Spinal stereotactic radiotherapy for painful spinal metastasis

Conventional external beam radiotherapy is the standard of care for patients with cancer who have localised metastatic bone pain. Pain response is reported as a combination of complete (defined as a pain score of 0 on an 11-point scale of 0–10) and partial (defined as a reduction of ≥2 points, without an increase in analgesic consumption) responses, in accordance with the International Consensus Pain Response Endpoints to promote consistent reporting in clinical trials. 1 Chow E Hoskin P Mitera G et al. Update of the international consensus on palliative radiotherapy endpoints for future clinical trials in bone metastases. Int J Radiat Oncol Biol Phys. 2012; 82: 1730-1737 Summary Full Text Full Text PDF PubMed Scopus (225) Google Scholar Pooled data from almost 30 randomised trials show that 65% of patients treated with conventional external beam radiotherapy had an overall response for pain (ie, a partial or complete response) and 25% had a complete response for pain. 2 Rich SE Chow R Raman S et al. Update of the systematic review of palliative radiation therapy fractionation for bone metastases. Radiother Oncol. 2018; 126: 547-557 Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar This review 2 Rich SE Chow R Raman S et al. Update of the systematic review of palliative radiation therapy fractionation for bone metastases. Radiother Oncol. 2018; 126: 547-557 Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar also showed that dose escalation with multiple fractions of conventional external beam radiotherapy did not increase the complete response rate for pain. Therefore, a dose of 8 Gy in a single fraction is considered the gold standard for treating painful bone metastases. With the aim of further improving response rates for pain, stereotactic body radiotherapy, which enables the delivery of high doses of radiation with high precision, has been studied over the past 15 years in patients with bone metastases. Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2/3 trialStereotactic body radiotherapy at a dose of 24 Gy in two daily fractions was superior to conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions in improving the complete response rate for pain. These results suggest that use of conformal, image-guided, stereotactically dose-escalated radiotherapy is appropriate in the palliative setting for symptom control for selected patients with painful spinal metastases, and an increased awareness of the need for specialised and multidisciplinary involvement in the delivery of end-of-life care is needed. Full-Text PDF