scholarly journals Frequency of symptomatic vertebral body compression fractures requiring intervention following single-fraction stereotactic radiosurgery for spinal metastases

2017 ◽  
Vol 42 (1) ◽  
pp. E8 ◽  
Author(s):  
Michael S. Virk ◽  
James E. Han ◽  
Anne S. Reiner ◽  
Lily A. McLaughlin ◽  
Daniel M. Sciubba ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Vertebral Body ◽  
Cumulative Incidence ◽  
Spinal Metastases ◽  
Intensity Modulated Radiation Therapy ◽  
Cancer Center ◽  
Spinal Instability ◽  
Mechanical Instability ◽  
Single Fraction ◽  
Compression Fractures

OBJECTIVE The purpose of this study was to determine the rate of symptomatic vertebral body compression fractures (VCFs) requiring kyphoplasty or surgery in patients treated with 24-Gy single-fraction stereotactic radiosurgery (SRS). METHODS This retrospective analysis included all patients who had been treated with 24-Gy, single-fraction, image-guided intensity-modulated radiation therapy for histologically confirmed solid tumor metastases over an 8-year period (2005–2013) at Memorial Sloan Kettering Cancer Center. Charts and imaging studies were reviewed for post-SRS kyphoplasty or surgery for mechanical instability. A Spinal Instability Neoplastic Score (SINS) was calculated for each patient both at the time of SRS and at the time of intervention for VCF. RESULTS Three hundred twenty-three patients who had undergone single-fraction SRS between C-1 and L-5 were included in this analysis. The cumulative incidence of VCF 5 years after SRS was 7.2% (95% CI 4.1–10.2), whereas that of death following SRS at the same time point was 82.5% (95% CI 77.5–87.4). Twenty-six patients with 36 SRS-treated levels progressed to symptomatic VCF requiring treatment with kyphoplasty (6 patients), surgery (10 patients), or both (10 patients). The median time to symptomatic VCF was 13 months. Seven patients developed VCF at 11 levels adjacent to the SRS-treated level. Fractured levels had no evidence of tumor progression. The median SINS changed from 6.5 at SRS (interquartile range [IQR] 4.3–8.8) to 11.5 at stabilization (IQR 9–13). In patients without prior stabilization at the level of SRS, there was an association between the SINS and the time to fracture. CONCLUSIONS Five years after ablative single-fraction SRS to spinal lesions, the cumulative incidence of symptomatic VCF at the treated level without tumor recurrence was 7.2%. Higher SINSs at the time of SRS correlated with earlier fractures.

scholarly journals Risk of Fracture After Single Fraction Image-Guided Intensity-Modulated Radiation Therapy to Spinal Metastases

2009 ◽  
Vol 27 (30) ◽  
pp. 5075-5079 ◽  
Author(s):  
Peter S. Rose ◽  
Ilya Laufer ◽  
Patrick J. Boland ◽  
Andrew Hanover ◽  
Mark H. Bilsky ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Vertebral Fracture ◽  
High Risk ◽  
Vertebral Body ◽  
Spinal Metastases ◽  
Intensity Modulated Radiation Therapy ◽  
Risk Of Fracture ◽  
Single Fraction ◽  
Image Guided ◽  
Intensity Modulated

Purpose Single-fraction image-guided intensity-modulated radiation therapy (IG-IMRT) allows for tumoricidal treatment of traditionally radioresistant cancers while sparing critical adjacent structures. Risk of vertebral fracture after IG-IMRT for spinal metastases has not been defined. Patients and Methods We evaluated 62 consecutive patients undergoing single fraction IG-IMRT at 71 sites for solid organ metastases. A neuroradiologist and three spine surgeons evaluated prospectively obtained magnetic resonance/computed tomography (CT) imaging studies for post-treatment fracture development and tumor recurrence. Results Fracture progression was noted in 27 vertebrae (39%). Multivariate logistic regression analysis showed that CT appearance, lesion location, and percent vertebral body involvement independently predicted fracture progression. Lesions located between T10 and the sacrum were 4.6 times more likely to fracture than were lesions above T10 (95% CI, 1.1 to 19.7). Lytic lesions were 6.8 times more likely to fracture than were sclerotic and mixed lesions (95% CI, 1.4 to 33.3). As percent vertebral body involvement increased, odds of fracture also increased. Patients with fracture progression had significantly higher narcotic use, change in Karnofsky performance score, and a strong trend toward higher pain scores. Local tumor progression occurred in seven patients and contributed to one fracture. Obesity, posterior element involvement, bisphosphonate use, and local kyphosis did not confer increased risk. Conclusion Vertebral fracture is common after single fraction IG-IMRT for metastatic spine lesions. Lytic disease involving more than 40% of the vertebral body and location at or below T10 confer a high risk of fracture, the presence of which yields significantly poorer clinical outcomes. These results may help clinicians identify high-risk patients who would benefit from prophylactic vertebro- or kyphoplasty.

