Prophylactic Dexamethasone on Pain Flare in Spine Metastasis Stereotactic Body Radiotherapy and Hypofractionated Radiotherapy / 肿瘤防治研究

Objective To explore the incidence of pain flare (PF) in spine metastasis stereotactic body radiotherapy (SBRT) or hypofractionated radiotherapy (HF) and the prophylactical effect of dexamethasone. Methods Sixty-five patients were treated with spine metastasis SBRT and randomly divided into control group (SBRT or HF, n=32) and treatment group (SBRT or HF and 4.5 mg dexamethasone, n=33). The brief pain inventory (BPI) was used to score the pain before, during and after treatment. PF was recorded and compared between two groups. Results The incidence of PF was 24.6% in all patients (control group: 37.5%, treatment group: 12.1%, P=0.018). PF in both group occurred in d1-2, accounting for 62.5% in all PF (control group: 66.7%, treatment group: 50%, P=0.551). The incidences of PF in control group were 66.7% and 33.3% for three and ten fractions scheme, respectively (P=0.001). However, the incidences of PF in treatment group were 50% and 50% for three and ten fractions scheme, respectively (P=0.643). Conclusion Oral dexamethasone has an excellent efficacy in prevention and treatment of PF in spine metastasis SBRT or HF, with significantly decreased incidence of PF. A phase Ⅲ clinical trial is required to finalize the optimal dose and schedule.

Lumbar spine metastasis in a breast cancer survivor after twelve years of disease-free survival

Spine metastasis is a common occurrence in breast cancer. The median time of spine metastasis from the diagnosis of breast cancer is approximately 3 years. In this case report, a 55 years old woman presented with insidious onset and progressively worsening severe low back pain. Spine MRI revealed L4-S1 heterogeneous marrow signal changes with L5 vertebral body collapse. She had undergone surgery, radiation, and chemotherapy for breast cancer 12 years prior. Although she had not received any anticancer treatment for 12 years, but she has been on regular follow up with the oncology team with no clinical evidence of local tumour recurrence. She had laminectomy and biopsy and the histological diagnosis was metastatic adenocarcinoma from breast cancer. She had palliative external beam radiation therapy and systemic chemotherapy with improvement in Karnofsky performance. We present a case of dormant micro metastasis re-activated 12 years after perceived cure for breast cancer.

Late-Developing Metastatic Malignant Melanoma in the Thoracic Spine Originating from Choroidal Melanoma

A 54-year-old woman visited Gangnam Severance Hospital for left side flank pain. She had a history of total removal of malignant melanoma on the left eye ball 20 years prior. No evaluation had been performed since then. A paravertebral mass at thoracic ninth level (T9) was discovered on spinal magnetic resonance imaging, and pathology confirmed malignant melanoma. Following positron emission tomography-computed tomography, no other metastasis was discovered. After removal of the paravertebral mass, palliative chemotherapy (dacabarzine + tamoxifene) was administered in 3 cycles over 2 months. Radiotherapy with simultaneous integrated boost technique was performed at 4,350 cGy total over 15 days, 290 cGy per delivery, and was administered with the first cycle of palliative chemotherapy. Despite this treatment, multiple metastases developed throughout her body 7 months later, and the patient is continuing chemotherapy.

Spine radiosurgery for the local treatment of spine metastases: Intensity-modulated radiotherapy, image guidance, clinical aspects and future directions

Many cancer patients will develop spinal metastases. Local control is important for preventing neurologic compromise and to relieve pain. Stereotactic body radiotherapy or spinal radiosurgery is a new radiation therapy technique for spinal metastasis that can deliver a high dose of radiation to a tumor while minimizing the radiation delivered to healthy, neighboring tissues. This treatment is based on intensity-modulated radiotherapy, image guidance and rigid immobilization. Spinal radiosurgery is an increasingly utilized treatment method that improves local control and pain relief after delivering ablative doses of radiation. Here, we present a review highlighting the use of spinal radiosurgery for the treatment of metastatic tumors of the spine. The data used in the review were collected from both published studies and ongoing trials. We found that spinal radiosurgery is safe and provides excellent tumor control (up to 94% local control) and pain relief (up to 96%), independent of histology. Extensive data regarding clinical outcomes are available; however, this information has primarily been generated from retrospective and nonrandomized prospective series. Currently, two randomized trials are enrolling patients to study clinical applications of fractionation schedules spinal Radiosurgery. Additionally, a phase I clinical trial is being conducted to assess the safety of concurrent stereotactic body radiotherapy and ipilimumab for spinal metastases. Clinical trials to refine clinical indications and dose fractionation are ongoing. The concomitant use of targeted agents may produce better outcomes in the future.

