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Moore-Palhares D, Zeng KL, Tseng CL, Chen H, Myrehaug S, Soliman H, Maralani P, Larouche J, Shakil H, Jerzak K, Ruschin M, Zhang B, Atenafu EG, Sahgal A, Detsky J. Stereotactic Body Radiation Therapy for Sacral Metastases: Deviation From Recommended Target Volume Delineation Increases the Risk of Local Failure. Int J Radiat Oncol Biol Phys 2024; 119:1110-1121. [PMID: 38395085 DOI: 10.1016/j.ijrobp.2024.01.213] [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: 07/25/2023] [Revised: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE Although spine stereotactic body radiation therapy (SBRT) is considered a standard of care in the mobile spine, mature evidence reporting outcomes specific to sacral metastases is lacking. Furthermore, there is a need to validate the existing sacral SBRT international consensus contouring guidelines to define the optimal contouring approach. We report mature rates of local failure (LF), adverse events, and the effect of contouring deviations in the largest experience to date specific to sacrum SBRT. METHODS AND MATERIALS Consecutive patients who underwent sacral SBRT from 2010 to 2021 were retrospectively reviewed. The primary endpoint was magnetic resonance imaging-based LF with a focus on adherence to target volume contouring recommendations. Secondary endpoints included vertebral compression fracture and neural toxicity. RESULTS Of the 215 sacrum segments treated in 112 patients, most received 30 Gy/4 fractions (51%), 24 Gy/2 fractions (31%), or 30 Gy/5 fractions (10%). Sixteen percent of segments were nonadherent to the consensus guideline with a more restricted target volume (undercontoured). The median follow-up was 21.4 months (range, 1.5-116.9 months). The cumulative incidence of LF at 1 and 2 years was 18.4% and 23.1%, respectively. In those with guideline adherent versus nonadherent contours, the LF rate at 1 year was 15.1% versus 31.4% and at 2 years 18.8% versus 40.0% (hazard ratio [HR], 2.5; 95% CI, 1.4-4.6; P = .003), respectively. On multivariable analysis, guideline nonadherence (HR, 2.4; 95% CI, 1.3-4.7; P = .008), radioresistant histology (HR, 2.4; 95% CI, 1.4-4.1; P < .001), and extraosseous extension (HR, 2.5; 95% CI, 1.3-4.7; P = .005) predicted for an increased risk of LF. The cumulative incidence of vertebral compression fracture was 7.1% at 1 year and 12.3% at 2 years. Seven patients (6.3%) developed peripheral nerve toxicity, of whom 4 had been previously radiated. CONCLUSIONS Sacral SBRT is associated with high efficacy rates and an acceptable toxicity profile. Adhering to consensus guidelines for target volume delineation is recommended to reduce the risk of LF.
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Affiliation(s)
- Daniel Moore-Palhares
- 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
| | - Hanbo Chen
- 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
| | - Hany Soliman
- 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
| | - Jeremie Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Husain Shakil
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Katarzyna Jerzak
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, 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
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Chmiel E, Senthi S, Siva S, Hardcastle N, Panettieri V, Russell C, Tacey M, Anderson N, Foroudi F. A multi-centre retrospective study of long-term outcomes of spinal re-irradiation with SABR. J Med Imaging Radiat Oncol 2024. [PMID: 38985969 DOI: 10.1111/1754-9485.13723] [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: 02/13/2024] [Accepted: 05/31/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Stereotactic ablative body radiotherapy (SABR) is a highly conformal technique utilising a high dose per fraction commonly employed in the re-treatment of spinal metastases. This study sought to determine the safety and efficacy of re-irradiation with SABR to previously treated spinal metastases. METHODS This was a retrospective analysis of patients at three Australian centres who have undergone spinal SABR after previous spinal radiotherapy to the same or immediately adjacent vertebral level. Efficacy was determined in terms of rates of local control, while safety was characterised by rates of serious complications. RESULTS Thirty-three spinal segments were evaluated from 32 patients. Median follow-up for all patients was 2.6 years, and median overall survival was 4.3 years. Eleven of 33 (33.3%) treated spinal segments had local progression, with a local control rate at 12 months of 71.4% (95% C.I. 55.2%-92.4%). Four patients (16.7%) went on to develop cauda equina or spinal cord compression. Thirteen out of 32 patients (40.6%) experienced acute toxicity, of which 12 were grade 2 or less. Five out of 30 spinal (16.7%) segments with follow-up imaging had a radiation-induced vertebral compression fracture. There was one case of radiation myelitis which occurred in a patient who had mediastinal radiotherapy with a treatment field which overlapped their prior spinal radiation. CONCLUSION The patients in this study experienced long median survival, durable tumour control and high rates of freedom from long-term sequelae of treatment. These results support the use of SABR in patients who progress in the spine despite previous radiotherapy.
