1
|
Alcorn S, Cortés ÁA, Bradfield L, Brennan M, Dennis K, Diaz DA, Doung YC, Elmore S, Hertan L, Johnstone C, Jones J, Larrier N, Lo SS, Nguyen QN, Tseng YD, Yerramilli D, Zaky S, Balboni T. External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:377-397. [PMID: 38788923 DOI: 10.1016/j.prro.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases. METHODS The ASTRO convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systematic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed. RESULTS For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with nonspine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction (800 cGy/1 fx), 2000 cGy/5 fx, 2400 cGy/6 fx, or 3000 cGy/10 fx. Spinal cord or cauda equina compression in patients who are ineligible for surgery and receiving conventional RT are recommended 800 cGy/1 fx, 1600 cGy/2 fx, 2000 cGy/5 fx, or 3000 cGy/10 fx. Symptomatic bone metastases in selected patients with good performance status without surgery or neurologic symptoms/signs are conditionally recommended stereotactic body RT over conventional palliative RT. Spine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, 2400 cGy/6 fx, or 2000 cGy/8 fx; nonspine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, or 2400 cGy/6 fx. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision making is recommended. CONCLUSIONS Based on published data, the ASTRO task force's recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.
Collapse
Affiliation(s)
- Sara Alcorn
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota.
| | - Ángel Artal Cortés
- Department of Medical Oncology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | | | - Kristopher Dennis
- Division of Radiation Oncology, Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Dayssy A Diaz
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Shekinah Elmore
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Hertan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Candice Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua Jones
- Department of Radiation Oncology, Rochester Regional Health, Rochester, New York
| | - Nicole Larrier
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, Texas
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sandra Zaky
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Issany A, Iovoli AJ, Wang R, Shekher R, Ma SJ, Goulenko V, Fekrmandi F, Prasad D. Vertebral body collapse after spine stereotactic body radiation therapy: a single-center institutional experience. Radiol Oncol 2024; 58:425-431. [PMID: 38861691 PMCID: PMC11406905 DOI: 10.2478/raon-2024-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/26/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Spine stereotactic body radiation therapy (SBRT) for the treatment of metastatic disease is increasingly utilized owing to improved pain and local control over conventional regimens. Vertebral body collapse (VBC) is an important toxicity following spine SBRT. We investigated our institutional experience with spine SBRT as it relates to VBC and spinal instability neoplastic score (SINS). PATIENTS AND METHODS Records of 83 patients with 100 spinal lesions treated with SBRT between 2007 and 2022 were reviewed. Clinical information was abstracted from the medical record. The primary endpoint was post-treatment VBC. Logistic univariate analysis was performed to identify clinical factors associated with VBC. RESULTS Median dose and number of fractions used was 24 Gy and 3 fractions, respectively. There were 10 spine segments that developed VBC (10%) after spine SBRT. Median time to VBC was 2.4 months. Of the 11 spine segments that underwent kyphoplasty prior to SBRT, none developed subsequent VBC. No factors were associated with VBC on univariate analysis. CONCLUSIONS The rate of vertebral body collapse following spine SBRT is low. Prophylactic kyphoplasty may provide protection against VBC and should be considered for patients at high risk for fracture.
Collapse
Affiliation(s)
- Arsh Issany
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA
| | - Austin J Iovoli
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Richard Wang
- Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, USA
| | - Rohil Shekher
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Victor Goulenko
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Fatemeh Fekrmandi
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| | - Dheerendra Prasad
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, New York, USA
| |
Collapse
|
3
|
Chen H, Atenafu EG, Zeng KL, Chan A, Detsky J, Myrehaug S, Soliman H, Tseng CL, Sahgal A, Maralani PJ. Magnetic Resonance Imaging Frequency After Stereotactic Body Radiation Therapy for Spine Metastases. Int J Radiat Oncol Biol Phys 2024; 119:1413-1421. [PMID: 38373656 DOI: 10.1016/j.ijrobp.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/03/2024] [Accepted: 02/08/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is increasingly being used to treat spine metastases. Current post-SBRT imaging surveillance strategies in this patient population may benefit from a more data-driven and personalized approach. The objective of this study was to develop risk-stratified post-SBRT magnetic resonance imaging (MRI) surveillance strategies using quantitative methods. METHODS AND MATERIALS Adult patients with bony spine metastases treated with SBRT between 2008 and 2021 and who had at least 2 follow-up spine MRIs were reviewed retrospectively. A recursive partitioning analysis model was developed to separate patients into different risk categories for post-SBRT progression anywhere within the spine. Imaging intervals were derived for each risk category using parametric survival regression based on multiple expected spine progression rates per scan. RESULTS A total of 446 patients and 1039 vertebral segments were included. Cumulative incidence of spine progression was 19.2% at 1 year, 26.7% at 2 years, and 35.3% at 4 years. The internally validated risk stratification model was able to divide patients into 3 risk categories based on epidural disease, paraspinal disease, and Spinal Instability Neoplastic Score category. The 4-year risk of spine progression was 23.4%, 39.0%, and 51.8%, respectively, for the low-, intermediate-, and high-risk groups. Using an expected per-scan spine progression rate of 3.75%, the low-risk group would require follow-up scans every 6.0 months (95% CI, 4.9-7.6) and the intermediate-risk group would require surveillance every 3.1 months (95% CI, 2.6-3.7). At an expected spine progression rate of 5%, the high-risk group would require surveillance every 1.3 months (95% CI, 1.1-1.6) during the first 13.2 months after SBRT and every 5.9 months thereafter (95% CI, 2.8-12.3). CONCLUSIONS Data-driven follow-up MRI surveillance intervals at a range of expected spine progression rates have been determined for patients at different risks of spine progression based on an internally validated, single-institution risk stratification model.
Collapse
Affiliation(s)
- Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada.
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Aimee Chan
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Pejman J Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Moraes FY, Gouveia AG, Marta GN, da Silva MF, Hamamura AC, Tsakiridis T, Yan M, Viani GA. Meta-Analysis of Stereotactic Body Radiation ThERapy in Nonspine BONE Metastases (MASTER-BONES). Int J Radiat Oncol Biol Phys 2024; 119:1403-1412. [PMID: 38244875 DOI: 10.1016/j.ijrobp.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/03/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024]
Abstract
PURPOSE The efficacy and safety of stereotactic body radiation therapy (SBRT) for patients with nonspine bone metastases remains in question. A systematic review and meta-analysis were performed to evaluate SBRT treatment outcomes in nonspine bone metastases. METHODS AND MATERIALS Eligible studies were retrieved from MEDLINE, Embase, Scielo, the Cochrane Library, and annual meeting proceedings through July 6, 2023. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline recommendations. Quantitative synthesis was performed using a random-effects model. Meta-regression was performed to determine correlation between clinical and treatment factors with the local failure (LF) and fracture rate. P values ≤.05 were deemed statistically significant. RESULTS Seven retrospective studies, with a total of 807 patients (1048 lesions) treated with SBRT were included, with median follow-up ranging from 7.6 to 26.5 months. The most common SBRT sites were pelvis (39.2%), ribs (25.8%), femur (16.7%), and humerus/shoulder region (8.7%). At 1 year, the LF and fracture rate were 7% (95% CI, 5.5%-8.5%; I2 = 0; n = 75/1048) and 5.3% (95% CI, 3%-7.5%; I2 = 0; n = 65/1010). The 2-year cumulative LF incidence was 12.1% (95% CI, 10%-15.5%). The overall survival and progression-free survival at 1 year were 82% (95% CI, 75%-88%; I2 = 82%; n = 746/867) and 33.5% (95% CI, 26%-41%; I2 = 0%; n = 51/152), with a median of 20.2 months (95% CI, 10.9-49.1 months) and 8.3 months (95% CI, 6.3-10.3 months) for overall survival and progression-free survival, respectively. Meta-regression analysis revealed a significant relationship between planning target volume and fracture rate (P < .05). Ribs (2.5%) followed by the femur (1.9%; 95% CI, 0%-6.1%) were the most common fracture sites. The occurrence of pain flare, fatigue, and dermatitis were 7%, 5.4%, and 0.65%, respectively. CONCLUSIONS Stereotactic body radiation proves both safety and efficacy for non-spine bone metastases, and although serious complications (grade 3) are rare, one case of grade 5 complication was reported. Careful consideration of target volume is crucial due to its link with a higher fracture risk.
Collapse
Affiliation(s)
- Fabio Ynoe Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Andre Guimaraes Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology, Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Gustavo Nader Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department, Hospital Sirio Libanês, São Paulo, Brazil
| | - Mauricio Fraga da Silva
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department, Santa Maria Federal University, Rio Grande do Sul, Brazil
| | - Ana Carolina Hamamura
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Theodoros Tsakiridis
- Department of Oncology, Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Michael Yan
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Gustavo Arruda Viani
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil.
| |
Collapse
|
5
|
Shea GKH, Kwan KYH. Management of Metastatic Spinal Disease - A Practical Approach. Global Spine J 2024:21925682231173646. [PMID: 39069670 DOI: 10.1177/21925682231173646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE This review presents a comprehensive approach to the management of spinal metastases. METHODS N/A. RESULTS The wide spectrum of clinical presentation in spinal metastases necessitates a personalized approach to treatment planning. This includes a comprehensive diagnostic workup, oncological management, palliation of symptoms, and surgical intervention if appropriate. A systematic and multidisciplinary approach allows optimal shared decision making to reach an evidence-informed and value-congruent treatment plan for the patient. We highlight how advances in stereotactic body radiotherapy (SBRT) and separation surgery may be incorporated into clinical management from a spine surgeon's perspective. CONCLUSION This review summarizes the approach and management of spinal metastases, its outcomes and complications.
Collapse
Affiliation(s)
- Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Kenny Yat Hong Kwan
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| |
Collapse
|
6
|
Roth C, Weiss K. Palliative Care Needs of Patients with Musculoskeletal Malignancies. Curr Oncol Rep 2024; 26:784-790. [PMID: 38789669 DOI: 10.1007/s11912-024-01543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE OF REVIEW This review aims to assess the literature regarding current treatment options for the palliative care of patients with advanced musculoskeletal malignancies whether primary or metastatic. RECENT FINDINGS The inclusion of specialized palliative care physicians, in conjunction with surgeons, medical oncologists, radiation oncologists, interventional radiologists, and mental health professionals, results in better control of end-of-life symptoms in both children and adults with terminal musculoskeletal malignancies. The palliative care of patients with musculoskeletal malignancies requires a multi-disciplinary team and benefits from specialized palliative care physicians. The unique impacts of musculoskeletal malignancies on ambulation and independence creates additional mental and physical burdens on patients and care-takers alike. Palliative care should focus on preserving ambulatory function and patient independence, in addition to managing chronic pain and other end-of-life symptoms common to these malignancies.
Collapse
Affiliation(s)
- Clark Roth
- Division of Orthopedic Oncology, Department of Orthopedic Surgery, The University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Kurt Weiss
- Division of Orthopedic Oncology, Department of Orthopedic Surgery, The University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
| |
Collapse
|
7
|
Ishaque AH, Alvi MA, Pedro K, Fehlings MG. Imaging protocols for non-traumatic spinal cord injury: current state of the art and future directions. Expert Rev Neurother 2024; 24:691-709. [PMID: 38879824 DOI: 10.1080/14737175.2024.2363839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 05/31/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Non-traumatic spinal cord injury (NTSCI) is a term used to describe damage to the spinal cord from sources other than trauma. Neuroimaging techniques such as computerized tomography (CT) and magnetic resonance imaging (MRI) have improved our ability to diagnose and manage NTSCIs. Several practice guidelines utilize MRI in the diagnostic evaluation of traumatic and non-traumatic SCI to direct surgical intervention. AREAS COVERED The authors review practices surrounding the imaging of various causes of NTSCI as well as recent advances and future directions for the use of novel imaging modalities in this realm. The authors also present discussions around the use of simple radiographs and advanced MRI modalities in clinical settings, and briefly highlight areas of active research that seek to advance our understanding and improve patient care. EXPERT OPINION Although several obstacles must be overcome, it appears highly likely that novel quantitative imaging features and advancements in artificial intelligence (AI) as well as machine learning (ML) will revolutionize degenerative cervical myelopathy (DCM) care by providing earlier diagnosis, accurate localization, monitoring for deterioration and neurological recovery, outcome prediction, and standardized practice. Some intriguing findings in these areas have been published, including the identification of possible serum and cerebrospinal fluid biomarkers, which are currently in the early phases of translation.
