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Lam FC, Guru S, AbuReesh D, Hori YS, Chuang C, Liu L, Wang L, Gu X, Szalkowski GA, Wang Z, Wohlers C, Tayag A, Emrich SC, Ustrzynski L, Zygourakis CC, Desai A, Hayden Gephart M, Byun J, Pollom EL, Rahimy E, Soltys S, Park DJ, Chang SD. Use of Carbon Fiber Implants to Improve the Safety and Efficacy of Radiation Therapy for Spine Tumor Patients. Brain Sci 2025; 15:199. [PMID: 40002531 PMCID: PMC11852773 DOI: 10.3390/brainsci15020199] [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: 12/31/2024] [Revised: 01/22/2025] [Accepted: 02/13/2025] [Indexed: 02/27/2025] Open
Abstract
Current standard of care treatment for patients with spine tumors includes multidisciplinary approaches, including the following: (1) surgical tumor debulking, epidural spinal cord decompression, and spine stabilization techniques; (2) systemic chemo/targeted therapies; (3) radiation therapy; and (4) surveillance imaging for local disease control and recurrence. Titanium pedicle screw and rod fixation have become commonplace in the spine surgeon's armamentarium for the stabilization of the spine following tumor resection and separation surgery. However, the high degree of imaging artifacts seen with titanium implants on postoperative CT and MRI scans can significantly hinder the accurate delineation of vertebral anatomy and adjacent neurovascular structures to allow for the safe and effective planning of downstream radiation therapies and detection of disease recurrence. Carbon fiber-reinforced polyetheretherketone (CFR-PEEK) spine implants have emerged as a promising alternative to titanium due to the lack of artifact signals on CT and MRI, allowing for more accurate and safe postoperative radiation planning. In this article, we review the tenants of the surgical and radiation management of spine tumors and discuss the safety, efficacy, and current limitations of CFR-PEEK spine implants in the multidisciplinary management of spine oncology patients.
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Affiliation(s)
- Fred C. Lam
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Santosh Guru
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Deyaldeen AbuReesh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Yusuke S. Hori
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Cynthia Chuang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Lianli Liu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Lei Wang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Xuejun Gu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Gregory A. Szalkowski
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Ziyi Wang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Christopher Wohlers
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Armine Tayag
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Sara C. Emrich
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Louisa Ustrzynski
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Corinna C. Zygourakis
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Atman Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Melanie Hayden Gephart
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - John Byun
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Erqi Liu Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Elham Rahimy
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (C.C.); (L.L.); (L.W.); (X.G.); (G.A.S.); (Z.W.); (C.W.); (J.B.); (E.L.P.); (E.R.); (S.S.)
| | - David J. Park
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
| | - Steven D. Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (F.C.L.); (S.G.); (D.A.); (Y.S.H.); (A.T.); (S.C.E.); (L.U.); (A.D.); (M.H.G.); (D.J.P.)
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Singh R, Valluri A, Lehrer EJ, Cao Y, Upadhyay R, Trifiletti DM, Lo SS, Redmond KJ, Sahgal A, Nguyen QN, Palmer JD. Clinical Outcomes After Stereotactic Body Radiation Therapy for Nonspinal Bone Metastases: A Systematic Review and Meta-analysis. Int J Radiat Oncol Biol Phys 2024; 119:1099-1109. [PMID: 38220068 DOI: 10.1016/j.ijrobp.2023.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 12/17/2023] [Accepted: 12/31/2023] [Indexed: 01/16/2024]
Abstract
There are limited data available on clinical outcomes after stereotactic body radiation therapy (SBRT) for nonspinal bone metastases. We performed a systematic review and meta-analysis to characterize local control (LC), overall survival (OS), pain response rates, and toxicity after SBRT. The primary outcomes were 1-year LC, incidence of acute and late grade 3 to 5 toxicities, and overall pain response rate at 3 months. The secondary outcome was 1-year OS. The Newcastle-Ottawa scale was used for assessment of study bias, with a median score of 5 for included studies (range, 4-8). Weighted random-effects meta-analyses were conducted to estimate effect sizes. We identified 528 patients with 597 nonspinal bone lesions in 9 studies (1 prospective study and 8 retrospective observational studies) treated with SBRT. The estimated 1-year LC rate was 94.6% (95% CI, 87.0%-99.0%). The estimated 3-month combined partial and complete pain response rate after SBRT was 87.7% (95% CI, 55.1%-100.0%). The estimated combined acute and late grade 3 to 5 toxicity rate was 0.5% (95% CI, 0%-5.0%), with an estimated pathologic fracture rate of 3.1% (95% CI, 0.2%-9.1%). The estimated 1-year OS rate was 71.0% (95% CI, 51.7%-87.0%). SBRT results in excellent LC and palliation of symptoms with minimal related toxicity. Prospective investigations are warranted to further characterize long-term outcomes of SBRT for patients with nonspinal bone metastases.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology and Neurosurgery, James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anisha Valluri
- Department of Radiation Oncology, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yilin Cao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rituraj Upadhyay
- Department of Radiation Oncology and Neurosurgery, James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joshua D Palmer
- Department of Radiation Oncology and Neurosurgery, James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia.
