Spine Stereotactic Radiosurgery Research Articles

SPINAL RADIOSURGICAL TREATMENT FOR THORACIC EPIDURAL CAVERNOUS HEMANGIOMA PRESENTING AS RADICULOMYELOPATHY

Image-guided stereotactic radiosurgery (SRS) was applied to a case of spinal epidural cavernous hemangioma in the thoracic spine. This report demonstrates the potential for spinal SRS in treating diseases that have previously required extensive invasive surgery. A 27-year-old woman with gait disturbance and shoulder pain radiating into the right upper arm and back presented for clinical evaluation. Magnetic resonance imaging revealed an extraforaminal epidural mass compressing the spinal cord at the T1-T2 and T2-T3 levels of the intervertebral foramen. The patient had previously undergone a decompressive laminectomy and open biopsy. Several months after this surgery, her radiculomyelopathy had not improved and appeared to be progressing. Intensity-modulated hypofractionated radiosurgery was performed on the lesion. The patient's radicular pain was remarkably improved within days, and associated neurological symptoms had largely disappeared within a few months. Subsequent follow-up magnetic resonance imaging at 12 and 36 months showed that the tumor mass was greatly reduced. No evidence of any complications associated with irradiation was apparent, and the patient continued to demonstrate a positive prognosis. A thoracic epidural cavernous hemangioma of proven pathology was successfully treated using state-of-the-art, spinal image-guided SRS. Based on our experience with other types of tumors, we determined that an effective treatment modality for this pathology would be a hypofractionated dose of 32 Gy in 4 fractions. This treatment protocol delivered rapid clinical benefits and long-term tumor control demonstrating the viability of SRS in the treatment of this difficult and rare condition.

Randomized trial of short-course versus long-course radiotherapy for palliation of painful vertebral bone metastases: A retrospective analysis of RTOG 97–14

9521 Background: RTOG 97–14 [Hartsell et al, breast/prostate cancer patients (pts) with painful bone metastases randomized to 8 Gy/1 fraction or 30 Gy/10 fractions], revealed no difference in pain relief or narcotic use 3 months post randomization. The 8 Gy regimen resulted in fewer acute toxicities, but higher rates of retreatment for recurrent pain. Single 8 Gy fractions for painful vertebral bone mets have not been well accepted, possibly due to provider concerns about efficacy and toxicity. The present study evaluates treatment differences in the subset of pts treated specifically for painful vertebral bone mets (PVBM). Methods: PVBM were treated to the cervical, thoracic, and/or lumbar spine. Chi-square test was used to evaluate population differences between PVBM and non-PVBM. Amongst PVBM, differences in retreatment rates (cumulative incidence method, Gray's test) and in pain relief/BPI worst pain score, narcotic use, and toxicity 3 months post randomization (chi-square test) were evaluated. Results: Of 909 eligible pts, 235 (26%) were PVBM. PVBM and non-PVBM pts differed in % of males [55% vs. 47%,p=0.03] and pts with multiple painful sites [57% vs. 38%,p<0.01]. Amongst PVBM, more 30 Gy pts had multiple sites treated [65% vs. 49%, p=0.02]. T [10% vs. 20%, p=0.01] here was no statistically significant difference (8 vs. 30 Gy) in pain relief [70% vs. 62%, p=0.59] or narcotic use [27% vs. 24%, p=0.76] at 3 months. There were significant differences in acute grade 2–4 toxicityand acute grade 2–4 GI toxicity [6% vs. 14%, p=0.01] at 3 months, lower toxicity seen in 8 Gy. Late toxicity was rare, with 1 grade 3 CNS event (8 Gy) and 1 grade 4 lung event (30 Gy). 8 Gy showed significantly higher 3-year retreatment rates [15% vs. 5%, p=0.01]. Conclusions: Although a clinically different pt population, the results for PVBM are comparable to those of the entire study population. Both 8 Gy/1 fraction and 30 Gy/10 fractions resulted in comparable pain relief and narcotic use at 3 months. Both were well tolerated with few adverse effects. 8 Gy had less acute toxicity, and a higher need for retreatment than 30 Gy. This may have implications for future research comparing single fraction conventional radiation therapy with stereotactic spine radiosurgery. No significant financial relationships to disclose.

Image-Guided Stereotactic Spine Radiosurgery on a Conventional Linear Accelerator

Stereotactic radiosurgery for spinal metastasis consists of a high radiation dose delivered to the tumor in 1 to 5 fractions. Due to the high radiation dose in a single or fewer treatments, the precision of tumor localization and dose delivery is of great concern. Many groups have published their experiences of spinal radiosurgery with the use of CyberKnife System (Accuray Inc.). In this study, we report in detail our approach to stereotactic spine radiosurgery (SSRS) using a conventional linear accelerator (Varian Trilogy), utilizing the features of kilovolt on-board imaging (kV-OBI) and cone beam computed tomography (CBCT) for image guidance. We present our experience in various aspects of the SSRS procedure, including patient simulation and immobilization, intensity-modulated radiation treatment (IMRT) planning and beam selection, portal dosimetry for patient planning quality assurance (QA), and the use of image guidance in tumor localization prior to and during treatment delivery.

