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Guckenberger M, Billiet C, Schnell D, Franzese C, Spałek M, Rogers S, Stelmes JJ, Aebersold DM, Hemmatazad H, Zimmermann F, Zimmer J, Zilli T, Bruni A, Baumert BG, Nägler F, Gut P, Förster R, Madani I. Dose-intensified stereotactic body radiotherapy for painful vertebral metastases: A randomized phase 3 trial. Cancer 2024. [PMID: 38581694 DOI: 10.1002/cncr.35310] [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: 12/20/2023] [Revised: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The purpose of this randomised study was to determine whether dose-intensified stereotactic body radiotherapy (SBRT) for painful vertebral metastases results in increased rates of pain improvement compared with conventional external beam radiotherapy (cEBRT) (control) 6 months after treatment. METHODS This randomized, controlled phase 3 trial was conducted between November 2016 and January 2023, when it was stopped early. Patients were eligible if they were aged 18 years or older; had one or two painful, stable, or potentially unstable vertebral metastases; and had a life expectancy of 1 year or longer according to the investigator's estimates. Patients received 48.5 grays (Gy) in 10 fractions (with epidural involvement) or 40 Gy in five fractions (without epidural involvement) in the SBRT group and 30 Gy in 10 fractions or 20 Gy in five fractions in the cEBRT group, respectively. The primary end point was an improvement in the pain score at the treated site by at least 2 points (on a visual analog scale from 0 to 10 points) at 6-month follow-up. Data were analyzed on an intention-to-treat and per-protocol basis. RESULTS Of 214 patients who were screened for eligibility, 63 were randomized 1:1 between SBRT (33 patients with 36 metastases) and cEBRT (30 patients with 31 metastases). The median age of all patients was 66 years, and 40 patients were men (63.5%). In the intention-to-treat analysis, the 6-month proportion of patients who had metastases with pain reduction by 2 or more points was significantly higher in the SBRT group versus the control group (69.4% vs. 41.9%, respectively; two-sided p = .02). Changes in opioid medication intake relative to baseline were nonsignificant between the groups. No differences were observed in vertebral compression fracture or adverse event rates between the groups. CONCLUSIONS Dose-intensified SBRT improved pain score more effectively than cEBRT at 6 months.
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Affiliation(s)
- Matthias Guckenberger
- University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | | | | | - Ciro Franzese
- Humanitas University, Humanitas Research Hospital IRCCS, Milan, Italy
| | - Mateusz Spałek
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Jean-Jacques Stelmes
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Luxemburg Health Directorate, Luxemburg, Luxemburg
| | - Daniel M Aebersold
- Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Hossein Hemmatazad
- Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Jörg Zimmer
- Städtisches Klinikum Dresden, Dresden, Germany
| | - Thomas Zilli
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Geneva University Hospital, Geneva, Switzerland
| | | | | | | | | | - Robert Förster
- University Hospital Zurich, Zurich, Switzerland
- Kantonsspital Winterthur, Winterthur, Switzerland
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Hu JX, Gong YN, Jiang XD, Jiang L, Zhuang HQ, Meng N, Liu XG, Wei F, Liu ZJ. Local Tumor Control for Metastatic Epidural Spinal Cord Compression Following Separation Surgery with Adjuvant CyberKnife Stereotactic Radiotherapy or Image-Guided Intensity-Modulated Radiotherapy. World Neurosurg 2020; 141:e76-e85. [PMID: 32360927 DOI: 10.1016/j.wneu.2020.04.183] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We sought to compare local tumor control after conventionally fractionated image-guided intensity-modulated radiotherapy (IMRT) versus adjuvant CyberKnife stereotactic body radiotherapy (SBRT) in patients who underwent separation surgery for metastatic epidural spinal cord compression (MESCC). METHODS We retrospectively reviewed patients with MESCC who were treated at our hospital. The Kaplan-Meier method was used to estimate local progression and overall survival. RESULTS Fifty-six patients with MESCC underwent separation surgery between 2013 and 2018, among whom 6 were lost to follow-up, 24 received conventionally fractionated image-guided IMRT, and 26 were treated with CyberKnife SBRT. The median follow-up was 16.5 months (range, 2.1-47.5 months). Eleven patients experienced local failure including 9 and 2 from the IMRT and SBRT groups, respectively. The local progression-free survival rates were significantly higher in the SBRT group than IMRT group at 6 months (95.5% vs. 82.0%), 1 year (90.9% vs. 71.8%), and 2 years (90.9% vs. 57.6%) (P = 0.035). Multivariate Cox proportional hazards regression analysis identified radiotherapy method (P = 0.034) and receipt of preoperative radiotherapy (P = 0.047) as significant predictors of local control, while visceral metastasis (P = 0.048) and high-malignancy primary tumor type (P = 0.002) were negative predictors of overall survival. Moreover, postoperative SBRT was noninferior to IMRT in terms of pain control, adverse effects, and performance in treating irradiated spinal metastases. CONCLUSIONS Hybrid surgery-radiosurgery therapy is a safe and effective treatment option for patients with MESCC. SBRT provided higher local control rates compared with IMRT. Thus postoperative SBRT should be considered for patients expected to have relatively long survival.