Collapse
Affiliation(s)
- Abdullah H Ishaque
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
8
|
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 PMCID: PMC11268289 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.
Collapse
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
| |
Collapse
|
9
|
Ito K, Nakajima Y, Taguchi K, Ogawa H, Saito M, Murofushi KN. Phase II Clinical Trial of Second Course of Stereotactic Body Radiotherapy for Spinal Metastases. Cancers (Basel) 2024; 16:2286. [PMID: 38927990 PMCID: PMC11201663 DOI: 10.3390/cancers16122286] [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: 03/19/2024] [Revised: 05/26/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE The optimal method for the second course of stereotactic body radiotherapy (SBRT) for spinal metastases remains poorly established. This single-center, single-arm, phase II trial was conducted to propose a safe and effective salvage spine SBRT. METHODS The patients initially treated with SBRT for spine-targeted protocol treatment, or for areas adjacent to the spine, were enrolled. The second SBRT dose was 30 Gy delivered in five fractions; the spinal cord dose constraint was 15.5 Gy at the maximum point dose. The brachial or lumbosacral plexuses were dose-constrained to <30 Gy if the boundary between the nerves and tumors was detected. The primary endpoint was dose-limiting toxicity (DLT) (grade ≥ 3 severe radiation-related toxicity) within a year after the second SBRT. RESULTS The second SBRT was administered to the same spinal level in 12 patients and to an adjacent spinal level in 8 patients. SBRT2 was performed for 14 painful lesions, 10 MESCC, and 6 oligometastases, with some lesions having multiple indications. The median interval between SBRT sessions was 21 months (range: 6-51 months). The median follow-up duration was 14 months. No radiation myelopathy or local failure was reported during the follow-up period. DLT was confirmed in two patients (10%) within a year, both of whom developed grade 3 lumbosacral plexopathy. These two patients received SBRT twice to the S1-2 and S1-5 vertebrae, respectively, and both experienced paralysis of the tibialis anterior muscle (L5 level). Grade 3 late adverse effects (including lumbosacral plexopathy and vertebral compression fracture) were observed in 25% of the patients throughout the entire follow-up period. CONCLUSIONS The second spine SBRT achieved good local control without causing myelopathy. However, one-quarter of the patients experienced grade 3 late adverse effects, suggesting that the treatment protocol carries a risk of toxicity.
Collapse
Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-ku, Tokyo 154-8525, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Makoto Saito
- Division of Clinical Research Support, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Keiko Nemoto Murofushi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| |
Collapse
|
10
|
Barzilai O, Sahgal A, Rhines LD, Versteeg AL, Sciubba DM, Lazary A, Weber MH, Schuster JM, Boriani S, Bettegowda C, Arnold PM, Clarke MJ, Laufer I, Fehlings MG, Gokaslan ZL, Fisher CG. Patient-Reported and Clinical Outcomes of Surgically Treated Patients With Symptomatic Spinal Metastases: Results From Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO), a Prospective, Multi-Institutional and International Study. Neurosurgery 2024:00006123-990000000-01181. [PMID: 38832791 DOI: 10.1227/neu.0000000000002989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/18/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The palliative impact of spine surgery for metastatic disease is evolving with improvements in surgical technique and multidisciplinary cancer care. The goal of this study was to prospectively evaluate long-term clinical outcomes including health-related quality-of-life (HRQOL) measures, using spine cancer-specific patient-reported-outcome (PRO) measures, in patients with symptomatic spinal metastases who underwent surgical management. METHODS The Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO, ClinicalTrials.gov identifier: NCT01825161) trial is a prospective-observational cohort study that included 10 specialist centers in North America and Europe. Patients aged 18 to 75 years who underwent surgery for spinal metastases were included. Prospective assessments included both spine tumor-specific and generic PRO tools which were collected for a minimum of 2 years post-treatment or until death. RESULTS Two hundred and eighty patients (51.8% female, mean age 57.9 years) were included. At presentation, the mean Charlson Comorbidity Index was 6.0, 35.7% had neurological deficits as defined by the American Spinal Cord Injury Association scores, 47.2% had high-grade epidural spinal cord compression (2-3), and 89.6% had impending or frank instability as measured by a Spinal Instability Neoplastic Score of ≥7. The most common primary tumor sites were breast (20.2%), lung (18.8%), kidney (16.2%), and prostate (6.5%). The median overall survival postsurgery was 501 days, and the 2-year progression-free-survival rate was 38.4%. Compared with baseline, significant and durable improvements in HRQOL were observed at the 6-week, 12-week, 26-week, 1-year, and 2-year follow-up assessments from a battery of PRO questionnaires including the spine cancer-specific, validated, Spine Oncology Study Group Outcomes Questionnaire v2.0, the Short Form 36 version 2, EuroQol-5 Dimension (3L), and pain numerical rating scale score. CONCLUSION Multi-institutional, prospective-outcomes data confirm that surgical decompression and/or stabilization provides meaningful and durable improvements in multiple HRQOL domains, including spine-specific outcomes based on the Spine Oncology Study Group Outcomes Questionnaire v2.0, for patients with metastatic spine disease.
Collapse
Affiliation(s)
- Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Laurence D Rhines
- Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Centre, Houston , Texas , USA
| | - Anne L Versteeg
- Division of Surgery, Department of Orthopaedic Surgery, University of Toronto, Toronto , Ontario , Canada
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset , New York , USA
| | - Aron Lazary
- National Center for Spinal Disorders, Buda Health Center, Budapest , Hungary
| | - Michael H Weber
- Spine Surgery Program, Department of Surgery, McGill University, Montreal , Québec , Canada
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia , Pennsylvania , USA
| | | | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Paul M Arnold
- Department of Neurosurgery, Carle Foundation Hospital, Urbana , Illinois , USA
| | - Michelle J Clarke
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Ilya Laufer
- Department of Neurosurgery, New York University Langone Health, New York , New York , USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, University Health Network, Toronto , Ontario , Canada
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Charles G Fisher
- Spine Surgery Institute, Vancouver General Hospital, University of British Columbia, Vancouver , British Columbia , Canada
| |
Collapse
|
11
|
Karger CP, Elter A, Dorsch S, Mann P, Pappas E, Oldham M. Validation of complex radiotherapy techniques using polymer gel dosimetry. Phys Med Biol 2024; 69:06TR01. [PMID: 38330494 DOI: 10.1088/1361-6560/ad278f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/08/2024] [Indexed: 02/10/2024]
Abstract
Modern radiotherapy delivers highly conformal dose distributions to irregularly shaped target volumes while sparing the surrounding normal tissue. Due to the complex planning and delivery techniques, dose verification and validation of the whole treatment workflow by end-to-end tests became much more important and polymer gel dosimeters are one of the few possibilities to capture the delivered dose distribution in 3D. The basic principles and formulations of gel dosimetry and its evaluation methods are described and the available studies validating device-specific geometrical parameters as well as the dose delivery by advanced radiotherapy techniques, such as 3D-CRT/IMRT and stereotactic radiosurgery treatments, the treatment of moving targets, online-adaptive magnetic resonance-guided radiotherapy as well as proton and ion beam treatments, are reviewed. The present status and limitations as well as future challenges of polymer gel dosimetry for the validation of complex radiotherapy techniques are discussed.
Collapse
Affiliation(s)
- Christian P Karger
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Alina Elter
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Stefan Dorsch
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Philipp Mann
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Evangelos Pappas
- Radiology & Radiotherapy Sector, Department of Biomedical Sciences, University of West Attica, Athens, Greece
| | - Mark Oldham
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| |
Collapse
|
12
|
Sacino AN, Chen H, Sahgal A, Bettegowda C, Rhines LD, Maralani P, Redmond KJ. Stereotactic body radiation therapy for spinal metastases: A new standard of care. Neuro Oncol 2024; 26:S76-S87. [PMID: 38437670 PMCID: PMC10911798 DOI: 10.1093/neuonc/noad225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Advancements in systemic therapies for patients with metastatic cancer have improved overall survival and, hence, the number of patients living with spinal metastases. As a result, the need for more versatile and personalized treatments for spinal metastases to optimize long-term pain and local control has become increasingly important. Stereotactic body radiation therapy (SBRT) has been developed to meet this need by providing precise and conformal delivery of ablative high-dose-per-fraction radiation in few fractions while minimizing risk of toxicity. Additionally, advances in minimally invasive surgical techniques have also greatly improved care for patients with epidural disease and/or unstable spines, which may then be combined with SBRT for durable local control. In this review, we highlight the indications and controversies of SBRT along with new surgical techniques for the treatment of spinal metastases.
Collapse
Affiliation(s)
- Amanda N Sacino
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chetan Bettegowda
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Laurence D Rhines
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
13
|
Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
Collapse
Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
14
|
Zhang M, Zhang M, Yu M, Song Y, Wang Y. A study on short-term efficacy and safety of Iodine-125 brachytherapy coupled with preoperative arterial chemoembolization for hypervascular spinal metastasis. Brachytherapy 2024; 23:207-213. [PMID: 38044181 DOI: 10.1016/j.brachy.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/05/2023] [Accepted: 10/05/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE Hypervascular spinal metastatic malignancies can cause severe pain and intraoperative bleeding and selection of appropriate treatment can be challenging. This study aimed to observe the short-term efficacy and safety of Iodine-125 brachytherapy (125I BT) combined with preoperative transcatheter arterial chemoembolization (TACE) for hypervascular spinal metastasis. METHODS This study included a total of 33 patients (39 lesions) with hypervascular spinal metastasis. All of them carried out a regimen of TACE followed by 125I BT under CT guidance. A brachytherapy planning system has been utilized for the purpose of designing treatment plans and optimizing dose distribution. Pain relief was evaluated using a numeric rating scale (NRS) and intraoperative bleeding was recorded. Follow-up was conducted for 6 months to observe the local control rate and clinical complications. RESULTS All patients tolerated combined treatment well and intraoperative blood loss of every patient was not more than 10 ml. The 2- and 6- month local disease control rates were 92.3% and 83.8%. The NRS scores for thirty-three tumor patients before surgery and after one week, two, and six months of surgery were recorded as 7.33 ± 1.80, 7.39 ± 1.89, 3.15 ± 2.35, and 4.16 ± 2.15, respectively. The NRS score 2 months after treatment was found considerably lower in comparison to the NRS score before operation (p < 0.05). CONCLUSIONS According to our findings, 125I BT as well as preoperative TACE leads to perioperative hemostasis, pain alleviation, and reduced tumor burden, indicating that this combined treatment could be effective and promising for hypervascular spinal metastases.
Collapse
Affiliation(s)
- Menglong Zhang
- Department of Minimally Invasive Intervention, Ganzhou People's Hospital, Zhanggong District, Ganzhou, Jiangxi, China.
| | - Menglin Zhang
- Chengyang District People's Hospital of Qingdao, Shandong, China
| | - Miaoshen Yu
- Department of Minimally Invasive Intervention, Ganzhou People's Hospital, Zhanggong District, Ganzhou, Jiangxi, China
| | - Yusheng Song
- Department of Minimally Invasive Intervention, Ganzhou People's Hospital, Zhanggong District, Ganzhou, Jiangxi, China
| | - Yan Wang
- Department of Minimally Invasive Intervention, Ganzhou People's Hospital, Zhanggong District, Ganzhou, Jiangxi, China
| |
Collapse
|
15
|
Ujkic L, Sutanto R, Knöll P, Zarghooni K, Rosenbrock J, Walter S. [Acute spinal cord compression under systemic therapy - radiotherapy or surgery?]. Aktuelle Urol 2024; 55:50-53. [PMID: 37758040 DOI: 10.1055/a-2099-1847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Vertebral bodies are one of the most common metastasis sites found in advanced prostate cancer and have a significant impact on patients' quality of life. Spinal metastases frequently cause severe back pain and in some occasions can lead to secondary complications, with serious neurological deficits and loss of function. The main treatment goals include adequate pain management, controlling tumour growth and restoring spinal stability. Publications on the role of surgery - both conventional and stereotactic radiotherapy, and either as an individual modality or in combination - have been inconclusive. The NOMS score has proven to be useful in making treatment decisions. Existing data show better outcomes in patients with surgical therapy, both when performed in isolation and also combined with radiotherapy, in which some of the cohorts studied including patients with primary cancer other than prostate cancer. Comparative studies that specifically investigate the superiority of specific therapy modalities for metastatic prostate carcinoma are scarce. Similarly, there are limited data on microsurgical interventions for spinal metastases. Radiotherapy alone is crucial in the setting of palliation, especially for pain relief, and its effectiveness has been shown in many studies. The patient's life expectancy plays a crucial role in deciding the most appropriate treatment approach. Given the complexity of the patient population, a multimodal therapy approach is necessary. Current trends in therapy favour greater use of surgical interventions, particularly in the early detection of spinal metastases.
