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Patel PP, Esposito EP, Zhu J, Chen X, Khan M, Kleinberg L, Lubelski D, Theodore N, Lo SFL, Hun Lee S, Kebaish K, Bydon A, Redmond KJ. Antiresorptive Medications Prior to Stereotactic Body Radiotherapy for Spinal Metastasis are Associated with Reduced Incidence of Vertebral Body Compression Fracture. Global Spine J 2024; 14:1778-1785. [PMID: 36749660 DOI: 10.1177/21925682231156394] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVE Antiresorptive drugs are often given to minimize fracture risk for bone metastases, but data regarding optimal time or ability to reduce stereotactic body radiotherapy (SBRT)-induced fracture risk is limited. This study examines the association between antiresorptive use surrounding spinal SBRT and vertebral compression fracture (VCF) incidence to provide information regarding effectiveness and optimal timing of use. METHODS Patients treated with SBRT for spinal metastases at a single institution between 2009-2020 were included. Kaplan-Meier analysis was used to compare cumulative incidence of VCF for those taking antiresorptive drugs pre-SBRT, post-SBRT only, and none at all. Cox proportional hazards and Fine-Gray competing risk models were used to identify additional factors associated with VCF. RESULTS Of the 234 patients (410 vertebrae) analyzed, 49 (20.9%) were taking bisphosphonates alone, 42 (17.9%) were taking denosumab alone, and 25 (10.7%) were taking both. Kaplan-Meier analysis revealed a statistically significant lower VCF incidence for patients initiating antiresorptive drugs before SBRT compared to those taking none at all (4% vs 12% at 1 year post-SBRT, P = .045; and 4% vs 23% at 2 years, P = .008). On multivariate analysis, denosumab duration (HR: .87, P = .378) or dose (HR: 1.00, P = .644) as well as bisphosphonate duration (HR: .98, P= .739) or dose (HR: .99, P= .741) did not have statistical significance on VCF incidence. CONCLUSION Initiating antiresorptive agents before SBRT may reduce the risk of treatment-induced VCF. Antiresorptive drugs are underutilized in patients with spine metastases and may represent a useful intervention to minimize toxicity and improve long-term outcomes.
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Affiliation(s)
- Palak P Patel
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Edward P Esposito
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jiafeng Zhu
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Majid Khan
- Department of Radiology, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hoftstra, Manhasset, NY, USA
| | - Sang Hun Lee
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ali Bydon
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Ito K, Nakajima Y, Taguchi K, Ogawa H, Saito M, Murofushi KN. Phase II Clinical Trial of Second Course of Stereotactic Body Radiotherapy for Spinal Metastases. Cancers (Basel) 2024; 16:2286. [PMID: 38927990 PMCID: PMC11201663 DOI: 10.3390/cancers16122286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/26/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE The optimal method for the second course of stereotactic body radiotherapy (SBRT) for spinal metastases remains poorly established. This single-center, single-arm, phase II trial was conducted to propose a safe and effective salvage spine SBRT. METHODS The patients initially treated with SBRT for spine-targeted protocol treatment, or for areas adjacent to the spine, were enrolled. The second SBRT dose was 30 Gy delivered in five fractions; the spinal cord dose constraint was 15.5 Gy at the maximum point dose. The brachial or lumbosacral plexuses were dose-constrained to <30 Gy if the boundary between the nerves and tumors was detected. The primary endpoint was dose-limiting toxicity (DLT) (grade ≥ 3 severe radiation-related toxicity) within a year after the second SBRT. RESULTS The second SBRT was administered to the same spinal level in 12 patients and to an adjacent spinal level in 8 patients. SBRT2 was performed for 14 painful lesions, 10 MESCC, and 6 oligometastases, with some lesions having multiple indications. The median interval between SBRT sessions was 21 months (range: 6-51 months). The median follow-up duration was 14 months. No radiation myelopathy or local failure was reported during the follow-up period. DLT was confirmed in two patients (10%) within a year, both of whom developed grade 3 lumbosacral plexopathy. These two patients received SBRT twice to the S1-2 and S1-5 vertebrae, respectively, and both experienced paralysis of the tibialis anterior muscle (L5 level). Grade 3 late adverse effects (including lumbosacral plexopathy and vertebral compression fracture) were observed in 25% of the patients throughout the entire follow-up period. CONCLUSIONS The second spine SBRT achieved good local control without causing myelopathy. However, one-quarter of the patients experienced grade 3 late adverse effects, suggesting that the treatment protocol carries a risk of toxicity.
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-ku, Tokyo 154-8525, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Makoto Saito
- Division of Clinical Research Support, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Keiko Nemoto Murofushi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
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Issany A, Iovoli AJ, Wang R, Shekher R, Ma SJ, Goulenko V, Fekrmandi F, Prasad D. Vertebral body collapse after spine stereotactic body radiation therapy: a single-center institutional experience. Radiol Oncol 2024; 0:raon-2024-0033. [PMID: 38861691 DOI: 10.2478/raon-2024-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/26/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Spine stereotactic body radiation therapy (SBRT) for the treatment of metastatic disease is increasingly utilized owing to improved pain and local control over conventional regimens. Vertebral body collapse (VBC) is an important toxicity following spine SBRT. We investigated our institutional experience with spine SBRT as it relates to VBC and spinal instability neoplastic score (SINS). PATIENTS AND METHODS Records of 83 patients with 100 spinal lesions treated with SBRT between 2007 and 2022 were reviewed. Clinical information was abstracted from the medical record. The primary endpoint was post-treatment VBC. Logistic univariate analysis was performed to identify clinical factors associated with VBC. RESULTS Median dose and number of fractions used was 24 Gy and 3 fractions, respectively. There were 10 spine segments that developed VBC (10%) after spine SBRT. Median time to VBC was 2.4 months. Of the 11 spine segments that underwent kyphoplasty prior to SBRT, none developed subsequent VBC. No factors were associated with VBC on univariate analysis. CONCLUSIONS The rate of vertebral body collapse following spine SBRT is low. Prophylactic kyphoplasty may provide protection against VBC and should be considered for patients at high risk for fracture.
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Affiliation(s)
- Arsh Issany
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA
| | - Austin J Iovoli
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Richard Wang
- Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, USA
| | - Rohil Shekher
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Victor Goulenko
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Fatemeh Fekrmandi
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Dheerendra Prasad
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
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4
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Dibs K, Facer B, Mageswaran P, Raval R, Thomas E, Gogineni E, Beyer S, Pan J, Klamer B, Ayan A, Bourekas E, Boulter D, Fetko N, Cochran E, Zoller I, Chakravarthy V, Tili E, Elder JB, Lonser R, Elguindy A, Soghrati S, Marras W, Grecula J, Chakravarti A, Palmer J, Blakaj DM. Vertebral Compression Fracture After Spine Stereotactic Body Radiotherapy: The Role of Vertebral Endplate Disruption. Neurosurgery 2024; 94:797-804. [PMID: 37902322 DOI: 10.1227/neu.0000000000002742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/13/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Vertebral compression fracture (VCF) is a common, but serious toxicity of spinal stereotactic body radiotherapy (SBRT). Several variables that place patients at high risk of VCF have previously been identified, including advanced Spinal Instability Neoplastic Score (SINS), a widely adopted clinical decision criterion to assess spinal instability. We examine the role of tumoral endplate (EP) disruption in the risk of VCF and attempt to incorporate it into a simple risk stratification system. METHODS This study was a retrospective cohort study from a single institution. Demographic and treatment information was collected for patients who received spinal SBRT between 2013 and 2019. EP disruption was noted on pre-SBRT computed tomography scan. The primary end point of 1-year cumulative incidence of VCF was assessed on follow-up MRI and computed tomography scans at 3-month intervals after treatment. RESULTS A total of 111 patients were included. The median follow-up was 18 months. Approximately 48 patients (43%) had at least one EP disruption. Twenty patients (18%) experienced a VCF at a median of 5.2 months from SBRT. Patients with at least one EP disruption were more likely to experience VCF than those with no EP disruption (29% vs 6%, P < .001). A nomogram was created using the variables of EP disruption, a SINS of ≥7, and adverse histology. Patients were stratified into groups at low and high risk of VCF, which were associated with 2% and 38% risk of VCF ( P < .001). CONCLUSION EP disruption is a novel risk factor for VCF in patients who will undergo spinal SBRT. A simple nomogram incorporating EP disruption, adverse histology, and SINS score is effective for quickly assessing risk of VCF. These data require validation in prospective studies and could be helpful in counseling patients regarding VCF risk and referring for prophylactic interventions in high-risk populations.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Benjin Facer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Prasath Mageswaran
- The Spine Research Institute, College of Engineering, The Ohio State University, Columbus , Ohio , USA
| | - Raju Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Emile Gogineni
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Sasha Beyer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Jeff Pan
- Department of Biostatistics, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Brett Klamer
- Department of Biostatistics, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Ahmet Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Eric Bourekas
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Nicholas Fetko
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Ian Zoller
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Vikram Chakravarthy
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Esmerina Tili
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - J Bradley Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Russel Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Ahmed Elguindy
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Soheil Soghrati
- The Spine Research Institute, College of Engineering, The Ohio State University, Columbus , Ohio , USA
| | - William Marras
- The Spine Research Institute, College of Engineering, The Ohio State University, Columbus , Ohio , USA
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Joshua Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus , Ohio , USA
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Moore A, Zhang Z, Fei T, Zhang L, Accomando L, Schmitt AM, Higginson DS, Mueller BA, Zinovoy M, Gelblum DY, Yerramilli D, Xu AJ, Brennan VS, Guttmann DM, Grossman CE, Dover LL, Shaverdian N, Pike LRG, Cuaron JJ, Dreyfuss A, Lis E, Barzilai O, Bilsky MH, Yamada Y. 40 Gray in 5 Fractions for Salvage Reirradiation of Spine Lesions Previously Treated With Stereotactic Body Radiotherapy. Neurosurgery 2024:00006123-990000000-01077. [PMID: 38456696 DOI: 10.1227/neu.0000000000002889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/04/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND AND PURPOSE A retrospective single-center analysis of the safety and efficacy of reirradiation to 40 Gy in 5 fractions (reSBRT) in patients previously treated with stereotactic body radiotherapy to the spine was performed. METHODS We identified 102 consecutive patients treated with reSBRT for 105 lesions between 3/2013 and 8/2021. Sixty-three patients (61.8%) were treated to the same vertebral level, and 39 (38.2%) to overlapping immediately adjacent levels. Local control was defined as the absence of progression within the treated target volume. The probability of local progression was estimated using a cumulative incidence curve. Death without local progression was considered a competing risk. RESULTS Most patients had extensive metastatic disease (54.9%) and were treated to the thoracic spine (53.8%). The most common regimen in the first course of stereotactic body radiotherapy was 27 Gy in 3 fractions, and the median time to reSBRT was 16.4 months. At the time of simulation, 44% of lesions had advanced epidural disease. Accordingly, 80% had myelogram simulations. Both the vertebral body and posterior elements were treated in 86% of lesions. At a median follow-up time of 13.2 months, local failure occurred in 10 lesions (9.5%). The 6- and 12-month cumulative incidences of local failure were 4.8% and 6%, respectively. Seven patients developed radiation-related neuropathy, and 1 patient developed myelopathy. The vertebral compression fracture rate was 16.7%. CONCLUSION In patients with extensive disease involvement, reSBRT of spine metastases with 40 Gy in 5 fractions seems to be safe and effective. Prospective trials are needed to determine the optimal dose and fractionation in this clinical scenario.
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Affiliation(s)
- Assaf Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Radiation Oncology, Davidoff Cancer Center, Petach Tikva, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Teng Fei
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lei Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Accomando
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam M Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel S Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Melissa Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Victoria S Brennan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David M Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Craig E Grossman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura L Dover
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexandra Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eric Lis
- Department of Imaging, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Sacino AN, Chen H, Sahgal A, Bettegowda C, Rhines LD, Maralani P, Redmond KJ. Stereotactic body radiation therapy for spinal metastases: A new standard of care. Neuro Oncol 2024; 26:S76-S87. [PMID: 38437670 PMCID: PMC10911798 DOI: 10.1093/neuonc/noad225] [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] [Indexed: 03/06/2024] Open
Abstract
Advancements in systemic therapies for patients with metastatic cancer have improved overall survival and, hence, the number of patients living with spinal metastases. As a result, the need for more versatile and personalized treatments for spinal metastases to optimize long-term pain and local control has become increasingly important. Stereotactic body radiation therapy (SBRT) has been developed to meet this need by providing precise and conformal delivery of ablative high-dose-per-fraction radiation in few fractions while minimizing risk of toxicity. Additionally, advances in minimally invasive surgical techniques have also greatly improved care for patients with epidural disease and/or unstable spines, which may then be combined with SBRT for durable local control. In this review, we highlight the indications and controversies of SBRT along with new surgical techniques for the treatment of spinal metastases.
