Dr. Gutt is a radiation oncologist at the Washington DC VAMC. Dr. Dawson and Dr. Cheuk are radiation oncologists at the James J. Peters VAMC in the Bronx, New York, and assistant professors at Mount Sinai School of Medicine in New York. Dr. Kelly and Dr. Dawson are radiation oncologists at the New Jersey VAHCS in East Orange, New Jersey. Dr. Fosmire is a radiation oncologist at the Richard L. Roudebush VAMC in Indianapolis, Indiana. Dr. Moghanaki is a radiation oncologist at the Hunter Holmes McGuire VAMC and an assistant professor at Virginia Commonwealth University Massey Cancer Center, both in Richmond, Virginia. Dr. Jolly is a radiation oncologist at the VA Ann Arbor HCS in and an associate professor at the University of Michigan, Ann Arbor.
References
In addition to providing pain relief, RT is used in the treatment of impending fractures either, adjuvant after surgical stabilization or alone for lower risk lesions. 19 Factors that impact fracture risk include location of the metastasis (weight-bearing bones, such as femurs, which are at particularly high risk), length of bone involved, and extent of cortical involvement. Mirels’ scoring system was developed to predict fracture risk in patients with bone metastasis, based on 4 criteria: the extent of cortical involvement, the location of the metastasis, the osteolytic vs osteoblastic appearance of the lesion, and the degree of pain. 20 Surgical fixation can be considered, based on the total score and corresponding fracture risk. When appropriate, surgical stabilization should be considered by an orthopedic surgeon prior to initiating RT.
Postoperative RT after surgical stabilization has been associated with a reduced rate of secondary surgical procedures as well as with improved functional status. 21 Radiotherapy promotes remineralization and bone healing and prevents the loss of surgical fixation by treating any residual tumor. A retrospective review of 60 patients with metastatic disease in weight-bearing bones with pathologic fracture or impending pathologic fracture demonstrated that surgery followed by RT was associated with improved functional status as well as with improved overall survival (OS). 22,23 For patients in whom surgery is not indicated, the consulting radiation oncologist should consider factors such as the location of the metastasis in weight-bearing vs nonweight bearing bones, the size and extent of the metastasis, and associated symptoms when making a treatment recommendation. In patients at fracture risk from bone metastases, bisphosphonates should also be considered as part of the treatment regimen. 24
Spinal Cord Compression
About 5% to 10% of patients diagnosed with cancer will develop spinal cord compression during the course of their disease. 25 Spinal cord compression is considered a medical emergency that can result in significant pain and neurologic symptoms, including weakness, paralysis, parasthesias, and incontinence. Early treatment of spinal cord compression can prevent onset or progression of these symptoms; furthermore, early treatment prior to loss of ambulation is associated with improved long-term ambulatory function. 26,27
Treatment decisions for spinal metastases with an associated concern for cord compression should be made after a consultation with both a neurosurgeon and a radiation oncologist. Early initiation of steroids is recommended to aid in tumor shrinkage for potential symptom relief. 28 A standard way to administer dexamethasone is with a 10-mg loading dose followed by 16 mg per day, divided into 4 doses of 4 mg. Higher steroid doses showed no benefit in a prospective randomized trial comparing 96 mg with 16 mg of dexamethasone daily. 29
Surgical decompression should be considered initial management of spinal cord compression. For patients treated surgically, local RT is indicated postoperatively as well. Randomized data show that surgery followed by RT provides better ambulatory function than does RT alone in patients with paralysis of < 2 days’ duration. 30 Some patients with metastatic disease are not good candidates for surgery due to comorbidities, poor performance status, life expectancy < 3 months, or multilevel spinal involvement.
