Disseminated intravascular coagulation in a patient treated with strontium-89 for metastatic carcinoma of the prostate.

Strontium-89 is effective in the palliation of bone pain caused by skeletal metastases. Its primary side effect is mild thrombocytopenia that typically recovers in 3 or 4 months. Subclinical disseminated intravascular coagulation is reported to be present in approximately 10% to 20% of patients with advanced prostate cancer. These patients may be at increased risk for severe marrow depression after radionuclide therapy for bone pain palliation. This report describes a patient with painful bony metastases resulting from prostate carcinoma. He had a normal platelet count and no clinical evidence of a coagulation disorder at the time of strontium-89 therapy, and a severe disseminated intravascular coagulation developed and lead to death after treatment. A normal platelet count before strontium-89 therapy does not preclude subsequent disseminated intravascular coagulation, and we support the Society of Nuclear Medicine's bone pain treatment procedure guideline that patients referred for bone palliation should be screened for disseminated intravascular coagulation before therapy.     

Gamma camera imaging of osseous metastatic lesions by strontium-89 bremsstrahlung

The aim of this study was to optimise the parameters affecting the Bremsstrahlung scintigraphy of patients injected with strontium-89 chloride. The parameters considered were : (1) instrumental detection efficiency, and (2) tissue attenuation factor for ⁸⁹Sr calibrated sources, which permit quantitative evaluation of the activity in a given bone lesion. Some typical examples of in vivo ⁸⁹Sr imaging are presented to illustrate the clinical utility of the imaging procedure developed by us, which is implemented in our department for all patients treated with ⁸⁹Sr chloride. Received 7 April and in revised form 14 July 1997     

Usefulness of strontium-89 for bone pain palliation in metastatic breast cancer patients

Most studies of prostate cancer have shown that strontium-89 chloride (89Sr) is effective in the palliation of metastatic bone pain, refractory to conventional analgesia. The aim of this study was to evaluate the usefulness of 89Sr for bone pain palliation in breast cancer patients. Forty women were treated with 148 MBq of 89Sr. Six patients were retreated, receiving two or more doses. The Karnofsky performance status was assessed and pain and analgesia were scored on scales of 9 and 5 points, respectively. The efficacy of 89Sr was evaluated at 3 months of treatment. The response was good in 60% of the patients and partial in 32%; there was no response in the remaining 8% (pre-treatment Karnofsky < or = 60). The duration of the response was 120+/-143 days. In the patients retreated, the response was good in 83% and partial in 17%, without significant differences compared with the first dose, but the pre-treatment Karnofsky and the duration of the efficacy were lower (P < 0.05). A transient and slight decrease of leukocyte and platelet counts after the first month of treatment with 59Sr was observed. In conclusion, breast cancer patients with metastatic bone pain can benefit from therapy with 89Sr. If necessary, the treatment may be repeated safely and with the same efficacy as is achieved after the first dose. A low functional performance status could be a cause of the lower effectiveness of 89Sr.     

Treatment of metastatic bone pain with repeated doses of strontium-89 in patients with prostate neoplasm

This study has aimed to evaluate the usefulness of repeated treatment with 89Sr in patients with prostate neoplasm and metastatic bone pain. Seventeen patients with partial or complete response after the first dose were retreated with two or more doses (total of 39 doses). The Karnofsky functional status, pain and degree of analgesia were assessed. After the first dose the response was good in 68% of the patients and partial in 32%. After the second dose, the response was good in 62% of the patients, partial in 15% and there was no response in 23% of the cases. The pre-treatment Karnofsky functional status and duration of the effect of 89Sr was lower after the second dose (p = 0.03, p = 0.02), but there were no statistically significant differences in the type of response. In conclusion, re-treatment with 89Sr can be administered safely and with a similar response to that achieved after the first dose.     

Effective use of strontium-89 in osseous metastases

Bone is one of the organs to which cancer metastasizes most frequently. However, it is not a vital organ, therefore, survival after the occurrence of osseous metastasis is relatively favorable. Improvements of medical treatment bring prolonged survival to patients with osseous metastases. But this makes us to recognize the importance of quality of life (QOL) due to several factors, including pain. It is important for oncologists to know how to deal with such painful osseous metastases, as pain relief may enable patients to live their remaining lives to the fullest. Strontium-89 (89Sr) has been used worldwide as in Japan, while being reported to have positive effects on pain relief and QOL improvement in patients with osseous metastases. This review paper is aimed to present not only the history, roles, and medical characters of 89Sr, but also new aspects, such as how to use bone turnover markers, which location of osseous metastases is suitable for effective use of 89Sr.     

Comparison of strontium-89 solution sources in UK hospitals, 2003.

Concerns have been raised within the nuclear medicine field about the accuracy of measurements of 89Sr. The 85Sr impurity present in the 89Sr solution has a significant effect on the response of radionuclide calibrators used in hospitals. A comparison was conducted between the National Physical Laboratory (NPL) and the UK hospital physics community. Only 58% of the results were within 5% of the NPL value. Work at NPL has resulted in correction factors for the NPL secondary standard radionuclide calibrator and for Capintec calibrators, which will produce a significant improvement in performance.     

