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Stereotactic body radiotherapy for de novo spinal metastases: systematic review

International Stereotactic Radiosurgery Society practice guidelines

Zain A. Husain, Arjun Sahgal, Antonio De Salles, Melissa Funaro, Janis Glover, Motohiro Hayashi, Masahiro Hiraoka, Marc Levivier, Lijun Ma, Roberto Martínez-Alvarez, J. Ian Paddick, Jean Régis, Ben J. Slotman and Samuel Ryu

/worsened neurological symptoms. 13 The data suggest that a suboptimal radiation dose might not be a good palliative treatment for patients with spinal metastases. Stereotactic body radiation therapy (SBRT), with its delivery of a substantially higher BED than otherwise delivered conventionally, was developed with the intent to improve complete response rates to pain and local control. 23 The current data seem to support this potential; however, the current literature is limited to data from a few prospective trials and predominantly retrospective studies. Furthermore, most of the

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Kristin J. Redmond, Simon S. Lo, Scott G. Soltys, Yoshiya Yamada, Igor J. Barani, Paul D. Brown, Eric L. Chang, Peter C. Gerszten, Samuel T. Chao, Robert J. Amdur, Antonio A. F. De Salles, Matthias Guckenberger, Bin S. Teh, Jason Sheehan, Charles R. Kersh, Michael G. Fehlings, Moon-Jun Sohn, Ung-Kyu Chang, Samuel Ryu, Iris C. Gibbs and Arjun Sahgal

recurrence rates following conventional RT remain as high as 34%. 7 , 8 , 13 , 15 , 25 , 28 Over the past decade, significant advances have been made to allow precise delivery of RT using stereotactic techniques with submillimeter accuracy. Stereotactic body radiation therapy (SBRT) allows safe delivery of higher biologically equivalent doses in fewer fractions. Data from retrospective and prospective studies suggest that spinal SBRT for intact vertebral metastases is associated with high rates of local control with a low risk of marginal failure even in radioresistant

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Dennis T. Lockney, Angela Y. Jia, Eric Lis, Natalie A. Lockney, Chengbao Liu, Benjamin Hopkins, Daniel S. Higginson, Yoshiya Yamada, Ilya Laufer, Mark Bilsky and Adam M. Schmitt

S tereotactic body radiation therapy (SBRT) has emerged as a highly effective treatment modality for obtaining durable local control of a variety of primary cancers, including early-stage lung cancer and metastatic lesions in both bone and soft tissues. The delivery of a high biologically effective dose (BED) by administering large radiation doses in a few fractions is especially attractive for the treatment of tumors with a radioresistant histology and also for tumors that have been previously irradiated. However, when treating spinal tumors, ensuring dose

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Robert J. Rothrock, Yi Li, Eric Lis, Stephanie Lobaugh, Zhigang Zhang, Patrick McCann, Patricia Mae G. Santos, T. Jonathan Yang, Ilya Laufer, Mark H. Bilsky, Adam Schmitt, Yoshiya Yamada and Daniel S. Higginson

regimen, with a concurrent course of high-dose dexamethasone to prevent radiation-induced edema and resultant myelopathy. 9 , 10 For tumors with relatively radioresistant histologies, such as colorectal adenocarcinoma, soft-tissue sarcomas, or renal cell carcinomas, we favor stereotactic body radiation therapy (SBRT) as the radiation modality to achieve more durable local control, as is recommended in current National Comprehensive Cancer Network guidelines. 11 However, the proximity of epidural disease to the spinal cord can limit the dose distribution. A predominant

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Varun Puvanesarajah, Sheng-fu Larry Lo, Nafi Aygun, Jason A. Liauw, Ignacio Jusué-Torres, Ioan A. Lina, Uri Hadelsberg, Benjamin D. Elder, Ali Bydon, Chetan Bettegowda, Daniel M. Sciubba, Jean-Paul Wolinsky, Daniele Rigamonti, Lawrence R. Kleinberg, Ziya L. Gokaslan, Timothy F. Witham, Kristin J. Redmond and Michael Lim

