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Quashie EE, Li XA, Prior P, Awan M, Schultz C, Tai A. Obtaining organ-specific radiobiological parameters from clinical data for radiation therapy planning of head and neck cancers. Phys Med Biol 2023; 68:245015. [PMID: 37903437 DOI: 10.1088/1361-6560/ad07f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/30/2023] [Indexed: 11/01/2023]
Abstract
Objective.Different radiation therapy (RT) strategies, e.g. conventional fractionation RT (CFRT), hypofractionation RT (HFRT), stereotactic body RT (SBRT), adaptive RT, and re-irradiation are often used to treat head and neck (HN) cancers. Combining and/or comparing these strategies requires calculating biological effective dose (BED). The purpose of this study is to develop a practical process to estimate organ-specific radiobiologic model parameters that may be used for BED calculations in individualized RT planning for HN cancers.Approach.Clinical dose constraint data for CFRT, HFRT and SBRT for 5 organs at risk (OARs) namely spinal cord, brainstem, brachial plexus, optic pathway, and esophagus obtained from literature were analyzed. These clinical data correspond to a particular endpoint. The linear-quadratic (LQ) and linear-quadratic-linear (LQ-L) models were used to fit these clinical data and extract relevant model parameters (alpha/beta ratio, gamma/alpha,dTand BED) from the iso-effective curve. The dose constraints in terms of equivalent physical dose in 2 Gy-fraction (EQD2) were calculated using the obtained parameters.Main results.The LQ-L and LQ models fitted clinical data well from the CFRT to SBRT with the LQ-L representing a better fit for most of the OARs. The alpha/beta values for LQ-L (LQ) were found to be 2.72 (2.11) Gy, 0.55 (0.30) Gy, 2.82 (2.90) Gy, 6.57 (3.86) Gy, 5.38 (4.71) Gy, and the dose constraint EQD2 were 55.91 (54.90) Gy, 57.35 (56.79) Gy, 57.54 (56.35) Gy, 60.13 (59.72) Gy and 65.66 (64.50) Gy for spinal cord, optic pathway, brainstem, brachial plexus, and esophagus, respectively. Additional two LQ-L parametersdTwere 5.24 Gy, 5.09 Gy, 7.00 Gy, 5.23 Gy, and 6.16 Gy, and gamma/alpha were 7.91, 34.02, 8.67, 5.62 and 4.95.Significance.A practical process was developed to extract organ-specific radiobiological model parameters from clinical data. The obtained parameters can be used for biologically based radiation planning such as calculating dose constraints of different fractionation regimens.
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Affiliation(s)
- Edwin E Quashie
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
- Department of Radiation Oncology, Brown University School of Medicine, Providence, RI 02903, United States of America
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI 02903, United States of America
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Phillip Prior
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
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Fan Q, Pham H, Zhang P, Li X, Li T. Evaluation of a proprietary software application for motion monitoring during stereotactic paraspinal treatment. J Appl Clin Med Phys 2022; 23:e13594. [PMID: 35338583 PMCID: PMC9195043 DOI: 10.1002/acm2.13594] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 12/10/2021] [Accepted: 03/04/2022] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Stereotactic paraspinal treatment has become increasingly popular due to its favorable clinical outcome. An often-overlooked factor that compromises the effectiveness of such treatment is the patients' involuntary intrafractional motion. This work introduces and validates a proprietary software application that quantifies such motion for accurate patient monitoring during treatment. METHODS The software uses a separate full-trajectory cone-beam computed tomography (CBCT) after daily patient setup to establish reference projections. Once treatment starts, the software grabs the intrafraction motion review (IMR) image acquired by TrueBeam via the Varian iTools Capture software and compares it against the corresponding reference projection to instantly determine the 2D shifts of the vertebrae being monitored using the classical downhill simplex optimization method. To evaluate its performance, an anthropomorphic phantom was shifted 0, 0.6, 1.2, 1.8, 2.4, 3.0, and 5 mm in three orthogonal directions, immediately after the full-trajectory CBCT but prior to treatment. Depending on the scenario of shift, a nine-field fixed gantry intensity-modulated radiation therapy (IMRT) plan and/or a four partial-posterior-arcs volume-modulated radiation therapy (VMAT) plan were delivered. For the IMRT plan, three IMR images were acquired sequentially every 200 monitor units (MU) at each treatment angle. For the VMAT plan, one IMR image was acquired every 15° of each arc. For each IMR image, the software-reported 2D shift was compared with the ground truth. Certain tests were repeated with 1°, 2°, and 3° of rotation, pitch, and roll, respectively. Some of these tests were also repeated independently on separate days. RESULTS Based on the group of tests that involved only the IMRT delivery, the maximum standard deviation of the software-reported shifts for each set of three IMR images was 0.16 mm, with 95th percentile at 0.02 mm. For translational shift, the maximum registration error was 0.44 mm, with 95th percentile at 0.23 mm. Left unaccounted for, rotation and pitch degraded the registration accuracy mainly in the longitudinal direction, while roll degraded it mainly in the lateral direction. The degradation of registration accuracy is positively related to the degree of rotation, pitch, and roll. The maximum registration errors under 3° rotation, pitch, and roll were 2.97, 1.44, 2.72 mm, respectively. Based on the group of tests that compared IMRT delivery with VMAT delivery, the registration errors slightly increased as magnitude of shifts increased; however, they were well under the 0.5-mm threshold. No significant differences in registration errors were observed between IMRT and VMAT deliveries. In addition, the variation in registration errors among different days was limited for both IMRT and VMAT deliveries. CONCLUSIONS Our proprietary software has high repeatability, both intrafractionally and interfractionally, and high accuracy in registering IMR images with the reference projections for motion monitoring, regardless of the magnitude of shifts or treatment delivery technique. Rotation, pitch, and roll degrade registration accuracy and need to be accounted for in the future work.
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Affiliation(s)
- Qiyong Fan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hai Pham
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Pengpeng Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Xiang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Tianfang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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3
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Jensen PJ, Torok JA, Goodwin CR, Floyd SR, Wu Q, Wu QJ, Kirkpatrick JP. Purposeful irradiation of the epidural space to enhance local control without compromising cord sparing in spine radiosurgery †. JOURNAL OF RADIOSURGERY AND SBRT 2022; 8:21-26. [PMID: 35387408 PMCID: PMC8930062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/05/2021] [Indexed: 01/03/2023]
Abstract
Purpose The epidural space is a frequent site of cancer recurrence after spine stereotactic radiosurgery (SSRS). This may be due to microscopic disease in the epidural space which is underdosed to obey strict spinal cord dose constraints. We hypothesized that the epidural space could be purposefully irradiated to prescription dose levels, potentially reducing the risk of recurrence in the epidural space without increasing toxicity. Methods and materials SSRS clinical treatment plans with spinal cord contours, spinal planning target volumes (PTVspine), and delivered dose distributions were retrospectively identified. An epidural space PTV (PTVepidural) was contoured to avoid the spinal cord and focus on regions near the PTVspine. Clinical plan constraints included PTVspine constraints (D95% and D5%, based on prescription dose) and spinal cord constraints (Dmax < 1300 cGy, D10% < 1000 cGy). Plans were revised with three prescriptions of 1800, 2000 and 2400 cGy in two sets, with one set of revisions (supplemented plans) designed to additionally target the PTVepidural by optimizing PTVepidural D95% in addition to meeting every clinical plan constraint. Clinical and revised plans were compared according to their PTVepidural DVH distributions, and D95% distributions. Results Seventeen SSRS plans meeting the above criteria were identified. Supplemented plans had higher doses to the epidural low-dose regions at all prescription levels. Epidural PTV D95% values for the supplemented plans were all statistically significantly different from the values of the base plans (p < 10-4). The epidural PTV D95% increases depended on the initial prescription, increasing from 11.52 to 16.90 Gy, 12.23 to 18.85 Gy, and 13.87 to 19.54 Gy for target prescriptions of 1800, 2000 and 2400 cGy, respectively. Conclusions Purposefully targeting the epidural space in SSRS may increase control in the epidural space without significantly increasing the risk of spinal cord toxicity. A clinical trial of this approach should be considered.
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Affiliation(s)
- P. James Jensen
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA
| | - Jordan A. Torok
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA
| | - C. Rory Goodwin
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA, Department of Neurosurgery, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC 27710 USA
| | - Scott R. Floyd
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA
| | - Qiuwen Wu
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA
| | - Q. Jackie Wu
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA
| | - John P. Kirkpatrick
- Department of Radiation Oncology, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC, USA, Department of Neurosurgery, The Duke Center for Brain and Spine Metastasis, Duke Cancer Institute, Durham, NC 27710 USA
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Kowalchuk RO, Cousins D, Spencer KM, Richardson KM, Larner JM, Showalter TN, McAllister WH, Sheehan JP, Kersh CR, Dutta SW. Local control of 1-5 fraction radiotherapy regimens for spinal metastases: an analysis of the impacts of biologically effective dose and primary histology. Rep Pract Oncol Radiother 2021; 26:883-891. [PMID: 34992859 PMCID: PMC8726428 DOI: 10.5603/rpor.a2021.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/18/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This analysis evaluates the impacts of biologically effective dose (BED) and histology on local control (LC) of spinal metastases treated with highly conformal radiotherapy to moderately-escalated doses. MATERIALS AND METHODS Patients were treated at two institutions from 2010-2020. Treatments with less than 5 Gy per fraction or 8 Gy in 1 fraction were excluded. The dataset was divided into three RPA classes predictive of survival (1). The primary endpoint was LC. RESULTS 223 patients with 248 treatments met inclusion criteria. Patients had a median Karnofsky Performance Status (KPS ) of 80, and common histologies included breast (29.4%), non-small cell lung cancer (15.7%), and prostate (13.3%). A median 24 Gy was delivered in 3 fractions (BED: 38.4 Gy) to a median planning target volume (PTV) of 37.3 cc. 2-year LC was 75.7%, and 2-year OS was 42.1%. Increased BED was predictive of improved LC for primary prostate cancer (HR = 0.85, 95% CI: 0.74-0.99). Patients with favorable survival (RPA class 1) had improved LC with BED ≥ 40 Gy (p = 0.05), unlike the intermediate and poor survival groups. No grade 3-5 toxicities were reported. CONCLUSIONS Moderately-escalated treatments were efficacious and well-tolerated. BED ≥ 40 Gy may improve LC, particularly for prostate cancer and patients with favorable survival.
