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Patel PP, Esposito EP, Zhu J, Chen X, Khan M, Kleinberg L, Lubelski D, Theodore N, Lo SFL, Hun Lee S, Kebaish K, Bydon A, Redmond KJ. Antiresorptive Medications Prior to Stereotactic Body Radiotherapy for Spinal Metastasis are Associated with Reduced Incidence of Vertebral Body Compression Fracture. Global Spine J 2024; 14:1778-1785. [PMID: 36749660 DOI: 10.1177/21925682231156394] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVE Antiresorptive drugs are often given to minimize fracture risk for bone metastases, but data regarding optimal time or ability to reduce stereotactic body radiotherapy (SBRT)-induced fracture risk is limited. This study examines the association between antiresorptive use surrounding spinal SBRT and vertebral compression fracture (VCF) incidence to provide information regarding effectiveness and optimal timing of use. METHODS Patients treated with SBRT for spinal metastases at a single institution between 2009-2020 were included. Kaplan-Meier analysis was used to compare cumulative incidence of VCF for those taking antiresorptive drugs pre-SBRT, post-SBRT only, and none at all. Cox proportional hazards and Fine-Gray competing risk models were used to identify additional factors associated with VCF. RESULTS Of the 234 patients (410 vertebrae) analyzed, 49 (20.9%) were taking bisphosphonates alone, 42 (17.9%) were taking denosumab alone, and 25 (10.7%) were taking both. Kaplan-Meier analysis revealed a statistically significant lower VCF incidence for patients initiating antiresorptive drugs before SBRT compared to those taking none at all (4% vs 12% at 1 year post-SBRT, P = .045; and 4% vs 23% at 2 years, P = .008). On multivariate analysis, denosumab duration (HR: .87, P = .378) or dose (HR: 1.00, P = .644) as well as bisphosphonate duration (HR: .98, P= .739) or dose (HR: .99, P= .741) did not have statistical significance on VCF incidence. CONCLUSION Initiating antiresorptive agents before SBRT may reduce the risk of treatment-induced VCF. Antiresorptive drugs are underutilized in patients with spine metastases and may represent a useful intervention to minimize toxicity and improve long-term outcomes.
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Affiliation(s)
- Palak P Patel
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Edward P Esposito
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jiafeng Zhu
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Majid Khan
- Department of Radiology, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hoftstra, Manhasset, NY, USA
| | - Sang Hun Lee
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ali Bydon
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Chen Y, Qin S, Zhao W, Wang Q, Liu K, Xin P, Yuan H, Zhuang H, Lang N. MRI feature-based radiomics models to predict treatment outcome after stereotactic body radiotherapy for spinal metastases. Insights Imaging 2023; 14:169. [PMID: 37817044 PMCID: PMC10564690 DOI: 10.1186/s13244-023-01523-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023] Open
Abstract
OBJECTIVE This study aimed to extract radiomics features from MRI using machine learning (ML) algorithms and integrate them with clinical features to build response prediction models for patients with spinal metastases undergoing stereotactic body radiotherapy (SBRT). METHODS Patients with spinal metastases who were treated using SBRT at our hospital between July 2018 and April 2023 were recruited. We assessed their response to treatment using the revised Response Evaluation Criteria in Solid Tumors (version 1.1). The lesions were categorized into progressive disease (PD) and non-PD groups. Radiomics features were extracted from T1-weighted image (T1WI), T2-weighted image (T2WI), and fat-suppression T2WI sequences. Feature selection involved intraclass correlation coefficients, minimal-redundancy-maximal-relevance, and least absolute shrinkage and selection operator methods. Thirteen ML algorithms were employed to construct the radiomics prediction models. Clinical, conventional imaging, and radiomics features were integrated to develop combined models. Model performance was evaluated using receiver operating characteristic (ROC) curve analysis, and the clinical value was assessed using decision curve analysis. RESULTS We included 194 patients with 142 (73.2%) lesions in the non-PD group and 52 (26.8%) in the PD group. Each region of interest generated 2264 features. The clinical model exhibited a moderate predictive value (area under the ROC curve, AUC = 0.733), while the radiomics models demonstrated better performance (AUC = 0.745-0.825). The combined model achieved the best performance (AUC = 0.828). CONCLUSION The MRI-based radiomics models exhibited valuable predictive capability for treatment outcomes in patients with spinal metastases undergoing SBRT. CRITICAL RELEVANCE STATEMENT Radiomics prediction models have the potential to contribute to clinical decision-making and improve the prognosis of patients with spinal metastases undergoing SBRT. KEY POINTS • Stereotactic body radiotherapy effectively delivers high doses of radiation to treat spinal metastases. • Accurate prediction of treatment outcomes has crucial clinical significance. • MRI-based radiomics models demonstrated good performance to predict treatment outcomes.
