ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases

Same-Day Magnetic Resonance-Guided Single-Fraction Stereotactic Body Radiation Therapy for Painful Non-Spine Bone Metastases - A Single-Center Study ("BONE SHOT")

Introduction and background

There is evidence for efficacy of high-dose single-fraction stereotactic body radiotherapy (SF-SBRT) for painful non-spine bone metastases (NSBMs). This study ("BONE SHOT") assessed feasibility of same-day magnetic resonance-guided (MRg) planning and SF-SBRT delivery, recorded toxicity and assessed efficacy for treating metastatic patients with NSBMs.

Materials and methods

Patients with painful (≥3/10 points on a 0-10 numeric rating scale (NRS) for pain) and radiologically confirmed NSBMs from solid organ malignancies were eligible for this prospectively acquired, single-center study. Patients received MRg-SF-SBRT via MR-Linac (ViewRay®) with same-day consultation, consent, planning and treatment. Drop-out rate, procedure times, acute toxicity and pain response were recorded.

Results

Between June 2019 and June 2020, 13 patients with 15 NSBMs were treated per protocol. Mean patient age was 64 (range, 30-87) years; most common primary cancer was gastrointestinal malignancies (38.5 %); most commonly treated site was pelvis (53.3 %). All workflows were completed as planned. Median on-table time for contouring, planning and delivery was 65 (range, 57-112) minutes. Treatments were well tolerated; one patient developed "pain flair"; no grade ≥ 3 toxicities were registered. At one week following SBRT, overall and complete pain response rates were 73.3 % and 20.0 %, respectively, which evolved to 66.7 % and 53.3 % at four weeks after SBRT; median pre-treatment pain score was 6 points, which was reduced by a median of 5 points (P = 0.0028) at four weeks.

Conclusion

The same-day MRg-SF-SBRT workflow for NSBMs was feasible, safe, and preliminary results indicate promising efficacy, warranting future trials investigating this intervention.

Esophagus-sparing radiotherapy for complicated spinal metastases (ESO-SPARE). A randomized phase III clinical trial

BACKGROUND

Patients receiving palliative radiotherapy (RT) for complicated spinal metastases in the cervical and thoracic spine may develop dysphagia due to esophageal and pharyngeal irradiation. This phase III trial investigated if esophagus/pharynx-sparing VMAT/IMRT could reduce patient-reported peak dysphagia without affecting ambulatory function compared to standard VMAT/IMRT.

METHODS

This dual-center, single-blind, phase III trial (NCT05109819) randomized adult patients with complicated spinal metastases (C1-T12) receiving 1-10 fraction RT to either conventional or esophagus/pharynx-sparing VMAT/IMRT. Patient-reported outcomes (PRO-CTCAE) were collected daily for five weeks, and EQ-5D-5L, EORTC-QLQ-C30, weight, and analgesic use were assessed weekly for nine weeks. Co-primary endpoints were peak dysphagia (first five weeks) and ambulatory function (EQ-5D-5L mobility) at nine weeks, analyzed by Wilcoxon rank-sum test. The association between esophageal dosimetric parameters and "severe-or-worse" dysphagia was assessed.

RESULTS

From May 2021-April 2024, 188 patients were randomized (standard: 92 included, 60 analyzed; esophagus-sparing: 96 included, 70 analyzed). Fourteen esophagus-sparing patients did not receive the intended intervention. These patients were recategorized as standard for per-protocol analysis. Dysphagia (any grade) occurred in 64 % (standard) and 55 % (esophagus-sparing) of patients. Intention-to-treat analysis found no differences in peak dysphagia (p = 0.20) or ambulatory status (p = 0.30). Per-protocol analysis found significant difference in peak dysphagia (p = 0.50). Dosimetric parameters (D0.027 cc-D5cc, V15Gy-V25Gy) correlated with "severe-or-worse" dysphagia.

CONCLUSION

Esophagus-sparing VMAT/IMRT did not reduce peak dysphagia in the intention-to-treat analysis but showed a significant benefit in the per-protocol analysis. Higher esophageal dose and larger irradiated volumes correlated with risk of "severe-or-worse" dysphagia, suggesting that esophagus/pharynx-sparing RT may particularly benefit patients receiving high-dose, large-field radiation.

Cancer Pain: Radiotherapy as a Double-Edged Sword

Cancer pain is a common issue for patients, especially in the advanced stages of cancer, and significantly affects the quality of life (QoL), treatment tolerance, and overall treatment outcomes. Pain may be caused by primary tumors, metastases, or as a consequence of the inflammatory reaction of tissues surrounding the tumor following radiotherapy (RT). Effective pain management is crucial, especially with RT being a key method for alleviating cancer pain, particularly in cases of bone and soft tissue metastases. RT provides relief for 60-80% of patients by reducing tumor size and mitigating associated pain. Radiotherapy itself can also induce pain, especially radiation-induced neuropathic pain, which may require further treatment. Despite these potential side effects, RT remains an essential tool in managing cancer pain, though careful management of its toxicities is necessary to improve patient QoL and survival.

A critical appraisal of clinical guidelines on radiotherapy treatments for spinal metastasis

This review systematically reviewed the current guidelines related to radiotherapy for spinal metastases, summarized the relevant recommendations, and assessed the quality of their supporting evidence. The guidelines on radiotherapy for spinal metastases were searched by the keyword "guidelines" and "spinal metastasis". The most updated guidelines on radiotherapy for spinal metastasis were selected based on pre-defined inclusion and exclusion criteria. AGREE II was used to evaluate the quality of these guidelines. In addition, the related recommendations were extracted, and their quality was assessed using an evidence-grading scale. Nine guidelines established between 2013 and 2024 were included in this study. Three of the guidelines had an applicability rating of less than 50%. The difference in scores was the largest in rigor of development (range 48.50-88.03%). A total of 44 recommendations based on indications, re-irradiation, radiation dose and regimen, and emergency radiotherapy, were extracted and evaluated for SM. In conclusion, this study summarizes nine guidelines on radiotherapy for SM and provides useful information for improving treatment outcomes in patients with SM. All nine guidelines scored low in terms of adaptability, and most recommendations were based on a moderate-to-high LOE. The timing of re-radiotherapy varies across guidelines and fractionated radiotherapy regimens are available for specific SM patients. SBRT is more suitable than RBRT for patients with oligo-metastases, but more high-quality evidence is needed to confirm the more advantages of SBRT compared with conventional radiotherapy.

Pain response to palliative radiotherapy in bone metastases vs. non-bone lesions: Prospective study

BACKGROUND

This study compared the pain response to palliative radiotherapy for bone metastases and non-bone lesions based on the International Consensus on Palliative Radiotherapy Effectiveness (ICPRE) criteria.

METHODS

This two-cohort study used data from a prospective cohort of 867 registered lesions from 500 patients conducted between August 2021 and September 2023. Pain responses were assessed using the ICPRE criteria at prespecified timings of 2, 4, 12, 24, 36, and 52 weeks. The primary outcome was the pain response rate within 12 weeks, comparing two groups of patients with bone and non-bone lesions. A multivariate logistic regression analysis was conducted to adjust for confounding covariates based on opioid use, irradiation history, performance status, NRS, primary disease, and radiation dose.

RESULTS

Among 678 lesions from 440 patients who met the criteria, 541 (80 %) and 137 (20 %) were in the bone and non-bone cohort, including primary tumors, lymph node metastases, and others. The mean age was 63 years, and 45 % were female. Treatment included conventional radiotherapy of a single 8 Gy dose, 20 Gy in 5 fractions, and 30 Gy in 10 fractions, used in 89 % of lesions. While opioid use (67 %) and re-irradiation rates (22 %) were not different between cohorts, the non-bone cohort had shorter median survival (4.9 months vs. 6.3 months, P = 0.017) and more frequently fractionated irradiation (85 % vs. 67 %, P < 0.001). No differences were observed in pain response rates between the two groups (57 % vs. 62 %, P = 0.33), which remained consistent after adjusting covariates. Re-irradiation and opioid were associated with negative impacts on pain response in the bone cohort. In contrast, the increased irradiation dose was identified as potentially affecting the non-bone cohort.

