Abstract
Introduction: A cancer patient may
present to the orthopaedic surgeon for disabling bone pain,
pathological fracture and/or neurological deficit due to
spinal cord or nerve root compression. Bone pain due to skeletal
metastasis causes significant morbidity among cancer
patients and is equally difficult to treat for an orthopaedic
surgeon .Many a times multiple bones are affected
simultaneously. A single large hemibody radiation field is shown
to be effective in alleviation of pain in such patients. We
present results of ten patients treated with this technique at
our institute.
Materials and Methods: Ten documented cases of
disseminated bone metastasis due to malignancy were evaluated
to assess the efficacy of hemibody radiation for pain control.
Intensity of the pain was scored according to the 10th visual
analogue score. The upper and the lower segment of the body was
exposed to a radiation dose of 6 Gy and 8 Gy respectively in
single fraction using photon beam megavoltage unit by 6 MV
photons of linear accelerator.
Results:A Hemibody radiation
provided pain relief ranging from 64% to 100% .Complete pain
relief was achieved in 7 patients. Onset of relief was within
first 48 hrs and lasted for rest of their lives. Analgesic
requirement came down to less than 25% and was mainly required
for untreated other half. Four patients were treated for other
half after 6 weeks of first session. No significant
gastrointestinal ,hematological or pulmonary toxicity was noted
.The quality of life was significantly improved.
Conclusion:Hemibody radiation
gives fast, effective and lasting pain relief in any patient
presenting with multiple bony metastasis with reduced analgesic
requirement and better quality of life.
J.Orthopaedics 2006;3(3)e11
Introduction:
Metastatic tumors to the bones present to the orthopaedic
surgeon in one of three settings First and most common, a
patient with a known primary tumor is seen with a painful lesion
in the spine or extremity. Second, a patient may have a
pathological fracture , with or without a history of a known
primary tumour. Third and least commonly- a patient with a spine
or extremity pain arrives in clinic without a history of a known
primary tumour. The survival of patients with bony metastasis is
often prolonged and pain is the most common symptom in more than
two third of the patients. Most of the times multiple bones are
affected simultaneously, making life miserable for these
patients. Hemibody radiation can be used to treat overt multiple
metastasis , relieving patients pain in a single sitting. We
present a series of ten patients treated with this technique at
our institute.
Method and materials
Between June 2004 and September 2005 ten patients with
multiple painful skeletal metastasis due to various malignancies
were treated at our radiotherapy department using hemibody
radiation. 3 patients had breast carcinoma, 2 had prostate
carcinoma, 2 had lung carcinoma , 1 had thyroid, 1 had renal
cell and 1 had oral cavity malignancy. 3 patients received
upper hemibody radiation, 3 had lower hemibody radiation and 4
had both, upper and lower hemibody radiation .
Selection
criteria included1
-
Bone pain not
controlled with narcotics
-
Age less than 75
years
-
Karnofsky
performance status of 70 or higher
-
Adequate
myocardial, renal, hepatic, lung and bone-marrow function
-
Life expectancy
of 6 weeks or more
Previous radiotherapy to any local site is not a
contraindication, but in case of radiotherapy to lungs or
mediastinum previously ,these sites needed to be blocked. It is
avoided in patients requiring surgery in a near future because
of transient depression of blood counts.
A comprehensive pre-medication schedule was followed
to reduce stress reaction.
-
40 mg
prednisolone orally (24 hrs before in divided doses)
-
Overnight
hydration with 2 liters of fluid(5%dextrose,normal saline,
ringer lactate)
-
Nothing orally
for 6 hrs
-
Injection
Dexamethasone 2 cc IV
-
Injection
Ranitidine IV
Hemibody radiation was delivered using photon beam from
megavoltage unit by 6 MV photons of Linear accelerator going
through anterior and posterior portals to cover the entire
region in a single portal at extended skin to source distance.
A midline tumor dose of 6 Gy to UHBI (Upper Hemibody
Irradiation) and 8 Gy to LHBI (Lower Hemibody Irradiation) was
given. After 6 weeks of first radiation other half was treated
in 4 patients.
Patients were discharged on the same day and called for
follow up after 15 days, when complete blood count is repeated
to assess bone marrow depression .Visual analogue score was used
to report degree of pain relief. This score contains digits from
1 to 10.The person is asked to compare the severity of current
pain to worst pain he has ever faced in life. (like labour pain,
surgical pain, fracture pain) Having known the current pain at
the beginning of the treatment, when patient comes for the
follow up ,the pain relief can be assessed by asking him to
compare his pre-treatment pain with the post treatment one. This
does have its limitations, but for all practical purpose it is
the easiest and the simplest type.
Results
Hemibody radiation provided pain relief ranging from 64% to
100%. Complete pain relief was obtained in 7 patients( 2 with
breast, 3 with prostate and 1 each with lung and thyroid
malignancy). Onset of relief was within 48 hours. Pain relief
lasted for 7 to 8 months in 8 patients and till death in other 2
patients. Analgesic requirement came down to 25%, and it was
mainly required for the untreated other half of the body. With
pain relief patients were able to walk with support and were
able to perform their routine work with improved quality of
life.
Discussion :
Approximately 80% of bone metastases originate from primary site
in the lungs, breast, kidney, thyroid, prostate and
gastrointestinal tract2. The overall management of the patient
with metastatic disease requires team efforts from medical
oncologist, radiotherapist, orthopaedic surgeon and
psychotherapist.
Orthopaedic surgeon’s main role is in prevention and treatment
of pathological fracture. A pathological fracture of neck of
femur is best treated by prosthetic replacement, along with
debulking of tumour and postoperative radiotherapy. Other
pathological fractures of the weight bearing bones of the lower
extremity are best treated by debulking of tumor, open
reduction, strong internal fixation with or without
polymethylmethacrylate supplementation, and postoperative
radiotherapy. If the lesion is radiosensitive, as in myeloma
there is no need to debulk the tumor. Pathological fractures of
the major upper limb bones are treated in similar manner.