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Affiliation(s)
- Jin Xin Hu
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Yi Ning Gong
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Xu Dong Jiang
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China.
| | - Hong Qing Zhuang
- Department of Radiation Oncology, Cancer Center, Peking University Health Science Center, Haidian District, Beijing, China
| | - Na Meng
- Department of Radiation Oncology, Cancer Center, Peking University Health Science Center, Haidian District, Beijing, China
| | - Xiao Guang Liu
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
| | - Zhong Jun Liu
- Department of Orthopedics, Peking University Third Hospital, Haidian District, Beijing, China
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3
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Guckenberger M, Sweeney RA, Hawkins M, Belderbos J, Andratschke N, Ahmed M, Madani I, Mantel F, Steigerwald S, Flentje M. Dose-intensified hypofractionated stereotactic body radiation therapy for painful spinal metastases: Results of a phase 2 study. Cancer 2018; 124:2001-2009. [DOI: 10.1002/cncr.31294] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/11/2017] [Accepted: 01/05/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | - Reinhart A. Sweeney
- Department of Radiation Oncology; Leopoldina Hospital Schweinfurt; Schweinfurt Germany
| | - Maria Hawkins
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories; University of Oxford; Oxford United Kingdom
| | - Jose Belderbos
- Department of Radiation Oncology; Netherlands Cancer Institute; Amsterdam the Netherlands
| | - Nicolaus Andratschke
- Department of Radiation Oncology; University Hospital Zurich; Zurich Switzerland
| | - Merina Ahmed
- Department of Radiotherapy; Royal Marsden NHS Foundation Trust/Institute of Cancer Research; Sutton United Kingdom
| | - Indira Madani
- Department of Radiation Oncology; University Hospital Zurich; Zurich Switzerland
| | - Frederick Mantel
- Department of Radiation Oncology; University Hospital Würzburg; Würzburg Germany
| | - Sabrina Steigerwald
- Department of Radiation Oncology; University Hospital Würzburg; Würzburg Germany
| | - Michael Flentje
- Department of Radiation Oncology; University Hospital Würzburg; Würzburg Germany
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4
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He J, Xiao J, Peng X, Duan B, Li Y, Ai P, Yao M, Chen N. Dose escalation by image-guided intensity-modulated radiotherapy leads to an increase in pain relief for spinal metastases: a comparison study with a regimen of 30 Gy in 10 fractions. Oncotarget 2017; 8:112330-112340. [PMID: 29348828 PMCID: PMC5762513 DOI: 10.18632/oncotarget.18979] [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: 12/15/2016] [Accepted: 06/18/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Under the existing condition that the optimum radiotherapy regimen for spinal metastases is controversial, this study investigates the benefits of dose escalation by image-guided intensity-modulated radiotherapy (IG-IMRT) with 60-66 Gy in 20-30 fractions for spinal metastases. RESULTS In the dose-escalation group, each D50 of planning gross tumor volume (PGTV) was above 60 Gy and each Dmax of spinal cord planning organ at risk volume (PRV) was below 48 Gy. The median biological effective dose (BED) of Dmax of spinal cord was lower in the dose-escalation group compared with that in the 30-Gy group (69.70 Gy vs. 83.16 Gy, p < 0.001). After one month and three months of the radiotherapy, pain responses were better in the dose-escalation group than those in the 30-Gy group (p = 0.005 and p = 0.024), and the complete pain relief rates were respectively 73.69% and 34.29% (p = 0.006), 73.69% and 41.38% (p = 0.028) in two compared groups. In the dose-escalation group, there is a trend of a longer duration of pain relief, a longer overall survival and a lower incidence of acute radiation toxicities. No late radiation toxicities were observed in both groups. MATERIALS AND METHODS Dosimetric parameters and clinical outcomes, including pain response, duration of pain relief, radiation toxicities and overall survival, were compared among twenty-five metastatic spinal lesions irradiated with the dose-escalation regimen and among forty-four lesions treated with the 30-Gy regimen. CONCLUSIONS Conventionally-fractionated IG-IMRT for spinal metastases could escalate dose to the vertebral lesions while sparing the spinal cord, achieving a better pain relief without increasing radiation complications.
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Affiliation(s)
- Jinlan He
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianghong Xiao
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xingchen Peng
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Baofeng Duan
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yan Li
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ping Ai
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Min Yao
- Department of Radiation Oncology, Case Comprehensive Cancer Center, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
| | - Nianyong Chen
- Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Spratt DE, Beeler WH, de Moraes FY, Rhines LD, Gemmete JJ, Chaudhary N, Shultz DB, Smith SR, Berlin A, Dahele M, Slotman BJ, Younge KC, Bilsky M, Park P, Szerlip NJ. An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report. Lancet Oncol 2017; 18:e720-e730. [PMID: 29208438 DOI: 10.1016/s1470-2045(17)30612-5] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 02/08/2023]
Abstract
Spinal metastases are becoming increasingly common because patients with metastatic disease are living longer. The close proximity of the spinal cord to the vertebral column limits many conventional therapeutic options that can otherwise be used to treat cancer. In response to this problem, an innovative multidisciplinary approach has been developed for the management of spinal metastases, leveraging the capabilities of image-guided stereotactic radiosurgery, separation surgery, vertebroplasty, and minimally invasive local ablative approaches. In this Review, we discuss the variables that should be considered during the management of these patients and review the role of each discipline and their respective management options to provide optimal care. This work is synthesised into a practical algorithm to aid clinicians in the management of patients with spinal metastasis.