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Affiliation(s)
- Yongye Chen
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Siyuan Qin
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Weili Zhao
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Qizheng Wang
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Ke Liu
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Peijin Xin
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Hongqing Zhuang
- Department of radiotherapy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Ning Lang
- Department of Radiology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
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Predictive model based on DCE-MRI and clinical features for the evaluation of pain response after stereotactic body radiotherapy in patients with spinal metastases. Eur Radiol 2023:10.1007/s00330-023-09437-y. [PMID: 36735042 DOI: 10.1007/s00330-023-09437-y] [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: 10/03/2022] [Revised: 12/12/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the correlation of conventional MRI, DCE-MRI and clinical features with pain response after stereotactic body radiotherapy (SBRT) in patients with spinal metastases and establish a pain response prediction model. METHODS Patients with spinal metastases who received SBRT in our hospital from July 2018 to April 2022 consecutively were enrolled. All patients underwent conventional MRI and DCE-MRI before treatment. Pain was assessed before treatment and in the third month after treatment, and the patients were divided into pain-response and no-pain-response groups. A multivariate logistic regression model was constructed to obtain the odds ratio and 95% confidence interval (CI) for each variable. C-index was used to evaluate the model's discrimination performance. RESULTS Overall, 112 independent spinal lesions in 89 patients were included. There were 73 (65.2%) and 39 (34.8%) lesions in the pain-response and no-pain-response groups, respectively. Multivariate analysis showed that the number of treated lesions, pretreatment pain score, Karnofsky performance status score, Bilsky grade, and the DCE-MRI quantitative parameter Ktrans were independent predictors of post-SBRT pain response in patients with spinal metastases. The discrimination performance of the prediction model was good; the C index was 0.806 (95% CI: 0.721-0.891), and the corrected C-index was 0.754. CONCLUSION Some imaging and clinical features correlated with post-SBRT pain response in patients with spinal metastases. The model based on these characteristics has a good predictive value and can provide valuable information for clinical decision-making. KEY POINTS • SBRT can accurately irradiate spinal metastases with ablative doses. • Predicting the post-SBRT pain response has important clinical implications. • The prediction models established based on clinical and MRI features have good performance.
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Chen X, LeCompte MC, Gui C, Huang E, Khan MA, Hu C, Sciubba DM, Kleinberg LR, Lo SFL, Redmond KJ. Deviation from consensus contouring guidelines predicts inferior local control after spine stereotactic body radiotherapy. Radiother Oncol 2022; 173:215-222. [PMID: 35667571 DOI: 10.1016/j.radonc.2022.05.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE To analyze the impact of target delineation on local control (LC) after stereotactic body radiotherapy (SBRT) for spine metastasis. MATERIALS AND METHODS Patients with de novo metastasis of the spine treated with SBRT, excluding those with prostate or hematologic malignancies, were retrospectively reviewed. Deviations from consensus contouring guidelines included incomplete coverage of involved vertebral compartments, omission of adjacent compartments, or unnecessary circumferential coverage. Univariable and multivariable Cox proportional hazard analyses were performed using death as a competing risk. RESULTS 283 patients with 360 discrete lesions were included with a median follow up of 14.6 months (range 1.2-131.3). The prescription dose was 24-27Gy in 2-3 fractions for the majority of lesions. Median survival after SBRT was 18.3 months (95% confidence interval [CI]: 14.8-22.8). The 1 and 2-year LC rates were 81.1% (95% CI: 75.5-85.6%) and 70.6% (95% CI: 63.2-76.8%), respectively. In total, 60 deviations (16.7%) from consensus contouring guidelines were identified. Deviation from guidelines was associated with inferior LC (1-year LC 63.0% vs 85.5%, p<0.001). GI primary, epidural extension, and paraspinal extension were all associated with inferior LC on univariable analyses. After adjusting for confounding factors, deviation from guidelines was the strongest predictor of inferior LC (HR 3.52, 95% CI: 2.11-5.86, p<0.001). Among guideline-compliant treatments, progressions were mainly in field (61%) and/or epidural (49%), while marginal (42%) and/or epidural progressions (58%) were most common for those with deviations. CONCLUSIONS Adherence to consensus contouring guidelines for spine SBRT is associated with superior LC and fewer marginal misses.
