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Li W, Lin Y, Li HH, Shen X, Chen RC, Gao H. Biological optimization for hybrid proton-photon radiotherapy. Phys Med Biol 2024; 69:115040. [PMID: 38759678 DOI: 10.1088/1361-6560/ad4d51] [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: 03/01/2024] [Accepted: 05/17/2024] [Indexed: 05/19/2024]
Abstract
Objective.Hybrid proton-photon radiotherapy (RT) is a cancer treatment option to broaden access to proton RT. Additionally, with a refined treatment planning method, hybrid RT has the potential to offer superior plan quality compared to proton-only or photon-only RT, particularly in terms of target coverage and sparing organs-at-risk (OARs), when considering robustness to setup and range uncertainties. However, there is a concern regarding the underestimation of the biological effect of protons on OARs, especially those in close proximity to targets. This study seeks to develop a hybrid treatment planning method with biological dose optimization, suitable for clinical implementation on existing proton and photon machines, with each photon or proton treatment fraction delivering a uniform target dose.Approach.The proposed hybrid biological dose optimization method optimized proton and photon plan variables, along with the number of fractions for each modality, minimizing biological dose to the OARs and surrounding normal tissues. To mitigate underestimation of hot biological dose spots, proton biological dose was minimized within a ring structure surrounding the target. Hybrid plans were designed to be deliverable separately and robustly on existing proton and photon machines, with enforced uniform target dose constraints for the proton and photon fraction doses. A probabilistic formulation was utilized for robust optimization of setup and range uncertainties for protons and photons. The nonconvex optimization problem, arising from minimum monitor unit constraint and dose-volume histogram constraints, was solved using an iterative convex relaxation method.Main results.Hybrid planning with biological dose optimization effectively eliminated hot spots of biological dose, particularly in normal tissues surrounding the target, outperforming proton-only planning. It also provided superior overall plan quality and OAR sparing compared to proton-only or photon-only planning strategies.Significance.This study presents a novel hybrid biological treatment planning method capable of generating plans with reduced biological hot spots, superior plan quality to proton-only or photon-only plans, and clinical deliverability on existing proton and photon machines, separately and robustly.
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Affiliation(s)
- Wangyao Li
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, KS 66160, United States of America
| | - Yuting Lin
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, KS 66160, United States of America
| | - Harold H Li
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, KS 66160, United States of America
| | - Xinglei Shen
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, KS 66160, United States of America
| | - Ronald C Chen
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, KS 66160, United States of America
| | - Hao Gao
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, KS 66160, United States of America
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Dastgheyb SS, Dreyfuss AD, LaRiviere MJ, Mohiuddin JJ, Baumann BC, Shabason J, Lustig RA, Dorsey JF, Lin A, Grady SM, O'Malley BW, Lee JY, Newman JG, Schuster JM, Alonso-Basanta M. A Prospective Phase I/II Clinical Trial of High-Dose Proton Therapy for Chordomas and Chondrosarcomas. Adv Radiat Oncol 2024; 9:101456. [PMID: 38550376 PMCID: PMC10972808 DOI: 10.1016/j.adro.2024.101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/19/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose The purpose of this study was to evaluate the feasibility and safety of dose-escalated proton beam therapy for treating chordomas and chondrosarcomas of the skull base and spine. Methods: A prospective cohort of 54 patients (42 with chordomas and 12 with chondrosarcomas) was enrolled between 2010 and 2018. The primary endpoints were feasibility and <20% rate of acute grade ≥3 toxicity, and secondary endpoints included cancer-specific outcomes and toxicities. Patients were followed with magnetic resonance imaging or computed tomography at 3-month intervals. Proton beam therapy was delivered with doses up to 79.2 Gy using protons only, combination protons/intensity modulated radiation therapy (IMRT), or IMRT only. Results Feasibility endpoints were met, with only 2 out of 54 patient radiation therapy plans failing to meet dosimetric constraints with protons, and 4 out of 54 experiencing a delay or treatment break >5 days, none for toxicities related to treatment. There were no grade 4 acute toxicities and 1 grade 3 acute toxicity (sensory neuropathy). The only 2 grade 3 late toxicities recorded, osteoradionecrosis and intranasal carotid blowout (mild and not emergently treated), occurred in a single patient. We report overall survival as 83% at 5 years, with local failure-free survival and progression-free survival rates of 72% and 68%, respectively. Five patients developed distant disease, and among the 9/54 patients who died, 4 deaths were not attributed to treatment or recurrence. Conclusions Our findings suggest that high-dose proton therapy alone or in combination with IMRT is a safe and effective treatment option for chordomas and chondrosarcomas of the skull base and spine.
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Affiliation(s)
- Sana S. Dastgheyb
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexandra D. Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael J. LaRiviere
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jahan J. Mohiuddin
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Brian C. Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jacob Shabason
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A. Lustig
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay F. Dorsey
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean M. Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bert W. O'Malley
- University of Maryland School of Medicine, University of Maryland, Baltimore, Maryland
| | - John Y.K. Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G. Newman
- Department of Otorhinolaryngology/Head and Neck Surgery, Medical University of South Carolina, Hollings Cancer Center, Charleston, South Carolina
| | - James M. Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Nachankar A, Schafasand M, Hug E, Martino G, Góra J, Carlino A, Stock M, Fossati P. Sacral-Nerve-Sparing Planning Strategy in Pelvic Sarcomas/Chordomas Treated with Carbon-Ion Radiotherapy. Cancers (Basel) 2024; 16:1284. [PMID: 38610962 PMCID: PMC11010899 DOI: 10.3390/cancers16071284] [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: 02/01/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
To minimize radiation-induced lumbosacral neuropathy (RILSN), we employed sacral-nerve-sparing optimized carbon-ion therapy strategy (SNSo-CIRT) in treating 35 patients with pelvic sarcomas/chordomas. Plans were optimized using Local Effect Model-I (LEM-I), prescribed DRBE|LEM-I|D50% (median dose to HD-PTV) = 73.6 (70.4-76.8) Gy (RBE)/16 fractions. Sacral nerves were contoured between L5-S3 levels. DRBE|LEM-I to 5% of sacral nerves-to-spare (outside HD-CTV) (DRBE|LEM-I|D5%) were restricted to <69 Gy (RBE). The median follow-up was 25 months (range of 2-53). Three patients (9%) developed late RILSN (≥G3) after an average period of 8 months post-CIRT. The RILSN-free survival at 2 years was 91% (CI, 81-100). With SNSo-CIRT, DRBE|LEM-I|D5% for sacral nerves-to-spare = 66.9 ± 1.9 Gy (RBE), maintaining DRBE|LEM-I to 98% of HD-CTV (DRBE|LEM-I|D98%) = 70 ± 3.6 Gy (RBE). Two-year OS and LC were 100% and 93% (CI, 84-100), respectively. LETd and DRBE with modified-microdosimetric kinetic model (mMKM) were recomputed retrospectively. DRBE|LEM-I and DRBE|mMKM were similar, but DRBE-filtered-LETd was higher in sacral nerves-to-spare in patients with RILSN than those without. At DRBE|LEM-I cutoff = 64 Gy (RBE), 2-year RILSN-free survival was 100% in patients with <12% of sacral nerves-to-spare voxels receiving LETd > 55 keV/µm than 75% (CI, 54-100) in those with ≥12% of voxels (p < 0.05). DRBE-filtered-LETd holds promise for the SNSo-CIRT strategy but requires longer follow-up for validation.
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Affiliation(s)
- Ankita Nachankar
- ACMIT Gmbh, 2700 Wiener Neustadt, Austria
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (E.H.); (P.F.)
| | - Mansure Schafasand
- Department of Medical Physics, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (M.S.); (G.M.); (J.G.); (A.C.); (M.S.)
- Department of Radiation Oncology, Medical University of Vienna, 1090 Wien, Austria
- Division Medical Physics, Karl Landsteiner University of Health Sciences, 3500 Krems an der Donau, Austria
| | - Eugen Hug
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (E.H.); (P.F.)
| | - Giovanna Martino
- Department of Medical Physics, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (M.S.); (G.M.); (J.G.); (A.C.); (M.S.)
| | - Joanna Góra
- Department of Medical Physics, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (M.S.); (G.M.); (J.G.); (A.C.); (M.S.)
| | - Antonio Carlino
- Department of Medical Physics, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (M.S.); (G.M.); (J.G.); (A.C.); (M.S.)
| | - Markus Stock
- Department of Medical Physics, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (M.S.); (G.M.); (J.G.); (A.C.); (M.S.)
- Division Medical Physics, Karl Landsteiner University of Health Sciences, 3500 Krems an der Donau, Austria
| | - Piero Fossati
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria; (E.H.); (P.F.)
- Division Radiation Oncology, Karl Landsteiner University of Health Sciences, 3500 Krems an der Donau, Austria
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4
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Yeung CM, Bilsky M, Boland PJ, Vaynrub M. The Role of En Bloc Resection in the Modern Era for Primary Spine Tumors. Spine (Phila Pa 1976) 2024; 49:46-57. [PMID: 37732462 PMCID: PMC10750970 DOI: 10.1097/brs.0000000000004821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/27/2023] [Indexed: 09/22/2023]
Abstract
STUDY DESIGN A literature review. OBJECTIVE The aim of this review is to provide an overview of benign and malignant primary spine tumors and a balanced analysis of the benefits and limitations of (and alternatives to) surgical treatment with en bloc resection. SUMMARY OF BACKGROUND DATA Primary spine tumors are rare but have the potential to cause severe morbidity, either from the disease itself or as a result of treatment. The prognosis, goals, and treatment options vary significantly with the specific disease entity. Appropriate initial management is critical; inappropriate surgery before definitive treatment can lead to recurrence and may render the patient incurable, as salvage options are often inferior. METHODS We performed a comprehensive search of the PubMed database for articles relevant to primary spine neoplasms and en bloc spine surgery. Institutional review board approval was not needed. RESULTS Although Enneking-appropriate en bloc surgery can be highly morbid, it often provides the greatest chance for local control and/or patient survival. However, there is growing data to support modern radiotherapy as a feasible and less morbid approach to certain primary neoplasms that historically were considered radioresistant. CONCLUSIONS Choosing the optimal approach to primary spine tumors is complex. A comprehensive and up-to-date assessment of the evidence is required to guide patient care and to balance the often-competing goals of prolonging life and preserving quality of life.
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Affiliation(s)
- Caleb M. Yeung
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Patrick J. Boland
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Chen Q, Zheng K, Xu M, Yan N, Hai G, Yu X. Anlotinib combined with radiotherapy and chemotherapy for recurrent pelvic osteosarcoma treatment: a case report and literature review. Front Oncol 2023; 13:1283932. [PMID: 38156107 PMCID: PMC10753991 DOI: 10.3389/fonc.2023.1283932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/17/2023] [Indexed: 12/30/2023] Open
Abstract
At present, the treatment of recurrent pelvic osteosarcoma is too simple, and most of the patients are treated with chemotherapy, radiotherapy, and/or combined surgery. Here, we report a 29-year-old man diagnosed with local recurrent pelvic osteosarcoma. Imaging showed that the tumor had obvious enhancement and abundant blood vessels. There was no indication of surgery. After the patient's consent was obtained, we used anlotinib as a sequential treatment to chemotherapy. During the first course of adjuvant chemotherapy, we treated the patient with intensity-modulated radiotherapy (IMRT) with a total dose of 60 Gy equivalents. No disease recurrence was reported at 25 months after multimodal combination therapy.
