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Aziz K, Koffler D, Vassantachart A, Rattani A, Ankrah NK, Gogineni E, Andraos TY, Sahgal A, Vellayappan B, Dunne EM, Siva S, Moraes FY, Guckenberger M, Lubelski D, Chao S, Combs S, Chang E, Amin AG, Foote M, Gibbs I, Kim M, Palmer J, Lo S, Redmond KJ. Radiosurgery Society Case-Based Guide to Stereotactic Body Radiation Therapy for Challenging Cases of Spinal Metastases. Pract Radiat Oncol 2024:S1879-8500(24)00212-1. [PMID: 39233007 DOI: 10.1016/j.prro.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE Spinal stereotactic body radiation therapy (SBRT) has become the standard of care in management of patients with limited sites of metastatic disease, radio-resistant histologies, painful vertebral metastases with long life expectancy and cases of reirradiation. Our case-based guidelines aim to assist radiation oncologists in the appropriate utilization of SBRT for common, yet challenging, cases of spinal metastases. MATERIALS AND METHODS Cases were selected to include scenarios of large volume sacral disease with nerve entrapment, medically inoperable disease abutting the thecal sac, and local failure after prior SBRT. Relevant literature was reviewed, and areas requiring further investigation were discussed to offer a framework for evidence-based clinical practice. RESULTS Spinal SBRT can be effectively delivered in challenging cases following multidisciplinary discussion by utilizing a methodical approach to patient selection, appropriate dose selection, and adherence to evidence-based dose constraints. CONCLUSIONS The Radiosurgery Society's case-based practice review offers guidance to practicing physicians treating technically challenging SBRT candidate patients with spinal metastases.
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Affiliation(s)
- Khaled Aziz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Koffler
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - April Vassantachart
- Department of Radiation Oncology, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Abbas Rattani
- Department of Radiation Oncology, Tufts Medical Center, Boston, Massachusetts 02111, USA
| | - Nii-Kwanchie Ankrah
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emile Gogineni
- Department of Radiation Oncology, Arthur G. James Cancer Hospital/The Ohio State University, Columbus, OH, USA
| | - Therese Y Andraos
- Department of Radiation Oncology, Arthur G. James Cancer Hospital/The Ohio State University, Columbus, OH, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore
| | - Emma M Dunne
- Department of Radiation Oncology, British Columbia Cancer Agency - Vancouver Centre, Vancouver, British Columbia, Canada
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Fabio Y Moraes
- Department of Oncology - Division of Radiation Oncology, Kingston Health Sciences Centre and Queen's University, Kingston, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniel Lubelski
- Department of Neurological Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie Combs
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich (TUM), Munich, Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences, Helmholtz Zentrum Munich, Neuherberg, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Eric Chang
- Department of Radiation Oncology, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA 98115, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, and ICON Cancer Centre, Brisbane, Queensland, Australia
| | - Iris Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Joshua Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital/The Ohio State University, Columbus, OH, USA
| | - Simon Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Milano MT, Doucette C, Mavroidis P, Yorke E, Ryckman J, Mahadevan A, Kapitanova I, Kong FMS, Grimm J, Marks LB. Hypofractionated Stereotactic Radiation Therapy Dosimetric Tolerances for the Inferior Aspect of the Brachial Plexus: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 118:931-943. [PMID: 36682981 PMCID: PMC11325459 DOI: 10.1016/j.ijrobp.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/17/2022] [Accepted: 11/06/2022] [Indexed: 01/22/2023]
Abstract
We sought to systematically review and summarize dosimetric factors associated with radiation-induced brachial plexopathy (RIBP) after stereotactic body radiation therapy (SBRT) or hypofractionated image guided radiation therapy (HIGRT). From published studies identified from searches of PubMed and Embase databases, data quantifying risks of RIBP after 1- to 10-fraction SBRT/HIGRT were extracted and summarized. Published studies have reported <10% risks of RIBP with maximum doses (Dmax) to the inferior aspect of the brachial plexus of 32 Gy in 5 fractions and 25 Gy in 3 fractions. For 10-fraction HIGRT, risks of RIBP appear to be low with Dmax < 40 to 50 Gy. For a given dose value, greater risks are anticipated with point volume-based metrics (ie, D0.03-0.035cc: minimum dose to hottest 0.03-0.035 cc) versus Dmax. With SBRT/HIGRT, there were insufficient published data to predict risks of RIBP relative to brachial plexus dose-volume exposure. Minimizing maximum doses and possibly volume exposure of the brachial plexus can reduce risks of RIBP after SBRT/HIGRT. Further study is needed to better understand the effect of volume exposure on the brachial plexus and whether there are location-specific susceptibilities along or within the brachial plexus structure.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York.
