Single frActIoN eighT Gray Palliative Radiotherapy With Modulated Intensity for Pain Reduction

Non-randomized, monocentric, observational study to evaluate the response in terms of reduction of painful symptoms from bone metastases to radiotherapy with high personalization of treatment: performed with modern technology, supplied with modulated intensity technique with concomitant integrated boost, according to selection of patients in accordance with prognosis determined by specific prognostic score

Palliative antalgic oncological treatments concern a chronically-evolving disease patient with pain control problems, and are a complex problem from different points of view: logistic, clinical and scientific research. An increasing number of patients are afflicted due to the increased incidence of cancer in all its phases and the potential chronicity of the disease linked to new therapies.

The use of palliative anti-radiation radiotherapy treatments involves up to 40% of patients in a Radiotherapy Center. Radiotherapy was used in the palliative treatment of symptomatic bone metastases to improve quality of life (QoL) of these patients. This is the easiest way to respond to problems of home care or long-term care (eg: Hospice). This need is particularly accentuated for patients with a more severe situation. To reduce the overall duration of the treatment, it is necessary to manage hypofractionated regulators (ie with dose fractionation which daily dispense a dose higher than 2Gy). In fact, hypofractionated regimes concern the gold standard for these clinical presentations.

With the same pain control, multiple fractionation boards report better symptom control over time and are therefore very often preferred for patients with a prognosis\> 6 months. On the other hand, the treatment regimen with 8 Gy in single therapy session is suggested as preferable for patients with a worse prognosis (ie less than 6 months of life expectancy). Evidence from literature suggests that palliative radiation therapy is effective in controlling pain even in the last weeks of the patient's life and therefore useful to improve the conditions of patients with a more severe prognosis.

The identification of patients with the worst prognosis to which single-agent radiotherapy is reserved is another crucial aspect. Unfortunately, although clinically validated in scientific trials, the routine use of prognostic scores is rarely used in everyday clinical practice to characterize life expectancy and define the most appropriate treatment regimen. This aspect limits the effective personalization of palliative treatments of this type.

Furthermore, the indications available in the literature do not specify a univocally shared standard of technical approach to radiant treatment. The Consensus Conference whose data have been reported by Chow et al. considers as potentially applicable both non-conformed techniques (e.g .: single back beam) and the most modern conformational techniques. The less conformed techniques have the defect of distributing in a more variable way the dose inside the target to irradiate and to save less well the organs at risk (OAR) with consequent increase of the risk of toxicity that could reduce the beneficial to the patient given by the reduction of pain from metastases.

Finally, the prescription of the single 8 Gy radiotherapy session in daily practice is still not sufficiently widespread, as evidenced by international literature . Due to the peculiar characteristics of the patients who need these treatments, scientific research aimed at optimizing these therapies is a need for assistance and even ethics.

This particular analysis, within the Umbrella Protocol, focuses on patients with uncomplicated and painful vertebral bone metastases, and is aimed at observing and recording the efficacy of treatment in a single 8 Gy session, applied in good clinical practice. according to available evidence.

Particular attention is paid to applying a high degree of personalization of the treatment and a modern approach to the technology of performing the radiant treatment. The personalization of the treatment will be favored by the routine use of: i) a valid prognostic score for the expected survival, the Mizumoto prognostic Score (Mizumoto M, 2008), to identify patients with the worst prognosis to offer treatment in a single session. The use of the most advanced radiation dose administration technologies will be applied by choosing (in the spectrum of technologies applicable to these clinical presentations) the most modern modulated intensity radiotherapy (IMRT). IMRT allows to reduce the dose administered to the OAR and to concentrate the areas with the highest dose concentration (the so-called "hot spots") only within the evidence of disease (or "Gross tumor Volume" - GTV). Through the integrated simultaneous boost (SIB) method in IMRT, it is possible, in fact, to check the extent and location of the "hot zones" by specifying, through precise prescription, the maximum desired amount and the topographic limits to the inside of the target prescribed at the dose of 8 Gy, however doing "drop" the dose to the surrounding OAR.

The hypothesis of the study is to observe the rates of pain control and the need to retract the patient, when applied to personalization of indications and maximum technological support. These results could be a basis of scientific evidence to further support the clinical orientation towards the use of the single fraction of radiotherapy with consequent improvement in the quality of life of these patients. Furthermore, such data will be able to feed further analyzes aimed at the cost / effectiveness of this approach.

Eligibility Criteria:
Inclusion Criteria:

* Patients diagnosed with spinal bone metastases from solid, uncomplicated tumor
* Established primary or secondary tumor histology correlated to the treatment lesion
* Age \>18 years
* Obtaining informed consent
* Symptomatic patients (NRS\> = 4) at the treatment site
* Prognosis \<6 months according to Mizumoto Prognostic Score (i.e. Class B or C)
* Spine Instability Neoplastic Score (SINS) \<7

Exclusion Criteria:

* Concurrent disorders (psychiatric and otherwise) which, in the opinion of the investigator, make data collection unreliable
* Impossibility to assign specific NRS for each CTV to be enrolled
* Previous radiotherapy at the same site or at the level of adjoining metamers (higher or lower than the one to be enrolled)
* Radiometabolic therapy
* Previous enrollment of the same patient for 3 irradiated lesions
* Epidural compression of the spinal cord or of the cauda equina
* Injuries affecting\> 25% of the medullary canal and / or a distance \<5 mm from the medulla or from the cauda
* Injuries with indication of surgical stabilization
* Pregnancy