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Waltenberger M, Vogel MME, Bernhardt D, Münch S, Dobiasch S, Redmond KJ, Lo SS, Acker G, Fehlings MG, Ringel F, Vajkoczy P, Meyer B, Combs SE. Radiotherapy concepts for spinal metastases-results from an online survey among radiation oncologists of the German Society for Radiation Oncology. Strahlenther Onkol 2024; 200:159-174. [PMID: 37272996 PMCID: PMC10805849 DOI: 10.1007/s00066-023-02082-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE Spinal metastases (SM) are a common radiotherapy (RT) indication. There is limited level I data to drive decision making regarding dose regimen (DR) and target volume definition (TVD). We aim to depict the patterns of care for RT of SM among German Society for Radiation Oncology (DEGRO) members. METHODS An online survey on conventional RT and Stereotactic Body Radiation Therapy (SBRT) for SM, distributed via e‑mail to all DEGRO members, was completed by 80 radiation oncologists between February 24 and April 29, 2022. Participation was voluntary and anonymous. RESULTS A variety of DR was frequently used for conventional RT (primary: n = 15, adjuvant: n = 14). 30 Gy/10 fractions was reported most frequently. TVD in adjuvant RT was heterogenous, with a trend towards larger volumes. SBRT was offered in 65% (primary) and 21% (adjuvant) of participants' institutions. A variety of DR was reported (primary: n = 40, adjuvant: n = 27), most commonly 27 Gy/3 fractions and 30 Gy/5 fractions. 59% followed International Consensus Guidelines (ICG) for TVD. CONCLUSION We provide a representative depiction of RT practice for SM among DEGRO members. DR and TVD are heterogeneous. SBRT is not comprehensively practiced, especially in the adjuvant setting. Further research is needed to provide a solid data basis for detailed recommendations.
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Affiliation(s)
- Maria Waltenberger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Sophie Dobiasch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum, Munich, Germany
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Güliz Acker
- Department of Neurosurgery, Charité Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum, Munich, Germany
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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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Implementation of triggered kilovoltage imaging for stereotactic radiotherapy of the spine for patients with spinal fixation hardware. Phys Imaging Radiat Oncol 2023; 25:100422. [PMID: 36875327 PMCID: PMC9978845 DOI: 10.1016/j.phro.2023.100422] [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: 08/06/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Background and purpose Mitigation of intrafraction motion (IM) is valuable in stereotactic radiotherapy (SRT) radiotherapy where submillimeter accuracy is desired. The purpose of this study was to investigate the application of triggered kilovoltage (kV) imaging for spine SRT patients with hardware by correlating kV imaging with patient motion and summarizing implications of tolerance for IM based on calculated dose. Materials and methods Ten plans (33 fractions) were studied, correlating kV imaging during treatment with pre- and post-treatment cone beam computed tomography (CBCT). Images were taken at 20-degree gantry angle intervals during the arc-based treatment. The contour of the hardware with a 1 mm expansion was displayed at the treatment console to manually pause treatment delivery if the hardware was visually detected outside the contour. The treatment CBCTs were compared using retrospective image registration to assess the validity of contour-based method for pausing treatment. Finally, plans were generated to estimate dose volume objective differences in case of 1 mm deviation. Results When kV imaging during treatment was used with the 1 mm contour, 100 % of the post-treatment CBCTs reported consistent results. One patient in the cohort exhibited motion greater than 1 mm during treatment which allowed intervention and re-setup during treatment. The average translational motion was 0.35 mm. Treatment plan comparison at 1 mm deviation showed little differences in calculated dose for the target and cord. Conclusions Utilizing kV imaging during treatment is an effective method of assessing IM for SRT spine patients with hardware without increasing treatment time.
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Cellini F, Di Rito A, Siepe G, Pastore F, Lattanzi E, Meaglia I, Tozzi A, Manfrida S, Longo S, Saldi S, Cassese R, Arcidiacono F, Fiore M, Masiello V, Mazzarella C, Diroma A, Miccichè F, Maurizi F, Dominici L, Scorsetti M, Santarelli M, Fusco V, Aristei C, Deodato F, Gambacorta MA, Maranzano E, Muto P, Valentini V, Morganti AG, Marino L, Donati CM, Di Franco R. Prognostic Score in Radiotherapy Practice for Palliative Treatments (PROPHET) Study for Bone Metastases: An Investigation Into the Clinical Effect on Treatment Prescription. Adv Radiat Oncol 2022; 8:101134. [PMID: 36632087 PMCID: PMC9827357 DOI: 10.1016/j.adro.2022.101134] [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: 10/14/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose Bone metastases frequently occur during malignant disease. Palliative radiation therapy (PRT) is a crucial part of palliative care because it can relieve pain and improve patients' quality of life. Often, a clinician's survival estimation is too optimistic. Prognostic scores (PSs) can help clinicians tailor PRT indications to avoid over- or undertreatment. Although the PS is supposed to aid radiation oncologists (ROs) in palliative-care scenarios, it is unclear what type of support, and to what extent, could impact daily clinical practice. Methods and Materials A national-based investigation of the prescriptive decisions on simulated clinical cases was performed in Italy. Nine clinical cases from real-world clinical practice were selected for this study. Each case description contained complete information regarding the parameters defining the prognosis class according to the PS (in particular, the Mizumoto Prognostic Score, a validated PS available in literature and already applied in some clinical trials). Each case description contained complete information regarding the parameters defining the prognosis class according to the PS. ROs were interviewed through questionnaires, each comprising the same 3 questions per clinical case, asking (1) the prescription after detailing the clinical case features but not the PS prognostic class definition; (2) whether the RO wanted to change the prescription once the PS prognostic class definition was revealed; and (3) in case of a change of the prescription, a new prescriptive option. Three RO categories were defined: dedicated to PRT (RO-d), nondedicated to PRT (RO-nd), and resident in training (IT). Interviewed ROs were distributed among different regions of the country. Results Conversion rates, agreements, and prescription trends were investigated. The PS determined a statistically significant 11.12% of prescription conversion among ROs. The conversion was higher for the residents and significantly higher for worse prognostic scenario subgroups, respectively. The PS improved prescriptive agreement among ROs (particularly for worse-prognostic-scenario subgroups). Moreover, PS significantly increased standard prescriptive approaches (particularly for worse-clinical-case presentations). Conclusions To the best of our knowledge, the PROPHET study is the first to directly evaluate the potential clinical consequences of the regular application of any PS. According to the Prophet study, a prognostic score should be integrated into the clinical practice of palliative radiation therapy for bone metastasis and training programs in radiation oncology.