scholarly journals Single-fraction versus multifraction spinal stereotactic radiosurgery for spinal metastases from renal cell carcinoma: secondary analysis of Phase I/II trials

2016 ◽  
Vol 24 (5) ◽  
pp. 829-836 ◽  
Author(s):  
Amol J. Ghia ◽  
Eric L. Chang ◽  
Andrew J. Bishop ◽  
Hubert Y. Pan ◽  
Nicholas S. Boehling ◽  
...  
Keyword(s):  
Renal Cell Carcinoma ◽  
Cell Carcinoma ◽  
Stereotactic Radiosurgery ◽  
Renal Cell ◽  
Tumor Volume ◽  
Secondary Analysis ◽  
Spinal Metastases ◽  
Survival Duration ◽  
Single Fraction ◽  
Entire Cohort

OBJECTIVE The objective of this study was to compare fractionation schemes and outcomes of patients with renal cell carcinoma (RCC) treated in institutional prospective spinal stereotactic radiosurgery (SSRS) trials who did not previously undergo radiation treatment at the site of the SSRS. METHODS Patients enrolled in 2 separate institutional prospective protocols and treated with SSRS between 2002 and 2011 were included. A secondary analysis was performed on patients with previously nonirradiated RCC spinal metastases treated with either single-fraction (SF) or multifraction (MF) SSRS. RESULTS SSRS was performed in 47 spinal sites on 43 patients. The median age of the patients was 62 years (range 38–75 years). The most common histological subtype was clear cell (n = 30). Fifteen sites underwent surgery prior to the SSRS, with laminectomy the most common procedure performed (n = 10). All SF SSRS was delivered to a dose of 24 Gy (n = 21) while MF regiments were either 27 Gy in 3 fractions (n = 20) or 30 Gy in 5 fractions (n = 6). The median overall survival duration for the entire cohort was 22.8 months. The median local control (LC) for the entire cohort was 80.6 months with 1-year and 2-year actuarial LC rates of 82% and 68%, respectively. Single-fraction SSRS correlated with improved 1- and 2-year actuarial LC relative to MF SSRS (95% vs 71% and 86% vs 55%, respectively; p = 0.009). On competing risk analysis, SF SSRS showed superior LC to MF SSRS (subhazard ratio [SHR] 6.57, p = 0.014). On multivariate analysis for LC with tumor volume (p = 0.272), number of treated levels (p = 0.819), gross tumor volume (GTV) coverage (p = 0.225), and GTV minimum point dose (p = 0.97) as covariates, MF SSRS remained inferior to SF SSRS (SHR 5.26, p = 0.033) CONCLUSIONS SSRS offers durable LC for spinal metastases from RCC. Single-fraction SSRS is associated with improved LC over MF SSRS for previously nonirradiated RCC spinal metastases.

Radiation-Sensitive Spine Tumor

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.

scholarly journals Delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation: Case report with histopathologic-MRI correlation

2015 ◽  
Vol 21 (6) ◽  
pp. 742-749 ◽  
Author(s):  
Adam N Wallace ◽  
Ross Vyhmeister ◽  
Andy C Hsi ◽  
Clifford G Robinson ◽  
Randy O Chang ◽  
...  
Keyword(s):  
Case Report ◽  
Radiofrequency Ablation ◽  
Stereotactic Radiosurgery ◽  
Vertebral Body ◽  
Spinal Metastases ◽  
Imaging Findings ◽  
Pain Palliation ◽  
Percutaneous Radiofrequency Ablation ◽  
Emerging Therapies

Stereotactic radiosurgery and percutaneous radiofrequency ablation are emerging therapies for pain palliation and local control of spinal metastases. However, the post-treatment imaging findings are not well characterized and the risk of long-term complications is unknown. We present the case of a 46-year-old woman with delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation of a painful lumbar metastasis. Histopathologic-MRI correlation confirmed osteonecrosis as the underlying etiology and demonstrated that treatment-induced vascular fibrosis and tumor progression can have identical imaging appearances.

scholarly journals Spine stereotactic radiosurgery for the treatment of multiple myeloma

2017 ◽  
Vol 26 (3) ◽  
pp. 282-290 ◽  
Author(s):  
Jacob A. Miller ◽  
Ehsan H. Balagamwala ◽  
Samuel T. Chao ◽  
Todd Emch ◽  
John H. Suh ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Radiation Therapy ◽  
Vertebral Fracture ◽  
Pain Relief ◽  
Stereotactic Radiosurgery ◽  
Median Time ◽  
Cumulative Incidence ◽  
Single Fraction ◽  
Pain Scores

