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Abstract
PURPOSE OF REVIEW The purpose of this manuscript is to review the progress in the field of therapeutics for malignant pheochromocytomas and sympathetic paraganglioma (MPPG) over the past 5 years. RECENT FINDINGS The manuscript will describe the clinical predictors of survivorship and their influence on the first TNM staging classification for pheochromocytomas and sympathetic paragangliomas, the treatment of hormonal complications, and the rationale that supports the resection of the primary tumor and metastases in patients with otherwise incurable disease. Therapeutic options for patients with bone metastasis to the spine will be presented. The manuscript will also review chemotherapy and propose a maintenance regimen with dacarbazine for patients initially treated with cyclophosphamide, vincristine, and dacarbazine. Finally, the manuscript will review preliminary results of several phase 2 clinical trials of novel radiopharmaceutical agents and tyrosine kinase inhibitors. MPPGs are very rare neuroendocrine tumors. MPPGs are usually characterized by a large tumor burden, excessive secretion of catecholamines, and decreased overall survival. Recent discoveries have enhanced our knowledge of the pathogenesis and phenotypes of MPPG. This knowledge is leading to a better understanding of the indications and limitations of the currently available localized and systemic therapies as well as the development of phase 2 clinical trials for novel medications.
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Younge KC, Kuchta JR, Mikell JK, Rosen B, Bredfeldt JS, Matuszak MM. The impact of a high-definition multileaf collimator for spine SBRT. J Appl Clin Med Phys 2017; 18:97-103. [PMID: 28960753 PMCID: PMC5689933 DOI: 10.1002/acm2.12197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 08/07/2017] [Accepted: 08/15/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose Advanced radiotherapy delivery systems designed for high‐dose, high‐precision treatments often come equipped with high‐definition multi‐leaf collimators (HD‐MLC) aimed at more finely shaping radiation dose to the target. In this work, we study the effect of a high definition MLC on spine stereotactic body radiation therapy (SBRT) treatment plan quality and plan deliverability. Methods and Materials Seventeen spine SBRT cases were planned with VMAT using a standard definition MLC (M120), HD‐MLC, and HD‐MLC with an added objective to reduce monitor units (MU). M120 plans were converted into plans deliverable on an HD‐MLC using in‐house software. Plan quality and plan deliverability as measured by portal dosimetry were compared among the three types of plans. Results Only minor differences were noted in plan quality between the M120 and HD‐MLC plans. Plans generated with the HD‐MLC tended to have better spinal cord sparing (3% reduction in maximum cord dose). HD‐MLC plans on average had 12% more MU and 55% greater modulation complexity as defined by an in‐house metric. HD‐MLC plans also had significantly degraded deliverability. Of the VMAT arcs measured, 94% had lower gamma passing metrics when using the HD‐MLC. Conclusion Modest improvements in plan quality were noted when switching from M120 to HD‐MLC at the expense of significantly less accurate deliverability in some cases.
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Affiliation(s)
- Kelly C. Younge
- Department of Radiation OncologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - John R. Kuchta
- Department of Radiation OncologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Justin K. Mikell
- Department of Radiation OncologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Benjamin Rosen
- Department of Radiation OncologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Jeremy S. Bredfeldt
- Department of Radiation OncologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Martha M. Matuszak
- Department of Radiation OncologyUniversity of Michigan Health SystemAnn ArborMIUSA
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Lee HL, Kuo CC, Tsai JT, Chen CY, Wu MH, Chiou JF. Magnetic Resonance-Guided Focused Ultrasound Versus Conventional Radiation Therapy for Painful Bone Metastasis: A Matched-Pair Study. J Bone Joint Surg Am 2017; 99:1572-1578. [PMID: 28926387 DOI: 10.2106/jbjs.16.01248] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) is an alternative local therapy for patients with painful bone metastasis for whom standard conventional radiation therapy (RT) has failed. However, the therapeutic effects of MRgFUS as a first-line treatment for bone metastasis remain uncertain. METHODS A matched-pair study was conducted to compare the therapeutic effects of MRgFUS with those of conventional RT as a first-line treatment for patients with painful bone metastasis. The MRgFUS and RT-treated groups were matched 1:2 by age, sex, primary cancer, pretreatment pain score, and treated site. RESULTS According to the criteria for patient eligibility and matching, 21 and 42 patients (total, 63 patients) with bone metastasis treated with MRgFUS and conventional RT, respectively, were enrolled for analyses. The median ages of the MRgFUS and RT-treated patients were 59 and 61 years, respectively. Among the enrolled patients, 52% were male and 48% were female. The results showed that both MRgFUS and RT were effective. However, MRgFUS was more efficient than RT in terms of the time course of pain palliation as it yielded a significantly higher response rate at 1 week after treatment (71% versus 26%, p = 0.0009). CONCLUSIONS MRgFUS provides a similar overall treatment response rate but faster pain relief compared with conventional RT and has the potential to serve as the first-line treatment for painful bone metastasis in selected patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hsin-Lun Lee
- 1Departments of Radiation Oncology (H.-L.L. and J.-F.C.) and Orthopaedic Surgery (M.-H.W.), Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan 2The Ph.D. Program for Translational Medicine, College of Medical Science and Technology, Taipei Medical University and Academia Sinica, Taipei Medical University, Taipei, Taiwan 3Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan 4Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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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: 2.3] [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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Yoo GS, Park HC, Yu JI, Lim DH, Cho WK, Lee E, Jung SH, Han Y, Kim ES, Lee SH, Eoh W, Park SJ, Chung SS, Lee CS, Lee JH. Stereotactic ablative body radiotherapy for spinal metastasis from hepatocellular carcinoma: its oncologic outcomes and risk of vertebral compression fracture. Oncotarget 2017; 8:72860-72871. [PMID: 29069831 PMCID: PMC5641174 DOI: 10.18632/oncotarget.20529] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/30/2017] [Indexed: 12/13/2022] Open
Abstract
Spinal metastases from hepatocellular carcinoma (HCC) require high-dose irradiation for durable pain and tumor control. Stereotactic ablative body radiotherapy (SABR) enables the delivery of high-dose radiation. However, but vertebral compression fracture (VCF) can be problematic. The aim of his study is to evaluate the outcome and risk of VCF after SABR for spinal metastasis from HCC. We retrospectively reviewed 33 lesions in 42 spinal segments from 29 patients who received SABR with 1 fraction (16-20 Gy), or 3 fractions (18-45 Gy) from September 2009 to January 2015. The 1-year local control (LC) rate was 68.3%. Radiographic grade of cord compression (RGCC) was the only independent prognostic factor associated with LC (P = 0.007). The 1-year ultimate LC rate including the outcome of salvage re-irradiation was 87.2%. The pain response rate was 73.3% according to the categories of the International Bone Metastases Consensus Group. The 1-year VCF-free rate was 71.5%. Pre-existing VCF (P < 0.001) and only-lytic change (P = 0.017) were associated with a higher post-SABR VCF rate. One-third of post-SABR VCFs required interventions. SABR for spinal metastases from HCC provided efficacious LC, especially for lesions with RGCC ≤ II, and showed effective and durable pain relief. As VCF after SABR occurred frequently for vertebral segments with pre-existing VCF and only-lytic change, early preventive vertebroplasty is considerable for those high-risk vertebral segments.
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Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eonju Lee
- Department of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon-si, Korea
| | - Sang Hoon Jung
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youngyih Han
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Sang Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Whan Eoh
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se-Jun Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Soo Chung
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyuk Lee
- Department of Medicine (Division of Hepatology), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Sohn S, Kim J, Chung CK, Lee NR, Chang UK, Sohn MJ. A Nationwide Study of Stereotactic Radiosurgery in a Newly Diagnosed Spine Metastasis Population. Stereotact Funct Neurosurg 2017; 95:189-196. [DOI: 10.1159/000475764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 04/05/2017] [Indexed: 11/19/2022]
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Hazelaar C, Dahele M, Scheib S, Slotman BJ, Verbakel WF. Verifying tumor position during stereotactic body radiation therapy delivery using (limited-arc) cone beam computed tomography imaging. Radiother Oncol 2017; 123:355-362. [DOI: 10.1016/j.radonc.2017.04.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/26/2017] [Accepted: 04/29/2017] [Indexed: 11/16/2022]
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Tseng CL, Eppinga W, Charest-Morin R, Soliman H, Myrehaug S, Maralani PJ, Campbell M, Lee YK, Fisher C, Fehlings MG, Chang EL, Lo SS, Sahgal A. Spine Stereotactic Body Radiotherapy: Indications, Outcomes, and Points of Caution. Global Spine J 2017; 7:179-197. [PMID: 28507888 PMCID: PMC5415159 DOI: 10.1177/2192568217694016] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN A broad narrative review. OBJECTIVES The objective of this article is to provide a technical review of spine stereotactic body radiotherapy (SBRT) planning and delivery, indications for treatment, outcomes, complications, and the challenges of response assessment. The surgical approach to spinal metastases is discussed with an overview of emerging minimally invasive techniques. METHODS A comprehensive review of the literature was conducted on the techniques, outcomes, and developments in SBRT and surgery for spinal metastases. RESULTS The optimal management of patients with spinal metastases is complex and requires multidisciplinary assessment from an oncologic team that is familiar with the shifting paradigm as a consequence of evolving techniques in surgery and stereotactic radiation, as well as new developments in systemic agents. The Spinal Instability Neoplastic Score and the epidural spinal cord compression (Bilsky) grading system are useful tools that facilitate communication among oncologic team members and can direct management by providing a baseline assessment of risks prior to therapy. The combined multimodality approach with "separation surgery" followed by postoperative spine SBRT achieves thecal sac decompression, improves tumor control, and avoids complications that may be associated with more extensive surgery. CONCLUSION Spine SBRT is a highly effective treatment that is capable of delivering ablative doses to the target while sparing the critical organs-at-risk, chiefly the critical neural tissues, within a short and manageable schedule. At the same time, surgery occupies an important role in select patients, particularly with the expanding availability and expertise in minimally invasive techniques. With rapid adoption of spine SBRT in centers outside of the academic setting, it is imperative for the practicing oncologist to understand the relevance and application of these evolving concepts.