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Affiliation(s)
- Amanda N Sacino
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chetan Bettegowda
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Laurence D Rhines
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, Maryland, USA
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7
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de Almeida RAA, Ghia AJ, Amini B, Wang C, Alvarez-Breckenridge CA, Li J, Rhines LD, Tom MC, North RY, Beckham TH, Tatsui CE. Quantification of MRI Artifacts in Carbon Fiber Reinforced Polyetheretherketone Thoracolumbar Pedicle Screw Constructs prior to Spinal Stereotactic Radiosurgery. Pract Radiat Oncol 2024; 14:103-111. [PMID: 37914081 DOI: 10.1016/j.prro.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/05/2023] [Accepted: 10/13/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Carbon fiber reinforced polyetheretherketone (CFRP) is a nonmetallic material that is a subject of growing interest in the field of spinal instrumentation manufacturing. The radiolucency and low magnetic susceptibility of CFRP has potential to create less interference with diagnostic imaging compared with titanium implants. However, an objective comparison of the image artifact produced by titanium and CFRP implants has not been described. Spinal oncology, particularly after resection of spinal tumors and at the time of spinal stereotactic radiosurgery planning, relies heavily on imaging interpretation for evaluating resection, adjuvant treatment planning, and surveillance. We present a study comparing measurements of postoperative magnetic resonance imaging artifacts between titanium and CFRP pedicle screw constructs in the setting of separation surgery for metastatic disease. METHODS AND MATERIALS The diameter of the signal drop around the screws (pedicle screw artifact) and the diameter of the spinal canal free from artifacts (canal visualization) were measured in consecutive patients who had spinal instrumentation followed by spinal stereotactic radiosurgery in the June 2019 to May 2022 timeframe. The spinal cord presented a shift at the screw level in sagittal images which was also measured (Sagittal Distortion, SagD). RESULTS Fifty patients, corresponding to 356 screws and 183 vertebral levels, were evaluated overall. CFRP produced less artifacts in all the 3 parameters compared with titanium: mean pedicle screw artifact (CFRP = 5.8 mm, Ti = 13.2 mm), canal visualization (CFRP = 19.2 mm, Ti = 15.5 mm), and SagD (CFRP = .5 mm, Ti = 1.9 mm), all P < .001. In practice, these findings translate into better-quality magnetic resonance imaging. CONCLUSIONS The initial perceived advantages are easier evaluation of postoperative imaging, facilitating radiation treatment planning, recurrence detection, and avoidance in repeating a suboptimal computed tomography myelogram. Further clinical studies analyzing long-term outcomes of patients treated with CFRP implants are necessary.
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Affiliation(s)
| | - Amol J Ghia
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Behrang Amini
- Department of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Texas
| | - Chenyang Wang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Jing Li
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Laurence D Rhines
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas
| | - Martin C Tom
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Robert Y North
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas
| | - Thomas H Beckham
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Claudio E Tatsui
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas.
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8
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Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
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Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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9
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Olson R, Abraham H, Leclerc C, Benny A, Baker S, Matthews Q, Chng N, Bergman A, Mou B, Dunne EM, Schellenberg D, Jiang W, Chan E, Atrchian S, Lefresne S, Carolan H, Valev B, Tyldesley S, Bang A, Berrang T, Clark H, Hsu F, Louie AV, Warner A, Palma DA, Howell D, Barry A, Dawson L, Grendarova P, Walker D, Sinha R, Tsai J, Bahig H, Thibault I, Koul R, Senthi S, Phillips I, Grose D, Kelly P, Armstrong J, McDermott R, Johnstone C, Vasan S, Aherne N, Harrow S, Liu M. Single vs. multiple fraction non-inferiority trial of stereotactic ablative radiotherapy for the comprehensive treatment of oligo-metastases/progression: SIMPLIFY-SABR-COMET. BMC Cancer 2024; 24:171. [PMID: 38310262 PMCID: PMC10838428 DOI: 10.1186/s12885-024-11905-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 01/21/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Radiotherapy delivery regimens can vary between a single fraction (SF) and multiple fractions (MF) given daily for up to several weeks depending on the location of the cancer or metastases. With limited evidence comparing fractionation regimens for oligometastases, there is support to explore toxicity levels to nearby organs at risk as a primary outcome while using SF and MF stereotactic ablative radiotherapy (SABR) as well as explore differences in patient-reported quality of life and experience. METHODS This study will randomize 598 patients in a 1:1 ratio between the standard arm (MF SABR) and the experimental arm (SF SABR). This trial is designed as two randomized controlled trials within one patient population for resource efficiency. The primary objective of the first randomization is to determine if SF SABR is non-inferior to MF SABR, with respect to healthcare provider (HCP)-reported grade 3-5 adverse events (AEs) that are related to SABR. Primary endpoint is toxicity while secondary endpoints include lesional control rate (LCR), and progression-free survival (PFS). The second randomization (BC Cancer sites only) will allocate participants to either complete quality of life (QoL) questionnaires only; or QoL questionnaires and a symptom-specific survey with symptom-guided HCP intervention. The primary objective of the second randomization is to determine if radiation-related symptom questionnaire-guided HCP intervention results in improved reported QoL as measured by the EuroQoL-5-dimensions-5levels (EQ-5D-5L) instrument. The primary endpoint is patient-reported QoL and secondary endpoints include: persistence/resolution of symptom reporting, QoL, intervention cost effectiveness, resource utilization, and overall survival. DISCUSSION This study will compare SF and MF SABR in the treatment of oligometastases and oligoprogression to determine if there is non-inferior toxicity for SF SABR in selected participants with 1-5 oligometastatic lesions. This study will also compare patient-reported QoL between participants who receive radiation-related symptom-guided HCP intervention and those who complete questionnaires alone. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT05784428. Date of Registration: 23 March 2023.
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Affiliation(s)
- Robert Olson
- University of British Columbia, Vancouver, Canada.
- University of Northern British Columbia, Prince George, Canada.
- BC Cancer - Prince George, 1215 Lethbridge Street, Prince George, BC, V2M7A9, Canada.
- Department of Radiation Oncology, BC Cancer - Centre for the North, 1215 Lethbridge Street, Prince George, British Columbia, V2M 7E9, Canada.
| | - Hadassah Abraham
- BC Cancer - Prince George, 1215 Lethbridge Street, Prince George, BC, V2M7A9, Canada
| | - Curtis Leclerc
- University of British Columbia, Vancouver, Canada
- BC Cancer - Prince George, 1215 Lethbridge Street, Prince George, BC, V2M7A9, Canada
| | | | - Sarah Baker
- BC Cancer - Surrey, Surrey, British Columbia, Canada
| | - Quinn Matthews
- BC Cancer - Prince George, 1215 Lethbridge Street, Prince George, BC, V2M7A9, Canada
| | - Nick Chng
- BC Cancer - Prince George, 1215 Lethbridge Street, Prince George, BC, V2M7A9, Canada
| | - Alanah Bergman
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
| | - Benjamin Mou
- BC Cancer - Kelowna, Kelowna, British Columbia, Canada
| | - Emma M Dunne
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
| | | | - Will Jiang
- BC Cancer - Surrey, Surrey, British Columbia, Canada
| | - Elisa Chan
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
| | | | - Shilo Lefresne
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
| | - Hannah Carolan
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
| | - Boris Valev
- BC Cancer- Victoria, Victoria, British Columbia, Canada
| | | | - Andrew Bang
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
| | - Tanya Berrang
- BC Cancer- Victoria, Victoria, British Columbia, Canada
| | - Haley Clark
- BC Cancer - Surrey, Surrey, British Columbia, Canada
| | - Fred Hsu
- BC Cancer- Abbotsford, Abbotsford, British Columbia, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Warner
- Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - David A Palma
- Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Laura Dawson
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Debra Walker
- Patient partner, BC Cancer-Prince George, Prince George, BC, Canada
| | - Rishi Sinha
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jillian Tsai
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Houda Bahig
- Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | - Rashmi Koul
- Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | | | - Iain Phillips
- Western General Hospital/Edinburgh Cancer Centre, Edinburgh, Scotland
| | - Derek Grose
- Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - Paul Kelly
- Bon Secours Radiotherapy Cork (In Partnership with UPMC Hillman Cancer Centre), Cork, Ireland
| | | | | | - Candice Johnstone
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Srini Vasan
- Precision Cancer Center, Ashland, Kentucky, United States of America
| | - Noel Aherne
- Riverina Cancer Care Centre, Wagga Wagga, New South Wales, Australia
| | - Stephen Harrow
- Western General Hospital/Edinburgh Cancer Centre, Edinburgh, Scotland
| | - Mitchell Liu
- BC Cancer - Vancouver, Vancouver, British Columbia, Canada
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10
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Waltenberger M, Vogel MME, Bernhardt D, Münch S, Dobiasch S, Redmond KJ, Lo SS, Acker G, Fehlings MG, Ringel F, Vajkoczy P, Meyer B, Combs SE. Radiotherapy concepts for spinal metastases-results from an online survey among radiation oncologists of the German Society for Radiation Oncology. Strahlenther Onkol 2024; 200:159-174. [PMID: 37272996 PMCID: PMC10805849 DOI: 10.1007/s00066-023-02082-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE Spinal metastases (SM) are a common radiotherapy (RT) indication. There is limited level I data to drive decision making regarding dose regimen (DR) and target volume definition (TVD). We aim to depict the patterns of care for RT of SM among German Society for Radiation Oncology (DEGRO) members. METHODS An online survey on conventional RT and Stereotactic Body Radiation Therapy (SBRT) for SM, distributed via e‑mail to all DEGRO members, was completed by 80 radiation oncologists between February 24 and April 29, 2022. Participation was voluntary and anonymous. RESULTS A variety of DR was frequently used for conventional RT (primary: n = 15, adjuvant: n = 14). 30 Gy/10 fractions was reported most frequently. TVD in adjuvant RT was heterogenous, with a trend towards larger volumes. SBRT was offered in 65% (primary) and 21% (adjuvant) of participants' institutions. A variety of DR was reported (primary: n = 40, adjuvant: n = 27), most commonly 27 Gy/3 fractions and 30 Gy/5 fractions. 59% followed International Consensus Guidelines (ICG) for TVD. CONCLUSION We provide a representative depiction of RT practice for SM among DEGRO members. DR and TVD are heterogeneous. SBRT is not comprehensively practiced, especially in the adjuvant setting. Further research is needed to provide a solid data basis for detailed recommendations.
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Affiliation(s)
- Maria Waltenberger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Sophie Dobiasch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum, Munich, Germany
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Güliz Acker
- Department of Neurosurgery, Charité Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum, Munich, Germany
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11
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Redmond KJ, Hattangadi-Gluth J, Pollum EL, Trifiletti DM, Kim MM, Milano M. Navigating the Spinal Frontier: Recent Data on Stereotactic Body Radiation Therapy for Spine Metastases. Int J Radiat Oncol Biol Phys 2024; 118:313-317. [PMID: 38220248 DOI: 10.1016/j.ijrobp.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Erqi Liu Pollum
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michael Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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12
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Patel PP, Cao Y, Chen X, LeCompte MC, Kleinberg L, Khan M, McNutt T, Bydon A, Kebaish K, Theodore N, Larry Lo SF, Lee SH, Lubelski D, Redmond KJ. Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression. Adv Radiat Oncol 2024; 9:101327. [PMID: 38260225 PMCID: PMC10801652 DOI: 10.1016/j.adro.2023.101327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 07/21/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Although surgical decompression is the gold standard for metastatic epidural spinal cord compression (MESCC) from solid tumors, not all patients are candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with stereotactic body radiation therapy (SBRT) to high-grade MESCC. Methods and Materials Patients with Bilsky grade 2 to 3 MESCC from solid tumor metastases treated with SBRT at a single institution from 2009 to 2020 were retrospectively reviewed. Patients who received upfront surgery before SBRT were included only if postsurgical Bilsky grade remained ≥2. Neurologic examinations, magnetic resonance imaging, pain assessments, and analgesic usage were assessed every 3 to 4 months post-SBRT. Cumulative incidence of local recurrence was calculated with death as a competing risk, and overall survival was estimated by Kaplan-Meier. Results One hundred forty-three patients were included. The cumulative incidence of local recurrence was 5.1%, 7.5%, and 14.1% at 6, 12, and 24 months, respectively. At first post-SBRT imaging, 16.2% of patients with initial Bilsky grade 2 improved to grade 1, and 53.8% of patients were stable. Five of 13 patients (38.4%) with initial Bilsky grade 3 improved to grade 1 to 2. Pain response at 3 and 6 months post-SBRT was complete in 45.4% and 55.7%, partial in 26.9% and 13.1%, stable in 24.1% and 27.9%, and worse in 3.7% and 3.3% of patients, respectively. At 3 and 6 months after SBRT, 17.8% and 25.0% of patients had improved ambulatory status and 79.7% and 72.4% had stable status. Conclusions We report the largest series to date of patients with high-grade MESCC treated with SBRT. The excellent local control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.