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Affiliation(s)
- Edward Chmiel
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sashendra Senthi
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Shankar Siva
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Hardcastle
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vanessa Panettieri
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Mark Tacey
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Nigel Anderson
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Farshad Foroudi
- Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
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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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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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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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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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Hirashima H, Nakamura M, Nakamura K, Matsuo Y, Mizowaki T. Dosimetric verification of four dose calculation algorithms for spine stereotactic body radiotherapy. JOURNAL OF RADIATION RESEARCH 2024; 65:109-118. [PMID: 37996097 PMCID: PMC10803157 DOI: 10.1093/jrr/rrad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/18/2023] [Accepted: 10/16/2023] [Indexed: 11/25/2023]
Abstract
The applications of Type B [anisotropic analytical algorithm (AAA) and collapsed cone (CC)] and Type C [Acuros XB (AXB) and photon Monte Carlo (PMC)] dose calculation algorithms in spine stereotactic body radiotherapy (SBRT) were evaluated. Water- and bone-equivalent phantoms were combined to evaluate the percentage depth dose and dose profile. Subsequently, 48 consecutive patients with clinical spine SBRT plans were evaluated. All treatment plans were created using AXB in Eclipse. The prescription dose was 24 Gy in two fractions at a 10 MV FFF on TrueBeam. The doses were then recalculated with AAA, CC and PMC while maintaining the AXB-calculated monitor units and beam arrangement. The dose index values obtained using the four dose calculation algorithms were then compared. The AXB and PMC dose distributions agreed with the bone-equivalent phantom measurements (within ±2.0%); the AAA and CC values were higher than those in the bone-equivalent phantom region. For the spine SBRT plans, PMC, AAA and CC were overestimated compared with AXB in terms of the near minimum and maximum doses of the target and organ at risk, respectively; the mean dose difference was within 4.2%, which is equivalent with within 1 Gy. The phantom study showed that the results from AXB and PMC agreed with the measurements within ±2.0%. However, the mean dose difference ranged from 0.5 to 1 Gy in the spine SBRT planning study when the dose calculation algorithms changed. Users should incorporate a clinical introduction that includes an awareness of these differences.