CONCLUSIONS

This study suggested palliative radiotherapy is effective for painful non-bone lesions and potential dose-dependency for pain response, highlighting the need for future randomized controlled trials to determine the optimal radiation dose.

Palliative stereotactic body radiotherapy for spinal and non-spinal bone metastases: combining tradition and innovation

Bone metastases can cause pain, fractures, radiculopathy, and metastatic epidural spinal cord compression, all of which substantially impair patients' quality of life. Conventional external beam radiotherapy (cEBRT) has been the standard treatment for symptomatic bone metastases. While the effectiveness and safety of cEBRT are well established, it has certain limitations, including a short duration of pain relief, limited long-term tumor control, and suboptimal efficacy against radioresistant tumors. Over the past decade, stereotactic body radiotherapy (SBRT) has been explored as a palliative treatment for bone metastases. SBRT enables the delivery of high doses of radiation to bone lesions by maximizing dose conformality. This treatment characteristic yields several clinical advantages, including considerable pain relief, durable tumor control, and efficacy against radioresistant tumors. SBRT has the potential to overcome the limitations of cEBRT and represents a promising approach that could revolutionize the treatment of bone metastases. This review addresses three clinical scenarios: painful spinal metastases, painful non-spinal bone metastases, and metastatic epidural spinal cord compression. For each scenario, we summarized the evidence for cEBRT and SBRT, highlighting the utility and potential of SBRT as an emerging treatment option.

Stereotactic radiotherapy for spinal and non-spinal bone metastases: a patterns-of-care analysis in German-speaking countries as part of a project of the interdisciplinary Radiosurgery and Stereotactic Radiotherapy Working Group of the DEGRO/DGMP

BACKGROUND AND PURPOSE

Bone metastases constitute a common indication for both conventional radiotherapy (RT) and stereotactic body radiotherapy (SBRT). Although in recent years guidelines have been proposed for SBRT of spinal and non-spinal metastases, little is known about the use of bone SBRT and the actual patterns of care in German-speaking countries.

MATERIAL AND METHODS

We performed an online survey among radiation oncologists (ROs) registered with the interdisciplinary Radiosurgery and Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (DEGRO) and the German Society for Medical Physics (DGMP) to collect valuable and robust cross-sectional data on patterns of care for bone SBRT in German-speaking countries.

RESULTS

Of the registered ROs, 35.5% (75/211) completed the online survey. ROs working in high-volume centers irradiating more than 100 patients with bone metastases annually represented the largest group, with 58.7%. Ablative SBRT was mostly performed for bone oligometastases (78.7%). For symptom-directed palliative radiotherapy, the majority of responding physicians (84.3%) still mostly recommend moderately hypofractionated treatment. Nevertheless, 60.9% of participating ROs stated using bone SBRT at least occasionally, also for palliative purposes such as pain control. Our survey also revealed a certain reluctance for the concomitant use of systemic therapies with bone SBRT and heterogeneity regarding target volume definition and dosing for bone SBRT.

CONCLUSION

Our survey demonstrates that bone SBRT for spinal and non-spinal metastases for oligometastatic disease (OMD) is broadly available in clinical routine care in German-speaking countries. A large heterogeneity regarding indications, dose, and fractionation concepts remains, requiring further efforts for standardization of bone SBRT.

Patterns of failure after stereotactic body radiotherapy to non-spine bone metastases

BACKGROUND AND PURPOSE

Stereotactic body radiotherapy (SBRT) has proven useful for non-spine bone metastases (NSBM). We analyzed local relapse rates and patterns of failure after NSBM-SBRT, contrasting our results with existing contouring guidelines.

MATERIALS AND METHODS

We conducted a retrospective analysis of NSBM-SBRT treatments performed between 2013 and 2024 in a single institution. Clinical, pathologic, and treatment-related data were collected. Failure patterns were assessed based on imaging tests and categorized as in-field, marginal/out-of-field.

RESULTS

Among 119 NSBM-SBRT treatments in 85 patients, the most common primary tumors were prostate (36.1%) and breast cancer (24.4%). The coxal bone was the predominant metastatic site (52.9%). The median follow-up was 32.8 months. OS rates at 1, 2, and 3 years were 90.1%, 83.5%, and 75.8%, respectively. Twenty seven relapses were observed in the treated bone with a median recurrent tumor volume of 9.9 cm3 and a median time to recurrence of 15.1 months. Relapse-free survival in the treated bone was 89.4%, 78.5%, and 74.2% at 1, 2, and 3 years, respectively. Median recurrent tumor volume within the CTV was 50.6% and the median distance from the relapse center to the initial tumor was 11.4 mm.

CONCLUSION

NSBM-SBRT provides effective local control with relapses often occurring near the initial tumor lesion. While adherence to existing contouring guidelines captures most scenarios, consideration of larger CTV expansions may be warranted in cases with poorer prognosis. Further studies are needed to identify risk factors for relapses outside the margins and optimize volume delineation in these scenarios.

A Single-Center Experience of the Same-Day Palliative Radiotherapy for Patients Referred to the Radiotherapy Department

Background: Rapid initiation of radiotherapy plays an increasingly important role in palliation of advanced cancer. Objective: We performed a retrospective analysis to determine the current status of same-day palliative radiotherapy in patients referred to the Radiotherapy Department of a medium-sized institution in Japan. Materials and Methods: The incidence by year, sex, age, primary cancer site, indication for radiotherapy, radiotherapy regimens, response rates to radiotherapy, and treatment waiting times were studied in 96 patients who received same-day palliative radiotherapy between 2016 and 2023. Results: The annual incidence of same-day palliative radiotherapy was 5.9%. The study included 61 males (aged 42-96) and 35 females (aged 42-97). The most common tumor was non-Hodgkin's lymphoma, followed by lung cancer. The main indications were malignant spinal cord compression and symptomatic brain metastases. Prostate cancer is the leading cause of malignant spinal cord compressions. Of the 96 patients, 84 received same-day palliative radiotherapy for oncological emergencies. Various radiotherapy regimens have been used, ranging from conventional 40 Gy in 20 fractions to hypofractionated 8 Gy in a single fraction. The response rates were 69.0% for spinal cord compression, 91.7% for symptomatic brain metastases, 100% for hollow organ compression and/or obstruction, and 100% for uncontrolled tumor bleeding. The mean time from the end of the consultation to the end of treatment was 262 ± 90 minutes. Conclusion: Same-day palliative radiotherapy is indispensable, especially in oncologic emergencies. Therefore, criteria for its appropriateness should be established.

Clinical, Diagnostic and Therapeutic Framework of mHSPC and nmCRPC: A Multidisciplinary Consensus Project of the Italian Society for Uro-Oncology (SIUrO)

The recent evidences provided in metastatic hormone sensitive prostate cancer (nmHSPC) and in nonmetastatic castration resistant (nmCRPC) introduced the possibility to adopt Androgen Receptor Signaling inhibitor (ARSi) alone (both settings) or with chemotherapy (in mHSPC). In daily clinical practice there are some opening questions regarding the inclusion of next generation imaging, mainly PSMA-PET, how integrate local treatment as radiotherapy, how to select patients or drugs in a multiple-choice scenario, and how to manage patients with comorbidities and polypharmacy. These issues led the Italian Society for Uro-Oncology (SIUrO) to develop a consensus project involving all of the most important Italian scientific societies engaged in the multidisciplinary and multiprofessional management of the disease. This paper describes the items and statements approved, with the aim to support clinicians in managing metastatic hormone sensitive and nonmetastatic castration resistant prostate cancer patients.

Prevalence and characterization of pain in radiation oncology: the PREDORT multicenter cross-sectional study

BACKGROUND

Pain in cancer patients has enormous impact on their quality-of-life. Radiation therapy (RT) is a cornerstone in cancer treatment. The objective of the PREDORT study is to estimate the prevalence of pain in patients attending at Radiation Oncology (RO) Services.

