A prospective trial of short-fractionation radiotherapy for the palliation of liver metastases

Use of Radiotherapy in Advanced Breast Cancer: The Role of a Nurse

OBJECTIVES

Systemic therapy is the mainstay in advanced breast cancer (ABC), but innovations in radiation oncology have given radiotherapy a crucial role in the treatment of both intracranial and extracranial ABC. Breast cancer specialists include, in addition to medical and clinical oncologists, breast cancer nurses with unique theoretical knowledge and significant clinical experience. This review aims to discuss the function of radiotherapy in ABC and to highlight the role and importance of specialized nursing care for ABC patients receiving radiotherapy.

DATA SOURCES

An extensive literature review was conducted on the role of radiotherapy and its implementation in various settings of ABC and the pivotal contribution of nursing practices to the quality of life of these patients, with a particular focus on symptom and side effect management and prevention, education, as well as unmet patient needs. The Advanced Breast Cancer International Consensus Guidelines (ABC-5) were also included. All the above data were combined with the expert and practical considerations of breast cancer specialists within the team.

CONCLUSION

The sophisticated application of radiotherapy and the complexity of ABC patient management, concerning symptoms, side effects, and overall well-being necessitate collaborative efforts to optimize patient care. Breast cancer nurses hold a central role in this framework.

IMPLICATIONS FOR NURSING PRACTICE

The significance of specialized nursing in contributing to comprehensive patient care for ABC patients treated with radiotherapy outlines the need for extensive training that aims to provide a holistic approach and entails physical, mental, and emotional support and patient and caregiver education.

Palliative radiotherapy for multiple liver metastases: a retrospective analysis of 73 cases

BACKGROUND

Whole-liver radiotherapy for diffuse liver metastases can improve symptoms and abnormal liver-related blood data. However, whole-liver radiotherapy is uncommonly used in clinical practice in Japan. Therefore, we aimed to clarify palliative radiotherapy outcomes in Japanese patients with liver metastases.

METHODS

We retrospectively reviewed databases in our institution to identify patients treated with radiotherapy (8 Gy in a single fraction) for multiple liver metastases between December 2014 and April 2021. The endpoints included pain response, liver-related blood data and adverse effects. We investigated aspartate transaminase, alanine transaminase, lactate dehydrogenase, alkaline phosphatase, γ-glutamyl transpeptidase and albumin. The mean values at whole-liver radiotherapy and after 2-4 weeks were compared using the Wilcoxon rank-sum test.

RESULTS

A total of 73 cases in 71 patients were included. The median clinical target volume was 2118 ml (range, 133-7867 ml). Fifty-seven patients (78%) had finished aggressive treatment at the time of radiotherapy. The median follow-up period was 6 weeks. The pain response rate was 64% (18/28). The mean values of five parameters significantly improved 2-4 weeks after radiotherapy compared to those at baseline: aspartate transaminase (118 vs. 83 U/l P < 0.01); alanine transaminase (84 vs. 61 U/l P < 0.01); lactate dehydrogenase (1351 vs. 1007 U/l P = 0.027); alkaline phosphatase (1624 vs. 1216 U/l P < 0.01) and γ-glutamyl transpeptidase (663 vs. 450 U/l P = 0.037). No patients experienced radiation-induced liver disease.

CONCLUSIONS

Palliative radiotherapy is efficient and safe in Japanese patients with liver metastases. These findings will help encourage whole-liver radiotherapy use in Japan.

Novel Use of Low-Dose Radiotherapy to Modulate the Tumor Microenvironment of Liver Metastases

Despite multiple therapeutic approaches, the presence of liver metastases carries a guarded prognosis, urgently necessitating further clinical and scientific research to develop curative interventions. The liver is an immunoprivileged organ that suppresses the effectiveness of immunotherapies in patients with hepatic metastases. Cancer immunotherapies have been successfully bolstered by low-dose radiotherapy (LDRT), which is capable of reprogramming the tumor microenvironment (TME) from an immunosuppressive to an immunostimulatory one. Likewise, LDRT may be able to revoke the immune privilege enjoyed by the liver, permitting successful immunotherapies there. Here, we first review challenges that face the treatment of liver metastases. We next outline emerging preclinical and clinical evidence supporting enhanced systemic tumor control of LDRT in the context of cancer immunotherapy. Finally, we will discuss the rationale of combining liver-directed LDRT with immunostimulatory strategies to overcome immune resistance and achieve better clinical response. This notion is supported by a recent case study in which a patient who had progressed following T cell therapy experienced a complete response after LDRT to the liver.

