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Newman WC, Larsen AG, Bilsky MH. The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:487-499. [PMID: 37116749 DOI: 10.1016/j.recot.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023] Open
Abstract
Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: Neurological status, Oncologic tumor behavior, Mechanical stability, and Systemic disease burden and medical co-morbidities.
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Affiliation(s)
- W C Newman
- Memorial Sloan Kettering Cancer Center, India
| | - A G Larsen
- Memorial Sloan Kettering Cancer Center, India; Weill Medical College of Cornell University, India
| | - M H Bilsky
- Memorial Sloan Kettering Cancer Center, India; Weill Medical College of Cornell University, India.
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2
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Newman WC, Larsen AG, Bilsky MH. The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:S487-S499. [PMID: 37562765 DOI: 10.1016/j.recot.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 08/12/2023] Open
Abstract
Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: neurological status, Oocologic tumor behavior, mechanical stability and systemic disease burden and medical co-morbidities.
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Affiliation(s)
- W C Newman
- Memorial Sloan Kettering Cancer Center, Chennai, Tamil Nadu, India
| | - A G Larsen
- Memorial Sloan Kettering Cancer Center, Chennai, Tamil Nadu, India; Weill Medical College of Cornell University, India
| | - M H Bilsky
- Memorial Sloan Kettering Cancer Center, Chennai, Tamil Nadu, India; Weill Medical College of Cornell University, India.
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Key BM, Callstrom MR, Filippiadis D. Musculoskeletal Interventional Oncology: A Contemporary Review. AJR Am J Roentgenol 2023; 221:503-516. [PMID: 37222277 DOI: 10.2214/ajr.23.29110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Musculoskeletal interventional oncology is an emerging field that addresses the limitations of conventional therapies for bone and soft-tissue tumors. The field's growth has been driven by evolving treatment paradigms, expanding society guidelines, mounting supportive literature, technologic advances, and cross-specialty collaboration with medical, surgical, and radiation oncology. Safe, effective, and durable pain palliation, local control, and stabilization of musculoskeletal tumors are increasingly achieved through an expanding array of contemporary minimally invasive percutaneous image-guided treatments, including ablation, osteoplasty, vertebral augmentation (with or without mechanical reinforcement via implants), osseous consolidation via percutaneous screw fixation (with or without osteoplasty), tumor embolization, and neurolysis. These interventions may be used for curative or palliative indications and can be readily combined with systemic therapies. Therapeutic approaches include the combination of different interventional oncology techniques as well as the sequential application of such techniques with other local treatments, including surgery or radiation. This article reviews the current practice of interventional oncology treatments for the management of patients with bone and soft-tissue tumors with a focus on emerging technologies and techniques.
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Affiliation(s)
- Brandon M Key
- Department of Radiology, Division of Vascular & Interventional Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Rm 2803, Milwaukee, WI 53226
| | - Matthew R Callstrom
- Department of Radiology, Division of Vascular & Interventional Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Rm 2803, Milwaukee, WI 53226
| | - Dimitrios Filippiadis
- Department of Diagnostic and Interventional Radiology, University General Hospital "Attikon" Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Guckenberger M, Dahele M, Ong WL, Sahgal A. Stereotactic Body Radiation Therapy for Spinal Metastases: Benefits and Limitations. Semin Radiat Oncol 2023; 33:159-171. [PMID: 36990633 DOI: 10.1016/j.semradonc.2022.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Progress in biological cancer characterization, targeted systemic therapies and multimodality treatment strategies have shifted the goals of radiotherapy for spinal metastases from short-term palliation to long-term symptom control and prevention of compilations. This article gives an overview of the spine stereotactic body radiotherapy (SBRT) methodology and clinical results of SBRT in cancer patients with painful vertebral metastases, metastatic spinal cord compression, oligometastatic disease and in a reirradiation situation. Outcomes after dose-intensified SBRT are compared with results of conventional radiotherapy and patient selection criteria will be discussed. Though rates of severe toxicity after spinal SBRT are low, strategies to minimize the risk of vertebral compression fracture, radiation induced myelopathy, plexopathy and myositis are summarized, to optimize the use of SBRT in multidisciplinary management of vertebral metastases.