METHODS

A prospective, multicenter study was designed for patients treated at the RO Services of reference hospitals. Patients were seen in their initial Nursing consultation, during which key data was collected, including demographic and comorbidities data, medical history, and oncological and pain characteristics. The study has received approval from the Ethics Committee of Navarra, and all patients signed the Informed Consent.

RESULTS

Of the 860 participating patients, 306 reported some type of pain, which implies a prevalence of 35.6%. Of them, 213 identified a cause of oncological origin. The proportion of pain was similar among sexes, but the proportion of non-cancer pain was higher among women (p < 0.05). Regarding pain intensity, the magnitude of breakthrough pain in patients with oncological pain is nearly 1 point greater than in patients with non-oncological pain (7.53 vs 6.81; p = 0.064). Cancer pain is more likely to be limiting of normal life than non-cancer pain (59% versus 38%, p < 0.001). Regarding analgesic treatment, only 60/306 patients (19.6%) were receiving strong opioids. There were 68 patients with pain without any treatment (22.2%).

CONCLUSIONS

The prevalence of pain in cancer patients referred to RO services is 35.6%, with the prevalence of exclusively oncological pain being 24.8%. Understanding and addressing oncological pain is essential to provide comprehensive care to patients.

Trends in single-fraction palliative radiotherapy across the COVID-19 pandemic in Japan: a nationwide claims study

This study aimed to evaluate the recent trends in single-fraction conventional radiotherapy (CRT) as palliative treatment in Japan, using data from the National Database published by the Ministry of Health, Labor, and Welfare. Data from fiscal year (FY) 2014 to FY2022, specifically related to the utilization of single-fraction CRT, were analyzed. Multi-fraction CRT, stereotactic body radiotherapy (SBRT), intensity-modulated radiotherapy (IMRT), and brachytherapy were excluded. The primary outcome was the cumulative and annual number of single-fraction CRT courses. Additionally, quarterly course data from FY2019 to FY2022, the period for which monthly data were available, were assessed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on single-fraction CRT utilization. Of the total 2 315 607 radiotherapy courses, we identified 33 221 single-fraction CRT courses after excluding multi-fraction CRT (n = 1 835 650), SBRT (n = 33 935), IMRT (n = 332 827), and brachytherapy (n = 113 195). The annual number of single-fraction CRT courses increased from 1730 in FY2014 to 5642 in FY2022, with an average annual growth rate of 0.28 (range: -0.07 to 0.65). Outpatient courses significantly increased, particularly from FY2019 onward, surpassing inpatient courses in FY2022 (2914 vs 2728). The highest annual increase was observed in FY2020, particularly from April to December, although this upward trend did not persist in 2021. In conclusion, single-fraction CRT has exhibited a consistent upward trend, highlighting its expanding role in palliative radiotherapy. Although the COVID-19 pandemic temporarily accelerated this trend, its impact has already subsided, with growth rates returning to pre-pandemic levels.

Reirradiation of bone metastasis: A narrative review of the literature

Patients with bone metastasis are prevalent among those receiving palliative radiotherapy (RT), with approximately 20 % requiring reirradiation (reirradiation). The goal of bone reirradiation may be local control (oligoreoccurrence or oligoprogression of a previously treated lesion or in a previous treatment field) or symptomatic (threatening or painful progression). Published data on bone reirradiation indicate almost two-thirds of overall pain response. The primary organ at risk (especially for spine treatment) is the spinal cord. The risk of radiation myelitis is<1 % for cumulative doses of<50Gy. Intensity-modulated RT (IMRT) and stereotactic RT (SRT) appear to be safer than three-dimensional RT (3DRT), although randomized trials comparing these techniques in reirradiation are lacking. Reirradiation requires multidisciplinary assessment. Alternative treatments for bone metastases (surgery, interventional radiology, etc.) must be considered. Patients should have a performance status≤2, with at least a 1-month interval between treatments. The planning process involves reviewing previous RT plans, cautious dose adjustments, and precise target delineation and dose distribution to minimize toxicity. Cumulative dosimetry, patient consent, and vigilant post-treatment monitoring and dose reporting are crucial.

Whether Primary Bone-Only Oligometastatic Nasopharyngeal Carcinoma Patients Benefit From Radiotherapy to the Bones on the Basis of Palliative Chemotherapy Plus Locoregional Radiotherapy?-A Large-Cohort Retrospective Study

OBJECTIVES

Whether to perform local radiotherapy on metastatic bone for primary bone-only oligometastatic nasopharyngeal carcinoma (NPC) patients remains unclear. Therefore, we analyzed the treatment methods and their survival and developed a prognostic model to predict outcomes and guide personalized treatment.

MATERIALS AND METHODS

We studied 308 primary bone-only oligometastatic NPC patients who were treated with either palliative chemotherapy (PCT) alone, PCT combined with locoregional radiotherapy (LRRT), or PCT, LRRT, and radiotherapy to metastatic bones (bRT). The primary endpoint was overall survival (OS). Cox regression was utilized to identify independent prognostic factors, leading to the construction of a nomogram model. Patients were stratified into two risk groups based on median prognostic scores, and treatment modalities were compared using log-rank test while employing the inverse probability of treatment weighting (IPTW) to balance baseline characteristics and adjust for sample size differences between risk groups.

RESULTS

The best OS was observed in the group treated with PCT, LRRT, and bRT (HR = 0.60, 95% CI: 0.45-0.81, p = 0.002). Multivariable analysis revealed that age, N stage, pre-treatment levels of LDH, and EBV DNA were independent prognostic factors for OS. In total, 155 patients were in low-risk group while 153 were in high-risk group. Before and after IPTW, the high-risk group benefited from the PCT, LRRT, and bRT regimen (adjusted HR = 0.53, 95% CI: 0.42-0.67, p < 0.001; unadjusted HR = 0.59, 95% CI: 0.42-0.83, p = 0.007), while the low-risk group did not (adjusted HR = 0.79, 95% CI: 0.56-1.11, p = 0.345; unadjusted HR = 0.65, 95% CI: 0.37-1.14, p = 0.309).

CONCLUSION

Best outcomes of the whole cohort were seen with PCT + LRRT + bRT. Our study identified age, N stage, pre-treatment LDH levels, and EBV DNA levels as independent prognostic factors for OS. The high-risk group demonstrated a longer OS when treated with PCT + LRRT + bRT, whereas the low-risk group did not benefit from the combinatorial treatment.

Sustainability in radiation oncology: opportunities for enhancing patient care and reducing CO2 emissions in breast cancer radiotherapy at selected German centers

BACKGROUND AND OBJECTIVE

Radiotherapy often entails a substantial travel burden for patients accessing radiation oncology centers. The total travel distance for such treatments is primarily influenced by two factors: fractionation schedules and the distances traveled. Specific data on these aspects are not well documented in Germany. This study aims to quantify the travel distances for routine breast cancer patients of five radiation oncology centers located in metropolitan, urban, and rural areas of Germany and to record the CO2 emissions resulting from travel.

METHODS

We analyzed the geographic data of breast cancer patients attending their radiotherapy treatments and calculated travelling distances using Google Maps. Carbon dioxide emissions were estimated assuming a standard 40-miles-per-gallon petrol car emitting 0.168 kg of CO2 per kilometer.

RESULT

Addresses of 4198 breast cancer patients treated between 2018 and 2022 were analyzed. Our sample traveled an average of 37.2 km (minimum average: 14.2 km, maximum average: 58.3 km) for each radiation fraction. This yielded an estimated total of 6.2 kg of CO2 emissions per visit, resulting in 156.2 kg of CO2 emissions when assuming 25 visits (planning, treatment, and follow-up).

CONCLUSION

Our study highlights the environmental consequences associated with patient commutes for external-beam radiotherapy, indicating that reducing the number of treatment fractions can notably decrease CO2 emissions. Despite certain assumptions such as the mode of transport and possible inaccuracies in patient addresses, optimizing fractionation schedules not only reduces travel requirements but also achieves greater CO2 reductions while keeping improved patient outcomes as the main focus.

Neuropathic Pain in Cancer: What Are the Current Guidelines?