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Affiliation(s)
- Francesco Cellini
- Dipartimento Universitario Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Corresponding author: Cellini Francesco, MD
| | - Alessia Di Rito
- Radiotherapy Unit - IRCCS Istituto Tumori 'Giovanni Paolo II' Bari - Italy
| | - Giambattista Siepe
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Ilaria Meaglia
- Department of Radiotherapy, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Angelo Tozzi
- Department of Radiotherapy, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Stefania Manfrida
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Silvia Longo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Simonetta Saldi
- Section of Radiation Oncology, Perugia General Hospital, Perugia, Italy
| | | | - Fabio Arcidiacono
- Radiation Oncology, Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | - Michele Fiore
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico
| | - Valeria Masiello
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Ciro Mazzarella
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Antonio Diroma
- Dipartimento Universitario Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Miccichè
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Francesca Maurizi
- Radiation Oncology, A.O. Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Luca Dominici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Vincenzo Fusco
- Radiotherapy Oncology Department, IRCCS CROB, Rionero In Vulture, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Francesco Deodato
- Dipartimento Universitario Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Radiotherapy Unit, Gemelli Molise Hospital, Campobasso, Italy
| | - Maria A. Gambacorta
- Dipartimento Universitario Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Ernesto Maranzano
- Radiotherapy Oncology Centre, Santa Maria Hospital, Terni, Italy
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Paolo Muto
- Department of Radiation Oncology, Istituto Nazionale Tumori–IRCCS–Fondazione G. Pascale, Napoli, Italy
| | - Vincenzo Valentini
- Dipartimento Universitario Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Alessio G. Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- DIMES, Alma Mater Studiorum–Bologna University, Bologna, Italy
| | - Lorenza Marino
- Radiation Oncology Department, Humanitas Istituto Clinico Catanese, Misterbianco, Catania, Italy
| | - Costanza M. Donati
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic, and Specialty Medicine–DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy
| | - Rossella Di Franco
- Department of Radiation Oncology, Istituto Nazionale Tumori–IRCCS–Fondazione G. Pascale, Napoli, Italy
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Dibs K, Palmer JD, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Grecula J, Guiou M, Soghrati S, Tili E, Raval RR, Mendel E, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Blakaj DM. Feasibility, safety, and efficacy of circumferential spine stereotactic body radiotherapy. Front Oncol 2022; 12:912799. [PMID: 36505845 PMCID: PMC9727181 DOI: 10.3389/fonc.2022.912799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background With advances in systemic therapy translating to improved survival in metastatic malignancies, spine metastases have become an increasingly common source of morbidity. Achieving durable local control (LC) for patients with circumferential epidural disease can be particularly challenging. Circumferential stereotactic body radiotherapy (SBRT) may offer improved LC for circumferential vertebral and/or epidural metastatic spinal disease, but prospective (and retrospective) data are extremely limited. We sought to evaluate the feasibility, toxicity, and cancer control outcomes with this novel approach to circumferential spinal disease. Methods We retrospectively identified all circumferential SBRT courses delivered between 2013 and 2019 at a tertiary care institution for post-operative or intact spine metastases. Radiotherapy was delivered to 14-27.5 Gy in one to five fractions. Feasibility was assessed by determining the proportion of plans for which ≥95% planning target volume (PTV) was coverable by ≥95% prescription dose. The primary endpoint was 1-year LC. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity were assessed. Detailed dosimetric data were collected. Results Fifty-eight patients receiving 64 circumferential SBRT courses were identified (median age 61, KPS ≥70, 57% men). With a median follow-up of 15 months, the 12-month local control was 85% (eight events). Five and three recurrences were in the epidural space and bone, respectively. On multivariate analysis, increased PTV and uncontrolled systemic disease were significantly associated with an increased likelihood of LF; ≥95% PTV was covered by ≥95% prescription dose in 94% of the cases. The rate of new or progressive vertebral compression fracture was 8%. There were no myelitis events or any grade 3+ acute or late toxicities. Conclusions For patients with circumferential disease, circumferential spine SBRT is feasible and may offer excellent LC without significant toxicity. A prospective evaluation of this approach is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N. Prasad
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C. Bourekas
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S. Ayan
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S. Marras
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael Guiou
- Department of Radiation Oncology, Green Bay Oncology, Green Bay, WI, United States
| | - Soheil Soghrati
- Department of Mechanical and Aerospace Engineering at the Ohio State University, Columbus, OH, United States
| | - Esmerina Tili
- Department of Anesthesiology, Ohio State College of Medicine, Columbus, OH, United States
| | - Raju R. Raval
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James B. Elder