Clinical application of advances and innovation in radiation treatment of hepatocellular carcinoma

Background:

Hepatocellular carcinoma (HCC) management has evolved over the past two decades, with the development of newer treatment modalities. While various options are available, unmet needs are reflected through the mixed treatment outcome for intermediate-stage HCC. As HCC is radiosensitive, radiation therapies have a significant role in management. Radiation therapies offer local control for unresectable lesions and for patients who are not surgical candidates. Radiotherapy also provides palliation in metastatic disease, and acts as a bridge to resection and transplantation in selected patients. Advancements in radiotherapy modalities offer improved dose planning and targeted delivery, allowing for better tumor response and safer dose escalations while minimizing the risks of radiation-induced liver damage. Radiotherapy modalities are broadly classified into external beam radiation therapy and selective internal radiation therapy. With emerging modalities, radiotherapy plays a complementary role in the multidisciplinary care of HCC patients.

Aim:

We aim to provide an overview of the role and clinical application of radiation therapies in HCC management.

Relevance for Patients:

The continuous evolution of radiotherapy techniques allows for improved therapeutic outcomes while mitigating unwanted adverse effects, making it an attractive modality in HCC management. Rigorous clinical studies, quality research and comprehensive datasets will further its application in the present era of evidence-based practice in Medicine.

Magnetic Resonance Imaging-Guided Adaptive Radiotherapy for Colorectal Liver Metastases

Technological advances have enabled well tolerated and effective radiation treatment for small liver metastases. Stereotactic ablative radiation therapy (SABR) refers to ablative dose delivery (>100 Gy BED) in five fractions or fewer. For larger tumors, the safe delivery of SABR can be challenging due to a more limited volume of healthy normal liver parenchyma and the proximity of the tumor to radiosensitive organs such as the stomach, duodenum, and large intestine. In addition to stereotactic treatment delivery, controlling respiratory motion, the use of image guidance, adaptive planning and increasing the number of radiation fractions are sometimes necessary for the safe delivery of SABR in these situations. Magnetic Resonance (MR) image-guided adaptive radiation therapy (MRgART) is a new and rapidly evolving treatment paradigm. MR imaging before, during and after treatment delivery facilitates direct visualization of both the tumor target and the adjacent normal healthy organs as well as potential intrafraction motion. Real time MR imaging facilitates non-invasive tumor tracking and treatment gating. While daily adaptive re-planning permits treatment plans to be adjusted based on the anatomy of the day. MRgART therapy is a promising radiation technology advance that can overcome many of the challenges of liver SABR and may facilitate the safe tumor dose escalation of colorectal liver metastases.

External Beam Radiation Therapy for Liver Metastases

Stereotactic ablative radiotherapy (SABR) commonly is used for small liver metastases. Modern conformal radiotherapy techniques, including 3-dimensional conformal radiotherapy and intensity-modulated radiation therapy, enable the safe delivery of SABR to small liver volumes. For larger tumors, the safe delivery of SABR can be challenging due to a more limited volume of healthy normal liver parenchyma and the proximity of the tumor to radiosensitive organs, such as the stomach, duodenum, and large intestine. Controlling respiratory motion, the use of image guidance, and increasing the number of radiation fractions sometimes are necessary for the safe delivery of SABR in these situations.

