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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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2
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Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
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Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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3
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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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Harel R, Kaisman-Elbaz T, Emch T, Elson P, Chao ST, Suh JH, Angelov L. A quantitative and comparative evaluation of stereotactic spine radiosurgery local control: proposing a consistent measurement methodology. Neurosurg Focus 2022; 53:E10. [DOI: 10.3171/2022.8.focus22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Stereotactic body radiotherapy (SBRT) is a precise and conformal treatment modality used in the management of metastatic spine tumors. Multiple studies have demonstrated its safety and efficacy for pain and tumor control. However, no uniform quantitative imaging methodology exists to evaluate response to treatment in these patients. This study presents radiographic local control rates post-SBRT, systematically compares measurements acquired according to WHO and Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and explores the relationship to patient outcome.
METHODS
The authors performed a retrospective review of prospectively obtained data from a cohort of 59 consecutive patients (81 metastatic isocenters) treated with SBRT and followed with serial MRI scans. Measurements were performed by a neuroradiologist blinded to the patients’ clinical course. Local control status was determined according to both WHO and RECIST measurements, and agreement between the measuring methodologies was calculated and reported.
RESULTS
Eighty-one isocenters (111 vertebral bodies) were treated with SBRT. The mean treatment dose was 13.96 Gy and the median follow-up duration was 10.8 months, during which 408 MRI scans were evaluated with both WHO and RECIST criteria for each scan point. Imaging demonstrated a mean unidimensional size decrease of 0.2 cm (p = 0.14) and a mean area size decrease of 0.99 cm2 (p = 0.03). Although 88% of the case classifications were concordant and the agreement was significant, WHO criteria were found to be more sensitive to tumor size change. The local control rates according to WHO and RECIST were 95% and 98%, respectively.
CONCLUSIONS
Although WHO volumetric measurements are admittedly superior for tumor size measurement, RECIST is simpler, reproducible, and for the first time is shown here to be comparable to WHO criteria. Thus, the application of RECIST methodology appears to be a suitable standard for evaluating post-SBRT treatment response. Moreover, using comprehensive and consistent measuring approaches, this study substantiates the efficacy of SBRT in the treatment of spine metastases.
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Affiliation(s)
- Ran Harel
- Department of Neurosurgery, Sheba Medical Center Affiliated to Tel-Aviv University, Tel-Aviv, Israel
| | - Tehila Kaisman-Elbaz
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - Todd Emch
- Imaging Institute, Cleveland Clinic, Cleveland
| | - Paul Elson
- Quantitative Health Sciences, Cleveland Clinic, Cleveland; and
| | - Samuel T Chao
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
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Terzi S, Pipola V, Griffoni C, Trentin F, Carretta E, Monetta A, Vita F, Bandiera S, Barbanti-Bròdano G, Ghermandi R, Evangelisti G, Tedesco G, Girolami M, Cavallari C, Gasbarrini A. Clear Cell Renal Cell Carcinoma Spinal Metastases: Which Factors Matter to the Overall Survival? A 10-Year Experience of a High-Volume Tumor Spine Center. Diagnostics (Basel) 2022; 12:diagnostics12102442. [PMID: 36292130 PMCID: PMC9600183 DOI: 10.3390/diagnostics12102442] [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: 08/10/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
Clear cell renal cell carcinoma (ccRCC) usually spreads in the spinal region causing instability or spinal cord compression leading to neurological deficits. Therefore, surgical treatment is required for improving the outcome of patients. The aim of this study is to identify which prognostic factors could affect overall survival in patients affected by ccRCC. Methods: Retrospective cohort study of patients with ccRCC spinal metastases, surgically treated from November 2009 to April 2019. Demographic and clinical data were collected. The Kaplan−Meier method was used to estimate overall survival, and the log-rank test was used to evaluate differences in survival among potentially prognostic factors. Results: A total of 69 patients were surgically treated and followed up for a median period of 65 months. The average age at the time of surgery was 62.6 years old. The median overall survival (OS) was 34.7 months (95% CI 20.8−51.9) and 5-year OS was 31.2% (95% CI 19.2−44.1). A high Tokuhashi score (p = 0.0217), the presence of visceral metastases (p < 0.001), other bone metastases (p = 0.02012) and the kind of surgical treatment (p = 0.0395) are the main prognostic factors that influence the OS. Moreover, 3-year progression-free survival (PFS) was analyzed: the median PFS was 53.1 months and the % 3-year PFS was 62.9% (45.2−76.3). In the multivariate analysis, only pre-operative radiation therapy had a significant impact on 3-year PFS (95% CI 0.929−12.994, p = 0.0643). Conclusion: The results of this study suggest that the absence of visceral metastases and an aggressive surgery as en-bloc, when feasible, could prolong the survival rate and improve quality of life for patients.