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Affiliation(s)
| | - David Cousins
- Department of Radiation Oncology, University of Virginia, Charlottesville, United States
| | - Kelly M. Spencer
- Radiosurgery Center, University of Virginia/Riverside, Newport News, United States
| | - K. Martin Richardson
- Radiosurgery Center, University of Virginia/Riverside, Newport News, United States
| | - James M. Larner
- Department of Radiation Oncology, University of Virginia, Charlottesville, United States
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, United States
| | - William H. McAllister
- Department of Neurosurgery, Riverside Regional Medical Center, Newport News, United States
| | - Jason P. Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, United States
| | - C. Ronald Kersh
- Radiosurgery Center, University of Virginia/Riverside, Newport News, United States
| | - Sunil W. Dutta
- Department of Radiation Oncology, Emory University, Atlanta, United States
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Kavya S, Reghu R. An Overview of High-grade Glioma: Current and Emerging Treatment Approaches. CURRENT CANCER THERAPY REVIEWS 2021. [DOI: 10.2174/1573394716666200721155514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
High grade glioma is one of the severe form of tumour that progresses in the glial cells
of the brain and spinal cord. Age, gender, exposure to infections, race, ethnicity, viruses and allergens,
environmental carcinogens, diet, head injury or trauma and ionizing radiation may report
with increased glioma risk. Headache, seizure mainly generalized tonic-clonic seizure, memory
loss and altered sensorium are considered as common symptoms of glioma. Magnetic Resonance
Imaging (MRI), CT scans, neurological examinations and biopsy are considered as the diagnostic
option for glioma. Treatment for glioma mainly depended upon the tumour progression, malignancy,
cell type, age, location of tumour growth and anatomic structure. The standard treatment includes
surgery, radiation therapy and chemotherapy. Temozolomide is usually prescribed at a
dosage of 75 mg/m2 and began in combination with radiation therapy and continued daily. The primary
indicator of hepatotoxicity is the elevation of the liver profiles, i.e. the changes in any of the
liver panels may be considered to be hepatotoxic. Serum glutamic oxaloacetic transaminase (SGOT),
Serum Glutamic Pyruvic Transaminase (SGPT), Alkaline phosphatase (ALP) are rising panels
of the liver, which are elevated during toxicity. In some patients, albumin and globulin levels
may show variations. Treatment for glioma associated symptoms like seizures, depression anxiety
etc. are also mentioned along with supportive care for glioma. New trends in the treatment for glioma
are RINTEGA, an experimental immunotherapeutic agent and bevazizumab, a recombinant
monoclonal, a humanized antibody against the VEGF ligand [VEGF-A (vascular endothelial
growth factor)] in tumor cells.
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Affiliation(s)
- S.G. Kavya
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
| | - R. Reghu
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
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Grimm J, Vargo JA, Mavroidis P, Moiseenko V, Emami B, Jain S, Caudell JJ, Clump DA, Ling DC, Das S, Moros EG, Vinogradskiy Y, Xue J, Heron DE. Initial Data Pooling for Radiation Dose-Volume Tolerance for Carotid Artery Blowout and Other Bleeding Events in Hypofractionated Head and Neck Retreatments. Int J Radiat Oncol Biol Phys 2021; 110:147-159. [PMID: 33583641 DOI: 10.1016/j.ijrobp.2020.12.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Dose-volume data for injury to carotid artery and other major vessels in stereotactic body radiation therapy (SBRT)/SABR head and neck reirradiation were reviewed, modeled, and summarized. METHODS AND MATERIALS A PubMed search of the English-language literature (stereotactic and carotid and radiation) in April 2018 found 238 major vessel maximum point doses in 6 articles that were pooled for logistic modeling. Two subsequent studies with dose-volume major vessel data were modeled separately for comparison. Attempts were made to separate carotid blowout syndrome from other bleeding events (BE) in the analysis, but we acknowledge that all except 1 data set has some element of BE interspersed. RESULTS Prior radiation therapy (RT) dose was not uniformly reported per patient in the studies included, but a course on the order of conventionally fractionated 70 Gy was considered for the purposes of the analysis (with an approximately ≥6-month estimated interval between prior and subsequent treatment in most cases). Factors likely associated with reduced risk of BE include nonconsecutive daily treatment, lower extent of circumferential tumor involvement around the vessel, and no surgical manipulation before or after SBRT. CONCLUSIONS Initial data pooling for reirradiation involving the carotid artery resulted in 3 preliminary models compared in this Hypofractionated Treatment Effects in the Clinic (HyTEC) report. More recent experiences with alternating fractionation schedules and additional risk-reduction strategies are also presented. Complications data for the most critical structures such as spinal cord and carotid artery are so limited that they cannot be viewed as strong conclusions of probability of risk, but rather, as a general guideline for consideration. There is a great need for better reporting standards as noted in the High Dose per Fraction, Hypofractionated Treatment Effects in the Clinic introductory paper.
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Affiliation(s)
- Jimm Grimm
- Department of Radiation Oncology, Geisinger Health System, Danville, Pennsylvania; Department of Medical Imaging and Radiation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - John A Vargo
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Panayiotis Mavroidis
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Vitali Moiseenko
- Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Bahman Emami
- Department of Radiation Oncology, Loyola University, Maywood, Illinois
| | - Sheena Jain
- Bott Cancer Center, Holy Redeemer Hospital, Meadowbrook, Pennsylvania
| | - Jimmy J Caudell
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - David A Clump
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Diane C Ling
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Shiva Das
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Eduardo G Moros
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | - Jinyu Xue
- Department of Radiation Oncology, New York University School of Medicine, New York, New York
| | - Dwight E Heron
- Department of Radiation Oncology, Bon Secours Mercy Health System, Youngstown, Ohio
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Wang X, Chen D, Xie T, Zhang W. Predicting women's intentions to screen for breast cancer based on the health belief model and the theory of planned behavior. J Obstet Gynaecol Res 2019; 45:2440-2451. [DOI: 10.1111/jog.14109] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Xinbo Wang
- Nursing School of Jilin University Changchun China
| | - Dandan Chen
- Nursing School of Jilin University Changchun China
| | - Tingting Xie
- Nursing School of Jilin University Changchun China
| | - Wei Zhang
- Nursing School of Jilin University Changchun China
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8
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Pacelli R, Caroprese M, Palma G, Oliviero C, Clemente S, Cella L, Conson M. Technological evolution of radiation treatment: Implications for clinical applications. Semin Oncol 2019; 46:193-201. [PMID: 31395286 DOI: 10.1053/j.seminoncol.2019.07.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023]
Abstract
The contemporary approach to the management of a cancer patient requires an "ab initio" involvement of different medical domains in order to correctly design an individual patient's pathway toward cure. With new therapeutic tools in every medical field developing faster than ever before the patient care outcomes can be achieved if all surgical, drug, and radiation options are considered in the design of the appropriate therapeutic strategy for a given patient. Radiation therapy (RT) is a clinical discipline in which experts from different fields continuously interact in order to manage the multistep process of the radiation treatment. RT is found to be an appropriate intervention for diverse indications in about 50% of cancer patients during the course of their disease. Technologies are essential in dealing with the complexity of RT treatments and for driving the increasingly sophisticated RT approaches becoming available for the treatment of Cancer. High conformal techniques, namely intensity modulated or volumetric modulated arc techniques, ablative techniques (Stereotactic Radiotherapy and Stereotactic Radiosurgery), particle therapy (proton or carbon ion therapy) allow for success in treating irregularly shaped or critically located targets and for the sharpness of the dose fall-off outside the target. The advanced on-board imaging, including real-time position management systems, makes possible image-guided radiation treatment that results in substantial margin reduction and, in select cases, implementation of an adaptive approach. The therapeutic gains of modern RT are also due in part to the enhanced anticancer activity obtained by coadministering RT with chemotherapy, targeted molecules, and currently immune checkpoints inhibitors. These main clinically relevant steps forward in Radiation Oncology represent a change of gear in the field that may have a profound impact on the management of cancer patients.
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Affiliation(s)
- Roberto Pacelli
- Department of Advanced Biomedical Sciences, University "Federico II", Napoli, Italy.
| | - Mara Caroprese
- Department of Advanced Biomedical Sciences, University "Federico II", Napoli, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimages, National Research Council, Napoli, Italy
| | | | | | - Laura Cella
- Institute of Biostructures and Bioimages, National Research Council, Napoli, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, University "Federico II", Napoli, Italy
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Silva SR, Gliniewicz A, Martin B, Prabhu VC, Germanwala AV, Melian E, Jones GA, Solanki AA. Oligometastatic Disease State Is Associated with Improved Local Control in Patients Undergoing Three or Five Fraction Spine Stereotactic Body Radiotherapy. World Neurosurg 2019; 122:e342-e348. [DOI: 10.1016/j.wneu.2018.10.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022]
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10
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Volume effects in radiosurgical spinal cord dose tolerance: how small is too small? ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s13566-018-0371-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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11
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Osborn VW, Lee A, Yamada Y. Stereotactic Body Radiation Therapy for Spinal Malignancies. Technol Cancer Res Treat 2019; 17:1533033818802304. [PMID: 30343661 PMCID: PMC6198394 DOI: 10.1177/1533033818802304] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Stereotactic body radiation therapy and stereotactic radiosurgery have become important treatment options for the treatment of spinal malignancies. A better understanding of dose tolerances with more conformal technology have allowed administration of higher and more ablative doses. In this review, the framework for approaching a patient with spinal metastases and primary tumors will be discussed as well as details on the delivery of this treatment.
