Management of recurrent or progressive spinal metastases: reirradiation techniques and surgical principles

Abstract With the growing incidence of new cases and the increasing prevalence of patients living longer with spine metastasis, a methodological approach to the management of patients with recurrent or progressive disease is increasing in relevance and importance in clinical practice. As a result, disease management has evolved in these patients using advanced surgical and radiotherapy technologies. Five key goals in the management of patients with spine metastases include providing pain relief, controlling metastatic disease at the treated site, improving neurologic deficits, maintaining or improving functional status, and minimizing further mechanical instability. The focus of this review is on advanced reirradiation techniques, given that the majority of patients will be treated with upfront conventional radiotherapy and further treatment on progression is often limited by the cumulative tolerance of nearby organs at risk. This review will also discuss novel surgical approaches such as separation surgery, minimally invasive percutaneous instrumentation, and laser interstitial thermal therapy, which is increasingly being coupled with spine reirradiation to maximize outcomes in this patient population. Lastly, given the complexities of managing recurrent spinal disease, this review emphasizes the importance of multidisciplinary care from neurosurgery, radiation oncology, medical oncology, neuro-oncology, rehabilitation medicine, and palliative care.

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Integrating Evidence-Based Medicine for Treatment of Spinal Metastases Into a Decision Framework: Neurologic, Oncologic, Mechanicals Stability, and Systemic Disease

Journal of Clinical Oncology ◽

10.1200/jco.2017.72.7362 ◽

2017 ◽

Vol 35 (21) ◽

pp. 2419-2427 ◽

Cited By ~ 48

Author(s):

Ori Barzilai ◽

Ilya Laufer ◽

Yoshiya Yamada ◽

Daniel S. Higginson ◽

Adam M. Schmitt ◽

...

Keyword(s):

Organs At Risk ◽

Systemic Disease ◽

Spinal Metastases ◽

Current Evidence ◽

Tumor Control ◽

High Dose ◽

Mechanical Instability ◽

Decision Framework ◽

Clear Trend ◽

Definitive Therapy

Patients with cancer are frequently affected by spinal metastases. Treatment is palliative, with the principle goals of pain relief, preservation of neurologic function, and improvement in quality of life. In the past decade, we have witnessed a dramatic change in the treatment paradigms due to the development of improved surgical strategies and systemic and radiation therapy. The most important change to these paradigms has been the integration of spinal stereotactic radiosurgery (SSRS), allowing delivery of tumoricidal radiation doses with sparing of nearby organs at risk. High-dose SSRS provides durable tumor control when used either as definitive therapy or as a postoperative adjuvant therapy. Integration of SSRS has fundamentally changed the indications for and type of surgery performed for metastatic spine tumors. Although the role for surgical intervention is well established, a clear trend toward less-aggressive, often minimally invasive techniques has been observed. Targeted therapies are also rapidly changing the way cancer is being treated and have demonstrated improved survival for a number of malignancies. As these treatment decisions become more complex, a multidisciplinary approach including medical oncologists, radiation oncologists, surgeons, interventionalists, and pain specialists is required. In this article, the current evidence affecting the treatment of spinal metastases is integrated into a decision framework that considers four principal assessments of a patient’s spine disease: NOMS (neurologic, oncologic, mechanical instability, and systemic disease).

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43: Predictors of Toxicity in a Randomized Study of Hypofractionated Versus Conventional Radiotherapy for Glioblastoma: Dosimetric Analysis of Organs at Risk

Radiotherapy and Oncology ◽

10.1016/s0167-8140(21)08921-0 ◽

2021 ◽

Vol 163 ◽

pp. S21

Author(s):

Fan Yang ◽

Deepak Dinakaran ◽

Amr A. Heikal ◽

Sunita Ghosh ◽

Shima Yaghoobpour Tari ◽

...

