Radiation therapy for painful bone metastases; aiming at optimal treatment schedules

PURPOSE: To evaluate the pain relief obtained by radiation therapy for painful bone metastases, with a special regard to general condition. MATERIALS AND METHODS: Between June 1998 and May 2000, 54 patients with 86 painful bone metastases were treated with radiation therapy whose effects could be evaluated for a minimum period of 6 months or until death. Treatment schedules were 3 Gy/fraction/day (30-36 Gy/10-12 fractions) in usual cases (61 lesions), 4-8 Gy/fraction/day (8-20 Gy/1-5 fractions) in patients with a poor general condition (9 lesions), and 2 Gy/fraction/day (40-50 Gy/20-25 fractions) in lesions with a large radiation field (16 lesions). RESULTS: Complete pain relief without medication (CR) was achieved in 40 lesions (47%). Significant predictors for CR were primary site (p = 0.0003), performance status (p = 0.0060), pain score (p = 0.0190), narcotic score (p < 0.0001), and prognosis (p < 0.0001), but no difference was found in CR among treatment schedules. No evidence of severe radiation-induced complication was seen. CONCLUSION: General condition (performance status and prognosis) has an influence on pain relief. Compared with the daily 2 Gy protocol, the daily 3 Gy protocol has the advantage of shorter treatment time. The treatment schedule should be assessed in patients with a large radiation field and/or poor general condition. Especially for the patients with poor general condition, combined pain medication should be considered.

Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps.

OBJECTIVE: This retrospective study compared differences in preoperative pain and medication use in patients with moderate to severe pain who sought emergency endodontic care for teeth with irreversible pulpitis and for symptomatic teeth with necrotic pulps. STUDY DESIGN: A total of 323 patients seeking emergency endodontic treatment completed questionnaires regarding their biographical information, pain, pain history, and medications. Teeth were tested for vitality, mobility, percussion, and palpation pain. Lymphadenopathy was also evaluated. RESULTS: Patients with irreversible pulpitis waited significantly (P <.05) longer before seeking emergency care (9 days vs 4 days) than patients with symptomatic teeth with necrotic pulps. No differences (P >.05) were found between the groups in terms of analgesic or antibiotic use and pain relief from preoperative narcotic medications. Nonnarcotic analgesics were reported to significantly reduce pain more often in patients with symptomatic teeth with necrotic pulps. There were sex differences in the group of patients with irreversible pulpitis: More women than men were taking analgesic medications and, in the group having symptomatic teeth with necrotic pulps, more men than women reported pain relief from their analgesic medications. CONCLUSION: Patients with irreversible pulpitis wait longer to seek emergency treatment. A majority (81%-83%) of emergency patients with moderate to severe pain will have taken some type of medication(s) to help control their pain, and more women than men with irreversible pulpitis will take an analgesic. By taking their preoperative medication(s), this group of patients will get relief 62% to 65% of the time; furthermore, more men than women with symptomatic teeth with necrotic pulps will experience pain relief.

Long-term pain relief during spinal cord stimulation. The effect of patient selection.

We reviewed our experience with spinal cord stimulation (SCS) in treating 116 patients with pain in one or both legs. All these patients were selected for an initial week of trial stimulation by the criteria: pain due to a known benign organic cause, failure of conventional pain control methods and absence of major personality disorders. Selected patients included 78 with the Failed Back Surgery Syndrome (FBSS), in whom proven correlation existed between the clinical picture and the neuroradiological and electromyogram abnormalities. Eighty-four out of 116 selected patients underwent definitive SCS implantation after 1 week of trial stimulation with excellent results (more than 75% pain relief). They were followed clinically every 3 months for a mean follow-up period of 47 months. Forty-five patients (54%) continued to experience at least 50% of pain relief at the latest follow up. Seventy-seven patients (91%) were able to reduce their medication intake and 50 patients (60%) reported an improvement in lifestyle. FBSS patients responded more positively to the trial stimulation than the other patients. However, the later outcome was not affected by patient selection as long-term benefit was similar in all definitive SCS patients irrespective of aetiology.

Once-a-week lower hemibody irradiation (HBI) for metastatic cancers.

Hemibody irradiation (HBI) of 8 Gy has been shown to produce pain relief in widespread metastatic disease. The major problems occurred with high dose (over 6 Gy) to the upper hemibody. Because 8 Gy lower HBI was well tolerated, we decided to study the efficacy and tolerance of even higher radiation doses given to the lower hemibody. Nineteen patients with widespread metastatic cancers in the lower hemibody were treated from 1982 to 1984 with 16 Gy (8 Gy one week apart) to the lower hemibody (from top of iliac crest to knee joint) after premedication with an antiemetic. All the patients tolerated this high dose, lower HBI well, except for two patients who had slight nausea and vomiting, and one patient who had moist reaction in the perineum. There was no significant bone marrow depression. All patients had improvement in performance status and had prompt pain relief, ten (53%) with complete pain relief and nine (47%) with partial pain relief. The median duration of pain relief was 5 months. Ten of the 15 patients who died were pain-free at the time of death. The four patients still living are free of pain. The median survival was 7 months, and five patients survived 1 year. High dose (8 Gy X 2 spaced one week apart), lower HBI produces prolonged, prompt and effective palliation of pain with minimal morbidity and is well tolerated. It probably does not prolong survival. Because it requires only two treatments spaced one week apart, it is a very convenient and cost effective regimen for the sick and elderly patient.