OBJECTIVE The objective of this study was to define symptomatic and radiographic outcomes following spine stereotactic radiosurgery (SRS) for the treatment of multiple myeloma. METHODS All patients with pathological diagnoses of myeloma undergoing spine SRS at a single institution were included. Patients with less than 1 month of follow-up were excluded. The primary outcome measure was the cumulative incidence of pain relief after spine SRS, while secondary outcomes included the cumulative incidences of radiographic failure and vertebral fracture. Pain scores before and after treatment were prospectively collected using the Brief Pain Inventory (BPI), a validated questionnaire used to assess severity and impact of pain upon daily functions. RESULTS Fifty-six treatments (in 38 patients) were eligible for inclusion. Epidural disease was present in nearly all treatment sites (77%). Moreover, preexisting vertebral fracture (63%), thecal sac compression (55%), and neural foraminal involvement (48%) were common. Many treatment sites had undergone prior local therapy, including external beam radiation therapy (EBRT; 30%), surgery (23%), and kyphoplasty (21%). At the time of consultation for SRS, the worst, current, and average BPI pain scores at these treatment sites were 6, 4, and 4, respectively. The median prescription dose was 16 Gy in a single fraction. The median clinical follow-up duration after SRS was 26 months. The 6- and 12-month cumulative incidences of radiographic failure were 6% and 9%, respectively. Among painful treatment sites, 41% achieved pain relief adjusted for narcotic usage, with a median time to relief of 1.6 months. The 6- and 12-month cumulative incidences of adjusted pain progression were 13% and 15%, respectively. After SRS, 1-month and 3-month worst, current, and average BPI scores all significantly decreased (p < 0.01). Vertebral fracture occurred following 12 treatments (21%), with an 18% cumulative incidence of fracture at 6 and 12 months. Two patients (4%) developed pain flare following spine SRS. CONCLUSIONS This study reports the largest series of myeloma lesions treated with spine SRS. A rapid and durable symptomatic response was observed, with a median time to pain relief of 1.6 months. This response was durable among 85% of patients at 12 months following treatment, with 91% local control. The efficacy and minimal toxicity of spine SRS is likely related to the delivery of ablative and conformal radiation doses to the target. SRS should be considered with doses of 14–16 Gy in a single fraction for patients with multiple myeloma and limited spinal disease, myelosuppression requiring “marrow-sparing” radiation therapy, or recurrent disease after EBRT.

Stereotactic radiosurgery for spinal metastases from renal cell carcinoma

2005 ◽  
Vol 3 (4) ◽  
pp. 288-295 ◽  
Author(s):  
Peter C. Gerszten ◽  
Steven A. Burton ◽  
Cihat Ozhasoglu ◽  
William J. Vogel ◽  
William C. Welch ◽  
...  
Keyword(s):  
Renal Cell Carcinoma ◽  
Tumor Progression ◽  
Cell Carcinoma ◽  
Stereotactic Radiosurgery ◽  
Renal Cell ◽  
Spinal Metastases ◽  
External Beam Radiation ◽  
Content Type ◽  
Single Fraction ◽  
Fine Print

Object. The role of stereotactic radiosurgery in treating renal cell carcinoma (RCC) metastases to the spine has previously been limited. In this study the authors evaluated the clinical outcome in patients with spinal RCC who underwent single-fraction radiosurgery. Methods. Forty-eight patients with 60 RCC metastases to the spine (six cervical, 26 thoracic, 18 lumbar, and 10 sacral) were treated with a single-fraction radiosurgery technique and were followed for a period of 14 to 48 months (median 37 months). All patients were successfully treated in an outpatient setting. The tumor volume ranged from 5.5 to 203 cm3 (mean 61.9 cm3). Forty-two of the total 60 lesions had been previously treated with external-beam radiation therapy (EBRT). The maximum tumor dose was maintained at 17.5 to 25 Gy (mean 20 Gy). The volume of the spinal cord exposed to greater than 8 Gy ranged from 0.01 to 3 cm3 (mean 0.64 cm3); the volume of the spinal canal at the cauda equina level exposed to greater than 8 Gy ranged from 0.01 to 2.2 cm3 (mean 0.65 cm3). No radiation-induced toxicity occurred during the follow-up period. Axial and radicular pain improved in 34 (89%) of 38 patients who were treated primarily for pain. Tumor control was demonstrated in seven of eight patients treated primarily for radiographically documented tumor progression. In time six patients required open surgical intervention for tumor progression that had caused neurological dysfunction after radiosurgery. Conclusions. Spinal radiosurgery can be a successful therapeutic modality for the delivery of large-dose single-fraction radiation to RCC spinal metastases that are often poorly controlled with conventional EBRT modalities.

