Low rate of thoracic toxicity in palliative paraspinal single-fraction stereotactic body radiation therapy

Gomez, Daniel R.; Hunt, Margie; Jackson, Andrew; O'Meara, W; Bukanova, Elena N.; Zeléfsky, Michael J.; Yamada, Yoshiya; Rosenzweig, Kenneth E.

doi:10.1016/j.radonc.2009.10.017

Cited by 36 publications

(16 citation statements)

References 17 publications

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“…The guidelines of dose constraints for the esophagus in single-fraction SBRT in Memorial Sloan-Kettering Cancer Center were as follows: level 1 dose constraint of esophagus is 15 Gy/2 mL, while level 2 is 20 Gy/2 mL [11], which are consistent with our findings. Timmerman [12] recommended dose constraints of esophagus for single-fraction SBRT to be 14.5 Gy to less than 5 mL (endpoint ≥ grade 3).…”

Section: Discussionsupporting

confidence: 89%

Esophageal tolerance to high-dose stereotactic radiosurgery

Lee

Chang

et al. 2013

Radiat Oncol J

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PurposeEsophageal tolerance is needed to guide the safe administration of stereotactic radiosurgery (SRS). We evaluated comprehensive dose-volume parameters of acute esophageal toxicity in patients with spinal metastasis treated with SRS.Materials and MethodsFrom May 2008 to May 2011, 30 cases in 27 patients with spinal metastasis received single fraction SRS to targets neighboring esophagus. Endpoints evaluated include length (mm), volume (mL), maximal dose (Gy), and series of dose-volume thresholds from the dose-volume histogram (volume of the organ treated beyond a threshold dose).ResultsThe median time from the start of irradiation to development of esophageal toxicity was 2 weeks (range, 1 to 12 weeks). Six events of grade 1 esophageal toxicity occurred. No grade 2 or higher events were observed. V15 of external surface of esophagus was found to predict acute esophageal toxicity revealed by multivariate analysis (odds radio = 1.272, p = 0.047).ConclusionIn patients with spinal metastasis who received SRS for palliation of symptoms, the threshold dose-volume parameter associated with acute esophageal toxicity was found to be V15 of external surface of esophagus. Restrict V15 to external surface of esophagus as low as possible might be safe and feasible in radiosurgery.

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Section: Discussionsupporting

confidence: 89%

Esophageal tolerance to high-dose stereotactic radiosurgery

Lee

Chang

et al. 2013

Radiat Oncol J

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“…Other series have reported similar parameters predictive for injury (16, 17). Gomez et al reported an early low rate of esophageal toxicity with single-fraction intrathoracic SRS (11). This analysis was limited by a small cohort and limited dosimetric analysis.…”

Section: Discussionmentioning

confidence: 99%

“…Early in the cohort, dose-volume constraints for esophagus were at the discretion of attending physicians. After analysis of initial toxicity (11), formal dose-volume limits were instituted, with ≤15 Gy permissible to 2 cm 3 of esophagus. If not achievable, the limit could be increased to no more than 20 Gy to 2 cm 3 at the discretion of the attending physician.…”

Section: Methodsmentioning

confidence: 99%

Esophageal Toxicity From High-Dose, Single-Fraction Paraspinal Stereotactic Radiosurgery