. Unfortunately, control rates after conventional radiation therapy are not ideal for most solid tumors because the radiation dose must be limited to respect the tolerance of the spinal cord and other adjacent structures. 11 Recently, spine stereotactic body radiation therapy (SBRT) has been used to precisely deliver radiation, allowing for dose escalation and improved local control while limiting the dose to the adjacent normal structures and spinal cord. 1 , 4 , 12 , 15 , 16 , 25 , 32 , 33 A recent meta-analysis reported a local control rate of 92% and symptomatic relief

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Jonathan E. Leeman, Mark Bilsky, Ilya Laufer, Michael R. Folkert, Neil K. Taunk, Joseph R. Osborne, Julio Arevalo-Perez, Joan Zatcky, Kaled M. Alektiar, Yoshiya Yamada and Daniel E. Spratt

therapy options for many types of sarcomas. Therefore, treatment of spinal lesions from metastatic sarcoma typically involves surgery and radiotherapy. Stereotactic body radiotherapy (SBRT) is a modern technique that uses high-dose-per-fraction radiation delivered precisely to the target lesion. SBRT results in local control rates > 85%, with minimal impact of histology. 1 , 6 , 10 , 11 , 15 , 19 Across a mixture of cancer types, investigators have shown that 83% of patients with metastatic disease to the spine have multilevel involvement at the time of presentation

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Ronny Kalash, Scott M. Glaser, John C. Flickinger, Steven Burton, Dwight E. Heron, Peter C. Gerszten, Johnathan A. Engh, Nduka M. Amankulor and John A. Vargo

T he majority of primary spinal cord tumors are benign noninfiltrative lesions, such as meningiomas or schwannomas, for which microsurgical resection has long been recognized as a standard of care. 1 However, tumor location, patient age, and medical comorbidities can challenge the application of microsurgery. Building on the successful use of stereotactic body radiation therapy (SBRT) for the management of malignant metastatic spinal tumors and frame-based stereotactic radiosurgery (SRS) for unresectable benign intracranial lesions, SBRT for benign spinal

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Ilya Laufer and Mark H. Bilsky

integration of spine stereotactic body radiotherapy (SBRT), which provides histology-independent, durable tumor control when compared to conventional external-beam radiation therapy (cEBRT). 61 The ability of SBRT to deliver an ablative radiation dose has fundamentally changed treatment paradigms when used as definitive therapy or as a postoperative adjuvant. Based on responses to SBRT, surgery has largely transitioned from aggressive gross-total or en bloc resection to simple separation surgery focused on spinal cord decompression to create a target for radiation. SBRT

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Reirradiation spine stereotactic body radiation therapy for spinal metastases: systematic review

International Stereotactic Radiosurgery Society practice guidelines

Sten Myrehaug, Arjun Sahgal, Motohiro Hayashi, Marc Levivier, Lijun Ma, Roberto Martinez, Ian Paddick, Jean Régis, Samuel Ryu, Ben Slotman and Antonio De Salles

%, respectively, and CR rates of only 14% and 11%, respectively. 6 This suggests that there is a critical need to improve outcomes in these patients. With the advent of modern radiation planning and image-guided radiotherapy apparatuses, the ability to deliver stereotactic ablative radiation to body targets gave rise to stereotactic body radiotherapy (SBRT), which is also known as spine stereotactic radiosurgery. In fact, the field started with reirradiation as the primary application, and in 1995 Hamilton et al. 11 reported the first spine SBRT series (5 patients) based on a

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Ahmed Hashmi, Matthias Guckenberger, Ron Kersh, Peter C. Gerszten, Frederick Mantel, Inga S. Grills, John C. Flickinger, John H. Shin, Daniel K. Fahim, Brian Winey, Kevin Oh, B. C. John Cho, Daniel Létourneau, Jason Sheehan and Arjun Sahgal

. These data highlight the need for more effective treatments in the retreatment indication. It is also important to recognize that the decision to re-irradiate with additional cEBRT limits further treatment options significantly due to toxicity concerns, and this is of particular relevance to spinal metastases because the spinal cord and cauda equina (critical neural tissue [CNT]) can tolerate only so much cumulative exposure. Stereotactic body radiotherapy (SBRT) has been defined by several national and international bodies and associations as the precise delivery