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Adida S, Sefcik RK, Gerszten PC. Comment on "The 5-factor modified frailty index as a prognostic factor for stereotactic radiosurgery in meningioma management". J Neurooncol 2025; 173:493-494. [PMID: 40029505 DOI: 10.1007/s11060-025-04983-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2025] [Accepted: 02/20/2025] [Indexed: 03/05/2025]
Affiliation(s)
- Samuel Adida
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St Suite B-400, Pittsburgh, PA, 15213, USA
| | - Roberta K Sefcik
- Department of Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St Suite B-400, Pittsburgh, PA, 15213, USA.
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Gasho JO, de Reus D, Pierik RJ, Amelink J, Schwab JH, Tobert DG. Postoperative External Beam Versus Stereotactic Body Radiation Therapy as Adjuvant to Surgically Treated Spinal Metastases. Global Spine J 2025:21925682251345753. [PMID: 40401649 PMCID: PMC12098324 DOI: 10.1177/21925682251345753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2025] [Revised: 05/06/2025] [Accepted: 05/13/2025] [Indexed: 05/23/2025] Open
Abstract
Study DesignRetrospective cohort.ObjectivesWith rising cancer rates and survival, effective palliative treatments are crucial. For decades, conventional external beam RT (cEBRT) has been the standard for palliation but is dose-limited. The efficacy of postoperative radiotherapy for spinal metastases with stereotactic body radiation therapy (SBRT) in direct comparison to cEBRT remains understudied. We aim to compare clinical outcomes after treatment with cEBRT or SBRT for patients with spinal metastases.MethodsEligible patients included those who received palliative RT with cEBRT or SBRT between January 2017 and December 2022 at Massachusetts General Hospital. A matched cohort of 204 patients was created using propensity score matching. Reoperation, overall survival (OS), and postoperative complications were evaluated. Multivariable logistic regression was used to adjust for residual bias after propensity score matching.Results81 patients treated with cEBRT were matched with 123 patients treated with SBRT. Reoperation rate was 13.2%, with no significant difference between the cEBRT and SBRT groups (12.4% vs 13.8%, P = 0.76). Median OS was 15.9 months (IQR, 6.7-40.6 months). Kaplan-Meier analysis revealed no significant association between type of radiotherapy and either reoperation or OS (P = 0.40 and P = 0.56, respectively). When comparing reoperation by radiation modality, multivariable logistic regression analysis showed no significant difference.ConclusionWe observed that SBRT does not reduce rates of reoperation or complications, nor does it improve overall survival. These findings suggest that conventional radiotherapy remains a viable postoperative treatment for spinal metastases, especially when SBRT is not available or feasible, or when cost is a significant concern.
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Affiliation(s)
- Jordan O. Gasho
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel de Reus
- Department of Orthopedic Surgery, University Medical Center Utrecht-Utrecht University, Utrecht, Netherlands
| | - Robert-Jan Pierik
- Department of Orthopedic Surgery, University Medical Center Utrecht-Utrecht University, Utrecht, Netherlands
| | - Jantijn Amelink
- Department of Orthopedic Surgery, University Medical Center Utrecht-Utrecht University, Utrecht, Netherlands
| | - Joseph H. Schwab
- Department of Orthopedic Surgery, Cedars-Sinai Hospital, Los Angeles, CA, USA
| | - Daniel G. Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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3
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Figueroa R, Malano F, Cuadra A, Guarda J, Leiva J, Leyton F, López A, Solé C, Valente M. Development and Validation of Monte Carlo Methods for Converay: A Proof-of-Concept Study. Cancers (Basel) 2025; 17:1189. [PMID: 40227815 PMCID: PMC11988178 DOI: 10.3390/cancers17071189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Revised: 03/21/2025] [Accepted: 03/24/2025] [Indexed: 04/15/2025] Open
Abstract
BACKGROUND Radiotherapy technology has undergone significant advancements, driven by the pursuit of improved tumor control probabilities and reduced normal tissue complication probabilities. This has been achieved primarily through innovative approaches that prioritize high dose conformity on complex treatment targets. The CONVERAY project introduces a groundbreaking teletherapy system featuring a convergent X-ray beam, which enables highly conformal dose distributions by converging photons to a focal spot, thereby achieving exceptionally high fluence rates. METHODS Customized Monte Carlo subroutines have been developed to simulate particle fluence and associated dosimetry effects for the CONVERAY device. This simulation approach facilitated a detailed, step-by-step characterization of radiation fluence and interaction processes, enabling seamless integration with a conventional clinical linear accelerator head. Key physical properties of the radiation beam have been comprehensively characterized for various CONVERAY configurations, providing a solid foundation for evaluating the corresponding dosimetry performance. RESULTS Monte Carlo simulations successfully tracked the phase state of the CONVERAY device, characterizing the influence of individual components on convergent photon beam production. Simulations evaluated dosimetry performance, confirming the device's capability to achieve high dose concentrations around the focal spot. Preliminary tests on realistic scenarios (intracranial and pulmonary irradiations) demonstrated promising spatial dose concentration within tumor volumes, while gantry rotation significantly improved dose conformation. CONCLUSIONS This proof-of-concept Monte Carlo study of the CONVERAY prototype provided critical insights into the generation of convergent X-ray beams, validating the device's ability to achieve its primary objective. Notably, simulation results reveal the potential for exceptionally high dose concentrations within complex treatment volumes, demonstrating promising dosimetry performance.
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Affiliation(s)
- Rodolfo Figueroa
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
- Departamento de Ciencias Físicas, Universidad de La Frontera, Temuco 4811230, Chile
| | - Francisco Malano
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
- Departamento de Ciencias Físicas, Universidad de La Frontera, Temuco 4811230, Chile
| | | | - Jaime Guarda
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
| | - Jorge Leiva
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
| | - Fernando Leyton
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
| | - Adlin López
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
- Departamento de Ciencias Físicas, Universidad de La Frontera, Temuco 4811230, Chile
| | - Claudio Solé
- Clínica IRAM, Santiago 7630370, Chile; (A.C.); (C.S.)
- Facultad de Medicina, Universidad Diego Portales, Santiago 8370067, Chile
| | - Mauro Valente
- Centro de Excelencia de Física e Ingeniería en Salud (CFIS), Universidad de La Frontera, Temuco 4811230, Chile; (F.M.); (J.G.); (J.L.); (F.L.); (A.L.)
- Departamento de Ciencias Físicas, Universidad de La Frontera, Temuco 4811230, Chile
- Instituto de Física E. Gaviola (IFEG), CONICET & Facultad de Matemática, Astronomía, Física y Computación (FAMAF), Universidad Nacional de Córdoba, Córdoba 5000, Argentina
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Adida S, Taori S, Bhatia S, Kann MR, Burton SA, Flickinger JC, Olson AC, Sefcik RK, Zinn PO, Gerszten PC. A case series and review of stereotactic body radiation therapy for contiguous multilevel spine metastases. J Neurooncol 2025; 171:299-309. [PMID: 39527381 DOI: 10.1007/s11060-024-04863-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Accepted: 10/21/2024] [Indexed: 11/16/2024]
Abstract
PURPOSE A majority of published series report on stereotactic body radiation therapy (SBRT) for 1-2 contiguous vertebral levels due to concerns regarding setup accuracy and radiation toxicity. This study evaluates patients with metastases spanning ≥ 3 contiguous levels treated with SBRT and augments its findings with a review of other studies investigating multilevel spine SBRT. METHODS Analysis of a prospectively collected database of 49 patients with 55 metastases spanning ≥ 3 contiguous vertebral levels treated with SBRT at a single institution (2002-2023) was performed. Outcomes identified included local failure (LF), pain response, overall survival, and toxicity. The median single-fraction prescription dose was 15 Gy (range: 8-18); multifractionated treatment utilized prescription doses of 18-30 Gy in 2-5 fractions. RESULTS Median follow-up was 7 months (range: 1-103). The 6-month, 1-year, and 2-year cumulative incidence rates of LF were 7%, 11%, and 11%, respectively. No prognostic factors were associated with LF. Pain was reported to improve or remain stable for 49 lesions (89%). Ten adverse radiation events (18%) were identified; pain flare (5%), dermatitis (4%), and vertebral compression fracture (VCF, 9%). The 3-month, 6-month, and 1-year cumulative incidence rates of VCF were 4%, 7%, and 7%, respectively. No instances of esophageal toxicity or myelopathy were observed. CONCLUSIONS This study of multilevel SBRT is one of the largest to investigate outcomes in this challenging clinical scenario. Spine SBRT confers low rates of LF and toxicity for patients with multilevel disease, which was previously considered a relative contraindication. Spine SBRT may be considered in this patient population instead of low-dose palliative RT.
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Affiliation(s)
- Samuel Adida
- School of Medicine, University of Pittsburgh Medical Center, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Suchet Taori
- School of Medicine, University of Pittsburgh Medical Center, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Shovan Bhatia
- School of Medicine, University of Pittsburgh Medical Center, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Michael R Kann
- School of Medicine, University of Pittsburgh Medical Center, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Steven A Burton
- Department of Radiation Oncology, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA
| | - Adam C Olson
- Department of Radiation Oncology, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA
| | - Roberta K Sefcik
- Department of Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St Suite B-400, Pittsburgh, PA, 15213, USA
| | - Peter C Gerszten
- Department of Radiation Oncology, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA.
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St Suite B-400, Pittsburgh, PA, 15213, USA.
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5
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Sekar V, Walsh J, Pearson LH, Barzilai O, Sharif S, Zileli M. Radiation therapy, radiosurgery, chemotherapy and targeted therapies for metastatic spine tumors: WFNS Spine committee recommendations. Neurosurg Rev 2024; 48:12. [PMID: 39739070 DOI: 10.1007/s10143-024-03123-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Revised: 11/11/2024] [Accepted: 11/15/2024] [Indexed: 01/02/2025]
Abstract
OBJECTIVE This review aims to formulate the most current, evidence-based recommendations regarding radiation therapy, radiosurgery, and chemotherapy for patients with metastatic spine tumors. METHODS A systematic literature using PRISMA methodology was performed from 2010-2023 using the search terms "radiosurgery," "radiation therapy," "external beam radiation therapy," or "stereotactic body radiation therapy" in conjunction with "spinal," "spine," "metastasis," "metastases," or "metastatic." RESULTS Spinal metastases should be managed in a multidisciplinary team consisting of spine surgeons, radiation oncologists, radiologists and oncologists. Patients identified as potential candidates for SRS/EBRT using internationally recognized frameworks and criteria should be assessed by surgeons to see if surgical cyto-reduction/ separation surgery can be achieved. Choices for treatment of recurrence include re-irradiation with SBRT vs EBRT, surgical debulking, additional chemotherapy or palliative care. There is a lack of current clinical evidence to support the routine use of targeted therapies in the management of metastatic spinal tumors. CONCLUSIONS Improving the management of spinal metastasis will lead to increased quality of life and improved survival. This review provides current, evidence-based guidelines on radiation therapy, radiosurgery, and chemotherapy for patients with metastatic spine tumors.
