Risk for surgical complications after previous stereotactic body radiotherapy of the spine

Radiation Oncology, Sep 2017

Stereotactic body radiotherapy (SBRT) for vertebral metastases has emerged as a promising technique, offering high rates of symptom relief and local control combined with low risk of toxicity. Nonetheless, local failure or vertebral instability may occur after spine SBRT, generating the need for subsequent surgery in the irradiated region. This study evaluated whether there is an increased incidence of surgical complications in patients previously treated with SBRT at the index level. Based upon a retrospective international database of 704 cases treated with SBRT for vertebral metastases, 30 patients treated at 6 different institutions were identified who underwent surgery in a region previously treated with SBRT. Thirty patients, median age 59 years (range 27–84 years) underwent SBRT for 32 vertebral metastases followed by surgery at the same vertebra. Median follow-up time from SBRT was 17 months. In 17 cases, conventional radiotherapy had been delivered prior to SBRT at a median dose of 30 Gy in median 10 fractions. SBRT was administered with a median prescription dose of 19.3 Gy (range 15–65 Gy) delivered in median 1 fraction (range 1–17) (median EQD2/10 = 44 Gy). The median time interval between SBRT and surgical salvage therapy was 6 months (range 1–39 months). Reasons for subsequent surgery were pain (n = 28), neurological deterioration (n = 15) or fracture of the vertebral body (n = 13). Open surgical decompression (n = 24) and/or stabilization (n = 18) were most frequently performed; Five patients (6 vertebrae) were treated without complications with vertebroplasty only. Increased fibrosis complicating the surgical procedure was explicitly stated in one surgical report. Two durotomies occurred which were closed during the operation, associated with a neurological deficit in one patient. Median blood loss was 500 ml, but five patients had a blood loss of more than 1 l during the procedure. Delayed wound healing was reported in two cases. One patient died within 30 days of the operation. In this series of surgical interventions following spine SBRT, the overall complication rate was 19%, which appears comparable to primary surgery without previous SBRT. Prior spine SBRT does not appear to significantly increase the risk of intra- and post-surgical complications.

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Risk for surgical complications after previous stereotactic body radiotherapy of the spine

Roesch et al. Radiation Oncology Risk for surgical complications after previous stereotactic body radiotherapy of the spine Johannes Roesch 0 John B.C. Cho 2 Daniel K. Fahim 1 Peter C. Gerszten 7 John C. Flickinger 6 Inga S. Grills 5 Maha Jawad 5 Ronald Kersh 4 Daniel Letourneau 2 Frederick Mantel 9 Arjun Sahgal 8 John H. Shin 3 Brian Winey 10 Matthias Guckenberger 0 0 Department of Radiation Oncology, University Hospital Zurich , Zurich , Switzerland 1 Department of Neurosurgery, William Beaumont Hospital , Royal Oak, Michigan , USA 2 Princess Margaret Cancer Centre, Radiation Medicine Program , Toronto , Canada 3 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts , USA 4 Department of Radiation Oncology, Riverside Medical Center , Newport News, Virginia , USA 5 Department of Radiation Oncology, William Beaumont Hospital , Royal Oak, Michigan , USA 6 Department of Radiation Oncology, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania , USA 7 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania , USA 8 Department of Radiation Oncology, Sunnybrook Health Sciences Centre , Toronto , Canada 9 Department of Radiation Oncology, University Hospital Würzburg , Würzburg , Germany 10 Department of Radiation Oncology, Massachusetts General Hospital , Boston, Massachusetts , USA Object: Stereotactic body radiotherapy (SBRT) for vertebral metastases has emerged as a promising technique, offering high rates of symptom relief and local control combined with low risk of toxicity. Nonetheless, local failure or vertebral instability may occur after spine SBRT, generating the need for subsequent surgery in the irradiated region. This study evaluated whether there is an increased incidence of surgical complications in patients previously treated with SBRT at the index level. Methods: Based upon a retrospective international database of 704 cases treated with SBRT for vertebral metastases, 30 patients treated at 6 different institutions were identified who underwent surgery in a region previously treated with SBRT. Results: Thirty patients, median age 59 years (range 27-84 years) underwent SBRT for 32 vertebral metastases followed by surgery at the same vertebra. Median follow-up time from SBRT was 17 months. In 17 cases, conventional radiotherapy had been delivered prior to SBRT at a median dose of 30 Gy in median 10 fractions. SBRT was administered with a median prescription dose of 19.3 Gy (range 15-65 Gy) delivered in median 1 fraction (range 1-17) (median EQD2/10 = 44 Gy). The median time interval between SBRT and surgical salvage therapy was 6 months (range 1-39 months). Reasons for subsequent surgery were pain (n = 28), neurological deterioration (n = 15) or fracture of the vertebral body (n = 13). Open surgical decompression (n = 24) and/or stabilization (n = 18) were most frequently performed; Five patients (6 vertebrae) were treated without complications with vertebroplasty only. Increased fibrosis complicating the surgical procedure was explicitly stated in one surgical report. Two durotomies occurred which were closed during the operation, associated with a neurological deficit in one patient. Median blood loss was 500 ml, but five patients had a blood loss of more than 1 l during the procedure. Delayed wound healing was reported in two cases. One patient died within 30 days of the operation. Conclusion: In this series of surgical interventions following spine SBRT, the overall complication rate was 19%, which appears comparable to primary surgery without previous SBRT. Prior spine SBRT does not appear to significantly increase the risk of intra- and post-surgical complications. Spine tumor; Stereotactic radiotherapy of the spine; Radiosurgery; SBRT; Spine surgery; Complications Background The skeleton is one of the most common sites of metastatic disease spread in cancer patients with approximately 300,000 cases per year in the United States [ 1, 2 ]. Depending on the type of cancer, bony metastases occur in up to 70% of patients [3]. Furthermore, the spine is the most common site of bony metastasis, with postmortem detection of vertebral metastases in 30 to 36% of patients who died from neoplastic disease [ 4–6 ]. Pain medication combined with conventional radiotherapy (RT) is the standard of care for symptomatic bone metastases. However, recent developments in RT treatment planning and delivery enabled dose escalation within one or few treatment sessions and thus stereotactic body radiation therapy (SBRT) has emerged as a promising treatment technique [ 7 ]. By offering high rates of symptom relief and local control combined with low rates of toxicity, its acceptance and use are increasing [ 8, 9 ]. Nonetheless, symptomatic local failure or spinal instability after spine SBRT may occur, generating the need for subsequent surgery in the irradiated region [ 10, 11 ]. Prior RT is known to cause tiss (...truncated)


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Johannes Roesch, John B.C. Cho, Daniel K. Fahim, Peter C. Gerszten, John C. Flickinger, Inga S. Grills, Maha Jawad, Ronald Kersh, Daniel Letourneau, Frederick Mantel, Arjun Sahgal, John H. Shin, Brian Winey, Matthias Guckenberger. Risk for surgical complications after previous stereotactic body radiotherapy of the spine, Radiation Oncology, 2017, pp. 1, Volume 12, Issue 1, DOI: 10.1186/s13014-017-0887-8