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Guninski RS, Cuccia F, Alongi F, Andratschke N, Belka C, Bellut D, Dahele M, Josipovic M, Kroese TE, Mancosu P, Minniti G, Niyazi M, Ricardi U, Munck Af Rosenschold P, Sahgal A, Tsang Y, Verbakel WFAR, Guckenberger M. Efficacy and safety of SBRT for spine metastases: A systematic review and meta-analysis for preparation of an ESTRO practice guideline. Radiother Oncol 2024; 190:109969. [PMID: 37922993 DOI: 10.1016/j.radonc.2023.109969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND AND PURPOSE Advances in characterizing cancer biology and the growing availability of novel targeted agents and immune therapeutics have significantly changed the prognosis of many patients with metastatic disease. Palliative radiotherapy needs to adapt to these developments. In this study, we summarize the available evidence for stereotactic body radiotherapy (SBRT) in the treatment of spinal metastases. MATERIALS AND METHODS A systematic review and meta-analysis was performed using PRISMA methodology, including publications from January 2005 to September 2021, with the exception of the randomized phase III trial RTOG-0631 which was added in April 2023. Re-irradiation was excluded. For meta-analysis, a random-effects model was used to pool the data. Heterogeneity was assessed with the I2-test, assuming substantial and considerable as I2 > 50 % and I2 > 75 %, respectively. A p-value < 0.05 was considered statistically significant. RESULTS A total of 69 studies assessing the outcomes of 7236 metastases in 5736 patients were analyzed. SBRT for spine metastases showed high efficacy, with a pooled overall pain response rate of 83 % (95 % confidence interval [CI] 68 %-94 %), pooled complete pain response of 36 % (95 % CI: 20 %-53 %), and 1-year local control rate of 94 % (95 % CI: 86 %-99 %), although with high levels of heterogeneity among studies (I2 = 93 %, I2 = 86 %, and 86 %, respectively). Furthermore, SBRT was safe, with a pooled vertebral fracture rate of 9 % (95 % CI: 4 %-16 %), pooled radiation induced myelopathy rate of 0 % (95 % CI 0-2 %), and pooled pain flare rate of 6 % (95 % CI: 3 %-17 %), although with mixed levels of heterogeneity among the studies (I2 = 92 %, I2 = 0 %, and 95 %, respectively). Only 1.7 % of vertebral fractures required surgical stabilization. CONCLUSION Spine SBRT is characterized by a favorable efficacy and safety profile, providing durable results for pain control and disease control, which is particularly relevant for oligometastatic patients.
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Affiliation(s)
- R S Guninski
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - F Cuccia
- ARNAS Civico Hospital, Radiation Oncology Unit, Palermo, Italy
| | - F Alongi
- Advanced Radiation Department, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar-Verona, Italy. University of Brescia, Italy
| | - N Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - C Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany. German Cancer Consortium (DKTK), partner site Munich, Munich, Germany. Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - D Bellut
- University Hospital Zurich, University of Zurich, Department of Neurosurgery. Zurich, Switzerland
| | - M Dahele
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Radiation Oncology and Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, The Netherlands
| | - M Josipovic
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - T E Kroese
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - P Mancosu
- IRCCS Humanitas Research Hospital, Medical Physics Unit, Radiation Oncology department, via Manzoni 56, I-20089 Rozzano, Milan, Italy
| | - G Minniti
- Department of Radiological Sciences, Oncology and Anatomical PathologySapienza University of Rome, Rome; IRCCS Neuromed, Pozzilli, IS, Italy
| | - M Niyazi
- Department of Radiation Oncology, University hospital Tübingen, Tübingen, Germany
| | - U Ricardi
- University of Turin, Department of Oncology, Turin, Italy
| | - P Munck Af Rosenschold
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Medical Radiation Physics, Lund University, Lund, Sweden
| | - A Sahgal
- Odette Cancer Center of the Sunnybrook Health Sciences Center, Department of Radiation Oncology, Toronto, Canada
| | - Y Tsang
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Canada
| | - W F A R Verbakel
- Amsterdam University Medical Center, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - M Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Hannan R, McLaughlin MF, Pop LM, Pedrosa I, Kapur P, Garant A, Ahn C, Christie A, Zhu J, Wang T, Robles L, Durakoglugil D, Woldu S, Margulis V, Gahan J, Brugarolas J, Timmerman R, Cadeddu J. Phase 2 Trial of Stereotactic Ablative Radiotherapy for Patients with Primary Renal Cancer. Eur Urol 2023; 84:275-286. [PMID: 36898872 PMCID: PMC10440291 DOI: 10.1016/j.eururo.2023.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/17/2023] [Accepted: 02/15/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Most renal cell carcinomas (RCCs) are localized and managed by active surveillance, surgery, or minimally invasive techniques. Stereotactic ablative radiation (SAbR) may provide an innovative non-invasive alternative although prospective data are limited. OBJECTIVE To investigate whether SAbR is effective in the management of primary RCCs. DESIGN, SETTING, AND PARTICIPANTS Patients with biopsy-confirmed radiographically enlarging primary RCC (≤5 cm) were enrolled. SAbR was delivered in either three (12 Gy) or five (8 Gy) fractions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was local control (LC) defined as a reduction in tumor growth rate (compared with a benchmark of 4 mm/yr on active surveillance) and pathologic evidence of tumor response at 1 yr. Secondary endpoints included LC by the Response Evaluation Criteria in Solid Tumors (RECIST 1.1), safety, and preservation of kidney function. Exploratory tumor cell-enriched spatial protein and gene expression analysis were conducted on pre- and post-treatment biopsy samples. RESULTS AND LIMITATIONS Target accrual was reached with the enrollment of 16 ethnically diverse patients. Radiographic LC at 1 yr was observed in 94% of patients (15/16; 95% confidence interval: 70, 100), and this was accompanied by pathologic evidence of tumor response (hyalinization, necrosis, and reduced tumor cellularity) in all patients. By RECIST, 100% of the sites remained without progression at 1 yr. The median pretreatment growth rate was 0.8 cm/yr (interquartile range [IQR]: 0.3, 1.4), and the median post-treatment growth rate was 0.0 cm/yr (IQR: -0.4, 0.1, p < 0.002). Tumor cell viability decreased from 4.6% to 0.7% at 1 yr (p = 0.004). With a median follow-up of 36 mo for censored patients, the disease control rate was 94%. SAbR was well tolerated with no grade ≥2 (acute or late) toxicities. The average glomerular filtration rate declined from a baseline of 65.6 to 55.4 ml/min at 1 yr (p = 0.003). Spatial protein and gene expression analyses were consistent with the induction of cellular senescence by radiation. CONCLUSIONS This clinical trial adds to the growing body of evidence suggesting that SAbR is effective for primary RCC supporting its evaluation in comparative phase 3 clinical trials. PATIENT SUMMARY In this clinical trial, we investigated a noninvasive treatment option of stereotactic radiation therapy for the treatment of primary kidney cancer and found that it was safe and effective.
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Affiliation(s)
- Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Mark F McLaughlin
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA
| | - Laurentiu M Pop
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA
| | - Ivan Pedrosa
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Payal Kapur
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Pathology, University of Texas Southwestern, Dallas, TX, USA
| | - Aurelie Garant
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chul Ahn
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, University of Texas Southwestern, Dallas, TX, USA
| | - Alana Christie
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Zhu
- Quantitative Biomedical Research Center, Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tao Wang
- Quantitative Biomedical Research Center, Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Liliana Robles
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA
| | - Deniz Durakoglugil
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA
| | - Solomon Woldu
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Vitaly Margulis
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Jeffrey Gahan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - James Brugarolas
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffrey Cadeddu
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA
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Dason S, Lacuna K, Hannan R, Singer EA, Runcie K. State of the Art: Multidisciplinary Management of Oligometastatic Renal Cell Carcinoma. Am Soc Clin Oncol Educ Book 2023; 43:e390038. [PMID: 37253211 DOI: 10.1200/edbk_390038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Oligometastatic renal cell carcinoma (OM-RCC) refers to patients who have limited (typically up to 5) metastatic lesions. Although management principles may overlap, OM-RCC is distinguishable from oligoprogressive RCC, which describes progression of disease to a limited number of sites while receiving systemic therapy. Cytoreductive nephrectomy and metastasectomy are common surgical considerations in OM-RCC, and indications are discussed in this review. It is evident that stereotactic ablative radiotherapy is effective in RCC and is being applied increasingly in the oligometastatic setting. Finally, we will review advances in systemic therapy and the role of active surveillance before the initiation of systemic therapy.
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Affiliation(s)
- Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Kristine Lacuna
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, NY
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eric A. Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Karie Runcie
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, NY
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Stereotactic Body Radiotherapy for Kidney Cancer: Ready for Prime Time? Clin Oncol (R Coll Radiol) 2023; 35:163-176. [PMID: 36443137 DOI: 10.1016/j.clon.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
The standard treatment for renal cell carcinoma (RCC) is surgery. However, a number of patients will not be candidates for surgical treatment or will reject this therapeutic approach. Therefore, alternative approaches are required. Historically, radiotherapy has been considered an ineffective treatment for RCC due to the radioresistance of renal tumour cells to conventional fractionation and the increased rate of toxicity. Stereotactic body radiotherapy (SBRT) is a radiotherapy technique that provides a non-invasive ablative treatment with remarkable rates of local control in both primary tumours and metastases in several locations, with a low associated morbidity due to the highly conformal dose and the use of image-guided techniques. Current evidence shows that a higher dose per fraction, achieving a higher biological effective dose, can overcome the radioresistance of RCC cells. Therefore, SBRT, as well as the combination of SBRT and new emerging immune therapies, has a potential role in the local treatment of primary RCC and oligometastatic RCC patients.
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5
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Harel R, Kaisman-Elbaz T, Emch T, Elson P, Chao ST, Suh JH, Angelov L. A quantitative and comparative evaluation of stereotactic spine radiosurgery local control: proposing a consistent measurement methodology. Neurosurg Focus 2022; 53:E10. [DOI: 10.3171/2022.8.focus22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Stereotactic body radiotherapy (SBRT) is a precise and conformal treatment modality used in the management of metastatic spine tumors. Multiple studies have demonstrated its safety and efficacy for pain and tumor control. However, no uniform quantitative imaging methodology exists to evaluate response to treatment in these patients. This study presents radiographic local control rates post-SBRT, systematically compares measurements acquired according to WHO and Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and explores the relationship to patient outcome.
METHODS
The authors performed a retrospective review of prospectively obtained data from a cohort of 59 consecutive patients (81 metastatic isocenters) treated with SBRT and followed with serial MRI scans. Measurements were performed by a neuroradiologist blinded to the patients’ clinical course. Local control status was determined according to both WHO and RECIST measurements, and agreement between the measuring methodologies was calculated and reported.
RESULTS
Eighty-one isocenters (111 vertebral bodies) were treated with SBRT. The mean treatment dose was 13.96 Gy and the median follow-up duration was 10.8 months, during which 408 MRI scans were evaluated with both WHO and RECIST criteria for each scan point. Imaging demonstrated a mean unidimensional size decrease of 0.2 cm (p = 0.14) and a mean area size decrease of 0.99 cm2 (p = 0.03). Although 88% of the case classifications were concordant and the agreement was significant, WHO criteria were found to be more sensitive to tumor size change. The local control rates according to WHO and RECIST were 95% and 98%, respectively.
