatic identification and segmentation of vertebrae on CBCT images was shown to be robust and effective. The next step will be the clinical implementation of the algorithm within the online planning and delivery treatment technique for patients with spinal bone metastases.

Dexamethasone for the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases—A pilot study

Purpose To investigate the efficacy of dexamethasone as a prophylactic adjuvant analgesic to decrease pain flare and to assess its safety and tolerance of dexamethasone.

A Population-based Study of the Fractionation of Palliative Radiotherapy for Bone Metastasis in Ontario

To describe the use of palliative radiotherapy (PRT) for bone metastases in Ontario between 1984 and 2001 and identify factors associated with the choice of fractionation. Electronic RT records from the nine provincial RT centers in Ontario were linked to the Ontario Cancer Registry to identify all courses of PRT for bone metastases. Between 1984 and 2001, 44,884 patients received 74,432 courses of PRT for bone metastases in Ontario. The mean number of courses per patient was 1.7, and 65% of patients received only a single course of PRT for bone metastasis. The mean number of fractions per course was 3.9. The proportion of patients treated with a single fraction increased from 27.2% in 1984-1986 to 40.3% in 1987-1992 and decreased thereafter. Single fractions were used more frequently in patients with a shorter life expectancy, in older patients, and in patients who lived further from an RT center. Single fractions were used more frequently when the prevailing waiting time for RT was longer. There were wide variations in the use of single fractions among the different RT centers (intercenter range, 11.8-62.3%). Intercenter variations persisted throughout the study period and were not explained by differences in case mix. Despite increasing evidence of the effectiveness of single-fraction PRT for bone metastases, most patients continued to receive fractionated PRT throughout the two decades of this study. Single fractions were used more frequently when waiting times were longer. There was persistent, unexplained variation in the fractionation of PRT among different centers.

Dexamethasone for the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases—A pilot study

Dexamethasone for the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases—A pilot study

Dexamethasone for the Prophylaxis of Radiation-induced Pain Flare following Palliative Radiotherapy for Bone Metastases: a Pilot Study

Dexamethasone for the Prophylaxis of Radiation-induced Pain Flare following Palliative Radiotherapy for Bone Metastases: a Pilot Study

Dexamethasone for the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases—a pilot study

To investigate the efficacy of dexamethasone as a prophylactic adjuvant analgesic to decrease pain flare and to assess its safety and tolerance of dexamethasone. Patients treated with a single 8 Gy for bone metastases took 8 mg dexamethasone before the radiation treatment. The Brief Pain Inventory was administered at baseline and then daily for 10 days after radiation. Pain flare was defined as a two-point increase in the worst pain or a 25% increase in the analgesic intake when compared with the baseline. Thirty-three patients (23 males, 10 females) had complete follow-up data. Their median age was 73 years old. Ten patients had progressive worsening pain during the entire 10-day follow-up. A total of eight patients (24%; 95% CI, 10-39%) experienced pain flare during the 10-day follow-up. Two patients had a 1-day pain flare on day 3. Three patients had a 1-day pain flare on day 7. Three other patients had a prolonged pain flare: one had a 3-day pain flare on days 2-4, one had a 3-day pain flare on days 4-6, and the other, a 6-day pain flare on days 3-8. The half-life of dexamethasone is 36-54 h. Only one patient (3%) experienced pain flare in the first 2 days of follow-up with the action of dexamethasone. Dexamethasone was well tolerated. Dexamethasone might be effective in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases. Randomized trials are required to confirm the finding.

2571: The Incidence of Consultation for Palliative Radiotherapy for Painful Bone Metastasis in a Single Cancer Center

Palliative care comprises 25–40% of the workload of most radiation oncology facilities. Several randomized trials have shown good pain relief with minimal side effects from short course palliative radiotherapy for painful bone metastasis. Here we evaluate the rate of referral of consultations for palliative radiotherapy for bone metastasis in a rural radiotherapy facility.

2568: Dexamethasone for the Prophylaxis of Radiation-Induced Pain Flare Following Palliative Radiotherapy for Bone Metastases

2568: Dexamethasone for the Prophylaxis of Radiation-Induced Pain Flare Following Palliative Radiotherapy for Bone Metastases

2559: A Population-Based Study of the Fractionation of Palliative Radiotherapy for Bone Metastases in Ontario

2559: A Population-Based Study of the Fractionation of Palliative Radiotherapy for Bone Metastases in Ontario