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Affiliation(s)
- Vashisht Sekar
- Department of Neurological Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - Jamie Walsh
- Department of Neurological Surgery, Queens University Belfast, Belfast, Northern Ireland
| | - Luke H Pearson
- Department of Neurological Surgery, University of Florida Jacksonville, Jacksonville, FL, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Hospital, New York, USA
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Mehmet Zileli
- Department of Neurosurgery, Sanko University, Gaziantep, Türkiye
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Tom MC, Komatineni S, Wang C, de Almeida RAA, Ghia AJ, Beckham TH, Perni S, McAleer MF, Swanson T, Yeboa DN, De BS, Rooney MK, Bishop AJ, Reddy JP, Yang Y, Ludmir EB, Zhang S, Amini B, Alvarez-Breckenridge C, North RY, Rhines LD, Li J, Tatsui CE. Spinal laser interstitial thermal therapy and radiotherapy for thoracic metastatic epidural spinal cord compression. J Neurooncol 2024; 170:289-296. [PMID: 39325339 DOI: 10.1007/s11060-024-04777-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 07/09/2024] [Indexed: 09/27/2024]
Abstract
PURPOSE Spinal laser interstitial thermal therapy (sLITT) is a less invasive alternative to surgery for metastatic epidural spinal cord compression. Here, we analyze outcomes of patients treated with sLITT either in conjunction with radiotherapy or as a standalone salvage therapy. METHODS We included patients with thoracic vertebral metastatic cord compression treated with sLITT. Outcomes included freedom from local failure (FFLF) and overall survival (OS). Factors associated with FFLF were identified with univariable and multivariable analyses via a Cox proportional hazards model. RESULTS Between 2013-2022, 129 patients received sLITT to 144 vertebral segments; 69% were radiotherapy naïve, 81% were radioresistant histologies, and 74% were centered in the vertebral body. Median age was 61 years. Pre-sLITT Bilsky score was 3 in 28%, 2 in 33%, and 1c in 37%. Radiotherapy was delivered in conjunction with sLITT for 80% of cases, including 68% that received stereotactic radiotherapy, at a median of 5 days after sLITT. Median follow-up was 9.1 months. One-year FFLF and OS was 80% and 78%, respectively. On multivariable analysis, variables independently associated with adverse FFLF included paraspinal/foraminal disease location (p = 0.001), and post-sLITT imaging Bilsky score of 2 (p = 0.073) or 3 (p = 0.011). Prior radiotherapy, technique of radiotherapy, and time between radiotherapy and sLITT were not associated with FFLF. CONCLUSION sLITT with radiotherapy is an effective minimally invasive treatment approach for thoracic metastatic epidural spinal cord compression. Early treatment response may serve as a prognostic imaging biomarker.
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Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Suraj Komatineni
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Subha Perni
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Todd Swanson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian S De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael K Rooney
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yumeng Yang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shizhen Zhang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Behrang Amini
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Robert Y North
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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McVeigh LG, Linzey JR, Strong MJ, Duquette E, Evans JR, Szerlip NJ, Jackson WC. Stereotactic body radiotherapy for treatment of spinal metastasis: A systematic review of the literature. Neurooncol Adv 2024; 6:iii28-iii47. [PMID: 39430390 PMCID: PMC11485818 DOI: 10.1093/noajnl/vdad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2024] Open
Abstract
Background Advances in local and systemic therapies continue to improve overall survival for patients with cancer, increasing the incidence of spine metastases. Up to 15% of patients with solid tumors develop spinal metastases. Spinal metastases can be particularly devastating for quality of life given the potential pain, neurological deficits from spinal cord compression or cauda equina syndrome, spinal instability, and pathological fractures that may result. Stereotactic body radiotherapy (SBRT) with or without adding less invasive surgical techniques for stabilization or separation has gained favor. SBRT uses smaller, more precise treatment volumes, allowing for higher doses per fracture, thus increasing ablative abilities. Methods We conducted a systematic review using MEDLINE, Embase (Elsevier), and Web of Science to identify all articles investigating the effectiveness of SBRT in providing local disease control, pain control, and relief of spinal cord compression for patients with metastatic disease of the spine. Results The review yielded 84 articles that met inclusion criteria. The evidence indicates SBRT provides excellent local control and pain control for patients with spine metastesis, and this remains true for patients with spinal cord compression managed with surgical separation followed by postoperative spine SBRT. Conclusion While not all patients are appropriate candidates for SBRT, carefully considering appropriate frameworks that consider the patient's overall prognosis can guide a multidisciplinary team toward the patients who will benefit the most from this treatment modality.
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Affiliation(s)
- Luke G McVeigh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J Strong
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth Duquette
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph R Evans
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas J Szerlip
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
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Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
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Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Nguyen EK, Korol R, Ali S, Cumal A, Erler D, Louie AV, Nguyen TK, Poon I, Cheung P, Chu W, Soliman H, Vesprini D, Sahgal A, Chen H. Predictors of pathologic fracture and local recurrence following stereotactic body radiation therapy to 505 non-spine bone metastases. Radiother Oncol 2023; 186:109792. [PMID: 37414253 DOI: 10.1016/j.radonc.2023.109792] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Stereotactic Body Radiation Therapy (SBRT) is increasingly applied to treat non-spine bone metastases (NSBM) though data remains limited on this approach. In this retrospective study, we report outcomes and predictors of local failure (LF) and pathological fracture (PF) post-SBRT for NSBM using a mature single-institution database. METHODS Patients with NSBM treated with SBRT between 2011 and 2021 were identified. The primary objective was to assess the rates of radiographic LF. Secondary objectives were to assess the rates of in-field PF, overall survival (OS), and late grade ≥ 3 toxicity. Competing risks analysis was used to assess rates of LF and PF. Univariable regression and multivariable regression (MVR) were performed to investigate predictors of LF and PF. RESULTS A total of 373 patients with 505 NSBM were included in this study. Median follow-up was 26.5 months. The cumulative incidence of LF at 6, 12, and 24 months were 5.7%, 7.9%, and 12.6%, respectively. The cumulative incidence of PF at 6, 12, and 24 months were 3.8%, 6.1%, and 10.9%, respectively. Lytic NSBM (HR = 2.18; p < 0.01), a lower biologically effective dose (HR = 1.11 per 5 Gy10 decrease; p = 0.04), and a PTV ≥ 54 cc (HR = 4.32; p < 0.01) predicted for a higher risk of LF on MVR. Lytic NSBM (HR = 3.43; p < 0.01), mixed (lytic/sclerotic) lesions (HR = 2.70; p = 0.04), and rib metastases (HR = 2.68; p < 0.01) predicted for a higher risk of PF on MVR. CONCLUSION SBRT is an effective modality to treat NSBM with high rates of radiographic local control with an acceptable rate of PF. We identify predictors of both LF and PF that can serve to inform practice and trial design.
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Affiliation(s)
- Eric K Nguyen
- Department of Radiation Oncology, Walker Family Cancer Center, Niagara Health, St. Catharines, Ontario L2S 0A9, Canada
| | - Renee Korol
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Saher Ali
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Aaron Cumal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Darby Erler
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Center, Western University, London, Ontario N6A 5W9, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - William Chu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Danny Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada.
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10
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Sherry AD, Maroongroge S, De B, Amini B, Conley AP, Bishop AJ, Wang C, Beckham T, Tom M, Briere T, Li J, Yeboa DN, McAleer MF, North R, Tatsui CE, Rhines LD, Ghia AJ. Management of chordoma and chondrosarcoma with definitive dose-escalated single-fraction spine stereotactic radiosurgery. J Neurooncol 2023; 164:377-386. [PMID: 37667065 PMCID: PMC11917496 DOI: 10.1007/s11060-023-04432-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE The management of chordoma or chondrosarcoma involving the spine is often challenging due to adjacent critical structures and tumor radioresistance. Spine stereotactic radiosurgery (SSRS) has radiobiologic advantages compared with conventional radiotherapy, though there is limited evidence on SSRS in this population. We sought to characterize the long-term local control (LC) of patients treated with SSRS. METHODS We retrospectively reviewed patients with chordoma or chondrosarcoma treated with dose-escalated SSRS, defined as 24 Gy in 1 fraction to the gross tumor volume. Overall survival (OS) was calculated by Kaplan-Meier functions. Competing risk analysis using the cause-specific hazard function estimated LC time. RESULTS Fifteen patients, including 12 with chordoma and 3 with chondrosarcoma, with 22 lesions were included. SSRS intent was definitive, single-modality in 95% of cases (N = 21) and post-operative in 1 case (5%). After a median censored follow-up time of 5 years (IQR 4 to 8 years), median LC time was not reached (IQR 8 years to not reached), with LC rates of 100%, 100%, and 90% at 1 year, 2 years, and 5 years. The median OS was 8 years (IQR 3 years to not reached). Late grade 3 toxicity occurred after 23% of treatments (N = 5, fracture), all of which were managed successfully with stabilization. CONCLUSION Definitive dose-escalated SSRS to 24 Gy in 1 fraction appears to be a safe and effective treatment for achieving durable local control in chordoma or chondrosarcoma involving the spine, and may hold particular importance as a low-morbidity alternative to surgery in selected cases.
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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Sean Maroongroge
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Brian De
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony P Conley
- Department of Sarcoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Thomas Beckham
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Martin Tom
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Robert North
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA.