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Dukagjin M. Blakaj,
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Rühle A, Nya Yompang VA, Spohn SKB, Stoian R, Zamboglou C, Gkika E, Grosu AL, Nicolay NH, Sprave T. Palliative radiotherapy of bone metastases in octogenarians: How do the oldest olds respond? Results from a tertiary cancer center with 288 treated patients. Radiat Oncol 2022; 17:153. [PMID: 36071522 PMCID: PMC9450461 DOI: 10.1186/s13014-022-02122-2] [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: 07/08/2022] [Accepted: 08/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accompanied by the demographic change, the number of octogenarian cancer patients with bone metastases will increase in the future. Palliative radiotherapy constitutes an effective analgesic treatment; however, as pain perception and bone metabolism change with increasing age, the analgesic efficacy of radiotherapy may be altered in elderly patients. We therefore investigated the treatment outcomes of palliative radiotherapy for bone metastases in octogenarians. METHODS Patients between 80 and 89 years undergoing radiotherapy for bone metastases between 2009 and 2019 at a tertiary cancer center were analyzed for patterns-of-care, pain response and overall survival (OS). Logistic regression analyses were carried out to examine parameters associated with pain response, and Cox analyses were conducted to reveal prognostic parameters for OS. RESULTS A total of 288 patients with 516 irradiated lesions were included in the analysis. The majority (n = 249, 86%) completed all courses of radiotherapy. Radiotherapy led to pain reduction in 176 patients (61%) at the end of treatment. Complete pain relief at the first follow-up was achieved in 84 patients (29%). Bisphosphonate administration was significantly associated with higher rates of pain response at the first follow-up (p < 0.05). Median OS amounted to 9 months, and 1-year, 2-year and 3-year OS were 43%, 28% and 17%. In the multivariate analysis, ECOG (p < 0.001), Mizumoto score (p < 0.01) and Spinal Instability Neoplastic Score (SINS) (p < 0.001) were independent prognosticators for OS. CONCLUSION Palliative radiotherapy for bone metastases constitutes a feasible and effective analgesic treatment in octogenarian patients. ECOG, Mizumoto score and SINS are prognosic variables for survival and may aid treatment decisions regarding radiotherapy fractionation in this patient group. Single-fraction radiotherapy with 8 Gy should be applied for patients with uncomplicated bone metastases and poor prognosis. Prospective trials focusing on quality of life of these very old cancer patients with bone metastases are warranted to reveal the optimal radiotherapeutic management for this vulnerable population.
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Affiliation(s)
- Alexander Rühle
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Verlaine Ange Nya Yompang
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Simon K B Spohn
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Raluca Stoian
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany. .,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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7
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vanNiekerk W, Lazeroms T, Rogers S, Lomax N, Hälg R, Gajdos V, Özden I, Kessler E, Riesterer O. Optimized workflow to minimise intra-fractional motion during stereotactic body radiotherapy of spinal metastases. Tech Innov Patient Support Radiat Oncol 2022; 24:40-47. [PMID: 36203742 PMCID: PMC9530958 DOI: 10.1016/j.tipsro.2022.09.007] [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: 06/28/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022] Open
Abstract
More frequent mid-treatment image guidance improved accuracy of treatment delivery 97 % of treatment fractions showed an intra-fraction motion of less than 1 mm /1° using mid-arc image guidance Treatment delivery was optimized within a standard treatment timeslot without applying substantial additional radiation dose ExacTrac portal verifications during and between arcs to monitor and correct patient position, limits additional dose to the patient and OAR
Background and purpose This study evaluated translational and rotational intra-fractional patient movement during spinal stereotactic body radiotherapy (SBRT) using 6D positioning based on 3D cone beam computerized tomography (CBCT) and stereoscopic kilovoltage imaging (ExacTrac). The aim was to determine whether additional intra-fractional image verification reduced intra-fractional motion without significantly prolonging treatment time, whilst maintaining acceptable imaging related dose. Materials and methods A retrospective analysis of 38 patients with 41 primary tumour volumes treated with SBRT between September 2018 and May 2021 was performed. Three different image-guided radiotherapy (IGRT) workflows were assessed. The translational and rotational positioning errors for the different imaging workflows, 3D translational vectors and estimates of imaging dose delivered for the different imaging workflows were evaluated. Results As the frequency of intra-fractional imaging increased from workflow 1 to 3, the mean intra-fraction 3D translational vector improved from 0.91 mm (±0.52 mm), to 0.64 (±0.34 mm). 85 %, 83 % and 97 % of images were within a tolerance of 1 mm/1° for workflows 1, 2 and 3 respectively, based on post treatment CBCT images. The average treatment time for workflow 3 was 13 min, as compared to 12 min for workflows 1 and 2. The effective dose per treatment for IGRT workflows 1, 2 and 3 measured 0.6 mSv, 0.95 mSv and 1.8 mSv respectively. Conclusion The study demonstrated that the use of additional intra-fractional stereoscopic kilovoltage image-guidance during spinal SBRT, reduced the number of measurements deemed “out of tolerance” and treatment delivery could be optimized within a standard treatment timeslot without applying substantial additional radiation dose.