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Affiliation(s)
- Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael C LeCompte
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chengcheng Gui
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ellen Huang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Majid A Khan
- Department of Radiology, Thomas Jefferson University. Philadelphia, PA, United States
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital. Manhasset, NY, United States
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital. Manhasset, NY, United States
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Guo L, Ke L, Zeng Z, Yuan C, Wu Z, Chen L, Lu L. Stereotactic body radiotherapy for spinal metastases: a review. Med Oncol 2022; 39:103. [DOI: 10.1007/s12032-021-01613-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023]
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Sciubba DM, Pennington Z, Colman MW, Goodwin CR, Laufer I, Patt JC, Redmond KJ, Saylor P, Shin JH, Schwab JH, Schoenfeld AJ. Spinal metastases 2021: a review of the current state of the art and future directions. Spine J 2021; 21:1414-1429. [PMID: 33887454 DOI: 10.1016/j.spinee.2021.04.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 02/03/2023]
Abstract
Spinal metastases are an increasing societal health burden secondary to improvements in systemic therapy. Estimates indicate that 100,000 or more people have symptomatic spine metastases requiring management. While open surgery and external beam radiotherapy have been the pillars of treatment, there is growing interest in more minimally invasive technologies (eg separation surgery) and non-operative interventions (eg percutaneous cementoplasty, stereotactic radiosurgery). The great expansion of these alternatives to open surgery and the prevalence of adjuvant therapeutic options means that treatment decision making is now complex and reliant upon multidisciplinary collaboration. To help facilitate construction of care plans that meet patient goals and expectations, clinical decision aids and prognostic scores have been developed. These have been shown to have superior predictive value relative to more classic prediction models and may become an increasingly important aspect of the clinical practice of spinal oncology. Here we overview current therapeutic advances in the management of spine metastases and highlight emerging areas for research. Given the rapid advancements in surgical technologies and adjuvants, the field is likely to undergo further transformative changes in the coming decade.
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Affiliation(s)
- Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA.
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Matthew W Colman
- Department of Orthopaedic Surgery, Rush University School of Medicine, Chicago, IL USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Ilya Laufer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Joshua C Patt
- Department of Orthopaedic Surgery, Atrium Musculoskeletal Institute, Levine Cancer Institute, Carolinas Medical Center - Atrium Health, Charlotte, NC 28204, USA
| | - Kristin J Redmond
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Philip Saylor
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard medical School, Boston, MD 02115, USA
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Electron beam intraoperative radiotherapy for metastatic epidural spinal cord compression: a prospective observational study. Clin Exp Metastasis 2021; 38:219-225. [PMID: 33629217 DOI: 10.1007/s10585-021-10078-y] [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: 10/06/2020] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
To assess the additional effects of intraoperative radiotherapy (IORT) with decompression surgery and adjuvant external beam radiotherapy (EBRT) for metastatic epidural spinal cord compression (MESCC). This single-arm institutional prospective observational study recruited patients between June 2017 and March 2020 and included those with symptoms of spinal cord compression owing to metastases, who were diagnosed using MRI. Patients with radiation-sensitive primary tumors and those who could not tolerate surgery were excluded. The treatment protocol comprised decompression surgery and electron beam IORT of 20 Gy in a single fraction followed by EBRT of 30 Gy in 10 fractions. The primary endpoints included the 1-year local failure rate and ambulatory functions. The study was closed in May 2019 owing to changes in treatment policies at our institution. Twenty patients were registered between June 2017 and May 2019. Although all patients completed surgery and IORT, 2 did not receive postoperative EBRT. Patients most commonly had colorectal cancer (4 patients), followed by thyroid cancer, renal cell carcinoma, lung cancer, breast cancer, sarcomas, and other cancers (3, 3, 2, 2, 2, and 4 patients, respectively). The median follow-up duration was 16 months (range 2-30 months); the 1-year local failure rate was 16%. On comparing ambulatory functions pre-treatment and at 1 year after treatment, improvement, no change, and worsening were observed in 3, 9, and 0 patients, respectively. This study's findings suggest that decompression surgery and IORT followed by EBRT are effective in achieving local control and maintaining ambulation in patients with MESCC.
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Vargas E, Susko MS, Mummaneni PV, Braunstein SE, Chou D. Vertebral body fracture rates after stereotactic body radiation therapy compared with external-beam radiation therapy for metastatic spine tumors. J Neurosurg Spine 2020; 33:870-876. [PMID: 32796141 DOI: 10.3171/2020.5.spine191383] [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: 12/01/2019] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic body radiation therapy (SBRT) is utilized to deliver highly conformal, dose-escalated radiation to a target while sparing surrounding normal structures. Spinal SBRT can allow for durable local control and palliation of disease while minimizing the risk of damage to the spinal cord; however, spinal SBRT has been associated with an increased risk of vertebral body fractures. This study sought to compare the fracture rates between SBRT and conventionally fractionated external-beam radiation therapy (EBRT) in patients with metastatic spine tumors. METHODS Records from patients treated at the University of California, San Francisco, with radiation therapy for metastatic spine tumors were retrospectively reviewed. Vertebral body fracture and local control rates were compared between SBRT and EBRT. Ninety-six and 213 patients were identified in the SBRT and EBRT groups, respectively. Multivariate analysis identified the need to control for primary tumor histology (p = 0.003 for prostate cancer, p = 0.0496 for renal cell carcinoma). The patient-matched EBRT comparison group was created by matching SBRT cases using propensity scores for potential confounders, including the Spinal Instability Neoplastic Score (SINS), the number and location of spine levels treated, sex, age at treatment, duration of follow-up (in months) after treatment, and primary tumor histology. Covariate balance following group matching was confirmed using the Student t-test for unequal variance. Statistical analysis, including propensity score matching and multivariate analysis, was performed using R software and related packages. RESULTS A total of 90 patients met inclusion criteria, with 45 SBRT and 45 EBRT matched cases. Balance of the covariates, SINS, age, follow-up time, and primary tumor histology after the matching process was confirmed between groups (p = 0.062, p = 0.174, and 0.991, respectively, along with matched tumor histology). The SBRT group had a higher 5-year rate of vertebral body fracture at 22.22% (n = 10) compared with 6.67% (n = 3) in the EBRT group (p = 0.044). Survival analysis was used to adjust for uneven follow-up time and showed a significant difference in fracture rates between the two groups (p = 0.044). SBRT also was associated with a higher rate of local control (86.67% vs 77.78%). CONCLUSIONS Patients with metastatic cancer undergoing SBRT had higher rates of vertebral body fractures compared with patients undergoing EBRT, and this difference held up after survival analysis. SBRT also had higher rates of initial local control than EBRT but this difference did not hold up after survival analysis, most likely because of a high percentage of radiosensitive tumors in the EBRT cohort.