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Patel PP, Esposito EP, Zhu J, Chen X, Khan M, Kleinberg L, Lubelski D, Theodore N, Lo SFL, Hun Lee S, Kebaish K, Bydon A, Redmond KJ. Antiresorptive Medications Prior to Stereotactic Body Radiotherapy for Spinal Metastasis are Associated with Reduced Incidence of Vertebral Body Compression Fracture. Global Spine J 2023:21925682231156394. [PMID: 36749660 DOI: 10.1177/21925682231156394] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVE Antiresorptive drugs are often given to minimize fracture risk for bone metastases, but data regarding optimal time or ability to reduce stereotactic body radiotherapy (SBRT)-induced fracture risk is limited. This study examines the association between antiresorptive use surrounding spinal SBRT and vertebral compression fracture (VCF) incidence to provide information regarding effectiveness and optimal timing of use. METHODS Patients treated with SBRT for spinal metastases at a single institution between 2009-2020 were included. Kaplan-Meier analysis was used to compare cumulative incidence of VCF for those taking antiresorptive drugs pre-SBRT, post-SBRT only, and none at all. Cox proportional hazards and Fine-Gray competing risk models were used to identify additional factors associated with VCF. RESULTS Of the 234 patients (410 vertebrae) analyzed, 49 (20.9%) were taking bisphosphonates alone, 42 (17.9%) were taking denosumab alone, and 25 (10.7%) were taking both. Kaplan-Meier analysis revealed a statistically significant lower VCF incidence for patients initiating antiresorptive drugs before SBRT compared to those taking none at all (4% vs 12% at 1 year post-SBRT, P = .045; and 4% vs 23% at 2 years, P = .008). On multivariate analysis, denosumab duration (HR: .87, P = .378) or dose (HR: 1.00, P = .644) as well as bisphosphonate duration (HR: .98, P= .739) or dose (HR: .99, P= .741) did not have statistical significance on VCF incidence. CONCLUSION Initiating antiresorptive agents before SBRT may reduce the risk of treatment-induced VCF. Antiresorptive drugs are underutilized in patients with spine metastases and may represent a useful intervention to minimize toxicity and improve long-term outcomes.
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Affiliation(s)
- Palak P Patel
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Edward P Esposito
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jiafeng Zhu
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Majid Khan
- Department of Radiology, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hoftstra, Manhasset, NY, USA
| | - Sang Hun Lee
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ali Bydon
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Holistic Approach to the Diagnosis and Treatment of Patients with Tumor Metastases to the Spine. Cancers (Basel) 2022; 14:cancers14143480. [PMID: 35884541 PMCID: PMC9317366 DOI: 10.3390/cancers14143480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 01/04/2023] Open
Abstract
The treatment of neoplastic spine metastases requires multi-faceted assessment and an interdisciplinary approach to patients. The metastases do not show specific symptoms but are often the first confirmation of the presence of a primary tumor in a patient. The diagnostic process includes imaging and invasive procedures, e.g., biopsy. It is essential to qualify the patient for an appropriate treatment using dedicated scales. Decompression of the spinal cord is a critical issue to save or restore neurological function in a patient with spine metastases. Surgical treatment ought to meet three criteria: release spinal cord and nerve roots, restore the spine’s anatomical relations, and ensure the internal stabilization of the spine. A good result from surgical treatment enables the continuation of radiotherapy, chemotherapy, hormone therapy, and targeted molecular therapy. Stereotactic radiosurgery and stereotactic body radiotherapy are more effective ways of treating spine metastases than conventional external beam radiotherapy. They allow higher doses of radiation, concentrated precisely at the tumor site. Our review summarizes the established and emerging concepts in the treatment of spine metastases. A holistic approach to the patient enables the selection of the appropriate therapy.