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Affiliation(s)
- Hideaki Hirashima
- 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 Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
- 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
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 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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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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Guninski RS, Cuccia F, Alongi F, Andratschke N, Belka C, Bellut D, Dahele M, Josipovic M, Kroese TE, Mancosu P, Minniti G, Niyazi M, Ricardi U, Munck Af Rosenschold P, Sahgal A, Tsang Y, Verbakel WFAR, Guckenberger M. Efficacy and safety of SBRT for spine metastases: A systematic review and meta-analysis for preparation of an ESTRO practice guideline. Radiother Oncol 2024; 190:109969. [PMID: 37922993 DOI: 10.1016/j.radonc.2023.109969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND AND PURPOSE Advances in characterizing cancer biology and the growing availability of novel targeted agents and immune therapeutics have significantly changed the prognosis of many patients with metastatic disease. Palliative radiotherapy needs to adapt to these developments. In this study, we summarize the available evidence for stereotactic body radiotherapy (SBRT) in the treatment of spinal metastases. MATERIALS AND METHODS A systematic review and meta-analysis was performed using PRISMA methodology, including publications from January 2005 to September 2021, with the exception of the randomized phase III trial RTOG-0631 which was added in April 2023. Re-irradiation was excluded. For meta-analysis, a random-effects model was used to pool the data. Heterogeneity was assessed with the I2-test, assuming substantial and considerable as I2 > 50 % and I2 > 75 %, respectively. A p-value < 0.05 was considered statistically significant. RESULTS A total of 69 studies assessing the outcomes of 7236 metastases in 5736 patients were analyzed. SBRT for spine metastases showed high efficacy, with a pooled overall pain response rate of 83 % (95 % confidence interval [CI] 68 %-94 %), pooled complete pain response of 36 % (95 % CI: 20 %-53 %), and 1-year local control rate of 94 % (95 % CI: 86 %-99 %), although with high levels of heterogeneity among studies (I2 = 93 %, I2 = 86 %, and 86 %, respectively). Furthermore, SBRT was safe, with a pooled vertebral fracture rate of 9 % (95 % CI: 4 %-16 %), pooled radiation induced myelopathy rate of 0 % (95 % CI 0-2 %), and pooled pain flare rate of 6 % (95 % CI: 3 %-17 %), although with mixed levels of heterogeneity among the studies (I2 = 92 %, I2 = 0 %, and 95 %, respectively). Only 1.7 % of vertebral fractures required surgical stabilization. CONCLUSION Spine SBRT is characterized by a favorable efficacy and safety profile, providing durable results for pain control and disease control, which is particularly relevant for oligometastatic patients.
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Affiliation(s)
- R S Guninski
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - F Cuccia
- ARNAS Civico Hospital, Radiation Oncology Unit, Palermo, Italy
| | - F Alongi
- Advanced Radiation Department, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar-Verona, Italy. University of Brescia, Italy
| | - N Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - C Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany. German Cancer Consortium (DKTK), partner site Munich, Munich, Germany. Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - D Bellut
- University Hospital Zurich, University of Zurich, Department of Neurosurgery. Zurich, Switzerland
| | - M Dahele
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Radiation Oncology and Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, The Netherlands
| | - M Josipovic
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - T E Kroese
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - P Mancosu
- IRCCS Humanitas Research Hospital, Medical Physics Unit, Radiation Oncology department, via Manzoni 56, I-20089 Rozzano, Milan, Italy
| | - G Minniti
- Department of Radiological Sciences, Oncology and Anatomical PathologySapienza University of Rome, Rome; IRCCS Neuromed, Pozzilli, IS, Italy
| | - M Niyazi
- Department of Radiation Oncology, University hospital Tübingen, Tübingen, Germany
| | - U Ricardi
- University of Turin, Department of Oncology, Turin, Italy
| | - P Munck Af Rosenschold
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Medical Radiation Physics, Lund University, Lund, Sweden
| | - A Sahgal
- Odette Cancer Center of the Sunnybrook Health Sciences Center, Department of Radiation Oncology, Toronto, Canada
| | - Y Tsang
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Canada
| | - W F A R Verbakel
- Amsterdam University Medical Center, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - M Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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10
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Waltenberger M, Strick C, Vogel MME, Diehl C, Combs SE. SBRT of Spinal Metastases Using a Simultaneous Integrated Boost Concept in Oligometastatic Cancer Patients Is Safe and Effective. Cancers (Basel) 2023; 15:5813. [PMID: 38136357 PMCID: PMC10741748 DOI: 10.3390/cancers15245813] [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: 10/31/2023] [Revised: 11/27/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
(1) Purpose: To assess the safety and effectivity of stereotactic body radiotherapy (SBRT) on spinal metastases utilizing a simultaneous integrated boost (SIB) concept in oligometastatic cancer patients. (2) Methods: 62 consecutive patients with 71 spinal metastases received SIB-SBRT between 01/2013 and 09/2022 at our institution. We retrospectively analyzed toxicity, local tumor control (LC), and progression-free (PFS) and overall survival (OS) following SIB-SBRT and assessed possible influencing factors (Kaplan-Meier estimator, log-rank test and Cox proportional-hazards model). (3) Results: SIB-SBRT was delivered in five fractions, mostly with 25/40 Gy (n = 43; 60.56%) and 25/35 Gy (n = 19, 26.76%). Estimated rates of freedom from VCF were 96.1/90.4% at one/two years. VCF development was significantly associated with osteoporosis (p < 0.001). No ≥ grade III acute and one grade III late toxicity (VCF) were observed. Estimated LC rates at one/two years were 98.6/96.4%, and histology was significantly associated with local treatment failure (p = 0.039). Median PFS/OS was 10 months (95% CI 6.01-13.99)/not reached. Development of metastases ≥ one year after initial diagnosis and Karnofsky Performance Score ≥ 90% were predictors for superior PFS (p = 0.038) and OS (p = 0.012), respectively. (4) Conclusion: Spinal SIB-SBRT yields low toxicity and excellent LC. It may be utilized in selected oligometastatic patients to improve prognosis. To the best of our knowledge, we provide the first clinical data on the toxicity and effectivity of SIB-SBRT in spinal metastases in a larger patient cohort.
