Outcomes Specific to Spinal Metastases with Paraspinal Disease Extension Following Spine Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

Spinal metastases with paraspinal disease (PD) extension are known to have worse outcomes following stereotactic body radiotherapy (SBRT). Characteristics of the PD itself have not been investigated to determine the impact on outcomes such as local control, which is the purpose of this study.

MATERIALS/METHODS

We retrospectively reviewed those patients who had SBRT for spinal metastases with PD disease, identified from a prospectively maintained database. Spinal metastases previously irradiated or surgical resected were excluded. The extent of PD was classified as involving the rib, neuroforamina, and muscle invasion. The gross tumor volume of PD (GTV_PD) and the clinical target volume of PD (CTV_PD) were segregated from the bony compartments based on the treatment plan contours. The outcomes of interest included the cumulative risk of local failure (LF), re-irradiation rates (ReRT), and overall survival (OS). LF and ReRT were estimated for each treated sites using the competing risk model (death as the competing risk), while OS was evaluated per patient using the Kaplan Meier method.

RESULTS

A total of 86 patients with 96 spinal metastases sites with PD were included. Of the 96 treated sites, 65% (62/96), 29% (28/96) and 6% (6/96) of PD spanned 1, 2, and 3 vertebral levels respectively. The median follow-up was 12.4months (range: 0.6-100months). The 6- and 12-month OS for the cohort was 81% and 51%, respectively. 33/86 (38%) patients had radioresistant cancer (gastrointestinal, renal cell carcinoma, thyroid, sarcoma, or melanoma). Involvement of rib, neuroforamina and muscle invasion were observed in 39% (37/96), 65% (62/96) and 21% (20/96) of the treated sites, respectively. Epidural disease was present in 57% (55/96) of treated sites. The median GTV_PD volume was 7cc (range: 0.3-114cc), and the median CTV_PD volume was 24cc (range: 0.4-248cc). The prescribed doses were 24 Gy/2 fractions (fx) (80%), 28 Gy/2 fx (10%) and 30 Gy/4 fx (10%). There were 84 treated sites with at least one post-treatment MRI available for LF assessment. The crude LF risk was 32% (27/84), and the 6- and 12-month cumulative LF rates were 12% and 28%, respectively. There was a trend towards an increased risk of LF when PD involved the rib (35% vs 24% at 1 year respectively, P = 0.07) and muscle (67% vs 20% at 1 year respectively; P = 0.06), but no difference in LF for neuroforamina involvement (26% vs 34% at 1 year respectively, P = 0.5). There were no differences in LF based on cancer radioresistance (P = 0.6), GTV_PD volume (P = 0.3) or CTV_PD volume (P = 0.4). Of the 96 treated sites, 14% (14/96) were re-irradiated (9 with repeat SBRT and 5 with conventional EBRT) at a median of 15 months (range: 4.7-59 months) post initial SBRT. The cumulative incidence of ReRT at 6- and 12-months were 1.2% and 7.3%, respectively.

CONCLUSION

PD involving adjacent rib and muscle may be associated with worse LF following SBRT. Further expansion of the cohort and dosimetric analyses are ongoing.

Molecular Status Predicts for Local Control in Patients with Non-Small Cell Lung Cancer Spinal Metastases Following Spine Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

We report outcomes after spine stereotactic body radiotherapy (SBRT) in patients with metastatic non-small cell lung cancer (NSCLC), to determine the significance of programmed death-ligand 1 (PD-L1) status and epidermal growth factor (EGFR) mutation on local failure (LF) rate.

MATERIALS/METHODS

A total of 165 patients and 389 spinal segments were retrospectively reviewed from 2009 to 2021. Baseline patient characteristics, treatment and outcomes were abstracted. Primary endpoint was LF and secondary outcomes included overall survival (OS) and vertebral compression fracture (VCF) rates. OS was estimated using the Kaplan-Meier method. Cumulative LF and VCF rates were calculated using competing risk analysis method. Multivariable analysis (MVA) evaluated factors predictive of LF and VCF.

