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ORIGINAL ARTICLE
An Effective Palliation For Multiple Painful Skeletal Metastases: Hemibody Radiation

*Dr.Sanket R Diwanji, +Dr. Nehal D Shah

*Consultant Orthopaedic Surgeon, Muni Seva Ashram and Kailash Cancer Hospital & Research Centre, Goraj, Baroda, India.
+Resident in Radiology, SSG Hospital and Medical College, Baroda, India

Address for Correspondence
Dr.Sanket R Diwanji
B-201, Jal-Tarang Apartment, Halar Cross Road,
Valsad-396001, Gujarat, India.
Phone:+91-9825658983;   +91-9426565623; +91-2632-259357
Fax: 91-2668-268048
E-mail: sanket_diwanji@yahoo.co.in

Abstract

Introduction: A cancer patient may present to the orthopaedic surgeon for disabling bone pain, pathological fracture and/or  neurological deficit  due to spinal cord or nerve root compression. Bone pain due to skeletal metastasis causes significant morbidity  among   cancer patients  and is equally difficult to treat for an orthopaedic surgeon .Many a times multiple bones  are affected simultaneously. A single large hemibody radiation field is shown to be effective in alleviation of pain in  such patients. We present results of ten patients treated with this technique at our institute.
Materials and Methods: Ten documented cases of disseminated  bone metastasis due to malignancy were evaluated to assess the efficacy of hemibody radiation for pain control. Intensity of the pain was scored according to the 10th visual analogue score. The upper and the lower segment of the body was exposed to a radiation dose of 6 Gy and 8 Gy respectively in single fraction using photon beam megavoltage  unit by 6 MV photons of linear accelerator.
Results:A Hemibody radiation provided pain relief ranging from  64% to 100% .Complete pain relief was achieved in 7 patients. Onset of relief  was within first  48 hrs and lasted for rest of their lives. Analgesic requirement came down to less than 25% and was mainly required for untreated other half. Four patients were treated for other half after 6 weeks of first session. No significant gastrointestinal ,hematological or pulmonary toxicity was noted .The quality of life was significantly improved.
Conclusion:Hemibody radiation gives fast, effective and lasting pain relief in any patient presenting with multiple bony metastasis with reduced analgesic requirement and better quality of life.

J.Orthopaedics 2006;3(3)e11

Introduction:

Metastatic tumors to the bones present to the orthopaedic surgeon  in one of three settings First and  most common, a patient with a known primary tumor is seen with a painful lesion in the spine or extremity. Second, a patient may have a pathological fracture , with or without a history of a known primary tumour. Third and least commonly- a patient with a spine or extremity pain arrives in clinic without a history of a known primary tumour. The survival of patients with bony metastasis is often prolonged and pain is the most common symptom in more than two third of the patients. Most of the times multiple bones are affected simultaneously, making life miserable for these patients. Hemibody radiation can be used to treat overt multiple metastasis , relieving patients pain in a single sitting. We  present a series of ten patients treated with this technique at our institute.

Method and materials  

Between June 2004 and September 2005 ten patients with multiple painful skeletal metastasis due to various malignancies were treated at our radiotherapy department using hemibody radiation. 3  patients had breast carcinoma, 2 had prostate carcinoma, 2 had lung carcinoma , 1 had thyroid, 1 had renal cell and 1 had oral cavity malignancy. 3  patients received upper hemibody radiation, 3 had lower hemibody radiation and 4 had both, upper and lower hemibody radiation .

Selection criteria included1

  • Bone pain not controlled with narcotics

  • Age less than 75 years

  • Karnofsky performance status of 70 or higher

  • Adequate myocardial, renal, hepatic, lung and bone-marrow function

  • Life expectancy of 6 weeks or more

Previous radiotherapy to any local site is not a contraindication, but in case of radiotherapy to  lungs or mediastinum previously ,these sites needed to be blocked. It is avoided in patients requiring surgery in a near future because of transient depression of blood counts.

A comprehensive pre-medication schedule was followed to reduce stress reaction.