| | | | - Panayiotis Mavroidis
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jeff Ryckman
- Department of Radiation Oncology, West Virginia University, Parkersburg, West Virginia
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Irina Kapitanova
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital/Li Ka Shing School of Medicine, Shenzhen/Hong Kong, China
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Noureldine MHA, Shimony N, Jallo GI. Malignant Spinal Tumors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:565-581. [PMID: 37452954 DOI: 10.1007/978-3-031-23705-8_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Malignant spinal tumors constitute around 22% of all primary spinal tumors. The most common location of metastases to the spinal region is the extradural compartment. The molecular and genetic characterization of these tumors was the basis for the updated WHO classification of CNS tumors in 2016, where many CNS tumors are now diagnosed according to their genetic profile rather than relying solely on the histopathological appearance. Magnetic resonance imaging (MRI) is the current gold standard for the initial evaluation and subsequent follow-up on intradural spinal cord tumors, and the imaging sequences must include T2-weighted images (WI), short time inversion recovery (STIR), and pre- and post-contrast T1-WI in the axial, sagittal, and coronal planes. The clinical presentation is highly variable and depends on the tumor size, growth rate, type, infiltrative, necrotic and hemorrhagic potential as well as the exact location within the spinal compartment. Surgical intervention remains the mainstay of management of symptomatic and radiographically enlarging spinal tumors, where the goal is to achieve maximal safe resection. Tumor recurrences are managed with repeat surgical resection (preferred whenever possible and safe), radiotherapy, chemotherapy, or any combination of these therapies.
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Affiliation(s)
- Mohammad Hassan A Noureldine
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Johns Hopkins University School of Medicine, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
| | - Nir Shimony
- Johns Hopkins University School of Medicine, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
- Geisinger Medical Center, Institute of Neuroscience, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - George I Jallo
- Institute for Brain Protections Sciences, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA.
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4
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Monk SH, Biester EC, Kadakia KC, Healy AT, Heinzerling JH. Esophageal-meningeal fistula after anterior cervical corpectomy, stereotactic body radiation therapy (SBRT), and bevacizumab-containing systemic therapy for metastatic epidural spinal cord compression (MESCC). INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Hrycushko B, van der Kogel AJ, Phillips L, Chhabra A, Folkert MR, Sayre JW, Vernino S, Hassan-Rezaeian N, Yamada Y, Timmerman R, Medin PM. Brachial Plexus Tolerance to Single-Session SAbR in a Pig Model. Int J Radiat Oncol Biol Phys 2021; 112:565-571. [PMID: 34597718 DOI: 10.1016/j.ijrobp.2021.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/10/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE The single-session dose tolerance of the spinal nerves has been observed to be similar to that of the spinal cord in pigs, counter to the perception that peripheral nerves are more tolerant to radiation. This pilot study aims to obtain a first impression of the single-session dose-response of the brachial plexus using pigs as a model. METHODS AND MATERIALS Ten Yucatan minipigs underwent computed tomography and magnetic resonance imaging for treatment planning, followed by single-session stereotactic ablative radiotherapy. A 2.5-cm length of the left-sided brachial plexus cords was irradiated. Pigs were distributed in 3 groups with prescription doses of 16 (n = 3), 19 (n = 4), and 22 Gy (n = 3). Neurologic status was assessed by observation for changes in gait and electrodiagnostic examination. Histopathologic examination was performed with light microscopy of paraffin-embedded sections stained with Luxol fast blue/periodic acid-Schiff and Masson's trichrome. RESULTS Seven of the 10 pigs developed motor deficit to the front limb of the irradiated side, with a latency from 5 to 8 weeks after irradiation. Probit analysis of the maximum nerve dose yields an estimated ED50 of 19.3 Gy for neurologic deficit, but the number of animals was insufficient to estimate 95% confidence intervals. No motor deficits were observed at a maximum dose of 17.6 Gy for any pig. Nerve conduction studies showed an absence of sensory response in all responders and absent or low motor response in most of the responders (71%). All symptomatic pigs showed histologic lesions to the left-sided plexus consistent with radiation-induced neuropathy. CONCLUSIONS The single-session ED50 for symptomatic plexopathy in Yucatan minipigs after irradiation of a 2.5-cm length of the brachial plexus cords was determined to be 19.3 Gy. The dose-response curve overlaps that of the spinal nerves and the spinal cord in the same animal model. The relationship between the brachial plexus tolerance in pigs and humans is unknown, and caution is warranted when extrapolating for clinical use.
