, prevent or minimize neurological decline, and improve overall quality of life. 11 Spinal metastasis treatments can comprise stand-alone monotherapies including conventional external-beam radiation therapy (cEBRT), spinal stereotactic radiosurgery (SRS), surgery, and occasionally chemotherapy. However, treatment often requires multimodality regimens. Many factors are important in the overall decision-making process in the treatment of patients with metastatic spine disease. These factors include the neurological status of the patient, location of the tumor and degree
E. Emily Bennett, Camille Berriochoa, Ghaith Habboub, Scott Brigeman, Samuel T. Chao and Lilyana Angelov
Amol J. Ghia, Eric L. Chang, Andrew J. Bishop, Hubert Y. Pan, Nicholas S. Boehling, Behrang Amini, Pamela K. Allen, Jing Li, Laurence D. Rhines, Nizar M. Tannir, Claudio E. Tatsui, Paul D. Brown and James N. Yang
therapy to palliate pain, prevent disease progression and pathological fracture, and halt or reverse neurological compromise. 17 However, for radioresistant tumors, including RCC, conventionally fractionated radiation has been shown to lead to suboptimal local control (LC). 21 , 25 , 37 With improved progression-free survival and overall survival rates due to the use of targeted therapies in patients with metastatic RCC, addressing bone metastases with modalities that can provide durable LC has become a growing concern. 9 , 12 Spinal stereotactic radiosurgery (SSRS
Dhiego Chaves de Almeida Bastos, Richard George Everson, Bruno Fernandes de Oliveira Santos, Ahmed Habib, Rafael A. Vega, Marilou Oro, Ganesh Rao, Jing Li, Amol J. Ghia, Andrew J. Bishop, Debra Nana Yeboa, Behrang Amini, Laurence D. Rhines and Claudio Esteves Tatsui
T he role of surgery in the management of spinal metastatic disease continues to evolve, especially regarding its pairing with recent advances in systemic treatment and radiotherapy. Improved functional outcomes have been demonstrated with decompressive surgery and spinal stabilization followed by conventional external-beam radiation therapy (cEBRT) over cEBRT alone in patients with symptomatic epidural spinal cord compression (ESCC). 12 More recently, spinal stereotactic radiosurgery (SSRS) has emerged as a highly effective treatment, overcoming the
Dong-Won Shin, Moon-Jun Sohn, Han-Seong Kim, Dong-Joon Lee, Sang Ryong Jeon, Yoon Joon Hwang and Eek-Hoon Jho
In this study the authors sought to evaluate clinical outcomes after using stereotactic radiosurgery (SRS) to treat benign and malignant spinal neurogenic tumors.
The authors reviewed a total of 66 procedures of spinal SRS performed between 2001 and 2013 for 110 tumors in 58 patients with spinal neurogenic tumors, which included schwannomas, neurofibromas, and malignant peripheral nerve sheath tumors (MPNSTs). The clinical and radiological findings were evaluated in patients with benign neurogenic tumors. For the 4 patients with MPNSTs, the authors reported overall survival and results of additional immunohistochemical staining to predict the survival difference among the patients.
Of the 92 benign neurogenic tumors, 65 tumors that were serially followed up using MRI after SRS showed significant change in mean tumor volume, from a mean of 12.0 ± 2.6 cm3 pre-SRS to 10.8 ± 2.5 cm3 post-SRS (p = 0.027), over an average of 44 months. The local control rate of benign neurogenic tumors was 95.4%. The 34 patients who presented with clinical symptoms of pain showed a significant symptomatic improvement. The initial mean visual analog scale (VAS) score was 6.0 and decreased dramatically to 1.0 after SRS during an average follow-up period of 10.9 months (median of 8.1 months). Although the proportions of transient swelling and loss of intramural enhancement were significantly different among the groups, there was no statistically significant correlation between those 2 factors and local tumor control (p = 0.253 and 0.067, respectively; Fisher’s exact text). Cross-table analysis also indicated that there was no statistically significant relationship between groups with loss of intramural enhancement and transient swelling. The median survival of neurofibromatosis Type 1 (NF1)-related and sporadic MPNSTs was 1.13 and 5.8 years, respectively. Immunohistochemical results showed that S100 was expressed in a sporadic MPNST or neurofibroma, whereas topoisomerase-IIa was expressed in NF1-related MPNSTs.
SRS is an effective treatment modality for benign neurogenic tumors, while MPNSTs showed heterogeneity in their responses to SRS.
Claudio E. Tatsui, R. Jason Stafford, Jing Li, Jonathan N. Sellin, Behrang Amini, Ganesh Rao, Dima Suki, Amol J. Ghia, Paul Brown, Sun-Ho Lee, Charles E. Cowles, Jeffrey S. Weinberg and Laurence D. Rhines
, preservation of continence, pain control, and maintenance or restoration of functional performance, compared with cEBRT alone. A better understanding of radiobiology and technological advancements in image guidance over the last decade has allowed the development of spinal stereotactic radiosurgery (SSRS), in which radiation is contoured to cover a specific target volume with a steep falloff in radiation delivered to surrounding tissues, limiting the toxicity to organs in proximity to the tumor. 18 , 39 The delivery of high doses of radiation in single-dose 40 or
Jonathan N. Sellin, William Reichardt, Andrew J. Bishop, Dima Suki, Laurence D. Rhines, Stephen H. Settle, Paul D. Brown, Jing Li, Ganesh Rao, Eric L. Chang and Claudio E. Tatsui
11 Gerszten PC , Burton SA , Ozhasoglu C , Welch WC : Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution . Spine (Phila Pa 1976) 32 : 193 – 199 , 2007 12 Hamilton AJ , Lulu BA , Fosmire H , Stea B , Cassady JR : Preliminary clinical experience with linear accelerator-based spinal stereotactic radiosurgery . Neurosurgery 36 : 311 – 319 , 1995 13 Klimo P Jr , Schmidt MH : Surgical management of spinal metastases . Oncologist 9 : 188 – 196 , 2004 14 Kong FM , Ten Haken
Peter C. Gerszten, Cihat Ozhasoglu, Steven A. Burton, Shalom Kalnicki and William C. Welch
The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. Its use for the treatment of spinal lesions has been limited by the availability of effective target-immobilizing devices. In this study the authors evaluated the CyberKnife Real-Time Image-Guided Radiosurgery System for spinal lesion treatment involving a single-fraction radiosurgical technique.