Stereotactic Spine Radiosurgery (SRS) for Pain and Tumor Control in Patients with Spinal Metastases from Renal Cell Carcinoma: A Prospective Study

Stereotactic Spine Radiosurgery (SRS) for Pain and Tumor Control in Patients with Spinal Metastases from Renal Cell Carcinoma: A Prospective Study

Evaluation of Patient Positioning Accuracy during Stereotactic Spinal Radiosurgery using Cone Beam CT

Evaluation of Patient Positioning Accuracy during Stereotactic Spinal Radiosurgery using Cone Beam CT

Preliminary Guidelines for Avoidance of Radiation-induced Myelopathy Following Spine Stereotactic Body Radiosurgery (SBRS)

Preliminary Guidelines for Avoidance of Radiation-induced Myelopathy Following Spine Stereotactic Body Radiosurgery (SBRS)

SU‐GG‐T‐468: Image‐Guided Stereotactic Spinal Radiosurgery with a Conventional Linear‐Accelerator

Purpose: As large experiences of spinal radiosurgery were reported by using CyberKnife, this study evaluates our experiences with spinal radiosurgery given by a conventional linear‐accelerator, utilizing the features of KV‐OBI and CBCT. Method and Materials: Image‐guided stereotactic radiosurgery is used in our clinic to treat spinal metastases with 16–18 Gy in a single‐fraction, or 20–30 Gy in 5‐fractions. Treatment is delivered using nine co‐planar IMRT‐beams in 20–25 minutes. The success of spinal radiosurgery requires sparing of the proximal spinal cord and high precision of dose delivery. With proper beam arrangement and dose optimization, the maximal cord dose can be minimized to 60–65% of the prescription dose. Stereotactic localization of the metastatic vertebrae‐body is achieved by KV‐OBI and CBCT guidance before and during the treatment. The shifts based on OBI♯1 are made from the skin marks after initial setup. Next, CBCT further verifies the patient alignment. Two more OBIs before every three fields ensure patient immobility and allow iso shifts if necessary. Results: Couch shifts were recorded for a sample of 12 patients, a total of 27 fractions in this evaluation. It is found that the ranges of the shifts guided by OBI♯1 from skin marks are: 1.4 cm longitudinal, 0.9 cm vertical, 0.7 cm lateral, and 2° in‐plane couch rotation, while CBCT and consecutive OBI♯2 and ♯3 before every three fields found little patient movements. Conclusion: The conventional linear‐accelerator is able to deliver stereotactic radiosurgery treatment of spinal metastases with a high degree of accuracy, as guided by OBI and CBCT image techniques, in combination with proper patient setup, immobilization, and skin marks. No body‐wrap or fiducials are necessary in our approach. The study also finds that OBI and CBCT are equivalent due to the proper patient setup procedures in our approach. CBCT is beneficial for localizing C7/T1 for treatment.

Clinical Assessment Of Stereotactic IGRT: Spinal Radiosurgery

The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. Its use for the treatment of spinal lesions has been limited because of the availability of effective target immobilization devices. Recent advances in stereotactic IGRT have allowed for spinal applications. Large clinical experience with spinal radiosurgery to properly assess clinical outcomes has previously been limited. At our institution, we have developed a successful multidisciplinary spinal radiosurgery program in which 542 spinal lesions (486 malignant and 56 benign lesions) were treated with a single-fraction radiosurgery technique. Patient ages ranged from 18 to 85 years (mean 56 years). Lesion location included 92 cervical, 234 thoracic, 130 lumbar, and 86 sacral. The most common metastatic tumors were renal cell (89 cases), breast (74 cases), and lung (71 cases). The most common benign tumors were neurofibroma (24 cases), schwannoma (13 cases), and meningioma (7 cases). Eighty-nine cervical lesions were treated using skull tracking. Thoracic, lumbar, and sacral tumors were tracked relative to either gold or stainless steel fiducial markers. The maximum intratumoral dose ranged from 12.5 to 30 Gy (mean 20 Gy). Tumor volume ranged from 0.16 to 298 mL (mean 47 mL). Three hundred thirty-seven lesions had received prior external beam irradiation with spinal cord doses precluding further conventional irradiation. The primary indication for radiosurgery was pain in 326 cases, as a primary treatment modality in 70 cases, for tumor radiographic tumor progression in 65 cases, for post-surgical treatment in 38 cases, for progressive neurological deficit in 35 cases, and as a radiation boost in 8 cases. Follow-up period was at least 3 to 49 months. Axial and/or radicular pain improved in 300 of 326 cases (92%). Long-term tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. Thirty of 35 patients (85%) with progressive neurological deficits experienced at least some improvement after treatment. Spinal stereotactic radiosurgery is now a feasible, safe, and clinically effective technique for the treatment of a variety of spinal lesions. The potential benefits of radiosurgical ablation of spinal lesions are short treatment time in an outpatient setting with essentially no recovery time and excellent symptomatic response. This technique offers a new therapeutic modality for the primary treatment of a variety of spinal lesions, including the treatment of neoplasms in medically inoperable patients, previously irradiated sites, for lesions not amenable to open surgical techniques, and as an adjunct to surgery.