Cytotoxicity Evaluation of Dimethoxy and Trimethoxy Indanonic Spiroisoxazolines Against Cancerous Liver Cells

Background:

3'-(3,4-dimethoxyphenyl)-4'-(4-(methylsulfonyl)phenyl)-4'H-spiro [indene-2,5'-isoxazol]-1(3H)-one and 4'-(4-(methylsulfonyl)phenyl)-3'-(3,4,5-trimethoxyphenyl)- 4'H-spiro[indene-2,5'-isoxazol]-1(3H)-one compounds containing indanonic spiroisoxazoline core are widely known for their antiproliferative activities and investigation of tubulin binding modes.

Objective:

To evaluate the cytotoxicity effect of Dimethoxy and Trimethoxy Indanonic Spiroisoxazolines against HepG2 cancerous liver cell line and to perform a comparison with other known anti-liver cancer drugs.

Methods:

The evaluation of cytotoxicity of dimethoxy and trimethoxy indanonic spiroisoxazoline compounds, Oxaliplatin, Doxorubicin, 5-fluorouracil and Cisplatin against HepG2 (hepatocellular liver carcinoma) cell line has been performed using MTT assay and analyzed by GraphPad PRISM software (version 8.0.2).

Results:

Potent cytotoxicity effects against HepG2 cell line, comparable to Cisplatin (IC50= 0.047±0.0045 µM), Oxaliplatin (IC50= 0.0051µM), Doxorubicin (IC50= 0.0014µM) and 5- fluorouracil (IC50= 0.0089 µM), were shown by both dimethoxy (IC50= 0.059±0.012 µM) and trimethoxy (IC50= 0.086±0.019 µM) indanonic spiroisoxazoline compounds.

Conclusion:

In vitro biological evaluations revealed that dimethoxy and trimethoxy indanonic spiroisoxazoline compounds are good candidates for the development of new anti-liver cancer agents.

Palliative Liver Radiotherapy (RT) for Symptomatic Hepatocellular Carcinoma (HCC)

This study aims at evaluating the symptom response, response duration, and toxicity of single dose palliative liver radiotherapy (RT) for symptomatic HCC patients. We reviewed unresectable HCC patients treated with palliative RT in our institution. Eligible patients were unsuitable or refractory to trans-arterial chemoembolization (TACE) and stereotactic body radiotherapy (SBRT), with an index symptom of pain or abdominal discomfort. The primary outcome was the percentage of patients with clinical improvement of index symptom at 1 month. Secondary outcomes were response duration, toxicities, alpha-feto protein (AFP) response, and radiological response. Fifty-two patients were included in the study. The index symptom was pain in 34 patients (65.4%), and abdominal discomfort (34.6%) in 18 patients. At 1 month, 51.9% of patients had improvement of symptoms. Median time to symptom progression was 89 days (range: 12–392 days). Treatment was well tolerated with only 2 patients (3.8%) developing grade 3 GI toxicities. AFP response, radiological response rate, and disease control rate at 3 months were 48.6%, 15.1%, and 54.5% respectively. Half of the patients had improvement of index symptoms after receiving palliative liver RT with median response duration of 3 months. The treatment was well tolerated with minimal toxicities.

Radiotherapy may improve survival of ES-SCLC with distant metastasis only for patients with one metastatic site: A population-based study

The aim of the present study was to investigate the prognostic impact of RT on patients with extensive stage small cell lung cancer (ES-SCLC) and distant metastasis. Using the Surveillance Epidemiology and End Results (SEER) database, 8,595 patients with ES-SCLC exhibiting distant metastasis treated between 2010 and 2013 were identified. Patient baseline characteristics were compared using the χ² test. The Kaplan-Meier test was used to analyze subgroup cancer-specific survival (CSS) rate, and differences were compared using a log-rank test. Univariate and multivariate Cox regression models were used to analyze the prognostic variables on CSS. RT was determined to be an independent prognostic factor for patient CSS (P<0.001). In addition, RT could improve the CSS of patients with ES-SCLC with one metastatic lesion (hazard ratio, 0.63; 95% confidence interval, 0.59-0.68; P<0.001), including the bone, brain, liver and lung metastatic sites. However, for patients with two metastatic sites, RT did not improve CSS regardless of metastasis pattern (all P>0.05). To conclude, RT may improve the survival rate of patients with ES-SCLC with distant metastasis, particularly in those with only one metastatic site.