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Affiliation(s)
- W.M. vanNiekerk
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
- Corresponding author.
| | - T. Lazeroms
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
| | - S.J. Rogers
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
| | - N. Lomax
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
| | - R.A. Hälg
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
| | - V. Gajdos
- Klinik für Strahlentherapie und Radioonkologie, Universitätsspital Basel, Switzerland
| | - I. Özden
- Fachstelle Strahlenschutz, Kantonsspital Aarau, Switzerland
| | - E. Kessler
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
| | - O. Riesterer
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Switzerland
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8
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van der Velden J, Willmann J, Spałek M, Oldenburger E, Brown S, Kazmierska J, Andratschke N, Menten J, van der Linden Y, Hoskin P. ESTRO ACROP guidelines for external beam radiotherapy of patients with uncomplicated bone metastases. Radiother Oncol 2022; 173:197-206. [PMID: 35661676 DOI: 10.1016/j.radonc.2022.05.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/16/2022] [Accepted: 05/26/2022] [Indexed: 12/20/2022]
Abstract
After liver and lungs, bone is the third most common metastatic site (Nystrom et al., 1977). Almost all malignancies can metastasize to the skeleton but 80% of bone metastases originate from breast, prostate, lung, kidney and thyroid cancer (Mundy, 2002). Introduction of effective systemic treatment in many cancers has prolonged patients' survival, including those with bone metastases. Bone metastases may significantly reduce quality of life due to related symptoms and possible complications, such as pain and neurologic compromise. The most serious complications of bone metastases are skeletal-related events (SRE), defined as pathologic fracture, spinal cord compression, pain, or other symptoms requiring an urgent intervention such as surgery or radiotherapy. In turn, growing access to modern diagnostic tools allows early detection of asymptomatic bone metastases that could be successfully managed with local treatment avoiding development of SRE. The treatment for bone metastases should focus on relieving existing symptoms and preventing new ones. Radiotherapy is the standard of care for patients with symptomatic bone metastases, providing durable pain relief with minimal toxicity and reasonable cost-effectiveness. Historically, the dose was prescribed in one to five fractions and delivered using simple planning techniques. While 3D-conformal radiotherapy is still widely used for treating bone metastases, introduction of highlyconformal radiotherapy techniques such as stereotactic body radiotherapy (SBRT) have opened new therapeutic possibilities that should be considered in selected patients with bone metastases.
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Affiliation(s)
- Joanne van der Velden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht 3584 CX, Netherlands
| | - Jonas Willmann
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Mateusz Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Eva Oldenburger
- Department of Radiation Oncology, University Hospital Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Stephanie Brown
- Mount Vernon Cancer Centre, Northwood, UK and University of Manchester, United Kingdom
| | - Joanna Kazmierska
- Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland; Electroradiology Department, University of Medical Sciences, Poznan, Poland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Johan Menten
- Department of Radiation Oncology, University Hospital Leuven, Herestraat 49, B3000 Leuven, Belgium; Catholic University Leuven, B3000 Leuven, Belgium
| | - Yvette van der Linden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht 3584 CX, Netherlands
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, UK and University of Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, United Kingdom
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9
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Spałek MJ, Teterycz P, Borkowska A, Poleszczuk J, Rutkowski P. Stereotactic radiotherapy for soft tissue and bone sarcomas: real-world evidence. Ther Adv Med Oncol 2022; 14:17588359211070646. [PMID: 35186124 PMCID: PMC8848098 DOI: 10.1177/17588359211070646] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction: Selected patients with locally advanced or metastatic soft tissue and bone sarcomas (STBS) may benefit from intensive local treatment, such as stereotactic radiotherapy (SRT). This study aimed to summarize the utilization and outcomes of SRT in STBS and to identify predictive factors for progression and survival. Materials and methods: Consecutive patients with advanced STBS who underwent STBS in a sarcoma tertiary center were identified. We collected tumor- and treatment-related factors. Endpoints comprised time to local progression (TTLP), local progression-free survival (LPFS), time to progression, progression-free survival, and overall survival (OS). The Cox proportional-hazards model was used to identify prognostic factors. Results: We identified 141 patients who underwent 233 SRTs. Median follow-up was 21 months. Local and distant progression occurred after 19 and 163 SRTs, respectively. SRT for lung metastases was predictive for better TTLP and LPFS (hazard ratio, HR = 0.12, p = 0.007 and HR = 0.42, p = 0.002, respectively). Bone sarcoma (HR for TTLP = 3.18, p = 0.043; HR for LPFS = 1.99, p = 0.028) and lower administered dose (HR for TTLP = 0.98, p = 0.007; HR for LPFS = 0.99, p = 0.012) were predictive for worse TTLP and LPFS. SRT for oligometastases (HR = 0.46, p = 0.021) and lung metastases (HR = 0.55, p = 0.046) was predictive for better OS, whereas diagnosis of bone sarcoma (HR = 2.05, p = 0.029) was predictive for worse OS. Conclusion: SRT provides excellent local control in STBS patients without significant toxicity. Patients with oligometastatic disease, lung metastases, and soft tissue sarcomas benefit the most from SRT. The dose escalation moderately enhances local control; however, it does not translate into better survival.
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Affiliation(s)
- Mateusz Jacek Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Paweł Teterycz
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Department of Computational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Aneta Borkowska
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jan Poleszczuk
- Department of Computational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Polish Academy of Sciences, Nalecz Institute of Biocybernetics and Biomedical Engineering, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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10
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Gottumukkala S, Srivastava U, Brocklehurst S, Mendel JT, Kumar K, Yu FF, Agarwal A, Shah BR, Vira S, Raj KM. Fundamentals of Radiation Oncology for Treatment of Vertebral Metastases. Radiographics 2021; 41:2136-2156. [PMID: 34623944 DOI: 10.1148/rg.2021210052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The fields of both radiology and radiation oncology have evolved considerably in the past few decades, resulting in an increased ability to delineate between tumor and normal tissue to precisely target and treat vertebral metastases with radiation therapy. These scientific advances have also led to improvements in assessing treatment response and diagnosing toxic effects related to radiation treatment. However, despite technological innovations yielding greatly improved rates of palliative relief and local control of osseous spinal metastases, radiation therapy can still lead to a number of acute and delayed posttreatment complications. Treatment-related adverse effects may include pain flare, esophageal toxic effects, dermatitis, vertebral compression fracture, radiation myelopathy, and myositis, among others. The authors provide an overview of the multidisciplinary approach to the treatment of spinal metastases, indications for surgical management versus radiation therapy, various radiation technologies and techniques (along with their applications for spinal metastases), and current principles of treatment planning for conventional and stereotactic radiation treatment. Different radiologic criteria for assessment of treatment response, recent advances in radiologic imaging, and both common and rare complications related to spinal irradiation are also discussed, along with the imaging characteristics of various adverse effects. Familiarity with these topics will not only assist the diagnostic radiologist in assessing treatment response and diagnosing treatment-related complications but will also allow more effective collaboration between diagnostic radiologists and radiation oncologists to guide management decisions and ensure high-quality patient care. ©RSNA, 2021.