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Affiliation(s)
- Enrique Vargas
- Departments of1Neurosurgery and
- 3School of Medicine, University of California, San Francisco, California
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Rothrock RJ, Li Y, Lis E, Lobaugh S, Zhang Z, McCann P, Santos PMG, Yang TJ, Laufer I, Bilsky MH, Schmitt A, Yamada Y, Higginson DS. Hypofractionated spinal stereotactic body radiation therapy for high-grade epidural disease. J Neurosurg Spine 2020; 33:680-687. [PMID: 32707555 DOI: 10.3171/2020.4.spine20118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To characterize the clinical outcomes when stereotactic body radiation therapy (SBRT) alone is used to treat high-grade epidural disease without prior surgical decompression, the authors conducted a retrospective cohort study of patients treated at the Memorial Sloan Kettering Cancer Center between 2014 and 2018. The authors report locoregional failure (LRF) for a cohort of 31 cases treated with hypofractionated SBRT alone for grade 2 epidural spinal cord compression (ESCC) with radioresistant primary cancer histology. METHODS High-grade epidural disease was defined as grade 2 ESCC, which is notable for radiographic deformation of the spinal cord by metastatic disease. Kaplan-Meier survival curves and cumulative incidence functions were generated to examine the survival and incidence experiences of the sample level with respect to overall survival, LRF, and subsequent requirement of vertebral same-level surgery (SLS) due to tumor progression or fracture. Associations with dosimetric analysis were also examined. RESULTS Twenty-nine patients undergoing 31 episodes of hypofractionated SBRT alone for grade 2 ESCC between 2014 and 2018 were identified. The 1-year and 2-year cumulative incidences of LRF were 10.4% (95% CI 0-21.9) and 22.0% (95% CI 5.5-38.4), respectively. The median survival was 9.81 months (95% CI 8.12-18.54). The 1-year cumulative incidence of SLS was 6.8% (95% CI 0-16.0) and the 2-year incidence of SLS was 14.5% (95% CI 0.6-28.4). All patients who progressed to requiring surgery had index lesions at the thoracic apex (T5-7). CONCLUSIONS In carefully selected patients, treatment of grade 2 ESCC disease with hypofractionated SBRT alone offers a 1-year cumulative incidence of LRF similar to that in low-grade ESCC and postseparation surgery adjuvant hypofractionated SBRT. Use of SBRT alone has a favorable safety profile and a low cumulative incidence of progressive disease requiring open surgical intervention (14.5%).
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Affiliation(s)
| | | | | | | | | | - Patrick McCann
- 5Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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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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Gong Y, Xu L, Zhuang H, Jiang L, Wei F, Liu Z, Li Y, Yu M, Ni K, Liu X. Efficacy and safety of different fractions in stereotactic body radiotherapy for spinal metastases: A systematic review. Cancer Med 2019; 8:6176-6184. [PMID: 31489788 PMCID: PMC6797563 DOI: 10.1002/cam4.2546] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In the treatment of spinal metastases, stereotactic body radiotherapy (SBRT) delivers precise, high-dose radiation to the target region while sparing the spinal cord. A range of doses and fractions had been reported; however, the optimal prescribed scheme remains unclear. METHODS Two reviewers performed independent literature searches of the PubMed, EMBASE, Cochrane Database, and Web of Science databases. Articles were divided into one to five fractions groups. The Methodological Index for Non-randomized Studies (MINORS) was used to assess the quality of studies. Local control (LC) and overall survival (OS) were presented for the included studies and a pooled value was calculated by the weighted average. RESULTS The 38 included studies comprised 3,754 patients with 4,731 lesions. The average 1-year LCs for the one to five fractions were 92.7%, 84.6%, 86.8%, 82.6%, and 80.6%, respectively. The average 1-year OS for the one to five fractions were 53.0%, 70.4%, 60.1%, 48%, and 80%, respectively. The 24 Gy/single fraction scheme had a higher 1-year LC (98.1%) than those of 24 Gy/two fractions (85.4%), 27 Gy/three fractions (84.9%), and 24 Gy/three fractions (89.0%). The incidence of vertebral compression fracture was 10.3%, with 10.7% in the single-fraction group and 10.1% in the multi-fraction group. The incidence of radiation-induced myelopathy was 0.19%; three and two patients were treated with single-fraction and multi-fraction SBRT, respectively. The incidence of radiculopathy was 0.30% and all but one patient were treated with multi-fraction SBRT. CONCLUSIONS SBRT provided satisfactory efficacy and acceptable safety for spinal metastases. Single-fraction SBRT demonstrated a higher local control rate than those of the other factions, especially the 24 Gy dose. The risk of vertebral compression fracture (VCF) was slightly higher in single-fraction SBRT and more patients developed radiculopathy after multi-fraction SBRT.