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Affiliation(s)
- Chia-Lin Tseng
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada,Chia-Lin Tseng, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada M4 N 3M5.
| | - Wietse Eppinga
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Hany Soliman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Mikki Campbell
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Young K. Lee
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Charles Fisher
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Eric L. Chang
- University of Southern California, Los Angeles, CA, USA
| | | | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Tatsui CE, Belsuzarri TAB, Oro M, Rhines LD, Li J, Ghia AJ, Amini B, Espinoza H, Brown PD, Rao G. Percutaneous surgery for treatment of epidural spinal cord compression and spinal instability: technical note. Neurosurg Focus 2017; 41:E2. [PMID: 27690655 DOI: 10.3171/2016.8.focus16175] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE An emerging paradigm for treating patients with epidural spinal cord compression (ESCC) caused by metastatic tumors is surgical decompression and stabilization, followed by stereotactic radiosurgery. In the setting of rapid progressive disease, interruption or delay in return to systemic treatment can lead to a negative impact in overall survival. To overcome this limitation, the authors introduce the use of spinal laser interstitial thermotherapy (sLITT) in association with percutaneous spinal stabilization to facilitate a rapid return to oncological treatment. METHODS The authors retrospectively reviewed a consecutive series of patients with ESCC and spinal instability who were considered to be poor surgical candidates and instead were treated with sLITT and percutaneous spinal stabilization. Demographic data, Spine Instability Neoplastic Scale score, degree of epidural compression before and after the procedure, length of hospital stay, and time to return to oncological treatment were analyzed. RESULTS Eight patients were treated with thermal ablation and percutaneous spinal stabilization. The primary tumors included melanoma (n = 3), lung (n = 3), thyroid (n = 1), and renal cell carcinoma (n = 1). The median Karnofsky Performance Scale score before and after the procedure was 60, and the median hospital stay was 5 days (range 3-18 days). The median Spine Instability Neoplastic Scale score was 13 (range 12-16). The mean modified postoperative ESCC score (2.75 ± 0.37) was significantly lower than the preoperative score (4.5 ± 0.27) (Mann-Whitney test, p = 0.0044). The median time to return to oncological treatment was 5 days (range 3-10 days). CONCLUSIONS The authors present the first cohort of sLITT associated with a percutaneous spinal stabilization for the treatment of ESCC and spinal instability. This minimally invasive technique can allow a faster recovery without prejudice of adjuvant systemic treatment, with adequate local control and spinal stabilization.
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Affiliation(s)
| | | | | | | | | | | | - Behrang Amini
- Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Heron Espinoza
- Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
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Volume of Lytic Vertebral Body Metastatic Disease Quantified Using Computed Tomography–Based Image Segmentation Predicts Fracture Risk After Spine Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2017; 97:75-81. [DOI: 10.1016/j.ijrobp.2016.09.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/01/2016] [Accepted: 09/20/2016] [Indexed: 11/21/2022]
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Hong JC, Salama JK. The expanding role of stereotactic body radiation therapy in oligometastatic solid tumors: What do we know and where are we going? Cancer Treat Rev 2017; 52:22-32. [PMID: 27886588 DOI: 10.1016/j.ctrv.2016.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/01/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
The spectrum hypothesis posits that there are distinct clinical states of metastatic progression. Early data suggest that aggressive treatment of more biologically indolent metastatic disease, characterized by metastases limited in number and destination organ, may offer an opportunity to alter the disease course, potentially allowing for longer survival, delay of systemic therapy, or even cure. The development of stereotactic body radiation therapy (SBRT) has opened new avenues for the treatment of oligometastatic disease. Early data support the use of SBRT for treating oligometastases in a number of organs, with promising rates of treated metastasis control and overall survival. Ongoing investigation is required to definitively establish benefit, determine the appropriate treatment regimen, refine patient selection, and incorporate SBRT with systemic therapies.
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Affiliation(s)
- Julian C Hong
- Department of Radiation Oncology, Duke University, Durham, NC, United States
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, NC, United States.
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van der Velden JM, Verkooijen HM, Seravalli E, Hes J, Gerlich AS, Kasperts N, Eppinga WSC, Verlaan JJ, van Vulpen M. Comparing conVEntional RadioTherapy with stereotactIC body radiotherapy in patients with spinAL metastases: study protocol for an randomized controlled trial following the cohort multiple randomized controlled trial design. BMC Cancer 2016; 16:909. [PMID: 27871280 PMCID: PMC5117527 DOI: 10.1186/s12885-016-2947-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/10/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Standard radiotherapy is the treatment of first choice in patients with symptomatic spinal metastases, but is only moderately effective. Stereotactic body radiation therapy is increasingly used to treat spinal metastases, without randomized evidence of superiority over standard radiotherapy. The VERTICAL study aims to quantify the effect of stereotactic radiation therapy in patients with metastatic spinal disease. METHODS/DESIGN This study follows the 'cohort multiple Randomized Controlled Trial' design. The VERTICAL study is conducted within the PRESENT cohort. In PRESENT, all patients with bone metastases referred for radiation therapy are enrolled. For each patient, clinical and patient-reported outcomes are captured at baseline and at regular intervals during follow-up. In addition, patients give informed consent to be offered experimental interventions. Within PRESENT, 110 patients are identified as a sub cohort of eligible patients (i.e. patients with unirradiated painful, mechanically stable spinal metastases who are able to undergo stereotactic radiation therapy). After a protocol amendment, also patients with non-spinal bony metastases are eligible. From the sub cohort, a random selection of patients is offered stereotactic radiation therapy (n = 55), which patients may accept or refuse. Only patients accepting stereotactic radiation therapy sign informed consent for the VERTICAL trial. Non-selected patients (n = 55) receive standard radiotherapy, and are not aware of them serving as controls. Primary endpoint is pain response after three months. Data will be analyzed by intention to treat, complemented by instrumental variable analysis in case of substantial refusal of the stereotactic radiation therapy in the intervention arm. DISCUSSION This study is designed to quantify the treatment response after (stereotactic) radiation therapy in patients with symptomatic spinal metastases. This is the first randomized study in palliative care following the cohort multiple Randomized Controlled Trial design. This design addresses common difficulties associated with classic pragmatic randomized controlled trials, such as disappointment bias in patients allocated to the control arm, slow recruitment, and poor generalizability. TRIAL REGISTRATION The Netherlands Trials Register number NL49316.041.14. ClinicalTrials.gov registration number NCT02364115 . Date of trial registration February 1, 2015.
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Affiliation(s)
- Joanne M van der Velden
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Helena M Verkooijen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jochem Hes
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - A Sophie Gerlich
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Nicolien Kasperts
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Wietse S C Eppinga
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Bernstein MB, Chang EL, Amini B, Pan H, Cabanillas M, Wang XA, Allen PK, Rhines LD, Tatsui C, Li J, Brown PD, Ghia AJ. Spine Stereotactic Radiosurgery for Patients with Metastatic Thyroid Cancer: Secondary Analysis of Phase I/II Trials. Thyroid 2016; 26:1269-75. [PMID: 27334245 DOI: 10.1089/thy.2016.0046] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Metastatic deposits to the spine in thyroid cancer patients represent the most common site of bone involvement and can contribute to pain, neurologic deficits, and death. This study sought to determine the efficacy and safety of spine stereotactic radiosurgery (SSRS) for thyroid cancer patients. METHODS Thyroid cancer patients with spine metastases were selected and analyzed from a cohort of patients who were prospectively enrolled in two single-institution Phase I/II studies. SSRS was delivered in single or multi-fraction schedules. Dose regimens ranged from 16-18 Gy in one fraction to 27-30 Gy in three to five fractions. Toxicity was graded according to the NCI-CTC toxicity scale. Local control was determined by serial post-treatment magnetic resonance imaging scans showing no evidence of progressive disease. Patients were followed until date of death or date of last known visit for survival analyses. Local control and overall survival rates were carried out using Kaplan-Meier estimates. The log-rank test was used to assess the equality of the survivor function across groups. A p-value of ≤0.05 was considered to be statistically significant. RESULTS A total of 27 spine lesions were treated in 23 patients over a six-year period. Median follow-up was 28.9 months (range 5-93 months). Local control was 88% at two years and 79% at three years. In patients with progressive disease following conventional radiation therapy, local control for salvage SSRS remained at 88% at three years. Patients requiring upfront surgical intervention and treated with adjuvant SSRS achieved sustained control rates of 86% at three years. Overall survival rates were 85% and 67% at one and two years, respectively. In patients classified with oligoprogression and controlled extra-spinal disease, overall survival was significantly higher than those with evidence of systemic progression (81% vs. 45% at two years; p = 0.01). Univariate analysis did not show significant correlations between local control and age, systemic disease status, prior (131)I therapy, SSRS fraction regimen, spine location, histological subtype, or time from initial diagnosis to evidence of spinal metastasis. No patient experienced any grade 3-5 toxicity. Pain flare was reported in 30% of patients, with only three patients (13%) requiring narcotics or short-course steroids. There was no evidence of vertebral body fracture in any patient that achieved local control in the treated area. CONCLUSIONS SSRS for thyroid metastases as a primary or adjuvant/salvage therapy is well tolerated and yields high rates of local control.