scholarly journals A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis

2020 ◽  
Vol 32 (4) ◽  
pp. 499-506 ◽  
Author(s):  
Jeff Ehresman ◽  
Andrew Schilling ◽  
Zach Pennington ◽  
Chengcheng Gui ◽  
Xuguang Chen ◽  
...  
Keyword(s):  
Bone Quality ◽  
Signal Intensity ◽  
Scoring System ◽  
Spinal Metastasis ◽  
Multivariable Analysis ◽  
Spinal Metastases ◽  
Vertebral Compression Fractures ◽  
Spinal Instability ◽  
The Novel ◽  
Compression Fractures

OBJECTIVEVertebral compression fractures (VCFs) in patients with spinal metastasis can lead to destabilization and often carry a high risk profile. It is therefore important to have tools that enable providers to predict the occurrence of new VCFs. The most widely used tool for bone quality assessment, dual-energy x-ray absorptiometry (DXA), is not often available at a patient’s initial presentation and has limited sensitivity. While the Spinal Instability Neoplastic Score (SINS) has been associated with VCFs, it does not take patients’ baseline bone quality into consideration. To address this, the authors sought to develop an MRI-based scoring system to estimate trabecular vertebral bone quality (VBQ) and to assess this system’s ability to predict the occurrence of new VCFs in patients with spinal metastasis.METHODSCases of adult patients with a diagnosis of spinal metastasis, who had undergone stereotactic body radiation therapy (SBRT) to the spine or neurosurgical intervention at a single institution between 2012 and 2019, were retrospectively reviewed. The novel VBQ score was calculated for each patient by dividing the median signal intensity of the L1–4 vertebral bodies by the signal intensity of cerebrospinal fluid (CSF). Multivariable logistic regression analysis was used to identify associations of demographic, clinical, and radiological data with new VCFs.RESULTSAmong the 105 patients included in this study, 56 patients received a diagnosis of a new VCF and 49 did not. On univariable analysis, the factors associated with new VCFs were smoking status, steroid use longer than 3 months, the SINS, and the novel scoring system—the VBQ score. On multivariable analysis, only the SINS and VBQ score were significant predictors of new VCFs and, when combined, had a predictive accuracy of 89%.CONCLUSIONSAs a measure of bone quality, the novel VBQ score significantly predicted the occurrence of new VCFs in patients with spinal metastases independent of the SINS. This suggests that baseline bone quality is a crucial factor that requires assessment when evaluating these patients’ conditions and that the VBQ score is a novel and simple MRI-based measure to accomplish this.

scholarly journals International Variability in Spinal Metastasis Treatment: A Survey of the AO Spine Community

2021 ◽  
pp. 219256822110469
Author(s):  
Zach Pennington ◽  
Jose L. Porras ◽  
Sheng-Fu Larry Lo ◽  
Daniel M. Sciubba
Keyword(s):  
Multidisciplinary Team ◽  
Spinal Metastasis ◽  
Spinal Metastases ◽  
Fellowship Training ◽  
Cancer Center ◽  
Spinal Instability ◽  
Multidisciplinary Teams ◽  
Practice Setting ◽  
Surgical Specialty

Study Design International survey. Objectives To assess variability in the treatment practices for spinal metastases as a function of practice setting, surgical specialty, and fellowship training among an international group of spine surgeons. Methods An anonymous internet-based survey was disseminated to the AO Spine membership. The questionnaire contained items on practice settings, fellowship training, indications used for spinal metastasis surgery, surgical strategies, multidisciplinary team use, and postoperative follow-up priorities and practice. Results 341 gave complete responses to the survey with 76.3% identifying spinal oncology as a practice focus and 95.6% treating spinal metastases. 80% use the Spinal Instability Neoplastic Score (SINS) to guide instrumentation decision-making and 60.7% recruit multidisciplinary teams for some or all cases. Priorities for postoperative follow-up are adjuvant radiotherapy (80.9%) and systemic therapy (74.8%). Most schedule first follow-up within 6 weeks of surgery (62.2%). Significant response heterogeneity was seen when stratifying by practice in an academic or university-affiliated center, practice in a cancer center, completion of a spine oncology fellowship, and self-identification as a tumor specialist. Respondents belonging to any of these categories were more likely to utilize SINS ( P < .01-.02), recruit assistance from plastic surgeons (all P < .01), and incorporate radiation oncologists in postoperative care ( P < .01-.03). Conclusions The largest variability in practice strategies is based upon practice setting, spine tumor specialization, and completion of a spine oncology fellowship. These respondents were more likely to use evidenced-based practices. However, the response variability indicates the need for consensus building, particularly for postoperative spine metastasis care pathways and multidisciplinary team use.

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