Purpose: The epidural space is a frequent site of cancer recurrence after spine stereotactic radiosurgery (SSRS). This may be due to microscopic disease in the epidural space which is underdosed to obey strict spinal cord dose constraints. We hypothesized that the epidural space could be purposefully irradiated to prescription dose levels, potentially reducing the risk of recurrence in the epidural space without increasing toxicity. Methods and materials: SSRS clinical treatment plans with spinal cord contours, spinal planning target volumes (PTVspine), and delivered dose distributions were retrospectively identified. An epidural space PTV (PTVepidural) was contoured to avoid the spinal cord and focus on regions near the PTVspine. Clinical plan constraints included PTVspine constraints (D95% and D5%, based on prescription dose) and spinal cord constraints (Dmax < 1300 cGy, D10% < 1000 cGy). Plans were revised with three prescriptions of 1800, 2000 and 2400 cGy in two sets, with one set of revisions (supplemented plans) designed to additionally target the PTVepidural by optimizing PTVepidural D95% in addition to meeting every clinical plan constraint. Clinical and revised plans were compared according to their PTVepidural DVH distributions, and D95% distributions. Results: Seventeen SSRS plans meeting the above criteria were identified. Supplemented plans had higher doses to the epidural low-dose regions at all prescription levels. Epidural PTV D95% values for the supplemented plans were all statistically significantly different from the values of the base plans (p < 10-4). The epidural PTV D95% increases depended on the initial prescription, increasing from 11.52 to 16.90 Gy, 12.23 to 18.85 Gy, and 13.87 to 19.54 Gy for target prescriptions of 1800, 2000 and 2400 cGy, respectively. Conclusions: Purposefully targeting the epidural space in SSRS may increase control in the epidural space without significantly increasing the risk of spinal cord toxicity. A clinical trial of this approach should be considered.
Purpose: The epidural space is a frequent site of cancer recurrence after spine stereotactic radiosurgery (SSRS). This may be due to microscopic disease in the epidural space which is underdosed to obey strict spinal cord dose constraints. We hypothesized that the epidural space could be purposefully irradiated to prescription dose levels, potentially reducing the risk of recurrence in the epidural space without increasing toxicity. Methods and materials: SSRS clinical treatment plans with spinal cord contours, spinal planning target volumes (PTVspine), and delivered dose distributions were retrospectively identified. An epidural space PTV (PTVepidural) was contoured to avoid the spinal cord and focus on regions near the PTVspine. Clinical plan constraints included PTVspine constraints (D95% and D5%, based on prescription dose) and spinal cord constraints (Dmax < 1300 cGy, D10% < 1000 cGy). Plans were revised with three prescriptions of 1800, 2000 and 2400 cGy in two sets, with one set of revisions (supplemented plans) designed to additionally target the PTVepidural by optimizing PTVepidural D95% in addition to meeting every clinical plan constraint. Clinical and revised plans were compared according to their PTVepidural DVH distributions, and D95% distributions. Results: Seventeen SSRS plans meeting the above criteria were identified. Supplemented plans had higher doses to the epidural low-dose regions at all prescription levels. Epidural PTV D95% values for the supplemented plans were all statistically significantly different from the values of the base plans (p < 10-4). The epidural PTV D95% increases depended on the initial prescription, increasing from 11.52 to 16.90 Gy, 12.23 to 18.85 Gy, and 13.87 to 19.54 Gy for target prescriptions of 1800, 2000 and 2400 cGy, respectively. Conclusions: Purposefully targeting the epidural space in SSRS may increase control in the epidural space without significantly increasing the risk of spinal cord toxicity. A clinical trial of this approach should be considered.
Authors: Brett W Cox; Daniel E Spratt; Michael Lovelock; Mark H Bilsky; Eric Lis; Samuel Ryu; Jason Sheehan; Peter C Gerszten; Eric Chang; Iris Gibbs; Scott Soltys; Arjun Sahgal; Joe Deasy; John Flickinger; Mubina Quader; Stefan Mindea; Yoshiya Yamada Journal: Int J Radiat Oncol Biol Phys Date: 2012-05-19 Impact factor: 7.038
Authors: Arjun Sahgal; Joe H Chang; Lijun Ma; Lawrence B Marks; Michael T Milano; Paul Medin; Andrzej Niemierko; Scott G Soltys; Wolfgang A Tomé; C Shun Wong; Ellen Yorke; Jimm Grimm; Andrew Jackson Journal: Int J Radiat Oncol Biol Phys Date: 2019-10-10 Impact factor: 7.038
Authors: Amit K Garg; Xin-Shelley Wang; Almon S Shiu; Pamela Allen; James Yang; Mary Frances McAleer; Syed Azeem; Laurence D Rhines; Eric L Chang Journal: Cancer Date: 2011-02-11 Impact factor: 6.860
Authors: Arjun Sahgal; Lijun Ma; Iris Gibbs; Peter C Gerszten; Sam Ryu; Scott Soltys; Vivian Weinberg; Shun Wong; Eric Chang; Jack Fowler; David A Larson Journal: Int J Radiat Oncol Biol Phys Date: 2009-09-16 Impact factor: 7.038
Authors: Eric L Chang; Almon S Shiu; Ehud Mendel; Leni A Mathews; Anita Mahajan; Pamela K Allen; Jeffrey S Weinberg; Barry W Brown; Xin Shelly Wang; Shiao Y Woo; Charles Cleeland; Moshe H Maor; Laurence D Rhines Journal: J Neurosurg Spine Date: 2007-08
Authors: John W Nelson; David S Yoo; John H Sampson; Robert E Isaacs; Nicole A Larrier; Lawrence B Marks; Fang-Fang Yin; Q Jackie Wu; Zhiheng Wang; John P Kirkpatrick Journal: Int J Radiat Oncol Biol Phys Date: 2008-11-10 Impact factor: 7.038
Authors: Ori Barzilai; Stefano Boriani; Charles G Fisher; Arjun Sahgal; Jorrit Jan Verlaan; Ziya L Gokaslan; Aron Lazary; Chetan Bettegowda; Laurence D Rhines; Ilya Laufer Journal: Global Spine J Date: 2019-05-08