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Affiliation(s)
- Palak P. Patel
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yilin Cao
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael C. LeCompte
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Majid Khan
- Department of Radiology, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Khaled Kebaish
- Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Sheng-fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hoftstra, Manhasset, New York
| | - Sang H. Lee
- Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
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13
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Sahgal A, Kellett S, Nguyen T, Maralani P, Greenspoon J, Linden K, Pearce A, Siddiqi F, Ruschin M. A Cancer Care Ontario Consensus-Based Organizational Guideline for the Planning and Delivery of Spine Stereotactic Body Radiation Therapy Treatment in Ontario. Pract Radiat Oncol 2023; 13:499-509. [PMID: 37597616 DOI: 10.1016/j.prro.2023.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/21/2023]
Abstract
The proposed recommendations are primarily based on the consensus opinion and in-field experience of the Ontario Health/Cancer Care Ontario stereotactic body radiation therapy (SBRT) for Spine Metastasis Guideline Development Group and published literature when available. Primary consideration was given to the perceived benefits for patients and the small likelihood of harm arising from recommendation implementation. Apart from the magnetic resonance imaging (MRI) follow-up strategy, all evidence was considered indirect and was provided by the working group in conjunction with their collective expertise in the field of SBRT. The application of an SBRT program requires a multidisciplinary team consisting of a radiation oncologist, spine surgeon, neuroradiologist, medical physicist, medical dosimetrist, and radiation therapist. In Canada, linear accelerators are the most used treatment delivery units and should follow technology-specific quality assurance procedures. Immobilization technique is location dependant. Treatment planning MRI sequences should be acquired no more than 14 days from the date of treatment. In the case of epidural disease, simulation MRI should be completed no more than 7 days from the date of treatment. After treatment, patients should be followed with routine clinical visits every 3 months for the first year, every 3 to 6 months during years 2 and 3, and every 4 to 6 months thereafter. The recommendations enclosed provide a framework for the minimum requirements for a cancer center in Ontario, Canada to offer SBRT for spine metastases.
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Affiliation(s)
- Arjun Sahgal
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
| | - Sarah Kellett
- Program in Evidence-Based Care, Hamilton, Ontario, Canada
| | | | | | | | | | | | - Fawaz Siddiqi
- London Health Sciences Center, London, Ontario, Canada
| | - Mark Ruschin
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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14
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Bryant JM, Doniparthi A, Weygand J, Cruz-Chamorro R, Oraiqat IM, Andreozzi J, Graham J, Redler G, Latifi K, Feygelman V, Rosenberg SA, Yu HHM, Oliver DE. Treatment of Central Nervous System Tumors on Combination MR-Linear Accelerators: Review of Current Practice and Future Directions. Cancers (Basel) 2023; 15:5200. [PMID: 37958374 PMCID: PMC10649155 DOI: 10.3390/cancers15215200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Magnetic resonance imaging (MRI) provides excellent visualization of central nervous system (CNS) tumors due to its superior soft tissue contrast. Magnetic resonance-guided radiotherapy (MRgRT) has historically been limited to use in the initial treatment planning stage due to cost and feasibility. MRI-guided linear accelerators (MRLs) allow clinicians to visualize tumors and organs at risk (OARs) directly before and during treatment, a process known as online MRgRT. This novel system permits adaptive treatment planning based on anatomical changes to ensure accurate dose delivery to the tumor while minimizing unnecessary toxicity to healthy tissue. These advancements are critical to treatment adaptation in the brain and spinal cord, where both preliminary MRI and daily CT guidance have typically had limited benefit. In this narrative review, we investigate the application of online MRgRT in the treatment of various CNS malignancies and any relevant ongoing clinical trials. Imaging of glioblastoma patients has shown significant changes in the gross tumor volume over a standard course of chemoradiotherapy. The use of adaptive online MRgRT in these patients demonstrated reduced target volumes with cavity shrinkage and a resulting reduction in radiation dose to uninvolved tissue. Dosimetric feasibility studies have shown MRL-guided stereotactic radiotherapy (SRT) for intracranial and spine tumors to have potential dosimetric advantages and reduced morbidity compared with conventional linear accelerators. Similarly, dosimetric feasibility studies have shown promise in hippocampal avoidance whole brain radiotherapy (HA-WBRT). Next, we explore the potential of MRL-based multiparametric MRI (mpMRI) and genomically informed radiotherapy to treat CNS disease with cutting-edge precision. Lastly, we explore the challenges of treating CNS malignancies and special limitations MRL systems face.
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Affiliation(s)
- John Michael Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ajay Doniparthi
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA;
| | - Joseph Weygand
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ruben Cruz-Chamorro
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Ibrahim M. Oraiqat
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Jacqueline Andreozzi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Jasmine Graham
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Gage Redler
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
| | - Daniel E. Oliver
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA (I.M.O.); (J.A.); (G.R.); (K.L.); (H.-H.M.Y.)
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15
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Tanaka O, Taniguchi T, Nakaya S, Adachi K, Kiryu T, Makita C, Matsuo M. Stereotactic body radiation therapy to the spine: contouring the cauda equina instead of the spinal cord is more practical as the organ at risk. Rep Pract Oncol Radiother 2023; 28:407-415. [PMID: 37795406 PMCID: PMC10547411 DOI: 10.5603/rpor.a2023.0040] [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: 11/02/2022] [Accepted: 06/05/2023] [Indexed: 10/06/2023] Open
Abstract
Background Stereotactic body radiotherapy (SBRT) is recognized as a curative treatment for oligometastasis. The spinal cord becomes the cauda equina at the lumbar level, and the nerves are located dorsally. Recently, a consensus has been reached that the cauda equina should be contoured as an organ at risk (OAR). Here, we examined the separate contouring benefits for the spinal canal versus the cauda equina only as the OAR. Materials and methods A medical physicist designed a simulation plan for 10 patients with isolated lumbar metastasis. The OAR was set with three contours: the whole spinal canal, cauda equina only, and cauda equina with bilateral nerve roots. The prescribed dose for the planning target volume (PTV) was 30 Gy/3 fx. Results For the constrained QAR doses, D90 and D95 were statistically significant due to the different OAR contouring. The maximum dose (Dmax) was increased to the spinal canal when the cauda equina max was set to ≤ 20 Gy, but dose hotspots were observed in most cases in the medullary area. The Dmax and PTV coverage were negatively correlated for the cauda equina and the spinal canal if Dmax was set to ≤ 20 Gy for both. Conclusions A portion of the spinal fluid is also included when the spinal canal is set as the OAR. Thus, the PTV coverage rate will be poor if the tumor is in contact with the spinal canal. However, the PTV coverage rate increases if only the cauda equina is set as the OAR.
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Affiliation(s)
- Osamu Tanaka
- Department of Radiation Oncology, Asahi University Hospital, Gifu City, Gifu, Japan
| | - Takuya Taniguchi
- Department of Radiation Oncology, Asahi University Hospital, Gifu City, Gifu, Japan
| | - Shuto Nakaya
- Department of Radiation Oncology, Asahi University Hospital, Gifu City, Gifu, Japan
| | - Kousei Adachi
- Department of Radiation Oncology, Asahi University Hospital, Gifu City, Gifu, Japan
| | - Takuji Kiryu
- Department of Radiation Oncology, Asahi University Hospital, Gifu City, Gifu, Japan
| | - Chiyoko Makita
- Department of Radiology, Gifu University Hospital, Gifu City, Gifu, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, Gifu City, Gifu, Japan
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16
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Ito K, Taguchi K, Nakajima Y, Ogawa H, Sugita S, Murofushi KN. Incidence and Prognostic Factors of Painful Vertebral Compression Fracture Caused by Spine Stereotactic Body Radiotherapy. J Clin Med 2023; 12:jcm12113853. [PMID: 37298048 DOI: 10.3390/jcm12113853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/28/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023] Open
Abstract
Most studies of vertebral compression fractures (VCF) caused by stereotactic body radiotherapy (SBRT) do not discuss the symptoms of this complication. In this paper, we aimed to determine the rate and prognostic factors of painful VCF caused by SBRT for spinal metastases. Spinal segments with VCF in patients treated with spine SBRT between 2013 and 2021 were retrospectively reviewed. The primary endpoint was the rate of painful VCF (grades 2-3). Patient demographic and clinical characteristics were evaluated as prognosticators. In total, 779 spinal segments in 391 patients were analyzed. The median follow-up after SBRT was 18 (range: 1-107) months. Sixty iatrogenic VCFs (7.7%) were identified. The rate of painful VCF was 2.4% (19/779). Eight (1.0%) VCFs required surgery for internal fixation or spinal canal decompression. The painful VCF rate was significantly higher in patients with no posterolateral tumor involvement than in those with bilateral or unilateral involvement (50% vs. 23%; p = 0.042); it was also higher in patients with spine without fixation than in those with fixation (44% vs. 0%; p < 0.001). Painful VCFs were confirmed in only 2.4% of all the irradiated spinal segments. The absence of posterolateral tumor involvement and no fixation was significantly associated with painful VCF.
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-ku, Tokyo 154-8525, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiation Oncology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Shurei Sugita
- Department of Orthopedics, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Keiko Nemoto Murofushi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
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17
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Iramina H, Nakamura M, Nakamura K, Fujimoto T, Mizowaki T. Quantification of six-degree-of-freedom motion during beam delivery in spine stereotactic body radiotherapy using intra-irradiation cone-beam computed tomography imaging technique. Phys Med 2023; 110:102605. [PMID: 37167776 DOI: 10.1016/j.ejmp.2023.102605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/22/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE Quantifying intra-fractional six-degree-of-freedom (6DoF) residual errors or motion from approved patient setups is necessary for accurate beam delivery in spine stereotactic body radiotherapy. However, previously reported errors were not acquired during beam delivery. Therefore, we aimed to quantify the 6DoF residual errors and motions during arc beam delivery using a concurrent cone-beam computed tomography (CBCT) imaging technique, intra-irradiation CBCT. METHODS Consecutive 15 patients, 19 plans for various treatment sites, and 199 CBCT images were analyzed. Pre-irradiation CBCT was performed to verify shifts from the initial patient setup using the ExacTrac system. During beam delivery by two or three co-planar full-arc rotations, CBCT imaging was performed concurrently. Subsequently, an intra-irradiation CBCT image was reconstructed. Pre- and intra-irradiation CBCT images were rigidly registered to a planning CT image based on the bone to quantify 6DoF residual errors. RESULTS 6DoF residual errors quantified using pre- and intra-irradiation CBCTs were within 2.0 mm/2.0°, except for one measurement. The mean elapsed time (mean ± standard deviation [min:sec]) after pre-irradiation CBCT to the end of the last arc beam delivery was 6:08 ± 1:25 and 7:54 ± 2:14 for the 2- and 3-arc plans, respectively. Root mean squares of residual errors for several directions showed significant differences; however, they were within 1.0 mm/1.0°. Time-dependent analysis revealed that the residual errors tended to increase with elapsed time. CONCLUSION The errors represent the optimal intra-fractional error compared with those acquired using the pre-, inter-beam, and post-6DoF image guidance and can be acquired within a standard treatment timeslot.
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Affiliation(s)
- Hiraku Iramina
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Mitsuhiro Nakamura
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Kiyonao Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takahiro Fujimoto
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
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18
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Nguyen EK, Ruschin M, Zhang B, Soliman H, Myrehaug S, Detsky J, Chen H, Sahgal A, Tseng CL. Stereotactic body radiotherapy for spine metastases: a review of 24 Gy in 2 daily fractions. J Neurooncol 2023; 163:15-27. [PMID: 37155133 DOI: 10.1007/s11060-023-04327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) has proven to be a highly effective treatment for selected patients with spinal metastases. Randomized evidence shows improvements in complete pain response rates and local control with lower retreatment rates favoring SBRT, compared to conventional external beam radiotherapy (cEBRT). While there are several reported dose-fractionation schemes for spine SBRT, 24 Gy in 2 fractions has emerged with Level 1 evidence providing an excellent balance between minimizing treatment toxicity while respecting patient convenience and financial strain. METHODS We provide an overview of the 24 Gy in 2 SBRT fraction regimen for spine metastases, which was developed at the University of Toronto and tested in an international Phase 2/3 randomized controlled trial. RESULTS The literature summarizing global experience with 24 Gy in 2 SBRT fractions suggests 1-year local control rates ranging from 83-93.9%, and 1-year rates of vertebral compression fracture ranging from 5.4-22%. Reirradiation of spine metastases that failed prior cEBRT is also feasible with 24 Gy in 2 fractions, and 1-year local control rates range from 72-86%. Post-operative spine SBRT data are limited but do support the use of 24 Gy in 2 fractions with reported 1-year local control rates ranging from 70-84%. Typically, the rates of plexopathy, radiculopathy and myositis are under 5% in those series reporting mature follow up, with no cases of radiation myelopathy (RM) reported in the de novo setting when the spinal cord avoidance structure is limited to 17 Gy in 2 fractions. However, re-irradiation RM has been observed following 2 fraction SBRT. More recently, 2-fraction dose escalation with 28 Gy, with a higher dose constraint to the critical neural tissues, has been reported suggesting improved rates of local control. This regimen may be important in those patients with radioresistant histologies, high grade epidural disease, and/or paraspinal disease. CONCLUSION The dose-fractionation of 24 Gy in 2 fractions is well-supported by published literature and is an ideal starting point for centers looking to establish a spine SBRT program.