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Affiliation(s)
- Maria Waltenberger
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (C.S.); (M.M.E.V.); (C.D.); (S.E.C.)
- German Cancer Consortium (DKTK), Partner Site Munich, a Partnership between DKFZ and University Hospital Klinikum Rechts der Isar, 81675 Munich, Germany
| | - Christian Strick
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (C.S.); (M.M.E.V.); (C.D.); (S.E.C.)
| | - Marco M. E. Vogel
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (C.S.); (M.M.E.V.); (C.D.); (S.E.C.)
| | - Christian Diehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (C.S.); (M.M.E.V.); (C.D.); (S.E.C.)
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (C.S.); (M.M.E.V.); (C.D.); (S.E.C.)
- German Cancer Consortium (DKTK), Partner Site Munich, a Partnership between DKFZ and University Hospital Klinikum Rechts der Isar, 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
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11
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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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12
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Pezzulla D, Re A, Cilla S, Ferro M, Romano C, Bonome P, Di Franco R, Muto P, Mattiucci G, Deodato F, Macchia G. Spine Instability Neoplastic Score (SINS) as a Predictive Tool in Conventional Radiotherapy: A Narrative Review. Cancer Invest 2023; 41:774-780. [PMID: 37812173 DOI: 10.1080/07357907.2023.2269566] [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: 05/25/2023] [Accepted: 10/07/2023] [Indexed: 10/10/2023]
Abstract
AIMS This narrative review seeks to identify the SINS score application in the radiation oncology field. METHODS This literature review was performed searching papers on MEDLINE published from January 2010 to August 2022. RESULTS In terms of vertebral painful lesions and RT symptomatic responses, the SINS score could be an interesting aid in order to choose the right therapeutic approach. Lesions with higher level of instability, and therefore higher SINS score, could did not find any significant benefit from radiation therapy which is more effective on the tumor-related pain component. For SINS as a predictor of adverse event after RT or its changes after RT, we obtained contrasting results. CONCLUSIONS The reported few experiences showed ambiguous conclusions. Further prospective studies are needed.