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Affiliation(s)
- Virginia W Osborn
- 1 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,2 Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Anna Lee
- 1 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,2 Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Yoshiya Yamada
- 1 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Cramer CK, Ververs JD, Jones FS, Hsu W, Chan MD, Wolfe SQ. Will immunotherapy change the role of spine radiosurgery in high-grade epidural disease? A case report and a call for an update of current treatment algorithms. JOURNAL OF RADIOSURGERY AND SBRT 2019; 6:153-156. [PMID: 31641551 PMCID: PMC6774494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/08/2019] [Indexed: 06/10/2023]
Abstract
Epidural disease closer than 3 mm from the spinal cord is sometimes regarded as a contraindication to spine radiosurgery (SRS) or stereotactic body radiotherapy (SBRT). Current guidelines on the management of high-grade epidural disease recommend surgical decompression followed by conventionally fractionated external-beam radiotherapy (EBRT) or post-operative SBRT [1, 2]. For patients with high-grade epidural disease who are medically inoperable, conventional EBRT is typically recommended, even though clinical response rates are lower and durability is limited[3]. A few expert centers use decompressive SRS in a single fraction for high-grade epidural disease[4, 5], but this technique has not been incorporated into treatment algorithms such as the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework [1, 2]. Here we present a case where five-fraction SBRT followed by immunotherapy resulted in a complete radiographic and clinical response for a patient with epidural disease that was compressing the thecal sac. We compare the radiographic response in this patient to data in a prior publication that quantified the improvement in thecal sac patency after decompressive SRS, and we suggest that current treatment algorithms need to be updated in the era of immunotherapy.
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Affiliation(s)
- Christina Kehl Cramer
- Department of Radiation Oncology at Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - James D. Ververs
- Department of Radiation Oncology at Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Wesley Hsu
- Department of Neurosurgery at Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Michael David Chan
- Department of Radiation Oncology at Wake Forest School of Medicine, Winston-Salem, NC, USA
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Treatment plan quality and delivery accuracy assessments on 3 IMRT delivery methods of stereotactic body radiotherapy for spine tumors. Med Dosim 2018; 44:11-14. [PMID: 29429794 DOI: 10.1016/j.meddos.2017.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/21/2017] [Accepted: 12/22/2017] [Indexed: 02/07/2023]
Abstract
Stereotactic body radiotherapy (SBRT) for spine tumors has demonstrated clinical effectiveness. The treatment planning and delivery techniques have evolved from dynamic conformal arc therapy, to fixed gantry angle intensity modulated radiotherapy (IMRT), and most recently to volumetric modulated arc therapy (VMAT). A hybrid-arc (HARC) planning and delivery method combining dynamic conformal arc therapy delivery with a number of equally spaced IMRT beams is proposed. In this study we investigated plan quality, delivery accuracy, and efficiency of 3 delivery techniques: IMRT, HARC, and VMAT. Patients who underwent spine SBRT treatments were randomly selected from an Institutional Review Board-approved registry. For each patient, the prescription dose was 14 to 16 Gy in a single fraction to cover >90% of the tumor (without planning margin) while constraining V10Gy ≤ 10% of the spinal cord and the maximum point dose (MPD) of the spinal cord ≤ 14 Gy. All cases were clinically treated with fixed gantry step-shoot IMRT plans and then re-planned with VMAT using Pinnacle 9.0 and with HARC using Brainlab iPlan 4.5. Student t-test was used to compare the dosimetric end points, including V16Gy to the planning target volume, homogeneity index, MPDPTV, the conformity index, V10Gy of the spinal cord, and MPDcord. To compare the accuracy of delivery, we delivered all plans on a phantom and conducted gamma index (GI) comparisons with 3 mm/3% and 2 mm/2% criteria. All plans met our clinical requirements. Among 3 techniques, there were no differences on dose coverage to the tumor volume, maximum dose to the spinal cord, and plan homogeneity index (p > 0.05). The average V10Gy of the spinal cord was 6.66 ± 0.03%, 5.49 ± 0.03%, and 4.76 ± 0.02% for IMRT, HARC, and VMAT plans, respectively. Accordingly, the conformity indices were 1.30 ± 0.11 and 1.29 ± 0.20, 1.53 ± 0.29, respectively. VMAT plans were significantly (p < 0.05) less conformal but significantly (p < 0.05) lower V10Gy of the spinal cord than those from HARC and IMRT plans. With delivery accuracy measured by GIs, the average GIs of 3%/3 mm were 92.6 ± 1.1%, 96.5 ± 2.7%, 99.0 ± 1.1% for IMRT, HARC, and VMAT plans, respectively. The differences were significant (p < 0.05). Accordingly, the average monitor units were 9238 ± 2242, 9853 ± 2548 and 5091 ± 910. The plan quality created from the 3 planning techniques can meet the clinical requirement. Adding arc beams in delivery such as in HARC and VMAT plans improves the delivery accuracy. VMAT is the most efficient delivery method.
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A Detailed Dosimetric Analysis of Spinal Cord Tolerance in High-Dose Spine Radiosurgery. Int J Radiat Oncol Biol Phys 2017; 99:598-607. [DOI: 10.1016/j.ijrobp.2017.05.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/02/2017] [Accepted: 05/31/2017] [Indexed: 11/22/2022]
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15
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Wang X, Zhao Z, Luo D, Yang JN, Yang J, Chang EL, Brown PD, Li J, McAleer MF, Ghia AJ. Submillimeter alignment of more than three contiguous vertebrae in spinal SRS/SBRT with 6-degree couch. J Appl Clin Med Phys 2017; 18:225-236. [PMID: 28786235 PMCID: PMC5875814 DOI: 10.1002/acm2.12153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/14/2017] [Accepted: 06/21/2017] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to identify regions of spinal column in which more than three contiguous vertebrae can be reliably and quickly aligned within 1 mm using a 6‐degree (6D) couch and full body immobilization device. We analyzed 45 cases treated over a 3‐month period. Each case was aligned using ExacTrac x‐ray positioning system with integrated 6D couch to be within 1° and 1 mm in all six dimensions. Cone‐Beam computed tomography (CBCT) with at least 17.5 cm field of view (FOV) in the superior–inferior direction was taken immediately after ExacTrac positioning. It was used to examine the residual error of five to nine contiguous vertebrae visible in the FOV. The residual error of each vertebra was determined by expanding/contracting the vertebrae contour with a margin in millimeter integrals on the planning CT such that the new contours would enclose the corresponding vertebrae contour on CBCT. Submillimeter initial setup accuracy was consistently achieved in 98% (40/41) cases for a span of five or more vertebrae starting from T2 vertebra and extending caudally to S5. The curvature of spinal column along the cervical region and cervicothoracic junction was not easily reproducible between treatment and simulation. Fifty‐seven percent (8/14) of cases in this region had residual setup error of more than 1 mm in nearby vertebrae after alignment using 6D couch with image guidance. In conclusion, 6D couch integrated with image guidance is convenient and accurately corrects small rotational shifts. Consequently, more than three contiguous vertebrae can be aligned within 1 mm with immobilization that reliably reproduces the curvature of the thoracic and lumbar spinal column. Ability of accurate setup is becoming less a concern in limiting the use of stereotactic radiosurgery or stereotactic body radiation therapy to treat multilevel spinal target.
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Affiliation(s)
- Xin Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxiang Zhao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dershan Luo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James N Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric L Chang
- Departments of Radiation Oncology, University of Southern California Keck School of Medicine, Norris Cancer Hospital, Los Angeles, CA, USA
| | - Paul D Brown
- Departments of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Romano KD, Trifiletti DM, Bauer-Nilsen K, Wages NA, Watkins WT, Read PW, Showalter TN. Clinical outcomes of helical conformal versus nonconformal palliative radiation therapy for axial skeletal metastases. Pract Radiat Oncol 2017; 7:e479-e487. [PMID: 28666907 DOI: 10.1016/j.prro.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/22/2017] [Accepted: 04/06/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Palliative radiation therapy (RT) for bone metastases has traditionally been delivered with conventional, nonconformal RT (NCRT). Conformal RT (CRT) is potentially more complex and expensive than NCRT, but may reduce normal tissue dose and subsequently toxicity. In this retrospective analysis, we compared CRT with NCRT to investigate the association between conformality and toxicity. METHODS AND MATERIALS A retrospective analysis of patients receiving palliative RT for axial skeletal bone metastases from 2012 to 2014 was conducted. Patient and treatment characteristics were obtained including dosimetric variables, acute toxicity, and subjective pain during treatment and in the acute posttreatment period (≤60 days after completion). Statistical analyses included t tests, χ2 tests, and multivariate logistic regression. RESULTS A total of 179 patients and 254 bone metastases were identified (142 CRT, 112 NCRT). The CRT and NCRT groups were well matched for baseline characteristics (number of fractions, field size, treatment sites, and concurrent chemotherapy). In multivariate logistic regression models, technique (CRT vs NCRT) was not associated with development of acute toxicity. Regarding toxicity, Eastern Cooperative Oncology Group performance status and total dose were significantly associated with a higher rate of acute toxicity during RT (odds ratios, 0.649 and 1.129 and P = .027 and .044, respectively), and only a higher number of vertebral bodies in the treatment field was significantly associated with acute toxicity post-treatment (odds ratios, 1.219, P = .028). CRT was associated with improvement in bone pain during and posttreatment (P = .049 and .045, respectively). CONCLUSIONS Our results demonstrate no difference in acute toxicity following palliative RT with CRT compared with NCRT for painful bone metastases; however, treatment volume did predict for increased toxicity. Larger studies may further elucidate the value of CRT including the impact of dose escalation for bone metastases and differences in patient reported outcomes between RT techniques.