Successful treatment of unresectable advanced rectal cancer with liver metastases by hemostasis re-irradiation of the rectal cancer and palliative low-dose whole-liver radiation therapy: a case report

A 72-year-old man was admitted to the hospital with fatigue. Colonoscopy revealed a 50 × 50 mm rectal tumor with bleeding. Based on close inspection, he was diagnosed with unresectable advanced rectal cancer with multiple liver metastases. Chemotherapy was administered as 10 cycles of bevacizumab + mFOLFOX6 and 7 cycles of bevacizumab + FOLFIRI. Nine months later, he presented with hematochezia and progression of anemia. It was difficult to stop the bleeding via endoscopy. He underwent radiation therapy (39 Gy in 13 fractions), and hemostasis was confirmed. Then, further chemotherapy was performed with 3 cycles of bevacizumab + FOLFIRI and 2 cycles of TAS102. However 14 months after the initial visit, he presented with right hypochondralgia and abdominal fullness due to the progression of multiple liver metastases. Palliative low-dose whole-liver radiation therapy (WLRT) (30 Gy in 10 fractions) was performed. He developed Grade 2 nausea, but his right hypochondralgia reduced, liver dysfunction improved, and he successfully completed radiotherapy. At approximately the same time his anemia progressed, and colonoscopy revealed recurrent bleeding from the tumor. Re-irradiation (15 Gy in 5 fractions) of the rectal tumor was carried out and a blood transfusion was performed for the bleeding. He was discharged after confirmation the anemia had not progressed. Few reports have been published on the use of both palliative re-irradiation to stop bleeding from rectal cancer and palliative low-dose WLRT. Based on our experience with this case, we believe that palliative radiotherapy can be useful in treating patients with a poor prognosis.

Radioembolization treatment for liver metastases

The liver is an organ that, due to vascularisation and functions, is prone to metastases. Most liver metastases are observed in cases of gastrointestinal cancers in: stomach, colon, gallbladder, and bile ducts. Metastatic lesions are also observed in lung, breast, thyroid, kidney, and pancreatic cancer. One of the best known and most effective ways of liver lesion treatment is Metastasectomy. Unfortunately, lesions are frequently inoperable. Apart from chemotherapy, it is possible to apply local treatment such as TACE (trans-arterial chemoembolisation), RFA (Radio Frequency Ablation), and SBRT (Stereotactic Body Radiation Therapy). One of the newest methods of inoperable lesion treatment is radioembolisation (SIRT). Intravascular administration of microspheres containing radioisotope 90Y allows delivery of a higher dose of radiation directly to the tumour than traditional radiation with an external beam, while maintaining a small dose to healthy liver methods. Conducted clinical studies confirm the efficacy and safety of SIRT. It is an interesting alternative to other ways of treatment.

Systematic review of patient reported quality of life following stereotactic ablative radiotherapy for primary and metastatic liver cancer

Background

Stereotactic ablative radiotherapy (SABR) is a safe and effective modality in patients with liver cancer who are ineligible for other local therapies. However SABR is not current standard of practice and requires further validation. Patient reported quality of life (QOL) is key to this validation, yet no systematic reviews to date have been performed to analyse QOL following liver SABR. QOL is a critical part of therapy evaluation, particularly in disease states with short life expectancy. The purpose of this study was to conduct a systematic review of QOL outcomes for liver SABR.

Materials and methods

MEDLINE and EMBASE databases from 1996 to October 2015 were queried to obtain English language studies analysing QOL following liver SABR. Included studies described patient-reported QOL as either a primary or secondary endpoint, and analysed QOL change over time. Studies were screened, and relevant data were abstracted and analysed.