Minimally Invasive Spinal Stabilization Using Fluoroscopic-Guided Percutaneous Screws as a Form of Palliative Surgery in Patients with Spinal Metastasis

STUDY DESIGN: Prospective cohort study. PURPOSE: To report the outcome of 50 patients with spinal metastases treated with minimally invasive stabilization (MISt) using fluoroscopic guided percutaneous pedicle screws with/without minimally invasive decompression. OVERVIEW OF LITERATURE: The advent of minimally invasive percutaneous pedicle screw stabilization system has revolutionized the treatment of spinal metastasis. METHODS: Between 2008 and 2013, 50 cases of spinal metastasis with pathological fracture(s) with/without neurology deficit were treated by MISt at our institution. The patients were assessed by Tomita score, pain score, operation time, blood loss, neurological recovery, time to ambulation and survival. RESULTS: The mean Tomita score was 6.3+/-2.4. Thirty seven patients (74.0%) required minimally invasive decompression in addition to MISt. The mean operating time was 2.3+/-0.5 hours for MISt alone and 3.4+/-1.2 hours for MISt with decompression. Mean blood loss for MISt alone and MISt with decompression was 0.4+/-0.2 L and 1.7+/-0.9 L, respectively. MISt provided a statistically significant reduction in visual analog scale pain score with mean preoperative score of 7.9+/-1.4 that was significantly decreased to 2.5+/-1.2 postoperatively (p=0.000). For patients with neurological deficit, 70% displayed improvement of one Frankel grade and 5% had an improvement of 2 Frankel grades. No patient was bed-ridden postoperatively, with the average time to ambulation of 3.4+/-1.8 days. The mean overall survival time was 11.3 months (range, 2-51 months). Those with a Tomita score or =8 with a mean survival of 14.1+/-12.5 months and 6.8+/-4.9 months, respectively (p=0.019). There were no surgical complications, except one case of implant failure. CONCLUSIONS: MISt is an acceptable treatment option for spinal metastatic patients, providing good relief of instability back pain with no major complications.

Dosimetric comparison of stereotactic body radiation therapy plans for spine metastasis using flattening filter free and flattening filter modes / 中华放射医学与防护杂志

Objective To compare the dosimetric difference of stereotactic body radiation therapy (SBRT) plans for spine metastasis using 6 MV X-ray flattening filter free (FFF) and flattening filter (FF) modes.Methods A total of nine previously treated patients with a total of twelve spine metastasis were retrospectively included and replanned using FFF-SBRT and FF-SBRT, respectively.The dose-volume histograms (DVH), target conformity index (CI), monitor unites (MUs) and treatment time of target volume, organs at risk and normal tissues were compared between the plans.Results Both FFF-SBRT and FF-SBRT met the clinical objectives.Dose distribution of target volume, organs at risk and normal tissues were similar.MUs of the FFF-SBRT were significantly higher than that of FF-SBRT (t =-5.20, P ＜0.0l), while the treatment time was almost half of the latter (t =17.27, P ＜ 0.01).Conclusions Two plan modes are both clinically acceptable.FFF-SBRT plans are delivered in less time and with better efficiency.Trial registration Chinese clinical trial registry, ChiCTR-TRC-14004281.

Role and perspective of multiple session stereotactic body radiotherapy in the treatment for spine metastatic tumor / 中国医学装备

Spine metastasis stereotactic body radiation therapy delivers conformal high radiation dose to the tumor target, and steep falloff dose gradients protect adjacent normal structures, especially spinal cord. Some studies demonstrated stereotactic body radiation therapy for metastatic tumors of the spine is safe and clinically effective. 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. Although the technique is being increasingly used in clinical practice, the optimal fractionation schedule remains uncertain. Based on the research of radiobiologic principles, radiological physics and clinical data, multiple session stereotactic body radiation therapy has some advantage in clinic.

Contemporary treatment with radiosurgery for spine metastasis and spinal cord compression in 2015

With the progress of image-guided localization, body immobilization system, and computerized delivery of intensity-modulated radiation delivery, it became possible to perform spine radiosurgery. The next question is how to translate the high technology treatment to the clinical application. Clinical trials have been performed to demonstrate the feasibility of spine radiosurgery and efficacy of the treatment in the setting of spine metastasis, leading to the randomized trials by a cooperative group. Radiosurgery has also demonstrated its efficacy to decompress the spinal cord compression in selected group of patients. The experience indicates that spine radiosurgery has a potential to change the clinical practice in the management of spine metastasis and spinal cord compression.

A Case Report of Recurrent Malignant Paraganglioma with Lung and Spine Metastasis that Occurred Sixteen Years after Primary Tumor Excision / 대한내과학회지

Paragangliomas are rare tumors that arise from the extra-adrenal chromaffin cells, and malignancy is defined by the presence of metastases to sites that normally lack chromaffin tissue. The main therapeutic targets are tumor reduction and control of excessive catecholamine secretion. Currently, the adjuvant therapy to surgery is radiotherapy treatment using high-dose MIBG; chemotherapy is currently evolving. We report herein a case of malignant paraganglioma with lung and spine metastasis that occurred 16 years after primary tumor excision and was treated with high dose MIBG radiotherapy and chemotherapy.

