Background: Postoperative wound dehiscence is a major complication following spinal metastasis surgery, particularly in patients who receive preoperative radiotherapy or molecular-targeted therapy; however, preventive strategies remain limited. Objective: In this study, we aimed to identify the risk factors for postoperative wound dehiscence and evaluate the clinical utility of a novel curved skin incision (CSI) technique, designed to avoid irradiated areas, in comparison with the conventional midline incision (MI) technique. Methods: Logistic regression analysis was conducted on 107 patients who underwent MI between 2013 and 2018. Based on the results, we developed the CSI technique. Propensity score matching was performed to compare postoperative wound dehiscence in 29 matched pairs of patients treated with either CSI or MI from 2019 to 2021. Results: Preoperative radiotherapy and molecular-targeted therapy were found to be significant risk factors for wound dehiscence. CSI, which circumvents irradiated skin, was associated with a substantially lower rate of wound dehiscence than MI. Conclusions: The CSI technique offers a simple, reproducible, and effective surgical approach to reduce postoperative wound complications in high-risk patients. Its clinical benefit, especially for those with prior radiotherapy, suggests that it may serve as a valuable addition to standard spinal metastasis surgery.

Cancer pain is a common issue for patients, especially in the advanced stages of cancer, and significantly affects the quality of life (QoL), treatment tolerance, and overall treatment outcomes. Pain may be caused by primary tumors, metastases, or as a consequence of the inflammatory reaction of tissues surrounding the tumor following radiotherapy (RT). Effective pain management is crucial, especially with RT being a key method for alleviating cancer pain, particularly in cases of bone and soft tissue metastases. RT provides relief for 60-80% of patients by reducing tumor size and mitigating associated pain. Radiotherapy itself can also induce pain, especially radiation-induced neuropathic pain, which may require further treatment. Despite these potential side effects, RT remains an essential tool in managing cancer pain, though careful management of its toxicities is necessary to improve patient QoL and survival.

The current study aims to investigate the current practice of bone metastasis management in patients with non-small cell lung cancer.

An online questionnaire was administered to 92 oncologists. A survey was developed and revised by dedicated experts and was composed of five sections: i) general and work characteristics, ii) diagnostic issues, ii) bone-targeted agents issues, iii) radiotherapy issues, and iv) supportive care issues. Descriptive statistics was applied.

The 18F-FDG PET is the preferred evaluation for skeletal assessment for both patients with (62 %) and without (54 %) bone lesions at the CT scan; MRI (63 %) and 18F-FDG PET (61 %) are the most chosen radiographic assessments when a bone oligoprogression is suspected. The number of bone metastatic lesions was the main factor considered when deciding whether to start bone-targeted agents (57 %). In choosing between bone-targeted agents, renal toxicity was the most considered factor (62 %). Over half of the participants did not stop the systemic treatment during stereotactic radiotherapy (68 %) and considered re-irradiation on progressive bone metastases at least 6 months after prior radiotherapy (55 %). Overall, 64 % and 41 % of participants assessed patients' body weight and physical activity, respectively. Oral nutritional supplements or a specific diet were recommended by 34 % and 46 % of clinicians; 40 % of them also advised their patients to increase their physical activity levels, while 54 % were worried that exercise might increase the risk of skeletal-related adverse events.

Lung-cancer dedicated clinicians pay great attention to bone metastases-related diagnostic, bone-targeted agents, and radiotherapy issues, whereas the integration of supportive care approaches seem less standardized.

The appearance of symptomatic tumor-related vaginal bleeding and pain in advanced incurable cancer patients with pelvic gynecological malignancies remains a therapeutic challenge in oncological treatment. The aim of our analysis was to evaluate the efficacy and safety of palliative hemostatic radiotherapy.

We retrospectively identified patients who had received palliative hemostatic radiotherapy (RT) at our institution between 2011 and 2023 and evaluated acute toxicity, local control, cessation of bleeding, and pain relief.

In total, 40 patients with a median planning target volume of 804 cm3 were treated with a median total dose of 39 Gy in 13 fractions, resulting in 6‑month and 1‑year local control rates of 66.9 and 60.8%, respectively. No higher-grade (>grade III) acute RT-induced toxicity appeared. Complete cessation of bleeding was achieved in 80.0% of all patients after a median of 16 days and pain relief was documented in 60.9% at first follow-up. 37.5% of the women required a blood transfusion and 25% an additional tamponade with local hemostatic agents. Successful stopping of bleeding was significantly less frequent in patients receiving anticoagulation concurrently with radiation and in the case of infield re-irradiation. Patients with a higher total RT dose had cessation of bleeding significantly more often, with a cut-off value of at least EQD2 (α/β = 10) = 36 Gy. The applied RT technique and planning target volume had no significant influence on the occurrence of bleeding cessation.

Palliative hemostatic radiotherapy for locally advanced pelvic gynecological malignancies is safe and effective in achieving high control rates of hemostasis in tumor bleeding and pain relief.

Background This study aimed to examine the influence of wearing a corset with radiation therapy (RT) on pain, activities of daily living (ADL), and quality of life (QoL) in patients with thoracic or lumbar spinal bone metastases one month after RT. Methodology Fifty-two patients (24 males and 28 females) with thoracic or lumbar spinal bone metastases whose measurements were recorded at our institute between July 2012 and December 2016 were included in this study. Age, sex, ADL, pain, spinal instability, and QoL were investigated in our analyses. Patients were divided into stable (0-6 points) and unstable (7-18 points) groups based on their spinal instability neoplastic score. Patients in the stable and unstable groups performed early mobilization depending on their condition. The unstable group wore corsets. The corsets were soft and were worn for three months from the start of RT. Results The unstable group showed significant improvements in ADL and QoL and a significant reduction in pain one month after RT (P < 0.05). The stable group showed a significant improvement in QoL one month after RT (P < 0.05). Conclusions Corsets were effective for enabling early movement without lowering QoL in patients with spinal instability of thoracic or lumbar bone metastases.