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Affiliation(s)
- Qian Chen
- Department of Orthopedics, The 960th Hospital of the People’s Liberation Army, Jinan, Shandong, China
| | - Kai Zheng
- Department of Orthopedics, The 960th Hospital of the People’s Liberation Army, Jinan, Shandong, China
| | - Ming Xu
- Department of Orthopedics, The 960th Hospital of the People’s Liberation Army, Jinan, Shandong, China
| | - Ning Yan
- Department of Radiotherapy, The 960th Hospital of the People’s Liberation Army, Jinan, Shandong, China
| | - Gong Hai
- Department of Radiotherapy, The 960th Hospital of the People’s Liberation Army, Jinan, Shandong, China
| | - Xiuchun Yu
- Department of Orthopedics, The 960th Hospital of the People’s Liberation Army, Jinan, Shandong, China
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Thio QCBS, van Wulfften Palthe ODR, Bramer JAM, DeLaney TF, Bredella MA, Dempster DW, Zhou H, Hornicek FJ, Chen YLE, Schwab JH. Pilot Study: Short Term Impact of Radiation Therapy on Bone Mineral Density and Bone Metabolism. Calcif Tissue Int 2023; 113:640-650. [PMID: 37910222 PMCID: PMC10673955 DOI: 10.1007/s00223-023-01149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
Despite the risk of complications, high dose radiation therapy is increasingly utilized in the management of selected bone malignancies. In this study, we investigate the impact of moderate to high dose radiation (over 50 Gy) on bone metabolism and structure. Between 2015 and 2018, patients with a primary malignant bone tumor of the sacrum that were either treated with high dose definitive radiation only or a combination of moderate to high dose radiation and surgery were prospectively enrolled at a single institution. Quantitative CTs were performed before and after radiation to determine changes in volumetric bone mineral density (BMD) of the irradiated and non-irradiated spine. Bone histomorphometry was performed on biopsies of the irradiated sacrum and the non-irradiated iliac crest of surgical patients using a quadruple tetracycline labeling protocol. In total, 9 patients were enrolled. Two patients received radiation only (median dose 78.3 Gy) and 7 patients received a combination of preoperative radiation (median dose 50.4 Gy), followed by surgery. Volumetric BMD of the non-irradiated lumbar spine did not change significantly after radiation, while the BMD of the irradiated sacrum did (pre-radiation median: 108.0 mg/cm3 (IQR 91.8-167.1); post-radiation median: 75.3 mg/cm3 (IQR 57.1-110.2); p = 0.010). The cancellous bone of the non-irradiated iliac crest had a stable bone formation rate, while the irradiated sacrum showed a significant decrease in bone formation rate [pre-radiation median: 0.005 mm3/mm2/year (IQR 0.003-0.009), post-radiation median: 0.001 mm3/mm2/year (IQR 0.001-0.001); p = 0.043]. Similar effects were seen in the cancellous and endocortical envelopes. This pilot study shows a decrease of volumetric BMD and bone formation rate after high-dose radiation therapy. Further studies with larger cohorts and other endpoints are needed to get more insight into the effect of radiation on bone. Level of evidence: IV.
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Affiliation(s)
- Quirina C B S Thio
- Department of Orthopedic Surgery, Academic University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Massachusetts General Hospital, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Olivier D R van Wulfften Palthe
- Department of Orthopedic Surgery, Academic University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jos A M Bramer
- Department of Orthopedic Surgery, Academic University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David W Dempster
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, New York, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, New York, USA
| | | | - Yen-Lin E Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Redmond KJ, Schaub SK, Lo SFL, Khan M, Lubelski D, Bilsky M, Yamada Y, Fehlings M, Gogineni E, Vajkoczy P, Ringel F, Meyer B, Amin AG, Combs SE, Lo SS. Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy. Cancers (Basel) 2023; 15:cancers15082359. [PMID: 37190287 DOI: 10.3390/cancers15082359] [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: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY 11549, USA
| | - Majid Khan
- Department of Radiology, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurological Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael Fehlings
- Department of Neurosurgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Emile Gogineni
- Department of Radiation Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charite University Hospital, 10117 Berlin, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, 80333 Munich, Germany
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA 98115, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, 81675 Munich, Germany
| | - Simon S Lo
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
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Abunimer AM, Hammoudeh L, Dee EC, Lak AM, Chi J, Lu Y, Groff M, Shin JH, Lam MB, Zaidi HA. Gross total resection of spinal chondrosarcoma is associated with improved locoregional relapse-free survival and overall survival. 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; 32:994-1002. [PMID: 36592209 DOI: 10.1007/s00586-022-07505-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 10/05/2022] [Accepted: 12/15/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Spinal chondrosarcomas are rare malignant osseous tumors. The low incidence of spinal chondrosarcomas and the complexity of spine anatomy have led to heterogeneous treatment strategies with varying curative and survival rates. The goal of this study is to investigate prognostic factors for locoregional recurrence-free survival (LRFS) and overall survival (OS) comparing en bloc vs. piecemeal resection for the management of spinal chondrosarcoma. METHODS We retrospectively identified patients who underwent curative-intent resection of primary and metastatic spinal chondrosarcoma over a 25-year period. Univariate and multivariate survival analyses were conducted with LRFS as primary endpoint and OS as secondary endpoint. LRFS and OS were modeled using the Kaplan-Meier method and assessed using Cox regression analysis. RESULTS For 72 patients who underwent first resection, the median follow-up time was 5.1 years (95% CI 2.2-7.0). Thirty-three patients (45.8%) had en bloc resection, and 39 (54.2%) had piecemeal resection. Of the 68 patients for whom extent of resection was known, 44 patients had gross total resection (GTR) and 24 patients had subtotal resection. In survival analyses, both LRFS and OS showed statistically significant difference based on the extent of resection (p = 0.001; p = 0.04, respectively). However, only LRFS showed statistically significant difference when assessing the type of resection (p = 0.02). In addition, higher tumor grade and more invasive disease were associated with worse LRFS and OS rates. CONCLUSION Although in our study en bloc and GTR were associated with improved survival, heterogenous and complex spinal presentations may limit total resection. Therefore, the surgical management should be tailored individually to ensure the best local control and maximum preservation of function.
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Affiliation(s)
- Abdullah M Abunimer
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Department of Orthopedic Surgery, Hamad General Hospital, Doha, Qatar
| | - Lubna Hammoudeh
- Department of Radiation Medicine, The Oregon Health & Science University Hospital, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Asad M Lak
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - John Chi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Yi Lu
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Michael Groff
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - John H Shin
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Dana Farber Cancer Institute, Boston, USA.
| | - Hasan A Zaidi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.
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Halvorsen SC, Benita Y, Hopton M, Hoppe B, Gunnlaugsson HO, Korgaonkar P, Vanderburg CR, Nielsen GP, Trepanowski N, Cheah JH, Frosch MP, Schwab JH, Rosenberg AE, Hornicek FJ, Sassi S. Transcriptional Profiling Supports the Notochordal Origin of Chordoma and Its Dependence on a TGFΒ1-TBXT Network. THE AMERICAN JOURNAL OF PATHOLOGY 2023; 193:532-547. [PMID: 36804377 DOI: 10.1016/j.ajpath.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 12/23/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
Chordoma is a rare malignant tumor demonstrating notochordal differentiation. It is dependent on brachyury (TBXT), a hallmark notochordal gene and transcription factor, and shares histologic features and the same anatomic location as the notochord. In this study, we perform a molecular comparison of chordoma and notochord to identify dysregulated cellular pathways. The lack of a molecular reference from appropriate control tissue limits our understanding of chordoma and its relationship to notochord. Accordingly, we conducted an unbiased comparison of chordoma, human notochord, and an atlas of normal and cancerous tissue using gene expression profiling to clarify the chordoma/notochord relationship and potentially identify novel drug targets. We found striking consistency in gene expression profiles between chordoma and notochord, supporting the hypothesis that chordoma develops from notochordal remnants. We identified a 12-gene diagnostic chordoma signature and found that the TBXT/transforming growth factor (TGF)-β/SOX6/SOX9 pathway is hyperactivated in the tumor, suggesting that pathways associated with chondrogenesis are a central driver of chordoma development. Experimental validation in chordoma cells confirms these findings and emphasizes the dependence of chordoma proliferation and survival on TGF-β. Our computational and experimental evidence provides the first molecular connection between notochord and chordoma and identifies core members of a chordoma regulatory pathway involving TBXT. This pathway provides new therapeutic targets for this unique malignant neoplasm and highlights TGF-β as a prime druggable candidate.
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Affiliation(s)
- Stefan C Halvorsen
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Yair Benita
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Megan Hopton
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Brooke Hoppe
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hilmar Orn Gunnlaugsson
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Parimal Korgaonkar
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Charles R Vanderburg
- Harvard NeuroDiscovery Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts
| | - G Petur Nielsen
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicole Trepanowski
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jaime H Cheah
- High Throughput Sciences Facility, Koch Institute of MIT, Cambridge, Massachusetts
| | - Matthew P Frosch
- C.S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew E Rosenberg
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis J Hornicek
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
| | - Slim Sassi
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
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10
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Li W, Zhang W, Lin Y, Chen RC, Gao H. Fraction optimization for hybrid proton-photon treatment planning. Med Phys 2023. [PMID: 36786202 DOI: 10.1002/mp.16297] [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: 11/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Hybrid proton-photon radiotherapy (RT) can provide better plan quality than proton or photon only RT, in terms of robustness of target coverage and sparing of organs-at-risk (OAR). PURPOSE This work develops a hybrid treatment planning method that can optimize the number of proton and photon fractions as well as proton and photon plan variables, so that the hybrid plans can be clinically delivered day-to-day using either proton or photon machine. METHODS In the new hybrid treatment planning method, the total dose distribution (sum of proton dose and photon dose) is optimized for robust target coverage and optimal OAR sparing, by jointly optimizing proton spots and photon fluences, while the target dose uniformity is also enforced individually on both proton dose and photon dose, so that the hybrid plans can be separately and robustly delivered on proton or photon machine. To ensure the target dose uniformity for proton and photon plans, the number of proton and photon fractions is explicitly modeled and optimized, so that the target dose for proton and photon dose components is constrained to be a constant fraction of the total prescription dose while the plan quality based on total dose is optimized. The feasibility of hybrid planning using the proposed method is validated with representative clinical cases including abdomen, lung, head-and-neck (HN), and brain. RESULTS For all cases, hybrid plans provided better overall plan quality and OAR sparing than proton-only or photon-only plans, better target dose uniformity and robustness than proton-only plans, quantified by treatment planning objectives and dosimetric parameters. Moreover, for HN and brain cases, hybrid plans also had better target coverage than photon-only plans. CONCLUSIONS We have developed a new hybrid treatment planning method that optimizes number of proton and photon fractions as well as proton spots and photon fluences, for generating hybrid plans that can be separately and robustly delivered on proton or photon machines. Preliminary results have demonstrated that hybrid plans generated by the new method have better plan quality than proton-only or photon-only plans.
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Affiliation(s)
- Wangyao Li
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Weijie Zhang
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Yuting Lin
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ronald C Chen
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Hao Gao
- Department of Radiation Oncology, Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
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11
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Chang C, Charyyev S, Harms J, Slopsema R, Wolf J, Refai D, Yoon T, McDonald MW, Bradley JD, Leng S, Zhou J, Yang X, Lin L. A component method to delineate surgical spine implants for proton Monte Carlo dose calculation. J Appl Clin Med Phys 2022; 24:e13800. [PMID: 36210177 PMCID: PMC9859997 DOI: 10.1002/acm2.13800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/09/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Metallic implants have been correlated to local control failure for spinal sarcoma and chordoma patients due to the uncertainty of implant delineation from computed tomography (CT). Such uncertainty can compromise the proton Monte Carlo dose calculation (MCDC) accuracy. A component method is proposed to determine the dimension and volume of the implants from CT images. METHODS The proposed component method leverages the knowledge of surgical implants from medical supply vendors to predefine accurate contours for each implant component, including tulips, screw bodies, lockers, and rods. A retrospective patient study was conducted to demonstrate the feasibility of the method. The reference implant materials and samples were collected from patient medical records and vendors, Medtronic and NuVasive. Additional CT images with extensive features, such as extended Hounsfield units and various reconstruction diameters, were used to quantify the uncertainty of implant contours. RESULTS For in vivo patient implant estimation, the reference and the component method differences were 0.35, 0.17, and 0.04 cm3 for tulips, screw bodies, and rods, respectively. The discrepancies by a conventional threshold method were 5.46, 0.76, and 0.05 cm3 , respectively. The mischaracterization of implant materials and dimensions can underdose the clinical target volume coverage by 20 cm3 for a patient with eight lumbar implants. The tulip dominates the dosimetry uncertainty as it can be made from titanium or cobalt-chromium alloys by different vendors. CONCLUSIONS A component method was developed and demonstrated using phantom and patient studies with implants. The proposed method provides more accurate implant characterization for proton MCDC and can potentially enhance the treatment quality for proton therapy. The current proof-of-concept study is limited to the implant characterization for lumbar spine. Future investigations could be extended to cervical spine and dental implants for head-and-neck patients where tight margins are required to spare organs at risk.