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Affiliation(s)
- Silvia Terzi
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Valerio Pipola
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Correspondence:
| | - Cristiana Griffoni
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Federica Trentin
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Elisa Carretta
- Department of Programming and Monitoring, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Annalisa Monetta
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Fabio Vita
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Stefano Bandiera
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | | | - Riccardo Ghermandi
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Gisberto Evangelisti
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Giuseppe Tedesco
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Girolami
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Carlotta Cavallari
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Kuah T, Vellayappan BA, Makmur A, Nair S, Song J, Tan JH, Kumar N, Quek ST, Hallinan JTPD. State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers (Basel) 2022; 14:cancers14133289. [PMID: 35805059 PMCID: PMC9265325 DOI: 10.3390/cancers14133289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 12/23/2022] Open
Abstract
Metastatic Spinal Cord Compression (MSCC) is a debilitating complication in oncology patients. This narrative review discusses the strengths and limitations of various imaging modalities in diagnosing MSCC, the role of imaging in stereotactic body radiotherapy (SBRT) for MSCC treatment, and recent advances in deep learning (DL) tools for MSCC diagnosis. PubMed and Google Scholar databases were searched using targeted keywords. Studies were reviewed in consensus among the co-authors for their suitability before inclusion. MRI is the gold standard of imaging to diagnose MSCC with reported sensitivity and specificity of 93% and 97% respectively. CT Myelogram appears to have comparable sensitivity and specificity to contrast-enhanced MRI. Conventional CT has a lower diagnostic accuracy than MRI in MSCC diagnosis, but is helpful in emergent situations with limited access to MRI. Metal artifact reduction techniques for MRI and CT are continually being researched for patients with spinal implants. Imaging is crucial for SBRT treatment planning and three-dimensional positional verification of the treatment isocentre prior to SBRT delivery. Structural and functional MRI may be helpful in post-treatment surveillance. DL tools may improve detection of vertebral metastasis and reduce time to MSCC diagnosis. This enables earlier institution of definitive therapy for better outcomes.
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Affiliation(s)
- Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Correspondence: ; Tel.: +65-6779-5555
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore;
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Shalini Nair
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Junda Song
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
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Jabehdar Maralani P, Tseng CL, Baharjoo H, Wong E, Kapadia A, Dasgupta A, Howard P, Chan AKM, Atenafu EG, Lu H, Tyrrell P, Das S, Payabvash S, Detsky J, Husain Z, Myrehaug S, Soliman H, Chen H, Heyn C, Symons S, Sahgal A. The Initial Step Towards Establishing a Quantitative, Magnetic Resonance Imaging-Based Framework for Response Assessment of Spinal Metastases After Stereotactic Body Radiation Therapy. Neurosurgery 2021; 89:884-891. [PMID: 34392364 PMCID: PMC8645191 DOI: 10.1093/neuros/nyab310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/09/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are no established threshold values regarding the degree of growth on imaging when assessing response of spinal metastases treated with stereotactic body radiation therapy (SBRT). OBJECTIVE To determine a magnetic resonance imaging-based minimum detectable difference (MDD) in gross tumor volume (GTV) and its association with 1-yr radiation site-specific (RSS) progression-free survival (PFS). METHODS GTVs at baseline and first 2 post-SBRT scans (Post1 and Post2, respectively) for 142 spinal segments were contoured, and percentage volume change between scans calculated. One-year RSS PFS was acquired from medical records. The MDD was determined. The MDD was compared against optimal thresholds of GTV changes associated with 1-yr RSS PFS using Youden's J index, and receiver operating characteristic curves between timepoints compared to determine