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Affiliation(s)
- Michael B Bernstein
- 1 Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Eric L Chang
- 2 Department of Radiation Oncology, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Behrang Amini
- 3 Division of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Hubert Pan
- 1 Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Maria Cabanillas
- 4 Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Xin A Wang
- 5 Division of Radiation Physics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Pamela K Allen
- 1 Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Laurence D Rhines
- 6 Division of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Claudio Tatsui
- 6 Division of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Jing Li
- 1 Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Paul D Brown
- 1 Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Amol J Ghia
- 1 Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
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Mian OY, Thomas O, Lee JJY, Le Y, McNutt T, Lim M, Rigamonti D, Wolinsky JP, Sciubba DM, Gokaslan ZL, Redmond K, Kleinberg L. Timely stereotactic body radiotherapy (SBRT) for spine metastases using a rapidly deployable automated planning algorithm. SPRINGERPLUS 2016; 5:1337. [PMID: 27563532 PMCID: PMC4981010 DOI: 10.1186/s40064-016-2961-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/29/2016] [Indexed: 11/10/2022]
Abstract
Purpose/objectives The complex planning and quality assurance required for spine SBRT are a barrier to implementation in time-sensitive or limited resource clinical situations. We developed and validated an automated inverse planning algorithm designed to streamline planning and allow rapid delivery of conformal single fraction spine SBRT using widely available technology. Materials/methods The Rapid Spine (RaSp) automated script successfully generated single fraction SBRT plans for fourteen complex spinal lesions previously treated at a single high-volume institution. Automated RaSp plans were limited to 5 beams with a total of 15 segments (allowing calculation-based verification) and optimized based on RTOG 0631 objectives. Standard single fraction (16 Gy) stereotactic IMRT plans were generated for the same set of complex spinal lesions and used for comparison. A conservative 2 mm posterior isocenter shift was used to simulate minor set-up error. Results Automated plans were generated in under 5 min from target definition and had a mean dose to the PTV of 1663 cGy (SD 131.5), a dose to 90 % of PTV (D90) of 1358 cGy (SD 111.0), and a maximum point dose (Dmax) to the PTV of 2055 cGy (SD 195.2) on average. IMRT plans took longer to generate but yielded more favorable dose escalation with a mean dose to the PTV of 1891 cGy (SD 117.6), D90 of 1731 cGy (SD 126.5), and Dmax of 2218 cGy (SD 195.7). A 2 mm posterior shift resulted in a 20 % (SD 10.5 %) increase in cord dose for IMRT plans and a 10 % (SD 5.3 %) increase for RaSp plans. The 2 mm perturbation caused 3 cord dose violations for the IMRT plans and 1 violation for corresponding RaSp plans. Conclusion The Rapid Spine plan method yields timely and dosimetrically reasonable SBRT plans which meet RTOG 0631 objectives and are suitable for rapid yet robust pretreatment quality assurance followed by expedited treatment delivery. RaSp plans reduce the tradeoff between rapid treatment and optimal dosimetry in urgent cases and limited resource situations.
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Affiliation(s)
- Omar Y Mian
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH USA
| | - Owen Thomas
- Delmarva Radiation Services, Tunnell Cancer Center, Rehoboth Beach, DE USA
| | - Joy J Y Lee
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Yi Le
- Department of Radiation Oncology, Indiana University, Indianapolis, IN USA
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Michael Lim
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Daniele Rigamonti
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Jean-Paul Wolinsky
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Kristin Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD USA
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Cohen J, Alan N, Zhou J, Kojo Hamilton D. The 100 most cited articles in metastatic spine disease. Neurosurg Focus 2016; 41:E10. [DOI: 10.3171/2016.5.focus16158] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field.
METHODS
A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency.
RESULTS
The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations).
CONCLUSIONS
The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.
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Postoperative Stereotactic Body Radiation Therapy (SBRT) for Spine Metastases: A Critical Review to Guide Practice. Int J Radiat Oncol Biol Phys 2016; 95:1414-1428. [DOI: 10.1016/j.ijrobp.2016.03.027] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 01/08/2016] [Accepted: 03/21/2016] [Indexed: 11/18/2022]
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Yazici G, Sari SY, Yedekci FY, Yucekul A, Birgi SD, Demirkiran G, Gultekin M, Hurmuz P, Yazici M, Ozyigit G, Cengiz M. The dosimetric impact of implants on the spinal cord dose during stereotactic body radiotherapy. Radiat Oncol 2016; 11:71. [PMID: 27225270 PMCID: PMC4880816 DOI: 10.1186/s13014-016-0649-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 05/17/2016] [Indexed: 01/14/2023] Open
Abstract
Background The effects of spinal implants on dose distribution have been studied for conformal treatment plans. However, the dosimetric impact of spinal implants in stereotactic body radiotherapy (SBRT) treatments has not been studied in spatial orientation. In this study we evaluated the effect of spinal implants placed in sawbone vertebra models implanted as in vivo instrumentations. Methods Four different spinal implant reconstruction techniques were performed using the standard sawbone lumbar vertebrae model; 1. L2-L4 posterior instrumentation without anterior column reconstruction (PI); 2. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (AIAC); 3. L2-L4 posterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (PIAC); 4. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with chest tubes filled with bone cement (AIABc). The target was defined as the spinous process and lamina of the lumbar (L) 3 vertebra. A thermoluminescent dosimeter (TLD, LiF:Mg,Ti) was located on the measurement point anterior to the spinal cord. The prescription dose was 8 Gy and the treatment was administered in a single fraction using a CyberKnife® (Accuray Inc., Sunnyvale, CA, USA). We performed two different treatment plans. In Plan A beam interaction with the rod was not limited. In plan B the rod was considered a structure of avoidance, and interaction between the rod and beam was prevented. TLD measurements were compared with the point dose calculated by the treatment planning system (TPS). Results and discussion In plan A, the difference between TLD measurement and the dose calculated by the TPS was 1.7 %, 2.8 %, and 2.7 % for the sawbone with no implant, PI, and PIAC models, respectively. For the AIAC model the TLD dose was 13.8 % higher than the TPS dose; the difference was 18.6 % for the AIABc model. In plan B for the AIAC and AIABc models, TLD measurement was 2.5 % and 0.9 % higher than the dose calculated by the TPS, respectively. Conclusions Spinal implants may be present in the treatment field in patients scheduled to undergo SBRT. For the types of implants studied herein anterior rod instrumentation resulted in an increase in the spinal cord dose, whereas use of a titanium cage had a minimal effect on dose distribution. While planning SBRT in patients with spinal reconstructions, avoidance of the rod and preventing interaction between the rod and beam might be the optimal solution for preventing unexpectedly high spinal cord doses.
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Affiliation(s)
- Gozde Yazici
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - Sezin Yuce Sari
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Fazli Yagiz Yedekci
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Altug Yucekul
- Department of Orthopedics and Traumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Sumerya Duru Birgi
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Gokhan Demirkiran
- Department of Orthopedics and Traumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Melis Gultekin
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Pervin Hurmuz
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Muharrem Yazici
- Department of Orthopedics and Traumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Gokhan Ozyigit
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Mustafa Cengiz
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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Thibault I, Chang EL, Sheehan J, Ahluwalia MS, Guckenberger M, Sohn MJ, Ryu S, Foote M, Lo SS, Muacevic A, Soltys SG, Chao S, Gerszten P, Lis E, Yu E, Bilsky M, Fisher C, Schiff D, Fehlings MG, Ma L, Chang S, Chow E, Parelukar WR, Vogelbaum MA, Sahgal A. Response assessment after stereotactic body radiotherapy for spinal metastasis: a report from the SPIne response assessment in Neuro-Oncology (SPINO) group. Lancet Oncol 2016; 16:e595-603. [PMID: 26678212 DOI: 10.1016/s1470-2045(15)00166-7] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/07/2015] [Accepted: 07/13/2015] [Indexed: 12/11/2022]
Abstract
The SPine response assessment In Neuro-Oncology (SPINO) group is a committee of the Response Assessment in Neuro-Oncology working group and comprises a panel of international experts in spine stereotactic body radiotherapy (SBRT). Here, we present the group's first report on the challenges in standardising imaging-based assessment of local control and pain for spinal metastases. We review current imaging modalities used in SBRT treatment planning and tumour assessment and review the criteria for pain and local control in registered clinical trials specific to spine SBRT. We summarise the results of an international survey of the panel to establish the range of current practices in assessing tumour response to spine SBRT. The ultimate goal of the SPINO group is to report consensus criteria for tumour imaging, clinical assessment, and symptom-based response criteria to help standardise future clinical trials.
