Bone met re-treatment

[Grubbe-a-dub-dub]

Single fx for painful bone mets is awesome and will be my go-to regimen of choice, pandemic or not.

After a single fraction of 8 Gy for noncomplicated bone or spine metastasis, what dose are you using for re-treatment for areas that did not respond? How long is a good enough time to wait for max pain benefit before retreating?

For many areas, I simply repeat the 8 Gy, but I am wary in the spine to avoid overdosing the cord or equina.

I've seen this discussed elsewhere like the mednet and I see it draws many opinions and sparks a good deal of conversation.

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[RadOncDoc21]

As a palliative care expert (I am not), I always switch my regimen. If I did 30 Gy/10, I may just do 8 Gy in one. Vice versa, but also depends on time out, etc. I guess you could still give 8 Gy in one, but I like to try new things if I see something didn’t work.

 

[ramsesthenice]

As a palliative care expert (I am not), I always switch my regimen. If I did 30 Gy/10, I may just do 8 Gy in one. Vice versa, but also depends on time out, etc. I guess you could still give 8 Gy in one, but I like to try new things if I see something didn’t work.

Are you trying to kill someone? MR guided pencil beam proton radiosurgery is the only safe way of treating in this situation.

In all seriousness, I totally agree. If whatever I did the first time didn't give a gratifying response I typically change it up. But if you got a nice response and its been a good while (6+ months) 8 x 1 is absolutely fine, even on the cord.

 

[RADONC4285]

It depends on how fast the symptoms returned. If 8 Gy x 1 provided good relief for a good while, then repeating the same thing makes sense. If symptoms returned fast, then makes sense to change fractionation, like the colleague above stated. As far as cord dose goes, it's usually safe to make sure you're under TG101 recommendations for the number of fractions you're doing if it's 5 fx or less combined (assuming no dose forgiveness). can go a bit higher if it's been a while between fractions.

 

[scarbrtj]

Single fx for painful bone mets is awesome and will be my go-to regimen of choice, pandemic or not.

After a single fraction of 8 Gy for noncomplicated bone or spine metastasis, what dose are you using for re-treatment for areas that did not respond? How long is a good enough time to wait for max pain benefit before retreating?

For many areas, I simply repeat the 8 Gy, but I am wary in the spine to avoid overdosing the cord or equina.

I've seen this discussed elsewhere like the mednet and I see it draws many opinions and sparks a good deal of conversation.

Equina is aka "peripheral nervous system"; thus I would (and do) retreat 30/10 any bony site or L3 or lower after single 8 Gy as soon as 2 weeks later if the patient is still in significant pain. Re: 8 Gy once and 8 Gy again to the spine, there's data from using 8.5 Gy once to the spine, and then another 8.5 Gy to the same portion of spine one week later, with zero adverse spinal cord events noted. Thus 8 Gy times two to the spinal cord is very, very safe. If I were retreating in non-equina, cord proper (c-spine e.g.) I would be OK with 21 Gy in 7 fractions as a retreat (after 8 Gy) putting you at about the equivalent of 45 Gy/25 fx at a/b=3* for 8 Gy/1 fx & 21 Gy/7 fx. (I suppose one could argue we should be leaning toward higher SBRTish doses for spine mets now for most pts?)

* I know some people like a/b= 2

 

[RickyScott]

As a palliative care expert (I am not), I always switch my regimen. If I did 30 Gy/10, I may just do 8 Gy in one. Vice versa, but also depends on time out, etc. I guess you could still give 8 Gy in one, but I like to try new things if I see something didn’t work.

Totally agree.

 

[mavrik13]

This has been studied in a RCT, and 8/1 is non-inferior to 20/5 for reirradiation. Some caveats (like most RCTs done in the palliative setting), but I would have no reservation with repeat 8/1.

Single versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial - PubMed

Canadian Cancer Society Research Institute, US National Cancer Institute, Cancer Council Australia, Royal Adelaide Hospital, Dutch Cancer Society, and Assistance Publique-Hôpitaux de Paris.

pubmed.ncbi.nlm.nih.gov

 

[StIGMA]

SBRT (whichever your preferred dose/fractionation) is another good option in this setting.

 

[FrostyHammer]

I'm only a semi believer in SBRT for painful mets (for many reasons) but if there's anyone I'd consider it in, it would be these types of cases.

 

[Palex80]

SBRT (whichever your preferred dose/fractionation) is another good option in this setting.