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Affiliation(s)
- Eric K Nguyen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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19
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Eckstein J, Gogineni E, Sidiqi B, Lisser N, Parashar B. Effect of Immunotherapy and Stereotactic Body Radiation Therapy Sequencing on Local Control and Survival in Patients With Spine Metastases. Adv Radiat Oncol 2023; 8:101179. [PMID: 36896213 PMCID: PMC9991541 DOI: 10.1016/j.adro.2023.101179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) is commonly used to treat spinal metastases in combination with immunotherapy (IT). The optimal sequencing of these modalities is unclear. This study aimed to investigate whether sequencing of IT and SBRT was associated with differences in local control (LC), overall survival (OS), and toxicity when treating spine metastases. Methods and Materials All patients at our institution who received spine SBRT from 2010 to 2019 with systemic therapy data available were reviewed retrospectively. The primary endpoint was LC. Secondary endpoints were toxicity (fracture and radiation myelitis) and OS. Kaplan-Meier analysis was used to determine whether IT sequencing (before versus after SBRT) and use of IT were associated with LC or OS. Results A total of 191 lesions in 128 patients met inclusion criteria with 50 (26%) lesions in 33 (26%) patients who received IT. Fourteen (11%) patients with 24 (13%) lesions received the first IT dose before SBRT, whereas 19 (15%) patients with 26 (14%) lesions received the first dose after SBRT. LC did not differ between lesions treated with IT before SBRT versus after SBRT (1 year 73% versus 81%, log rank = 0.275, P = .600). Fracture risk was not associated with IT timing (χ2 = 0.137, P = .934) or receipt of IT (χ2 = 0.508, P = .476), and no radiation myelitis events occurred. Median OS was 31.8 versus 6.6 months for the IT after SBRT versus IT before SBRT cohorts, respectively (log rank = 13.193, P < .001). On Cox univariate analysis and multivariate analysis, receipt of IT before SBRT and Karnofsky performance status <80 were associated with worse OS. IT treatment versus none was not associated with any difference in LC (log rank = 1.063, P = .303) or OS (log rank = 1.736, P = .188). Conclusions Sequencing of IT and SBRT was not associated with any difference in LC or toxicity, but delivering IT after SBRT versus before SBRT was associated with improved OS.
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Affiliation(s)
- Jacob Eckstein
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
| | - Emile Gogineni
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Baho Sidiqi
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
| | - Noah Lisser
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
| | - Bhupesh Parashar
- Department of Radiation Medicine, Zucker School of Medicine, Hofstra, Northwell Health, New York, New York
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20
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Redmond KJ, Schaub SK, Lo SFL, Khan M, Lubelski D, Bilsky M, Yamada Y, Fehlings M, Gogineni E, Vajkoczy P, Ringel F, Meyer B, Amin AG, Combs SE, Lo SS. Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy. Cancers (Basel) 2023; 15:cancers15082359. [PMID: 37190287 DOI: 10.3390/cancers15082359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY 11549, USA
| | - Majid Khan
- Department of Radiology, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurological Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael Fehlings
- Department of Neurosurgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Emile Gogineni
- Department of Radiation Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charite University Hospital, 10117 Berlin, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, 80333 Munich, Germany
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA 98115, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, 81675 Munich, Germany
| | - Simon S Lo
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
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21
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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22
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Claridge Mackonis ER, Hardcastle N, Haworth A. A survey of compliance with stereotactic ablative body radiotherapy quality recommendations. J Med Imaging Radiat Oncol 2023. [PMID: 36996443 DOI: 10.1111/1754-9485.13526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 03/05/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Many publications have proposed quality standards for stereotactic ablative body radiotherapy (SABR). However, data on the level of compliance with these guidelines is lacking in the literature. This study aimed to understand how these guidelines are applied in the clinic and to identify barriers to implementing such recommendations. METHODS Interviews were conducted with multidisciplinary staff at radiation oncology centres across New South Wales formulated around the RANZCR Guidelines for Safe Practice of Stereotactic Body (Ablative) Radiation Therapy. The interview responses were grouped into 20 topics, assessed against the guidelines and thematically analysed. RESULTS Good compliance with the guidelines was found, with more than 80% of centres achieving satisfactory results in more than half the topics. The areas with the lowest compliance were auditing, risk assessment and reporting recommendations. Barriers to the quality of SABR treatments included limited training opportunities, low patient numbers and a lack of clear requirements on comprehensive auditing and reporting. CONCLUSION Overall, the centres surveyed reported good compliance with most of the RANZCR SABR guidelines. The tasks with the lowest compliance were those that monitor quality outcomes. Potential strategies for improvement include inclusion in clinical trials and the use of databases which link treatment parameters, dosimetry and outcomes. Further work will focus on the barriers identified in this survey and propose practical solutions to improve compliance in these areas.
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Affiliation(s)
- Elizabeth Ruth Claridge Mackonis
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Nick Hardcastle
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
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23
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Chakravarthy VB, Schachner B, Amin AG, Reiner AS, Yamada Y, Schmitt A, Higginson DS, Laufer I, Bilsky MH, Barzilai O. The Impact of Targetable Mutations on Clinical Outcomes of Metastatic Epidural Spinal Cord Compression in Patients With Non-Small-Cell Lung Cancer Treated With Hybrid Therapy (Surgery Followed by Stereotactic Body Radiation Therapy). Neurosurgery 2023; 92:557-564. [PMID: 36477376 PMCID: PMC10158890 DOI: 10.1227/neu.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/19/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In treatment of metastatic epidural spinal cord compression (MESCC), hybrid therapy, consisting of separation surgery, followed by stereotactic body radiation therapy, has become the mainstay of treatment for radioresistant pathologies, such as non-small-cell lung cancer (NSCLC). OBJECTIVE To evaluate clinical outcomes of MESCC secondary to NSCLC treated with hybrid therapy and to identify clinical and molecular prognostic predictors. METHODS This is a single-center, retrospective study. Adult patients (≥18 years old) with pathologically confirmed NSCLC and spinal metastasis who were treated with hybrid therapy for high-grade MESCC or nerve root compression from 2012 to 2019 are included. Outcome variables evaluated included overall survival (OS) and progression-free survival, local tumor control in the competing risks setting, surgical and radiation complications, and clinical-genomic correlations. RESULTS One hundred and three patients met inclusion criteria. The median OS for this cohort was 6.5 months, with progression of disease noted in 5 (5%) patients at the index tumor level requiring reoperation and/or reirradiation at a mean of 802 days after postoperative stereotactic body radiation therapy. The 2-year local control rate was 94.6% (95% CI: 89.8-99.3). Epidermal growth factor receptor (EGFR) treatment-naïve patients who initiated EGFR-targeted therapy after hybrid therapy had significantly longer OS (hazard ratio 0.47, 95% CI 0.23-0.95, P = .04) even after adjusting for smoking status. The presence of EGFR exon 21 mutation was predictive of improved progression-free survival. CONCLUSION Hybrid therapy in NSCLC resulted in 95% local control at 2 years after surgery. EGFR treatment-naïve patients initiating therapy after hybrid therapy had significantly improved survival advantage. EGFR-targeted therapy initiated before hybrid therapy did not confer survival benefit.
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Affiliation(s)
- Vikram B. Chakravarthy
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Anubhav G. Amin
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel S. Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mark H. Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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24
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Zeng KL, Abugarib A, Soliman H, Myrehaug S, Husain ZA, Detsky J, Ruschin M, Karotki A, Atenafu EG, Larouche J, Campbell M, Maralani P, Sahgal A, Tseng CL. Dose-Escalated 2-Fraction Spine Stereotactic Body Radiation Therapy: 28 Gy Versus 24 Gy in 2 Daily Fractions. Int J Radiat Oncol Biol Phys 2023; 115:686-695. [PMID: 36309076 DOI: 10.1016/j.ijrobp.2022.09.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) for spine metastases improves pain response rates compared with conventional external beam radiation therapy; however, the optimal fractionation schedule is unclear. We report local control and toxicity outcomes after dose-escalated 2-fraction spine SBRT. METHODS AND MATERIALS A prospectively maintained institutional database of over 600 patients and 1400 vertebral segments treated with spine SBRT was reviewed to identify those prescribed 28 or 24 Gy in 2 daily fractions. The primary endpoint was magnetic resonance imaging based local failure (LF), and secondary endpoints included overall survival and vertebral compression fracture (VCF). RESULTS A total of 947 treated vertebral segments in 482 patients were identified, of which 301 segments in 159 patients received 28 Gy, and 646 segments in 323 patients received 24 Gy in 2 fractions. Median follow-up per patient was 23.5 months, and median overall survival was 49.1 months. In the 28 Gy cohort, the 6-, 12-, and 24-month cumulative incidences of LF were 3.5%, 5.4%, and 11.1%, respectively, versus 6.0%, 12.5%, and 17.6% in the 24 Gy cohort, respectively (P = .008). On multivariable analysis, 24 Gy (hazard ratio [HR], 1.525; 95% confidence interval, 1.039-2.238; P = .031), paraspinal disease extension (HR, 1.422; 95% confidence interval, 1.010-2.002; P = .044), and epidural extension in either radioresistant or radiosensitive histologies (HR, 2.117 and 1.227, respectively; P = .003) were prognostic for higher rates of LF. Risk of VCF was 5.5%, 7.6%, and 10.7% at 6, 12, and 24 months, respectively, and was similar between cohorts (P = .573). Spinal malalignment (P < .001), baseline VCF (P = .003), junctional spine location (P = .030), and greater minimum dose to 90% of planning target volume were prognostic for higher rates of VCF. CONCLUSIONS Dose escalation to 28 Gy in 2 daily fractions was associated with improved local control without increasing the risk of VCF. The 2-year local control rates are consistent with those predicted by the Hypofractionated Treatment Effects in the Clinic spine tumor control probability model, and these data will inform a proposed dose escalation randomized trial.
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Affiliation(s)
- K Liang Zeng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Abugarib
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Clinical Oncology Department, Sohag University Hospital, Sohag, Egypt
| | - Hany Soliman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain A Husain
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aliaksandr Karotki
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mikki Campbell
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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25
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Chakravarthy VB, Schachner B, Amin A, Reiner AS, Yamada Y, Schmitt A, Higginson DS, Laufer I, Bilsky MH, Barzilai O. Long-Term Clinical Outcomes of Patients with Colorectal Cancer with Metastatic Epidural Spinal Cord Compression Treated with Hybrid Therapy (Surgery Followed by Stereotactic Body Radiation Therapy). World Neurosurg 2023; 169:e89-e95. [PMID: 36272727 PMCID: PMC10414758 DOI: 10.1016/j.wneu.2022.10.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hybrid therapy, consisting of separation surgery followed by stereotactic body radiation therapy, has become the mainstay treatment for radioresistant spinal metastases. Histology-specific outcomes for hybrid therapy are scarce. In clinical practice, colorectal cancer (CRC) is particularly thought to have poor outcomes regarding spinal metastases. The goal of this study was to evaluate clinical outcomes for patients treated with hybrid therapy for spinal metastases from CRC. METHODS This retrospective study was performed at a tertiary cancer center. Adult patients with CRC spinal metastasis who were treated with hybrid therapy for high-grade epidural spinal cord or nerve root compression from 2005 to 2020 were included. Outcome variables evaluated included patient demographics, overall survival and progression-free survival, surgical and radiation complications, and clinical-genomic correlations. RESULTS Inclusion criteria were met by 50 patients. Progression of disease occurred in 7 (14%) patients at the index level, requiring reoperation and/or reirradiation at a mean of 400 days after surgery. Postoperative complications occurred in 16% of patients, with 3 (6%) requiring intervention. APC exon 14 and 16 mutations were found in 15 of 17 patients tested and in all 3 of 7 local failures tested. Twenty patients (40%) underwent further radiation due to disease progression at other spinal levels. CONCLUSIONS Hybrid therapy in patients with CRC resulted in 86.7% local control at 2 years after surgery, with limited complications. APC mutations are commonly present in CRC patients with spine metastases and may suggest worse prognosis. Patients with CRC spinal metastases commonly progress outside the index treatment level.