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Affiliation(s)
- Isabelle Thibault
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Quebec, Université Laval, Quebec City, QC, Canada
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | | | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland; Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzberg, Germany
| | - Moon-Jun Sohn
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook University, New York, NY, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Simon S Lo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Alexander Muacevic
- Department of Neurosurgery, University of Munich Hospital, Munich, Germany
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA, USA
| | - Samuel Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Peter Gerszten
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Eugene Yu
- Department of Radiology, University Health Network, Toronto, ON, Canada
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Charles Fisher
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - David Schiff
- Division of Neuro-Oncology, University of Virginia Health System, Charlottesville, VA, USA
| | - Michael G Fehlings
- Department of Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Susan Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Edward Chow
- Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Wendy R Parelukar
- NCIC Clinical Trials Group Division, Cancer Research Institute, Queen's University Kingston, ON, Canada
| | - Michael A Vogelbaum
- Brain Tumor and Neuro-Oncology Center and Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada.
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Hazelaar C, Dahele M, Mostafavi H, van der Weide L, Slotman BJ, Verbakel WF. Subsecond and Submillimeter Resolution Positional Verification for Stereotactic Irradiation of Spinal Lesions. Int J Radiat Oncol Biol Phys 2016; 94:1154-62. [DOI: 10.1016/j.ijrobp.2016.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/11/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022]
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Yang H, Cai BN, Wang XS, Cong XH, Xu W, Wang JY, Yang J, Xu SP, Ju ZJ, Ma L. Dose Evaluation of Fractionated Schema and Distance From Tumor to Spinal Cord for Spinal SBRT with Simultaneous Integrated Boost: A Preliminary Study. Med Sci Monit 2016; 22:598-607. [PMID: 26902177 PMCID: PMC4767138 DOI: 10.12659/msm.897146] [Citation(s) in RCA: 2] [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: 12/17/2015] [Accepted: 01/28/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study investigated and quantified the dosimetric impact of the distance from the tumor to the spinal cord and fractionation schemes for patients who received stereotactic body radiation therapy (SBRT) and hypofractionated simultaneous integrated boost (HF-SIB). MATERIAL AND METHODS Six modified planning target volumes (PTVs) for 5 patients with spinal metastases were created by artificial uniform extension in the region of PTV adjacent spinal cord with a specified minimum tumor to cord distance (0-5 mm). The prescription dose (biologic equivalent dose, BED) was 70 Gy in different fractionation schemes (1, 3, 5, and 10 fractions). For PTV V100, Dmin, D98, D95, and D1, spinal cord dose, conformity index (CI), V30 were measured and compared. RESULTS PTV-to-cord distance influenced PTV V100, Dmin, D98, and D95, and fractionation schemes influenced Dmin and D98, with a significant difference. Distances of ≥2 mm, ≥1 mm, ≥1 mm, and ≥0 mm from PTV to spinal cord meet dose requirements in 1, 3, 5, and 10 fractionations, respectively. Spinal cord dose, CI, and V30 were not impacted by PTV-to-cord distance and fractionation schemes. CONCLUSIONS Target volume coverage, Dmin, D98, and D95 were directly correlated with distance from the spinal cord for spine SBRT and HF-SIB. Based on our study, ≥2 mm, ≥1 mm, ≥1 mm, and ≥0 mm distance from PTV to spinal cord meets dose requirements in 1, 3, 5 and 10 fractionations, respectively.
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Affiliation(s)
- Hao Yang
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
- Department of Radiation Oncology, Inner Mongolia Cancer Hospital and The Affiliated People’s Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, P.R. China
| | - Bo-ning Cai
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Xiao-shen Wang
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Xiao-hu Cong
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Wei Xu
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Jin-yuan Wang
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Jun Yang
- Department of Oncology, First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, P.R. China
| | - Shou-ping Xu
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Zhong-jian Ju
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Lin Ma
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
- Department of Radiation Oncology, Hainan Branch of Chinese PLA General Hospital, Haitang Bay, Sanya, Hainan, P.R. China
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De Ornelas-Couto M, Bossart E, Ly B, Monterroso MI, Mihaylov I. Radiation therapy for stereotactic body radiation therapy in spine tumors: linac or robotic? Biomed Phys Eng Express 2016. [DOI: 10.1088/2057-1976/2/1/015012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Yang J, Ma L, Wang XS, Xu WX, Cong XH, Xu SP, Ju ZJ, Du L, Cai BN, Yang J. Dosimetric evaluation of 4 different treatment modalities for curative-intent stereotactic body radiation therapy for isolated thoracic spinal metastases. Med Dosim 2016; 41:105-12. [PMID: 26831753 DOI: 10.1016/j.meddos.2015.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 09/28/2015] [Accepted: 10/14/2015] [Indexed: 12/25/2022]
Abstract
To investigate the dosimetric characteristics of 4 SBRT-capable dose delivery systems, CyberKnife (CK), Helical TomoTherapy (HT), Volumetric Modulated Arc Therapy (VMAT) by Varian RapidArc (RA), and segmental step-and-shoot intensity-modulated radiation therapy (IMRT) by Elekta, on isolated thoracic spinal lesions. CK, HT, RA, and IMRT planning were performed simultaneously for 10 randomly selected patients with 6 body types and 6 body + pedicle types with isolated thoracic lesions. The prescription was set with curative intent and dose of either 33Gy in 3 fractions (3F) or 40Gy in 5F to cover at least 90% of the planning target volume (PTV), correspondingly. Different dosimetric indices, beam-on time, and monitor units (MUs) were evaluated to compare the advantages/disadvantages of each delivery modality. In ensuring the dose-volume constraints for cord and esophagus of the premise, CK, HT, and RA all achieved a sharp conformity index (CI) and a small penumbra volume compared to IMRT. RA achieved a CI comparable to those from CK, HT, and IMRT. CK had a heterogeneous dose distribution in the target as its radiosurgical nature with less dose uniformity inside the target. CK had the longest beam-on time and the largest MUs, followed by HT and RA. IMRT presented the shortest beam-on time and the least MUs delivery. For the body-type lesions, CK, HT, and RA satisfied the target coverage criterion in 6 cases, but the criterion was satisfied in only 3 (50%) cases with the IMRT technique. For the body + pedicle-type lesions, HT satisfied the criterion of the target coverage of ≥90% in 4 of the 6 cases, and reached a target coverage of 89.0% in another case. However, the criterion of the target coverage of ≥90% was reached in 2 cases by CK and RA, and only in 1 case by IMRT. For curative-intent SBRT of isolated thoracic spinal lesions, RA is the first choice for the body-type lesions owing to its delivery efficiency (time); the second choice is CK or HT; HT is the preferential choice for the body + pedicle-type lesions. This study suggests further clinical investigations with longer follow-up for these studied cases.
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Affiliation(s)
- Jun Yang
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China; Department of Oncology, First Affiliated Hospital of Xinxiang Medical University, 88 Jiankang Road, Weihui, Henan, 453100, China
| | - Lin Ma
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China; Department of Radiation Oncology, Hainan Branch of Chinese PLA General Hospital, Haitang Bay, Sanya, 572000, China
| | - Xiao-Shen Wang
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Wei Xu Xu
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xiao-Hu Cong
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Shou-Ping Xu
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhong-Jian Ju
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Lei Du
- Department of Radiation Oncology, Hainan Branch of Chinese PLA General Hospital, Haitang Bay, Sanya, 572000, China
| | - Bo-Ning Cai
- Department of Radiation Oncology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Jack Yang
- Department of Radiation Oncology, Monmouth Medical Center, 300 2nd Avenue, Long Branch, NJ 07740, USA
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Kairn T, Papworth D, Crowe SB, Anderson J, Christie DRH. Dosimetric quality, accuracy, and deliverability of modulated radiotherapy treatments for spinal metastases. Med Dosim 2016; 41:258-66. [PMID: 27545010 DOI: 10.1016/j.meddos.2016.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/23/2016] [Accepted: 06/16/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Tanya Kairn
- Genesis Cancer Care Queensland, Auchenflower, Australia; School of Chemistry, Physics, and Mechanical Engineering, Queensland University of Technology, Brisbane, Australia.
