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Koide Y, Haimoto S, Shimizu H, Aoyama T, Kitagawa T, Shindo Y, Nagai N, Hashimoto S, Tachibana H, Kodaira T. Re-irradiation spine stereotactic body radiotherapy following high-dose conventional radiotherapy for metastatic epidural spinal cord compression: a retrospective study. Jpn J Radiol 2024; 42:662-672. [PMID: 38413551 DOI: 10.1007/s11604-024-01539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/22/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE We aimed to evaluate the efficacy and safety of re-irradiation stereotactic body radiation therapy (SBRT) in patients with metastatic epidural spinal cord compression (MESCC) following high-dose conventional radiotherapy. MATERIALS AND METHODS Twenty-one patients met the following eligibility criteria: with an irradiation history of 50 Gy2 equivalent dose in 2-Gy fractions (EQD2) or more, diagnosed MESCC in the cervical or thoracic spines, and treated with re-irradiation SBRT of 24 Gy in 2 fractions between April 2018 and March 2023. Prior treatment was radiotherapy alone, not including surgery. The primary endpoint was a 1-year local failure rate. Overall survival (OS) and treatment-related adverse events were assessed as the secondary endpoints. Since our cohort includes one treatment-related death (TRD) of esophageal perforation, the cumulative esophageal dose was evaluated to find the dose constraints related to severe toxicities. RESULTS The median age was 68, and 14 males were included. The primary tumor sites (esophagus/lung/head and neck/others) were 6/6/7/2, and the median initial radiotherapy dose was 60 Gy2 EQD2 (range: 50-105 Gy2, 60-70/ > 70 Gy2 were 11/4). Ten patients underwent surgery followed by SBRT and 11 SBRT alone. At the median follow-up time of 10.4 months, 17 patients died of systemic disease progression including one TRD. No radiation-induced myelopathy or nerve root injuries occurred. Local failure occurred in six patients, with a 1-year local failure rate of 29.3% and a 1-year OS of 55.0%. Other toxicities included five cases of vertebral compression fractures (23.8%) and one radiation pneumonitis. The cumulative esophageal dose was recommended as follows: Dmax < 203, D0.035 cc < 187, and D1cc < 167 (Gy3 in biological effective dose). CONCLUSION Re-irradiation spine SBRT may be effective for selected patients with cervical or thoracic MESCC, even with high-dose irradiation histories. The cumulative dose assessment across the original and re-irradiated esophagus was recommended to decrease the risk of severe esophageal toxicities.
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Affiliation(s)
- Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan.
| | - Shoichi Haimoto
- Department of Neurosurgery, Aichi Cancer Center Hospital, Chikusa-Ku, Nagoya, Japan
| | - Hidetoshi Shimizu
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Takahiro Aoyama
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Tomoki Kitagawa
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Yurika Shindo
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Naoya Nagai
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Shingo Hashimoto
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
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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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Grosinger AJ, Alcorn SR. An Update on the Management of Bone Metastases. Curr Oncol Rep 2024; 26:400-408. [PMID: 38539021 PMCID: PMC11021281 DOI: 10.1007/s11912-024-01515-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE OF REVIEW Increasing life expectancy among patients with advanced cancer has placed a greater emphasis on optimizing pain control and quality of life. Concurrently, significant advancements in radiotherapy for bone metastases have permitted for dose escalation strategies such as stereotactic radiotherapy. This review aims to provide updated information on the management of bone metastases in light of these developments. RECENT FINDINGS We reviewed recent studies regarding the role and details of external beam radiotherapy for bone metastases, with emphasis on differences by treatment site as well as intention (palliative versus ablative for oligometastases). Conventional palliative radiotherapy remains a mainstay of management. While stereotactic radiotherapy may augment durability of pain relief and even survival time, there are significant questions remaining regarding optimal dosing and patient selection. Radiotherapy for bone metastases continues to evolve, particularly with increasing use of stereotactic radiotherapy. Future studies are needed to clarify optimal dose, fractionation, modality, and patient selection criteria among different radiotherapy approaches.
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Affiliation(s)
- Alexander J Grosinger
- Department of Radiation Oncology, University of Minnesota Medical School, Mail Code 494, 420 Delaware St. SE, Minneapolis, MN, 55455-0110, USA
| | - Sara R Alcorn
- Department of Radiation Oncology, University of Minnesota Medical School, Mail Code 494, 420 Delaware St. SE, Minneapolis, MN, 55455-0110, USA.
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Burgess L, Nguyen E, Tseng CL, Guckenberger M, Lo SS, Zhang B, Nielsen M, Maralani P, Nguyen QN, Sahgal A. Practice and principles of stereotactic body radiation therapy for spine and non-spine bone metastases. Clin Transl Radiat Oncol 2024; 45:100716. [PMID: 38226025 PMCID: PMC10788412 DOI: 10.1016/j.ctro.2023.100716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 01/17/2024] Open
Abstract
Radiotherapy is the dominant treatment modality for painful spine and non-spine bone metastases (NSBM). Historically, this was achieved with conventional low dose external beam radiotherapy, however, stereotactic body radiotherapy (SBRT) is increasingly applied for these indications. Meta-analyses and randomized clinical trials have demonstrated improved pain response and more durable tumor control with SBRT for spine metastases. However, in the setting of NSBM, there is limited evidence supporting global adoption and large scale randomized clinical trials are in need. SBRT is technically demanding requiring careful consideration of organ at risk tolerance, and strict adherence to technical requirements including immobilization, simulation, contouring and image-guidance procedures. Additional considerations include follow up practices after SBRT, with appropriate imaging playing a critical role in response assessment. Finally, there is renewed research into promising new technologies that may further refine the use of SBRT in both spinal and NSBM in the years to come.