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Affiliation(s)
- Yining Gong
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Lingyi Xu
- Eight-Year-Program, Grade 2015, Health Science Center, Peking University, Beijing, China
| | - Hongqing Zhuang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Yan Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Miao Yu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Kaiwen Ni
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
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Outcomes in the radiosurgical management of metastatic spine disease. Adv Radiat Oncol 2019; 4:283-293. [PMID: 31011673 PMCID: PMC6460302 DOI: 10.1016/j.adro.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/29/2018] [Indexed: 01/08/2023] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) is a common treatment option for patients with metastatic tumors of the spine. The optimal treatment-, tumor-, and patient-specific characteristics necessary to achieve durable outcomes remain less well understood given the heterogeneous nature of the patient population this modality typically serves. The objective of this analysis was to better understand the determinants underlying SBRT spine treatment outcomes. Methods and Materials A total of 127 patients with 287 spine tumors were treated between March 2010 and May 2015. The median total doses for single-fraction and hypofractionated courses of treatment were 16 Gy (range, 16-20 Gy) and 24 Gy (range, 16-40 Gy), respectively. Radiologic local control and numeric pain score data were measured, and univariate and multivariate analyses were done to determine factors predictive of treatment response. Results Median follow-up was 5.9 months (range, 1-61 months). Radiologic local control was achieved in 84.7% of patients at 6 months and in 74.7% of patients at 1 year. Local control was found to be affected by the Spinal Instability Neoplastic Score, and was worse in patients with scores ≥7 (hazard ratio [HR]: 4.25; 95% confidence interval [CI], 1.57-11.51). Patients who required upfront surgical intervention to alleviate spinal cord compression, address mechanical spinal instability, or both had worse local control than those who did not require surgery (HR: 2.32; 95% CI, 1.04-5.17). Patients treated with a hypofractionated course compared with a single fraction had worse radiologic local control (HR: 2.63; 95% CI, 1.27-5.45). No patients developed radiation-induced myelitis after treatment, and the vertebral compression fracture rate was 9.1% after SBRT. Conclusions Patients with potentially unstable spines or needing upfront spinal surgery before SBRT are less likely to achieve durable radiologic local control. Additionally, patients treated with single-fraction regimens have improved local control compared with those treated with hypofractionated radiation.
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Lee JH, Lee SH. Selecting the Appropriate Radiation Therapy Technique for Malignant Spinal Cord Compression Syndrome. Front Oncol 2019; 9:65. [PMID: 30886830 PMCID: PMC6409356 DOI: 10.3389/fonc.2019.00065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 01/23/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jun-Ho Lee
- Department of Emergency Medical Technology, Daejeon University, Daejeon, South Korea
| | - Seok Ho Lee
- Department of Radiation Oncology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, South Korea
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14
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Long-Term Outcomes After Stereotactic Radiosurgery for Spine Metastases: Radiation Dose-Response for Late Toxicity. Int J Radiat Oncol Biol Phys 2018; 101:602-609. [PMID: 29678526 DOI: 10.1016/j.ijrobp.2018.02.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE To document the 5- and 10-year rates of late toxicity and vertebral compression fracture (VCF) in long-term survivors after stereotactic radiosurgery for spine metastases. METHODS AND MATERIALS A retrospective review was performed on 562 patients treated with SRS for spine metastases between April 2001 and July 2011. Selecting those with at least 5-year survival after SRS, included were 43 patients who collectively underwent 84 treatments at 54 spine sites. Most were treated with single-fraction stereotactic radiosurgery to a median dose of 16 Gy (range, 12-24 Gy), and 56% of sites had received prior external beam radiation therapy. Late toxicities and VCFs occurring in the absence of tumor progression were recorded. Binary logistic regression was used to identify predictors of late complications. RESULTS Nine patients (17% of treatment sites) developed grade ≥2 late toxicities at a median time of 12.8 months (range, 4.2-59.0 months). Actuarial 5- and 10-year rates of grade ≥2 late toxicity were 17% and 17%, respectively. On multivariate analysis, only cumulative biologically effective dose (BED3) > 200 Gy (or EQD22Gy [2-Gy equivalent dose calculated using an α/β ratio of 2] > 130 Gy) was associated with grade ≥2 late toxicity (P = .036). Maximum point BED3 > 110 Gy (or EQD22Gy > 70 Gy) to spinal cord or cauda equina was associated with grade ≥2 late neuropathy (P = .017). Nine VCFs (18%) occurred at a median time of 10.2 months (range, 3.2-57.2 months), with 5- and 10-year VCF rates of 17% and 17%, respectively. CONCLUSION Stereotactic radiosurgery for primary treatment and reirradiation of spinal metastases is associated with a moderate risk of late toxicity with 10-year follow-up. Risk of late toxicity significantly increases with cumulative BED3 > 200 Gy and spinal cord or cauda equina point BED3 > 110 Gy. Patients remain at moderate risk of VCF up to 5 years after treatment, with a plateau in incidence thereafter up to 10 years.