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Affiliation(s)
- Brian Hrycushko
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Albert J van der Kogel
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Lauren Phillips
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Michael R Folkert
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - James W Sayre
- Departments of Biostatistics; Radiology, University of California Los Angeles, California
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Nima Hassan-Rezaeian
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert Timmerman
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Paul M Medin
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas.
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Perdomo-Pantoja A, Holmes C, Lina IA, Liauw JA, Puvanesarajah V, Goh BC, Achebe CC, Cottrill E, Elder BD, Grayson WL, Redmond KJ, Hur SC, Witham TF. Effects of Single-Dose Versus Hypofractionated Focused Radiation on Vertebral Body Structure and Biomechanical Integrity: Development of a Rabbit Radiation-Induced Vertebral Compression Fracture Model. Int J Radiat Oncol Biol Phys 2021; 111:528-538. [PMID: 33989720 DOI: 10.1016/j.ijrobp.2021.04.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Vertebral compression fracture is a common complication of spinal stereotactic body radiation therapy. Development of an in vivo model is crucial to fully understand how focal radiation treatment affects vertebral integrity and biology at various dose fractionation regimens. We present a clinically relevant animal model to analyze the effects of localized, high-dose radiation on vertebral microstructure and mechanical integrity. Using this model, we test the hypothesis that fractionation of radiation dosing can reduce focused radiation therapy's harmful effects on the spine. METHODS AND MATERIALS The L5 vertebra of New Zealand white rabbits was treated with either a 24-Gy single dose of focused radiation or 3 fractionated 8-Gy doses over 3 consecutive days via the Small Animal Radiation Research Platform. Nonirradiated rabbits were used as controls. Rabbits were euthanized 6 months after irradiation, and their lumbar vertebrae were harvested for radiologic, histologic, and biomechanical testing. RESULTS Localized single-dose radiation led to decreased vertebral bone volume and trabecular number and a subsequent increase in trabecular spacing and thickness at L5. Hypofractionation of the radiation dose similarly led to reduced trabecular number and increased trabecular spacing and thickness, yet it preserved normalized bone volume. Single-dose irradiated vertebrae displayed lower fracture loads and stiffness compared with those receiving hypofractionated irradiation and with controls. The hypofractionated and control groups exhibited similar fracture load and stiffness. For all vertebral samples, bone volume, trabecular number, and trabecular spacing were correlated with fracture loads and Young's modulus (P < .05). Hypocellularity was observed in the bone marrow of both irradiated groups, but osteogenic features were conserved in only the hypofractionated group. CONCLUSIONS Single-dose focal irradiation showed greater detrimental effects than hypofractionation on the microarchitectural, cellular, and biomechanical characteristics of irradiated vertebral bodies. Correlation between radiologic measurements and biomechanical properties supported the reliability of this animal model of radiation-induced vertebral compression fracture, a finding that can be applied to future studies of preventative measures.