Results

Of 2181 initially screened studies, 5 met all inclusion criteria. Extracted studies included a total of 392 eligible patients with hepatocellular carcinoma, liver metastases and intrahepatic cholangiocarcinoma. Four studies were prospective in design, and only one study was a conference abstract. Extracted studies were heterogeneous in dose prescription used (11–70 Gy in 3–30 fractions), in addition to reported QOL metrics (EORTC QLQ C-15 PAL,/C-30/LM-21, EuroQol 5D, FACT-Hep, FLIC) and final endpoints (range 6 weeks to 12 months). Despite this there were few statistically significant declines in QOL scores following SABR. Four studies demonstrated transient fatigue in the first 1–4 weeks, while 2 studies showed transient worsening of appetite at 1 month. In all but one instance (loss of appetite at 6 weeks), levels returned to insignificant difference baseline by the final endpoints. All studies showed no significant QOL decline in any domain at their respective endpoints. In studies with overlapping QOL tools, estimates of 3-month post SABR global QOL were similar.

Conclusion

Results of this systematic review demonstrate well-preserved post liver SABR QOL. These findings strengthen the argument for liver SABR, and should aim to support future comparative effectiveness trials with other local modalities including surgery, chemoembolization and radiofrequency ablation, with a focus on QOL outcomes as an important endpoint.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-017-0818-8) contains supplementary material, which is available to authorized users.

Resurrection of whole liver radiotherapy-A case report

INTRODUCTION

This is a case report of a patient of lymphoma with liver metastasis who had persistent pain and jaundice despite multiple lines of chemotherapy. She underwent palliative liver irradiation. This is an uncommon modality due to fear of radiation induced hepatitis. We reviewed literature available on the use of liver irradiation for palliation and concluded that it can be safely used with good results. A 33-year-old female with Non-Hodgkin's Lymphoma (NHL) presented with obstructive jaundice. She underwent stenting followed by chemotherapy. She was lost to follow up to later present with a progressively increasing right hypochondrial mass, pain and icterus. Ultrasound abdomen revealed massive hepatomegaly with hypodense lesions in both liver lobes and centring the porta with dilatation of biliary radicals. Despite multiple lines of chemotherapy and use of opioids, there was no symptomatic relief in pain, size of mass or any decrease in biochemical parameters. Then she was offered palliative radiation in the form of partial liver irradiation to a dose of 21Gy/7 fractions. She had >50% pain relief after 2 fractions and was off opioids by last fraction. Liver span reduced from 6cm to 1cm below costal margin in mid clavicular line. Radiologically 60% reduction in size of liver lesions was observed. Also, a decreasing trend in biochemical parameters was observed. Use of whole or partial liver irradiation is rare in clinical practice due to fear of radiation induced hepatitis by conventional techniques. Newer techniques of delivering radiation can highly improvise accuracy and permit further dose escalation.

Stereotactic Body Radiation Therapy for Liver Cancer: A Review of the Technology

Stereotactic body radiation therapy has been adopted in the treatment of liver cancer because of its highly conformal dose distribution when compared with other conventional approaches, and many studies have been published to report the positive clinical outcome associated with this technique. To achieve the precision needed to maintain or to improve the therapeutic ratio, various strategies are applied in different components in the stereotactic body radiation therapy process. Immobilization devices are used in minimizing geometric uncertainty induced by treatment positioning and internal organ motion. Along with a better definition of target by the integration of multimodality imaging, planning target volume margin to compensate for the uncertainty can be reduced to minimize inclusion of normal tissue in the treatment volume. In addition, sparing of normal tissue from irradiation is improved by the use of high precision treatment delivery technologies such as intensity-modulated radiotherapy or volumetric modulated arc therapy. Target localization before treatment delivery with image guidance enables reproduction of the patient's geometry for delivering the planned dose. The application of these advanced technologies contributes to the evolution of the role of radiation therapy in the treatment of liver cancer, making it an important radical or palliative treatment modality.

Meta-analysis of diagnosis of liver metastatic cancers: comparison of (18) FDG PET-CT and gadolinium-enhanced MRI

INTRODUCTION

We performed a meta-analysis to compare the performance of 18F-fluorodeoxyglucose ((18) FDG) positron emission tomography-CT (PET-CT) with that of gadolinium-enhanced MRI for the detection of liver metastatic cancers.