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Affiliation(s)
- Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia.
| | - Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | | | - Nolan A Wages
- Department of Public Health Sciences, Division of Translational Research & Applied Statistics, University of Virginia, Charlottesville, Virginia
| | - William T Watkins
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Paul W Read
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
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Boyce-Fappiano D, Elibe E, Zhao B, Siddiqui MS, Lee I, Rock J, Ryu S, Siddiqui F. Reirradiation of the spine with stereotactic radiosurgery: Efficacy and toxicity. Pract Radiat Oncol 2017; 7:e409-e417. [PMID: 28673511 DOI: 10.1016/j.prro.2017.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the potential benefits and adverse effects associated with reirradiating the spinal cord when at least 1 course of radiation therapy (RT) is stereotactic radiosurgery (SRS). METHODS AND MATERIALS This institutional review board-approved retrospective review included 162 patients (237 reirradiated spine lesions). All patients received SRS at our institution between 2001 and 2013. Electronic medical records were reviewed for clinical exams and radiologic tests (computed tomography/magnetic resonance imaging). Primary endpoints were pain, neurological, radiographic responses, and the development of adverse effects. RESULTS A total of 120 patients (74.1%) were deceased with a median survival of 13 months. Time between courses of RT was a median of 10.2 months. Median SRS dose was 16 Gy in 1 fraction, whereas the median conventional external beam radiation therapy (cEBRT) dose was 30 Gy in 10 fractions. The median tumor equivalent dose in 2-Gy fractions (EQD2) for SRS doses was 34.7 Gy, whereas the median tumor EQD2 for cEBRT was 32.5 Gy, providing a median total tumor EQD2 of 69.3 Gy (22-145.6 Gy). The median critical nervous tissue EQD2 for SRS and cEBRT was 56 Gy and 37.5 Gy, respectively, resulting in a median total critical nervous tissue EQD2 of 93.5 Gy. Overall pain, neurological, and radiographic response rates were 81%, 82%, and 71%, respectively. Adverse effects occurred in 11 (6.8%) patients. Seventy-seven vertebral compression fractures were observed, 22 (9.3%) of which may be attributed to RT. CONCLUSIONS Our results demonstrate that reirradiation achieves favorable response rates with minimal toxicity if recommended dose constraints to the spinal cord with SRS are carefully observed. To the best of our knowledge, this is the largest reported single-institution experience analyzing the efficacy and toxicity of reirradiation of the spine when at least 1 course of RT is stereotactic radiosurgery.
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Affiliation(s)
| | - Erinma Elibe
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Bo Zhao
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - M Salim Siddiqui
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Ian Lee
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Jack Rock
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook University School of Medicine, Stony Brook, New York
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan.
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Ahmed KA, Torres-Roca JF. Stereotactic Body Radiotherapy in the Management of Oligometastatic Disease. Cancer Control 2016; 23:21-9. [PMID: 27009453 DOI: 10.1177/107327481602300105] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The treatment of oligometastatic disease has become common as imaging techniques have advanced and the management of systemic disease has improved. Use of highly targeted, hypofractionated regimens of stereotactic body radiotherapy (SBRT) is now a primary management option for patients with oligometastatic disease. METHODS The properties of SBRT are summarized and the results of retrospective and prospective studies of SBRT use in the management of oligometastases are reviewed. Future directions of SBRT, including optimizing dose and fractionation schedules, are also discussed. RESULTS SBRT can deliver highly conformal, dosed radiation treatments for ablative tumors in a few treatment sessions. Phase 1/2 trials and retrospective institutional results support use of SBRT as a treatment option for oligometastatic disease metastasized to the lung, liver, and spine, and SBRT offers adequate toxicity profiles with good rates of local control. Future directions will involve optimizing dose and fractionation schedules for select histologies to improve rates of local control while limiting toxicity to normal structures. CONCLUSIONS SBRT offers an excellent management option for patients with oligometastases. However, additional research is still needed to optimize dose and fractionation schedules.
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Chang JH, Shin JH, Yamada YJ, Mesfin A, Fehlings MG, Rhines LD, Sahgal A. Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them? Spine (Phila Pa 1976) 2016; 41 Suppl 20:S238-S245. [PMID: 27488294 PMCID: PMC5552170 DOI: 10.1097/brs.0000000000001823] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVES To summarize the risks of 3 key complications of stereotactic body radiotherapy (SBRT) for spinal metastases, that is, radiation myelopathy (RM), vertebral compression fracture (VCF), and epidural disease progression, and to discuss strategies for minimizing them. SUMMARY OF BACKGROUND DATA RM, VCF and epidural disease progression are now recognized as important risks following SBRT for spine metastases. It is unclear at this stage exactly how large these risks are and what strategies can be employed to minimize these risks. METHODS A systematic review of the literature using MEDLINE and a review of the bibliographies of reviewed articles on SBRT for spinal metastases were conducted. RESULTS The initial literature search revealed a total of 376 articles, of which 38 were pertinent to the study objectives. The risk of RM following SBRT was found to be dependent on the maximum dose to the spinal cord and estimated to be ≤5% if the recommended published thecal sac dose constraints are adhered to. The crude risk of VCF was 13.7% (range: 0.7%-40.5%), and, on average, 45% were surgically salvaged. It has been shown that the risk of VCF is dependent on several anatomic and tumor-related factors including the SBRT dose per fraction. The crude risk of local failure at 1 year was 21.4% (range: 12%-27%) of which 67% (range: 38%-96%) occurred within the epidural space. The grade of epidural disease has been shown to be associated with the risk of local failure. CONCLUSION The risk of RM after spinal SBRT is low in particular if recommended dose metrics are adhered to. There is a significant risk of both VCF and epidural disease progression after spinal SBRT. These risks can potentially be minimized by identifying the risk factors for these complications, and performing careful radiotherapy and surgical planning. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Joe H. Chang
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard University, Boston, MA
| | - Yoshiya J. Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY
| | - Michael G. Fehlings
- Department of Neurosurgery and Spinal Program, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laurence D. Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Thureau S, Vieillard MH, Supiot S, Lagrange JL. [Radiotherapy of bone metastases]. Cancer Radiother 2016; 20 Suppl:S227-34. [PMID: 27523421 DOI: 10.1016/j.canrad.2016.07.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Radiotherapy plays a major role in palliative treatment of bone metastases. Recent developments of stereotactic radiotherapy and intensity modulated radiation therapy give the possibility to treat oligometastatic diseases. The objective of this paper is to report indications and treatment modalities of radiotherapy in these situations.
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Affiliation(s)
- S Thureau
- Quantif-Litis EA 4108, département de radiothérapie et de physique médicale, centre Henri-Becquerel, rue d'Amiens, 76038 Rouen, France
| | - M-H Vieillard
- Service de rhumatologie, hôpital Salengro, CHRU de Lille, rue Émile-Lainé, 59037 Lille, France; Département d'oncologie générale, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59020 Lille, France
| | - S Supiot
- Service de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - J-L Lagrange
- Service de radiotherapie, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Université Paris Est Créteil, avenue du Général-de-Gaulle, 94010 Créteil cedex, France.
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Bahig H, Simard D, Létourneau L, Wong P, Roberge D, Filion E, Donath D, Sahgal A, Masucci L. A Study of Pseudoprogression After Spine Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 96:848-856. [PMID: 27788956 DOI: 10.1016/j.ijrobp.2016.07.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To determine the incidence of pseudoprogression (PP) after spine stereotactic body radiation therapy based on a detailed and quantitative assessment of magnetic resonance imaging (MRI) morphologic tumor alterations, and to identify predictive factors distinguishing PP from local recurrence (LR). METHODS AND MATERIALS A retrospective analysis of 35 patients with 49 spinal segments treated with spine stereotactic body radiation therapy, from 2009 to 2014, was conducted. The median number of follow-up MRI studies was 4 (range, 2-7). The gross tumor volumes (GTVs) within each of the 49 spinal segments were contoured on the pretreatment and each subsequent follow-up T1- and T2-weighted MRI sagittal sequence. T2 signal intensity was reported as the mean intensity of voxels constituting each volume. LR was defined as persistent GTV enlargement on ≥2 serial MRI studies for ≥6 months or on pathologic confirmation. PP was defined as a GTV enlargement followed by stability or regression on subsequent imaging within 6 months. Kaplan-Meier analysis was used for estimation of actuarial local control, disease-free survival, and overall survival. RESULTS The median follow-up was 23 months (range, 1-39 months). PP was identified in 18% of treated segments (9 of 49) and LR in 29% (14 of 49). Earlier volume enlargement (5 months for PP vs 15 months for LR, P=.005), greater GTV to reference nonirradiated vertebral body T2 intensity ratio (+30% for PP vs -10% for LR, P=.005), and growth confined to 80% of the prescription isodose line (80% IDL) (8 of 9 PP cases vs 1 of 14 LR cases, P=.002) were associated with PP on univariate analysis. Multivariate analysis confirmed an earlier time to volume enlargement and growth within the 80% IDL as significant predictors of PP. LR involved the epidural space in all but 1 lesion, whereas PP was confined to the vertebral body in 7 of 9 cases. CONCLUSIONS PP was observed in 18% of treated spinal segments. Tumor growth confined to the 80% IDL and earlier time to tumor enlargement were predictive for PP.
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Affiliation(s)
- Houda Bahig
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Dany Simard
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Létourneau
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Philip Wong
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Edith Filion
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - David Donath
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laura Masucci
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.