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Affiliation(s)
- Donato Pezzulla
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
| | - Alessia Re
- UOC Radioterapia Oncologica, Mater Olbia Hospital, Olbia, Italy
| | - Savino Cilla
- Medical Physics Unit, Responsible Research Hospital, Campobasso, Italy
| | - Milena Ferro
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Responsible Research Hospital, Campobasso, Italy
| | - Paolo Bonome
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
| | - Rossella Di Franco
- Department of Radiation Oncology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - Paolo Muto
- Department of Radiation Oncology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - Giancarlo Mattiucci
- UOC Radioterapia Oncologica, Mater Olbia Hospital, Olbia, Italy
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
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13
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Zeng KL, Sahgal A, Tseng CL. In Reply to Sari et al. Int J Radiat Oncol Biol Phys 2023; 116:690-692. [PMID: 37270249 DOI: 10.1016/j.ijrobp.2022.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 12/29/2022] [Indexed: 06/05/2023]
Affiliation(s)
- K Liang Zeng
- Odette Cancer Centre, 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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14
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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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15
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Khan MA, Jennings JW, Baker JC, Smolock AR, Shah LM, Pinchot JW, Wessell DE, Kim CY, Lenchik L, Parsons MS, Huhnke G, Shek-Man Lo S, Lu Y, Potter C, Reitman C, Sahgal A, Sharma A, Yalla NM, Beaman FD, Kapoor BS, Burns J. ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update. J Am Coll Radiol 2023; 20:S102-S124. [PMID: 37236738 DOI: 10.1016/j.jacr.2023.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Majid A Khan
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Jack W Jennings
- Research Author, Washington University, Saint Louis, Missouri
| | - Jonathan C Baker
- Mallinckrodt Institute of Radiology Washington University School of Medicine, St. Louis, Missouri
| | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | | | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina
| | - Leon Lenchik
- Panel Vice-Chair, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, St. Louis, Missouri
| | - Gina Huhnke
- Deaconess Hospital, Evansville, Indiana American College of Emergency Physicians
| | - Simon Shek-Man Lo
- University of Washington School of Medicine, Seattle, Washington Commission on Radiation Oncology
| | - Yi Lu
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Christopher Potter
- Brigham & Women's Hospital, Boston, Massachusetts Committee on Emergency Radiology-GSER
| | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina North American Spine Society
| | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Commission on Radiation Oncology
| | - Akash Sharma
- Mayo Clinic, Jacksonville, Florida Commission on Nuclear Medicine and Molecular Imaging
| | - Naga M Yalla
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri, Primary care physician
| | | | | | - Judah Burns
- Specialty Chair, Montefiore Medical Center, Bronx, New York
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16
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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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17
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Pathak RS, Tibdewal A, Kinhikar R, Wakeham K, Akbarov K, Cordero L, Khandavalli A, Agarwal JP. Practice Patterns and Perspectives on Stereotactic Body Radiation Therapy for the Metastatic Spine From Lower- and Middle-Income Countries. JCO Glob Oncol 2022; 8:e2200167. [PMID: 36103640 PMCID: PMC9812512 DOI: 10.1200/go.22.00167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE We wanted to understand the current practice patterns and stereotactic body radiation therapy (SBRT) utilization for spine metastases in lower- and middle-income countries (LMICs). METHODS A questionnaire was designed to identify the current practice patterns of treating spine metastases, uptake of spine SBRT in routine care, dose fractionations commonly used, and the perceived benefits and toxicities of using ablative doses. Individuals registering for a spine SBRT workshop were requested to answer the questionnaire. RESULTS We received 395 responses from radiation oncologists (ROs) working in 12 different LMICs. The majority of respondents were from an academic institute (57.5%). Two hundred seventy-four respondents further identified themselves from the government/public sector (44.89%), corporate/private sector (47.89%), not-for-profit organization (5.4%), or public-private partnership (5.4%). The respondents indicated that 8.43%, 27.46%, 41.73%, and 10.04% of the spine metastases patients are treated using clinical marking, X-ray-based, 3D conformal radiation therapy, and SBRT, respectively. A third of the respondents did not have any experience of spine SBRT; those with high-volume practice were predominantly from an academic institute. The majority of respondents would use spine SBRT to reduce pain severity (71.9%) and achieve durable pain control (61.01%) in the setting of oligometastases (92.73%) and reirradiation (56.69%). Respondents preferred 3- to 5-fraction regimens (64.9%) over 1-2 fractions (33.68%). The top three reasons for not using spine SBRT were resource constraints (50%), lack of machine (37.11%), and lack of training (27.34%). CONCLUSION There is heterogeneity in spine SBRT practice and utilization between academic and nonacademic institutes. Resource and infrastructure constraints along with lack of training are limiting the use of SBRT among ROs from LMICs. Collaborative studies from LMICs will help in resolving unique challenges posed by resource constraints.