89Strontium therapy of bone metastases of carcinoma of the prostatic gland.

Following a firm diagnostic and therapeutic schedule for patients with prostatic carcinoma. 89Strontium therapy was introduced for multiple metastases. Positive skeletal scintigraphy with 99mTc-EHDP induced check for affinity to Sr using 85Sr scintigraphy. Of 80 patients, multiple metastases were found in 26. Therapy with 1 mCi of 89Sr-chloride was started in 20 cases. In 8 patients, relief from severe pain appeared shortly afterward, and a further 8 it was possible to prevent the development of pain. Moderate success in 3 cases and a failure to provide relief in 1 were observed.     

Hemi-body radiotherapy in the management of metastatic carcinoma

Hemi-body radiotherapy has been used extensively during the last 14 years to provide effective palliation for patients with widespread metastatic carcinoma. A series of 125 consecutive assessable treatments using this technique is reported. The morbidity was minimal. The response rate overall was 82% and a response rate of 85% was obtained in patients with carcinoma of the prostate.     

89Sr therapy: strontium plasma clearance in disseminated prostatic carcinoma

Strontium plasma clearance is an important factor determining the absorbed dose to metastases and bone marrow in patients receiving 89Sr radionuclide therapy for metastatic bone disease. Amongst male patients with disseminated prostatic carcinoma, the renal component of strontium clearance is frequently greatly reduced compared with values reported for healthy middle aged men. We report a study of renal and gut strontium plasma clearance, renal function, calcium urinary excretion, parathyroid function and extent of skeletal osteoblastic metastatic disease in patients referred for radiostrontium therapy for metastasised prostatic malignancy. The wide variation in net strontium clearance was principally due to variation in the renal component. Low values of strontium renal clearance were found to correlate with the elevation of serum PTH and nephrogenous cyclic AMP, which in turn correlated with extent of skeletal metastatic disease. This suggests that the osteosclerotic metastases characteristic of prostatic carcinoma induce secondary hyperparathyroidism due to the high avidity of the skeleton for calcium. The resulting reduction in strontium excretion may be beneficial to the objectives of radiostrontium therapy.     

89Sr Therapy: Strontium plasma clearance in disseminated prostatic carcinoma

Strontium plasma clearance is an important factor determining the absorbed dose to metastases and bone marrow in patients receiving ⁸⁹Sr radionuclide therapy for metastatic bone disease. Amongst male patients with disseminated prostatic carcinoma, the renal component of strontium clearance is frequently greatly reduced compared with values reported for healthy middle aged men. We report a study of renal and gut strontium plasma clearance, renal function, calcium urinary excretion, parathyroid function and extent of skeletal osteoblastic metastatic disease in patients referred for radiostrontium therapy for metastasised prostatic malignancy. The wide variation in net strontium clearance was principally due to variation in the renal component. Low values of strontium renal clearance were found to correlate with the elevation of serum PTH and nephrogenous cyclic AMP, which in turn correlated with extent of skeletal metastatic disease. This suggests that the osteosclerotic metastases characteristic of prostatic carcinoma induce secondary hyperparathyroidism due to the high avidity of the skeleton for calcium. The resulting reduction in strontium excretion may be beneficial to the objectives of radiostrontium therapy.     

Characteristic X-ray imaging for palliative therapy using strontium-89 chloride: understanding the mechanism of nuclear medicine imaging of strontium-89 chloride

Strontium-89 (Sr-89) chloride is a targeted palliative therapy used for painful bone metastasis in which repeated doses can be administered, and its usefulness has been reported in the case of bone metastasis of various primary tumors. However, the effectiveness of the pain relief treatment is only described using a subjective index such as the visual analog scale, which lacks objectivity. Although various attempts at quantifying the effectiveness of Sr-89 chloride therapy have been reported using nuclear medicine imaging for energy peaks around 70–80 keV, the principle of Sr-89 chloride imaging has not been explained. In this study, the principle of nuclear medicine imaging for Sr-89 chloride was evaluated using a fundamental study. Additionally, the optimal collimator for acquiring Sr-89 chloride image data was evaluated. Based on the results, the principle of nuclear medicine imaging for Sr-89 chloride could be explained: the energy peaks were characteristic X-rays produced by interactions between gamma rays (514 keV) emitted from Sr-85, which is included during the manufacturing process of the Sr-89 chloride solution, and the lead collimator used in the imaging. The optimal collimator for generating characteristic X-rays efficiently was identified as a middle-to-high energy collimator.     

Bone pain palliation with strontium-89 in cancer patients with bone metastases.