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Affiliation(s)
- Chih‐Wei Chang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Joseph Harms
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Roelf Slopsema
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jonathan Wolf
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Daniel Refai
- Department of NeurosurgeryEmory UniversityAtlantaGeorgiaUSA
| | - Tim Yoon
- Department of OrthopaedicsEmory UniversityAtlantaGeorgiaUSA
| | - Mark W. McDonald
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Shuai Leng
- Department of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA,Department of Biomedical InformaticsEmory UniversityAtlantaGeorgiaUSA
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
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12
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Gao J, Huang R, Yin H, Song D, Meng T. Research hotspots and trends of chordoma: A bibliometric analysis. Front Oncol 2022; 12:946597. [PMID: 36185236 PMCID: PMC9523362 DOI: 10.3389/fonc.2022.946597] [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: 05/17/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Chordoma is a type of mesenchymal malignancy with a high recurrence rate and poor prognosis. Due to its rarity, the tumorigenic mechanism and optimal therapeutic strategy are not well known. Methods All relevant articles of chordoma research from 1 January 2000 to 26 April 2022 were obtained from Web of Science Core Collection database. Blibliometrix was used to acquire basic publication data. Visualization and data table of collaboration network, dynamic analysis, trend topics, thematic map, and factorial analysis were acquired using Blibliometrix package. VOSviewer was used to generate a visualization map of co-citation analysis and co-occurrence. Results A total of 2,285 articles related to chordoma were identified. The most influential and productive country/region was the United States, and Capital Medical University has published the most articles. Among all high-impact authors, Adrienne M. Flanagan had the highest average citation rate. Neurosurgery was the important periodical for chordoma research with the highest total/average citation rate. We focused on four hotspots in recent chordoma research. The research on surgical treatment and radiotherapy was relatively mature. The molecular signaling pathway, targeted therapy and immunotherapy for chordoma are not yet mature, which will be the future trends of chordoma research. Conclusion This study indicates that chordoma studies are increasing. Surgery and radiotherapy are well reported and always play fundamental roles in chordoma treatment. The molecular signaling pathway, targeted therapy, and immunotherapy of chordoma are the latest research hotspots.
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Affiliation(s)
- Jianxuan Gao
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Tongji University Cancer Center, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Runzhi Huang
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Huabin Yin
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dianwen Song
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Tong Meng, ; Dianwen Song,
| | - Tong Meng
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Tongji University Cancer Center, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Tong Meng, ; Dianwen Song,
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13
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Huo X, Wang K, Song L, Yang Y, Zhu S, Ma J, Tian K, Fan Y, Wang L, Wu Z. Bibliometric analysis of publication trends in chordoma research (1992−2021). INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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14
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Jabbar R, Jankowski J, Pawełczyk A, Szmyd B, Solek J, Pierzak O, Wojdyn M, Radek M. Cervical Paraspinal Chordoma: A Literature Review with a Novel Case Report. J Clin Med 2022; 11:jcm11144117. [PMID: 35887879 PMCID: PMC9325254 DOI: 10.3390/jcm11144117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 02/01/2023] Open
Abstract
Chordomas are rare malignant neoplasms, accounting for 1–4% of all primary bone tumors. Most spinal chordomas occur in the sacrococcygeal region and the base of the skull; however, 6% of chordomas are observed in the cervical spine. In these cases, the lesion is mainly located in the midline. These tumors slowly grow before becoming symptomatic and encase the surrounding vascular and nerve structures. Patients with advanced chordoma have a poor prognosis due to local recurrence with infiltration and destruction of adjacent bone and tissues. Systemic chemotherapy options have not been fully effective in these tumors, especially for recurrent chordomas. Thus, new combinations of currently available targeted molecular and biological therapies with radiotherapy have been proposed as potential treatment modalities. Here, the present paper describes the case of a 41-year-old male with a C2–C4 chordoma located paravertebrally, who underwent surgical resection with a debulking procedure for a cervical chordoma. Computed tomography angiography revealed a paraspinal mass with bone remodeling and the MRI showed a paravertebral mass penetrating to the spinal canal with a widening of the intervertebral C2–C3 foramen. Initially, the tumor was diagnosed as schwannoma based on its localization and imaging features; however, the histopathology specimen confirmed the diagnosis of chordoma. This case study highlights the effectivity of radical surgical resection as a mainstay treatment for chordomas, discusses neuroimaging, diagnosis, and the use of currently available targeted therapies and forthcoming treatment strategies, as alternative treatment options for chordoma.
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Affiliation(s)
- Redwan Jabbar
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Jakub Jankowski
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Agnieszka Pawełczyk
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Bartosz Szmyd
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Julia Solek
- Department of Pathology, Chair of Oncology, Medical University of Lodz, 92-213 Lodz, Poland;
| | - Olaf Pierzak
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Maciej Wojdyn
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Maciej Radek
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
- Correspondence:
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15
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Shah AA, Lozano-Calderon SA, Berner EA, Austen WG, Winograd JM, Park HY, Bernthal NM, Crawford BM, Hornicek FJ. Pedicled vastus lateralis myocutaneous flap for sacropelvic defects after wide oncologic resection: Wound complications and outcomes. J Surg Oncol 2022; 126:978-985. [PMID: 35809223 DOI: 10.1002/jso.27006] [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: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Adequate coverage of the soft tissue defects from wide resection of sacropelvic malignancies remains challenging. The vastus lateralis flap has been described for coverage in the setting of trauma and infection. This flap has not been described for coverage of sacropelvic tumor defects. METHODS This is a retrospective cohort study of adult patients who underwent wide resection of a primary sacropelvic malignancy with reconstruction employing a pedicled vastus lateralis flap at two tertiary care centers. Patient demographics, tumor staging, and rate of complications were assessed. RESULTS Twenty-eight patients were included, with a median age of 51 years. The most common primary tumor was chondrosarcoma followed by chondroblastic osteosarcoma. The median follow-up was 1.1 years. There were 10 cases of wound infection requiring re-operation and three cases of flap failure. CONCLUSIONS We describe a pedicled vastus lateralis flap for coverage of defects after wide resection of sacropelvic malignancies. A large proportion of our cohort had independent risk factors for wound complications. Even with a cohort with high baseline risk for wound complications, we show that the use of a pedicled vastus lateralis flap is a safe reconstructive option with a wound complication rate in line with the literature.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Emily A Berner
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William G Austen
- Division of Plastic & Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan M Winograd
- Division of Plastic & Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Howard Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Brooke M Crawford
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Francis J Hornicek
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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16
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Amstutz F, Fabiano S, Marc L, Weber DC, Lomax AJ, Unkelbach J, Zhang Y. Combined proton-photon therapy for non-small cell lung cancer. Med Phys 2022; 49:5374-5386. [PMID: 35561077 PMCID: PMC9544482 DOI: 10.1002/mp.15715] [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: 12/14/2021] [Revised: 04/18/2022] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Advanced non-small cell lung cancer (NSCLC) is still a challenging indication for conventional photon radiotherapy. Proton therapy has the potential to improve outcomes, but proton treatment slots remain a limited resource despite an increasing number of proton therapy facilities. This work investigates the potential benefits of optimally combined proton-photon therapy delivered using a fixed horizontal proton beam line in combination with a photon Linac, which could increase accessibility to proton therapy for such a patient cohort. MATERIALS AND METHODS A treatment planning study has been conducted on a patient cohort of seven advanced NSCLC patients. Each patient had a planning CT and multiple repeated CTs from three different days and for different breath-holds on each day. Treatment plans for combined proton-photon therapy (CPPT) were calculated for individual patients by optimizing the combined cumulative dose on the initial planning CT only (non-adapted) as well as on each daily CT respectively (adapted). The impact of inter-fractional changes and/or breath-hold variability was then assessed on the repeat breath-hold CTs. Results were compared to plans for IMRT or IMPT alone, as well as against combined treatments assuming a proton gantry. Plan quality was assessed in terms of dosimetric, robustness and NTCP metrics. RESULTS Combined treatment plans improved plan quality compared to IMRT treatments, especially in regard to reductions of low and medium doses to organs at risk (OARs), which translated into lower NTCP estimates for three side effects. For most patients, combined treatments achieved results close to IMPT-only plans. Inter-fractional changes impact mainly the target coverage of combined and IMPT treatments, while OARs doses were less affected by these changes. With plan adaptation however, target coverage of combined treatments remained high even when taking variability between breath-holds into account. CONCLUSIONS Optimally combined proton-photon plans improve treatment plan quality compared to IMRT only, potentially reducing the risk of toxicity while also allowing to potentially increase accessibility to proton therapy for NSCLC patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Florian Amstutz
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Silvia Fabiano
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Louise Marc
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.,Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
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17
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Chen ATC, Hong CBC, Narazaki DK, Rubin V, Serante AR, Ribeiro Junior U, de Lima LGCA, Coimbra BGMM, Cristante AF, Teixeira WGJ. High dose image-guided, intensity modulated radiation therapy (IG-IMRT) for chordomas of the sacrum, mobile spine and skull base: preliminary outcomes. J Neurooncol 2022; 158:23-31. [PMID: 35451720 DOI: 10.1007/s11060-022-04003-w] [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: 02/09/2022] [Accepted: 04/03/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To report preliminary outcomes of high dose image-guided intensity modulated radiotherapy (IG-IMRT) in the treatment of chordomas of the sacrum, mobile spine and skull base. METHODS Retrospective analysis of chordoma patients treated with surgery and/or radiotherapy (RT) in a single tertiary cancer center. Initial treatment was categorized as (A) Adjuvant or definitive high-dose RT (78 Gy/39fx or 24 Gy/1fx) vs (B) surgery-only or low dose RT. The primary endpoint was the cumulative incidence of local failure. RESULTS A total of 31 patients were treated from 2010 through 2020. Median age was 55 years, tumor location was 64% sacrum, 13% lumbar, 16% cervical and 6% clivus. Median tumor volume was 148 cc (8.3 cm in largest diameter), 42% of patients received curative-intent surgery and 65% received primary RT (adjuvant or definitive). 5-year cumulative incidence of local failure was 48% in group A vs 83% in group B (p = 0.041). Tumor size > 330 cc was associated with local failure (SHR 2.2, 95% CI 1.12 to 7.45; p = 0.028). Eight patients developed distant metastases, with a median metastases-free survival of 56.1 months. 5-year survival for patients that received high dose RT was 72% vs 76% in patients that received no or low dose RT (p = 0.63). CONCLUSION Our study suggests high-dose photon IG-IMRT improves local control in the initial management of chordomas. Health systems should promote reference centers with clinical expertise and technical capabilities to improve outcomes for this complex disease.
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Affiliation(s)
- Andre Tsin Chih Chen
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Arnaldo, 251, 4SS, São Paulo, SP, CEP 01246-000, Brazil.
| | - Carlos Bo Chur Hong
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Arnaldo, 251, 4SS, São Paulo, SP, CEP 01246-000, Brazil
| | - Douglas Kenji Narazaki
- Department of Spine Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | - Virginio Rubin
- Department of Radiology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | - Alexandre Ruggieri Serante
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Arnaldo, 251, 4SS, São Paulo, SP, CEP 01246-000, Brazil
| | - Ulysses Ribeiro Junior
- Department of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | | | | | - Alexandre Fogaça Cristante
- Department of Spine Surgery of Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | - William Gemio Jacobsen Teixeira
- Department of Spine Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
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18
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Nogueira LM, Jemal A, Yabroff KR, Efstathiou JA. Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e229025. [PMID: 35476066 PMCID: PMC9047654 DOI: 10.1001/jamanetworkopen.2022.9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, those surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To assess patterns of use of PBT according to the present American Society of Radiation Oncology (ASTRO) clinical indications in the US. DESIGN, SETTING, AND PARTICIPANTS Individuals newly diagnosed with cancer between 2004 and 2018 were selected from the National Cancer Database. Data analysis was performed from October 4, 2021, to February 22, 2022. ASTRO's Model Policies (2017) were used to classify patients into group 1, for which health insurance coverage for PBT treatment is recommended, and group 2, for which coverage is recommended only if additional requirements are met. MAIN OUTCOMES AND MEASURES Use of PBT. RESULTS Of the 5 919 368 patients eligible to receive PBT included in the study, 3 206 902 were female (54.2%), and mean (SD) age at diagnosis was 62.6 (12.3) years. Use of PBT in the US increased from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12%; P < .001) due to increases in group 1 from 0.4% in 2010 to 2.2% in 2018 (APC, 21.97; P < .001) and increases in group 2 from 0.03% in 2014 to 0.1% in 2018 (APC, 30.57; P < .001). From 2010 to 2018, among patients in group 2, PBT targeted to the breast increased from 0.0% to 0.9% (APC, 51.95%), and PBT targeted to the lung increased from 0.1% to 0.7% (APC, 28.06%) (P < .001 for both). Use of PBT targeted to the prostate decreased from 1.4% in 2011 to 0.8% in 2014 (APC, -16.48%; P = .03) then increased to 1.3% in 2018 (APC, 12.45; P < .001). Most patients in group 1 treated with PBT had private insurance coverage in 2018 (1039 [55.4%]); Medicare was the most common insurance type among those in group 2 (1973 [52.5%]). CONCLUSIONS AND RELEVANCE The findings of this study show an increase in the use of PBT in the US between 2004 to 2018; prostate was the only cancer site for which PBT use decreased temporarily between 2011 and 2014, increasing again between 2014 and 2018. These findings may be especially relevant for Medicare radiation oncology coverage policies.