Stereotactic body radiotherapy for solitary spine metastasis

A clear consensus has not been established regarding the best treatment for solitary bone metastasis. Here, we reviewed the medical records of patients with a controlled primary malignancy who had only solitary spine metastasis without metastasis to the extraspinal bone or viscera and underwent treatment between April 2007 and December 2012 with stereotactic body radiosurgery using CyberKnife, with a total dose of 24 Gy in three to four fractions. During that time, there were only four cases. This was effective in each case, and all the four patients had no local failure and remained alive at a median follow-up of 68 months (range, 64 to 80 months). Although our experience is limited, this study suggests that stereotactic body radiotherapy could be a feasible, safe, effective, and noninvasive alternative treatment for solitary spine metastasis in patients who are medically inoperable or unsuitable for surgery.

Helical tomotherapy for spine oligometastases from gastrointestinal malignancies

PURPOSE: This study evaluated the treatment effectiveness and proper radiation dose of helical tomotherapy (HT) in spine oligometastases from gastrointestinal cancers. MATERIALS AND METHODS: From 2006 to 2010, 20 gastrointestinal cancer patients were treated with HT for spine oligometastases (31 spine lesions). The gross tumor volume (GTV) was the tumor evident from magnetic resonance imaging images fused with simulation computed tomography images. Clinical target volume (CTV) encompassed involved vertebral bodies or dorsal elements. We assumed that the planning target volume was equal to the CTV. We assessed local control rate after HT for 31 spine metastases. Pain response was scored by using a numeric pain intensity scale (NPIS, from 0 to 10). RESULTS: Spine metastatic lesions were treated with median dose of 40 Gy (range, 24 to 51 Gy) and median 5 Gy per fraction (range, 2.5 to 8 Gy) to GTV with median 8 fractions (range, 3 to 20 fraction). Median biologically equivalent dose (BED, alpha/beta = 10 Gy) was 52 Gy10 (range, 37.5 to 76.8 Gy10) to GTV. Six month local control rate for spine metastasis was 90.3%. Overall infield failure rate was 15% and outfield failure rate was 75%. Most patients showed pain relief after HT (93.8%). Median local recurrence free survival was 3 months. BED over 57 Gy10 and oligometastases were identified as prognostic factors associated with improved local progression free survival (p = 0.012, p = 0.041). CONCLUSION: HT was capable of delivering higher BED to metastatic lesions in close proximity of the spinal cord. Spine metastases from gastrointestinal tumors were sensitive to high dose radiation, and BED (alpha/beta = 10 Gy) higher than 57 Gy10 could improve local control.

Prognostic Factors for Survival in Spinal Metastases / 中国康复理论与实践

@#Objective To investigate the factors that affect the survival of patient with spinal metastases.Methods The clinical,imaging and pathologic data of 56 patients with pathologically confirmed spinal metastases were analyzed retrospectively with Cox regression.Results The type of primary tumor(P=0.001) and age(P=0.034) significantly affect the survival.Conclusion The type of primary tumor is of most significant factor affecting survival.

Spine Metastases as the Initial Sign of Differentiated Thyroid Carcinoma: Two Case Reports / 대한내분비외과학회지

Bone metastases as the first manifestation of thyroid carcinoma are extremely rare. Interestingly, evaluation at appropriate initials and proper treatment will lead to satisfactory long-term survival. We report here on two such cases; the patients presented with back pain and fine needle aspiration cytology of spine lesion revealed a metastatic carcinoma. A wide excision of the bone lesion was carried out and the histopathology was consistent with features of metastatic carcinoma of the thyroid. The management of thyroid carcinoma and the subsequent bone metastases is reviewed and the controversial points are highlighted.

Paraplegia Following Continuous Epidural Block in a Hepatoma Case with Spine Metastasis / 대한마취과학회지

We report a patient with a previously undiagnosed spine metastasis that developed into paraplegia following a continuous epidural block. This is an uncommon and quite rare complication. A 52-year-old male hepatoma case with upper abdominal cancer pain was indicated for a celiac plexus block. A continuous epidural block was performed prior to the celiac plexus block. A Tuohy needle was introduced at the Tll-12 interspace and an epidural catheter was inserted about 15cm in length cephalad through the needle. During the procedure, a saline solution was infused through the Tuohy needle and epidural catheter. The tip of the catheter was expected to be near the T, level. The upper abdominal pain was subsided after the injection of 3 ml of 1% lidocaine and 3 ml of 0.5% bupivacaine via the epidural catheter around noon time. When we made ward rounds that evening, the patient complained of motor weakness and sensory change below T; however, the local anesthetics were injected continuously through the epidural catheter every 4 hours. Next morning, because the patient complained of paraplegia, the epidural injection was discontinued. Under the suspicion of spinal cord compression, a computed tomogram of the thoracic spine was taken. It showed an osteolytic destruction of the right pedicle of T, due to a metastatic tumor. This suggested subclinical tumor invasion to the epidural space. The infusion of saline and local anesthetics through the Tuohy needle and the epidural catheter may increase the epidural pressure and compress the spinal cord. A laminectomy was refused by the family and the patient was discharged from the hospital after 6 treatments of radiotherapy without any improvement. It is advisable to take a spine CT or bone acan in terminal cancer patients before an epidural block, and when paraplegia develops after an epidural block.