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Non-inferiority randomised phase 3 trial comparing two radiation schedules (single vs. five fractions) in malignant spinal cord compression. Br J Cancer 2020; 122:1315-1323. [PMID: 32157242 PMCID: PMC7188681 DOI: 10.1038/s41416-020-0768-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 11/11/2022] Open
Abstract
Background The optimal EBRT schedule for MSCC is undetermined. Our aim was to determine whether a single fraction (SF) was non-inferior to five daily fractions (5Fx), for functional motor outcome. Methods Patients not proceeding with surgical decompression in this multicentre non-inferiority, Phase 3 trial were randomised to 10 Gy/SF or 20 Gy/5Fx. A change in mobility from baseline to 5 weeks for each patient, was evaluated by a Modified Tomita score: 1 = ‘Walk unaided’, 2 = ‘With walking aid’ and 3 = ‘Bed-bound’. The margin used to establish non-inferiority was a detrimental change of −0.4 in the mean difference between arms. Results One-hundred and twelve eligible patients were enrolled. Seventy-three patients aged 30–87 were evaluated for the primary analysis. The 95% CI for the difference in the mean change in mobility scores between arms was −0.12 to 0.6. Since −0.4 is not included in the interval, there is evidence that 10 Gy/SF is non-inferior to 20 Gy/5Fx. One grade 3 AE was reported in the 5Fx arm. Twelve (26%) patients in the 5Fx arm had a Grade 2–3 AE compared with six (11%) patients in the SF arm (p = 0.093). Conclusion For mobility preservation, one 10-Gy fraction is non-inferior to 20 Gy in five fractions, in patients with MSCC not proceeding with surgical decompression. Clinical Trial Registration Cancer Trials Ireland ICORG 05-03; NCT00968643; EU-20952.
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Hypofractionated radiotherapy for complicated bone metastases in patients with poor performance status: a phase II international trial. TUMORI JOURNAL 2018; 105:181-187. [DOI: 10.5301/tj.5000658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: To evaluate the efficacy and safety of hypofractionated radiotherapy (16 Gy in 2 fractions, 1 week apart) in patients with complicated bone metastases and poor performance status. Methods: A prospective single-arm phase II clinical trial was conducted from July 2014 to May 2016. The primary endpoint was pain response as defined in the International Consensus on Palliative Radiotherapy Endpoints. Secondary endpoints included quality of life as measured by quality of life questionnaire (QLQ) PAL-15 and QLQ-BM22 European Organisation for Research and Treatment of Cancer guidelines, pain flare, adverse events, re-irradiation, and skeletal complications. Results: Fifty patients were enrolled. There were 23 men with a median age of 58 years (range 26-86). Of the 50 patients, 38 had an extraosseous soft tissue component, 18 needed postsurgical radiation, 3 had neuropathic pain, and 3 had an impending fracture in a weight-bearing bone. At 2 months, 33 patients were alive (66%). Four (12.5%) had a complete response and 12 (37.5%) had a partial response. A statistically significant improvement was seen in the functional interference (p = 0.01) and psychosocial aspects (p = 0.03) of the BM22. No patient had spinal cord compression. One patient required surgery for pathologic fracture, and another re-irradiation. Conclusions: Hypofractionated radiotherapy (16 Gy in 2 fractions of 8 Gy 1 week apart) achieved satisfactory pain relief and safety results in patients with complicated bone metastases and poor performance status.
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What Is the Value of Surgical Intervention for Sacral Metastases? PLoS One 2016; 11:e0168313. [PMID: 27992502 PMCID: PMC5167270 DOI: 10.1371/journal.pone.0168313] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 11/30/2016] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the impact of surgery on local control and quality of life for patients with sacral metastases and to determine whether the complications of surgery were acceptable. Methods Curettage for metastatic lesions of the sacrum was performed in 154 patients with obvious sacral nerve compression symptoms between July 1997 and July 2014. Potential risk factors were evaluated in univariate analysis for associations with local control; multivariate conditional logistic regression was used to identify the combined effects. Complications were recorded. The pre- and postoperative visual analogue scale of pain, Eastern Cooperative Oncology Group (ECOG) scores, and quality of life scores were collected to evaluate the impact of surgery. Results The cumulative survival rates were 71.8%, 41.1%, and 22.5% and the local control rates were 95.4%, 90.9%, and 79.4% at 6, 12, and 24 months, respectively. Tumors with rapid growth, the lack of preoperative radiotherapy, and application of aortic balloon occlusion were significantly associated with good local control. There were 29 (18.8%) complications related to surgery. The mean pain scores were 7.04 preoperatively, 1.66 at 1 month postoperatively (p = 0.003), and 1.51 at 3 months postoperatively (p = 0.002). The mean ECOG scores were 2.82 preoperatively and 1.47 3 months postoperatively (p < 0.001). There were significant improvements from preoperatively to 3 months postoperatively in global health status (43.3 vs. 52.1), pain (62.0 vs. 33.2), and constipation (51.4 vs. 30.3) (p < 0.001). Conclusions Surgery for sacral metastasis is effective to palliate pain rapidly and improve constipation and quality of life and has a low rate of complications.