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Toxicities Following Stereotactic Ablative Radiotherapy Treatment of Locally-Recurrent and Previously Irradiated Head and Neck Squamous Cell Carcinoma. Semin Radiat Oncol 2016; 26:112-9. [DOI: 10.1016/j.semradonc.2015.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wang X, Ghia AJ, Zhao Z, Yang J, Luo D, Briere TM, Pino R, Li J, McAleer MF, Weksberg DC, Chang EL, Brown PD, Yang JN. Prospective evaluation of target and spinal cord motion and dosimetric changes with respiration in spinal stereotactic body radiation therapy utilizing 4-D CT. JOURNAL OF RADIOSURGERY AND SBRT 2016; 4:191-201. [PMID: 29296444 PMCID: PMC5658802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/09/2016] [Indexed: 06/07/2023]
Abstract
PURPOSE To assess the dosimetric effects of respiratory motion on the target and spinal cord in spinal stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS Thirty patients with 33 lesions were enrolled on a prospective clinical protocol and simulated with both free-breathing and four-dimensional (4-D) computed tomography (CT). We studied the target motion using 4-D data (10 phases) by registering a secondary image dataset (phase 1 to 9) to a primary image dataset (phase 0) and analyzing the displacement in both translational and rotational directions. The study of dosimetric impacts from respiration includes both the effect of potential target and spinal cord motion and anatomic changes in the beam path. A clinical step-and-shoot IMRT plan generated on the free-breathing CT was copied to the 4-D datasets to evaluate the difference in the dose-volume histogram of target and normal tissues in each phase of a breathing cycle. RESULTS Twenty three lesions had no motion in a breathing cycle; four lesions had anterior-posterior motion ≤ 0.2 mm; two lesions had lateral motion ≤ 0.2 mm; and eight lesions had superior-inferior motion, most ≤ 0.2 mm with the worst at 0.6 mm. The difference of maximum dose to 0.01 cm3 of spinal cord in different phases of a breathing cycle was within 20 cGy in worst case. Target volumes that received the prescription dose (V100) varied little, with deviations of V100 of each phase from the average CT < 1% in most cases. Only when lesions were close to the diaphragm (e.g., at T11) did the V100 deviate by about 7% in the worst case scenario. However, this was caused by a small dose difference of 20 cGy to part of the target volume. CONCLUSIONS Breathing induced target and spinal cord motion is negligible compared with other setup uncertainties. Dose calculation using averaged or free-breathing CT is reliable when posterior beams are used.
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Affiliation(s)
- Xin Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J. Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxiang Zhao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dershan Luo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina M. Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ramiro Pino
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary F. McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David C. Weksberg
- Department of Radiation Oncology, PinnacleHealth Cancer Institute, Harrisburg, PA, USA
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Norris Cancer Hospital, Los Angeles, CA, USA
| | - Paul D. Brown
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James N. Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Xin-Ye N, Ren L, Yan H, Yin FF. Sensitivity of 3D Dose Verification to Multileaf Collimator Misalignments in Stereotactic Body Radiation Therapy of Spinal Tumor. Technol Cancer Res Treat 2015; 15:NP25-NP34. [PMID: 26525748 DOI: 10.1177/1533034615610251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 08/17/2015] [Accepted: 09/08/2015] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This study aimed to detect the sensitivity of Delt 4 on ordinary field multileaf collimator misalignments, system misalignments, random misalignments, and misalignments caused by gravity of the multileaf collimator in stereotactic body radiation therapy. METHODS (1) Two field sizes, including 2.00 cm (X) × 6.00 cm (Y) and 7.00 cm (X) × 6.00 cm (Y), were set. The leaves of X1 and X2 in the multileaf collimator were simultaneously opened. (2) Three cases of stereotactic body radiation therapy of spinal tumor were used. The dose of the planning target volume was 1800 cGy with 3 fractions. The 4 types to be simulated included (1) the leaves of X1 and X2 in the multileaf collimator were simultaneously opened, (2) only X1 of the multileaf collimator and the unilateral leaf were opened, (3) the leaves of X1 and X2 in the multileaf collimator were randomly opened, and (4) gravity effect was simulated. The leaves of X1 and X2 in the multileaf collimator shifted to the same direction. The difference between the corresponding 3-dimensional dose distribution measured by Delt 4 and the dose distribution in the original plan made in the treatment planning system was analyzed with γ index criteria of 3.0 mm/3.0%, 2.5 mm/2.5%, 2.0 mm/2.0%, 2.5 mm/1.5%, and 1.0 mm/1.0%. RESULTS (1) In the field size of 2.00 cm (X) × 6.00 cm (Y), the γ pass rate of the original was 100% with 2.5 mm/2.5% as the statistical standard. The pass rate decreased to 95.9% and 89.4% when the X1 and X2 directions of the multileaf collimator were opened within 0.3 and 0.5 mm, respectively. In the field size of 7.00 (X) cm × 6.00 (Y) cm with 1.5 mm/1.5% as the statistical standard, the pass rate of the original was 96.5%. After X1 and X2 of the multileaf collimator were opened within 0.3 mm, the pass rate decreased to lower than 95%. The pass rate was higher than 90% within the 3 mm opening. (2) For spinal tumor, the change in the planning target volume V18 under various modes calculated using treatment planning system was within 1%. However, the maximum dose deviation of the spinal cord was high. In the spinal cord with a gravity of -0.25 mm, the maximum dose deviation minimally changed and increased by 6.8% than that of the original. In the largest opening of 1.00 mm, the deviation increased by 47.7% than that of the original. Moreover, the pass rate of the original determined through Delt 4 was 100% with 3 mm/3% as the statistical standard. The pass rate was 97.5% in the 0.25 mm opening and higher than 95% in the 0.5 mm opening A, 0.25 mm opening A, whole gravity series, and 0.20 mm random opening. Moreover, the pass rate was higher than 90% with 2.0 mm/2.0% as the statistical standard in the original and in the 0.25 mm gravity. The difference in the pass rates was not statistically significant among the -0.25 mm gravity, 0.25 mm opening A, 0.20 mm random opening, and original as calculated using SPSS 11.0 software with P > .05. CONCLUSIONS Different analysis standards of Delt 4 were analyzed in different field sizes to improve the detection sensitivity of the multileaf collimator position on the basis of 90% throughout rate. In stereotactic body radiation therapy of spinal tumor, the 2.0 mm/2.0% standard can reveal the dosimetric differences caused by the minor multileaf collimator position compared with the 3.0 mm/3.0% statistical standard. However, some position derivations of the misalignments that caused high dose amount to the spinal cord cannot be detected. However, some misalignments were not detected when a large number of multileaf collimator were administered into the spinal cord.
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Affiliation(s)
- Ni Xin-Ye
- Department of Radiation Oncology, Second People's Hospital of Changzhou, Nanjing Medical University, Changzhou, China
| | - Lei Ren
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Hui Yan
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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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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Rose JN, Crook JM. The role of radiation therapy in the treatment of metastatic castrate-resistant prostate cancer. Ther Adv Urol 2015; 7:135-45. [PMID: 26161144 DOI: 10.1177/1756287215576647] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In the setting of castrate-resistant prostate cancer, patients present with a variety of symptoms, including bone metastases, spinal cord compression and advanced pelvic disease. Fortunately, a variety of radiotherapeutic options exist for palliation. This article focuses on these options, including both external beam radiotherapy and radiopharmaceuticals.
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Affiliation(s)
- Jim N Rose
- Department of Radiation Oncology, British Columbia Cancer Agency, Cancer Centre for the Southern Interior, Kelowna, BC, Canada
| | - Juanita M Crook
- Department of Radiation Oncology, Cancer Centre for the Southern Interior, 399 Royal Avenue, Kelowna, BC, Canada V1Y 5L3
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Amini A, Altoos B, Bourlon MT, Bedrick E, Bhatia S, Kessler ER, Flaig TW, Fisher CM, Kavanagh BD, Lam ET, Karam SD. Local control rates of metastatic renal cell carcinoma (RCC) to the bone using stereotactic body radiation therapy: Is RCC truly radioresistant? Pract Radiat Oncol 2015; 5:e589-e596. [PMID: 26142027 DOI: 10.1016/j.prro.2015.05.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/11/2015] [Accepted: 05/17/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE We report the radiographic and clinical response rate of stereotactic body radiation therapy (SBRT) compared with conventional fractionated external beam radiation therapy (CF-EBRT) for renal cell carcinoma (RCC) bone lesions treated at our institution. METHODS AND MATERIALS Forty-six consecutive patients were included in the study, with 95 total lesions treated (50 SBRT, 45 CF-EBRT). We included patients who had histologic confirmation of primary RCC and radiographic evidence of metastatic bone lesions. The most common SBRT regimen used was 27 Gy in 3 fractions. RESULTS Median follow-up was 10 months (range, 1-64 months). Median time to symptom control between SBRT and CF-EBRT were 2 (range, 0-6 weeks) and 4 weeks (range, 0-7 weeks), respectively. Symptom control rates with SBRT and CF-EBRT were significantly different (P = .020) with control rates at 10, 12, and 24 months of 74.9% versus 44.1%, 74.9% versus 39.9%, and 74.9% versus 35.7%, respectively. The median time to radiographic failure and unadjusted pain progression was 7 months in both groups. When controlling for gross tumor volume, dose per fraction, smoking, and the use of systemic therapy, biologically effective dose ≥80 Gy was significant for clinical response (hazard ratio [HR], 0.204; 95% confidence interval [CI], 0.043-0.963; P = .046) and radiographic (HR, 0.075; 95% CI, 0.013-0.430; P = .004). When controlling for gross tumor volume and total dose, biologically effective dose ≥80 Gy was again predictive of clinical local control (HR, 0.140; 95% CI, 0.025-0.787; P = .026). Toxicity rates were low and equivalent in both groups, with no grade 4 or 5 toxicity reported. CONCLUSIONS SBRT is both safe and effective for treating RCC bone metastases, with rapid improvement in symptoms after treatment and more durable clinical and radiographic response rate. Future prospective trials are needed to further define efficacy and toxicity of treatment, especially in the setting of targeted agents.