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Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Department of Radiation Oncology, Massachusetts General Hospital, Boston
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19
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Banfield W, Ioakeim-Ioannidou M, Goldberg S, Ahmed S, Schwab J, Cote G, Choy E, Shin J, Hornicek F, Liebsch N, Chen Y, MacDonald SM, DeLaney T. Definitive high-dose, proton-based radiation for unresected mobile spine and sacral chordomas. Radiother Oncol 2022; 171:139-145. [DOI: 10.1016/j.radonc.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/18/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
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20
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Ingley KM, Maleddu A, Grange FL, Gerrand C, Bleyer A, Yasmin E, Whelan J, Strauss SJ. Current approaches to management of bone sarcoma in adolescent and young adult patients. Pediatr Blood Cancer 2022; 69:e29442. [PMID: 34767314 DOI: 10.1002/pbc.29442] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/02/2021] [Accepted: 10/16/2021] [Indexed: 01/05/2023]
Abstract
Bone tumors are a group of histologically diverse diseases that occur across all ages. Two of the commonest, osteosarcoma (OS) and Ewing sarcoma (ES), are regarded as characteristic adolescent and young adult (AYA) cancers with an incidence peak in AYAs. They are curable for some but associated with unacceptably high rates of treatment failure and morbidity. The introduction of effective new therapeutics for bone sarcomas is slow, and to date, complex biology has been insufficiently characterized to allow more rapid therapeutic exploitation. This review focuses on current standards of care, recent advances that have or may soon change that standard of care and challenges to the expert clinical research community that we suggest must be met.
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Affiliation(s)
- Katrina M Ingley
- London Sarcoma Service, University College London Hospitals NHS Trust, London, UK
| | - Alessandra Maleddu
- London Sarcoma Service, University College London Hospitals NHS Trust, London, UK
| | - Franel Le Grange
- London Sarcoma Service, University College London Hospitals NHS Trust, London, UK
| | - Craig Gerrand
- London Sarcoma Service, Department of Orthopaedic Oncology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | - Archie Bleyer
- Oregon Health and Science University, Portland, Oregon
| | - Ephia Yasmin
- Reproductive Medicine Unit, University College London Hospitals NHS Trust, London, UK
| | - Jeremy Whelan
- London Sarcoma Service, University College London Hospitals NHS Trust, London, UK
| | - Sandra J Strauss
- London Sarcoma Service, University College London Hospitals NHS Trust, London, UK.,UCL Cancer Institute, London, UK
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21
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Court C, Briand S, Mir O, Le Péchoux C, Lazure T, Missenard G, Bouthors C. Management of chordoma of the sacrum and mobile spine. Orthop Traumatol Surg Res 2022; 108:103169. [PMID: 34890865 DOI: 10.1016/j.otsr.2021.103169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
Chordoma is a very rare, poorly known malignancy, with slow progression, mainly located in the sacrum and spine. All age groups may be affected, with a diagnostic peak in the 5th decade of life. Clinical diagnosis is often late. Histologic diagnosis is necessary, based on percutaneous biopsy. Specific markers enable diagnosis and prediction of response to novel treatments. New radiation therapy techniques can stabilize the tumor for 5 years in inoperable patients, but en-bloc resection is the most effective treatment, and should be decided on after a multidisciplinary oncology team meeting in an expert reference center. The type of resection is determined by fine analysis of invasion. According to the level of resection, the patients should be informed and prepared for the expected vesico-genito-sphincteral neurologic sequelae. In tumors not extending above S3, isolated posterior resection is possible. Above S3, a double approach is needed. Anterior release of the sacrum is performed laparoscopically or by robot; resection uses a posterior approach. Posterior wall reconstruction is performed, with an associated flap. Spinopelvic stabilization is necessary in trans-S1 resection. Total or partial sacrectomy shows high rates of complications: intraoperative blood loss, infection or mechanical issues. Neurologic sequelae depend on the level of root sacrifice. No genital-sphincteral function survives S3 root sacrifice. Patient survival depends on initial resection quality and the center's experience. Immunotherapy is an ongoing line of research.
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Affiliation(s)
- Charles Court
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France.
| | - Sylvain Briand
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Olivier Mir
- Service d'Oncologie, Institut Gustave Roussy, Université Paris Saclay, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France
| | - Cécile Le Péchoux
- Service d'Oncologie, Institut Gustave Roussy, Université Paris Saclay, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France
| | - Thierry Lazure
- Service d'Anatomopathologie de l'Hôpital de Bicêtre, Université Paris Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Gilles Missenard
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Charlie Bouthors
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
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22
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Pennington Z, Ehresman J, Pittman PD, Ahmed AK, Lubelski D, McCarthy EF, Goodwin CR, Sciubba DM. Chondrosarcoma of the spine: a narrative review. Spine J 2021; 21:2078-2096. [PMID: 33971325 DOI: 10.1016/j.spinee.2021.04.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/19/2021] [Accepted: 04/28/2021] [Indexed: 02/03/2023]
Abstract
Chondrosarcoma is an uncommon primary bone tumor with an estimated incidence of 0.5 per 100,000 patient-years. Primary chondrosarcoma of the mobile spine and sacrum cumulatively account for less than 20% of all cases, most .commonly causing patients to present with focal pain with or without radiculopathy, or myelopathy secondary to neural element compression. Because of the rarity, patients benefit from multidisciplinary care at academic tertiary-care centers. Current standard-of-care consists of en bloc surgical resection with negative margins; for high grade lesions adjuvant focused radiation with ≥60 gray equivalents is taking an increased role in improving local control. Prognosis is dictated by lesion grade at the time of resection. Several groups have put forth survival calculators and epidemiological evidence suggests prognosis is quite good for lesions receiving R0 resection. Future efforts will be focused on identifying potential chemotherapeutic adjuvants and refining radiation treatments as a means of improving local control.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Mayo Clinic, Rochester, MN USA 55905; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287.
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ USA 85013.
| | - Patricia D Pittman
- Department of Neuropathology, Duke University School of Medicine, Durham, NC USA 27710
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287
| | - Edward F McCarthy
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC USA 27710
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY USA 11030.
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23
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Baig Mirza A, Bartram J, Okasha M, Al Banna Q, Vastani A, Maratos E, Gullan R, Thomas N. Surgical Management of Spinal Chordoma: A Systematic Review and Single-Center Experience. World Neurosurg 2021; 156:e111-e129. [PMID: 34506978 DOI: 10.1016/j.wneu.2021.09.001] [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: 07/13/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Chordoma is a rare neoplasm of the neuraxis derived from remnants of the primitive notochord. The importance of wide margins and use of adjuvant therapy in spinal chordomas are still contentious points in the management of spinal chordomas. We conducted a systematic review of the surgical management of spinal chordomas alongside our 10-year institutional experience. METHODS A systematic search of the literature was performed in November 2020 using Embase and MEDLINE for articles regarding the surgical management of chordomas arising from the mobile spine and sacrum. We also searched for all adult patients who were surgically managed for spinal chordomas at our institute between 2010 and 2020. In both the systematic review and our institutional case series, data on adequacy of resection, use of adjuvant therapy, complications, recurrence (local or metastatic), and survival outcomes were collected. RESULTS We identified and analyzed 42 articles, yielding 1531 patients, from which the overall gross total or wide resection rate was 54.9%. Among the 8 cases in our institutional experience (4 sacral, 3 cervical, and 1 lumbar), we achieved gross total resection in 50% of initial operations. The recurrence rate was 25% in our gross total resection group and 50% where initial resection was subtotal. Of patients, 75% had no evidence of recurrence at most recent follow-up. CONCLUSIONS Albeit difficult at times because of the proximity to neurovascular tissue, achieving a wide resection followed by adjuvant therapy for spinal chordomas is of great importance. Multidisciplinary discussion is valuable to ensure the best outcome for the patient.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | - James Bartram
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Qusai Al Banna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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24
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Sallabanda M, Garcia R, Lorenzana L, Santaolalla I, Abarca J, Sallabanda K. Treatment of Chordomas and Chondrosarcomas With CyberKnife Robotic Hypofractionated Radiosurgery: A Single Institution Experience. Cureus 2021; 13:e17012. [PMID: 34405079 PMCID: PMC8352833 DOI: 10.7759/cureus.17012] [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] [Accepted: 08/06/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction The aim of this study is to determine the efficacy and safety of CyberKnife® (Accuray, Inc., Sunnyvale, CA) hypofractionated radiosurgery (HfRS) in the treatment of chordomas and chondrosarcomas. Methods A total of 24 patients retrospectively identified with chordomas (19 patients) or chondrosarcomas (five patients) were treated between 2012 and 2019 with HfRS as monotherapy or an adjuvant, rescue, or combination therapy. Tumors were located in the skull base (75%) and vertebral spine (25%). Of these, 19 patients underwent previous partial resection and four patients received previous conventional external beam radiation therapy (EBRT) (60-74 Gy). Exclusive or rescue HfRS (20 patients) was administered in five fractions with a median dose of 37.5 Gy (30-40 Gy). Combined tomotherapy-EBRT treatment (median dose: 54 Gy) and HfRS (16.5-30 Gy in 3-12 fractions) were performed in four patients with bulky chordomas. Results The median follow-up from HfRS was 28 months. During clinical follow-up, no deaths were registered with overall survival (OS) of 100% and the actuarial local recurrence-free survival (LRFS) was 93% at one year, 85% at three years, and 68% at five years. Acute toxicity related to HfRS was present in a single patient. Conclusions It is seen that HfRS is effective and safe for chordomas and chondrosarcomas, with rates of LRFS comparable to other radiation modalities.
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Affiliation(s)
| | - Rafael Garcia
- Radiation Oncology, Genesis Care Cyberknife Center, Madrid, ESP
| | - Luis Lorenzana
- Neurosurgery, Genesis Care Cyberknife Center, Madrid, ESP
| | | | - Javier Abarca
- Neurological Surgery, Hospital General de Alicante, Madrid, ESP
| | - Kita Sallabanda
- Radiosurgery/Neurosurgery, Hospital Clinico Universitario San Carlos, Madrid, ESP
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25
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Eaton BR, Schwarz R, Vatner R, Yeh B, Claude L, Indelicato DJ, Laack N. Osteosarcoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28352. [PMID: 32779875 DOI: 10.1002/pbc.28352] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022]
Abstract
Osteosarcoma is a rare tumor that requires complex multidisciplinary management. This paper reviews the general management and standard radiotherapy guidelines for osteosarcoma in both North America and Europe in a joined effort between the Children's Oncology Group and International Society of Pediatric Oncology. Standard treatment involves multiagent induction chemotherapy followed by surgical resection for local tumor control and consolidation local control to metastatic sites. Radiotherapy is reserved for cases with a marginal or incomplete resection or for definitive treatment in the case of unresectable disease. We present supporting data for the role of chemotherapy, surgery, and radiation therapy.