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Affiliation(s)
| | - Anil Tibdewal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | | | - Katherine Wakeham
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
| | - Kamal Akbarov
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Lisbeth Cordero
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | | | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India,Jai Prakash Agarwal, Department of Radiation Oncology, Tata Memorial Centre, 1131, Homi Bhabha Block, Dr. E Borges Road, Parel, Mumbai, Maharashtra, India 400012; e-mail:
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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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19
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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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20
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Gui C, Chen X, Sheikh K, Mathews L, Lo SFL, Lee J, Khan MA, Sciubba DM, Redmond KJ. Radiomic modeling to predict risk of vertebral compression fracture after stereotactic body radiation therapy for spinal metastases. J Neurosurg Spine 2022; 36:294-302. [PMID: 34560656 DOI: 10.3171/2021.3.spine201534] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the treatment of spinal metastases with stereotactic body radiation therapy (SBRT), vertebral compression fracture (VCF) is a common and potentially morbid complication. Better methods to identify patients at high risk of radiation-induced VCF are needed to evaluate prophylactic measures. Radiomic features from pretreatment imaging may be employed to more accurately predict VCF. The objective of this study was to develop and evaluate a machine learning model based on clinical characteristics and radiomic features from pretreatment imaging to predict the risk of VCF after SBRT for spinal metastases. METHODS Vertebral levels C2 through L5 containing metastases treated with SBRT were included if they were naive to prior surgery or radiation therapy, target delineation was based on consensus guidelines, and 1-year follow-up data were available. Clinical features, including characteristics of the patient, disease, and treatment, were obtained from chart review. Radiomic features were extracted from the planning target volume (PTV) on pretreatment CT and T1-weighted MRI. Clinical and radiomic features selected by least absolute shrinkage and selection operator (LASSO) regression were included in random forest classification models, which were trained to predict VCF within 1 year after SBRT. Model performance was assessed with leave-one-out cross-validation. RESULTS Within 1 year after SBRT, 15 of 95 vertebral levels included in the analysis demonstrated new or progressive VCF. Selected clinical features included BMI, performance status, total prescription dose, dose to 99% of the PTV, lumbar location, and 2 components of the Spine Instability Neoplastic Score (SINS): lytic tumor character and spinal misalignment. Selected radiomic features included 5 features from CT and 3 features from MRI. The best-performing classification model, derived from a combination of selected clinical and radiomic features, demonstrated a sensitivity of 0.844, specificity of 0.800, and area under the receiver operating characteristic (ROC) curve (AUC) of 0.878. This model was significantly more accurate than alternative models derived from only selected clinical features (AUC = 0.795, p = 0.048) or only components of the SINS (AUC = 0.579, p < 0.0001). CONCLUSIONS In the treatment of spinal metastases with SBRT, a machine learning model incorporating both clinical features and radiomic features from pretreatment imaging predicted VCF at 1 year after SBRT with excellent sensitivity and specificity, outperforming models developed from clinical features or components of the SINS alone. If validated, these findings may allow more judicious selection of patients for prophylactic interventions.
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Affiliation(s)
- Chengcheng Gui
- 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Xuguang Chen
- 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Khadija Sheikh
- 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Liza Mathews
- 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Sheng-Fu L Lo
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore; and
| | - Junghoon Lee
- 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Majid A Khan
- 3Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore; and
| | - Kristin J Redmond
- 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore
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21
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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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22
