Radiotherapy for Symptomatic Metastases to Bone in Children

Background Few studies have addressed the efficacy of palliative radiotherapy (RT) for pediatric osteosarcoma (OS), a disease generally considered to be radioresistant. We describe symptom relief, local control, and toxicity associated with palliative RT among children with OS. Procedure Patients diagnosed with OS at age 18 and under and treated with RT for palliation of symptomatic metastases or local recurrence at the primary site from 1997 to 2017 were included. We retrospectively reviewed details of RT, symptom improvement, local control, survival, and toxicity. Results Thirty‐two courses of palliative RT were given to 20 patients with symptomatic metastatic and/or locally recurrent primary disease. The median equivalent dose in 2 Gy fractions (EQD2) was 40.0 Gy (range, 20.0–60.4). The median number of fractions per course was 15 (range, 5–39). Symptom improvement occurred in 24 (75%) courses of RT at a median time of 15.5 days (range, 3–43). In nine courses (37.5%), symptoms recurred after a median duration of symptom relief of 140 days (range, 1–882). Higher EQD2 correlated with longer duration of response (r = 0.39, P = 0.0003). Imaging revealed local failure in 3 of 14 courses followed with surveillance imaging studies (21.4%). The median time to progression was 12.9 months (range, 4.4–21.8). The median follow‐up time following the first course of palliative RT was 17.5 months (range, 1.74–102.24), and median time to overall survival was 19.4 months. Toxicity was mild, with grade 2 toxicity occurring in one course (3.1%). Conclusions RT is an effective method of symptom palliation for patients with recurrent or metastatic OS, with higher delivered dose correlating with longer symptom relief and with little associated toxicity.

Section: Discussionmentioning

confidence: 99%

Outcomes for pediatric patients with osteosarcoma treated with palliative radiotherapy

Chen

Yoo

Gutkin

et al. 2019

“…Sixty percent of the patients had complete or good response, 38% had little response, and only one patient had no response. Deutsch and Tersak reported outcomes on 37 children treated with 150 courses of palliative RT, with neuroblastoma as the most common malignant histology. Ninety‐three percent of the patients were considered to have a good clinical response, of which 40% were treated with a single fraction of RT.…”

Section: Discussionmentioning

confidence: 99%

Practice patterns of palliative radiation therapy in pediatric oncology patients in an international pediatric research consortium

Rao

Chen

Ermoian

et al. 2017

Background/Objectives: The practice of palliative radiation therapy (RT) is based on extrapolation from adult literature. We evaluated patterns of pediatric palliative RT to describe regimens used to identify opportunity for future pediatric-specific clinical trials. Results: Of 3,225 pediatric patients, 365 (11%) were treated with palliative intent to a total of 427 disease sites. Anesthesia was required in 10% of patients. Treatment was delivered to metastatic disease in 54% of patients. Histologies included neuroblastoma (30%), osteosarcoma (18%), leukemia/lymphoma (12%), rhabdomyosarcoma (12%), medulloblastoma/ependymoma (12%), Ewing sarcoma (8%), and other (8%). Indications included pain (43%), intracranial symptoms (23%), respiratory compromise (14%), cord compression (8%), and abdominal distention (6%).Sites included nonspine bone (35%), brain (16% primary tumors, 6% metastases), abdomen/pelvis (15%), spine (12%), head/neck (9%), and lung/mediastinum (5%). Re-irradiation comprised 16% of cases. Techniques employed three-dimensional conformal RT (41%), intensity-modulated RT (23%), conventional RT (26%), stereotactic body RT (6%), protons (1%), electrons (1%), and other (2%). The most common physician-reported barrier to consideration of palliative RT was the concern about treatment toxicity (83%). Conclusion:There is significant diversity of practice in pediatric palliative RT. Combined with ongoing research characterizing treatment response and toxicity, these data will inform the design of forthcoming clinical trials to establish effective regimens and minimize treatment toxicity for this patient population. K E Y W O R D Spalliative radiation therapy, palliative therapy, pediatric radiation therapy Abbreviations: RT, radiation therapy; SBRT, stereotactic body radiation therapy

“…While dose and fractionation schemes for palliative RT have been extensively studied in adults particularly with bone or brain metastases,– the optimal dose for palliating disease in pediatric cancer patients has not been well studied. Bone metastases have been studied in several reports of palliative RT in children, but there continues to be limited data to form a consensus recommendation …”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes and toxicity following palliative radiotherapy for childhood cancers

Mak

Lee

Balboni

et al. 2017

Background: Few reports of palliative radiotherapy (RT) for pedialltric malignancies have been published. We described clinical indications, outcomes, and toxicities for children who received palliative RT.Procedure: Pediatric patients (age ≤18 years) treated with palliative RT for incurable cancer from January 1 2008 to February 26, 2014 were included. Diagnosis, details of RT, treatment response, toxicity, and survival were retrospectively reviewed.Results: Forty-six patients received 76 RT courses. Fifteen patients (33%) had ≥2 courses. Median age at palliative RT was 10.3 years; 54% were male. The most common diagnoses were neuroblastoma (20%) and diffuse intrinsic pontine glioma (17%). The most common indications for RT were oligometastatic disease in asymptomatic patients (39%) and pain (25%). The most common treatment sites were brain (32%) and bone (29%). Median RT dose was 30 Gy. Median number of RT fractions was 12. Sixty-five treatment courses (86%) were delivered with fraction sizes ≥2.5 Gy.Twenty-seven treatment courses (36%) were given under general anesthesia. Median follow-up was 3.9 months. Grade 1-2 RT-related toxicity occurred in 21% of treatment courses and 4-8% up to 12 months after RT. Two patients had Grade 3 toxicity during RT (esophagitis). Of symptomatic patients, 91%, 73%, 58%, and 43% had improved or stable symptoms during RT and 0-3, 3-6, and 6-12 months afterwards, respectively. Median survival after palliative RT was 4.2 months. Four of 21 surviving patients (19%) had hospice care at last follow-up. Conclusions:Palliative RT was well tolerated in children with incurable malignancies, with most cases associated with acceptable toxicity, and improved or stable symptoms.