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Affiliation(s)
- Bree R Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Rudolf Schwarz
- Radiotherapy and Radiooncology, Outpatient Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralph Vatner
- Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Brian Yeh
- Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Line Claude
- Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Daniel J Indelicato
- Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Nadia Laack
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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26
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Pennington Z, Ehresman J, Elsamadicy AA, Shin JH, Goodwin CR, Schwab JH, Sciubba DM. Systematic review of charged-particle therapy for chordomas and sarcomas of the mobile spine and sacrum. Neurosurg Focus 2021; 50:E17. [PMID: 33932924 DOI: 10.3171/2021.2.focus201059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term local control in patients with primary chordoma and sarcoma of the spine and sacrum is increasingly reliant upon en bloc resection with negative margins. At many institutions, adjuvant radiation is recommended; definitive radiation is also recommended for the treatment of unresectable tumors. Because of the high off-target radiation toxicities associated with conventional radiotherapy, there has been growing interest in the use of proton and heavy-ion therapies. The aim of this study was to systematically review the literature regarding these therapies. METHODS The PubMed, OVID, Embase, and Web of Science databases were queried for articles describing the use of proton, combined proton/photon, or heavy-ion therapies for adjuvant or definitive radiotherapy in patients with primary sarcoma or chordoma of the mobile spine and sacrum. A qualitative synthesis of the results was performed, focusing on overall survival (OS), progression-free survival (PFS), disease-free survival (DFS), and disease-specific survival (DSS); local control; and postradiation toxicities. RESULTS Of 595 unique articles, 64 underwent full-text screening and 38 were included in the final synthesis. All studies were level III or IV evidence with a high risk of bias; there was also significant overlap in the reported populations, with six centers accounting for roughly three-fourths of all reports. Five-year therapy outcomes were as follows: proton-only therapies, OS 67%-82%, PFS 31%-57%, and DFS 52%-62%; metastases occurred in 17%-18% and acute toxicities in 3%-100% of cases; combined proton/photon therapy, local control 62%-85%, OS 78%-87%, PFS 90%, and DFS 61%-72%; metastases occurred in 12%-14% and acute toxicities in 84%-100% of cases; and carbon ion therapy, local control 53%-100%, OS 52%-86%, PFS (only reported for 3 years) 48%-76%, and DFS 50%-53%; metastases occurred in 2%-39% and acute toxicities in 26%-48%. There were no studies directly comparing outcomes between photon and charged-particle therapies or comparing outcomes between radiation and surgical groups. CONCLUSIONS The current evidence for charged-particle therapies in the management of sarcomas of the spine and sacrum is limited. Preliminary evidence suggests that with these therapies local control and OS at 5 years are comparable among various charged-particle options and may be similar between those treated with definitive charged-particle therapy and historical surgical cohorts. Further research directly comparing charged-particle and photon-based therapies is necessary.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aladine A Elsamadicy
- 2Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - John H Shin
- 3Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C Rory Goodwin
- 4Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Joseph H Schwab
- 5Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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27
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Indelicato DJ, Rotondo RL, Mailhot Vega RB, Holtzman AL, Looi WS, Morris CG, Sandler ES, Aldana PR, Bradley JA. Local Control After Proton Therapy for Pediatric Chordoma. Int J Radiat Oncol Biol Phys 2021; 109:1406-1413. [PMID: 33253819 DOI: 10.1016/j.ijrobp.2020.11.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Due to the location and high dose required for disease control, pediatric chordomas are theoretically well-suited for treatment with proton therapy, but their low incidence limits the clinical outcome data available in the literature. We sought to report the efficacy and toxicity of proton therapy among a single-institution cohort. METHODS AND MATERIALS Between 2008 and 2019, 29 patients with a median age of 14.8 years (range, 3.8-21.8) received passive-scattered proton therapy for nonmetastatic chordoma. No patient received prior irradiation. Twenty-four tumors arose in the clivus/cervical spine region and 5 in the lumbosacral spine. Twenty-six tumors demonstrated classic well-differentiated histology and 3 were dedifferentiated or not otherwise specified. Approximately half of the tumors underwent specialized testing: 14 were brachyury-positive and 10 retained INI-1. Three patients had locally recurrent tumors after surgery alone (n = 2) or surgery + chemotherapy (n = 1), and 17 patients had gross disease at the time of radiation. The median radiation dose was 73.8 Gy relative biological effectivness (range, 69-75.6). RESULTS With a median follow-up of 4.3 years (range, 1.0-10.7), the 5-year estimates of local control, progression-free survival, and overall survival rates were 85%, 82%, and 86%, respectively. No disease progression was observed beyond 3 years. Excluding 3 patients with dedifferentiated/not-otherwise-specified chordoma, the 5-year local control, progression-free survival, and overall survival rates were 92%, 92%, and 91%, respectively. Serious toxicities included 3 patients with hardware failure or related infection requiring revision surgery, 2 patients with hormone deficiency, and 2 patients with Eustachian tube dysfunction causing chronic otitis media. No patient experienced brain stem injury, myelopathy, vision loss, or hearing loss after radiation. CONCLUSIONS In pediatric patients with chordoma, proton therapy is associated with a low risk of serious toxicity and high efficacy, particularly in well-differentiated tumors. Complete resection may be unnecessary for local control, and destabilizing operations requiring instrumentation may result in additional complications after therapy.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Wen S Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatrics, Nemours Childrens Specialty Clinic, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Meazza C, Luksch R, Luzzati A. Managing axial bone sarcomas in childhood. Expert Rev Anticancer Ther 2021; 21:747-764. [PMID: 33593222 DOI: 10.1080/14737140.2021.1891886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Axial osteosarcoma and Ewing sarcoma are rare, aggressive neoplasms with a worse prognosis than with tumors involving the extremities because they are more likely to be associated with larger tumor volumes, older age, primary metastases, and a poor histological response to chemotherapy. The 5-year OS rates are reportedly in the range of 18-41% for axial osteosarcoma, and 46-64% for Ewing sarcoma.Area covered: The treatment of axial bone tumors is the same as for extremity bone tumors, and includes chemotherapy, surgery and/or radiotherapy.Expert opinion: Local treatment of axial tumors is particularly difficult due to their proximity to neurological and vascular structures, which often makes extensive and en bloc resections impossible without causing significant morbidity. The incidence of local relapse is consequently high, and this is the main issue in the treatment of these tumors. Radiotherapy is an option in the case of surgical resections with close or positive margins, as well as for inoperable tumors. Delivering high doses of RT to the spinal cord can be dangerous. Given the complexity and rarity of these tumors, it is essential for this subset of patients to be treated at selected reference institutions with specific expertise and multidisciplinary skills.
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Affiliation(s)
- Cristina Meazza
- Pediatric Oncology Unit, Medical Oncology and Emathology Department, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy
| | - Roberto Luksch
- Pediatric Oncology Unit, Medical Oncology and Emathology Department, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy
| | - Alessandro Luzzati
- Orthopedic Oncology and Spinal Reconstruction Surgery, Orthopedic Oncology Department, IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
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29
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Nunna RS, Patel S, Patil SN, Ansari D, Burch TG, Mehta AI, Chapman J, Oskouian RJ. Incidence, Management, and Outcomes of Adult Patients with Spinal Chondrosarcoma in the United States. World Neurosurg 2021; 149:e316-e328. [PMID: 33601078 DOI: 10.1016/j.wneu.2021.02.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/07/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Spinal chondrosarcomas are rare primary malignant neoplasms composed of cartilage-producing cells. They are slow-growing but locally aggressive lesions that have high rates of recurrence and progression after treatment. We provide the largest comprehensive analysis of prognostic factors, treatment modalities, and survival outcomes in patients with spinal chondrosarcoma using a large, prospectively collected national database. METHODS Patients with diagnosis codes specific for chondrosarcoma of the spine, sacrum, and coccyx were queried from the National Cancer Database (NCDB) during 2004-2016. Outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization. RESULTS A total of 1843 individuals were identified with a diagnosis of chondrosarcoma, 82.1% of which were at the sacrum or coccyx and 17.9% at the spine. The mean overall survival of patients in our cohort was 7.91 years. Increased age, larger tumor, dedifferentiated histology, and presence of metastases were associated with worsened overall survival. Regarding management, 77.7% of patients received surgical intervention and both partial and radical resection were associated with significantly improved overall survival (P < 0.001). Neither radiotherapy nor chemotherapy administration improved overall survival; however, among patients who received radiation, those who received higher-dose radiation had significantly improved overall survival compared with those who received lower-dose radiation. CONCLUSIONS Surgical resection significantly improves overall survival in patients with spinal chondrosarcoma. In those patients receiving radiation, those who receive high doses have improved overall survival compared with those who receive lower doses. Further studies into optimal radiation modality and doses are required.
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Affiliation(s)
- Ravi S Nunna
- Department of Neurosurgery, Swedish Medical Center, Seattle, Washington, USA
| | - Saavan Patel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Shashank N Patil
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Darius Ansari
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Taylor G Burch
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jens Chapman
- Department of Neurosurgery, Swedish Medical Center, Seattle, Washington, USA
| | - Rod J Oskouian
- Department of Neurosurgery, Swedish Medical Center, Seattle, Washington, USA.
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Charyyev S, Chang CW, Harms J, Oancea C, Yoon ST, Yang X, Zhang T, Zhou J, Lin L. A novel proton counting detector and method for the validation of tissue and implant material maps for Monte Carlo dose calculation. Phys Med Biol 2021; 66:045003. [PMID: 33296888 DOI: 10.1088/1361-6560/abd22e] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The presence of artificial implants complicates the delivery of proton therapy due to inaccurate characterization of both the implant and the surrounding tissues. In this work, we describe a method to characterize implant and human tissue mimicking materials in terms of relative stopping power (RSP) using a novel proton counting detector. Each proton is tracked by directly measuring the deposited energy along the proton track using a fast, pixelated spectral detector AdvaPIX-TPX3 (TPX3). We considered three scenarios to characterize the RSPs. First, in-air measurements were made in the presence of metal rods (Al, Ti and CoCr) and bone. Then, measurements of energy perturbations in the presence of metal implants and bone in an anthropomorphic phantom were performed. Finally, sampling of cumulative stopping power (CSP) of the phantom were made at different locations of the anthropomorphic phantom. CSP and RSP information were extracted from energy spectra at each beam path. To quantify the RSP of metal rods we used the shift in the most probable energy (MPE) of CSP from the reference CSP without a rod. Overall, the RSPs were determined as 1.48, 2.06, 3.08, and 5.53 from in-air measurements; 1.44, 1.97, 2.98, and 5.44 from in-phantom measurements, for bone, Al, Ti and CoCr, respectively. Additionally, we sampled CSP for multiple paths of the anthropomorphic phantom ranging from 18.63 to 25.23 cm deriving RSP of soft tissues and bones in agreement within 1.6% of TOPAS simulations. Using minimum error of these multiple CSP, optimal mass densities were derived for soft tissue and bone and they are within 1% of vendor-provided nominal densities. The preliminary data obtained indicates the proposed novel method can be used for the validation of material and density maps, required by proton Monte Carlo Dose calculation, provided by competing multi-energy computed tomography and metal artifact reduction techniques.
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Affiliation(s)
- Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Chih-Wei Chang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Joseph Harms
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | | | - S Tim Yoon
- Department of Orthopaedics, Emory University, Atlanta, GA, United States of America
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Tiezhi Zhang
- Department of Radiation Oncology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
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Konieczkowski DJ, DeLaney TF, Yamada YJ. Radiation Strategies for Spine Chordoma: Proton Beam, Carbon Ions, and Stereotactic Body Radiation Therapy. Neurosurg Clin N Am 2020; 31:263-288. [PMID: 32147017 DOI: 10.1016/j.nec.2019.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgery alone provides suboptimal local control of spine and sacral chordomas. Radiotherapy (RT) may improve local control in patients undergoing surgery and be used as definitive-intent treatment in patients not undergoing surgery. Although conventional-dose RT is inadequate for these radioresistant tumors, newer techniques allow treatment of the tumor to higher, more effective doses while limiting spinal cord dose to safe levels. The best local control is achieved when RT is delivered in the primary setting; RT dose is a critical determinant of local control. RT should be considered for all spine and sacral chordoma patients.
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Affiliation(s)
- David J Konieczkowski
- Harvard Radiation Oncology Program, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Poel R, Belosi F, Albertini F, Walser M, Gisep A, Lomax AJ, Weber DC. Assessing the advantages of CFR-PEEK over titanium spinal stabilization implants in proton therapy—a phantom study. ACTA ACUST UNITED AC 2020; 65:245031. [DOI: 10.1088/1361-6560/ab8ba0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Bongers MER, Ogink PT, Chu KF, Patel A, Rosenthal B, Shin JH, Lee SG, Hornicek FJ, Schwab JH. The use of autologous free vascularized fibula grafts in reconstruction of the mobile spine following tumor resection: surgical technique and outcomes. J Neurosurg Spine 2020; 34:283-292. [PMID: 33157532 DOI: 10.3171/2020.6.spine20521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Reconstruction of the mobile spine following total en bloc spondylectomy (TES) of one or multiple vertebral bodies in patients with malignant spinal tumors is a challenging procedure with high failure rates. A common reason for reconstructive failure is nonunion, which becomes more problematic when using local radiation therapy. Radiotherapy is an integral part of the management of primary malignant osseous tumors in the spine. Vascularized grafts may help prevent nonunion in the radiotherapy setting. The authors have utilized free vascularized fibular grafts (FVFGs) for reconstruction of the spine following TES. The purpose of this article is to describe the surgical technique for vascularized reconstruction of defects after TES. Additionally, the outcomes of consecutive cases treated with this technique are reported. METHODS Thirty-nine patients were treated at the authors' tertiary care institution for malignant tumors in the mobile spine using FVFG following TES between 2010 and 2018. Postoperative union, reoperations, complications, neurological outcome, and survival were reported. The median follow-up duration was 50 months (range 14-109 months). RESULTS The cohort consisted of 26 males (67%), and the median age was 58 years. Chordoma was the most prevalent tumor (67%), and the lumbar spine was most affected (46%). Complete union was seen in 26 patients (76%), the overall complication rate was 54%, and implant failure was the most common complication, with 13 patients (33%) affected. In 18 patients (46%), one or more reoperations were needed, and the fixation was surgically revised 15 times (42% of reoperations) in 10 patients (26%). A reconstruction below the L1 vertebra had a higher proportion of implant failure (67%; 8 of 12 patients) compared with higher resections (21%; 5 of 24 patients) (p = 0.011). Graft length, number of resected vertebrae, and docking the FVFG on the endplate or cancellous bone was not associated with union or implant failure on univariate analysis. CONCLUSIONS The FVFG is an effective reconstruction technique, particularly in the cervicothoracic spine. However, high implant failure rates in the lumbar spine have been seen, which occurred even in cases in which the graft completely healed. Methods to increase the weight-bearing capacity of the graft in the lumbar spine should be considered in these reconstructions. Overall, the rates of failure and revision surgery for FVFG compare with previous reports on reconstruction after TES.