This frameless image-guided radiosurgery system uses the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the target without the use of frame-based fixation. Cervical lesions were located and tracked relative to osseous skull landmarks; lower spinal lesions were tracked relative to percutaneously placed gold fiducial bone markers. Fifty-six spinal lesions in 46 consecutive patients were treated using single-fraction radiosurgery (26 cervical, 15 thoracic, and 11 lumbar, and four sacral). There were 11 benign and 45 metastatic lesions.
Tumor volume ranged from 0.3 to 168 ml (mean 26.7 ml). Thirty-one lesions had previously received external-beam radiotherapy with maximum spinal cord doses. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Tumor dose was maintained at 12 to 18 Gy to the 80% isodose line; spinal cord lesions receiving greater than 8 Gy ranged from 0 to 1.3 ml (mean 0.3 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Axial and radicular pain improved in all patients who were symptomatic prior to treatment.
Spinal stereotactic radiosurgery involving a frameless image-guided system was found to be feasible and safe. The major potential benefits of radiosurgical ablation of spinal lesions are short treatment time in an outpatient setting with rapid recovery and symptomatic response. This procedure offers a successful alternative therapeutic modality for the treatment of a variety of spinal lesions not amenable to open surgical techniques; the intervention can be performed in medically untreatable patients, lesions located in previously irradiated sites, or as an adjunct to surgery.
Peter C. Gerszten, Cihat Ozhasoglu, Steven A. Burton, William J. Vogel, Barbara A. Atkins, Shalom Kalnicki and William C. Welch
The role of stereotactic radiosurgery in the treatment of benign intracranial lesions is well established. Its role in the treatment of benign spinal lesions is more limited. Benign spinal lesions should be amenable to radiosurgical treatment similar to their intracranial counterparts. In this study the authors evaluated the effectiveness of the CyberKnife for benign spinal lesions involving a single-fraction radiosurgical technique.
The CyberKnife is a frameless radiosurgery system in which an orthogonal pair of x-ray cameras is coupled to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, whereby the therapy beam is guided to the intended target without the use of frame-based fixation. Cervical spine lesions were located and tracked relative to skull osseous landmarks; lower spinal lesions were tracked relative to percutaneously placed fiducial bone markers. Fifteen patients underwent single-fraction radiosurgery (12 cervical, one thoracic, and two lumbar). Histological types included neurofibroma (five cases), paraganglioma (three cases), schwannoma (two cases), meningioma (two cases), spinal chordoma (two cases), and hemangioma (one case).
Radiation dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographic tumor volume with no margin. The tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 16 Gy). Tumor volume ranged from 0.3 to 29.3 ml (mean 6.4 ml). Spinal canal volume receiving more than 8 Gy ranged from 0.0 to 0.9 ml (mean 0.2 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Pain improved in all patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging (mean 12 months).
Spinal stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of benign spinal lesions. Its major potential benefits are the relatively short treatment time in an outpatient setting and the minimal risk of side effects. This new technique offers an alternative therapeutic modality for the treatment of a variety of benign spinal neoplasms in cases in which surgery cannot be performed, in cases with previously irradiated sites, and in cases involving lesions not amenable to open surgical techniques or as an adjunct to surgery.
Antonio A. F. De Salles, Alessandra G. Pedroso, Paul Medin, Nzhde Agazaryan, Timothy Solberg, Cynthia Cabatan-Awang, Dulce M. Espinosa, Judith Ford and Michael T. Selch
radiosurgery applications for the spine is obvious: the histological varieties that are so successfully treated by radiosurgery in the brain are also prevalent in the spine. The progress of near—real time computer-generated image fusion has allowed the development of stereotactic techniques that no longer depend on a rigid fixation device, 17 as were the initial surgically invasive attempts of spinal stereotactic radiosurgery. 12 The Stanford group pioneered the frameless approach matching pretreatment “scout” computerized tomography scans and oblique radiographs
.3171/2015.5.SPINE15114 2015.5.SPINE15114 The 100 most-cited articles in spinal oncology Rafael De la Garza-Ramos Mario Benvenutti-Regato Enrique Caro-Osorio 5 2016 24 5 810 823 10.3171/2015.8.SPINE15674 2015.8.SPINE15674 Lateral access to paravertebral tumors Akwasi Ofori Boah Noel I. Perin 5 2016 24 5 824 828 10.3171/2015.6.SPINE1529 2015.6.SPINE1529 Single-fraction versus multifraction spinal stereotactic radiosurgery for spinal metastases from renal cell carcinoma: secondary analysis of Phase I/II trials Amol J. Ghia Eric L. Chang Andrew J. Bishop Hubert Y. Pan