ESTRO 2023

Session Item

Tuesday

May 16

09:15 - 10:30

Strauss 3

Guidelines

Chair: , Italy;

Chair: Fiona Mcdonald, United Kingdom

Session Code: 4070

Session Type: Symposium

Track: Interdisciplinary

09:25 - 09:35

ESTRO-ACROP guidelines for external beam radiotherapy of patients with complicated and uncomplicated bone metastases

Speaker: Peter Hoskin, United Kingdom

Presentation Number: SP-0994

Abstract

Abstract Title:

ESTRO-ACROP guidelines for external beam radiotherapy of patients with complicated and uncomplicated bone metastases

Authors:

Peter Hoskin¹, Nicolaus Andratschke², Johan Menten³, Joanna Kazmierska⁴, Yvette van der Linden⁵, Mateusz Spałek⁶, Joanne van der Velden⁵, Jonas Willmann⁷, Stephanie Brown⁸, Eva Oldenburger⁹

¹Mount Vernon Cancer Centre and University of Manchester, Division of Cancer Sciences, Northwood and Manchester, United Kingdom; ²University Hospital Zurich, Department of Radiation Oncology, Zurich, Switzerland; ³Catholic University Leuven, Radiaton Oncology, Leuven, Belgium; ⁴Greater Poland Cancer Centre, Radiotherapy Department II, Poznan, Poland; ⁵University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands; ⁶Maria Sklodowska-Curie National Research Institute of Oncology, Department of Soft Tissue/Bone Sarcoma and Melanoma, Warsaw, Poland; ⁷University Hospital Zurich, Department of Radiation Oncology, Zurich, Poland; ⁸Mount Vernon Hospital, Cancer Centre, Northwood, United Kingdom; ⁹University Hospital Leuven, Department of Radiation Oncology, Leuven, Belgium

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Abstract Text

These guidelines address the management of bone metastases in the context of external beam therapy covering diagnosis, prognostic scores and treatment. They are presented as two manuscripts the first on uncomplicated bone metastases defined as those with no associated actual or threatened pathological fracture and no neurological complications and the second on complicated bone metastases.

The uncomplicated section covers diagnosis, the concept of oligometastases and their management, dose, fractionation and technique for external beam radiotherapy and includes reirradiation. Clinical assessment should include a pain score, performance status and an estimation of the predicted survival. Single doses are advocated for both initial and reirradiation of painful bone metastases; the concept of pain flare after radiotherapy is recognised and high dose stereotactic radiotherapy and IMRT are not recommended in the absence of clear evidence of their superiority over simpler techniques.

The complicated bone metastases section covers pathological fracture, spinal canal compression, neuropathic pain and prophylactic treatment. In metastatic spinal canal compression full evaluation with whole spine MRI and surgical referral for spinal instability is recommended. Surgical referral should also be considered for single site compression in patients with < 48 hours paraplegia and life expectancy of >3 months. High dose steroids and local radiotherapy using single doses of 8-10Gy are otherwise recommended. Re-irradiation is possible within a cumulative dose limit of BED ≤100 - 135.5 Gy2. Stereotactic radiotherapy is not recommended for cord compression. Neuropathic pain should be treated with a single dose of 8Gy. Pathological fracture risk should be undertaken using established scoring systems. Single doses of 8Gy, 20Gy in 5 fractions or 30Gy in 10 fractions should be used for threatened or actual pathological fracture where surgery is not feasible.

All recommendations are evidence based with levels of evidence referenced throughout.