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Cazzato RL, De Marini P, Leonard-Lorant I, Dalili D, Koch G, Autrusseau PA, Mayer T, Weiss J, Auloge P, Garnon J, Gangi A. Percutaneous thermal ablation of sacral metastases: Assessment of pain relief and local tumor control. Diagn Interv Imaging 2021; 102:355-361. [PMID: 33487588 DOI: 10.1016/j.diii.2020.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To retrospectively report on safety, pain relief and local tumor control achieved with percutaneous ablation of sacral bone metastases. MATERIALS AND METHODS From February 2009 to June 2020, 23 consecutive patients (12 women and 11 men; mean age, 60±8 [SD] years; median, 60; range: 48-80 years) with 23 sacral metastases underwent radiofrequency (RFA) or cryo-ablation (CA), with palliative or curative intent at our institution. Patients' demographics and data pertaining to treated metastases, procedure-related variables, safety, and clinical evolution following ablation were collected and analyzed. Pain was assessed with numerical pain rating scale (NPRS). RESULTS Sixteen (70%) patients were treated with palliative and 7 (30%) with curative intent. Mean tumor diameter was 38±19 (SD) mm (median, 36; range: 11-76). External radiation therapy had been performed on five metastases (5/23; 22%) prior to ablation. RFA was used in 9 (39%) metastases and CA in the remaining 14 (61%). Thermo-protective measures and adjuvant bone consolidation were used whilst treating 20 (87%) and 8 (35%) metastases, respectively. Five (22%) minor complications were recorded. At mean 31±21 (SD) (median, 32; range: 2-70) months follow-up mean NPRS was 2±2 (SD) (median, 1; range: 0-6) vs. 5±1 (median, 5; range: 4-8; P<0.001) at the baseline. Three metastases out of 7 (43%) undergoing curative ablation showed local progression at mean 4±4 (SD) (median, 2; range: 1-8) months follow-up. CONCLUSION Percutaneous ablation of sacral metastases is safe and results in significant long-lasting pain relief. Local tumor control seems sub-optimal; however, further investigations are needed to confirm these findings due to paucity of data.
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Affiliation(s)
- Roberto L Cazzato
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France.
| | - Pierre De Marini
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Ian Leonard-Lorant
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Danoob Dalili
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, OX37LD Oxford, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, Strand, WC2R 2LS London, United Kingdom
| | - Guillaume Koch
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Pierre A Autrusseau
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Theo Mayer
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Julia Weiss
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Pierre Auloge
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Julien Garnon
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Afshin Gangi
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000 Strasbourg, France; School of Biomedical Engineering and Imaging Sciences, King's College London, Strand, WC2R 2LS London, United Kingdom
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De la Pinta C. SBRT in non-spine bone metastases: a literature review. Med Oncol 2020; 37:119. [PMID: 33221952 DOI: 10.1007/s12032-020-01442-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Abstract
Stereotactic Body Radiotherapy (SBRT) is a technique for delivering high doses of radiation to tumors while preserving the normal tissues located around this area. Bone metastases are frequent in cancer patients. They can be distressingly painful or may cause pathological fractures. Radiation therapy is a fundamental aspect of treatment for bone metastases. The objective of this study is to analyze the literature on non-spine bone metastasis treated with SBRT, including immobilization, volume delineation, dose and fractionation, local control, side effects, and assessment of response after treatment. Full-text articles written in English language and published in the last 10 years were included in this review and were accessible on PubMed and MEDLINE. We examined 78 articles. A total of 40 studies were included in this review. Most were retrospective studies. The articles included were evaluated for content and validation. The immobilization systems and imaging tests used for tumor delimitation were variable between studies. The use of CTV (Clinical Target Volume) has not been defined. Doses and fractions were variable from 15 to 24 Gy/1 fraction to 24-50 Gy in 3-5 fractions, with local control being around 90% with a low rate of side effects. We review state of the art in SBRT non-spine metastases. SBRT can result in better local control and pain management in non-spine bone metastases patients. We need more research in volume delineation determining whether or not to use CTV and the role of MRI in volume contouring, optimal doses, and fractionation according to histology and a reliable response assessment tool. Studies that compare SBRT to conventional radiotherapy in local control and pain control are needed.
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Tuleasca C, Al-Risi AS, David P, Adam C, Aghakhani N, Parker F. Paragangliomas of the spine: a retrospective case series in a national reference French center. Acta Neurochir (Wien) 2020; 162:831-837. [PMID: 31873794 DOI: 10.1007/s00701-019-04186-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/16/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Primary paragangliomas (PG) of the spine are extremely rare entities. The present study reviews our experience over a period of 30 years. METHODS This is a retrospective, single center, observational study. Patients surgically treated for a spinal PG with confirmed anatomopathological diagnosis were included. The McCormick classification was used as a reference for clinical evaluation. Follow-up MRI and clinical assessment took place at 6 weeks, 3 months, 6 months, and 1 year after surgery and on yearly basis after. RESULTS Six cases have been operated in our institution. The mean age was 37.8 (median 35.5, 30-53). The mean follow-up period was 9.6 years (median 9.5, 1-23). Preoperative duration of symptoms varied between a few hours to 4 years. Low back pain was most common sign. One presented with hemorrhage and acute onset of paraplegia. All patients underwent single surgery, with the exception of one case, which had two surgeries on the same anatomical site and a third surgery on another location of the same tumor type. Preoperatively, McCormick scale was I in four cases, and II and IV in one case, respectively. Postoperatively, all patients in McCormick I retained the same class; one patient in McCormick II passed to McCormick III; the case in McCormick IV recovered to McCormick II. Five of eight surgeries achieved total resection, while two surgeries accomplished a partial microsurgical excision and one a gross total resection. Three patients had spinal leptomeningeal dissemination. Two of them benefited from extended spine radiotherapy, while the other of a "wait-and-scan" policy. Spinal leptomeningeal dissemination was stable in all patients at last follow-up. CONCLUSION We consider surgery as primary treatment in all PG. In our experience, preoperative diagnosis is difficult and caution must be taken to perioperative course in these cases. We do not routinely perform postoperative radiation if there is a residual tumor. We regularly perform clinical and radiological follow-up, so as to be able to document recurrent cases, which have been reported even up to 30 years after primary surgical excision.