OPINION STATEMENT

Neuropathic cancer pain is experienced by 30-40% of patients with cancer. It significantly reduces quality of life and overall wellbeing for patients living with and beyond cancer. The underlying mechanisms of neuropathic pain in patients with cancer are complex and involve direct tumour involvement, nerve compression or infiltration, chemotherapy and/or radiotherapy-induced nerve damage, or post-surgical complications. It is crucial for healthcare professionals to assess and manage neuropathic cancer pain effectively. There is increasing recognition that standardisation of neuropathic pain assessment leads to tailored management and improved patient outcomes. Pain management strategies, including medication, interventional analgesia, physical and complementary therapy, can help alleviate neuropathic pain and improve the patient's comfort and quality of life.

External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline

PURPOSE

This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases.

METHODS

The ASTRO convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systematic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed.

RESULTS

For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with nonspine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction (800 cGy/1 fx), 2000 cGy/5 fx, 2400 cGy/6 fx, or 3000 cGy/10 fx. Spinal cord or cauda equina compression in patients who are ineligible for surgery and receiving conventional RT are recommended 800 cGy/1 fx, 1600 cGy/2 fx, 2000 cGy/5 fx, or 3000 cGy/10 fx. Symptomatic bone metastases in selected patients with good performance status without surgery or neurologic symptoms/signs are conditionally recommended stereotactic body RT over conventional palliative RT. Spine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, 2400 cGy/6 fx, or 2000 cGy/8 fx; nonspine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, or 2400 cGy/6 fx. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision making is recommended.

CONCLUSIONS

Based on published data, the ASTRO task force's recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.

Hyoid metastasis an unusual location from lung cancer

Bone metastases from lung cancer account for 8.5%, with those located in the hyoid bone being extremely rare. In this editorial, we made a review about Hsu et al case report highlighted the importance of palliative radiotherapy, even with an unusual but effective scheme in pain control in a patient with non-small cell lung cancer in stage IV.

Palliative radiotherapy for painful non-bone lesions in patients with advanced cancer: a single center retrospective study

PURPOSE

This retrospective study aimed to assess the efficacy and safety of palliative radiotherapy for painful non-bone lesions in patients with advanced cancer.

MATERIALS AND METHODS

We enrolled patients with painful non-bone lesions who underwent conventional palliative radiotherapy between September 2018 and September 2022. The treatment targets included primary tumor lesions, lymph node metastases, non-bone hematogenous metastases, and other lesions. The primary endpoint was the overall pain response rate in evaluable patients, determined based on the International Consensus Pain Response Endpoint criteria. The secondary endpoints included overall survival, pain recurrence, and adverse events.

RESULTS

Of the 420 screened patients, 142 received palliative radiotherapy for painful non-bone lesions, and 112 were evaluable. A pain response was achieved in 67 patients (60%) of the 112 evaluable patients within a median of 1.2 months. Among these patients, 25 exhibited complete response, 42 partial response, 18 indeterminate response, and 27 pain progression. The median survival time was 5.5 months, recorded at a median follow-up of 6.0 months, during which 67 patients died. Multivariate analysis identified poor performance status scores of 2-4, opioid use, and re-irradiation as independent factors associated with a reduced likelihood of achieving a pain response. Pain recurrence occurred in 18 patients over a median of 4.1 months. Seventeen patients had grade 1-2 adverse events, while none experienced grade 3 or higher toxicity.

CONCLUSION

Palliative radiotherapy can potentially be a safe and well-tolerated modality for managing painful non-bone lesions, with a low rate of adverse events.

Re-irradiation spine stereotactic body radiotherapy following high-dose conventional radiotherapy for metastatic epidural spinal cord compression: a retrospective study

PURPOSE

 We aimed to evaluate the efficacy and safety of re-irradiation stereotactic body radiation therapy (SBRT) in patients with metastatic epidural spinal cord compression (MESCC) following high-dose conventional radiotherapy.

MATERIALS AND METHODS

 Twenty-one patients met the following eligibility criteria: with an irradiation history of 50 Gy2 equivalent dose in 2-Gy fractions (EQD2) or more, diagnosed MESCC in the cervical or thoracic spines, and treated with re-irradiation SBRT of 24 Gy in 2 fractions between April 2018 and March 2023. Prior treatment was radiotherapy alone, not including surgery. The primary endpoint was a 1-year local failure rate. Overall survival (OS) and treatment-related adverse events were assessed as the secondary endpoints. Since our cohort includes one treatment-related death (TRD) of esophageal perforation, the cumulative esophageal dose was evaluated to find the dose constraints related to severe toxicities.

RESULTS

 The median age was 68, and 14 males were included. The primary tumor sites (esophagus/lung/head and neck/others) were 6/6/7/2, and the median initial radiotherapy dose was 60 Gy2 EQD2 (range: 50-105 Gy2, 60-70/ > 70 Gy2 were 11/4). Ten patients underwent surgery followed by SBRT and 11 SBRT alone. At the median follow-up time of 10.4 months, 17 patients died of systemic disease progression including one TRD. No radiation-induced myelopathy or nerve root injuries occurred. Local failure occurred in six patients, with a 1-year local failure rate of 29.3% and a 1-year OS of 55.0%. Other toxicities included five cases of vertebral compression fractures (23.8%) and one radiation pneumonitis. The cumulative esophageal dose was recommended as follows: Dmax < 203, D0.035 cc < 187, and D1cc < 167 (Gy3 in biological effective dose).

CONCLUSION

 Re-irradiation spine SBRT may be effective for selected patients with cervical or thoracic MESCC, even with high-dose irradiation histories. The cumulative dose assessment across the original and re-irradiated esophagus was recommended to decrease the risk of severe esophageal toxicities.

Lymphocyte-to-C Reactive Protein Ratio is an Independent Predictor of Survival Benefits for Hepatocellular Carcinoma Patients Receiving Radiotherapy

Background

Stereotactic body radiotherapy (SBRT) has emerged as an alternative approach for patients with hepatocellular carcinoma (HCC), and we aim to find potential prognostic biomarkers for HCC patients who received SBRT.

Methods

In this study, we retrospectively analyzed HCC patients who underwent SBRT in our institution from January 2018 to December 2022. The inflammatory parameters, along with baseline patients' characteristics were collected to elucidate the potential relationship with survival benefits and liver toxicities.

Results

Overall, 35 patients were enrolled in our study. For the efficacy population (25 patients who underwent SBRT for primary liver lesions), the objective response rate (ORR) and disease control rate (DCR) were 60% and 100%, respectively. The median progression-free survival (PFS) was 9.9 months [95% confidence interval (CI) 5.6-14.1 months], and the median overall survival (OS) was 18.5 months (95% CI 14.2-22.8 months). We further confirmed that higher baseline lymphocyte-C-reactive protein ratio (LCR) (≥2361.11) was positively related to both longer PFS (12.0 vs 4.3 months, P = 0.002) and OS (21.9 vs 11.4 months, P = 0.022). Moreover, patients with diabetes and higher alpha-fetoprotein (AFP) (≥400 ng/mL) were also found to be associated with worse OS. The most common hepatotoxicity was elevated gamma-glutamyl transferase (GGT) (84.0%).

Conclusion

In conclusion, for patients with inoperable HCC, SBRT resulted in satisfactory local control, survival benefits, and acceptable liver toxicity. Pre-radiotherapy LCR might be an independent and readily available predictor for survival, which facilitates us to find the most appropriate treatment options.

Incidence and radiotherapy treatment patterns of complicated bone metastases

Background

Despite the encouraging results of the SCORAD trial, single fraction radiotherapy (SFRT) remains underused for patients with complicated bone metastases with rates as low as 18-39%. We aimed to evaluate the incidence and treatment patterns of these metastases in patients being referred to a tertiary centre for palliative radiotherapy.

Materials and methods

We performed a retrospective review of all bone metastases treated at our centre from January 2013 until December 2017. Lesions were classified as uncomplicated or complicated. Complicated was defined as associated with (impending) fracture, existing spinal cord or cauda equina compression. Our protocol suggests using SFRT for all patients with complicated bone metastases, except for those with symptomatic neuraxial compression and a life expectancy of ≥28 weeks.

