Clinical Practice Guidelines for the management of locally advanced ...

olus) in addition to radiotherapy ambulant at six months compared with 33% of those treated with
radiotherapy alone (p=0.05). The addition of dexamethasone significantly (p=0.046) improved the
probability of surviving with gait function in the year following treatment without a significant
increase in serious toxicities. The Vecht trial comparing high and low doses of dexamethasone
showed no difference in pain, ambulation rates or bladder function between the two arms but the low
power of the study (37 patients) cannot exclude clinically important differences.
Evidence summary Level References
There is one small trial of high-dose dexamethasone and
radiotherapy versus radiotherapy alone. This demonstrated a
significant improvement in ambulation rates in the steroid arm.
The optimal dose of steroids is unknown, with one small trial
demonstrating no significant difference in efficacy of higher-dose
dexamethasone over lower doses.
Recommendations
II 85
II 87
Patients being treated with radiotherapy for malignant spinal cord compression should also
receive dexamethasone.
Grade C
The optimal dose of dexamethasone remains to be defined.
Grade D
5.2.2 Hemibody (widefield) external beam radiotherapy
Hemibody radiotherapy refers to the practice of irradiation of either the lower body half (pelvis and
legs) or the upper body half (upper lumbar spine, chest, arms with or without the skull). It was a
commonly used treatment for prostate cancer with multifocal pain when effective chemotherapy or
radionucleide therapy was not available.
There are no controlled trials comparing pain responses with and without hemibody radiotherapy.
One low-quality RCT (Poulter 1992, n=499, 33% prostate cancer patients 88 ) examined whether
hemibody radiation in addition to local radiation retarded disease progression for patients with
moderately to severely painful single or multiple bone metastases. The addition of hemibody radiation
(8Gy, single fraction) to local radiotherapy significantly retarded disease progression as evidenced by
increase in lesion size (p=0.03) and number (p=0.01). However, in this study 88 , hemibody radiation
was associated with a significant increase in grades 3 and 4 haematological toxicity (p=0.004), with
leukopenia being significantly worse (p=0.01).
A quasi-randomised controlled trial by Scarantino (n=144, 70% prostate cancer) 89 examined the
effects of increasing the dose of hemibody irradiation in conjunction with local radiotherapy on
progression and toxicity. This study was unable to show that increasing multi-fraction hemibody
radiation dose from 10Gy to 20Gy significantly reduced the development of new metastases when
given in conjunction with local radiotherapy.
65
Overt metastatic disease and/or loco-regional progressive disease