Collapse
Affiliation(s)
- Lidija Ujkic
- Klinik für Orthopädie, Unfallchirurgie und plastisch-ästhetische Chirurgie, Uniklinik Köln, Köln, Germany
| | - Ricardo Sutanto
- Klinik für Radioonkologie, Cyberknife und Strahlentherapie, Uniklinik Köln, Köln, Germany
| | - Peter Knöll
- Klinik für Orthopädie, Unfallchirurgie und plastisch-ästhetische Chirurgie, Uniklinik Köln, Köln, Germany
| | - Kourosh Zarghooni
- Klinik für Orthopädie und Unfallchirurgie, HELIOS Klinikum Hildesheim, Hildesheim, Germany
| | - Johannes Rosenbrock
- Klinik für Radioonkologie, Cyberknife und Strahlentherapie, Uniklinik Köln, Köln, Germany
| | - Sebastian Walter
- Klinik für Orthopädie, Unfallchirurgie und plastisch-ästhetische Chirurgie, Uniklinik Köln, Köln, Germany
| |
Collapse
|
16
|
Ciérvide R, Hernando O, López M, Montero Á, Zucca D, Sánchez E, Álvarez B, García-Aranda M, Chen Zhao X, Valero J, Alonso R, Martí J, de la Casa MÁ, Alonso L, García J, Garcia de Acilu P, Prado A, Fernandez Leton P, Rubio C. Stereotactic body radiation therapy (SBRT) for spinal metastases: 12 years of a single center experience. Clin Transl Oncol 2023; 25:3395-3404. [PMID: 37058207 DOI: 10.1007/s12094-023-03188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE To assess the clinical outcomes of patients with spine metastases treated with SBRT at our institution. MATERIALS AND METHODS Patients with spine metastases treated with SBRT (1 fraction/18 Gy or 5 fractions/7 Gy) during the last 12 years have been analyzed. All patients were simulated supine in a vacuum cushion or with a shoulder mask. CT scans and MRI image registration were performed. Contouring was based on International Spine-Radiosurgery-Consortium-Consensus-Guidelines. Highly conformal-techniques (IMRT/VMAT) were used for treatment planning. Intra and interfraction (CBCT or X-Ray-ExacTrac) verification were mandatory. RESULTS From February 2010 to January 2022, 129 patients with spinal metastases were treated with SBRT [1 fraction/18 Gy (75%) or 5 fractions/7 Gy] (25%). For patients with painful metastases (74/129:57%), 100% experienced an improvement in pain after SBRT. With a median follow-up of 14.2 months (average 22.9; range 0.5-140) 6 patients (4.6%) experienced local relapse. Local progression-free survival was different, considering metastases's location (p < 0.04). The 1, 2 and 3 years overall survival (OS) were 91.2%, 85.1% and 83.2%, respectively. Overall survival was significantly better for patients with spine metastases of breast and prostate cancers compared to other tumors (p < 0.05) and significantly worse when visceral metastases were present (p < 0.05), when patients were metastatic de novo (p < 0.05), and in those patients receiving single fraction SBRT (p: 0.01). CONCLUSIONS According to our experience, SBRT for patients with spinal metastases was effective in terms of local control and useful to reach pain relief. Regarding the intent of the treatment, an adequate selection of patients is essential to propose this ablative approach.
Collapse
Affiliation(s)
- Raquel Ciérvide
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain.
| | - Ovidio Hernando
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Mercedes López
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Ángel Montero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Daniel Zucca
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Beatriz Álvarez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Mariola García-Aranda
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Xin Chen Zhao
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Jeannette Valero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Rosa Alonso
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Jaime Martí
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Miguel Ángel de la Casa
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Leire Alonso
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Juan García
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Paz Garcia de Acilu
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Alejandro Prado
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Pedro Fernandez Leton
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Carmen Rubio
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| |
Collapse
|
17
|
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.
Collapse
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.
| |
Collapse
|
18
|
Ito K, Taguchi K, Nakajima Y, Ogawa H, Sugita S, Murofushi KN. Incidence and Prognostic Factors of Painful Vertebral Compression Fracture Caused by Spine Stereotactic Body Radiotherapy. J Clin Med 2023; 12:jcm12113853. [PMID: 37298048 DOI: 10.3390/jcm12113853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/28/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023] Open
Abstract
Most studies of vertebral compression fractures (VCF) caused by stereotactic body radiotherapy (SBRT) do not discuss the symptoms of this complication. In this paper, we aimed to determine the rate and prognostic factors of painful VCF caused by SBRT for spinal metastases. Spinal segments with VCF in patients treated with spine SBRT between 2013 and 2021 were retrospectively reviewed. The primary endpoint was the rate of painful VCF (grades 2-3). Patient demographic and clinical characteristics were evaluated as prognosticators. In total, 779 spinal segments in 391 patients were analyzed. The median follow-up after SBRT was 18 (range: 1-107) months. Sixty iatrogenic VCFs (7.7%) were identified. The rate of painful VCF was 2.4% (19/779). Eight (1.0%) VCFs required surgery for internal fixation or spinal canal decompression. The painful VCF rate was significantly higher in patients with no posterolateral tumor involvement than in those with bilateral or unilateral involvement (50% vs. 23%; p = 0.042); it was also higher in patients with spine without fixation than in those with fixation (44% vs. 0%; p < 0.001). Painful VCFs were confirmed in only 2.4% of all the irradiated spinal segments. The absence of posterolateral tumor involvement and no fixation was significantly associated with painful VCF.
Collapse
Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-ku, Tokyo 154-8525, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Department of Radiation Oncology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Shurei Sugita
- Department of Orthopedics, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Keiko Nemoto Murofushi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| |
Collapse
|
19
|
Cruz-Lim EM, Cereno RE, Cañal JP, Vega G, Inocencio E, Mou B. Challenges to Improving Access to Stereotactic Body Radiation Therapy and Radiosurgery in the Philippines: A Case Study for Lower-Middle Income Countries. Int J Radiat Oncol Biol Phys 2023; 116:430-438. [PMID: 37179092 DOI: 10.1016/j.ijrobp.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Ella Mae Cruz-Lim
- Department of Radiation Oncology, Zamboanga City Medical Center, Zamboanga City, Philippines; Department of Radiation Oncology, BC Cancer Kelowna, Kelowna, Canada.
| | - Reno Eufemon Cereno
- Department of Radiation Oncology, BC Cancer Kelowna, Kelowna, Canada; Department of Radiation Oncology, Manila Doctors Hospital, Manila, Philippines
| | - Johanna Patricia Cañal
- Division of Radiation Oncology, Department of Radiology, Philippine General Hospital, Manila, Philippines
| | - Gaudencio Vega
- Department of Radiation Oncology, The Medical City, Manila, Philippines
| | - Elrick Inocencio
- Division of Radiation Oncology, Department of Radiology, Philippine General Hospital, Manila, Philippines
| | - Benjamin Mou
- Department of Radiation Oncology, BC Cancer Kelowna, Kelowna, Canada
| |
Collapse
|
20
|
Iramina H, Nakamura M, Nakamura K, Fujimoto T, Mizowaki T. Quantification of six-degree-of-freedom motion during beam delivery in spine stereotactic body radiotherapy using intra-irradiation cone-beam computed tomography imaging technique. Phys Med 2023; 110:102605. [PMID: 37167776 DOI: 10.1016/j.ejmp.2023.102605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/22/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE Quantifying intra-fractional six-degree-of-freedom (6DoF) residual errors or motion from approved patient setups is necessary for accurate beam delivery in spine stereotactic body radiotherapy. However, previously reported errors were not acquired during beam delivery. Therefore, we aimed to quantify the 6DoF residual errors and motions during arc beam delivery using a concurrent cone-beam computed tomography (CBCT) imaging technique, intra-irradiation CBCT. METHODS Consecutive 15 patients, 19 plans for various treatment sites, and 199 CBCT images were analyzed. Pre-irradiation CBCT was performed to verify shifts from the initial patient setup using the ExacTrac system. During beam delivery by two or three co-planar full-arc rotations, CBCT imaging was performed concurrently. Subsequently, an intra-irradiation CBCT image was reconstructed. Pre- and intra-irradiation CBCT images were rigidly registered to a planning CT image based on the bone to quantify 6DoF residual errors. RESULTS 6DoF residual errors quantified using pre- and intra-irradiation CBCTs were within 2.0 mm/2.0°, except for one measurement. The mean elapsed time (mean ± standard deviation [min:sec]) after pre-irradiation CBCT to the end of the last arc beam delivery was 6:08 ± 1:25 and 7:54 ± 2:14 for the 2- and 3-arc plans, respectively. Root mean squares of residual errors for several directions showed significant differences; however, they were within 1.0 mm/1.0°. Time-dependent analysis revealed that the residual errors tended to increase with elapsed time. CONCLUSION The errors represent the optimal intra-fractional error compared with those acquired using the pre-, inter-beam, and post-6DoF image guidance and can be acquired within a standard treatment timeslot.
Collapse
Affiliation(s)
- Hiraku Iramina
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Mitsuhiro Nakamura
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Kiyonao Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takahiro Fujimoto
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| |
Collapse
|
21
|
Nguyen EK, Ruschin M, Zhang B, Soliman H, Myrehaug S, Detsky J, Chen H, Sahgal A, Tseng CL. Stereotactic body radiotherapy for spine metastases: a review of 24 Gy in 2 daily fractions. J Neurooncol 2023; 163:15-27. [PMID: 37155133 DOI: 10.1007/s11060-023-04327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) has proven to be a highly effective treatment for selected patients with spinal metastases. Randomized evidence shows improvements in complete pain response rates and local control with lower retreatment rates favoring SBRT, compared to conventional external beam radiotherapy (cEBRT). While there are several reported dose-fractionation schemes for spine SBRT, 24 Gy in 2 fractions has emerged with Level 1 evidence providing an excellent balance between minimizing treatment toxicity while respecting patient convenience and financial strain. METHODS We provide an overview of the 24 Gy in 2 SBRT fraction regimen for spine metastases, which was developed at the University of Toronto and tested in an international Phase 2/3 randomized controlled trial. RESULTS The literature summarizing global experience with 24 Gy in 2 SBRT fractions suggests 1-year local control rates ranging from 83-93.9%, and 1-year rates of vertebral compression fracture ranging from 5.4-22%. Reirradiation of spine metastases that failed prior cEBRT is also feasible with 24 Gy in 2 fractions, and 1-year local control rates range from 72-86%. Post-operative spine SBRT data are limited but do support the use of 24 Gy in 2 fractions with reported 1-year local control rates ranging from 70-84%. Typically, the rates of plexopathy, radiculopathy and myositis are under 5% in those series reporting mature follow up, with no cases of radiation myelopathy (RM) reported in the de novo setting when the spinal cord avoidance structure is limited to 17 Gy in 2 fractions. However, re-irradiation RM has been observed following 2 fraction SBRT. More recently, 2-fraction dose escalation with 28 Gy, with a higher dose constraint to the critical neural tissues, has been reported suggesting improved rates of local control. This regimen may be important in those patients with radioresistant histologies, high grade epidural disease, and/or paraspinal disease. CONCLUSION The dose-fractionation of 24 Gy in 2 fractions is well-supported by published literature and is an ideal starting point for centers looking to establish a spine SBRT program.
Collapse
Affiliation(s)
- Eric K Nguyen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| |
Collapse
|
22
|
Dupuis P, François M, Baudier T, Sunyach MP, Brahmi T, Ayadi M, Biston MC. Evaluation of a dedicated software for semi-automated VMAT planning of spine Stereotactic Body Radiotherapy (SBRT). Phys Med 2023; 109:102578. [PMID: 37084679 DOI: 10.1016/j.ejmp.2023.102578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/01/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023] Open
Abstract
PURPOSE To determine whether SBRT of spinal metastasis using a dedicated treatment planning system (TPS) and delivered with a gantry-based LINAC could provide plans of similar quality to the Cyberknife technology. Additional comparison was also done with other commercial TPS used for volumetric modulated arc therapy (VMAT) planning. MATERIALS AND METHODS Thirty Spine SBRT patients, previously treated in our institution with CyberKnife (Accuray, Sunnyvale) using Multiplan TPS, were replanned in VMAT with an dedicated TPS (Elements Spine SRS, Brainlab, Munich) and our clinical TPS (Monaco, Elekta LTD, Stockholm), using exactly the same arc geometry. The comparison was done by assessing differences in dose delivered to PTV, CTV and spinal cord, calculating modulation complexity scores (MCS) and performing quality control (QA) of the plans. RESULTS Regardless of the vertebra level, in general, no statistical difference was found in PTV coverage between all TPS. Conversely, PTV and CTV D50% were found significantly higher for the dedicated TPS compared to others. In addition, the dedicated TPS also resulted in better gradient index (GI) than clinical VMAT TPS, whatever the vertebral level, and better GI than Cyberknife TPS for the thoracic level only. The D2% to the spinal cord was generally significantly lower with the dedicated TPS compared with others. No significant difference was found in the MCS between both VMAT TPS. All QA were clinically acceptable. CONCLUSION The Elements Spine SRS TPS offers very effective and user-friendly semi-automated planning tools and is secure and promising for gantry-based LINAC spinal SBRT.