Actually SBRT is the superior retreatment option in patients failing classic palliative RT. This has been shown in many retrospective series.
I consider repeat RT in the form of SBRT as the treatment of choice in all patients which still have several months/years to live and are failing in previously irradiated bone mets.
I've seen often the problem that the second course was also standard EBRT, like 1 x 8 Gy or 10 x 3 Gy and down the road the necessity arose to reirradiate again. And that's when things get tricky...

 

[RadOncDoc21]

Actually SBRT is the superior retreatment option in patients failing classic palliative RT. This has been shown in many retrospective series.
I consider repeat RT in the form of SBRT as the treatment of choice in all patients which still have several months/years to live and are failing in previously irradiated bone mets.
I've seen often the problem that the second course was also standard EBRT, like 1 x 8 Gy or 10 x 3 Gy and down the road the necessity arose to reirradiate again. And that's when things get tricky...

Anecdotally I never had to re-irradiate 3 times but i guess I would consider SBRT now as another option. This is why Stanford pays attendings fellowship wages to learn how to treat bone mets.

 

[MersiHadzi]

Agree with above. Wanted to share what’s on the front page of latest OT ... IR increasingly wants front-line access to patients with bone mets.

 

[medgator]

Agree with above. Wanted to share what’s on the front page of latest OT ... IR increasingly wants front-line access to patients with bone mets.

Just like they want to get first crack at the early stage lung pts first. RFA probably as ineffective for bone mets as it is for RFA compared to SBRT/radiation in early stage lung

 

[scarbrtj]

Agree with above. Wanted to share what’s on the front page of latest OT ... IR increasingly wants front-line access to patients with bone mets.

Another way of saying that another specialty wants to cut in on the #4 indication for radiotherapy in America. Does rad onc have any active explorations underway into cutting in on any other specialties' top indications/procedures? Anyone? Bueller?

 

[medgator]

Another way of saying that another specialty wants to cut in on the #4 indication for radiotherapy in America. Does rad onc have any active explorations underway into cutting in on any other specialties' top indications/procedures? Anyone? Bueller?

SBRT in early stage lung? It's pretty much equivalent to surgery in Japan afaik.

Hasn't SRS/SRT already cut into the craniotomy business for awhile now?

Pretty sure aggressive rad oncs somewhere are probably cutting into TACE/RFA for liver mets/HCC via SBRT as well

 

[FrostyHammer]

Another way of saying that another specialty wants to cut in on the #4 indication for radiotherapy in America. Does rad onc have any active explorations underway into cutting in on any other specialties' top indications/procedures? Anyone? Bueller?

I think everyone knows that SBRT for operable early stage NSCLC is the clearest and most promising example...it's only a matter of time before we win that war, unless you ask the bitterly pessimistic radoncs.

 

[Lamount]

In this trial comparing palliative TRT regimens for primary control in incurable NSCLC, 8.5 Gy x 2 had a fairly low incidence of spinal cord toxicity. 2/143 got transient Lhermitte’s sign and no myelopathy (in that arm). RT was prescribed AP/PA mid plain. Fractions were one week apart. They limited spinal cord treatment to 12 cm and gave prednisone. Who knows what the spine hotspots were

this would lead me to believe repeating 8 Gy x1 is probably safe.

 

[ramsesthenice]

I'm only a semi believer in SBRT for painful mets (for many reasons) but if there's anyone I'd consider it in, it would be these types of cases.

I think it’s fine to do, but I have not been particularly wowed with the results. Need more time to draw a final conclusion, but anecdotally results seem really similar to conventional IMO.

 

[FrostyHammer]

I think it’s fine to do, but I have not been particularly wowed with the results. Need more time to draw a final conclusion, but anecdotally results seem really similar to conventional IMO.

Agree - one can find randomized data for both efficacy and lack thereof. Not sure what to think, likely relates to the particular endpoint in the trial and measuring thereof

 

[Ray D. Ayshun]

If you give 8/1 retreatment and it doesn't work, then you'll wonder if more RT might help. If you SBRT it on retreatment, the answer to that question is no. The rub, I suppose, is wondering if SBRT is worth the increased risk of the RT causing the pain.

 

[radOresident]

have you considered having the patient sent to a referral hub with a Metastatic Disease Site Specialist for this complex clinical scenario?

 

[Krukenberg]

Just like they want to get first crack at the early stage lung pts first. RFA probably as ineffective for bone mets as it is for RFA compared to SBRT/radiation in early stage lung

At our institution, They are really aggressive with doing cryoablation for bone mets when they are able to get their hands on a metastatic patient through a liver or adrenal met referral. No oncologic training though—we had a shared patient on death’s doorstep who was going under for this invasive procedure. Would’ve been much better off with 8gy x1 but my attending didn’t want to piss the IR off. For that instance I agree with her that 8gy x1 isn’t worth the trouble, but I worry about it becoming a pattern.