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Glicksman RM, Tjong MC, Neves-Junior WFP, Spratt DE, Chua KLM, Mansouri A, Chua MLK, Berlin A, Winter JD, Dahele M, Slotman BJ, Bilsky M, Shultz DB, Maldaun M, Szerlip N, Lo SS, Yamada Y, Vera-Badillo FE, Marta GN, Moraes FY. Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases: A Review. JAMA Oncol 2020; 6:567-577. [PMID: 31895403 DOI: 10.1001/jamaoncol.2019.5351] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Rising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application. Objective To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies. Evidence Review The MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases. Results Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease. Conclusions and Relevance These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.
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Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Kevin L M Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Mark Bilsky
- Department of Neurosurgery, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcos Maldaun
- Division of Neurosurgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Yoshiya Yamada
- Department of Radiation Oncology, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.,Division of Radiation Oncology, Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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8
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Barzilai O, McLaughlin L, Lis E, Reiner AS, Bilsky MH, Laufer I. Utility of Cement Augmentation via Percutaneous Fenestrated Pedicle Screws for Stabilization of Cancer-Related Spinal Instability. Oper Neurosurg (Hagerstown) 2020; 16:593-599. [PMID: 30508168 DOI: 10.1093/ons/opy186] [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: 02/01/2018] [Accepted: 09/20/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation. OBJECTIVE To evaluate the safety and efficacy of cement augmentation via fenestrated screws. METHODS A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2- <6 mo) and long term (6-12 mo). RESULTS Cement augmentation was performed in 216 fenestrated pedicle screws in 53 patients. Three patients required reoperation. One patient had an asymptomatic screw fracture at 6 mo postoperatively that did not require intervention. No cases of lucency around the pedicle screws, rod fractures, or cement extravasation into the spinal canal were observed. Eight cases of asymptomatic, radiographically-detected venous extravasation were found. Systemic complications included a pulmonary cement embolism, a lower extremity deep vein thrombosis, and a postoperative mortality secondary to pulmonary failure from widespread metastatic pulmonary infiltration. Significant improvement in PRO measures was found in short- and long-term analysis. CONCLUSION Cement augmentation of pedicle screws is an effective method to enhance the durability of spinal constructs in the cancer population. Risks include cement extravasation into draining blood vessels, but risk of clinically significant extravasation appears to be exceedingly low.
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Affiliation(s)
- Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lily McLaughlin
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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Rousselle A, Amelot A, Thariat J, Jacob J, Mercy G, De Marzi L, Feuvret L. Metallic implants and CT artefacts in the CTV area: Where are we in 2020? Cancer Radiother 2020; 24:658-666. [PMID: 32859465 DOI: 10.1016/j.canrad.2020.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/18/2022]
Abstract
Radiation therapy (RT) is one of the main modalities of cancer treatment worldwide with computed tomography (CT), as the most commonly used imaging method for treatment planning system (TPS). Image reconstruction errors may greatly affect all the radiation therapy planning process, such as target delineation, dose calculation and delivery, particularly with particle therapy. Metallic implants, such as hip and spinal implants, and dental filling significantly deteriorate image quality. These hardware structures are often very complex in geometry leading to geometric complex artefacts in the clinical target volume (CTV) area, rendering the delineation of CTV challenging. In our review, we focus on the methods to overcome artefact consequences on CTV delineation: 1- medical approaches anticipating issues associated with imaging artefacts during preoperative multidisciplinary discussions while following standard recommendations; 2- common metal artefact reduction (MAR) methods such as manually override artefact regions, ballistics avoiding beam paths through implanted materials, megavoltage-CT (MVCT); 3- prospects with radiolucent implants, MAR algorithms and various methods of dual energy computed tomography (DECT). Despite substantial and broad evidence for their benefits, there is still no universal solution for cases involving implanted metallic devices. There is still a high need for research efforts to adapt technologies to our issue: "how do I accurately delineate the ideal CTV in a metal artefact area?"