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Affiliation(s)
- Constantin Tuleasca
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, Paris, France.
- Faculté de Médecine, Sorbonne Université, Paris, France.
- Centre Hospitalier Universitaire Vaudois (CHUV), Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland.
- Signal Processing Laboratory (LTS 5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland.
- Faculty of Biology and Medicine (FBM), University of Lausanne (Unil), Lausanne, Switzerland.
| | - Ahmed Salim Al-Risi
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, Paris, France
| | - Philippe David
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, Paris, France
| | - Clovis Adam
- Laboratoire de neuropathologie, GHU Paris-Sud-Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Nozar Aghakhani
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, Paris, France
| | - Fabrice Parker
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, Paris, France
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Fridley J, Gokaslan ZL. The evolution of surgical management for vertebral column tumors. J Neurosurg Spine 2019; 30:417-423. [PMID: 30933909 DOI: 10.3171/2018.12.spine18708] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 12/14/2018] [Indexed: 11/06/2022]
Abstract
In BriefThere has been a significant shift in treatment paradigms for both primary and metastatic spine tumors over the last several decades. This article highlights some of the more important treatment advances that practitioners should be made aware of. It is important to not only incorporate these changes into individual practice but also appreciate the treatment trends that herald a significantly different future for spine tumor treatment.
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Voynov G, Heron DE, Burton S, Grandis J, Quinn A, Ferris R, Ozhasoglu C, Vogel W, Johnson J. Frameless Stereotactic Radiosurgery for Recurrent Head and Neck Carcinoma. Technol Cancer Res Treat 2016; 5:529-35. [PMID: 16981796 DOI: 10.1177/153303460600500510] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to assess the feasibility and toxicity of stereotactic radiosurgery (CK-SRS) using the CyberKnife® Frameless Radiosurgery System (Accuray Inc., Sunnyvale, CA) in the management of recurrent squamous cell carcinoma of the head and neck region (SCCHN). Between November 2001 and February 2004, 22 patients with recurrent, previously irradiated SCCHN were treated with CK-SRS. The following endpoints were assessed post-CK-SRS: local control (LC), cause-specific survival (CSS), overall survival (OS), symptom relief, and acute and late toxicity. Kaplan-Meier survival analyses were used to estimate the LC, CSS, and OS rates. Clinical symptoms were graded as “improved,” “stable,” or “progressed” after CK-SRS. Acute and late toxicity were graded according to the National Cancer Institute Common Toxicity Criteria (CTC) scale, version 2.0. Seventeen patients were followed until their death. The median follow-up in the remaining five patients was 19 months (range 11–40 months). The median survival time for the entire cohort was 12 months from the time of CK-SRS. The 2-year LC, CSS, and OS rates were 26%, 26%, and 22%, respectively. After CK-SRS, symptoms were improved or stable in all but one patient who reported increasing pain. The treatment was well tolerated, with one case each of Grade 2 and 3 mucositis. There were no acute Grade 4 or 5 CTC toxicities. There were no late toxicities in this cohort. Frameless stereotactic radiosurgery for recurrent SCCHN is feasible and safe in the setting of high doses of prior irradiation. The majority of patients experienced palliation of disease without excess toxicity.
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Affiliation(s)
- George Voynov
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, USA
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Sahgal A, Chou D, Ames C, Ma L, Lamborn K, Huang K, Chuang C, Aiken A, Petti P, Weinstein P, Larson D. Image-Guided Robotic Stereotactic Body Radiotherapy for Benign Spinal Tumors: The University of California San Francisco Preliminary Experience. Technol Cancer Res Treat 2016; 6:595-604. [DOI: 10.1177/153303460700600602] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We evaluate our preliminary experience using the Cyberknife® Radiosurgery System in treating benign spinal tumors. A retrospective review of 16 consecutively treated patients, comprising 19 benign spinal tumors, was performed. Histologic types included neurofibroma [11], chordoma [4], hemangioma [2], and meningioma [2]. Three patients had Neurofibromatosis Type 1 (NF1). Only one tumor, recurrent chordoma, had been previously irradiated, and as such not considered in the local failure analysis. Local failure, for the remaining 18 tumors, was based clinically on symptom progression and/or tumor enlargement based on imaging. Indications for spine stereotactic body radiotherapy (SBRT) consisted of either adjuvant to subtotal resection (5/19), primary treatment alone (12/19), boost following external beam radiotherapy (1/19), and salvage following previous radiation (1/19). Median tumor follow-up is 25 months (2–37), and one patient (with NF1) died at 12 months from a stroke. The median total dose, number of fractions, and prescription isodose was 21 Gy (10–30 Gy), 3 fx (1–5 fx), 80% (42–87%). The median tumor volume was 7.6 cc (0.2–274.1 cc). The median V100 (volume V receiving 100% of the prescribed dose) and maximum tumor dose was 95% (77–100%) and 26.7 Gy (15.4–59.7 Gy), respectively. Three tumors progressed at 2, 4, and 36 months post-SR (n=18). Two tumors were neurofibromas (both in NF1 patients), and the third was an intramedullary hemangioblastoma. Based on imaging, two tumors had MRI documented progression, three had regressed, and 13 were unchanged (n=18). With short follow-up, local control following Cyberknife spine SBRT for benign spinal tumors appear acceptable.