Stereotactic body radiation therapy (SBRT) is an effective treatment for spinal metastases; however, outcomes specific to a geriatric population have not been described. This study aims to investigate the efficacy and safety of spine SBRT, in particular the rate of iatrogenic vertebral compression fracture (VCF), in patients aged 70 and older.

From a prospectively maintained single-institutional database of 976 patients and 2407 spinal segments treated with SBRT for vertebral metastases between 2008 and 2021, all patients aged 70 or above were retrospectively reviewed. The primary outcome is the risk of VCF. Secondary outcomes included magnetic resonance imaging-based local failure and overall survival.

A total of 252 consecutive patients with 580 spinal segments treated with spine SBRT were reviewed. The median age was 75.8 (range: 70-90.3) years and the median (interquartile range) follow-up duration was 16.9 (6.4-41.3) months. The median overall survival of the entire cohort was 20.3 months and the 2-year local failure rate was 14.3%. The cumulative risk of VCF at 12 and 24 months were 8.4% and 12.3%, respectively. Significant predictors of VCF on multivariable analyses included greater biologically equivalent dose, baseline fracture, and increasing age. In particular, the 2-year VCF rate and median time to VCF were 30.3% and 3.4 months for those 86 and older, compared with 11.2% and 12.8 months for those younger than 86, respectively (P = .0011).

Spine SBRT should be considered in a geriatric population; however, for those 86 and older, we suggest caution due to the significant risk of VCF.

Palliative radiotherapy (PRT) toward the end of life (EOL) in advanced tumor disease is contentious. Although EOL RT can alleviate cancer-related symptoms, relief typically occurs weeks to months after treatment, potentially compromising the quality of life of patients during the final stages. This study aims to assess factors influencing the decision-making process regarding EOL RT.

This retrospective study of a real-world cohort included 684 consecutive patients with a diagnosis of a solid tumor who died between 2017 and 2021. In these patients, factors potentially influencing the administration of EOL RT were analyzed.

Of the 684 patients, 164 received PRT, with 60 (36.6%) receiving EOL RT within the last 30 days of life. The median time from the last RT session to death was 55 days. Significant factors influencing EOL RT administration were age ≤65 years (odds ratio [OR], 1.75 [95% CI, 1.02 to 3.01]), Union for International Cancer Control stage IV (OR, 2.77 [95% CI, 1.41 to 5.46]), lung cancer (OR, 2.16 [95% CI, 1.00 to 4.68]), palliative care referral (OR, 1.80 [95% CI, 0.98 to 3.30]), systemic anticancer treatment ≤30 days before death (OR, 1.87 [95% CI, 1.05 to 3.33]), and Eastern Cooperative Oncology Group performance status ≥2 (OR, 3.73 [95% CI, 1.88 to 7.40]). Furthermore, RT near the EOL was more likely administered at multiple sites (OR, 2.08 [95% CI, 1.00 to 4.29]) and with ≤5 fractions (OR, 2.37 [95% CI, 1.23 to 4.57]), while being associated with lower response rates (OR, 0.43 [95% CI, 0.21 to 0.86]) and increased therapy discontinuation (OR, 4.40 [95% CI, 1.45 to 13.37]).

These findings highlight varying RT patterns influenced by specific factors, demonstrating the complexity of EOL treatment decisions in advanced cancer care. Identifying key factors for personalized, patient-centered EOL RT decisions warrants further investigation.

Systematic review.

In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries.

Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications.

Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation.

In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Metastatic prostate cancer (mPCa) is an advanced form of cancer that spreads beyond the prostate to distant organs such as bones and lymph nodes. While prostate-specific antigen (PSA) testing is commonly used for diagnosis, rare cases with normal PSA levels complicate detection. This case highlights the crucial role of immunohistochemistry (IHC) in diagnosing mPCa with normal PSA and its management in resource-limited settings.

A 63-year-old male presented with 2 months of persistent back pain without neurological deficits. Initial diagnostics, including PSA levels, CT, MRI, and TRUS guided prostate biopsy, revealed no prostate abnormalities. However, an MRI and Bone scan showed a suspicious vertebral lesion, and a subsequent biopsy confirmed malignancy. IHC demonstrated overexpression of alpha-methyl acyl-CoA racemase (AMACR), leading to the diagnosis of mPCa. The patient underwent bilateral subcapsular orchiectomy and received external beam radiotherapy (EBRT) to manage symptoms and control disease progression.

This case highlights the diagnostic challenges of mPCa in patients with normal PSA levels. Standard diagnostics, including imaging and biopsy, may fail to detect prostate cancer, making IHC, specifically AMACR, an essential tool for diagnosis. Early surgical intervention followed by EBRT offered significant symptomatic relief and disease control.

This case demonstrates the importance of IHC in diagnosing atypical presentations of mPCa with normal PSA. A multidisciplinary approach combining surgery and radiotherapy can improve outcomes and quality of life, even in resource-limited settings.

Lattice radiotherapy can potentially deliver high doses to the tumor core, while conventional doses to the periphery resulting in improved response rates in large tumors (> 5 cm). We assessed the feasibility of planning lattice radiotherapy and dosimetrically compared it with conventional radiotherapy.