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Gerszten PC. Spine Metastases: From Radiotherapy, Surgery, to Radiosurgery. Neurosurgery 2014; 61 Suppl 1:16-25. [DOI: 10.1227/neu.0000000000000375] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Peter C. Gerszten
- Departments of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Shiue K, Sahgal A, Chow E, Lutz ST, Chang EL, Mayr NA, Wang JZ, Cavaliere R, Mendel E, Lo SS. Management of metastatic spinal cord compression. Expert Rev Anticancer Ther 2014; 10:697-708. [DOI: 10.1586/era.10.47] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Lo SS, Chang EL, Yamada Y, Sloan AE, Suh JH, Mendel E. Stereotactic radiosurgery and radiation therapy for spinal tumors. Expert Rev Neurother 2014; 7:85-93. [PMID: 17187488 DOI: 10.1586/14737175.7.1.85] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spinal tumors constitute 15% of all CNS neoplasms. Radiation therapy can be administered for palliation of pain and spinal cord compression. However, the amount of radiation that can be administered is often limited by the tolerance of the spinal cord, especially in cases where prior radiation therapy has been given. Stereotactic radiosurgery and radiotherapy allow the delivery of a higher dose of radiation to spinal lesions, while limiting the spinal cord dose to below the tolerance level. These are technically demanding procedures and should be performed only when proper equipment and expertise are available. Data on spinal stereotactic radiosurgery and radiotherapy have emerged in recent years. This review summarizes the clinical applications of stereotactic radiosurgery and radiotherapy for spinal tumors.
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Affiliation(s)
- Simon S Lo
- Department of Radiation Medicine, Ohio State University Medical Center, Columbus, OH 43210, USA.
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A prospective study of patients with impending spinal cord compression treated with palliative radiotherapy alone. JOURNAL OF RADIOTHERAPY IN PRACTICE 2013. [DOI: 10.1017/s1460396912000301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractImpending malignant spinal cord compression (IMSCC) may be defined as compression of the thecal sac, without any visible pressure on the spinal cord itself. Although there is a perception that IMSCC patients have a better prognosis and less severe clinical symptoms than true malignant spinal cord compression (MSCC) patients, these factors have never been documented in the literature.PurposeTo record the characteristics, management and functional outcome of a group of patients with IMSCC, who were treated with radiotherapy in our institution, and compare these parameters with similar data on MSCC patients.Materials and methodsData (gender, age, primary oncological diagnosis, pain, performance status and neurological status) were prospectively collected for 28 patients. Patients were then followed up post treatment to document their response to treatment and treatment-related toxicity.ResultsThe median survival of our group of IMSCC patients is similar to that of an MSCC patient. In addition, the IMSCC group exhibits significant clinical symptoms including neurological deficit.ConclusionAlthough further studies are necessary, we have found that IMSCC patients in this study share similar prognosis and clinical symptoms with MSCC patients. Clinicians should be aware of this when communicating with IMSCC patients and their families, and short-course radiotherapy should be considered.
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Kapadia NS, Mamet R, Zornosa C, Niland JC, D'Amico TA, Hayman JA. Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer. Cancer 2012; 118:4339-45. [PMID: 22252390 DOI: 10.1002/cncr.27401] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/03/2011] [Accepted: 12/09/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Receipt of chemotherapy at the end of life (EOL) is considered an indicator of poor quality of care for medical oncology. The objective of this study was to characterize the use of radiotherapy (RT) in patients with nonsmall cell lung cancer (NSCLC) during the same period. METHODS Treatment characteristics of patients with incurable NSCLC who received RT at the EOL, defined as within 14 days of death, were analyzed from the National Comprehensive Cancer Network NSCLC Outcomes Database. RESULTS Among 1098 patients who died, 10% had received EOL RT. Patients who did and did not receive EOL RT were similar in terms of sex, race, comorbid disease, and Eastern Cooperative Oncology Group performance status. On multivariable logistic regression analysis, independent predictors of receiving EOL RT included stage IV disease (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.09-3.83) or multiorgan involvement (OR, 1.75; 95% CI, 1.08-2.84) at diagnosis, age <65 years at diagnosis (OR, 1.85; 95% CI, 1.21-2.83), and treating institution (OR, 1.24-5.94; P = .02). Nearly 50% of EOL RT recipients did not complete it, most commonly because of death or patient preference. CONCLUSIONS In general, EOL RT was received infrequently, was delivered more commonly to younger patients with more advanced disease, and often was not completed as planned. There also was considerable variation in its use among National Comprehensive Cancer Network institutions. Next steps include expanding this research to other cancers and settings and investigating the clinical benefit of such treatment.