CONCLUSIONS
Although WHO volumetric measurements are admittedly superior for tumor size measurement, RECIST is simpler, reproducible, and for the first time is shown here to be comparable to WHO criteria. Thus, the application of RECIST methodology appears to be a suitable standard for evaluating post-SBRT treatment response. Moreover, using comprehensive and consistent measuring approaches, this study substantiates the efficacy of SBRT in the treatment of spine metastases.
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Affiliation(s)
- Ran Harel
- Department of Neurosurgery, Sheba Medical Center Affiliated to Tel-Aviv University, Tel-Aviv, Israel
| | - Tehila Kaisman-Elbaz
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - Todd Emch
- Imaging Institute, Cleveland Clinic, Cleveland
| | - Paul Elson
- Quantitative Health Sciences, Cleveland Clinic, Cleveland; and
| | - Samuel T Chao
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
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The Emerging Role of Radiation Therapy in Renal Cell Carcinoma. Cancers (Basel) 2022; 14:cancers14194693. [PMID: 36230615 PMCID: PMC9564246 DOI: 10.3390/cancers14194693] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Stereotactic ablative radiation therapy (SAbR) is a safe and effective local therapy for renal cell cancer (RCC) with emerging and evolving indications. In this review we provide an overview of the evidence to support SAbR for RCC in a variety of clinical settings. Abstract Advancements in radiation delivery technology have made it feasible to treat tumors with ablative radiation doses via stereotactic ablative radiation therapy (SAbR) at locations that were previously not possible. Renal cell cancer (RCC) was initially thought to be radioresistant, even considered toxic, in the era of conventional protracted course radiation. However, SAbR has been demonstrated to be safe and effective in providing local control to both primary and metastatic RCC by using ablative radiation doses. SAbR can be integrated with other local and systemic therapies to provide optimal management of RCC patients. We will discuss the rationale and available evidence for the integration and sequencing of SAbR with local and systemic therapies for RCC.
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7
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Dibs K, Blakaj DM, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Lee H, Grecula J, Raval RR, Mendel E, Scharschmidt T, Lonser R, Chakravarti A, Elder JB, Palmer JD. Spine Stereotactic Body Radiotherapy to Three or More Contiguous Vertebral Levels. Front Oncol 2022; 12:912804. [PMID: 35756685 PMCID: PMC9213679 DOI: 10.3389/fonc.2022.912804] [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: 04/04/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background With survival improving in many metastatic malignancies, spine metastases have increasingly become a source of significant morbidity; achieving durable local control (LC) is critical. Stereotactic body radiotherapy (SBRT) may offer improved LC and/or symptom palliation. However, due to setup concerns, SBRT is infrequently offered to patients with ≥3 contiguous involved levels. Because data are limited, we sought to evaluate the feasibility, toxicity, and cancer control outcomes of spine SBRT delivered to ≥3 contiguous levels. Methods We retrospectively identified all SBRT courses delivered between 2013 and 2019 at a tertiary care institution for postoperative or intact spine metastases. Radiotherapy was delivered to 14-35 Gy in 1-5 fractions. Patients were stratified by whether they received SBRT to 1-2 or ≥3 contiguous levels. The primary endpoint was 1-year LC and was compared between groups. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity was assessed. In-depth dosimetric data were collected. Results Overall, 165 patients with 194 SBRT courses were identified [54% were men, median age was 61 years, 93% had Karnofsky Performance Status (KPS) ≥70, and median follow-up was 15 months]. One hundred thirteen patients (68%) received treatment to 1-2 and 52 to 3-7 (32%) levels. The 1-year LC was 88% (89% for 1-2 levels vs. 84% for ≥3 levels, p = 0.747). On multivariate analysis, uncontrolled systemic disease was associated with inferior LC for patients with ≥3 treated levels. No other demographic, disease, treatment, or dosimetric variables achieved significance. Rates of new/progressive fracture were equivalent (8% vs. 9.5%, p = 0.839). There were no radiation-induced myelopathy or grade 3+ acute or late toxicities in either group. Coverage of ≥95% of the planning target volume with ≥95% prescription dose was similar between groups (96% 1-2 levels vs. 89% ≥3 levels, p = 0.078). Conclusions For patients with ≥3 contiguous involved levels, spine SBRT is feasible and may offer excellent LC without significant toxicity. Prospective evaluation is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N Prasad
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C Bourekas
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S Marras
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Hyeri Lee
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Arnab Chakravarti
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
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Guo L, Ke L, Zeng Z, Yuan C, Wu Z, Chen L, Lu L. Stereotactic body radiotherapy for spinal metastases: a review. Med Oncol 2022; 39:103. [DOI: 10.1007/s12032-021-01613-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023]
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9
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The role of stereotactic body radiation therapy and its integration with systemic therapies in metastatic kidney cancer: a multicenter study on behalf of the AIRO (Italian Association of Radiotherapy and Clinical Oncology) genitourinary study group. Clin Exp Metastasis 2021; 38:527-537. [PMID: 34748125 DOI: 10.1007/s10585-021-10131-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
Although systemic therapy represents the standard of care for polymetastatic kidney cancer, stereotactic body radiation therapy (SBRT) may play a relevant role in the oligometastatic setting. We conducted a multicenter study including oligometastatic kidney cancer treated with SBRT. We retrospectively analyzed 207 patients who underwent 245 SBRT treatments on 385 lesions, including 165 (42.9%) oligorecurrent (OR) and 220 (57.1%) oligoprogressive (OP) lesions. Most common sites were lung (30.9%) for OR group, and bone (32.7%) for OP group. Among 78 (31.8%) patients receiving concomitant systemic therapy, sunitinib (61.5%) and pazopanib (15.4%) were the most common for OR patients, while sunitinib (49.2%) and nivolumab (20.0%) for OP patients. End points were local control (LC), progression free survival (PFS), overall survival (OS), time to next systemic therapy (TTNS) and toxicity. Median follow-up was 18.6 months. 1, 2 and 3-year LC rates were 89.4%, 80.1% and 76.6% in OR patients, and 82.7%, 76.9% and 64.3% in those with OP, respectively. LC for OP group was influenced by clear cell histology (p = 0.000), total number of lesions (p = 0.004), systemic therapy during SBRT (p = 0.012), and SBRT dose (p = 0.012). Median PFS was 37.9 months. 1, 2- and 3-year OS was 92.7%, 86.4% and 81.8%, respectively. Median TTNS was 15.8 months for OR patients, and 13.9 months for OP patients. No grade 3 or higher toxicities were reported for both groups. SBRT may be considered an effective safe option in the multidisciplinary management of both OR and OP metastases from kidney cancer.
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10
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Lee MY, Ouyang Z, LaHurd D, Xia P, Chao ST, Suh JH, Angelov L, Magnelli A, Balik S, Balagamwala EH. A Volumetric Dosimetry Analysis of Vertebral Body Fracture Risk after Single Fraction Spine Stereotactic Body Radiotherapy. Pract Radiat Oncol 2021; 11:480-487. [PMID: 34303836 DOI: 10.1016/j.prro.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Vertebral compression fractures (VCF) are a common and severe complication of spine stereotactic body radiotherapy (SBRT). We sought to analyze how volumetric dosimetry and clinical factors were associated with the risk of VCF. METHODS AND MATERIALS We evaluated 173 spinal segments undergoing single fraction SBRT in 85 patients from a retrospective database. Vertebral bodies were contoured and dosimetric values were calculated. Competing risk models were used to evaluate the effect of clinical and dosimetry variables on the risk of VCF. RESULTS Our primary endpoint was development of a post SBRT VCF. New or progressive fractures were noted in 21/173 vertebrae (12.1%); the median time to fracture was 322 days. Median follow up time was 426 days. Upon multivariable analysis, the percentages of vertebral body volume receiving >20 Gy and >24 Gy were significantly associated with increased risk of VCF (HR: 1.036, 1.104; p = 0.029, 0.044 respectively). No other patient or treatment factors were found to be significant on multivariable analysis. Sensitivity analysis revealed that the percentages of vertebral body volume receiving >20 Gy and >24 Gy required to obtain 90% sensitivity for predicting vertebral body fracture were 24% and 0%, respectively. CONCLUSIONS VCF is a common complication after SBRT with a crude incidence of 12.1%. Treatment plans that permit higher volumes receiving doses >20 Gy and >24 Gy to the vertebral body are associated with increased risk of VCF. In order to achieve 90% sensitivity for predicting VCF post SBRT, the percentage of vertebral volume receiving >20 Gy should be <24% and maximum point dose should be <24 Gy. These results may help guide clinicians when evaluating spine SBRT treatment plans to minimize the risk of developing post-treatment VCF.
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Affiliation(s)
- Maxwell Y Lee
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Zi Ouyang
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Danielle LaHurd
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Ping Xia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Lilyana Angelov
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Anthony Magnelli
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Salim Balik
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Ehsan H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
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11
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Abstract
A significant proportion of metastatic renal cell carcinoma (mRCC) patients present with oligometastatic disease. Retrospective and limited prospective data suggests that a subgroup of patients with oligometastatic mRCC benefits from aggressive local therapy. With the emerging data of high local control efficacy with low toxicity of stereotactic ablative radiation (SAbR) for both CNS and extra-cranial mRCC, SAbR may play a critical role in the multi-modality management of mRCC patients with oligometastatic disease. In addition to local control benefit, the benefit of SAbR in this patient population can range from longitudinal disease control, maintaining quality of life, deferring systemic therapy, immune-modulation and even improving survival. A review of the retrospective data suggests that SAbR benefits oligometastatic mRCC patients with metachronous metastases, and perhaps those with indolent biology. Large prospective trials are indicated to successfully integrate SAbR of oligometastatic mRCC with the available systemic therapies to harness the optimal benefit of SAbR for this patient population.
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Affiliation(s)
- Sean All
- Department of Radiation Oncology, University of Texas at Southwestern Medical Center, Dallas, TX
| | - Aurelie Garant
- Department of Radiation Oncology, University of Texas at Southwestern Medical Center, Dallas, TX
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas at Southwestern Medical Center, Dallas, TX.
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12
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The Reintroduction of Radiotherapy Into the Integrated Management of Kidney Cancer. ACTA ACUST UNITED AC 2020; 26:448-459. [PMID: 32947313 DOI: 10.1097/ppo.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of renal cell carcinoma (RCC) has been increasing, with a moderate subgroup of individuals who later develop metastatic disease. Historically, metastatic RCC has been managed with systemic therapy because RCC was believed to be radioresistant. Local therapies, such as stereotactic body radiation therapy, also known as stereotactic ablative radiotherapy, which utilize focused high-dose-rate radiation delivered over a limited number of treatments, have been successful in controlling local disease and, in some cases, extending survival in patients with intracranial and extracranial metastatic RCC. Stereotactic ablative radiotherapy is highly effective in treating intact disease when patients are not surgical candidates. Stereotactic ablative radiotherapy is well tolerated when used in conjunction with systemic therapy such as tyrosine kinase inhibitors and immune checkpoint inhibitors. These successes have prompted investigators to evaluate the efficacy of stereotactic body radiation therapy in novel settings such as neoadjuvant treatment of advanced RCC with tumor thrombus and oligometastatic/oligoprogressive disease states.