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Affiliation(s)
- Sujana Gottumukkala
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Udayan Srivastava
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Samantha Brocklehurst
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - J Travis Mendel
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Kiran Kumar
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Fang F Yu
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Amit Agarwal
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Bhavya R Shah
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Shaleen Vira
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
| | - Karuna M Raj
- From the Department of Radiation Oncology (S.G., S.B., K.K.), Department of Radiology (U.S., F.F.Y., A.A., B.R.S., K.M.R.), and Departments of Orthopaedic Surgery and Neurosurgery (S.V.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and Rio Grande Urology, El Paso, Tex (J.T.M.)
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11
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Blakaj DM, Palmer JD, Dibs K, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Katzir M, Yildiz VO, Grecula J, Arnett A, Raval R, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Mendel E. Postoperative Stereotactic Body Radiotherapy for Spinal Metastasis and Predictors of Local Control. Neurosurgery 2021; 88:1021-1027. [PMID: 33575784 DOI: 10.1093/neuros/nyaa587] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Spine surgery is indicated for select patients with mechanical instability, pain, and/or malignant epidural spinal cord compression, with or without neurological compromise. Stereotactic body radiotherapy (SBRT) is an option for durable local control (LC) for metastatic spine disease. OBJECTIVE To determine factors associated with LC and progression-free survival (PFS) for patients receiving postoperative stereotactic spine radiosurgery. METHODS We analyzed consecutive patients from 2013 to 2019 treated with surgical intervention followed by SBRT. Surgical interventions included laminectomy and vertebrectomy. SBRT included patients treated with 1 to 5 fractions of radiosurgery. We analyzed LC, PFS, overall survival (OS), and toxicity. Univariate and multivariate analyses were performed. RESULTS A total of 63 patients were treated with a median follow-up of 12.5 mo. Approximately 75% of patients underwent vertebrectomy and 25% underwent laminectomy. One-year cumulative incidence of local failure was 19%. LC was significantly improved for patients receiving radiosurgery ≤40 d from surgery compared to that for patients receiving radiosurgery ≥40 d from surgery, 94% vs 75%, respectively, at 1 yr (P = .03). Patients who received preoperative embolization had improved LC with 1-yr LC of 88% vs 76% for those who did not receive preoperative embolization (P = .037). Significant predictors for LC on multivariate analysis were time from surgery to radiosurgery, higher radiotherapy dose, and preoperative embolization. The 1-yr PFS and OS was 56% and 60%, respectively. CONCLUSION Postoperative radiosurgery has excellent and durable LC for spine metastasis. An important consideration when planning postoperative radiosurgery is minimizing delay from surgery to radiosurgery. Preoperative embolization and higher radiotherapy dose were associated with improved LC warranting further study.
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Affiliation(s)
- Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric C Bourekas
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - William S Marras
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Prasath Mageswaran
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Miki Katzir
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Vedat O Yildiz
- Center for Biostatistics, College of Medicine Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ehud Mendel
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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12
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Guckenberger M, Mantel F, Sweeney RA, Hawkins M, Belderbos J, Ahmed M, Andratschke N, Madani I, Flentje M. Long-Term Results of Dose-Intensified Fractionated Stereotactic Body Radiation Therapy (SBRT) for Painful Spinal Metastases. Int J Radiat Oncol Biol Phys 2021; 110:348-357. [PMID: 33412262 DOI: 10.1016/j.ijrobp.2020.12.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 12/16/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To report long-term outcome of fractionated stereotactic body radiation therapy (SBRT) for painful spinal metastases. METHODS AND MATERIALS This prospective, single-arm, multicenter phase 2 clinical trial enrolled 57 patients with 63 painful, unirradiated spinal metastases between March 2012 and July 2015. Patients were treated with 48.5 Gy in 10 SBRT fractions (long life expectancy [Mizumoto score ≤4]) or 35 Gy in 5 SBRT fractions (intermediate life expectancy [Mizumoto score 5-9]). Pain response was defined as pain improvement of a minimum of 2 points on a visual analog scale, and net pain relief was defined as the sum of time with pain response (complete and partial) divided by the overall follow-up time. RESULTS All 57 patients received treatment per protocol; 32 and 25 patients were treated with 10- and 5-fraction SBRT, respectively. The median follow-up of living patients was 60 months (range, 33-74 months). Of evaluable patients, 82% had complete or partial pain response (responders) at 3 months' follow-up (primary endpoint), and pain response remained stable over 5 years. Net pain relief was 74% (95% CI, 65%-80%). Overall survival rates of 1, 3, and 5 years were 59.6% (95% CI, 47%-72%), 33.3% (95% CI, 21%-46%), and 21% (95% CI, 10%-32%), respectively. Freedom from local spinal-metastasis progression was 82% at the last imaging follow-up. Late grade-3 toxicity was limited to pain in 2 patients (nonresponders). There were no cases of myelopathy. SBRT resulted in long-term improvements of all dimensions of the 5-level EuroQol 5-Dimension Questionnaire except anxiety/depression. CONCLUSIONS Fractionated SBRT achieved durable pain response and improved quality of life at minimum late toxicity.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Frederick Mantel
- Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Reinhart A Sweeney
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Maria Hawkins
- Medical Physics and Biomedical Engineering, University College London, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Merina Ahmed
- Department of Radiation Therapy, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Sutton, United Kingdom
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Indira Madani
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany
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13
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Glicksman RM, Tjong MC, Neves-Junior WFP, Spratt DE, Chua KLM, Mansouri A, Chua MLK, Berlin A, Winter JD, Dahele M, Slotman BJ, Bilsky M, Shultz DB, Maldaun M, Szerlip N, Lo SS, Yamada Y, Vera-Badillo FE, Marta GN, Moraes FY. Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases: A Review. JAMA Oncol 2020; 6:567-577. [PMID: 31895403 DOI: 10.1001/jamaoncol.2019.5351] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Rising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application. Objective To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies. Evidence Review The MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases. Results Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease. Conclusions and Relevance These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.
