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.

BACKGROUNDThe spine is the most common site of bony metastases in patients with osseous breast carcinoma metastases. Spine metastases are the source of significant pain and occasionally neurologic deficit in this patient population. Conventional external beam radiotherapy lacks the precision to allow delivery of large single‐fraction doses of radiation and simultaneously limit the dose to radiosensitive structures such as the spinal cord. This study evaluated the clinical efficacy of the treatment of spinal breast carcinoma metastases with a single‐fraction radiosurgical technique.METHODSIn this prospective cohort evaluation, 68 breast carcinoma metastases to the spine in 50 patients were treated with a single‐fraction radiosurgery technique with a follow‐up period of 6–48 months, median 16 months. The most common indication for radiosurgery treatment was pain in 57 lesions, as a primary treatment modality in 8 patients, and for radiographic tumor progression, as a postsurgical boost, and for a progressive neurologic deficit in 1 patient each.RESULTSTumor volume ranged from 0.8–197 cm3 (mean, 27.7 cm3). Maximum tumor dose was maintained at 15–22.5 Gy (mean, 19 Gy). No radiation‐induced toxicity occurred during the follow‐up period (6–48 mo). Long‐term axial and radicular pain improvement occurred in 55 of 57 (96%) patients who were treated primarily for pain. Long‐term radiographic tumor control was seen in all patients who underwent radiosurgery as their primary treatment modality, for radiographic tumor progression, or as a postsurgical treatment.CONCLUSIONSSpinal radiosurgery was found to be feasible, safe, and clinically effective for the treatment of spinal metastases from breast carcinoma. The results indicate the potential of radiosurgery in the treatment of patients with spinal breast metastases, especially those with solitary sites of spine involvement, to improve long‐term palliation. Cancer 2005. © 2005 American Cancer Society.

Object. Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and irradiation for the underlying malignant process. The authors evaluated a treatment paradigm of closed fracture reduction and fixation involving kyphoplasty and subsequent spinal radiosurgery. Methods. Twenty-six patients (six men and 20 women, mean age 72 years) with pathological compression fractures (16 thoracic and 10 lumbar) were prospectively evaluated. Histological diagnoses included 11 lung, nine breast, four renal, one cholangiocarcioma, and one ocular melanoma. Seven lesions had received prior external-beam radiation therapy. All patients underwent kyphoplasty that involved the percutaneous transpedicular technique. Fiducial markers allowing for image guidance during CyberKnife treatment were placed, at time of the kyphoplasty, in the pedicles at adjacent levels. Patients underwent single-fraction radiosurgery (mean time after kyphoplasty 12 days) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy (mean 18 Gy) to the 80% isodose line. The treated tumor volume ranged from 12.7 to 37.1 cm3. No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (range 11–24 months, median 16 months). Axial pain improved in 24 (92%) of 26 patients. Conclusions. The combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be clinically effective in patients with pathological fractures; there was no significant spinal canal compromise. In this technique two minimally invasive surgical procedures are combined to avoid the morbidity associated with open surgery while providing both immediate fracture fixation and administering a single-fraction tumoricidal radiation dose.

The aim of this study was to assess the feasibility and toxicity of stereotactic radiosurgery (CK-SRS) using the CyberKnife Frameless Radiosurgery System (Accuray Inc., Sunnyvale, CA) in the management of recurrent squamous cell carcinoma of the head and neck region (SCCHN). Between November 2001 and February 2004, 22 patients with recurrent, previously irradiated SCCHN were treated with CK-SRS. The following endpoints were assessed post-CK-SRS: local control (LC), cause-specific survival (CSS), overall survival (OS), symptom relief, and acute and late toxicity. Kaplan-Meier survival analyses were used to estimate the LC, CSS, and OS rates. Clinical symptoms were graded as "improved," "stable," or "progressed" after CK-SRS. Acute and late toxicity were graded according to the National Cancer Institute Common Toxicity Criteria (CTC) scale, version 2.0. Seventeen patients were followed until their death. The median follow-up in the remaining five patients was 19 months (range 11-40 months). The median survival time for the entire cohort was 12 months from the time of CK-SRS. The 2-year LC, CSS, and OS rates were 26%, 26%, and 22%, respectively. After CK-SRS, symptoms were improved or stable in all but one patient who reported increasing pain. The treatment was well tolerated, with one case each of Grade 2 and 3 mucositis. There were no acute Grade 4 or 5 CTC toxicities. There were no late toxicities in this cohort. Frameless stereotactic radiosurgery for recurrent SCCHN is feasible and safe in the setting of high doses of prior irradiation. The majority of patients experienced palliation of disease without excess toxicity.

Object Patients with symptomatic pathological compression fractures require a stabilization procedure for mechanical control of back pain as well as radiation therapy for the underlying malignant process. In this study the authors evaluated a treatment paradigm of closed fracture reduction and fixation in which kyphoplasty was used, followed by single-fraction spinal radiosurgery performed with the CyberKnife. Methods Twenty-six patients (six men and 20 women, mean age 72 years) with histologically confirmed pathological compression fractures (16 thoracic, 10 lumbar) were prospectively evaluated. For inclusion in the study, the patients' presenting symptoms were limited to pain without neurological deficits. Histological findings included 11 lung, nine breast, and four renal carcinomas, one cholangiocarcinoma, and one ocular melanoma. All patients underwent kyphoplasty of the affected vertebral body, for which a percutaneous transpedicular procedure was used. Fiducial markers that allow image guidance for CyberKnife radiosurgery were placed into the pedicles at the adjacent levels at the time of the kyphoplasty procedure. Patients then underwent single-fraction radiosurgery (at a mean of 12 days after kyphoplasty) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy to the 80% isodose line (mean 18 Gy). Treated tumor volume ranged from 12.7 to 37.1 cm3. Axial pain improved in 24 (92%) of 26 patients during the follow-up period of 7 to 20 months. Conclusions A combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be safe and clinically effective for patients with pathological fractures without significant spinal canal compromise. This technique combines two minimally invasive surgical procedures, thereby avoiding the morbidity associated with open surgery while providing immediate fracture fixation as well as a single-fraction tumoricidal radiation dose.