METHODS

The MEDLINE and EMBASE databases were searched for relevant original articles. The histology and/or imaging follow-up data served as the reference standard. We calculated the pooled sensitivities, specificities, positive likelihood ratios, negative likelihood ratios and constructed summary receiver operating characteristic curves for (18) FDG PET-CT and gadolinium-enhanced MRI, respectively.

RESULTS

Ten studies (1105 patients) were included for this meta-analysis. (18) FDG PET-CT has similar patient-based specificity (1.00 and 0.99), positive likelihood ratios (253.1 and 138.2), negative likelihood ratios (0.16 and 0.10) and area under curves (0.99 and 0.99) with gadolinium-enhanced MRI. Gadolinium-enhanced MRI tends to have higher sensitivity (0.91 and 0.84) than (18) FDG PET-CT.

CONCLUSION

Both (18) FDG PET-CT and gadolinium-enhanced MRI have excellent diagnostic performance for the detection of liver metastatic cancer.

Treatment of hepatic metastases of colorectal cancer by robotic stereotactic radiation (Cyberknife ®)

Cyberknife(®) is a dedicated stereotactic radiotherapy device. This new technology permits precise delivery of high dose gradient radiation therapy while sparing the surrounding organs at risk. Hepatic metastases of colorectal cancer (HMCRC) are an example of a lesion where treatment with Cyberknife(®) is indicated because they are located in a radio-sensitive organ and curative treatment is based on focal eradication (resection, radiofrequency ablation,...). The local control rate at one year is reported to be 70 to 100% depending on the study. Tolerance is excellent with less than a 5% rate of acute grade 3 or 4 side effects (nausea, vomiting, gastro-duodenal ulcer). The specific hepatotoxicity of radiotherapy, so-called radiation-induced liver disease (RILD), was found in only one study. Candidates for stereotactic radiotherapy are patients in whom disease is controlled except for intrahepatic disease with 1-3 hepatic metastases ≤ 6 cm in size who have contraindications for surgery, a WHO stage ≤ 2, a volume of healthy liver ≥ 700 cm(3) and normal liver function. It is actually a very simple treatment that results in very good local control with few contraindications. Its place in the management strategy of liver metastases needs further clarification.

Phase II trial of palliative radiotherapy for hepatocellular carcinoma and liver metastases

PURPOSE

To evaluate the feasibility and response of liver radiotherapy (RT) in improving symptoms and quality of life in patients with hepatocellular carcinoma (HCC) or liver metastases (LM).

PATIENTS AND METHODS

Eligible patients had HCC or LM, unsuitable for or refractory to standard therapies, with an index symptom of pain, abdominal discomfort, nausea, or fatigue. The Brief Pain Inventory (BPI), Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep), and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) were completed by patients at baseline and each follow-up. The primary outcome was the percentage of patients with a clinically significant change at 1 month in the BPI subscale of symptom on average in the past 24 hours. Secondary outcomes were improvement in other BPI subscales and at other time points, FACT-Hep and EORTC QLQ-C30 at each follow-up, and toxicity at 1 week.

RESULTS

Forty-one patients (30 men and 11 women) with HCC (n = 21) or LM (n = 20) were accrued. At 1 month, 48% had an improvement in symptom on average in the past 24 hours. Fifty-two percent of patients had improvement in symptom at its worst, 37% at its least, and 33% now. Improvements in the FACT-G and hepatobiliary subscale were seen in 23% and 29% of patients, respectively, at 1 month. There were also improvements in EORTC QLQ-C30 functional (range, 11% to 21%) and symptom (range, 11% to 50%) domains. One patient developed grade 3 nausea at 1 week.

CONCLUSION

Improvements in symptoms were observed at 1 month in a substantial proportion of patients. A phase III study of palliative liver RT is planned. [Corrected]

An international survey on liver metastases radiotherapy

BACKGROUND

An international survey of radiation therapy (RT) of liver metastases was undertaken by the Liver Cancer Workgroup of the Third International Consensus on Metastases Workshop at the 2010 American Society for Radiation Oncology (ASTRO) meeting.

