The use of image guided laser interstitial thermotherapy to supplement spine stereotactic radiosurgery to manage metastatic epidural spinal cord compression: Proof of concept and dosimetric analysis

OBJECT High-grade malignant spinal cord compression is commonly managed with a combination of surgery aimed at removing the epidural tumor, followed by spinal stereotactic radiosurgery (SSRS) aimed at local tumor control. The authors here introduce the use of spinal laser interstitial thermotherapy (SLITT) as an alternative to surgery prior to SSRS. METHODS Patients with a high degree of epidural malignant compression due to radioresistant tumors were selected for study. Visual analog scale (VAS) scores for pain and quality of life were obtained before and within 30 and 60 days after treatment. A laser probe was percutaneously placed in the epidural space. Real-time thermal MRI was used to monitor tissue damage in the region of interest. All patients received postoperative SSRS. The maximum thickness of the epidural tumor was measured, and the degree of epidural spinal cord compression (ESCC) was scored in pre- and postprocedure MRI. RESULTS In the 11 patients eligible for study, the mean VAS score for pain decreased from 6.18 in the preoperative period to 4.27 within 30 days and 2.8 within 60 days after the procedure. A similar VAS interrogating the percentage of quality of life demonstrated improvement from 60% preoperatively to 70% within both 30 and 60 days after treatment. Imaging follow-up 2 months after the procedure demonstrated a significant reduction in the mean thickness of the epidural tumor from 8.82 mm (95% CI 7.38–10.25) before treatment to 6.36 mm (95% CI 4.65–8.07) after SLITT and SSRS (p = 0.0001). The median preoperative ESCC Grade 2 was scored as 4, which was significantly higher than the score of 2 for Grade 1b (p = 0.04) on imaging follow-up 2 months after the procedure. CONCLUTIONS The authors present the first report on an innovative minimally invasive alternative to surgery in the management of spinal metastasis. In their early experience, SLITT has provided local control with low morbidity and improvement in both pain and the quality of life of patients.

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Phase 1 study of spinal cord constraint relaxation with single session spine stereotactic radiosurgery in the primary management of patients with inoperable, previously irradiated metastatic epidural spinal cord compression

North American Spine Society Journal (NASSJ) ◽

10.1016/j.xnsj.2021.100066 ◽

2021 ◽

pp. 100066

Author(s):

Amol J Ghia ◽

Nandita Guha-Thakurta ◽

Juhee Song ◽

Peter Thall ◽

Tina M Briere ◽

...

Keyword(s):

Spinal Cord ◽

Stereotactic Radiosurgery ◽

Spinal Cord Compression ◽

Phase 1 ◽

Cord Compression ◽

Single Session ◽

Phase 1 Study ◽

Constraint Relaxation ◽

Primary Management

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Hybrid surgery–radiosurgery therapy for metastatic epidural spinal cord compression: A prospective evaluation using patient-reported outcomes

Neuro-Oncology Practice ◽

10.1093/nop/npx017 ◽

2017 ◽

Vol 5 (2) ◽

pp. 104-113 ◽

Cited By ~ 4

Author(s):

Ori Barzilai ◽

Mary-Kate Amato ◽

Lily McLaughlin ◽

Anne S Reiner ◽

Shahiba Q Ogilvie ◽

...

Keyword(s):

Spinal Cord ◽

Stereotactic Radiosurgery ◽

Spinal Cord Compression ◽

Patient Reported Outcomes ◽

Cord Compression ◽

Pain Severity ◽

Hybrid Surgery ◽

Hybrid Therapy ◽

Therapy Effect ◽

Patient Reported

Abstract Background Patient-reported outcomes (PRO) represent an important measure of cancer therapy effect. For patients with metastatic epidural spinal cord compression (MESCC), hybrid therapy using separation surgery and stereotactic radiosurgery preserves neurologic function and provides tumor control. There is currently a paucity of data reporting PRO after such combined modality therapy for MESCC. Delineation of hybrid surgery–radiosurgery therapy effect on PRO validates the hybrid approach as an effective therapy resulting in meaningful symptom relief. Patients and Methods Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory—Spine Tumor (MDASI-SP), PROs validated in the cancer population, were prospectively collected. Patients with MESCC who underwent separation surgery followed by stereotactic radiosurgery were included. Separation surgery included a posterolateral approach without extensive cytoreductive tumor excision. A median postoperative radiosurgery dose of 2700 cGy was delivered. The change in PRO 3 months after the hybrid therapy represented the primary study outcome. Preoperative and postoperative evaluations were analyzed using the Wilcoxon signed-rank test for matched pairs. Results One hundred eleven patients were included. Hybrid therapy resulted in a significant reduction in the BPI items “worst” and “right now” pain (P < .0001), and in all BPI constructs (severity, interference with daily activities, and pain experience, P < .001). The MDASI-SP demonstrated reduction in spine-specific pain severity and interference with general activity (P < .001), along with decreased symptom interference (P < .001). Conclusions Validated PRO instruments showed that in patients with MESCC, hybrid therapy with separation surgery and radiosurgery results in a significant decrease in pain severity and symptom interference. These prospective data confirm the benefit of hybrid therapy for treatment of MESCC and should facilitate referral of patients with MESCC for surgical evaluation.

