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Extracranial radiosurgery—applications in the management of benign intradural spinal neoplasms

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Abstract

Stereotactic radiosurgery has enabled the delivery of higher doses of radiation and decreased fractionation due to improved accuracy. Spinal radiosurgery has been increasingly utilized for the management of metastatic extradural spinal disease. However, surgical resection remains the primary treatment strategy for intradural spinal tumors. Preliminary evidence suggests that radiosurgical ablation with stereotactic radiation for intradural spinal lesions may be efficacious in certain clinical scenarios. Local tumor control, pain relief, and improvement in neurologic function with minimal morbidity have been reported in short-term follow-up. However, long-term efficacy of radiosurgery in the management of intradural spinal neoplasms necessitates further validation. As extracranial radiosurgery is a newly evolving modality, a continuative review of the current literature is appropriate. Until a standardized therapeutic window of safety and efficacy can be determined, the recommendation of radiosurgical applications for benign spinal tumors should be reserved for carefully selected cases.

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Author information

Authors and Affiliations

  1. Midwestern University, Glendale, AZ, USA

    Christine Saraceni

  2. Department of Radiation Oncology, Arizona Oncology Services, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

    Jonathan B. Ashman

  3. Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA, 19107, USA

    James S. Harrop

Authors
  1. Christine Saraceni
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  2. Jonathan B. Ashman
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  3. James S. Harrop
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Corresponding author

Correspondence to James S. Harrop.

Additional information

Comments

Stephanie E. Combs, Jürgen Debus, Heidelberg, Germany

Saraceni and colleagues report on the use of extracranial radiosurgery for the treatment of benign intradural spinal neoplasms. The authors summarize the different technical approaches possible for radiosurgery, including the Cyberknife® Robotic Technique and stereotactic radiosurgery using a linear accelerator (LINAC).

The authors summarize and discuss the clinical results on radiosurgery of benign spinal tumors and conclude that radiosurgery can be applied safely in patients with benign spinal neoplasms not amenable to a complete surgical resection. However, timely surgical resection should be performed as the first treatment of choice in cases with tumors leading to extensive spinal cord compression, if mechanical destabilization is present or for highly radioresistant tumors. We would like to congratulate the authors on this nice work that reports not only high tumor control rates, but also discusses the risk attributed to high-dose single fraction radiosurgery with respect to radiation tolerance of the adjacent normal tissue, i.e., mainly the spinal chord.

When treating patients with benign spinal tumors, this risk for treatment toxicity must be considered diligently, keeping in mind the unimpaired life expectancy of the patients with non-malignant diseases. Most data on radiosurgery treatment have been gathered from patients with fast growing, malignant tumors. However, long-term radiation injury, especially high-grade toxicity, might develop not within months after treatment, but over years of follow-up.

The most important factors associated with long-term sequelae, which in the case of spinal tumors is mainly radiation-induced myelopathy, include the total dose applied, fraction size, the length of the treatment volume or the spinal volume receiving radiation dose, as well as the duration of treatment. The tolerance dose of the spinal chord to conventional fractionated external beam radiation therapy lies somewhere between 45 and 50 Gy delivered in conventional fractionation of 1.8 to 2 Gy (1–3). However, most volumes treated included much larger volumes than exposed in most cases of radiosurgery or in fractionated stereotactic radiotherapy (FSRT). Therefore, concluding from the published literature, a risk of 5% for myelopathy can be estimated after 57 to 61 Gy applied in fractions of 2 Gy.

Until now, the threshold for spinal cord toxicity after single-dose treatment of spinal tumors has not been determined; however, the existing literature has shown distinct differences between radiation sensitivity of different regions of the spinal cord. Moreover, preceding surgical interventions may also sensitize the spinal cord to subsequent radiation (3).

Therefore, the treatment volume must influence the indication for spinal radiosurgery, since the risk for side effects certainly increases with growing treatment volumes.

Optimal delineation of the target volume, including modern imaging modalities such as advanced MR imaging or PET scanning using tumor-specific markers can help delineate the optimal target volume. Additionally, it must be kept in mind that potential microscopic spread should be considered when defining target volumes, and that the goal of applying high-dose techniques to spinal tumors with low morbidity should not counteract optimal oncological treatment.