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Affiliation(s)
| | - Paul T Ogink
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
| | | | - Anuj Patel
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
| | - Brett Rosenthal
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
| | | | - Sang-Gil Lee
- 4Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Francis J Hornicek
- 5Department of Orthopedic Surgery, Orthopedic Oncology Service, University of California, Los Angeles Medical Center, Los Angeles, California
| | - Joseph H Schwab
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
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Carbon fiber-reinforced PEEK versus titanium implants: an in vitro comparison of susceptibility artifacts in CT and MR imaging. Neurosurg Rev 2020; 44:2163-2170. [PMID: 32930911 PMCID: PMC8338834 DOI: 10.1007/s10143-020-01384-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 02/01/2023]
Abstract
Artifacts in computed tomography (CT) and magnetic resonance imaging (MRI) due to titanium implants in spine surgery are known to cause difficulties in follow-up imaging, radiation planning, and precise dose delivery in patients with spinal tumors. Carbon fiber–reinforced polyetheretherketon (CFRP) implants aim to reduce these artifacts. Our aim was to analyze susceptibility artifacts of these implants using a standardized in vitro model. Titanium and CFRP screw-rod phantoms were embedded in 3% agarose gel. Phantoms were scanned with Siemens Somatom AS Open and 3.0-T Siemens Skyra scanners. Regions of interest (ROIs) were plotted and analyzed for CT and MRI at clinically relevant localizations. CT voxel–based imaging analysis showed a significant difference of artifact intensity and central overlay between titanium and CFRP phantoms. For the virtual regions of the spinal canal, titanium implants (ti) presented − 30.7 HU vs. 33.4 HU mean for CFRP (p < 0.001), at the posterior margin of the vertebral body 68.9 HU (ti) vs. 59.8 HU (CFRP) (p < 0.001) and at the anterior part of the vertebral body 201.2 HU (ti) vs. 70.4 HU (CFRP) (p < 0.001), respectively. MRI data was only visually interpreted due to the low sample size and lack of an objective measuring system as Hounsfield units in CT. CT imaging of the phantom with typical implant configuration for thoracic stabilization could demonstrate a significant artifact reduction in CFRP implants compared with titanium implants for evaluation of index structures. Radiolucency with less artifacts provides a better interpretation of follow-up imaging, radiation planning, and more precise dose delivery.
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Müller BS, Ryang YM, Oechsner M, Düsberg M, Meyer B, Combs SE, Wilkens JJ. The dosimetric impact of stabilizing spinal implants in radiotherapy treatment planning with protons and photons: standard titanium alloy vs. radiolucent carbon-fiber-reinforced PEEK systems. J Appl Clin Med Phys 2020; 21:6-14. [PMID: 32476247 PMCID: PMC7484848 DOI: 10.1002/acm2.12905] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/13/2020] [Accepted: 04/20/2020] [Indexed: 12/17/2022] Open
Abstract
Background Throughout the last years, carbon‐fibre‐reinforced PEEK (CFP) pedicle screw systems were introduced to replace standard titanium alloy (Ti) implants for spinal instrumentation, promising improved radiotherapy (RT) treatment planning accuracy. We compared the dosimetric impact of both implants for intensity modulated proton (IMPT) and volumetric arc photon therapy (VMAT), with the focus on uncertainties in Hounsfield unit assignment of titanium alloy. Methods Retrospective planning was performed on CT data of five patients with Ti and five with CFP implants. Carbon‐fibre‐reinforced PEEK systems comprised radiolucent pedicle screws with thin titanium‐coated regions and titanium tulips. For each patient, one IMPT and one VMAT plan were generated with a nominal relative stopping power (SP) (IMPT) and electron density (ρ) (VMAT) and recalculated onto the identical CT with increased and decreased SP or ρ by ±6% for the titanium components. Results Recalculated VMAT dose distributions hardly deviated from the nominal plans for both screw types. IMPT plans resulted in more heterogeneous target coverage, measured by the standard deviation σ inside the target, which increased on average by 7.6 ± 2.3% (Ti) vs 3.4 ± 1.2% (CFP). Larger SPs lead to lower target minimum doses, lower SPs to higher dose maxima, with a more pronounced effect for Ti screws. Conclusions While VMAT plans showed no relevant difference in dosimetric quality between both screw types, IMPT plans demonstrated the benefit of CFP screws through a smaller dosimetric impact of CT‐value uncertainties compared to Ti. Reducing metal components in implants will therefore improve dose calculation accuracy and lower the risk for tumor underdosage.
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Affiliation(s)
- Birgit S Müller
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Institute of Innovative Radiotherapy, Helmholtz Zentrum München, Neuherberg, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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Xie L, Xu J, Sun X, Liu K, Li X, He F, Liu X, Gu J, Lv Z, Yang R, Tang X, Yan T, Li D, Yang Y, Dong S, Sun K, Shen D, Guo W. Apatinib for Treatment of Inoperable Metastatic or Locally Advanced Chondrosarcoma: What We Can Learn About the Biological Behavior of Chondrosarcoma from a Two-Center Study. Cancer Manag Res 2020; 12:3513-3525. [PMID: 32547189 PMCID: PMC7237692 DOI: 10.2147/cmar.s253201] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/05/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose For patients who have chondrosarcoma in the unresectable setting, antiangiogenic agents are reportedly effective. This multicenter, retrospective study investigated the antitumor activity of apatinib in patients with unresectable chondrosarcoma to gain insight into the biological behavior of this disease. Methods All of the patients with unresectable chondrosarcoma who were diagnosed between October 1, 2009, and November 1, 2019, in two sarcoma centers affiliated with Peking University were evaluated. Relevant information was collected from the medical records at both centers, from which patients receiving apatinib for systemic therapy were selected for analysis. Results In total, efficacy analysis was conducted in 33 patients with a median follow-up time of 22.1 (Q1, Q3, 14.6, 23.0) months. There were 20/33 (60.0%) conventional chondrosarcomas (grades 2–3), 5/33 (15.2%) dedifferentiated chondrosarcomas, 4/33 (12.1%) mesenchymal chondrosarcomas, 3/33 (9.1%) extraskeletal myxoid chondrosarcoma, and 1/33 (3.1%) clear-cell chondrosarcomas with 87.9% in metastatic and 12.1% in locally advanced states. The objective response rate was 6/33 (18.2%). The median progression-free survival (PFS) was 12.4 months (Q1, Q3, 7.0, 21.2), while the median overall survival has not yet been reached. Rare variants of chondrosarcoma tended to have a longer PFS than conventional chondrosarcoma (P=0.06). Based on clinicopathological factors Cox and univariate analysis, only extraskeletal myxoid chondrosarcoma and baseline target lesions <60 mm benefited from the drug apatinib (P=0.14 and P=0.00), respectively. Grade 3 or higher adverse events were frequent in 11/33 (39.3%) of patients who discontinued apatinib due to deterioration of their general condition. Conclusion Apatinib had clinically meaningful activity in patients with inoperable high-grade chondrosarcoma. However, special caution should be made in managing toxicity due to the indolent behavior and slow growth pattern after using this drug. Patients with a smaller tumor size and extraskeletal myxoid chondrosarcoma subtype might benefit from this therapy more. Clinical Trial Registration Registered February 7, 2020, with clinicaltrials.gov: NCT04260113.
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Affiliation(s)
- Lu Xie
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Jie Xu
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xin Sun
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Kuisheng Liu
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xiaowei Li
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Fangzhou He
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xinyu Liu
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Jin Gu
- Surgical Oncology, Peking University Shougang Hospital, Beijing, People's Republic of China
| | - Zhe Lv
- Radiology Department, Peking University Shougang Hospital, Beijing, People's Republic of China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Dasen Li
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Yi Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Sen Dong
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Kunkun Sun
- Pathology Department, Peking University People's Hospital, Beijing, People's Republic of China
| | - Danhua Shen
- Pathology Department, Peking University People's Hospital, Beijing, People's Republic of China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
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The sacral chordoma margin. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:1415-1422. [PMID: 32402509 DOI: 10.1016/j.ejso.2020.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Aim of the manuscript is to discuss how to improve margins in sacral chordoma. BACKGROUND Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in >50% after surgery. METHODS A multidisciplinary meeting of the "Chordoma Global Consensus Group" was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. RESULTS En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. CONCLUSION Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients.
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Houdek MT, Hevesi M, Griffin AM, Yaszemski MJ, Sim FH, Ferguson PC, Rose PS, Wunder JS. Can the ACS-NSQIP surgical risk calculator predict postoperative complications in patients undergoing sacral tumor resection for chordoma? J Surg Oncol 2020; 121:1036-1041. [PMID: 32034772 DOI: 10.1002/jso.25865] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The ACS-NSQIP surgical risk calculator is an online tool that estimates the risk of postoperative complications. Sacrectomies for chordoma are associated with a high rate of complications. This study was to determine if the ACS-NSQIP calculator can predict postoperative complications following sacrectomy. METHODS Sixty-five (42 male, 23 female) patients who underwent sacrectomy were analyzed using the Current Procedural Terminology (CPT) codes: 49215 (excision of presacral/sacral tumor), 63001 (laminectomy of sacral vertebrae), 63728 (laminectomy for biopsy/excision of sacral neoplasm) and 63307 (sacral vertebral corpectomy for intraspinal lesion). The predicted rates of complications were compared to the observed rates. RESULTS Complications were noted in 44 (68%) patients. Of the risk factors available to input to the ACS-NSQIP calculator, tobacco use (OR, 20.4; P < .001) was predictive of complications. The predicted risk of complications based off the CPT codes were: 49215 (16%); 63011 (6%); 63278 (11%) and 63307 (15%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (49215, AUC 0.65); (63011, AUC 0.66); (63307, AUC 0.67); (63278, AUC 0.64). CONCLUSION The ACS-NSQIP calculator was a poor predictor of complications and was marginally better than a coin flip in its ability to predict complications following sacrectomy for chordoma.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Franklin H Sim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
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Wright CH, Wright J, Cioffi G, Hdeib A, Kasliwal MK, Kruchko C, Barnholtz-Sloan JS, Sloan AE. Association of cancer center type with treatment patterns and overall survival for patients with sacral and spinal chordomas: an analysis of the National Cancer Database from 2004 to 2015. J Neurosurg Spine 2020; 32:311-320. [DOI: 10.3171/2019.7.spine19566] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEChordomas of the spine and sacrum are a rare but debilitating cancer and require complex multidisciplinary care. Studies of other such rare cancers have demonstrated an association of high-volume and/or multidisciplinary centers with improved outcomes and survival. Such an association has been proposed for chordomas, but evidence to support this claim is lacking. The authors performed a study to investigate if treatment facility type is associated with patterns of care and survival for patients with spinal and sacral chordomas by assessing records from a US-based cancer database.METHODSIn this observational retrospective cohort study, the authors identified 1266 patients from the National Cancer Database with vertebral column or sacral chordomas diagnosed between 2004 and 2015. The primary study outcome was overall survival, and secondary outcomes included odds of receiving treatment and time to treatment, defined as radiation therapy, surgery, and/or any treatment, including surgery, radiation therapy, chemotherapy, or participation in clinical trials. The results were adjusted for age, sex, race/ethnicity, level of education, income, and Charlson/Deyo score.RESULTSOf the 1266 patients identified, the mean age at diagnosis was 59.70 years (SD 16.2 years), and the patients were predominantly male (n = 791 [62.50%]). Patients treated at community cancer programs demonstrated an increased risk of death (HR 1.98, 95% CI 1.13–3.47, p = 0.018) when compared to patients treated at academic/research programs (ARPs). The median survival was longest for those treated at ARPs (131.45 months) compared to community cancer programs (79.34 months, 95% CI 48.99–123.17) and comprehensive community cancer programs (CCCPs) (109.34 months, 95% CI 84.76–131.45); 5-year survival rates were 76.08%, 52.71%, and 61.57%, respectively. Patients treated at community cancer programs and CCCPs were less likely to receive any treatment compared to those treated at ARPs (OR 6.05, 95% CI 2.62–13.95, p < 0.0001; OR 3.74, 95% CI 2.23–6.28, p < 0.0001, respectively). Patients treated at CCCPs and community cancer programs were less likely to receive surgery than those treated at ARPs (OR 2.69, 95% CI 1.82–3.97, p = 0.010; OR = 2.64, 95% CI 1.22–5.71, p = 0.014, respectively). Patients were more likely to receive any treatment (OR 0.59, 95% CI 0.40–0.87, p = 0.007) and surgery (OR 0.58, 95% CI 0.38–0.88, p < 0.0001) within 30 days at a CCCP compared to an ARP. There were no differences in odds of receiving radiation therapy or time to radiation by facility type.CONCLUSIONSClinical care at an ARP is associated with increased odds of receiving treatment that is associated with improved overall survival for patients with spinal and sacral chordomas, suggesting that ARPs provide the most comprehensive specialized care for patients with this rare and devastating oncological disease.