which timeframe had the best association. RESULTS A total of 17 of the 142 segments demonstrated progression. The MDD was 10.9%. Baseline-Post2 demonstrated the best performance (area under the curve [AUC] 0.90). Only Baseline-Post2 had an optimal threshold > MDD at 14.7%. Due to large distribution of GTVs, volumes were split into tertiles. Small tumors (GTV < 2 cc) had optimal thresholds of 42.0%, 71.3%, and 37.2% at Baseline-Post1 (AUC 0.81), Baseline-Post2 (AUC 0.89), and Post1-Post2 (AUC 0.77), respectively. Medium tumors (2 ≤ GTV ≤ 8.3 cc) all demonstrated optimal thresholds < MDD, with AUCs ranging from 0.65 to 0.84. Large tumors (GTV > 8.3 cc) had 2 timepoints where optimal thresholds > MDD: Baseline-Post2 (13.3%; AUC 0.97) and Post1-Post2 (11.8%; AUC 0.66). Baseline-Post2 had the best association with RSS PFS for all tertiles. CONCLUSION Given a MDD of 10.9%, for small GTVs, larger (>37%) changes were required before local failure could be determined, compared to 11% to 13% for medium/large tumors.
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Affiliation(s)
| | - Chia-Lin Tseng
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | | | - Erin Wong
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Anish Kapadia
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Peter Howard
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Aimee K M Chan
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Canada
| | - Hua Lu
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Pascal Tyrrell
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Department of Statistical Sciences, University of Toronto, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Sunit Das
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | | | - Jay Detsky
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chris Heyn
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Sean Symons
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
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8
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Chakravarthy VB, Khan HA, Srivatsa S, Emch T, Chao ST, Krishnaney AA. Factors associated with adjacent-level tumor progression in patients receiving surgery followed by radiosurgery for metastatic epidural spinal cord compression. Neurosurg Focus 2021; 50:E15. [PMID: 33932922 DOI: 10.3171/2021.2.focus201097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Separation surgery followed by spine stereotactic radiosurgery (SSRS) has been shown to achieve favorable rates of local tumor control and patient-reported outcomes in patients with metastatic epidural spinal cord compression (MESCC). However, rates and factors associated with adjacent-level tumor progression (ALTP) in this population have not yet been characterized. The present study aimed to identify factors associated with ALTP and examine its association with overall survival (OS) in patients receiving surgery followed by radiosurgery for MESCC. METHODS Thirty-nine patients who underwent separation surgery followed by SSRS for MESCC were identified using a prospectively collected database and were retrospectively reviewed. Radiological measurements were collected from preoperative, postoperative, and post-SSRS MRI. Statistical analysis was conducted using the Kaplan-Meier product-limit method and Cox proportional hazards test. Subgroup analysis was conducted for patients who experienced ALTP into the epidural space (ALTP-E). RESULTS The authors' cohort included 39 patients with a median OS of 14.7 months (range 2.07-96.3 months). ALTP was observed in 16 patients (41.0%) at a mean of 6.1 ± 5.4 months postradiosurgery, of whom 4 patients (10.3%) experienced ALTP-E. Patients with ALTP had shorter OS (13.0 vs 17.1 months, p = 0.047) compared with those without ALTP. Factors associated with an increased likelihood of ALTP included the amount of bone marrow infiltrated by tumor at the index level, amount of residual epidural disease following separation surgery, and prior receipt of radiotherapy at the index level (p < 0.05). Subgroup analysis revealed that primary tumor type, amount of preoperative epidural disease, time elapsed between surgery and radiosurgery, and prior receipt of radiotherapy at the index level were significantly associated with ALTP-E (p < 0.05). CONCLUSIONS To the authors' knowledge, this study is the first to identify possible risk factors for ALTP, and they suggest that it may be associated with shorter OS in patients receiving surgery followed by radiosurgery for MESCC. Future studies with higher power should be conducted to further characterize factors associated with ALTP in this population.
