Is there any role for stereotactic body radiotherapy in the management of metastatic epidural spinal cord compression?

Lo, Simon S.; Kubicky, Charlotte Dai; Chang, Eric L.; Sahgal, Arjun

doi:10.2217/cns.14.53

Cited by 6 publications

(4 citation statements)

References 11 publications

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“…There is emerging evidence for spine SBRT in patients with cord compression but at present it should not be considered the standard of care and caution should be utilized unless in the context of a prospective clinical trial. 22 For Bilsky 2 tumors, if decompression is feasible, then there may be therapeutic benefit to downgrading the epidural disease to a Bilsky 0 or 1 following SBRT, as reported by Al-Omair et al 23 Otherwise, SBRT for Bilsky 2 disease remains appropriate as a relative contraindication. Ideally, there should be at least 2 to 3 millimeters between the disease and the spinal cord to maximize tumor coverage considering that the typical dose fall-off at this interface ranges between 15% and 20% per millimeter.…”

Section: Indications and Patient Assessmentmentioning

confidence: 96%

The era of stereotactic body radiotherapy for spinal metastases and the multidisciplinary management of complex cases

Kumar

Nater

Hashmi

et al. 2015

Neuro-Oncology Practice

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Spinal metastases are increasingly becoming a focus of attention with respect to treating with locally “ablative” intent, as opposed to locally “palliative” intent. This is due to increasing survival rates among patients with metastatic disease, early detection as a result of increasing availability of spinal MRI, the recognition of the oligometastatic state as a distinct sub-group of favorable metastatic patients and the advent of stereotactic body radiotherapy (SBRT). Although conventionally fractionated radiation therapy has been utilized for decades, the rates of complete pain relief and local control for complex tumors are sub-optimal. SBRT has the advantage of delivering high total doses in few fractions (typically, 24 Gy in 1 or 2 fractions to 30–45 Gy in 5 fractions) that can be considered “ablative”. With mature clinical experience emerging among early adopters, we are realizing beyond efficacy the limitations of spine SBRT. In particular, toxicities such as vertebral compression fracture, and epidural disease progression as the most common pattern of local tumor progression. As a result, the multidisciplinary evaluation of cases prior to SBRT is emphasized with the intent to identify patients who could benefit from surgical stabilization or down-staging of epidural disease. The purpose of this review is to provide an overview of the current literature with respect to outcomes, technical details for safe delivery, patient selection criteria, common and uncommon side effects of therapy, and the increasing use of minimally invasive surgical techniques that can improve both safety and local control.

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Section: Indications and Patient Assessmentmentioning

confidence: 96%

The era of stereotactic body radiotherapy for spinal metastases and the multidisciplinary management of complex cases

Kumar

Nater

Hashmi

et al. 2015

Neuro-Oncology Practice

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“…Although no high-quality prospective randomized study data are available so far, some studies have demonstrated stereotactic body radiation therapy (SBRT) with simultaneous integrated boost (SIB) for metastatic tumors of the spine is safe and clinically effective [ 1 , 2 ]. This technique markedly improved local control with an excellent symptomatic response compared with conventional external beam radiation therapy techniques, and is beginning to change the treatment paradigms for metastatic spine disease, both as post-operative adjuvant therapy and primary definitive local treatment [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

“…The dose falloff and the dose constraints for spinal cord require a certain target-to-cord distance, and a too-narrow distance results in an under-dose in the epidural space, where metastatic progression is the most common [ 4 – 9 ]. The indication of SBRT as the primary treatment for metastatic epidural spinal cord compression (MESCC) and tumors abutting the spinal cord is controversial [ 1 , 3 ]. Some research institutions and clinical trials, including the RTOG 0631 trial, suggest a minimum distance of at least 2–5 mm from tumor to spinal cord to ensure a good dose distribution [ 7 , 10 – 13 ].…”

