Stereotactic radiosurgery for spinal metastases: a literature review

Joaquim, Andrei Fernandes; Ghizoni, Enrico; Tedeschi, Hélder; Pereira, Eduardo Baldon; Giacomini, Leonardo

doi:10.1590/s1679-45082013000200020

Cited by 44 publications

(24 citation statements)

References 40 publications

(77 reference statements)

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“…2, 17 The goals of intervention for spinal metastasis typically include local disease control, pain relief, maintenance of neurological integrity, and avoidance of spinal instability. 17 Radiotherapy is the mainstay of treatment, with surgery indicated for instability, urgent decompression, pain relief, and tumor biopsy.…”

Section: Discussionmentioning

confidence: 99%

Tumor pseudoprogression of spinal metastasis after radiosurgery: a novel concept and case reports

Taylor

Weaver

2015

SPI

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Radiosurgery for primary and metastatic tumors of the central nervous system is increasing in utility and intensity. Known complications in the brain include radiation necrosis and the well-documented phenomenon of pseudoprogression. Known complications of radiosurgery to spinal column tumors include radiation myelopathy and delayed vertebral compression fractures; however, the concept of pseudoprogression of spinal column tumors has not been previously described. The authors review 2 cases of spinal metastasis treated with stereotactic radiosurgery (SRS) and attempt to define the concept of spine tumor pseudoprogression. Two patients who had undergone SRS to the spine for metastatic disease presented in early follow-up (3 and 7 weeks) with symptomatic complaints consisting of axial pain, radicular pain, or evidence of cord compression. In both patients, MRI revealed evidence of tumor enlargement. In one patient, the lesion had grown by 9 mm and 7.7 mm in the axial and sagittal planes, respectively. In the other patient, the tumor growth resulted in a 5-mm decrease in spinal canal diameter with epidural compression and right foraminal encroachment. Because of the absence of progressive neurological deficit, myelopathy, mechanical symptomatology of instability, or vertebral compression fracture, the first patient was treated expectantly with a corticosteroid taper and had improvement of symptoms at 1 month and near-total radiographic resolution of the tumor. In the second patient, worsening symptoms suggested a need for surgical intervention to address presumed radiosurgical failure and tumor progression. During surgery, only necrotic tumor cells were observed, without viable tumor. Follow-up imaging over 1 year showed ongoing local control. To their knowledge, the authors report the first description of pseudoprogression involving spinal column metastasis in the literature and aim to alert the treating physician to this clinical situation. Unlike brain tumor pseudoprogression, spine tumor pseudoprogression is a relatively early posttreatment phenomenon, measured in days to 2 months. The authors believe that the acute inflammatory response associated with tumor necrosis and disruption of the tumor capillary integrity caused by radiotherapy is an important component in the development of pseudoprogression. Future studies will be fundamental in assigning clinical significance, defining the incidence and predictors, and affecting future management of this phenomenon.

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Section: Discussionmentioning

confidence: 99%

Tumor pseudoprogression of spinal metastasis after radiosurgery: a novel concept and case reports

Taylor

Weaver

2015

SPI

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“…30 Gy in 10 fractions) and stereotactic radiosurgery (SRS -e.g. 16 to 24 Gy single fraction or 24 to 30 Gy in 3 to 5 fractions) 10,11,12,13,14,15,22 . These hypofractionated radiation doses are ablative to the tumor while sparing normal tissue tolerance.…”

Section: Patient's Evaluation -Treatment Decision Processmentioning

confidence: 99%

“…Before image-guided techniques for radiation therapy, more aggressive excisions were required for treating radioresistant tumors, which resulted in increased morbidity and extended procedures in these severely ill patients. SRS has demonstrated local control of up to 90% even in histologies considered poor responsible for cE-BRT, such as melanoma and renal cell carcinoma 14,15 . The need for cytoreductive surgery has decreased over the past 10 years for treating SM with the high tumor control rates obtained using SRS has changed the paradigm of maximal tumor resection to the era of "separation" surgery -a procedure that separates the tumor from the dural sac to allow good conditions for delivery radiation therapy after the procedure 10 .…”

Section: Open Surgerymentioning

confidence: 99%

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An update in the management of spinal metastases

Joaquim

Powers

Laufer

et al. 2015

Arq. Neuro-Psiquiatr.