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Affiliation(s)
- Nirav S Kapadia
- Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, Michigan, USA
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Hall WA, Stapleford LJ, Hadjipanayis CG, Curran WJ, Crocker I, Shu HKG. Stereotactic body radiosurgery for spinal metastatic disease: an evidence-based review. Int J Surg Oncol 2011; 2011:979214. [PMID: 22312536 PMCID: PMC3263656 DOI: 10.1155/2011/979214] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 05/02/2011] [Indexed: 12/25/2022] Open
Abstract
Spinal metastasis is a problem that afflicts many cancer patients. Traditionally, conventional fractionated radiation therapy and/or surgery have been the most common approaches for managing such patients. Through technical advances in radiotherapy, high dose radiation with extremely steep drop off can now be delivered to a limited target volume along the spine under image-guidance with very high precision. This procedure, known as stereotactic body radiosurgery, provides a technique to rapidly treat selected spinal metastasis patients with single- or limited-fraction treatments that have similar to superior efficacies compared with more established approaches. This review describes current treatment systems in use to deliver stereotactic body radiosurgery as well as results of some of the larger case series from a number of institutions that report outcomes of patients treated for spinal metastatic disease. These series include nearly 1400 patients and report a cumulative local control rate of 90% with myelopathy risk that is significantly less than 1%. Based on this comprehensive review of the literature, we believe that stereotactic body radiosurgery is an established treatment modality for patients with spinal metastatic disease that is both safe and highly effective.
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Affiliation(s)
- William A. Hall
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, Suite CT-104, Atlanta, GA 30322, USA
| | - Liza J. Stapleford
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, Suite CT-104, Atlanta, GA 30322, USA
| | - Costas G. Hadjipanayis
- Department of Neurosurgery, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Walter J. Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, Suite CT-104, Atlanta, GA 30322, USA
| | - Ian Crocker
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, Suite CT-104, Atlanta, GA 30322, USA
| | - Hui-Kuo G. Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, Suite CT-104, Atlanta, GA 30322, USA
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Tolérance à l’irradiation des tissus sains : moelle épinière. Cancer Radiother 2010; 14:269-76. [DOI: 10.1016/j.canrad.2010.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 03/22/2010] [Accepted: 03/28/2010] [Indexed: 11/20/2022]
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Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes? Spine (Phila Pa 1976) 2009; 34:S78-92. [PMID: 19829280 DOI: 10.1097/brs.0b013e3181b8b6f5] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVE To determine the options, indications, and outcomes for conventional radiotherapy and radiosurgery for metastatic spine disease. METHODS Three research questions were determined through a consensus among a multidisciplinary panel of spine oncology experts. A systematic review of the literature was conducted regarding radiotherapy and radiosurgery for metastatic spine disease using PubMed, Embase, the Cochrane Evidence Based Medicine Database, and a review of bibliographies of reviewed articles. RESEARCH QUESTIONS 1. What are the clinical outcomes of the current indications for conventional radiotherapy alone and stereotactic radiosurgery for metastatic spine disease? 2. What are the current dose recommendations and fractionation schedules for conventional spine radiotherapy and stereotactic radiosurgery for metastatic spine disease? 3. What are the current known patterns of failure and complications after conventional spine radiation and stereotactic radiosurgery for metastatic spine disease? RESULTS For conventional radiotherapy, the initial literature search yielded a total of 531 potentially relevant abstracts. Each of these abstracts was reviewed for relevance, and 62 were selected for in-depth review. Forty-nine studies met all the inclusion criteria. References from the articles included in the analysis and review articles were also examined for potential inclusion in the study. For conventional radiotherapy, 3 randomized trials (high-quality evidence), 4 prospective studies (moderate-quality evidence), and over 40 nonprospective data sets (low- or very-low-quality evidence) that included over 5000 patients in the literature were included in this review. Drawing from the same databases, a systematic search for radiosurgery yielded 195 abstracts, of which 29 met all inclusion criteria. They all represented single-institution reports (low- or very-low-quality data). No randomized data are available for spine radiosurgery. CONCLUSION A systematic review of the available evidence suggests that conventional radiotherapy is safe and effective with good symptomatic response and local control, particularly for radiosensitive histologies. A strong recommendation can be made with moderate quality evidence that conventional fractionated radiotherapy is an appropriate initial therapy option for patients with spine metastases in cases in which no relative contraindication exists. A systematic review of the available evidence suggests that radiosurgery is safe and provides an incremental benefit over conventional radiotherapy with more durable symptomatic response and local control independent of histology, even in the setting of prior fractionated radiotherapy. A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of oligometastatic disease and/or radioresistant histology.
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Sahgal A, Larson DA, Chang EL. Stereotactic body radiosurgery for spinal metastases: a critical review. Int J Radiat Oncol Biol Phys 2008; 71:652-65. [PMID: 18514775 DOI: 10.1016/j.ijrobp.2008.02.060] [Citation(s) in RCA: 210] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 02/06/2008] [Accepted: 02/13/2008] [Indexed: 12/13/2022]
Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, ON, Canada
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Nebbia J, Ortholan C, Gerard J. Radiotherapy in cancer pain management. EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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