Results

Overall, 37 % of all bone metastases were classified as complicated. Most often as a result of an (impending) fracture (56 %) or spinal cord compression (44 %). In 93 % of cases, complicated lesions were located in the spine, most commonly originating from prostate, breast and lung cancer (60 %). Median survival of patients with complicated bone metastases was 4 months. The use of SFRT for complicated bone metastases increased from 51 % to 85 % over the study period, reaching 100 % for patients with the poorest prognosis.

Conclusions

Approximately 37 % of bone metastases are classified as complicated with the majority related to (impending) fracture. Patients with complicated bone metastases have a median survival of 4 months and were mostly treated with SFRT.

ESTRO clinical practice guideline: Stereotactic body radiotherapy for spine metastases

BACKGROUND AND PURPOSE

Recent progress in diagnostics and treatment of metastatic cancer patients have improved survival substantially. These developments also affect local therapies, with treatment aims shifting from short-term palliation to long-term symptom or disease control. There is consequently a need to better define the value of stereotactic body radiotherapy (SBRT) for the treatment of spinal metastases.

METHODS

This ESTRO clinical practice guideline is based on a systematic literature review conducted according to PRISMA standards, which formed the basis for answering four key questions about the indication and practice of SBRT for spine metastases.

RESULTS

The analysis of the key questions based on current evidence yielded 22 recommendations and 5 statements with varying levels of endorsement, all achieving a consensus among experts of at least 75%. In the majority, the level of evidence supporting the recommendations and statements was moderate or expert opinion, only, indicating that spine SBRT is still an evolving field of clinical research. Recommendations were established concerning the selection of appropriate patients with painful spine metastases and oligometastatic disease. Recommendations about the practice of spinal SBRT covered technical planning aspects including dose and fractionation, patient positioning, immobilization and image-guided SBRT delivery. Finally, recommendations were developed regarding quality assurance protocols, including description of potential SBRT-related toxicity and risk mitigation strategies.

CONCLUSIONS

This ESTRO clinical practice guideline provides evidence-based recommendations and statements regarding the selection of patients with spinal metastases for SBRT and its safe implementation and practice. Enrollment of patients into well-designed prospective clinical trials addressing clinically relevant questions is considered important.

Efficacy and safety of SBRT for spine metastases: A systematic review and meta-analysis for preparation of an ESTRO practice guideline

BACKGROUND AND PURPOSE

Advances in characterizing cancer biology and the growing availability of novel targeted agents and immune therapeutics have significantly changed the prognosis of many patients with metastatic disease. Palliative radiotherapy needs to adapt to these developments. In this study, we summarize the available evidence for stereotactic body radiotherapy (SBRT) in the treatment of spinal metastases.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed using PRISMA methodology, including publications from January 2005 to September 2021, with the exception of the randomized phase III trial RTOG-0631 which was added in April 2023. Re-irradiation was excluded. For meta-analysis, a random-effects model was used to pool the data. Heterogeneity was assessed with the I2-test, assuming substantial and considerable as I2 > 50 % and I2 > 75 %, respectively. A p-value < 0.05 was considered statistically significant.

RESULTS

A total of 69 studies assessing the outcomes of 7236 metastases in 5736 patients were analyzed. SBRT for spine metastases showed high efficacy, with a pooled overall pain response rate of 83 % (95 % confidence interval [CI] 68 %-94 %), pooled complete pain response of 36 % (95 % CI: 20 %-53 %), and 1-year local control rate of 94 % (95 % CI: 86 %-99 %), although with high levels of heterogeneity among studies (I2 = 93 %, I2 = 86 %, and 86 %, respectively). Furthermore, SBRT was safe, with a pooled vertebral fracture rate of 9 % (95 % CI: 4 %-16 %), pooled radiation induced myelopathy rate of 0 % (95 % CI 0-2 %), and pooled pain flare rate of 6 % (95 % CI: 3 %-17 %), although with mixed levels of heterogeneity among the studies (I2 = 92 %, I2 = 0 %, and 95 %, respectively). Only 1.7 % of vertebral fractures required surgical stabilization.

CONCLUSION

Spine SBRT is characterized by a favorable efficacy and safety profile, providing durable results for pain control and disease control, which is particularly relevant for oligometastatic patients.

Poor adherence to national guidance in the management of patients with metastatic bone disease

Cite this article: Bone Joint J 2024;106-B(1):6–8.

Esketamine inhibits the c-Jun N-terminal kinase pathway in the spinal dorsal horn to relieve bone cancer pain in rats

Cancer-induced bone pain (CIBP) is one of the most common and feared symptoms in patients with advanced tumors. The X-C motif chemokine ligand 12 (CXCL12) and the CXCR4 receptor have been associated with glial cell activation in bone cancer pain. Moreover, mitogen-activated protein kinases (MAPKs), as downstream CXCL12/CXCR4 signals, and c-Jun, as activator protein AP-1 components, contribute to the development of various types of pain. However, the specific CIBP mechanisms remain unknown. Esketamine is a non-selective N-methyl-d-aspartic acid receptor (NMDA) inhibitor commonly used as an analgesic in the clinic, but its analgesic mechanism in bone cancer pain remains unclear. We used a tumor cell implantation (TCI) model and explored that CXCL12/CXCR4, p-MAPKs, and p-c-Jun were stably up-regulated in the spinal cord. Immunofluorescence images showed activated microglia in the spinal cord on day 14 after TCI and co-expression of CXCL12/CXCR4, p-MAPKs (p-JNK, p-ERK, p-p38 MAPK), and p-c-Jun in microglia. Intrathecal injection of the CXCR4 inhibitor AMD3100 reduced JNK and c-Jun phosphorylations, and intrathecal injection of the JNK inhibitor SP600125 and esketamine also alleviated TCI-induced pain and reduced the expression of p-JNK and p-c-Jun in microglia. Overall, our data suggest that the CXCL12/CXCR4-JNK-c-Jun signaling pathway of microglia in the spinal cord mediates neuronal sensitization and pain hypersensitivity in cancer-induced bone pain and that esketamine exerts its analgesic effect by inhibiting the JNK-c-Jun pathway.

Interim analysis of patient-reported outcome compliance and dosimetry in a phase 3 randomized clinical trial of oesophagus-sparing spinal radiotherapy

BACKGROUND

The randomized clinical trial ESO-SPARE investigates if oesophagus-sparing radiotherapy (RT) can reduce dysphagia in patients with metastatic spinal cord compression (MSCC). Patient-reported outcome (PRO) is the only follow-up measure. Due to the fragile patient population, low respondent compliance was anticipated. We performed a planned interim analysis of dosimetry and respondent compliance, to ensure that the protocol requirements were met.

METHODS

Patients >18 years referred for cervical/thoracic MSCC radiotherapy in 1-10 fractions were included from two centres. Patients were randomized (1:1) to standard RT or oesophagus-sparing RT, where predefined oesophageal dose constraints were prioritized over target coverage. Patients completed a trial diary with daily reports of dysphagia for 5 weeks (PRO-CTC-AE) and weekly quality of life reports for 9 weeks (QLQ-C30, EQ-5D-5L). According to power calculation, 124 patients are needed for primary endpoint analysis. The sample size was inflated to 200 patients to account for the fragile patient population. The co-primary endpoints, peak patient-reported dysphagia, and preserved ability to walk (EQ-5D-5L), are analysed at 5 and 9 weeks, respectively. The interim analysis was conducted 90 days after the inclusion of patient no 100. Respondent compliance was assessed at 5 and 9 weeks. In all RT plans, oesophagus and target doses were evaluated regarding adherence to protocol constraints.

RESULTS

From May 2021 to November 2022, 100 patients were included. Fifty-two were randomized to oesophagus-sparing RT. In 23% of these plans, oesophagus constraints were violated. Overall, the dose to both target and oesophagus was significantly lower in the oesophagus-sparing plans. Only 51% and 41% of the patients were evaluable for co-primary endpoint analysis at five and nine weeks, respectively. Mortality and hospitalization rates were significantly larger in patients who completed <4 days PRO questionnaires.