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Affiliation(s)
- Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Whitney H Beeler
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Fabio Y de Moraes
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada; Department of Radiation Oncology, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - David B Shultz
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Sean R Smith
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Alejandro Berlin
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Max Dahele
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Kelly C Younge
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Image-guided radiation therapy (IGRT): practical recommendations of Italian Association of Radiation Oncology (AIRO). Radiol Med 2016; 121:958-965. [DOI: 10.1007/s11547-016-0674-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 08/16/2016] [Indexed: 12/22/2022]
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7
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Lo SS, Slotman BJ, Lock M, Nagata Y, Guckenberger M, Siva S, Foote M, Tan D, Teh BS, Mayr NA, Chang EL, Timmerman RD, Sahgal A. The development of stereotactic body radiotherapy in the past decade: a global perspective. Future Oncol 2015; 11:2721-2733. [PMID: 26338676 DOI: 10.2217/fon.15.220] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
In the past 10 years, there has been an exponential increase in the incorporation of stereotactic body radiotherapy, also known as stereotactic ablative radiotherapy, into the armamentarium against various types of cancer in different settings worldwide. In this article in the 10th year anniversary issue of Future Oncology, representatives from the USA, Canada, Japan, Germany, The Netherlands, Australia and Singapore will provide individual perspectives of the development of stereotactic body radiotherapy in their respective countries.
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Affiliation(s)
- Simon S Lo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Michael Lock
- Department of Radiation Oncology, London Regional Cancer Program, University of Western Ontario, London, ON, Canada
| | - Yasushi Nagata
- Department of Radiation Oncology, Hiroshima University, Hiroshima, Japan
| | | | - Shankar Siva
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Queensland, Australia
| | - Daniel Tan
- Asian American Radiation Oncology, Singapore
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX, USA
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine & Norris Cancer Center at the University of Southern California, Los Angeles, CA, USA
| | - Robert D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
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8
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Guckenberger M, Mantel F, Gerszten PC, Flickinger JC, Sahgal A, Létourneau D, Grills IS, Jawad M, Fahim DK, Shin JH, Winey B, Sheehan J, Kersh R. Safety and efficacy of stereotactic body radiotherapy as primary treatment for vertebral metastases: a multi-institutional analysis. Radiat Oncol 2014; 9:226. [PMID: 25319530 PMCID: PMC4205292 DOI: 10.1186/s13014-014-0226-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/30/2014] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate patient selection criteria, methodology, safety and clinical outcomes of stereotactic body radiotherapy (SBRT) for treatment of vertebral metastases. Materials and methods Eight centers from the United States (n = 5), Canada (n = 2) and Germany (n = 1) participated in the retrospective study and analyzed 301 patients with 387 vertebral metastases. No patient had been exposed to prior radiation at the treatment site. All patients were treated with linac-based SBRT using cone-beam CT image-guidance and online correction of set-up errors in six degrees of freedom. Results 387 spinal metastases were treated and the median follow-up was 11.8 months. The median number of consecutive vertebrae treated in a single volume was one (range, 1-6), and the median total dose was 24 Gy (range 8-60 Gy) in 3 fractions (range 1-20). The median EQD210 was 38 Gy (range 12-81 Gy). Median overall survival (OS) was 19.5 months and local tumor control (LC) at two years was 83.9%. On multivariate analysis for OS, male sex (p < 0.001; HR = 0.44), performance status <90 (p < 0.001; HR = 0.46), presence of visceral metastases (p = 0.007; HR = 0.50), uncontrolled systemic disease (p = 0.007; HR = 0.45), >1 vertebra treated with SBRT (p = 0.04; HR = 0.62) were correlated with worse outcomes. For LC, an interval between primary diagnosis of cancer and SBRT of ≤30 months (p = 0.01; HR = 0.27) and histology of primary disease (NSCLC, renal cell cancer, melanoma, other) (p = 0.01; HR = 0.21) were correlated with worse LC. Vertebral compression fractures progressed and developed de novo in 4.1% and 3.6%, respectively. Other adverse events were rare and no radiation induced myelopathy reported. Conclusions This multi-institutional cohort study reports high rates of efficacy with spine SBRT. At this time the optimal fractionation within high dose practice is unknown.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University of Wuerzburg, Wuerzburg, Germany. .,Department of Radiation Oncology, University of Zurich, Zurich, Switzerland.
| | - Frederick Mantel
- Department of Radiation Oncology, University of Wuerzburg, Wuerzburg, Germany.
| | - Peter C Gerszten
- Department Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - John C Flickinger
- Department Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada.
| | - Daniel Létourneau
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Canada.
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - Maha Jawad
- Department of Radiation Oncology, Beaumont Health System, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - Daniel K Fahim
- Department of Neurosurgery, Beaumont Health System, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Brian Winey
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Ron Kersh
- Riverside Medical Center, Newport News, VA, USA.
