The most common locations of metastases from esophageal cancer are the lung and liver, and bone metastases are relatively uncommon. However, there are still patients who find bone metastases after initial diagnosis or treatment, often with severe pain that affects quality of life.
Bone metastases typically occur in locations such as the vertebrae and iliac bones. The symptoms at the time of detection are mostly site-specific pain, which may be accompanied by percussion and pressure pain. Also, fractures can occur in severe cases due to tumor encroachment.
The presence of bone metastases means that the tumor has developed blood dissemination and systemic chemotherapy is needed. The tumor has been found to be a major source of pain, but systemic chemotherapy is not effective in relieving severe localized pain, and long-term pain medication can cause side effects and poor pain relief. At this point, radiotherapy becomes the preferred means of targeting metastatic lesions.
In this article, we look at the development of a treatment plan for bone metastases from esophageal cancer through a case study, and you can see that there is still hope for targeting the lesion for pain relief and improving quality of life.
Visit experience
Mr. Ding is 56 years old, lives in Inner Mongolia, and is used to eating large pieces of meat and drinking alcohol. in the summer of 2017, Mr. Ding developed dysphagia, especially noticeable during large bites of food. The burning sensation in his chest was also significantly worse when he drank alcohol. By fall, he had to eat staple foods that had to be sent down with water or thin porridge, and also had meat chunks stuck in his esophagus.
He had a gastroscopy, cervicothoracic abdominal CT at the local hospital, and a mass was found in the middle esophagus that occupied 3/4 of the week and was about to block the entire esophagus. Pathological biopsy showed a moderately differentiated squamous cell carcinoma.
He was seen at Peking University Cancer Hospital, and after completing a full body workup that did not reveal metastases, he underwent radical esophageal cancer surgery in late 2017, removing the lower and middle esophagus and bringing the stomach up into the chest to join the remaining esophagus.
Post-operatively, Mr. Ding recovered well and also followed his doctor’s advice to have post-operative adjuvant radiation therapy.
Before he was discharged from the hospital, the doctor specifically told Mr. Ding that he should be reviewed every 3 months after surgery, preferably at the operating hospital, because the doctor knew his condition better. But he did not comply.
Recurrence of metastasis
In July 2018, he felt back pain from time to time and thought he had a lumbar strain. After resting at home for 1 month, the pain got worse, and he had trouble sleeping at night.
A bone scan at the local hospital showed radioactive thickening at the second vertebra of his lumbar spine, and combined with a history of esophageal cancer, the doctor determined that bone metastases were likely to be present.
When he heard the word “metastasis”, Mr. Ding was devastated. The company’s main business is to provide a wide range of products and services to the market. He bought some painkillers ibuprofen, but the pain was basically not relieved. He still can’t sleep all night and has no appetite.
After a week like that, Mr. Ding decided to go back to Beijing for treatment.
Second visit
Mr. Ding found the doctor who did his surgery. After an initial examination, he was advised to see a medical oncologist and radiation therapist. The doctor determined that he was in severe pain and prescribed oxycodone-based oral pain medication first; he also completed chest CT, gastroscopy, abdominal B-ultrasound, and brain MRI, which showed no signs of metastasis anywhere else in his body except for bone metastases.
The doctor told him that systemic chemotherapy was necessary because the tumor had spread to the bone. However, because of the current poor pain relief, it was recommended to go to radiotherapy first to address the pain.
The radiation therapist said:
You have only bone metastases and no recurrence of the original esophageal lesion or other organs, so there is no need to be so pessimistic; radiotherapy can completely control the bone metastases and provide effective pain relief.
For single, solitary metastases, systemic chemotherapy combined with local radiotherapy has a better efficacy.
Here, Mr. Ding felt a little relieved to hear this. But combined with his previous experience, he was fearful of side effects.
The radiotherapist said:
Post-surgical radiotherapy is prophylactic treatment to avoid residual lesions lurking in the diseased esophagus or adjacent locations, so the scope of irradiation is relatively large and includes the surgical area between the two lungs, so the side effects are more pronounced. However, this time, only the lumbar metastases were treated, and the dose was not as high, so the side effects were mild.
The doctor designed a 30Gy/10 session local radiotherapy plan for him, which means a total irradiation dose of 30 gorie (Gy) in 10 sessions. This was done once a day, Monday through Friday, with a weekend off, for a total of two weeks of treatment.
Halfway through radiation therapy, his pain was no longer significant; near the end, he no longer needed pain medication at all. After completing treatment, examination of the lumbar spine also revealed no further bone destruction.
Currently, Mr. Ding is hopeful for the future and is ready to go to medical oncology for chemotherapy.
Summary
Esophageal cancer is a high incidence in northern China and one of the characteristic cancers in China. Because the early symptoms are mild, most people do not care about it and it is often in the middle to late stage when it is detected.
Advanced cancer generally refers to the occurrence of distant organ metastases, which are often not suitable for surgical treatment. The efficiency of systemic chemotherapy for esophageal cancer is only 10% to 20%. So advanced tumors lose the chance of cure.
But that doesn’t mean there’s no hope, and it doesn’t mean you have to “go home and die. The first time I saw the patient, I was able to get to the bottom of the problem. Some patients can survive long term after receiving a combination of systemic chemotherapy + local radiotherapy.
Unlike pain medications that “treat the symptoms but not the root cause,” radiation therapy targets the cause of the pain and controls the progression of the lesion with a pain relief rate of 60% or more, and a complete pain relief rate of 33% within 4 weeks.
Radiation therapy for esophageal cancer bone metastases is recommended for 30-40Gy/10-20 doses. A study in the United States has shown that an 8Gy/dose regimen also achieves better treatment outcomes. Each of the two regimens has its own advantages. In 2011, the American Society for Radiation Oncology (ASTRO) expert consensus stated that multiple fractional irradiation is recommended for patients with a long survival expectancy, while a single 8Gy irradiation is more recommended for patients with a short survival expectancy or limited activity.
Disclaimer:
Tumor disease and treatment options are extremely complex and treatment should be fully individualized, and this case does not represent a “like patient” treatment decision. Please seek professional advice from a competent physician regarding your specific treatment plan.
Co-Author: Dr. Yangzi Zhang, Peking University Cancer Hospital