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Affiliation(s)
| | - Christina Holmes
- Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, Tallahassee, Florida
| | - Ioan A Lina
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason A Liauw
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Varun Puvanesarajah
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian C Goh
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Chukwuebuka C Achebe
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Warren L Grayson
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Soojung C Hur
- Department of Mechanical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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7
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Hrycushko B, van der Kogel AJ, Phillips L, Folkert M, Sayre JW, Vernino S, Hassan-Rezaeian N, Foster RD, Yamada Y, Timmerman R, Medin PM. Existence of a Dose-Length Effect in Spinal Nerves Receiving Single-Session Stereotactic Ablative Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 106:1010-1016. [PMID: 31953062 DOI: 10.1016/j.ijrobp.2019.11.417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE The spinal nerves have been observed to have a similar single-session dose tolerance to that of the spinal cord in pigs. Small-animal studies have shown that spinal cord dose tolerance depends on the length irradiated. This work aims to determine whether a dose-length effect exists for spinal nerves. METHODS AND MATERIALS Twenty-seven Yucatan minipigs underwent computed tomography and magnetic resonance imaging for treatment planning, followed by single-session stereotactic ablative radiation therapy. A 0.5 cm length of the left-sided C6, C7, and C8 spinal nerves was targeted. The pigs were distributed into 6 groups with prescription doses of 16 Gy (n = 5), 18 Gy (n = 5), 20 Gy (n = 5), 22 Gy (n = 5), 24 Gy (n = 5), or 36 Gy (n = 2) and corresponding maximum doses of 16.7, 19.1, 21.3, 23.1, 25.5, and 38.6 Gy, respectively. Neurologic status was assessed with a serial electrodiagnostic examination and daily observation of gait for approximately 52 weeks. A histopathologic examination of paraffin-embedded sections with Luxol fast blue/periodic acid-Schiff's staining was also performed. RESULTS Marked gait change was observed in 8 of 27 irradiated pigs. The latency for responding pigs was 11 to 16 weeks after irradiation. The affected animals presented with a limp in the left front limb, and 62.5% of these pigs had electrodiagnostic evidence of denervation in the C6 and C7 innervated muscles. A probit analysis showed the dose associated with a 50% incidence of gait change is 23.9 Gy (95% confidence interval, 22.5-25.8 Gy), which is 20% higher than that reported in a companion study where a 1.5 cm length was irradiated. All symptomatic pigs had demyelination and fibrosis in the irradiated nerves, but the contralateral nerves and spinal cord were normal. CONCLUSIONS A dose-length effect was observed for single-session irradiation of the spinal nerves in a Yucatan minipig model.
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Affiliation(s)
- Brian Hrycushko
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | | | - Lauren Phillips
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Folkert
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - James W Sayre
- Department of Biostatistics of Radiology, University of California Los Angeles, California
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
| | | | - Ryan D Foster
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert Timmerman
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Paul M Medin
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas.
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Meola A, Soltys S, Schmitt A, Gerszten PC, Chang SD. Stereotactic Radiosurgery for Benign Spinal Tumors. Neurosurg Clin N Am 2020; 31:231-235. [PMID: 32147014 DOI: 10.1016/j.nec.2019.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Benign spinal tumors are rare clinical conditions, including meningiomas, schwannomas, and neurofibromas. Although these tumors are usually treated with open surgical resection, spinal stereotactic radiosurgery may be a safe and effective alternative to surgery in selected patients.
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Affiliation(s)
- Antonio Meola
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Dr, Stanford, CA 94305, USA
| | - Adam Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Peter C Gerszten
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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9
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Moraes FY, Chen X, Yan M, Spratt DE, Redmond K, Jackson WC, Yamada YJ. Evolving Role of Stereotactic Body Radiation Therapy in the Management of Spine Metastases: Defining Dose and Dose Constraints. Neurosurg Clin N Am 2020; 31:167-189. [PMID: 32147009 DOI: 10.1016/j.nec.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
When treating solid tumor spine metastases, stereotactic high-dose-per-fraction radiation, given in a single fraction or in a hypofractionated approach, has proved to be a highly effective and safe therapeutic option for any tumor histology, in the setting of de novo therapy, as salvage treatment of local progression after previous radiation, and in the postoperative setting. There are variations in practice based on the clinical presentation, goals of therapy, as well as institutional preferences. As a biologically potent therapy, a thoughtful and careful attention to detail with patient selection, treatment planning, and delivery is crucial for treatment success.