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Affiliation(s)
- Christina Huang Wright
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
| | - James Wright
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
| | - Gino Cioffi
- 4Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
- 5Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Alia Hdeib
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
- 3Seidman Cancer Center and Case Comprehensive Cancer Center
| | - Manish K. Kasliwal
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
| | - Carol Kruchko
- 5Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Jill S. Barnholtz-Sloan
- 4Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
- 5Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Andrew E. Sloan
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
- 3Seidman Cancer Center and Case Comprehensive Cancer Center
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Abstract
Bone sarcomas are rare tumors arising in bone, representing only a small fraction of solid malignant tumors. Desmoids are benign, infiltrative soft tissue neoplasms. Because of their scarcity and a paucity of data, the management of these tumors can be challenging, especially for clinicians who infrequently encounter these tumors. This article reviews the current literature regarding the diagnosis, work-up, and treatment of these uncommon mesenchymal tumors.
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Affiliation(s)
- Jeremy M Brownstein
- Francis H. Burr Proton Beam Therapy Center, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA; Department of Radiation Oncology, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Harvard Medical School, Francis H. Burr Proton Therapy Center, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA.
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Hypofractionated radiotherapy for non-metastatic bone and soft tissue sarcomas. Cancer Radiother 2019; 23:853-859. [PMID: 31640927 DOI: 10.1016/j.canrad.2019.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/01/2019] [Accepted: 06/10/2019] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate the efficacy and toxicity of hypofractionated radiotherapy in non-metastatic soft tissue and bone sarcomas. PATIENTS AND METHODS Thirty patients underwent hypofractionated radiotherapy between 2007 and 2015. Overall, 17 patients underwent primary hypofractionated radiotherapy, nine underwent hypofractionated radiotherapy for reirradiation, and four received a boost dose via hypofractionated radiotherapy after external beam radiotherapy. Most common disease sites were head and neck and retroperitoneum. Hypofractionated radiotherapy was administered with a definitive, adjuvant, or neoadjuvant intent. RESULTS Median age was 37 years (range: 11-82 years). Median hypofractionated radiotherapy dose was 35Gy (range: 20-50Gy) in three to five fractions. Median follow-up was 21 months (range: 1-108 months). One- and 2-year overall survival rate was 75% and 52%, respectively. One- and 2-year local recurrence-free survival rate was 59% and 48%, with local recurrence rates of 16% and 33% in 1 and 2 years, respectively. Univariate analysis revealed tumour size (P=0.04), hypofractionated radiotherapy intent (P=0.016) and reirradiation (P=0.001) as prognostic factors for local recurrence-free survival. Severe late toxicity was observed in one patient as grade 3 trismus. CONCLUSION Hypofractionated radiotherapy as the primary treatment or for reirradiation has been shown to be safe in the treatment of bone and soft tissue sarcomas. It can provide relatively good local control and survival rates.
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Barber SM, Konakondla S, Nakhla J, Fridley JS, Xia J, Oyelese AA, Telfeian AE, Gokaslan ZL. Spinal dural resection for oncological purposes: a systematic analysis of risks and outcomes in patients with malignant spinal tumors. J Neurosurg Spine 2019; 32:69-78. [PMID: 31628279 DOI: 10.3171/2019.7.spine19477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Oncological outcomes for many malignant primary spinal tumors and isolated spinal metastases have been shown to correlate with extent of resection. For tumors with dural involvement, some authors have described spinal dural resection at the time of tumor resection in the interest of improving oncological outcomes. The complication profile associated with resection of the spinal dura for oncological purposes, however, and the relative influence of resecting tumor-involved dura on progression-free survival are not well defined. The authors performed a systematic review of the literature and identified cases in which the spinal dura was resected for oncological purposes in the interest of better understanding the associated risks and outcomes of this technique. METHODS Electronic databases (PubMed/MEDLINE, Scopus) were systematically searched to identify studies that reported clinical and/or oncological outcomes of patients with malignant spinal neoplasms undergoing resection of tumor-involved dura at the time of surgical intervention. RESULTS Ten articles describing 15 patients were included in the analysis. The most common tumor histologies were chordoma (3/15, 20%), giant cell tumor (3/15, 20%), epithelioid sarcoma (2/15, 13.3%), osteosarcoma (2/15, 13.3%), and metastasis (2/15, 13.3%). Procedure-related complications were reported in 40% of patients. A trend was seen toward an increased complication rate in redo (66.7%) versus index (16.7%) operations, but this trend did not reach statistical significance (p = 0.24). New, unexpected postoperative neurological deficits were seen in 3 patients (of 14 reporting, 21.4%). A single patient experienced a profound, unexpected neurological deterioration (paraparesis/paraplegia) after surgery, which reportedly improved considerably at latest follow-up. Tumor recurrence was seen in 3 cases (of 12 reporting, 25%) at a mean of 28.34 ± 21.1 months postoperatively. The overall mean radiographic follow-up period was 49.6 ± 36.5 months. CONCLUSIONS Resection of the spinal dura for oncological purposes is rarely performed, although a limited number of reports and small series have demonstrated that it is feasible. Spinal dural resection is primarily performed in patients with isolated, primary spinal neoplasms with an intent to cure. The risk associated with spinal dura resection is nontrivial and the complication profile is significant. The influence of dural resection on oncological outcomes is not well defined, and further study is needed before definitive conclusions may be drawn regarding the oncological benefit of dural resection for any particular patient or pathology.
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Affiliation(s)
- Sean M Barber
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
- 2Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas; and
| | - Sanjay Konakondla
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Jonathan Nakhla
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Jared S Fridley
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Jimmy Xia
- 3Weill Cornell Medical College, New York, New York
| | - Adetokunbo A Oyelese
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Albert E Telfeian
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Ziya L Gokaslan
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
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Revisiting the Role of Radiation Therapy in Chondrosarcoma: A National Cancer Database Study. Sarcoma 2019; 2019:4878512. [PMID: 31736653 PMCID: PMC6815626 DOI: 10.1155/2019/4878512] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/15/2019] [Accepted: 08/19/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although chondrosarcomas (CS) are mostly considered radioresistant, advancements in radiotherapy have brought attention to its use in these patients. Using the largest registry of primary bone tumors, the National Cancer Database (NCDB), we sought to better characterize the current use of radiotherapy in CS patients and identify any potential survival benefit with higher radiation doses and advanced radiation therapies. Methods We retrospectively analyzed CS patients in the NCDB from 2004 to 2015 who underwent radiotherapy. The Kaplan–Meier method with statistical comparisons was used to identify which individual variables related to dosage and delivery modality were associated with improved 5-year survival rates. Multivariate proportional hazards analyses were performed to determine independent predictors of survival. Results Of 5,427 patients with a histologic diagnosis of chondrosarcoma, 680 received a form of radiation therapy (13%). The multivariate proportional hazards analysis controlling for various patient, tumor, and treatment variables, including RT dose and modality, demonstrated that while overall radiation therapy (RT) was not associated with improved survival (HR 0.96, 95% CI 0.76–1.20), when examining just the patient cohort with positive surgical margins, RT trended towards improved survival (HR 0.81, 95% CI 0.58–1.13). When comparing advanced and conventional RT modalities, advanced RT was associated with significantly decreased mortality (HR 0.55, 95% CI 0.38–0.80). However, advanced modality and high-dose RT both trended only toward improved survival compared to patients who did not receive any RT (HR 0.74, 95% CI 0.52–1.06 and HR 0.93, 95% CI 0.71–1.21, respectively). Conclusions Despite the suggested radioresistance of CS, modern radiotherapies may present a treatment option for certain patients. Our results support a role for high-dose, advanced radiation therapies in selected high-risk CS patients with tumors in surgically challenging locations or unplanned positive margins. While there is an associated survival rate benefit, further, prospective studies are needed for validation.
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Nourollahi S, Ghate A, Kim M. Optimal modality selection in external beam radiotherapy. MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2019; 36:361-380. [PMID: 30192934 DOI: 10.1093/imammb/dqy013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 08/07/2018] [Accepted: 08/13/2018] [Indexed: 12/25/2022]
Abstract
The goal in external beam radiotherapy (EBRT) for cancer is to maximize damage to the tumour while limiting toxic effects on the organs-at-risk. EBRT can be delivered via different modalities such as photons, protons and neutrons. The choice of an optimal modality depends on the anatomy of the irradiated area and the relative physical and biological properties of the modalities under consideration. There is no single universally dominant modality. We present the first-ever mathematical formulation of the optimal modality selection problem. We show that this problem can be tackled by solving the Karush-Kuhn-Tucker conditions of optimality, which reduce to an analytically tractable quartic equation. We perform numerical experiments to gain insights into the effect of biological and physical properties on the choice of an optimal modality or combination of modalities.
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Affiliation(s)
- Sevnaz Nourollahi
- Department of Industrial & Systems Engineering, University of Washington, Seattle, USA
| | - Archis Ghate
- Department of Industrial & Systems Engineering, University of Washington, Seattle, USA
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, USA
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Asavei T, Bobeica M, Nastasa V, Manda G, Naftanaila F, Bratu O, Mischianu D, Cernaianu MO, Ghenuche P, Savu D, Stutman D, Tanaka KA, Radu M, Doria D, Vasos PR. Laser-driven radiation: Biomarkers for molecular imaging of high dose-rate effects. Med Phys 2019; 46:e726-e734. [PMID: 31357243 PMCID: PMC6899889 DOI: 10.1002/mp.13741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 04/11/2019] [Accepted: 07/03/2019] [Indexed: 12/15/2022] Open
Abstract
Recently developed short‐pulsed laser sources garner high dose‐rate beams such as energetic ions and electrons, x rays, and gamma rays. The biological effects of laser‐generated ion beams observed in recent studies are different from those triggered by radiation generated using classical accelerators or sources, and this difference can be used to develop new strategies for cancer radiotherapy. High‐power lasers can now deliver particles in doses of up to several Gy within nanoseconds. The fast interaction of laser‐generated particles with cells alters cell viability via distinct molecular pathways compared to traditional, prolonged radiation exposure. The emerging consensus of recent literature is that the differences are due to the timescales on which reactive molecules are generated and persist, in various forms. Suitable molecular markers have to be adopted to monitor radiation effects, addressing relevant endogenous molecules that are accessible for investigation by noninvasive procedures and enable translation to clinical imaging. High sensitivity has to be attained for imaging molecular biomarkers in cells and in vivo to follow radiation‐induced functional changes. Signal‐enhanced MRI biomarkers enriched with stable magnetic nuclear isotopes can be used to monitor radiation effects, as demonstrated recently by the use of dynamic nuclear polarization (DNP) for biomolecular observations in vivo. In this context, nanoparticles can also be used as radiation enhancers or biomarker carriers. The radiobiology‐relevant features of high dose‐rate secondary radiation generated using high‐power lasers and the importance of noninvasive biomarkers for real‐time monitoring the biological effects of radiation early on during radiation pulse sequences are discussed.