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Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Kevin L M Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Mark Bilsky
- Department of Neurosurgery, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcos Maldaun
- Division of Neurosurgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Yoshiya Yamada
- Department of Radiation Oncology, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.,Division of Radiation Oncology, Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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Chen X, Gui C, Grimm J, Huang E, Kleinberg L, Lo L, Sciubba D, Khan M, Redmond KJ. Normal tissue complication probability of vertebral compression fracture after stereotactic body radiotherapy for de novo spine metastasis. Radiother Oncol 2020; 150:142-149. [PMID: 32540335 DOI: 10.1016/j.radonc.2020.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/27/2020] [Accepted: 06/07/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Stereotactic body radiotherapy (SBRT) for spine metastases is associated with post-treatment vertebral compression fracture (VCF). The purpose of this study is to identify clinical and radiation planning characteristics that predict post-SBRT VCF through a novel normal tissue complication probability (NTCP) analysis. METHODS Patients with de novo spine metastases treated with SBRT between 2009 and 2018 at a single institution were included. Those who had surgical stabilization or radiation to the same site prior to SBRT were excluded. VCF was defined as new development or progression of existing vertebral body height loss not attributable to tumor growth. Probit NTCP models were constructed and fitted using a maximum likelihood approach. A multivariate proportional hazard model was used to estimate time to VCF using the Fine and Gray method. RESULTS Three hundred and two vertebral segments from 193 patients were treated with a median dose of 24 Gy in 3 fractions (range 15-30 Gy in 1-5 fractions). With a median follow up of 13.9 months, local control was 89.3% at 1 year. A total of 26 SBRT-induced VCFs were observed, with 1 and 2-year cumulative incidences of 4.6% and 6.7%. NTCP modeling demonstrated a steep response of VCF risk to the dose to 80% and 50% volume of the planning target volume (PTV D80% and D50%), but not maximum dose or dose to 1 cc or 10% of PTV. D80% of 25 Gy and D50% of 28 Gy in 3 fractions corresponded to 10% VCF risk. On multivariate analysis, lower body mass index (HR 0.90 per unit increase, p = 0.04), total spinal instability neoplastic score (SINS, HR 2.44 unstable vs stable, p = 0.04), and PTV D80% (HR 1.11 for every Gy increase, p = 0.003) were associated with increased VCF risk. CONCLUSIONS SBRT provides excellent tumor control for spinal metastases and is associated with low rate of VCF in our cohort. NTCP modeling suggests that the larger volume of spine receiving lower doses are more closely associated with post-SBRT VCF than high dose regions. Under current target delineation methods, common SBRT regimens such as 24 Gy in 2 fractions or 27 Gy in 3 fractions may be inherently associated with VCF risk of 10% or greater. Consensus contouring guidelines should be reevaluated to minimize the volume of irradiated spine in light of these new data.
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Affiliation(s)
- Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Jimm Grimm
- Department Radiation Oncology, Geisinger Health System, Danville, United States
| | - Ellen Huang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Larry Lo
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Daniel Sciubba
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Majid Khan
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, United States.
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15
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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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16
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Mantel F, Sweeney RA, Klement RJ, Hawkins MA, Belderbos J, Ahmed M, Toussaint A, Polat B, Flentje M, Guckenberger M. Risk factors for vertebral compression fracture after spine stereotactic body radiation therapy: Long-term results of a prospective phase 2 study. Radiother Oncol 2019; 141:62-66. [PMID: 31526672 DOI: 10.1016/j.radonc.2019.08.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify frequency, clinical relevance and risk factors for vertebral compression fracture (VCF) after spine stereotactic body radiation therapy (SBRT) with long-term follow up (FU). METHODS From 2012 to 2015, 61 lesions (56 patients) were treated within a prospective multicenter phase 2 study (NCT01594892) of SBRT for painful vertebral metastases. Post-SBRT VCF were identified. Anatomical segments, normal and tumor tissue of treated vertebrae were segmented for volumetric analyses. Predictive factors for VCF were identified by logistic regression. RESULTS Median clinical and radiological FU for all patients was 16.2 months (range, 0-68.2) and 7.8 months (range, 0-66.9), respectively. Local metastasis control was observed in 82% of lesions at last imaging FU. Post-SBRT VCF occurred in 21 lesions (34.4%): 16.4% showed a progressive VCF, while a new VCF occurred in 18.0%. 3/56 (5.4%) patients developed painful VCF defined as pain increase by ≥2 on the visual analogue scale (VAS) and 2 (3.6%) patients required surgical stabilization. Pre-SBRT VCF, localization in the thoracic spine, Bilsky score >0, SINS score, pre-SBRT osteolytic volume and metastatic vertebral body (VB) involvement were predictive factors for VCF on univariate analysis. Relative VB involvement, osteolytic volume and pre-SBRT VCF remained in the multivariate logistic regression model that had AUC = 0.930, 83.3% sensitivity and 96.6% specificity. CONCLUSION Spine SBRT resulted in favorable long-term pain and local metastasis control. Despite post-SBRT VCF being observed after one third of treatments, this was symptomatic in only 5% of patients. Predictive factors for developing VCF were identified which could contribute to better selection of patients for spine SBRT.