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Affiliation(s)
- Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Xuguang Chen
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Yan
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Kristen Redmond
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Loi M, Nuyttens JJ, Desideri I, Greto D, Livi L. Single-Fraction Radiotherapy (SFRT) For Bone Metastases: Patient Selection And Perspectives. Cancer Manag Res 2019; 11:9397-9408. [PMID: 31807069 PMCID: PMC6842277 DOI: 10.2147/cmar.s186630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/22/2019] [Indexed: 01/02/2023] Open
Abstract
Bone metastases are a frequent and important source of morbidity in cancer patients. Stereotactic body radiation therapy (SBRT) is an established treatment option for local control and pain relief of bone metastases, and it is increasingly used as upfront treatment, postoperative consolidation or salvage treatment after prior RT. However, heterogeneity of dose schedules described in literature represents a severe limitation in the definition of the role of SBRT as a standard of care. No consensus is available on the use of single versus multiple fraction SBRT for bone metastases. Advantages of single-fraction SBRT include shorter overall duration of treatment, absence of inter-fraction uncertainty, improved compliance, theoretical increased efficacy, and lower costs. However, caution has been advised due to reports of severe late toxicities, in particular, vertebral collapse fracture (VCF). The aim of this paper is to review dose fractionation and indications for the management of bone metastases using SBRT.
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Affiliation(s)
- Mauro Loi
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Joost J Nuyttens
- Radiotherapy Department, Erasmus MC Cancer Center, Rotterdam, The Netherlands
| | - Isacco Desideri
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Daniela Greto
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Radiotherapy Department, University of Florence, Florence, Italy
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11
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[Dysphagia in cervical spine diseases]. HNO 2019; 67:801-814. [PMID: 31485696 DOI: 10.1007/s00106-019-00738-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Dysphagia is a common symptom and can be indicative of a variety of heterogeneous diseases. "Classical" diseases of the head and neck region, such as acute tonsillitis, peritonsillar abscesses, diverticula, and benign or malignant tumors are common causes of dysphagia. However, it can also occur in the context of neurological diseases, e.g., as a result of stroke or as an age-related phenomenon (presbyphagia). Pathologies of the cervical spine can also be a cause of dysphagia. In this context, congenital or acquired diseases, inflammatory or degenerative processes, cervical spine surgery, and (malignant) masses of the cervical spine should be taken into account. Particular dysphagia with a positive history of previous operative interventions on the cervical spine or symptoms such as chronic back pain and trauma should give rise to consideration of a cervical spine-related cause.