RESULTS

Median follow-up was 13 months (range, 0.5-95 months). Median OS was 18.4 months (95% CI 11.4-24.6). Median age was 67 years (range, 28.2-89.9). 52% were female, 76% had an adenocarcinoma histology and 61% had a smoking history. 49/165 (29%) had an EGFR mutation. PD-L1 status was analyzed in 109/165 (66%) patients with 16% PD-L1 ≥ 50%, 20% PD-L1 1-49% and 35% PD-L1 <1%. Of 389 segments, 79% were de novo and 21% were previously radiated. At baseline, 35% had a VCF, 27% had epidural disease, 27% had paraspinal extension, and 49% were Spinal Instability in Neoplasia Score (SINS) stable. 239/389 (61%) were treated with either 24 or 28 Gy in 2 SBRT fractions. Within 1 month of SBRT, 39/165 (24%) had a tyrosine kinase inhibitor, 27/165 (16%) immunotherapy (IO) with or without chemotherapy, and 31/165 (19%) chemotherapy alone. LF cumulative incidence at 1- and 2-years was 16.3% (95% CI 12.8-20.3%) and 25.4% (95% CI 20.9%-30%), respectively. EGFR positivity (p<0.0001), PD-L1≥50% (p = 0.013) and treatment with IO within 1 month of SBRT (p = 0.004) predicted for improved local control on MVA. The 1- and 2-year LF rate in EGFR-positive vs. negative patients were 12.9% vs. 16.6% and 17.7% vs. 28.8%, respectively, and in those PD-L1 ≥50% vs PD-L1<50% were 7.8% vs. 19.6% and 7.8% vs. 38.1% respectively. Cumulative incidence of VCF at 1- and 2-years were 6.6% (95% CI 4.4-9.4%) and 8.8% (95% CI 6.1-12.0%). MVA identified prior SBRT to the same treated segment (P<0.0001) and a baseline VCF (p<0.0001) as significant predictors. 18/389 (4.6%) had radiation-induced radiculopathy and no radiation myelopathy events detected.

CONCLUSION

We identify the predictive utility of EGFR mutation and PD-L1 ≥50% status on local control in NSCLC patients with spinal metastases treated with spine SBRT, and a therapeutic benefit with peri-SBRT IO.

Stereotactic Body Radiotherapy (SBRT) for Sacral Metastases: Deviation from Recommended Target Volume Delineation Predicts Higher Risk of Local Failure

PURPOSE/OBJECTIVE(S)

A international consensus recommendation was published to guide target volume delineation specific to sacral stereotactic body radiotherapy (SBRT). We report outcomes after sacrum SBRT, focusing on the impact of contouring deviation on local failure (LF) risk, with an aim to validate this guideline.

MATERIALS/METHODS

All patients who underwent SBRT to any level between S1 and S5 from 2010 to 2021 were identified from a prospectively maintained institutional database. The primary outcome was magnetic resonance-based LF. Secondary outcomes included vertebral compression fracture (VCF) and overall survival (OS). Cumulative LF and VCF rates were calculated per segment using the competing risk analysis method. Kaplan Meier analysis was used to estimate OS per patient. Cox proportional hazards model was used to assess predictive factors of LF, VCF, and OS.

RESULTS

A total of 215 treated sacral segments in 112 patients were retrospectively reviewed. The median follow-up was 13 months (range, 0.4-116.9). The median age was 64 years (range, 18-86), and 56% were male. Most patients (52%) had treatment to a single segment. The median clinical target volume (CTV) was 129.2 cc (range, 5.8-753.5). Most segments were treated with 30 Gy/4 fractions (51%), 24 Gy/2 fractions (31%), or 30 Gy/5 fractions (10%). Thirty-one percent of segments were of radioresistant histology (gastrointestinal, kidney, melanoma, sarcoma, or thyroid primary), and 51% had extraosseous disease. Sixteen percent of segments were under-contoured per consensus guidelines, with incomplete coverage of the involved sector (71%), omission of the adjacent uninvolved sector (17%), or both (11%) as the causes for deviation. The cumulative incidence of LF was 18.4% (95% CI 13.5-24.0) at 12-months and 23.1% (95% CI 17.6-29.0) at 24-months. On multivariate analysis (MVA), under-contouring (HR 2.4, 95% CI 1.3-4.7, p = 0.008), radioresistant histology (HR 2.4, 95% CI 1,4-4.1, p = 0.001), and extraosseous extension (HR 2.5, 95% CI 1.3-4.7, p = 0.005) were predictors of increased risk of LF. The LF rates at 12/24-months were 15.1%/18.8% for segments contoured per guideline versus 31.4%/40.0% for those under-contoured. The cumulative incidence of VCF was 7.1% (95% CI 4.1-11.1) at 12-months and 12.3% (95% CI 8.2-17.2) at 24-months. On MVA, female gender was the only risk factor for VCF (HR 2.3, 95% CI 1.1-5.2, p = 0.04). The median OS was 29.5 months (95% CI 17.5-59.2). On MVA, primary kidney (HR 4.7, 95% CI 1.7-12.5, p = 0.002) or lung histology (HR 3.4, 95% CI 1.3-8.5, p = 0.010), the presence of liver (HR 2.8, 95% CI 1.2-6.4, p = 0.016) or lung (HR 2.5, 95% CI 1.3-5.1, p = 0.008) metastases, ECOG performance status 2 or 3 (HR 3.3, 95% CI 1.2-8.2, p = 0.013), and the presence of sensory or motor deficit (HR 2.6, 95% CI 1.2-5.4, p = 0.012) were prognostic for worse OS.