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Affiliation(s)
- A Rousselle
- Department of Radiation Oncology, Sorbonne Université, AP-HP, hôpitaux universitaires La Pitié Salpêtrière-Charles-Foix, 75013 Paris, France
| | - A Amelot
- Department of Neurosurgery, CHRU de Tours, 37000 Tours, France
| | - J Thariat
- Department of Radiation Oncology, centre François-Baclesse/ARCHADE, Laboratoire de physique corpusculaire IN2P3-UMR6534 - Normandie Université, 1400 Caen, France
| | - J Jacob
- Department of Radiation Oncology, Sorbonne Université, AP-HP, hôpitaux universitaires La Pitié Salpêtrière-Charles-Foix, 75013 Paris, France
| | - G Mercy
- Department of Medical Imaging, Sorbonne Université, AP-HP, hôpitaux universitaires La Pitié Salpêtrière-Charles-Foix, 75013 Paris, France
| | - L De Marzi
- Institut Curie, PSL Research University, Radiation Oncology Department, Proton Therapy Centre, Centre universitaire, 91898 Orsay, France
| | - L Feuvret
- Department of Radiation Oncology, Sorbonne Université, AP-HP, hôpitaux universitaires La Pitié Salpêtrière-Charles-Foix, 75013 Paris, France.
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Delgado-López PD, Roldán-Delgado H, Corrales-García EM. Stereotactic body radiation therapy and minimally invasive surgery in the management of spinal metastases: a change in the paradigm. Neurocirugia (Astur) 2019; 31:119-131. [PMID: 31668627 DOI: 10.1016/j.neucir.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/26/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
Abstract
The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2 to 3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies.
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Affiliation(s)
| | - Héctor Roldán-Delgado
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Canarias, Tenerife, España
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12
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Lis E, Laufer I, Barzilai O, Yamada Y, Karimi S, McLaughlin L, Krol G, Bilsky MH. Change in the cross-sectional area of the thecal sac following balloon kyphoplasty for pathological vertebral compression fractures prior to spine stereotactic radiosurgery. J Neurosurg Spine 2019; 30:111-118. [PMID: 30497230 DOI: 10.3171/2018.6.spine18206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPercutaneous vertebral augmentation procedures such as vertebroplasty and kyphoplasty are often performed in cancer patients to relieve mechanical axial-load pain due to pathological collapse deformities. The collapsed vertebrae in these patients can be associated with varying degrees of spinal canal compromise that can be worsened by kyphoplasty. In this study the authors evaluated changes to the spinal canal, in particular the cross-sectional area of the thecal sac, following balloon kyphoplasty (BKP) prior to stereotactic radiosurgery (SRS).METHODSThe authors retrospectively reviewed the records of all patients with symptomatic vertebral compression fractures caused by metastatic disease who underwent kyphoplasty prior to single-fraction SRS. The pre-BKP cross-sectional image, usually MRI, was compared to the post-BKP CT myelogram required for radiation treatment planning. The cross-sectional area of the thecal sac was calculated pre- and postkyphoplasty, and intraprocedural CT imaging was reviewed for epidural displacement of bone fragments, tumor, or polymethylmethacrylate (PMMA) extravasation. The postkyphoplasty imaging was also evaluated for evidence of fracture progression or fracture reduction.RESULTSAmong 30 consecutive patients, 41 vertebral levels were treated with kyphoplasty, and 24% (10/41) of the augmented levels showed a decreased cross-sectional area of the thecal sac. All 10 of these vertebral levels had preexisting epidural disease and destruction of the posterior vertebral body cortex. No bone fragments were displaced posteriorly. Minor epidural PMMA extravasation occurred in 20% (8/41) of the augmented levels but was present in only 1 of the 10 vertebral segments that showed a decreased cross-sectional area of the thecal sac postkyphoplasty.CONCLUSIONSIn patients with preexisting epidural disease and destruction of the posterior vertebral body cortex who are undergoing BKP for pathological fractures, there is an increased risk of further mass effect upon the thecal sac and the potential to alter the SRS treatment planning.