Keyword(s):

At Risk ◽

Organs At Risk ◽

Randomized Study ◽

Conventional Radiotherapy ◽

Dosimetric Analysis

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An update in the management of spinal metastases

Arquivos de Neuro-Psiquiatria ◽

10.1590/0004-282x20150099 ◽

2015 ◽

Vol 73 (9) ◽

pp. 795-802 ◽

Cited By ~ 20

Author(s):

Andrei F. Joaquim ◽

Ann Powers ◽

Ilya Laufer ◽

Mark H. Bilsky

Keyword(s):

New Technologies ◽

Systemic Disease ◽

Spinal Metastases ◽

Integrated Approach ◽

External Beam Radiation ◽

Tumor Control ◽

Mechanical Instability ◽

Beam Radiation ◽

Definitive Therapy ◽

Neurologic Function

The best clinical treatment for spinal metastases requires an integrated approach with input from an interdisciplinary cancer team. The principle goals of treatment are maintenance or improvement in neurologic function and ambulation, spinal stability, durable tumor control, and pain relief. The past decade has witnessed an explosion of new technologies that have impacted our ability to reach these goals, such as separation surgery and minimally invasive spinal procedures. The biggest advance, however, has been the evolution of stereotactic radiosurgery that has demonstrated durable tumor control both when delivered as definitive therapy and as a postoperative adjuvant even for tumors considered markedly resistant to conventional external beam radiation. In this paper, we perform an update on the management of spinal metastases demonstrating the integration of these new technologies into a decision framework NOMS that assesses four basic aspects of a patient’s spine disease: Neurologic, Oncologic, Mechanical Instability and Systemic disease.

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Radiation-Sensitive Spine Tumor

Spinal Neurosurgery ◽

10.1093/med/9780190887773.003.0017 ◽

2018 ◽

pp. 159-174

Author(s):

Adam M. Robin ◽

Ilya Laufer

Keyword(s):

Spinal Cord ◽

Multiple Myeloma ◽

Spinal Cord Compression ◽

Cauda Equina ◽

Spinal Metastases ◽

Cord Compression ◽

External Beam Radiation ◽

Spinal Instability ◽

Mechanical Instability

A decision-making framework called NOMS (neurologic, oncologic, mechanical and systemic) facilitates and guides therapeutic decisions for patients with spinal metastases. Patients should be evaluated for signs of myelopathy or cauda equina syndrome. The Epidural Spinal Cord Compression (ESCC) scale facilitates reporting of the degree of radiographic spinal cord compression. A determination of the expected histology-specific tumor response to conventionally fractionated external beam radiation (cEBRT) and systemic therapy should be made. Radiation therapy effectively treats biologic pain for radiosensitive tumors such as multiple myeloma. Patients should undergo a careful evaluation of movement-associated pain as tumor-induced spinal instability is an independent indication for surgery. Determination of tumor-associated mechanical instability can be facilitated by the Spinal Instability Neoplastic Score (SINS). Herein, the authors present a case of spinal multiple myeloma managed using the NOMS framework and in consideration of current evidence and treatment paradigms.

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Spine Stereotactic Body Radiotherapy: Indications, Outcomes, and Points of Caution

Global Spine Journal ◽

10.1177/2192568217694016 ◽

2017 ◽

Vol 7 (2) ◽

pp. 179-197 ◽

Cited By ~ 38

Author(s):

Chia-Lin Tseng ◽

Wietse Eppinga ◽

Raphaele Charest-Morin ◽

Hany Soliman ◽

Sten Myrehaug ◽

...

Keyword(s):

Minimally Invasive ◽

Stereotactic Body Radiotherapy ◽

Organs At Risk ◽

Spinal Metastases ◽

Response Assessment ◽

Tumor Control ◽

Spinal Instability ◽

Minimally Invasive Techniques ◽

Stereotactic Radiation ◽

Invasive Techniques

Study Design: A broad narrative review. Objectives: The objective of this article is to provide a technical review of spine stereotactic body radiotherapy (SBRT) planning and delivery, indications for treatment, outcomes, complications, and the challenges of response assessment. The surgical approach to spinal metastases is discussed with an overview of emerging minimally invasive techniques. Methods: A comprehensive review of the literature was conducted on the techniques, outcomes, and developments in SBRT and surgery for spinal metastases. Results: The optimal management of patients with spinal metastases is complex and requires multidisciplinary assessment from an oncologic team that is familiar with the shifting paradigm as a consequence of evolving techniques in surgery and stereotactic radiation, as well as new developments in systemic agents. The Spinal Instability Neoplastic Score and the epidural spinal cord compression (Bilsky) grading system are useful tools that facilitate communication among oncologic team members and can direct management by providing a baseline assessment of risks prior to therapy. The combined multimodality approach with “separation surgery” followed by postoperative spine SBRT achieves thecal sac decompression, improves tumor control, and avoids complications that may be associated with more extensive surgery. Conclusion: Spine SBRT is a highly effective treatment that is capable of delivering ablative doses to the target while sparing the critical organs-at-risk, chiefly the critical neural tissues, within a short and manageable schedule. At the same time, surgery occupies an important role in select patients, particularly with the expanding availability and expertise in minimally invasive techniques. With rapid adoption of spine SBRT in centers outside of the academic setting, it is imperative for the practicing oncologist to understand the relevance and application of these evolving concepts.