Collapse
Affiliation(s)
- Pauline Dupuis
- Centre Léon Bérard, 28 rue Laennec, 69373 LYON Cedex 08, France.
| | - Madani François
- Centre Léon Bérard, 28 rue Laennec, 69373 LYON Cedex 08, France
| | - Thomas Baudier
- Centre Léon Bérard, 28 rue Laennec, 69373 LYON Cedex 08, France; CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Villeurbanne, France
| | | | - Tristan Brahmi
- Centre Léon Bérard, 28 rue Laennec, 69373 LYON Cedex 08, France
| | - Myriam Ayadi
- Centre Léon Bérard, 28 rue Laennec, 69373 LYON Cedex 08, France
| | - Marie-Claude Biston
- Centre Léon Bérard, 28 rue Laennec, 69373 LYON Cedex 08, France; CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Villeurbanne, France
| |
Collapse
|
23
|
Maciejczak A, Gasik R, Kotrych D, Rutkowski P, Antoniak K, Derenda M, Dobiecki K, Górski R, Grzelak L, Guzik G, Harat M, Janusz W, Jarmużek P, Łątka D, Maciejczyk A, Mandat T, Potaczek T, Rocławski M, Trembecki Ł, Załuski R. Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1300-1325. [PMID: 36854861 DOI: 10.1007/s00586-023-07546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/31/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities. METHODS The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies. RESULTS The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies. CONCLUSION The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.
Collapse
Affiliation(s)
- A Maciejczak
- Department of Neurosurgery, Szpital Wojewódzki Tarnów, University of Rzeszów, Rzeszów, Poland.
| | - R Gasik
- Department of Neuroorthopedics and Neurology, National Geriatrics, Rheumatology and Rehabilitation Institute, Warsaw, Poland
| | - D Kotrych
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - K Antoniak
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - M Derenda
- Department of Neurosurgery, University of Warmia and Mazury, Olsztyn, Poland
| | - K Dobiecki
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - R Górski
- Department of Neurosurgery and Spine Surgery, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | - L Grzelak
- Department of Neurosurgery, City Hospital, Toruń, Poland
| | - G Guzik
- Department of Oncologic Orthopedics, Sub-Carpathian Oncology Center, Brzozów, Poland
| | - M Harat
- Department of Oncology and Brachytherapy, Oncology Center Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - W Janusz
- Department of Orthopedics and Traumatology, Medical University of Lublin, Lublin, Poland
| | - P Jarmużek
- Department of Neurosurgery, University of Zielona Góra, Zielona Góra, Poland
| | - D Łątka
- Department of Neurosurgery, University of Opole, Opole, Poland
| | - A Maciejczyk
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - T Mandat
- Department of Nervous System Neoplasms, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - T Potaczek
- Department of Orthopedics and Rehabilitation, University Hospital Zakopane, Jagiellonian University, Kraków, Poland
| | - M Rocławski
- Department of Orthopaedics, Medical University of Gdansk, Gdańsk, Poland
| | - Ł Trembecki
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - R Załuski
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
24
|
Ratnakumaran R, van As N, Khoo V, McDonald F, Tait D, Ahmed M, Taylor H, Griffin C, Dunne EM, Tree AC. Patterns of Failure After Stereotactic Body Radiotherapy to Sacral Metastases. Clin Oncol (R Coll Radiol) 2023; 35:339-346. [PMID: 36805131 DOI: 10.1016/j.clon.2023.01.020] [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: 12/16/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
AIMS Stereotactic body radiotherapy (SBRT) is increasingly used to treat sacral metastases. We analysed our centre's local relapse rates and patterns of failure after sacral SBRT and assessed whether using the consensus contouring recommendation (CCR) may have prevented local relapse. MATERIALS AND METHODS We conducted a single-centre retrospective review of patients treated with sacral SBRT between February 2012 and December 2021. The cumulative incidence of local relapse, patterns of failure and overall survival were determined. Two investigators reviewed planning computed tomography scans and imaging at relapse to determine if local relapse was potentially preventable with a larger CCR-derived radiotherapy field. RESULTS In total, 34 patients received sacral SBRT, with doses ranging from 24 to 40 Gy over three to five fractions. The most frequently used schedule was 30 Gy in three fractions. Common primaries treated included prostate (n = 16), breast (n = 6), lung (n = 3) and renal (n = 3) cancers. The median follow-up was 20 months (interquartile range 13-55 months). The cumulative incidence of local relapse (4/34) was 2.9% (95% confidence interval 0.2-13.2), 6.3% (95% confidence interval 1.1-18.5) and 16.8% (95% confidence interval 4.7-35.4) at 6 months, 1 year and 2 years, respectively. The patterns of failure were local-only (1/34), local and distant (3/34) and distant relapse (10/34). The overall survival was 96.7% (95% confidence interval 90.5-100) and 90.6% (95% confidence interval 78.6-100) at 1 and 2 years, respectively. For prostate/breast primaries, the cumulative incidence of local relapse was 4.5% (95% confidence interval 0.3-19.4), 4.5% (95% confidence interval 0.3-19.4) and 12.5% (95% confidence interval 1.7-34.8) at 6 months, 1 and 2 years, respectively. Twenty-nine cases (85.3%) deviated from the CCR. Sacral relapse was potentially preventable if the CCR was used in one patient (2.9% of the whole cohort and 25% of the relapsed cohort). DISCUSSION We have shown excellent local control rates with sacral SBRT, which was largely planned with a margin expansion approach.
Collapse
Affiliation(s)
- R Ratnakumaran
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK.
| | - N van As
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - V Khoo
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - F McDonald
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - D Tait
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - M Ahmed
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - H Taylor
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - C Griffin
- The Institute of Cancer Research, Clinical Trials and Statistics Unit, London, UK
| | - E M Dunne
- Department of Radiation Oncology, BC Cancer - Vancouver Centre, Vancouver, British Columbia, Canada
| | - A C Tree
- The Royal Marsden NHS Foundation Trust, Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| |
Collapse
|
25
|
Mikula AL, Pennington Z, Lakomkin N, Clarke MJ, Rose PS, Bydon M, Freedman B, Sebastian AS, Lu L, Kowalchuk RO, Merrell KW, Fogelson JL, Elder BD. Independent predictors of vertebral compression fracture following radiation for metastatic spine disease. J Neurosurg Spine 2022; 37:617-623. [PMID: 35426824 DOI: 10.3171/2022.2.spine211613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to determine independent risk factors for vertebral compression fracture (VCF) following radiation for metastatic spine disease, including low bone mineral density as estimated by Hounsfield units (HU). METHODS A retrospective chart review identified patients with a single vertebral column metastasis treated with radiation therapy, a pretreatment CT scan, and a follow-up CT scan at least 6 weeks after treatment. Patients with primary spine tumors, preradiation vertebroplasty, preradiation spine surgery, prior radiation to the treatment field, and proton beam treatment modality were excluded. The HU were measured in the vertebral bodies at the level superior to the metastasis, within the tumor and medullary bone of the metastatic level, and at the level inferior to the metastasis. Variables collected included basic demographics, Spine Instability Neoplastic Score (SINS), presenting symptoms, bone density treatment, primary tumor pathology, Weinstein-Boriani-Biagini (WBB) classification, Enneking stage, radiation treatment details, chemotherapy regimen, and prophylactic vertebroplasty. RESULTS One hundred patients with an average age of 63 years and average follow-up of 18 months with radiation treatment dates ranging from 2017 to 2020 were included. Fifty-nine patients were treated with external-beam radiation therapy, with a median total dose of 20 Gy (range 8-40 Gy). Forty-one patients were treated with stereotactic body radiation therapy, with a median total dose of 24 Gy (range 18-39 Gy). The most common primary pathologies included lung (n = 22), prostate (n = 21), and breast (n = 14). Multivariable logistic regression analysis (area under the curve 0.89) demonstrated pretreatment HU (p < 0.01), SINS (p = 0.02), involvement of ≥ 3 WBB sectors (p < 0.01), primary pathology other than prostate (p = 0.04), and ongoing chemotherapy treatment (p = 0.04) to be independent predictors of postradiation VCF. Patients with pretreatment HU < 145 (n = 32), 145-220 (n = 31), and > 220 (n = 37) had a fracture rate of 59%, 39%, and 11%, respectively. An HU cutoff of 157 was found to maximize sensitivity (71%) and specificity (75%) in predicting postradiation VCF. CONCLUSIONS Low preradiation HU, higher SINS, involvement of ≥ 3 WBB sectors, ongoing chemotherapy, and nonprostate primary pathology were independent predictors of postradiation VCF in patients with metastatic spine disease. Low bone mineral density, as estimated by HU, is a novel and potentially modifiable risk factor for VCF.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Lichun Lu
- 3Department of Physiology and Biomedical Engineering; and
| | - Roman O Kowalchuk
- 4Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth W Merrell
- 4Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | |
Collapse
|
26
|
Ito K, Saito T, Nakamura N, Imano N, Hoskin P. Stereotactic body radiotherapy versus conventional radiotherapy for painful bone metastases: a systematic review and meta-analysis of randomised controlled trials. Radiat Oncol 2022; 17:156. [PMID: 36100905 PMCID: PMC9472415 DOI: 10.1186/s13014-022-02128-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is a promising approach in treating painful bone metastases. However, the superiority of SBRT over conventional external beam radiotherapy (cEBRT) remains controversial. Therefore, this systematic review and meta-analysis of randomised controlled trials was conducted to compare SBRT and cEBRT for the treatment of bone metastases. METHODS A search was conducted using PubMed on January 22, 2022, with the following inclusion criteria: (i) randomised controlled trials comparing SBRT with cEBRT for bone metastases and (ii) endpoint including pain response. Effect sizes across studies were pooled using random-effects models in a meta-analysis of risk ratios. RESULTS A total of 1246 articles were screened, with 7 articles comprising 964 patients (522 and 442 patients in the SBRT and cEBRT arms, respectively) meeting the inclusion criteria. The overall pain response (OR) rates of bone metastases at 3 months were 45% and 36% in the SBRT and cEBRT arms, respectively. The present analyses showed no significant difference between the two groups. In four studies included for the calculation of OR rates of spinal metastases at three months, the OR rates were 40% and 35% in the SBRT and cEBRT arms, respectively, with no significant difference between the two groups. The incidence of severe adverse effects and health-related quality of life outcomes were comparable between the two arms. CONCLUSIONS The superiority of SBRT over cEBRT for pain palliation in bone metastases was not confirmed in this meta-analysis. Although SBRT is a standard of care for bone metastases, patients receiving SBRT should be selected appropriately.
Collapse
Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Tetsuo Saito
- Department of Radiation Oncology, Arao Municipal Hospital, 2600, Arao, Arao-shi, Kumamoto, 864-0041, Japan.
| | - Naoki Nakamura
- Department of Radiation Oncology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae Ward, Kawasaki, Kanagawa, 216-8511, Japan
| | - Nobuki Imano
- Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami Ward, Hiroshima, 734-8551, Japan
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Rd, Northwood, HA6 2RN, UK.,Division of Cancer Sciences, University of Manchester, 604 E College Ave, North Manchester, 46962, UK
| |
Collapse
|
27
|
Ong W, Zhu L, Zhang W, Kuah T, Lim DSW, Low XZ, Thian YL, Teo EC, Tan JH, Kumar N, Vellayappan BA, Ooi BC, Quek ST, Makmur A, Hallinan JTPD. Application of Artificial Intelligence Methods for Imaging of Spinal Metastasis. Cancers (Basel) 2022; 14:4025. [PMID: 36011018 PMCID: PMC9406500 DOI: 10.3390/cancers14164025] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Spinal metastasis is the most common malignant disease of the spine. Recently, major advances in machine learning and artificial intelligence technology have led to their increased use in oncological imaging. The purpose of this study is to review and summarise the present evidence for artificial intelligence applications in the detection, classification and management of spinal metastasis, along with their potential integration into clinical practice. A systematic, detailed search of the main electronic medical databases was undertaken in concordance with the PRISMA guidelines. A total of 30 articles were retrieved from the database and reviewed. Key findings of current AI applications were compiled and summarised. The main clinical applications of AI techniques include image processing, diagnosis, decision support, treatment assistance and prognostic outcomes. In the realm of spinal oncology, artificial intelligence technologies have achieved relatively good performance and hold immense potential to aid clinicians, including enhancing work efficiency and reducing adverse events. Further research is required to validate the clinical performance of the AI tools and facilitate their integration into routine clinical practice.
