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Northeast Florida Medicine
Vol. 67, No. 1 2016
21
Palliative Care
1990s-2000s to a dose of 8 Gy in one fraction. A review of
multiple randomized studies revealed the early pain response
to be equivalent compared to a fractionated approach, but
suggested that a single fraction may have a slightly higher
risk of pain flare, pathologic fracture, and a significantly
higher risk of retreatment.
27
Therefore, an 8 Gy fraction is
best offered to patients with a shorter life expectancy and
in an area not at significant risk for pathologic fracture.
SRS has been attempted to achieve a better response
with a convenient one day treatment. A current phase III
trial is evaluating if improved pain relief is obtained with a
16-Gy SRS treatment compared with a conventional 8 Gy
treatment. A current cost-analysis of this study suggests that
SBRT is not cost effective compared to conventional RT in
patients with a limited life-expectancy,
28
and this will need
to be weighed when considering treatment options.
Of interest is the radioisotope radium-223, an alpha
particle emitter with a proclivity for dissemination in
bone tumor sites. It was found to confer both a survival
benefit and significant prolongation of time to first symp-
tomatic skeletal events (15.6 months versus 9.8 months)
in patients with castration-resistant prostate cancer with
symptomatic bone metastases.
29,30
In addition, treatment
with the radioisotope decreased the incidence of radiation
for symptomatic metastases, spinal cord compression,
symptomatic pathological bone fracture and the need for
orthopedic surgical intervention.
Thorax
Thoracic radiotherapy may provide symptomatic relief of
hemoptysis, cough, chest pain or other symptoms of thoracic
progression. Asystematic reviewrevealed that radiotherapyhas
partial and complete responses of 80 percent and 70 percent
for hemoptysis, 64 percent and 55 percent for chest pain, and
50 percent and 30 percent for cough, respectively.
31
This same
review found dysphagia to be themost common acute toxicity
in 15-20 percent of patients, followed by pneumonitis in 3
percent, and very rare myelopathy in <0.5 percent.
32
Radiotherapy is also commonly used when tumor bulk
threatens the integrity of adjacent structures. The superior
vena cava (SVC) is easily compressed and tumor burden
within the mediastinum (often from small or non-small
cord. Furthermore, leptomeningeal spread or intramedullary
metastases can also lead to pain or neurologic symptoms.
The prognostic factors for survival in patients with spinal
metastases are similar to those with brain metastases.
17
To improve chances of neurologic recovery, steroids
should be initiated immediately. Neurosurgical and radiation
oncology consultations should be obtained to optimize the
treatment approach. A randomized trial found that decom-
pressive surgical resection with adjuvant radiation therapy
improves outcomes comparedwith radiation alone.
18
In select
cases with vertebral body collapse, interventional radiology
may be consulted to discuss the role of vertebroplasty or
kyphoplasty. If surgery is performed, radiotherapy is typically
given as an adjuvant to decrease the risk of local recurrence.
If surgery is not recommended, radiation may be utilized as
the definitive treatment. For patients undergoing radiation
alone, good pretreatment ambulatory status, radiosensitive
histology, younger age, lack of visceral metastases and slow
rapidity of motor symptoms correlate with a higher proba-
bility of post-treatment ambulation.
19
For definitive RT, the standard dose to the spine is 30 Gy
in 10 fractions. Compared with less protracted regimens (8
Gy x 1, 4 Gy x 5), 30 Gy in 10 fractions improved the rate
of local control significantly.
20
For patients with an excel-
lent prognosis and oligometastatic disease, dose escalation
with SBRT is also an acceptable treatment option and has
demonstrated excellent long-term control.
21
A randomized
trial comparing 8 Gy of conventional RT vs 16-18 Gy SRS
is ongoing.
22
Bone
Bone metastases typically present with localized and pro-
gressive pain, but can also present with pathologic fracture,
neurologic symptoms, and difficulty ambulating. For up to
a few isolated lesions, external beam radiotherapy (EBRT)
shows pain improvement in up to 60-80 percent of patients,
and complete pain relief in up to 30 percent of patients.
23
It is
also believed that radiation can help stabilize bonemetastases
at risk for pathologic fracture through remineralization.
24
Multiple older studies found no difference in initial relief
of pain when different radiation fractionation schemes were
utilized.
25,26
Further dose reduction was attempted in the