Reirradiation Human Spinal Cord Tolerance for Stereotactic Body Radiotherapy

Sahgal, Arjun; Ma, Lijun; Weinberg, Vivian; Gibbs, Iris C.; Chao, Sam; Chang, Ung-Kyu; Werner‐Wasik, Maria; Angelov, L.; Chang, Eric L.; Sohn, Moon‐Jun; Soltys, Scott G.; Létourneau, D.; Ryu, Sam; Gerszten, Peter C.; Fowler, Jack F.; Wong, C. Shun; Larson, David A.

doi:10.1016/j.ijrobp.2010.08.021

Cited by 242 publications

(165 citation statements)

References 26 publications

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“…For patients with prior radiation who received reirradiation by SBRT, dosimetric analysis of five myelopathy cases also suggested the importance of the point maximum dose. 4 A summary of these dose limits is provided in Table 1. These multi-institutional analyses were based on dosimetric data collected on the thecal sac and not the true spinal cord itself.…”

Section: Strategies To Mitigate Injurymentioning

confidence: 99%

“…Unfortunately, there are emerging reports of radiation myelopathy following SBRT retreatment. 4 Recent advances in SBRT challenge the conventional concepts of cord tolerance to fractionated radiation therapy. Therefore, we consider it timely to review the pathobiology of radiation myelopathy and summarize the experimental and human data on cord tolerance in the modern era of SBRT.…”

Section: Introductionmentioning

confidence: 99%

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Pathobiology of radiation myelopathy and strategies to mitigate injury

2015

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Study design: This is a narrative review of the literature. Objectives: The objectives of this study were to review the current concepts underlying the pathobiology of radiation-induced spinal cord injury; to discuss potential biologic strategies to mitigate spinal cord injury following radiation; and to provide an update on the clinical guidelines to prevent injury in the era of image-guided stereotactic body radiotherapy (SBRT). Setting: This study was conducted in Toronto, Canada. Methods: A MEDLINE search was performed using the following terms: radiation injury; radiation myelopathy; CNS radiation injury; brain necrosis, radiation; demyelination, radiation; blood-brain barrier, radiation; white matter necrosis; and SBRT. Results and conclusion: The biologic response of the spinal cord after radiation is a continuously evolving process. Death of vascular endothelial cells and disruption of the blood-spinal cord barrier leads to a complex injury response, resulting in demyelination and tissue necrosis. At present, there is no evidence that the pathobiology of cord injury after SBRT is different from that after standard fractionation. Although permanent myelopathy has become a rare complication following conventional fractionated radiation treatment, cases of radiation myelopathy have re-emerged with the increasing role of spine stereotactic body radiation therapy and reirradiation. Experimental biologic strategies targeting the injury response pathways hold promise in mitigating this dreaded late effect of radiation treatment.

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Section: Strategies To Mitigate Injurymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Pathobiology of radiation myelopathy and strategies to mitigate injury

2015

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“…In our initial report, we did not observe that the critical neural tissue dose was a predictive factor in these patients. This may reflect that our maximum point volume doses administered to the critical neural tissue-which are based on published evidence-based recommendations 12,14 -are sufficient and represent a balance between efficacy and safety. However, we cannot comment on whether the number of epidural disease progression cases could have been reduced if we escalated the dose delivered to the critical neural tissue beyond our institutional practice.…”

Section: Discussionmentioning

confidence: 99%

Patterns of epidural progression following postoperative spine stereotactic body radiotherapy: implications for clinical target volume delineation

Chan¹,

Thibault²,

Atenafu³

et al. 2016

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OBJECT The authors performed a pattern-of-failure analysis, with a focus on epidural disease progression, in patients treated with postoperative spine stereotactic body radiotherapy (SBRT). METHODS Of the 70 patients with 75 spinal metastases (cases) treated with postoperative spine SBRT, there were 26 cases of local disease recurrence and 25 cases with a component of epidural disease progression. Twenty-four of the 25 cases had preoperative epidural disease with subsequent epidural disease progression, and this cohort was the focus of this epidural-specific pattern-of-failure investigation. Preoperative, postoperative, and follow-up MRI scans were reviewed, and epidural disease was characterized based on location according to a system in which the vertebral anatomy is divided into 6 sectors, with the anterior compartment comprising Sectors 1, 2, and 6, and the posterior compartment comprising Sectors 3, 4, and 5. RESULTS Patterns of epidural progression are reported specifically for the 24 cases with preoperative epidural disease and subsequent epidural progression. Epidural disease progression within the posterior compartment was observed to be significantly lower in those with preoperative epidural disease confined to the anterior compartment than in those with preoperative epidural disease involving both anterior and posterior compartments (56% vs 93%, respectively; p = 0.047). In a high proportion of patients with epidural disease progression, treatment failure was found in the anterior compartment, including both those with preoperative epidural disease confined to the anterior compartment and those with preoperative epidural disease involving both anterior and posterior compartments (100% vs. 73%, respectively). When epidural disease was confined to the anterior compartment on the preoperative and postoperative MRIs, no epidural disease progression was observed in Sector 4, which is the most posterior sector. Postoperative epidural disease characteristics alone were not predictive of the pattern of epidural treatment failure. CONCLUSIONS Reviewing the extent of epidural disease on preoperative MRI is imperative when planning postoperative SBRT. When epidural disease is confined to the anterior epidural sectors pre- and postoperatively, covering the entire epidural space circumferentially with a prophylactic “donut” distribution may not be needed.