Collapse
Affiliation(s)
- Wilson Ong
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
| | - Lei Zhu
- Department of Computer Science, School of Computing, National University of Singapore, 13 Computing Drive, Singapore 117417, Singapore
| | - Wenqiao Zhang
- Department of Computer Science, School of Computing, National University of Singapore, 13 Computing Drive, Singapore 117417, Singapore
| | - Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
| | - Desmond Shi Wei Lim
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
| | - Xi Zhen Low
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
| | - Yee Liang Thian
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Ee Chin Teo
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E, Lower Kent Ridge Road, Singapore 119228, Singapore
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E, Lower Kent Ridge Road, Singapore 119228, Singapore
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore
| | - Beng Chin Ooi
- Department of Computer Science, School of Computing, National University of Singapore, 13 Computing Drive, Singapore 117417, Singapore
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| |
Collapse
|
28
|
Palliative Efficacy of High-Dose Stereotactic Body Radiotherapy Versus Conventional Radiotherapy for Painful Non-Spine Bone Metastases: A Propensity Score-Matched Analysis. Cancers (Basel) 2022; 14:cancers14164014. [PMID: 36011008 PMCID: PMC9406761 DOI: 10.3390/cancers14164014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: The superiority of stereotactic body radiotherapy (SBRT) over conventional external beam radiotherapy (cEBRT) in terms of pain palliation for bone metastases remains controversial. (2) Methods: This propensity score-matched study compared the overall pain response (OR) 3 months after radiotherapy among patients with painful (≥2 points on a 0-to-10 scale) non-spine bone metastases. Patients with lesions that were treated with SBRT or cEBRT and whose pain scores were evaluated 3 months after radiotherapy were included in this study. Pain response was evaluated according to the International Consensus Criteria. (3) Results: A total of 234 lesions (SBRT, n = 129; cEBRT, n = 105) were identified in our institutional database. To reduce the confounding effects, 162 patients were selected using a propensity score-matched analysis (n = 81 for each treatment). The OR rate at 3 months after SBRT was significantly higher than that after cEBRT (76.5% vs. 56.8%; p = 0.012). A noteworthy finding of our study is that the same trend was observed even after 6 months (75.9% vs. 50.0%; p = 0.011). The 1-year local failure rates after SBRT and cEBRT were 10.2% and 33.3% (p < 0.001), respectively. (4) Conclusions: Our findings suggest that SBRT is superior to cEBRT for pain palliation in patients with non-spine bone metastases.
Collapse
|
29
|
Lucido JJ, Mullikin TC, Abraha F, Harmsen WS, Vaishnav BD, Brinkman DH, Kowalchuk RO, Marion JT, Johnson-Tesch BA, Sherif OE, Brown PD, Rose PS, Owen D, Morris JM, Waddle MR, Siontis BL, Stish BJ, Pafundi DH, Laack NN, Olivier KR, Park SS, Merrell KW. Single and multi-fraction spine stereotactic body radiation therapy and the risk of radiation induced myelopathy. Adv Radiat Oncol 2022; 7:101047. [PMID: 36188436 PMCID: PMC9515434 DOI: 10.1016/j.adro.2022.101047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/04/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose This study reports on the risk of radiation-induced myelitis (RM) of the spinal cord from a large single-institutional experience with 1 to 5 fraction stereotactic body radiation therapy (SBRT) to the spine. Methods and Materials A retrospective review of patients who received spine SBRT to a radiation naïve level at or above the conus medullaris between 2007 and 2019 was performed. Local failure determination was based on SPIne response assessment in Neuro-Oncology criteria. RM was defined as neurologic symptoms consistent with the segment of cord irradiated in the absence of neoplastic disease recurrence and graded by Common Toxicity Criteria for Adverse Events, version 4.0. Rates of adverse events were estimated and dose-volume statistics from delivered treatment plans were extracted for the planning target volumes and spinal cord. Results A total of 353 lesions in 277 patients were identified that met the specified criteria, for which 270, 70, and 13 lesions received 1-, 3-, and 5-fraction treatments, respectively, with a median follow-up of 46 months (95% confidence interval [CI], 41-52 months) for all surviving patients. The median overall survival was 33.0 months (95% CI, 29-43). The median D0.03cc to the spinal cord was 11.7 Gy (interquartile range [IQR], 10.5-12.4), 16.7 Gy (IQR, 12.8-20.6), and 26.0 Gy (IQR, 24.1-28.1), for 1-, 3-, 5-fractions. Using an a/b = 2Gy for the spinal cord, the median single-fraction equivalent-dose (SFED2) was 11.7 Gy (IQR, 10.2-12.5 Gy) and the normalized biological equivalent dose (nBED2/2) was 19.9 Gy (IQR, 15.4-22.8 Gy). One patient experienced grade 2 RM after a single-fraction treatment. The cumulative probability of RM was 0.3% (95% CI, 0%-2%). Conclusions Spine SBRT is safe while limiting the spinal cord (as defined on treatment planning magnetic resonance imaging or computed tomography myelogram) D0.03cc to less than 14 Gy, 21.9 Gy, and 30 Gy, for 1, 3, and 5-fractions, consistent with standard guidelines.
Collapse
|
30
|
Stereotactic Body Radiation Therapy versus Conventional External Beam Radiation Therapy for Painful Bone Metastases: A Systematic Review and Meta-analysis of Randomized Trials. Crit Rev Oncol Hematol 2022; 178:103775. [PMID: 35917886 DOI: 10.1016/j.critrevonc.2022.103775] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To compare the efficacy and safety of stereotactic body radiation therapy (SBRT) and conventional external beam radiation therapy (cEBRT) in patients with previously unirradiated painful bone metastases (BM). METHODS We searched biomedical databases for eligible randomized trials (RCTs). The outcomes of interest were pain response, local progression, overall survival (OS) and adverse events. We used established tools to assess the quality of the individual trials and certainty of the pooled evidence. We performed meta-analyses using random effects models. RESULTS Six RCTs were identified. SBRT improved complete pain response rates at 3 months (OR, 3.38; 95% CI, 1.88-6.07; high certainty), reduced local progression rates (OR, 0.19; 95% CI, 0.06-0.62; high certainty) and increase pain flare rates. There were no differences for other outcomes. CONCLUSION Among patients with previously unirradiated painful BM, SBRT significantly improved complete pain response rates at 3 months, delayed local progression and increase pain flare rates.
Collapse
|
31
|
Kuah T, Vellayappan BA, Makmur A, Nair S, Song J, Tan JH, Kumar N, Quek ST, Hallinan JTPD. State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers (Basel) 2022; 14:3289. [PMID: 35805059 PMCID: PMC9265325 DOI: 10.3390/cancers14133289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 12/23/2022] Open
Abstract
Metastatic Spinal Cord Compression (MSCC) is a debilitating complication in oncology patients. This narrative review discusses the strengths and limitations of various imaging modalities in diagnosing MSCC, the role of imaging in stereotactic body radiotherapy (SBRT) for MSCC treatment, and recent advances in deep learning (DL) tools for MSCC diagnosis. PubMed and Google Scholar databases were searched using targeted keywords. Studies were reviewed in consensus among the co-authors for their suitability before inclusion. MRI is the gold standard of imaging to diagnose MSCC with reported sensitivity and specificity of 93% and 97% respectively. CT Myelogram appears to have comparable sensitivity and specificity to contrast-enhanced MRI. Conventional CT has a lower diagnostic accuracy than MRI in MSCC diagnosis, but is helpful in emergent situations with limited access to MRI. Metal artifact reduction techniques for MRI and CT are continually being researched for patients with spinal implants. Imaging is crucial for SBRT treatment planning and three-dimensional positional verification of the treatment isocentre prior to SBRT delivery. Structural and functional MRI may be helpful in post-treatment surveillance. DL tools may improve detection of vertebral metastasis and reduce time to MSCC diagnosis. This enables earlier institution of definitive therapy for better outcomes.
Collapse
Affiliation(s)
- Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore;
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Shalini Nair
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Junda Song
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| |
Collapse
|
32
|
Lucia F, Geier M, Schick U, Bourbonne V. Narrative Review of Synergistics Effects of Combining Immunotherapy and Stereotactic Radiation Therapy. Biomedicines 2022; 10:biomedicines10061414. [PMID: 35740435 PMCID: PMC9219862 DOI: 10.3390/biomedicines10061414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 12/24/2022] Open
Abstract
Stereotactic radiotherapy (SRT) has become an attractive treatment modality in full bloom in recent years by presenting itself as a safe, noninvasive alternative to surgery to control primary or secondary malignancies. Although the focus has been on local tumor control as the therapeutic goal of stereotactic radiotherapy, rare but intriguing observations of abscopal (or out-of-field) effects have highlighted the exciting possibility of activating antitumor immunity using high-dose radiation. Furthermore, immunotherapy has revolutionized the treatment of several types of cancers in recent years. However, resistance to immunotherapy often develops. These observations have led researchers to combine immunotherapy with SRT in an attempt to improve outcomes. The benefits of this combination would come from the stimulation and suppression of various immune pathways. Thus, in this review, we will first discuss the immunomodulation induced by SRT with the promising results of preclinical studies on the changes in the immune balance observed after SRT. Then, we will discuss the opportunities and risks of the combination of SRT and immunotherapy with the preclinical and clinical data available in the literature. Furthermore, we will see that many perspectives are conceivable to potentiate the synergistic effects of this combination with the need for prospective studies to confirm the encouraging data.
Collapse
Affiliation(s)
- François Lucia
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (U.S.); (V.B.)
- LaTIM, INSERM, UMR 1101, University of Brest, 29200 Brest, France
- Correspondence:
| | - Margaux Geier
- Medical Oncology Department, University Hospital, 29200 Brest, France;
| | - Ulrike Schick
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (U.S.); (V.B.)
- LaTIM, INSERM, UMR 1101, University of Brest, 29200 Brest, France
| | - Vincent Bourbonne
- Radiation Oncology Department, University Hospital, 29200 Brest, France; (U.S.); (V.B.)
- LaTIM, INSERM, UMR 1101, University of Brest, 29200 Brest, France
| |
Collapse
|
33
|
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.
Collapse
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.
| |
Collapse
|
34
|
Multi-Omics Approaches for the Prediction of Clinical Endpoints after Immunotherapy in Non-Small Cell Lung Cancer: A Comprehensive Review. Biomedicines 2022; 10:biomedicines10061237. [PMID: 35740259 PMCID: PMC9219996 DOI: 10.3390/biomedicines10061237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized the management of locally advanced and advanced non-small lung cancer (NSCLC). With an improvement in the overall survival (OS) as both first- and second-line treatments, ICIs, and especially programmed-death 1 (PD-1) and programmed-death ligands 1 (PD-L1), changed the landscape of thoracic oncology. The PD-L1 level of expression is commonly accepted as the most used biomarker, with both prognostic and predictive values. However, even in a low expression level of PD-L1, response rates remain significant while a significant number of patients will experience hyperprogression or adverse events. The dentification of such subtypes is thus of paramount importance. While several studies focused mainly on the prediction of the PD-L1 expression status, others aimed directly at the development of prediction/prognostic models. The response to ICIs depends on a complex physiopathological cascade, intricating multiple mechanisms from the molecular to the macroscopic level. With the high-throughput extraction of features, omics approaches aim for the most comprehensive assessment of each patient. In this article, we will review the place of the different biomarkers (clinical, biological, genomics, transcriptomics, proteomics and radiomics), their clinical implementation and discuss the most recent trends projecting on the future steps in prediction modeling in NSCLC patients treated with ICI.
