PDF herunterladen
Semin intervent Radiol 2007; 24(4): 363-374
DOI: 10.1055/s-2007-992324
© Thieme Medical Publishers

Palliative Radiation Therapy in the Management of Brain Metastases, Spinal Cord Compression, and Bone Metastases

Samir V. Sejpal1 , Amit Bhate1 , William Small1  Jr. 
  • 1Department of Radiation Oncology, Northwestern University, Chicago, Illinois
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
11. Dezember 2007 (online)

Auch verfügbar auf
    Lizenzen und Reprints

ABSTRACT

Radiation therapy plays an important role in both curative and palliative cancer treatment. Palliative radiation therapy is given to alleviate symptoms, restore function, relieve suffering caused by cancer, and improve quality of life. Pain relief, control of bleeding or ulceration, prevention of impending compression or obstruction from tumor, and shrinkage of tumor masses causing symptoms are indications for palliative radiotherapy. Palliative radiotherapy is a very effective tool in alleviating pain symptoms and generally well tolerated. Common fractionation schemes are 8 Gy delivered in one fraction and 30 Gy delivered in 10 fractions. This article discusses general principles of administering palliative radiation therapy. Site-specific treatment is addressed, divided into palliative radiotherapy for brain metastases, spinal cord compression, and bone metastases. In each of these areas, we discuss presentation, management, and therapeutic strategies.

KEYWORDS

Palliative care - brain metastases - whole brain radiotherapy - spinal cord compression - bone metastases

