What is the efficacy of Hemibody (widefield) external beam radiotherapy in the palliation of uncomplicated bone pain?
Hemibody radiotherapy refers to the practice of irradiation of either the lower body half (pelvis and legs) or the upper body half (upper lumbar spine, chest, arms with or without the skull). It was a commonly used treatment for prostate cancer with multifocal pain when effective chemotherapy or radionucleide therapy was not available.
There are no controlled trials comparing pain responses with and without hemibody radiotherapy.
One low-quality RCT (Poulter 1992, n=499, 33% prostate cancer patients) examined whether hemibody radiation in addition to local radiation retarded disease progression for patients with moderately to severely painful single or multiple bone metastases. The addition of hemibody radiation (8Gy, single fraction) to local radiotherapy significantly retarded disease progression as evidenced by increase in lesion size (p=0.03) and number (p=0.01). However, in this study, hemibody radiation was associated with a significant increase in grades 3 and 4 haematological toxicity (p=0.004), with leukopenia being significantly worse (p=0.01).
A quasi-randomised controlled trial by Scarantino (n=144, 70% prostate cancer) examined the effects of increasing the dose of hemibody irradiation in conjunction with local radiotherapy on progression and toxicity. This study was unable to show that increasing multi-fraction hemibody radiation dose from 10Gy to 20Gy significantly reduced the development of new metastases when given in conjunction with local radiotherapy.
A second low-quality RCT by Salazar 2001 (n=156, 32% prostate cancer) examined escalating doses of hemibody radiotherapy without local radiotherapy. When given alone, increasing hemibody radiation dose as multi-fraction regimens from 8Gy to 15Gy did not significantly improve overall pain responses (response rates 89% and 92%). However, it did significantly (p=0.016) improve complete pain responses without an apparent increase in grade 3–4 toxicity (16% at 8Gy and 8% at 15Gy).
Evidence summary and recommendations
|There are no controlled trials comparing pain responses with and without hemibody radiotherapy.||II||, |
| Increasing hemibody radiation doses above 8Gy does not improve overall pain palliation.
There is no good evidence to support the use of fractionated hemibody irradiation over a single fraction.
Adding hemibody radiation to local external beam radiotherapy while retarding progression increases grade 3–4 haematological toxicity.
- Poulter CA, Cosmatos D, Rubin P, Urtasun R, Cooper JS, Kuske RR, et al. A report of RTOG 8206: a phase III study of whether the addition of single dose hemibody irradiation to standard fractionated local field irradiation is more effective than local field irradiation alone in the treatment of symptomatic osseous metastases. Int J Radiat Oncol Biol Phys 1992;23(1):207-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1374061.
- Scarantino CW, Caplan R, Rotman M, Coughlin C, Demas W, Delrowe J. A phase I/II study to evaluate the effect of fractionated hemibody irradiation in the treatment of osseous metastases--RTOG 88-22. Int J Radiat Oncol Biol Phys 1996 Aug 1;36(1):37-48 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8823257.
- Salazar OM, Sandhu T, da Motta NW, Escutia MA, Lanzós-Gonzales E, Mouelle-Sone A, 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 2001 Jul 1;50(3):765-75 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11395246.