Collapse
|
35
|
Henzen D, Schmidhalter D, Guyer G, Stenger-Weisser A, Ermiş E, Poel R, Deml MC, Fix MK, Manser P, Aebersold DM, Hemmatazad H. Feasibility of postoperative spine stereotactic body radiation therapy in proximity of carbon and titanium hybrid implants using a robotic radiotherapy device. Radiat Oncol 2022; 17:94. [PMID: 35549961 PMCID: PMC9097088 DOI: 10.1186/s13014-022-02058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/22/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE To assess the feasibility of postoperative stereotactic body radiation therapy (SBRT) for patients with hybrid implants consisting of carbon fiber reinforced polyetheretherketone and titanium (CFP-T) using CyberKnife. MATERIALS AND METHODS All essential steps within a radiation therapy (RT) workflow were evaluated. First, the contouring process of target volumes and organs at risk (OAR) was done for patients with CFP-T implants. Second, after RT-planning, the accuracy of the calculated dose distributions was tested in a slab phantom and an anthropomorphic phantom using film dosimetry. As a third step, the accuracy of the mandatory image guided radiation therapy (IGRT) including automatic matching was assessed using the anthropomorphic phantom. For this goal, a standard quality assurance (QA) test was modified to carry out its IGRT part in presence of CFP-T implants. RESULTS Using CFP-T implants, target volumes could precisely delineated. There was no need for compromising the contours to overcome artifact obstacles. Differences between measured and calculated dose values were below 11% for the slab phantom, and at least 95% of the voxels were within 5% dose difference. The comparisons for the anthropomorphic phantom showed a gamma-passing rate (5%, 1 mm) of at least 97%. Additionally the test results with and without CFP-T implants were comparable. No issues concerning the IGRT were detected. The modified machine QA test resulted in a targeting error of 0.71 mm, which corresponds to the results of the unmodified standard tests. CONCLUSION Dose calculation and delivery of postoperative spine SBRT is feasible in proximity of CFP-T implants using a CyberKnife system.
Collapse
Affiliation(s)
- Dominik Henzen
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gian Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Stenger-Weisser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ekin Ermiş
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Poel
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Caspar Deml
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Karl Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Matthias Aebersold
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hossein Hemmatazad
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
36
|
Ito K, Nakajima Y, Ogawa H, Taguchi K, Sugita S. Risk of radiculopathy caused by second course of spine stereotactic body radiotherapy. Jpn J Clin Oncol 2022; 52:911-916. [DOI: 10.1093/jjco/hyac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/08/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
Stereotactic body radiotherapy is used to treat spinal metastases; however, 10% of patients experience local failure. We aimed to clarify the outcomes of the second course of stereotactic body radiotherapy for spinal metastases with a uniform fractionation schedule at our institution.
Methods
Data of patients treated with a second salvage stereotactic body radiotherapy course at the same spinal level or adjacent level from July 2018 to December 2020 were retrospectively reviewed. The initial prescribed dose was 24 Gy in two fractions, and the second dose 30 or 35 Gy in five fractions. The spinal cord dose constraint at the second course was 15.5 Gy at the maximum point dose. The endpoints were local failure and adverse effects. Local failure was defined as tumor progression using imaging.
Results
We assessed 19 lesions in 17 patients, with radioresistant lesions in 14 (74%) cases, the second stereotactic body radiotherapy to the same/adjacent spinal level in 13/6 cases, the median interval between stereotactic body radiotherapy of 23 (range, 6–52) months, and lesions compressing the cord in 5 (26%) cases. The median follow-up period was 19 months. The 12- and 18-month local failure rates were 0% and 8%, respectively. Radiation-induced myelopathy, radiculopathy and vertebral compression fractures were observed in 0 (0%), 4 (21%) and 2 (11%) lesions, respectively. Three patients with radiculopathy experienced almost complete upper or lower limb paralysis.
Conclusions
The second course of salvage stereotactic body radiotherapy for spinal metastases achieved good local control with a reduced risk of myelopathy. However, a high occurrence rate of radiation-induced radiculopathy has been confirmed.
Collapse
Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
- Department of Radiological Sciences, Komazawa University, Setagaya-ku, Tokyo, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Shurei Sugita
- Department of Orthopedic surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| |
Collapse
|
37
|
Ito K, Nakajima Y, Ikuta S. Stereotactic body radiotherapy for spinal oligometastases: a review on patient selection and the optimal methodology. Jpn J Radiol 2022; 40:1017-1023. [PMID: 35396669 PMCID: PMC9529679 DOI: 10.1007/s11604-022-01277-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/25/2022] [Indexed: 12/24/2022]
Abstract
Stereotactic body radiotherapy (SBRT) has excellent local control and low toxicity for spinal metastases and is widely performed for spinal oligometastases. However, its additional survival benefit to standard of care, including systemic therapy, is unknown because the results of large-scale randomized controlled trials regarding SBRT for oligometastases have not been reported. Consequently, the optimal patient population among those with spinal oligometastases and the optimal methodology for spine SBRT remain unclear. The present review article discusses two topics: evidence-based optimal patient selection and methodology. The following have been reported to be good prognostic factors: young age, good performance status, slow-growing disease with a long disease-free interval, minimal disease burden, and mild fluorodeoxyglucose accumulation in positron emission tomography. In addition, we proposed four measures as the optimal SBRT method for achieving excellent local control: (i) required target delineation; (ii) recommended dose fraction schedule (20 or 24 Gy in a single fraction for spinal oligometastases and 35 Gy in five fractions for lesions located near the spinal cord); (iii) optimizing dose distribution for the target; (iv) dose constraint options for the spinal cord.
Collapse
Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677 Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677 Japan
- Department of Radiological Sciences, Komazawa University, Tokyo, Japan
| | - Syuzo Ikuta
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677 Japan
| |
Collapse
|
38
|
Keyak JH, Eijansantos ML, Rosecrance KG, Wong D, Feizi S, Meldosian AL, Peddinti P, Les CM, Skinner HB, Sehgal V. A preliminary safety assessment of vertebral augmentation with 32P brachytherapy bone cement. Phys Med Biol 2022; 67. [PMID: 35294928 PMCID: PMC9045587 DOI: 10.1088/1361-6560/ac5e5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/16/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Comprehensive treatment for vertebral metastatic lesions commonly involves vertebral augmentation (vertebroplasty or kyphoplasty) to relieve pain and stabilize the spine followed by multiple sessions of radiotherapy. We propose to combine vertebral augmentation and radiotherapy into a single treatment by adding 32P, a β-emitting radionuclide, to bone cement, thereby enabling spinal brachytherapy to be performed without irradiating the spinal cord. The goal of this study was to address key dosimetry and safety questions prior to performing extensive animal studies. The 32P was in the form of hydroxyapatite powder activated by neutron bombardment in a nuclear reactor. We performed ex vivo dosimetry experiments to establish criteria for safe placement of the cement within the sheep vertebral body. In an in vivo study, we treated three control ewes and three experimental ewes with brachytherapy cement containing 2.23–3.03 mCi 32P ml−1 to identify the preferred surgical approach, to determine if 32P leaches from the cement and into the blood, urine, or feces, and to identify unexpected adverse effects. Our ex vivo experiments showed that cement with 4 mCi 32P ml−1 could be safely implanted in the vertebral body if the cement surface is at least 4 mm from the spinal cord in sheep and 5 mm from the spinal cord in humans. In vivo, a lateral retroperitoneal surgical approach, ventral to the transverse processes, was identified as easy to perform while allowing a safe distance to the spinal cord. The blood, urine, and feces of the sheep did not contain detectable levels of 32P, and the sheep did not experience any neurologic or other adverse effects from the brachytherapy cement. These results demonstrate, on a preliminary level, the relative safety of this brachytherapy cement and support additional development and testing.
Collapse
|
39
|
Abugharib A, Zeng KL, Tseng CL, Soliman H, Myrehaug S, Husain Z, Maralani PJ, Larouche J, Cheung P, Emmenegger U, Atenafu EG, Sahgal A, Detsky JS. Spine Stereotactic Body Radiotherapy for Prostate Cancer Metastases and the Impact of Hormone Sensitivity Status on Local Control. Neurosurgery 2022; 90:743-749. [PMID: 35343467 DOI: 10.1227/neu.0000000000001909] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is used to deliver ablative dose of radiation to spinal metastases. OBJECTIVE To report the first dedicated series of spine SBRT specific to prostate cancer (PCa) metastases with outcomes reported according to hormone sensitivity status. METHODS A prospective database was reviewed identifying patients with PCa treated with spine SBRT. This included those with hormone-sensitive PCa (HSPC) and castrate-resistant PCa (CRPC). The primary end point was MRI-based local control (LC). RESULTS A total of 183 spine segments in 93 patients were identified; 146 segments had no prior radiation and 37 had been previously radiated; 27 segments were postoperative. The median follow-up was 31 months. At the time of SBRT, 50 patients had HSPC and the remaining 43 had CRPC. The most common fractionation scheme was 24-28 Gy in 2 SBRT fractions (76%). LC rates at 1 and 2 years were 99% and 95% and 94% and 78% for the HSPC and CRPC cohorts, respectively. For patients treated with de novo SBRT, a higher risk of local failure was observed in patients with CRPC (P = .0425). The 1-year and 2-year overall survival rates were significantly longer at 98% and 95% in the HSPC cohort compared with 79% and 65% in the CRPC cohort (P = .0005). The cumulative risk of vertebral compression fracture at 2 years was 10%. CONCLUSION Favorable LC rates were observed after spine SBRT for PCa metastases; strategies to improve long-term LC in patients with CRPC require further investigation.
Collapse
Affiliation(s)
- Ahmed Abugharib
- Department of Clinical Oncology, Sohag University Hospital, Sohag University, Sohag, Egypt.,Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeremie Larouche
- Department of Surgery, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay S Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
40
|
Dunne E, Liu M, Lo S, Sahgal A. The Changing Landscape for the Treatment of Painful Spinal Metastases: is Stereotactic Body Radiation Therapy the New Standard of Care? Clin Oncol (R Coll Radiol) 2022; 34:325-331. [DOI: 10.1016/j.clon.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 02/08/2022] [Indexed: 11/25/2022]
|
41
|
Koide Y, Shimizu H, Miyauchi R, Haimoto S, Tanaka H, Watanabe Y, Adachi S, Kato D, Aoyama T, Kitagawa T, Tachibana H, Kodaira T. Fully automated rigid image registration versus human registration in postoperative spine stereotactic body radiation therapy: a multicenter non-inferiority study. JOURNAL OF RADIATION RESEARCH 2022; 63:115-121. [PMID: 34927197 PMCID: PMC8776699 DOI: 10.1093/jrr/rrab113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/07/2021] [Accepted: 11/01/2021] [Indexed: 06/14/2023]
Abstract
To confirm the fully automated rigid image registration (A-RIR) accuracy in postoperative spine stereotactic body radiation therapy (SBRT), we conducted a multicenter non-inferiority study compared to the human rigid image registration (H-RIR). Twenty-eight metastatic cancer patients who underwent postoperative spine SBRT are enrolled-image registration (IR) of planning computed tomography (CT) and CT-myelogram for delineating the spinal cord. The adopted A-RIR workflow is a contour-focused algorithm performing a rigid registration by maximizing normalized mutual information (NMI) restricted to the data contained within the automatically extracted contour. Three radiation oncologists (ROs) from multicenters were prompted to review two blinded registrations and choose one for clinical use. Indistinguishable cases were allowed to vote equivalent, counted A-RIR side. A-RIR is considered non-inferior to H-RIR if the lower limit of the 95% confidence interval (CI) of A-RIR preferable/equivalent is greater than 0.45. We also evaluated the NMI improvement from the baseline and the translational/rotational errors between A-RIR and H-RIR. The A-RIR preferable/equivalent was selected in 21 patients (0.75, 95% CI: 0.55-0.89), demonstrating non-inferiority to H-RIR. The A-RIR's NMI improvement was greater than H-RIR in 24 patients: the mean value ± SD was 0.225 ± 0.115 in A-RIR and 0.196 ± 0.114 in H-RIR (P < 0.001). The absolute translational error was 0.38 ± 0.31 mm. The rotational error was -0.03 ± 0.20, 0.05 ± 0.19, -0.04 ± 0.20 degrees in axial, coronal, and sagittal planes (range: -0.66-0.52). In conclusion, A-RIR shows non-inferior to H-RIR in CT and CT-myelogram registration for postoperative spine SBRT planning.