REFERENCES

  • 1 Kirkbride P, Bezjak A. Therapies with palliative intent. In: Berger AM, Portenoy RK, Weissman DE Principles and Practice of Palliative Care and Supportive Oncology. Philadelphia; Lippincott Williams & Wilkins 1998: 685-697
    Google Scholar
  • 2 Barnes E A, Palmer J L, Bruera E. Prevalence of symptom control and palliative care. Abstracts presented at the annual meeting of the American Society for Therapeutic Radiology and Oncology.  Int J Radiat Oncol Biol Phys. 2002;  54 211-214
    PubMedGoogle Scholar
  • 3 Nielsen O S. Present status of palliative radiotherapy.  Eur J Cancer. 2001;  37(suppl 7) S279-S288
    PubMedGoogle Scholar
  • 4 Tsao M N, Lloyd N S, Wong R K et al.. Radiotherapeutic management of brain metastases: a systematic review and meta-analysis.  Cancer Treat Rev. 2005;  31 256-273
    CrossrefPubMedGoogle Scholar
  • 5 Khuntia D, Brown P, Li J et al.. Whole-brain radiotherapy in the management of brain metastasis.  J Clin Oncol. 2006;  24 1295-1304
    CrossrefPubMedGoogle Scholar
  • 6 Tham Y L, Sexton K, Kramer R et al.. Primary breast cancer phenotypes associated with propensity for central nervous system metastases.  Cancer. 2006;  107 696-704
    CrossrefPubMedGoogle Scholar
  • 7 Slimane K, Andre F, Delaloge S et al.. Risk factors for brain relapse in patients with metastatic breast cancer.  Ann Oncol. 2004;  15 1640-1644
    CrossrefPubMedGoogle Scholar
  • 8 Miller K D, Weathers T, Haney L G et al.. Occult central nervous system involvement in patients with metastatic breast cancer: prevalence, predictive factors and impact on overall survival.  Ann Oncol. 2003;  14 1072-1077
    CrossrefPubMedGoogle Scholar
  • 9 Porter A T, David M. Palliative care for bone, spinal cord, brain and liver metastases. In: Gunderson LL, Tepper JE Clinical Radiation Oncology. Philadelphia; Elsevier 2007: 437-455
    Google Scholar
  • 10 Narayana A, Liebel S A. Primary and metastatic brain tumors. In: Liebel SA, Phillips TL Textbook of Radiation Oncology. Philadelphia; Elsevier 2004: 463-495
    Google Scholar
  • 11 Gaspar L, Scott C, Rotman M et al.. Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials.  Int J Radiat Oncol Biol Phys. 1997;  37 745-751
    Google Scholar
  • 12 Sneed P K, Larson D A, Wara W M. Radiotherapy for cerebral metastases.  Neurosurg Clin N Am. 1996;  7 505-515
    PubMedGoogle Scholar
  • 13 Cairncross J G, Kim J H, Posner J B. Radiation therapy for brain metastases.  Ann Neurol. 1980;  7 529-541
    CrossrefPubMedGoogle Scholar
  • 14 Nieder C, Berberich W, Schnabel K. Tumor-related prognostic factors for remission of brain metastases after radiotherapy.  Int J Radiat Oncol Biol Phys. 1997;  39 25-30
    CrossrefPubMedGoogle Scholar
  • 15 Borgelt B, Gelber R, Kramer S et al.. The palliation of brain metastases: final results of the first two studies by the Radiation Therapy Oncology Group.  Int J Radiat Oncol Biol Phys. 1980;  6 1-9
    CrossrefPubMedGoogle Scholar
  • 16 Murray K J, Scott C, Greenberg H M et al.. A randomized phase III study of accelerated hyperfractionation versus standard in patients with unresected brain metastases: a report of the Radiation Therapy Oncology Group (RTOG) 9104.  Int J Radiat Oncol Biol Phys. 1997;  39 571-574
    CrossrefPubMedGoogle Scholar
  • 17 Komarnicky L T, Phillips T L, Martz K et al.. A randomized phase III protocol for the evaluation of misonidazole combined with radiation in the treatment of patients with brain metastases (RTOG-7916).  Int J Radiat Oncol Biol Phys. 1991;  20 53-58
    PubMedGoogle Scholar
  • 18 Phillips T L, Scott C B, Leibel S A et al.. Results of a randomized comparison of radiotherapy and bromodeoxyuridine with radiotherapy alone for brain metastases: report of RTOG trial 89-05.  Int J Radiat Oncol Biol Phys. 1995;  33 339-348
    CrossrefPubMedGoogle Scholar
  • 19 Borgelt B, Gelber R, Larson M et al.. Ultra-rapid high dose irradiation schedules for the palliation of brain metastases: final results of the first two studies by the Radiation Therapy Oncology Group.  Int J Radiat Oncol Biol Phys. 1981;  7 1633-1638
    PubMedGoogle Scholar
  • 20 Patchell R A, Tibbs P A, Walsh J W et al.. A randomized trial of surgery in the treatment of single metastases to the brain.  N Engl J Med. 1990;  322 494-500
    CrossrefPubMedGoogle Scholar
  • 21 Noordijk E M, Vecht C J, Haaxma-Reiche H et al.. The choice of treatment of single brain metastasis should be based on extracranial tumor activity and age.  Int J Radiat Oncol Biol Phys. 1994;  29 711-717
    CrossrefPubMedGoogle Scholar
  • 22 Patchell R A, Tibbs P A, Regine W F et al.. Postoperative radiotherapy in the treatment of single brain metastases to the brain.  JAMA. 1998;  280 1485-1489
    CrossrefPubMedGoogle Scholar
  • 23 Andrews D W, Scott C B, Sperduto P W et al.. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomized trial.  Lancet. 2004;  363 1665-1672
    PubMedGoogle Scholar
  • 24 Mehta M P, Tsao M N, Whelan T J et al.. The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases.  Int J Radiat Oncol Biol Phys. 2005;  63 37-46
    CrossrefPubMedGoogle Scholar
  • 25 Kondziolka D, Patel A, Lunsford L D et al.. Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases.  Int J Radiat Oncol Biol Phys. 1999;  45 427-434
    PubMedGoogle Scholar
  • 26 Aoyama H, Shirato H, Tago M et al.. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial.  JAMA. 2006;  295 2483-2491
    CrossrefPubMedGoogle Scholar
  • 27 Mehta M P, Rodrigus P, Terhaard C H et al.. Survival and neurologic outcomes in a randomized trial of motexafin gadolinium and whole-brain radiation therapy in brain metastases.  J Clin Oncol. 2003;  21 2529-2536