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Affiliation(s)
- Vikram B Chakravarthy
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ben Schachner
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Anubhav Amin
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel S Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Neurosurgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
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Dibs K, Palmer JD, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Grecula J, Guiou M, Soghrati S, Tili E, Raval RR, Mendel E, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Blakaj DM. Feasibility, safety, and efficacy of circumferential spine stereotactic body radiotherapy. Front Oncol 2022; 12:912799. [PMID: 36505845 PMCID: PMC9727181 DOI: 10.3389/fonc.2022.912799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background With advances in systemic therapy translating to improved survival in metastatic malignancies, spine metastases have become an increasingly common source of morbidity. Achieving durable local control (LC) for patients with circumferential epidural disease can be particularly challenging. Circumferential stereotactic body radiotherapy (SBRT) may offer improved LC for circumferential vertebral and/or epidural metastatic spinal disease, but prospective (and retrospective) data are extremely limited. We sought to evaluate the feasibility, toxicity, and cancer control outcomes with this novel approach to circumferential spinal disease. Methods We retrospectively identified all circumferential SBRT courses delivered between 2013 and 2019 at a tertiary care institution for post-operative or intact spine metastases. Radiotherapy was delivered to 14-27.5 Gy in one to five fractions. Feasibility was assessed by determining the proportion of plans for which ≥95% planning target volume (PTV) was coverable by ≥95% prescription dose. The primary endpoint was 1-year LC. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity were assessed. Detailed dosimetric data were collected. Results Fifty-eight patients receiving 64 circumferential SBRT courses were identified (median age 61, KPS ≥70, 57% men). With a median follow-up of 15 months, the 12-month local control was 85% (eight events). Five and three recurrences were in the epidural space and bone, respectively. On multivariate analysis, increased PTV and uncontrolled systemic disease were significantly associated with an increased likelihood of LF; ≥95% PTV was covered by ≥95% prescription dose in 94% of the cases. The rate of new or progressive vertebral compression fracture was 8%. There were no myelitis events or any grade 3+ acute or late toxicities. Conclusions For patients with circumferential disease, circumferential spine SBRT is feasible and may offer excellent LC without significant toxicity. A prospective evaluation of this approach is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N. Prasad
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C. Bourekas
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S. Ayan
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S. Marras
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael Guiou
- Department of Radiation Oncology, Green Bay Oncology, Green Bay, WI, United States
| | - Soheil Soghrati
- Department of Mechanical and Aerospace Engineering at the Ohio State University, Columbus, OH, United States
| | - Esmerina Tili
- Department of Anesthesiology, Ohio State College of Medicine, Columbus, OH, United States
| | - Raju R. Raval
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James B. Elder
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Dukagjin M. Blakaj,
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Vilotte F, Pasquier D, Blanchard P, Supiot S, Khalifa J, Schick U, Lacornerie T, Vieillevigne L, Marre D, Chapet O, Latorzeff I, Magne N, Meyer E, Cao K, Belkacemi Y, Bibault J, Berge-Lefranc M, Faivre J, Gnep K, Guimas V, Hasbini A, Langrand-Escure J, Hennequin C, Graff P. Recommendations for stereotactic body radiation therapy for spine and non-spine bone metastases. A GETUG (French society of urological radiation oncolgists) consensus using a national two-round modified Delphi survey. Clin Transl Radiat Oncol 2022; 37:33-40. [PMID: 36052019 PMCID: PMC9424259 DOI: 10.1016/j.ctro.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background and purpose The relevance of metastasis-directed stereotactic body radiation therapy (SBRT) remains to be demonstrated through phase III trials. Multiple SBRT procedures have been published potentially resulting in a disparity of practices. Therefore, the french society of urological radiation oncolgists (GETUG) recognized the need for joint expert consensus guidelines for metastasis-directed SBRT in order to standardize practice in trials carried out by the group. Materials and methods After a comprehensive literature review, 97 recommendation statements were created regarding planning and delivery of spine bone (SBM) and non-spine bone metastases (NSBM) SBRT. These statements were then submitted to a national online two-round modified Delphi survey among main GETUG investigators. Consensus was achieved if a statement received ≥ 75 % agreements, a trend to consensus being defined as 65-74 % agreements. Any statement without consensus at round one was re-submitted in round two. Results Twenty-one out of 29 (72.4%) surveyed experts responded to both rounds. Seventy-five statements achieved consensus at round one leaving 22 statements needing a revote of which 16 achieved consensus and 5 a trend to consensus. The final rate of consensus was 91/97 (93.8%). Statements with no consensus concerned patient selection (3/19), dose and fractionation (1/11), prescription and dose objectives (1/9) and organs at risk delineation (1/15). The voting resulted in the writing of step-by-step consensus guidelines. Conclusion Consensus guidelines for SBM and NSBM SBRT were agreed upon using a validated modified Delphi approach. These guidelines will be used as per-protocole recommendations in ongoing and further GETUG clinical trials.
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Affiliation(s)
- F. Vilotte
- Department of Radiation Oncology, Institut Bergonié, 229 Cours de l'Argonne, 33076 Bordeaux, France
| | - D. Pasquier
- Department of Radiation Oncology, Centre Oscar Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France
| | - P. Blanchard
- Department of Radiation Oncology, Institut Gustave Roussy, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - S. Supiot
- Department of Radiation Oncology, Institut de Cancérologie de L'Ouest, Boulevard Professeur Jacques Monod, 44800 Saint Herblain, France
| | - J. Khalifa
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopole, 1 AV Irène Joliot Curie, 31059 Toulouse, France
| | - U. Schick
- Department of Radiation Oncology, CHU de Brest, Hôpital Morvan, avenue Foch, 29200 Brest, France
| | - T. Lacornerie
- Division of Radiation Medical Physics, Centre Oscar Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France
| | - L. Vieillevigne
- Division of Radiation Medical Physics, Institut Universitaire du Cancer de Toulouse-Oncopole, 1 AV Irène Joliot Curie, 31059 Toulouse, France
| | - D. Marre
- Division of Radiation Medical Physics, Groupe ONCORAD Garonne, Clinique Pasteur, Bât Atrium, 1 rue de la petite vitesse, 31300 Toulouse, France
| | - O. Chapet
- Department of Radiation Oncology, CH Lyon Sud 165 Chemin Du Grand Revoyet, 69310 Pierre-bénite, France
| | - I. Latorzeff
- Department of Radiation Oncology, Groupe ONCORAD Garonne, Clinique Pasteur, Bât Atrium, 1 rue de la petite vitesse, 31300 Toulouse, France
| | - N. Magne
- Department of Radiation Oncology, Institut de cancérologie Lucien Neuwirth, 108 bis AV Albert Raimond, 42270 Saint Priest en Jarez, France
| | - E. Meyer
- Department of Radiation Oncology, Centre François Baclesse, 3 Av. du Général Harris, 14000 Caen, France
| | - K. Cao
- Department of Radiation Oncology, Institut Curie Paris, 26 rue d’Ulm, 75005 Paris, France
| | - Y. Belkacemi
- Department of Radiation Oncology, Hôpital Henri-Mondor, 1 rue Gustave Eiffel, 94000 Créteil, France
| | - J.E. Bibault
- Department of Radiation Oncology, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - M. Berge-Lefranc
- Department of Radiation Oncology, Centre Saint Michel, rue du Docteur Schweitzer, 17000 La Rochelle, France
| | - J.C. Faivre
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, 6 Av. de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - K. Gnep
- Department of Radiation Oncology, Centre Eugène Marquis, AV de la Bataille Flandres Dunkerque, 35000 Rennes, France
| | - V. Guimas
- Department of Radiation Oncology, Institut de Cancérologie de L'Ouest, Boulevard Professeur Jacques Monod, 44800 Saint Herblain, France
| | - A. Hasbini
- Department of Radiation Oncology, Clinique Pasteur, 32 r Auguste Kervern, 29200 Brest, France
| | - J. Langrand-Escure
- Department of Radiation Oncology, Institut de cancérologie Lucien Neuwirth, 108 bis AV Albert Raimond, 42270 Saint Priest en Jarez, France
| | - C. Hennequin
- Department of Radiation Oncology, Hôpital Saint Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - P. Graff
- Department of Radiation Oncology, Institut Curie Saint Cloud, 35 rue Dailly, 92210 Saint Cloud, France
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Dibs K, Blakaj DM, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Lee H, Grecula J, Raval RR, Mendel E, Scharschmidt T, Lonser R, Chakravarti A, Elder JB, Palmer JD. Spine Stereotactic Body Radiotherapy to Three or More Contiguous Vertebral Levels. Front Oncol 2022; 12:912804. [PMID: 35756685 PMCID: PMC9213679 DOI: 10.3389/fonc.2022.912804] [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: 04/04/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background With survival improving in many metastatic malignancies, spine metastases have increasingly become a source of significant morbidity; achieving durable local control (LC) is critical. Stereotactic body radiotherapy (SBRT) may offer improved LC and/or symptom palliation. However, due to setup concerns, SBRT is infrequently offered to patients with ≥3 contiguous involved levels. Because data are limited, we sought to evaluate the feasibility, toxicity, and cancer control outcomes of spine SBRT delivered to ≥3 contiguous levels. Methods We retrospectively identified all SBRT courses delivered between 2013 and 2019 at a tertiary care institution for postoperative or intact spine metastases. Radiotherapy was delivered to 14-35 Gy in 1-5 fractions. Patients were stratified by whether they received SBRT to 1-2 or ≥3 contiguous levels. The primary endpoint was 1-year LC and was compared between groups. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity was assessed. In-depth dosimetric data were collected. Results Overall, 165 patients with 194 SBRT courses were identified [54% were men, median age was 61 years, 93% had Karnofsky Performance Status (KPS) ≥70, and median follow-up was 15 months]. One hundred thirteen patients (68%) received treatment to 1-2 and 52 to 3-7 (32%) levels. The 1-year LC was 88% (89% for 1-2 levels vs. 84% for ≥3 levels, p = 0.747). On multivariate analysis, uncontrolled systemic disease was associated with inferior LC for patients with ≥3 treated levels. No other demographic, disease, treatment, or dosimetric variables achieved significance. Rates of new/progressive fracture were equivalent (8% vs. 9.5%, p = 0.839). There were no radiation-induced myelopathy or grade 3+ acute or late toxicities in either group. Coverage of ≥95% of the planning target volume with ≥95% prescription dose was similar between groups (96% 1-2 levels vs. 89% ≥3 levels, p = 0.078). Conclusions For patients with ≥3 contiguous involved levels, spine SBRT is feasible and may offer excellent LC without significant toxicity. Prospective evaluation is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N Prasad
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C Bourekas
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S Marras
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Hyeri Lee
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Arnab Chakravarti
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
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Chen X, LeCompte MC, Gui C, Huang E, Khan MA, Hu C, Sciubba DM, Kleinberg LR, Lo SFL, Redmond KJ. Deviation from consensus contouring guidelines predicts inferior local control after spine stereotactic body radiotherapy. Radiother Oncol 2022; 173:215-222. [PMID: 35667571 DOI: 10.1016/j.radonc.2022.05.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE To analyze the impact of target delineation on local control (LC) after stereotactic body radiotherapy (SBRT) for spine metastasis. MATERIALS AND METHODS Patients with de novo metastasis of the spine treated with SBRT, excluding those with prostate or hematologic malignancies, were retrospectively reviewed. Deviations from consensus contouring guidelines included incomplete coverage of involved vertebral compartments, omission of adjacent compartments, or unnecessary circumferential coverage. Univariable and multivariable Cox proportional hazard analyses were performed using death as a competing risk. RESULTS 283 patients with 360 discrete lesions were included with a median follow up of 14.6 months (range 1.2-131.3). The prescription dose was 24-27Gy in 2-3 fractions for the majority of lesions. Median survival after SBRT was 18.3 months (95% confidence interval [CI]: 14.8-22.8). The 1 and 2-year LC rates were 81.1% (95% CI: 75.5-85.6%) and 70.6% (95% CI: 63.2-76.8%), respectively. In total, 60 deviations (16.7%) from consensus contouring guidelines were identified. Deviation from guidelines was associated with inferior LC (1-year LC 63.0% vs 85.5%, p<0.001). GI primary, epidural extension, and paraspinal extension were all associated with inferior LC on univariable analyses. After adjusting for confounding factors, deviation from guidelines was the strongest predictor of inferior LC (HR 3.52, 95% CI: 2.11-5.86, p<0.001). Among guideline-compliant treatments, progressions were mainly in field (61%) and/or epidural (49%), while marginal (42%) and/or epidural progressions (58%) were most common for those with deviations. CONCLUSIONS Adherence to consensus contouring guidelines for spine SBRT is associated with superior LC and fewer marginal misses.