CONCLUSION

Sacral SBRT is associated with high rates of efficacy and an acceptable VCF risk. Adherence to target volume delineation consensus guidelines reduces the risk of LF.

Virtual reality as a learning tool in spinal anatomy and surgical techniques

Background

Surgical simulation is a valuable educational tool for trainees to practice in a safe, standardized, and controlled environment. Interactive feedback-based virtual reality (VR) has recently moved to the forefront of spine surgery training, with most commercial products focusing on instrumentation. There is a paucity of learning tools directed at decompression principles. The purpose of this study was to evaluate the efficacy of VR simulation and its educational role in learning spinal anatomy and decompressive techniques.

Methods

A VR simulation module was created with custom-developed software. Orthopaedic and neurosurgical trainees were prospectively enrolled and interacted with patient-specific 3D models of lumbar spinal stenosis while wearing a headset. A surgical toolkit allowed users to perform surgical decompression, specifically removing soft tissues and bone. The module allowed users to perform various techniques in posterior decompressions and comprehend anatomic areas of stenosis. Pre- and post-module testing, and utility questionnaires were administered to provide both quantitative and qualitative evaluation of the module as a learning device.

Results

28 trainees were enrolled (20-orthopaedic, 8-neurosurgery) in the study. Pre-test scores on anatomic knowledge progressively improved and showed strong positive correlation with year-in-training (Pearson's r = 0.79). Following simulation, the average improvement in post-test scores was 11.4% in junior trainees (PGYI-III), and 1.0% in senior trainees (PGYIII-Fellows). Knowledge improvement approached statistical significance amongst junior trainees (p = 0.0542). 89% of participants found the VR module useful in understanding and learning the pathology of spinal stenosis. 71% found it useful in comprehending decompressive techniques. 96% believed it had utility in preoperative planning with patient-specific models.

Conclusions

Our original VR spinal decompression simulation has shown to be overwhelmingly positively received amongst trainees as both a learning module of patho-anatomy and patient-specific preoperative planning, with particular benefit for junior trainees.

Lymphoma recurrence 5 years or more following diffuse large B-cell lymphoma: Clinical characteristics and outcome

