Vertebral Body Compression Fracture Following Spine SBRT
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1 RADIATION ONCOLOGY & MOLECULAR RADIATION SCIENCES Vertebral Body Compression Fracture Following Spine SBRT Kristin J. Redmond, MD, MPH
2 Disclosure & Disclaimer An honorarium is provided by Accuray for this presentation The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.
3 Disclosures Research funding from Elekta AB Honorarium from AstraZeneca for educational seminar Consultant for Medtronic Research funding from Accuray
4 Spine SBRT Outcomes Spine SBRT allows 80-90% local control in de novo, re-irradiation and post-op settings Similar local control in traditionally radioresistant primaries
5 Local Control by Histology Pain control Imaging RCC (n=93) 94% 87% Breast (n=83) 96% 100% Lung (n=80) 93% 100% Melanoma (n=38) 96% 75% Gerszten Spine 2007
6 Toxicity
7 Acute Toxicity: Pain Flare Chiang IJROBP 2013
8 Acute toxicity: Pain Flare Chiang IJROBP 2013
9 Acute toxicity: Pain Flare Chiang IJROBP 2013
10 RT-Induced Myelopathy Saghal 2012
11 Vertebral Body Compression Fracture One of most frequent and potentially most clinically significant toxicities
12 Vertebral Compression Fracture: 24 Gy in 2 fraction to T7 Pre-RT 3 months post SBRT
13 Vertebral Compression Fracture: 24 Gy in 2 fraction to T7 Pre-RT 3 months post SBRT
14 Vertebral Compression Fracture: 24 Gy in 2 fraction to T7 Pre-RT 3 months post SBRT
15 Vertebral Compression Fracture: 24 Gy in 2 fraction to T7 Treatment plan 3 months post SBRT
16 Vertebral Compression Fracture: 24 Gy in 2 fraction to T7 Treatment plan 3 months post SBRT
17 Toxicity: Vertebral Compression Fracture Saghal JCO 2013
18 Toxicity: Vertebral Compression Fracture Saghal JCO 2013
19 De Novo vs. Progressive VCF 9 studies involving 2768 vertebrae differentiated de novo from progressive 314 fractures developed (13.9%) - 5.6% de novo (range 3%-20%) - 5.8% VCF progression (range 2.7%-14.7%) Faruqi Neursurgery 2017
20 Implications of VCF Patients with progressive fracture: - Greater narcotic use - Deterioration in KPS - Higher pain scores Rose JCO 2009 Boehling JNS 2012
21 Surgical Intervention for VCF 9 studies reported therapeutic interventions for 353 VCF 131 (37.1%) underwent surgical intervention - 63% percutaneous cement - 37% open or minimally invasive spinal instrumentation Faruqi Neursurgery 2017
22 Pathophysiology: Acute Fracture Combination: - Acute intense inflammatory reaction -Tumor vasculature mediated effects - Apoptotic cell death Faruqi Neursurgery 2017
23 Pathophysiology: Late Fracture Al-Omair JNS 2013
24 Pathophysiology: Late Fracture Al-Omair JNS 2013
25 Pathophysiology: Late Fracture 20 Gy x 1 Al-Omair JNS 2013
26 Pathophysiology: Late Fracture Al-Omair JNS 2013
27 Pathophysiology: Late Fracture Al-Omair JNS 2013
28 Pathophysiology: 20 Gy x 1 Abundant bone (arrows) and necrotic cells (arrow heads) Al-Omair JNS 2013
29 Pathophysiology: 20 Gy x 1 Fragments of bone and necrotic tissue Al-Omair JNS 2013
30 Factors Predictive of VCF: Dose Saghal JCO 2013
31 Factors Predictive of VCF: Dose Dose related! Saghal JCO 2013
32 Factors Predictive of VCF: Dose Dose related! Saghal JCO 2013
33 Factors Predictive of VCF: Spinal Instability Neoplastic Score Stable: 0-6 Potentially unstable: 7-12 Unstable: >12 Fisher Spine 2011
34 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
35 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
36 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
37 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
38 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
39 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
40 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
41 Factors Predictive of VCF: Spinal Instability Neoplastic Score Median prescription dose 18 Gy x 1 and 9 Gy x 3 Lee JNO 2016
42 Factors Predictive of VCF: Spinal Instability Neoplastic Score Lee JNO 2016
43 Factors Predictive of VCF: Spinal Instability Neoplastic Score Lee JNO 2016
44 Factors Predictive of VCF: Spinal Instability Neoplastic Score Fracture more likely to be symptomatic in unstable vertebra Lee JNO 2016
45 Factors Predictive of VCF: Spinal Instability Neoplastic Score 47% patients with fracture underwent surgical procedure! Lee JNO 2016
46 Factors Predictive of VCF: Lytic Involvement Semi-automated segmentation of osteolytic and osteoblastic tumor Thibault IJROBP 2017
47 Factors Predictive of VCF: Lytic Involvement Semi-automated segmentation of osteolytic and osteoblastic tumor Thibault IJROBP 2017
48 Factors Predictive of VCF: Lytic Involvement Semi-automated segmentation of osteolytic and osteoblastic tumor Thibault IJROBP 2017
49 Factors Predictive of VCF Semi-automated segmentation of osteolytic and osteoblastic tumor Thibault IJROBP 2017
50 Factors Predictive of VCF Multi-institutional database Jawad JNS 2016
51 Factors Predictive of VCF Multi-institutional database Jawad JNS 2016
52 Factors Predictive of VCF Review of 11 studies: Faruqi Neurosurgery 2017
53 Can fractures be prevented? Retrospective: 86% received 20 Gy in 1 fraction Cement augmentation if SINS >10 and >33% vertebral body involved Rate VCF 4% Gestaut JNO 2017
54 Dosimetry of Prophylactic Cement Retrospective: 17 patients with kyphoplasty prior to SBRT No difference in dosimetry between kyphoplasty and other patients Dosimetric errors due to uncorrected electron density values insignificant Barzilai JNS Spine 2017
55 Future Directions More accurate modeling to better delineate individual patient fracture risk Cement augmentation or surgical stabilization before SBRT in high risk patients
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