The dosimetric impact of stabilizing spinal implants in radiotherapy treatment planning with protons and photons: standard titanium alloy vs. radiolucent carbon‐fiber‐reinforced PEEK systems

Müller, Birgit Sabine; Ryang, Yu‐Mi; Oechsner, Markus; Düsberg, Mathias; Meyer, Bernhard; Combs, Stephanie E.; Wilkens, Jan J.

doi:10.1002/acm2.12905

Cited by 37 publications

(38 citation statements)

References 34 publications

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“…Two "other" responses were received, including a statement that the radiolucent "rods do not fracture" (9/10) and that radiolucent implants "allow precise visualization of the cord in the context of instrumentation without requiring a CT myelogram" (10/10). The importance of radiolucent spinal implants to anterior column reconstruction received an average score of 7.0 (2-10), while the importance of rods and screws for posterior column reconstruction received respective scores of 5.6 (2-10) and 6.3 (2)(3)(4)(5)(6)(7)(8)(9)(10).…”

Section: Clinical Conceptmentioning

confidence: 99%

“…Unlike titanium, CF and CFR-PEEK does not impede imaging or perturb radiation, improving the accuracy of dosing and delivery. [8][9][10] Furthermore, these radiolucent implants have a modulus of elasticity closer to that of compact cortical bone, decreasing the stress at the implant-host bone interface. [6,11] This is especially important among patients with osteoporotic or diseased bone as it decreases the risk for subsequent implant-related mechanical complications such as subsidence, loosening, and fracture.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Attitudes and trends in the use of radiolucent spinal implants: A survey of the North American Spine Society section of spinal oncology

Zavras

Schoenfeld

Patt

et al. 2022

North American Spine Society Journal (NASSJ)

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Section: Clinical Conceptmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Attitudes and trends in the use of radiolucent spinal implants: A survey of the North American Spine Society section of spinal oncology

Zavras

Schoenfeld

Patt

et al. 2022

North American Spine Society Journal (NASSJ)

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“…26 Other photon therapy simulations have also found that CFRP systems result in superior dosimetric quality compared with titanium systems. 21,27 In another simulation study involving a 6-MV photon beam, investigators found that the maximum dose perturbation was less than 5% for CFRP screws, compared with more than 30% perturbation for the titanium screws. 28…”

Section: Advantages Of Cfrp Hardware With Radiotherapymentioning

confidence: 99%

Carbon fiber–reinforced PEEK instrumentation in the spinal oncology population: a retrospective series demonstrating technique, feasibility, and clinical outcomes

Neal¹,

Richards²,

Curley³

et al. 2021

Neurosurgical Focus

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OBJECTIVE The authors aimed to demonstrate the feasibility and advantages of carbon fiber–reinforced PEEK (CFRP) composite implants in patients with both primary and secondary osseous spinal tumors. METHODS Twenty-eight spinal tumor patients who underwent fixation with CFRP hardware were retrospectively identified in a Spine Tumor Quality Database at a single institution. Demographic, procedural, and follow-up data were retrospectively collected. RESULTS The study population included 14 females and 14 males with a mean age of 60 years (range 30–86 years). Five patients had primary bone tumors, and the remaining patients had metastatic tumors. Breast cancer was the most common metastatic tumor. The most common presenting symptom was axial spine pain (25 patients, 89%), and the most common Spine Instability Neoplastic Score was 7 (range 6–14). Two patients in this series had anterior cervical procedures. The remaining patients underwent posterior thoracolumbar fixation. The average fusion length included 4.6 vertebral segments (range 3–8). The mean clinical follow-up time with surgical or oncology teams was 6.5 months (range 1–23 months), and the mean interval for last follow-up imaging (CT or MRI) was 6.5 months (range 1–22 months). Eighteen patients received postoperative radiation at the authors’ institution (16 with photon therapy, 2 with proton therapy). Eleven of the patients (39%) in this series died. At the last clinical follow-up, 26 patients (93%) had stable or improved neurological function compared with their preoperative status. At the last imaging follow-up, local disease control was observed in 25 patients (89%). Two patients required reoperation in the immediate postoperative period, one for surgical site infection and the other for compressive epidural hematoma. One patient was noted to have lucencies around the most cephalad screws 3 months after surgery. No hardware fracture or malfunction occurred intraoperatively. No patients required delayed surgery for hardware loosening, fracture, or other failure. Early tumor recurrence was detected in 3 patients. Early detection was attributed to the imaging characteristics of the CFRP hardware. CONCLUSIONS CFRP spinal implants appear to be safe and comparable to conventional titanium implants in terms of functionality. The imaging characteristics of CFRP hardware facilitate radiation planning and assessment of surveillance imaging. CFRP hardware may enhance safety and efficacy, particularly with particle therapy dosimetry. Larger patient populations with longer-term follow-up are needed to confirm the various valuable aspects of CFRP spinal implants.

