Bone mets question

[samysmiley]

I admit this is a a dumb question that I should have the answer to, but I cannot find it online. My chairman came to QA conference for the first time in a while and asked this.

Let's say you have a patient with a bone met in his R femur. Its not painful, it's lytic, and it's eating up about 40% of the cortex. This person is an extremely active runner. How long after RT can he resume his running?

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[XRT_doc]

I admit this is a a dumb question that I should have the answer to, but I cannot find it online. My chairman came to QA conference for the first time in a while and asked this.

Let's say you have a patient with a bone met in his R femur. Its not painful, it's lytic, and it's eating up about 40% of the cortex. This person is an extremely active runner. How long after RT can he resume his running?

3 months, stop if it's hurting again

 

[Palex80]

I'd check with imaging before recommending to run again. If you see recalcification, you can interpret it as increased stability.
But you need to wait usually 3 months to see any kind of recalcification.

On a side note:
Have you considered operative treatment followed by RT? The patient seems to have a good PS and with 40% of the femur gone one could argue for a femur intremedullary nail with postoperative RT. Morbidity is minimal and stability greatly improved.

 

[Damn_Daniel]

Rod might be a good idea, but significant rehab involved.

It's reasonable to treat, but do most people treat painless bone mets? What's the indication? What's the endpoint? I'll occasionally do it when asked by the referring, but with obscenities under my breath,

 

[seper]

I treat painless mets in weight-bearing bones when cortical bone is eroded. Goal is decreased fracture risk. As someone pointed out here, there are no data to support this?

 

[Damn_Daniel]

Hmm. If it's not for pain, and it's for decreased fracture risk, do you not use single fraction?

 

[medgator]

Hmm. If it's not for pain, and it's for decreased fracture risk, do you not use single fraction?

https://www.astro.org/uploadedFiles...es/ASTRO_bone_mets_guideline_full_version.pdf

What is it with you and the hardcore hypofractionation?

 

[Damn_Daniel]

HAHAHAHAHAHAHA!!!

Have you actually read the paper you sent? Have you looked at the questions they've addressed? It's about "painful" bone mets. "Painful" = causing pain. This case = "no pain". No answers on painless bone metastases in weight bearing joints. I'm just curious about bone remodeling. It would make more sense to fractionate, like 30 Gy in 10fx, because there is no pain component. But, I don't know if that's true. Let me guess. Next week you'll put this same paper up.

 

[seper]

Yes, I almost always use 800 X 1 for lytic painless lesions of weight-bearing bones.

 

[medgator]

HAHAHAHAHAHAHA!!!

Have you actually read the paper you sent? Have you looked at the questions they've addressed? It's about "painful" bone mets. "Painful" = causing pain. This case = "no pain". No answers on painless bone metastases in weight bearing joints. I'm just curious about bone remodeling. It would make more sense to fractionate, like 30 Gy in 10fx, because there is no pain component. But, I don't know if that's true. Let me guess. Next week you'll put this same paper up.

And you'll probably still fail to understand it (Hint: check out paragraph 1, page 14).

 

[Damn_Daniel]

Oh my goodness. The reference regarding femoral cortical involvement is from that Green Journal article that looked at the Dutch Study (two things I hate: cultural intolerance and the Dutch).

What they are saying is for PAINFUL lesions with <3cm cortical involvement, do a single fraction, for PAIN relief. For PAINFUL lesions >3cm, put a rod in it, that is probably most effective. And if their condition is limited (doubtful in a person who is a RUNNER! and wants to RUN! after treatment), then you can consider a longer treatment schedule for PAIN relief. But here is the kicker, for those that read .... the study said when you look at the level of cortical involvement, then the radiation treatment schedule was NOT predictive of fracture. You gotta actually read the references. It's really important. Keep in mind that all references from that section refer to PAINFUL metastases. The quirky finding that patients treated with a single fraction seemed to have a higher fracture rates - that was just due to more patients with >3cm cortical involvement.

Study you are referencing.

 

[scarbrtj]

Seems like this is a real "physics" question. That is, we need to know the physical structure of his bone, make an estimate of its load-bearing potential, then we would need the weight of the runner and calculate the impact forces transmitted up through his femur as he runs. There are computer programs which can simulate these forces based on the biometrics of the runner. If those impact forces outweigh the estimated load-bearing force his 60%-remaining-cortex femur can handle, he shouldn't run. If those forces are 50%-100% of calculated, I'd still say: no running. If the forces are <50% calculated, run with caution. Less than 25%, run away! So in many ways the answer to this question will be different from person to person (will depend of size and strength of bone, how much the person weighs, the particular gravitational field present depending on where on Earth they are, etc.).

 

[Damn_Daniel]

Truly is, but where are your measurements and assessments coming from? Or is this, like Keynesian economics, rampant speculation?

Seems like this is a real "physics" question. That is, we need to know the physical structure of his bone, make an estimate of its load-bearing potential, then we would need the weight of the runner and calculate the impact forces transmitted up through his femur as he runs. There are computer programs which can simulate these forces based on the biometrics of the runner. If those impact forces outweigh the estimated load-bearing force his 60%-remaining-cortex femur can handle, he shouldn't run. If those forces are 50%-100% of calculated, I'd still say: no running. If the forces are <50% calculated, run with caution. Less than 25%, run away! So in many ways the answer to this question will be different from person to person (will depend of size and strength of bone, how much the person weighs, the particular gravitational field present depending on where on Earth they are, etc.).