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Background: Diffuse large B-cell lymphoma (DLBCL) usually relapses early following treatment but some relapses happen 5 years or later. Few data exist regarding clinical characteristics and outcome of these patients (pts). Methods: We performed a retrospective analysis of all pts from two centers in Lyon/France between 1980–2003 who presented a biopsy proven relapse 5 years or later following diagnosis of DLBCL. All available biopsies were revised and immunohistochemistry (IHC) completed. Results: Among 1492 pts with DLBCL, 54 were eligible. Clinical characteristics at diagnosis were: median age 57 y; stage I-II 63% (34/54); IPI low/low intermediate 84% (41/49) and extranodal involvement (EN) 66% (35/53). IHC at diagnosis: CD20 100% (46/46), CD10 28% (10/36), bcl-6 53% (9/17), MUM1 48% (11/23), bcl-2 68% (19/28), germinal-center phenotype (GC) 57% (12/21) and non-GC 43% (9/21). 47/53 received CHOP/ACVBP-like regimens, 1 autologous transplantation (ASCT) and 1 rituximab. Median time from diagnosis to relapse was 7.4 years (5–20.5 years). 44 pts (81%) had DLBCL histology at time of relapse and 10 pts (19%) indolent histology. MUM1 expression at diagnosis was associated with DLBCL histology at relapse (p=0.037). Clinical characteristics at relapse were: median age 66 y; stage I-II 48% (26/54); 73% (31/43) with DLBCL at relapse had EN. 54% (15/28) with DLBCL at relapse had a GC phenotype and 46% (13/28) a non-GC phenotype. Treatment at relapse included rituximab in 21/54 and ASCT in 15/54 with 7 pts receiving both. Estimated 5-year event-free survival (EFS) and overall survival (OS) after relapse were 25% and 35% for all pts. Pts with DLBCL histology at relapse had an estimated 5-year EFS and OS of 18% and 28%. Pts with indolent histology had an estimated 5-year EFS and OS of 55% and 67%. Conclusions: Patients with DLBCL who present a late relapse usually had localized stage, favorable IPI and extranodal involvement at diagnosis. However, even if initial characteristics at time of first treatment were favorable, outcome of pts with DLBCL at time of relapse remains poor and aggressive treatment, such as ASCT, should be pursue whenever possible. Some patients relapsed with indolent histology and have a better outcome.

No significant financial relationships to disclose.

Paramètres sociaux de la reproduction familiale au Saguenay (1842-1911)

Les fiches de famille du fichier-réseau de la population du Saguenay sont ici utilisées pour faire ressortir les paramètres sociaux de la reproduction familiale dans cette région entre 1842 et 1911, soit à l'époque du peuplement. Une attention particulière est accordée a) au rapport de la parenté comme support de la société rurale, étudié à travers certaines formes de corésidence, b) aux inégalités qui accompagnent la transmission des avoirs fonciers et l'établissement des enfants, c) à l'alphabétisation, comme indicateur de différenciation sociale. On observe que, malgré les écarts créés entre aînés et cadets, entre garçons et filles, la reproduction familiale poursuit une orientation égalitaire. Cette orientation sera toutefois compromise par les tensions et contraintes accompagnant la saturation des terres arables, vers 1920-1930.

Psychosocial predictors of labor/delivery complications and infant birth weight: a prospective multivariate study

Using a multidimensional approach to measure stress, this study prospectively examined the influence of maternal stress, social support and coping styles on labor/delivery complications and infant birth weight. Beginning in the third month of pregnancy, stress was assessed monthly. In each trimester, data on social support, coping strategies, lifestyle behaviors and pregnancy progress were collected. One month following delivery, information on labor, delivery and infant status was obtained. The final sample consisted of 80 women. The results demonstrated that women who experienced greater stress during pregnancy had a more difficult labor/delivery, even after controlling for parity. Younger maternal age was also linked with intrapartum complications. Perceived prenatal social support emerged as a predictor of infant birth weight. Women who reported less satisfaction with their social support in the second trimester gave birth to infants of lower birth weight. The results suggest an association between specific psychosocial variables and negative birth outcomes.

Psychosocial correlates of prepartum and postpartum depressed mood

BACKGROUND

The aim of the present study was to delineate the influence of maternal stress, social support and coping styles on depressed mood during pregnancy and the early postpartum period.

METHODS

Beginning in the third month of pregnancy, data on numerous variables including daily stress (Hassles), state-anxiety (STAI-state), pregnancy-specific stress (PEQ) and depressed mood (DACL) were collected monthly. In each trimester social support (SSQ), coping strategies (CISS) and pregnancy progress were assessed. Approximately 4-5 weeks following delivery, information on labor, delivery and infant status was collected and the DACL and the Edinburgh Postnatal Depression Scale (EPDS) were administered. The final sample consisted of 80 women.

RESULTS

Approximately 16% of the women in this sample experienced depressed mood in the postpartum and 25% of the sample reported depressed mood only during pregnancy. Women depressed only during pregnancy and those depressed in the postpartum reported more emotional coping and higher trait and state anxiety during gestation. More hassles during pregnancy was related to prepartum depressed mood, but not postpartum depressed mood. Consistent with the literature, the best predictor of postpartum depressed mood was depressed mood during pregnancy.

