1
|
Ong WL, Milne RL, Foroudi F, Millar JL. Stereotactic Body Radiation Therapy for Spine Metastases-Findings from an Australian Population-Based Study. Curr Oncol 2023; 30:7777-7788. [PMID: 37623045 PMCID: PMC10453727 DOI: 10.3390/curroncol30080564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
Background: To evaluate the use of stereotactic body radiation therapy (SBRT) for spine metastases and the associated factors in Australia. Methods: The Victorian Radiotherapy Minimum Dataset, which captures all episodes of radiotherapy delivered in the state of Victoria, was accessed to evaluate the patterns and trends of SBRT for spine metastases. The primary outcome was SBRT use and associated factors. Results: There were 6244 patients who received 8861 courses of radiotherapy for spine metastases between 2012 and 2017. Of these, 277 (3%) courses were SBRT, which increased from 0.4% in 2012 to 5% in 2017 (P-trend < 0.001). There was a higher proportion of SBRT use in patients with prostate cancer (6%) and melanoma (4%) compared to other cancers (2-3%) (p < 0.001). Patients from the highest socioeconomic quintiles (5%) were more likely to be treated with SBRT compared to patients from the lowest socioeconomic quintiles (3%) (p < 0.001). There was a higher proportion of SBRT use in private radiotherapy centres (6%) compared to public radiotherapy centres (1%) (p < 0.001). No spine SBRT was delivered in regional centres. In multivariate analyses, the year of treatment, age, primary cancers and radiotherapy centres were independently associated with SBRT use. Conclusion: This is the first Australian population-based study quantifying the increasing use of spine SBRT; however, the overall use of spine SBRT remains low. We anticipate an ongoing increase in spine SBRT, as spine SBRT gradually becomes the standard-of-care treatment for painful spine metastases.
Collapse
Affiliation(s)
- Wee Loon Ong
- Alfred Health Radiation Oncology, Melbourne 3004, Australia
- Central Clinical School, Monash University, Melbourne 3004, Australia
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
| | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne 3004, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
- Precision Medicine, School of Clinical Sciences, Monash Health, Monash University, Melbourne 3168, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg 3084, Australia
| | - Jeremy L. Millar
- Alfred Health Radiation Oncology, Melbourne 3004, Australia
- Central Clinical School, Monash University, Melbourne 3004, Australia
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Sharma S, Kamal R, Rathi AK. Vertebral hemangioma - the current radiation therapy perspective. Rep Pract Oncol Radiother 2023; 28:93-101. [PMID: 37122908 PMCID: PMC10132198 DOI: 10.5603/rpor.a2023.0009] [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: 07/21/2021] [Accepted: 02/06/2023] [Indexed: 05/02/2023] Open
Abstract
Vertebral hemangiomas are benign tumors of the spine, most often detected incidentally and on other instances, when signs and symptoms of the disease arise. About 10% of the population are affected worldwide with a female to male ratio of 2:1. The majority of these cases are asymptomatic and no intervention is generally required. Less often, back pain and neurological deficit may occur. Such hemangiomas are termed aggressive by the Enneking staging and warrant treatment. In this review, staging and diagnostics are discussed in detail followed by treatment options. Treatment options entail Surgical intervention, Percutaneous ethanol injection, radiofrequency ablation and Radiation Therapy. There are no set guidelines on preference or order of the treatment options. Further, in this review, studies favouring Radiation therapy regimes and their outcomes are elaborated.
Collapse
Affiliation(s)
- Shambhavi Sharma
- Department of Radiotherapy, Maulana Azad medical College, New Delhi, India
| | - Rose Kamal
- Department of Radiation Oncology, Amrita Institute of Medical Sciences and Research Centre, Faridabad, Haryana, India
| | - Arun Kumar Rathi
- Department of Radiotherapy, Maulana Azad medical College, New Delhi, India
| |
Collapse
|
4
|
Chang SY, Ha JH, Seo SG, Chang BS, Lee CK, Kim H. Prognosis of Single Spinal Metastatic Tumors: Predictive Value of the Spinal Instability Neoplastic Score System for Spinal Adverse Events. Asian Spine J 2018; 12:919-926. [PMID: 30213176 PMCID: PMC6147885 DOI: 10.31616/asj.2018.12.5.919] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/04/2018] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN This was a retrospective cohort study. PURPOSE We evaluated the predictive value of the Spinal Instability Neoplastic Score (SINS) system for spinal adverse events (SAEs) in patients with single spinal metastatic tumor. OVERVIEW OF LITERATURE The SINS system was developed to assess spinal instability in patients with single metastatic spinal tumor. However, the system's potential predictive value for SAEs has been partially studied. METHODS This system was applied to a retrospective cohort of 78 patients with single spinal metastatic tumors. The patients underwent surgical treatment and were postoperatively followed up for at least 2 years or until death. The attribution of each score and total SINS to SAE (vertebral compression fracture [VCF] and spinal cord compression [SCC]) occurrence was assessed using the Cox proportional hazards model. RESULTS SAEs occurred on average 7 months after diagnosis of spinal metastasis. The mean survival rate post diagnosis was 43 months. Multivariate analysis using the Cox proportional hazards model revealed that the pain (p =0.029) and spinal alignment (p =0.001) scores were significantly related to VCF occurrence, whereas the pain (p =0.008) and posterolateral involvement (p =0.009) scores were related to SCC occurrence. CONCLUSIONS Among the components of the SINS system, while pain and spinal alignment showed a significant association with VCF occurrence, pain and posterolateral involvement showed association with SCC occurrence.
