Combining a Customized Immobilization System with an Innovative Use of the ExacTrac System for Precise Volumetric Modulated Arc Therapy of Challenging Forearm Sarcomas

Ferini, Gianluca; Palmisciano, Paolo; Zagardo, Valentina; Viola, Anna; Illari, Salvatore Ivan; Marchese, Valentina; Umana, Giuseppe E.; Valenti, Vito

doi:10.1016/j.prro.2022.10.005

Cited by 4 publications

(7 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Pre-operative treatment with chemotherapy and/or radiotherapy should also be considered depending on histology ( 18 ). Radiotherapy for intermediate and high grade sarcomas may be highly challenging, depending on the complexity of the affected body site, which could recommend the use of advanced stereotactic techniques ( 19 ).…”

Section: Discussionmentioning

confidence: 99%

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy

et al. 2023

View full text Add to dashboard Cite

IntroductionTomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery.MethodsFirst-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4–S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4–S1 promontory.ResultsPatient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op.ConclusionThese are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.

show abstract

Section: Discussionmentioning

confidence: 99%

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy

et al. 2023

View full text Add to dashboard Cite

show abstract

“…Sarcomas have traditionally been considered to be radioresitant; however, RT has now been routinely incorporated into sarcoma treatment regimens for more than a century ( 27 ). The introduction of newer RT modalities, such as IGRT, intensity modulation RT, volumetric modulated arc therapy, stereotactic RT, and proton-based RT has revolutionized the field of radiation oncology, while resulting in fewer toxicities ( 8 , 27 , 28 ). Given the locally aggressive nature of the tumor and risk of local and distant recurrence, several authors recommend surgery with concomitant radiotherapy as the standard of care for MPNSTs ( 3 , 4 , 14 , 29 – 32 ).…”

Section: Discussionmentioning

confidence: 99%

“…We employed the use of the ExacTrac imaging system, a customized immobilization device, and VMAT to reduce unintended radiation exposure to the forearm bones ( 8 ). Unlike classic treatment verification systems, ExacTrac allowed real-time indirect monitoring of the target setup during the daily radiation dose delivery through an infrared-based optical positioning system, using markers placed on the volar surface of the patient’s forearm.…”

Section: Discussionmentioning

confidence: 99%

“…The clinical target volume was decided as the whole tumor bed including the entire flexor muscle compartment of the right forearm, extending from the elbow to the wrist. The tumor bed was irradiated with a total dose of 70 Gy in fractions of 2 Gy/day under ExacTrac image guidance as described by Ferini et al (8) (Figure 4). To avoid excessive radiation-induced injury to the radius and ulna, which closely abutted the high-dose radiotherapy target, we adopted an image-guided radiotherapy (IGRT)-volumetric modulated arc therapy (VMAT) approach rather than three-dimensional conformal radiotherapy verified through classic low-contrast resolution kilovoltage imaging systems or megavoltage electronic imaging devices.…”

Section: Case Reportmentioning

confidence: 99%

“…Second, it hinders the precise delivery of high radiation doses in the adjuvant or neoadjuvant radiotherapy setting ( 7 ). This can be circumvented by immobilization systems for accurate and reproducible positioning, rigorous set-up verification, and meticulous planning to ensure precise RT delivery ( 8 ). Furthermore, for improved planning, techniques such as volumetric modulated arc therapy (VMAT) that allow for accurate dose sculpting are now widely available.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Case Report: Adjuvant image-guided radiation therapy reduces surgical invasiveness in malignant peripheral nerve sheath tumors

Harikar

Ferini²,

Palmisciano

et al. 2023

Front. Oncol.

Self Cite

View full text Add to dashboard Cite

IntroductionMalignant peripheral nerve sheath tumors (MPNSTs) are a group of rare soft tissue sarcomas of mesenchymal origin. These tumors generally require extensive local excision owing to their aggressive potential. Though the role of radiotherapy is controversial, in this report, we present the case of an MPNST in the forearm that was treated with microsurgery followed by image-guided radiation therapy to achieve complete tumor disappearance at the 18-month follow-up.Case reportA 69-year-old woman with underlying paranoid schizophrenia was referred to our department with pain, severe swelling, and ecchymosis of her right forearm. Physical examination showed hypoesthesia in the segments innervated by the median nerve and reduced motor strength of her right hand. A gadolinium-enhanced MRI showed a large malignant peripheral nerve sheath tumor (13 x 8 x 7 cm) of the median nerve in the forearm. She underwent microsurgical en-bloc tumor resection with sparing of the median nerve. Thirty-five days postoperatively, she underwent image-guided radiotherapy (IGRT) using volumetric modulated arc therapy (VMAT). Serial MRI scans of the forearm with Gadolinium and whole-body CT scan with contrast enhancement at 30 days, 6 months, 1 year, and 18 months postoperatively documented no tumor recurrence, remnants, or metastases.ConclusionsIn this report, we demonstrate the successful use of advanced radiotherapy techniques such as IGRT while avoiding demolitive surgery for MPNST. Though a longer follow-up is necessary, at the 18-month follow-up, the patient demonstrated good outcomes from surgical resection followed by adjuvant RT for MPNST in the forearm.

show abstract

Considerations on surgery invasiveness and response and toxicity patterns in classic palliative radiotherapy for acrometastases of the hand: a hint for a potential role of stereotactic body radiation therapy? A case report and literature review

Ferini¹,

Zagardo²,

Viola³

et al. 2023

Front. Oncol.

Self Cite

View full text Add to dashboard Cite

BackgroundThe rarity of hand acrometastases hampers the consensus-building for their optimal management among the involved oncology professionals. In the current literature, demolitive surgery overcomes the use of palliative radiotherapy, which proved to be ineffective in more than 30% of cases treated with classic palliative dose schemes, carrying also a not negligible radiation-related adverse event rate. Against this background, stereotactic body radiation therapy (SBRT) could emerge as a well-balanced therapeutic option.Case summaryHere we describe the methods and outcomes of a SBRT treatment of a painful and function-limiting hand acrometastasis in a patient with a history of stage IIIB lung adenocarcinoma. We delivered a total dose of 30 Gy in five daily fractions to a soft-tissue metastasis abutting the fifth metacarpal bone through the SBRT protocol generally used for intracranial treatments. A few weeks later, the patient reported a clinical complete response with acrometastasis and pain disappearance, function recovery, and no significant toxicity. The acrometastasis was the first sign of an atypical cancer progression.ConclusionsSBRT for hand acrometastases is feasible and might have the best therapeutic profile among the currently available treatment options for this rare clinical scenario. Larger investigations are needed to confirm the present single-case experience.

show abstract

Combining a Customized Immobilization System with an Innovative Use of the ExacTrac System for Precise Volumetric Modulated Arc Therapy of Challenging Forearm Sarcomas

Cited by 4 publications

References 10 publications

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy

Case Report: Adjuvant image-guided radiation therapy reduces surgical invasiveness in malignant peripheral nerve sheath tumors

Considerations on surgery invasiveness and response and toxicity patterns in classic palliative radiotherapy for acrometastases of the hand: a hint for a potential role of stereotactic body radiation therapy? A case report and literature review

Contact Info

Product

Resources

About