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13
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Spencer KL, van der Velden JM, Wong E, Seravalli E, Sahgal A, Chow E, Verlaan JJ, Verkooijen HM, van der Linden YM. Systematic Review of the Role of Stereotactic Radiotherapy for Bone Metastases. J Natl Cancer Inst 2020; 111:1023-1032. [PMID: 31119273 PMCID: PMC6792073 DOI: 10.1093/jnci/djz101] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/07/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background Stereotactic radiotherapy (SBRT) might improve pain and local control in patients with bone metastases compared to conventional radiotherapy, although an overall estimate of these outcomes is currently unknown. Methods A systematic review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Embase, and Cochrane databases were systematically searched to identify studies reporting pain response and local control among patients with bone metastases from solid-organ tumors who underwent SBRT in 1–6 fractions. All studies prior to April 15, 2017, were included. Study quality was assessed by predefined criteria, and pain response and local control rates were extracted. Results A total of 2619 studies were screened; 57 were included (reporting outcomes for 3995 patients) of which 38 reported pain response and 45 local control rates. Local control rates were high with pain response rates above those previously reported for conventional radiotherapy. Marked heterogeneity in study populations and delivered treatments were identified such that quantitative synthesis was not appropriate. Reported toxicity was limited. Of the pain response studies, 73.7% used a retrospective cohort design and only 10.5% used the international consensus endpoint definitions of pain response. The median survival within the included studies ranged from 8 to 30.4 months, suggesting a high risk of selection bias in the included observational studies. Conclusions This review demonstrates the potential benefit of SBRT over conventional palliative radiotherapy in improving pain due to bone metastases. Given the methodological limitations of the published literature, however, large randomized trials are now urgently required to better quantify this benefit.
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Affiliation(s)
- Katie L Spencer
- Correspondence to: Katie Spencer, MB, BChir, FRCR, Cancer Epidemiology Group, Level 11 Worsley Building, Clarendon Way, University of Leeds, Leeds LS2 9NL, West Yorkshire, UK (e-mail: )
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14
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Miccio JA, Oladeru OT, Jun Ma S, Johung KL. Radiation Therapy for Patients with Advanced Renal Cell Carcinoma. Urol Clin North Am 2020; 47:399-411. [PMID: 32600541 DOI: 10.1016/j.ucl.2020.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stereotactic radiosurgery and stereotactic body radiation therapy (SBRT) have led to a resurgence of the use of radiotherapy in the management of advanced renal cell carcinoma (RCC). These techniques provide excellent local control and palliation of metastatic sites of disease with minimal toxicity. Additionally, SBRT to the primary tumor may be efficacious and well tolerated in select patients that are not surgical candidates. Emerging data suggest that SBRT may potentiate the immune response, and current and future study will evaluate if SBRT can improve survival outcomes in patients with metastatic RCC.
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Affiliation(s)
- Joseph A Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA
| | | | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA.
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15
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Singh R, Lehrer EJ, Dahshan B, Palmer JD, Sahgal A, Gerszten PC, Zaorsky NG, Trifiletti DM. Single fraction radiosurgery, fractionated radiosurgery, and conventional radiotherapy for spinal oligometastasis (SAFFRON): A systematic review and meta-analysis. Radiother Oncol 2020; 146:76-89. [PMID: 32114269 DOI: 10.1016/j.radonc.2020.01.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE To perform a systematic review/meta-analysis of outcomes for patients with spinal metastases treated with stereotactic radiosurgery (SRS) (either single-fraction (SF-SRS) or multiple-fraction (MF-SRS)) or conventional radiotherapy (RT). MATERIALS AND METHODS Thirty-seven studies were identified. Primary outcomes were 1-year local control (LC) and acute/late grade 3-5 toxicities (including vertebral compression fractures (VCF)). Weighted random effects meta-analyses using the DerSimonian and Laird methods and meta-regressions were conducted to characterize and compare effect sizes. Mixed effects regression models were used in dose analyses. RESULTS A total of 3237 patients with 4911 lesions were included; 43.8%, 19.7%, and 36.5% of lesions received SF-SRS, MF-SRS, or RT, respectively. SF-SRS resulted in improved 1-year LC (92.9% (95% CI: 86.4-97.4%); p = 0.007) compared to RT (81.0% (95% CI: 69.2-90.5%)) with no difference between MF-SRS (82.1%; p = 0.86) and RT. On subgroup analysis of de novo metastases, superior 1-year LC following SF-SRS (95.5% (95% CI: 87.4-99.6%)) was maintained compared to RT (83.6% (95% CI: 70.4-93.5%); p = 0.007). A 4.7% increase in LC was noted for each 10 Gy10 increase in biologically effective dose (BED10, assuming an alpha/beta = 10) with SRS (p < 0.001). No difference in toxicities were found between SF-SRS (0.4%), MF-SRS (0.2%), or RT (0%). Higher VCF rates were noted following SF-SRS (19.5%) vs. MF-SRS (9.6%; p = 0.039)) with no correlation between dose and VCF rates. CONCLUSION SF-SRS resulted in superior LC with a roughly 5% LC benefit for every 10 Gy10 increase in BED10 with higher VCF rates compared to MF-SRS. If LC is the goal of treatment, then SRS may be a preferred treatment modality. However, these results are hypothesis-generating, and prospective randomized clinical trials are indicated to definitively address the question of whether SRS results in improved LC compared to RT.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Basem Dahshan
- Department of Radiation Oncology, West Virginia University School of Medicine, Morgantown, USA
| | - Joshua D Palmer
- Department of Radiation Oncology and Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Hospital, Toronto, Canada
| | - Peter C Gerszten
- Departments of Neurosurgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA
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16
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Beeler WH, Speth KA, Broderick MT, Jairath NK, Ballouz D, Gharzai LA, Jackson WC, Kim MM, Owen D, Szerlip NJ, Paradis KC, Spratt DE. Local Control and Toxicity of Multilevel Spine Stereotactic Body Radiotherapy. Neurosurgery 2020; 86:E164-E172. [PMID: 31541240 DOI: 10.1093/neuros/nyz348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/16/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Spine stereotactic body radiotherapy (sSBRT) is commonly limited to 1 or 2 vertebral levels given a paucity of efficacy and toxicity data when more than 2 levels are treated. OBJECTIVE To prove our hypothesis that multilevel sSBRT could provide similar rates of local control (LC) (primary endpoint) and toxicity as single-level treatment using the same clinical target, planning target, and planning organ-at-risk volumes. METHODS We analyzed consecutive cases of sSBRT treated from 2013 to 2017. Time-to-event outcomes for single-level and multilevel cases were compared using mixed effect Cox models and differences in toxicity rates were evaluated using linear mixed effect models. All models incorporate a patient-level random intercept to account for any within-patient correlation across cases. RESULTS There were 101 single-level and 84 multilevel sSBRT cases (2-7 continuous vertebral levels). One-year LC was 95% vs 85%, respectively. After adjusting for baseline covariates, dose delivered, and accounting for within-patient correlation, there was no significant difference in time to local failure (hazard ratio, HR 1.79 [0.59-5.4]; P = .30). Pain improved in 83.5% of the 139 initially symptomatic tumors. There were no significant differences in grade 2+ acute or late toxicities between single-level and multilevel sSBRT. CONCLUSION With rigorous patient immobilization, quality assurance, and image guidance, multilevel sSBRT provides high rates of LC, similar to single-level treatment, without need for larger planning volume margins. Efforts to improve prognostication and case selection for multilevel sSBRT are warranted to ensure that the benefits of improved LC over palliative radiation are justified.
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Affiliation(s)
- Whitney H Beeler
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kelly A Speth
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | - Neil K Jairath
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Dena Ballouz
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Kelly C Paradis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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17
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Ouyang Z, LaHurd DV, Balagamwala EH, Chao ST, Suh JH, Xia P. Treatment planning of VMAT and step-and-shoot IMRT delivery techniques for single fraction spine SBRT: An intercomparative dosimetric analysis and phantom-based quality assurance measurements. J Appl Clin Med Phys 2019; 21:62-68. [PMID: 31821729 PMCID: PMC6964769 DOI: 10.1002/acm2.12788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To retrospectively compare clinically treated step-and-shoot intensity modulated radiotherapy (ssIMRT) and volumetric modulated arc therapy (VMAT) spine stereotactic body radiotherapy (SBRT) plans in dosimetric endpoints and pretreatment quality assurance (QA) measurements. METHODS Five single fraction spine SBRT (18 Gy) cases - including one cervical, two thoracic, and two lumbar spines - clinically treated with ssIMRT were replanned with VMAT, and all plans were delivered to a phantom for comparing plan quality and delivery accuracy. Furthermore, we analyzed 98 clinically treated plans (18 Gy single fraction), including 34 ssIMRT and 29 VMAT for cervical/thoracic spine, and 19 ssIMRT and 16 VMAT for lumbar spine. The conformality index (CI) and homogeneity index (HI) were calculated, and QA measurement records were compared. For the spinal cord/cauda equina, the maximum dose to 0.03 cc (D0.03cc ) and volume receiving 10 or 12 Gy (V10Gy /V12Gy ) were recorded. Statistical significance was tested with the Mann-Whitney U test. RESULTS Compared to ssIMRT, replanned VMAT plans had lower V10Gy /V12Gy and D0.03cc to the spinal cord/cauda equina in all five cases, and better CI in three out of five cases. The VMAT replans were slightly less homogeneous than those of ssIMRT plans. Both modalities passed IMRT QA with >95% passing rate with (3%, 3 mm) gamma criteria. With the 98 clinical cases, for cervical/thoracic ssIMRT and VMAT plans, the median V10Gy of spinal cord was 4.15% and 1.85% (P = 0.004); the median D0.03cc of spinal cord was 10.85 Gy and 10.10 Gy (P = 0.032); the median CI was 1.28 and 1.08 (P = 0.009); the median HI were 1.34 and 1.33 (P = 0.697), respectively. For lumbar spine, no significant dosimetric endpoint differences were observed. The two modalities were comparable in delivery accuracy. CONCLUSION From our clinically treated plans, we found that VMAT plans provided better dosimetric quality and comparable delivery accuracy when compared to ssIMRT for single fraction spine SBRT.
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Affiliation(s)
- Zi Ouyang
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Danielle V LaHurd
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ehsan H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ping Xia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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18
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Combination with Stereotactic Body Radiotherapy Offers a Promising Strategy to Overcome Resistance to Immunotherapy in Advanced Renal Cell Cancer. JOURNAL OF ONCOLOGY 2019; 2019:1483406. [PMID: 31871454 PMCID: PMC6906880 DOI: 10.1155/2019/1483406] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/24/2019] [Accepted: 10/26/2019] [Indexed: 02/05/2023]
Abstract
Immunotherapy for renal cell cancer (RCC) has witnessed several developments for more than two decades. Checkpoint inhibitors, including anti-CTLA-4 and anti-PD-1/PD-L1 blockers, have changed the treatment landscape for patients with advanced RCC in the past 3 years. Despite these advances, more than 55% RCC patients become resistant to different immunotherapies without other treatment combination. Among various attempts at overcoming resistance to immunotherapy, stereotactic body radiotherapy (SBRT) has been found to potentiate the activity of immunotherapy agents through several potential mechanisms, including normalization of microvessels to alleviate tumor hypoxia, improvement in efficient delivery of drugs, abundant neoantigen exposure, and recruitment of antitumor immune cells to alter the immunosuppressive tumor microenvironment. Preclinical studies and clinical case reports have predicted that the combination of SBRT, an immunotherapy, may lead to remarkable results. This review aims to provide the biological basis for the feasibility of combining SBRT to overcome immunotherapy resistance and to review the currently available clinical evidence of this combination therapy in patients with advanced RCC.
