Radiotherapy for painful bone metastases: a systematic review.

University of Oxford, Churchill Hospital, UK.
Clinical Oncology (Impact Factor: 2.83). 02/1997; 9(3):150-4. DOI: 10.1016/S0936-6555(97)80070-2
Source: PubMed
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    ABSTRACT: Palliative radiotherapy constitutes nearly 50% of the workload in radiotherapy. Surveys on the patterns of practice in radiotherapy have been published from North America and Europe. Our objective was to determine the current pattern of practice of radiation oncologists in Canada for the palliation of bone metastases. A survey was sent to 300 practicing radiation oncologists in Canada. Five case scenarios were presented. The first three were patients with a single symptomatic site: breast cancer patient with pelvic metastasis, lung cancer male with metastasis to L3 and L1, respectively. The last two were breast and prostate cancer patients with multiple symptomatic bone metastases. A total of 172 questionnaires were returned (57%) for a total of 860 responses. For the three cases with a single painful bone metastasis, over 98% would prescribe radiotherapy. The doses ranged from a single 8 to 30 Gy in ten fractions. Of the 172 respondents, 117 (68%) would use the same dose fractionation for all three cases, suggesting that they had a standard dose fractionation for palliative radiotherapy. The most common dose fractionation was 20 Gy in five fractions used by 84/117 (72%), and 8 Gy in one fraction by 19/117 (16%). In all five case scenarios, 81% would use a short course of radiotherapy (single 8 Gy, 17%; 20 Gy in five fractions, 64%), while 10% would prescribe 30 Gy in ten fractions. For the two cases with diffuse symptomatic bone metastases, half body irradiation (HBI) and radionuclides were recommended more frequently in prostate cancer than in breast cancer (46/172 vs. 4/172, P<0. 0001; and 93/172 vs. 10/172, P<0.0001, respectively). Strontium was the most commonly recommended radionuclide (98/103=95%). Since systemic radionuclides are not readily available in our health care system, 41/98 (42%) of radiation oncologists who would recommend strontium were not familiar with the dose. Bisphosphonates were recommended more frequently in breast cancer than in prostate cancer 13/172 (8%) vs. 1/172 (0.6%), P=0.001. Local field external radiotherapy remains the mainstay of therapy, and the most common fractionation for bone metastases in Canada is 20 Gy in five fractions compared with 30 Gy in ten fractions in the US. Despite randomized trials showing similar results for single compared with fractionated radiotherapy, the majority of us still advocate five fractions. The frequency of employing a single fractionation has not changed since the last national survey in 1992. Nearly 70% use a standard dose fractionation to palliate localized painful metastasis by radiotherapy, independent of the site of involvement or tumor type. The pattern of practice of palliative radiotherapy for bone metastases in Canada is different to that reported previously from the US. The reasons why the results of randomized studies on bone metastases have no impact on the patterns of practice are worth exploring.
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    ABSTRACT: La radiothérapie antalgique des métastases osseuses de première intention est un traitement efficace quel que soit le fractionnement (traitement mono- ou plurifractionné). La radiothérapie peut également être proposée en cas d’échec ou d’efficacité insuffisante d’une première irradiation (après avoir éliminé une fracture) ou l’apparition de nouveaux sites douloureux. Les autres indications sont les compressions médullaires en adjuvant à la chirurgie ou de façon exclusive et les irradiations après chirurgie pour métastase des os longs. Le développement de la radiothérapie de haute précision (en conditions stéréotaxiques) augmente les possibilités de réirradiation lorsque les doses maximales admissibles par les tissus sains ont été atteintes. Elle cherche à améliorer le contrôle local, voire la survie, chez les patients oligométastatiques. Abstract First-line palliative radiotherapy for painful bone metastases is an effective treatment whatever its fractionation (single or multiple fractions). It is also advisable after failure or insufficient effect of a first irradiation, or the appearance of new painful site. Other indications are spinal cord compression, either as an adjuvant to surgery or as sole treatment, and after surgery for long-bone metastases. The development of high-precision techniques (stereotactic conditions) enlarges the possibility of re-irradiation while tolerance doses to normal tissues have already been delivered. Local control and possibly overall survival could be improved in oligometastatic patients.
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    ABSTRACT: Metastatic spinal tumours are the most common type of bone metastasis. Various methods have been used to treat metastatic spinal lesions, including radiotherapy, chemotherapy, isotope therapy, bisphosphonate therapy, analgesics, and surgery. Conservative treatments such as radiotherapy and chemotherapy are not appropriate and usually are ineffective in patients with vertebral fractures and/or spinal instability. Minimally invasive surgical treatments using non-vascular interventional technology, such as percutaneous vertebroplasty (PVP), have been successfully performed in the clinical setting. PVP is a non-invasive procedure that creates small wounds and is usually associated with only minor complications. In the present study, we will review the clinical status and prospects for the use PVP combined with 125I seed implantation (PVPI) to treat spinal metastases. The scientific evidence for this treatment, including safety, efficacy, and outcome measures, as well as comparisons with other therapies, was analysed in detail. PVPI effectively alleviates pain in metastatic spinal tumour patients, and the use of interstitial 125I seed implants can enhance the clinical outcomes. In conclusion, PVPI is a safe, reliable, effective, and minimally invasive treatment. The techniques of PVP and 125I seed implantation complement each other and strengthen the treatment’s effect, presenting a new alternative treatment for spinal metastases with potentially wide application.
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