Abstract
Bone metastases are the most common cause of cancer-related pain. Radiation therapy (RT) is a very common and effective treatment to relieve pain. Conventionally fractionated RT typically consists of the following regimens: 8 Gy in a single treatment, 20 Gy in five fractions, 24 Gy in six fractions, or 30 Gy in ten fractions. All treatment regimens have similar rates of pain relief (range 50–80%), with single-fraction treatment often requiring retreatment. While many painful bony metastases can be managed with RT alone, some may be more complex, often requiring multidisciplinary management, including the need for surgical stabilization or augmentation prior to RT. There are multiple assessment tools including the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which allows clinicians to assess the proper course of treatment for these patients. For patients with good prognosis, oligometastatic disease, or those presenting with more radioresistant tumors, stereotactic body radiotherapy (SBRT) may be another option, which offers ablative doses of radiation delivered over several treatments. This chapter reviews the fundamentals of RT for palliation.
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References
Nguyen J, Chow E, Zeng L et al (2011) Palliative response and functional interference outcomes using the Brief Pain Inventory for spinal bony metastases treated with conventional radiotherapy. Clin Oncol (R Coll Radiol) 23:485–491
Culleton S, Kwok S, Chow E (2011) Radiotherapy for pain. Clin Oncol (R Coll Radiol) 23:399–406
Pituskin E, Fairchild A, Dutka J et al (2010) Multidisciplinary team contributions within a dedicated outpatient palliative radiotherapy clinic: a prospective descriptive study. Int J Radiat Oncol Biol Phys 78:527–532
Chow E, Harris K, Fan G et al (2007) Palliative radiotherapy trials for bone metastases: a systematic review. J Clin Oncol 25:1423–1436
Lutz S, Berk L, Chang E et al (2011) Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys 79:965–976
Fakiris AJ, McGarry RC, Yiannoutsos CT et al (2009) Stereotactic body radiation therapy for early-stage non-small-cell lung carcinoma: four-year results of a prospective phase II study. Int J Radiat Oncol Biol Phys 75:677–682
Timmerman R, Paulus R, Galvin J et al (2010) Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA 303:1070–1076
Amini A, Altoos B, Bourlon MT et al (2015) Local control rates of metastatic renal cell carcinoma (RCC) to the bone using stereotactic body radiation therapy: Is RCC truly radioresistant? Pract Radiat Oncol 5:e589–e596
Hoskin PJ, Price P, Easton D et al (1992) A prospective randomised trial of 4 Gy or 8 Gy single doses in the treatment of metastatic bone pain. Radiother Oncol 23:74–78
Niewald M, Tkocz HJ, Abel U et al (1996) Rapid course radiation therapy vs. more standard treatment: a randomized trial for bone metastases. Int J Radiat Oncol Biol Phys 36:1085–1089
Jeremic B, Shibamoto Y, Acimovic L et al (1998) A randomized trial of three single-dose radiation therapy regimens in the treatment of metastatic bone pain. Int J Radiat Oncol Biol Phys 42:161–167
Nielsen OS, Bentzen SM, Sandberg E et al (1998) Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases. Radiother Oncol 47:233–240
Yarnold JR (1999) 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up. Bone Pain Trial Working Party. Radiother Oncol 52:111–121
Steenland E, Leer JW, van Houwelingen H et al (1999) The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study. Radiother Oncol 52:101–109
Roos DE, Turner SL, O’Brien PC et al (2005) Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology Group, TROG 96.05). Radiother Oncol 75:54–63
Hartsell WF, Scott CB, Bruner DW et al (2005) Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 97:798–804
Kaasa S, Brenne E, Lund JA et al (2006) Prospective randomised multicenter trial on single fraction radiotherapy (8 Gy x 1) versus multiple fractions (3 Gy x 10) in the treatment of painful bone metastases. Radiother Oncol 79:278–284
Foro Arnalot P, Fontanals AV, Galceran JC et al (2008) Randomized clinical trial with two palliative radiotherapy regimens in painful bone metastases: 30 Gy in 10 fractions compared with 8 Gy in single fraction. Radiother Oncol 89:150–155
Sande TA, Ruenes R, Lund JA et al (2009) Long-term follow-up of cancer patients receiving radiotherapy for bone metastases: results from a randomised multicentre trial. Radiother Oncol 91:261–266
Wu JS, Wong R, Johnston M et al (2003) Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 55:594–605
Chow R, Hoskin P, Chan S et al (2017) Efficacy of multiple fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review. Radiother Oncol 122:323–331
Rutter CE, Yu JB, Wilson LD et al (2015) Assessment of national practice for palliative radiation therapy for bone metastases suggests marked underutilization of single-fraction regimens in the United States. Int J Radiat Oncol Biol Phys 91:548–555
McDonald R, Chow E, Lam H et al (2014) International patterns of practice in radiotherapy for bone metastases: a review of the literature. J Bone Oncol 3:96–102
Laufer I, Rubin DG, Lis E et al (2013) The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 18:744–751
Bilsky MH, Laufer I, Fourney DR et al (2010) Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine 13:324–328
Wallace AN, Robinson CG, Meyer J et al (2015) The metastatic spine disease multidisciplinary working group algorithms. Oncologist 20:1205–1215
