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William Y. Tong, Michael R. Folkert, Jeffrey P. Greenfield, Yoshiya Yamada, and Suzanne L. Wolden

% of the prescription dose within 3–4 mm ( Fig. 1 ). F ig . 1. Percent depth dose (PDD) curve for an intraoperative 32 P brachytherapy plaque, with measurements for radiation dose at a depth relative to prescription dose (10 Gy to 1-mm depth). Case Report History A 6-year-old girl with multiply recurrent high-risk neuroblastoma was referred to our radiation oncology and neurosurgical services because of progressive disease in her thoracic spine resulting in spinal cord compression. She had been in her usual state of good health (41 months

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Athos Patsalides, Yoshiya Yamada, Mark Bilsky, Eric Lis, Ilya Laufer, and Yves Pierre Gobin

spinal epidural disease, and had already been treated with surgery and SRS at that level. Each patient’s history, clinical condition, and imaging were reviewed at the spinal tumor board, and the consensus among neurosurgery and radiation oncology experts was that these patients were not candidates for further surgery or radiation. All patients underwent spinal MRI scans with contrast within 4 weeks of study enrollment. The grading of epidural disease and spinal canal compromise was based on axial MR images, using the following classification for epidural spinal cord

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Repeat decompression surgery for recurrent spinal metastases

Presented at the 2009 Joint Spine Section Meeting

Ilya Laufer, Andrew Hanover, Eric Lis, Yoshiya Yamada, and Mark Bilsky

, Samii H : Surgical results for spinal metastases . Acta Neurochir (Wien) 140 : 957 – 967 , 1998 10 Maranzano E , Latini P : Effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial . Int J Radiat Oncol Biol Phys 32 : 959 – 967 , 1995 11 Oken MM , Creech RH , Tormey DC , : Toxicity and response criteria of the Eastern Cooperative Oncology Group . Am J Clin Oncol 5 : 649 – 655 , 1982 12 Patchell RA , Tibbs PA , Regine WF , Payne R , Saris S

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Ori Barzilai, Lily McLaughlin, Eric Lis, Yoshiya Yamada, Mark H. Bilsky, and Ilya Laufer

complexity. To facilitate complex decision-making, use of the “NOMS” framework 14 has been implemented in many spine oncology practices. NOMS accounts for 4 major considerations: neurological, oncological, mechanical instability, and systemic status and comorbidities. Use of such treatment algorithms has allowed tailored surgical treatment with appropriate indications alongside systemic and radiation therapies. The data presented in this analysis derives from a patient population managed using this framework in a multidisciplinary fashion and reports the long-term safety

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Evangelia Katsoulakis, Nadeem Riaz, Brett Cox, James Mechalakos, Joan Zatcky, Mark Bilsky, and Yoshiya Yamada

Object

The objective of this study was to investigate the feasibility and safety of delivering a third course of radiation to patients with multiply recurrent metastatic disease to the spine.

Methods

Between 2009 and 2011, 10 patients received a third course of radiation to spinal metastases at Memorial Sloan–Kettering Cancer Center using image-guided intensity-modulated radiation therapy (IMRT). Patient and tumor characteristics, dosimetry details, and outcomes were obtained using retrospective chart review. Spinal imaging was performed prior to treatment and at regular follow-up intervals. The cumulative biologically effective dose (BED) to the spinal cord and cauda equina was calculated and was normalized to 2 Gy equivalents (Gy2/2). Toxicity and local control were assessed.

Results

The median time between the first and second courses of radiation was 18.5 months and the median time between the second and third courses was 11.5 months. The median follow-up from the third course of radiation was 12 months and the median overall survival was 13 months. Pain or neurological symptoms were improved in 80% of patients. The median spinal cord maximum dose normalized BED (nBED) for the whole cohort was 70.73 Gy2/2 (range 51.9–101.7 Gy2/2). The median dose to 5% of the spinal cord D05 nBED for the entire cohort was 59.4 Gy2/2. Acute toxicity was most commonly fatigue and dermatitis, with 1 patient experiencing Grade 3 fatigue and 1 patient Grade 3 dermatitis. Late toxicity was limited to 2 cases of Grade 1 dysphagia. There was 1 case of Grade 1 neuropathy and 1 case of Grade 2 neuropathy. The crude rate of local control was 80% with 1 in-field failure and 1 marginal failure.

Conclusions

In this cohort of patients, a third course of IMRT to the spine was well tolerated with no significant late toxicities. Used as salvage therapy for select patients, a third course of radiation is a safe and effective treatment strategy.

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Jeremy C. Wang, Patrick Boland, Nandita Mitra, Yoshiya Yamada, Eric Lis, Michael Stubblefield, and Mark H. Bilsky

require shorter operative times. Acknowledgment We would like to thank Andrew Wilton, M.S., for his assistance in statistical analysis. Abbreviations used in this paper ASIA = American Spinal Injury Association ; EBRT = external-beam radiation therapy ; ECOG = Eastern Cooperative Oncology Group ; ESCC = epidural spinal cord compression ; IMRT = intensity-modulated radiation therapy ; MR = magnetic resonance ; PLL = posterior longitudinal ligament ; PMMA

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Ori Barzilai, Natalie DiStefano, Eric Lis, Yoshiya Yamada, D. Michael Lovelock, Andrew N. Fontanella, Mark H. Bilsky, and Ilya Laufer

S pinal metastases are present in approximately 30% of oncology patients, 22 and with improved diagnostics and targeted therapies, the incidence of spine tumors is expected to increase. The morbidity associated with spinal metastases includes severe pain associated with instability and neurological injury from spinal cord or nerve root compression. 17 The goals of treatment for spinal metastases include treatment of the local tumor, restoration of spinal stability, and palliation of symptoms. Stereotactic radiosurgery (SRS) has the ability to produce a sharp

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Ilya Laufer, J. Bryan Iorgulescu, Talia Chapman, Eric Lis, Weiji Shi, Zhigang Zhang, Brett W. Cox, Yoshiya Yamada, and Mark H. Bilsky

significantly superior rates of overall ambulation (84% vs 57%), maintenance of ambulation (94% vs 74%), recovery of ambulation (62% vs 19%), bowel and bladder continence, narcotic requirements, and survival in patients who underwent surgical decompression followed by cEBRT compared with cEBRT alone. Based on these data and expert opinion, the Spine Oncology Study Group published recommendations that patients with high-grade spinal cord compression resulting from solid tumor malignancies undergo surgical decompression followed by RT. 1 The pain, functional, and neurological

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Jennifer Keam, Mark H. Bilsky, Ilya Laufer, Weiji Shi, Zhigang Zhang, Moses Tam, Joan Zatcky, Dale M. Lovelock, and Yoshiya Yamada

targeted for treatment. Following conventional palliative radiation, patients were typically observed in follow-up with radiation oncology on an as-needed basis. A total of 19 patients received conventional palliative radiation preoperatively at an outside hospital and not at MSKCC. All IGRT patients in this study were treated at MSKCC. Image-guided radiation therapy was performed using linear accelerator gantry-mounted cone beam CT with Memorial body cradle immobilization. Computed tomography target delineation was performed by the treating radiation oncologist with

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Eric Lis, Ilya Laufer, Ori Barzilai, Yoshiya Yamada, Sasan Karimi, Lily McLaughlin, George Krol, and Mark H. Bilsky

OBJECTIVE

Percutaneous 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).

METHODS

The 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.

RESULTS

Among 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.

CONCLUSIONS

In 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.