RELIABILITY OF RISK FACTORS AND SCORING SYSTEMS IN PREDICTING FRACTURING IN METASTATIC FEMORAL BONE

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The role of radiotherapy in pain treatment
Yvette van der Linden Radiotherapy Institute
Friesland Leeuwarden, The Netherlands
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Introduction

• Radiotherapy
• Local treatment
• Photon energy -gt DNA damage
• Reduction of tumor cells -gt shrinkage

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Linear accelerator
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Indications for treating pain

• Primary tumor
• Curative intent
• Combined modality
• Organ sparing
• Palliative intent
• Short course
• Few side effects
• Metastases

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Head and neck cancer

• Corry et al, RO 2005
• N 30, incurable disease
• 14 Gy / 4 fr.
• 56 pain relief
• 67 improvement QOL

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Head and neck cancer
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Esophageal cancer

• Homs et al. Eur.J.Cancer 2004
• stent vs. brachytherapy
• N 209
• palliative effect 82 vs 115 days

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Lung cancer

• Macbeth et al. 2001 Cochrane review
• N 2926 NSCLC stage III and IV
• Short course RT
• 16 Gy / 2fr.
• 30 Gy / 10fr.
• Symptom control in 70

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Lung cancer
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Breast cancer

• Locally advanced
• Curative -gt combined modality
• Palliative -gt RT alone
• 51 Gy / 17 fr.

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Breast cancer

• Recurrence local / locoregional
• re irradiation hyperthermia -gt
• 32 Gy in 8 fractions, 2x week
• (van der Zee et al, DDHCC)

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Indications- metastases

• Bone
• Pain
• Pathological fracture
• Spinal cord compression
• Brain
• Cutaneous
• Lymph nodes

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Bone metastases- pain
N gt 3300 patients

• Sze et al, Cochrane 2004
• Wu et al, IJROBP 2003
• Single fraction multiple fractions
• Response 60-70, CR 33
• Duration 11-24 weeks
• Net pain relief 70-80
• van der Linden, DBMS, 2005

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Bone metastases- fracture

• Goal -gt remineralisation
• Impending
• Koswig et al, Strahlenther.Onc. 1999
• N 107
• 8 Gy SF vs. 30 Gy / 10 fr.
• Higher dose -gt more remineralization
• Actual -gt postoperative RT
• Townsend et al, IJROBP 1995
• N 64
• 53 vs 11 (MV, Plt 0.01) functionality

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postoperatively
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Brain metastases

• Tsao et al, Cancer Tr. Rev. 2005
• EBRT
• Stereotactic RT
• 60-90 improvement of
• neurological symptoms
• OS benefit in single metastasis

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Radiation techniques

• Reduce treatment related side effects
• Acute
• mucositis, diarrhea, abdominal pain, nausea,
  vomiting, itching, dermatitis
• Late
• xerostomia, fibrosis, bowel adhesions,
• damage to spinal cord
• Prognosis performance scale

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Radiation techniques

• Improved imaging techniques
• (PET) CT based planning

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PET-CT
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Radiation techniques

• Improved radiation techniques
• Conformal RT
• Stereotactic RT
• Intensity Modulated RT
• Image Guided RT

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Single posterior field
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IMRT
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Conclusions

• Radiotherapy effective for treating pain
• Curative and palliative intent
• Improved imaging
• Evolving radiation techniques
• ? less side effects
• ? more effective treatment

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Time investment

• Prognosis single 10 20
• 3m 0.1 13 29
• 6m 0.05 7 14
• 12m 0.027 3.3 7

P. Hoskin, meeting IAEA 2005
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Indications- primary tumor

• Head and neck cancer
• Gynecological cancer
• Esophageal cancer
• Lung cancer
• Breast cancer
• Rectal cancer
• Lymphoma

curative and palliative
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Lung cancer

• Kramer et al, JCO 2005
• N 297
• 16 Gy / 2 fr.
• 30 Gy / 10 fr.

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Pancoast tumor
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Bone metastases- pain
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Bone metastases- spinal cord compression

• Rades et al, JCO 2005
• N 1304

Motor function
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Bone metastases- spinal cord compression

• Poor prognosis lt 4-6 months -gt 8 Gy SF
• Intermediate/good prognosis -gt 30 Gy MF

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Lymphoma
Curative intent
Palliative intent
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4-field technique
conformal technique
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Stereotactic radiotherapy
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Conclusion

• Supportive care needs multidisciplinary approach
  !!