 

[medgator]

At our institution, They are really aggressive with doing cryoablation for bone mets when they are able to get their hands on a metastatic patient through a liver or adrenal met referral. No oncologic training though—we had a shared patient on death’s doorstep who was going under for this invasive procedure. Would’ve been much better off with 8gy x1 but my attending didn’t want to piss the IR off. For that instance I agree with her that 8gy x1 isn’t worth the trouble, but I worry about it becoming a pattern.

IR doesn't refer to rad Onc typically so not sure why the worry. They have training more akin to gen surg/procedural, no real oncology training at all.

IRL, i stopped sending my lung biopsies to the unscrupulous IRs in town once we got wind that they were offering them RFA after doing the biopsy without consulting with pulm, CT surg etc

 

[Palex80]

Anecdotally I never had to re-irradiate 3 times but i guess I would consider SBRT now as another option. This is why Stanford pays attendings fellowship wages to learn how to treat bone mets.

Here's a case. Patient with prostate cancer, several bone metastases.

I had to treat his sternum repeatedly in the past decade.

2013 treated with 10 x 3 Gy

2016 came back with pain, got 8 x 3.5 Gy (note that he was treated for gynecomastia due to ADT in 2014 -->treated volumes contoured to avoid overlap of beams)

2018 isoloated progression in the cranial part of the sternum (manubrium) while on enzalutamide, received 8 x 3.5 Gy with partial overlap to the previous treatment volumes of the sternum (also note the previously treated volumes at the spine (2x) and shoulders).

2020 progression at the distal part of the sternum, had to be retreated due to pain with 6 x 4 Gy

The skin is rather dark after all these treatment courses and with patches of telengiectasia.
Apart from that, nothing noted on the CT scans in terms of lung toxicity. Heart is in good shape too.
He is now on the 7th line of systemic treatment and running out of options.
Cumulative dose at small parts of the sternum is beyond 110 Gy delivered at 3-4 Gy per day over 7 years.

Certainly a lot easier to retreat the sternum than the spine, but necessity to reirradiate bone mets is a fact in patients surviving many years with stage IV disease (this particular patient is now 9 years at stage IV prostate cancer and 20 sites treated).

 

[scarbrtj]

Here's a case. Patient with prostate cancer, several bone metastases.

I had to treat his sternum repeatedly in the past decade.

2013 treated with 10 x 3 Gy
View attachment 330144

2016 came back with pain, got 8 x 3.5 Gy (note that he was treated for gynecomastia due to ADT in 2014 -->treated volumes contoured to avoid overlap of beams)
View attachment 330145

2018 isoloated progression in the cranial part of the sternum (manubrium) while on enzalutamide, received 8 x 3.5 Gy with partial overlap to the previous treatment volumes of the sternum (also note the previously treated volumes at the spine (2x) and shoulders).
View attachment 330146

2020 progression at the distal part of the sternum, had to be retreated due to pain with 6 x 4 Gy
View attachment 330147

The skin is rather dark after all these treatment courses and with patches of telengiectasia.
Apart from that, nothing noted on the CT scans in terms of lung toxicity. Heart is in good shape too.
He is now on the 7th line of systemic treatment and running out of options.
Cumulative dose at small parts of the sternum is beyond 110 Gy delivered at 3-4 Gy per day over 7 years.

Certainly a lot easier to retreat the sternum than the spine, but necessity to reirradiate bone mets is a fact in patients surviving many years with stage IV disease (this particular patient is now 9 years at stage IV prostate cancer and 20 sites treated).

Yowsa! Thanks for sharing. He needs a Medalert bracelet saying "NO PRECORDIAL THUMPS PLEASE."

 

[Ray D. Ayshun]

I like my grilled cheese with 4 slices

 

[Lamount]

Here's a case. Patient with prostate cancer, several bone metastases.

I had to treat his sternum repeatedly in the past decade.

2013 treated with 10 x 3 Gy
View attachment 330144

2016 came back with pain, got 8 x 3.5 Gy (note that he was treated for gynecomastia due to ADT in 2014 -->treated volumes contoured to avoid overlap of beams)
View attachment 330145

2018 isoloated progression in the cranial part of the sternum (manubrium) while on enzalutamide, received 8 x 3.5 Gy with partial overlap to the previous treatment volumes of the sternum (also note the previously treated volumes at the spine (2x) and shoulders).
View attachment 330146

2020 progression at the distal part of the sternum, had to be retreated due to pain with 6 x 4 Gy
View attachment 330147

The skin is rather dark after all these treatment courses and with patches of telengiectasia.
Apart from that, nothing noted on the CT scans in terms of lung toxicity. Heart is in good shape too.
He is now on the 7th line of systemic treatment and running out of options.
Cumulative dose at small parts of the sternum is beyond 110 Gy delivered at 3-4 Gy per day over 7 years.