This retrospective dosimetric study evaluated 10 patients with large tumors (> 5 cm) treated with palliative intent with a dose of 20Gy in five fractions. High-dose lattice points were created at doses of 50Gy in non-hepatic tumors and 35Gy in hepatic tumors. Lattice plans were compared with treatment plans regarding dose coverage and organ-at-risk dosimetry.

Treated sites included soft tissue metastases to the neck, lungs, abdomen, pelvis, and liver. The mean lesion volume was 1103 cc (352-3173 cc). The maximum tumor size was 16 cm. The target volume coverage was > 95% in all but one case (88% to achieve organ constraints). Dosimetry and organ-at-risk doses were similar in both palliative treatment and simulated lattice plans.

Lattice radiotherapy is feasible in large tumors using volumetric-modulated arc therapy and achieves good coverage while meeting organ constraints. However, a prospective clinical evaluation is required to confirm its efficacy.

Intra-articular metastatic disease is a rare and unique manifestation of cancer metastasis, often originating from primary tumors such as lung adenocarcinoma, colorectal carcinoma, and malignant melanoma. The clinical symptoms frequently mimic chronic inflammatory arthritis, complicating diagnosis and treatment. This study aims to provide a comprehensive review of the incidence, clinical presentation, management strategies, and outcomes for patients with primary diagnosed cancers that metastasize to intra-articular locations, underscoring the specialized nature of this field.

We conducted a systematic search of PubMed, Medline, and Embase databases in July 2024, yielding 239 articles on intra-articular metastasis in cancer patients. Twenty-one studies met the inclusion criteria after screening. Five reviewers abstracted and analyzed data on patient demographics, metastatic details, diagnostic evidence, treatment modalities, and outcomes.

The search yielded 239 articles, from which 21 studies met the inclusion criteria. The patient cohort is 24 cases with a mean age of 58.8 years. Of the 24 patients included, 18 (75%) were males and 6 (25%) were females. Colorectal carcinoma was the most frequent primary tumor (33.3%), followed by lung cancer (25%). The knees were predominantly affected by the metastases. Diagnostic modalities varied; magnetic resonance imaging, arthrocentesis, and biopsy were the most commonly used procedures. Treatment approaches were again varied and included chemotherapy, radiation therapy, and surgery in some instances.

Intra-articular metastases, though rare, present significant diagnostic and therapeutic challenges. The clinical manifestations often mimic inflammatory arthritis, complicating timely diagnosis. As underscored by this study, effective management requires a multidisciplinary approach tailored to the patient's primary cancer type and overall health status. This highlights the complexity of the disease and the need for collaborative care. Future research should focus on increasing awareness and early detection to improve patient outcomes.

Patients undergoing radiation therapy may terminate treatment for any number of reasons. The incidence of treatment termination (TT) during radiation therapy has not been studied. Herein, we present a cohort of TT at a large multicenter radiation oncology department over 10 years.

TTs between January 2013 and January 2023 were prospectively analyzed as part of an ongoing departmental quality and safety program. TT was defined as any premature discontinuation of therapy after initiating radiation planning. The rate of TT was calculated as a percentage of all patients starting radiation planning. All cases were presented at monthly morbidity and mortality conferences with a root cause reviewed.

A total of 1448 TTs were identified out of 31,199 planned courses of care (4.6%). Six hundred eighty-six (47.4%) involved patients treated with curative intent, whereas 753 (52.0%) were treated with palliative intent, and 9 (0.6%) were treated for benign disease. The rate of TT decreased from 8.49% in 2013 to 3.02% in 2022, with rates decreasing yearly. The most common disease sites for TT were central nervous system (21.7%), head and neck (19.3%), thorax (17.5%), and bone (14.2%). The most common causes of TT were hospice and/or patient expiration (35.9%), patient choice unrelated to toxicity (35.2%), and clinician choice unrelated to toxicity (11.5%).

This 10-year prospective review of TTs identified a year-over-year decrease in TTs as a percentage of planned patients. This decrease may be associated with the addition of root cause reviews for TTs and discussions monthly at morbidity and mortality rounds, coupled with departmental upstream quality initiatives implemented over time. Understanding the reasons behind TTs may help decrease preventable TTs. Although some TTs may be unavoidable, open discourse and quality improvement changes effectively reduce TT incidents over time.

The 3-variable number-of-risk-factors (NRF) model is a prognostic tool for patients undergoing palliative radiotherapy (PRT). However, there is little research on the NRF model for patients with painful non-bone-metastasis tumours treated with PRT, and the efficacy of the NRF model in predicting survival is unclear to date. Therefore, we aimed to assess the prognostic accuracy of a 3-variable NRF model in patients undergoing PRT for bone and non- bone-metastasis tumours.

This was a secondary analysis of studies on PRT for bone-metastasis (BM) and PRT for miscellaneous painful tumours (MPTs), including non-BM tumours. Patients were grouped in the NRF model and survival was compared between groups. Discrimination was evaluated using a time-independent C-index and a time-dependent area under the receiver operating characteristic curve (AUROC). A calibration curve was used to assess the agreement between predicted and observed survival.

We analysed 485 patients in the BM group and 302 patients in the MPT group. The median survival times in the BM group for groups I, II, and III were 35.1, 10.1, and 3.3 months, respectively (P < 0.001), while in the MPT group, they were 22.1, 9.5, and 4.6 months, respectively (P < 0.001). The C-index was 0.689 in the BM group and 0.625 in the MPT group. In the BM group, time-dependent AUROCs over 2 to 24 months ranged from 0.738 to 0.765, while in the MPT group, they ranged from 0.650 to 0.689, with both groups showing consistent accuracy over time. The calibration curve showed a reasonable agreement between the predicted and observed survival.