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Affiliation(s)
- Laura Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric Nguyen
- Department of Radiation Oncology, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nielsen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, MD Anderson Cancer Centre, University of Texas, Houston, TX, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Bindels BJJ, Mercier C, Gal R, Verlaan JJ, Verhoeff JJC, Dirix P, Ost P, Kasperts N, van der Linden YM, Verkooijen HM, van der Velden JM. Stereotactic Body and Conventional Radiotherapy for Painful Bone Metastases: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2355409. [PMID: 38345820 PMCID: PMC10862159 DOI: 10.1001/jamanetworkopen.2023.55409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/12/2023] [Indexed: 02/15/2024] Open
Abstract
Importance Conventional external beam radiotherapy (cEBRT) and stereotactic body radiotherapy (SBRT) are commonly used treatment options for relieving metastatic bone pain. The effectiveness of SBRT compared with cEBRT in pain relief has been a subject of debate, and conflicting results have been reported. Objective To compare the effectiveness associated with SBRT vs cEBRT for relieving metastatic bone pain. Data Sources A structured search was performed in the PubMed, Embase, and Cochrane databases on June 5, 2023. Additionally, results were added from a new randomized clinical trial (RCT) and additional unpublished data from an already published RCT. Study Selection Comparative studies reporting pain response after SBRT vs cEBRT in patients with painful bone metastases. Data Extraction and Synthesis Two independent reviewers extracted data from eligible studies. Data were extracted for the intention-to-treat (ITT) and per-protocol (PP) populations. The study is reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures Overall and complete pain response at 1, 3, and 6 months after radiotherapy, according to the study's definition. Relative risk ratios (RRs) with 95% CIs were calculated for each study. A random-effects model using a restricted maximum likelihood estimator was applied for meta-analysis. Results There were 18 studies with 1685 patients included in the systematic review and 8 RCTs with 1090 patients were included in the meta-analysis. In 7 RCTs, overall pain response was defined according to the International Consensus on Palliative Radiotherapy Endpoints in clinical trials (ICPRE). The complete pain response was reported in 6 RCTs, all defined according to the ICPRE. The ITT meta-analyses showed that the overall pain response rates did not differ between cEBRT and SBRT at 1 (RR, 1.14; 95% CI, 0.99-1.30), 3 (RR, 1.19; 95% CI, 0.96-1.47), or 6 (RR, 1.22; 95% CI, 0.96-1.54) months. However, SBRT was associated with a higher complete pain response at 1 (RR, 1.43; 95% CI, 1.02-2.01), 3 (RR, 1.80; 95% CI, 1.16-2.78), and 6 (RR, 2.47; 95% CI, 1.24-4.91) months after radiotherapy. The PP meta-analyses showed comparable results. Conclusions and Relevance In this systematic review and meta-analysis, patients with painful bone metastases experienced similar overall pain response after SBRT compared with cEBRT. More patients had complete pain alleviation after SBRT, suggesting that selected subgroups will benefit from SBRT.
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Affiliation(s)
- Bas J. J. Bindels
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Carole Mercier
- Department of Radiation Oncology, Iridium Netwerk, Antwerpen, Belgium
- Integrated Personalised and Precision Oncology Network, University Antwerp, Antwerp, Belgium
| | - Roxanne Gal
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Netwerk, Antwerpen, Belgium
- Integrated Personalised and Precision Oncology Network, University Antwerp, Antwerp, Belgium
| | - Piet Ost
- Department of Radiation Oncology, Iridium Netwerk, Antwerpen, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Nicolien Kasperts
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yvette M. van der Linden
- Department of Radiation Oncology and Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Helena M. Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Ohira S, Ikawa T, Inui S, Kanayama N, Ueda Y, Miyazaki M, Nishio T, Koizumi M, Konishi K. Improvement of target coverage using automated non-coplanar volumetric modulated arc therapy planning in stereotactic radiotherapy for cervical metastatic spinal tumors. Med Dosim 2023:S0958-3947(23)00039-0. [PMID: 37202230 DOI: 10.1016/j.meddos.2023.04.001] [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: 01/24/2023] [Accepted: 04/04/2023] [Indexed: 05/20/2023]
Abstract
This study aimed to compare dosimetric parameters for targets and organs at risk (OARs) between volumetric modulated arc therapy (VMAT) and automated VMAT (HyperArc, HA) plans in stereotactic radiotherapy for patients with cervical metastatic spine tumors. VMAT plans were generated for 11 metastases using the simultaneous integrated boost technique to deliver 35 to 40 and 20 to 25 Gy for high dose and elective dose planning target volume (PTVHD and PTVED), respectively. The HA plans were retrospectively generated using 1 coplanar and 2 noncoplanar arcs. Subsequently, the doses to the targets and OARs were compared. The HA plans provided significantly higher (p < 0.05) Dmin (77.4 ± 13.1%), D99% (89.3 ± 8.9%), and D98% (92.5 ± 7.7%) for gross tumor volume (GTV) than those of the VMAT plans (73.4 ± 12.2%, 84.2 ± 9.6 and 87.3 ± 8.8% for Dmin, D99% and D98%, respectively). In addition, D99% and D98% for PTVHD were significantly higher in the HA plans, whereas dosimetric parameters were comparable between the HA and VMAT plans for PTVED. The Dmax values for the brachial plexus, esophagus, and spinal cord were comparable, and no significant difference was observed in the Dmean for the larynx, pharyngeal constrictor, thyroid, parotid grand (left and right), and Submandibular gland (left and right). The HA plans provided significantly higher target coverage of GTV and PTVHD, with a comparable dose for OARs with VMAT plans. The results of this study may contribute to the improvement of local control in clinical practice.
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Affiliation(s)
- Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan; Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shoki Inui
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Teiji Nishio
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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