Cox

Jackson

Hunt

et al. 2012

International Journal of Radiation Oncology*Biology*Physics

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118

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Purpose To report the esophageal toxicity from single-fraction paraspinal stereotactic radiosurgery (SRS) and identify dosimetric and clinical risk factors for toxicity. Methods and Materials 204 spinal metastases abutting the esophagus (182 patients) were treated with high-dose single-fraction SRS during 2003-2010. Toxicity was scored using NCI CTCAE 4.0. Dose-volume histograms (DVHs) were combined to generate a comprehensive atlas of complication incidence that identifies risk factors for toxicity. Correlation of dose-volume factors with esophageal toxicity were assessed using Fishers exact test and logistic regression. Clinical factors were correlated with toxicity. Results The median dose to the planning treatment volume was 24 Gy. Median follow-up was 12 months (range 3-81). There were 31 (15%) acute and 24 (12%) late esophageal toxicities. The rate of grade ≥3 acute or late toxicity was 6.8% (14 patients). Fisher’s exact test resulted in significant median splits for grade ≥3 toxicity at V12 = 3.78 cm3 (relative risk [RR] 3.7, p = 0.05), V15 = 1.87 cm3 (RR 13, p = 0.0013), V20 = 0.11 cm3 (RR = 6, p = 0.01), and V22 = 0.0 cm3 (RR 13, p = 0.0013). The median split for D2.5 cm3 (14.02 Gy) was also a significant predictor of toxicity (RR6; p=0.01). A highly significant logistic regression model was generated based on D2.5 cm3. 100% (n = 7) of grade ≥4 toxicities were associated with radiation recall reactions after adriamycin or gemcitabine chemotherapy or iatrogenic manipulation of the irradiated esophagus. Conclusions High dose, single fraction paraspinal SRS has a low rate of grade ≥ 3 esophageal toxicity. Severe esophageal toxicity is minimized with careful attention to esophageal doses during treatment planning. Iatrogenic manipulation of the irradiated esophagus and systemic agents classically associated with radiation recall reactions are associated with development of grade ≥4 toxicity.

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“…Comparing to spinal cord, the dose constraints to the esophagus in spinal SRS/SBRT are less understood. Even though the dose constraint standard has yet been established for esophagus, partial volume constraints, such as dose to a small volume of 1 to 5 cc (D1 cc to D5 cc), and Dmax have been suggested in previous reports and used in clinical trials 18, 19, 20. Unlike a point dose, such as Dmax to the cord, which is unlikely to be effected by the extra vertebrae, a partial volume parameter, like D1 cc, generally increases with move critical structure volume receiving dose.…”

Section: Discussionmentioning

confidence: 99%

Submillimeter alignment of more than three contiguous vertebrae in spinal SRS/SBRT with 6‐degree couch

Wang

Zhao

Luo

et al. 2017

J Applied Clin Med Phys

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The purpose of this study is to identify regions of spinal column in which more than three contiguous vertebrae can be reliably and quickly aligned within 1 mm using a 6‐degree (6D) couch and full body immobilization device. We analyzed 45 cases treated over a 3‐month period. Each case was aligned using ExacTrac x‐ray positioning system with integrated 6D couch to be within 1° and 1 mm in all six dimensions. Cone‐Beam computed tomography (CBCT) with at least 17.5 cm field of view (FOV) in the superior–inferior direction was taken immediately after ExacTrac positioning. It was used to examine the residual error of five to nine contiguous vertebrae visible in the FOV. The residual error of each vertebra was determined by expanding/contracting the vertebrae contour with a margin in millimeter integrals on the planning CT such that the new contours would enclose the corresponding vertebrae contour on CBCT. Submillimeter initial setup accuracy was consistently achieved in 98% (40/41) cases for a span of five or more vertebrae starting from T2 vertebra and extending caudally to S5. The curvature of spinal column along the cervical region and cervicothoracic junction was not easily reproducible between treatment and simulation. Fifty‐seven percent (8/14) of cases in this region had residual setup error of more than 1 mm in nearby vertebrae after alignment using 6D couch with image guidance. In conclusion, 6D couch integrated with image guidance is convenient and accurately corrects small rotational shifts. Consequently, more than three contiguous vertebrae can be aligned within 1 mm with immobilization that reliably reproduces the curvature of the thoracic and lumbar spinal column. Ability of accurate setup is becoming less a concern in limiting the use of stereotactic radiosurgery or stereotactic body radiation therapy to treat multilevel spinal target.

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Low rate of thoracic toxicity in palliative paraspinal single-fraction stereotactic body radiation therapy

Cited by 36 publications

References 17 publications

Esophageal tolerance to high-dose stereotactic radiosurgery

Esophageal tolerance to high-dose stereotactic radiosurgery

Esophageal Toxicity From High-Dose, Single-Fraction Paraspinal Stereotactic Radiosurgery

Submillimeter alignment of more than three contiguous vertebrae in spinal SRS/SBRT with 6‐degree couch

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