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Affiliation(s)
- Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael C LeCompte
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chengcheng Gui
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ellen Huang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Majid A Khan
- Department of Radiology, Thomas Jefferson University. Philadelphia, PA, United States
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital. Manhasset, NY, United States
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital. Manhasset, NY, United States
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Henzen D, Schmidhalter D, Guyer G, Stenger-Weisser A, Ermiş E, Poel R, Deml MC, Fix MK, Manser P, Aebersold DM, Hemmatazad H. Feasibility of postoperative spine stereotactic body radiation therapy in proximity of carbon and titanium hybrid implants using a robotic radiotherapy device. Radiat Oncol 2022; 17:94. [PMID: 35549961 PMCID: PMC9097088 DOI: 10.1186/s13014-022-02058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background and purpose To assess the feasibility of postoperative stereotactic body radiation therapy (SBRT) for patients with hybrid implants consisting of carbon fiber reinforced polyetheretherketone and titanium (CFP-T) using CyberKnife. Materials and methods All essential steps within a radiation therapy (RT) workflow were evaluated. First, the contouring process of target volumes and organs at risk (OAR) was done for patients with CFP-T implants. Second, after RT-planning, the accuracy of the calculated dose distributions was tested in a slab phantom and an anthropomorphic phantom using film dosimetry. As a third step, the accuracy of the mandatory image guided radiation therapy (IGRT) including automatic matching was assessed using the anthropomorphic phantom. For this goal, a standard quality assurance (QA) test was modified to carry out its IGRT part in presence of CFP-T implants. Results Using CFP-T implants, target volumes could precisely delineated. There was no need for compromising the contours to overcome artifact obstacles. Differences between measured and calculated dose values were below 11% for the slab phantom, and at least 95% of the voxels were within 5% dose difference. The comparisons for the anthropomorphic phantom showed a gamma-passing rate (5%, 1 mm) of at least 97%. Additionally the test results with and without CFP-T implants were comparable. No issues concerning the IGRT were detected. The modified machine QA test resulted in a targeting error of 0.71 mm, which corresponds to the results of the unmodified standard tests. Conclusion Dose calculation and delivery of postoperative spine SBRT is feasible in proximity of CFP-T implants using a CyberKnife system.
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Affiliation(s)
- Dominik Henzen
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gian Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Stenger-Weisser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ekin Ermiş
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Poel
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Caspar Deml
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Karl Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Matthias Aebersold
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hossein Hemmatazad
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Cassidy V, Amdur RJ. Esophageal Damage from Thoracic Spine SBRT. Pract Radiat Oncol 2022; 12:392-396. [PMID: 35513255 DOI: 10.1016/j.prro.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
The risk of serious esophageal damage from stereotactic body radiotherapy (SBRT) for a spine metastasis increases when the target is in the upper thoracic or cervical spine because the esophagus almost touches the anterior edge of the vertebral body at these levels. This report describes a case of severe esophageal damage from SBRT to the T-2 vertebral body, reviews pertinent literature, and suggests implications for future research and practice.
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Affiliation(s)
- Vincent Cassidy
- From the Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Robert J Amdur
- From the Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL.
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Utility of expanded anterior column resection versus decompression-alone for local control in the management of carcinomatous vertebral column metastases undergoing adjuvant stereotactic radiotherapy. Spine J 2022; 22:835-846. [PMID: 34718175 DOI: 10.1016/j.spinee.2021.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/03/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT With improvements in adjuvant radiotherapy and minimally invasive surgical techniques, separation surgery has become the default surgical intervention for spine metastases at many centers. However, it is unclear if there is clinical benefit from anterior column resection in addition to simple epidural debulking prior to stereotactic body radiotherapy (SBRT). PURPOSE To examine the effect of anterior column debulking versus epidural disease resection alone in the local control of metastases to the bony spine. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Ninety-seven patients who underwent open surgery followed by SBRT for spinal metastases at a single comprehensive cancer center. OUTCOME MEASURES Local tumor recurrence following surgery and SBRT. METHODS Data were collected regarding radiation dose, cancer histology, extent of anterior column resection, and recurrence. Tumor involvement was categorized using the International Spine Radiosurgery Consortium guidelines. Univariable analyses were conducted to determine predictors of local recurrence and time to local recurrence. RESULTS Among the 97 included patients, mean age was 60.5±11.4 years and 51% of patients were male. The most common primary tumor types were lung (20.6%), breast (17.5%), kidney (13.4%) and prostate (12.4%). Recurrence was seen in 17 patients (17.5%) and local control rates were: 85.5% (1-year), 81.1% (2-year), and 54.9% (5-year). Overall predictors of local recurrence were tumor pathology (p<.01; renal cell carcinoma and colorectal adenocarcinoma associated with poorest PFS) and undergoing anterior column debulking versus epidural decompression-alone (p=.03). Only tumor pathology predicted time to local recurrence (p<.01), though inspection of Kaplan-Meier functions showed superior long-term local control in patients with radiosensitive tumor pathologies, no previous irradiation of the metastasis, and who underwent anterior column resection versus epidural removal alone. Median time to recurrence was 288 days with 100% of lesions showing anterior column recurrence and recurrence in the epidural space. CONCLUSIONS With the increasing shift towards surgery as a neoadjuvant to radiotherapy for patients with spinal column metastases, the role for surgical debulking has become less clear. In the present study, we find that anterior column debulking as opposed to epidural debulking-alone decreases the odds of local recurrence and improves long-term local control.
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Ito K, Nakajima Y, Ogawa H, Taguchi K, Sugita S. Risk of radiculopathy caused by second course of spine stereotactic body radiotherapy. Jpn J Clin Oncol 2022; 52:911-916. [DOI: 10.1093/jjco/hyac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/08/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
Stereotactic body radiotherapy is used to treat spinal metastases; however, 10% of patients experience local failure. We aimed to clarify the outcomes of the second course of stereotactic body radiotherapy for spinal metastases with a uniform fractionation schedule at our institution.
Methods
Data of patients treated with a second salvage stereotactic body radiotherapy course at the same spinal level or adjacent level from July 2018 to December 2020 were retrospectively reviewed. The initial prescribed dose was 24 Gy in two fractions, and the second dose 30 or 35 Gy in five fractions. The spinal cord dose constraint at the second course was 15.5 Gy at the maximum point dose. The endpoints were local failure and adverse effects. Local failure was defined as tumor progression using imaging.
Results
We assessed 19 lesions in 17 patients, with radioresistant lesions in 14 (74%) cases, the second stereotactic body radiotherapy to the same/adjacent spinal level in 13/6 cases, the median interval between stereotactic body radiotherapy of 23 (range, 6–52) months, and lesions compressing the cord in 5 (26%) cases. The median follow-up period was 19 months. The 12- and 18-month local failure rates were 0% and 8%, respectively. Radiation-induced myelopathy, radiculopathy and vertebral compression fractures were observed in 0 (0%), 4 (21%) and 2 (11%) lesions, respectively. Three patients with radiculopathy experienced almost complete upper or lower limb paralysis.
Conclusions
The second course of salvage stereotactic body radiotherapy for spinal metastases achieved good local control with a reduced risk of myelopathy. However, a high occurrence rate of radiation-induced radiculopathy has been confirmed.
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
- Department of Radiological Sciences, Komazawa University, Setagaya-ku, Tokyo, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Shurei Sugita
- Department of Orthopedic surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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Abugharib A, Zeng KL, Tseng CL, Soliman H, Myrehaug S, Husain Z, Maralani PJ, Larouche J, Cheung P, Emmenegger U, Atenafu EG, Sahgal A, Detsky JS. Spine Stereotactic Body Radiotherapy for Prostate Cancer Metastases and the Impact of Hormone Sensitivity Status on Local Control. Neurosurgery 2022; 90:743-749. [PMID: 35343467 DOI: 10.1227/neu.0000000000001909] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is used to deliver ablative dose of radiation to spinal metastases. OBJECTIVE To report the first dedicated series of spine SBRT specific to prostate cancer (PCa) metastases with outcomes reported according to hormone sensitivity status. METHODS A prospective database was reviewed identifying patients with PCa treated with spine SBRT. This included those with hormone-sensitive PCa (HSPC) and castrate-resistant PCa (CRPC). The primary end point was MRI-based local control (LC). RESULTS A total of 183 spine segments in 93 patients were identified; 146 segments had no prior radiation and 37 had been previously radiated; 27 segments were postoperative. The median follow-up was 31 months. At the time of SBRT, 50 patients had HSPC and the remaining 43 had CRPC. The most common fractionation scheme was 24-28 Gy in 2 SBRT fractions (76%). LC rates at 1 and 2 years were 99% and 95% and 94% and 78% for the HSPC and CRPC cohorts, respectively. For patients treated with de novo SBRT, a higher risk of local failure was observed in patients with CRPC (P = .0425). The 1-year and 2-year overall survival rates were significantly longer at 98% and 95% in the HSPC cohort compared with 79% and 65% in the CRPC cohort (P = .0005). The cumulative risk of vertebral compression fracture at 2 years was 10%. CONCLUSION Favorable LC rates were observed after spine SBRT for PCa metastases; strategies to improve long-term LC in patients with CRPC require further investigation.
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Affiliation(s)
- Ahmed Abugharib
- Department of Clinical Oncology, Sohag University Hospital, Sohag University, Sohag, Egypt.,Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeremie Larouche
- Department of Surgery, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay S Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Katz MS, Mihai A, Milano MT. A Dose of Reality: Embracing the Unseen to Improve Stereotactic Radiotherapy. Clin Oncol (R Coll Radiol) 2022; 34:395-397. [PMID: 35094939 DOI: 10.1016/j.clon.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/30/2021] [Accepted: 01/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- M S Katz
- Department of Radiation Medicine, Lowell General Hospital, Lowell, MA, USA.
| | - A Mihai
- Department of Radiation Oncology, Beacon Hospital, Sandyford, Dublin, Ireland
| | - M T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
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Koide Y, Shimizu H, Miyauchi R, Haimoto S, Tanaka H, Watanabe Y, Adachi S, Kato D, Aoyama T, Kitagawa T, Tachibana H, Kodaira T. Fully automated rigid image registration versus human registration in postoperative spine stereotactic body radiation therapy: a multicenter non-inferiority study. JOURNAL OF RADIATION RESEARCH 2022; 63:115-121. [PMID: 34927197 PMCID: PMC8776699 DOI: 10.1093/jrr/rrab113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/07/2021] [Accepted: 11/01/2021] [Indexed: 06/14/2023]
Abstract
To confirm the fully automated rigid image registration (A-RIR) accuracy in postoperative spine stereotactic body radiation therapy (SBRT), we conducted a multicenter non-inferiority study compared to the human rigid image registration (H-RIR). Twenty-eight metastatic cancer patients who underwent postoperative spine SBRT are enrolled-image registration (IR) of planning computed tomography (CT) and CT-myelogram for delineating the spinal cord. The adopted A-RIR workflow is a contour-focused algorithm performing a rigid registration by maximizing normalized mutual information (NMI) restricted to the data contained within the automatically extracted contour. Three radiation oncologists (ROs) from multicenters were prompted to review two blinded registrations and choose one for clinical use. Indistinguishable cases were allowed to vote equivalent, counted A-RIR side. A-RIR is considered non-inferior to H-RIR if the lower limit of the 95% confidence interval (CI) of A-RIR preferable/equivalent is greater than 0.45. We also evaluated the NMI improvement from the baseline and the translational/rotational errors between A-RIR and H-RIR. The A-RIR preferable/equivalent was selected in 21 patients (0.75, 95% CI: 0.55-0.89), demonstrating non-inferiority to H-RIR. The A-RIR's NMI improvement was greater than H-RIR in 24 patients: the mean value ± SD was 0.225 ± 0.115 in A-RIR and 0.196 ± 0.114 in H-RIR (P < 0.001). The absolute translational error was 0.38 ± 0.31 mm. The rotational error was -0.03 ± 0.20, 0.05 ± 0.19, -0.04 ± 0.20 degrees in axial, coronal, and sagittal planes (range: -0.66-0.52). In conclusion, A-RIR shows non-inferior to H-RIR in CT and CT-myelogram registration for postoperative spine SBRT planning.
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Affiliation(s)
- Yutaro Koide
- Corresponding author. Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1–1, Chikusa-ku, Nagoya, Aichi, Japan. . Tel: (052) 762-6111
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Akinduro OO, De Biase G, Goyal A, Meyer JH, Sandhu SJS, Kowalchuk RO, Trifiletti DM, Sheehan J, Merrell KW, Vora SA, Broderick DF, Clarke MJ, Bydon M, McClendon J, Kalani MA, Quiñones-Hinojosa A, Abode-Iyamah K. Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis? J Neurooncol 2022; 156:329-339. [PMID: 34993721 DOI: 10.1007/s11060-021-03915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.