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12
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Lindberg K, Grozman V, Lindberg S, Onjukka E, Lax I, Lewensohn R, Wersäll P. Radiation-induced brachial plexus toxicity after SBRT of apically located lung lesions. Acta Oncol 2019; 58:1178-1186. [PMID: 31066326 DOI: 10.1080/0284186x.2019.1601255] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: To evaluate the rate and dose response of brachial plexus toxicity post stereotactic body radiation therapy (SBRT) of apically situated lung lesions. Material/methods: We retrospectively identified all patients with apically located tumors, defined by the epicenter of the tumor being located superiorly to the aortic arch, and treated with SBRT between 2008 and 2013. Patients with a shorter follow-up than 6 months were excluded. Primary aim was to evaluate radiation-induced brachial plexopathy (RIBP). Dose to the plexus was assessed by a retrospective delineation of the brachial plexus on the CT used for treatment planning. Then, Dmax, D0.1cc, D1cc and D3.0cc of the brachial plexus were collected from the dose-volume histograms (DVH) and recalculated to the biologically effective dose (BED) using α/β = 3 Gy. A normal tissue complication probability (NTCP) model, based on four different dose-volume parameters (BED3,max, BED3,0.1cc, BED3,1.0cc, BED3,3.0cc) was fitted to the data. Results: Fifty-two patients with 56 apically located tumors were identified. Median prescription dose per fraction was 15 Gy (range 6-17) and median number of fractions was 3 (3-10). With a median follow-up of 30 months (6.1-72) seven patients experienced maximum grade 2 (scored 3 times) or 3 (scored 4 times) RIBP after a median of 8.7 months (range 4.0-31). Three patients had combined symptoms with pain, sensory and motor affection and four patients had isolated pain. Median BED3,max for the patients experiencing RIBP was 381 Gy (range 30-524) versus BED3,max of 34 Gy (range 0.10-483) for the patients without RIBP. The NTCP models showed a very high predictive ability (area under the receiver operating characteristic curve (AUC) 0.80-0.88). Conclusion: SBRT of apically located lung lesions may cause severe neurological symptoms; for a three-fraction treatment, we suggest that the maximum dose to the plexus should be kept ≤30 Gy (130 Gy BED3).
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Affiliation(s)
- Karin Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumors, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Vitali Grozman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Section of Thoracic Radiology, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Onjukka
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ingmar Lax
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Rolf Lewensohn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumors, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wersäll
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
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Local control and vertebral compression fractures following stereotactic body radiotherapy for spine metastases. J Bone Oncol 2019; 15:100218. [PMID: 30815342 PMCID: PMC6378905 DOI: 10.1016/j.jbo.2019.100218] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 11/20/2022] Open
Abstract
SBRT provides a satisfying local control rate of 88% in patients with spMets. Post-SBRT vertebral compression rate of 4% corresponds to the current literature. >6 months of bisphosphonates use is associated with lower fracture-free survival.
Purpose We aimed to retrospectively assess the incidence of vertebral compression fractures (VCF), examine clinicopathologic factors potentially associated with VCF, and evaluate treatment response in patients who received stereotactic body radiotherapy (SBRT) for spine metastases (spMets). Methods and Materials We identified 78 patients with 125 spMets at baseline and subsequent assessments. Patients received SBRT doses of 16 or 18 Gy. Patients with pre-existing VCF and co-existing local progression were excluded. Spine instability neoplastic score (SINS) was used for spMets categorization. Response to SBRT and VCF were assessed according to the Positron Emission tomography Response Criteria In Solid Tumors (PERCIST) and Genant scores, respectively. Kaplan–Meier analyses were used to assess local control of disease and vertebral compression fracture-free survival (FFS). Results We treated 103 cases with single spMets and 11 cases involving double spMets with SBRT. Progressive disease was reported in 3.2% and 8.2% of the cases in the first and last PET/CT reports, respectively. The distribution of treatment response in the remaining patients was: complete response in 30.6% of patients, partial response in 47.1% of patients, and stable disease in 22.3% of patients in the first PET/CT; complete response in 62.3% of patients, partial response in 16.7% of patients, and stable disease in 21% of patients at the last monitoring. Local failures were observed in 15 (12%) of cases. Median SINS was 5 (range: 1−13); majority of patients in our cohort (70.4%) were categorized as stable according to SINS, five (4%) patients had Grade 3 VCF at a median time of 16 months after SBRT (range: 2−22 months), and 60% of VCF occurred after an interval of at least 12 months after SBRT. No bisphosphonate usage was significantly associated with VCF (r = −0.204; p = 0.022). Median FFS was 21 months. Univariate analyses indicated that female gender (p < 0.001), bisphosphonate use (p = 0.005), >6 months of bisphosphonates use (p = 0.002), and the lowest vertebral body collapse score (p = 0.023) were associated with higher FFS. Female gender (p = 0.007), >6 months of bisphosphonates usage (p = 0.018), and the lowest vertebral body collapse score (p = 0.044) retained independent significance. Conclusions This study demonstrated that spine SBRT with doses of 16–18 Gy promises good local control of disease with acceptable VCF rates. Lowest vertebral body collapse score, female gender, and >6 months of bisphosphonate use were significantly associated with longer FFS.