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Perdomo-Pantoja A, Holmes C, Lina IA, Liauw JA, Puvanesarajah V, Goh BC, Achebe CC, Cottrill E, Elder BD, Grayson WL, Redmond KJ, Hur SC, Witham TF. Effects of Single-Dose Versus Hypofractionated Focused Radiation on Vertebral Body Structure and Biomechanical Integrity: Development of a Rabbit Radiation-Induced Vertebral Compression Fracture Model. Int J Radiat Oncol Biol Phys 2021; 111:528-538. [PMID: 33989720 DOI: 10.1016/j.ijrobp.2021.04.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Vertebral compression fracture is a common complication of spinal stereotactic body radiation therapy. Development of an in vivo model is crucial to fully understand how focal radiation treatment affects vertebral integrity and biology at various dose fractionation regimens. We present a clinically relevant animal model to analyze the effects of localized, high-dose radiation on vertebral microstructure and mechanical integrity. Using this model, we test the hypothesis that fractionation of radiation dosing can reduce focused radiation therapy's harmful effects on the spine. METHODS AND MATERIALS The L5 vertebra of New Zealand white rabbits was treated with either a 24-Gy single dose of focused radiation or 3 fractionated 8-Gy doses over 3 consecutive days via the Small Animal Radiation Research Platform. Nonirradiated rabbits were used as controls. Rabbits were euthanized 6 months after irradiation, and their lumbar vertebrae were harvested for radiologic, histologic, and biomechanical testing. RESULTS Localized single-dose radiation led to decreased vertebral bone volume and trabecular number and a subsequent increase in trabecular spacing and thickness at L5. Hypofractionation of the radiation dose similarly led to reduced trabecular number and increased trabecular spacing and thickness, yet it preserved normalized bone volume. Single-dose irradiated vertebrae displayed lower fracture loads and stiffness compared with those receiving hypofractionated irradiation and with controls. The hypofractionated and control groups exhibited similar fracture load and stiffness. For all vertebral samples, bone volume, trabecular number, and trabecular spacing were correlated with fracture loads and Young's modulus (P < .05). Hypocellularity was observed in the bone marrow of both irradiated groups, but osteogenic features were conserved in only the hypofractionated group. CONCLUSIONS Single-dose focal irradiation showed greater detrimental effects than hypofractionation on the microarchitectural, cellular, and biomechanical characteristics of irradiated vertebral bodies. Correlation between radiologic measurements and biomechanical properties supported the reliability of this animal model of radiation-induced vertebral compression fracture, a finding that can be applied to future studies of preventative measures.
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Affiliation(s)
| | - Christina Holmes
- Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, Tallahassee, Florida
| | - Ioan A Lina
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason A Liauw
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Varun Puvanesarajah
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian C Goh
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Chukwuebuka C Achebe
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Warren L Grayson
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Soojung C Hur
- Department of Mechanical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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23
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Kim H, Pyo H, Park HC, Lim DH, Yu JI, Park W, Ahn YC, Choi DH, Oh D, Noh JM, Cho WK, Yoo GS, Jung SH, Kim ES, Lee SH, Park SJ, Lee CS. Clinical and dosimetric risk factors for vertebral compression fracture after single-fraction stereotactic body radiation therapy for spine metastases. J Bone Oncol 2021; 28:100368. [PMID: 34026479 PMCID: PMC8131921 DOI: 10.1016/j.jbo.2021.100368] [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: 02/03/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 10/31/2022] Open
Abstract
Objectives This analysis was performed to evaluate the incidence of vertebral compression fracture (VCF) and determine the contributing factors for VCF in patients undergoing single-fraction stereotactic body radiotherapy (SBRT) for spinal bone metastases (SBM). Methods A retrospective review of medical records was conducted for patients undergoing SBRT for SBM at our institution between January 2010 and December 2018. Patients who had undergone neither pre-SBRT surgical excision nor post-SBRT prophylactic fixation were included. The effects of clinical and dosimetric parameters were analyzed with respect to VCF risk. The following dosimietric parameters of the planning target volume (PTV) were calculated: mean/minimum/maximum dose, radiation dose to 10-90% volume, and irradiated volume receiving more than 10-25 Gy (PTV_V10 - 25 Gy). Results Among 163 patients (179 vertebrae), 21 (12.8%) experienced VCF. The 1-year and 2-year VCF rates were 12.1% and 13.2%, respectively. Among dosimetric parameters, PTV_V15 Gy was the most significant for VCF prediction. In a univariate analysis, breast or prostate primary, no vertebral body collapse, and PTV_V15 Gy ≤42 cm3 were significantly associated with a lower incidence rate of VCF. In a multivariate analysis, PTV_V15 Gy was the only significant factor for VCF risk. The 1-year VCF rate was 3.8% in patients with PTV_V15 Gy ≤42 cm3, while it was 22.1% in those with PTV_V15 Gy > 42 cm3 (p < 0.01). Conclusions SBRT-related VCF was found in 12% of patients in our institution. The PTV_V15 Gy is a significant factor for VCF prediction.
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Affiliation(s)
- Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Jung
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Sang Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se-Jun Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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