MATERIAL AND METHODS

Canadian, European, Australian, New Zealand and American centers participated in this online survey. The survey had four objectives: 1) to describe the practice patterns for RT of liver metastases; 2) to report on the use of low-dose RT for symptomatic liver metastases; 3) to report on the use of technology; and 4) to describe the regional differences in the management of liver metastases.

RESULTS

A total of 69 individuals treating liver metastases with radiotherapy responded to the survey. Regional response rates ranged from 39% to 50%. The primary professional affiliation of all respondents was evenly distributed amongst ASTRO, CARO, ESTRO and TROG/RANZCR. A 36% increase in the average annual number of referrals over the past five years is reported. The majority of referrals were for radical RT. The most common technologies used were 4D-CT (61%), SBRT (55%), IGRT (50%), and/or IMRT (28%). A uniform treatment approach was not found. The most commonly employed radical regimens were 45 Gy in 3 fractions, 40-50 Gy in 5 fractions, and 45 Gy in 15 fractions. Palliative regimens included 20 Gy in 5 fractions, 30 Gy in 10 fractions, 8 Gy in 1 fraction, and 10 Gy in 2 fractions.

CONCLUSIONS

This survey suggests radiation oncologists will be seeing more referrals for liver RT. The majority of experience in liver metastases RT is with radical SBRT for focal metastases rather than low-dose palliative RT for symptom control. There is significant variation in technology utilization and dose regimens. Prospective studies or registries may allow for comparison of regimens and identification of parameters to optimize patient selection.

Radiotherapy for liver metastases: a review of evidence

Over the past decade, there has been an increasing use of radiotherapy (RT) for the treatment of liver metastases. Most often, ablative doses are delivered to focal liver metastases with the goal of local control and ultimately improving survival. In contrast, low-dose whole-liver RT may be used for the palliation of symptomatic diffuse metastases. This review examines the available clinical data for both approaches. The review found that RT is effective both for local ablation of focal liver metastases and for palliation of patients with symptomatic liver metastases. However, there is a lack of a high level of evidence from randomized clinical trials.

Radiation therapy for liver metastases

Liver metastases are a common source of cancer morbidity and mortality and are often the only site of metastases. In the last 2 decades, major technological advancements in radiation treatment planning and delivery have resulted in resurgence in the use of radiation therapy (RT) as a treatment for liver tumors. With the advent of 3-dimensional conformal radiation treatment (CRT), partial liver irradiation became possible. Stereotactic body radiation therapy (SBRT) is a further enhancement, defined as highly focused, stereotactically localized and administered, high-dose RT delivered in a hypofractionated course. There is now more than a decade of experience with CRT and SBRT for the treatment of liver metastases. In selected patients, very high local control rates have been observed, with minimal toxicity. Patients most likely to benefit from RT are those with liver confined disease, focal distribution of metastases, and metastases more than 1.5 cm from luminal gastrointestinal organs. There is growing evidence that strategies using aggressive or ablative local therapies as an adjunct to systemic therapy might achieve improvements in overall outcome as long as they are administered safely.

Nabilone for the treatment of paraneoplastic night sweats: a report of four cases

ABSTRACT Night sweats are one of many symptoms experienced by patients with advanced cancer. The prevalence of night sweats ranges from 10%-48% in cancer patients. Persistent night sweats tend to decrease quality of life through interference with sleep. A recent study has demonstrated that night sweats occur as part of a symptom pattern, and are associated with the anorexia-cachexia symptom cluster. In addition, night sweats represent one of the symptoms that displays a tendency not to improve as patients with advanced cancer approach end of life. This paper serves to report on the successful management of four patients suffering from persistent paraneoplastic night sweats using the synthetic orally administered cannabinoid nabilone. The four patients had been referred to a regional consultative palliative medicine program and identified night sweats as one of their most significant symptomatic concerns reported on their Edmonton Symptom Assessment System (ESAS) questionnaires.

Regional Cancer Pain Syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.