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    • The first variant in the non

    2019-05-22

    The first variant in the non-spine topic describes a patient with an excellent performance status, a favorable life expectancy, and an asymptomatic methysergide Supplier lesion which does not pose an obvious risk for pathologic fracture. While the authors acknowledge that research has begun to determine whether patients with bone-only metastatic disease and otherwise favorable findings may be treated aggressively, they stop short of endorsing curative-intent therapy for patients with “oligometastases” because the available data do not yet prove the usefulness of such an approach [8]. Their recommendations therefore call for an osteoclast inhibitor and a hormone blocking agent, with radiotherapy reserved for an oligometastatic treatment trial. The results of ongoing research may well come to indicate that patients in this most favorable clinical circumstance of metastatic disease should be treated more aggressively than others with less favorable prognostic indicators. The second variant describes a patient with a good performance status who has a painful lesion in a weight-bearing bone. The task force defined the need for quickly establishing a pain medicine regimen while concurrently consulting an orthopedic surgeon to assess the need for surgical pinning to prevent pathologic fracture [9–11]. Given a low risk of fracture determined by the surgeon, the team recommended external beam radiotherapy (EBRT) based upon CT, fluoroscopic, or clinical simulation, with radiation delivery through anterior and posterior fields sparing a skin strip to minimize the risk of long term lymphedema of the extremity. While the panel detailed the pain relief equivalency between a single 8Gy fraction and multi-fraction schedules, they pointed out the data which suggests that the use of fractionated regimens might minimize the risk of subsequent pathologic fracture in this setting [12]. The group essentially declared that pain relief equivalency has been conclusively determined for either single fraction or multi-fraction regimens, obviating the need for further research to examine that question. Finally, the existence of a fairly significant tumor burden in that patient led to recommendations for considering systemic chemotherapy and osteoclast inhibitors. In the third variant, the patient has suffered a pathologic fracture from a lytic metastasis in a weight-bearing bone that required surgical stabilization. The panel recommended postoperative radiotherapy with 30Gy in 10 fractions planned by CT, fluoroscopic or clinical simulation, with anterior and posterior opposed fields and a skin strip spared to once again minimize the risk of long term lymphedema. The vignette is valuable in its ability to highlight the need for orthopedic consultation to assess and provide surgical stabilization as well as the need for communication for the patient to receive the necessary post-operative adjuvant radiotherapy. Given a good performance status and significant tumor burden, recommendations were made for considerations of systemic chemotherapy, hormonal ablation treatment, and an osteoclast inhibitor. The patient in variant number 4 has previously received palliative radiotherapy for a site of painful bony disease with a good initial response, though their pain has recurred and the panel was tasked with evaluating the safety and efficacy of EBRT re-treatment to the same painful site. The panel described the available re-treatment data as being of low quality because it was mostly retrospective, single-institutional, and dated [13–18]. Given those limitations, the group recommended caution when treating volumes containing normal tissue structures which might suffer side effects from the combined palliative doses. The brachial plexus was found to be one normal tissue at risk in this particular case, and the team also reminded the reader to re-evaluate the affected long bone for risk of pathologic fracture before offering re-irradiation. The panel therefore recommended treatment planned by CT, fluoroscopic, or clinical simulation, with anterior and posterior opposed fields sparing a skin strip to minimize the risk for upper extremity edema. Given limited data regarding the best dose to use in this setting, the panel recommended placing the patient on an available re-treatment protocol [19]. When completed, the results of that trial will need to serve as a template for the appropriateness of re-treatment to the same painful site, given the lack of prospective data available at this time. While the use of systemic chemotherapy was not thought to be wholly inappropriate, the patient\'s poor performance status and prognosis led the group to suggest that the patient be seen by a palliative care team and be given the option to choose hospice care.