The NRF model predicted survival moderately well in both the BM and MPT groups.

Colorectal cancer is a prevalent malignancy; it ranks as the third leading cause of cancer-related deaths globally. Despite the effectiveness of surgical intervention for primary tumors, ~30% of patients develop metastases, commonly in the regional lymph nodes, liver, lungs, and peritoneum. Bone metastasis is relatively rare but can occur, typically affecting vertebrae, pelvis, femur, and humerus. This study presents a 68-year-old patient with a history of locally advanced colon cancer who presented with a rapidly enlarging, painful sternal mass. Imaging and biopsy confirmed metastatic colon adenocarcinoma in the sternum. The patient was treated with radiation therapy, resulting in significant symptomatic relief and tumor reduction. This case highlights the rarity of sternal metastasis from colorectal cancer. Given the poor prognosis associated with skeletal metastases in colorectal cancer, this case emphasizes the need for vigilance in monitoring for atypical metastatic sites and the importance of tailored palliative care strategies.

This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases.

The ASTRO convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systematic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed.

For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with nonspine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction (800 cGy/1 fx), 2000 cGy/5 fx, 2400 cGy/6 fx, or 3000 cGy/10 fx. Spinal cord or cauda equina compression in patients who are ineligible for surgery and receiving conventional RT are recommended 800 cGy/1 fx, 1600 cGy/2 fx, 2000 cGy/5 fx, or 3000 cGy/10 fx. Symptomatic bone metastases in selected patients with good performance status without surgery or neurologic symptoms/signs are conditionally recommended stereotactic body RT over conventional palliative RT. Spine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, 2400 cGy/6 fx, or 2000 cGy/8 fx; nonspine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, or 2400 cGy/6 fx. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision making is recommended.

Based on published data, the ASTRO task force's recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.

This review aims to assess the literature regarding current treatment options for the palliative care of patients with advanced musculoskeletal malignancies whether primary or metastatic.

The inclusion of specialized palliative care physicians, in conjunction with surgeons, medical oncologists, radiation oncologists, interventional radiologists, and mental health professionals, results in better control of end-of-life symptoms in both children and adults with terminal musculoskeletal malignancies. The palliative care of patients with musculoskeletal malignancies requires a multi-disciplinary team and benefits from specialized palliative care physicians. The unique impacts of musculoskeletal malignancies on ambulation and independence creates additional mental and physical burdens on patients and care-takers alike. Palliative care should focus on preserving ambulatory function and patient independence, in addition to managing chronic pain and other end-of-life symptoms common to these malignancies.

The optimal method for the second course of stereotactic body radiotherapy (SBRT) for spinal metastases remains poorly established. This single-center, single-arm, phase II trial was conducted to propose a safe and effective salvage spine SBRT.

The patients initially treated with SBRT for spine-targeted protocol treatment, or for areas adjacent to the spine, were enrolled. The second SBRT dose was 30 Gy delivered in five fractions; the spinal cord dose constraint was 15.5 Gy at the maximum point dose. The brachial or lumbosacral plexuses were dose-constrained to <30 Gy if the boundary between the nerves and tumors was detected. The primary endpoint was dose-limiting toxicity (DLT) (grade ≥ 3 severe radiation-related toxicity) within a year after the second SBRT.

The second SBRT was administered to the same spinal level in 12 patients and to an adjacent spinal level in 8 patients. SBRT2 was performed for 14 painful lesions, 10 MESCC, and 6 oligometastases, with some lesions having multiple indications. The median interval between SBRT sessions was 21 months (range: 6-51 months). The median follow-up duration was 14 months. No radiation myelopathy or local failure was reported during the follow-up period. DLT was confirmed in two patients (10%) within a year, both of whom developed grade 3 lumbosacral plexopathy. These two patients received SBRT twice to the S1-2 and S1-5 vertebrae, respectively, and both experienced paralysis of the tibialis anterior muscle (L5 level). Grade 3 late adverse effects (including lumbosacral plexopathy and vertebral compression fracture) were observed in 25% of the patients throughout the entire follow-up period.

The second spine SBRT achieved good local control without causing myelopathy. However, one-quarter of the patients experienced grade 3 late adverse effects, suggesting that the treatment protocol carries a risk of toxicity.

Aims of the study were to assess the differences in the diagnostic efficacy of 68Ga-somatostatin receptor analogs (68Ga-SSAs) and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting bone metastases in neuroendocrine neoplasm (NEN) and to analyze the correlation between imaging features and clinical features of BMs.

We retrospectively analyzed the clinical and imaging data of 213 NEN patients who underwent 68Ga-SSA PET/CT and were finally diagnosed as BMs by pathology or follow-up. Of those, 103 patients underwent 18F-FDG PET/CT within 7 days after 68Ga-SSA PET/CT.

