The Role of Radiotherapy in Long Bone Metastases and Pelvis

  • Michele Fiore
  • Carla Germana Rinaldi
  • Sara RamellaEmail author


Bone metastases are a common complication of advanced cancer that can cause severe and debilitating effects. External beam radiation therapy (EBRT) provides significant palliation of painful bone metastases in around 70% of patients, induces remineralization, prevents impending fractures, and promotes healing of pathological fractures, reducing the skeletal-related events (SRE). Hypofractionated schedules are used for the treatment of bone metastases; the most commonly used are a single 8 Gy, 20 Gy in five daily treatments (4 Gy per treatment), and 30 Gy in ten daily treatments (3 Gy per treatment). Postoperative external beam irradiation can significantly reduce disease progression and subsequent loss of fixation. In the postoperative setting, the treatment field should include the entire interlocking device, nails, or prosthesis in order to remove any microscopic dissemination of disease. Two-dimensional or 3D conformal radiotherapy could be used for treatment planning. Simple field assessment (anteroposterior-posteroanterior AP-PA field) is often used for treatment planning of long bones, leading to a shorter treatment time. For pelvic bone metastases, a more complex field assessment could be considered to lessen the dose to the organs at risk, leading to a better tolerability of the treatment itself. Recent technological advances, such as intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT), can be used in a particular setting of oligometastatic patients to deliver a substantial dose of radiation to the tumor and spare healthy normal tissues.


  1. 1.
    Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;79(4):965–76. Scholar
  2. 2.
    Kakhki VR, Anvari K, Sadeghi R, Mahmoudian AS, Torabian-Kakhki M. Pattern and distribution of bone metastases in common malignant tumors. Nucl Med Rev Cent East Eur. 2013;16(2):66–9. Scholar
  3. 3.
    Bauer HC. Controversies in the surgical management of skeletal metastases. J Bone Joint Surg Br. 2005;87(5):608–17.CrossRefPubMedGoogle Scholar
  4. 4.
    Canale ST, Beaty HJ. Campbell’s operative orthopaedics. 12th ed. Oxford: Mosby Elsevier; 2013.Google Scholar
  5. 5.
    Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20 Pt 2):6243s–9s.CrossRefPubMedGoogle Scholar
  6. 6.
    Mantyh P. Bone cancer pain: causes, consequences, and therapeutic opportunities. Pain. 2013;154(Suppl 1):S54–62. Epub 2013 Jul 31CrossRefPubMedGoogle Scholar
  7. 7.
    Pituskin E, Fairchild A, Dutka J, Gagnon L, Driga A, Tachynski P, et al. Multidisciplinary team contributions within a dedicated outpatient palliative radiotherapy clinic: a prospective descriptive study. Int J Radiat Oncol Biol Phys. 2010;78(2):527–32.CrossRefPubMedGoogle Scholar
  8. 8.
    Chow E, Wong R, Hruby G, Connolly R, Franssen E, Fung KW, et al. Prospective patient-based assessment of effectiveness of palliative radiotherapy for bone metastases. Radiother Oncol. 2001;61:77–82.CrossRefPubMedGoogle Scholar
  9. 9.
    McDonald R, Chow E, Rowbottom L, Bedard G, Lam H, Wong E, et al. Quality of life after palliative radiotherapy in bone metastases: a literature review. J Bone Oncol. 2014;4(1):24–31. Scholar
  10. 10.
    Hoskin PJ. Bisphosphonates and radiation therapy for palliation of metastatic bone disease. Cancer Treat Rev. 2003;29(4):321–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Saarto T, Janes R, Tenhunen M, Kouri M. Palliative radiotherapy in the treatment of skeletal metastases. Eur J Pain. 2002;6(5):323–30.CrossRefPubMedGoogle Scholar
  12. 12.