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15
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Barzilai O, DiStefano N, Lis E, Yamada Y, Lovelock DM, Fontanella AN, Bilsky MH, Laufer I. Safety and utility of kyphoplasty prior to spine stereotactic radiosurgery for metastatic tumors: a clinical and dosimetric analysis. J Neurosurg Spine 2017; 28:72-78. [PMID: 29087812 DOI: 10.3171/2017.5.spine1746] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of kyphoplasty treatment prior to spine stereotactic radiosurgery (SRS) in patients with spine metastases. METHODS A retrospective review of charts, radiology reports, and images was performed for all patients who received SRS (single fraction; either standalone or post-kyphoplasty) at a large tertiary cancer center between January 2012 and July 2015. Patient and tumor variables were documented, as well as treatment planning data and dosimetry. To measure the photon scatter due to polymethyl methacrylate, megavolt photon beam attenuation was determined experimentally as it passed through a kyphoplasty cement phantom. Corrected electron density values were recalculated and compared with uncorrected values. RESULTS Of 192 treatment levels in 164 unique patients who underwent single-fraction SRS, 17 (8.8%) were treated with kyphoplasty prior to radiation delivery to the index level. The median time from kyphoplasty to SRS was 22 days. Four of 192 treatments (2%) demonstrated local tumor recurrence or progression at the time of analysis. Of the 4 local failures, 1 patient had kyphoplasty prior to SRS. This recurrence occurred 18 months after SRS in the setting of widespread systemic disease and spinal tumor progression. Dosimetric review demonstrated a lower than average treatment dose for this case compared with the rest of the cohort. There were no significant differences in dosimetry analysis between the group of patients who underwent kyphoplasty prior to SRS and the remaining patients in the cohort. A preliminary analysis of polymethyl methacrylate showed that dosimetric errors due to uncorrected electron density values were insignificant. CONCLUSIONS In cases without epidural spinal cord compression, stabilization with cement augmentation prior to SRS is safe and does not alter the efficacy of the radiation or preclude physicians from adhering to SRS planning and contouring guidelines.
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Affiliation(s)
| | | | | | | | | | | | - Mark H Bilsky
- Departments of1Neurosurgery.,5Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Ilya Laufer
- Departments of1Neurosurgery.,5Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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16
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Bian C, Chen N, Li XL, Zhou XG, Lin H, Jiang LB, Liu WM, Chen Q, Dong J. Surgery Combined with Radiotherapy to Treat Spinal Tumors: A Review of Published Reports. Orthop Surg 2017; 8:97-104. [PMID: 27384717 DOI: 10.1111/os.12230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/07/2016] [Indexed: 12/11/2022] Open
Abstract
Spinal tumors result in high morbidity and a high rate of lower limb paralysis. Both surgical therapy and radiation therapy (RT) are used to treat spinal tumors; however, how best to combine these two therapies to maximize the benefits and minimize the risks is still being debated. It is also difficult to decide the optimal timing, course and dose of RT, especially in pregnant women and children. The aim of this review is to assist surgeons who are dealing with spinal tumors by providing comprehensive information about advanced techniques for administering RT with greater precision and safety, and about the impact of various ways of combining surgery and RT on therapeutic outcomes. We here review published reports about treating spinal tumors with a combination of these two forms of therapy and attempt to draw appropriate conclusions concerning selection of optimal treatment protocols. Our conclusion is that postoperative radiotherapy, especially with high-precision, low-dose and multiple fractions, and brachytherapy are promising therapies to combined with surgery.