Spinal Radiosurgery for Metastatic Disease of the Spine

Metastatic tumor in the spinal column is common, causing symptomatic spinal cord compression in approximately 25,000 patients annually. Although surgical treatment of spinal metastases has become safer, less invasive, and more efficacious in recent years, there remains a subset of patients for whom other treatment modalities are needed. Stereotactic radiosurgery, which has long been used in the treatment of intracranial lesions, has recently been applied to the spine and enables the effective treatment of metastatic lesions. We review the evolution of stereotactic radiosurgery and its applications in the spine, including a description of two commercially available systems. Although a relatively new technique, the use of stereotactic radiosurgery in the spine has advanced rapidly in the past decade. Spinal stereotactic radiosurgery is an effective and safe modality for the treatment of spinal metastatic disease. Future challenges involve the refinement of noninvasive fiducial tracking systems and the discernment of optimal doses needed to treat various lesions. Additionally, dose-tolerance limits of normal structures need to be further developed. Increased experience will likely make stereotactic radiosurgery of the spine an important treatment modality for a variety of metastatic lesions.

Stereotactic radiosurgery and radiation therapy for spinal tumors

Spinal tumors constitute 15% of all CNS neoplasms. Radiation therapy can be administered for palliation of pain and spinal cord compression. However, the amount of radiation that can be administered is often limited by the tolerance of the spinal cord, especially in cases where prior radiation therapy has been given. Stereotactic radiosurgery and radiotherapy allow the delivery of a higher dose of radiation to spinal lesions, while limiting the spinal cord dose to below the tolerance level. These are technically demanding procedures and should be performed only when proper equipments and expertise are available. Data on spinal stereotactic radiosurgery and radiotherapy have emerged in recent years. This review summarizes the clinical applications of stereotactic radiosurgery and radiotherapy for spinal tumors.

2062: Image-Guided Spinal Radiosurgery for Epidural Compression of Multiple Myeloma

Multiple myeloma with spinal epidural compression has been treated with external beam radiosurgery with palliative intent. Although there has been a good clinical response, there is need for a durable tumor control and prompt neurological recovery as this may impact quality of life. Based on the accuracy of spinal stereotactic radiosurgery demonstrated in our institution, we extended the spinal radiosurgery to treat metastatic epidural compression. The purpose of this study is to determine tumor control by radiosurgery for epidural compression by multiple myeloma.

Surgery Insight: current management of epidural spinal cord compression from metastatic spine disease

Metastatic epidural spinal cord compression (MESCC) is becoming a more common clinically encountered entity as advancing systemic antineoplastic treatment modalities improve survival in cancer patients. Although treatment of MESCC remains a palliative endeavor, emerging surgical techniques, in combination with imaging modalities that detect spinal metastatic disease at an early stage, are resulting in improved outcomes. Here, we review the clinical presentation, diagnostic work-up and management options in the management of MESCC. A treatment paradigm is outlined with emphasis on early circumferential surgical decompression of the spinal cord with concomitant spinal stabilization. Radiation therapy has a clearly defined role in the treatment of patients with MESCC, particularly those with radiation-sensitive tumors in the setting of non-bony spinal cord compression and those with a limited life expectancy. Spinal stereotactic radiosurgery, vertebroplasty, and kyphoplasty, are emerging treatment options that are beginning to be used in selected patients with MESCC.

Interventional stereotactic radiation for traumatic spinal cord injury (SCI) in patients with confirmed paralysis

Interventional stereotactic radiation for traumatic spinal cord injury (SCI) in patients with confirmed paralysis

P82. Significant pain relief and few complications seen in initial experience with spine stereotactic radiosurgery

BACKGROUND CONTEXT: The most common complaint of symptomatic patients with spinal tumors is pain. The treatment paradigm for these tumors often includes radiation therapy, which can control tumor growth and reduce pain. Stereotactic radiosurgery (SRS) offers the ability to deliver a high dose to the lesion with sharp dose fall-off, limiting exposure to adjacent organs. SRS to the spine therefore has the potential to benefit many patients by reducing pain, limiting toxicity, and controlling tumor growth. As spinal SRS is a new technique, dose-response and toxicity are not well understood.