The BM detection rate of 68Ga-SSA PET/CT was higher than 18F-FDG PET/CT (86.4% vs. 66.0%, p = 0.02) in 103 patients with dual scanning. Meanwhile, the number of positive lesions in 68Ga-SSA PET/CT was significantly more than in 18F-FDG PET/CT (3.37 ± 1.95 vs. 2.23 ± 2.16, t = 4.137, p < 0.001). Most bone metastasis lesions presented as osteogenic change in CT (55.4%, 118/213). Concerning the primary tumor, the most frequent were of pancreatic origin (26.3%, 56/213), followed by rectal origin (22.5%, 48/213), thymic origin in 33 cases (15.5%), pulmonary origin in 29 cases (13.6%), paraganglioma in 20 cases (9.4%). The efficiency of 68Ga-SSA PET/CT to detect BMs was significantly correlated with the primary site (p = 0.02), with thymic carcinoid BMs being the most difficult to detect, and the positive rate was only 60.6% (20/33). However, 18F-FDG PET/CT positive rate was 76.92% (10/13) in thymic carcinoid BMs. In addition, the BMs of 7 patients in this study were detected by 68Ga-SSA PET earlier than CT for 4.57 months (range: 2-10 months).

68Ga-SSA PET/CT has higher sensitivity for detecting the BMs of NEN than 18F-FDG and detects the BM earlier than CT. Moreover, 18F-FDG PET/CT should be a complement for diagnosing the BMs of thymic carcinoids.

Introduction: Financial toxicity has negative implications for patient well-being and health outcomes. There is a gap in understanding financial toxicity for patients undergoing palliative radiotherapy (RT). Methods: A review of patients treated with palliative RT was conducted from January 2021 to December 2022. The FACIT-COST (COST) was measured (higher scores implying better financial well-being). Financial toxicity was graded according to previously suggested cutoffs: Grade 0 (score ≥26), Grade 1 (14-25), Grade 2 (1-13), and Grade 3 (0). FACIT-TS-G was used for treatment satisfaction, and EORTC QLQ-C30 was assessed for global health status and functional scales. Results: 53 patients were identified. Median COST was 25 (range 0-44), 49% had Grade 0 financial toxicity, 32% Grade 1, 15% Grade 2, and 4% Grade 3. Overall, cancer caused financial hardship among 45%. Higher COST was weakly associated with higher global health status/Quality of Life (QoL), physical functioning, role functioning, and cognitive functioning; moderately associated with higher social functioning; and strongly associated with improved emotional functioning. Higher income or Medicare or private coverage (rather than Medicaid) was associated with less financial toxicity, whereas an underrepresented minority background or a non-English language preference was associated with greater financial toxicity. A multivariate model found that higher area income (HR .80, P = .007) and higher cognitive functioning (HR .96, P = .01) were significantly associated with financial toxicity. Conclusions: Financial toxicity was seen in approximately half of patients receiving palliative RT. The highest risk groups were those with lower income and lower cognitive functioning. This study supports the measurement of financial toxicity by clinicians.

Painful pelvic and spinal bone metastases are a considerable challenge for doctors and patients. Conventional therapies include morphine-equivalent medication (MeM) and local radiotherapy (RT), but these interventions are not always successful. More recently, hyperthermia (HT) has been applied to complement RT and MeM, and this complex approach has shown promising synergistic results. The objective of our study was to present the results of RT combined with a special kind of HT (modulated electrohyperthermia, mEHT), in which some of the thermal effect is contributed by equivalent nonthermal components, drastically reducing the necessary power and energy. This retrospective study included 61 patients divided into three groups with pelvic and spinal bone metastases to compare the effects of RT and mEHT alone and in combination (RT + mEHT). A detailed evaluation of pain intensity, measured by the brief pain inventory score, MeM use, and breakthrough pain episodes, revealed no significant differences between RT and mEHT alone; thus, these individual methods were considered equivalent. However, RT + mEHT yielded significantly better results in terms of the above parameters. Clinically, mEHT has a lower risk of adverse thermal effects, and due to its efficacy, mEHT can be used to treat RT-resistant lesions.

Palliative radiotherapy (PRT) is frequently used to treat symptoms of advanced cancer, however benefits are questionable when life expectancy is limited. The 30-day mortality rate after PRT is a potential quality indicator, and results from a recent meta-analysis suggest a benchmark of 16% as an upper limit. In this population-based study from Queensland, Australia, we examined 30-day mortality rates following PRT and factors associated with decreased life expectancy.

Retrospective population data from Queensland Oncology Repository was used. Study population data included 22,501 patients diagnosed with an invasive cancer who died from any cause between 2008 and 2017 and had received PRT. Thirty-day mortality rates were determined from the date of last PRT fraction to date of death. Cox proportional hazards models were used to identify factors independently associated with risk of death within 30 days of PRT.

Overall 30-day mortality after PRT was 22.2% with decreasing trend in more recent years (P = 0.001). Male (HR = 1.20, 95% CI = 1.13-1.27); receiving 5 or less radiotherapy fractions (HR = 2.97, 95% CI = 2.74-3.22 and HR = 2.17, 95% CI = 2.03-2.32, respectively) and receiving PRT in a private compared to public facility (HR = 1.61, 95% CI = 1.51-1.71) was associated with decreased survival.

The 30-day mortality rate in Queensland following PRT is higher than expected and there is scope to reduce unnecessarily protracted treatment schedules. We encourage other Australian and New Zealand centres to examine and report their own 30-day mortality rate following PRT and would support collaboration for 30-day mortality to become a national and international quality metric for radiation oncology centres.

