Palliative Radionuclide Bone Therapy

1. Bone scan
The patient should have had recent bone scintigraphy (less than 8 wk) documenting increased osteoblastic activity in the
painful sites.

5. CBC
Complete blood counts should be obtained, preferably on the day of, and not more than 7d before, treatment.
platelet count > 60,000/mL and preferably 100,000/mL;
leukocyte count > 2,400–3,000/ml and preferably 5,000/mL;
absolute granulocyte count > 2,000/mL;
hemoglobin level should be more than 10g/dL

Results below these blood count levels are not absolute contraindications to treatment but raise the chance of infection or
bleeding. Practitioners should be aware of counts over the preceding weeks; a rapid recent fall without signs of recovery
should be considered a probable contraindication.

2. Nerve compression
Ascertain that osseous or soft-tissue abnormalities, which might cause cord or other nerve compression or pathologic fracture
in an extremity, are not present.

Radionuclide therapy would be indicated in these circumstances only in conjunction with local radiation therapy or surgical
intervention and especially if there are other painful bone metastases. These beta-emitters may also be effective if pain
persists at the single treated site.

7. Pain severity
Before using radionuclide therapy the pain usually should be severe enough to limit activity and/or to require narcotic
analgesia for control of symptoms.

There are no definitive data on the efficacy of the treatment of asymptomatic or minimally painful osteoblastic metastatic
disease in terms of delaying the time to the onset of future clinically significant bone pain.

8. DIC
Active disseminated intravascular coagulation (DIC) may be a risk factor for severe thrombocytopenia post-therapy. Deaths
have been reported in patients with DIC after therapy with beta-emitting radiopharmaceuticals, and this potential risk must
be sought and carefully considered before radionuclide therapy in the presence of DIC, especially if a rapid recent fall in
platelet count has occurred.

9.1. Renal failure
Hypercalcemia should not deter radionuclide treatment unless accompanied by renal failure.

11. Route of administration
The radiopharmaceutical should be administered slowly through an intravenous catheter or a running intravenous line.

13.1. Near death
A patient who has a life expectancy of less than 4–6 wk is unlikely to benefit from radionudlide therapy, and,

13.1. Death
at his/her death, the pathologist will require certain precautions (goggles, double gloving) if an autopsy is performed less
than 1 wk after administration. There is no problem with cremation if the crematorium annually handles bodies containing less
than 2 mCi of all radionuclides except 131I, which has a 200 mCi/y limit.

14. Dose
89Sr-chloride 1.5–2.2 MBq/kg (40–60 mCi/kg) or 148 MBq (4 mCi).
153Sm-lexidronam 1 mCi/kg
32P-sodium phosphate 185–370 MBq (5–10 mCi) intravenously (often in divided doses) or 370–444 MBq (10–12 mCi) orally.

Patients have responded to up to 7 dosages of radiotracer if needed, but the risk of marrow toxicity rises with each
subsequent dosage.

15. Repeat
The procedure may be repeated 12 or more wk after the first injection if blood counts are at the suggested levels. The
response rate after the second treatment is about 50% and may occur even if there was no response to the first
treatment.

9.3. Hydration
The patient should remain well hydrated before, during, and after the procedure.

10. Fasting
The patient need not fast before administration of the radiopharmaceutical.

3. Myelosuppressive chemotherapy
In general, patients should not have received long-acting myelosuppressive chemotherapy for 6–8 wk, and systemic radioisotope
therapy for approximately 4 wk before treatment and for about 12 wk after treatment.

4. Radiation
The patient should not have received external beam hemibody radiation within 2–3 mo before treatment, except for radiotherapy
to local areas performed to prevent fracture or spinal compression.

6. Hormone therapy
The presence or absence of nonandrogenic hormone therapy is irrelevant to treatment.

9.2. bisphosphonates therapy
Recent administration of etidronate or other bisphosphonates may decrease the uptake of radionucide therapy at the tumor site
and, consequently, decrease the effectiveness of pain palliation. If bisphosphonates have been administered within 2 wk
before the planned therapy, a bone scan should be considered to confirm adequate uptake at the tumor site. Bisphosphonate
therapy probably should not be given for at least 48 hr after radionuclide therapy.

12. Hospitalization
Hospitalization is not required for the radionuclide therapy.