Krishnan MS, Epstein-Peterson Z, Chen YH et al (2014) Predicting life expectancy in patients with metastatic cancer receiving palliative radiotherapy: the TEACHH model. Cancer 120:134–141
Moussazadeh N, Lis E, Katsoulakis E et al (2015) Five-year outcomes of high-dose single-fraction spinal stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 93:361–367
De Meerleer G, Khoo V, Escudier B et al (2014) Radiotherapy for renal-cell carcinoma. Lancet Oncol 15:e170–e177
Chen FH, Chiang CS, Wang CC et al (2009) Radiotherapy decreases vascular density and causes hypoxia with macrophage aggregation in TRAMP-C1 prostate tumors. Clin Cancer Res 15:1721–1729
Kioi M, Vogel H, Schultz G et al (2010) Inhibition of vasculogenesis, but not angiogenesis, prevents the recurrence of glioblastoma after irradiation in mice. J Clin Invest 120:694–705
Song CW, Cho LC, Yuan J et al (2013) Radiobiology of stereotactic body radiation therapy/stereotactic radiosurgery and the linear-quadratic model. Int J Radiat Oncol Biol Phys 87:18–19
Katsoulakis E, Kumar K, Laufer I et al (2017) Stereotactic body radiotherapy in the treatment of spinal metastases. Semin Radiat Oncol 27:209–217
Hellman S, Weichselbaum RR (1995) Oligometastases. J Clin Oncol 13:8–10
Weichselbaum RR, Hellman S (2011) Oligometastases revisited. Nat Rev Clin Oncol 8:378–382
NRG-BR002. A phase IIR/III trial of standard of care therapy with or without Stereotactic Body Radiotherapy (SBRT) and/or surgical ablation for newly oligometastatic breast cancer. https://www.nrgoncology.org/Clinical-Trials/Protocol-Table
NRG-LU002. Maintenance systemic therapy versus consolidative Stereotactic Body Radiation Therapy (SBRT) plus maintenance systemic therapy for limited metastatic Non-Small Cell Lung Cancer (NSCLC): a randomized phase II/III Trial. https://www.nrgoncology.org/Clinical-Trials/Protocol-Table
Gomez DR, Blumenschein GR, Lee JJ et al (2016) Local consolidative therapy versus maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer without progression after first-line systemic therapy: a multicentre, randomised, controlled, phase 2 study. Lancet Oncol 17:1672–1682
van der Linden YM, Lok JJ, Steenland E et al (2004) Single fraction radiotherapy is efficacious: a further analysis of the Dutch Bone Metastasis Study controlling for the influence of retreatment. Int J Radiat Oncol * Bio * Phys 59:528–537
Jeremic B, Shibamoto Y, Igrutinovic I (2002) Second single 4 gy reirradiation for painful bone metastasis. J Pain Symp Manage 23:26–30
Mithal NP, Needham PR, Hoskin PJ (1994) Retreatment with radiotherapy for painful bone metastases. Int J Radiat Oncol * Bio * Phys 29:1011–1014
Hayashi S, Hoshi H, Iida T (2002) Reirradiation with local-field radiotherapy for painful bone metastases. Radiat Med 20:231–236
Sahgal A, Ames C, Chou D et al (2009) Stereotactic body radiotherapy is effective salvage therapy for patients with prior radiation of spinal metastases. Int J Radiat Oncol * Bio * Phys 74:723–731
Mahadevan A, Floyd S, Wong E et al (2011) Stereotactic body radiotherapy reirradiation for recurrent epidural spinal metastases. Int J Radiat Oncol * Bio * Phys 81:1500–1505
Gerszten PC, Burton SA, Ozhasoglu C et al (2007) Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 32:193–199
Garg AK, Shiu AS, Yang J et al (2012) Phase 1/2 trial of single-session stereotactic body radiotherapy for previously unirradiated spinal metastases. Cancer 118:5069–5077
Gilbert HA, Kagan AR, Nussbaum H et al (1977) Evaluation of radiation therapy for bone metastases: pain relief and quality of life. AJR Am J Roentgenol 129:1095–1096
McDonald R, Chow E, Rowbottom L et al (2015) Quality of life after palliative radiotherapy in bone metastases: a literature review. J Bone Oncol 4:24–31
Mirels H (1989) Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 256–64
Fisher CG, DiPaola CP, Ryken TC et al (2010) A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 35:E1221–E1229
Mavrogenis AF, Angelini A, Vottis C et al (2016) Modern palliative treatments for metastatic bone disease: awareness of advantages, disadvantages, and guidance. Clin J Pain 32:337–350
McDonald R, Chow E, Rowbottom L et al (2014) Incidence of pain flare in radiation treatment of bone metastases: a literature review. J Bone Oncol 3:84–89
Greenwood TJ, Wallace A, Friedman MV et al (2015) Combined ablation and radiation therapy of spinal metastases: a novel multimodality treatment approach. Pain Phys 18:573–581
Di Staso M, Zugaro L, Gravina GL et al (2011) A feasibility study of percutaneous Radiofrequency Ablation followed by Radiotherapy in the management of painful osteolytic bone metastases. Eur Radiol 21:2004–2010
Theurich S, Rothschild SI, Hoffmann M et al (2016) Local tumor treatment in combination with systemic ipilimumab immunotherapy prolongs overall survival in patients with advanced malignant melanoma. Cancer Immunol Res 4:744–754
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Amini, A., Shinde, A., Wong, J. (2021). Palliative Radiation for Cancer Pain Management. In: Leitner, A., Chang, C. (eds) Fundamentals of Cancer Pain Management. Cancer Treatment and Research, vol 182. Springer, Cham. https://doi.org/10.1007/978-3-030-81526-4_10
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DOI: https://doi.org/10.1007/978-3-030-81526-4_10
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