Certainly a lot easier to retreat the sternum than the spine, but necessity to reirradiate bone mets is a fact in patients surviving many years with stage IV disease (this particular patient is now 9 years at stage IV prostate cancer and 20 sites treated).

I would just keep him away from that guy in Indian Jones 2

 

[elementaryschooleconomics]

Yowsa! Thanks for sharing. He needs a Medalert bracelet saying "NO PRECORDIAL THUMPS PLEASE."

 

[ramsesthenice]

I would just keep him away from that guy in Indian Jones 2

Might make it easier to survive "birthing" an alien?

Re Cryo: oncology has been our best friend in regards to this. A couple years ago IR started trying to creep into the bone mets business at our center. Bottom line, most of our oncologists believe RT plays an important role in metastatic patients (probably more than they should based on clinical data alone at this point truth be told...but we won't do too much truth telling just yet 🙂 ) and they more or less shut it down. I can't remember the last time IR suggested trying to cryo anything outside of the liver.

 

[medgator]

Might make it easier to survive "birthing" an alien?

Re Cryo: oncology has been our best friend in regards to this. A couple years ago IR started trying to creep into the bone mets business at our center. Bottom line, most of our oncologists believe RT plays an important role in metastatic patients (probably more than they should based on clinical data alone at this point truth be told...but we won't do too much truth telling just yet 🙂 ) and they more or less shut it down. I can't remember the last time IR suggested trying to cryo anything outside of the liver.

Some of the med oncs near me have gotten annoyed with the IRs over TACEing/Y90ingn liver mets in pts too

 

[Palex80]

Some of the med oncs near me have gotten annoyed with the IRs over TACEing/Y90ingn liver mets in pts too

I'm perfectly fine with criticizing interventional radiologists for pushing techniques like RFA for T1 NSCLC without well documented evidence in trials. However, I also have to recognize that out IR colleagues have managed to conduct randomized trials in liver interventions, consolidating the role of their treatment modalities. We (the radiation oncologists) have not been that eager unfortunately and most of the data we base our practice on are phase-II single arm trials.
We definetely need to work on that better.

 

[ramsesthenice]

I'm perfectly fine with criticizing interventional radiologists for pushing techniques like RFA for T1 NSCLC without well documented evidence in trials. However, I also have to recognize that out IR colleagues have managed to conduct randomized trials in liver interventions, consolidating the role of their treatment modalities. We (the radiation oncologists) have not been that eager unfortunately and most of the data we base our practice on are phase-II single arm trials.
We definetely need to work on that better.

No question and its something that many of of us have harped on many times here.

Some of the med oncs near me have gotten annoyed with the IRs over TACEing/Y90ingn liver mets in pts too

Sounds like someone needs a refresher on the difference between arterial and venous blood supplies between HCCs and Mets and why TACE is a good idea for one but not the other. At our center this would never happen but we are a pretty busy transplant center. Our oncologists and surgeons (appropriately) consider resection the treatment of choice for most liver tumors and even when it is obvious we almost certainly will not be pursuing surgery virtually all cases are discussed at our HPB tumor board. Liver malignancies deserve a lot more discussion than they usually get. There are lots of options and when you have a room full of thoughtful people that actually understand and acknowledge the strengths and limitations of each you can have some pretty interesting discussions.

 

[IRattending2021]

No question and its something that many of of us have harped on many times here.



Sounds like someone needs a refresher on the difference between arterial and venous blood supplies between HCCs and Mets and why TACE is a good idea for one but not the other. At our center this would never happen but we are a pretty busy transplant center. Our oncologists and surgeons (appropriately) consider resection the treatment of choice for most liver tumors and even when it is obvious we almost certainly will not be pursuing surgery virtually all cases are discussed at our HPB tumor board. Liver malignancies deserve a lot more discussion than they usually get. There are lots of options and when you have a room full of thoughtful people that actually understand and acknowledge the strengths and limitations of each you can have some pretty interesting discussions.

Agreed. At where I am I would do fiducial markers for SBRT in patients who are not great locoregional therapy candidates and I TACED a lesion that was sent to me by a radonc.

it can work.