Collapse
Affiliation(s)
- Yutaro Koide
- Corresponding author. Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1–1, Chikusa-ku, Nagoya, Aichi, Japan. . Tel: (052) 762-6111
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Cost-effectiveness of treatment strategies for spinal metastases. Pract Radiat Oncol 2022; 12:236-244. [PMID: 35045365 DOI: 10.1016/j.prro.2021.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE We analyze the cost-effectiveness of standard palliative external beam radiation (EBRT, 8 Gy in 1 fraction), stereotactic body radiation therapy (SBRT, 24 Gy in 2 fractions), and radiofrequency ablation (RFA) for painful spinal metastases. Single-fraction SBRT (delivering 24 Gy) is also assessed. METHODS AND MATERIALS A Markov state transition model was constructed. Key model parameters were derived from prospective clinical trial data. Strategies were compared using the incremental cost-effectiveness ratio (ICER), with effectiveness in quality-adjusted life years (QALYs) and a willingness-to-pay (WTP) threshold of $100,000 per QALY gained. Costs included both hospital and professional costs using 2020 Medicare reimbursement. RESULTS The base case demonstrated that 2-fraction SBRT was not cost-effective compared to single-fraction EBRT, with an ICER of $194,145/QALY gained. RFA was a dominated treatment strategy (more costly and less effective) in this model. Probabilistic sensitivity analysis demonstrated that EBRT was favored in 66% of model iterations. If median survival were improved after SBRT, two-fraction SBRT became cost-effective, with ICER of $80,394, $57,062, and $47,038 for 3, 6, and 9-month improvements in survival. Because two-fraction SBRT data reported 18% of patients with indeterminant pain response at 3 months, and two-fraction SBRT is infrequently used in clinical practice, single-fraction SBRT data was also assessed. Single-fraction SBRT delivering 24 Gy was cost-effective compared to single-fraction EBRT, with an ICER of $92,833/QALY gained. CONCLUSIONS For appropriately chosen patients, single-fraction SBRT is more cost-effective than conventional EBRT or RFA. Conventional EBRT remains a cost-effective treatment for patients with poor expected survival.
Collapse
|
43
|
Cazzato RL, Jennings JW, Autrusseau PA, De Marini P, Auloge P, Tomasian A, Garnon J, Gangi A. Percutaneous image-guided cryoablation of spinal metastases: over 10-year experience in two academic centers. Eur Radiol 2022; 32:4137-4146. [PMID: 35028752 DOI: 10.1007/s00330-021-08477-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/26/2021] [Accepted: 11/15/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To report on safety and clinical effectiveness of cryoablation for the treatment of spinal metastases (SM) in patients needing pain palliation or local tumor control (LTC). METHODS All consecutive patients with SM who underwent cryoablation from May 2008 to September 2020 in two academic centers were retrospectively identified and included in the present analysis. Patient characteristics, goal of treatment (curative/palliative), SM characteristics, procedural details, and clinical outcomes (pain relief; local tumor control [LTC]) were analyzed. RESULTS There were 74 patients (35 women; median age 61 years) accounting for 105 SM. Additional cementoplasty was used for 76 SM (76/105; 72.4%). There were 9 complications (out of 105 SM [8.5%]; 2 major and 7 minor) in 8 patients. Among the 64 (64/74; 86.5%) patients with painful SM, the mean Numerical Pain Rating Scale dropped from 6.8 ± 2.2 (range, 0-10) at the baseline to 4.1 ± 2.4 (range, 0-9; p < 0.0001) at 24 h, 2.5 ± 2.6 (range, 0-9; p < 0.0001) at 1 month, and 2.4 ± 2.5 (range, 0-9; p < 0.0001) at the last available follow-up (mean 14.7 ± 19.6 months; median 6). Thirty-four patients (34/64; 53.1%) were completely pain-free at the last follow-up. At mean 25.9 ± 21.2 months (median 16.5) of follow-up, LTC was achieved in 23/28 (82.1%) SM in 21 patients undergoing cryoablation with curative intent. CONCLUSION Cryoablation of SM, often performed in combination with vertebral augmentation, is safe, achieves fast and sustained pain relief, and provides high rates of LTC at mean 2-year follow-up. KEY POINTS •Cryoablation of spinal metastases is safe. •Cryoablation of spinal metastases allows rapid and sustained pain relief. •The mean 2-year rate of local tumor control after cryoablation of spinal metastases is 82.1%.
Collapse
Affiliation(s)
- Roberto Luigi Cazzato
- Department of Interventional Radiology, University Hospital of Strasbourg, 1, place de l'hôpital, 67000, Strasbourg, France. .,Medical Oncology, Institut de Cancérologie Strasbourg Europe, 17, Rue Albert Calmette, 67200, Strasbourg, France.
| | - Jack W Jennings
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO, 63110, USA
| | - Pierre-Alexis Autrusseau
- Department of Interventional Radiology, University Hospital of Strasbourg, 1, place de l'hôpital, 67000, Strasbourg, France
| | - Pierre De Marini
- Department of Interventional Radiology, University Hospital of Strasbourg, 1, place de l'hôpital, 67000, Strasbourg, France
| | - Pierre Auloge
- Department of Interventional Radiology, University Hospital of Strasbourg, 1, place de l'hôpital, 67000, Strasbourg, France
| | - Anderanik Tomasian
- Department of Radiology, University of Southern California, 1500 San Pablo St, Los Angeles, CA, 90033, USA
| | - Julien Garnon
- Department of Interventional Radiology, University Hospital of Strasbourg, 1, place de l'hôpital, 67000, Strasbourg, France
| | - Afshin Gangi
- Department of Interventional Radiology, University Hospital of Strasbourg, 1, place de l'hôpital, 67000, Strasbourg, France.,School of Biomedical Engineering and Imaging Sciences, King's College London, Strand London, London, WC2R 2LS, UK
| |
Collapse
|
44
|
Ito K, Nakajima Y, Ogawa H, Taguchi K. Fracture risk following stereotactic body radiotherapy for long bone metastases. Jpn J Clin Oncol 2021; 52:47-52. [PMID: 34648002 DOI: 10.1093/jjco/hyab164] [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] [Received: 08/09/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy is a new treatment modality for long bone metastasis and has not been discussed in literature. We aimed to clarify stereotactic body radiotherapy outcomes for long bone metastases. METHODS Data of patients receiving stereotactic body radiotherapy for long bone metastases (July 2016-November 2020) were retrospectively reviewed. The prescribed dose was 30 or 35 Gy in five fractions. The endpoints were local failure and adverse effects. Local failure was defined as radiological tumor growth within the irradiation field. Adverse effects were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5. RESULTS Nineteen osseous lesions in 17 patients were assessed. The target lesions included 13 femoral, 4 humeral and 2 radial lesions. The median follow-up duration was 14 (range, 3-62) months. The 12- and 18-month local failure rates were 0 and 11%, respectively. Following 2 and 46 months of stereotactic body radiotherapy, two lesions (11%) resulted in painful femoral fractures (grade 3). Both patients underwent bipolar hip arthroplasty and could walk normally after surgery. In the late phase, one patient developed radiculopathy (almost complete paralysis of grasp) and another developed grade 2 limb edema. Other grade 2 or more severe acute and late toxicities were not observed during the follow-up period. CONCLUSIONS Stereotactic body radiotherapy for long bone metastases achieved excellent local control and caused two femoral fractures. We argue that stereotactic body radiotherapy for curative intent should not be contraindicated in long bone oligometastasis because fractures do not directly contribute to life expectancy.
Collapse
Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan.,Department of Radiological Sciences, Komazawa University, Tokyo, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kentaro Taguchi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| |
Collapse
|
45
|
Giaj-Levra N, Figlia V, Cuccia F, Mazzola R, Nicosia L, Ricchetti F, Rigo M, Attinà G, Vitale C, Sicignano G, De Simone A, Naccarato S, Ruggieri R, Alongi F. Reduction of inter-observer differences in the delineation of the target in spinal metastases SBRT using an automatic contouring dedicated system. Radiat Oncol 2021; 16:197. [PMID: 34627313 PMCID: PMC8502264 DOI: 10.1186/s13014-021-01924-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Approximately one third of cancer patients will develop spinal metastases, that can be associated with back pain, neurological symptoms and deterioration in performance status. Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) have been offered in clinical practice mainly for the management of oligometastatic and oligoprogressive patients, allowing the prescription of high total dose delivered in one or few sessions to small target volumes, minimizing the dose exposure of normal tissues. Due to the high delivered doses and the proximity of critical organs at risk (OAR) such as the spinal cord, the correct definition of the treatment volume becomes even more important in SBRT treatment, thus making it necessary to standardize the method of target definition and contouring, through the adoption of specific guidelines and specific automatic contouring tools. An automatic target contouring system for spine SBRT is useful to reduce inter-observer differences in target definition. In this study, an automatic contouring tool was evaluated. METHODS Simulation CT scans and MRI data of 20 patients with spinal metastases were evaluated. To evaluate the advantage of the automatic target contouring tool (Elements SmartBrush Spine), which uses the identification of different densities within the target vertebra, we evaluated the agreement of the contours of 20 spinal target (2 cervical, 9 dorsal and 9 lumbar column), outlined by three independent observers using the automatic tool compared to the contours obtained manually, and measured by DICE similarity coefficient. RESULTS The agreement of GTV contours outlined by independent operators was superior with the use of the automatic contour tool compared to manually outlined contours (mean DICE coefficient 0.75 vs 0.57, p = 0.048). CONCLUSIONS The dedicated contouring tool allows greater precision and reduction of inter-observer differences in the delineation of the target in SBRT spines. Thus, the evaluated system could be useful in the setting of spinal SBRT to reduce uncertainties of contouring increasing the level of precision on target delivered doses.
Collapse
Affiliation(s)
- Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy.
| | - Vanessa Figlia
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Francesco Cuccia
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Luca Nicosia
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Francesco Ricchetti
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Michele Rigo
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Giorgio Attinà
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Claudio Vitale
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Gianluisa Sicignano
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Antonio De Simone
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Stefania Naccarato
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A.Sempreboni 5, 37124, Negrar Di Valpolicella, VR, Italy.,University of Brescia, Brescia, Italy
| |
Collapse
|
46
|
Yassine AA, Lo WCY, Saeidi T, Ferguson D, Whyne CM, Akens MK, Betz V, Lilge L. Photodynamic therapy outcome modelling for patients with spinal metastases: a simulation-based study. Sci Rep 2021; 11:17871. [PMID: 34504208 PMCID: PMC8429418 DOI: 10.1038/s41598-021-97407-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/18/2021] [Indexed: 02/07/2023] Open
Abstract
Spinal metastases often occur in the advanced stages of breast, lung or prostate cancer, resulting in a significant impact on the patient's quality of life. Current treatment modalities for spinal metastases include both systemic and localized treatments that aim to decrease pain, improve mobility and structural stability, and control tumour growth. With the development of non-toxic photosensitizer drugs, photodynamic therapy (PDT) has shown promise as a minimally invasive non-thermal alternative in oncology, including for spinal metastases. To apply PDT to spinal metastases, predictive algorithms that optimize tumour treatment and minimize the risk of spinal cord damage are needed to assess the feasibility of the treatment and encourage a broad acceptance of PDT in clinical trials. This work presents a framework for PDT modelling and planning, and simulates the feasibility of using a BPD-MA mediated PDT to treat bone metastases at two different wavelengths (690 nm and 565 nm). An open-source software for PDT planning, PDT-SPACE, is used to evaluate different configurations of light diffusers (cut-end and cylindrical) fibres with optimized power allocation in order to minimize the damage to spinal cord or maximize tumour destruction. The work is simulated on three CT images of metastatically involved vertebrae acquired from three patients with spinal metastases secondary to colorectal or lung cancer. Simulation results show that PDT at a 565 nm wavelength has the ability to treat 90% of the metastatic lesion with less than 17% damage to the spinal cord. However, the energy required, and hence treatment time, to achieve this outcome with the 565 nm is infeasible. The energy required and treatment time for the longer wavelength of 690 nm is feasible ([Formula: see text] min), but treatment aimed at 90% of the metastatic lesion would severely damage the proximal spinal cord. PDT-SPACE provides a simulation platform that can be used to optimize PDT delivery in the metastatic spine. While this work serves as a prospective methodology to analyze the feasibility of PDT for tumour ablation in the spine, preclinical studies in an animal model are ongoing to elucidate the spinal cord damage extent as a function of PDT dose, and the resulting short and long term functional impairments. These will be required before there can be any consideration of clinical trials.
