Treatment options for palliation of painful bone metastases

How Are Bone Metastases Treated?

To relieve the pain from bone mets, the main treatment options are pain killers and external radiation. Although the majority of patients experience complete or partial relief of pain following external radiation therapy, the effect is not immediate and has been shown in some studies to be transient in more than half of patients. (Lutz, S. et al Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-based Guideline. Int. J. Radiation Oncology Biol. Phys., Vol. 79, No. 4, pp. 965–976, 2011)

For patients who are not eligible or do not respond to traditional therapies, thermal ablation techniques, including focused ultrasound, radiofrequency ablation and cryoablation, are being used to treat painful metastatic bone disease.

When discussing the treatment options available, your physician may consider several factors including the primary tumor location, if the pain is localized to a specific metastasis, where the painful metastasis/es are located, the extent of any bone damage, the stability of the affected bone/s, treatments you have received and your overall health.

Systematic therapies
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Analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are prescribed to alleviate the pain. Chemotherapy, hormonal therapy, bisphosphonates and other bone modifying agents may be used to treat the disease itself and may have an indirect effect on pain.

MR-guided Focused Ultrasound (MRgFUS)
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MRgFUS for pain palliation of bone metastases is performed without any incision, by directing ultrasound energy to destroy the nerves conducting the pain. The treatment results in fast pain relief (usually within 3 days) and lasts for a duration of time similar to radiation treatment. The treatment is performed in a single session, usually does not require hospitalization and allows rapid recovery and return to normal activities.

Radiation Therapy
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The most common form of radiotherapy used for the treatment of painful bone metastases is EBRT (external beam radiation). It uses high-energy radiation to destroy the tumor locally and relieve symptoms such as pain. Pain relief is typically attained at 2- 3 weeks after treatment with a mean duration of pain relief of 3-6 months. (Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline Int J Radiat Oncol Biol Phys. 2011 Mar 15;79(4):965-76.)

Radiofrequency ablation (RFA)
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RFA is used for pain palliation of bone metastases by heating and destroying the tumor in the bone and ablating the nerves. The RFA procedure is performed with CT guidance to insert a probe through the skin to the tumor. Sometimes medical cement is inserted to aid in the stability of the bone.

Cryoablation
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Cryoablation is used for pain palliation of bone metastases by freezing and destroying the tumor in the bone and ablating the nerves. A needle or probe is inserted under CT or MRI guidance through the skin to the tumor to deliver very cold temperatures. Sometimes medical cement is applied to aid in the stability of the bone.

Surgery
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Surgery is mainly used to stabilize a weak bone to keep it from breaking, or to mend an existing fracture. The surgeon may insert screws, rods, pins, plates or cages.