Palliative RT for lytic secondary bone lesions

[Kroll2013]

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Is there an indication to do palliative Rt for secondary lytic bone lesion , with no pain but with a risk of fracture ? So the aim would be reducing risk of fx instead od treating pain symptoms?

 

[Gfunk6]

No. Radiation does not change the mechanics of a fracture. However, could consider surgical fixation followed by post-op XRT if warranted.

 

[radoncmonkey]

No. Radiation does not change the mechanics of a fracture. However, could consider surgical fixation followed by post-op XRT if warranted.

But we treat multiple myeloma all the time for palliation..and that's typically lytic lesions..?

 

[Gfunk6]

We treat frequently for multiple myeloma but the purpose of treatment is palliation of pain. If the patient is at high risk for fracture then prophylactic fixation needs to be considered. Use Mirel's score to determine risk of fracture: https://en.wikipedia.org/wiki/Mirel's_score

 

[seper]

I would disagree with a blanket statement like that. IMO, standard practice breakdown is as follows: >50% of cortical bone width erosion --> surgery; <50% --> XRT. The latter applies to painless lesions in weight-bearing bones.

No. Radiation does not change the mechanics of a fracture. However, could consider surgical fixation followed by post-op XRT if warranted.

 

[Treat]

I would disagree with a blanket statement like that. IMO, standard practice breakdown is as follows: >50% of cortical bone width erosion --> surgery; <50% --> XRT. The latter applies to painless lesions in weight-bearing bones.

May I know the rationale for treating a painless lesion with <50% erosion?
I actually agree with Gfunk - As far as I understand, XRT does not restore stability/decrease fracture risk.
If so, and if there is no pain, what is the benefit of XRT?

 

[Palex80]

There is no randomized evidence showing that XRT will result in less fractures. However we do have randomized evidence showing that fractionated RT leads to enhanced bone mineralisation in bones with osteolytic metastasis. And at least some of the retrospective studies show decreased rates of bone fracture with fractionated RT in comparison to single shot RT.
For example:
https://www.ncbi.nlm.nih.gov/pubmed/10577695

So it's not a very far fetched assumption that fractionated RT will increase bone remineralisation and result in less bone fractures in contrast to not irradiating at all.

In my practice we often irradiate painless bone mets, which seem in danger of fracturating.
You cannot surgically fix everything, for example lytic lesions in the sacrum or pelvis (not femural heads) are not candidates for prophylactic surgery.
Patients with such an indication are generally treated with 5 x 4 Gy or 10 x 3 Gy.

 

[medgator]

I would disagree with a blanket statement like that. IMO, standard practice breakdown is as follows: >50% of cortical bone width erosion --> surgery; <50% --> XRT. The latter applies to painless lesions in weight-bearing bones.

Yup, if the mirel score is high and ortho says no, I'll treat with XRT anyways. A met will eventually re-mineralize once the cancer is treated with XRT

 

[napoleondynamite]

Great discussion guys! I learned from both sides of the argument here.

 

[OTN]

We have an orthopedic oncologist in our practice (a GREAT asset, actually) who is pretty well-known, having come from a very large and well-known academic center prior to joining our group. For lytic lesions posing a fracture risk, he usually has us irradiate (30 in 10 usually) and follows up with surgical stabilization afterwards.

 

[Palex80]

Another option are interventional radiology procedures. CT guided vertebroplasty is a good indication for several cases, has its boundaries however too.

 

[Cancerdancer]

May I know the rationale for treating a painless lesion with <50% erosion?
I actually agree with Gfunk - As far as I understand, XRT does not restore stability/decrease fracture risk.
If so, and if there is no pain, what is the benefit of XRT?

If you believe a painless lesion with >50% erosion warrants fixation, then it's pretty clear why you would treat a lesion with <50% erosion...to prevent it from becoming more than 50% erosive. Do this all the time for femur lesions that are concerning when I'm radiating other bone mets. You don't go chasing these patients down or get referrals for them, but a lesion has to grow to get to the point of being a threat for fracture, and you can halt/slow that progression. It doesn't need to remineralize, it just needs to not progress...

 

[Treat]

If you believe a painless lesion with >50% erosion warrants fixation, then it's pretty clear why you would treat a lesion with <50% erosion...to prevent it from becoming more than 50% erosive. Do this all the time for femur lesions that are concerning when I'm radiating other bone mets. You don't go chasing these patients down or get referrals for them, but a lesion has to grow to get to the point of being a threat for fracture, and you can halt/slow that progression. It doesn't need to remineralize, it just needs to not progress...

I guess it depends on whether the patient is going to receive systemic treatment, and if RT will delay that. If the patient needs RT to another site anyway, I would accept your argument.

Anyway, can any kind soul provide a link to the evidence for RT resulting in remineralization?

As for the Dutch bone mets trial that Palex quoted, i'm just not sure the conclusion can be drawn that RT results in less fractures?

 

[Mandelin Rain]

Do we evidence for everything?

I can tell you prima facie that a bone with a treated met stands a better chance of remineralizing than one harboring an untreated, actively growing met.

Nonetheless... http://www.ncbi.nlm.nih.gov/pubmed/10554645

I agree that if I see a patient for just about any reason and notice a moderate sized femoral met, I'm more likely than not to treat it even if it doesn't hurt. What's the downside? The up side is potentially preventing a devastating hip fracture that spells curtains for a patient's QOL and often kills them.

 

[medgator]

Do we evidence for everything?

I can tell you prima facie that a bone with a treated met stands a better chance of remineralizing than one harboring an untreated, actively growing met.

Nonetheless... http://www.ncbi.nlm.nih.gov/pubmed/10554645

I agree that if I see a patient for just about any reason and notice a moderate sized femoral met, I'm more likely than not to treat it even if it doesn't hurt. What's the downside? The up side is potentially preventing a devastating hip fracture that spells curtains for a patient's QOL and often kills them.

Agreed.

I think all of us know what happens to OS in a bed-ridden patient. Just look at the Patchell cord compression study data in terms of how lack of ambulatory function affected the OS outcomes between the surgery vs no surgery arms.

 

[seper]

nice find, thanks

"Nonetheless... http://www.ncbi.nlm.nih.gov/pubmed/10554645"