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19
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Loi M, Nuyttens JJ, Desideri I, Greto D, Livi L. Single-Fraction Radiotherapy (SFRT) For Bone Metastases: Patient Selection And Perspectives. Cancer Manag Res 2019; 11:9397-9408. [PMID: 31807069 PMCID: PMC6842277 DOI: 10.2147/cmar.s186630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/22/2019] [Indexed: 01/02/2023] Open
Abstract
Bone metastases are a frequent and important source of morbidity in cancer patients. Stereotactic body radiation therapy (SBRT) is an established treatment option for local control and pain relief of bone metastases, and it is increasingly used as upfront treatment, postoperative consolidation or salvage treatment after prior RT. However, heterogeneity of dose schedules described in literature represents a severe limitation in the definition of the role of SBRT as a standard of care. No consensus is available on the use of single versus multiple fraction SBRT for bone metastases. Advantages of single-fraction SBRT include shorter overall duration of treatment, absence of inter-fraction uncertainty, improved compliance, theoretical increased efficacy, and lower costs. However, caution has been advised due to reports of severe late toxicities, in particular, vertebral collapse fracture (VCF). The aim of this paper is to review dose fractionation and indications for the management of bone metastases using SBRT.
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Affiliation(s)
- Mauro Loi
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Joost J Nuyttens
- Radiotherapy Department, Erasmus MC Cancer Center, Rotterdam, The Netherlands
| | - Isacco Desideri
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Daniela Greto
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Radiotherapy Department, University of Florence, Florence, Italy
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20
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Stereotactic ablative radiation therapy for oligometastatic renal cell carcinoma (SABR ORCA): a meta-analysis of 28 studies. Eur Urol Oncol 2019; 2:515-523. [DOI: 10.1016/j.euo.2019.05.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 12/24/2022]
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21
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Guida A, Albiges L. Traitement des métastases osseuses du cancer du rein. Bull Cancer 2019; 105 Suppl 3:S268-S279. [PMID: 30595156 DOI: 10.1016/s0007-4551(18)30382-5] [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: 11/17/2022]
Abstract
TREATING PATIENTS WITH BONE METASTASES FROM RENAL CELL CARCINOMA Bone metastases (BMs) are common and cause morbidity in cancer patients. One third of metastatic renal cancer (mRCC) patients present metastatic disease to the bone. BMs cause severe complications such as fracture, spinal cord compression and pain requiring surgery or radiotherapy. Hypercalcaemia is a common feature in mRCC as well as an established poor prognosis factor. BMs impact negatively on prognosis and affect quality of life. Correct management of BMs from RCC requires a multimodal evaluation to optimize care and quality of life. In this review, we discuss current evidences on the role of systemic treatments in BMs management, bone-targeting agents benefits in skeletal-related events prevention and local therapeutic approaches to BM in mRCC. Define prognosis of systemic disease and identify the main goal of treatment are crucial for the selection of the best strategy.
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Affiliation(s)
| | - Laurence Albiges
- Département d'oncologie médicale, Gustave Roussy, Villejuif, France..
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22
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Finkelstein S, Raman S, Van Der Velden J, Zhang L, Tan C, Dhillon A, Tonolete F, Chiu N, Probyn L, McDonald R, Sahgal A, Chow E, Chin L. Changes in Volume and Density Parameters Measured on Computed Tomography Images Following Stereotactic Body Radiation Therapy of Nonspine Bone Metastases. Technol Cancer Res Treat 2019; 18:1533033819853532. [PMID: 31319776 PMCID: PMC6640058 DOI: 10.1177/1533033819853532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Volumetric and density parameters measured from computed tomography scans were investigated for evaluating treatment response of nonspine bone lesions following stereotactic body radiation therapy. Methods: Twenty-three patients treated with stereotactic body radiation therapy to nonspine bone metastases with pre- and post-treatment radiological follow-up with computed tomography imaging were identified in a retrospective review. An expert radiologist classified 26 lesions by type (lytic, sclerotic) and by response. Two independent radiation oncologists created separate contours of the bone and soft tissue lesion volumes. Density and volume were assessed relative to baseline values. Results: For bone-only lesions, all lesions designated as local control decreased in volume or remained within 20% of baseline volumes. Lytic lesions classified as progressive disease exhibited much larger volume increases. Lytic bone lesions showed indications of remineralization with some exhibiting immediate increases in density (1-6 months) and others decreasing initially then increasing back toward baseline between 7 and 12 months. The majority of sclerotic lesions, all classified as local control, decreased slightly in both volume and density. Lesions with both soft tissue and boney involvement resulted in contradictory results when employing both radiological and size parameters for assessing treatment response. Classification was dominated by changes in soft tissue volume, despite associated volume or density changes in the corresponding boney lesion. In contrast, when soft tissue volume changes were minimal (<20% increase), classification appeared to be related primarily to density changes and not bone volume. Conclusions: Volume and density changes show promise as quantitative parameters for classifying treatment responses of nonspine osseous lesions. Further work is required for clarifying how these metrics can be applied to lesions with both boney and soft tissue components.
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Affiliation(s)
- Samuel Finkelstein
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Raman
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joanne Van Der Velden
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Liying Zhang
- 3 Department of Medical Physics, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn Tan
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Amanpreet Dhillon
- 4 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Frances Tonolete
- 4 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Chiu
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Linda Probyn
- 4 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rachel McDonald
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- 1 Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lee Chin
- 3 Department of Medical Physics, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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23
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Guida A, Escudier B, Albiges L. Treating patients with renal cell carcinoma and bone metastases. Expert Rev Anticancer Ther 2018; 18:1135-1143. [PMID: 30183421 DOI: 10.1080/14737140.2018.1520097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Bone metastases (BMs) are common and cause morbidity in cancer patients. This review focuses on evidence in BMs from metastatic renal cell carcinoma (mRCC) management and discusses current evidence on the role of systemic treatments in BMs management, bone-targeting agents' benefits in skeletal-related events prevention and local therapeutic approaches to BM in mRCC. Areas covered: A comprehensive review of literature concerning incidence, prognosis, and therapeutic approaches of BMs was performed, focusing on the latest emerging evidence in management of BMs from mRCC. Expert commentary: One-third of mRCC patients present metastatic disease to the bone. BMs impact negatively the prognosis and decrease quality of life. Adequate management of BMs from RCC requires a multimodal evaluation to optimize care and quality of life. Both tyrosine-kinase inhibitors and immunotherapy may be effective in BMs treatment. BMs cause severe complications such as fracture, spinal cord compression, and pain requiring surgery or radiotherapy and several local approaches are available to achieve a local control of the disease. Defining prognosis of systemic disease and identifying the main goal of treatment is crucial for the selection of the best strategy.
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Affiliation(s)
- Annalisa Guida
- a Department of Medical Oncology , Gustave Roussy , Villejuif , France.,b Department of Biomedical, Metabolic and Neural Sciences , University of Modena and Reggio Emilia , Modena , Italy
| | - Bernard Escudier
- a Department of Medical Oncology , Gustave Roussy , Villejuif , France
| | - Laurence Albiges
- a Department of Medical Oncology , Gustave Roussy , Villejuif , France
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24
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Goodwin CR, Ahmed AK, Boone C, Abu-Bonsrah N, Xu R, Germscheid N, Fourney DR, Clarke M, Laufer I, Fisher CG, Bettegowda C, Sciubba DM. The Challenges of Renal Cell Carcinoma Metastatic to the Spine: A Systematic Review of Survival and Treatment. Global Spine J 2018; 8:517-526. [PMID: 30258759 PMCID: PMC6149047 DOI: 10.1177/2192568217737777] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The objective of this systematic review was to answer 2 key questions: (1) What is the clinical presentation and probability of symptomatic improvement following treatment for patients with renal cell carcinoma (RCC) of the spine? (2) What is the overall survival of patients diagnosed with spinal metastases from RCC? METHODS A literature review was performed to identify articles that reported on survival, clinical outcomes, and/or prognostic factors in the RCC population with spinal metastases from 1986 to 2016. RESULTS Forty-eight articles (807 patients) were included. The Fuhrman Nuclear Grade has been significantly associated with survival in previous studies but was underpowered in the current study. The Memorial Sloan-Kettering Cancer Center Score (MSKCC/Motzer) was also underpowered in the current study. From the time of spinal metastasis, the mean and median survival for patients with previously diagnosed primary RCC was 8.75 and 11.7 months, respectively, whereas synchronously diagnosed patients (primary RCC and spinal metastasis) had a mean and median survival of 6.75 and 11 months, respectively. Patients with a "low" (0-8), "intermediate" (9-11), or "high" (12-15) revised Tokuhashi score at initial presentation had a median survival of 5.4, 11.7, and 32.9 months, respectively. CONCLUSION Patients with either a synchronous or latent diagnosis of RCC survived greater than 6 months from the time of presentation. Initial Furhman grade, Tokuhashi score, and MSKCC/Motzer can be useful tools in informing patient-specific prognosis for those with metastatic RCC of the spine.