    CrossrefPubMedGoogle Scholar
  • 28 Mehta M P, Gervais R, Chabot P et al.. Motexafin gadolinium (MGd) combined with prompt whole brain radiation therapy prolongs time to neurologic progression in non-small cell lung cancer (NSCLC) patients with brain metastases: results of a phase III trial [abstract].  J Clin Oncol. 2006;  24 367s
    PubMedGoogle Scholar
  • 29 Stea B, Suh J, Shaw E et al.. Efaproxiral (Efaproxyn) as an adjunct to whole brain radiation therapy for the treatment of brain metastases originating from breast cancer: Updated survival results of the randomized REACH (RT-009) study. Presented at the San Antonio Breast Cancer Symposium San Antonio, TX; December 8-11, 2004 (Abstract 4064)
    Google Scholar
  • 30 Antonadou D, Paraskevaidis M, Sarris G et al.. Phase II randomized trial of temozolomide and concurrent radiotherapy in patients with brain metastases.  J Clin Oncol. 2002;  20 3644-3650
    CrossrefPubMedGoogle Scholar
  • 31 Verger E, Gil M, Yaya R et al.. Temozolomide and concomitant whole brain radiotherapy in patients with brain metastases: a phase II randomized trial.  Int J Radiat Oncol Biol Phys. 2005;  61 185-191
    CrossrefPubMedGoogle Scholar
  • 32 Rades D, Stalpers L J, Veninga T et al.. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression.  J Clin Oncol. 2005;  23 3366-3375
    CrossrefPubMedGoogle Scholar
  • 33 Patchell R A, Tibbs P A, Regine W F et al.. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial.  Lancet. 2005;  366 643-648
    CrossrefPubMedGoogle Scholar
  • 34 Prasad D, Schiff D. Malignant spinal-cord compression.  Lancet Oncol. 2005;  6 15-24
    PubMedGoogle Scholar
  • 35 Loblaw D A, Laperriere N J, Mackillop W J. A population-based study of malignant spinal cord compression in Ontario.  Clin Oncol (R Coll Radiol). 2003;  15 211-217
    CrossrefPubMedGoogle Scholar
  • 36 Loblaw D A, Perry J, Chambers A et al.. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the cancer care Ontario practice guidelines initiative's neuro-oncology disease site group.  J Clin Oncol. 2005;  23 2028-2037
    CrossrefPubMedGoogle Scholar
  • 37 Talcott J A, Stomper P C, Drislane F W et al.. Assessing suspected spinal cord compression: a multidisciplinary outcome analyses of 342 episodes.  Support Care Cancer. 1999;  7 31-38
    CrossrefPubMedGoogle Scholar
  • 38 Young R F, Post E M, King G A. Treatment of spinal epidural metastases: randomized prospective comparison of laminectomy and radiotherapy.  J Neurosurg. 1980;  53 741-748
    PubMedGoogle Scholar
  • 39 Rades D, Fehlauer F, Schulte R et al.. Prognostic factors for local control and survival after radiotherapy of metastatic spinal cord compression.  J Clin Oncol. 2006;  24 3388-3393
    CrossrefPubMedGoogle Scholar
  • 40 Maranzano E, Latini P, Beneventi S et al.. Comparison of two different radiotherapy schedules for spinal cord compression in prostate cancer.  Tumori. 1998;  84 472-477
    PubMedGoogle Scholar
  • 41 Vassiliou V, Kalogeropoulou C, Christopoulos C et al.. Combination Ibandronate and radiotherapy for the treatment of bone metastases: clinical evaluation and radiologic assessment.  Int J Radiat Oncol Biol Phys. 2007;  67 264-272
    PubMedGoogle Scholar
  • 42 Falkmer U, Jarhult J, Wersall P et al.. A systematic overview of radiation therapy effects in skeletal metastases.  Acta Oncol. 2003;  42 620-633
    CrossrefPubMedGoogle Scholar
  • 43 Coleman R E. Metastatic bone disease: clinical features, pathophysiology and treatment strategies.  Cancer Treat Rev. 2001;  27 165-176
    CrossrefPubMedGoogle Scholar
  • 44 Taube T, Elomaa I, Blomqvist C et al.. Histomorphometric evidence for osteoclast-mediated bone resorption in metastatic breast cancer.  Bone. 1994;  15 161-166
    CrossrefPubMedGoogle Scholar
  • 45 Vakaet L A, Boterberg T. Pain control by ionizing radiation of bone metastasis.  Int J Dev Biol. 2004;  48 599-606
    CrossrefPubMedGoogle Scholar
  • 46 Elomaa I. Use of bisphosphonates in skeletal metastasis.  Acta Oncol. 2000;  39 445-454
    PubMedGoogle Scholar
  • 47 Berenson J R. Recommendations for zoledronic acid treatment of patient with bone metastases.  Oncologist. 2005;  10 52-62
    CrossrefPubMedGoogle Scholar
  • 48 Kachnic L, Berk L. Palliative single-fraction radiation therapy: how much more evidence is needed.  J Natl Cancer Inst. 2005;  97 786-788
    PubMedGoogle Scholar
  • 49 Hartsell W F, Scott C B, Bruner D W et al.. Randomized trial of short- versus long-course radiotherapy for palliation of bone metastases.  J Natl Cancer Inst. 2005;  97 798-804
    PubMedGoogle Scholar
  • 50 Steenland E, Leer J W, van Houwelingen H et al.. The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study.  Radiother Oncol. 1999;  52 101-109
    CrossrefPubMedGoogle Scholar
  • 51 Bone Pain Trial Working Party . 8 Gy in single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up.  Radiother Oncol. 1999;  52 111-121
    CrossrefPubMedGoogle Scholar
  • 52 Poulter C A, Cosmatos D, Rubin P et al.. A report of RTOG 8206: a phase III study of whether the addition of single dose hemibody irradiation to standard fractionated local field irradiation is more effective than local field irradiation alone in the treatment of symptomatic osseous metastases.  Int J Radiat Oncol Biol Phys. 1992;  23 207-214
    PubMedGoogle Scholar

Samir V SejpalM.D. M.P.H. 

Chief Resident, Department of Radiation Oncology, Northwestern University

251 E. Huron Street, L-178, Chicago, IL 60611

eMail: Samir_Sejpal@yahoo.com