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    • br Radiotherapy for bone metastases As a palliative

    2019-06-11


    Radiotherapy for bone metastases As a palliative intervention, radiotherapy is effective and efficient at treating painful bone metastases, and the side effects associated with its use are manageable and usually self-limiting in nature. Between 50% and 80% of patients gain at least partial relief of their pain following external beam radiotherapy (EBRT), and complete relief may be seen in up to one-third [4]. External beam radiotherapy may be delivered to the same anatomic site of affected bone in the case of recurrent pain. Technological advances have created interest in the possibility that highly conformal therapies may improve either the rates of pain relief or the duration of the results of treatment, especially in cases of tumors located in bones of the spine. These treatments are termed stereotactic body radiation therapy (SBRT), or stereotactic ablative body radiotherapy (SABR), and are given by machines that deliver intensity modulated radiation therapy (IMRT), Cyberknife therapy, Tomotherapy, or proton therapy. Patients with spinal cord calcium channel blockers may receive EBRT primarily or as an adjuvant treatment after surgical decompression. Kyphoplasty or vertebroplasty may be used in cases where there is no spinal cord compression, but where spinal instability is noted and contributes to metastatic bone pain. Furthermore, injectable radiopharmaceuticals such as Strontium 89, Samarium 153, and Radium 223 may be delivered to patients with widespread tumors whose histologies are osteoblastic and therefore easily visualized on a Technetium 99 bone scan. Finally, the addition of osteoclast inhibiting agents may be considered concurrently or sequentially with EBRT.
    Emergence of radiotherapy guidelines
    International Consensus Conference Bone Metastases treatment recommendations The prelude to many of the questions posed and answers offered by the existing bone metastases treatment guidelines was contained in previous International Consensus Conference Bone Metastases treatment recommendation publications. The First International Consensus Workshop on radiation in the treatment of metastatic and locally advanced cancer convened in the United States in 1990 [5]. A group of 116 experts evaluated the available palliative radiotherapy data and generated consensus statements for the treatment of bone metastases, amongst other clinical circumstances. Those statements included treatment pathway recommendations, an assessment of international variations in treatment approach, the effects of successful treatment on quality of life, and the role of economic factors in the management of this patient group. The Second Workshop on Palliative Radiotherapy and Symptom Control convened in London in 2000 and confirmed the efficacy of EBRT in controlling pain caused by metastatic bone disease [6]. That group reviewed the efficacy of a single 8Gy fraction, they better defined the proper use of radiopharmaceuticals for patients with widespread painful disease, and they recommended the standardization of response measurement that led to the development of the International Consensus on Palliative Radiotherapy Endpoints document. Finally, the Third International Consensus Conference Workshop was held in conjunction with the ASTRO meeting with representatives from ASTRO, European Society for Therapeutic Radiology and Oncology (ESTRO), Trans-Tasman Radiation Oncology Group (TROG) and Canadian Association of Radiation Oncology (CARO) in San Diego, California, in 2010 and called for both formal treatment guidelines and a means by which to enhance palliative radiotherapy efforts in developing countries around the world.
    Formal radiotherapy bone metastases treatment guidelines The American College of Radiology (ACR) Appropriateness Criteria format employs common clinical circumstances, or “variants”, which serve as a means for an expert panel to vote upon the most appropriate interventions for that scenario (Table 1). The panel members collectively base their assessments upon the results of published literature, though the clinical experience of those experts may influence their decision-making, especially in situations where the available data set is incomplete. The bone metastases treatment panel consists of representatives from radiation oncology, nuclear medicine, orthopedic surgery, and medical oncology. The clinical case scenarios allow for recommendations about the best combination of interventions as well as an assessment of the proper radiotherapy treatment set-ups and fractionation schemes. While previous ACR publications have included all types of bone metastases situations in a single manuscript, the increasing complexity of treatment of spine metastases and spinal cord compression led to the division of “spine” and “non-spine” topics. The most recent update of the non-spine topic has just been published, while the spine topic update is still being formulated [7].