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9
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Long-term safety and efficacy of fractionated stereotactic body radiation therapy for spinal metastases. Strahlenther Onkol 2014; 190:1141-8. [DOI: 10.1007/s00066-014-0706-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 06/05/2014] [Indexed: 12/25/2022]
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10
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Mayer A, Póti Z. [Novel irradiation techniques in the treatment of solid tumours. Radiotherapy for metastases]. Orv Hetil 2014; 155:283-90. [PMID: 24534876 DOI: 10.1556/oh.2014.29832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Novel developments in percutaneous radiotherapy, such as positron emission tomography/computed tomography, adaptive radiation planning, intensity modulation radiotherapy and intensity modulated arc therapy (RapidArc), as well as the newer generation of image control (cone-beam computed tomography) and image guided radiotherapy ensure increased dosages of planning target volume and clinical target volume of solid tumours without damaging surrounding tissues and providing maximal protection. By raising the dosages of planned target volume and clinical target volume, these novel technical developments have created new indications in the treatment of solid tumours. With the aid of the cone-beam computed tomography and image guided radiotherapy the organ metastasis (lung, liver, spinal cord) and the primary tumour can be treated safety and effectively. Hypofractionation, dose escalation and the use of stereotactic devices can probably decrease radiation damage. The authors review the most common forms of evidence-based fractionation schemes used in irradiation therapy.
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Affiliation(s)
- Arpád Mayer
- Uzsoki utcai Kórház Fővárosi Onkoradiológiai Központ Budapest Uzsoki u. 29. 1145
| | - Zsuzsa Póti
- Uzsoki utcai Kórház Fővárosi Onkoradiológiai Központ Budapest Uzsoki u. 29. 1145
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11
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Gröger C, Hautmann MG, Loeschel R, Repp N, Kölbl O, Dobler B. Re-irradiation of spinal column metastases by IMRT: impact of setup errors on the dose distribution. Radiat Oncol 2013; 8:269. [PMID: 24238332 PMCID: PMC3842751 DOI: 10.1186/1748-717x-8-269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 11/03/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study investigates the impact of an automated image guided patient setup correction on the dose distribution for ten patients with in-field IMRT re-irradiation of vertebral metastases. METHODS 10 patients with spinal column metastases who had previously been treated with 3D-conformal radiotherapy (3D-CRT) were simulated to have an in-field recurrence. IMRT plans were generated for treatment of the vertebrae sparing the spinal cord. The dose distributions were compared for a patient setup based on skin marks only and a Cone Beam CT (CBCT) based setup with translational and rotational couch corrections using an automatic robotic image guided couch top (Elekta - HexaPOD™ IGuide® - system). The biological equivalent dose (BED) was calculated to evaluate and rank the effects of the automatic setup correction for the dose distribution of CTV and spinal cord. RESULTS The mean absolute value (± standard deviation) over all patients and fractions of the translational error is 6.1 mm (±4 mm) and 2.7° (±1.1 mm) for the rotational error. The dose coverage of the 95% isodose for the CTV is considerable decreased for the uncorrected table setup. This is associated with an increasing of the spinal cord dose above the tolerance dose. CONCLUSIONS An automatic image guided table correction ensures the delivery of accurate dose distribution and reduces the risk of radiation induced myelopathy.
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Affiliation(s)
- Christian Gröger
- Department of Radiotherapy, University Medical Center, Regensburg, Germany.
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12
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Ray GL, Buchsbaum JC, McMullen KP, Simoneaux RV, Hines M, Douglas JG, Johnstone PAS. Definitive treatment of leptomeningeal spinal metastases in children. Pediatr Blood Cancer 2013; 60:1839-41. [PMID: 23788317 DOI: 10.1002/pbc.24659] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 05/22/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Uniquely in children, the existence of leptomeningeal spinal metastases does not confer a uniformly grave prognosis. Although the radiation tolerance of the spinal cord is of significant concern in these cases, the chemo- and radiosensitivity of these lesions argues for an aggressive approach where possible. METHODS The records of the Indiana University Health Proton Therapy Center were reviewed for patients undergoing proton beam therapy with curative intent for LSM between January 1, 2004 and July 7, 2012. Patients with microscopic disease only on LP were not included. Particulars of therapy, including dose, field sizes, toxicities, and outcomes were collated. RESULTS Twenty-two children received therapy as described, of median age 5 years (range 1.1-17.1). Patients had medulloblastoma (n = 9), ATRT (n = 4), ependymoma, and PNET (n = 3 each). Five lesions (23%) were chemo-recurrent, though no patient had prior radiation to the spine. Median follow-up was 14 months (range 4-33) for all living patients. Fifteen (68%) children continued to have local control at last follow-up visit. Median dose was 37.8 Gy (range 21.6-54 Gy). Eight patients with chemo-recurrent disease or diffuse cord seeding did poorly, with local control and overall survival achieved in four. The 12-month overall survival was 68% with grade 1 skin erythema as the most frequent toxicity. CONCLUSIONS We describe a cohort of LSM patients treated with RT with definitive intent, and the only available data from the proton environment. Durable response is possible for these children in over two-thirds of cases. Significant toxicity was infrequent using proton radiotherapy and these fractionation schemes.