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Affiliation(s)
| | - Hammad A Khan
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Shaarada Srivatsa
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
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9
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Soltys SG, Grimm J, Milano MT, Xue J, Sahgal A, Yorke E, Yamada Y, Ding GX, Li XA, Lovelock DM, Jackson A, Ma L, El Naqa I, Gibbs IC, Marks LB, Benedict S. Stereotactic Body Radiation Therapy for Spinal Metastases: Tumor Control Probability Analyses and Recommended Reporting Standards. Int J Radiat Oncol Biol Phys 2021; 110:112-123. [PMID: 33516580 DOI: 10.1016/j.ijrobp.2020.11.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE We sought to investigate the tumor control probability (TCP) of spinal metastases treated with stereotactic body radiation therapy (SBRT) in 1 to 5 fractions. METHODS AND MATERIALS PubMed-indexed articles from 1995 to 2018 were eligible for data extraction if they contained SBRT dosimetric details correlated with actuarial 2-year local tumor control rates. Logistic dose-response models of collected data were compared in terms of physical dose and 3-fraction equivalent dose. RESULTS Data were extracted from 24 articles with 2619 spinal metastases. Physical dose TCP modeling of 2-year local tumor control from the single-fraction data were compared with data from 2 to 5 fractions, resulting in an estimated α/β = 6 Gy, and this was used to pool data. Acknowledging the uncertainty intrinsic to the data extraction and modeling process, the 90% TCP corresponded to 20 Gy in 1 fraction, 28 Gy in 2 fractions, 33 Gy in 3 fractions, and (with extrapolation) 40 Gy in 5 fractions. The estimated TCP for common fractionation schemes was 82% at 18 Gy, 90% for 20 Gy, and 96% for 24 Gy in a single fraction, 82% for 24 Gy in 2 fractions, and 78% for 27 Gy in 3 fractions. CONCLUSIONS Spinal SBRT with the most common fractionation schemes yields 2-year estimates of local control of 82% to 96%. Given the heterogeneity in the tumor control estimates extracted from the literature, with variability in reporting of dosimetry data and the definition of and statistical methods of reporting tumor control, care should be taken interpreting the resultant model-based estimates. Depending on the clinical intent, the improved TCP with higher dose regimens should be weighed against the potential risks for greater toxicity. We encourage future reports to provide full dosimetric data correlated with tumor local control to allow future efforts of modeling pooled data.
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Affiliation(s)
- Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California.
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Health System, Danville, Pennsylvania; Department of Medical Imaging and Radiation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - D Michael Lovelock
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Issam El Naqa
- Machine Learning Department, Moffitt Cancer Center, Tampa, Florida
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Lineberger Cancer Center, Chapel Hill, North Carolina
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis, Sacramento, California
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10
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Zeng KL, Sahgal A, Husain ZA, Myrehaug S, Tseng CL, Detsky J, Sarfehnia A, Ruschin M, Campbell M, Foster M, Das S, Lipsman N, Bjarnason GA, Atenafu EG, Maralani PJ, Soliman H. Local control and patterns of failure for "Radioresistant" spinal metastases following stereotactic body radiotherapy compared to a "Radiosensitive" reference. J Neurooncol 2021; 152:173-182. [PMID: 33453002 DOI: 10.1007/s11060-020-03691-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The concept of a radioresistant (RR) phenotype has been challenged with use of stereotactic body radiotherapy (SBRT). We compared outcomes following SBRT to RR spinal metastases to a radiosensitive cohort. METHODS Renal cell, melanoma, sarcoma, gastro-intestinal, and thyroid spinal metastases were identified as RR and prostate cancer (PCA) as radiosensitive. The primary endpoint was MRI-based local failure (LF). Secondary endpoints included overall survival (OS) and vertebral compression fracture (VCF). RESULTS From a prospectively maintained database of 1394 spinal segments in 605 patients treated with spine SBRT, 173 patients/395 RR spinal segments were compared to 94 patients/185 PCA segments. Most received 24-28 Gy in 2 fractions (68.9%) and median follow-up was 15.5 months (range, 1.4-84.2 months). 