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Advances in cancer treatment over the past decade, such biologics and immunotherapy are improving patient outcomes and consequently life expectancy. The most common sites for metastases in the general population with cancer are the liver and lungs, followed by bone. Considering bone metastases, the majority will affect the spine 1 . Some studies estimate that up to 40% of all patients with cancer will have spinal metastases (SM) during the course of their disease 2,3 . The most frequent histologic types of cancer that give rise to bone metastases are breast, prostate and lung cancer 4 . Most of the spinal metastases are diagnosed following the diagnosis of the primary cancer. However, in about 10% of the patients, SM is the first manifestation of an unknown primary tumor 1 . Spinal cord compression is expected in up to 20% of the patients with SM. Approximately 95% of the patients with SM will demonstrate epidural metastases, mainly affecting the vertebral body and the pedicle regions, whereas 5% will present with intradural and less than 1% with intramedullary metastases 5,6 . Symptomatic spinal cord compression occurs more frequently in the thoracic spine, followed by cervical and then lumbar. The greater incidence of SM in the thoracic spine is attributed to the higher number of vertebrae and small canal diameter AbstrActThe 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.Keywords: spinal metastases, bone metastases, diagnosis, management, treatment, NOMS.resumo O tratamento dos pacientes com metástases na coluna requer uma abordagem multidisciplinar por equipe especializada em oncologia. Os objetivos básicos do tratamento são a manutenção/ melhora da função neurológica com preservação da deambulação, manutenção da estabilidade da coluna, controle tumoral e alívio da dor. A última década testemunhou uma explosão de novas tecnologias que auxiliaram a atingir os objetivos terapêuticos, como a cirurgia de separação e procedimentos minimamente cirúrgicos minimamente invasivos. Contudo, o maior avanço terapêutico constitui-se d...

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“…Radiosurgery can be used in primary or salvage treatment of spinal metastases, improving local disease control and patient symptoms 3 , 4 . Stereotactic body radiotherapy (SBRT) is being increasingly used in the management of localized spine metastases 5 , 6 , 7 .…”

Section: Introductionmentioning

confidence: 99%

Intensity‐modulated radiotherapy versus proton radiotherapy versus carbon ion radiotherapy for spinal bone metastases: a treatment planning study

Rief

Chaudhri

Tonndorf-Martini

et al. 2015

J Applied Clin Med Phys

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Outcomes for selected patients with spinal metastases may be improved by dose escalation using stereotactic body radiotherapy (SBRT). As target geometry is complex, we compared SBRT plans using step‐and‐shoot intensity‐modulated radiotherapy (IMRT), carbon ion RT, and proton RT. We prepared plans treating cervical, thoracic, and lumbar metastases for three different techniques — IMRT, carbon ion, and proton plans — to deliver a median single 24 Gy fraction such that at least 90% of the planning target volume (PTV) received more than 18 Gy and were compared for PTV coverage, normal organ sparing, and estimated delivery time. PTV coverage did not show significant differences for the techniques, spinal cord dose sparing was lowered with the particle techniques. For the cervical lesion spinal cord maximum dose, dose of 1% (D1), and percent volume receiving 10 Gy (normalV10Gy) were 11.9 Gy, 9.1 Gy, and 0.5% in IMRT. This could be lowered to 4.3 Gy, 2.5 Gy, and 0% in carbon ion planning and to 8.1 Gy, 6.1 Gy, and 0% in proton planning. Regarding the thoracic lesion no difference was found for the spinal cord. For the lumbar lesion maximum dose, D1 and percent volume receiving 5 Gy (normalV5Gy) were 13.4 Gy, 8.9 Gy, and 8.9% for IMRT; 1.8 Gy, 0.7 Gy, and 0% for carbon ions; and 0 Gy,<0.01 Gy, and 0% for protons. Estimated mean treatment times were shorter in particle techniques (6–7 min vs. 12–14 min with IMRT). This planning study indicates that carbon ion and proton RT can deliver high‐quality PTV coverage for complex treatment volumes that surround the spinal cord.PACS number: 87.55.dk

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Stereotactic radiosurgery for spinal metastases: a literature review

Cited by 44 publications

References 40 publications

Tumor pseudoprogression of spinal metastasis after radiosurgery: a novel concept and case reports

Tumor pseudoprogression of spinal metastasis after radiosurgery: a novel concept and case reports

An update in the management of spinal metastases

Intensity‐modulated radiotherapy versus proton radiotherapy versus carbon ion radiotherapy for spinal bone metastases: a treatment planning study

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