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Affiliation(s)
- C. Rory Goodwin
- Duke University Medical Center, Durham, NC, USA,These authors contributed equally to this manuscript.,C. Rory Goodwin, Department of Neurosurgery,
Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA.
| | - A. Karim Ahmed
- The Johns Hopkins University School of Medicine, Baltimore, MD,
USA,These authors contributed equally to this manuscript
| | - Christine Boone
- The Johns Hopkins University School of Medicine, Baltimore, MD,
USA,These authors contributed equally to this manuscript
| | | | - Risheng Xu
- The Johns Hopkins University School of Medicine, Baltimore, MD,
USA
| | | | | | | | - Ilya Laufer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Charles G. Fisher
- University of British Columbia, Vancouver, British Columbia,
Canada,Vancouver General Hospital, Vancouver, British Columbia,
Canada
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25
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Verbiest A, De Meerleer G, Albersen M, Beuselinck B. Non-Surgical Ablative Treatment of Distant Extracranial Metastases for Renal Cell Carcinoma: A Systematic Review. KIDNEY CANCER 2018. [DOI: 10.3233/kca-170023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Annelies Verbiest
- Department of Oncology, Laboratory of Experimental Oncology, KU Leuven, Leuven, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiotherapy, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Benoit Beuselinck
- Department of Oncology, Laboratory of Experimental Oncology, KU Leuven, Leuven, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
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26
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Recursive partitioning analysis is predictive of overall survival for patients undergoing spine stereotactic radiosurgery. J Neurooncol 2018; 137:289-293. [DOI: 10.1007/s11060-017-2716-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/13/2017] [Indexed: 12/28/2022]
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27
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Radiosurgery for Treatment of Renal Cell Metastases to Spine: A Systematic Review of the Literature. World Neurosurg 2018; 109:e502-e509. [DOI: 10.1016/j.wneu.2017.10.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 09/30/2017] [Accepted: 10/03/2017] [Indexed: 12/25/2022]
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28
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Kim N, Lee H, Kim JS, Baek JG, Lee CG, Chang SK, Koom WS. Clinical outcomes of multileaf collimator-based CyberKnife for spine stereotactic body radiation therapy. Br J Radiol 2017; 90:20170523. [PMID: 28869401 PMCID: PMC5963365 DOI: 10.1259/bjr.20170523] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/20/2017] [Accepted: 08/23/2017] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Stereotactic body radiotherapy (SBRT) for spinal metastases is becoming a prevalent therapeutic option. We aimed to evaluate the clinical feasibility and outcomes of the recently developed multileaf collimator (MLC)-based CyberKnife (CK-M) for spine SBRT. METHODS We reviewed 119 patients of 144 cases with 229 lesions treated with CK between November 2014 and March 2016. The lesion features, dosimetric parameters and clinical outcomes were compared between fixed cone collimator based CK (CK-F) and CK-M. RESULTS Of 144 cases, 78 and 66 were treated with CK-F and CK-M, respectively. CK-M achieved an adequate target volume coverage that was comparable with CK-F (median 92 vs 90%; p = 0.03) even in larger targets (median 64.2 vs 46.7 cm3; p = 0.01), respectively. CK-M showed an improvement in the gradient index (p < 0.001) and no difference in conformity (p = 0.16). With CK-M, the median beam delivery time was significantly reduced by 30% (to 34 vs 48 min; p < 0.001). CK-M showed 1 year local control rates that were comparable to CK-F (77 vs 78%, respectively; p = 0.83). CONCLUSION CK-M exhibits dosimetric data and local control that are comparable with CK-F, but with significant treatment time reduction. CK-M could be widely used in spine SBRT. Advances in knowledge: Given the recently developed MLC in CK, we aimed to evaluate the clinical feasibility and outcomes of MLC compared with fixed cone-based CK. MLC showed equivalent plan quality and significant treatment time reduction with comparable radiological control. We report here MLC as an effective and tolerable treatment option in CK.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ho Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Geal Baek
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sei Kyung Chang
- Department of Radiation Oncology, CHA Bundang Medical Center, CHA University, Seongnam-si, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
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29
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Miller JA, Balagamwala EH, Berriochoa CA, Angelov L, Suh JH, Benzel EC, Mohammadi AM, Emch T, Magnelli A, Godley A, Qi P, Chao ST. The impact of decompression with instrumentation on local failure following spine stereotactic radiosurgery. J Neurosurg Spine 2017; 27:436-443. [DOI: 10.3171/2017.3.spine161015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVESpine stereotactic radiosurgery (SRS) is a safe and effective treatment for spinal metastases. However, it is unknown whether this highly conformal radiation technique is suitable at instrumented sites given the potential for microscopic disease seeding. The authors hypothesized that spinal decompression with instrumentation is not associated with increased local failure (LF) following SRS.METHODSA 2:1 propensity-matched retrospective cohort study of patients undergoing SRS for spinal metastasis was conducted. Patients with less than 1 month of radiographic follow-up were excluded. Each SRS treatment with spinal decompression and instrumentation was propensity matched to 2 controls without decompression or instrumentation on the basis of demographic, disease-related, dosimetric, and treatment-site characteristics. Standardized differences were used to assess for balance between matched cohorts.The primary outcome was the 12-month cumulative incidence of LF, with death as a competing risk. Lesions demonstrating any in-field progression were considered LFs. Secondary outcomes of interest were post-SRS pain flare, vertebral compression fracture, instrumentation failure, and any Grade ≥ 3 toxicity. Cumulative incidences analysis was used to estimate LF in each cohort, which were compared via Gray’s test. Multivariate competing-risks regression was then used to adjust for prespecified covariates.RESULTSOf 650 candidates for the control group, 166 were propensity matched to 83 patients with instrumentation. Baseline characteristics were well balanced. The median prescription dose was 16 Gy in each cohort. The 12-month cumulative incidence of LF was not statistically significantly different between cohorts (22.8% [instrumentation] vs 15.8% [control], p = 0.25). After adjusting for the prespecified covariates in a multivariate competing-risks model, decompression with instrumentation did not contribute to a greater risk of LF (HR 1.21, 95% CI 0.74–1.98, p = 0.45). The incidences of post-SRS pain flare (11% vs 14%, p = 0.55), vertebral compression fracture (12% vs 22%, p = 0.04), and Grade ≥ 3 toxicity (1% vs 1%, p = 1.00) were not increased at instrumented sites. No instrumentation failures were observed.CONCLUSIONSIn this propensity-matched analysis, LF and toxicity were similar among cohorts, suggesting that decompression with instrumentation does not significantly impact the efficacy or safety of spine SRS. Accordingly, spinal instrumentation may not be a contraindication to SRS. Future studies comparing SRS to conventional radiotherapy at instrumented sites in matched populations are warranted.
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Affiliation(s)
- Jacob A. Miller
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
| | | | | | - Lilyana Angelov
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
- 4Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - John H. Suh
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
| | - Edward C. Benzel
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 4Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - Alireza M. Mohammadi
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
- 4Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - Todd Emch
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 5Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anthony Magnelli
- 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Andrew Godley
- 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Peng Qi
- 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Samuel T. Chao
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
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30
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Husain ZA, Sahgal A, Chang EL, Maralani PJ, Kubicky CD, Redmond KJ, Fisher C, Laufer I, Lo SS. Modern approaches to the management of metastatic epidural spinal cord compression. CNS Oncol 2017; 6:231-241. [PMID: 28718323 PMCID: PMC6009217 DOI: 10.2217/cns-2016-0044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/28/2017] [Indexed: 12/25/2022] Open
Abstract
Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment to maximize neurologic function, ambulatory function and local control. Traditionally, options for MESCC included external beam radiation therapy with or without surgery. Surgery has usually been reserved for the patient with optimal performance status, single level MESCC or mechanical instability. Advances in external beam radiation therapy such as the development of stereotactic body radiation therapy have allowed for the delivery of high-dose radiation, allowing for both long-term pain and local control. Surgical advances, such as separation surgery, minimal access spine surgery and percutaneous instrumentation, have decreased surgical morbidity. This review summarizes the latest advances and evidence in MESCC to enable modern management.
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Affiliation(s)
- Zain A Husain
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT 06510, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Eric L Chang
- Department of Radiation Oncology, Norris Cancer Center & Keck School of Medicine at University of Southern California, Los Angeles, CA 90033, USA
| | - Pejman Jabehdar Maralani
- Department of Medical imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Charlotte D Kubicky
- Department of Radiation Medicine, Oregon Health Science Center, Portland, OR 97239, USA
| | - Kristin J Redmond
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Charles Fisher
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC V1Y 1T3, Canada
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA
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31
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Alongi F, Arcangeli S, Triggiani L, Mazzola R, Buglione di Monale E Bastia M, Fersino S, Baiguini A, Jereczek-Fossa BA, Magrini SM. Stereotactic ablative radiation therapy in renal cell carcinoma: From oligometastatic to localized disease. Crit Rev Oncol Hematol 2017; 117:48-56. [PMID: 28807235 DOI: 10.1016/j.critrevonc.2017.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/30/2017] [Accepted: 07/10/2017] [Indexed: 12/31/2022] Open
Abstract
Renal Cell Carcinoma (RCC) has historically been considered a radioresistant cancer, and radiotherapy was usually delivered with a palliative goal. Stereotactic ablative radiotherapy (SABR) allows the delivery of high doses on small treatment volumes in a safe and effective way, thus opening the doors to new applicationsof radiotherapy both in the treatment of the primary and oligometastasic disease. Aim of the current review is to explore the state of art of SABR in the therapeutic approach to RCC.
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Affiliation(s)
- Filippo Alongi
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy; University of Brescia, Brescia, Italy
| | | | - Luca Triggiani
- Radiation Oncology, Spedali Civili of Brescia, Brescia, Italy
| | - Rosario Mazzola
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy.
| | | | - Sergio Fersino
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Anna Baiguini
- Radiation Oncology, Spedali Civili of Brescia, Brescia, Italy
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32
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Siva S, Kothari G, Muacevic A, Louie AV, Slotman BJ, Teh BS, Lo SS. Radiotherapy for renal cell carcinoma: renaissance of an overlooked approach. Nat Rev Urol 2017. [PMID: 28631740 DOI: 10.1038/nrurol.2017.87] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Conventional radiotherapy previously had a limited role in the definitive treatment of renal cell carcinoma (RCC), owing to the disappointing outcomes of several trials and the perceived radioresistance of this type of cancer. In this context, radiotherapy has been relegated largely to the palliation of symptoms in patients with metastatic disease, with variable rates of response. Following the availability of newer technologies that enable safe delivery of high-dose radiotherapy, stereotactic ablative radiotherapy (SABR) has become increasingly used in patients with RCC. Preclinical evidence demonstrates that RCC cells are sensitive to ablative doses of radiotherapy (≥8-10 Gy). Trials in the setting of intracranial and extracranial oligometastases, as well as primary RCC, have demonstrated excellent tumour control using this approach. Additionally, an awareness of the capacity of high-dose radiation to stimulate antitumour immunity has resulted in novel combinations of SABR with immunotherapies. Here we describe the historical application of conventional radiotherapy, the current biological understanding of the effects of radiation, and the clinical evidence supporting the use of ablative radiotherapy in RCC. We also explore emerging opportunities to combine systemic targeted agents or immunotherapies with radiation. Radiotherapy, although once an overlooked approach, is moving towards the forefront of RCC treatment.
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Affiliation(s)
- Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Grattan Street, Melbourne, Victoria 3000, Australia
| | - Gargi Kothari
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Grattan Street, Melbourne, Victoria 3000, Australia
| | - Alexander Muacevic
- European Cyberknife Center, Max-Lebsche-Platz 31, Munich D-81377, Germany
| | - Alexander V Louie
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada
| | - Ben J Slotman
- Radiation Oncology, VU University Medical Center, De Boelelaan, PO Box 7057, Amsterdam, 1007 MB, Netherlands
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, 6565 Fannin, Ste#DB1-077, Houston, Texas 77030, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, Washington 98195-6043, USA
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33
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Stubblefield MD, Ibanez K, Riedel ER, Barzilai O, Laufer I, Lis E, Yamada Y, Bilsky MH. Peripheral nervous system injury after high-dose single-fraction image-guided stereotactic radiosurgery for spine tumors. Neurosurg Focus 2017; 42:E12. [PMID: 28245730 DOI: 10.3171/2016.11.focus16348] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The object of this study was to determine the percentage of high-dose (1800-2600 cGy) single-fraction stereotactic radiosurgery (SF-SRS) treatments to the spine that result in peripheral nervous system (PNS) injury. METHODS All patients treated with SF-SRS for primary or metastatic spine tumors between January 2004 and May 2013 and referred to the Rehabilitation Medicine Service for evaluation and treatment of neuromuscular, musculoskeletal, or functional impairments or pain were retrospectively identified. RESULTS Five hundred fifty-seven SF-SRS treatments in 447 patients resulted in 14 PNS injuries in 13 patients. All injures resulted from SF-SRS delivered to the cervical or lumbosacral spine at 2400 cGy. The overall percentage of SF-SRS treatments resulting in PNS injury was 2.5%, increasing to 4.5% when the thoracic spine was excluded from analysis. The median time to symptom onset following SF-SRS was 10 months (range 4-32 months). The plexus (cervical, brachial, and/or lumbosacral) was affected clinically and/or electrophysiologically in 12 (86%) of 14 cases, the nerve root in 2 (14%) of 14, and both in 6 (43%) of 14 cases. All patients experienced pain and most (93%) developed weakness. Peripheral nervous system injuries were CTCAE Grade 1 in 14% of cases, 2 in 64%, and 3 in 21%. No dose relationship between SF-SRS dose and PNS injury was detected. CONCLUSIONS Single-fraction SRS to the spine can result in PNS injury with major implications for function and quality of life.