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Metastatic epidural spinal cord compression

Journal of Surgical Case Reports ◽

10.1093/jscr/rjaa217 ◽

2020 ◽

Vol 2020 (8) ◽

Author(s):

Preci Hamilton ◽

Peyton Lawrence ◽

Christian Valentin Eisenring

Keyword(s):

Spinal Cord ◽

Stereotactic Radiosurgery ◽

Spinal Cord Compression ◽

Scoring Systems ◽

Cord Compression ◽

Tumor Burden ◽

Pedicle Screw Fixation ◽

Limb Weakness ◽

Neoplastic Lesion ◽

Spinal Sagittal Alignment

Abstract Up-to-date management for metastatic epidural spinal cord compression is based on appropriate scoring systems. In this case, separation surgery and stereotactic radiosurgery achieved an optimized outcome. A 75-year-old man had thoracic band-like pain, left lower limb weakness and difficulty ambulating for 6 weeks. Spinal images showed a T4 metastatic epidural spinal cord compression with a pathological fracture of T4 and T10 and L3 lytic lesions. There was no other neoplastic lesion. The metastasized T4 was decompressed by a posterolateral right costotransversectomy, vertebrectomy and insertion of an expandable titanium cage. The spinal sagittal alignment was restored with T1–T7 pedicle screw fixation. Post-operatively the pain and motor power improved significantly so that the patient was discharged home. Separation surgery and adjuvant stereotactic radiosurgery of the spine successfully improved tumor burden, pain control and overall prognosis.

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Conventional Radiotherapy and Stereotactic Radiosurgery in the Management of Metastatic Spine Disease

Technology in Cancer Research & Treatment ◽

10.1177/1533033820945798 ◽

2020 ◽

Vol 19 ◽

pp. 153303382094579

Author(s):

Hao-ran Zhang ◽

Ji-kai Li ◽

Xiong-gang Yang ◽

Rui-qi Qiao ◽

Yong-Cheng Hu

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Life Expectancy ◽

Stereotactic Radiosurgery ◽

Spinal Cord Compression ◽

Spinal Metastases ◽

Scoring Systems ◽

Cord Compression ◽

Conventional Radiotherapy ◽

Radiation Induced

Spinal metastases are a common manifestation of malignant tumors that can cause severe pain, spinal cord compression, pathological fractures, and hypercalcemia, and these clinical manifestations will ultimately reduce the health-related quality of life and even shorten life expectancy in patient with cancer. Effective management of spinal bone metastases requires multidisciplinary collaboration, including radiologists, surgeons, radiation oncologists, medical oncologists, and pain specialists. In the past few decades, conventional radiotherapy has been the most common form of radiotherapy, which can achieve favorable local control and pain relief; however, it lacks precise methods of delivering radiation and thus cannot provide sufficient tumoricidal dose. The advent of stereotactic radiosurgery has changed this situation by using highly focused radiation beams guided by 3-dimensional imaging to deliver a high biologic equivalent dose to the target region, and the spinal cord can be identified and excluded from the target volume to reduce the risk of radiation-induced myelopathy. Separation surgery can provide a 2- to 3-mm safe separation of tumor and spinal cord to avoid radiation-induced damage to the spinal cord. Targets for separation surgery include decompression of metastatic epidural spinal cord compression and spinal stabilization without partial or en bloc tumor resection. Combined with conventional radiotherapy, stereotactic radiosurgery can provide better local tumor control and pain relief. Several scoring systems have been developed to estimate the life expectancy of patients with spinal metastases treated with radiotherapy. Thorough understanding of radiotherapy-related knowledge including the dose-fractionation schedule, separation surgery, efficacy and safety, scoring systems, and feasibility of combination with other treatment methods is critical to providing optimal patient care.

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