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Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Dean Chou
- Department of Neurologic Surgery University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Christopher Ames
- Department of Neurologic Surgery University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Lijun Ma
- Department of Radiation Oncology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Kathleen Lamborn
- Department of Epidemiology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Kim Huang
- Department of Radiation Oncology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Cynthia Chuang
- Department of Radiation Oncology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Ashley Aiken
- Department of Radiology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Paula Petti
- Department of Radiation Oncology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - Phil Weinstein
- Department of Neurologic Surgery University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
| | - David Larson
- Department of Radiation Oncology University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143, USA
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Bhattacharya I, Hoskin P. Stereotactic Body Radiotherapy for Spinal and Bone Metastases. Clin Oncol (R Coll Radiol) 2015; 27:298-306. [DOI: 10.1016/j.clon.2015.01.030] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/11/2015] [Accepted: 01/27/2015] [Indexed: 12/25/2022]
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Abstract
Treatment options for metastatic and primary spinal tumors have expanded in recent years, in part due to the advances made in stereotactic radiosurgery. For metastatic spinal tumors, our institution utilizes the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which provides a treatment paradigm based on the neurologic, oncologic, mechanical and systemic status of the patient. Radiosurgery as a supplement to surgical decompression has allowed for less-invasive surgical procedures carrying minimal morbidity while still providing effective local tumor control. Although wide en bloc excision has traditionally been the goal for the treatment of high-grade primary spine tumors, recent studies have shown promise for radiosurgery in providing control in tumors such as chordomas and high-grade sarcomas. Despite advances in radiosurgery, there continues to be limitations in providing effective conformational doses with minimal toxicity to critical structures. One of the ways to circumvent this and supplement external beam radiation is through the use of brachytherapy delivered by radioactive plaque or seeds.
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Affiliation(s)
- James K C Liu
- Spine Tumor Center, Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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11
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Groves ML, Zadnik PL, Kaloostian P, Sui J, Goodwin CR, Wolinsky JP, Witham TF, Bydon A, Gokaslan ZL, Sciubba DM. Epidemiologic, functional, and oncologic outcome analysis of spinal sarcomas treated surgically at a single institution over 10 years. Spine J 2015; 15:110-4. [PMID: 25041727 DOI: 10.1016/j.spinee.2014.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/17/2014] [Accepted: 07/09/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal sarcomas are aggressive tumors that originate from the cells of mesechymal origin, specifically fat, cartilage, bone, and muscle. They are high-grade lesions, and treatment of spinal sarcomas can involve chemotherapy, radiation therapy, and surgery. In the appendicular skeleton, sarcomas are often treated with amputation, however, in the spinal column, surgical resection poses a unique set of challenges. PURPOSE To better understand the optimal treatment regimens and the impact of en bloc or intralesional resection on patient outcome. STUDY DESIGN A cohort of 25 sarcoma patients treated at a single medical institution between 2002 and 2012 was reviewed. PATIENT SAMPLE AND OUTCOME MEASURES Patients were classified by tumor type for subgroup analysis, including chondrosarcoma, osteosarcoma, and other malignant spinal sarcomas. Demographic data for review included patient age, tumor type, tumor location, surgery type, exposure to chemotherapy, and radiation therapy. METHODS Survival statistics and Kaplan-Meier curves were calculated using GraphPad Prism 5.0. The threshold for statistical significance was set at p<.05. Unpaired, two-tailed, equal variance t tests were performed for statistical analyses in Microsoft Excel 2010. RESULTS Twenty-five patients with spinal sarcomas were treated over the 10-year period. Diagnosis included chondrosarcoma (n=9), osteosarcoma (n=4), and other sarcomas (n=12). Mean age at the time of diagnosis was 42 years. Pain was present at the time of diagnosis in 92% patients. Median survival after surgery was 59.5 months for chondrosarcoma, undefined for other sarcomas, and 16.8 months for osteosarcoma. Median survival after en bloc resection was undefined. Median survival after intralesional resection was 17.8 months. The difference in median survival between en bloc and intralesional resection was statistically significant (p=.049). CONCLUSIONS The authors report the largest cohort of patients with spinal sarcoma. Median survival in this cohort was the longest for patients with sarcomas of varying pathologies. Median survival was longer for chondrosarcoma. En bloc resection demonstrated a survival advantage over intralesional resection. Long-term follow-up is needed for patients with spinal sarcoma to establish definitive survival data.
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Affiliation(s)
- Mari L Groves
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Patricia L Zadnik
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Paul Kaloostian
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Jackson Sui
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - C Rory Goodwin
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Jean-Paul Wolinsky
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Timothy F Witham
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Ali Bydon
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Ziya L Gokaslan
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA
| | - Daniel M Sciubba
- The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-185, Baltimore, MD 21205, USA.
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12
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Abstract
OBJECTIVES The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis, and surgical management of the malignant primary sacral tumors. METHODS A PubMed search was conducted using a combination of the following items: (('Spinal Neoplasms'[Mesh]) AND 'Sacrum'[Mesh]) NOT ('Metastasis' OR 'Metastases' OR 'Benign'). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors. RESULTS Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and oncologic outcome, and the recurrence-free and disease-specific survival of this rare patient category. DISCUSSION Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols.
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Abstract
The number of patients who will develop metastatic spinal tumors is estimated to be between 5 and 10% of all cancer patients. As the therapy for systemic cancer improves, the number of patients developing symptomatic spinal tumors that require local therapy will increase. Over the last 10 years there has been a dramatic evolution in our ability to treat spinal tumors. These advances have not only been created by improvements in surgical techniques and instrumentation, but also developments in radiographic imaging, radiation therapy and chemotherapy. It is important for spine surgeons, radiologists, and radiation and medical oncologists to continue developing techniques for spinal salvage that will improve pain relief, achieve mechanical stability, improve or maintain neurologic function and sustain local tumor control. The evolution of these technologies will help to provide palliation and improve quality of life for patients with metastatic disease.