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Affiliation(s)
| | | | | | | | - Ilya Laufer
- Neurosurgery.,Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | | | - Yoshiya Yamada
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York; and
| | - Mark H Bilsky
- Neurosurgery.,Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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34
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Bennett EE, Berriochoa C, Habboub G, Brigeman S, Chao ST, Angelov L. Rapid and complete radiological resolution of an intradural cervical cord lung cancer metastasis treated with spinal stereotactic radiosurgery: case report. Neurosurg Focus 2017; 42:E10. [PMID: 28041319 DOI: 10.3171/2016.9.focus16254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Stereotactic radiosurgery (SRS) has emerged as a treatment option for patients with spinal metastatic disease. Although SRS has been shown to be successful in a multitude of extradural metastatic tumors causing cord compression, very few cases of intradural treatment have been reported. The authors present a rare case of an intradural extramedullary metastatic small cell lung cancer lesion to the cervical spine resulting in cord compression in an area that had also been extensively pretreated with conventional external-beam radiation therapy. The patient underwent successful SRS to this metastatic site, with rapid and complete resolution of his lesion.
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Affiliation(s)
| | | | - Ghaith Habboub
- Department of Neurological Surgery.,Neurological Institute
| | - Scott Brigeman
- Case Western Reserve University Medical School, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology.,Taussig Cancer Institute, and.,The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic; and
| | - Lilyana Angelov
- Department of Neurological Surgery.,Neurological Institute.,Taussig Cancer Institute, and.,The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic; and
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35
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Sharma M, Bennett EE, Rahmathulla G, Chao ST, Koech HK, Gregory SN, Emch T, Magnelli A, Meola A, Suh JH, Angelov L. Impact of cervicothoracic region stereotactic spine radiosurgery on adjacent organs at risk. Neurosurg Focus 2017; 42:E14. [DOI: 10.3171/2016.10.focus16364] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE
Stereotactic radiosurgery (SRS) of the spine is a conformal method of delivering a high radiation dose to a target in a single or few (usually ≤ 5) fractions with a sharp fall-off outside the target volume. Although efforts have been focused on evaluating spinal cord tolerance when treating spinal column metastases, no study has formally evaluated toxicity to the surrounding organs at risk (OAR), such as the brachial plexus or the oropharynx, when performing SRS in the cervicothoracic region. The aim of this study was to evaluate the radiation dosimetry and the acute and delayed toxicities of SRS on OAR in such patients.
METHODS
Fifty-six consecutive patients (60 procedures) with a cervicothoracic spine tumor involving segments within C5–T1 who were treated using single-fraction SRS between February 2006 and July 2014 were included in the study. Each patient underwent CT simulation and high-definition MRI before treatment. The clinical target volume and OAR were contoured on BrainScan and iPlan software after image fusion. Radiation toxicity was evaluated using the common toxicity criteria for adverse events and correlated to the radiation doses delivered to these regions. The incidence of vertebral body compression fracture (VCF) before and after SRS was evaluated also.
RESULTS
Metastatic lesions constituted the majority (n = 52 [93%]) of tumors treated with SRS. Each patient was treated with a median single prescription dose of 16 Gy to the target. The median percentage of tumor covered by SRS was 93% (maximum target dose 18.21 Gy). The brachial plexus received the highest mean maximum dose of 17 Gy, followed by the esophagus (13.8 Gy) and spinal cord (13 Gy). A total of 14 toxicities were encountered in 56 patients (25%) during the study period. Overall, 14% (n = 8) of the patients had Grade 1 toxicity, 9% (n = 5) had Grade 2 toxicity, 2% (n = 1) had Grade 3 toxicity, and none of the patients had Grade 4 or 5 toxicity. The most common (12%) toxicity was dysphagia/odynophagia, followed by axial spine pain flare or painful radiculopathy (9%). The maximum radiation dose to the brachial plexus showed a trend toward significance (p = 0.066) in patients with worsening post-SRS pain. De novo and progressive VCFs after SRS were noted in 3% (3 of 98) and 4% (4 of 98) of vertebral segments, respectively.
CONCLUSIONS
From the analysis, the current SRS doses used at the Cleveland Clinic seem safe and well tolerated at the cervicothoracic junction. These preliminary data provide tolerance benchmarks for OAR in this region. Because the effect of dose-escalation SRS strategies aimed at improving local tumor control needs to be balanced carefully with associated treatment-related toxicity on adjacent OAR, larger prospective studies using such approaches are needed.
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Affiliation(s)
| | | | | | - Samuel T. Chao
- 2Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, and
| | | | | | - Todd Emch
- 3Imaging Institute, Section of Neuroradiology, Cleveland Clinic, Cleveland, Ohio; and
| | - Anthony Magnelli
- 2Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, and
| | | | - John H. Suh
- 2Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, and
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36
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Harel R, Pfeffer R, Levin D, Shekel E, Epstein D, Tsvang L, Ben Ayun M, Alezra D, Zach L. Spine radiosurgery: lessons learned from the first 100 treatment sessions. Neurosurg Focus 2017; 42:E3. [DOI: 10.3171/2016.9.focus16332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE
Local therapy to spine tumors has been shown to be effective in selected cases. Spinal radiosurgery (SRS) is an evolving radiotherapy regimen allowing for noninvasive, highly efficacious local treatment. The learning curve can compromise the results of any newly employed technology and should be studied to minimize its effects. In this paper the first 100 SRSs performed at several medical centers are presented and analyzed for the effects of the learning curve on outcome.
METHODS
A retrospective analysis was undertaken to evaluate data from patients treated with SRS at Sheba Medical Center and Assuta Medical Centers in the period from September 2011 to February 2016. Medical history, clinical and neurological findings, pathological diagnoses, SRS variables, complications, and follow-up data were collected and analyzed. Local control rates were calculated, and local treatment failure cases were qualitatively studied.
RESULTS
One hundred treatment sessions were performed for 118 lesions at 179 spinal levels in 80 patients. The complication rate was low and did not correlate with a learning curve. Mean follow-up time was 302 days, and the overall local control rate was 95%. The local control rate was dose dependent and increased from 87% (among 35 patients receiving a dose of 16 Gy) to 97% (among 65 patients receiving a dose of 18 Gy). The 6 treatment failure cases are discussed in detail.
CONCLUSIONS
Spinal radiosurgery is a safe and effective treatment. Comprehensive education of the treating team and continuous communication are essential to limit the effects of the learning curve on outcome.
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Affiliation(s)
- Ran Harel
- 1Stereotactic Radiosurgery Unit and
- 2Spine Surgery Unit, Talpiot Medical Leadership Program, Department of Neurosurgery, Sheba Medical Center, Ramat Gan
- 3Sackler Medical School, Tel-Aviv University
| | - Raphael Pfeffer
- 4Department of Radiotherapy, Assuta Medical Centers, Tel-Aviv; and
| | - Daphne Levin
- 4Department of Radiotherapy, Assuta Medical Centers, Tel-Aviv; and
| | - Efrat Shekel
- 4Department of Radiotherapy, Assuta Medical Centers, Tel-Aviv; and
| | - Dan Epstein
- 4Department of Radiotherapy, Assuta Medical Centers, Tel-Aviv; and
| | - Lev Tsvang
- 5Radiation Oncology Unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Maoz Ben Ayun
- 5Radiation Oncology Unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Dror Alezra
- 5Radiation Oncology Unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Leor Zach
- 3Sackler Medical School, Tel-Aviv University
- 5Radiation Oncology Unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
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Miller JA, Balagamwala EH, Angelov L, Suh JH, Rini B, Garcia JA, Ahluwalia M, Chao ST. Spine stereotactic radiosurgery with concurrent tyrosine kinase inhibitors for metastatic renal cell carcinoma. J Neurosurg Spine 2016; 25:766-774. [DOI: 10.3171/2016.4.spine16229] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECT
Systemic control of metastatic renal cell carcinoma (mRCC) has substantially improved with the development of VEGF, mTOR, and checkpoint inhibitors. The current first-line standard of care is a VEGF tyrosine kinase inhibitor (TKI). In preclinical models, TKIs potentiate the response to radiotherapy. Such improved efficacy may prolong the time to salvage therapies, including whole-brain radiotherapy or second-line systemic therapy.
As the prevalence of mRCC has increased, the utilization of spine stereotactic radiosurgery (SRS) has also increased. However, clinical outcomes following concurrent treatment with SRS and TKIs remain largely undefined. The purpose of this investigation was to determine the safety and efficacy of TKIs when delivered concurrently with SRS. The authors hypothesized that first-line TKIs delivered concurrently with SRS significantly increase local control compared with SRS alone or TKIs alone, without increased toxicity.
METHODS
A retrospective cohort study of patients undergoing spine SRS for mRCC was conducted. Patients undergoing SRS were divided into 4 cohorts: those receiving concurrent first-line TKI therapy (A), systemic therapy–naïve patients (B), and patients who were undergoing SRS with (C) or without (D) concurrent TKI treatment after failure of first-line therapy. A negative control cohort (E) was also included, consisting of patients with spinal metastases managed with TKIs alone. The primary outcome was 12-month local failure, defined as any in-field radiographic progression. Multivariate competing risks regression was used to determine the independent effect of concurrent first-line TKI therapy upon local failure.
RESULTS
One hundred patients who underwent 151 spine SRS treatments (232 vertebral levels) were included. At the time of SRS, 46% were receiving concurrent TKI therapy. In each SRS cohort, the median prescription dose was 16 Gy in 1 fraction. Patients in Cohort A had the highest burden of epidural disease (96%, p < 0.01).
At 12 months, the cumulative incidence of local failure was 4% in Cohort A, compared with 19%–27% in Cohorts B–D and 57% in Cohort E (p < 0.01). Multivariate competing risks regression demonstrated that concurrent first-line TKI treatment (Cohort A) was independently associated with a local control benefit (HR 0.21, p = 0.04). In contrast, patients treated with TKIs alone (Cohort E) experienced an increased rate of local failure (HR 2.43, p = 0.03). No toxicities of Grade 3 or greater occurred following SRS with concurrent TKI treatment, and the incidence of post-SRS vertebral fracture (overall 21%) and pain flare (overall 17%) were similar across cohorts.
