3. Metastatic Bone Disease Metastasis Sites Vertebra (69%) Pelvis (41%) Femur (25%) Hip (14%) Malawer, MM and Delaney, TF. Treatment of Metastatic Cancer to the Bone. In: Devita VT, Hellman S, Rosenberg SA (eds). Cancer: Principles and Practice of Oncology. 4th ed. Philadelphia: JB Lippincott; 1993:2225-2245.
4. Level of Metastases Thoracic 70% Lumbar 20% Cervical 10%
5. Radiology: How to Evaluate Imaging tests X-ray Bone scan Sensitive, not specific. False positives: trauma, arthritis, infection CT (CAT scan) PET scan MRI scan Bone biopsy for confirmation Blood tests Calcium, alkaline phosphatase Bone Scan
6. Bone Scan A nuclear medicine bone scan would show bone mets as dark areas
7. PET scans may show the mets very clearly
8. PET scans can show bone mets that are in hard to see areas like the ribs or scapula
9. An MRI may show a bone met better than a regular X-ray
10. MRI imaging T1 T2
11. Clinical features of bony metastases Bone pain Pathological fracture Nerve compression Hypercalcaemia
12. APPROACH Life expectancy Biopsy Histology to predict the response to non operative management Stability Clinical presentation Pain and Neurological status
13. Treatment of bone metstasis Multi-disciplinary approach Medical. Surgical. Radiotherapy. Radionuclid. Chemotherapy & Hormonal Therapy
15. How does RT reduce pain ? Cell kill reduced tumor size and pressure effects Endothelial damage of micro-vasculature reduced blood flow. Reduces edema Reduces pain related neuro-transmitter concentrations Bone promotes re-mineralisation leading to structural stability.
16. Indications of Radiotherapy As Primary Treatment 1. Radiosensitive tumor not previously irradiated 2. Widespread spinal metastases with multilevel neural compression 3. Total neurological deficits below the level of compression > 48 hours 4. Patients condition (or prognosis) precludes surgery: high surgical risk or short life expectancy Penas-Prado M, Loghin ME. Spinal cord compression in cancer patients: review of diagnosis and treatment. Curr Oncol Rep. 2008 Jan;10(1):78- 85.
17. Radiotherapy Modalities Conventional External Beam Radiotherapy (EBRT) Intensity-modulated radiation therapy (IMRT) Stereotactic radiotherapy Stereotactic radiosurgery Radioisotopes Finn MA, Vrionis FD, Schmidt MH. Spinal radiosurgery for metastatic disease of the spine. Cancer Control. 2007 Oct;14(4):405-11.
18. Radiation Results Overall 85% response rate Complete relief in 54% 50% respond by 2 weeks, 80% by 1 month Median duration of pain relief 12-15 weeks The Xrays or scans may take months to show improvement (Recalcification by 2-3 months)
19. Bone met at L2 Radiation field A typical course of radiation is 10 treatments ( in some cases it is necessary to go slower, 20 to 25)
20. Palliative xrt - bone metastases treatment planning M. Raphael Pfeffer,Oncology Institute, Chaim Sheba Medical Center good margins e.g. add 1-2 vertebrae on each side include nearby asymptomatic lesions avoid irradiating entire limb circumference reduce irradiated volume of bowel/bladder bone marrow toxicity
21. Fractionation regimens 8 Gy in 1 fraction 20 Gy in 5 fractions 24 Gy in 6 fractions 30 Gy in 10 fractions Endpoints using pain relief, narcotic relief and quality of life measures show consistent similarity in the regimens
22. Single Vs Multi-Fraction
23. SYSTEMATIC REVIEW
24. Single fraction v multifraction more convenient less costly shorter time with acute side effects fear of high doses per fraction higher retreatment rate( 2-2,5 times higher) concern about toxicity in long-term survivors flare of bone pain maybe be higher
25. Single fraction v multifraction caution Problematic retreatment Previous treatment to the spine Femoral axial cortical involvment > 3 cm Surgical stabilization procedure Spinal cord compression or radicular nerve pain
26. Re-irradiation Not covering the spinal cord 1 x 8 Gy or 5 x 4Gy(Grade C) Covering the spinal cord 8 x 2,5 Gy (Grade D)
27. Adjuvant Radiotherapy Done after operative decompression Patchell et al study Wait 3 weeks for wound healing before starting radiation
28. Post-operative Patient received 30Gy/10fx
29. Radiopharmaceuticals Use of Radiopharmaceuticals does not obviate the need for EBRT. Ideal for osteoblastic, multi-focal and wide-spread disease.
30. Hemi-body Irradiation For multiple lesions, when facilities for radionuclide therapy is un-available. More suited for lower hemibody than upper. Ideally treated using 6MV photons or higher Keep lung dose to < 6 Gy for upper HBI
31. Palliative xrt -single fraction half body iradiation lower half body 8 Gy upper half body 6 Gy good short term palliation (~3 months) onset of pain relief Half Body xrt 50% @ 3 days, 100% @ 14 days Focal XRT 50% @ 7 days, 80% @ 14 days Salazar Cancer 1986 M. Raphael Pfeffer,Oncology Institute, Chaim Sheba Medical Center
32. Bisphosphonates and RT Bisphosphonates and RT can be given
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