Treatment of spinal neoplasms using frameless stereotactic radiosurgery

Purpose of study: The use of stereotactic radiosurgery for the treatment of spinal lesions has been limited by the availability of effective target immobilization devices. Thi≈s study evaluated the feasibility of treating spinal neoplasms with a single-fraction radiosurgical technique using the CyberKnife Image-Guided Radiosurgery System. During treatment, a real-time image-guidance system tracks the patient's tumor. Information about tumor position is communicated to a robotic arm that aims the radiation-generating linear accelerator.Methods used: Nineteen consecutive patients with spinal neoplasms were treated. The location in the spine included 14 cervical, 2 thoracic and 3 lumbar. Fourteen lesions were metastatic, and five were primary. Cervical lesions were tracked relative to the skull; lower spinal lesions were tracked relative to percutaneously placed fiducial markers. Tumor volume ranged from 0.8 to 74.9 cc (mean, 17.1 cc). Fourteen lesions had received prior external beam irradiation. Dose plans were calculated based on computed tomography images acquired using 1- to 3-mm slices. Each plan was tested using a phantom to assure 1-mm accuracy. Tumor dose was maintained at 12 to 14 Gy to the 80% isodose line; spinal cord volume receiving greater than 8 Gy ranged from 0.0 to 1.4 cc (mean, .35 cc).of findings: All patients tolerated the procedure in an outpatient setting. No acute radiation toxicity or new neurological deficits occurred. One patient had a transient flare of neck pain. Axial and radicular pain improved in all patients who were symptomatic before treatment.Relationship between findings and existing knowledge: This study describes the largest series using a revolutionary therapeutic modality for the treatment of spinal neoplasms.Overall significance of findings: Spinal stereotactic radiosurgery using a frameless image-guided system was found to be safe and accurate. The major potential benefits of radiosurgical ablation of spinal neoplasms are short treatment time in an outpatient setting with rapid recovery time and good palliative effect. This device offers an alternative therapeutic modality for the treatment of metastatic lesions in medically inoperable patients, previously irradiated sites and for lesions not amenable to open surgical techniques or as an adjunct to surgery. Studies are currently underway to assess the efficacy of this novel treatment.Disclosures: Device or drug: CyberKnife Image-Guided Radiosurgery System. Status: approved.Conflict of interest: Peter C. Gerszten, speaker's bureau for Accuracy Inc. (Sunnyvale, CA.)

Respiration Induced Target Drift in Spinal Stereotactic Radiosurgery: Evaluation of Skeletal Fixation in a Porcine Model

Respiration Induced Target Drift in Spinal Stereotactic Radiosurgery: Evaluation of Skeletal Fixation in a Porcine Model

Frame Based Stereotactic Spinal Radiosurgery: Experience from the First 19 Patients Treated

Frame Based Stereotactic Spinal Radiosurgery: Experience from the First 19 Patients Treated

Preliminary Clinical Experience with Linear Accelerator-based Spinal Stereotactic Radiosurgery

Preliminary Clinical Experience with Linear Accelerator-based Spinal Stereotactic Radiosurgery

Preliminary Clinical Experience with Linear Accelerator-based Spinal Stereotactic Radiosurgery

A prototype device called an extracranial stereotactic radiosurgery frame was used to deliver stereotactic radiosurgery, with a modified linear accelerator, to metastatic neoplasms in the cervical, thoracic, and lumbar regions in five patients. In all patients, the neoplasms had failed to respond to spinal cord tolerance doses delivered by standard external fractionated radiation therapy to a median dose of 45 Gy (range, 33-65 Gy/11-30 fractions). The tumors were treated with single-fraction stereotactic radiosurgery with the spinal stereotactic frame for immobilization, localization, and treatment. The median number of isocenters was one (range, one to five) with a median single fraction dose of 10 Gy (range, 8-10 Gy) with median normalization to 80% isodose contour (range, 80-160%). There has been a single complication of esophagitis to date from radiosurgery of a tumor involving the C6-T1 segments; the esophagitis resolved with medical therapy. Median follow-up in this group of patients has been 6 months (range, 1-12 mo). To date, there has been no radiographic or clinical progression of the treated tumor in any patient. Two patients have died from systemic metastatic disease. In the three surviving patients, there has been computed tomographic- or magnetic resonance-documented regression of the treated tumor with a decrease of thecal sac compression with a median follow-up of 6 months (range, 3-14 mo). These five patients represent the first clinical application of stereotactic radiosurgery in the spine. The results suggest that extracranial radiosurgery may be suitable for the treatment of paraspinal neoplasms after external fractionated radiation therapy, even in the face of spinal cord compression.