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Affiliation(s)
- Mark H Bilsky
- Neurosurgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Lo SS, Chang EL, Yamada Y, Sloan AE, Suh JH, Mendel E. Stereotactic radiosurgery and radiation therapy for spinal tumors. Expert Rev Neurother 2014; 7:85-93. [PMID: 17187488 DOI: 10.1586/14737175.7.1.85] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spinal tumors constitute 15% of all CNS neoplasms. Radiation therapy can be administered for palliation of pain and spinal cord compression. However, the amount of radiation that can be administered is often limited by the tolerance of the spinal cord, especially in cases where prior radiation therapy has been given. Stereotactic radiosurgery and radiotherapy allow the delivery of a higher dose of radiation to spinal lesions, while limiting the spinal cord dose to below the tolerance level. These are technically demanding procedures and should be performed only when proper equipment and expertise are available. Data on spinal stereotactic radiosurgery and radiotherapy have emerged in recent years. This review summarizes the clinical applications of stereotactic radiosurgery and radiotherapy for spinal tumors.
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Affiliation(s)
- Simon S Lo
- Department of Radiation Medicine, Ohio State University Medical Center, Columbus, OH 43210, USA.
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15
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Azar AT, Eljamel MS. Medical Robotics. ROBOTICS 2013. [DOI: 10.4018/978-1-4666-4607-0.ch054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Medical robotics is an interdisciplinary field that focuses on developing electromechanical devices for clinical applications. The goal of this field is to enable new medical techniques by providing new capabilities to the physician or by providing assistance during surgical procedures. Medical robotics is a relatively young field, as the first recorded medical application occurred in 1985 for a brain biopsy. It has tremendous potential for improving the precision and capabilities of physicians when performing surgical procedures, and it is believed that the field will continue to grow as improved systems become available. This chapter offers a comprehensive overview about medical robotics field and its applications. It begins with an introduction to robotics, followed by a historical review of their use in medicine. Clinical applications in several different medical specialties are discusssed. The chapter concludes with a discussion of technology challenges and areas for future research.
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Abstract
Medical robotics is an interdisciplinary field that focuses on developing electromechanical devices for clinical applications. The goal of this field is to enable new medical techniques by providing new capabilities to the physician or by providing assistance during surgical procedures. Medical robotics is a relatively young field, as the first recorded medical application occurred in 1985 for a brain biopsy. It has tremendous potential for improving the precision and capabilities of physicians when performing surgical procedures, and it is believed that the field will continue to grow as improved systems become available. This chapter offers a comprehensive overview about medical robotics field and its applications. It begins with an introduction to robotics, followed by a historical review of their use in medicine. Clinical applications in several different medical specialties are discusssed. The chapter concludes with a discussion of technology challenges and areas for future research.
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Thariat J, Leysalle A, Vignot S, Marcy PY, Lacout A, Bera G, Lagrange JL, Clezardin P, Chiras J. Traitement local ablatif de la maladie oligométastatique osseuse (hors chirurgie). Cancer Radiother 2012; 16:330-8. [DOI: 10.1016/j.canrad.2012.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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Feiz-Erfan I, Fox BD, Nader R, Suki D, Chakrabarti I, Mendel E, Gokaslan ZL, Rao G, Rhines LD. Surgical treatment of sacral metastases: indications and results. J Neurosurg Spine 2012; 17:285-91. [PMID: 22900506 DOI: 10.3171/2012.7.spine09351] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hematogenous metastases to the sacrum can produce significant pain and lead to spinal instability. The object of this study was to evaluate the palliative benefit of surgery in patients with these metastases. METHODS The authors retrospectively reviewed all cases involving patients undergoing surgery for metastatic disease to the sacrum at a single tertiary cancer center between 1993 and 2005. RESULTS Twenty-five patients (21 men, 4 women) were identified as having undergone sacral surgery for hematogenous metastatic disease during the study period. Their median age was 57 years (range 25-71 years). The indications for surgery included palliation of pain (in 24 cases), need for diagnosis (in 1 case), and spinal instability (in 3 cases). The most common primary disease was renal cell carcinoma. Complications occurred in 10 patients (40%). The median overall survival was 11 months (95% CI 5.4-16.6 months). The median time from the initial diagnosis to the diagnosis of metastatic disease in the sacrum was 14 months (95% CI 0.0-29.3 months). The numerical pain scores (scale 0-10) were improved from a median of 8 preoperatively to a median of 3 postoperatively at 90 days, 6 months, and 1 year (p < 0.01). Postoperative modified Frankel grades improved in 8 cases, worsened in 3 (due to disease progression), and remained unchanged in 14 (p = 0.19). Among patients with renal cell carcinoma, the median overall survival was better in those in whom the sacrum was the sole site of metastatic disease than in those with multiple sites of metastatic disease (16 vs 9 months, respectively; p = 0.053). CONCLUSIONS Surgery is effective to palliate pain with acceptable morbidity in patients with metastatic disease to the sacrum. In the subgroup of patients with renal cell carcinoma, those with the sacrum as their solitary site of metastatic disease demonstrated improved survival.