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11
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Ramadan S, Arifin AJ, Nguyen TK. The Role of Post-Operative Radiotherapy for Non-Spine Bone Metastases (NSBMs). Cancers (Basel) 2023; 15:3315. [PMID: 37444424 DOI: 10.3390/cancers15133315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Non-spine bone metastases (NSBMs) can cause significant morbidity and deterioration in the quality of life of cancer patients. This paper reviews the role of post-operative radiotherapy (PORT) in the management of NSBMs and provides suggestions for clinical practice based on the best available evidence. We identified six retrospective studies and several reviews that examined PORT for NSBMs. These studies suggest that PORT reduces local recurrence rates and provides effective pain relief. Based on the literature, PORT was typically delivered as 20 Gy in 5 fractions or 30 Gy in 10 fractions within 5 weeks of surgery. Complete coverage of the surgical hardware is an important consideration when designing an appropriate radiation plan and leads to improved local control. Furthermore, the integration of PORT in a multidisciplinary team with input from radiation oncologists and orthopedic surgeons is beneficial. A multimodal approach including PORT should be considered for an NSBM that requires surgery. However, phase III studies are needed to answer many remaining questions and optimize the management of NSBMs.
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Affiliation(s)
- Sherif Ramadan
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Andrew J Arifin
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
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12
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Maciejczak A, Gasik R, Kotrych D, Rutkowski P, Antoniak K, Derenda M, Dobiecki K, Górski R, Grzelak L, Guzik G, Harat M, Janusz W, Jarmużek P, Łątka D, Maciejczyk A, Mandat T, Potaczek T, Rocławski M, Trembecki Ł, Załuski R. Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1300-1325. [PMID: 36854861 DOI: 10.1007/s00586-023-07546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/31/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities. METHODS The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies. RESULTS The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies. CONCLUSION The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.
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Affiliation(s)
- A Maciejczak
- Department of Neurosurgery, Szpital Wojewódzki Tarnów, University of Rzeszów, Rzeszów, Poland.
| | - R Gasik
- Department of Neuroorthopedics and Neurology, National Geriatrics, Rheumatology and Rehabilitation Institute, Warsaw, Poland
| | - D Kotrych
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - K Antoniak
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - M Derenda
- Department of Neurosurgery, University of Warmia and Mazury, Olsztyn, Poland
| | - K Dobiecki
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - R Górski
- Department of Neurosurgery and Spine Surgery, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | - L Grzelak
- Department of Neurosurgery, City Hospital, Toruń, Poland
| | - G Guzik
- Department of Oncologic Orthopedics, Sub-Carpathian Oncology Center, Brzozów, Poland
| | - M Harat
- Department of Oncology and Brachytherapy, Oncology Center Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - W Janusz
- Department of Orthopedics and Traumatology, Medical University of Lublin, Lublin, Poland
| | - P Jarmużek
- Department of Neurosurgery, University of Zielona Góra, Zielona Góra, Poland
| | - D Łątka
- Department of Neurosurgery, University of Opole, Opole, Poland
| | - A Maciejczyk
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - T Mandat
- Department of Nervous System Neoplasms, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - T Potaczek
- Department of Orthopedics and Rehabilitation, University Hospital Zakopane, Jagiellonian University, Kraków, Poland
| | - M Rocławski
- Department of Orthopaedics, Medical University of Gdansk, Gdańsk, Poland
| | - Ł Trembecki
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - R Załuski
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
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13
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Pathak RS, Tibdewal A, Kinhikar R, Wakeham K, Akbarov K, Cordero L, Khandavalli A, Agarwal JP. Practice Patterns and Perspectives on Stereotactic Body Radiation Therapy for the Metastatic Spine From Lower- and Middle-Income Countries. JCO Glob Oncol 2022; 8:e2200167. [PMID: 36103640 PMCID: PMC9812512 DOI: 10.1200/go.22.00167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE We wanted to understand the current practice patterns and stereotactic body radiation therapy (SBRT) utilization for spine metastases in lower- and middle-income countries (LMICs). METHODS A questionnaire was designed to identify the current practice patterns of treating spine metastases, uptake of spine SBRT in routine care, dose fractionations commonly used, and the perceived benefits and toxicities of using ablative doses. Individuals registering for a spine SBRT workshop were requested to answer the questionnaire. RESULTS We received 395 responses from radiation oncologists (ROs) working in 12 different LMICs. The majority of respondents were from an academic institute (57.5%). Two hundred seventy-four respondents further identified themselves from the government/public sector (44.89%), corporate/private sector (47.89%), not-for-profit organization (5.4%), or public-private partnership (5.4%). The respondents indicated that 8.43%, 27.46%, 41.73%, and 10.04% of the spine metastases patients are treated using clinical marking, X-ray-based, 3D conformal radiation therapy, and SBRT, respectively. A third of the respondents did not have any experience of spine SBRT; those with high-volume practice were predominantly from an academic institute. The majority of respondents would use spine SBRT to reduce pain severity (71.9%) and achieve durable pain control (61.01%) in the setting of oligometastases (92.73%) and reirradiation (56.69%). Respondents preferred 3- to 5-fraction regimens (64.9%) over 1-2 fractions (33.68%). The top three reasons for not using spine SBRT were resource constraints (50%), lack of machine (37.11%), and lack of training (27.34%). CONCLUSION There is heterogeneity in spine SBRT practice and utilization between academic and nonacademic institutes. Resource and infrastructure constraints along with lack of training are limiting the use of SBRT among ROs from LMICs. Collaborative studies from LMICs will help in resolving unique challenges posed by resource constraints.
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Affiliation(s)
| | - Anil Tibdewal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | | | - Katherine Wakeham
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
| | - Kamal Akbarov
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Lisbeth Cordero
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | | | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India,Jai Prakash Agarwal, Department of Radiation Oncology, Tata Memorial Centre, 1131, Homi Bhabha Block, Dr. E Borges Road, Parel, Mumbai, Maharashtra, India 400012; e-mail:
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14
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Guo L, Ke L, Zeng Z, Yuan C, Wu Z, Chen L, Lu L. Stereotactic body radiotherapy for spinal metastases: a review. Med Oncol 2022; 39:103. [DOI: 10.1007/s12032-021-01613-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023]
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15
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Henzen D, Schmidhalter D, Guyer G, Stenger-Weisser A, Ermiş E, Poel R, Deml MC, Fix MK, Manser P, Aebersold DM, Hemmatazad H. Feasibility of postoperative spine stereotactic body radiation therapy in proximity of carbon and titanium hybrid implants using a robotic radiotherapy device. Radiat Oncol 2022; 17:94. [PMID: 35549961 PMCID: PMC9097088 DOI: 10.1186/s13014-022-02058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/22/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE To assess the feasibility of postoperative stereotactic body radiation therapy (SBRT) for patients with hybrid implants consisting of carbon fiber reinforced polyetheretherketone and titanium (CFP-T) using CyberKnife. MATERIALS AND METHODS All essential steps within a radiation therapy (RT) workflow were evaluated. First, the contouring process of target volumes and organs at risk (OAR) was done for patients with CFP-T implants. Second, after RT-planning, the accuracy of the calculated dose distributions was tested in a slab phantom and an anthropomorphic phantom using film dosimetry. As a third step, the accuracy of the mandatory image guided radiation therapy (IGRT) including automatic matching was assessed using the anthropomorphic phantom. For this goal, a standard quality assurance (QA) test was modified to carry out its IGRT part in presence of CFP-T implants. RESULTS Using CFP-T implants, target volumes could precisely delineated. There was no need for compromising the contours to overcome artifact obstacles. Differences between measured and calculated dose values were below 11% for the slab phantom, and at least 95% of the voxels were within 5% dose difference. The comparisons for the anthropomorphic phantom showed a gamma-passing rate (5%, 1 mm) of at least 97%. Additionally the test results with and without CFP-T implants were comparable. No issues concerning the IGRT were detected. The modified machine QA test resulted in a targeting error of 0.71 mm, which corresponds to the results of the unmodified standard tests. CONCLUSION Dose calculation and delivery of postoperative spine SBRT is feasible in proximity of CFP-T implants using a CyberKnife system.
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Affiliation(s)
- Dominik Henzen
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gian Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Stenger-Weisser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ekin Ermiş
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Poel
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Caspar Deml
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Karl Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Matthias Aebersold
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hossein Hemmatazad
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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16
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Colosimo C, Pasqualetti F, Aristei C, Borghesi S, Forte L, Mignogna M, Badii D, Bosio M, Paiar F, Nanni S, Bertocci S, Lastrucci L, Parisi S, Ingrosso G. Stereotactic radiotherapy for bone oligometastases. Rep Pract Oncol Radiother 2022; 27:40-45. [PMID: 35402030 PMCID: PMC8989454 DOI: 10.5603/rpor.a2022.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/20/2021] [Indexed: 12/25/2022] Open
Abstract
About 60–90% of cancer patients are estimated to develop bone metastases, particularly in the spine. Bone scintigraphy, computed tomography (CT ) and magnetic resonance imaging (MRI ) are currently used to assess metastatic bone disease; positron emission tomography/computed tomography (PET-CT ) has become more widespread in clinical practice because of its high sensitivity and specificity with about 95% diagnostic accuracy. The most common and well-known radiotracer is 18F-fluorodeoxyglucose (18FDG); several other PET-radiotracers are currently under investigation for different solid tumors, such as 11C or 18FDG-choline and prostate specific membrane antigen (PSMA)-PET/CT for prostate cancer. In treatment planning, standard and investigational imaging modalities should be registered with the planning CT so as to best define the bone target volume. For target volume delineation of spine metastases, the International Spine Radiosurgery Consortium (ISRC ) of North American experts provided consensus guidelines. Single fraction stereotactic radiotherapy (SRT ) doses ranged from 12 to 24 Gy; fractionated SRT administered 21–27 Gy in 3 fractions or 20–35 Gy in 5 fractions. After spine SRT, less than 5% of patients experienced grade ≥ 3 acute toxicity. Late toxicity included the extremely rare radiation-induced myelopathy and a 14% risk of de novo vertebral compression fractures.