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Affiliation(s)
- Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Basel Altoos
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Maria T Bourlon
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado.,Medical Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Edward Bedrick
- Department of Biostatistics and Bioinformatics Shared Resource, University of Colorado Denver, Aurora, Colorado
| | - Shilpa Bhatia
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth R Kessler
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Thomas W Flaig
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Elaine T Lam
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Sana D Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
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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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Lee SH, Lee KC, Choi J, Ahn SH, Lee SH, Sung KH, Kil SH. Clinical applicability of biologically effective dose calculation for spinal cord in fractionated spine stereotactic body radiation therapy. Radiol Oncol 2015; 49:185-91. [PMID: 26029031 PMCID: PMC4387996 DOI: 10.1515/raon-2015-0008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/05/2015] [Indexed: 12/25/2022] Open
Abstract
Background. The aim of the study was to investigate whether biologically effective dose (BED) based on linear-quadratic model can be used to estimate spinal cord tolerance dose in spine stereotactic body radiation therapy (SBRT) delivered in 4 or more fractions. Patients and methods. Sixty-three metastatic spinal lesions in 47 patients were retrospectively evaluated. The most frequently prescribed dose was 36 Gy in 4 fractions. In planning, we tried to limit the maximum dose to the spinal cord or cauda equina less than 50% of prescription or 45 Gy2/2. BED was calculated using maximum point dose of spinal cord. Results. Maximum spinal cord dose per fraction ranged from 2.6 to 6.0 Gy (median 4.3 Gy). Except 4 patients with 52.7, 56.4, 62.4, and 67.9 Gy2/2, equivalent total dose in 2-Gy fraction of the patients was not more than 50 Gy2/2 (12.1–67.9, median 32.0). The ratio of maximum spinal cord dose to prescription dose increased up to 82.2% of prescription dose as epidural spinal cord compression grade increased. No patient developed grade 2 or higher radiation-induced spinal cord toxicity during follow-up period of 0.5 to 53.9 months. Conclusions. In fractionated spine SBRT, BED can be used to estimate spinal cord tolerance dose, provided that the dose per fraction to the spinal cord is moderate, e.g. < 6.0 Gy. It appears that a maximum dose of up to 45–50 Gy2/2 to the spinal cord is tolerable in 4 or more fractionation regimen.
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Affiliation(s)
- Seung Heon Lee
- Department of Radiation Oncology; Gachon University Gil Medical Center, Republic of Korea
| | - Kyu Chan Lee
- Department of Radiation Oncology; Gachon University Gil Medical Center, Republic of Korea
| | - Jinho Choi
- Department of Radiation Oncology; Gachon University Gil Medical Center, Republic of Korea
| | - So Hyun Ahn
- Department of Radiation Oncology; Gachon University Gil Medical Center, Republic of Korea
| | - Seok Ho Lee
- Department of Radiation Oncology; Gachon University Gil Medical Center, Republic of Korea
| | - Ki Hoon Sung
- Department of Radiation Oncology; Gachon University Gil Medical Center, Republic of Korea
| | - Se Hee Kil
- Gachon Medical Research Institute, Gachon University Gil Medical Center, Republic of Korea
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van Oorschot B, Polat B, Rades D. Strahlentherapie beim metastasierten Nierenzellkarzinom. DER ONKOLOGE 2014. [DOI: 10.1007/s00761-014-2778-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
Advances in radiotherapy planning and delivery have been used to treat patients with limited metastatic disease. With these techniques, high rates of treated metastasis control and low toxicity have been reported. Some patients have long disease-free intervals after radiotherapy similar to those seen after surgical resection. Ongoing studies will determine the benefit of these irradiation techniques to treat limited metastases, identify appropriate candidates, and assist in integrating these treatments into management strategies for specific diseases.
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Affiliation(s)
- Joseph K Salama
- Joseph K. Salama, Duke University, Durham, NC; and Michael T. Milano, University of Rochester, Rochester, NY.
| | - Michael T Milano
- Joseph K. Salama, Duke University, Durham, NC; and Michael T. Milano, University of Rochester, Rochester, NY
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Gerszten PC. Spine Metastases: From Radiotherapy, Surgery, to Radiosurgery. Neurosurgery 2014; 61 Suppl 1:16-25. [DOI: 10.1227/neu.0000000000000375] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Peter C. Gerszten
- Departments of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jain AK, Yamada YJ. The role of stereotactic body radiotherapy and stereotactic radiosurgery in the re-irradiation of metastatic spinal tumors. Expert Rev Anticancer Ther 2014; 14:1141-52. [PMID: 25066490 DOI: 10.1586/14737140.2014.940326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiotherapy (SBRT) and stereotactic radiosurgery (SRS) are advanced radiotherapy delivery techniques that allow for the delivery of high-dose per fraction radiation. Advances in imaging technology and intensity modulation have allowed SRS and SBRT to be used for the treatment of tumors in close proximity to the spinal cord and cauda equina, in particular spinal metastases. While the initial treatment of spinal metastases is often conventional palliative radiotherapy, treatment failure is not uncommon, and conventional re-irradiation may not be feasible due to spinal cord tolerance. SBRT and SRS have emerged as important techniques for the treatment of spinal metastases in the proximity of previously irradiated spinal cord. Here we review the current data on the use of SBRT and SRS spinal re-irradiation, and future directions for these important treatment modalities.
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Affiliation(s)
- Anshu K Jain
- Department of Radiation Oncology, Columbia University Medical Center and New York Presbyterian Hospital, 622 W. 168th St, New York, NY 10032, USA
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Radiothérapie stéréotaxique hypofractionnée des métastases osseuses. Cancer Radiother 2014; 18:342-9. [DOI: 10.1016/j.canrad.2014.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/14/2014] [Accepted: 04/29/2014] [Indexed: 11/21/2022]
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Long-term safety and efficacy of fractionated stereotactic body radiation therapy for spinal metastases. Strahlenther Onkol 2014; 190:1141-8. [DOI: 10.1007/s00066-014-0706-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 06/05/2014] [Indexed: 12/25/2022]
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Patel PR, Kirkpatrick J, Salama JK, Nelson J, Broadwater G, Allen K, Clough R, Yin FF, Wang Z, Chang Z, Kelsey C, Ghafoori AP. Stereotactic ablative body radiotherapy (SABR) for effective palliation of metastases: factors affecting local control. JOURNAL OF RADIOSURGERY AND SBRT 2014; 3:123-129. [PMID: 29296393 PMCID: PMC5675484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 05/21/2014] [Indexed: 06/07/2023]
Abstract
We analyzed factors associated with inferior local control following stereotactic ablative body radiotherapy (SABR) for palliation of metastases. We reviewed records of patients receiving SABR for metastases at Duke University from 2006-2010. Biologically effective dose (BED) was calculated using the linear-quadratic model. Toxicity was assessed by CTCAE v4.0. The Kaplan-Meier method was used to estimate overall survival (OS) and local control (LC) within subgroups (primary or salvage SABR). Univariate (UVA) and multivariate (MVA) regression analysis was used. Fifty and 33 patients received primary and salvage SABR, respectively. 105 lesions were treated (52 spine, 27 lung, 7 liver, 11 other); 67 primary SABR and 38 salvage. Median clinical follow-up was 11.1 months and 10.3 months with imaging of the treated lesion. One patient received SABR x3 and died from toxicity. 88% of symptomatic patients improved after SABR. 1-year LC and OS were 83% and 50%, respectively. Primary SABR had higher BED and was associated with improved LC on UVA (HR 3.0, p=0.01) and MVA (p=0.02); treatment site and histology were not. SABR results in effective palliation of metastases regardless of prior treatment. In the absence of prior EBRT, SABR can be delivered with higher BED and may be associated with better outcomes.
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Affiliation(s)
- Pretesh R. Patel
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - John Kirkpatrick
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - Joseph K. Salama
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - John Nelson
- Naval Medical Center Portsmouth, John Paul Jones Circle, Portsmouth, VA 23708, USA
| | - Gloria Broadwater
- Biostatistics, Duke University Medical Center, Box 2717 Med Ctr, Hock Plaza, 2424 Erwin Rd, Rm 8023, Durham, NC 27705, USA
| | - Karen Allen
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - Robert Clough
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - Fang-Fang Yin
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - Zhiheng Wang
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - Zheng Chang
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - Christopher Kelsey
- Department Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA
| | - A. Paiman Ghafoori
- University Medical Center Brackenridge, Austin CyberKnife, 1400 North IH 35, Austin, TX 78701, USA
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Gröger C, Hautmann MG, Loeschel R, Repp N, Kölbl O, Dobler B. Re-irradiation of spinal column metastases by IMRT: impact of setup errors on the dose distribution. Radiat Oncol 2013; 8:269. [PMID: 24238332 PMCID: PMC3842751 DOI: 10.1186/1748-717x-8-269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 11/03/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study investigates the impact of an automated image guided patient setup correction on the dose distribution for ten patients with in-field IMRT re-irradiation of vertebral metastases. METHODS 10 patients with spinal column metastases who had previously been treated with 3D-conformal radiotherapy (3D-CRT) were simulated to have an in-field recurrence. IMRT plans were generated for treatment of the vertebrae sparing the spinal cord. The dose distributions were compared for a patient setup based on skin marks only and a Cone Beam CT (CBCT) based setup with translational and rotational couch corrections using an automatic robotic image guided couch top (Elekta - HexaPOD™ IGuide® - system). The biological equivalent dose (BED) was calculated to evaluate and rank the effects of the automatic setup correction for the dose distribution of CTV and spinal cord. RESULTS The mean absolute value (± standard deviation) over all patients and fractions of the translational error is 6.1 mm (±4 mm) and 2.7° (±1.1 mm) for the rotational error. The dose coverage of the 95% isodose for the CTV is considerable decreased for the uncorrected table setup. This is associated with an increasing of the spinal cord dose above the tolerance dose. CONCLUSIONS An automatic image guided table correction ensures the delivery of accurate dose distribution and reduces the risk of radiation induced myelopathy.