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Affiliation(s)
| | - Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Anshit Goyal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jenna H Meyer
- Department of Neurosurgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | | | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Marta GN, de Arruda FF, Miranda FA, Silva ARNS, Neves-Junior WFP, Mancini A, Hanna SA, Abreu CECV, da Silva JLF, Nascimento JEV, Haddad CMK, Moraes FY, Gadia R. Stereotactic ablative radiation therapy for spinal metastases: experience at a single Brazilian institution. Rep Pract Oncol Radiother 2021; 26:756-763. [PMID: 34760310 DOI: 10.5603/rpor.a2021.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022] Open
Abstract
Background This study aims to assess the clinical outcomes of patients with spine metastases who underwent stereotactic ablative radiation therapy (SABR) as part of their treatment. SABR has arisen as a contemporary treatment option for spinal metastasis patients with good prognoses. Materials and methods Between November 2010 and September 2018, Spinal SABR was performed in patients with metastatic disease in different settings: radical (SABR only), postoperative (after decompression and/or fixation surgery), and reirradiation. Local control (LC), pain control, overall survival (OS) and toxicities were reported. Results Eighty-five patients (corresponding to 96 treatments) with spine metastases were included. The median age was 59 years (range, 23-91). In most SA BR (82.3%, n = 79) was performed as the first local spine treatment, while in 12 settings (12.5%), fixation and/or decompression surgery was performed prior to SABR. Two-year overall survival rate was 74.1%, and median survival was 19 months. The LC rate at 2 years was 72.3%. With regard to pain control, among 67 patients presenting with pain before SA BR, 83.3% had a complete response, 12.1% had a partial response, and 4.6% had progression. Vertebral compression fractures occurred in 10 patients (11.7%), of which 5 cases occurred in the reirradiation setting. Radiculopathy and myelopathy were not observed. No grade III or IV toxicities were seen. Conclusion This is the first study presenting a Brazilian experience with spinal SA BR, and the results confirm its feasibility and safety. SABR was shown to produce good local and pain control rates with low rates of adverse events.
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Affiliation(s)
- Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | | | - Fabiana A Miranda
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Alice R N S Silva
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | | | - Anselmo Mancini
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Samir A Hanna
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Carlos E C V Abreu
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | | | | | | | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University - Kingston Health Science Centre, Kingston, ON, Canada
| | - Rafael Gadia
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
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Faruqi S, Chen H, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan J, Suh J, Yomo S, Sahgal A. Stereotactic Radiosurgery for Postoperative Spine Malignancy: A Systematic Review and International Stereotactic Radiosurgery Society (ISRS) Practice Guidelines. Pract Radiat Oncol 2021; 12:e65-e78. [PMID: 34673275 DOI: 10.1016/j.prro.2021.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/17/2021] [Accepted: 10/03/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine safety and efficacy of postoperative spine stereotactic body radiation therapy (SBRT) in the published literature, and to present practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). MATERIALS AND METHODS A systematic review of the literature was performed, specific to postoperative spine SBRT, using PubMed and Embase databases. A meta-analysis for 1-year local control (LC), overall survival (OS) and vertebral compression fracture (VCF) probability was conducted. RESULTS The literature search revealed 251 potentially relevant articles after duplicates were removed. Of these 56 were reviewed in-depth for eligibility and 12 met all the inclusion criteria for analysis. 7 studies were retrospective, 2 prospective observational and 3 were prospective phase I/II clinical trials. Outcomes for a total of 461 patients and 499 spinal segments were reported. 10 studies used an MRI fused to CT-simulation for treatment planning, 2 investigations reported on all patients receiving a CT-myelogram at the time of planning. Meta-analysis for 1 year LC and OS was 88.9% and 57%, respectively. The crude reported VCF rate was 5.6%. One case of myelopathy was described in a patient with a previously irradiated spinal segment. One patient developed an esophageal fistula requiring surgical repair. CONCLUSIONS Postoperative spine SBRT delivers a high 1-year LC with acceptably low toxicity. Patients that may benefit from this include those with oligometastatic disease, radioresistant histology, paraspinal masses and/or those with a history of prior irradiation to the affected spinal segment. The ISRS recommends a minimum interval of 8 to 14 days after invasive surgery prior to simulation for SBRT, with initiation of radiotherapy within 4 weeks of surgery. An MRI fused to the planning CT, and/or the use of a CT-myelogram, are necessary for target and organ-at-risk delineation. A planning organ-at-risk volume (PRV) of 1.5 to 2mm for the spinal cord is advised.
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Affiliation(s)
- Salman Faruqi
- Department of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Alberta, Canada.
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
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Lopez-Campos F, Cacicedo J, Couñago F, García R, Leaman-Alcibar O, Navarro-Martin A, Pérez-Montero H, Conde-Moreno A. SEOR SBRT-SG stereotactic body radiation therapy consensus guidelines for non-spine bone metastasis. Clin Transl Oncol 2021; 24:215-226. [PMID: 34633602 DOI: 10.1007/s12094-021-02695-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/11/2021] [Indexed: 12/31/2022]
Abstract
The use of stereotactic body radiation therapy (SBRT) to treat non-spine bone metastases (NSBM) is becoming increasingly common in clinical practice. The clinical advantages of SBRT include good pain control and high local control rates, although only limited data are available. The Spanish Society of Radiation Oncology (SEOR) SBRT group recently convened a task force of experts in the field to address key questions related to SBRT for NSBM, including treatment indications, planning, techniques, and dose fractionation. The task force reviewed the available literature to develop evidence-based recommendations for the safe application of NSBM SBRT and to standardize and optimize SBRT processes. The present document provides a comprehensive analysis of the available data, including ongoing clinical trials and controversies, providing clinically applicable recommendations.
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Affiliation(s)
- F Lopez-Campos
- Radiation Oncology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - J Cacicedo
- Radiation Oncology Department, Osakidetza/Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo, Spain.,Department of Surgery, Radiology and Physical Medicine of the University of the Basque Country (UPV/EHU), Vizcaya, Spain
| | - F Couñago
- Radiation Oncology Department, Hospital Universitario Quirón Salud, Hospital La Luz, Madrid, Universidad Europea de Madrid (UEM), Madrid, Spain
| | - R García
- Radiation Oncology Department, Hospital Ruber Internacional Madrid, Madrid, Spain
| | - O Leaman-Alcibar
- Radiation Oncology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - A Navarro-Martin
- Radiation Oncology Department, Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - H Pérez-Montero
- Radiation Oncology Department, Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - A Conde-Moreno
- Radiation Oncology Department, Hospital Universitario y Politécnico La Fe, Valencia, CEU Cardenal Herrera University, Castellón, Spain
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Sciubba DM, Pennington Z, Colman MW, Goodwin CR, Laufer I, Patt JC, Redmond KJ, Saylor P, Shin JH, Schwab JH, Schoenfeld AJ. Spinal metastases 2021: a review of the current state of the art and future directions. Spine J 2021; 21:1414-1429. [PMID: 33887454 DOI: 10.1016/j.spinee.2021.04.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 02/03/2023]
Abstract
Spinal metastases are an increasing societal health burden secondary to improvements in systemic therapy. Estimates indicate that 100,000 or more people have symptomatic spine metastases requiring management. While open surgery and external beam radiotherapy have been the pillars of treatment, there is growing interest in more minimally invasive technologies (eg separation surgery) and non-operative interventions (eg percutaneous cementoplasty, stereotactic radiosurgery). The great expansion of these alternatives to open surgery and the prevalence of adjuvant therapeutic options means that treatment decision making is now complex and reliant upon multidisciplinary collaboration. To help facilitate construction of care plans that meet patient goals and expectations, clinical decision aids and prognostic scores have been developed. These have been shown to have superior predictive value relative to more classic prediction models and may become an increasingly important aspect of the clinical practice of spinal oncology. Here we overview current therapeutic advances in the management of spine metastases and highlight emerging areas for research. Given the rapid advancements in surgical technologies and adjuvants, the field is likely to undergo further transformative changes in the coming decade.
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Affiliation(s)
- Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA.
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Matthew W Colman
- Department of Orthopaedic Surgery, Rush University School of Medicine, Chicago, IL USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Ilya Laufer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Joshua C Patt
- Department of Orthopaedic Surgery, Atrium Musculoskeletal Institute, Levine Cancer Institute, Carolinas Medical Center - Atrium Health, Charlotte, NC 28204, USA
| | - Kristin J Redmond
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Philip Saylor
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard medical School, Boston, MD 02115, USA
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Pokhrel D, Stephen J, Webster A, Bernard ME. Double-vertebral segment SBRT via novel ring-mounted Halcyon Linac: Plan quality, delivery efficiency and accuracy. Med Dosim 2021; 47:20-25. [PMID: 34412963 DOI: 10.1016/j.meddos.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
To evaluate the plan quality, treatment delivery efficiency, and accuracy of single-isocenter/multi-target (SIMT) volumetric modulated arc therapy (VMAT) of double-vertebral segments stereotactic body radiation therapy (SBRT) on Halcyon ring delivery system (RDS). In-house multi-target end-to-end phantom testing and independent dose verification using the MD Anderson's single-isocenter/multi-target (lung/spine targets) thorax phantom were completed. Six previously treated patients with 2-vertebral segments on thoracic and/or lumber spine were replanned on Halcyon RDS with 6MV-FFF beam using a single-isocenter placed between the vertebral segments. Three full VMAT arcs with 0° and ±10° collimator angles and advanced Acuros-based dose engine for heterogeneity corrections were used. Prescription was 35 Gy in 5 fractions to each vertebral-segment, simultaneously. For comparison, Halcyon VMAT-SBRT plans were retrospectively created on SBRT-dedicated Truebeam with a 6MV-FFF beam using identical planning geometry and optimization objectives. Target coverage, conformity index (CI), heterogeneity index (HI), gradient index (GI), dose to 2-cm away from each target (D2-cm), and dose to adjacent organs-at-risk (OAR) were evaluated per NRG-BR002 protocol. Treatment delivery parameters were evaluated for both plans. In-house phantom measurements showed acceptable spatial accuracy (< 1mm within 5-cm from the isocenter) of conebeam CT-guided Halcyon SBRT treatments. The MD Anderson phantom irradiation credentialing results met IROC requirements for protocol patients. Mean isocenter-to-tumor center distance was 3.3 ± 0.6-cm (range 2.4 to 4.3-cm). Mean combined PTV was 57.3 ± 31.3 cc (range 20.1 to 99.9 cc). Both Halcyon and Truebeam SIMT-VMAT plans met NRG-BR002 compliance criteria and show similar CI, HI, GI, D2-cm. Maximal and volumetric doses to adjacent OAR including dose to partial spinal cord were lower with Halcyon RDS. Average total monitor units, modulation, and overall treatment time were lower with Halcyon plans by 130 MU, 0.2, 3.8 min, respectively, with similar beam-on time. Average pre-treatment patient-specific portal-dosimetry QA results on Halcyon showed a high pass rate of 99.6%, compared to SBRT-dedicated Truebeam pass rate of 96.8%, for 2%/2 mm clinical gamma passing criteria, suggesting more accurate treatment delivery on Halcyon RDS. SBRT treatment of double-vertebral segments via SIMT-VMAT plans on Halcyon for selected patients is feasible and dosimetrically superior to Truebeam Linac. Faster treatment delivery (<10 min) of double-vertebral segment SBRT on Halcyon could reduce patient intolerance due to severe back pain, potentially reduce intra-fraction motion errors, and improve patient throughput, and clinic workflow.
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Affiliation(s)
- Damodar Pokhrel
- University of Kentucky, Department of Radiation Medicine, Lexington, KY, USA.
| | - Joseph Stephen
- University of Kentucky, Department of Radiation Medicine, Lexington, KY, USA
| | - Aaron Webster
- University of Kentucky, Department of Radiation Medicine, Lexington, KY, USA
| | - Mark E Bernard
- University of Kentucky, Department of Radiation Medicine, Lexington, KY, USA
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Chen X, Lo SFL, Bettegowda C, Ryan DM, Gross JM, Hu C, Kleinberg L, Sciubba DM, Redmond KJ. High-dose hypofractionated stereotactic body radiotherapy for spinal chordoma. J Neurosurg Spine 2021; 35:674-683. [PMID: 34388713 DOI: 10.3171/2021.2.spine202199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal chordoma is locally aggressive and has a high rate of recurrence, even after en bloc resection. Conventionally fractionated adjuvant radiation leads to suboptimal tumor control, and data regarding hypofractionated regimens are limited. The authors hypothesized that neoadjuvant stereotactic body radiotherapy (SBRT) may overcome its intrinsic radioresistance, improve surgical margins, and allow preservation of critical structures during surgery. The purpose of this study is to review the feasibility and early outcomes of high-dose hypofractionated SBRT, with a focus on neoadjuvant SBRT. METHODS Electronic medical records of patients with spinal chordoma treated using image-guided SBRT between 2009 and 2019 at a single institution were retrospectively reviewed. RESULTS Twenty-eight patients with 30 discrete lesions (24 in the mobile spine) were included. The median follow-up duration was 20.8 months (range 2.3-126.3 months). The median SBRT dose was 40 Gy (range 15-50 Gy) in 5 fractions (range 1-5 fractions). Seventeen patients (74% of those with newly diagnosed lesions) received neoadjuvant SBRT, of whom 15 (88%) underwent planned en bloc resection, all with negative margins. Two patients (12%) developed surgical wound-related complications after neoadjuvant SBRT and surgery, and 4 (two grade 3 and two grade 2) experienced postoperative complications unrelated to the surgical site. Of the remaining patients with newly diagnosed lesions, 5 received adjuvant SBRT for positive or close surgical margins, and 1 received SBRT alone. Seven recurrent lesions were treated with SBRT alone, including 2 after failure of prior conventional radiation. The 2-year overall survival rate was 92% (95% confidence interval [CI] 71%-98%). Patients with newly diagnosed chordoma had longer median survival (not reached) than those with recurrent lesions (27.7 months, p = 0.006). The 2-year local control rate was 96% (95% CI 74%-99%). Among patients with radiotherapy-naïve lesions, no local recurrence was observed with a biologically effective dose ≥ 140 Gy, maximum dose of the planning target volume (PTV) ≥ 47 Gy, mean dose of the PTV ≥ 39 Gy, or minimum dose to 80% of the PTV ≥ 36 Gy (5-fraction equivalent doses). All acute toxicities from SBRT were grade 1-2, and no myelopathy was observed. CONCLUSIONS Neoadjuvant high-dose, hypofractionated SBRT for spinal chordoma is safe and does not increase surgical morbidities. Early outcomes at 2 years are promising, although long-term follow-up is pending.