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Affiliation(s)
- Eric Lis
- 1Department of Radiology, Neuroradiology Service; and
| | | | | | - Yoshiya Yamada
- 3Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sasan Karimi
- 1Department of Radiology, Neuroradiology Service; and
| | | | - George Krol
- 1Department of Radiology, Neuroradiology Service; and
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13
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Laufer I, Bilsky MH. Advances in the treatment of metastatic spine tumors: the future is not what it used to be. J Neurosurg Spine 2019; 30:299-307. [PMID: 30835704 DOI: 10.3171/2018.11.spine18709] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
An improved understanding of tumor biology, the ability to target tumor drivers, and the ability to harness the immune system have dramatically improved the expected survival of patients diagnosed with cancer. However, many patients continue to develop spine metastases that require local treatment with radiotherapy and surgery. Fortunately, the evolution of radiation delivery and operative techniques permits durable tumor control with a decreased risk of treatment-related toxicity and a greater emphasis on restoration of quality of life and daily function. Stereotactic body radiotherapy allows delivery of ablative radiation doses to the majority of spine tumors, reducing the need for surgery. Among patients who still require surgery for decompression of the spinal cord or spinal column stabilization, minimal access approaches and targeted tumor excision and ablation techniques minimize the surgical risk and facilitate postoperative recovery. Growing interdisciplinary collaboration among scientists and clinicians will further elucidate the synergistic possibilities among systemic, radiation, and surgical interventions for patients with spinal tumors and will bring many closer to curative therapies.
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Multidisciplinary Management of Spinal Metastasis and Vertebral Instability: A Systematic Review. World Neurosurg 2019; 128:e944-e955. [PMID: 31100530 DOI: 10.1016/j.wneu.2019.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/03/2019] [Accepted: 05/04/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this systematic literature review is to evaluate recent attempts in creating a standardized multidisciplinary approach combining tumor treatment with current vertebral stabilization techniques for palliative treatment of vertebral metastasis in patients who do not fall into the NOMS (neurologic, oncologic, mechanical, systemic) framework. METHODS We performed a systematic literature search for studies using a tumor modality in conjunction with kyphoplasty or vertebroplasty. In addition, the bibliographies of selected articles were examined for additional studies not viewed in database searches, which led to the use of additional search terms. RESULTS A total of 563 articles were found after our database search. Eighteen studies fulfilled our inclusion criteria. Articles were then divided into categories based on combinations of tumor modality. Multiple studies reported significant decreases in visual analog scale scores after combined procedures with very low rates of symptomatic complications. Studies that compared their combination with control treatment groups showed greater clinical efficacy. CONCLUSIONS Although multidisciplinary management of spinal metastasis using a combination of tumor ablation techniques with vertebral stabilization has been recommended in the previous literature, this review shows that no combination of treatment carried demonstrably different results in pain score reduction, reduced analgesic intake, or improved quality of life. In addition, there is no consensus of standardized variables to evaluate efficacy of treatment, limiting the efficacy of treatment results for the analyzed studies. Although not explicitly included in the initial NOMS framework, our results support the consideration of concomitant percutaneous kyphoplasty or vertebroplasty in these patients on a case-by-case basis.