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Kenny C, Gilheaney Ó, Walsh D, Regan J. Oropharyngeal Dysphagia Evaluation Tools in Adults with Solid Malignancies Outside the Head and Neck and Upper GI Tract: A Systematic Review. Dysphagia 2018; 33:303-320. [PMID: 29607447 DOI: 10.1007/s00455-018-9892-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/28/2018] [Indexed: 12/14/2022]
Abstract
Dysphagia is often associated with head and neck and upper gastrointestinal (GI) tract cancers. Evidence suggests that those with solid malignancies in other primary sites may also have swallowing difficulties. Timely and accurate identification of dysphagia is important given the impact it has on hydration, medical treatment, nutrition, prognosis, and quality of life. A systematic review was conducted to identify swallow screening, evaluation, and quality of life tools for those with solid malignancies outside the head and neck and upper GI tract. Ten electronic databases, one journal and two published conference proceedings were searched. Following deduplication, 7435 studies were examined for relevance. No tools were validated solely in this cancer population, though some included this group in larger cohorts. Comments are provided on the diagnostic properties and applicability of these tools. In the absence of appropriate diagnostic instruments, the exact prevalence of dysphagia and its impact on clinical and psychosocial well-being remain unknown. Accurate and adequate measurement of therapeutic intervention is also compromised. This review establishes the need for validated dysphagia evaluation tools for this clinical population.
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Affiliation(s)
- Ciarán Kenny
- Academic Department of Palliative Medicine, Our Lady's Hospice & Care Services, Harold's Cross, Dublin 6W, Ireland.
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland.
| | - Órla Gilheaney
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
| | - Declan Walsh
- Academic Department of Palliative Medicine, Our Lady's Hospice & Care Services, Harold's Cross, Dublin 6W, Ireland
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland
- School of Medicine & Medical Science, University College Dublin, Dublin 4, Ireland
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin 2, Ireland
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Ottenhausen M, Ntoulias G, Bodhinayake I, Ruppert FH, Schreiber S, Förschler A, Boockvar JA, Jödicke A. Intradural spinal tumors in adults-update on management and outcome. Neurosurg Rev 2018; 42:371-388. [PMID: 29455369 DOI: 10.1007/s10143-018-0957-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/16/2018] [Accepted: 02/06/2018] [Indexed: 12/28/2022]
Abstract
Among spinal tumors that occur intradurally, meningiomas, nerve sheath tumors, ependymomas, and astrocytomas are the most common. While a spinal MRI is the state of the art to diagnose intradural spinal tumors, in some cases CT scans, angiography, CSF analyses, and neurophysiological examination can be valuable. The management of these lesions depends not only on the histopathological diagnosis but also on the clinical presentation and the anatomical location, allowing either radical resection as with most extramedullary lesions or less invasive strategies as with intramedullary lesions. Although intramedullary lesions are rare and sometimes difficult to manage, well-planned treatment can achieve excellent outcome without treatment-related deficits. Technical advances in imaging, neuromonitoring, minimally invasive approaches, and radiotherapy have improved the outcome of intradural spinal tumors. However, the outcome in malignant intramedullary tumors remains poor. While surgery is the mainstay treatment for many of these lesions, radiation and chemotherapy are of growing importance in recurrent and multilocular disease. We reviewed the literature on this topic to provide an overview of spinal cord tumors, treatment strategies, and outcomes. Typical cases of extra- and intramedullary tumors are presented to illustrate management options and outcomes.
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Affiliation(s)
- Malte Ottenhausen
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Georgios Ntoulias
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany
| | | | | | - Stefan Schreiber
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Annette Förschler
- Department of Radiology and Neuroradiology, Schlossparkklinik, Berlin, Germany
| | - John A Boockvar
- Department of Neurosurgery, Lenox Hill Hospital, New York, USA
| | - Andreas Jödicke
- Department of Neurosurgery, Vivantes Klinikum Neukölln, Berlin, Germany.
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