Background This study aimed to assess the efficacy of different radiation therapy regimens in treating patients with symptomatic bone metastases. Methodology A retrospective study was conducted by assigning patients with symptomatic bone metastases from different primary cancers into three groups, namely, Arms A, B, and C. The radiation dose delivered in each arm was as follows: 8 Gray (Gy) in a single fraction for Arm A, 20 Gy in five fractions at the rate of 4 Gy per fraction for Arm B, and 30 Gy in 10 fractions at the rate of 3 Gy per fraction for Arm C. Each arm consisted of 15 patients. A comparison was conducted across all three arms to evaluate pain relief based on the Visual Analog Scale (VAS), performance score improvement based on the Eastern Cooperative Oncology Group (ECOG), and analgesic requirement based on the World Health Organization (WHO) step ladder at one week, one month, and three months. Results The pain relief was measured using the VAS in three different arms, i.e., Arm A, B, and C. After one week, the pain relief was 66.67%, 60%, and 60%, respectively. After one month, it was 73.33% in all three arms. At three months, it was 80%, 86.67%, and 86.67%, respectively. The study also measured the improvement in the ECOG performance score. The improvement in all three arms was 60% after one week and 66.67% in Arm A and 73.33% in Arms B and C after one month. After three months, the improvement was 73.33%, 80%, and 80% in Arms A, B, and C, respectively. The decrease in analgesic usage was also measured in all three arms. After one week, it was 60% in all three arms. After one month, it was 66.67%, 73.33%, and 73.33% in Arms A, B, and C, respectively. At three months, it was 73.33%, 80%, and 80% in Arms A, B, and C, respectively. No significant statistical difference was found between the three arms. Conclusions The efficacy of a single 8 Gy arm was almost equivalent to that of other arms of multifractionated regimens in terms of improvement in pain and performance score and decreased use of analgesics for a short duration of follow-up. For high-volume cancer centers and patients with economic constraints, a single-fraction regime provides effective palliation for painful bone metastases.

Esophageal cancer (EC) is a common and devastating tumor of the upper digestive tract. Unfortunately, by the time any symptoms have manifested, the disease has often progressed to an advanced stage and is accompanied by macro- and micrometastases, including in the bones. The treatment of esophageal cancer with bone metastases remains clinically challenging, given the poor prognosis associated with this condition. Effective prognostic biomarkers can help medical staff choose the appropriate operation and treatment plan, that is for most beneficial for making patients. Current treatments for esophageal cancer with bone metastases include pain-relieving drugs, surgical therapy, radiotherapy (RT), chemotherapy (CT, including molecular-targeted drug therapy), endocrine therapy (ET), bisphosphonates (BPs) and interventional therapy. Of these robust measures, radiotherapy has emerged as a particularly promising therapy for bone metastases from esophageal cancer. Substantial progress has been made in radiation therapy techniques since the discovery of X-rays by Roentgen in 1895. In its palliative capacity, the key goals of radiotherapy are to relieve the patients' bone pain and debilitate effects, including relieving spinal cord compression, correcting the spinal deformity and restoring spinal stability. However, it is worth mentioning that RT for esophageal cancer has various side effects. Currently, the available studies focused exclusively on radiotherapy for ECBM are too small to draw any definitive conclusions, and each of these studies has significant limitations. In this review, in addition to the epidemiology described at the beginning, we will explore the current prognostic biomarkers and radiotherapy for esophageal cancer, with a particular focus on those with bone metastases.

Recent progress in diagnostics and treatment of metastatic cancer patients have improved survival substantially. These developments also affect local therapies, with treatment aims shifting from short-term palliation to long-term symptom or disease control. There is consequently a need to better define the value of stereotactic body radiotherapy (SBRT) for the treatment of spinal metastases.

This ESTRO clinical practice guideline is based on a systematic literature review conducted according to PRISMA standards, which formed the basis for answering four key questions about the indication and practice of SBRT for spine metastases.

The analysis of the key questions based on current evidence yielded 22 recommendations and 5 statements with varying levels of endorsement, all achieving a consensus among experts of at least 75%. In the majority, the level of evidence supporting the recommendations and statements was moderate or expert opinion, only, indicating that spine SBRT is still an evolving field of clinical research. Recommendations were established concerning the selection of appropriate patients with painful spine metastases and oligometastatic disease. Recommendations about the practice of spinal SBRT covered technical planning aspects including dose and fractionation, patient positioning, immobilization and image-guided SBRT delivery. Finally, recommendations were developed regarding quality assurance protocols, including description of potential SBRT-related toxicity and risk mitigation strategies.

This ESTRO clinical practice guideline provides evidence-based recommendations and statements regarding the selection of patients with spinal metastases for SBRT and its safe implementation and practice. Enrollment of patients into well-designed prospective clinical trials addressing clinically relevant questions is considered important.

Pain associated with breast cancer is a prevalent problem that negatively affects quality of life. Breast cancer pain is not limited to the disease course itself but is also induced by current therapeutic strategies. This, combined with the increasing number of patients living with breast cancer, make pain management for breast cancer patients an increasingly important area of research. This narrative review presents a summary of pain associated with breast cancer, including pain related to the cancer disease process itself and pain associated with current therapeutic modalities including radiation, chemotherapy, immunotherapy, and surgery. Current pain management techniques, their limitations, and novel analgesic strategies are also discussed.

These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.

Lung cancer is the leading cause of cancer-related deaths worldwide. Bone is a common metastatic site of lung cancer, about 50% of bone metastatic patients will experience skeletal related events (SREs). SREs not only seriously impact the quality of life of patients, but also shorten their survival time. The treatment of bone metastasis requires multi-disciplinary therapy (MDT) and development of individualized treatment plan. In order to standardize the diagnosis and treatment of bone metastasis in lung cancer, the expert group of the MDT Committee of the Chinese Medical Doctor Association has developed the expert consensus on the diagnosis and treatment of lung cancer bone metastasis.

To assess the clinical outcomes of patients with spine metastases treated with SBRT at our institution.