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Barzilai O, Boriani S, Fisher CG, Sahgal A, Verlaan JJ, Gokaslan ZL, Lazary A, Bettegowda C, Rhines LD, Laufer I. Essential Concepts for the Management of Metastatic Spine Disease: What the Surgeon Should Know and Practice. Global Spine J 2019; 9:98S-107S. [PMID: 31157152 PMCID: PMC6512191 DOI: 10.1177/2192568219830323] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [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 Literature review. OBJECTIVE To provide an overview of the recent advances in spinal oncology, emphasizing the key role of the surgeon in the treatment of patients with spinal metastatic tumors. METHODS Literature review. RESULTS Therapeutic advances led to longer survival times among cancer patients, placing significant emphasis on durable local control, optimization of quality of life, and daily function for patients with spinal metastatic tumors. Recent integration of modern diagnostic tools, precision oncologic treatment, and widespread use of new technologies has transformed the treatment of spinal metastases. Currently, multidisciplinary spinal oncology teams include spinal surgeons, radiation and medical oncologists, pain and rehabilitation specialists, and interventional radiologists. Consistent use of common language facilitates communication, definition of treatment indications and outcomes, alongside comparative clinical research. The main parameters used to characterize patients with spinal metastases include functional status and health-related quality of life, the spinal instability neoplastic score, the epidural spinal cord compression scale, tumor histology, and genomic profile. CONCLUSIONS Stereotactic body radiotherapy revolutionized spinal oncology through delivery of durable local tumor control regardless of tumor histology. Currently, the major surgical indications include mechanical instability and high-grade spinal cord compression, when applicable, with surgery providing notable improvement in the quality of life and functional status for appropriately selected patients. Surgical trends include less invasive surgery with emphasis on durable local control and spinal stabilization.
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Affiliation(s)
- Ori Barzilai
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Charles G. Fisher
- University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Arjun Sahgal
- University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Ziya L. Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
- The Miriam Hospital, Providence, RI, USA
| | - Aron Lazary
- National Center for Spinal Disorders and Buda Health Center, Budapest, Hungary
| | | | | | - Ilya Laufer
- Memorial Sloan-Kettering Cancer Center, New York, NY
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Patel MS, Ghasem A, Greif DN, Huntley SR, Conway SA, Al Maaieh M. Evaluating Treatment Strategies for Spinal Lesions in Multiple Myeloma: A Review of the Literature. Int J Spine Surg 2018; 12:571-581. [PMID: 30364863 DOI: 10.14444/5070] [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: 02/02/2023] Open
Abstract
Background Vertebral disease is a major cause of morbidity in 70% of patients diagnosed with multiple myeloma (MM). Associated osteolytic lesions and vertebral fractures are well documented in causing debilitating pain, functional restrictions, spinal deformity, and cord compression. Currently, treatment modalities for refractory MM spinal pain include systemic therapy, radiotherapy, cementoplasty (vertebroplasty/kyphoplasty), and radio frequency ablation. Our objectives were to report on the efficacy of existing treatments for MM patients with refractory spinal pain, to determine if a standardized treatment algorithm has been described, and to set the foundation upon which future prospective studies can be designed. Methods A systematic search of the PubMed database was performed for studies relevant to the treatment of vertebral disease in MM patients. A multitude of search terms in various combinations were used, including but not limited to: "vertebroplasty," "kyphoplasty," "radiation," "multiple myeloma," "radiotherapy," and "radiosurgery." Results Our preliminary search resulted in 219 articles, which subsequently resulted in 19 papers following abstract, title, full-text, and bibliography review. These papers were then grouped by treatment modality: radiotherapy, cementoplasty, or combination therapy. Significant pain and functional score improvement across all treatment modalities was found in the majority of the literature. While complications of treatment occurred, few were noted to be clinically significant. Conclusions Treatment options-radiotherapy and/or cementoplasty-for vertebral lesions and pathologic fractures in MM patients demonstrate significant radiographic and clinical improvement. However, there is no consensus in the literature as to the optimal treatment modality as a result of a limited number of studies reporting head-to-head comparisons. One study did find significantly improved pain and functional scores with preserved vertebral height in favor of kyphoplasty over radiotherapy. When not contraindicated, we advocate for some form of cementoplasty. Further prospective studies are required before implementation of a standardized treatment protocol. Level of Evidence 5.
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Affiliation(s)
| | - Alexander Ghasem
- University of Miami, Department of Orthopedic Surgery, Miami, Florida
| | - Dylan N Greif
- University of Miami Miller School of Medicine, Miami, Florida
| | | | - Sheila A Conway
- University of Miami, Department of Orthopedic Surgery, Miami, Florida
| | - Motasem Al Maaieh
- University of Miami, Department of Orthopedic Surgery, Miami, Florida
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