| | | | - Scott B Crowe
- School of Chemistry, Physics, and Mechanical Engineering, Queensland University of Technology, Brisbane, Australia; Cancer Care Services, Royal Brisbane and Women׳s Hospital, Herston, Australia
| | | | - David R H Christie
- Genesis Cancer Care Queensland, Auchenflower, Australia; School of Medicine, Bond University, Robina, Australia
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Salvage Stereotactic Body Radiotherapy (SBRT) Following In-Field Failure of Initial SBRT for Spinal Metastases. Int J Radiat Oncol Biol Phys 2015; 93:353-60. [PMID: 26383680 DOI: 10.1016/j.ijrobp.2015.03.029] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/04/2015] [Accepted: 03/26/2015] [Indexed: 12/15/2022]
Abstract
PURPOSE We report our experience in salvaging spinal metastases initially irradiated with stereotactic body radiation therapy (SBRT), who subsequently progressed with imaging-confirmed local tumor progression, and were re-irradiated with a salvage second SBRT course to the same level. METHODS AND MATERIALS From a prospective database, 56 metastatic spinal segments in 40 patients were identified as having been irradiated with a salvage second SBRT course to the same level. In addition, 24 of 56 (42.9%) segments had initially been irradiated with conventional external beam radiation therapy before the first course of SBRT. Local control (LC) was defined as no progression on magnetic resonance imaging at the treated segment, and calculated according to the competing risk model. Overall survival (OS) was evaluated for each patient treated by use of the Kaplan-Meier method. RESULTS The median salvage second SBRT total dose and number of fractions was 30 Gy in 4 fractions (range, 20-35 Gy in 2-5 fractions), and for the first course of SBRT was 24 Gy in 2 fractions (range, 20-35 Gy in 1-5 fractions). The median follow-up time after salvage second SBRT was 6.8 months (range, 0.9-39 months), the median OS was 10.0 months, and the 1-year OS rate was 48%. A longer time interval between the first and second SBRT courses predicted for better OS (P=.02). The crude LC was 77% (43/56), the 1-year LC rate was 81%, and the median time to local failure was 3.0 months (range, 2.7-16.7 months). Of the 13 local failures, 85% (11/13) and 46% (6/13) showed progression within the epidural space and paraspinal soft tissues, respectively. Absence of baseline paraspinal disease predicted for better LC (P<.01). No radiation-induced vertebral compression fractures or cases of myelopathy were observed. CONCLUSION A second course of spine SBRT, most often with 30 Gy in 4 fractions, for spinal metastases that failed initial SBRT is a feasible and efficacious salvage treatment option.
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Chan MW, Thibault I, Atenafu EG, Yu E, John Cho BC, Letourneau D, Lee Y, Yee A, Fehlings MG, Sahgal A. Patterns of epidural progression following postoperative spine stereotactic body radiotherapy: implications for clinical target volume delineation. J Neurosurg Spine 2015; 24:652-9. [PMID: 26682603 DOI: 10.3171/2015.6.spine15294] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors performed a pattern-of-failure analysis, with a focus on epidural disease progression, in patients treated with postoperative spine stereotactic body radiotherapy (SBRT). METHODS Of the 70 patients with 75 spinal metastases (cases) treated with postoperative spine SBRT, there were 26 cases of local disease recurrence and 25 cases with a component of epidural disease progression. Twenty-four of the 25 cases had preoperative epidural disease with subsequent epidural disease progression, and this cohort was the focus of this epidural-specific pattern-of-failure investigation. Preoperative, postoperative, and follow-up MRI scans were reviewed, and epidural disease was characterized based on location according to a system in which the vertebral anatomy is divided into 6 sectors, with the anterior compartment comprising Sectors 1, 2, and 6, and the posterior compartment comprising Sectors 3, 4, and 5. RESULTS Patterns of epidural progression are reported specifically for the 24 cases with preoperative epidural disease and subsequent epidural progression. Epidural disease progression within the posterior compartment was observed to be significantly lower in those with preoperative epidural disease confined to the anterior compartment than in those with preoperative epidural disease involving both anterior and posterior compartments (56% vs. 93%, respectively; p = 0.047). In a high proportion of patients with epidural disease progression, treatment failure was found in the anterior compartment, including both those with preoperative epidural disease confined to the anterior compartment and those with preoperative epidural disease involving both anterior and posterior compartments (100% vs. 73%, respectively). When epidural disease was confined to the anterior compartment on the preoperative and postoperative MRIs, no epidural disease progression was observed in Sector 4, which is the most posterior sector. Postoperative epidural disease characteristics alone were not predictive of the pattern of epidural treatment failure. CONCLUSIONS Reviewing the extent of epidural disease on preoperative MRI is imperative when planning postoperative SBRT. When epidural disease is confined to the anterior epidural sectors pre- and postoperatively, covering the entire epidural space circumferentially with a prophylactic "donut" distribution may not be needed.
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Affiliation(s)
| | | | | | - Eugene Yu
- Radiology, University Health Network, University of Toronto
| | - B C John Cho
- Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto; and
| | - Daniel Letourneau
- Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto; and
| | - Young Lee
- Department of Radiation Oncology, Odette Cancer Centre, and
| | - Albert Yee
- Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto;
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, and.,Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto; and
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Asbell SO, Grimm J, Xue J, Chew MS, LaCouture TA. Introduction and Clinical Overview of the DVH Risk Map. Semin Radiat Oncol 2015; 26:89-96. [PMID: 27000504 DOI: 10.1016/j.semradonc.2015.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Radiation oncologists need reliable estimates of risk for various fractionation schemes for all critical anatomical structures throughout the body, in a clinically convenient format. Reliable estimation theory can become fairly complex, however, and estimates of risk continue to evolve as the literature matures. To navigate through this efficiently, a dose-volume histogram (DVH) Risk Map was created, which provides a comparison of radiation tolerance limits as a function of dose, fractionation, volume, and risk level. The graphical portion of the DVH Risk Map helps clinicians to easily visualize the trends, whereas the tabular portion provides quantitative precision for clinical implementation. The DVH Risk Map for rib tolerance from stereotactic ablative body radiotherapy (SABR) and stereotactic body radiation therapy (SBRT) is used as an example in this overview; the 5% and 50% risk levels for 1-5 fractions for 5 different volumes are given. Other articles throughout this issue of Seminars in Radiation Oncology present analysis of new clinical datasets including the DVH Risk Maps for other anatomical structures throughout the body.
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Affiliation(s)
- Sucha O Asbell
- Department of Radiation Oncology, MD Anderson at Cooper University Hospital, Camden, NJ
| | - Jimm Grimm
- Holy Redeemer Hospital, Bott Cancer Center, Meadowbrook, PA.
| | - Jinyu Xue
- Department of Radiation Oncology, MD Anderson at Cooper University Hospital, Camden, NJ
| | | | - Tamara A LaCouture
- Department of Radiation Oncology, MD Anderson at Cooper University Hospital, Camden, NJ
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Guerrero E, Ahmed M. The role of stereotactic ablative radiotherapy (SBRT) in the management of oligometastatic non small cell lung cancer. Lung Cancer 2015; 92:22-8. [PMID: 26775592 DOI: 10.1016/j.lungcan.2015.11.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/22/2015] [Indexed: 12/29/2022]
Abstract
Our understanding of metastatic disease has evolved significantly in the last 20 years. Considered strictly a systemic issue, local treatment would only have significant impact in terms of palliation. However, Hellman and Weichselbaum stated that there might be an intermediate state, in which controlling limited metastatic sites could improve oncologic outcomes. This is called an oligometastatic state, a point between locally confined cancer and widespread disease [1,2]. As treatment with chemotherapy alone for non small cell lung cancer (NSCLC) yields median survivals of 8-11 months [3] and minimal chances of long term survival, new strategies are needed to offer better odds for metastatic patients. Outcomes tend to be better in patients with low volume metastatic disease. [4,5], leading us to question whether the oligometastatic group of patients will gain from a more radical treatment paradigm. In this setting, ablative treatments like surgery or SBRT may provide longer survival and better local control times. There is a rationale for the use of ablative local treatments, as most failures after chemotherapy occur at sites initially affected by disease, and these sites could be a source of further dissemination. Also, chemotherapy resistance can adversely impact resolution of metastatic disease [6]. In rare cases, the abscopal effect (an immune effect arising after radiotherapy in non irradiated metastatic sites) has been described [7,8]. In this review article, we address the impact of SBRT in oligometastatic NSCLC, the most relevant prognostic factors, indications and a site specific review. This review will focus on SBRT for extracranial disease as the role for intracranial SBRT is established.
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Affiliation(s)
- Eduardo Guerrero
- Radiation Oncology Department, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Merina Ahmed
- Academic Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, UK.
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Caruso JP, Cohen-Inbar O, Bilsky MH, Gerszten PC, Sheehan JP. Stereotactic radiosurgery and immunotherapy for metastatic spinal melanoma. Neurosurg Focus 2015; 38:E6. [PMID: 25727228 DOI: 10.3171/2014.11.focus14716] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of metastatic spinal melanoma involves maximizing local control, preventing recurrence, and minimizing treatment-associated toxicity and spinal cord damage. Additionally, therapeutic measures should promote mechanical stability, facilitate rehabilitation, and promote quality of life. These objectives prove difficult to achieve given melanoma's elusive nature, radioresistant and chemoresistant histology, vascular character, and tendency for rapid and early metastasis. Different therapeutic modalities exist for metastatic spinal melanoma treatment, including resection (definitive, debulking, or stabilization procedures), stereotactic radiosurgery, and immunotherapeutic techniques, but no single treatment modality has proven fully effective. The authors present a conceptual overview and critique of these techniques, assessing their effectiveness, separately and combined, in the treatment of metastatic spinal melanoma. They provide an up-to-date guide for multidisciplinary treatment strategies. Protocols that incorporate specific, goal-defined surgery, immunotherapy, and stereotactic radiosurgery would be beneficial in efforts to maximize local control and minimize toxicity.