Patients with spine metastases treated with SBRT (1 fraction/18 Gy or 5 fractions/7 Gy) during the last 12 years have been analyzed. All patients were simulated supine in a vacuum cushion or with a shoulder mask. CT scans and MRI image registration were performed. Contouring was based on International Spine-Radiosurgery-Consortium-Consensus-Guidelines. Highly conformal-techniques (IMRT/VMAT) were used for treatment planning. Intra and interfraction (CBCT or X-Ray-ExacTrac) verification were mandatory.

From February 2010 to January 2022, 129 patients with spinal metastases were treated with SBRT [1 fraction/18 Gy (75%) or 5 fractions/7 Gy] (25%). For patients with painful metastases (74/129:57%), 100% experienced an improvement in pain after SBRT. With a median follow-up of 14.2 months (average 22.9; range 0.5-140) 6 patients (4.6%) experienced local relapse. Local progression-free survival was different, considering metastases's location (p < 0.04). The 1, 2 and 3 years overall survival (OS) were 91.2%, 85.1% and 83.2%, respectively. Overall survival was significantly better for patients with spine metastases of breast and prostate cancers compared to other tumors (p < 0.05) and significantly worse when visceral metastases were present (p < 0.05), when patients were metastatic de novo (p < 0.05), and in those patients receiving single fraction SBRT (p: 0.01).

According to our experience, SBRT for patients with spinal metastases was effective in terms of local control and useful to reach pain relief. Regarding the intent of the treatment, an adequate selection of patients is essential to propose this ablative approach.

Half of the patients with cancer who undergo radiation therapy do so with palliative intent.

To determine the proportion of undergoing radiation in the last month of life, patient characteristics, cancer course, the type and duration of radiation, whether palliative care was involved, and the of radiation with aggressive cancer care metrics.

One thousand seven hundred twenty-seven patients who died of cancer between January 1, 2018, and December 31, 2019, were included. Demographics, cancer stage, palliative care referral, advance directives, use of home health care, radiation timing, and survival were collected. Type of radiation, course, and intent were reviewed. Chi-square analysis was utilized for categorical variables, and Kruskal-Wallis tests for continuous variables. A stepwise selection was used to build a Cox proportional hazard model.

Two hundred thirty-three patients underwent radiation in the last month of life. Younger patients underwent radiation 67.3 years (SD 11.52) versus 69.2 years (SD 11.96). 42.6% had radiation within two weeks of death. The average fraction number was 5.5. Individuals undergoing radiation were more likely to start chemotherapy within the last 30 days of life, continue chemotherapy within two weeks of death, be admitted to the ICU, and have two or more hospitalizations or emergency room visits. Survival measured from the date of diagnosis was shorter for those undergoing radiation, 122 days (IQR 58-462) versus 474 days (IQR 225-1150). Palliative care consultations occurred later in those undergoing radiation therapy.

Radiation therapy in the last month of life occurs in younger patients with rapidly progressive cancer, who are subject to more aggressive cancer care, and have late palliative care consults.

Patients undergoing external beam radiation therapy for the palliative treatment of painful bony metastases may have difficulty maintaining a still position on a rigid uncovered couch top, both during CT simulation as well as during patient setup, image guidance, and treatment on the linear accelerator. For these patients, a thin foam pad or mattress is sometimes used to mitigate patient discomfort. It was desired to quantify the effect of the padding in cases in which the patient is to be treated supine with posterior beams when the majority of the beam weighting traverses both the couch and the pad. Ion chamber measurements in-phantom were acquired with 6 MV, 10 MV, and 15 MV photon beams. At depths of maximum dose, the pad resulted in a difference of signal collected ≤1%. At the phantom surface, the pad resulted in an increase in signal ranging from 1% to 6.5% for the measured beams. CT data of the pad, both with and without applied pressure, indicated that the pad had average HU values close to air.

There is no current standard-of-care follow-up strategy for patients who receive palliative radiotherapy (PRT) for bone metastases. Within our institution there is currently a heterogenous practice in which some providers schedule routine follow up 1-3 months after initial PRT while others do follow up only as needed (PRN).

Our study aims to compare rates of retreatment based on follow-up strategies (planned vs. PRN), explore factors that potentially affect retreatment, and evaluate whether provider follow-up strategy correlates with measurable differences in quality of care.

In a retrospective chart review, PRT courses for bone metastases at our single institution were divided by follow-up strategies (planned vs. PRN). Demographic, clinical, and PRT data were collected and analyzed via descriptive statistics. The relationship between planned follow-up appointment and subsequent retreatment was studied.

More patients received retreatment within one year of initial PRT in the planned follow-up group than in the PRN follow-up group (40.4% vs. 14.4%, p<0.001). Retreatment was achieved sooner in the planned follow-up group than in the PRN follow-up group (137 days vs. 156 days). When accounting for other variables, having a planned follow-up appointment remains the most important factor in establishing retreatment (OR = 3.32, 2.11-5.29, p<0.001).

Having a planned follow-up appointment after the initial course of PRT improves identification of patients who would benefit from additional treatment, thus improving patient experience and quality of care.

Retrospective cohort study.

To compare outcomes of percutaneous pedicle screw fixation (PPSF) to open posterior stabilization (OPS) in spinal instability patients and minimal access separation surgery (MASS) to open posterior stabilization and decompression (OPSD) in metastatic spinal cord compression (MSCC) patients.