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Affiliation(s)
- Frederick Mantel
- Department of Radiation Oncology, University Hospital Wuerzburg, Germany.
| | - Reinhart A Sweeney
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, Germany
| | - Rainer J Klement
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, Germany
| | - Maria A Hawkins
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, United Kingdom
| | - Jose Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Merina Ahmed
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Sutton, United Kingdom
| | - André Toussaint
- Department of Radiation Oncology, University Hospital Wuerzburg, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Wuerzburg, Germany
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Wuerzburg, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Wuerzburg, Germany; Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
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17
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Guckenberger M, Sweeney RA, Hawkins M, Belderbos J, Andratschke N, Ahmed M, Madani I, Mantel F, Steigerwald S, Flentje M. Dose-intensified hypofractionated stereotactic body radiation therapy for painful spinal metastases: Results of a phase 2 study. Cancer 2018; 124:2001-2009. [DOI: 10.1002/cncr.31294] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/11/2017] [Accepted: 01/05/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | - Reinhart A. Sweeney
- Department of Radiation Oncology; Leopoldina Hospital Schweinfurt; Schweinfurt Germany
| | - Maria Hawkins
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories; University of Oxford; Oxford United Kingdom
| | - Jose Belderbos
- Department of Radiation Oncology; Netherlands Cancer Institute; Amsterdam the Netherlands
| | - Nicolaus Andratschke
- Department of Radiation Oncology; University Hospital Zurich; Zurich Switzerland
| | - Merina Ahmed
- Department of Radiotherapy; Royal Marsden NHS Foundation Trust/Institute of Cancer Research; Sutton United Kingdom
| | - Indira Madani
- Department of Radiation Oncology; University Hospital Zurich; Zurich Switzerland
| | - Frederick Mantel
- Department of Radiation Oncology; University Hospital Würzburg; Würzburg Germany
| | - Sabrina Steigerwald
- Department of Radiation Oncology; University Hospital Würzburg; Würzburg Germany
| | - Michael Flentje
- Department of Radiation Oncology; University Hospital Würzburg; Würzburg Germany
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18
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Yang H, Cai BN, Wang XS, Cong XH, Xu W, Wang JY, Yang J, Xu SP, Ju ZJ, Ma L. Dose Evaluation of Fractionated Schema and Distance From Tumor to Spinal Cord for Spinal SBRT with Simultaneous Integrated Boost: A Preliminary Study. Med Sci Monit 2016; 22:598-607. [PMID: 26902177 PMCID: PMC4767138 DOI: 10.12659/msm.897146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/28/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study investigated and quantified the dosimetric impact of the distance from the tumor to the spinal cord and fractionation schemes for patients who received stereotactic body radiation therapy (SBRT) and hypofractionated simultaneous integrated boost (HF-SIB). MATERIAL AND METHODS Six modified planning target volumes (PTVs) for 5 patients with spinal metastases were created by artificial uniform extension in the region of PTV adjacent spinal cord with a specified minimum tumor to cord distance (0-5 mm). The prescription dose (biologic equivalent dose, BED) was 70 Gy in different fractionation schemes (1, 3, 5, and 10 fractions). For PTV V100, Dmin, D98, D95, and D1, spinal cord dose, conformity index (CI), V30 were measured and compared. RESULTS PTV-to-cord distance influenced PTV V100, Dmin, D98, and D95, and fractionation schemes influenced Dmin and D98, with a significant difference. Distances of ≥2 mm, ≥1 mm, ≥1 mm, and ≥0 mm from PTV to spinal cord meet dose requirements in 1, 3, 5, and 10 fractionations, respectively. Spinal cord dose, CI, and V30 were not impacted by PTV-to-cord distance and fractionation schemes. CONCLUSIONS Target volume coverage, Dmin, D98, and D95 were directly correlated with distance from the spinal cord for spine SBRT and HF-SIB. Based on our study, ≥2 mm, ≥1 mm, ≥1 mm, and ≥0 mm distance from PTV to spinal cord meets dose requirements in 1, 3, 5 and 10 fractionations, respectively.