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Rief H, Chaudhri N, Tonndorf-Martini E, Bruckner T, Rieken S, Bostel T, Förster R, Schlampp I, Debus J, Sterzing F. Intensity-modulated radiotherapy versus proton radiotherapy versus carbon ion radiotherapy for spinal bone metastases: a treatment planning study. J Appl Clin Med Phys 2015; 16:186–194. [PMID: 26699573 PMCID: PMC5690994 DOI: 10.1120/jacmp.v16i6.5618] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/10/2015] [Accepted: 06/19/2015] [Indexed: 11/23/2022] Open
Abstract
Outcomes for selected patients with spinal metastases may be improved by dose escalation using stereotactic body radiotherapy (SBRT). As target geometry is complex, we compared SBRT plans using step‐and‐shoot intensity‐modulated radiotherapy (IMRT), carbon ion RT, and proton RT. We prepared plans treating cervical, thoracic, and lumbar metastases for three different techniques — IMRT, carbon ion, and proton plans — to deliver a median single 24 Gy fraction such that at least 90% of the planning target volume (PTV) received more than 18 Gy and were compared for PTV coverage, normal organ sparing, and estimated delivery time. PTV coverage did not show significant differences for the techniques, spinal cord dose sparing was lowered with the particle techniques. For the cervical lesion spinal cord maximum dose, dose of 1% (D1), and percent volume receiving 10 Gy (V10Gy) were 11.9 Gy, 9.1 Gy, and 0.5% in IMRT. This could be lowered to 4.3 Gy, 2.5 Gy, and 0% in carbon ion planning and to 8.1 Gy, 6.1 Gy, and 0% in proton planning. Regarding the thoracic lesion no difference was found for the spinal cord. For the lumbar lesion maximum dose, D1 and percent volume receiving 5 Gy (V5Gy) were 13.4 Gy, 8.9 Gy, and 8.9% for IMRT; 1.8 Gy, 0.7 Gy, and 0% for carbon ions; and 0 Gy,<0.01 Gy, and 0% for protons. Estimated mean treatment times were shorter in particle techniques (6–7 min vs. 12–14 min with IMRT). This planning study indicates that carbon ion and proton RT can deliver high‐quality PTV coverage for complex treatment volumes that surround the spinal cord. PACS number: 87.55.dk
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Li T, Ozhasoglu C, Burton S, Flickinger J, Heron DE, Huq MS. A method to improve dose gradient for robotic radiosurgery. J Appl Clin Med Phys 2015; 16:333-339. [PMID: 26699588 PMCID: PMC5690989 DOI: 10.1120/jacmp.v16i6.5748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/15/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022] Open
Abstract
For targets with substantial volume, collimators of relatively large size are usually selected to minimize the treatment time in robotic radiosurgery. Their large penumbrae may adversely affect the dose gradient around the target. In this study, we implement and evaluate an inner‐shell planning method to increase the dose gradient and reduce dose to normal tissues. Ten patients previously treated with CyberKnife M6 system were randomly selected with the only criterion being that PTV be larger than 2 cm3. A new plan was generated for each patient in which the PTV was split into two regions: a 5 mm inner shell and a core, and a 7.5 mm Iris collimator was exclusively applied to the shell, with other appropriate collimators applied to the core depending on its size. The optimization objective, functions, and constraints were the same as in the corresponding clinical plan. The results were analyzed for V12 Gy, V9 Gy, V5 Gy, and gradient index (GI). Volume reduction was found for the inner‐shell method at all studied dose levels as compared to the clinical plans. The absolute dose‐volume reduction ranged from 0.05 cm3 to 18.5 cm3 with a mean of 5.6 cm3 for 12 Gy, from 0.2 cm3 to 38.1 cm3 with a mean of 9.8 cm3 for 9 Gy, and from 1.5 cm3 to 115.7 cm3 with a mean of 24.8 cm3 for 5 Gy, respectively. The GI reduction ranged from 3.2% to 23.6%, with a mean of 12.6%. Paired t‐test for GI has a p‐value of 0.0014. The range for treatment time increase is from ‐3 min to 20 min, with a mean of 7.0 min. We conclude that irradiating the PTV periphery exclusively with the 7.5 mm Iris collimator, rather than applying mixed collimators to the whole PTV, can substantially improve the dose gradient, while maintaining good coverage, conformity, and reasonable treatment time. PACS number: 87.55.de
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Wallace AN, Vyhmeister R, Hsi AC, Robinson CG, Chang RO, Jennings JW. Delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation: Case report with histopathologic-MRI correlation. Interv Neuroradiol 2015; 21:742-9. [PMID: 26500233 DOI: 10.1177/1591019915609131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/28/2015] [Indexed: 12/22/2022] Open
Abstract
Stereotactic radiosurgery and percutaneous radiofrequency ablation are emerging therapies for pain palliation and local control of spinal metastases. However, the post-treatment imaging findings are not well characterized and the risk of long-term complications is unknown. We present the case of a 46-year-old woman with delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation of a painful lumbar metastasis. Histopathologic-MRI correlation confirmed osteonecrosis as the underlying etiology and demonstrated that treatment-induced vascular fibrosis and tumor progression can have identical imaging appearances.
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Affiliation(s)
- Adam N Wallace
- Mallinckrodt Institute of Radiology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ross Vyhmeister
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Andy C Hsi
- Department of Pathology and Immunology, Division of Anatomic Pathology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Clifford G Robinson
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Randy O Chang
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Jack W Jennings
- Mallinckrodt Institute of Radiology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
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Ponsky L, Lo SS, Zhang Y, Schluchter M, Liu Y, Patel R, Abouassaly R, Welford S, Gulani V, Haaga JR, Machtay M, Ellis RJ. Phase I dose-escalation study of stereotactic body radiotherapy (SBRT) for poor surgical candidates with localized renal cell carcinoma. Radiother Oncol 2015; 117:183-7. [DOI: 10.1016/j.radonc.2015.08.030] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/26/2015] [Accepted: 08/29/2015] [Indexed: 12/01/2022]
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85
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Wallace AN, Robinson CG, Meyer J, Tran ND, Gangi A, Callstrom MR, Chao ST, Van Tine BA, Morris JM, Bruel BM, Long J, Timmerman RD, Buchowski JM, Jennings JW. The Metastatic Spine Disease Multidisciplinary Working Group Algorithms. Oncologist 2015; 20:1205-15. [PMID: 26354526 DOI: 10.1634/theoncologist.2015-0085] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 07/17/2015] [Indexed: 12/25/2022] Open
Abstract
The Metastatic Spine Disease Multidisciplinary Working Group consists of medical and radiation oncologists, surgeons, and interventional radiologists from multiple comprehensive cancer centers who have developed evidence- and expert opinion-based algorithms for managing metastatic spine disease. The purpose of these algorithms is to facilitate interdisciplinary referrals by providing physicians with straightforward recommendations regarding the use of available treatment options, including emerging modalities such as stereotactic body radiation therapy and percutaneous tumor ablation. This consensus document details the evidence supporting the Working Group algorithms and includes illustrative cases to demonstrate how the algorithms may be applied.
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Affiliation(s)
- Adam N Wallace
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Clifford G Robinson
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeffrey Meyer
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nam D Tran
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Afshin Gangi
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew R Callstrom
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samuel T Chao
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian A Van Tine
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan M Morris
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian M Bruel
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeremiah Long
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert D Timmerman
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jacob M Buchowski
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jack W Jennings
- Mallinckrodt Institute of Radiology, Department of Radiation Oncology, Department of Internal Medicine, and Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neurooncology Program, H. Lee Moffitt Cancer Center and Research Institute, Department of Neurosurgery, and Department of Orthopedics, University of South Florida College of Medicine, Tampa, Florida, USA; Department of Interventional Radiology, University of Strasbourg School of Medicine, Strasbourg, France; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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Lo SS, Kubicky CD, Chang EL, Sahgal A. Is there any role for stereotactic body radiotherapy in the management of metastatic epidural spinal cord compression? CNS Oncol 2015; 4:1-4. [PMID: 25586420 DOI: 10.2217/cns.14.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Simon S Lo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, 11100 Euclid Avenue, Lerner Tower B181, Cleveland, OH 44106, USA
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Han Z, Bondeson JC, Lewis JH, Mannarino EG, Friesen SA, Wagar MM, Balboni TA, Alexander BM, Arvold ND, Sher DJ, Hacker FL. Evaluation of initial setup accuracy and intrafraction motion for spine stereotactic body radiation therapy using stereotactic body frames. Pract Radiat Oncol 2015; 6:e17-24. [PMID: 26603596 DOI: 10.1016/j.prro.2015.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/21/2015] [Accepted: 08/27/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE The purposes of this study were (1) to evaluate the initial setup accuracy and intrafraction motion for spine stereotactic body radiation therapy (SBRT) using stereotactic body frames (SBFs) and (2) to validate an in-house-developed SBF using a commercial SBF as a benchmark. METHODS AND MATERIALS Thirty-two spine SBRT patients (34 sites, 118 fractions) were immobilized with the Elekta and in-house (BHS) SBFs. All patients were set up with the Brainlab ExacTrac system, which includes infrared and stereoscopic kilovoltage x-ray-based positioning. Patients were initially positioned in the frame with the use of skin tattoos and then shifted to the treatment isocenter based on infrared markers affixed to the frame with known geometry relative to the isocenter. ExacTrac kV imaging was acquired, and automatic 6D (6 degrees of freedom) bony fusion was performed. The resulting translations and rotations gave the initial setup accuracy. These translations and rotations were corrected for by use of a robotic couch, and verification imaging was acquired that yielded residual setup error. The imaging/fusion process was repeated multiple times during treatment to provide intrafraction motion data. RESULTS The BHS SBF had greater initial setup errors (mean±SD): -3.9±5.5mm (0.2±0.9°), -1.6±6.0mm (0.5±1.4°), and 0.0±5.3mm (0.8±1.0°), respectively, in the vertical (VRT), longitudinal (LNG), and lateral (LAT) directions. The corresponding values were 0.6±2.7mm (0.2±0.6°), 0.9±5.3mm (-0.2±0.9°), and -0.9±3.0mm (0.3±0.9°) for the Elekta SBF. The residual setup errors were essentially the same for both frames and were -0.1±0.4mm (0.1±0.5°), -0.2±0.4mm (0.0±0.4°), and 0.0±0.4mm (0.0±0.4°), respectively, in VRT, LNG, and LAT. The intrafraction shifts in VRT, LNG, and LAT were 0.0±0.4mm (0.0±0.3°), 0.0±0.5mm (0.0±0.4°), and 0.0±0.4mm (0.0±0.3°), with no significant difference observed between the 2 frames. CONCLUSIONS These results showed that the combination of the ExacTrac system with either SBF was highly effective in achieving both setup accuracy and intrafraction stability, which were on par with that of mask-based cranial radiosurgery.
