Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
Department of Oncology, Princess Margaret Hospital, Hong Kong, China.
Radiother Oncol. 2021 Oct;163:55-67. doi: 10.1016/j.radonc.2021.07.022. Epub 2021 Jul 29.
In patients with bone metastases (BM), radiotherapy (RT) is used to alleviate symptoms, reduce the risk of fracture, and improve quality of life (QoL). However, with the emergence of concepts like oligometastases, minimal invasive surgery, ablative therapies such as stereotactic ablative RT (SABR), radiosurgery (SRS), thermal ablation, and new systemic anticancer therapies, there have been a paradigm shift in the multidisciplinary approach to BM with the aim of preserving mobility and function survival. Despite guidelines on using single-dose RT in uncomplicated BM, its use remains relatively low. In uncomplicated BM, single-fraction RT produces similar overall and complete response rates to RT with multiple fractions, although it is associated with a higher retreatment rate of 20% versus 8%. Complicated BM can be characterised as the presence of impending or existing pathologic fracture, a major soft tissue component, existing spinal cord or cauda equina compression and neuropathic pain. The rate of complicated BM is around 35%. Unfortunately, there is a lack of prospective trials on RT in complicated BM and the best dose/fractionation regimen is not yet established. There are contradictory outcomes in studies reporting BM pain control rates and time to pain reduction when comparing SABR with Conventional RT. While some studies showed that SABR produces a faster reduction in pain and higher pain control rates than conventional RT, other studies did not show differences. Moreover, the local control rate for BM treated with SABR is higher than 80% in most studies, and the rate of grade 3 or 4 toxicity is very low. The use of SABR may be preferred in three circumstances: reirradiation, oligometastatic disease, and radioresistant tumours. Local ablative therapies like SABR can delay change or use of systemic therapy, preserve patients' Qol, and improve disease-free survival, progression-free survival and overall survival. Moreover, despite the potential benefit of SABR in oligometastatic disease, there is a need to establish the optial indication, RT dose fractionation, prognostic factors and optimal timing in combination with systemic therapies for SABR. This review evaluates the role of RT in BM considering these recent treatment advances. We consider the definition of complicated BM, use of single and multiple fractions RT for both complicated and uncomplicated BM, reirradiation, new treatment paradigms including local ablative treatments, oligometastatic disease, systemic therapy, physical activity and rehabilitation.
在患有骨转移（BM）的患者中，放射治疗（RT）用于缓解症状、降低骨折风险和提高生活质量（QoL）。然而，随着寡转移、微创手术、立体定向消融放疗（SABR）、放射外科（SRS）、热消融和新的全身抗癌治疗等概念的出现，BM 的多学科治疗方法发生了范式转变，旨在保留移动能力和功能生存。尽管有关于在简单 BM 中使用单次剂量 RT 的指南，但实际上其使用率相对较低。在简单 BM 中，单次分割 RT 的总反应率和完全反应率与多次分割 RT 相似，尽管它的再治疗率为 20%，而后者为 8%。复杂 BM 可表现为即将发生或现有的病理性骨折、主要软组织成分、现有的脊髓或马尾神经压迫和神经性疼痛。复杂 BM 的发生率约为 35%。不幸的是，目前在复杂 BM 中进行 RT 的前瞻性试验较少，最佳剂量/分割方案尚未确定。在比较 SABR 与常规 RT 时，关于 BM 疼痛控制率和疼痛缓解时间的研究结果存在矛盾。虽然一些研究表明 SABR 比常规 RT 更快地减轻疼痛和产生更高的疼痛控制率，但其他研究并未显示出差异。此外，大多数研究显示 SABR 治疗 BM 的局部控制率高于 80%，3 或 4 级毒性发生率非常低。在以下三种情况下可能更倾向于使用 SABR：再放疗、寡转移疾病和放射抗拒肿瘤。SABR 等局部消融治疗可延迟系统治疗的改变或使用，保持患者的生活质量，并改善无病生存、无进展生存和总生存。此外，尽管 SABR 在寡转移疾病中具有潜在益处，但需要确定最佳适应症、RT 剂量分割、预后因素以及与系统治疗相结合的最佳时机。本综述评估了考虑到这些最近的治疗进展，RT 在 BM 中的作用。我们考虑了复杂 BM 的定义、复杂和简单 BM 的单次和多次分割 RT 的使用、再放疗、包括局部消融治疗在内的新治疗模式、寡转移疾病、系统治疗、体力活动和康复。