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Affiliation(s)
- Xuguang Chen
- Departments of1Radiation Oncology and Molecular Radiation Sciences
| | | | | | | | - John M Gross
- 4Pathology, Johns Hopkins University School of Medicine; and
| | - Chen Hu
- 5Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ito K, Sugita S, Nakajima Y, Furuya T, Hiroaki O, Hayakawa S, Hozumi T, Saito M, Karasawa K. Phase II clinical trial of separation surgery followed by stereotactic body radiotherapy for metastatic epidural spinal cord compression. Int J Radiat Oncol Biol Phys 2021; 112:106-113. [PMID: 34715257 DOI: 10.1016/j.ijrobp.2021.07.1690] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/24/2021] [Accepted: 07/16/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is a postoperative treatment option for spinal metastases. As data on surgery with SBRT are limited to retrospective studies, this single-center, single-arm, phase II study aimed to prospectively evaluate the outcomes of separation surgery and SBRT for metastatic epidural spinal cord compression (MESCC). METHODS Patients with symptomatic MESCC due to a solid carcinoma were enrolled. The protocol for treatments comprised preoperative embolization, separation surgery, and spine SBRT. Surgical procedures were performed via the posterior approach, with decompression and a fixation procedure. The prescribed dose for spine SBRT was 24 Gy in two fractions. The primary endpoint was the 12-month local failure (LF) rate. The secondary endpoints were ambulatory functions and adverse effects. RESULTS Thirty-three patients were registered between November 2017 and October 2019. All patients satisfied the inclusion criteria, and all but one completed the protocol treatment. Twenty-three patients (70%) had radioresistant lesions. The Bilsky grade at registration was 1c, 2, and 3 in 4, 8, and 21 patients, respectively. The median follow-up duration after registration was 15 (range 3-35) months. Three months after the administration of treatments according to the protocol, 90% of the patients (26/29) had diseases of Bilsky grade ≤ 1. The 12-month LF rate was 13%. Twenty patients could walk normally or with a cane 12 months after registration. Radiation-induced myelopathy, radiculopathy, and vertebral compression fracture were observed in zero, one, and six patients, respectively. CONCLUSIONS Separation surgery with SBRT for MESCC was effective in decompression and long-term local control. These findings warrant larger randomized controlled trials to compare SBRT with conventional radiotherapy.
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital.
| | - Shurei Sugita
- Department of Orthopedic surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Tomohisa Furuya
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Ogawa Hiroaki
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Sara Hayakawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Takahiro Hozumi
- Department of Orthopedic surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Makoto Saito
- Division of Clinical Research Support, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
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Blakaj DM, Palmer JD, Dibs K, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Katzir M, Yildiz VO, Grecula J, Arnett A, Raval R, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Mendel E. Postoperative Stereotactic Body Radiotherapy for Spinal Metastasis and Predictors of Local Control. Neurosurgery 2021; 88:1021-1027. [PMID: 33575784 DOI: 10.1093/neuros/nyaa587] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Spine surgery is indicated for select patients with mechanical instability, pain, and/or malignant epidural spinal cord compression, with or without neurological compromise. Stereotactic body radiotherapy (SBRT) is an option for durable local control (LC) for metastatic spine disease. OBJECTIVE To determine factors associated with LC and progression-free survival (PFS) for patients receiving postoperative stereotactic spine radiosurgery. METHODS We analyzed consecutive patients from 2013 to 2019 treated with surgical intervention followed by SBRT. Surgical interventions included laminectomy and vertebrectomy. SBRT included patients treated with 1 to 5 fractions of radiosurgery. We analyzed LC, PFS, overall survival (OS), and toxicity. Univariate and multivariate analyses were performed. RESULTS A total of 63 patients were treated with a median follow-up of 12.5 mo. Approximately 75% of patients underwent vertebrectomy and 25% underwent laminectomy. One-year cumulative incidence of local failure was 19%. LC was significantly improved for patients receiving radiosurgery ≤40 d from surgery compared to that for patients receiving radiosurgery ≥40 d from surgery, 94% vs 75%, respectively, at 1 yr (P = .03). Patients who received preoperative embolization had improved LC with 1-yr LC of 88% vs 76% for those who did not receive preoperative embolization (P = .037). Significant predictors for LC on multivariate analysis were time from surgery to radiosurgery, higher radiotherapy dose, and preoperative embolization. The 1-yr PFS and OS was 56% and 60%, respectively. CONCLUSION Postoperative radiosurgery has excellent and durable LC for spine metastasis. An important consideration when planning postoperative radiosurgery is minimizing delay from surgery to radiosurgery. Preoperative embolization and higher radiotherapy dose were associated with improved LC warranting further study.
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Affiliation(s)
- Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric C Bourekas
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - William S Marras
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Prasath Mageswaran
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Miki Katzir
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Vedat O Yildiz
- Center for Biostatistics, College of Medicine Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ehud Mendel
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Boda-Heggemann J, Blanck O, Mehrhof F, Ernst F, Buergy D, Fleckenstein J, Tülümen E, Krug D, Siebert FA, Zaman A, Kluge AK, Parwani AS, Andratschke N, Mayinger MC, Ehrbar S, Saguner AM, Celik E, Baus WW, Stauber A, Vogel L, Schweikard A, Budach V, Dunst J, Boldt LH, Bonnemeier H, Rudic B. Interdisciplinary Clinical Target Volume Generation for Cardiac Radioablation: Multicenter Benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) Trial. Int J Radiat Oncol Biol Phys 2021; 110:745-756. [DOI: 10.1016/j.ijrobp.2021.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 02/05/2023]
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47
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Postoperative Stereotactic Body Radiation Therapy, Then Observe. Int J Radiat Oncol Biol Phys 2021; 109:316. [PMID: 33422274 DOI: 10.1016/j.ijrobp.2019.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/03/2019] [Accepted: 09/13/2019] [Indexed: 11/20/2022]
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Chakravarthy VB, Khan HA, Srivatsa S, Emch T, Chao ST, Krishnaney AA. Factors associated with adjacent-level tumor progression in patients receiving surgery followed by radiosurgery for metastatic epidural spinal cord compression. Neurosurg Focus 2021; 50:E15. [PMID: 33932922 DOI: 10.3171/2021.2.focus201097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Separation surgery followed by spine stereotactic radiosurgery (SSRS) has been shown to achieve favorable rates of local tumor control and patient-reported outcomes in patients with metastatic epidural spinal cord compression (MESCC). However, rates and factors associated with adjacent-level tumor progression (ALTP) in this population have not yet been characterized. The present study aimed to identify factors associated with ALTP and examine its association with overall survival (OS) in patients receiving surgery followed by radiosurgery for MESCC. METHODS Thirty-nine patients who underwent separation surgery followed by SSRS for MESCC were identified using a prospectively collected database and were retrospectively reviewed. Radiological measurements were collected from preoperative, postoperative, and post-SSRS MRI. Statistical analysis was conducted using the Kaplan-Meier product-limit method and Cox proportional hazards test. Subgroup analysis was conducted for patients who experienced ALTP into the epidural space (ALTP-E). RESULTS The authors' cohort included 39 patients with a median OS of 14.7 months (range 2.07-96.3 months). ALTP was observed in 16 patients (41.0%) at a mean of 6.1 ± 5.4 months postradiosurgery, of whom 4 patients (10.3%) experienced ALTP-E. Patients with ALTP had shorter OS (13.0 vs 17.1 months, p = 0.047) compared with those without ALTP. Factors associated with an increased likelihood of ALTP included the amount of bone marrow infiltrated by tumor at the index level, amount of residual epidural disease following separation surgery, and prior receipt of radiotherapy at the index level (p < 0.05). Subgroup analysis revealed that primary tumor type, amount of preoperative epidural disease, time elapsed between surgery and radiosurgery, and prior receipt of radiotherapy at the index level were significantly associated with ALTP-E (p < 0.05). CONCLUSIONS To the authors' knowledge, this study is the first to identify possible risk factors for ALTP, and they suggest that it may be associated with shorter OS in patients receiving surgery followed by radiosurgery for MESCC. Future studies with higher power should be conducted to further characterize factors associated with ALTP in this population.
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Affiliation(s)
| | - Hammad A Khan
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Shaarada Srivatsa
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
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Lawrence LSP, Chin LCL, Chan RW, Nguyen TK, Sahgal A, Tseng CL, Lau AZ. Method of computing direction-dependent margins for the development of consensus contouring guidelines. Radiat Oncol 2021; 16:71. [PMID: 33849576 PMCID: PMC8045331 DOI: 10.1186/s13014-021-01799-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Clinical target volume (CTV) contouring guidelines are frequently developed through studies in which experts contour the CTV for a representative set of cases for a given treatment site and the consensus CTVs are analyzed to generate margin recommendations. Measures of interobserver variability are used to quantify agreement between experts. In cases where an isotropic margin is not appropriate, however, there is no standard method to compute margins in specified directions that represent possible routes of tumor spread. Moreover, interobserver variability metrics are often measures of volume overlap that do not account for the dependence of disagreement on direction. To aid in the development of consensus contouring guidelines, this study demonstrates a novel method of quantifying CTV margins and interobserver variability in clinician-specified directions. METHODS The proposed algorithm was applied to 11 cases of non-spine bone metastases to compute the consensus CTV margin in each direction of intraosseous and extraosseous disease. The median over all cases for each route of spread yielded the recommended margins. The disagreement between experts on the CTV margin was quantified by computing the median of the coefficients of variation for intraosseous and extraosseous margins. RESULTS The recommended intraosseous and extraosseous margins were 7.0 mm and 8.0 mm, respectively. The median coefficient of variation quantifying the margin disagreement between experts was 0.59 and 0.48 for intraosseous and extraosseous disease. CONCLUSIONS The proposed algorithm permits the generation of margin recommendations in relation to adjacent anatomy and quantifies interobserver variability in specified directions. This method can be applied to future consensus CTV contouring studies.
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Affiliation(s)
- Liam S P Lawrence
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Lee C L Chin
- Department of Medical Physics, Odette Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachel W Chan
- Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, M4N 3M5, ON, Canada
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, Western University, London, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Angus Z Lau
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada. .,Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, M4N 3M5, ON, Canada.
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Ito K, Ogawa H, Nakajima Y. Efficacy and toxicity of re-irradiation spine stereotactic body radiotherapy with respect to irradiation dose history. Jpn J Clin Oncol 2021; 51:264-270. [PMID: 33020807 DOI: 10.1093/jjco/hyaa178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/03/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE We aimed to clarify the outcomes of re-irradiation stereotactic body radiotherapy for spinal metastases with a uniform dose fractionation schedule at our institution. METHODS Data of patients treated with re-irradiation stereotactic body radiotherapy for spinal metastases (September 2013-March 2020) were retrospectively reviewed. The prescribed dose was 24 Gy in two fractions. The spinal cord dose constraint and dose for previously irradiated cases ≥50 Gy in 25 fractions were 12.2 Gy (maximum dose) and 11 Gy, respectively. The endpoints were pain control, local failure and adverse effects. Pain status was measured on a scale of 0-10 using the patients' self-reports and pain response was defined using international consensus criteria. Local failure was defined as tumor progression on imaging evaluations. RESULTS We assessed 133 lesions in 123 patients, where 70 (52.6%) had three or more spinal levels treated, 58 (43.6%) had previous irradiation doses of 40 Gy or more and 53 (39.8%) had the targets compressing the cord. The median follow-up was 12 months and the 3-, 6- and 12-month pain response rate was 75, 64 and 59%, respectively. The 1-year local failure rate was 25.8%. Previous irradiation dose was not correlated with local failure rate (P = 0.13). Radiation-induced myelopathy, radiculopathy and vertebral compression fractures were observed in 4 (3.0%), 2 (1.5%) and 17 (13.8%) lesions, respectively. A trend towards an association between any toxicity and previous irradiation dose was not observed. CONCLUSIONS Re-irradiation spine stereotactic body radiotherapy achieved good local control and pain control, with reduced risk of radiation myelopathy.
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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