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Affiliation(s)
- Caterina Colosimo
- Operative Unit of Radiotherapy, Department of Oncology, San Luca Hospital, Lucca, Italy
| | - Francesco Pasqualetti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | - Simona Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - Letizia Forte
- Department of Radiotherapy, Livorno Hospital, ATNO, Italy
| | - Marcello Mignogna
- Operative Unit of Radiotherapy, Department of Oncology, San Luca Hospital, Lucca, Italy
| | | | - Manrico Bosio
- Department of Radiotherapy, Livorno Hospital, ATNO, Italy
| | - Fabiola Paiar
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Sara Nanni
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - Silvia Bertocci
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | | | - Silvana Parisi
- Radiation Oncology Unit - Department of Biomedical, Dental Science, and Morphological and Functional Images, University of Messina, Italy
| | - Gianluca Ingrosso
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
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Faruqi S, Chen H, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan J, Suh J, Yomo S, Sahgal A. Stereotactic Radiosurgery for Postoperative Spine Malignancy: A Systematic Review and International Stereotactic Radiosurgery Society (ISRS) Practice Guidelines. Pract Radiat Oncol 2021; 12:e65-e78. [PMID: 34673275 DOI: 10.1016/j.prro.2021.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/17/2021] [Accepted: 10/03/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine safety and efficacy of postoperative spine stereotactic body radiation therapy (SBRT) in the published literature, and to present practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). MATERIALS AND METHODS A systematic review of the literature was performed, specific to postoperative spine SBRT, using PubMed and Embase databases. A meta-analysis for 1-year local control (LC), overall survival (OS) and vertebral compression fracture (VCF) probability was conducted. RESULTS The literature search revealed 251 potentially relevant articles after duplicates were removed. Of these 56 were reviewed in-depth for eligibility and 12 met all the inclusion criteria for analysis. 7 studies were retrospective, 2 prospective observational and 3 were prospective phase I/II clinical trials. Outcomes for a total of 461 patients and 499 spinal segments were reported. 10 studies used an MRI fused to CT-simulation for treatment planning, 2 investigations reported on all patients receiving a CT-myelogram at the time of planning. Meta-analysis for 1 year LC and OS was 88.9% and 57%, respectively. The crude reported VCF rate was 5.6%. One case of myelopathy was described in a patient with a previously irradiated spinal segment. One patient developed an esophageal fistula requiring surgical repair. CONCLUSIONS Postoperative spine SBRT delivers a high 1-year LC with acceptably low toxicity. Patients that may benefit from this include those with oligometastatic disease, radioresistant histology, paraspinal masses and/or those with a history of prior irradiation to the affected spinal segment. The ISRS recommends a minimum interval of 8 to 14 days after invasive surgery prior to simulation for SBRT, with initiation of radiotherapy within 4 weeks of surgery. An MRI fused to the planning CT, and/or the use of a CT-myelogram, are necessary for target and organ-at-risk delineation. A planning organ-at-risk volume (PRV) of 1.5 to 2mm for the spinal cord is advised.
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Affiliation(s)
- Salman Faruqi
- Department of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Alberta, Canada.
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
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18
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Phase 1 study of spinal cord constraint relaxation with single session spine stereotactic radiosurgery in the primary management of patients with inoperable, previously irradiated metastatic epidural spinal cord compression. NORTH AMERICAN SPINE SOCIETY JOURNAL 2021; 6:100066. [PMID: 35141631 PMCID: PMC8820013 DOI: 10.1016/j.xnsj.2021.100066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
Background Patients with previously irradiated metastatic epidural spinal cord compression (MESCC) who are not surgical candidates are at high risk of neurologic deterioration due to disease in the setting of limited treatment options. We seek to establish the feasibility of using salvage spine stereotactic radiosurgery (SSRS) allowing for spinal cord dose constraint relaxation as the primary management of MESCC in inoperable patients monitoring for radiation related toxicity and radiographic local control (LC). Methods Inoperable patients with previously irradiated MESCC were enrolled on this prospective Phase 1 single institution protocol. Single fraction SSRS was delivered to a prescription dose of 18 Gy. Spinal cord constraint relaxation was performed incrementally from an initial allowable Dmax cohort of 8 Gy to 14 Gy in the final planned cohort. Patients were monitored every 3 months with follow-up visits and MRI scans. Results The trial was closed early due to slow accrual. From 2011 to 2014, 11 patients were enrolled of which 9 patients received SSRS. Five patients were in the 8 Gy cord Dmax cohort and 4 in the 10 Gy cord Dmax cohort. The median overall survival (OS) was 11.9 months (95% CI 7.1, 22 months). Of the 9 patients treated with SSRS, 1 died prior to post-SSRS evaluation. Of the remaining 8 patients, 5 experienced a local failure. Three of the five were treated with surgery while two received systemic therapy. Two of the five failures ultimately resulted in loss of neurologic function. The median LC was 9.1 months (95%CI 4.8, 20.1 months). With a median clinical follow-up of 6.8 months, there were no cases of RM. Conclusions Despite the limited life expectancy in this high-risk cohort of patients, strategies to optimize LC are necessary to prevent neurologic deterioration. Larger prospective trials exploring optimal dose/fractionation and cord constraints are required.
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Chakravarthy VB, Khan HA, Srivatsa S, Emch T, Chao ST, Krishnaney AA. Factors associated with adjacent-level tumor progression in patients receiving surgery followed by radiosurgery for metastatic epidural spinal cord compression. Neurosurg Focus 2021; 50:E15. [PMID: 33932922 DOI: 10.3171/2021.2.focus201097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Separation surgery followed by spine stereotactic radiosurgery (SSRS) has been shown to achieve favorable rates of local tumor control and patient-reported outcomes in patients with metastatic epidural spinal cord compression (MESCC). However, rates and factors associated with adjacent-level tumor progression (ALTP) in this population have not yet been characterized. The present study aimed to identify factors associated with ALTP and examine its association with overall survival (OS) in patients receiving surgery followed by radiosurgery for MESCC. METHODS Thirty-nine patients who underwent separation surgery followed by SSRS for MESCC were identified using a prospectively collected database and were retrospectively reviewed. Radiological measurements were collected from preoperative, postoperative, and post-SSRS MRI. Statistical analysis was conducted using the Kaplan-Meier product-limit method and Cox proportional hazards test. Subgroup analysis was conducted for patients who experienced ALTP into the epidural space (ALTP-E). RESULTS The authors' cohort included 39 patients with a median OS of 14.7 months (range 2.07-96.3 months). ALTP was observed in 16 patients (41.0%) at a mean of 6.1 ± 5.4 months postradiosurgery, of whom 4 patients (10.3%) experienced ALTP-E. Patients with ALTP had shorter OS (13.0 vs 17.1 months, p = 0.047) compared with those without ALTP. Factors associated with an increased likelihood of ALTP included the amount of bone marrow infiltrated by tumor at the index level, amount of residual epidural disease following separation surgery, and prior receipt of radiotherapy at the index level (p < 0.05). Subgroup analysis revealed that primary tumor type, amount of preoperative epidural disease, time elapsed between surgery and radiosurgery, and prior receipt of radiotherapy at the index level were significantly associated with ALTP-E (p < 0.05). CONCLUSIONS To the authors' knowledge, this study is the first to identify possible risk factors for ALTP, and they suggest that it may be associated with shorter OS in patients receiving surgery followed by radiosurgery for MESCC. Future studies with higher power should be conducted to further characterize factors associated with ALTP in this population.
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Affiliation(s)
| | - Hammad A Khan
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Shaarada Srivatsa
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
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20
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Bastos DCA, Vega RA, Traylor JI, Ghia AJ, Li J, Oro M, Bishop AJ, Yeboa DN, Amini B, Kumar VA, Rao G, Rhines LD, Tatsui CE. Spinal laser interstitial thermal therapy: single-center experience and outcomes in the first 120 cases. J Neurosurg Spine 2021; 34:354-363. [PMID: 33307530 DOI: 10.3171/2020.7.spine20661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to present the results of a consecutive series of 120 cases treated with spinal laser interstitial thermal therapy (sLITT) to manage epidural spinal cord compression (ESCC) from metastatic tumors. METHODS The electronic records of patients treated from 2013 to 2019 were analyzed retrospectively. Data collected included demographic, pathology, clinical, operative, and imaging findings; degree of epidural compression before and after sLITT; length of hospital stay; complications; and duration before subsequent oncological treatment. Independent-sample t-tests were used to compare means between pre- and post-sLITT treatments. Survival was estimated by the Kaplan-Meier method. Multivariate logistic regression was used to analyze predictive factors for local recurrence and neurological complications. RESULTS There were 110 patients who underwent 120 sLITT procedures. Spinal levels treated included 5 cervical, 8 lumbar, and 107 thoracic. The pre-sLITT Frankel grades were E (91.7%), D (6.7%), and C (1.7%). The preoperative ESCC grade was 1c or higher in 92% of cases. Metastases were most common from renal cell carcinoma (39%), followed by non-small cell lung carcinoma (10.8%) and other tumors (35%). The most common location of ESCC was in the vertebral body (88.3%), followed by paraspinal/foraminal (7.5%) and posterior elements (4.2%). Adjuvant radiotherapy (spinal stereotactic radiosurgery or conventional external beam radiation therapy) was performed in 87 cases (72.5%), whereas 33 procedures (27.5%) were performed as salvage after radiotherapy options were exhausted. sLITT was performed without need for spinal stabilization in 87 cases (72.5%). Post-sLITT Frankel grades were E (85%), D (10%), C (4.2%), and B (0.8%); treatment was associated with a median decrease of 2 ESCC grades. The local control rate at 1 year was 81.7%. Local control failure occurred in 25 cases (20.8%). The median progression-free survival was not reached, and overall survival was 14 months. Tumor location in the paraspinal region and salvage treatment were independent predictors of local recurrence, with hazard ratios of 6.3 and 3.3, respectively (p = 0.01). Complications were observed in 22 cases (18.3%). sLITT procedures performed in the lumbar and cervical spine had hazard ratios for neurological complications of 15.4 and 17.1 (p < 0.01), respectively, relative to the thoracic spine. CONCLUSIONS sLITT is safe and provides effective local control for high-grade ESCC from vertebral metastases in the thoracic spine, particularly when combined with adjuvant radiotherapy. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.
