Radiology Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

July 03, 2018

In This Article

Bone Metastases Radionuclide Therapy

European Association of Nuclear Medicine

Indications for radionuclide bone therapy with beta-emitting radionuclides include, but are not limited to (1) Painful metastatic bone lesions with osteoblastic response, as confirmed by areas of intense uptake on radionuclide bone scans, or (2) Primary painful bone tumors with an osteoblastic response, as confirmed by areas of intense uptake on radionuclide bone scans.

The alpha-emitter radium-223 is indicated for the radionuclide treatment of castration-resistant prostate cancer (CRPC) in patients with symptomatic bone metastases and no known visceral metastatic disease.

Pregnancy and breastfeeding are absolute contraindications.

In general, there is an increased risk of hematologic adverse reactions such as neutropenia and thrombocytopenia in patients with evidence of compromised bone marrow reserve (eg, following prior cytotoxic chemotherapy and/or radiation treatment, such as external beam radiation therapy, EBRT) or in patients with advanced diffuse metastatic infiltration of the bone. These patients should be treated only after careful clinical risk–benefit assessment. Close monitoring is necessary. Usually a superscan appearance on the bone scan corresponds to a major site of bone marrow involvement and is a contraindication because of possible side effects.

The following cell count limits should be applied to radionuclide treatment (except for radium-223): Haemoglobin <90 g/L; Total white cell count <3.5 × 109/L; Platelet count <100 × 109/L.

The presence of bone marrow involvement does not represent a contraindication per se, provided that blood values remain within the cited limits and the extent of substitution does not exceed a threshold above which severe myelotoxicity is expected.

Blood cell counts should be stable before undertaking bone palliation therapy. If there is any doubt or delay in performing the therapy due to low blood cell counts, it might be worthwhile repeating blood sampling just before the treatment to exclude rapid deterioration in blood cell counts before administration of the therapeutic radionuclides.

Poor renal function reduces the plasma clearance of bone-seeking radiopharmaceuticals, resulting in a higher whole-body dose and greater risk of myelotoxicity. Therefore, patients with severely reduced renal function (ie, creatinine >180 μmol/L and/or glomerular filtration rate <30 mL/min) should be excluded from radionuclide bone treatment.

Palliative therapy with strontium-89, samarium-153, or phosphorus-32 is inappropriate in patients with a life expectancy of less than 4 weeks. Life expectancy should preferably be greater than 3 months.

Radionuclide therapy can be recommended as a palliative treatment in patients with painful bone metastases with osteoblastic or mixed pattern (osteoblastic/osteoclastic) features.

Radionuclide treatment can be recommended to improve the quality of life in patients with osteoblastic or mixed pattern (osteoblastic/osteoclastic) bone metastases.

Radionuclide treatment can be recommended to prolong survival only with the alpha-emitting radium-223 in prostate cancer patients with osteoblastic or mixed pattern (osteoblastic/osteoclastic) bone metastases without visceral dissemination. There is no evidence that other therapeutic radionuclides improve overall survival.

Concomitant or sequential radionuclide and EBRT can be used in selected patients for the treatment of painful osteoblastic or mixed pattern (osteoblastic/osteoclastic) bone metastases.

Reference

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