1- and 2-year LF rates were 19.2% and 22.4% for RR metastases, respectively, which were significantly greater (p < 0.001) than PCA (3.2% and 8.4%, respectively). Epidural disease (HR: 2.47, 95% CI 1.65-3.71, p < 0.001) and RR histology (HR: 2.41, 95% CI 1.45-3.99, p < 0.001) predicted for greater LF. Median OS was 17.4 and 61.0 months for RR and PCA cohorts, respectively. Lung/liver metastases, polymetastatic disease and epidural disease predicted for worse OS. 2-year VCF rates were ~ 13% in both cohorts. Coverage of the CTV V90 (clinical target volume receiving 90% of prescription dose) by ≥ 87% (HR: 2.32, 95% CI 1.29-4.18, p = 0.005), no prior spine radiotherapy (HR: 1.96, 95% CI 1.09-3.55, p = 0.025), and a greater Spinal Instability Neoplasia Score (p = 0.013) predicted for VCF. CONCLUSIONS Higher rates of LF were observed after spine SBRT in RR metastases. Optimization strategies include dose escalation and aggressive management of epidural disease.
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Affiliation(s)
- K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Zain A Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Arman Sarfehnia
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Monica Foster
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Georg A Bjarnason
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada.
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11
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Spencer KL, van der Velden JM, Wong E, Seravalli E, Sahgal A, Chow E, Verlaan JJ, Verkooijen HM, van der Linden YM. Systematic Review of the Role of Stereotactic Radiotherapy for Bone Metastases. J Natl Cancer Inst 2020; 111:1023-1032. [PMID: 31119273 PMCID: PMC6792073 DOI: 10.1093/jnci/djz101] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/07/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background Stereotactic radiotherapy (SBRT) might improve pain and local control in patients with bone metastases compared to conventional radiotherapy, although an overall estimate of these outcomes is currently unknown. Methods A systematic review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Embase, and Cochrane databases were systematically searched to identify studies reporting pain response and local control among patients with bone metastases from solid-organ tumors who underwent SBRT in 1–6 fractions. All studies prior to April 15, 2017, were included. Study quality was assessed by predefined criteria, and pain response and local control rates were extracted. Results A total of 2619 studies were screened; 57 were included (reporting outcomes for 3995 patients) of which 38 reported pain response and 45 local control rates. Local control rates were high with pain response rates above those previously reported for conventional radiotherapy. Marked heterogeneity in study populations and delivered treatments were identified such that quantitative synthesis was not appropriate. Reported toxicity was limited. Of the pain response studies, 73.7% used a retrospective cohort design and only 10.5% used the international consensus endpoint definitions of pain response. The median survival within the included studies ranged from 8 to 30.4 months, suggesting a high risk of selection bias in the included observational studies. Conclusions This review demonstrates the potential benefit of SBRT over conventional palliative radiotherapy in improving pain due to bone metastases. Given the methodological limitations of the published literature, however, large randomized trials are now urgently required to better quantify this benefit.
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Affiliation(s)
- Katie L Spencer
- Correspondence to: Katie Spencer, MB, BChir, FRCR, Cancer Epidemiology Group, Level 11 Worsley Building, Clarendon Way, University of Leeds, Leeds LS2 9NL, West Yorkshire, UK (e-mail: )
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12
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O'Sullivan S, McDermott R, Keys M, O'Sullivan M, Armstrong J, Faul C. Imaging response assessment following stereotactic body radiotherapy for solid tumour metastases of the spine: Current challenges and future directions. J Med Imaging Radiat Oncol 2020; 64:385-397. [PMID: 32293114 DOI: 10.1111/1754-9485.13032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/09/2020] [Indexed: 01/01/2023]
Abstract
Patients with metastatic disease are routinely serially imaged to assess disease burden and response to systemic and local therapies, which places ever-expanding demands on our healthcare resources. Image interpretation following stereotactic body radiotherapy (SBRT) for spine metastases can be challenging; however, appropriate and accurate assessment is critical to ensure patients are managed correctly and resources are optimised. Here, we take a critical review of the merits and pitfalls of various imaging modalities, current response assessment guidelines, and explore novel imaging approaches and the potential for radiomics to add value in imaging assessment.
