Radiation therapy is used with a palliative intent to reduce the symptoms associated with variety of different cancers. For rib metastases, orthovoltage radiotherapy can be prescribed as a single treatment. For cutaneous lymphomas (mycosis fungoides), superficial X-rays can be used to deliver palliative doses to plaques that are causing pain or discomfort to the patient.
Bony Metastasis Lesions
For cancer patients who have been diagnosed with metastatic disease, the purpose of their treatment is symptom control. The goal of radiotherapy is to reduce pain, and so improve quality of life and reduce analgesic requirements.
Depending on the primary cancer type, the following treatment options are available for bone metastatic lesions.
1. Systemic therapy aims to treat disease around the whole body and includes:
a. Hormone therapy for hormone receptor positive cancers
b. Chemotherapy to destroy the cancer cells, shrink the tumor, reduce symptoms, and increase survival. Side-effects of chemotherapies differ, but include tiredness, nausea, and risk of serious infections.
c. Immune therapy to induce the body’s native immune response against the cancer cells. Side effects include auto-immune conditions such as colitis, pneumonitis, hepatitis, and skin rashes.
d. Bisphosphonates to reduce skeletal-related symptoms (e.g. pain and risk of fracture). Side effects include risk of hypocalcemia, renal dysfunction, and jaw osteonecrosis.
2. Radiation therapy can be given as single or multiple treatments for lesions that are symptomatic or are threatening complications. Rib metastases are often treated with orthovoltage radiation due to the ease and comfort of setup. Radiotherapy is effective at reducing pain and there tends to be minimal side effects associated with this treatment, although sometimes it causes skin reddening, and may cause mild pigmentation. Additionally, care needs to be taken to carefully control depth of dose delivered, in order not to deliver radiation to the underlying lung which can result in localized pneumonitis.
Cutaneous T Cell lymphomas (CTCL)
Treatment options for CTCL include:
- Moisturizers – these reduce dryness and irritation
- Skin Directed Therapies (SDT) – For early stage disease. These are all that is required for many patients.
- Topical steroid creams – These can give benefit, but responses are rarely complete or durable. Disadvantages include skin irritation and mild skin atrophy.
- Topical mechlorethamine (nitrogen mustard) – This can give good response, with variable duration of response. Side-effects include irritant contact dermatitis.
- Topical bexarotene – This can be effective. Irritant contact dermatitis is common.
- Phototherapy (UVA or UVB light therapy) – For early stage disease where disease is not controlled by topical therapy. Produces high complete remission rates. However, the duration of response is often limited. Repeated courses may be considered but the increased risk of skin cancer (including melanoma) limits the number of phototherapy courses in a lifetime.
- Radiation Therapy (note: MF is a highly radiosensitive disease)
- Localized radiotherapy treatment can be used in relatively low doses for all stages of disease, particularly for plaques and tumors, for palliative benefit. It can also be used for larger affected areas of the hands and feet or nodal disease. It can be given in combination with SDT. Side effects tend to be mild and include mild skin reddening and soreness.
- Total skin electron beam therapy is a highly effective radiotherapy treatment for MF with excellent complete response rates for all stages, but it is a very complex treatment to deliver. However, it is associated with significant toxicity in some patients, including fatigue, erythema and desquamation, alopecia, lower-leg edema, blisters and skin infection.
- Systemic Therapies – for treatment of early stage disease that is refractory to SDT, or for later stage disease. Examples include:
- Interferon-alpha – can achieve complete response in early stage disease in combination with phototherapy, and disease responses in late stage disease. Side effects include flu-like symptoms and low blood counts.
- Alemtuzumab (an anti-CD52 antibody) – can achieve good overall response and complete remission rates, but of short duration. Side effects include infection, specifically cytomegalovirus reactivation with the need for irradiated blood products.
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