CONCLUSION

Compliance was lower than anticipated and interventions to maintain study power are needed.

"Scan-(pre)Plan-Treat" Workflow for Bone Metastases Using the Ethos Therapy System: A Single-Center, In Silico Experience

Purpose

To report on the accuracy of automated delineation, treatment plan quality, and duration of an in-silico "scan-(pre)plan-treat" (SPT) workflow for vertebral bone metastases using a 1 × 8 Gy regimen.

Method and Materials

The cloud-based emulator system of the Ethos therapy system was used to adapt an organ-at-risk-sparing preplan created on the diagnostic CT to the anatomy-of-the-day using the cone beam CT made before treatment.

Results

SPT using the Ethos emulator system resulted in relatively good coverage of the PTV and acceptable dose to the OAR. Delivery time and plan homogeneity was the best for 7-field IMRT plan template.

Conclusions

A SPT workflow formula results in a highly conformal treatment delivery while maintaining an acceptable timeframe for the patient on the treatment couch.

Poor adherence to national guidance in the management of patients with metastatic bone disease

Cite this article: Bone Joint J 2024;106-B(1):6–8.

Spine Instability Neoplastic Score (SINS) as a Predictive Tool in Conventional Radiotherapy: A Narrative Review

AIMS

This narrative review seeks to identify the SINS score application in the radiation oncology field.

METHODS

This literature review was performed searching papers on MEDLINE published from January 2010 to August 2022.

RESULTS

In terms of vertebral painful lesions and RT symptomatic responses, the SINS score could be an interesting aid in order to choose the right therapeutic approach. Lesions with higher level of instability, and therefore higher SINS score, could did not find any significant benefit from radiation therapy which is more effective on the tumor-related pain component. For SINS as a predictor of adverse event after RT or its changes after RT, we obtained contrasting results.

CONCLUSIONS

The reported few experiences showed ambiguous conclusions. Further prospective studies are needed.

Prognostic Factors in Patients with Metastatic Spinal Cord Compression Secondary to Lung Cancer-A Retrospective UK Single-Centre Study

PURPOSE

Metastatic spinal cord compression (MSCC) is a severe complication of cancer that can lead to irreversible neurological impairment, necessitating prompt recognition and intervention. This retrospective, single-centre study aimed to determine the prognostic factors and survival rates among patients presenting with MSCC secondary to lung cancer.

METHODS AND MATERIALS

We identified 74 patients with epidural metastases-related spinal cord compression and a history of lung cancer through the electronic database of Medway Maritime Hospital in the United Kingdom (UK), spanning the period from April 2016 to September 2021. Among them, 39 were below 55 years old, while 35 were aged 55 years or older; 24 patients were diagnosed with small cell lung cancer (SCLC), and 50 patients had non-small cell lung cancer (NSCLC).

RESULTS

The median overall survival (OS) was 5.5 months, with 52 out of 74 patients dying within 6 months of diagnosis with MSCC. For the entire cohort, the statistically significant variables on multi-variate analysis were cancer type (NSCLC had improved OS), the number of involved vertebrae (one to two vertebrae involvement had improved OS), and the time taken to develop motor deficits (≤10 days to develop motor deficits had worsened OS). For the NSCLC cohort, the statistically significant variables on multivariate analysis were molecular alterations (patients with epidermal growth factor receptor (EGFR) mutation), pre-treatment ambulatory status, Eastern Cooperative Oncology Group (ECOG) performance status, and the time taken to develop motor deficits.

CONCLUSIONS

Within the entire cohort, patients diagnosed with NSCLC and spinal metastases affecting one to two vertebrae exhibited enhanced OS. Within the NSCLC subgroup, those with EGFR mutations who were ambulatory and possessed an ECOG performance status of 1-2 demonstrated improved OS. In both the entire cohort and the NSCLC subgroup, the development of motor deficits within a period of ≤10 days was associated with poor OS.

Factors affecting local control of bone metastases from radioresistant tumors treated with palliative external beam radiotherapy

BACKGROUND

This study aimed to evaluate the factors that affect the local control (LC) of bone metastases from radioresistant carcinomas (renal cell carcinoma, hepatocellular carcinoma [HCC], and colorectal carcinoma [CRC]) treated with palliative external-beam radiotherapy (EBRT).

METHODS AND MATERIALS

Between January 2010 and December 2020, 211 bone metastases in 134 patients were treated with EBRT in two hospitals (a cancer center and university hospital). Based on follow-up CT, these cases were reviewed retrospectively to evaluate LC at the EBRT site.

RESULTS

The median EBRT dose (BED10) was 39.0 Gy (range, 14.4-66.3 Gy). The median follow-up time of the imaging studies was 6 months (range, 1-107 months). The 0.5-year overall survival and LC rates of the EBRT sites were 73% and 73%, respectively. Multivariate analysis revealed that the primary sites (HCC/CRC), low EBRT dose (BED10) (≤ 39.0 Gy), and non-administration of post-EBRT bone modifying agents (BMAs) and/or antineoplastic agents (ATs) were statistically significant factors that negatively affected the LC of EBRT sites. In the absence of BMAs or ATs, the EBRT dose (BED10) escalation from 39.0 Gy improved the LC of EBRT sites. Based on ATs administration, the LC of EBRT sites was significantly affected by tyrosine kinase inhibitors and/or immune checkpoint inhibitors.

CONCLUSIONS

Dose escalation improves LC in bone metastases from radioresistant carcinomas. Higher EBRT doses are needed to treat patients for whom few effective systemic therapies remain available.

Prognostic implications of systemic immune-inflammation index in patients with bone metastases from hepatocellular carcinoma treated with radiotherapy

Background

Previous studies have shown that systemic inflammation indicators could predict the survival outcomes of patients with malignant tumors receiving various treatments. Radiotherapy, as a crucial treatment modality, effectively alleviates discomfort in patients with bone metastasis (BM) and greatly improves the quality of life for them. This study aimed to investigate the prognostic value of systemic inflammation index in hepatocellular carcinoma (HCC) patients with BM treated with radiotherapy.

Methods

We retrospectively analyzed clinical data collected from HCC patients with BM who received radiotherapy in our institution between January 2017 and December 2021. The pre-treatment neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) were derived to determine their relationship with overall survival (OS) and progression-free survival (PFS), using the Kaplan-Meier survival curves. The optimal cut-off value of the systemic inflammation indicators for predicting prognosis was assessed by receiver operating characteristic (ROC) curves. Univariate and multivariate analyses were performed to ultimately evaluate the factors associated with survival.

Results

The study included 239 patients with a median 14-month follow-up. The median OS was 18 months (95% confidence interval [CI] = 12.0-24.0) and the median PFS was 8.5 months (95% CI = 6.5-9.5). The optimal cut-off values for the patients were determined by ROC curve analysis as follows: SII =395.05, NLR=5.43 and PLR = 108.23. The area under the receiver operating characteristic curve values for SII, NLR and PLR in disease control prediction were 0.750, 0.665 and 0.676, respectively. Elevated systemic immune-inflammation index (SII>395.05) and higher NLR (NLR>5.43) were independently associated with poor OS and PFS. In multivariate analysis, Child-Pugh class (P = 0.038), intrahepatic tumor controlled (P = 0.019), SII (P = 0.001) and NLR (P = 0.007) were independent prognostic factors of OS and Child-Pugh class (P = 0.042), SII (P < 0.001) and NLR (P = 0.002) were independently correlated with PFS.

Conclusion

NLR and SII were associated with poor prognosis in HCC patients with BM receiving radiotherapy and might be considered reliable and independent prognostic biomarkers for HCC patients with BM.

Personalized Treatment for Patients With Lung Cancer

BACKGROUND

Lung cancer is the most common cause of death among all types of cancer in Germany, with an annual death rate of 45 000 patients. Over the past 15 years, innovations in diagnosis and treatment have prolonged the survival of patients with non-small-cell lung cancer in all tumor stages.

METHODS

This review of the diagnosis and treatment of lung cancer is based on current national and international guidelines, and on prospective trials with the highest possible level of evidence that were retrieved by a selective search of the literature.

