Strategy for bone metastases treatment in patients with impending cord compression or vertebral fractures: A pilot study

Abstract

Impending spinal cord compression and vertebral fractures are considered contraindications for radionuclide bone pain palliation therapy. However, most of the patients with widespread bone metastases already have weakened vertebral segments that may be broken. Therefore, local field external-beam radiotherapy or percutaneous vertebroplasty (VP) should be considered to improve the patient's quality of life and to institute subsequent appropriate treatment, including radionuclide therapy for bone pain palliation. The objective of this study was to develop a strategy for an effective treatment of bone metastases in patients with widespread bone metastases and intolerable pain, associated with impending cord compression or vertebral fractures. Eleven patients (5 females and 6 males, aged 32-62 years; mean age 53.8 ± 2.7 years) with multiple skeletal metastases from carcinomas of prostate (n = 3), breast (n = 3) and lung (n = 5) were studied. Their mean pain score measured on a visual analogue scale of 10 was found to be 8.64 ± 0.15 (range 8-9) and the mean number of levels with impending cord compression or vertebral fracture was 2.64 ± 0.34 (range 1–4). All patients underwent vertebroplasty and after 3–7 days received Sm-153 ethylene diamine tetra methylene phosphonic acid (EDTMP) therapy. Sm-153 EDTMP was administered according to the recommended standard bone palliation dose of 37 MBq/kg body weight. Whole body (WB) bone scan, computed tomography and magnetic resonance imaging (MRI) were performed before and after treatment in all patients. Pain relief due to stabilization of vertebrae after VP occurred within the first 12 hours (mean 4.8 ± 1.2 hours; range 0.5–12 hours), and the mean pain score was reduced to 4.36 ± 0.39 (range 2–6). Subsequent to Sm-153 EDTMP treatment, further pain relief occurred after 3.91 ± 0.39 days (range 2-6 days) and the pain score decreased to 0.55 ± 0.21 (range 0–2). The responses to treatment were found to be statistically significant (P < 0.0001). Based on the results on this limited patient population, we conclude that spinal stabilization using VP in patients with widespread bone metastases and impending cord compression is an effective way to decrease disability with pain and to facilitate subsequent systemic palliation of painful skeletal metastases by Sm-153 EDTMP therapy.

Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline

“…There has been an abundance of recently published studies, including clinical trials, affirming the safety and efficacy of familiar agents, samarium-153 and strontium-89, as well as rhenium-186 and radium-223 (Table 4). [17][18][19][20][21][22][23][24][25][26][27][28] Most intriguing is the growing evidence that, in patients with bone-only or bone-dominant disease, these agents may provide benefits beyond pain relief, including prevention of skeletal-related events and improved survival, although appropriate use of radiopharmaceuticals with the intention of improving survival is not addressed in this guideline. 18,29,30 Regarding the benefit of EBRT, a phase 3 RCT of samarium-153 with or without EBRT (8 Gy × 1 in 90% receiving EBRT) in metastatic prostate cancer with painful bony metastases demonstrated a significant improvement in pain relief with addition of EBRT and no extra toxicity.…”

“…The short list of available, small series on kyphoplasty or vertebroplasty plus radiation (EBRT, SBRT, or interstitial samarium-153), now includes a new prospective study of 11 patients treated with vertebroplasty and samarium-153. 20 However, these limited data do not allow definitive statements regarding combined regimens and highlight the importance of future prospective trials addressing proper patient selection, efficacy, toxicity, and timing in relation to radiation therapy.…”

Comparison of the Effect of Combined Treatment with Radiotherapy and Hyperthermia versus Exclusively Radiotherapy to Reduce Pain in Patients with Bone Metastases

“…Notably, palliative radiotherapy is very efficacious and pragmatic for patients with bone metastases, and the pain of many patients after treatment is alleviated and the response rate to palliative radiotherapy for localized painful patients is significantly higher than the response rate ensuing from palliative systemic treatments and ergo, radiotherapy is the basis of localized bone metastases, but because the mechanism of pain may be multifactorial, combined therapies, especially the combination of radiotherapy and hyperthermia, which acts as one of the important radiolaborant sensitivities, may be referred to any of the treatments exclusively; on the other hand, it may increase the therapeutic side effects [7,8].…”

“…One striking point to mention is that due to the mechanism of pain which may be multifactorial for exemplification combined therapies, especially the combination of radiotherapy and hyperthermia, that acts as one of the important radiolaborant sensitivities, may be referred to any of the treatments alone. It is worthwhile mentioning that in contrast to the mentioned view, it might increase the therapeutic side effects [7,8]. It is noteworthy that according to the review in related literature which will be stated later in this research paper, It can be asserted that researchers who are implicated with this research era have pursued advanced studies and in line with previous studies, the current study aims to compare the effect of combined treatment with radiotherapy and hyperthermia versus with radiotherapy only to reduce pain in patients with bone metastases in one selective oncology center in Tehran, Iran.…”

Therapeutic Intervention in Musculoskeletal Radiology: Current Practice and Future Directions

“…As described in the earlier section on vertebral augmentation techniques, the original cementoplasty procedure was performed in Amiens, France, in 1987 when cement was percutaneously injected into a painful hemangioma. This procedure was further adapted for use and implemented in painful metastatic disease and multiple myeloma, [205][206][207][208] with a 2016 review 209 concluding that both vertebroplasty and kyphoplasty may be effective in relieving pain and improving quality of life in patients with cancer-related vertebral fractures. The technique has also been adapted for various other anatomical sites, particularly the acetabulum and sacrum, 210,211 with positive results.…”