Is there an optimal timing between radiotherapy and surgery to reduce wound complications in metastatic spine disease? A systematic review

Abstract

Purpose Surgery with radiation therapy (RT) is more effective in treating spinal metastases, than RT alone. However, RT when administered in close proximity to surgery may predispose to wound complications. There exist limited guidelines on the optimal timing between RT and surgery. The purpose of this systematic review is to: (1) address whether pre-operative RT (preop-RT) and/or post-operative RT (postop-RT) is associated with wound complications and (2) define the safe interval between RT and surgery or vice versa. Methods PubMed, Embase and Scopus databases were systematically searched for articles dealing with spinal metastases, treated with surgery and RT, and discussing wound status. ResultsWe obtained 2332 articles from all databases, and after applying exclusion criteria, removing duplicates and reading the full text, we identified 27 relevant articles. Fourteen additional articles were identified by hand-search, leading to a total of 41 articles. All 41 mentioned wound complications/healing. Sixteen articles discussed preop-RT, 8 postop-RT, 15 both, and 2 mentioned intraoperative-RT with additional pre/postop-RT. Twenty studies mentioned surgery-RT time interval; one concluded that wound complications were higher when RT-surgery interval was ≤ 7 days. Seven studies reported significant association between preop-RT and wound complications. Conclusions Evidence is insufficient to draw definitive conclusion about optimal RT-surgery interval. However, based on published literature and expert opinions, we conclude that an interval of 2 weeks, the minimum being 7 days, is optimum between RT-surgery or vice versa; this can be reduced further by postop-stereotactic body RT. If RT-surgery window is > 12 months, wound-complications rise. Postop-RT has fewer wound complications versus preop-RT.

Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review

“…A recently published systemic review also advocated for 2 weeks (with a minimum of 7 days) between surgery and radiotherapy [ 50 ]. When the rates of wound complications were compared between SRS and conventional radiotherapy, many studies reported reduced wound complications in SRS patients [ 51 - 53 ].…”

Systematic review of charged-particle therapy for chordomas and sarcomas of the mobile spine and sacrum

“…51 As alluded to by the aforementioned survey, there is no high-quality evidence on what radiotherapy time frame provides the best LC while minimizing results. Yet, based on a recent review of level III/IV data in the spinal metastasis population, 2 weeks postoperatively may be an ideal time point, 53 in line with the results of the Dea et al survey. 51 Additionally, using smaller fractions may help reduce skin toxicities, a finding that the Hyogo group 39 cited as a primary reason for shifting from fractions of 4.4 to 2.2 RBE.…”

“…12 These skin toxicities are likely of increased importance in postoperative patients, as irradiation is a known risk factor for wound infection in spine oncology patients. 53 However, given that some recent evidence suggests that radiation may more strongly dictate LC than surgical margins, 9 many spinal oncologists recommend its use. 51 As alluded to by the aforementioned survey, there is no high-quality evidence on what radiotherapy time frame provides the best LC while minimizing results.…”

Outcomes of Patients With Spinal Metastases From Prostate Cancer Treated With Conventionally-Fractionated External Beam Radiation Therapy

“…After spinal surgery, patients were usually given a duration of at least 2 weeks to allow optimal wound healing before commencement of RT. 21 All patients underwent CT-based treatment planning. The target vertebral segments were identified using CT, MRI or PSMA-PET diagnostic imaging where available.…”