Collapse
Affiliation(s)
- Abdul-Amir Yassine
- grid.17063.330000 0001 2157 2938Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON M5S 3G8 Canada
| | - William C. Y. Lo
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA 02115 USA ,grid.116068.80000 0001 2341 2786Division of Health Sciences and Technology, Harvard-Massachusetts Institute of Technology, Cambridge, MA 02142 USA
| | - Tina Saeidi
- grid.17063.330000 0001 2157 2938Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7 Canada
| | - Dallis Ferguson
- grid.17063.330000 0001 2157 2938Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9 Canada ,grid.17063.330000 0001 2157 2938Orthopaedic Biomechanics Laboratory, Sunnybrook Research Institute, Toronto, ON M4N 3M5 Canada
| | - Cari M. Whyne
- grid.17063.330000 0001 2157 2938Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9 Canada ,grid.17063.330000 0001 2157 2938Orthopaedic Biomechanics Laboratory, Sunnybrook Research Institute, Toronto, ON M4N 3M5 Canada ,grid.17063.330000 0001 2157 2938Department of Surgery, University of Toronto, Toronto, ON M5G 1L7 Canada ,grid.17063.330000 0001 2157 2938Holland Bone and Joint Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5 Canada
| | - Margarete K. Akens
- grid.17063.330000 0001 2157 2938Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7 Canada ,grid.17063.330000 0001 2157 2938Department of Surgery, University of Toronto, Toronto, ON M5G 1L7 Canada ,grid.231844.80000 0004 0474 0428Techna Institute, University Health Network, Toronto, ON M5T 1P5 Canada
| | - Vaughn Betz
- grid.17063.330000 0001 2157 2938Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON M5S 3G8 Canada
| | - Lothar Lilge
- grid.17063.330000 0001 2157 2938Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7 Canada ,grid.231844.80000 0004 0474 0428Princess Margaret Cancer Center, University Health Network, Toronto, ON M5G 1L7 Canada
| |
Collapse
|
47
|
Tsukamoto S, Kido A, Tanaka Y, Facchini G, Peta G, Rossi G, Mavrogenis AF. Current Overview of Treatment for Metastatic Bone Disease. Curr Oncol 2021; 28:3347-3372. [PMID: 34590591 PMCID: PMC8482272 DOI: 10.3390/curroncol28050290] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/13/2021] [Accepted: 08/26/2021] [Indexed: 12/16/2022] Open
Abstract
The number of patients with bone metastasis increases as medical management and surgery improve the overall survival of patients with cancer. Bone metastasis can cause skeletal complications, including bone pain, pathological fractures, spinal cord or nerve root compression, and hypercalcemia. Before initiation of treatment for bone metastasis, it is important to exclude primary bone malignancy, which would require a completely different therapeutic approach. It is essential to select surgical methods considering the patient’s prognosis, quality of life, postoperative function, and risk of postoperative complications. Therefore, bone metastasis treatment requires a multidisciplinary team approach, including radiologists, oncologists, and orthopedic surgeons. Recently, many novel palliative treatment options have emerged for bone metastases, such as stereotactic body radiation therapy, radiopharmaceuticals, vertebroplasty, minimally invasive spine stabilization with percutaneous pedicle screws, acetabuloplasty, embolization, thermal ablation techniques, electrochemotherapy, and high-intensity focused ultrasound. These techniques are beneficial for patients who may not benefit from surgery or radiotherapy.
Collapse
Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
- Correspondence: ; Tel.: +81-744-22-3051
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840, Shijo-cho, Kashihara 634-8521, Nara, Japan;
| | - Giancarlo Facchini
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Giuliano Peta
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Giuseppe Rossi
- Department of Radiology and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (G.F.); (G.P.); (G.R.)
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 41 Ventouri Street, 15562 Athens, Greece;
| |
Collapse
|
48
|
Walker A, Bassale S, Shukla R, Kubicky CD. A Prognostic Index for Predicting Survival of Patients Undergoing Radiation Therapy for Spine Metastasis Using Recursive Partitioning Analysis. J Palliat Med 2021; 25:21-27. [PMID: 34382867 DOI: 10.1089/jpm.2020.0715] [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: 11/12/2022] Open
Abstract
Background: Physicians' estimate of life expectancy in patients with spine metastasis frequently impacts treatment decisions regarding surgery, radiation techniques, dose, and fractionation. Objective: We aimed to identify predictors of survival and generate a stratification schema that could guide clinical decision making. Materials and Methods: We identified 269 patients who have undergone surgery and/or radiation for spine metastasis from 2002 to 2013 at an academic medical institution in the United States. A univariate survival analysis was carried out using the Kaplan-Meier method. Differences in survival by histology were assessed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazards model, then using the same variables, recursive partitioning analysis (RPA) was conducted to determine risk groups associated with survival. Results: The median overall survival was 4.76 months. Twenty percent, 40%, and 57% of patients died within one, three, and six months of radiation treatment, respectively. RPA analysis resulted in three classes; class I included patients with Karnofsky Performance Status (KPS) ≥80. Class II included patients with KPS <80 and radioresistant or favorable histologies. Class III included all other histologies. Median survival in months was 11.4, 6.3, and 2.0, respectively. Conclusion: We developed a stratification schema predictive of survival in patients with spine metastasis. This RPA classification should be validated in independent patient populations from several institutions and may ultimately identify patients who are good candidates for more complex treatment regimens, such as stereotactic body radiotherapy.
Collapse
Affiliation(s)
- Allison Walker
- Department of Obstetrics and Gynecology, Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Solange Bassale
- Knight Cancer Institute Biostatistics Shared Resource and Oregon Health and Science University, Portland, Oregon, USA
| | - Rakendu Shukla
- Department of Obstetrics and Gynecology, Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Charlotte Dai Kubicky
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
49
|
Sahgal A, Myrehaug SD, Siva S, Masucci GL, Maralani PJ, Brundage M, Butler J, Chow E, Fehlings MG, Foote M, Gabos Z, Greenspoon J, Kerba M, Lee Y, Liu M, Liu SK, Thibault I, Wong RK, Hum M, Ding K, Parulekar WR. Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2/3 trial. Lancet Oncol 2021; 22:1023-1033. [PMID: 34126044 DOI: 10.1016/s1470-2045(21)00196-0] [Citation(s) in RCA: 197] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/25/2021] [Accepted: 03/31/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Conventional external beam radiotherapy is the standard palliative treatment for spinal metastases; however, complete response rates for pain are as low as 10-20%. Stereotactic body radiotherapy delivers high-dose, ablative radiotherapy. We aimed to compare complete response rates for pain after stereotactic body radiotherapy or conventional external beam radiotherapy in patients with painful spinal metastasis. METHODS This open-label, multicentre, randomised, controlled, phase 2/3 trial was done at 13 hospitals in Canada and five hospitals in Australia. Patients were eligible if they were aged 18 years and older, and had painful (defined as ≥2 points with the Brief Pain Inventory) MRI-confirmed spinal metastasis, no more than three consecutive vertebral segments to be included in the treatment volume, an Eastern Cooperative Oncology Group performance status of 0-2, a Spinal Instability Neoplasia Score of less than 12, and no neurologically symptomatic spinal cord or cauda equina compression. Patients were randomly assigned (1:1) with a web-based, computer-generated allocation sequence to receive either stereotactic body radiotherapy at a dose of 24 Gy in two daily fractions or conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions using standard techniques. Treatment assignment was done centrally by use of a minimisation method to achieve balance for the stratification factors of radiosensitivity, the presence or absence of mass-type tumour (extraosseous or epidural disease extension, or both) on imaging, and centre. The primary endpoint was the proportion of patients with a complete response for pain at 3 months after radiotherapy. The primary endpoint was analysed in the intention-to-treat population and all safety and quality assurance analyses were done in the as-treated population (ie, all patients who received at least one fraction of radiotherapy). The trial is registered with ClinicalTrials.gov, NCT02512965. FINDINGS Between Jan 4, 2016, and Sept 27, 2019, 229 patients were enrolled and randomly assigned to receive conventional external beam radiotherapy (n=115) or stereotactic body radiotherapy (n=114). All 229 patients were included in the intention-to-treat analysis. The median follow-up was 6·7 months (IQR 6·3-6·9). At 3 months, 40 (35%) of 114 patients in the stereotactic body radiotherapy group, and 16 (14%) of 115 patients in the conventional external beam radiotherapy group had a complete response for pain (risk ratio 1·33, 95% CI 1·14-1·55; p=0·0002). This significant difference was maintained in multivariable-adjusted analyses (odds ratio 3·47, 95% CI 1·77-6·80; p=0·0003). The most common grade 3-4 adverse event was grade 3 pain (five [4%] of 115 patients in the conventional external beam radiotherapy group vs five (5%) of 110 patients in the stereotactic body radiotherapy group). No treatment-related deaths were observed. INTERPRETATION Stereotactic body radiotherapy at a dose of 24 Gy in two daily fractions was superior to conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions in improving the complete response rate for pain. These results suggest that use of conformal, image-guided, stereotactically dose-escalated radiotherapy is appropriate in the palliative setting for symptom control for selected patients with painful spinal metastases, and an increased awareness of the need for specialised and multidisciplinary involvement in the delivery of end-of-life care is needed. FUNDING Canadian Cancer Society and the Australian National Health and Medical Research Council.
Collapse
Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| | - Sten D Myrehaug
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, University of Melbourne, VIC, Australia
| | - Giuseppina L Masucci
- Department of Radiation Oncology, Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | - Pejman J Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael Brundage
- Department of Cancer Care and Epidemiology, Queens's University, Kingston, ON, Canada
| | - James Butler
- Department of Radiation Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Edward Chow
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Mathew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Zsolt Gabos
- Department of Radiation Oncology, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Greenspoon
- Department of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | - Marc Kerba
- Department of Radiation Oncology, University of Calgary, Calgary, AB, Canada
| | - Young Lee
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mitchell Liu
- Department of Radiation Oncology, British Columbia Cancer Centre, Vancouver, BC, Canada
| | - Stanley K Liu
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Isabelle Thibault
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Quebec, Quebec City, QC, Canada
| | - Rebecca K Wong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Maaike Hum
- Canadian Clinical Trials Group, Queens's University, Kingston, ON, Canada
| | - Keyue Ding
- Canadian Clinical Trials Group, Queens's University, Kingston, ON, Canada
| | - Wendy R Parulekar
- Canadian Clinical Trials Group, Queens's University, Kingston, ON, Canada
| | | |
Collapse
|
50
|
Sharma R, Sagoo NS, Haider AS, Sharma N, Haider M, Sharma IK, Igbinigie M, Aya KL, Aoun SG, Vira S. Iodine-125 radioactive seed brachytherapy as a treatment for spine and bone metastases: A systematic review and meta-analysis. Surg Oncol 2021; 38:101618. [PMID: 34153905 DOI: 10.1016/j.suronc.2021.101618] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/24/2021] [Accepted: 06/06/2021] [Indexed: 11/25/2022]
Abstract
AIM To evaluate the analgesic efficacy, safety, and local tumor control of iodine-125 (125I) seed brachytherapy (BT) for the management of spine and bone metastases. METHODS A systematic literature search was conducted using PubMed, the Cochrane Library, and Scopus databases. Data regarding patient demographics, tumor characteristics, procedural parameters, and clinical outcomes were extracted and analyzed. RESULTS Fourteen studies (7 prospective, 7 retrospective) were included, accounting for 689 patients, in our review. Analgesic efficacy was assessed at baseline and various postoperative time points. Significant improvement in pain was noted at 4- and 24-week follow-ups (p < 0.01). Interestingly, all studies that combined 125I seed BT with cement augmentation reported relatively higher levels of pain reduction (mean pain reduction ≥4 points) as compared to the studies which applied 125I seed BT as a stand-alone therapy (mean pain reduction ≥2 points), at the last follow-up. Local tumor control rates ranged widely from 14% to 100% at varying follow-ups. Median overall survival ranged between 10 months and 25 months. The overall complication rate was 19% (130/689) and mainly included minor subcutaneous hemorrhage, fever, myelosuppression, and seed displacement. Metrics assessing performance and quality of life demonstrated significant improvements from baseline to posttreatment. CONCLUSION 125I seed BT, alone or in conjunction with cement augmentation, may be a viable salvage therapy in appropriately selected patients. However, further studies are needed to analyze the long-term efficacy of this intervention as a palliative and curative modality.
Collapse
Affiliation(s)
- Ruhi Sharma
- Ross University School of Medicine, Miramar, FL, USA
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ali S Haider
- Texas A&M University College of Medicine, Bryan, TX, USA
| | - Neha Sharma
- Roseman University of Health Sciences, South Jordan, UT, USA
| | - Maryam Haider
- McGovern Medical School at UTHealth, Houston, TX, USA
| | | | - Matthew Igbinigie
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kessiena L Aya
- Department of Orthopedic Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shaleen Vira
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|