CONCLUSIONS
The prognosis for patients with mRCC has significantly improved with TKIs. The present investigation suggests a local control benefit with the addition of concurrent first-line TKI therapy to spine SRS. These results have implications in the oligometastatic setting and support a body of preclinical radiobiological research.
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Affiliation(s)
| | | | - Lilyana Angelov
- 3Neurosurgery and
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - John H. Suh
- Departments of 2Radiation Oncology,
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Brian Rini
- 5Medical Oncology, Taussig Cancer Institute; and
| | | | - Manmeet Ahluwalia
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
- 5Medical Oncology, Taussig Cancer Institute; and
| | - Samuel T. Chao
- Departments of 2Radiation Oncology,
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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Chang JH, Shin JH, Yamada YJ, Mesfin A, Fehlings MG, Rhines LD, Sahgal A. Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them? Spine (Phila Pa 1976) 2016; 41 Suppl 20:S238-S245. [PMID: 27488294 PMCID: PMC5552170 DOI: 10.1097/brs.0000000000001823] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVES To summarize the risks of 3 key complications of stereotactic body radiotherapy (SBRT) for spinal metastases, that is, radiation myelopathy (RM), vertebral compression fracture (VCF), and epidural disease progression, and to discuss strategies for minimizing them. SUMMARY OF BACKGROUND DATA RM, VCF and epidural disease progression are now recognized as important risks following SBRT for spine metastases. It is unclear at this stage exactly how large these risks are and what strategies can be employed to minimize these risks. METHODS A systematic review of the literature using MEDLINE and a review of the bibliographies of reviewed articles on SBRT for spinal metastases were conducted. RESULTS The initial literature search revealed a total of 376 articles, of which 38 were pertinent to the study objectives. The risk of RM following SBRT was found to be dependent on the maximum dose to the spinal cord and estimated to be ≤5% if the recommended published thecal sac dose constraints are adhered to. The crude risk of VCF was 13.7% (range: 0.7%-40.5%), and, on average, 45% were surgically salvaged. It has been shown that the risk of VCF is dependent on several anatomic and tumor-related factors including the SBRT dose per fraction. The crude risk of local failure at 1 year was 21.4% (range: 12%-27%) of which 67% (range: 38%-96%) occurred within the epidural space. The grade of epidural disease has been shown to be associated with the risk of local failure. CONCLUSION The risk of RM after spinal SBRT is low in particular if recommended dose metrics are adhered to. There is a significant risk of both VCF and epidural disease progression after spinal SBRT. These risks can potentially be minimized by identifying the risk factors for these complications, and performing careful radiotherapy and surgical planning. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Joe H. Chang
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard University, Boston, MA
| | - Yoshiya J. Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY
| | - Michael G. Fehlings
- Department of Neurosurgery and Spinal Program, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laurence D. Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Park S, Kim KH, Rhee WJ, Lee J, Cho Y, Koom WS. Treatment outcome of radiation therapy and concurrent targeted molecular therapy in spinal metastasis from renal cell carcinoma. Radiat Oncol J 2016; 34:128-34. [PMID: 27306772 PMCID: PMC4938350 DOI: 10.3857/roj.2016.01718] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/14/2016] [Accepted: 05/16/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To evaluate the clinical outcomes of patients who underwent radiation therapy with or without targeted molecular therapy for the treatment of spinal metastasis from renal cell carcinoma (RCC). MATERIALS AND METHODS A total of 28 spinal metastatic lesions from RCC patients treated with radiotherapy between June 2009 and June 2015 were retrospectively reviewed. Thirteen lesions were treated concurrently with targeted molecular therapy (concurrent group) and 15 lesions were not (nonconcurrent group). Local control was defined as lack of radiographically evident local progression and neurological deterioration. RESULTS At a median follow-up of 11 months (range, 2 to 58 months), the 1-year local progression-free rate (LPFR) was 67.0%. The patients with concurrent targeted molecular therapy showed significantly higher LPFR than those without (p = 0.019). After multivariate analysis, use of concurrent targeted molecular therapy showed a tendency towards improved LPFR (hazard ratio, 0.13; 95% confidence interval, 0.01 to 1.16). There was no difference in the incidence of systemic progression between concurrent and nonconcurrent groups. No grade ≥2 toxicities were observed during or after radiotherapy. CONCLUSION Our study suggests the possibility that concurrent use of targeted molecular therapy during radiotherapy may improve LPFR. Further study with a large population is required to confirm these results.
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Affiliation(s)
- Sangjoon Park
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Joong Rhee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Yeona Cho
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
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Jung EW, Jung DL, Balagamwala EH, Angelov L, Suh JH, Djemil T, Magnelli A, Chao ST. Single-Fraction Spine Stereotactic Body Radiation Therapy for the Treatment of Chordoma. Technol Cancer Res Treat 2016; 16:302-309. [PMID: 27260562 DOI: 10.1177/1533034616652775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Chordoma is a radioresistant tumor that presents a therapeutic challenge with spine involvement, as high doses of radiation are needed for local control while limiting dose to the spinal cord. The purpose of this study is to determine the efficacy and safety of single-fraction spine stereotactic body radiation therapy for the treatment of spine chordoma. METHODS A retrospective review of our institutional database from 2006 to 2013 identified 8 patients (12 cases) with chordoma of the spine who were treated with spine stereotactic body radiation therapy. Surgical resection was performed in 7 of the 12 cases. The treatment volume was defined by the bony vertebral level of the tumor along with soft tissue extension appreciated on magnetic resonance imaging fusion. Medical records and imaging were assessed for pain relief and local control. Treatment toxicity was evaluated using Common Terminology Criteria for Adverse Events version 4.0. RESULTS Median age was 59 years (range, 17-91). Median target volume was 48 cm3 (1-304), and median prescription dose was 16 Gy (11-16). Median conformality index was 1.44 (1.14-3.21), and homogeneity index was 1.12 (1.05-1.19). With a median follow-up time of 9.7 months (.5-84), local control was achieved in 75% of the cases treated. One patient developed limited grade 2 spinal cord myelopathy that resolved with steroids. There were no other treatment toxicities from spine stereotactic body radiation therapy. CONCLUSION Single-fraction spine stereotactic body radiation therapy can be safely delivered to treat chordoma of the spine with the potential to improve pain symptoms. Although the early data are suggestive, long-term follow-up with more patients is necessary to determine the efficacy of spine stereotactic body radiation therapy in the treatment of chordoma of the spine.
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Affiliation(s)
- Edward W Jung
- 1 Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David L Jung
- 2 Case Western Reserve Medical School, Cleveland, OH, USA
| | - Ehsan H Balagamwala
- 1 Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lilyana Angelov
- 3 Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John H Suh
- 1 Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Toufik Djemil
- 1 Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony Magnelli
- 1 Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samuel T Chao
- 1 Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
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The effect of radiotherapy, and radiotherapy combined with bisphosphonates or RANK ligand inhibitors on bone quality in bone metastases. A systematic review. Radiother Oncol 2016; 119:194-201. [DOI: 10.1016/j.radonc.2016.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 11/17/2022]
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Otani K, Teshima T, Ito Y, Kawaguchi Y, Konishi K, Takahashi H, Ohigashi H, Oshima K, Araki N, Nishiyama K, Ishikawa O. Risk factors for vertebral compression fractures in preoperative chemoradiotherapy with gemcitabine for pancreatic cancer. Radiother Oncol 2016; 118:424-9. [PMID: 26806264 DOI: 10.1016/j.radonc.2016.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 01/05/2016] [Accepted: 01/10/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Preoperative chemoradiotherapy (CRT) with gemcitabine (GEM) for pancreatic cancer is often accompanied by vertebral compression fractures (VCFs). This study aimed to establish the incidence of VCFs and identify the related risk factors (RFs) to elucidate how to decrease the overall incidence of VCF. MATERIAL AND METHODS We investigated 220 patients with resectable or borderline-resectable pancreatic cancers who had completed preoperative CRT between 2006 and 2011. The RFs associated with VCF were analyzed in a total of 1308 thoracolumbar vertebral bodies. RESULTS Thirty-seven VCFs occurred in 25 patients (11%); the cumulative incidence at two years was 18.9%. Univariate analysis revealed female sex, age and high daily GEM concentration during radiotherapy as RFs for VCF. The multivariate mixed effects logistic regression model demonstrated that the most responsible factor was radiation dose (p<0.001). We estimated the radiation condition resulting in a fracture incidence of ⩽5% by counting the patient's number of the three RFs. For patients with three factors, the mean vertebral dose was 22.0 Gy. CONCLUSIONS The RFs for VCF after CRT were identified. The side effect of VCF might be avoided by regulating the radiation dose to neighboring vertebral bodies after considering the RFs.
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Affiliation(s)
- Keisuke Otani
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan.
| | - Yuri Ito
- Department of Cancer Epidemiology and Prevention Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Yoshifumi Kawaguchi
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Hidenori Takahashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Hiroaki Ohigashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Kazuya Oshima
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Nobuhito Araki
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Kinji Nishiyama
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Osamu Ishikawa
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
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De Bari B, Alongi F, Mortellaro G, Mazzola R, Schiappacasse L, Guckenberger M. Spinal metastases: Is stereotactic body radiation therapy supported by evidences? Crit Rev Oncol Hematol 2016; 98:147-58. [DOI: 10.1016/j.critrevonc.2015.11.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/01/2015] [Accepted: 11/04/2015] [Indexed: 12/21/2022] Open
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Sohn S, Chung CK, Sohn MJ, Kim SH, Kim J, Park E. Radiosurgery Compared with External Radiation Therapy as a Primary Treatment in Spine Metastasis from Hepatocellular Carcinoma : A Multicenter, Matched-Pair Study. J Korean Neurosurg Soc 2016; 59:37-43. [PMID: 26885284 PMCID: PMC4754585 DOI: 10.3340/jkns.2016.59.1.37] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 11/27/2022] Open
Abstract
Objective The aim of this multicenter, matched-pair study was to compare the outcomes of stereotactic radiosurgery (SRS) and conventional external radiation therapy (RT) when used as a primary treatment in spine metastasis from hepatocellular carcinoma (HCC). Methods From 2005 to 2012, 28 patients underwent SRS as the primary treatment in spine metastasis from HCC. Based on sex, age, number of spine metastasis, Child-Pugh classification, interval from original tumor to spine metastasis, and year of treatment, 28 patients who underwent RT were paired. Outcomes of interest were pain relief, progression free survival, toxicities, and further treatment. Results The perioperative visual analog scale (VAS) decrease was larger in SRS group than in RT group, but the difference was not significant (3.7 vs. 2.8, p=0.13). When pain medication was adjusted, the number of patients with complete (n=6 vs.3) or partial (n=12 vs.13) relief was larger in SRS group than in RT group; however, the difference was not significant (p=0.83). There was no significant difference in progression free survival (p=0.48). In SRS group, 32.1% of patients had 1 or more toxicities whereas the percentage in RT group was 63.0%, a significant difference (p=0.04). Six SRS patients and 7 RT patients received further intervention at the treated segment. Conclusion Clinical and radiological outcome were not significantly different between the two treatments. Toxicities, however, were more prevalent in the RT group.