Collapse
Affiliation(s)
- Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jae Hong Ha
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sang Gyo Seo
- Department of Orthopedic Surgery, Asan Medical Center, Seoul, Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Choon-Ki Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
5
|
Abstract
Several variables may be considered when deciding on optimal modality of radiation therapy for each cancer patient with bone pain, including prognosis, tumor histology, location and extent of metastases, and association with cord compression. Hypofractionated external beam radiation therapy is as effective as a multiple fraction radiotherapy course in most cases, although retreatment rates are higher after a single dose of radiation. Stereotactic body radiation may be used in cases of oligometastatic disease, repeat irradiation, and radiation-resistant tumors. Radiopharmaceuticals may be used for pain from diffuse bone metastases and have an overall survival benefit in patients with castrate-resistant prostate cancer.
Collapse
Affiliation(s)
- Ron Shiloh
- Department of Radiation Oncology, Dana-Faber Cancer Institute, Brigham and Women's Cancer Center, 20 Prospect Street, Boston, MA 01757, USA.
| | - Monica Krishnan
- Department of Radiation Oncology, Dana-Faber Cancer Institute, Brigham and Women's Cancer Center, 20 Prospect Street, Boston, MA 01757, USA
| |
Collapse
|
6
|
Huo M, Sahgal A, Pryor D, Redmond K, Lo S, Foote M. Stereotactic spine radiosurgery: Review of safety and efficacy with respect to dose and fractionation. Surg Neurol Int 2017; 8:30. [PMID: 28303210 PMCID: PMC5339918 DOI: 10.4103/2152-7806.200581] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/30/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is an emerging treatment option for spinal metastases with demonstrated efficacy in the upfront, postoperative, and re-treatment settings, as well as for tumor histologies considered radioresistant. Uncertainty exists regarding the optimal dose and fractionation schedule, with single and multifraction regimens commonly utilized. METHODS A literature search of the PubMed and Medline databases was conducted to identify papers specific to spine SBRT and the effect of varying dose/fractionation regimens on outcomes. Bibliographies of relevant papers were searched for further references, and international spine SBRT experts were consulted. RESULTS Local control rates generally exceed 80% at 1 year, while high rates of pain control have been attained. There is insufficient evidence to suggest superiority of either single or multiple fraction regimens with respect to local control and pain control. Low rates of toxicity have been reported, assuming strict dose constraints are respected. Radiation myelopathy may be the most morbid toxicity, although the rates are low. The risk of vertebral compression fracture appears to be associated with higher doses per fraction such as those used in single-fraction regimens. The Spinal Instability Neoplastic Score should be considered when evaluating patients for spine SBRT, and prophylactic stabilisation may be warranted. Pain flare is a relatively common toxicity which may be mediated with prophylactic dexamethasone. Because of the treatment complexity and potentially serious toxicities, strict quality assurance should occur at the organizational, planning, dosimetric, and treatment delivery levels. CONCLUSION Both single and multifraction regimens are safe and efficacious in spine SBRT for spinal metastases. There may be advantages to hypofractionated treatment over single-fraction regimens with respect to toxicity. Ongoing investigation is underway to define optimal dose and fractionation schedules.
Collapse
Affiliation(s)
- Michael Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Kristin Redmond
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, USA
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| |
Collapse
|
7
|
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVE To address the following questions in a systematic literature review: 1. How is spinal neoplastic instability defined or classified in the literature before and after the introduction of the Spinal Instability Neoplastic Score (SINS)? 2. How has SINS affected daily clinical practice? 3. Can SINS be used as a prognostic tool? SUMMARY OF BACKGROUND DATA Spinal neoplastic-related instability was defined in 2010 and simultaneously SINS was introduced as a novel tool with criteria agreed upon by expert consensus to assess the degree of spinal stability. METHODS PubMed, Embase, and clinical trial databases were searched with the key words "spinal neoplasm," "spinal instability," "spinal instability neoplastic score," and synonyms. Studies describing spinal neoplastic-related instability were eligible for inclusion. Primary outcomes included studies describing and/or defining neoplastic-related instability, SINS, and studies using SINS as a prognostic factor. RESULTS The search identified 1414 articles, of which 51 met the inclusion criteria. No precise definition or validated assessment tool was used specific to spinal neoplastic-related instability prior to the introduction of SINS. Since the publication of SINS in 2010, the vast majority of the literature regarding spinal instability has used SINS to assess or describe instability. Twelve studies specifically investigated the prognostic value of SINS in patients who underwent radiotherapy or surgery. CONCLUSION No consensus could be determined regarding the definition, assessment, or reporting of neoplastic-related instability before introduction of SINS. Defining spinal neoplastic-related instability and the introduction of SINS have led to improved uniform reporting within the spinal neoplastic literature. Currently, the prognostic value of SINS is controversial. LEVEL OF EVIDENCE N/A.
Collapse
|