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Affiliation(s)
- Chong Bian
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Nong Chen
- Department of Orthopaedic Surgery, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, China
| | - Xi-Lei Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Gang Zhou
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Lin
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Bo Jiang
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang-Mi Liu
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qian Chen
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Dong
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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17
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Kim M, Craft DL. Within the next five years, most radiotherapy treatment schedules will be designed using spatiotemporal optimization. Med Phys 2017; 43:2009. [PMID: 27147312 DOI: 10.1118/1.4943383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Minsun Kim
- Radiation Oncology, University of Washington, Seattle, Washington 98195-6043 (Tel: 206-598-8133; E-mail: )
| | - David L Craft
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts 02114 (Tel: 617-724-9528; E-mail: )
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Surgical Resection of Intradural Extramedullary Spinal Tumors: Patient Reported Outcomes and Minimum Clinically Important Difference. Spine (Phila Pa 1976) 2016; 41:1925-1932. [PMID: 27111764 DOI: 10.1097/brs.0000000000001653] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Analysis of prospectively collected longitudinal web-based registry data. OBJECTIVE To determine relative validity, responsiveness, and minimum clinically important difference (MCID) thresholds in patients undergoing surgery for intradural extramedullary (IDEM) spinal tumors. SUMMARY OF BACKGROUND DATA Patient-reported outcomes (PROs) are vital in establishing the value of care in spinal pathology. There is limited availability of prospective, quality studies reporting PROs for IDEM spine tumors. METHODS . A total of 40 patients were analyzed. Baseline, postoperative 3-month, and 12-month PROs were recorded: Oswestry Disability Index or Neck disability Index (ODI/NDI), Quality of life EuroQol-5D (EQ-5D), Short Form-12 (SF-12), Numeric Rating Scale (NRS)-pain scores. Responders were defined as those who achieved a level of improvement one or two, after surgery, on health transition index (HTI) of SF-36. Receiver-operating characteristic curves were generated to assess the validity of PROs, and the difference between standardized response means (SRMs) in responders versus nonresponders was utilized to determine the relative responsiveness of each PRO measure. MCID thresholds were derived using previously reported minimal detectable change approach. RESULTS A significant improvement across all PROs at 3-months and 12-months follow up was noted. The derived MCID thresholds were 13.9 points: ODI/NDI, 0.14 quality adjusted life years: EQ-5D, 2.8 points: SF-12PCS and 10.7 points: SF-12MCS, 1.9 points: NRS-back/neck pain, and 1.8 points: NRS-leg/arm pain. SF-12PCS was most accurate discriminator of meaningful improvement (area under the curve, AUC-0.83) and most responsive (SRM-1.36) to postoperative improvement. EQ-5D, ODI/NDI, NRS-pain scores were all accurate discriminator (AUC-0.7-0.8) and responsive measures (0.97-0.67) of meaningful postoperative improvement. SF-12MCS was neither a valid discriminator (AUC-0.48) nor a responsive measure (SRM: -1.5) of outcome. CONCLUSION Surgical resection of IDEM spinal tumors provides significant and sustained improvement in quality of life, general health, disability, and pain at 12-month after surgery. The surgically resected IDEM-specific clinically meaningful thresholds are reported. All the PROs reported in this study can accurately discriminate responders and nonresponder based on SF-36 HTI index except for SF-12 MCS. LEVEL OF EVIDENCE 3.
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19
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Redmond KJ, Lo SS, Soltys SG, Yamada Y, Barani IJ, Brown PD, Chang EL, Gerszten PC, Chao ST, Amdur RJ, De Salles AAF, Guckenberger M, Teh BS, Sheehan J, Kersh CR, Fehlings MG, Sohn MJ, Chang UK, Ryu S, Gibbs IC, Sahgal A. Consensus guidelines for postoperative stereotactic body radiation therapy for spinal metastases: results of an international survey. J Neurosurg Spine 2016; 26:299-306. [PMID: 27834628 DOI: 10.3171/2016.8.spine16121] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although postoperative stereotactic body radiation therapy (SBRT) for spinal metastases is increasingly performed, few guidelines exist for this application. The purpose of this study is to develop consensus guidelines to promote safe and effective treatment for patients with spinal metastases. METHODS Fifteen radiation oncologists and 5 neurosurgeons, representing 19 centers in 4 countries and having a collective experience of more than 1300 postoperative spine SBRT cases, completed a 19-question survey about postoperative spine SBRT practice. Responses were defined as follows: 1) consensus: selected by ≥ 75% of respondents; 2) predominant: selected by 50% of respondents or more; and 3) controversial: no single response selected by a majority of respondents. RESULTS Consensus treatment indications included: radioresistant primary, 1-2 levels of adjacent disease, and previous radiation therapy. Contraindications included: involvement of more than 3 contiguous vertebral bodies, ASIA Grade A status (complete spinal cord injury without preservation of motor or sensory function), and postoperative Bilsky Grade 3 residual (cord compression without any CSF around the cord). For treatment planning, co-registration of the preoperative MRI and postoperative T1-weighted MRI (with or without gadolinium) and delineation of the cord on the T2-weighted MRI (and/or CT myelogram in cases of significant hardware artifact) were predominant. Consensus GTV (gross tumor volume) was the postoperative residual tumor based on MRI. Predominant CTV (clinical tumor volume) practice was to include the postoperative bed defined as the entire extent of preoperative tumor, the relevant anatomical compartment and any residual disease. Consensus was achieved with respect to not including