  • 40 mg prednisolone orally (24 hrs before in divided doses)

  • Overnight hydration with 2 liters of  fluid(5%dextrose,normal saline, ringer lactate)

  • Nothing orally for 6 hrs

  • Injection Dexamethasone 2 cc IV

  • Injection Ranitidine IV

Hemibody radiation was delivered using photon beam from megavoltage unit by 6 MV photons of Linear accelerator going through anterior and posterior portals to cover the entire region in a single portal at extended skin to source distance. A  midline tumor dose of 6 Gy to UHBI (Upper Hemibody Irradiation) and 8 Gy to LHBI (Lower Hemibody Irradiation) was given. After 6 weeks of first radiation other half was treated in 4 patients.

Patients were discharged on the same day and called for follow up after 15 days, when complete blood count is repeated  to assess bone marrow depression .Visual analogue score was used to report degree of pain relief. This score contains digits from 1 to 10.The person is asked to compare the severity of current pain to worst pain he has ever faced in life. (like labour pain, surgical pain, fracture pain) Having known the current pain at the beginning of the treatment, when patient comes for the follow up ,the pain relief can be assessed by asking him to compare his pre-treatment pain with the post treatment one. This does have its limitations, but for all practical purpose it is the easiest and the simplest type.

Results 

Hemibody radiation provided pain relief ranging from 64% to 100%. Complete pain relief was obtained in 7 patients( 2 with breast, 3 with prostate and 1 each with lung and thyroid malignancy). Onset of relief was within 48 hours. Pain relief lasted for 7 to 8 months in 8 patients and till death in other 2 patients. Analgesic requirement came down to 25%, and it was mainly required for the untreated other half of the body. With pain relief patients were able to walk with support and were able to perform their routine work with improved quality of life.

Discussion :

Approximately 80% of bone metastases originate from primary site in the lungs, breast, kidney, thyroid, prostate and gastrointestinal tract2. The overall management of the patient with metastatic disease requires team efforts from medical oncologist, radiotherapist, orthopaedic surgeon and psychotherapist.

Orthopaedic surgeonís main role is in prevention and treatment of pathological fracture. A pathological fracture of neck of femur is best treated by prosthetic replacement, along with debulking of tumour and postoperative radiotherapy. Other pathological fractures of the weight bearing bones of the lower extremity are best treated by debulking of tumor, open reduction, strong internal fixation with or without polymethylmethacrylate supplementation, and postoperative radiotherapy. If the lesion is radiosensitive, as in myeloma there is no need to debulk the tumor. Pathological fractures of the major upper limb bones are treated in similar manner. Occasionally bone metastases known to be highly vascular (e.g. renal carcinoma) are treated by transcatheter arterial occlusion. Prophylactic nailing is recommended when a metastatic deposit causes significant pain , especially after radiotherapy, and if more than 50% of the cortex is destroyed , or if a femoral lesion is larger than 3 cm in diameter. Radiosensitive spinal tumors(e.g lymphoma and myeloma) are treated by radiotherapy and chemotherapy . However radioresistant tumors require decompression either by laminectomy or by anterior vertebral body resection and reconstruction2.

Total body irradiation (TBI) was first tried in treatment of disseminated malignancies over half a century ago. Because of  known radiosensitivity of hematological malignancies it became a suitable target module for TBI technique. The maximum dose delivered in TBI is around 300 rad in a single or fractionated dose3. Main adverse reaction of this was marrow suppression. This can be circumvented by UHBI/LHBI or autologous marrow transfusion4. Hemibody radiation can be easily used in centers not having facilities for marrow transplantation. This approach was invented  by radiotherapists of Princess  Margaret Hospital in Toronto. Fitzpatrick and Rider were able to explore the use of higher doses (600,800,1000 rad) given  in a single fraction to one half of the body in over 500 patients with advanced  and progressive cancer5. They found that relief of pain was dramatic with 800 rad ; this usually occurred within 24 hours and lasted for rest of patientís life over 75% of the time. Most of the studies recommend 600 rad and 800 rad  in a single fraction  for upper and lower half body respectively5,6. Uppelschoten et al achieved 39% complete pain relief with single dose of 600rad7. Nseyo et al recommend 500 rad and 700 rad for upper and lower hemibody respectively8,whereas Nag et al   tried  two doses of 800 rad spaced one week apart with minimal morbidity9. Miszczyk  and Sasiadek found that best symptomatic results were obtained in the cases of multiple myelomas(100% of pain relief),prostate cancers(the average degree of 78%) and lung cancers(88%).Considering histopathological diagnosis , the best answer was found in multiple myeloma and squamous cell carcinoma(88%)Taking in to account type of metastases the best result was obtained in the cases of osteolytic metastases10.  In our study also, patients with prostate cancer got 100% pain relief, which lasted for three months. HBI is effective in palliation of bone pain in patients with hormonally refractory prostate cancer8.