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Affiliation(s)
| | - Rafael A Vega
- 4Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Behrang Amini
- 3Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Vinodh A Kumar
- 3Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
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21
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Electron beam intraoperative radiotherapy for metastatic epidural spinal cord compression: a prospective observational study. Clin Exp Metastasis 2021; 38:219-225. [PMID: 33629217 DOI: 10.1007/s10585-021-10078-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
To assess the additional effects of intraoperative radiotherapy (IORT) with decompression surgery and adjuvant external beam radiotherapy (EBRT) for metastatic epidural spinal cord compression (MESCC). This single-arm institutional prospective observational study recruited patients between June 2017 and March 2020 and included those with symptoms of spinal cord compression owing to metastases, who were diagnosed using MRI. Patients with radiation-sensitive primary tumors and those who could not tolerate surgery were excluded. The treatment protocol comprised decompression surgery and electron beam IORT of 20 Gy in a single fraction followed by EBRT of 30 Gy in 10 fractions. The primary endpoints included the 1-year local failure rate and ambulatory functions. The study was closed in May 2019 owing to changes in treatment policies at our institution. Twenty patients were registered between June 2017 and May 2019. Although all patients completed surgery and IORT, 2 did not receive postoperative EBRT. Patients most commonly had colorectal cancer (4 patients), followed by thyroid cancer, renal cell carcinoma, lung cancer, breast cancer, sarcomas, and other cancers (3, 3, 2, 2, 2, and 4 patients, respectively). The median follow-up duration was 16 months (range 2-30 months); the 1-year local failure rate was 16%. On comparing ambulatory functions pre-treatment and at 1 year after treatment, improvement, no change, and worsening were observed in 3, 9, and 0 patients, respectively. This study's findings suggest that decompression surgery and IORT followed by EBRT are effective in achieving local control and maintaining ambulation in patients with MESCC.
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22
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Kowalchuk RO, Waters MR, Richardson KM, Spencer K, Larner JM, McAllister WH, Sheehan JP, Kersh CR. Stereotactic body radiation therapy for spinal metastases: a novel local control stratification by spinal region. J Neurosurg Spine 2021; 34:267-276. [PMID: 33096522 DOI: 10.3171/2020.6.spine20861] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study evaluated a large cohort of patients treated with stereotactic body radiation therapy for spinal metastases and investigated predictive factors for local control, local progression-free survival (LPFS), overall survival, and pain response between the different spinal regions. METHODS The study was undertaken via retrospective review at a single institution. Patients with a tumor metastatic to the spine were included, while patients with benign tumors or primary spinal cord cancers were excluded. Statistical analysis involved univariate analysis, Cox proportional hazards analysis, the Kaplan-Meier method, and machine learning techniques (decision-tree analysis). RESULTS A total of 165 patients with 190 distinct lesions met all inclusion criteria for the study. Lesions were distributed throughout the cervical (19%), thoracic (43%), lumbar (19%), and sacral (18%) spines. The most common treatment regimen was 24 Gy in 3 fractions (44%). Via the Kaplan-Meier method, the 24-month local control was 80%. Sacral spine lesions demonstrated decreased local control (p = 0.01) and LPFS (p < 0.005) compared with those of the thoracolumbar spine. The cervical spine cases had improved local control (p < 0.005) and LPFS (p < 0.005) compared with the sacral spine and trended toward improvement relative to the thoracolumbar spine. The 36-month local control rates for cervical, thoracolumbar, and sacral tumors were 86%, 73%, and 44%, respectively. Comparably, the 36-month LPFS rates for cervical, thoracolumbar, and sacral tumors were 85%, 67%, and 35%, respectively. A planning target volume (PTV) > 50 cm3 was also predictive of local failure (p = 0.04). Fewer cervical spine cases had disease with PTV > 50 cm3 than the thoracolumbar (p = 5.87 × 10-8) and sacral (p = 3.9 × 10-3) cases. Using decision-tree analysis, the highest-fidelity models for predicting pain-free status and local failure demonstrated the first splits as being cervical and sacral location, respectively. CONCLUSIONS This study presents a novel risk stratification for local failure and LPFS by spinal region. Patients with metastases to the sacral spine may have decreased local control due to increased PTV, especially with a PTV of > 50 cm3. Multidisciplinary care should be emphasized in these patients, and both surgical intervention and radiotherapy should be strongly considered.
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Affiliation(s)
- Roman O Kowalchuk
- 1Radiosurgery Center, Riverside Regional Medical Center (in partnership with University of Virginia Health System), Newport News
| | - Michael R Waters
- 1Radiosurgery Center, Riverside Regional Medical Center (in partnership with University of Virginia Health System), Newport News
| | - K Martin Richardson
- 1Radiosurgery Center, Riverside Regional Medical Center (in partnership with University of Virginia Health System), Newport News
| | - Kelly Spencer
- 1Radiosurgery Center, Riverside Regional Medical Center (in partnership with University of Virginia Health System), Newport News
| | | | - William H McAllister
- 3Department of Neurosurgery, Riverside Regional Medical Center, Newport News, Virginia
| | - Jason P Sheehan
- 4Neurosurgery, University of Virginia Health System, Charlottesville; and
| | - Charles R Kersh
- 1Radiosurgery Center, Riverside Regional Medical Center (in partnership with University of Virginia Health System), Newport News
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Soltys SG, Grimm J, Milano MT, Xue J, Sahgal A, Yorke E, Yamada Y, Ding GX, Li XA, Lovelock DM, Jackson A, Ma L, El Naqa I, Gibbs IC, Marks LB, Benedict S. Stereotactic Body Radiation Therapy for Spinal Metastases: Tumor Control Probability Analyses and Recommended Reporting Standards. Int J Radiat Oncol Biol Phys 2021; 110:112-123. [PMID: 33516580 DOI: 10.1016/j.ijrobp.2020.11.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE We sought to investigate the tumor control probability (TCP) of spinal metastases treated with stereotactic body radiation therapy (SBRT) in 1 to 5 fractions. METHODS AND MATERIALS PubMed-indexed articles from 1995 to 2018 were eligible for data extraction if they contained SBRT dosimetric details correlated with actuarial 2-year local tumor control rates. Logistic dose-response models of collected data were compared in terms of physical dose and 3-fraction equivalent dose. RESULTS Data were extracted from 24 articles with 2619 spinal metastases. Physical dose TCP modeling of 2-year local tumor control from the single-fraction data were compared with data from 2 to 5 fractions, resulting in an estimated α/β = 6 Gy, and this was used to pool data. Acknowledging the uncertainty intrinsic to the data extraction and modeling process, the 90% TCP corresponded to 20 Gy in 1 fraction, 28 Gy in 2 fractions, 33 Gy in 3 fractions, and (with extrapolation) 40 Gy in 5 fractions. The estimated TCP for common fractionation schemes was 82% at 18 Gy, 90% for 20 Gy, and 96% for 24 Gy in a single fraction, 82% for 24 Gy in 2 fractions, and 78% for 27 Gy in 3 fractions. CONCLUSIONS Spinal SBRT with the most common fractionation schemes yields 2-year estimates of local control of 82% to 96%. Given the heterogeneity in the tumor control estimates extracted from the literature, with variability in reporting of dosimetry data and the definition of and statistical methods of reporting tumor control, care should be taken interpreting the resultant model-based estimates. Depending on the clinical intent, the improved TCP with higher dose regimens should be weighed against the potential risks for greater toxicity. We encourage future reports to provide full dosimetric data correlated with tumor local control to allow future efforts of modeling pooled data.
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Affiliation(s)
- Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California.
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Health System, Danville, Pennsylvania; Department of Medical Imaging and Radiation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - D Michael Lovelock
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Issam El Naqa
- Machine Learning Department, Moffitt Cancer Center, Tampa, Florida
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Lineberger Cancer Center, Chapel Hill, North Carolina
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis, Sacramento, California
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24
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Li XM, Jin LB. Perioperative mortality of metastatic spinal disease with unknown primary: A case report and review of literature. World J Clin Cases 2021; 9:379-388. [PMID: 33521105 PMCID: PMC7812883 DOI: 10.12998/wjcc.v9.i2.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spinal metastases are common in patients with malignancies, but studies on those metastasized from unknown primaries are scarce due to the difficulty in treatment and the relatively poor prognosis. Knowledge of surgical complications, particularly perioperative mortality, in patients with spinal metastases from unidentified sources is still insufficient. CASE SUMMARY A 54-year-old man with chest-back pain was diagnosed with spinal metastasis in the seventh thoracic vertebra (T7). Radiographic examinations, as well as needle biopsy and immunohistochemical tests were performed to verify the characteristics of the lesion, resulting in an inconclusive diagnosis of poorly differentiated cancer from an unknown primary lesion. Therefore, spinal surgery was performed using the posterior approach to relieve symptoms and verify the diagnosis. Postoperative histologic examination indicated that this poorly differentiated metastatic cancer was possibly sarcomatoid carcinoma. As the patient experienced unexpectedly fast progression of the disease and died 16 d after surgery, the origin of this metastasis was undetermined. We discuss this case with respect to reported perioperative mortality in similar cases. CONCLUSION A comprehensive assessment prior to surgical decision-making is essential to reduce perioperative mortality risk in patients with spinal metastases from an unknown origin.
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Affiliation(s)
- Xiu-Mao Li
- Department of Orthopedics, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Li-Bin Jin
- Department of Orthopedics, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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25
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Glicksman RM, Tjong MC, Neves-Junior WFP, Spratt DE, Chua KLM, Mansouri A, Chua MLK, Berlin A, Winter JD, Dahele M, Slotman BJ, Bilsky M, Shultz DB, Maldaun M, Szerlip N, Lo SS, Yamada Y, Vera-Badillo FE, Marta GN, Moraes FY. Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases: A Review. JAMA Oncol 2020; 6:567-577. [PMID: 31895403 DOI: 10.1001/jamaoncol.2019.5351] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Rising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application. Objective To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies. Evidence Review The MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases. Results Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease. Conclusions and Relevance These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.
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Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Kevin L M Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Mark Bilsky
- Department of Neurosurgery, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcos Maldaun
- Division of Neurosurgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Yoshiya Yamada
- Department of Radiation Oncology, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.,Division of Radiation Oncology, Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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De la Pinta C. SBRT in non-spine bone metastases: a literature review. Med Oncol 2020; 37:119. [PMID: 33221952 DOI: 10.1007/s12032-020-01442-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Abstract
Stereotactic Body Radiotherapy (SBRT) is a technique for delivering high doses of radiation to tumors while preserving the normal tissues located around this area. Bone metastases are frequent in cancer patients. They can be distressingly painful or may cause pathological fractures. Radiation therapy is a fundamental aspect of treatment for bone metastases. The objective of this study is to analyze the literature on non-spine bone metastasis treated with SBRT, including immobilization, volume delineation, dose and fractionation, local control, side effects, and assessment of response after treatment. Full-text articles written in English language and published in the last 10 years were included in this review and were accessible on PubMed and MEDLINE. We examined 78 articles. A total of 40 studies were included in this review. Most were retrospective studies. The articles included were evaluated for content and validation. The immobilization systems and imaging tests used for tumor delimitation were variable between studies. The use of CTV (Clinical Target Volume) has not been defined. Doses and fractions were variable from 15 to 24 Gy/1 fraction to 24-50 Gy in 3-5 fractions, with local control being around 90% with a low rate of side effects. We review state of the art in SBRT non-spine metastases. SBRT can result in better local control and pain management in non-spine bone metastases patients. We need more research in volume delineation determining whether or not to use CTV and the role of MRI in volume contouring, optimal doses, and fractionation according to histology and a reliable response assessment tool. Studies that compare SBRT to conventional radiotherapy in local control and pain control are needed.
