diagnosing and treatment bone metastases, using PET scand and image guided IMRT to treat cancer

1. Bone Metastases

2. Bone Metastases Cancers that originate at another site (usually breast, prostate or lung) that spread to the bone are called bone metastases

3. Skeleton

4. The bones in the spine are numbered

5. More Spine Anatomy

6. Bone cancer in the spine can create problems if the tumor compresses the spinal cord inside the neural canal

7. Pain symptoms are related to the spot in the spine involved

8. Pelvic Anatomy

9. ribs spine pelvis femurs Most common sites for bone metastases

10. Some bone mets make the bone look too white (osteoblastic) others make dark holes (lytic)

11. Lytic = black hole in the bone Blastic = abnormal white area

12. An MRI may show a bone met better than a regular X-ray

13. Bone Scan A nuclear medicine bone scan would show bone mets as dark areas

14. PET scans may show the mets very clearly

15. PET scans can show bone mets that are in hard to see areas like the ribs or scapula

16. Chemotherapy can make the bones look abnormal on a PET scan because the bone marrow is working hard to make new blood Normal looking bones prior to chemoRx Same patient after receiving chemo All the bones look active (bright yellow on the scan) This is normal and not a sign of bone cancer

17. PET Scans can be used to help target the radiation three dimensionally PET showing the cancer pushing into the back of the right hip bone

18. Computer generated reconstruction showing the cancer in red and the radiation zone in orange

19. Bone met at L2 Radiation field A typical course of radiation is 10 treatments ( in some cases it is necessary to go slower, 20 to 25 trips)

21. Local Side Effects of Radiation for Bone mets Sore throat or dry mouth Trouble swallowing or dry cough Loose bowels or cramps Bladder or rectal irritation

23. Response of bone mets to radiation Symptoms respond within weeks The Xrays or scans may take months to show improvement, but eventually may come back to normal

24. PET showing near complete response by 4 months

25. 2006 2009 Response to Radiation Breast cancer metastatic to the left iliac bone, 3 years after radiation (still evidence of bone destruction on CT, but no longer hot on PET scan)

26. Bone Metastases to the Spine Involved vertebrae on the left and normal on the right

27. Kidney cancer in the spinal vertebrae surrounding the cord, and appearance after radiation…is it possible to safely radiate further?

28. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)