RESULTS

Improved outcomes in patients with non-small-cell lung cancer (85% of new diagnoses) were achieved with the aid of precise diagnostic techniques, including functional imaging and endobronchial procedures for localized disease stage. Contemporary surgical and radio-oncological technologies reduce the morbidity and expand the boundaries of local therapy. Molecular pathology, including the assessment of predictive biomarkers, is an integral part of the diagnostic evaluation of non-small-cell lung cancer in all tumor stages; it enables stratified cytotoxic/molecularly targeted treatments and immunotherapies and improves patient-reported outcomes. The percentage of long-term survivors in the metastatic stage has doubled by the introduction of immunotherapy. In contrast, there has been no major improvement in the survival of patients with small-cell lung cancer (15% of new diagnoses).

CONCLUSION

In addition to the implementation of lung cancer screening in high-risk populations, the further development and consistent implementation of personalized diagnosis and treatment in certified lung cancer centers can be expected to prolong survival and improve the patients' quality of life.

Multidisciplinary Approach to Spinal Metastases and Metastatic Spinal Cord Compression—A New Integrative Flowchart for Patient Management

Metastatic spine disease (MSD) and metastatic spinal cord compression (MSCC) are major causes of permanent neurological damage and long-term disability for cancer patients. The development of MSD is pathophysiologically framed by a cooperative interaction between general mechanisms of bone growth and specific mechanisms of spinal metastases (SM) expansion. SM most commonly affects the thoracic spine, even though multiple segments may be affected concomitantly. The great majority of SM are extradural, while intradural-extramedullary and intramedullary metastases are less frequently seen. The management of patients with SM is particularly complex and challenging, with multiple factors—such as the spinal stability status, primary tumor radio and chemosensitivity, cancer biological burden, patient performance status and comorbidities, and patient’s oncological prognosis—influencing the clinical decision-making process. Different frameworks were developed in order to systematize and support this process. A multidisciplinary, personalized approach, enriched by the expertise of each involved specialty, is crucial. We reviewed the most recent evidence and proposed an updated algorithmic approach to patients with MSD according to the clinical scenario of each patient. A flowchart-based approach offers an evidence-based management of MSD, providing a valuable clinical decision tool in a context of high uncertainty and quick-acting need.

A Systematic Review Supporting the Endocrine Society Clinical Practice Guideline on the Treatment of Hypercalcemia of Malignancy in Adults

CONTEXT

Hypercalcemia is a common complication of malignancy that is associated with high morbidity and mortality.

OBJECTIVE

To support development of the Endocrine Society Clinical Practice Guideline for the treatment of hypercalcemia of malignancy in adults.

METHODS

We searched multiple databases for studies that addressed 8 clinical questions prioritized by a guideline panel from the Endocrine Society. Quantitative and qualitative synthesis was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess certainty of evidence.

RESULTS

We reviewed 1949 citations, from which we included 21 studies. The risk of bias for most of the included studies was moderate. A higher proportion of patients who received bisphosphonate achieved resolution of hypercalcemia when compared to placebo. The incidence rate of adverse events was significantly higher in the bisphosphonate group. Comparing denosumab to bisphosphonate, there was no significant difference in the rate of patients who achieved resolution of hypercalcemia. Two-thirds of patients with refractory/recurrent hypercalcemia of malignancy who received denosumab following bisphosphonate therapy achieved resolution of hypercalcemia. Addition of calcitonin to bisphosphonate therapy did not affect the resolution of hypercalcemia, time to normocalcemia, or hypocalcemia. Only indirect evidence was available to address questions on the management of hypercalcemia in tumors associated with high calcitriol levels, refractory/recurrent hypercalcemia of malignancy following the use of bisphosphonates, and the use of calcimimetics in the treatment of hypercalcemia associated with parathyroid carcinoma. The certainty of the evidence to address all 8 clinical questions was low to very low.

CONCLUSION

The evidence summarized in this systematic review addresses the benefits and harms of treatments of hypercalcemia of malignancy. Additional information about patients' values and preferences, and other important decisional and contextual factors is needed to facilitate the development of clinical recommendations.

Factors Affecting Survival and Local Control in Patients with Bone Metastases Treated with Radiotherapy

The aim of this study was to evaluate the expected prognosis and factors affecting local control (LC) of the bone metastatic sites treated with palliative external beam radiotherapy (RT). Between December 2010 and April 2019, 420 cases (male/female = 240/180; median age [range]: 66 [12-90] years) with predominantly osteolytic bone metastases received RT and were evaluated. LC was evaluated by follow-up computed tomography (CT) image. Median RT doses (BED₁₀) were 39.0 Gy (range, 14.4-71.7 Gy). The 0.5-year overall survival and LC of RT sites were 71% and 84%, respectively. Local recurrence on CT images was observed in 19% (n = 80) of the RT sites, and the median recurrence time was 3.5 months (range, 1-106 months). In univariate analysis, abnormal laboratory data before RT (platelet count, serum albumin, total bilirubin, lactate dehydrogenase, or serum calcium level), high-risk primary tumor sites (colorectal, esophageal, hepatobiliary/pancreatic, renal/ureter, and non-epithelial cancers), no antineoplastic agents (ATs) administration after RT, and no bone modifying agents (BMAs) administration after RT were significantly unfavorable factors for both survival and LC of RT sites. Sex (male), performance status (≥3), and RT dose (BED₁₀) (<39.0 Gy) were significantly unfavorable factors for only survival, and age (≥70 years) and bone cortex destruction were significantly unfavorable factors for only LC of RT sites. In multivariate analysis, only abnormal laboratory data before RT influenced both unfavorable survival and LC of RT sites. Performance status (≥3), no ATs administration after RT, RT dose (BED₁₀) (<39.0 Gy), and sex (male) were significantly unfavorable factors for survival, and primary tumor sites and BMAs administration after RT were significantly unfavorable factors for LC of RT sites. In conclusion, laboratory data before RT was important factor both prognosis and LC of bone metastases treated with palliative RT. At least in patients with abnormal laboratory data before RT, palliative RT seemed to be focused on the only pain relief.

Efficacy and toxicity of primary re-irradiation for malignant spinal cord compression based on radiobiological modelling: a phase II clinical trial

BACKGROUND

The efficacy and safety of primary re-irradiation for MSCC are not known. Our aim was to establish the efficacy and safety of biologically effective dose-based re-irradiation.

METHODS

Patients presenting with MSCC at a previously irradiated spine segment, and not proceeding with surgical decompression, were eligible. A 3 Gray per fraction experimental schedule (minimum 18 Gy/6 fractions, maximum 30 Gy/10 fractions) was used, delivering a maximum cumulative spinal dose of 100 Gy2 if the interval since the last radiotherapy was within 6 months, or 130 Gy2 if longer. The primary outcome was a change in mobility from week 1 to week 5 post-treatment, as assessed by the Tomita score. The RTOG SOMA score was used to screen for spinal toxicity, and an MRI performed to assess for radiation-induced myelopathy (RIM).

RESULTS

Twenty-two patients were enroled, of whom eleven were evaluable for the primary outcome. Nine of eleven (81.8%) had stable or improved Tomita scores at 5 weeks. One of eight (12.5%) evaluable for late toxicity developed RIM.

CONCLUSIONS

Re-irradiation is an efficacious treatment for MSCC. There is a risk of RIM with a cumulative dose of 120 Gy2.

CLINICAL TRIAL REGISTRATION

Cancer Trials Ireland (ICORG 07-11); NCT00974168.

Percent of remaining life on palliative radiation treatment: solely a function of fractionation?

Background

This study analyzed the percent of remaining life (PRL) on treatment in patients irradiated for bone metastases. Bone metastases were treated together with other target volumes, if indicated, e.g. a 10-fraction treatment course that included brain and bone metastases. PRL was determined by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy.

Materials and methods

Different baseline parameters were assessed for association with dichotomized PRL (< 5% vs. ≥ 5%). The retrospective study included 219 patients (287 courses of palliative radiotherapy). After univariate analyses, multi-nominal logistic regression was employed.