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Affiliation(s)
- Theodor Asavei
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Mariana Bobeica
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Viorel Nastasa
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania.,National Institute for Laser, Plasma and Radiation Physics, 409 Atomistilor Street, RO-077125, Bucharest-Magurele, Romania
| | - Gina Manda
- Cellular and Molecular Medicine Department, "Victor Babes" National Institute of Pathology, 99-101 Splaiul Independentei, Bucharest, 050096, Romania
| | - Florin Naftanaila
- Carol Davila University of Medicine and Pharmacy Bucharest, Dr Carol Davila Central Mil University Emergency Hospital, 88th Mircea Vulcanescu Str, Bucharest, Romania.,Amethyst Radiotherapy Clinic, Dr Odaii 42, Otopeni, Romania
| | - Ovidiu Bratu
- Carol Davila University of Medicine and Pharmacy Bucharest, Dr Carol Davila Central Mil University Emergency Hospital, 88th Mircea Vulcanescu Str, Bucharest, Romania
| | - Dan Mischianu
- Carol Davila University of Medicine and Pharmacy Bucharest, Dr Carol Davila Central Mil University Emergency Hospital, 88th Mircea Vulcanescu Str, Bucharest, Romania
| | - Mihail O Cernaianu
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Petru Ghenuche
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Diana Savu
- Department of Life and Environmental Physics, Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Dan Stutman
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania.,National Institute for Laser, Plasma and Radiation Physics, 409 Atomistilor Street, RO-077125, Bucharest-Magurele, Romania.,Johns Hopkins University, 3400 N Charles St, Baltimore, Maryland, 21218, USA
| | - Kazuo A Tanaka
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Mihai Radu
- Department of Life and Environmental Physics, Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania
| | - Domenico Doria
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania.,Centre for Plasma Physics, School of Mathematics and Physics, Queen's University Belfast, Belfast, BT7 1NN, United Kingdom
| | - Paul R Vasos
- Extreme Light Infrastructure - Nuclear Physics ELI-NP, "Horia Hulubei" National Institute for Physics and Nuclear Engineering, 30 Reactorului Street, RO-077125, Bucharest-Magurele, Romania.,Research Institute of the University of Bucharest (ICUB), 36-46 B-dul M. Kogalniceanu, RO-050107, Bucharest, Romania
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Clinical results of carbon-ion radiotherapy with separation surgery for primary spine/paraspinal sarcomas. Int J Clin Oncol 2019; 24:1490-1497. [PMID: 31280398 DOI: 10.1007/s10147-019-01505-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the clinical outcome of combination of carbon-ion radiotherapy with separation surgery (CIRT-SS) in patients with primary spinal/paraspinal sarcoma (PSPS) and epidural spinal cord compression (ESCC). METHODS CIRT-SS was performed in 11 consecutive patients. Patients treated in the primary and salvage settings were categorized into Group A (n = 8) and Group B (n = 3), respectively. Clinical results and imaging findings were collected, with a particular focus on ESCC grade, treatment-associated adverse events (AEs), and the locoregional control (LRC) rate and overall survival (OS). RESULTS The median follow-up period from the start of CIRT-SS was 25 months (7-57 months). ESCC was improved by SS in all cases. No patients exhibited radiation-induced myelopathy (RIM), but three developed Grade 3 vertebral compression fracture (VCF) during follow-up. Locoregional recurrences were observed in four patients [Group A: 1 (12.5%), Group B: 3 (100%)]. Over the entire follow-up period, three patients developed distant metastases and two patients died. The 2-year LRC rate and OS were 70% and 80%, respectively. CONCLUSION CIRT-SS in the primary setting achieved acceptable LRC and OS without RIM in patients with PSPS and with ESCC. VCF was the most frequent AE associated with CIRT-SS.
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Anwar MA, El-Baba C, Elnaggar MH, Elkholy YO, Mottawea M, Johar D, Al Shehabi TS, Kobeissy F, Moussalem C, Massaad E, Omeis I, Darwiche N, Eid AH. Novel therapeutic strategies for spinal osteosarcomas. Semin Cancer Biol 2019; 64:83-92. [PMID: 31152785 DOI: 10.1016/j.semcancer.2019.05.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 12/24/2022]
Abstract
At the dawn of the third millennium, cancer has become the bane of twenty-first century man, and remains a predominant public health burden, affecting welfare and life expectancy globally. Spinal osteogenic sarcoma, a primary spinal malignant tumor, is a rare and challenging neoplastic disease to treat. After the conventional therapeutic modalities of chemotherapy, radiation and surgery have been exhausted, there is currently no available alternative therapy in managing cases of spinal osteosarcoma. The defining signatures of tumor survival are characterised by cancer cell ability to stonewall immunogenic attrition and apoptosis by various means. Some of these biomarkers, namely immune-checkpoints, have recently been exploited as druggable targets in osteosarcoma and many other different cancers. These promising strides made by the use of reinvigorated immunotherapeutic approaches may lead to significant reduction in spinal osteosarcoma disease burden and corresponding reciprocity in increase of survival rates. In this review, we provide the background to spinal osteosarcoma, and proceed to elaborate on contribution of the complex ecology within tumor microenvironment giving arise to cancerous immune escape, which is currently receiving considerable attention. We follow this section on the tumor microenvironment by a brief history of cancer immunity. Also, we draw on the current knowledge of treatment gained from incidences of osteosarcoma at other locations of the skeleton (long bones of the extremities in close proximity to the metaphyseal growth plates) to make a case for application of immunity-based tools, such as immune-checkpoint inhibitors and vaccines, and draw attention to adverse upshots of immune-checkpoint blockers as well. Finally, we describe the novel biotechnique of CRISPR/Cas9 that will assist in treatment approaches for personalized medication.
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Affiliation(s)
- M Akhtar Anwar
- Department of Pharmacology and Toxicology, American University of Beirut, Beirut, Lebanon
| | - Chirine El-Baba
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Muhammed H Elnaggar
- Biochemistry Department, Faculty of Science, Ain Shams University, Cairo, Egypt
| | - Yasmeen O Elkholy
- Microbiology Department, Faculty of Science, Cairo University, Giza, Egypt
| | - Mohamed Mottawea
- Faculty of Pharmacy, Modern University for Technology and Information, Cairo, Egypt
| | - Dina Johar
- Biomedical Sciences Program, Zewail University of Science and Technology, Giza, Egypt
| | | | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Charbel Moussalem
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Massaad
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ibrahim Omeis
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Darwiche
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon.
| | - A H Eid
- Department of Pharmacology and Toxicology, American University of Beirut, Beirut, Lebanon; Department of Biomedical Sciences, Qatar University, Doha, Qatar.
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Gatfield ER, Noble DJ, Barnett GC, Early NY, Hoole ACF, Kirkby NF, Jefferies SJ, Burnet NG. Tumour Volume and Dose Influence Outcome after Surgery and High-dose Photon Radiotherapy for Chordoma and Chondrosarcoma of the Skull Base and Spine. Clin Oncol (R Coll Radiol) 2019; 30:243-253. [PMID: 29402600 DOI: 10.1016/j.clon.2018.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 11/27/2022]
Abstract
AIMS To evaluate the long-term outcomes of patients with chordoma and low-grade chondrosarcoma after surgery and high-dose radiotherapy. MATERIALS AND METHODS High-dose photon radiotherapy was delivered to 28 patients at the Neuro-oncology Unit at Addenbrooke's Hospital (Cambridge, UK) between 1996 and 2016. Twenty-four patients were treated with curative intent, 17 with chordoma, seven with low-grade chondrosarcoma, with a median dose of 65 Gy (range 65-70 Gy). Local control and survival rates were calculated using the Kaplan-Meier method. RESULTS The median follow-up was 83 months (range 7-205 months). The 5 year disease-specific survival for chordoma patients treated with radical intent was 85%; the local control rate was 74%. The 5 year disease-specific survival for chondrosarcoma patients treated with radical intent was 100%; the local control rate was 83%. The mean planning target volume (PTV) was 274.6 ml (median 124.7 ml). A PTV of 110 ml or less was a good predictor of local control, with 100% sensitivity and 63% specificity. For patients treated with radical intent, this threshold of 110 ml or less for the PTV revealed a statistically significant difference when comparing local control with disease recurrence (P = 0.019, Fisher's exact test). Our data also suggest that the probability of disease control may be partly related to both target volume and radiotherapy dose. CONCLUSION Our results show that refined high-dose photon radiotherapy, following tumour resection by a specialist surgical team, is effective in the long-term control of chordoma and low-grade chondrosarcoma, even in the presence of metal reconstruction. The results presented here will provide a useful source for comparison between high-dose photon therapy and proton beam therapy in a UK setting, in order to establish best practice for the management of chordoma and low-grade chondrosarcoma.
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Affiliation(s)
- E R Gatfield
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK.
| | - D J Noble
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
| | - G C Barnett
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK
| | - N Y Early
- Department of Medical Physics and Clinical Engineering, Addenbrooke's Hospital, Cambridge, UK
| | - A C F Hoole
- Department of Medical Physics and Clinical Engineering, Addenbrooke's Hospital, Cambridge, UK
| | - N F Kirkby
- Division of Molecular and Clinical Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, UK; Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - S J Jefferies
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK
| | - N G Burnet
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
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Gao H. Hybrid proton-photon inverse optimization with uniformity-regularized proton and photon target dose. ACTA ACUST UNITED AC 2019; 64:105003. [DOI: 10.1088/1361-6560/ab18c7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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50
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van Wulfften Palthe ODR, Tromp I, Ferreira A, Fiore A, Bramer JAM, van Dijk NC, DeLaney TF, Schwab JH, Hornicek FJ. Sacral chordoma: a clinical review of 101 cases with 30-year experience in a single institution. Spine J 2019; 19:869-879. [PMID: 30445184 DOI: 10.1016/j.spinee.2018.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/31/2018] [Accepted: 11/01/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Local recurrence rates are high in sacral chordoma patients. Adjuvant radiotherapy may play a role in increasing local control. Patients with locally recurrent tumors continue to comprise a significant proportion of the sacral chordoma population and appear to have worse prognosis than those with primary tumors. High-quality studies comparing presentation and treatments for primary and first local recurrent sacral chordoma tumors are sparse. PURPOSE To determine: whether there is a difference in how primary and tumors at first recurrence present; the overall survival, local relapse-free survival, and distant relapse-free survival rates and prognostic factors for patients presenting with a primary tumor; overall survival, local relapse-free survival, and distant relapse-free survival rates and prognostic factors for patients presenting with a first local relapse; if there any differences in overall survival, local relapse-free survival, and distant relapse-free survival rates between patients presenting with a primary tumor and those with a first local relapse. STUDY DESIGN Retrospective case series. PATIENT SAMPLE One hundred one sacral chordoma cases. OUTCOME MEASURE Overall survival, local relapse-free survival, and distant relapse-free survival rates. METHODS Between 1978 and 2013, 131 patients with sacral chordoma were seen. Of them, 17 patients (13%) presented with a history of more than one local recurrence. One patient (1%) presented with multiple distant metastases. Ten patients (8%) had less than 36 months of follow-up and had no event (eg, death, local recurrence, or distant metastasis). A total of 102 patients met our inclusion criteria: patients with primary or first recurrent tumors, without metastatic disease, who underwent surgery and with at least 36 months of follow-up. One patient (1%) died intraoperatively; therefore, 101 patients were included in the present analysis. Cox proportional hazards regression analysis was performed for primary and local recurrent tumor separately and to compare primary and local recurrent tumors. RESULTS We analyzed 73 primary and 28 first time recurrent sacral chordomas. Tumor size at presentation was different for primary and recurrent tumors (primary median size: 158 cm3, interquartile range [IQR]: 46-634; recurrent median size: 39 cm3, IQR: 14-175; p=.001). Overall survival at 5 and 10years for the primary tumors was 79% and 59%, respectively. Local relapse-free survival at 5years was 86%. For primary tumors, not receiving radiation was an independent predictor for worse local relapse-free survival (hazard ratio [HR]: 0.20; 95% confidence interval [CI]: 0.0043-0.90; p=.004) and increased tumor size was an independent predictor for both worse overall survival (HR: 1.68; 95% CI: 1.38-2.42; p=.004) and worse distant relapse-free survival (HR: 2.25; 95% CI: 1.47-3.44; p<.001). For recurrent tumors, the 5- and 10-year overall survival was 65% and 40%, respectively. Local relapse-free survival at 5years was 79% for recurrent tumors. On bivariate analysis, increased tumor size was a significant predictor for worse survival (LR median: 338 mL; IQR: 218-503 mL; no LR median: 26 mL; IQR: 9-71 mL). A trend was seen toward better distant relapse survival for tumors presenting as a primary tumor (HR: 0.51; 95% CI: 0.25-1.06; p=.072). CONCLUSION Using a combination of surgical resection and adjuvant radiotherapy allowed us to obtain a good overall survival, local relapse-free survival, and distant relapse-free survival in patients presenting with either a primary tumor or with a first time local recurrent tumor.
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Affiliation(s)
- Olivier D R van Wulfften Palthe
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Isabel Tromp
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Al Ferreira
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Anne Fiore
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Jos A M Bramer
- Department of Orthopaedic Surgery, Amsterdam Medical Center - University Of Amsterdam, Meidreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - Niek C van Dijk
- Department of Orthopaedic Surgery, Amsterdam Medical Center - University Of Amsterdam, Meidreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Francis J Hornicek
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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