    Poulsen HS, Nielsen OS, Klee M, Rørth M. Palliative irradiation of bone metastases. Cancer Treat Rev. 1989;16(1):41–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Mercadante S. Malignant bone pain: pathophysiology and treatment. Pain. 1997;69(1–2):1–18.CrossRefPubMedGoogle Scholar
  14. 14.
    Tsay TP, Chen MH, Oyen OJ, Hahn SS, Marty JJ. The effect of cobalt-60 irradiation on bone marrow cellularity and alveolar osteoclasts. Proc Natl Sci Counc Repub China B. 1995;19(3):185–95.PubMedGoogle Scholar
  15. 15.
    Vakaet LA, Boterberg T. Pain control by ionizing radiation of bone metastasis. Int J Dev Biol. 2004;48(5–6):599–606.CrossRefPubMedGoogle Scholar
  16. 16.
    Cliffoard Chao KS, Perez CA, Brady LW. Radiation oncology management decisions. Philadelphia: Lippincott Williams & Wilkins; 2002.Google Scholar
  17. 17.
    Fletcher GH. Textbook of radiotherapy. Philadelphia: Lea & Febiger; 1980. p. 943–6.Google Scholar
  18. 18.
    Tong D, Gillick L, Hendrickson FR. The palliation of symptomatic osseous metastases: final results of the study by the Radiation Therapy Oncology Group. Cancer. 1982;50(5):893–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Hirokawa Y, Wadasaki K, Kashiwado K, Kagemoto M, Katsuta S, Honke Y, et al. A multi-institutional prospective randomized study of radiation therapy of bone metastases. Nihon Igaku Hoshasen Gakkai Zasshi. 1988;48(11):1425–31.PubMedGoogle Scholar
  20. 20.
    Rasmusson B, Vejborg I, Jensen AB, Andersson M, Banning AM, Hoffmann T, et al. Irradiation of bone metastases in breast cancer patients: a randomized study with 1 year follow-up. Radiother Oncol. 1995;34(3):179–84.CrossRefPubMedGoogle Scholar
  21. 21.
    Niewald M, Tkocz HJ, Abel U, Scheib T, Walter K, Nieder C, et al. Rapid course radiation therapy vs. more standard treatment: a randomized trial for bone metastases. Int J Radiat Oncol Biol Phys. 1996;36(5):1085–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Wu JS, Wong R, Johnston M, Bezjak A, Whelan T, Cancer Care Ontario Practice Guidelines Initiative Supportive Care Group. Meta-analysis of dose-fraction radiotherapy trias for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys. 2003;55(3):594–605.CrossRefPubMedGoogle Scholar
  23. 23.
    Sze WM, Shelley MD, Held I, Wilt TJ, Mason MD. Palliation of metastatic bone pain; single fraction versus multifraction radiotherapy: a systemic review of randomized trials. Clin Oncol (R Coll Radiol). 2003;15(6):345–52.CrossRefGoogle Scholar
  24. 24.
    Chow E, Harris K, Fan G, Tsao M, Sze WM. Palliative radiotherapy trials for bone metastases: systematic review. J Clin Oncol. 2007;25(11):1423–36.CrossRefPubMedGoogle Scholar
  25. 25.
    Chow E, Zeng L, Salvo N, Dennis K, Tsao M, Lutz S. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol). 2012;24(2):112–24. Scholar
  26. 26.
    Westhoff PG, de Graeff A, Monninkhof EM, Bollen L, Dijkstra SP, van der Steen-Banasik EM, et al. An easy tool to predict survival in patients receiving radiation therapy for painful bone metastases. Int J Radiat Oncol Biol Phys. 2014;90(4):739–47. Scholar
  27. 27.
    Sim FH. Metastatic bone disease of the pelvis and femur. Instr Course Lect. 1992;41:317–27.PubMedGoogle Scholar
  28. 28.
    Bonarigo BC, Rubin P. Nonunion of pathologic fracture after radiation therapy. Radiology. 1967;88(5):889–98.CrossRefPubMedGoogle Scholar
  29. 29.