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Affiliation(s)
- Zhaohui Han
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - John C Bondeson
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - John H Lewis
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Edward G Mannarino
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Scott A Friesen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Matthew M Wagar
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Brian M Alexander
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Nils D Arvold
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - David J Sher
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Fred L Hacker
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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Patel VB, Wegner RE, Heron DE, Flickinger JC, Gerszten P, Burton SA. Comparison of whole versus partial vertebral body stereotactic body radiation therapy for spinal metastases. Technol Cancer Res Treat 2015; 11:105-15. [PMID: 22335404 DOI: 10.7785/tcrt.2012.500239] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The purpose of this study is to evaluate the difference in clinical outcomes for patients with metastatic spine disease treated with a whole versus partial vertebral body contouring approach. A retrospective study was performed for the clinical outcomes of 154 metastatic lesions to the spine in 117 patients treated with stereotactic body radiation therapy (SBRT) using the Cyberknife(TM) Robotic Radiosurgery System. Each patient was treated with a single session of radiotherapy using either a whole (WB) or a partial vertebral body contour approach (PB). The primary endpoint was re-treatment rate and the secondary endpoints were pain status, neurologic status, toxicity, tumor control, and survival. The WB group had a lower re-treatment rate (11% (WB) vs. 18.6% (PB), p=0.285). Prior surgery status (β=1.953, OR=7.052, p<0.001) was correlated to the re-treatment rate. Trends for local tumor control were distinct for both treatment groups (X(2)=3.380, p-value=0.066). Treatment group (β=-1.1017, OR=0.362, p=0.029) was significantly correlated to the local tumor control rate. The 2-year survival was 25.7% in WB and 20.9% in PB (p=0.741). Contouring the whole vertebral body for stereotactic body radiation therapy treatment of metastatic spinal lesions shows potential benefits by reducing the risk of recurrence, improving symptomatic relief and providing improved local tumor control.
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Affiliation(s)
- Veeral B Patel
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
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89
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Outcomes for Spine Stereotactic Body Radiation Therapy and an Analysis of Predictors of Local Recurrence. Int J Radiat Oncol Biol Phys 2015; 92:1016-1026. [DOI: 10.1016/j.ijrobp.2015.03.037] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/16/2015] [Accepted: 03/30/2015] [Indexed: 11/21/2022]
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90
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Lo SSM, Ryu S, Chang EL, Galanopoulos N, Jones J, Kim EY, Kubicky CD, Lee CP, Rose PS, Sahgal A, Sloan AE, Teh BS, Traughber BJ, Van Poznak C, Vassil AD. ACR Appropriateness Criteria® Metastatic Epidural Spinal Cord Compression and Recurrent Spinal Metastasis. J Palliat Med 2015; 18:573-84. [DOI: 10.1089/jpm.2015.28999.sml] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Simon Shek-Man Lo
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Ryu
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Eric L. Chang
- University of Southern California-Keck School of Medicine, Los Angeles, California
| | | | - Joshua Jones
- University of Pennsylvania Perelman Center, Philadelphia, Pennsylvania
| | | | | | | | - Peter S. Rose
- Mayo Clinic, American Academy of Orthopaedic Surgeons, Rochester, Minnesota
| | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Bryan J. Traughber
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Catherine Van Poznak
- University of Michigan Comprehensive Cancer Center, American Society of Clinical Oncology, Ann Arbor, Michigan
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91
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Finnigan R, Burmeister B, Barry T, Jones K, Boyd J, Pullar A, Williams R, Foote M. Technique and early clinical outcomes for spinal and paraspinal tumours treated with stereotactic body radiotherapy. J Clin Neurosci 2015; 22:1258-63. [PMID: 25979254 DOI: 10.1016/j.jocn.2015.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/10/2015] [Accepted: 01/15/2015] [Indexed: 12/31/2022]
Abstract
We report technique and early clinical results of stereotactic body radiotherapy (SBRT) from Princess Alexandra Hospital. SBRT involves the precise delivery of highly conformal and image-guided external beam radiotherapy with high doses per fraction. It is increasingly being applied in management of spinal tumours. Thirty-six courses of spine SBRT in 34 patients were delivered between May 2010 and December 2013. Mean patient age was 58 years. Treatment was predominantly for metastatic disease, applied in de novo (n=22), retreatment (n=14) and postoperative (n=8) settings. Prescribed doses included 18-30 Gy in 1-5 fractions. SBRT technique evolved during the study period, resulting in a relative dose escalation. No severe acute toxicities were observed. At median follow-up of 7.4 months (range: 1.7-22.2), no late radiation myelopathy was observed. Risk of new/worsening vertebral compression fractures was 22% (n=8) and was significantly associated with increasing Spinal Instability Neoplastic Scores (p=0.0002). In-field control was 86% with relapse occurring at a median interval of 2.8 months (range: 1.9-4.7). Thirteen patients (36%) died and median overall survival has not been reached. SBRT is an evolving technology with promising early efficacy and safety results. The outcomes of this series are comparable with international literature, and await longer follow-up.
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Affiliation(s)
- Renee Finnigan
- Radiation Oncology Queensland, Southport, QLD, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Bryan Burmeister
- University of Queensland School of Medicine, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia
| | - Tamara Barry
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Kimberley Jones
- Centre for Experimental Haematology, University of Queensland School of Medicine, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Josh Boyd
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Andrew Pullar
- University of Queensland School of Medicine, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia
| | - Richard Williams
- Department of Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Matthew Foote
- University of Queensland School of Medicine, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia.
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92
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Bhattacharya I, Hoskin P. Stereotactic Body Radiotherapy for Spinal and Bone Metastases. Clin Oncol (R Coll Radiol) 2015; 27:298-306. [DOI: 10.1016/j.clon.2015.01.030] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/11/2015] [Accepted: 01/27/2015] [Indexed: 12/25/2022]
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93
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Verbakel WFAR, Gurney-Champion OJ, Slotman BJ, Dahele M. Sub-millimeter spine position monitoring for stereotactic body radiotherapy using offline digital tomosynthesis. Radiother Oncol 2015; 115:223-8. [PMID: 25910801 DOI: 10.1016/j.radonc.2015.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 03/24/2015] [Accepted: 04/10/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Spine stereotactic radiotherapy (SBRT) requires intrafraction motion <1-2mm. We evaluated the accuracy and precision of digital tomosynthesis (DTS) in combination with triangulation for spine position tracking. MATERIALS/METHODS Single-slice DTS images were generated from kV cone beam CT (CBCT) projection images. They were registered to reference DTS images reconstructed from the planning CT-scan to determine 2D shifts between actual patient position and treatment plan position. 3D spine position was obtained by triangulation of each registration with a previous registration, for every 1° of data. For 7 patients who underwent spine SBRT, the standard deviation (SD) of DTS+triangulation over one entire dataset was evaluated for different DTS angles (2-16°) and triangulation angles (1-46°). For 32 CBCT datasets, acquired before or after treatment of the 7 patients, using 4° DTS and 18° triangulation angle, SDs were determined and average positions were compared to clinically performed CBCT registrations. RESULTS Mean SDs were 0.29±0.10mm for lateral (range 0.1-0.55mm), 0.14±0.08 for longitudinal (0.05-0.39) and 0.24±0.10 for the vertical direction (0.10-0.57). Lateral and vertical SDs for thoracic spine were higher than for lumbar spine. Differences between clinical CBCT registration and DTS+triangulation were 0.1±0.26, 0.02±0.33 and -0.07±0.21mm. CONCLUSION The combination of DTS and triangulation allows for monitoring spine position with sub-mm accuracy and precision.