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Affiliation(s)
- Iman Feiz-Erfan
- Department of Neurosurgery, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas 77230-1402, USA
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The management of sacral schwannoma: report of four cases and review of literature. Sarcoma 2011; 2008:845132. [PMID: 18779869 PMCID: PMC2528062 DOI: 10.1155/2008/845132] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 07/28/2008] [Indexed: 11/18/2022] Open
Abstract
Sacral schwannoma is a rare retrorectal tumor in adults. Postoperative sacral neurological deficit is difficult to avoid. Currently, there is no established consensus regarding best treatment options. We present the management and outcomes of sacral schwannoma in 4 patients treated with intralesional curettage and postoperative radiation. There were 3 women and one man (average age: 45.5 years) with long duration of lumbosacral pain with or without radiculopathy. Intralesional curettage was performed by posterior approach and adjuvant radiation therapy with dosage of 5000–6600 cGy was given after surgery. The mean follow-up time was 18 months (range 4–23 months). Symptoms of radiculopathy had decreased in all patients. The recent radiographic findings show evidence of sclerosis at the sacrum one year postoperatively, but the size was unchanged. Intralesional curettage and adjuvant radiation therapy can be used in the treatment of sacral schwannoma to relieve symptoms and preserve neurological function.
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Grimm J, LaCouture T, Croce R, Yeo I, Zhu Y, Xue J. Dose tolerance limits and dose volume histogram evaluation for stereotactic body radiotherapy. J Appl Clin Med Phys 2011; 12:3368. [PMID: 21587185 PMCID: PMC5718687 DOI: 10.1120/jacmp.v12i2.3368] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 10/14/2010] [Accepted: 01/10/2011] [Indexed: 12/15/2022] Open
Abstract
Almost 20 years ago, Emami et al. presented a comprehensive set of dose tolerance limits for normal tissue organs to therapeutic radiation, which has proven essential to the field of radiation oncology. The paradigm of stereotactic body radiotherapy (SBRT) has dramatically different dosing schemes but, to date, there has still been no comprehensive set of SBRT normal organ dose tolerance limits. As an initial step toward that goal, we performed an extensive review of the literature to compare dose limits utilized and reported in existing publications. The impact on dose tolerance limits of some key aspects of the methods and materials of the various authors is discussed. We have organized a table of 500 dose tolerance limits of normal structures for SBRT. We still observed several dose limits that are unknown or not validated. Data for SBRT dose tolerance limits are still preliminary and further clinical trials and validation are required. This manuscript presents an extensive collection of normal organ dose tolerance limits to facilitate both clinical application and further research.
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Affiliation(s)
- Jimm Grimm
- Department of Radiation Oncology, Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA.
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21
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Ruggieri P, Mavrogenis AF, Ussia G, Angelini A, Papagelopoulos PJ, Mercuri M. Recurrence after and complications associated with adjuvant treatments for sacral giant cell tumor. Clin Orthop Relat Res 2010; 468:2954-61. [PMID: 20623262 PMCID: PMC2947682 DOI: 10.1007/s11999-010-1448-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The best treatment of giant cell tumor of the sacrum is controversial. It is unclear whether adjuvant treatment with intralesional surgery reduces recurrences or increases morbidity. QUESTIONS/PURPOSES We therefore asked whether adjuvants altered recurrence rates and complications after intralesional surgery for sacral giant cell tumors. METHODS We retrospectively studied 31 patients with sacral giant cell tumors treated with intralesional surgery with and without adjuvants. Survival to local recurrence was evaluated using Kaplan-Meier analysis. The differences in survival to local recurrence with and without adjuvants were evaluated using multivariate Cox regression analysis. Complications were recorded from clinical records and images. The minimum followup was 36 months (median, 108 months; range, 36-276 months). RESULTS Overall survival to local recurrence was 90% at 60 and 120 months. Survival to local recurrence with and without radiation was 91% and 89%, with and without embolization was 91% and 86%, and with and without local adjuvants was 88% and 92%, respectively. Adjuvants had no influence on local recurrence. Mortality was 6%: one patient died at 14 days postoperatively from a massive pulmonary embolism and another patient had radiation and died of a high-grade sarcoma. Fifteen of the 31 patients (48%) had one or more complications: eight patients (26%) had wound complications and seven patients (23%) had massive bleeding during curettage with hemodynamic instability. L5-S2 neurologic deficits decreased from 23% preoperatively to 13% postoperatively; S3-S4 deficits increased from 16% to 33%. CONCLUSIONS Adjuvants did not change the likelihood of local recurrence when combined with intralesional surgery but the complication rate was high.
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Affiliation(s)
- Pietro Ruggieri
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | | | - Giuseppe Ussia
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | - Andrea Angelini
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | | | - Mario Mercuri
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
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Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, Rhines LD, Gokaslan ZL. Diagnosis and management of metastatic spine disease. A review. J Neurosurg Spine 2010; 13:94-108. [PMID: 20594024 DOI: 10.3171/2010.3.spine09202] [Citation(s) in RCA: 259] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.
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Affiliation(s)
- Daniel M Sciubba
- Departments of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA.