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Affiliation(s)
- Geoffrey L Ray
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana; IU Health Proton Therapy Center, Bloomington, Indiana
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13
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Lee YK, Bedford JL, McNair HA, Hawkins MA. Comparison of deliverable IMRT and VMAT for spine metastases using a simultaneous integrated boost. Br J Radiol 2013; 86:20120466. [PMID: 23385999 DOI: 10.1259/bjr.20120466] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To effectively treat spine metastases, significant dose must be delivered to regions surrounding the spinal cord. We present a study comparing both step-and-shoot intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) techniques to deliver a concomitant hypofractionated prescription dose to the diseased region and to the involved vertebrae. METHODS Seven-field IMRT and a single arc VMAT were inversely planned on five (two cervical and three thoracic) spinal metastatic patients. Planning target volumes PTVm (macroscopic) and PTVe (elective involved vertebrae) and associated organs at risk were localised. Mean doses of 35 Gy to PTVm and 20 Gy to PTVe were prescribed in five fractions. Dose statistics, estimated delivery time and results of verification using Delta(4) (ScandiDos, Uppsala, Sweden) were compared. RESULTS Deliverable plans were achieved with both IMRT and VMAT. The coverage to PTV was similar for both IMRT and VMAT (p=0.5) and the dose to the regions adjacent to the spinal cord was 1% higher with VMAT (p=0.04). The mean delivery time for VMAT was 3.5 min compared with 10.5 min for IMRT. Fewer monitor units were required to deliver IMRT than to deliver VMAT. The median (range) percentage of measured points with a γ-index <1 with 3%/3 mm was 100 (99.9-100)% for IMRT and 100 (88.5-100)% for VMAT. CONCLUSION Both VMAT and IMRT can deliver the concomitant hypofractionated regime proposed, and both offer different benefits in dose delivery. IMRT is currently preferred for its superior pre-treatment verification results and shorter planning times. ADVANCES IN KNOWLEDGE This study explores the feasibility of delivering tumouricidal doses of radiation to metastatic spine disease in the vicinity of the spinal cord.
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Affiliation(s)
- Y K Lee
- Joint Department of Physics, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK.
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Guckenberger M, Hawkins M, Flentje M, Sweeney RA. Fractionated radiosurgery for painful spinal metastases: DOSIS - a phase II trial. BMC Cancer 2012; 12:530. [PMID: 23164174 PMCID: PMC3522547 DOI: 10.1186/1471-2407-12-530] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 11/10/2012] [Indexed: 12/25/2022] Open
Abstract
Background One third of all cancer patients will develop bone metastases and the vertebral column is involved in approximately 70% of these patients. Conventional radiotherapy with of 1–10 fractions and total doses of 8-30 Gy is the current standard for painful vertebral metastases; however, the median pain response is short with 3–6 months and local tumor control is limited with these rather low irradiation doses. Recent advances in radiotherapy technology – intensity modulated radiotherapy for generation of highly conformal dose distributions and image-guidance for precise treatment delivery – have made dose-escalated radiosurgery of spinal metastases possible and early results of pain and local tumor control are promising. The current study will investigate efficacy and safety of radiosurgery for painful vertebral metastases and three characteristics will distinguish this study. 1) A prognostic score for overall survival will be used for selection of patients with longer life expectancy to allow for analysis of long-term efficacy and safety. 2) Fractionated radiosurgery will be performed with the number of treatment fractions adjusted to either good (10 fractions) or intermediate (5 fractions) life expectancy. Fractionation will allow inclusion of tumors immediately abutting the spinal cord due to higher biological effective doses at the tumor - spinal cord interface compared to single fraction treatment. 3) Dose intensification will be performed in the involved parts of the vertebrae only, while uninvolved parts are treated with conventional doses using the simultaneous integrated boost concept. Methods / Design It is the study hypothesis that hypo-fractionated image-guided radiosurgery significantly improves pain relief compared to historic data of conventionally fractionated radiotherapy. Primary endpoint is pain response 3 months after radiosurgery, which is defined as pain reduction of ≥ 2 points at the treated vertebral site on the 0 to 10 Visual Analogue Scale. 60 patients will be included into this two-centre phase II trial. Conclusions Results of this study will refine the methods of patient selection, target volume definition, treatment planning and delivery as well as quality assurance for radiosurgery. It is the intention of this study to form the basis for a future randomized controlled trial comparing conventional radiotherapy with fractionated radiosurgery for palliation of painful vertebral metastases. Trial registration ClinicalTrials.gov Identifier: NCT01594892
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University of Würzburg, Josef-Schneider-Str, 11, Würzburg 97080, Germany.