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27
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Rothrock RJ, Li Y, Lis E, Lobaugh S, Zhang Z, McCann P, Santos PMG, Yang TJ, Laufer I, Bilsky MH, Schmitt A, Yamada Y, Higginson DS. Hypofractionated spinal stereotactic body radiation therapy for high-grade epidural disease. J Neurosurg Spine 2020; 33:680-687. [PMID: 32707555 DOI: 10.3171/2020.4.spine20118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To characterize the clinical outcomes when stereotactic body radiation therapy (SBRT) alone is used to treat high-grade epidural disease without prior surgical decompression, the authors conducted a retrospective cohort study of patients treated at the Memorial Sloan Kettering Cancer Center between 2014 and 2018. The authors report locoregional failure (LRF) for a cohort of 31 cases treated with hypofractionated SBRT alone for grade 2 epidural spinal cord compression (ESCC) with radioresistant primary cancer histology. METHODS High-grade epidural disease was defined as grade 2 ESCC, which is notable for radiographic deformation of the spinal cord by metastatic disease. Kaplan-Meier survival curves and cumulative incidence functions were generated to examine the survival and incidence experiences of the sample level with respect to overall survival, LRF, and subsequent requirement of vertebral same-level surgery (SLS) due to tumor progression or fracture. Associations with dosimetric analysis were also examined. RESULTS Twenty-nine patients undergoing 31 episodes of hypofractionated SBRT alone for grade 2 ESCC between 2014 and 2018 were identified. The 1-year and 2-year cumulative incidences of LRF were 10.4% (95% CI 0-21.9) and 22.0% (95% CI 5.5-38.4), respectively. The median survival was 9.81 months (95% CI 8.12-18.54). The 1-year cumulative incidence of SLS was 6.8% (95% CI 0-16.0) and the 2-year incidence of SLS was 14.5% (95% CI 0.6-28.4). All patients who progressed to requiring surgery had index lesions at the thoracic apex (T5-7). CONCLUSIONS In carefully selected patients, treatment of grade 2 ESCC disease with hypofractionated SBRT alone offers a 1-year cumulative incidence of LRF similar to that in low-grade ESCC and postseparation surgery adjuvant hypofractionated SBRT. Use of SBRT alone has a favorable safety profile and a low cumulative incidence of progressive disease requiring open surgical intervention (14.5%).
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Affiliation(s)
| | | | | | | | | | - Patrick McCann
- 5Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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The Evolving Role of Radiation Therapy in Patients with Metastatic Soft Tissue Sarcoma. Curr Oncol Rep 2020; 22:79. [DOI: 10.1007/s11912-020-00936-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Stereotactic radiosurgery for the treatment of bulky spine metastases. J Neurooncol 2020; 148:381-388. [DOI: 10.1007/s11060-020-03534-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
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30
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Hu JX, Gong YN, Jiang XD, Jiang L, Zhuang HQ, Meng N, Liu XG, Wei F, Liu ZJ. Local Tumor Control for Metastatic Epidural Spinal Cord Compression Following Separation Surgery with Adjuvant CyberKnife Stereotactic Radiotherapy or Image-Guided Intensity-Modulated Radiotherapy. World Neurosurg 2020; 141:e76-e85. [PMID: 32360927 DOI: 10.1016/j.wneu.2020.04.183] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We sought to compare local tumor control after conventionally fractionated image-guided intensity-modulated radiotherapy (IMRT) versus adjuvant CyberKnife stereotactic body radiotherapy (SBRT) in patients who underwent separation surgery for metastatic epidural spinal cord compression (MESCC). METHODS We retrospectively reviewed patients with MESCC who were treated at our hospital. The Kaplan-Meier method was used to estimate local progression and overall survival. RESULTS Fifty-six patients with MESCC underwent separation surgery between 2013 and 2018, among whom 6 were lost to follow-up, 24 received conventionally fractionated image-guided IMRT, and 26 were treated with CyberKnife SBRT. The median follow-up was 16.5 months (range, 2.1-47.5 months). Eleven patients experienced local failure including 9 and 2 from the IMRT and SBRT groups, respectively. The local progression-free survival rates were significantly higher in the SBRT group than IMRT group at 6 months (95.5% vs. 82.0%), 1 year (90.9% vs. 71.8%), and 2 years (90.9% vs. 57.6%) (P = 0.035). Multivariate Cox proportional hazards regression analysis identified radiotherapy method (P = 0.034) and receipt of preoperative radiotherapy (P = 0.047) as significant predictors of local control, while visceral metastasis (P = 0.048) and high-malignancy primary tumor type (P = 0.002) were negative predictors of overall survival. Moreover, postoperative SBRT was noninferior to IMRT in terms of pain control, adverse effects, and performance in treating irradiated spinal metastases. CONCLUSIONS Hybrid surgery-radiosurgery therapy is a safe and effective treatment option for patients with MESCC. SBRT provided higher local control rates compared with IMRT. Thus postoperative SBRT should be considered for patients expected to have relatively long survival.
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Affiliation(s)
- Jin Xin Hu
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Yi Ning Gong
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Xu Dong Jiang
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China.
| | - Hong Qing Zhuang
- Department of Radiation Oncology, Cancer Center, Peking University Health Science Center, Haidian District, Beijing, China
| | - Na Meng
- Department of Radiation Oncology, Cancer Center, Peking University Health Science Center, Haidian District, Beijing, China
| | - Xiao Guang Liu
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Zhong Jun Liu
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
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Moraes FY, Chen X, Yan M, Spratt DE, Redmond K, Jackson WC, Yamada YJ. Evolving Role of Stereotactic Body Radiation Therapy in the Management of Spine Metastases: Defining Dose and Dose Constraints. Neurosurg Clin N Am 2020; 31:167-189. [PMID: 32147009 DOI: 10.1016/j.nec.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
When treating solid tumor spine metastases, stereotactic high-dose-per-fraction radiation, given in a single fraction or in a hypofractionated approach, has proved to be a highly effective and safe therapeutic option for any tumor histology, in the setting of de novo therapy, as salvage treatment of local progression after previous radiation, and in the postoperative setting. There are variations in practice based on the clinical presentation, goals of therapy, as well as institutional preferences. As a biologically potent therapy, a thoughtful and careful attention to detail with patient selection, treatment planning, and delivery is crucial for treatment success.
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Affiliation(s)
- Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Xuguang Chen
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Yan
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Kristen Redmond
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Xu K, Li J, Hu M, Zhang H, Yang J, Gong H, Li B, Wan W, Xiao J. Prognostic Significance of Preoperative Inflammatory Biomarkers and Traditional Clinical Parameters in Patients with Spinal Metastasis from Clear Cell Renal Cell Carcinoma: A Retrospective Study of 95 Patients in a Single Center. Cancer Manag Res 2020; 12:59-70. [PMID: 32021423 PMCID: PMC6954859 DOI: 10.2147/cmar.s228570] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this retrospective study was to identify preoperative inflammatory biomarkers and clinical parameters and evaluate their prognostic significance in patients with spinal metastasis from clear cell renal cell carcinoma (CCRCC). Patients and methods Correlations of overall survival (OS) with traditional clinical parameters and inflammatory indicators including the neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), lymphocyte–monocyte ratio (LMR), albumin–globulin ratio (AGR), and C-reactive protein to albumin ratio (CRP/Alb ratio) were analyzed in 95 patients with spinal metastasis from CCRCA using the Kaplan–Meier method to identify potential prognostic factors. Factors with P values ≤ 0.1 were subjected to multivariate analysis by Cox regression analysis. P values ≤ 0.05 were considered statistically significant. Results The 95 patients included in this study were followed up by a mean of 48.8 months (median 51 months; range 6–132 months), during which 21 patients died, with a death rate of 22.1%. The statistical results indicated that patients with total piecemeal spondylectomy (TPS), targeted therapy, NLR < 3.8 and PLR < 206.9 had a significantly longer OS rate. Conclusion TPS and targeted therapy could significantly prolong the OS of patients with spinal metastasis from CCRCC. In addition, NLR and PLR are robust and convenient prognostic indicators that have a discriminatory ability superior to other inflammatory biomarkers.
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Affiliation(s)
- Kehan Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jialin Li
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Mengzi Hu
- Department of Orthopedics, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, People's Republic of China
| | - Hao Zhang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jian Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Haiyi Gong
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Bo Li
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Wei Wan
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
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Kowalchuk RO, Waters MR, Richardson KM, Spencer K, Larner JM, Sheehan JP, McAllister WH, Kersh CR. A comparison of stereotactic body radiation therapy for metastases to the sacral spine and treatment of the thoracolumbar spine. JOURNAL OF RADIOSURGERY AND SBRT 2020; 7:95-103. [PMID: 33282463 PMCID: PMC7717089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/27/2020] [Indexed: 06/12/2023]
Abstract
Background: This study compares the outcomes of stereotactic body radiation therapy (SBRT) for sacral and thoracolumbar spine metastases. Methods: This analysis considered each sacral spine SBRT treatment at a single institution and a cohort of consecutive thoracolumbar treatments. Results: 28 patients with 35 sacral treatments and 41 patients with 49 thoracolumbar treatments were included. Local control was 63% and 90%, respectively. The sacral cohort contained more lesions with ≥2 vertebrae and epidural and paraspinal involvement. Sacral patients had larger treatment volumes, increased rates of subsequent SBRT, decreased propensity for pain improvement, and decreased local control (p=0.02 on Kaplan-Meier analysis). Multivariate analysis demonstrated that PTV > 50 cc and epidural involvement were correlated with decreased local control. No cases had grade ≥3 toxicity. Conclusion: SBRT for sacral spine metastases is a distinct disease process than metastases to the thoracolumbar spine, resulting in lower rates of local control and pain improvement.