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“…Some of the critical areas of toxicity that patients would not otherwise be exposed to with conventional radiation, include a risk of radiation myelopathy [6][7][8], vertebral compression fracture (VCF) [9] and serious esophageal complications [10]. There are now evidence-based guidelines for spinal cord tolerance specific to spine SRS for both radiation naive and re-irradiated patients that can guide safe practice [6,7], we are learning about dose limits for the esophagus with single fraction SRS [10], and also predictors of VCF with respect to dosimetric and anatomic factors that may help select patients for stabilization prior to, or after, SRS [9]. Ultimately the patient can now be better informed as to the risks of spine SRS.…”

mentioning

confidence: 99%

“…Significant research has been completed to guide the community with respect to evidence based inclusion and exclusion criteria [4], there have been scope of practice guidelines specific to spine SRS published by the Canadian Association of Radiation Oncology (CARO) SBRT task force [1], there are international consensus guidelines to assist in target volume delineation [5], and we are now learning more about the potential long-term complications of this treatment from the predominantly retrospective reviews of institutional experiences that adopted this technique early on in its development. Some of the critical areas of toxicity that patients would not otherwise be exposed to with conventional radiation, include a risk of radiation myelopathy [6][7][8], vertebral compression fracture (VCF) [9] and serious esophageal complications [10]. There are now evidence-based guidelines for spinal cord tolerance specific to spine SRS for both radiation naive and re-irradiated patients that can guide safe practice [6,7], we are learning about dose limits for the esophagus with single fraction SRS [10], and also predictors of VCF with respect to dosimetric and anatomic factors that may help select patients for stabilization prior to, or after, SRS [9].…”

mentioning

confidence: 99%

Current Status And The Future Of Spine Radiosurgery

Sahgal¹

2012

J Spine

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Spine Radiosurgery (SRS), also known as spine stereotactic body radiotherapy (SBRT), represents a stark departure from the treatment of spinal metastases with conventional radiation. In the past, we simply delivered a dose of radiation aimed to achieve short term pain relief without the intention of long-term local tumor and pain control. The doses of 20 Gy in 5 fractions, 30 Gy in 10 fractions and 8 Gy in 1 fraction are most common, and were chosen based on the limiting factor of spinal cord tolerance.With advances in radiation technology that includes sophisticated body immobilization devices, intensity modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT) and robotic technology we are now able to dose escalate spinal metastases, and deposit 2 to 6 times the biologically effective dose as compared to conventional radiation while still sparing the spinal cord to a safe dose [1,2]. Spine SRS is based on routinely treating with 16-24 Gy in 1 fraction, 24 Gy in 2 fractions, and 24-30 Gy in 3 fractions, with the intent to improve long-term local tumor control rates and increase the rate of both complete pain relief and long-term pain control [2,3]. The philosophical shift is in the treatment intent, as we now aim to deliver a locally "curative" dose of radiation as opposed to a locally "palliative" dose of radiation to the metastatic patient. Ultimately, we hope these gains translate to a better quality of life for the patient with spinal metastases as these patients are still faced with incurable cancer.The field of spine SRS is emerging. Significant research has been completed to guide the community with respect to evidence based inclusion and exclusion criteria [4], there have been scope of practice guidelines specific to spine SRS published by the Canadian Association of Radiation Oncology (CARO) SBRT task force [1], there are international consensus guidelines to assist in target volume delineation [5], and we are now learning more about the potential long-term complications of this treatment from the predominantly retrospective reviews of institutional experiences that adopted this technique early on in its development. Some of the critical areas of toxicity that patients would not otherwise be exposed to with conventional radiation, include a risk of radiation myelopathy [6][7][8], vertebral compression fracture (VCF) [9] and serious esophageal complications [10]. There are now evidence-based guidelines for spinal cord tolerance specific to spine SRS for both radiation naive and re-irradiated patients that can guide safe practice [6,7], we are learning about dose limits for the esophagus with single fraction SRS [10], and also predictors of VCF with respect to dosimetric and anatomic factors that may help select patients for stabilization prior to, or after, SRS [9]. Ultimately the patient can now be better informed as to the risks of spine SRS.With respect to the current clinical evidence supporting efficacy, the indications for spine SRS can be broken down into those who are radiation naive, tho...

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Reirradiation Human Spinal Cord Tolerance for Stereotactic Body Radiotherapy

Cited by 242 publications

References 26 publications

Pathobiology of radiation myelopathy and strategies to mitigate injury

Pathobiology of radiation myelopathy and strategies to mitigate injury

Patterns of epidural progression following postoperative spine stereotactic body radiotherapy: implications for clinical target volume delineation

Current Status And The Future Of Spine Radiosurgery

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