LIMITATIONS

The sample size was relatively small and we relied solely on self-reported depressive symptomology.

CONCLUSIONS

The findings point to specific psychosocial variables which can be targeted early in pregnancy to reduce the rate of depressed mood in the prepartum and postpartum periods.

Variations in stress levels over the course of pregnancy: factors associated with elevated hassles, state anxiety and pregnancy-specific stress

This prospective study tracked hassles, pregnancy-specific stress, and state anxiety during pregnancy. A second objective was to identify predictors of each stress dimension. Pregnant women (n=161) completed the Hassles Scale, the Pregnancy-Specific Stress Questionnaire (PEQ), and the state-anxiety scale (STAI-state) monthly, beginning in the third month of pregnancy. Hassles were found to be stable throughout the pregnancy. Women reported significantly higher pregnancy-specific stress in the first and third trimester of pregnancy, whereas state anxiety increased in the third trimester compared with the first and second trimesters. Poorer marital adjustment predicted higher Hassles during pregnancy and higher PEQ and STAI-state in the third trimester. Women who reported that the pregnancy would have a negative impact on their career scored higher on Hassles during pregnancy and higher on the PEQ in the third trimester. The occurrence of a gestational complication during pregnancy was related to higher pregnancy-specific stress in the third trimester. Younger women also reported higher PEQ results in the third trimester. The data provide support for a multidimensional conceptualization of stress during pregnancy.

A prospective study of the impact of psychosocial and lifestyle variables on pregnancy complications

This prospective study examines the influence of maternal stress, social support and lifestyle variables reported over the course of pregnancy on subsequent gestational and intrapartum complications. Demographic and biomedical factors were also studied. One hundred and two women were followed on a monthly basis beginning in the third month of pregnancy. Measures of daily stress (hassles), state-anxiety (STAI-state) and pregnancy-specific stress were taken monthly. Pregnancy progress and lifestyle behaviors such as smoking, caffeine and alcohol intake were assessed by trimester. One month following delivery, a telephone interview was conducted to inquire about the labor/delivery and infant status. Sixty-three per cent of the women experienced a pregnancy complication. Three groups consisting of women who experienced gestational complications, intrapartum complications only, and no complications were formed. Women who subsequently experienced gestational complications reported over the course of their pregnancy higher levels of state-anxiety, daily hassles and pregnancy-specific stress beginning in the third month of pregnancy. Women who experienced complications during the intrapartum period only reported higher daily hassles during pregnancy and consumed more caffeinated beverages compared to the other groups. Primiparous women were more likely to experience gestational and/or intrapartum complications than multiparous women. These findings support a role for psychosocial variables in pregnancy complications. The results indicate that certain psychosocial and lifestyle variables may be differentially associated with complications occurring at various phases of pregnancy.

Release of 5-ASA from Pentasa in patients with Crohn's disease of the small intestine

BACKGROUND

Pentasa is a controlled-release tablet made from semipermeable microspheres and designed to continuously deliver therapeutic quantities of 5-ASA (5-aminosalicylic acid) throughout the gastrointestinal tract. Scintigraphic studies in healthy subjects have documented that 5-ASA release could occur in the small intestine. We tested here the disintegration of Pentasa in the digestive tract of nine patients with Crohn's disease of the small intestine.

MATERIALS

Each patient was given, after breakfast, a 250 mg tablet of Pentasa containing samarium-153 oxide. For 8 h the progression of the isotope in the gastrointestinal tract was followed using gamma camera scintigraphy. Plasma measurement of 5-ASA and acetylated 5-ASA was used to verify the liberation and absorption of 5-ASA.

RESULTS

The Pentasa tablet appeared completely dissolved in the stomach by 117 +/- 18 min. Samarium oxide was first detected in the small intestine 60 +/- 5 min after its ingestion; it reached the colon after 280 +/- 13 min and it was completely absent from the small intestine at 360 +/- 26 min. Plasma concentrations of 5-ASA started to rise after 67 +/- 7 min and were maximal at 222 +/- 25 min.

CONCLUSION

In patients with Crohn's disease of the small intestine, Pentasa microgranules start releasing 5-ASA in the proximal small intestine, acting locally to exert its beneficial effect.