the surgical hardware and incision in the CTV. PTV (planning tumor volume) expansion was controversial, ranging from 0 to 2 mm. The spinal cord avoidance structure was predominantly the true cord. Circumferential treatment of the epidural space and margin for paraspinal extension was controversial. Prescription doses and spinal cord tolerances based on clinical scenario, neurological compromise, and prior overlapping treatments were controversial, but reasonable ranges are presented. Fifty percent of those surveyed practiced an integrated boost to areas of residual tumor and density override for hardware within the beam path. Acceptable PTV coverage was controversial, but consensus was achieved with respect to compromising coverage to meet cord constraint and fractionation to improve coverage while meeting cord constraint. CONCLUSIONS The consensus by spinal radiosurgery experts suggests that postoperative SBRT is indicated for radioresistant primary lesions, disease confined to 1-2 vertebral levels, and/or prior overlapping radiotherapy. The GTV is the postoperative residual tumor, and the CTV is the postoperative bed defined as the entire extent of preoperative tumor and anatomical compartment plus residual disease. Hardware and scar do not need to be included in CTV. While predominant agreement was reached about treatment planning and definition of organs at risk, future investigation will be critical in better understanding areas of controversy, including whether circumferential treatment of the epidural space is necessary, management of paraspinal extension, and the optimal dose fractionation schedules.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The John Hopkins University, Baltimore, Maryland
| | - Simon S Lo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - Igor J Barani
- Department of Radiation Oncology, University of California, San Francisco
| | - Paul D Brown
- Department of Radiation Oncology, MD Anderson Cancer Center
| | - Eric L Chang
- Department of Radiation Oncology, Norris Cancer Center and Keck School of Medicine at University of Southern California
| | - Peter C Gerszten
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neurooncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Antonio A F De Salles
- Department of Neurological Surgery, Brain Research Institute, University of California, Los Angeles, California
| | | | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weill Cornell Medical College, Houston, Texas
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville
| | - Charles R Kersh
- Department of Radiation Oncology, Riverside Radiation Oncology Specialists, Newport News, Virginia
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Toronto Western Hospital, University of Toronto
| | - Moon-Jun Sohn
- Department of Neurological Surgery, Radiosurgery Center, Inje University Ilsan Paik Hospital, College of Medicine, Goyang; and
| | - Ung-Kyu Chang
- Department of Neurosurgery, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook Cancer Center, Stony Brook, New York
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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20
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Redmond KJ, Robertson S, Lo SS, Soltys SG, Ryu S, McNutt T, Chao ST, Yamada Y, Ghia A, Chang EL, Sheehan J, Sahgal A. Consensus Contouring Guidelines for Postoperative Stereotactic Body Radiation Therapy for Metastatic Solid Tumor Malignancies to the Spine. Int J Radiat Oncol Biol Phys 2016; 97:64-74. [PMID: 27843035 DOI: 10.1016/j.ijrobp.2016.09.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/31/2016] [Accepted: 09/10/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To develop consensus contouring guidelines for postoperative stereotactic body radiation therapy (SBRT) for spinal metastases. METHODS AND MATERIALS Ten spine SBRT specialists representing 10 international centers independently contoured the clinical target volume (CTV), planning target volume (PTV), spinal cord, and spinal cord planning organ at risk volume (PRV) for 10 representative clinical scenarios in postoperative spine SBRT for metastatic solid tumor malignancies. Contours were imported into the Computational Environment for Radiotherapy Research. Agreement between physicians was calculated with an expectation minimization algorithm using simultaneous truth and performance level estimation with κ statistics. Target volume definition guidelines were established by finding optimized confidence level consensus contours using histogram agreement analyses. RESULTS Nine expert radiation oncologists and 1 neurosurgeon completed contours for all 10 cases. The mean sensitivity and specificity were 0.79 (range, 0.71-0.89) and 0.94 (range, 0.90-0.99) for the CTV and 0.79 (range, 0.70-0.95) and 0.92 (range, 0.87-0.99) for the PTV), respectively. Mean κ agreement, which demonstrates the probability that contours agree by chance alone, was 0.58 (range, 0.43-0.70) for CTV and 0.58 (range, 0.37-0.76) for PTV (P<.001 for all cases). Optimized consensus contours were established for all patients with 80% confidence interval. Recommendations for CTV include treatment of the entire preoperative extent of bony and epidural disease, plus immediately adjacent bony anatomic compartments at risk of microscopic disease extension. In particular, a "donut-shaped" CTV was consistently applied in cases of preoperative circumferential epidural extension, regardless of extent of residual epidural extension. Otherwise more conformal anatomic-based CTVs were determined and described. Spinal instrumentation was consistently excluded from the CTV. CONCLUSIONS We provide consensus contouring guidelines for common scenarios in postoperative SBRT for spinal metastases. These consensus guidelines are subject to clinical validation.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Scott Robertson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook Cancer Center, Stony Brook, New York
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Amol Ghia
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Eric L Chang
- Department of Radiation Oncology, Norris Cancer Center and Keck School of Medicine at University of Southern California, Los Angeles, California
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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