Radiation Therapy
Radiofrequency Ablation
Surgery

Radiation therapy, radiofrequency ablation, and surgery are discussed as pain relief measures rather than as cures for primary disease. Chemotherapy may also play a role in management of cancer-associated pain for some malignancies.[1]

Local, half-body, or whole-body radiation enhances the effectiveness of analgesic drug and other noninvasive therapy by directly affecting the cause of pain (i.e., reducing primary and metastatic tumor bulk).[2] Radiation reduces both pain and its interference with function among ambulatory cancer patients with symptomatic bone metastases.[3] Single or multifraction regimens of external-beam radiation therapy are equally effective when radiation is administered for pain relief; however, retreatment is needed somewhat more often after single-fraction therapy.[4,5] Dosages must be chosen to achieve a balance between the amount of radiation required to kill tumor cells and that which would adversely affect normal cells or allow the repair of damaged tissue. Pain flare after radiation therapy can occur, but the incidence has not been well documented. A relatively small prospective randomized controlled trial comparing 8 Gy in one fraction to 20 Gy in five fractions reported pain flare in 15 (34%) of 44 patients for a median duration of 3 days. The flare occurred in 10 (44%) of 23 patients in the 8-Gy group and 5 (24%) of 21 patients in the 20-Gy group.[6]

A single intravenous injection of beta particle-emitting agents such as iodine¹³¹, phosphorus-32-orthophosphate, and strontium⁸⁹, as well as the investigational new drugs rhenium¹⁸⁶ and samarium¹⁵³,[7-9] can relieve pain of widespread bony metastases. Half the patients so treated respond to a second treatment if pain recurs. A prospective multicenter open-label trial of samarium Sm-153 suggests that multiple doses (i.e., more than two) may be administered to patients with advanced cancer and painful multifocal bone metastases with repeated benefit and adequate safety, if pain responds to the initial dose of samarium at week 4 posttreatment and then recurs.[10]

Radiofrequency ablation (RFA) of painful osteolytic bony metastases may provide pain relief. In a nonconsecutive 27-month period, 43 patients from nine sites across the United States and Europe underwent RFA. Of the 43 patients, 41 (95%) experienced a decrease in worst pain (at least 2 points on an 11-point scale) that continued for up to 24 hours. After peaking at week 1, the morphine equivalent daily dose decreased significantly at weeks 8 and 12, before rising again at week 24. Three patients experienced adverse events that included a second-degree skin burn at the grounding pad site, transient bladder and bowel incontinence after treatment of a sacral lesion, and an acetabular fracture 6 weeks after RFA of a lesion involving the ileum, ischium, and acetabulum. Other uncontrolled case reports confirm these findings.[11] Further study to determine potential risks and benefits may be warranted.[12]

Curative excision or palliative debulking of a tumor has potential to reduce pain directly, relieve symptoms of obstruction or compression, and improve prognosis, even increasing long-term survival. Oncologic surgeons and other health care providers should be familiar with the interactions of chemotherapy, radiation therapy, and surgical interventions to avoid or anticipate iatrogenic complications. They should also recognize characteristic pain syndromes that follow specific surgical procedures.

References

1. Beer TM, Eilers KM, Garzotto M, et al.: Quality of life and pain relief during treatment with calcitriol and docetaxel in symptomatic metastatic androgen-independent prostate carcinoma. Cancer 100 (4): 758-63, 2004.  [PUBMED Abstract]
   
   
2. Salazar OM, Sandhu T, da Motta NW, et al.: Fractionated half-body irradiation (HBI) for the rapid palliation of widespread, symptomatic, metastatic bone disease: a randomized Phase III trial of the International Atomic Energy Agency (IAEA). Int J Radiat Oncol Biol Phys 50 (3): 765-75, 2001.  [PUBMED Abstract]
   
   
3. Wu JS, Monk G, Clark T, et al.: Palliative radiotherapy improves pain and reduces functional interference in patients with painful bone metastases: a quality assurance study. Clin Oncol (R Coll Radiol) 18 (7): 539-44, 2006.  [PUBMED Abstract]
   
   
4. Saarto T, Janes R, Tenhunen M, et al.: Palliative radiotherapy in the treatment of skeletal metastases. Eur J Pain 6 (5): 323-30, 2002.  [PUBMED Abstract]
   
   
5. Hartsell WF, Scott CB, Bruner DW, et al.: Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 97 (11): 798-804, 2005.  [PUBMED Abstract]
   
   
6. Loblaw DA, Wu JS, Kirkbride P, et al.: Pain flare in patients with bone metastases after palliative radiotherapy--a nested randomized control trial. Support Care Cancer 15 (4): 451-5, 2007.  [PUBMED Abstract]
   
   
7. Sartor O, Reid RH, Hoskin PJ, et al.: Samarium-153-Lexidronam complex for treatment of painful bone metastases in hormone-refractory prostate cancer. Urology 63 (5): 940-5, 2004.  [PUBMED Abstract]
   
   
8. Liepe K, Runge R, Kotzerke J: The benefit of bone-seeking radiopharmaceuticals in the treatment of metastatic bone pain. J Cancer Res Clin Oncol 131 (1): 60-6, 2005.  [PUBMED Abstract]
   
   
9. Coronado M, Redondo A, Coya J, et al.: Clinical role of Sm-153 EDTMP in the treatment of painful bone metastatic disease. Clin Nucl Med 31 (10): 605-10, 2006.  [PUBMED Abstract]
   
   
10. Sartor O, Reid RH, Bushnell DL, et al.: Safety and efficacy of repeat administration of samarium Sm-153 lexidronam to patients with metastatic bone pain. Cancer 109 (3): 637-43, 2007.  [PUBMED Abstract]
    
    
11. Locklin JK, Mannes A, Berger A, et al.: Palliation of soft tissue cancer pain with radiofrequency ablation. J Support Oncol 2 (5): 439-45, 2004 Sep-Oct.  [PUBMED Abstract]
    
    
12. Goetz MP, Callstrom MR, Charboneau JW, et al.: Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study. J Clin Oncol 22 (2): 300-6, 2004.  [PUBMED Abstract]
    
    

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