Additionally, precise patient positioning and pre-treatment verification are essential when applying millimeter-precise treatment plans. Therefore, optimal and precise target definition and image-guided treatment inevitably complement each other.

Modern radiosurgery techniques are an essential part of the present-day radiation oncology arsenal and can be used as a safe and effective treatment alternative for a subgroup of patients. Alternative treatment opportunities, however, such as modern fractionated regimens should be considered when making management decisions. Alternative beam qualities, such as particle therapy, when available should also be taken into account due to the distinct physical characteristics potentially improving dose distribution, especially with respect to the integral dose to normal tissue. For radioresistant spinal tumors, such as chordomas and chondrosarcomas, high-LET particles, such as carbon ions, might also be beneficial due to their characteristic biological effects.

In conclusion, during the task of treating spinal tumors independently of histology, we are faced with dose- and treatment-limiting factors, and sophisticated techniques such as radiosurgery can help to overcome some of the limitations when applied cautiously to selected patients.

(1) Rampling R, Symonds P (1998) Radiation myelopathy. Curr Opin Neurol 11:627–632

(2) Marcus RB Jr, Million R (1990) The incidence of myelitis after irradiation of the cervical spinal cord. Int J Radiat Oncol Biol Phys 19:3–8

(3) Debus J, Hug EB, Liebsch NJ, O'Farrel D, Finkelstein D, Efird J, Munzenrider JE (1999) Dose-volume tolerance of the brainstem after high-dose radiotherapy. Front Radiat Ther Oncol 33:305–314

Comments

Ralf A. Schneider, Villigen, Switzerland

In the present issue, C. Saraceni, J. B. Ashman, and J. S. Harrop review equipment, techniques, and published clinical outcomes on extracranial, spinal radiosurgery of benign intradural neoplasms. This is an excellent manuscript, showing the currently available radiosurgery and stereotactic body radiotherapy (SBRT) equipment, as well as discussing the available update and literature on the subject.

Except for some missing photographs demonstrating dose distributions of the compared radiosurgical techniques, e.g., for a typical intradural spinal tumor, C. Saraceni, J. B. Ashman, and J. S. Harrop describe in detail the different radiosurgical techniques and their results.

The authors report on improvements in tumor control as well as long-term side effects after innovative non-invasive radiosurgical techniques compared to conventional photon irradiation. Indications for surgery and/or radiosurgery of benign intradural spinal neoplasms are very well explained by the authors. Especially, the discussion about dose constraints of organs at risks doing radiosurgery demonstrates impressively the difficulties in defining adequate dose limits to lower serious long-term toxicity.

The present issue shows impressively the technological progress in radiosurgery in the past 10–15 years. Today, radiosurgery is an excellent treatment option in the management of benign intradural spinal neoplasms. The availability and the frequency of radiosurgical treatments will be enhanced by the more precise and efficient application in the future.

Even with the best photon treatment technique, the ultimate goal of any high-dose radiotherapy is complete target coverage with minimum dose to critical organs at risk. Limitation of photon-based spinal radiosurgery is the physical characteristic of dose falloff from high to low isodoses. The higher the dose to the tumor, e.g., for atypical and anaplastic meningiomas, the more problematic could be the dose to organs at risk. Especially in younger patients with a long expectancy of life even low-dose areas in the thorax or abdomen may cause serious long-term side effects as for example second malignancies. This requires long periods of follow-up outcomes for those patients.

Worldwide, a significant number of modern proton radiation therapy units are under construction or already fully operational. Maybe particle therapy will improve further on toxicities because of a decreased integral dose surrounding the target volumes. It will be interesting to study the long-term results after proton irradiation in comparison to modern radiosurgical photon therapy in the next few decades. Depending on the developments of costs of particle therapy in the future, it might replace photon therapy because of the possibility to lower the irradiated volume significantly without compromising the target volume.

In summary, today, photon-based radiosurgery represents a tremendous technological advancement and has created promising opportunities in addition or in place of neurosurgical intervention. The present issue may help surgeons and radiation oncologists to decide in daily practice whether a patient may profit from radiosurgery or not.

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Saraceni, C., Ashman, J.B. & Harrop, J.S. Extracranial radiosurgery—applications in the management of benign intradural spinal neoplasms. Neurosurg Rev 32, 133–141 (2009). https://doi.org/10.1007/s10143-008-0183-z

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