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Affiliation(s)
- Hao Yang
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
- Department of Radiation Oncology, Inner Mongolia Cancer Hospital and The Affiliated People’s Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, P.R. China
| | - Bo-ning Cai
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Xiao-shen Wang
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Xiao-hu Cong
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Wei Xu
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Jin-yuan Wang
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Jun Yang
- Department of Oncology, First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, P.R. China
| | - Shou-ping Xu
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Zhong-jian Ju
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
| | - Lin Ma
- Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, P.R. China
- Department of Radiation Oncology, Hainan Branch of Chinese PLA General Hospital, Haitang Bay, Sanya, Hainan, P.R. China
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19
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Evaluation of efficacy and safety of robotic stereotactic body radiosurgery and hypofractionated stereotactic radiotherapy for vertebral metastases. Contemp Oncol (Pozn) 2015; 19:327-32. [PMID: 26557782 PMCID: PMC4631299 DOI: 10.5114/wo.2015.53371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/15/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022] Open
Abstract
Aim of the study The purpose of this study was to evaluate the efficacy and safety of applying CyberKnife (CK) radiosurgery in patients with spinal metastases. Material and methods Twenty-eight patients with vertebral metastases treated using the CK system were included in the study. Eleven patients suffered from pain, and in 1 case neurological symptoms were observed. The remaining patients were free from clinical symptoms of metastatic disease. The doses applied ranged between 8 and 40 Gy delivered in 4 fractions of 8–15 Gy. Results In the first follow-up evaluation (mean 4.5 months after the treatment), pain was stable in 5 of 8 evaluable cases and in 3 regression occurred. The last follow-up examination (mean 11 months after stereotactic radiosurgery) revealed stable ailments in 3 of 6 evaluable cases, improvement in 3 and new complaints in another 4 patients. In 17 patients imaging studies were conducted after a mean time of 11 months after CK treatment. Stabilization was confirmed in 11, regression in 4 and progression in 2 cases. Median overall survival was 20.6 months. Median progression-free survival was 12.6 months. No side effects attributable to the treatment were observed, but during follow-up transient or permanent deterioration in neurological status as a consequence of disease progression was diagnosed in 4 patients. Delivery time of a single fraction ranged between 0.5 and 1.5 hours. Conclusions Robotic stereotactic radiosurgery as part of multimodality therapy for metastatic spinal tumours is safe and effective. Because of long irradiation times, this kind of treatment is not suitable for patients in poor general condition.
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20
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Lubgan D, Ziegaus A, Semrau S, Lambrecht U, Lettmaier S, Fietkau R. Effective local control of vertebral metastases by simultaneous integrated boost radiotherapy: preliminary results. Strahlenther Onkol 2014; 191:264-71. [PMID: 25395089 DOI: 10.1007/s00066-014-0780-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/30/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND The primary endpoint was to improve local tumour control of patients with metastatic spinal tumours by stereotactic body radiotherapy (SBRT) and dose escalation by simultaneous, integrated boost (PTV-boost). We used a whole vertebral body (PTV-elective) contouring approach. Secondary endpoints were severity of acute and chronic adverse effects and overall survival. METHODS In all, 33 patients with metastases of the vertebral column were treated at Erlangen University Hospital. SBRT was given in 12 or 10 fractions. The metastatic lesion (PTV-boost) received 3.6 Gy (range 3.0-4.51 Gy) per fraction for a total of 42.0 Gy (24.36-48.0 Gy) and the whole vertebra (PTV-elective) received 2.85 Gy (range 1.8-3.6 Gy) per fraction for a total of 32.39 Gy (range 21.60-38.0 Gy). Patients were followed up every 3 months. RESULTS Local control rate of all patients was 93% at 12 and 24 months. The overall survival rate was 54% at 12 months, 38% at 24 months and 18% at 36 months. No radiation myelopathy occurred. The most frequently observed adverse events in 3 cases was oesophagitis grade 2. CONCLUSION SBRT with simultaneous, integrated boost was associated with excellent local control of 93% after 24 months. This result shows the possibility of delivering escalated doses to the target while still keeping the incidence of side effects low. This study forms the basis for a future randomised controlled trial comparing conventional radiotherapy (10 fractions of 3 Gy) with hypofractionated dose intensified SBRT (12 fractions of 3 Gy + integrated boost 12 fractions of 4 Gy) for improvement of local tumour control and pain.
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Affiliation(s)
- Dorota Lubgan
- Department of Radiation Oncology, Erlangen University Hospital, Universitätsstraße 27, 91054, Erlangen, Germany,
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21
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Reproducibility of the MRI-defined spinal cord position in stereotactic radiotherapy for spinal oligometastases. Radiother Oncol 2014; 113:230-4. [DOI: 10.1016/j.radonc.2014.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 09/30/2014] [Accepted: 11/01/2014] [Indexed: 12/25/2022]
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22
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Gröger C, Hautmann MG, Loeschel R, Repp N, Kölbl O, Dobler B. Re-irradiation of spinal column metastases by IMRT: impact of setup errors on the dose distribution. Radiat Oncol 2013; 8:269. [PMID: 24238332 PMCID: PMC3842751 DOI: 10.1186/1748-717x-8-269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 11/03/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study investigates the impact of an automated image guided patient setup correction on the dose distribution for ten patients with in-field IMRT re-irradiation of vertebral metastases. METHODS 10 patients with spinal column metastases who had previously been treated with 3D-conformal radiotherapy (3D-CRT) were simulated to have an in-field recurrence. IMRT plans were generated for treatment of the vertebrae sparing the spinal cord. The dose distributions were compared for a patient setup based on skin marks only and a Cone Beam CT (CBCT) based setup with translational and rotational couch corrections using an automatic robotic image guided couch top (Elekta - HexaPOD™ IGuide® - system). The biological equivalent dose (BED) was calculated to evaluate and rank the effects of the automatic setup correction for the dose distribution of CTV and spinal cord. RESULTS The mean absolute value (± standard deviation) over all patients and fractions of the translational error is 6.1 mm (±4 mm) and 2.7° (±1.1 mm) for the rotational error. The dose coverage of the 95% isodose for the CTV is considerable decreased for the uncorrected table setup. This is associated with an increasing of the spinal cord dose above the tolerance dose. CONCLUSIONS An automatic image guided table correction ensures the delivery of accurate dose distribution and reduces the risk of radiation induced myelopathy.
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Affiliation(s)
- Christian Gröger
- Department of Radiotherapy, University Medical Center, Regensburg, Germany.
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23
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Rolle der Strahlentherapie bei strahlensensiblen und strahlenresistenteren Knochentumoren. DER ONKOLOGE 2013. [DOI: 10.1007/s00761-013-2513-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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