Strontium-89 is a pure beta-emitting radioisotope, a chemical analogue of calcium, and it is therefore avidly concentrated by areas of high osteoblastic activity. Selective uptake and prolonged retention at sites of increased bone mineral turnover provide precise bone lesions targeting. 89Sr chloride (commercialised as Metastron) is typically administered in a single 150 MBq parenteral dose. Its radioactive emission poses very little radioprotection concerns. Overall, studies show pain relief in up to 80% of patients, of which 10 to 40% became effectively pain free. The mean duration of palliation was 3-4 months. The mechanism of pain relief is controversial ; it is probably, but not only, related to the absorbed dose in the tumour and bone. There is no clear dose-response relationship. The only reported toxicity is temporary myelosuppression. WBC and platelets should be monitored at least on a weekly basis until they return to baseline. It seems that only patients with a reasonably good general condition stand to benefit from this treatment. In conclusion, systemic radionuclide therapy using 89Sr represents a feasible, safe, effective, well tolerated and cost-effective palliative treatment in patients with refractory bone pain.     

Complete regression of multiple painful bone metastases from hepatocellular carcinoma after administration of strontium-89 chloride

A 69-year-old man received strontium-89 chloride intravenous injection to relieve uncontrollable pain from multiple hepatocellular carcinoma bone metastases. Pain was resolved 3 months later without opioid analgesics. Multiple bone metastases showed complete regression 4 months later. The patient lived for 1 year without recurrence of bone metastasis.     

89Strontium therapy of bone metastases of carcinoma of the prostatic gland

Following a firm diagnostic and therapeutic schedule for patients with prostatic carcinoma, ⁸⁹Strontium therapy was introduced for multiple metastases. Positive skeletal scintigraphy with ^99mTc-EHDP induced check for affinity to Sr using ⁸⁵Sr scintigraphy. Of 80 patients, multiple metastases were found in 26. Therapy with 1 mCi of ⁸⁹Sr-chloride was started in 20 cases. In 8 patients, relief from severe pain appeared shortly afterward, and a further 8 it was possible to prevent the development of pain. Moderate success in 3 cases and a failure to provide relief in 1 were observed.     

Magnetic resonance for radiotherapy management and treatment planning in prostatic carcinoma

MRI has an important role for radiotherapy (RT) treatment planning in prostate cancer (PCa) providing accurate visualization of the dominant intraprostatic lesion (DIL) and locoregional anatomy, assessment of local staging and depiction of implanted devices. MRI enables the radiation oncologist to optimize RT planning by better defining target tumour volumes (thereby increasing local tumour control), as well as decreasing morbidity (by minimizing the dose to adjacent normal structures). Using MRI, radiation oncologists can define the DIL for delivery of boost doses of RT using a variety of techniques including: stereotactic body radiotherapy, intensity-modulated radiotherapy, proton RT or brachytherapy to improve tumour control. Radiologists require a familiarity with the different RT methods used to treat PCa, as well as an understanding of the advantages and disadvantages of the various MR pulse sequences available for RT planning in order to provide an optimal multidisciplinary RT treatment approach to PCa. Understanding the expected post-RT appearance of the prostate and typical characteristics of local tumour recurrence is also important because MRI is rapidly becoming an integral component for diagnosis, image-guided histological sampling and treatment planning in the setting of biochemical failure after RT or surgery.     

Results of strontium-89 therapy in patients with prostate cancer resistant to chemotherapy

PURPOSE: Strontium-89 (Sr-89) chloride is an effective palliative treatment of the bone metastases of prostate cancer. Chemotherapy has also been shown to have a palliative benefit in this disease. We aimed to determine the benefits and complications of Sr-89 therapy in patients with prostate cancer who had become refractory to chemotherapy. We conducted a retrospective review of 14 treatments administered to 13 patients with chemotherapy-resistant and hormone-resistant prostate cancer. RESULTS: Of the 14 administered treatments, 8 (57%) resulted in improved pain control, with 2 patients able to stop analgesia. The median duration of response was 56 days. No prostate-specific antigen response was seen in the 8 patients tested. There was significant and prolonged bone marrow toxicity, with 6 patients requiring red blood cell transfusion. Prolonged thrombocytopenia was seen, with platelet counts remaining below baseline levels after treatment in all but one patient. Leukopenia was generally mild and not associated with infection. CONCLUSIONS: Sr-89 is an effective treatment of patients with chemotherapy-refractory prostate cancer, but careful and prolonged monitoring of hematologic parameters after therapy is required.     

Strontium-89 chloride for pain palliation in prostatic skeletal malignancy.

In a multi-centre study strontium-89 was shown to be effective in relieving bone pain from prostatic carcinoma in patients who had failed conventional therapies. Of 83 patients assessed at 3 months, following the administration of a dose of at least 1.5 MBq/kg, 75% derived benefit and 22% became pain free. Symptomatic improvement usually occurred within 6 weeks and continued for between 4 and 15 months (mean 6 months). Based on the dose estimation part of this study the recommended dose of strontium-89 is 150 MBq. Toxicity was low, provided platelet levels were above 100 x 10(9) l-1 at the time of treatment. Repeat treatments with strontium-89 may be given at intervals of not less than 3 months. Strontium-89 is administered intravenously on an out-patient basis with no special radiological protection precautions.