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Sheehan JP, Shaffrey CI, Schlesinger D, Williams BJ, Arlet V, Larner J. Radiosurgery in the treatment of spinal metastases: tumor control, survival, and quality of life after helical tomotherapy. Neurosurgery 2010; 65:1052-61; discussion 1061-2. [PMID: 19934964 DOI: 10.1227/01.neu.0000359315.20268.73] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The effectiveness and limitations of spinal radiosurgery using a helical TomoTherapy system for the treatment of spinal metastases are reviewed in this article. METHODS This is a retrospective review of patients who underwent stereotactic radiosurgery for spinal metastases between July 2004 and December 2007. Radiographic follow-up consisted of magnetic resonance imaging to assess tumor growth control as well as pre- and posttreatment x-rays, which were used to measure changes in segmental angulation and deformity. Clinical performance was assessed using the Karnofsky Performance Scale, Oswestry Disability Index, and visual analog scale. RESULTS Forty patients were treated for 110 metastatic tumors (range, 1-6 tumors per patient). The mean age at the time of radiosurgical treatment was 67 years (age range, 35-81 years). Twenty-three patients (57.5%) had undergone previous surgical resection. Pain was the most common presenting symptom, seen in 32 patients (80%). The mean Oswestry Disability Index score at presentation was 43 (range, 20-90), and the mean visual analog scale score was 6.2 (range, 0-10). The mean radiosurgical dose to the tumor was 17.3 Gy (range, 10-24 Gy). At a mean follow-up duration of 12.7 months (range, 4-32 months), decreased or stable tumor volume was seen in 90 (82%) of the tumors treated. There was improvement in pain in 34 patients (85%). The mean postradiosurgical Oswestry Disability Index score was 25 (range, 10-90), whereas the postradiosurgical visual analog scale score was 3.2 (range, 0-9). Progression of kyphosis was the most common radiographic sequela, experienced by 73% of patients alive at 12 months, with a mean change in angulation of 7.3 +/- 4.5 degrees. CONCLUSION Radiosurgery is effective as either primary or adjunctive treatment of metastatic tumors of the spine.
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Affiliation(s)
- Jason P Sheehan
- Departments of Neurological Surgery and Radiation Oncology, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908, USA.
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Fiducial-free real-time image-guided robotic radiosurgery for tumors of the sacrum/pelvis. Radiother Oncol 2009; 93:37-44. [DOI: 10.1016/j.radonc.2009.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 05/15/2009] [Accepted: 05/27/2009] [Indexed: 11/19/2022]
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopedics, ATTIKON General University Hospital, Athens University Medical School, Athens, Greece
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Sciubba DM, Petteys RJ, Garces-Ambrossi GL, Noggle JC, McGirt MJ, Wolinsky JP, Witham TF, Gokaslan ZL. Diagnosis and management of sacral tumors. J Neurosurg Spine 2009; 10:244-56. [PMID: 19320585 DOI: 10.3171/2008.12.spine08382] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sacral tumors pose significant challenges to the managing physician from diagnostic and therapeutic perspectives. Although these tumors are often diagnosed at an advanced stage, patients may benefit from good clinical outcomes if an aggressive multidisciplinary approach is used. In this review, the epidemiology, clinical presentation, imaging characteristics, treatment options, and published outcomes are discussed. Special attention is given to the specific anatomical constraints that make tumors in this region of the spine more difficult to effectively manage than those in the mobile portions of the spine.
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Affiliation(s)
- Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Papatheofanis FJ, Williams E, Chang SD. Cost-utility analysis of the cyberknife system for metastatic spinal tumors. Neurosurgery 2009; 64:A73-83. [PMID: 19165078 DOI: 10.1227/01.neu.0000341205.37067.de] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Using decision analysis, a cost-utility study evaluated the cost-effectiveness of CyberKnife (Accuray, Inc., Sunnyvale, CA) stereotactic radiosurgery (SRS) in comparison to external beam radiation therapy in the treatment of metastatic spinal malignancies. METHODS The published literature provided evidence on the effectiveness of the comparator interventions in the absence of primary outcomes data. Costs of care were derived from Centers for Medicare and Medicaid Services fee schedules. A Markov model was constructed from the payer perspective to simulate the outcomes of patients undergoing nonchemotherapeutic interventions for metastatic spinal tumors. Because cancer therapies bear significant health and economic consequences, the impact of treatment-related toxicities was integrated into the model. Given the terminal nature of these conditions and the limited life expectancy of the patient population, the time horizon for the analysis was limited to 12 months. RESULTS Patients treated with CyberKnife SRS gained an additional net health benefit of 0.08 quality-adjusted life year; the calculated cost of CyberKnife SRS was $1933 less than external beam radiation therapy for comparable effectiveness. The incremental cost per benefit for this strategy ($41 500 per quality-adjusted life year) met payers' willingness-to-pay criteria. CONCLUSION Cost-utility analysis demonstrated that CyberKnife SRS was a superior, cost-effective primary intervention for patients with metastatic spinal tumors compared with conventional external beam radiation therapy.
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Affiliation(s)
- Frank J Papatheofanis
- Division of Health Policy, Department of Radiology and Economics, Rebecca and John Moores Cancer Center, University of California, San Diego, California 92103-8758, USA.
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Calcerrada Díaz-Santos N, Blasco Amaro JA, Cardiel GA, Andradas Aragonés E. The safety and efficacy of robotic image-guided radiosurgery system treatment for intra- and extracranial lesions: A systematic review of the literature. Radiother Oncol 2008; 89:245-53. [DOI: 10.1016/j.radonc.2008.07.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 07/18/2008] [Accepted: 07/20/2008] [Indexed: 10/21/2022]
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Technology Insight: image-guided robotic radiosurgery—a new approach for noninvasive ablation of spinal lesions. ACTA ACUST UNITED AC 2008; 5:405-14. [DOI: 10.1038/ncponc1131] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 10/25/2007] [Indexed: 11/09/2022]
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Abstract
Giant cell tumors are benign but locally aggressive neoplasms that typically affect the extremities. When involving the spine, the tumors occur predominantly in the sacrum. Gross total resection of the tumor with wide margins yields good results in terms of survival. However, it carries a significant potential for morbidity and disability. Subtotal resection with adjuvant radiation carries a risk for recurrence or, more concerning, sarcomatous malignant transformation. Endovascular tumor embolizations have also been attempted to control unresectable tumors, and have been performed with moderate degrees of success. Outcomes are analyzed outcomes following surgery, radiation therapy, and tumor embolization.