    Frassica FJ, Frassica DA. Metastatic bone disease of the humerus. J Am Acad Orthop Surg. 2003;11(4):282–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Jacofsky DJ, Haidukewych GJ. Management of pathologic fractures of the proximal femur: state of the art. J Orthop Trauma. 2004;18(7):459–69.CrossRefPubMedGoogle Scholar
  31. 31.
    Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009;91(6):1503–16. Scholar
  32. 32.
    Biermann JS, Holt GE, Lewis VO, Schwartz HS, Yaszemski MJ. Metastatic bone disease: diagnosis, evaluation, and treatment. Instr Course Lect. 2010;59:593–606.PubMedGoogle Scholar
  33. 33.
    Ruggieri P, Mavrogenis AF, Casadei R, Errani C, Angelini A, Calabrò T, et al. Protocol of surgical treatment of long bone pathological fractures. Injury. 2010;41(11):1161–7. Scholar
  34. 34.
    Malviya A, Gerrand C. Evidence for orthopaedic surgery in the treatment of metastatic bone disease of the extremities: a review article. Palliat Med. 2012;26(6):788–96. Scholar
  35. 35.
    Quinn RH, Randall RL, Benevenia J, Berven SH, Raskin KA. Contemporary management of metastatic bone disease: tips and tools of the trade for general practitioners. Instr Course Lect. 2014;63:431–41.PubMedGoogle Scholar
  36. 36.
    Willeumier JJ, van der Linden YM, Dijkstra PD. Lack of clinical evidence for postoperative radiotherapy after surgical fixation of impending or actual pathologic fractures in the long bones in patients with cancer; a systematic review. Radiother Oncol. 2016;121(1):138–42. Scholar
  37. 37.
    Gunderson T. Clinical radiation oncology. 2nd ed. Philadelphia: Churchill Livingstone Elsevier; 2007.Google Scholar
  38. 38.
    Hoskin P, Goh V. Radiotherapy in practice—imaging. Oxford: Oxford University press; 2010. p. 260–1.CrossRefGoogle Scholar
  39. 39.
    Taylor A, Powell ME. Intensity-modulated radiotherapy—what is it? Cancer Imaging. 2004;4(2):68–73. Scholar
  40. 40.
    Griffioen G, Dahele M, Jeulink M, Senan S, Slotman B, Verbakel WF. Bowel-sparing intensity-modulated radiotherapy (IMRT) for palliation of large-volume pelvic bone metastases: rationale, technique and clinical implementation. Acta Oncol. 2013;52(4):877–80. Scholar
  41. 41.
    Bhattacharya IS, Hoskin PJ. Stereotactic body radiotherapy for spinal and bone metastases. Clin Oncol (R Coll Radiol). 2015;27(5):298–306. Scholar
  42. 42.
    Kim H, Rajagopalan MS, Beriwal S, Huq MS, Smith KJ. Cost-effectiveness analysis of single fraction of stereotactic body radiation therapy compared with single fraction of external beam radiation therapy for palliation of vertebral bone metastases. Int J Radiat Oncol Biol Phys. 2015;91(3):556–63.CrossRefPubMedGoogle Scholar
  43. 43.
    Gomez-Iturriaga A, Cacicedo J, Navarro A, Morillo V, Willisch P, Carvajal C, et al. Incidence of pain flare following palliative radiotherapy for symptomatic bone metastases: multicenter prospective observational study. BMC Palliat Care. 2015;14:48. Scholar
  44. 44.
    Chow E, Meyer RM, Ding K, Nabid A, Chabot P, Wong P. Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a double-blind, randomised placebo-controlled, phase 3 trial. Lancet Oncol. 2015;16(15):1463–72. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Michele Fiore
    • 1
  • Carla Germana Rinaldi
    • 1
  • Sara Ramella
    • 1
    Email author
  1. 1.Radioterapia OncologicaUniversità Campus BiomedicoRomeItaly

Personalised recommendations