Results

PRL on treatment ranged from 1-23%. Single-fraction radiotherapy resulted in < 5% PRL on treatment in all cases. All courses with 10 fractions resulted in at least 5% PRL on treatment. Significant associations were found between various baseline parameters and PRL category. With fractionation included in the regression model, 3 parameters retained significant p-values: Karnofsky performance status (KPS), none-bone target volume and fractionation (all with p < 0.001). If analyzed without fractionation, none-bone target volume (p < 0.001), hemoglobin (p < 0.001), KPS (p = 0.01), lack of additional systemic treatment (p = 0.01), and hypercalcemia (p = 0.04) were significant.

Conclusions

Fractionation is an easily modifiable factor with high impact on PRL. Patients with KPS < 70 and those treated for additional target types during the same course are at high risk of spending a larger proportion of their remaining life on treatment.

Biological and Clinical Aspects of Metastatic Spinal Tumors

Simple Summary

Spine metastases are a common life-threatening complication of advanced-stage malignancies and often result in poor prognosis. Symptomatic spine metastases develop in the course of about 10% of malignant neoplasms. Therefore, it is essential for contemporary medicine to understand metastatic processes in order to find appropriate, targeted therapeutic options. Our literature review aimed to describe the up-to-date knowledge about the molecular pathways and biomarkers engaged in the spine’s metastatic processes. Moreover, we described current data regarding bone-targeted treatment, the emerging targeted therapies, radiotherapy, and immunotherapy used for the treatment of spine metastases. We hope that knowledge comprehensively presented in our review will contribute to the development of novel drugs targeting specific biomarkers and pathways. The more we learn about the molecular aspects of cancer metastasis, the easier it will be to look for treatment methods that will allow us to precisely kill tumor cells.

Abstract

Spine metastases are a common life-threatening complication of advanced-stage malignancies and often result in poor prognosis. Symptomatic spine metastases develop in the course of about 10% of malignant neoplasms. Therefore, it is essential for contemporary medicine to understand metastatic processes in order to find appropriate, targeted therapeutic options. Thanks to continuous research, there appears more and more detailed knowledge about cancer and metastasis, but these transformations are extremely complicated, e.g., due to the complexity of reactions, the variety of places where they occur, or the participation of both tumor cells and host cells in these transitions. The right target points in tumor metastasis mechanisms are still being researched; that will help us in the proper diagnosis as well as in finding the right treatment. In this literature review, we described the current knowledge about the molecular pathways and biomarkers engaged in metastatic processes involving the spine. We also presented a current bone-targeted treatment for spine metastases and the emerging therapies targeting the discussed molecular mechanisms.

Palliative radiotherapy of bone metastases in octogenarians: How do the oldest olds respond? Results from a tertiary cancer center with 288 treated patients

BACKGROUND

Accompanied by the demographic change, the number of octogenarian cancer patients with bone metastases will increase in the future. Palliative radiotherapy constitutes an effective analgesic treatment; however, as pain perception and bone metabolism change with increasing age, the analgesic efficacy of radiotherapy may be altered in elderly patients. We therefore investigated the treatment outcomes of palliative radiotherapy for bone metastases in octogenarians.

METHODS

Patients between 80 and 89 years undergoing radiotherapy for bone metastases between 2009 and 2019 at a tertiary cancer center were analyzed for patterns-of-care, pain response and overall survival (OS). Logistic regression analyses were carried out to examine parameters associated with pain response, and Cox analyses were conducted to reveal prognostic parameters for OS.

RESULTS

A total of 288 patients with 516 irradiated lesions were included in the analysis. The majority (n = 249, 86%) completed all courses of radiotherapy. Radiotherapy led to pain reduction in 176 patients (61%) at the end of treatment. Complete pain relief at the first follow-up was achieved in 84 patients (29%). Bisphosphonate administration was significantly associated with higher rates of pain response at the first follow-up (p < 0.05). Median OS amounted to 9 months, and 1-year, 2-year and 3-year OS were 43%, 28% and 17%. In the multivariate analysis, ECOG (p < 0.001), Mizumoto score (p < 0.01) and Spinal Instability Neoplastic Score (SINS) (p < 0.001) were independent prognosticators for OS.

CONCLUSION

Palliative radiotherapy for bone metastases constitutes a feasible and effective analgesic treatment in octogenarian patients. ECOG, Mizumoto score and SINS are prognosic variables for survival and may aid treatment decisions regarding radiotherapy fractionation in this patient group. Single-fraction radiotherapy with 8 Gy should be applied for patients with uncomplicated bone metastases and poor prognosis. Prospective trials focusing on quality of life of these very old cancer patients with bone metastases are warranted to reveal the optimal radiotherapeutic management for this vulnerable population.

Reduction of oesophageal toxicity with VMAT dose-sparing radiotherapy in thoracic metastatic spinal cord compression: A feasibility study

•

Oesophageal delineation took a mean of 8.6 min.

•

Significant dose reduction for oesophageal V7.7 Gy, D2% and Dmean were achieved, without significant change in CTV coverage.

•

Reduction of oesophageal dose may lead to reduced acute toxicity in this patient group where quality of life is a key concern.

Background

Palliative radiotherapy for metastatic spinal cord compression (MSCC) is given to halt disease progression and sustain quality of life for patients with advanced cancer. Radiotherapy can however induce toxicity, contradicting treatment intention. Advanced radiotherapy offers possibility of sparing organs at risk (OARs). The purpose of this dosimetric study is to establish the feasibility and potential benefits of dose sparing of the oesophagus.

Materials and methods

30 patients receiving radiotherapy of 30 Gy/10# for MSCC were retrospectively included and the oesophagus delineated. Two new dose plans were created for each patient (eso-crop and PTV-crop) with the intention of optimising the oesophageal dose. In the eso-crop plan maintaining full target volume coverage was prioritised, for the PTV-crop plan oesophageal dose was further reduced through cropping the planning target volume (PTV) overlapping oesophageal/PTV-area. Time added for delineation was measured. Plans were compared using Wilcoxon signed rank test with p < 0.05 considered statistically significant. Bivariate associations between dose metrics and patient characteristics were quantified using linear regression models.

Results

Oesophageal delineation took a mean of 8.6 min. There was significant dose reduction for both V7.7 Gy, D2% and mean oesophageal dose, without significant change in CTV coverage. The mean achievable oesophageal dose reduction was 29.1% and 50.4% for the eso-crop and PTV crop plans, respectively. Minor changes in dose distribution to the lungs was observed, with increased mean and V20Gy for the eso-crop plan and decreased V5Gy to the PTV-crop plan.

Conclusion

This study demonstrated the possibility of significant dose sparing of the oesophageal dose using single arc VMAT without impacting on CTV coverage.

ESTRO ACROP guidelines for external beam radiotherapy of patients with uncomplicated bone metastases

After liver and lungs, bone is the third most common metastatic site (Nystrom et al., 1977). Almost all malignancies can metastasize to the skeleton but 80% of bone metastases originate from breast, prostate, lung, kidney and thyroid cancer (Mundy, 2002). Introduction of effective systemic treatment in many cancers has prolonged patients' survival, including those with bone metastases. Bone metastases may significantly reduce quality of life due to related symptoms and possible complications, such as pain and neurologic compromise. The most serious complications of bone metastases are skeletal-related events (SRE), defined as pathologic fracture, spinal cord compression, pain, or other symptoms requiring an urgent intervention such as surgery or radiotherapy. In turn, growing access to modern diagnostic tools allows early detection of asymptomatic bone metastases that could be successfully managed with local treatment avoiding development of SRE. The treatment for bone metastases should focus on relieving existing symptoms and preventing new ones. Radiotherapy is the standard of care for patients with symptomatic bone metastases, providing durable pain relief with minimal toxicity and reasonable cost-effectiveness. Historically, the dose was prescribed in one to five fractions and delivered using simple planning techniques. While 3D-conformal radiotherapy is still widely used for treating bone metastases, introduction of highlyconformal radiotherapy techniques such as stereotactic body radiotherapy (SBRT) have opened new therapeutic possibilities that should be considered in selected patients with bone metastases.