Editing Radiotherapy for Prostate Cancer (section)

== Radiation therapy for palliation ==

* '''Bone metastases'''
** Management options for the management of bone metastases include surgery, medical management, and radiation.
*** RT can treat most patients with highly effective symptom relief.
** '''A single-fraction regimen (800 cGy × 1)''' '''is the preferred regimen for patients with uncomplicated non-spinal bone metastasis'''
*** Appears to be as effective as other, more protracted regimens, is more cost-effective and less time-consuming for patients
** '''Metastasis to a weight-bearing region''' can be painful and disabling, both functionally and psychologically.
** '''Pathologic fracture is infrequent because prostate cancer produces primarily blastic metastases'''
*** '''Radiographic and clinical factors that warrant consideration of prophylactic surgical fixation (3):'''
***# '''Intramedullary lytic lesion length ≥ 50% of the cross-sectional diameter of the bone'''
***# '''Cortical lytic lesion length ≥ than the cross-sectional diameter of the bone'''
***# '''Lytic lesion > 2.5 cm in axial length'''
**** '''These patients should be evaluated by an orthopedic surgeon.'''
*** '''If a pathologic fracture has occurred in a weight-bearing region, surgical fixation is required for pain control and to promote adequate healing.'''
**** '''Postoperative radiation is required after surgical fixation.'''
** '''Spinal cord compression'''
*** '''Most serious complication of bone metastases'''
**** Epidural cord compressions arising from vertebral bodies accounts for the majority of spinal cord compressions; less frequently they are associated with soft-tissue masses involving the paravertebral region.
*** '''Diagnosis and Evaluation'''
**** '''<span style="color:#ff0000">Medical emergency; early diagnosis and therapy are critical'''
***** '''Failure to diagnose and treat promptly can lead to significant morbidity, including paraplegia and autonomic dysfunction'''
**** '''History and Physical Exam'''
***** '''The clinical syndrome often includes ≥1 of the following (3):'''
*****# '''Back pain'''
*****#* '''Pain is predominant symptom (≈95% of patients).'''
*****#* '''Back pain in a patient with a history of bone metastases should prompt an evaluation for epidural cord compression.'''
*****# '''Focal neurologic deficit (leg weakness, sensory levels)'''
*****# '''Changes in bladder or bowel control'''
****** Most of these patients have abnormalities on bone scintigraphs and/or abnormal findings on radiography at the time of diagnosis. '''However, a deficit on neurologic examination may be the only finding in patients who exhibit soft-tissue epidural metastasis in the paravertebral region.'''
**** '''Imaging'''
***** '''MRI is diagnostic modality of choice'''
*** '''Management'''
**** '''When the diagnosis of cord compression is made or even suspected, all patients should receive corticosteroid therapy (e.g., dexamethasone).'''
***** '''Steroids can decrease vasogenic edema and provide analgesic benefit'''
***** '''Loading dose of dexamethasone is 4-10 mg, followed by maintenance dose of 4-24 mg q6h'''
**** '''Definitive treatment should include radiation therapy, surgical decompression, or both'''
***** Situations in which surgery should be considered as an option before radiation (3):
*****# Unknown tissue diagnosis
*****# History of previous radiation to the same area
*****# Pathologic fracture with spinal instability or compression of the spinal cord by bone