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Levegrün S, Pöttgen C, Jawad JA, Berkovic K, Hepp R, Stuschke M. Megavoltage computed tomography image guidance with helical tomotherapy in patients with vertebral tumors: analysis of factors influencing interobserver variability. Int J Radiat Oncol Biol Phys 2012; 85:561-9. [PMID: 22658219 DOI: 10.1016/j.ijrobp.2012.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 03/03/2012] [Accepted: 04/07/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate megavoltage computed tomography (MVCT)-based image guidance with helical tomotherapy in patients with vertebral tumors by analyzing factors influencing interobserver variability, considered as quality criterion of image guidance. METHODS AND MATERIALS Five radiation oncologists retrospectively registered 103 MVCTs in 10 patients to planning kilovoltage CTs by rigid transformations in 4 df. Interobserver variabilities were quantified using the standard deviations (SDs) of the distributions of the correction vector components about the observers' fraction mean. To assess intraobserver variabilities, registrations were repeated after ≥4 weeks. Residual deviations after setup correction due to uncorrectable rotational errors and elastic deformations were determined at 3 craniocaudal target positions. To differentiate observer-related variations in minimizing these residual deviations across the 3-dimensional MVCT from image resolution effects, 2-dimensional registrations were performed in 30 single transverse and sagittal MVCT slices. Axial and longitudinal MVCT image resolutions were quantified. For comparison, image resolution of kilovoltage cone-beam CTs (CBCTs) and interobserver variability in registrations of 43 CBCTs were determined. RESULTS Axial MVCT image resolution is 3.9 lp/cm. Longitudinal MVCT resolution amounts to 6.3 mm, assessed as full-width at half-maximum of thin objects in MVCTs with finest pitch. Longitudinal CBCT resolution is better (full-width at half-maximum, 2.5 mm for CBCTs with 1-mm slices). In MVCT registrations, interobserver variability in the craniocaudal direction (SD 1.23 mm) is significantly larger than in the lateral and ventrodorsal directions (SD 0.84 and 0.91 mm, respectively) and significantly larger compared with CBCT alignments (SD 1.04 mm). Intraobserver variabilities are significantly smaller than corresponding interobserver variabilities (variance ratio [VR] 1.8-3.1). Compared with 3-dimensional registrations, 2-dimensional registrations have significantly smaller interobserver variability in the lateral and ventrodorsal directions (VR 3.8 and 2.8, respectively) but not in the craniocaudal direction (VR 0.75). CONCLUSION Tomotherapy image guidance precision is affected by image resolution and residual deviations after setup correction. Eliminating the effect of residual deviations yields small interobserver variabilities with submillimeter precision in the axial plane. In contrast, interobserver variability in the craniocaudal direction is dominated by the poorer longitudinal MVCT image resolution. Residual deviations after image guidance exist and need to be considered when dose gradients ultimately achievable with image guided radiation therapy techniques are analyzed.
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Affiliation(s)
- Sabine Levegrün
- Department of Radiotherapy, University Hospital Essen, Essen, Germany.
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RapidArc combined with the active breathing coordinator provides an effective and accurate approach for the radiotherapy of hepatocellular carcinoma. Strahlenther Onkol 2012; 188:262-8. [PMID: 22311151 DOI: 10.1007/s00066-011-0044-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 10/20/2011] [Indexed: 01/31/2023]
Abstract
PURPOSE The goal of this research was to investigate the feasibility of volumetric modulated arc therapy, RapidArc (RA), in association with the active breathing coordinator (ABC) for the treatment of hepatocellular carcinoma (HCC) with radiotherapy. PATIENTS AND MATERIALS A total of 12 patients with HCC, after receiving transcatheter arterial chemoembolization (TACE) treatment, underwent three-dimensional computer tomography (3D-CT) scanning associated with ABC using end inspiration hold (EIH), end expiration hold (EEH), and free breathing (FB) techniques. The three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and RA plans (three 135° arcs) were designed on different CT images, respectively. The liver volume, gross tumor volume (GTV), and planning target volume (PTV) of the three breath status and the dosimetric differences of the different plans were compared. RESULTS There were no significant differences in the volumes of live and GTV between the three breathing techniques (p > 0.05); the PTV in FB was greater than in the EEH and EIH (p < 0.05). The overall conformality index (CI) and homogeneity index (HI) for RA (CI 0.92, HI 0.90) were better than IMRT (CI 0.90, HI 0.89) and 3D-CRT (CI 0.70, HI 0.84) for the three breathing techniques (p< 0.05). The RA and IMRT significantly reduced the mean dose, V(20), V(30), and V(40) of normal liver compared to 3D-CRT, while the V(5) and V(10) in RA were higher than in IMRT. The mean values in mean dose, V(10), V(20), V(30), and V(40) of the normal liver were reduced from 13.12 Gy, 46%, 24%, 13%, and 8% in RA(FB) to 10.23 Gy, 35%, 16%, 8%, and 5% in RA(EEH) and 9.23 Gy, 32%, 16%, 8%, and 5% in RA(EIH ), respectively. In addition, the treatment time of RA was equal to 3D-CRT, which was significantly shorter than IMRT. CONCLUSION RA in conjunction with ABC for the treatment of HCC with radiotherapy can achieve better dose delivery and ensure the accuracy of the target volume, which spares more organs at risk, uses fewer monitor units, and shortens treatment time.