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Effectiveness and toxicity of conventional radiotherapy treatment for painful spinal metastases: a detailed course of side effects after opposing fields versus a single posterior field technique

Journal of Radiation Oncology ◽

10.1007/s13566-017-0328-1 ◽

2017 ◽

Vol 7 (1) ◽

pp. 17-26 ◽

Cited By ~ 4

Author(s):

Paulien G. Westhoff ◽

◽

Alexander de Graeff ◽

Evelyn M. Monninkhof ◽

Ilse de Pree ◽

...

Keyword(s):

Side Effects ◽

Spinal Metastases ◽

Conventional Radiotherapy ◽

Field Technique ◽

Posterior Field ◽

Radiotherapy Treatment

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SU-GG-T-168: Comparison of Target Coverage and Organs at Risk Dose between Simultaneous Integrated Boost Whole Field IMRT and a Junctioned IMRT with Conventional Radiotherapy Field in Treatment of Nasopharyngeal Carcinoma

Medical Physics ◽

10.1118/1.3468558 ◽

2010 ◽

Vol 37 (6Part18) ◽

pp. 3223-3223

Author(s):

J Chung ◽

J Lee ◽

J Kim ◽

I Kim ◽

B Choe ◽

...

Keyword(s):

At Risk ◽

Nasopharyngeal Carcinoma ◽

Organs At Risk ◽

Simultaneous Integrated Boost ◽

Target Coverage ◽

Conventional Radiotherapy ◽

Radiotherapy Field ◽

Integrated Boost

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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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Experimental and Numerical Models of Complex Clinical Scenarios; Strategies to Improve Relevance and Reproducibility of Joint Replacement Research

Journal of Biomechanical Engineering ◽

10.1115/1.4032368 ◽

2016 ◽

Vol 138 (2) ◽

Cited By ~ 1

Author(s):

Joan E. Bechtold ◽

Pascal Swider ◽

Curtis Goreham-Voss ◽

Kjeld Soballe

Keyword(s):

Bone Loss ◽

Joint Replacement ◽

Numerical Models ◽

Proper Function ◽

Surgical Approaches ◽

Research Review ◽

Mechanical Instability ◽

Implant Fixation ◽

Numerical Work ◽

Clinical Scenarios

This research review aims to focus attention on the effect of specific surgical and host factors on implant fixation, and the importance of accounting for them in experimental and numerical models. These factors affect (a) eventual clinical applicability and (b) reproducibility of findings across research groups. Proper function and longevity for orthopedic joint replacement implants relies on secure fixation to the surrounding bone. Technology and surgical technique has improved over the last 50 years, and robust ingrowth and decades of implant survival is now routinely achieved for healthy patients and first-time (primary) implantation. Second-time (revision) implantation presents with bone loss with interfacial bone gaps in areas vital for secure mechanical fixation. Patients with medical comorbidities such as infection, smoking, congestive heart failure, kidney disease, and diabetes have a diminished healing response, poorer implant fixation, and greater revision risk. It is these more difficult clinical scenarios that require research to evaluate more advanced treatment approaches. Such treatments can include osteogenic or antimicrobial implant coatings, allo- or autogenous cellular or tissue-based approaches, local and systemic drug delivery, surgical approaches. Regarding implant-related approaches, most experimental and numerical models do not generally impose conditions that represent mechanical instability at the implant interface, or recalcitrant healing. Many treatments will work well in forgiving settings, but fail in complex human settings with disease, bone loss, or previous surgery. Ethical considerations mandate that we justify and limit the number of animals tested, which restricts experimental permutations of treatments. Numerical models provide flexibility to evaluate multiple parameters and combinations, but generally need to employ simplifying assumptions. The objectives of this paper are to (a) to highlight the importance of mechanical, material, and surgical features to influence implant–bone healing, using a selection of results from two decades of coordinated experimental and numerical work and (b) discuss limitations of such models and the implications for research reproducibility. Focusing model conditions toward the clinical scenario to be studied, and limiting conclusions to the conditions of a particular model can increase clinical relevance and research reproducibility.

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