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Affiliation(s)
- Siobhra O'Sullivan
- St Luke's Institute of Cancer Research, St Luke's Radiation Oncology Network, Dublin 6, Ireland.,Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Ronan McDermott
- St Luke's Institute of Cancer Research, St Luke's Radiation Oncology Network, Dublin 6, Ireland.,Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Maeve Keys
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Maeve O'Sullivan
- Department of Radiology, Beaumont Hospital, Royal College of Surgeons of Ireland, Dublin 9, Ireland
| | - John Armstrong
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - Clare Faul
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
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13
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Mossa-Basha M, Gerszten PC, Myrehaug S, Mayr NA, Yuh WT, Jabehdar Maralani P, Sahgal A, Lo SS. Spinal metastasis: diagnosis, management and follow-up. Br J Radiol 2019; 92:20190211. [PMID: 31322920 DOI: 10.1259/bjr.20190211] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Spine metastatic disease is an increasingly common occurrence in cancer patients due to improved patient survival. Close proximity of the bony spinal column to the spinal cord limits many conventional treatments for metastatic disease. In the past decade, we have witnessed dramatic advancements in therapies, with improvements in surgical techniques and recent adoption of spine stereotactic radiotherapy techniques leading to improved patient outcomes. Multidisciplinary approaches to patient evaluation, treatment and follow-up are essential. Imaging plays an ever increasing role in disease detection, pre-treatment planning and assessment of patient outcomes. It is important for the radiologist to be familiar with imaging algorithms, best practices for surgery and/or radiotherapy and imaging findings in the post-treatment period that may indicate disease recurrence. In this review, we present a multidisciplinary discussion of spine metastases, with specific focus on pre-treatment imaging, planning, current treatment approaches, and post-treatment assessment.
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Affiliation(s)
| | - Peter C Gerszten
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - William Tc Yuh
- Department of Radiology, University of Washington, Seattle, WA
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA
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14
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Zeng KL, Tseng CL, Soliman H, Weiss Y, Sahgal A, Myrehaug S. Stereotactic Body Radiotherapy (SBRT) for Oligometastatic Spine Metastases: An Overview. Front Oncol 2019; 9:337. [PMID: 31119099 PMCID: PMC6504814 DOI: 10.3389/fonc.2019.00337] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/12/2019] [Indexed: 12/15/2022] Open
Abstract
The oligometastatic state is hypothesized to represent an intermediary state of cancer between widely metastatic disease and curable, localized disease. Advancements in radiotherapy have allowed for delivery of high precision, dose escalated treatment known as stereotactic body radiotherapy (SBRT) to targets throughout the body with excellent rates of local control. Recently, the first phase II randomized trial comparing conventional radiotherapy to comprehensive SBRT of oligometastatic disease demonstrated an overall survival and progression free survival advantage. The spine is a common site of metastasis, and a complex site for SBRT given the adjacent spinal cord and the tumor embedded within the bone tissue putting the patient at risk of fracture. Although there are expert spine SBRT guidelines for practice, there are as yet no reported randomized trials that proves superiority as compared to conventional radiation. The use of SBRT in patients with oligometastatic disease and spinal metastases is the focus of this review.