We analysed patients who underwent surgery for thoracolumbar metastatic spine disease (MSD) from Jan 2011 to Oct 2017. Patients were divided into minimally invasive spine surgery (MISS) and open spine surgery (OSS) groups. Spinal instability patients were treated with PPSF/OPS with pedicle screws. MSCC patients were treated with MASS/OPSD. Outcomes measured included intraoperative blood loss, operative time, duration of hospital stay and ASIA-score improvement. Time to initiate radiotherapy and perioperative surgical/non-surgical complications was recorded. Propensity scoring adjustment analysis was utilised to address heterogenicity of histological tumour subtypes.

Of 200 eligible patients, 61 underwent MISS and 139 underwent OSS for MSD. There was no significant difference in baseline characteristics between MISS and OSS groups. In the MISS group, 28 (45.9%) patients were treated for spinal instability and 33 (54.1%) patients were treated for MSCC. In the OSS group, 15 (10.8%) patients were treated for spinal instability alone and 124 (89.2%) were treated for MSCC. Patients who underwent PPSF had significantly lower blood loss (95 mL vs 564 mL; P < .001) and surgical complication rates(P < .05) with shorter length of stay approaching significance (6 vs 19 days; P = .100) when compared to the OPS group. Patients who underwent MASS had significantly lower blood loss (602 mL vs 1008 mL) and shorter length of stay (10 vs 18 days; P = .098) vs the OPSD group.

This study demonstrates the benefits of PPSF and MASS over OPS and OPSD for the treatment of MSD with spinal instability and MSCC, respectively.

Ultrasound has a deep penetrating ability with minimal or no tissue injury, while cancer-mediated complications during diagnosis, therapy, and surgery have become a serious challenge for clinicians and lead to the severity of the primary condition (cancer). The current study highlights the importance of ultrasound imaging and focused ultrasound therapy during cancer diagnosis, pain reduction, guidance for surgical resection of cancer, and the effectiveness of chemotherapy. We performed the bibliometric analysis on research domains involving ultrasound, cancer management, pain, and other challenges (chemotherapy, surgical guidance, and postoperative care), to observe the trend by which the research field has grown over the years and propose a possible future trend. The data was obtained from the Web of Science, processed, and exported as plain text files for analysis in the Bibliometrix R web interface using the Biblioshiny package. A total of 3248 documents were identified from 1100 journal sources. A total of 390 articles were published in 2022, with almost a 100% growth rate from previous years. Based on the various network analysis, we conclude that the outcome of the constant research in this domain will result in better patient care during the management of various diseases, including cancer and other co-morbidities.

This monocentric, single-arm, retrospective study investigated the role of stereotactic body radiotherapy in patients with metastatic castration resistant prostate cancer who experienced oligoprogression during androgen receptor targeted agents.

We retrospectively enrolled metastatic castration resistant prostate cancer patients treated with androgen receptor targeted agents between December 2016 and January 2022. All patients experienced an oligoprogression (defined as the appearance and/or the progression of ⩽5 bone or nodal or soft tissue metastases) during treatment with androgen receptor targeted agents and received stereotactic body radiotherapy upon oligoprogressive sites, preserving the androgen receptor targeted agents. Further stereotactic body radiotherapy upon new metastatic sites was permitted. Patients showing visceral metastases or receiving palliative radiotherapy were excluded. Progressive disease at >5 metastatic sites or the appearance of visceral metastases led to a change of the systemic treatment. Primary endpoints were 36-month survival rate and 36-month rate of patients receiving treatment with androgen receptor targeted agents. Secondary endpoints were local disease control, biochemical response and safety.

We analyzed data from 30 patients. The 36-month survival rate was 90% (27 patients); 36-month rate of patients who were still on treatment with androgen receptor targeted agents was 50%. 20 of 30 patients had performed imaging control after a single course of stereotactic body radiotherapy: overall response rate was 50%, while clinical benefit was 93%. No ⩾G2 adverse events related to stereotactic body radiotherapy were recorded.

Stereotactic body radiotherapy in oligoprogressive metastatic sites during androgen receptor targeted agent treatment resulted in a feasible and effective treatment to delay the start of next-line systemic treatment and prolong overall survival in metastatic castration resistant prostate cancer. Longer follow-up and further prospective studies are necessary to confirm our preliminary results.

Metastasis to bone is a common occurrence among epithelial tumors, with a high incidence rate in the Western world. As a result, bone lesions are a significant burden on the healthcare system, with a high morbidity index. These injuries are often symptomatic and can lead to functional limitations, which in turn cause reduced mobility in patients. Additionally, they can lead to secondary complications such as pathological fractures, spinal cord compression, hypercalcemia, or bone marrow suppression. The treatment of bone metastases requires collaboration between multiple healthcare professionals, including oncologists, orthopedists, neurosurgeons, physiatrists, and radiotherapists. The primary objective of this study is to evaluate the correlation between two methods used to assess local control. Specifically, the study aims to determine if a reduction in the volume of bone lesions corresponds to better symptomatic control in the clinical management of patients, and vice versa. To achieve this objective, the study evaluates morphological criteria by comparing pre- and post-radiotherapy treatment imaging using MRI and RECIST 1.1 criteria. MRI without contrast is the preferred diagnostic imaging method, due to its excellent tolerance by patients, the absence of exposure to ionizing radiation, and the avoidance of paramagnetic contrast media side effects. This imaging modality allows for accurate assessment of bone lesions. One of the secondary objectives of this study is to identify potentially useful parameters that can distinguish patients into two classes: "good" and "poor" responders to treatment, as reported by previous studies in the literature. These parameters can be evaluated from the imaging examinations by analyzing morphological changes and radiomic features on different sequences, such as T1, STIR (short tau inversion recovery), and DWI-MRI (diffusion-weighted).