Section: Introductionmentioning

confidence: 99%

Dose Evaluation of Fractionated Schema and Distance From Tumor to Spinal Cord for Spinal SBRT with Simultaneous Integrated Boost: A Preliminary Study

et al. 2016

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BackgroundThis study investigated and quantified the dosimetric impact of the distance from the tumor to the spinal cord and fractionation schemes for patients who received stereotactic body radiation therapy (SBRT) and hypofractionated simultaneous integrated boost (HF-SIB).Material/MethodsSix modified planning target volumes (PTVs) for 5 patients with spinal metastases were created by artificial uniform extension in the region of PTV adjacent spinal cord with a specified minimum tumor to cord distance (0–5 mm). The prescription dose (biologic equivalent dose, BED) was 70 Gy in different fractionation schemes (1, 3, 5, and 10 fractions). For PTV V100, Dmin, D98, D95, and D1, spinal cord dose, conformity index (CI), V30 were measured and compared.ResultsPTV-to-cord distance influenced PTV V100, Dmin, D98, and D95, and fractionation schemes influenced Dmin and D98, with a significant difference. Distances of ≥2 mm, ≥1 mm, ≥1 mm, and ≥0 mm from PTV to spinal cord meet dose requirements in 1, 3, 5, and 10 fractionations, respectively. Spinal cord dose, CI, and V30 were not impacted by PTV-to-cord distance and fractionation schemes.ConclusionsTarget volume coverage, Dmin, D98, and D95 were directly correlated with distance from the spinal cord for spine SBRT and HF-SIB. Based on our study, ≥2 mm, ≥1 mm, ≥1 mm, and ≥0 mm distance from PTV to spinal cord meets dose requirements in 1, 3, 5 and 10 fractionations, respectively.

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“…According to the WHO, Gliomas are further divided into four clinical grades based on their histology and pathology. 1 Grade I glioma is defined as relatively benign lesions. Although grades II, III, and IV gliomas usually have poorly defined margins and invade directly adjacent brain parenchyma.…”

Section: Introductionmentioning

confidence: 99%

Does Tenascin have Clinical Implications in Pathological Grade of Glioma Patients?

Kong

et al. 2015

Medicine

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Tenascin (TN) is an extracellular oligomeric glycoprotein that participates in the adhesion of cells to extracellular matrixc (ECM). Studies have shown that the expression levels of TN are upregulated in a variety of cancers, including colon cancer, lung cancer, brain tumor, and breast cancer. However, the implications and utilities of TN in clinical grading and prognosis of glioma patients were seldom reported and the effects of its pathway are still unclear and controversial. Thus, it is essential to carry out a meta-analysis to draw a convincing conclusion.A literature search was carried out up to April 2015. Data was collected using a purpose-designed form including glioma's WHO grade, etc. Differences were expressed as odds ratios (ORs) or standard mean differences (SMDs) with 95% confidence intervals (CIs). Galbr figure, Cochran's Q test, and I2 test were all performed to judge the heterogeneity between included studies. To examine the stability of the pooled results, a sensitivity analysis was performed. Potential publication bias was assessed by visual inspection of funnel plot. As this meta-analysis, as a systematic review, does not involve animal experiments or direct human trials, there is no need to conduct special ethic review and the ethical approval is not necessary.In this meta-analysis, 8 eligible studies involving 456 patients were incorporated. Six studies with dichotomous data revealed TN overexpression in glioma tissues and/or surrounding neoplastic vessels was closely associated with high WHO grade (III + IV) (odds ratio 3.398, 95% confidence interval 1.933, 5.974; P = 0.000); three continuous data studies showed there were close statistical associations between TN and WHO grade (SMD −2.114, 95% CI −2.580, −1.649; P = 0.000) too. Sensitivity analysis indicated a statistically robust result. No publication bias was revealed.Our meta-analysis suggests that TN expression is potentially associated with higher WHO grade of gliomas. More evidences on the basis of the evidence-based medicine are needed to prove it.

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Is there any role for stereotactic body radiotherapy in the management of metastatic epidural spinal cord compression?

Cited by 6 publications

References 11 publications

The era of stereotactic body radiotherapy for spinal metastases and the multidisciplinary management of complex cases

The era of stereotactic body radiotherapy for spinal metastases and the multidisciplinary management of complex cases

Dose Evaluation of Fractionated Schema and Distance From Tumor to Spinal Cord for Spinal SBRT with Simultaneous Integrated Boost: A Preliminary Study

Does Tenascin have Clinical Implications in Pathological Grade of Glioma Patients?

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