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Affiliation(s)
- Kang Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yonatan Weiss
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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15
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Finkelstein S, Raman S, Van Der Velden J, Zhang L, Tan C, Dhillon A, Tonolete F, Chiu N, Probyn L, McDonald R, Sahgal A, Chow E, Chin L. Changes in Volume and Density Parameters Measured on Computed Tomography Images Following Stereotactic Body Radiation Therapy of Nonspine Bone Metastases. Technol Cancer Res Treat 2019; 18:1533033819853532. [PMID: 31319776 PMCID: PMC6640058 DOI: 10.1177/1533033819853532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Volumetric and density parameters measured from computed tomography scans were investigated for evaluating treatment response of nonspine bone lesions following stereotactic body radiation therapy. Methods: Twenty-three patients treated with stereotactic body radiation therapy to nonspine bone metastases with pre- and post-treatment radiological follow-up with computed tomography imaging were identified in a retrospective review. An expert radiologist classified 26 lesions by type (lytic, sclerotic) and by response. Two independent radiation oncologists created separate contours of the bone and soft tissue lesion volumes. Density and volume were assessed relative to baseline values. Results: For bone-only lesions, all lesions designated as local control decreased in volume or remained within 20% of baseline volumes. Lytic lesions classified as progressive disease exhibited much larger volume increases. Lytic bone lesions showed indications of remineralization with some exhibiting immediate increases in density (1-6 months) and others decreasing initially then increasing back toward baseline between 7 and 12 months. The majority of sclerotic lesions, all classified as local control, decreased slightly in both volume and density. Lesions with both soft tissue and boney involvement resulted in contradictory results when employing both radiological and size parameters for assessing treatment response. Classification was dominated by changes in soft tissue volume, despite associated volume or density changes in the corresponding boney lesion. In contrast, when soft tissue volume changes were minimal (<20% increase), classification appeared to be related primarily to density changes and not bone volume. Conclusions: Volume and density changes show promise as quantitative parameters for classifying treatment responses of nonspine osseous lesions. Further work is required for clarifying how these metrics can be applied to lesions with both boney and soft tissue components.
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Affiliation(s)
- Samuel Finkelstein
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Raman
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joanne Van Der Velden
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Liying Zhang
- 3 Department of Medical Physics, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn Tan
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Amanpreet Dhillon
- 4 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Frances Tonolete
- 4 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Chiu
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Linda Probyn
- 4 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rachel McDonald
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lee Chin
- 3 Department of Medical Physics, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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16
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Marciscano AE, Thorek DLJ. Role of noninvasive molecular imaging in determining response. Adv Radiat Oncol 2018; 3:534-547. [PMID: 30370353 PMCID: PMC6200886 DOI: 10.1016/j.adro.2018.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 12/18/2022] Open
Abstract
The intersection of immunotherapy and radiation oncology is a rapidly evolving area of preclinical and clinical investigation. The strategy of combining radiation and immunotherapy to enhance local and systemic antitumor immune responses is intriguing yet largely unproven in the clinical setting because the mechanisms of synergy and the determinants of therapeutic response remain undefined. In recent years, several noninvasive molecular imaging approaches have emerged as a platform to interrogate the tumor immune microenvironment. These tools have the potential to serve as robust biomarkers for cancer immunotherapy and may hold several advantages over conventional anatomic imaging modalities and contemporary invasive tissue acquisition techniques. Given the key and expanding role of precision imaging in radiation oncology for patient selection, target delineation, image guided treatment delivery, and response assessment, noninvasive molecular-specific imaging may be uniquely suited to evaluate radiation/immunotherapy combinations. Herein, we describe several experimental imaging-based strategies that are currently being explored to characterize in vivo immune responses, and we review a growing body of preclinical data and nascent clinical experience with immuno-positron emission tomography molecular imaging as a putative biomarker for cancer immunotherapy. Finally, we discuss practical considerations for clinical translation to implement noninvasive molecular imaging of immune checkpoint molecules, immune cells, or associated elements of the antitumor immune response with a specific emphasis on its potential application at the interface of radiation oncology and immuno-oncology.
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Affiliation(s)
- Ariel E Marciscano
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel L J Thorek
- Radiological Chemistry and Imaging Laboratory, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri.,Department of Biomedical Engineering, Washington University in St Louis, St Louis, Missouri
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