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Affiliation(s)
- Seil Sohn
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.; Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.; Clinical Research Institute, Seoul National University Hospital, Seoul, Korea.; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Moon Jun Sohn
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Sung Hwan Kim
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jinhee Kim
- Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea
| | - Eunjung Park
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
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Zach L, Tsvang L, Alezra D, Ben Ayun M, Harel R. Volumetric Modulated Arc Therapy for Spine Radiosurgery: Superior Treatment Planning and Delivery Compared to Static Beam Intensity Modulated Radiotherapy. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6805979. [PMID: 26885513 PMCID: PMC4738705 DOI: 10.1155/2016/6805979] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/30/2015] [Indexed: 01/30/2023]
Abstract
PURPOSE Spine stereotactic radiosurgery (SRS) delivers an accurate and efficient high radiation dose to vertebral metastases in 1-5 fractions. We aimed to compare volumetric modulated arc therapy (VMAT) to static beam intensity modulated radiotherapy (IMRT) for spine SRS. METHODS AND MATERIALS Ten spine lesions of previously treated SRS patients were planned retrospectively using both IMRT and VMAT with a prescribed dose of 16 Gy to 100% of the planning target volume (PTV). The plans were compared for conformity, homogeneity, treatment delivery time, and safety (spinal cord dose). RESULTS All evaluated parameters favored the VMAT plan over the IMRT plans. D min in the IMRT was significantly lower than in the VMAT plan (7.65 Gy/10.88 Gy, p < 0.001), the Dice Similarity Coefficient (DSC) was found to be significantly better for the VMAT plans compared to the IMRT plans (0.77/0.58, resp., p value < 0.01), and an almost 50% reduction in the net treatment time was calculated for the VMAT compared to the IMRT plans (6.73 min/12.96 min, p < 0.001). CONCLUSIONS In our report, VMAT provides better conformity, homogeneity, and safety profile. The shorter treatment time is a major advantage and not only provides convenience to the painful patient but also contributes to the precision of this high dose radiation therapy.
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Affiliation(s)
- Leor Zach
- Radiation Oncology unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Lev Tsvang
- Radiation Oncology unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Dror Alezra
- Radiation Oncology unit, Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | | | - Ran Harel
- Stereotactic Radiosurgery Unit, Talpiot Medical Leadership Program, Department of Neurosurgery, Sheba Medical Center, Ramat Gan, Israel
- Spine Surgery Unit, Talpiot Medical Leadership Program, Department of Neurosurgery, Sheba Medical Center, Ramat Gan, Israel
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Asbell SO, Grimm J, Xue J, Chew MS, LaCouture TA. Introduction and Clinical Overview of the DVH Risk Map. Semin Radiat Oncol 2015; 26:89-96. [PMID: 27000504 DOI: 10.1016/j.semradonc.2015.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Radiation oncologists need reliable estimates of risk for various fractionation schemes for all critical anatomical structures throughout the body, in a clinically convenient format. Reliable estimation theory can become fairly complex, however, and estimates of risk continue to evolve as the literature matures. To navigate through this efficiently, a dose-volume histogram (DVH) Risk Map was created, which provides a comparison of radiation tolerance limits as a function of dose, fractionation, volume, and risk level. The graphical portion of the DVH Risk Map helps clinicians to easily visualize the trends, whereas the tabular portion provides quantitative precision for clinical implementation. The DVH Risk Map for rib tolerance from stereotactic ablative body radiotherapy (SABR) and stereotactic body radiation therapy (SBRT) is used as an example in this overview; the 5% and 50% risk levels for 1-5 fractions for 5 different volumes are given. Other articles throughout this issue of Seminars in Radiation Oncology present analysis of new clinical datasets including the DVH Risk Maps for other anatomical structures throughout the body.
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Affiliation(s)
- Sucha O Asbell
- Department of Radiation Oncology, MD Anderson at Cooper University Hospital, Camden, NJ
| | - Jimm Grimm
- Holy Redeemer Hospital, Bott Cancer Center, Meadowbrook, PA.
| | - Jinyu Xue
- Department of Radiation Oncology, MD Anderson at Cooper University Hospital, Camden, NJ
| | | | - Tamara A LaCouture
- Department of Radiation Oncology, MD Anderson at Cooper University Hospital, Camden, NJ
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Quantitative Evaluation of Local Control and Wound Healing Following Surgery and Stereotactic Spine Radiosurgery for Spine Tumors. World Neurosurg 2015; 87:48-54. [PMID: 26548834 DOI: 10.1016/j.wneu.2015.10.075] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The present study evaluated the optimal measuring criteria to assess spinal tumor response to surgery followed by stereotactic spine radiosurgery (SRS) and reports the local control and wound complication rates following combined multimodality treatment. METHODS AND MATERIALS Prospectively collected patient information was retrospectively reviewed to identify patients treated with spine surgery followed by SRS. Tumor sizes and volumetric assessment were formally measured. Local control status was defined according to World Health Organization (WHO, bidimensional), RECIST (unidimensional), or volumetric size change. Statistical comparative assessments of tumor measurements were performed. RESULTS Twenty-two patients were eligible for evaluation after having undergone surgery followed by single-fraction SRS within a 2-month period. Seventeen had follow-up magnetic resonance imaging (MRI) with a mean patient follow-up of 12.59 months (range 3-36 months). None developed wound complication after radiation therapy (95% lower confidence bound 13%). Two patients had clinical recurrence while 15 of 17 achieved local control (88.3%). A test of marginal homogeneity for RECIST versus WHO was not statistically significant, P = 1.0 suggesting similar response classifications with both systems. Spearman correlations among 1) volumetric assessment, 2) bidimensional size, and 3) unidimensional size were significant for all groups (P < 0.05). CONCLUSION High local control rates can be achieved with surgery followed by SRS. Further, adjuvant SRS following spine tumor surgery delivers less radiation to the wound than conventional radiation and thus potentially reduces wound complications. Unidimensional, bidimensional, and volumetric tumor assessments demonstrate similar results. Hence the use of the simpler RECIST criteria is suitable and appropriate for evaluating the response to treatment after spine radiosurgery.
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48
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McDonald R, Probyn L, Poon I, Erler D, Brotherston D, Soliman H, Cheung P, Chung H, Chu W, Loblaw A, Thavarajah N, Lang C, Chin L, Chow E, Sahgal A. Tumor Response After Stereotactic Body Radiation Therapy to Nonspine Bone Metastases: An Evaluation of Response Criteria. Int J Radiat Oncol Biol Phys 2015; 93:879-81. [DOI: 10.1016/j.ijrobp.2015.07.2288] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 12/26/2022]
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McDonald R, Probyn L, Poon I, Erler D, Brotherston D, Soliman H, Cheung P, Chung H, Chu W, Loblaw A, Thavarajah N, Lang C, Chin L, Chow E, Sahgal A. Computed Tomography Evaluation of Density Following Stereotactic Body Radiation Therapy of Nonspine Bone Metastases. Technol Cancer Res Treat 2015; 15:683-8. [PMID: 26351302 DOI: 10.1177/1533034615604068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Stereotactic body radiation therapy allows for the precise delivery of high-dose radiation to disease sites and is becoming increasingly used to treat nonspine bone metastases. Previous studies have shown that remineralization of lytic bone metastases follows after conventional radiotherapy. The objective of this study was to investigate changes in bone density in nonspine bone metastases following stereotactic body radiation therapy. METHODS A retrospective review was conducted for all patients treated with stereotactic body radiation therapy to nonspine bone metastases between May 2011 and April 2014. A minimum of 1 pretreatment and 1 posttreatment computed tomography scan was required. An independent musculoskeletal radiologist contoured the lesions on the most representative computed tomography slices. Density was measured in Hounsfield units and analyzed using pretreatment and posttreatment ratios. RESULTS Forty sites were treated (55% lytic, 30% sclerotic, and 15% mixed). The median follow-up duration was 7 months. Lytic osseous metastases from renal cell carcinoma progressed during initial follow-up imaging and then returned to baseline. Of 9 lytic lesions not from renal cell carcinoma, 6 showed an immediate increase in density and 2 remained stable. Six of 7 sclerotic lesions from prostate cancer showed decreased density throughout all follow-ups. CONCLUSION Stereotactic body radiation therapy is efficacious in the remineralization of lytic and demineralization of sclerotic nonspine bone metastases.
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Affiliation(s)
- Rachel McDonald
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Linda Probyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Darby Erler
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Drew Brotherston
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hans Chung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - William Chu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nemica Thavarajah
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Lang
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lee Chin
- Department of Physics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Amini A, Altoos B, Bourlon MT, Bedrick E, Bhatia S, Kessler ER, Flaig TW, Fisher CM, Kavanagh BD, Lam ET, Karam SD. Local control rates of metastatic renal cell carcinoma (RCC) to the bone using stereotactic body radiation therapy: Is RCC truly radioresistant? Pract Radiat Oncol 2015; 5:e589-e596. [PMID: 26142027 DOI: 10.1016/j.prro.2015.05.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/11/2015] [Accepted: 05/17/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE We report the radiographic and clinical response rate of stereotactic body radiation therapy (SBRT) compared with conventional fractionated external beam radiation therapy (CF-EBRT) for renal cell carcinoma (RCC) bone lesions treated at our institution. METHODS AND MATERIALS Forty-six consecutive patients were included in the study, with 95 total lesions treated (50 SBRT, 45 CF-EBRT). We included patients who had histologic confirmation of primary RCC and radiographic evidence of metastatic bone lesions. The most common SBRT regimen used was 27 Gy in 3 fractions. RESULTS Median follow-up was 10 months (range, 1-64 months). Median time to symptom control between SBRT and CF-EBRT were 2 (range, 0-6 weeks) and 4 weeks (range, 0-7 weeks), respectively. Symptom control rates with SBRT and CF-EBRT were significantly different (P = .020) with control rates at 10, 12, and 24 months of 74.9% versus 44.1%, 74.9% versus 39.9%, and 74.9% versus 35.7%, respectively. The median time to radiographic failure and unadjusted pain progression was 7 months in both groups. When controlling for gross tumor volume, dose per fraction, smoking, and the use of systemic therapy, biologically effective dose ≥80 Gy was significant for clinical response (hazard ratio [HR], 0.204; 95% confidence interval [CI], 0.043-0.963; P = .046) and radiographic (HR, 0.075; 95% CI, 0.013-0.430; P = .004). When controlling for gross tumor volume and total dose, biologically effective dose ≥80 Gy was again predictive of clinical local control (HR, 0.140; 95% CI, 0.025-0.787; P = .026). Toxicity rates were low and equivalent in both groups, with no grade 4 or 5 toxicity reported. CONCLUSIONS SBRT is both safe and effective for treating RCC bone metastases, with rapid improvement in symptoms after treatment and more durable clinical and radiographic response rate. Future prospective trials are needed to further define efficacy and toxicity of treatment, especially in the setting of targeted agents.
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Affiliation(s)
- Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Basel Altoos
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Maria T Bourlon
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado.,Medical Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Edward Bedrick
- Department of Biostatistics and Bioinformatics Shared Resource, University of Colorado Denver, Aurora, Colorado
| | - Shilpa Bhatia
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth R Kessler
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Thomas W Flaig
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Elaine T Lam
- Department of Medicine, Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Sana D Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
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