Occasionally bone metastases known to be highly vascular (e.g.
renal carcinoma) are treated by transcatheter arterial
occlusion. Prophylactic nailing is recommended when a metastatic
deposit causes significant pain , especially after radiotherapy,
and if more than 50% of the cortex is destroyed , or if a
femoral lesion is larger than 3 cm in diameter. Radiosensitive
spinal tumors(e.g lymphoma and myeloma) are treated by
radiotherapy and chemotherapy . However radioresistant tumors
require decompression either by laminectomy or by anterior
vertebral body resection and reconstruction2.
Total body irradiation (TBI) was first tried in treatment of
disseminated malignancies over half a century ago. Because of
known radiosensitivity of hematological malignancies it became a
suitable target module for TBI technique. The maximum dose
delivered in TBI is around 300 rad in a single or fractionated
dose3. Main adverse reaction of this was marrow suppression.
This can be circumvented by UHBI/LHBI or autologous marrow
transfusion4. Hemibody radiation can be easily used in centers
not having facilities for marrow transplantation. This approach
was invented by radiotherapists of Princess Margaret Hospital
in Toronto. Fitzpatrick and Rider were able to explore the use
of higher doses (600,800,1000 rad) given in a single fraction
to one half of the body in over 500 patients with advanced and
progressive cancer5. They found that relief of pain was dramatic
with 800 rad ; this usually occurred within 24 hours and lasted
for rest of patient’s life over 75% of the time. Most of the
studies recommend 600 rad and 800 rad in a single fraction for
upper and lower half body respectively5,6. Uppelschoten et al
achieved 39% complete pain relief with single dose of 600rad7.
Nseyo et al recommend 500 rad and 700 rad for upper and lower
hemibody respectively8,whereas Nag et al tried two doses of
800 rad spaced one week apart with minimal morbidity9. Miszczyk
and Sasiadek found that best symptomatic results were obtained
in the cases of multiple myelomas(100% of pain relief),prostate
cancers(the average degree of 78%) and lung
cancers(88%).Considering histopathological diagnosis , the best
answer was found in multiple myeloma and squamous cell
carcinoma(88%)Taking in to account type of metastases the best
result was obtained in the cases of osteolytic metastases10. In
our study also, patients with prostate cancer got 100% pain
relief, which lasted for three months. HBI is effective in
palliation of bone pain in patients with hormonally refractory
prostate cancer8.
Other modalities for palliative management of skeletal
metastasis include zolandronic acid injections and radionuclide
therapy using 32P and 89 Sr. None of these modalities provide as
lasting pain relief as hemibody radiation. Radionuclide therapy
is associated with high cost and severe bone marrow
depression1.
Although hemibody irradiation seems to have multiple
potentials and effective therapeutic measures , there are
certain limitations and several complications in its
implementation. It causes significant bone marrow depression
,acute radiation syndrome, radiation pneumonitis, alopecia,
hepatic, gastrointestinal and renal toxicities11. Uppelschoten
et al have reported 9% incidence of infield spinal cord
compression ,when radiation was given to vertebrae and 8%
incidence of pelvic fractures when radiation was given to
pelvis. Patients should be thoroughly screened for these
abnormalities and they should be rectified before giving HBI.
Conclusion:
Hemibody radiation provides fast ,effective and lasting pain
relief in any patient presenting with multiple painful bony
metastases with reduced analgesic requirement and better quality
of life. Besides radiation other supportive care and
psychosocial support forms an integral part of effective
treatment for these patients
Reference :
-
Powers W E, Ratanatharathorn V. Palliation of Bone metastases.
Principles & Practice of Radiation Oncology. Third Edition
.Philadelphia .Lippincott-Raven Publishers.1997.
2199-2215
-
Carnesale P G. Malignant tumours of bone. Campbell’s Operative
Orthopaedics. 9th edition.Mosby .732-736
-
Salazar O M .Systemic Radiation :Response & toxicity :Int J
Radiation Oncology Biological Physics. Nov-Dec 1978 ,Vol 4, No
11 & No 12, pp 937-949
-
Rowland C G . Single fraction half body radiation therapy. Clin
radiology (1979)30,1
-
Fitzpatrick R S ,Rider O P Half Body Radiotherapy.Int J
Radiation Oncol Biol Physics 1976 ;1:197-207
-
Biswal B M Assessment of the usefulness of hemibody irradiation
in painful bone metastasis. J Indian Medical Assoc.2004 Mar;
102(3):133-4,136-7
-
Uppelschoten JM , Wanders SL, de Jong JM. Single dose
radiotherapy (6 Gy):palliation in painful bone metastases.
Radiotherapy Oncology.1995 Sep; 36(3):198-202
-
Nseyo UO,Fontanesi J, Naftulin B N. Palliative hemibody
irradiation in hormonally refractory metastatic prostate cancer.
Urology.1989 Aug;34 (2): 76-9
-
Nag S ,Shah V .Once-a week lower hemibody irradiation (HBI) for
metastatic cancers.Int J radiation Oncol Biol Physics 1986 Jun;
12(6): 1003-5
-
Miszczyk L, Sasiadek W. The evaluation of the effectiveness of
half-body irradiation as palliative treatment in patints with
multiple bone metastases. Przegl. Lek 2001;58(5):431-4
-
Aziz H, Choi K,Sohn C , Yaes R, rotman M .Comparison of 32 P
therapy and sequential hemibody irradiation (HBI)for bony
metastases as methods of whole body irradiation
|