J Comput Assist Tomogr 1994 Nov-Dec ;18(6)
OBJECTIVE : Percutaneous injection of ethanol was evaluated in terminally ill cancer patients with painful osteolytic bone metastases treated previously without success by radiation or chemotherapy and conventional pain therapy. METHODS AND MATERIALS : Twenty-five patients with 27 bone metastases in various locations underwent one to three instillations of 3-25 ml ethanol (95%) under CT guidance, which allowed precise needle positioning and control of the diffusion of alcohol thus minimizing the complications. RESULTS : Within 24 to 48 h 74% of the cases experienced a reduction of analgesic needs. CONCLUSION : Percutaneous ethanol injection under CT guidance is useful in reducing pain and in improving the quality of life of patients with advanced stages of cancer and painful bone metastases.
Eur J Surg Oncol 1999 Feb ;25(1) :3-23
Bone metastases can present to a number of different specialties and their successful management requires a coordinated approach with good liaison between the specialists. Patients who respond to systemic therapy for their metastases have a good chance of being alive at 3 years, and 20% will be alive at 5 years. This means that it is worth palliating these patients properly. With this in mind, the intention of this document is to try and improve the process of care for women with metastatic bone disease from breast cancer. These guidelines consider all aspects of care from diagnosis to assessment of response to treatment, and describe the Quality Objectives that should be addressed at each stage. The level of available evidence is indicated throughout the document where possible. In considering diagnosis, the guidelines emphasize the value of having a dedicated orthopaedic surgeon specifically linked to each Cancer Unit. The attachment of a dedicated orthopaedic surgeon will ensure that mechanical problems are correctly identified, and that actual or imminent fracture is correctly managed. The latter is particularly important as the management of pathological fractures is not the same as that of traumatic fractures. The orthopaedic surgeon should also act as the liaison between his/her own Unit and the tertiary spinal or neurosurgical centres as necessary. In addition, empowering the radiologist means that the diagnostic process can be accelerated and refined. The place of different investigations in diagnosis, including tumour markers, is discussed. The guidelines emphasize the need for a definitive diagnosis before treatment in the (rare) case of a solitary metastasis. The treatment section discusses orthopaedic management, radiotherapy and systemic treatments (endocrine therapy, chemotherapy and bisphosphonates). The guidelines emphasize the emergency nature of spinal cord compression, describing the need for fast access to assessment and for good liaison between specialists. It is essential that these are available and widely publicized to ensure effective management. The role of radiotherapy in both local pain relief and spinal cord compression is discussed, and various techniques are described. Endocrine therapy and chemotherapy are discussed in relation to the disease-free interval, performance status, extent and site of metastatic disease, and oestrogen receptor status. Specific chemotherapy regimes are not discussed as these are subject to change and local protocols should be followed. The increasing evidence behind the role of bisphosphonates is reviewed. With many unanswered questions about the long-term use of this group of drugs, the guidelines offer a scoring system for deciding which patients might benefit most from long-term bisphosphonate therapy. The guidelines describe the possible ways of assessing response to treatment and the difficulties that may be encountered, including a discussion of the role of tumour markers in assessment of response. A final section looks at palliative care principles in bone pain management, acknowledging the need for continuation of good care throughout the patient's journey, from diagnosis onwards. We very much hope these guidelines will stimulate individuals and institutions to improve the process of delivering care to this group of patients.
Cancer 1997 Oct 15 ;80(8 Suppl) :1628-45
Pain management often is difficult in patients with bone metastases. Metastatic disease represents >40% of oncologic practice, and >70% of patients with metastatic disease have uncontrolled cancer-related pain. Significant morbidity caused by pathologic fracture and spinal cord compression can result from untreated bone metastases. Representing both a manifestation of systemic disease as well as causing localized symptoms, bone metastases require a multidisciplinary therapeutic approach. Radiation therapy provides both localized and systemic treatment options in addition to chemohormonal therapies and surgery. External beam irradiation provides palliation in >70% of patients through tumor regression of a localized lesion. Systemic radiopharmaceuticals treat multifocal disease either alone or as an adjuvant to external beam irradiation. Efficient and comprehensive management of bone metastases is imperative because of the associated symptoms, prior therapies, complex underlying medical problems, and clinical presentations that often require emergent interventions. Intensification of pain may be observed with hormonal therapy and systemic radiopharmaceuticals. Symptomatic relief from antineoplastic therapies generally requires 4-12 weeks and may be related to reossification. Symptoms, occurring due to the disease and/or while awaiting response to therapy, must be aggressively managed. Persistent or recurrent pain after therapy may be due to bony instability or fracture before reossification occurs. An Interdisciplinary Bone Metastases Clinic, with representatives from Diagnostic Radiology, Medical Oncology, Nuclear Medicine, Orthopedic Surgery, Pain and Symptom Management, Physical Medicine and Rehabilitation, and Radiation Oncology, was developed that allows coordinated evaluation, treatment, and symptom management of these complex clinical presentations.
Clin J Pain 1998 Dec ;14(4) :320-3
OBJECTIVE : To evaluate the use of a novel
nonpharmacologic analgesic therapy known as percutaneous electrical nerve
stimulation (PENS) in the management of opioid-resistant cancer pain. DESIGN
: PENS therapy was administered to three cancer patients on three or more
occasion using acupuncturelike needle probes that were stimulated for 30
minutes at frequencies of 4-100 Hz. RESULTS : Two of the three patients
achieved good to excellent pain relief that lasted 24-72 hours after each
treatment session. CONCLUSION : PENS therapy is a useful supplement to
opioid analgesics for the management of pain secondary to bony metastasis
in terminal cancer patients.