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Affiliation(s)
- Roman O. Kowalchuk
- University of Virginia/Riverside, Radiosurgery Center, 500 J Clyde Morris Blvd, Newport News, VA 23601, USA
| | - Michael R. Waters
- University of Virginia/Riverside, Radiosurgery Center, 500 J Clyde Morris Blvd, Newport News, VA 23601, USA
| | - K. Martin Richardson
- University of Virginia/Riverside, Radiosurgery Center, 500 J Clyde Morris Blvd, Newport News, VA 23601, USA
| | - Kelly Spencer
- University of Virginia/Riverside, Radiosurgery Center, 500 J Clyde Morris Blvd, Newport News, VA 23601, USA
| | - James M. Larner
- University of Virginia, Department of Radiation Oncology, 1215 Lee St, Charlottesville, VA 22903, USA
| | - Jason P. Sheehan
- University of Virginia, Department of Neurosurgery, 1215 Lee St, Charlottesville, VA 22903, USA
| | - William H. McAllister
- Riverside Regional Medical Center, Department of Neurosurgery, 500 J Clyde Morris Blvd, Newport News, VA 23601, USA
| | - Charles R. Kersh
- University of Virginia/Riverside, Radiosurgery Center, 500 J Clyde Morris Blvd, Newport News, VA 23601, USA
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Hadzipasic M, Giantini-Larsen AM, Tatsui CE, Shin JH. Emerging Percutaneous Ablative and Radiosurgical Techniques for Treatment of Spinal Metastases. Neurosurg Clin N Am 2020; 31:141-150. [DOI: 10.1016/j.nec.2019.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Alghamdi M, Sahgal A, Soliman H, Myrehaug S, Yang VXD, Das S, Wilson J, Campbell M, Lee YK, Cawricz M, Da Costa L, Atenafu EG, Tseng CL. Postoperative Stereotactic Body Radiotherapy for Spinal Metastases and the Impact of Epidural Disease Grade. Neurosurgery 2019; 85:E1111-E1118. [DOI: 10.1093/neuros/nyz349] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Postoperative stereotactic body radiotherapy (pSBRT) is an emerging indication for spinal metastases (SM).
OBJECTIVE
To report our experience with pSBRT for SM.
METHODS
A retrospective chart review was performed for prospectively collected data of patients treated between September 2008 to December 2015 with pSBRT and followed with serial spinal MRIs every 2 to 3 mo until death or last follow-up. Univariate and multivariable analyses were performed to identify predictive factors.
RESULTS
A total of 83 spinal segments in 47 patients treated with a median dose of 24 Gy in 2 fractions were included, with mostly lung and breast primaries. A total of 59.3% had preoperative high-grade epidural disease (ED) and 39.7% were unstable. The 12-mo cumulative incidence of local failure was 17% for all segments, and 33.3%, 21.8%, and 0% in segments with postoperative high-grade, low-grade, and no ED, respectively. Downgrading preoperative ED was predictive of better local control (P = .03). The grade of postoperative ED was also predictive for local control (P < .0001), as was a longer interval between prior radiotherapy and pSBRT in those previously irradiated (P = .004). The 12-mo overall survival rate was 55%. One case of radiculopathy, 3 vertebral compression fractures, and no cases of myelopathy, hardware failure, or skin breakdown were observed.
CONCLUSION
pSBRT is an effective and safe treatment. The association between downgrading preoperative ED and better local control following pSBRT is confirmed and supports the concept of separation surgery.
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Affiliation(s)
- Majed Alghamdi
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
- Department of Medicine, Faculty of Medicine, Al Baha University, Al Baha, Saudi Arabia
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Jefferson Wilson
- Department of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Young K Lee
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Monica Cawricz
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Leo Da Costa
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Low incidence of late failure and toxicity after spine stereotactic radiosurgery: Secondary analysis of phase I/II trials with long-term follow-up. Radiother Oncol 2019; 138:80-85. [DOI: 10.1016/j.radonc.2019.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/15/2019] [Accepted: 06/02/2019] [Indexed: 12/25/2022]
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Zeng KL, Tseng CL, Soliman H, Weiss Y, Sahgal A, Myrehaug S. Stereotactic Body Radiotherapy (SBRT) for Oligometastatic Spine Metastases: An Overview. Front Oncol 2019; 9:337. [PMID: 31119099 PMCID: PMC6504814 DOI: 10.3389/fonc.2019.00337] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/12/2019] [Indexed: 12/15/2022] Open
Abstract
The oligometastatic state is hypothesized to represent an intermediary state of cancer between widely metastatic disease and curable, localized disease. Advancements in radiotherapy have allowed for delivery of high precision, dose escalated treatment known as stereotactic body radiotherapy (SBRT) to targets throughout the body with excellent rates of local control. Recently, the first phase II randomized trial comparing conventional radiotherapy to comprehensive SBRT of oligometastatic disease demonstrated an overall survival and progression free survival advantage. The spine is a common site of metastasis, and a complex site for SBRT given the adjacent spinal cord and the tumor embedded within the bone tissue putting the patient at risk of fracture. Although there are expert spine SBRT guidelines for practice, there are as yet no reported randomized trials that proves superiority as compared to conventional radiation. The use of SBRT in patients with oligometastatic disease and spinal metastases is the focus of this review.
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Affiliation(s)
- Kang Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yonatan Weiss
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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38
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Barzilai O, Laufer I, Robin A, Xu R, Yamada Y, Bilsky MH. Hybrid Therapy for Metastatic Epidural Spinal Cord Compression: Technique for Separation Surgery and Spine Radiosurgery. Oper Neurosurg (Hagerstown) 2019; 16:310-318. [PMID: 29889256 PMCID: PMC7189205 DOI: 10.1093/ons/opy137] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 06/04/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite major advances in radiation and systemic treatments, surgery remains a critical step in the multidisciplinary treatment of metastatic spinal cord tumors. OBJECTIVE To describe the indications, rationale, and technique of "hybrid therapy" (separation surgery and concomitant spine stereotactic radiosurgery [SRS]) along with practical nuances. METHODS Separation surgery describes a posterolateral approach for circumferential epidural decompression and stabilization. The goal is to decompress the spinal cord, stabilize the spine, and create adequate separation between the neural elements and the tumor for SRS to achieve durable tumor control. RESULTS A transpedicular route to achieve ventrolateral access and limited resection of the tumorous vertebral body is carried out. In the setting of high-grade cord compression, caution must be taken when performing the tumor decompression. "Separation" of the ventral epidural tumor component anteriorly creates space for concomitant SRS while a simple laminectomy would not adequately achieve this goal. Dissection of the posterior longitudinal ligament allows maximal ventral decompression. Gross total tumor resection is not crucial for durable tumor control using the "hybrid therapy" model. Thus, attempts at ventral tumor resection may unnecessarily increase operative morbidity. Cement augmentation of the construct or vertebral body may improve construct stability. CT myelogram is the preferred exam for postoperative SRS planning. Radiosurgical planning constitutes a multidisciplinary effort and guidelines for contouring in the postoperative setting have recently become available. CONCLUSION Separation surgery is an effective, well-tolerated, and reproducible surgery. It provides safe margins for concomitant SRS. Combined, this "Hybrid Therapy" allows durable local control, maintenance of spinal stability, and palliation of symptoms, while minimizing operative morbidity.
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Affiliation(s)
- Ori Barzilai
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Adam Robin
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ran Xu
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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39
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Osborn VW, Lee A, Yamada Y. Stereotactic Body Radiation Therapy for Spinal Malignancies. Technol Cancer Res Treat 2019; 17:1533033818802304. [PMID: 30343661 PMCID: PMC6198394 DOI: 10.1177/1533033818802304] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Stereotactic body radiation therapy and stereotactic radiosurgery have become important treatment options for the treatment of spinal malignancies. A better understanding of dose tolerances with more conformal technology have allowed administration of higher and more ablative doses. In this review, the framework for approaching a patient with spinal metastases and primary tumors will be discussed as well as details on the delivery of this treatment.
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Affiliation(s)
- Virginia W Osborn
- 1 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,2 Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Anna Lee
- 1 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,2 Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Yoshiya Yamada
- 1 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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40
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Phase 1 Study of Spinal Cord Constraint Relaxation With Single Session Spine Stereotactic Radiosurgery in the Primary Management of Patients With Inoperable, Previously Unirradiated Metastatic Epidural Spinal Cord Compression. Int J Radiat Oncol Biol Phys 2018; 102:1481-1488. [DOI: 10.1016/j.ijrobp.2018.07.2023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/24/2018] [Accepted: 07/29/2018] [Indexed: 11/17/2022]
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41
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Ito K, Nihei K, Shimizuguchi T, Ogawa H, Furuya T, Sugita S, Hozumi T, Keisuke Sasai, Karasawa K. Postoperative re-irradiation using stereotactic body radiotherapy for metastatic epidural spinal cord compression. J Neurosurg Spine 2018; 29:332-338. [DOI: 10.3171/2018.1.spine171155] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVEThis study aimed to clarify the outcomes of postoperative re-irradiation using stereotactic body radiotherapy (SBRT) for metastatic epidural spinal cord compression (MESCC) in the authors’ institution and to identify factors correlated with local control.METHODSCases in which patients with previously irradiated MESCC underwent decompression surgery followed by spine SBRT as re-irradiation between April 2013 and May 2017 were retrospectively reviewed. The surgical procedures were mainly performed by the posterior approach and included decompression and fixation. The prescribed dose for spine SBRT was 24 Gy in 2 fractions. The primary outcome was local control, which was defined as elimination, shrinkage, or no change of the tumor on CT or MRI obtained approximately every 3 months after SBRT. In addition, various patient-, treatment-, and tumor-specific factors were evaluated to determine their predictive value for local control.RESULTSTwenty-eight cases were identified in the authors’ institutional databases as meeting the inclusion criteria. The histology of the primary disease was thyroid cancer in 7 cases, lung cancer in 6, renal cancer in 3, colorectal cancer in 3, and other cancers in 9. The most common previous radiation dose was 30 Gy in 10 fractions (15 cases). The mean interval since the most recent irradiation was 16 months (range 5–132 months). The median duration of follow-up after SBRT was 13 months (range 4–38 months). The 1-year local control rate was 70%. In the analysis of factors related to local control, Bilsky grade, number of vertebral levels in the treatment target, the interval between the latest radiotherapy and SBRT, recursive partitioning analysis (RPA), the prognostic index for spinal metastases (PRISM), and the revised Tokuhashi score were not significantly correlated with local control. The favorable group classified by the Rades prognostic score achieved a significantly higher 1-year local control rate than the unfavorable group (1-year local control rate: 100% vs 33%; p < 0.01). Radiation-induced myelopathy and vertebral compression fracture were observed in 1 and 3 patients, respectively. No other grade 3 or greater toxicities were encountered.CONCLUSIONSThe results indicate that spine SBRT as postoperative re-irradiation was effective, and it was especially useful for patients classified as having a good survival prognosis according to the Rades score.