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Affiliation(s)
- Wilko F A R Verbakel
- Department of Radiotherapy, VU University Medical Center, Amsterdam, The Netherlands.
| | | | - Ben J Slotman
- Department of Radiotherapy, VU University Medical Center, Amsterdam, The Netherlands
| | - Max Dahele
- Department of Radiotherapy, VU University Medical Center, Amsterdam, The Netherlands
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94
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Greco C, Pares O, Pimentel N, Moser E, Louro V, Morales X, Salas B, Fuks Z. Spinal metastases: From conventional fractionated radiotherapy to single-dose SBRT. Rep Pract Oncol Radiother 2015; 20:454-63. [PMID: 26696786 DOI: 10.1016/j.rpor.2015.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/27/2015] [Accepted: 03/22/2015] [Indexed: 12/15/2022] Open
Abstract
AIM To review the recent evolution of spine SBRT with emphasis on single dose treatments. BACKGROUND Radiation treatment of spine metastases represents a challenging problem in clinical oncology, because of the high risk of inflicting damage to the spinal cord. While conventional fractionated radiation therapy still constitutes the most commonly used modality for palliative treatment, notwithstanding its efficacy in terms of palliation of pain, local tumor control has been approximately 60%. This limited effectiveness is due to previous lack of technology to precisely target the tumor while avoiding the radiosensitive spinal cord, which constitutes a dose-limiting barrier to tumor cure. MATERIALS AND METHODS A thorough review of the available literature on spine SBRT has been carried out and critically assessed. RESULTS Stereotactic body radiotherapy (SBRT) emerges as an alternative, non-invasive high-precision approach, which allows escalation of tumor dose, while effectively sparing adjacent uninvolved organs at risk. Engaging technological advances, such as on-line Cone Beam Computed Tomography (CBCT), coupled with Dynamic Multi-Leaf Collimation (DMLC) and rapid intensity-modulated (IMRT) beam delivery, have promoted an interactive image-guided (IGRT) approach that precisely conforms treatment onto a defined target volume with a rapid dose fall-off to collateral non-target tissues, such as the spinal cord. Recent technological developments allow the use of the high-dose per fraction mode of hypofractionated SBRT for spinal oligometastatic cancer, even if only a few millimeters away from the tumor. CONCLUSION Single-dose spine SBRT, now increasingly implemented, yields unprecedented outcomes of local tumor ablation and safety, provided that advanced technology is employed.
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Affiliation(s)
- Carlo Greco
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Oriol Pares
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Nuno Pimentel
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Elizabeth Moser
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Vasco Louro
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Xavier Morales
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Barbara Salas
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Zvi Fuks
- Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
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95
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Husain ZA, Thibault I, Letourneau D, Ma L, Keller H, Suh J, Chiang V, Chang EL, Rampersaud RK, Perry J, Larson DA, Sahgal A. Stereotactic body radiotherapy: a new paradigm in the management of spinal metastases. CNS Oncol 2015; 2:259-70. [PMID: 25054466 DOI: 10.2217/cns.13.11] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Spine stereotactic body radiotherapy is based on delivering high biologically effective doses to spinal metastases, with the intent to maximize both tumor and pain control. The purpose of this review is to outline the technical details of spine stereotactic body radiotherapy, contrast clinical outcomes to low biologically effective dose conventional palliative radiotherapy, discuss the role of surgery in the era of spine stereotactic body radiotherapy, and summarize the major serious adverse events that patients would otherwise not be at risk of with conventional radiotherapy.
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Affiliation(s)
- Zain A Husain
- Department of Radiation Oncology, Yale School of Medicine, New Haven, CT, USA
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96
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LeRoux LG, Bredow S, Grosshans D, Schellingerhout D. Molecular imaging detects impairment in the retrograde axonal transport mechanism after radiation-induced spinal cord injury. Mol Imaging Biol 2015; 16:504-10. [PMID: 24395625 DOI: 10.1007/s11307-013-0713-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The goal of this study was to determine whether molecular imaging of retrograde axonal transport is a suitable technique to detect changes in the spinal cord in response to radiation injury. PROCEDURES The lower thoracic spinal cords of adult female BALB/c mice were irradiated with single doses of 2, 10, or 80 Gy. An optical imaging method was used to observe the migration of the fluorescently labeled nontoxic C-fragment of tetanus toxin (TTc) from an injection site in the calf muscles to the spinal cord. Changes in migration patterns compared with baseline and controls allowed assessment of radiation-induced alterations in the retrograde neuronal axonal transport mechanism. Subsequently, tissues were harvested and histological examination of the spinal cords performed. RESULTS Transport of TTc in the thoracic spinal cord was impaired in a dose-dependent manner. Transport was significantly decreased by 16 days in animals exposed to either 10 or 80 Gy, while animals exposed to 2 Gy were affected only minimally. Further, animals exposed to the highest dose also experienced significant weight loss by 9 days and developed posterior paralysis by 45 days. Marked histological changes including vacuolization, and white matter necrosis were observed in radiated cords after 30 days for mice exposed to 80 Gy. CONCLUSION Radiation of the spinal cord induces dose-dependent changes in retrograde axonal transport, which can be monitored by molecular imaging. This approach suggests a novel diagnostic modality to assess nerve injury and monitor therapeutic interventions.
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Affiliation(s)
- Lucia G LeRoux
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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97
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Khan L, Chiang A, Zhang L, Thibault I, Bedard G, Wong E, Loblaw A, Soliman H, Fehlings MG, Chow E, Sahgal A. Prophylactic dexamethasone effectively reduces the incidence of pain flare following spine stereotactic body radiotherapy (SBRT): a prospective observational study. Support Care Cancer 2015; 23:2937-43. [PMID: 25752882 DOI: 10.1007/s00520-015-2659-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/15/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study was to determine the incidence of pain flare (PF) in patients receiving spine stereotactic body radiotherapy (SBRT) treated with prophylactic oral dexamethasone (DEX) 1 h before and for 4 days following SBRT. METHODS Forty-seven patients were accrued on this prospective observational study. The first cohort of 24 patients was treated with 4 mg, while a second cohort of 23 patients treated with 8 mg of DEX. The Brief Pain Inventory (BPI) was used to score pain and functional interference each day during SBRT and for 10 days following. Comparisons between the 4 and 8 mg cohorts, in addition to our previously reported steroid naïve patients post SBRT (n = 41), were also performed. RESULTS The total incidence of PF was 19 % (9/47). The incidence in the 4 and 8 mg cohorts was 25 % (6/24) and 13 % (3/23), respectively, and the difference was not statistically significant (p = 0.46). Comparing functional interference, the 4 mg cohort had better profile in walking ability (p < 0.005) and relationships with others (p < 0.035) compared to the 8 mg cohort. Compared to our previously reported steroid naïve cohort, prophylactic DEX significantly reduced the incidence of PF (68 vs. 19 %, p < 0.0001, respectively), patients had lower worst pain scores, and improved general activity interference outcome. CONCLUSION We recommend prophylactic DEX for patients treated with spine SBRT. Our current practice is based on the 4 mg protocol primarily due to the improved functional interference outcomes. A randomized trial is required to finalize the optimal regimen and schedule.
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Affiliation(s)
- Luluel Khan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3 M5, Canada
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98
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Amoush A, Dalton A, Rabatic B, Huang K, Al-Basheer A. Volumetric modulated arc therapy for spine SBRT patients to reduce treatment time and intrafractional motion. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2015. [DOI: 10.14319/ijcto.0302.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Precisely focused radiation or surgical resection of limited metastases resulted in long-term disease control and survival in multiple studies of patients with oligometastatic breast cancer. The integration of these ablative techniques into standard systemic therapy regimens has the potential to be paradigm shifting, leaving many patients without evidence of disease. Although an attractive treatment option, the utility of these therapies have not been proven in controlled studies, and improved outcomes may be because of patient selection or favorable biology alone. Ongoing studies continue to refine radiation techniques and determine the role for ablative therapies in the management of patients with metastatic breast cancer (MBC). Additionally, patient selection for metastasis-directed therapies is based on clinical criteria, with many not benefiting from therapies that may have substantial toxicities. Recent reports are beginning to uncover the biology of oligometastatic cancer, but much work is needed. Current and developing trials that integrate both clinical and translational endpoints have the potential to transform management strategies in women with limited MBC.
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Affiliation(s)
- Joseph K Salama
- From the Department of Radiation Oncology, Duke University Medical Center, Durham, NC; The University of Chicago, Chicago, IL
| | - Steven J Chmura
- From the Department of Radiation Oncology, Duke University Medical Center, Durham, NC; The University of Chicago, Chicago, IL
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100
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Reproducibility of the MRI-defined spinal cord position in stereotactic radiotherapy for spinal oligometastases. Radiother Oncol 2014; 113:230-4. [DOI: 10.1016/j.radonc.2014.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 09/30/2014] [Accepted: 11/01/2014] [Indexed: 12/25/2022]
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