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Nikolajek K, Kufeld M, Muacevic A, Wowra B, Niyazi M, Ganswindt U. Spinal radiosurgery--efficacy and safety after prior conventional radiotherapy. Radiat Oncol 2011; 6:173. [PMID: 22177519 PMCID: PMC3264666 DOI: 10.1186/1748-717x-6-173] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 12/16/2011] [Indexed: 12/25/2022] Open
Abstract
Background Conventional external beam radiotherapy is a standard procedure for treatment of spinal metastases. In case of progression spinal cord tolerance limits further radiotherapy in pre-irradiated areas. Spinal stereotactic radiotherapy is a non-invasive option to re-treat pre-irradiated patients. Nevertheless, spinal radiosurgery results in relevant dose deposition within the myelon with potential toxicity. Aim of the study was to retrospectively analyse the efficacy and feasibility for salvage radiosurgery of spinal metastases. Methods During a period of 4 years (2005-2009) 70 lesions in 54 patients were treated in 60 radiosurgery sessions and retrospectively analysed. Clinical (pain, sensory and motor deficit) and radiological (CT/MRI) follow-up data were collected prospectively after radiosurgery. Pain - as main symptom - was classified by the Visual Analogue Scale (VAS) score. Every patient received single session radiosurgery after having been treated first-line with conventionally fractionated radiotherapy. Kaplan-Meier method and life tables were used to analyse freedom from local failure and overall survival. Results At a median follow-up of 14.5 months the actuarial rates of freedom from local failure at 6/12/18 months were 93%, 88% and 85%, respectively. The median radiosurgery dose was 1 × 18 Gy (range 10-28 Gy) to the median 70% isodose. The VAS score of patients with pain (median 6) dropped significantly (median 4, p = 0.002). In 6 out of 7 patients worse sensory or motor deficit after SRS was caused by local or distant failures (diagnosed by CT/MRI). One patient with metastatic renal cell carcinoma developed a progressive complete paraparesis one year after the last treatment at lumbar level L3. Due to multiple surgery and radiosurgery treatments at the lumbar region and further local progression, the exact reason remained unclear. Apart from that, no CTC grade III or higher toxicity has been observed. Conclusions By applying spinal radiosurgery relevant radiation doses can be limited to small parts of the myelon. This prevents myelopathic side effects and makes it an effective and safe treatment option for well-suited patients. Especially for previously irradiated patients with local failure or pain salvage SRS represents a valuable treatment option with high local control rates, low toxicity and significant pain reduction.
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Affiliation(s)
- Katharina Nikolajek
- Department of Radiation Oncology, Ludwig-Maximilians-University, Campus Grosshadern, Marchioninistr, 15, 81377 München, Germany
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Guckenberger M, Sweeney RA, Flickinger JC, Gerszten PC, Kersh R, Sheehan J, Sahgal A. Clinical practice of image-guided spine radiosurgery--results from an international research consortium. Radiat Oncol 2011; 6:172. [PMID: 22172095 PMCID: PMC3286433 DOI: 10.1186/1748-717x-6-172] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 12/15/2011] [Indexed: 03/10/2023] Open
Abstract
Background Spinal radiosurgery is a quickly evolving technique in the radiotherapy and neurosurgical communities. However, the methods of spine radiosurgery have not been standardized. This article describes the results of a survey about the methods of spine radiosurgery at five international institutions. Methods All institutions are members of the Elekta Spine Radiosurgery Research Consortium and have a dedicated research and clinical focus on image-guided radiosurgery. The questionnaire consisted of 75 items covering all major steps of spine radiosurgery. Results Strong agreement in the methods of spine radiosurgery was observed. In particular, similarities were observed with safety and quality assurance playing an important role in the methods of all institutions, cooperation between neurosurgeons and radiation oncologists in case selection, dedicated imaging for target- and organ-at-risk delineation, application of proper safety margins for the target volume and organs-at-risk, conformal planning and precise image-guided treatment delivery, and close clinical and radiological follow-up. In contrast, three major areas of uncertainty and disagreement were identified: 1) Indications and contra-indications for spine radiosurgery; 2) treatment dose and fractionation and 3) tolerance dose of the spinal cord. Conclusions Results of this study reflect the current practice of spine radiosurgery in large academic centers. Despite close agreement was observed in many steps of spine radiosurgery, further research in form of retrospective and especially prospective studies is required to refine the details of spinal radiosurgery in terms of safety and efficacy.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany.
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Ströfer M, Jelkmann W, Depping R. Curcumin decreases survival of Hep3B liver and MCF-7 breast cancer cells: the role of HIF. Strahlenther Onkol 2011; 187:393-400. [PMID: 21713389 DOI: 10.1007/s00066-011-2248-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 03/16/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Curcumin, a commonly used spice, affects the activities of cytokines, enzymes, and transcription factors that are linked to inflammation. Furthermore, curcumin has been assigned tumor growth inhibiting effects, possibly mediated by promoting hypoxia-inducible factor (HIF) degradation. HIFs are transcription factors that play a central role in the adaptation and response to low oxygen levels in metazoan cells. However, curcumin also exhibits properties of an iron chelator indicating its potential of inhibiting HIF-α prolyl hydroxylase (PHD) activity. METHODS We were interested in clarifying these divergent actions of curcumin in due consideration of the effects on radio-therapy. Thus, concentration- and time-dependent effects of curcumin on HIF-α and -β protein levels and activity in hepatoma and breast carcinoma cell cultures under normoxic and hypoxic conditions were studied. RESULTS It was shown that HIF-1α accumulated in normoxia after the application of higher doses of the drug. Curcumin proved to lower HIF-1α and HIF-2α protein levels in hypoxia. HIF-1β (ARNT; arylhydrocarbon nuclear translocator) protein levels and HIF transcriptional activity were reduced in normoxia and hypoxia after 4 h and 24 h incubation periods. Furthermore, curcumin treatment negatively impacted on clonogenic cell survival of Hep3B hepatoma and MCF-7 breast carcinoma cells. CONCLUSION Effects of curcumin on cell growth and survival factor expression suggest its potential benefit in the treatment of cancer without a direct radiosensitizing influence of curcumin on these cells.