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Affiliation(s)
- Christian Gröger
- Department of Radiotherapy, University Medical Center, Regensburg, Germany.
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Abstract
INTRODUCTION Irradiation of bone metastases primarily aims at alleviating pain, preventing fracture in the short term. The higher doses and more conformal dose distribution achievable while saving healthy tissue with new irradiation techniques have induced a paradigm shift in the management of bone metastases in a growing number of clinical situations. MATERIALS AND METHODS A search of the English and French literature was conducted using the keywords: bone metastases, radiotherapy, interventional radiology, vertebroplasty, radiofrequency, chemoembolization. RESULTS-DISCUSSION: Stereotactic irradiation yields pain relief rates greater than 90% in Phase I/II and retrospective studies. IMRT (static, rotational, helical) and stereotactic irradiation yield local control rates of 75-90% at 2 years. Some situations previously evaluated as palliative are currently treated more aggressively with optimized radiation sometimes combined modality interventional radiology. CONCLUSION A recommendation can only be made for stereotactic irradiation in vertebral oligometastases or reirradiation. In the absence of a sufficient level of evidence, the increasing use of conformal irradiation techniques can only reflect the daily practice and the patient benefit while integrating economic logic care. The impact of these aggressive approaches on survival remains to be formally demonstrated by interventional prospective studies or observatories including quality of life items and minimal 2-year follow-up.
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Kirkpatrick JP, Yin FF, Sampson JH. Radiotherapy and Radiosurgery for Tumors of the Central Nervous System. Surg Oncol Clin N Am 2013; 22:445-61. [DOI: 10.1016/j.soc.2013.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Owen D, Laack NN, Mayo CS, Garces YI, Park SS, Bauer HJ, Nelson K, Miller RW, Brown PD, Olivier KR. Outcomes and toxicities of stereotactic body radiation therapy for non-spine bone oligometastases. Pract Radiat Oncol 2013; 4:e143-e149. [PMID: 24890360 DOI: 10.1016/j.prro.2013.05.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is being applied more widely for oligometastatic disease. This technique is now being used for non-spine bony metastases in addition to liver, spine, and lung. However, there are few studies examining the toxicity and outcomes of SBRT for non-spine bone metastases. METHODS AND MATERIALS Between 2008 and 2012, 74 subjects with oligometastatic non-spine bony metastases of varying histologies were treated at the Mayo Clinic with SBRT. A total of 85 non-spine bony sites were treated. Median local control, overall survival, and progression-free survival were described. Acute toxicity (defined as toxicity <90 days) and late toxicity (defined as toxicity ≥90 days) were reported and graded as per standardized Common Toxicity Criteria for Adverse Events 4.0 criteria. RESULTS The median age of patients treated was 60 years. The most common histology was prostate cancer (31%) and most patients had fewer than 3 sites of disease at the time of simulation (64%). Most of the non-spine bony sites lay within the pelvis (65%). Dose and fractionation varied but the most common prescription was 24 Gy/1 fraction. Local recurrence occurred in 7 patients with a median time to failure of 2.8 months. Local control was 91.8% at 1 year. With a median follow-up of 7.6 months, median SBRT specific overall survival and progression-free survival were 9.3 months and 9.7 months, respectively. Eighteen patients developed acute toxicity (mostly grade 1 and 2 fatigue and acute pain flare); 9 patients developed grade 1-2 late toxicities. Two patients developed pathologic fractures but both were asymptomatic. There were no late grade 3 or 4 toxicities. CONCLUSIONS Stereotactic body radiation therapy is a feasible and tolerable treatment for non-spine bony metastases. Longer follow-up will be needed to accurately determine late effects.
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Affiliation(s)
- Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Charles S Mayo
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Heather J Bauer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Kathryn Nelson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Robert W Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Paul D Brown
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Rades D, Veninga T, Bajrovic A, Karstens JH, Schild SE. A validated scoring system to identify long-term survivors after radiotherapy for metastatic spinal cord compression. Strahlenther Onkol 2013; 189:462-6. [PMID: 23604188 DOI: 10.1007/s00066-013-0342-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 03/06/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aimed to develop and validate a scoring system to identify long-term survivors after conventional radiotherapy (RT) for metastatic spinal cord compression (MSCC). PATIENTS AND METHODS Data from 1,125 patients who had received long-course RT for MSCC were included in this study. Of these patients, 344 survived for over 12 months and 781 died within a year following RT. Based on differences between the distributions of patient characteristics in the two groups, a scoring system was developed. Scores ranged from 0 to 18 points and 15 points was selected as the cutoff for identifying long-term survivors. Data from the 1,125 long-course RT patients (test group) were compared to data from 773 patients receiving short-course RT (validation group). RESULTS A score of ≥ 15 points was associated with a 94 % proportion of long-term survivors. The 15-point cutoff resulted in a specificity of 98 % and a positive predictive value of 94 % for identification of long-term surviving patients. The proportions of long-term survivors for each scoring point in the validation group were very similar to those in the test group. CONCLUSION This new scoring system enabled identification of long-term survivors after RT for MSCC with very high specificity and positive predictive value. The score proved to be valid and reproducible.
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Affiliation(s)
- D Rades
- Department of Radiation Oncology, University of Lubeck, Ratzeburger Allee 160, Lubeck, Germany.
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Lee YK, Bedford JL, McNair HA, Hawkins MA. Comparison of deliverable IMRT and VMAT for spine metastases using a simultaneous integrated boost. Br J Radiol 2013; 86:20120466. [PMID: 23385999 DOI: 10.1259/bjr.20120466] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To effectively treat spine metastases, significant dose must be delivered to regions surrounding the spinal cord. We present a study comparing both step-and-shoot intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) techniques to deliver a concomitant hypofractionated prescription dose to the diseased region and to the involved vertebrae. METHODS Seven-field IMRT and a single arc VMAT were inversely planned on five (two cervical and three thoracic) spinal metastatic patients. Planning target volumes PTVm (macroscopic) and PTVe (elective involved vertebrae) and associated organs at risk were localised. Mean doses of 35 Gy to PTVm and 20 Gy to PTVe were prescribed in five fractions. Dose statistics, estimated delivery time and results of verification using Delta(4) (ScandiDos, Uppsala, Sweden) were compared. RESULTS Deliverable plans were achieved with both IMRT and VMAT. The coverage to PTV was similar for both IMRT and VMAT (p=0.5) and the dose to the regions adjacent to the spinal cord was 1% higher with VMAT (p=0.04). The mean delivery time for VMAT was 3.5 min compared with 10.5 min for IMRT. Fewer monitor units were required to deliver IMRT than to deliver VMAT. The median (range) percentage of measured points with a γ-index <1 with 3%/3 mm was 100 (99.9-100)% for IMRT and 100 (88.5-100)% for VMAT. CONCLUSION Both VMAT and IMRT can deliver the concomitant hypofractionated regime proposed, and both offer different benefits in dose delivery. IMRT is currently preferred for its superior pre-treatment verification results and shorter planning times. ADVANCES IN KNOWLEDGE This study explores the feasibility of delivering tumouricidal doses of radiation to metastatic spine disease in the vicinity of the spinal cord.
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Affiliation(s)
- Y K Lee
- Joint Department of Physics, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK.
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Bhatt AD, Schuler JC, Boakye M, Woo SY. Current and emerging concepts in non-invasive and minimally invasive management of spine metastasis. Cancer Treat Rev 2013; 39:142-52. [DOI: 10.1016/j.ctrv.2012.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 08/08/2012] [Accepted: 08/09/2012] [Indexed: 01/31/2023]
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[Localized Ewing sarcoma of the spine: a preliminary dose-escalation study comparing innovative radiation techniques in a single patient]. Cancer Radiother 2013; 17:26-33. [PMID: 23333459 DOI: 10.1016/j.canrad.2012.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 11/16/2012] [Accepted: 11/22/2012] [Indexed: 12/25/2022]
Abstract
PURPOSE Although radiosensitive, spinal locations of Ewing's sarcomas are challenging for the radiation oncologist due to poor radiation tolerance of the spinal cord. However, some favorable anatomical compartments - that may represent more than 20% - were associated with a better outcome and could benefit from a radiation dose escalation using the most recent radiation therapy techniques. MATERIALS AND METHODS We performed a dose escalation study on one patient, declined in two scenarios: (1) a tumour located within a single vertebral body and (2) a locally advanced disease involving the vertebral foramen and paraspinal soft tissues. Five dose-levels are proposed: 44.8Gy, 54.4Gy, 59.2Gy, 65.6Gy and 70.4Gy (1.6Gy per session, 8Gy per week). The 3D-conformational technique is compared with static intensity modulated radiation therapy (IMRT), helical tomotherapy, volumetric modulated arc therapy (VMAT), stereotactic body robotic radiation therapy (SBRT) and protontherapy (passive scattering). Two constraints had to be respected in order to skip to the next level: the planned target volume (PTV) coverage must exceed 95% and the D(2%) on the spinal cord shall not exceed a given constraint set at 50Gy in case 1 and 44Gy in case 2 due to initial neurological sufferance. RESULTS Only protontherapy, SBRT, helical tomotherapy and VMAT appear able to reach the last dose level while respecting the constraints in case 1. On the other hand, only helical tomotherapy seems capable of reaching 59.2Gy on the PTV in case 2. CONCLUSION With the most recent radiation therapy techniques, it becomes possible to deliver up to 70.4Gy in a favorable compartment in this sham patient. Unfavorable compartments can receive up to 59.2Gy. Definitive radiation therapy may be an interesting local treatment option to be validated in an early phase trial.
