Multifractionated image-guided and stereotactic intensity-modulated radiotherapy of paraspinal tumors: A preliminary report

Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, United States
International Journal of Radiation OncologyBiologyPhysics (Impact Factor: 4.26). 06/2005; 62(1):53-61. DOI: 10.1016/j.ijrobp.2004.09.006
Source: PubMed


The use of image-guided and stereotactic intensity-modulated radiotherapy (IMRT) techniques have made the delivery of high-dose radiation to lesions within close proximity to the spinal cord feasible. This report presents clinical and physical data regarding the use of IMRT coupled with noninvasive body frames (stereotactic and image-guided) for multifractionated radiotherapy.
The Memorial Sloan-Kettering Cancer Center (Memorial) stereotactic body frame (MSBF) and Memorial body cradle (MBC) have been developed as noninvasive immobilizing devices for paraspinal IMRT using stereotactic (MSBF) and image-guided (MBC) techniques. Patients were either previously irradiated or prescribed doses beyond spinal cord tolerance (54 Gy in standard fractionation) and had unresectable gross disease involving the spinal canal. The planning target volume (PTV) was the gross tumor volume with a 1 cm margin. The PTV was not allowed to include the spinal cord contour. All treatment planning was performed using software developed within the institution. Isocenter verification was performed with an in-room computed tomography scan (MSBF) or electronic portal imaging devices, or both. Patients were followed up with serial magnetic resonance imaging every 3-4 months, and no patients were lost to follow-up. Kaplan-Meier statistics were used for analysis of clinical data.
Both the MSBF and MBC were able to provide setup accuracy within 2 mm. With a median follow-up of 11 months, 35 patients (14 primary and 21 secondary malignancies) underwent treatment. The median dose previously received was 3000 cGy in 10 fractions. The median dose prescribed for these patients was 2000 cGy/5 fractions (2000-3000 cGy), which provided a median PTV V100 of 88%. In previously unirradiated patients, the median prescribed dose was 7000 cGy (5940-7000 cGy) with a median PTV V100 of 90%. The median Dmax to the cord was 34% and 68% for previously irradiated and never irradiated patients, respectively. More than 90% of patients experienced palliation from pain, weakness, or paresthesia; 75% and 81% of secondary and primary lesions, respectively, exhibited local control at the time of last follow-up. No cases of radiation-induced myelopathy or radiculopathy have thus far been encountered.
Precision stereotactic and image-guided paraspinal IMRT allows the delivery of high doses of radiation in multiple fractions to tumors within close proximity to the spinal cord while respecting cord tolerance. Although preliminary, the clinical results are encouraging.

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    • "With improved dose distributions and accuracy, SBRT has facilitated the safe painless delivery of high doses of radiation quickly to localized spine tumors. Multiple studies have confirmed the efficacy of SBRT with early symptomatic improvement seen in 86–96% of treated patients following delivery of one to five fractions (Gerszten et al., 2004,2007; Ryu et al., 2004,2008; Degen et al., 2005; Yamada et al., 2005,2008; Chang et al., 2007; Gibbs et al., 2007; Gagnon et al., 2009). Despite growing evidence supporting SBRT in poor prognosis, previously irradiated spine metastases patients, few studies have established local control rates for newly diagnosed relatively good prognosis patients with single VB metastases. "
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    Frontiers in Oncology 04/2012; 2:39. DOI:10.3389/fonc.2012.00039
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    • "Current therapies include surgical resection, radiation, and chemotherapy. In addition, with recent advances using intensity-modulated, proton and carbon-ion radiotherapy, radiation doses can be safely administered to microscopic residual tumor (10–12). "
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    • "Previously irradiated lesions were treated with a mean maximum dose of 20 Gy (range 12.5-25 Gy)11), a median dose 35 Gy (range 20-50.4 Gy)3), a median dose of 20 Gy in 5 fractions (range 20-30 Gy)43), and a median dose 20 Gy (range 10-30 Gy) in 1-5 fractions (median 2). "
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