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Affiliation(s)
- Mareike Ströfer
- Department of Physiology, Center for Structural and Cell Biology in Medicine, University of Luebeck, Luebeck, Germany.
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Damast S, Wright J, Bilsky M, Hsu M, Zhang Z, Lovelock M, Cox B, Zatcky J, Yamada Y. Impact of dose on local failure rates after image-guided reirradiation of recurrent paraspinal metastases. Int J Radiat Oncol Biol Phys 2010; 81:819-26. [PMID: 20888133 DOI: 10.1016/j.ijrobp.2010.06.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 05/28/2010] [Accepted: 06/11/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE To examine the impact of dose on local failure (LF) rates in the re-treatment of recurrent paraspinal metastases with image-guided intensity-modulated radiotherapy (IG-IMRT). METHODS AND MATERIALS The records of patients with in-field recurrence after previous spine radiation (median dose, 30 Gy) who received salvage IG-IMRT with either five 4-Gy (20-Gy group, n = 42) or five 6-Gy (30-Gy group, n = 55) daily fractions between January 2003 and August 2008 were reviewed. Institutional practice was 20 Gy before April 2006, when it changed to 30 Gy. A total of 47 cases (48%) were treated adjuvantly, after surgery to decompress epidural disease. LF after IG-IMRT was defined radiographically. RESULTS The median follow-up was 12.1 months (range, 0.2-63.6 months). The 1-year cumulative incidences of LF after 20 Gy and 30 Gy IG-IMRT were 45% and 26%, respectively (p = 0.04). Of all treatment characteristics examined (20-Gy vs. 30-Gy dose group, dose to 95% of the planned and gross target volume, tumor size, histology, receipt of surgery, and interval between first and second radiation), only dose group had a significant impact on actuarial LF incidence (p = 0.04; unadjusted HR, 0.51; 95% CI, 0.27-0.96). There was no incidence of myelopathy. CONCLUSIONS A significant decrease in LF after IG-IMRT with five 6-Gy fractions compared with five 4-Gy fractions was observed without increased risk of myelopathy. Until prospective data comparing stereotactic hypofractionated and single-fraction regimens become available, when reirradiating recurrent paraspinal metastases with IG-IMRT, administration of five 6-Gy daily fractions is reasonable.
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Affiliation(s)
- Shari Damast
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Verellen D, Depuydt T, Gevaert T, Linthout N, Tournel K, Duchateau M, Reynders T, Storme G, De Ridder M. Gating and tracking, 4D in thoracic tumours. Cancer Radiother 2010; 14:446-54. [PMID: 20673737 DOI: 10.1016/j.canrad.2010.06.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 06/03/2010] [Indexed: 12/25/2022]
Abstract
The limited ability to control for a tumour's location compromises the accuracy with which radiation can be delivered to tumour-bearing tissue. The resultant requirement for larger treatment volumes to accommodate target uncertainty restricts the radiation dose because more surrounding normal tissue is exposed. With image-guided radiation therapy (IGRT), these volumes can be optimized and tumouricidal doses may be delivered, achieving maximum tumour control with minimal complications. Moreover, with the ability of high precision dose delivery and real-time knowledge of the target volume location, IGRT has initiated the exploration of new indications in radiotherapy such as hypofractionated radiotherapy (or stereotactic body radiotherapy), deliberate inhomogeneous dose distributions coping with tumour heterogeneity (dose painting by numbers and biologically conformal radiation therapy), and adaptive radiotherapy. In short: "individualized radiotherapy". Tumour motion management, especially for thoracic tumours, is a particular problem in this context both for the delineation of tumours and organs at risk as well as during the actual treatment delivery. The latter will be covered in this paper with some examples based on the experience of the UZ Brussel. With the introduction of the NOVALIS system (BrainLAB, Feldkirchen, Germany) in 2000 and consecutive prototypes of the ExacTrac IGRT system, gradually a hypofractionation treatment protocol was introduced for the treatment of lung tumours and liver metastases evolving from motion-encompassing techniques towards respiratory-gated radiation therapy with audio-visual feedback and most recently dynamic tracking using the VERO system (BrainLAB, Feldkirchen, Germany). This evolution will be used to illustrate the recent developments in this particular field of research.
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Affiliation(s)
- D Verellen
- Department of Radiotherapy, UZ Brussel, Oncologisch Centrum, Laarbeeklaan 101, 1090 Brussels, Belgium.
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