Other modalities for palliative management of skeletal metastasis include zolandronic acid injections and radionuclide therapy using 32P and 89 Sr. None of these modalities provide as lasting pain relief as hemibody radiation. Radionuclide therapy is associated with high cost and severe bone marrow depression1. 

Although hemibody irradiation seems to have multiple potentials and  effective therapeutic measures , there are certain limitations and several complications in its implementation. It  causes significant bone marrow depression ,acute radiation syndrome, radiation pneumonitis, alopecia, hepatic, gastrointestinal and renal toxicities11. Uppelschoten et al have reported 9% incidence of infield spinal cord compression ,when radiation was given to vertebrae and 8% incidence of pelvic fractures when radiation was given to pelvis.  Patients should be thoroughly screened for these abnormalities and they should be rectified before giving HBI.

Conclusion:

Hemibody radiation provides fast ,effective and lasting pain relief in any patient presenting with multiple painful bony metastases with reduced analgesic requirement and better quality of life. Besides radiation  other supportive care and psychosocial support forms an integral part of effective treatment for these patients

 

Reference :

  1. Powers W E, Ratanatharathorn V. Palliation of Bone metastases. Principles & Practice  of Radiation Oncology. Third Edition .Philadelphia .Lippincott-Raven       Publishers.1997. 2199-2215 

  2. Carnesale P G. Malignant tumours of bone. Campbellís Operative Orthopaedics. 9th  edition.Mosby .732-736 

  3. Salazar O M .Systemic Radiation :Response & toxicity :Int J Radiation Oncology  Biological Physics. Nov-Dec 1978 ,Vol 4, No 11 & No 12, pp 937-949 

  4. Rowland C G . Single fraction half body radiation therapy. Clin radiology (1979)30,1

  5. Fitzpatrick R S ,Rider O P Half Body Radiotherapy.Int J Radiation Oncol Biol Physics   1976 ;1:197-207

  6. Biswal B M Assessment of the usefulness of hemibody irradiation in painful bone metastasis. J Indian Medical Assoc.2004 Mar; 102(3):133-4,136-7

  7. Uppelschoten JM , Wanders SL, de Jong JM. Single dose radiotherapy (6 Gy):palliation in painful bone metastases. Radiotherapy Oncology.1995 Sep;  36(3):198-202

  8. Nseyo UO,Fontanesi J, Naftulin B N. Palliative hemibody irradiation in hormonally refractory metastatic prostate cancer. Urology.1989 Aug;34 (2): 76-9

  9. Nag S ,Shah V .Once-a week lower hemibody irradiation (HBI) for metastatic cancers.Int J radiation Oncol Biol Physics 1986 Jun; 12(6): 1003-5 

  10. Miszczyk L, Sasiadek W. The evaluation of the effectiveness of half-body irradiation as palliative treatment in patints with multiple bone metastases. Przegl. Lek  2001;58(5):431-4

  11. Aziz H, Choi K,Sohn C , Yaes R, rotman M .Comparison of 32 P therapy and   sequential hemibody irradiation (HBI)for bony metastases as methods of whole body  irradiation

This is a peer reviewed paper 

Please cite as : Sanket R Diwanji: An Effective Palliation For Multiple Painful Skeletal Metastases: Hemibody Radiation

J.Orthopaedics 2006;3(3)e11

URL: http://www.jortho.org/2006/3/3/e11

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