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Affiliation(s)
- Kei Ito
- 1Division of Radiation Oncology, Department of Radiology, and
- 3Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Keiji Nihei
- 1Division of Radiation Oncology, Department of Radiology, and
| | | | - Hiroaki Ogawa
- 1Division of Radiation Oncology, Department of Radiology, and
| | - Tomohisa Furuya
- 1Division of Radiation Oncology, Department of Radiology, and
| | - Shurei Sugita
- 2Department of Orthopedics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital; and
| | - Takahiro Hozumi
- 2Department of Orthopedics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital; and
| | - Keisuke Sasai
- 3Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Zeng KL, Myrehaug S, Soliman H, Tseng CL, Atenafu EG, Campbell M, Faruqi S, Lee YK, Ruschin M, da Costa L, Yang V, Spears J, Heyn C, Maralani PJ, Whyne C, Yee A, Sahgal A. Stereotactic Body Radiotherapy for Spinal Metastases at the Extreme Ends of the Spine: Imaging-Based Outcomes for Cervical and Sacral Metastases. Neurosurgery 2018; 85:605-612. [DOI: 10.1093/neuros/nyy393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/25/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The unique anatomy and biomechanical features of the cervical spine and sacrum may impact treatment outcomes following spine stereotactic body radiotherapy (SBRT). Current data for spine metastases are not specific for these locations.
Objective
To report imaging-based SBRT outcomes to cervical and sacral metastases.
Methods
We retrospectively reviewed our prospective spine SBRT database for cervical and sacral metastases. Patients were followed at 2- to 3-mo intervals with a clinical visit and full spine magnetic resonance imaging (MRI) and we report overall survival (OS), vertebral compression fracture (VCF), and MR imaging-based local control (LC) rates.
Results
Fifty-two patients and 93 treated spinal segments were identified. Fifty-six segments were within the cervical spine and 37 within the sacrum, the median follow-up was 14.4 and 19.5 mo, and the median total dose/number of fractions was 24 Gy/2, respectively. Cumulative LC at 1 and 2 yr were 94.5% and 92.7% for the cervical cohort, and 86.5% and 78.7% in the sacral cohort, respectively. Lack of posterior spinal element involvement in the cervical spine (P < .0001) and absence of epidural disease (hazard ratio 0.275, 95% confidence interval 0.076-0.989, P = .048) in the sacral cohort predicted LC. Median OS was 16.3 and 28.5 mo in the cervical spine and sacrum cohorts, respectively. Two cases of sacral VCF, 1 brachial plexopathy, and 1 lumbar-sacral plexopathy were observed.
CONCLUSION
Although high rates of LC were observed, strategies specific to the sacrum may require further optimization.
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Affiliation(s)
- K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Salman Faruqi
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Young K Lee
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Victor Yang
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julian Spears
- Department of Neurosurgery, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Chris Heyn
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cari Whyne
- Orthopaedic Biomechanics Laboratory, Sunnybrook Research Institute, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Albert Yee
- Department of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Impact of Right-sided Primary Tumor Location Among Patients With Oligometastatic Colorectal Cancer Treated With Stereotactic Body Radiotherapy. Am J Clin Oncol 2018; 41:1172-1175. [PMID: 29664795 DOI: 10.1097/coc.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Among patients with colorectal cancer, those with right-sided primary tumors have worse outcomes in both the primary and metastatic setting. Patients with oligometastatic colorectal cancer (OMCC) have improved prognosis relative to those with diffusely metastatic disease. We aimed to assess if the trend toward worse outcomes with right-sided tumors remained in the oligometastatic setting. PATIENTS AND METHODS We analyzed 31 patients treated at a single institution with stereotactic body radiotherapy for OMCC from 2011 to 2014 to assess the impact that primary tumor location had on overall survival (OS) and progression-free survival (PFS). RESULTS Overall, patient local control was fair (66% at 2 y); however, distant control was only 37.4% at 2 years. The median OS was 2.4 years; the median PFS was 6.5 months. Patients with right-sided primary tumors had numerically worse median OS than those with left-sided or rectal primary tumors (1.4 vs. 3.7 y, P=0.09). Median PFS was significantly worse among those with right-sided primaries (2.9 vs. 10.8 mo, P=0.05). This held on multivariate analysis. CONCLUSIONS These results affirm that patients with OMCC have extended OS periods and that stereotactic body radiotherapy offers strong local control in these settings. We show that even in the oligometastatic setting those with right-sided primary tumors have worse outcomes relative to those with left-sided or rectal primary tumors. This suggests more aggressive treatment may be needed for those with oligometastatic right-sided colorectal cancer.
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Bishop AJ, Tao R, Guadagnolo BA, Allen PK, Rebueno NC, Wang XA, Amini B, Tatsui CE, Rhines LD, Li J, Chang EL, Brown PD, Ghia AJ. Spine stereotactic radiosurgery for metastatic sarcoma: patterns of failure and radiation treatment volume considerations. J Neurosurg Spine 2017. [DOI: 10.3171/2017.1.spine161045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEGiven the relatively lower radiosensitivity of sarcomas and the locally infiltrative patterns of spread, the authors sought to investigate spine stereotactic radiosurgery (SSRS) outcomes for metastatic sarcomas and to analyze patterns of failure.METHODSThe records of 48 patients with 66 sarcoma spinal metastases consecutively treated with SSRS between 2002 and 2013 were reviewed. The Kaplan-Meier method was used to estimate rates of overall survival (OS) and local control (LC). Local recurrences were categorized as occurring infield (within the 95% isodose line [IDL]), marginally (between the 20% and 95% IDLs), or out of field.RESULTSMedian follow-up time was 19 months (range 1–121 months), and median age was 53 years (range 17–85 years). The most commonly treated histology was leiomyosarcoma (42%). Approximately two-thirds of the patients were treated with definitive SSRS (44 [67%]) versus postoperatively (22 [33%]). The actuarial 1-year OS and LC rates were 67% and 81%, respectively. Eighteen patients had a local relapse, which was more significantly associated with postoperative SSRS (p = 0.04). On multivariate modeling, receipt of postoperative SSRS neared significance for poorer LC (p = 0.06, subhazard ratio [SHR] 2.33), while only 2 covariates emerged as significantly correlated with LC: 1) biological equivalent dose (BED) > 48 Gy (vs BED ≤ 48 Gy, p = 0.006, SHR 0.21) and 2) single vertebral body involvement (vs multiple bodies, p = 0.03, SHR 0.27). Of the 18 local recurrences, 14 (78%) occurred at the margin, and while the majority of these cases relapsed within the epidural space, 4 relapsed within the paraspinal soft tissue. In addition, 1 relapse occurred out of field. Finally, the most common acute toxicity was fatigue (15 cases), with few late toxicities (4 insufficiency fractures, 3 neuropathies).CONCLUSIONSFor metastatic sarcomas, SSRS provides durable tumor control with minimal toxicity. High-dose single-fraction regimens offer optimal LC, and given the infiltrative nature of sarcomas, when paraspinal soft tissues are involved, larger treatment volumes may be warranted.
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Affiliation(s)
| | | | | | | | | | | | | | - Claudio E. Tatsui
- 5Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Laurence D. Rhines
- 5Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Jing Li
- Departments of 1Radiation Oncology,
| | - Eric L. Chang
- 6Department of Radiation Oncology, USC Norris Cancer Hospital, Keck School of Medicine of USC, Los Angeles, California
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Huo M, Sahgal A, Pryor D, Redmond K, Lo S, Foote M. Stereotactic spine radiosurgery: Review of safety and efficacy with respect to dose and fractionation. Surg Neurol Int 2017; 8:30. [PMID: 28303210 PMCID: PMC5339918 DOI: 10.4103/2152-7806.200581] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/30/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is an emerging treatment option for spinal metastases with demonstrated efficacy in the upfront, postoperative, and re-treatment settings, as well as for tumor histologies considered radioresistant. Uncertainty exists regarding the optimal dose and fractionation schedule, with single and multifraction regimens commonly utilized. METHODS A literature search of the PubMed and Medline databases was conducted to identify papers specific to spine SBRT and the effect of varying dose/fractionation regimens on outcomes. Bibliographies of relevant papers were searched for further references, and international spine SBRT experts were consulted. RESULTS Local control rates generally exceed 80% at 1 year, while high rates of pain control have been attained. There is insufficient evidence to suggest superiority of either single or multiple fraction regimens with respect to local control and pain control. Low rates of toxicity have been reported, assuming strict dose constraints are respected. Radiation myelopathy may be the most morbid toxicity, although the rates are low. The risk of vertebral compression fracture appears to be associated with higher doses per fraction such as those used in single-fraction regimens. The Spinal Instability Neoplastic Score should be considered when evaluating patients for spine SBRT, and prophylactic stabilisation may be warranted. Pain flare is a relatively common toxicity which may be mediated with prophylactic dexamethasone. Because of the treatment complexity and potentially serious toxicities, strict quality assurance should occur at the organizational, planning, dosimetric, and treatment delivery levels. CONCLUSION Both single and multifraction regimens are safe and efficacious in spine SBRT for spinal metastases. There may be advantages to hypofractionated treatment over single-fraction regimens with respect to toxicity. Ongoing investigation is underway to define optimal dose and fractionation schedules.
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Affiliation(s)
- Michael Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Kristin Redmond
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, USA
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
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Rades D. [Value of postoperative stereotaxic body radiation therapy for spinal metastases]. Strahlenther Onkol 2016; 193:165-167. [PMID: 27957591 DOI: 10.1007/s00066-016-1089-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Dirk Rades
- Lehrstuhl für Strahlentherapie, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland.
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Pasquier D, Martinage G, Mirabel X, Lacornerie T, Makhloufi S, Faivre JC, Thureau S, Lartigau É. Radiothérapie stéréotaxique des métastases osseuses vertébrales. Cancer Radiother 2016; 20:500-7. [DOI: 10.1016/j.canrad.2016.07.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 07/13/2016] [Indexed: 12/11/2022]
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