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Oh SA, Kang MK, Kim SK, Yea JW. Comparison of IMRT and VMAT Techniques in Spine Stereotactic Radiosurgery with International Spine Radiosurgery Consortium Consensus Guidelines. PROGRESS IN MEDICAL PHYSICS 2013; 24:145. [DOI: 10.14316/pmp.2013.24.3.145] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Affiliation(s)
- Se An Oh
- Department of Radiation Oncology, Yeungnam University Medical Center, Daegu, Korea
- Department of Physics, Yeungnam University, Gyeongsan, Korea
| | - Min Kyu Kang
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Kyu Kim
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Korea
| | - Ji Woon Yea
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Korea
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Guckenberger M, Hawkins M, Flentje M, Sweeney RA. Fractionated radiosurgery for painful spinal metastases: DOSIS - a phase II trial. BMC Cancer 2012; 12:530. [PMID: 23164174 PMCID: PMC3522547 DOI: 10.1186/1471-2407-12-530] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 11/10/2012] [Indexed: 12/25/2022] Open
Abstract
Background One third of all cancer patients will develop bone metastases and the vertebral column is involved in approximately 70% of these patients. Conventional radiotherapy with of 1–10 fractions and total doses of 8-30 Gy is the current standard for painful vertebral metastases; however, the median pain response is short with 3–6 months and local tumor control is limited with these rather low irradiation doses. Recent advances in radiotherapy technology – intensity modulated radiotherapy for generation of highly conformal dose distributions and image-guidance for precise treatment delivery – have made dose-escalated radiosurgery of spinal metastases possible and early results of pain and local tumor control are promising. The current study will investigate efficacy and safety of radiosurgery for painful vertebral metastases and three characteristics will distinguish this study. 1) A prognostic score for overall survival will be used for selection of patients with longer life expectancy to allow for analysis of long-term efficacy and safety. 2) Fractionated radiosurgery will be performed with the number of treatment fractions adjusted to either good (10 fractions) or intermediate (5 fractions) life expectancy. Fractionation will allow inclusion of tumors immediately abutting the spinal cord due to higher biological effective doses at the tumor - spinal cord interface compared to single fraction treatment. 3) Dose intensification will be performed in the involved parts of the vertebrae only, while uninvolved parts are treated with conventional doses using the simultaneous integrated boost concept. Methods / Design It is the study hypothesis that hypo-fractionated image-guided radiosurgery significantly improves pain relief compared to historic data of conventionally fractionated radiotherapy. Primary endpoint is pain response 3 months after radiosurgery, which is defined as pain reduction of ≥ 2 points at the treated vertebral site on the 0 to 10 Visual Analogue Scale. 60 patients will be included into this two-centre phase II trial. Conclusions Results of this study will refine the methods of patient selection, target volume definition, treatment planning and delivery as well as quality assurance for radiosurgery. It is the intention of this study to form the basis for a future randomized controlled trial comparing conventional radiotherapy with fractionated radiosurgery for palliation of painful vertebral metastases. Trial registration ClinicalTrials.gov Identifier: NCT01594892
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University of Würzburg, Josef-Schneider-Str, 11, Würzburg 97080, Germany.
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A call for the aggressive treatment of oligometastatic and oligo-recurrent non-small cell lung cancer. Pulm Med 2012; 2012:480961. [PMID: 23125927 PMCID: PMC3483729 DOI: 10.1155/2012/480961] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/11/2012] [Indexed: 01/25/2023] Open
Abstract
Metastatic non-small cell lung cancer (NSCLC) carries a dismal prognosis. Clinical evidence suggests the existence of an intermediate, or oligometastatic, state when metastases are limited in number and/or location. In addition, following initial curative therapy, many patients present with limited metastatic disease, or oligo-recurrence. Metastasis-directed, anti-cancer therapies may benefit these patients. A growing evidence-base supports the use of hypofractionated, image-guided radiotherapy (HIGRT) for a variety of malignant conditions including inoperable stage I NSCLC and many metastatic sites. When surgical resection is not possible, HIGRT offers an effective alternative for local treatment of limited metastatic disease. Early studies have produced promising results when HIGRT was delivered to all known sites of disease in patients with oligometastatic/oligo-recurrent NSCLC. In a population of patients formerly considered rapidly terminal, these studies report five year overall survival rates of 13-22%. HIGRT for metastatic NSCLC warrants further study. We call for large, intergroup, and even international randomized trials incorporating HIGRT and other metastasis-directed therapies into the treatment of patients with oligometastatic/oligo-recurrent NSCLC.
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Yu HHM, Hoffe SE. Beyond the conventional role of external-beam radiation therapy for skeletal metastases: new technologies and stereotactic directions. Cancer Control 2012; 19:129-36. [PMID: 22487975 DOI: 10.1177/107327481201900207] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Radiation therapy is a common and effective treatment modality in the management of skeletal metastases. Recent advances in technology permitting delivery of an ablative radiation dose with an image-guided stereotactic approach improve the therapeutic threshold. METHODS The authors reviewed the literature on conventional external-beam radiation therapy and summarized the emerging data about image-guided stereotactic body radiation therapy (SBRT) for vertebral oligometastasis. RESULTS Pain control can be achieved effectively with conventional external-beam radiation therapy and may be further improved with image-guided spinal SBRT. Image-guided SBRT allows delivery of an ablative radiation dose with minimal toxicity, may potentially improve local tumor control, and may enhance clinical outcomes for histologies that are considered radioresistant. However, further understanding of long-term normal tissue toxicity is lacking. CONCLUSIONS Radiotherapy options are expanding for patients with skeletal metastases. Image-guided spinal SBRT can deliver a safe ablative radiation dose to improve pain control and potentially local tumor control. Randomized clinical trials are ongoing to assess clinical benefits and outcome with spinal SBRT.
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Affiliation(s)
- H-H M Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute Tampa, FL 33612, USA.
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Salama JK, Kirkpatrick JP, Yin FF. Stereotactic body radiotherapy treatment of extracranial metastases. Nat Rev Clin Oncol 2012; 9:654-65. [PMID: 23007273 DOI: 10.1038/nrclinonc.2012.166] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Radiotherapy is an integral treatment for patients with metastatic cancer, although it is usually reserved for palliation of pain, dyspnoea, oedema, bleeding and neurological symptoms. However, the administration of high-precision radiotherapy, termed stereotactic body radiotherapy (SBRT), has the potential to significantly affect the disease course for some patients with metastatic cancer by delivering high doses of radiation to the secondary tumours with limited high-dose delivery to adjacent healthy tissues. Indeed, such accurate delivery has been firmly established as a therapy for medically inoperable early-stage non-small-cell lung cancer. To date, the technique has demonstrated improvements in controlling metastasis and, in some cases, improved palliation compared with conventionally fractionated radiotherapy. Active areas of research in SBRT include patient selection for curative intent, optimization of SBRT planning techniques, dosing schema and integration of SBRT into systemic therapies. Given the improvements in cytotoxic and targeted therapies over the past decade, studies testing the careful integration of SBRT into standard systemic therapy regimens are needed. Further investigations are also needed to understand the basic biological mechanisms underlying SBRT because they are likely to be different to those mechanisms in conventional radiotherapy.
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Affiliation(s)
- Joseph K Salama
- Department of Radiation Oncology, Box 3085, Duke Cancer Institute, Durham, NC 27710, USA
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Schipani S, Wen W, Jin JY, Kim JK, Ryu S. Spine radiosurgery: a dosimetric analysis in 124 patients who received 18 Gy. Int J Radiat Oncol Biol Phys 2012; 84:e571-6. [PMID: 22975607 DOI: 10.1016/j.ijrobp.2012.06.049] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 06/22/2012] [Accepted: 06/24/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE To define the safely tolerated doses to organs at risk (OARs) adjacent to the target volume (TV) of spine radiosurgery (SRS) with 18-Gy in a single fraction. METHODS AND MATERIALS A total of 124 patient cases with 165 spine metastases were reviewed. An 18-Gy single-fraction regimen was prescribed to the 90% isodose line encompassing the TV. A constraint of 10 Gy to 10% of the spinal cord outlined 6 mm above and below the TV was used. Dosimetric data to OARs were analyzed. RESULTS A total of 124 patients (100%) were followed-up, and median follow-up time was 7 months (1-50 months). Symptoms and local control were achieved in 114 patients (92%). Acute Radiation Therapy Oncology Group (RTOG) grade 1 oral mucositis occurred in 11 of 11 (100%) patients at risk for oropharyngeal toxicity after cervical spine treatment. There were no RTOG grade 2-4 acute or late complications. Median TV was 43.2 cc (5.3-175.4 cc) and 90% of the TV received median dose of 19 Gy (17-19.8 Gy). Median (range) of spinal cord maximum dose (Dmax), dose to spinal cord 0.35 cc (Dsc0.35), and cord volume receiving 10 Gy (Vsc10) were 13.8 Gy (5.4-21 Gy), 8.9 Gy (2.6-11.4 Gy) and 0.33 cc (0-1.6 cc), respectively. Other OARs were evaluated when in proximity to the TV. Esophagus (n=58), trachea (n=28), oropharynx (n=11), and kidneys (n=34) received median (range) V10 and V15 of 3.1 cc (0-5.8 cc) and 1.2 cc (0-2.9 cc), 2.8 cc (0-4.9 cc), and 0.8 cc (0-2.1 cc), 3.4 cc (0-6.2 cc) and 1.6 cc (0-3.2 cc), 0.3 cc (0-0.8 cc) and 0.08 cc (0-0.1 cc), respectively. CONCLUSIONS Cord Dmax of 14 Gy and D0.35 of 10 Gy are safe dose constraints for 18-Gy single-fraction SRS. Esophagus V10 of 3 cc and V15 of 1 cc, trachea V10 of 3 cc, and V15 of 1 cc, oropharynx V10 of 3.5 cc and V15 of 1.5 cc, kidney V10 of 0.3 cc, and V15 of 0.1 cc are planning guidelines when these OARs are in proximity to the TV.
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Affiliation(s)
- Stefano Schipani
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
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