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“…58,59 CFR-PEEK rods, unlike titanium rods, are radiolucent and so create minimal artifact on the CT scans employed for radiation planning. 60,61 Additionally, CFR-PEEK rods better approximate the elastic modulus of cortical bone. 62 However, they have been found in cadaveric models to produce less-rigid constructs.…”

Section: Instrumentation and Radiotherapymentioning

confidence: 99%

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

Pennington

Ehresman

Elsamadicy

et al. 2021

Neurosurgical Focus

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OBJECTIVE Long-term local control in patients with primary chordoma and sarcoma of the spine and sacrum is increasingly reliant upon en bloc resection with negative margins. At many institutions, adjuvant radiation is recommended; definitive radiation is also recommended for the treatment of unresectable tumors. Because of the high off-target radiation toxicities associated with conventional radiotherapy, there has been growing interest in the use of proton and heavy-ion therapies. The aim of this study was to systematically review the literature regarding these therapies. METHODS The PubMed, OVID, Embase, and Web of Science databases were queried for articles describing the use of proton, combined proton/photon, or heavy-ion therapies for adjuvant or definitive radiotherapy in patients with primary sarcoma or chordoma of the mobile spine and sacrum. A qualitative synthesis of the results was performed, focusing on overall survival (OS), progression-free survival (PFS), disease-free survival (DFS), and disease-specific survival (DSS); local control; and postradiation toxicities. RESULTS Of 595 unique articles, 64 underwent full-text screening and 38 were included in the final synthesis. All studies were level III or IV evidence with a high risk of bias; there was also significant overlap in the reported populations, with six centers accounting for roughly three-fourths of all reports. Five-year therapy outcomes were as follows: proton-only therapies, OS 67%–82%, PFS 31%–57%, and DFS 52%–62%; metastases occurred in 17%–18% and acute toxicities in 3%–100% of cases; combined proton/photon therapy, local control 62%–85%, OS 78%–87%, PFS 90%, and DFS 61%–72%; metastases occurred in 12%–14% and acute toxicities in 84%–100% of cases; and carbon ion therapy, local control 53%–100%, OS 52%–86%, PFS (only reported for 3 years) 48%–76%, and DFS 50%–53%; metastases occurred in 2%–39% and acute toxicities in 26%–48%. There were no studies directly comparing outcomes between photon and charged-particle therapies or comparing outcomes between radiation and surgical groups. CONCLUSIONS The current evidence for charged-particle therapies in the management of sarcomas of the spine and sacrum is limited. Preliminary evidence suggests that with these therapies local control and OS at 5 years are comparable among various charged-particle options and may be similar between those treated with definitive charged-particle therapy and historical surgical cohorts. Further research directly comparing charged-particle and photon-based therapies is necessary.

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The dosimetric impact of stabilizing spinal implants in radiotherapy treatment planning with protons and photons: standard titanium alloy vs. radiolucent carbon‐fiber‐reinforced PEEK systems

Cited by 37 publications

References 34 publications

Attitudes and trends in the use of radiolucent spinal implants: A survey of the North American Spine Society section of spinal oncology

Attitudes and trends in the use of radiolucent spinal implants: A survey of the North American Spine Society section of spinal oncology

Carbon fiber–reinforced PEEK instrumentation in the spinal oncology population: a retrospective series demonstrating technique, feasibility, and clinical outcomes

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

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