The pathophysiology and options for management
of bone metastases as well as criteria for determining response to therapy
are reviewed. Bone metastases are frequently one of the first signs of
disseminated disease in cancer patients. In the majority of patients, the
primary tumor is in the breast, prostate, or lungs. Although almost all
patients will die of their disease, a proportion of the patients will survive
for several years. Treatment is primarily palliative : the intention is
to relieve pain, prevent fractures, maintain activity and mobility, and,
if possible, to prolong survival. Therapeutic options include local
treatment with radiotherapy and/or surgery, and systemic treatment using
chemotherapy, endocrine therapy, radioisotopes, agents such as diphosphonates,
which inhibit resorption of bone, as well as analgesic and antiinflammatory
drugs. The mechanisms by which pain is relieved by several of these therapies
remain unclear but actions beyond a simple tumoricidal effect appear to
be important. There have been few randomized trials comparing the therapeutic
options, and the criteria for assessing response to therapy have, in general,
been poorly defined. There is a need for rigorous clinical investigations
that assess the efficacy of the various therapeutic possibilities by using
well-defined and validated criteria of response.
Bone metastases are frequently one of the first signs of disseminated disease in cancer patients and are especially seen in patients with breast, prostate and lung cancer. The prognosis of these patients is generally poor and the treatment is primarily palliative : the intention is to relieve pain, prevent fractures, maintain activity and, if possible, to prolong survival. Besides analgesics the therapeutic options include local treatment with radiotherapy and/or surgery, and systemic treatment using chemotherapy, endocrine therapy, radioisotopes as well as bisphosphonates. Social and psychological supportive care is also very important. Radiotherapy plays an important role, but the other modalities such as bisphosphonates may also offer the same level of palliation, but their definite role has not been as clearly defined. There have been few randomized trials comparing the therapeutic options, and the criteria for assessing response to therapy have, in general, been poorly defined. There is a need for rigorous clinical investigations which assess the efficacy of the various therapeutic possibilities by using well-defined and validated response criteria such as pain and quality of life.
Int J Radiat Oncol Biol Phys 1994 Jul 30
PURPOSE : To evaluate the response to reirradiation
of painful bone metastases following initial treatment with radiotherapy.
METHODS AND MATERIALS : A retrospective analysis of 105 consecutive patients
treated with palliative radiotherapy for painful bone metastases. A total
of 280 individual treatment sites were identified, of which 57 were retreated
once and 8 were retreated twice. RESULTS : The overall response rate to
initial treatment was 84% for pain relief, and at first retreatment this
was 87%. Seven of eight patients retreated a second time also achieved
The presence of bone metastases predicts the presence of pain and is the most common cause of cancer-related pain. Although bone metastases do not involve vital organs, they may determine deleterious effects in patients with prolonged survival. Bone fractures, hypercalcaemia, neurologic deficits and reduced activity associated with bone metastases result in an overall compromise in the patient's quality of life. A metastasis is a consequence of a cascade of events including a progressive growth at the primary site, vascularization phase, invasion, detachment, embolization, survival in the circulation, arrest at the site of a metastasis, extravasion, evasion of host defense and progressive growth. Once cancer cells establish in the bone, the normal process of bone turnover is disturbed. The different mechanisms responsible for osteoclast activation correspond to typical radiologic features showing lytic, sclerotic or mixed metastases, according to the primary tumor. The release of chemical mediators, the increased pressure within the bone, microfractures, the stretching of periosteum, reactive muscle spasm, nerve root infiltration and compression of nerves by the collapse of vertebrae are the possible mechanisms of malignant bone pain. Pain is often disproportionate to the size or degree of bone involvement. A comprehensive assessment including a trusting relationship with the patient, taking a careful history of the pain complaint, the characteristics of the pain, the evaluation of the psychological status of the patient, neurological examination, the reviewing of diagnostic studies and laboratory findings, and individualization of the therapeutic approach, should precede any treatment. Radiotherapy is the cornerstone of the treatment. Low doses given in a single session are safe and effective, and reduce distress and inconvenience associated with repeated session. Radioisotopes are more imprecise in delivering specific doses of radiation, but have less toxicity and easy administration as well as effectiveness in subclinical sites of metastases, although storage, dispensing and administration should be under strict control. Chemotherapy and endocrine therapy are difficult to measure in terms of pain relief. Prophylactic fixation surgery can lead to improved survival and quality of life of patients with bone metastases. Surgical treatment should be undertaken when fracture occurs. Careful selection of patients for surgical spinal decompression is required. The potential benefits of surgical interventions have to be tempered with patient survival. The use of analgesics according to the WHO ladder is recommended. There is no clear evidence that non-steroidal anti-inflammatory drugs (NSAIDs) have a specific efficacy in malignant bone pain. The difficulty with incident pain is not a lack of response to systemic opioids, but rather that the doses required to control the incidental pain produce unacceptable side-effects at rest. Alternative measures are often required. The inhibition of bone resorption and hypercalcaemia can be reduced by the use of bisphosphonates. This class of drugs potentiate the effects of analgesics in improving metastatic bone pain. Invasive techniques are rarely indicated, but may provide analgesia in the treatment of pain resistant to the other modalities. Neural blockade should never be used as the sole modality for malignant bone pain, but should be considered as a helpful in specific pain situations. Careful appraisal and the application of a correct approach should enable the patient with bone metastases to obtain an acceptable pain relief despite the advanced nature of their malignant disease.