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Affiliation(s)
- Neal Luther
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital/Cornell, Room A-969, 525 East 68th Street, New York, NY 10021, USA
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Barnett GH, Linskey ME, Adler JR, Cozzens JW, Friedman WA, Heilbrun MP, Lunsford LD, Schulder M, Sloan AE. Stereotactic radiosurgery--an organized neurosurgery-sanctioned definition. J Neurosurg 2007; 106:1-5. [PMID: 17240553 DOI: 10.3171/jns.2007.106.1.1] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Gene H Barnett
- Taussig Cancer Center, Brain Tumor Institute, Cleveland, Ohio 44195, USA.
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Sansur CA, Pouratian N, Dumont AS, Schiff D, Shaffrey CI, Shaffrey ME. Part II: Spinal-cord neoplasms—primary tumours of the bony spine and adjacent soft tissues. Lancet Oncol 2007; 8:137-47. [PMID: 17267328 DOI: 10.1016/s1470-2045(07)70033-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Primary tumours of the bony spine and adjacent soft tissues most frequently present with pain although neurological deficits and spinal deformity can be present too. Knowledge of the spectrum of lesions that can affect the bony spine and the surrounding soft tissues is crucial in directing appropriate investigation and treatment. Patients need individualised approaches and treatment plans in view of the variations in tumour aggressiveness, spinal level, location within the vertebral body or posterior elements, involvement of soft tissues and structures surrounding the vertebral column, neurological deficits, and spinal instability.
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Affiliation(s)
- Charles A Sansur
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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Ho AK, Fu D, Cotrutz C, Hancock SL, Chang SD, Gibbs IC, Maurer CR, Adler JR. A Study of the Accuracy of CyberKnife Spinal Radiosurgery Using Skeletal Structure Tracking. Oper Neurosurg (Hagerstown) 2007; 60:ONS147-56; discussion ONS156. [PMID: 17297377 DOI: 10.1227/01.neu.0000249248.55923.ec] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
Objective:
New technology has enabled the increasing use of radiosurgery to ablate spinal lesions. The first generation of the CyberKnife (Accuray, Inc., Sunnyvale, CA) image-guided radiosurgery system required implanted radiopaque markers (fiducials) to localize spinal targets. A recently developed and now commercially available spine tracking technology called Xsight (Accuray, Inc.) tracks skeletal structures and eliminates the need for implanted fiducials. The Xsight system localizes spinal targets by direct reference to the adjacent vertebral elements. This study sought to measure the accuracy of Xsight spine tracking and provide a qualitative assessment of overall system performance.
Methods:
Total system error, which is defined as the distance between the centroids of the planned and delivered dose distributions and represents all possible treatment planning and delivery errors, was measured using a realistic, anthropomorphic head-and-neck phantom. The Xsight tracking system error component of total system error was also computed by retrospectively analyzing image data obtained from eleven patients with a total of 44 implanted fiducials who underwent CyberKnife spinal radiosurgery.
Results:
The total system error of the Xsight targeting technology was measured to be 0.61 mm. The tracking system error component was found to be 0.49 mm.
Conclusion:
The Xsight spine tracking system is practically important because it is accurate and eliminates the use of implanted fiducials. Experience has shown this technology to be robust under a wide range of clinical circumstances.
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Affiliation(s)
- Anthony K Ho
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California 94305-5304, USA.
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Muacevic A, Staehler M, Drexler C, Wowra B, Reiser M, Tonn JC. Technical description, phantom accuracy, and clinical feasibility for fiducial-free frameless real-time image-guided spinal radiosurgery. J Neurosurg Spine 2006; 5:303-12. [PMID: 17048766 DOI: 10.3171/spi.2006.5.4.303] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors describe the technical application of the Xsight Spine Tracking System, data pertaining to accuracy obtained during phantom testing, and the initial clinical feasibility of using this fiducial-free alignment system with the CyberKnife in spinal radiosurgery.
Methods
The Xsight integrates with the CyberKnife radiosurgery system to eliminate the need for implantation of radiographic markers or fiducials prior to spinal radiosurgery. It locates and tracks spinal lesions relative to spinal osseous landmarks. The authors performed 10 end-to-end tests of accuracy using an anthropomorphic head and cervical spine phantom. Xsight was also used in the treatment of 50 spinal lesions in 42 patients. Dose planning was based on 1.5-mm-thick computed tomography slices in which an inverse treatment planning technique was used.
All lesions could be treated using the fiducial-free tracking procedure. Phantom tests produced an overall mean targeting error of 0.52 ± 0.22 mm. The setup time for patient alignment averaged 6 minutes (range 2–45 minutes). The treatment doses varied from 12 to 25 Gy to the median prescription isodose of 65% (40 to 70%). The tumor volume ranged between 1.3 and 152.8 cm3The mean spinal cord volume receiving greater than 8 Gy was 0.69 ± 0.35 cm3No short-term adverse events were noted during the 1- to 7-month follow-up period. Axial and radicular pain was relieved in 14 of 15 patients treated for pain.
Conclusions
Fiducial-free tracking is a feasible, accurate, and reliable tool for radiosurgery of the entire spine. By eliminating the need for fiducial implantation, the Xsight system offers patients noninvasive radiosurgical intervention for intra- and paraspinal tumors.
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Zhou T, Tang J, Dieterich S, Cleary K. A robotic 3-D motion simulator for enhanced accuracy in CyberKnife stereotactic radiosurgery. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.ics.2004.03.296] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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