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Biomedical subjects

Peter C Gerszten

Publications and source records attributed to Peter C Gerszten.

At least 19 recordsLinked to original sources
PubMed2007

Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution.

STUDY DESIGN: A prospective nonrandomized, longitudinal cohort study. OBJECTIVE: To evaluate the clinical outcomes of single-fraction radiosurgery as part of the management of metastatic spine tumors. SUMMARY OF BACKGROUND DATA: The role of stereotactic radiosurgery for the treatment of spinal lesions has previously been limited by the availability of effective target immobilization and target tracking devices. Large clinical experience with spinal radiosurgery to properly assess clinical experience has previously been limited. METHODS: A cohort of 500 cases of spinal metastases underwent radiosurgery. Ages ranged from 18 to 85 years (mean 56). Lesion location included 73 cervical, 212 thoracic, 112 lumbar, and 103 sacral. RESULTS: The maximum intratumoral dose ranged from 12.5 to 25 Gy (mean 20). Tumor volume ranged from 0.20 to 264 mL (mean 46). Long-term pain improvement occurred in 290 of 336 cases (86%). Long-term tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. Twenty-seven of 32 cases (84%) with a progressive neurologic deficit before treatment experienced at least some clinical improvement. CONCLUSIONS: The results indicate the potential of radiosurgery in the treatment of patients with spinal metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.

Adult↗
PubMed2007

Combined percutaneous transpedicular tumor debulking and kyphoplasty for pathological compression fractures. Technical note.

Percutaneous balloon kyphoplasty has become a widely adopted treatment option for patients with pain due to pathological compression fractures. One potential risk of the procedure is the displacement of tumor into the spinal canal and resulting spinal cord or cauda equina injury during inflation of the balloon prior to polymethylmethacrylate (PMMA) placement. In addition, the presence of any remaining tumor between the PMMA and the fractured cortical bone can lead to suboptimal improvement in stabilization and subsequent pain relief. The authors describe a technique to remove tumor from within the vertebral body (VB) through a percutaneous working channel prior to kyphoplasty balloon inflation and augmentation. The technique was successfully used in all three patients who had presented with pain, and the pain improved in all three cases. There was no extravasation of PMMA into the spinal canal in any case. A combined VB tumor debulking and kyphoplasty technique offers the ability to improve the placement of PMMA within the diseased vertebral body, potentially leading to increased safety as well as clinical effectiveness for stabilization of these fractures.

Adult↗
PubMed2006

Radiosurgery for the treatment of spinal lung metastases.

BACKGROUND: Spinal metastases are a common source of pain as well as neurologic deficit in patients with lung cancer. Metastases from lung cancer traditionally have been believed to be relatively responsive to radiation therapy. However, conventional external beam radiotherapy lacks the precision to allow delivery of large single-fraction doses of radiation and simultaneously limit the dose to radiosensitive structures such as the spinal cord. The current study evaluated the efficacy of single-fraction radiosurgery for the treatment of spinal lung cancer metastases. METHODS: In the current prospective cohort evaluation, 87 lung cancer metastases to the spine in 77 patients were treated with a single-fraction radiosurgery technique with a follow-up period of 6 to 40 months (median, 12 months). The indication for radiosurgery treatment was pain in 73 cases, as a primary treatment modality in 7 cases, for radiographic tumor progression in 4 cases, and for progressive neurologic deficit in 3 cases. RESULTS: Tumor volume ranged from 0.2 to 264 cm(3) (mean, 25.7 cm(3)). The maximum tumor dose was maintained at 15 to 25 grays (Gy) (mean, 20 Gy; median, 20 Gy). No radiation-induced toxicity occurred during the follow-up period. Long-term axial and radicular pain improvement occurred in 65 of 73 patients (89%) who were treated primarily for pain. Long-term radiographic tumor control was observed in all patients who underwent radiosurgery as their primary treatment modality or for radiographic tumor progression. CONCLUSIONS: Spinal radiosurgery was found to be feasible, safe, and clinically effective for the treatment of spinal metastases from lung cancer. The results of the current study indicate the potential of radiosurgery in the treatment of patients with spinal lung metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.

Adult↗
PubMed2006

Radiosurgery for the treatment of spinal melanoma metastases.

BACKGROUND: The role of stereotactic radiosurgery in treating metastatic melanoma involving the spine has previously been limited. Conventional external beam radiotherapy lacks the precision to allow delivery of large single-fraction doses of radiation and simultaneously to limit the dose delivered to radiosensitive structures such as the spinal cord. This study evaluated the clinical efficacy of radiosurgery for the treatment of melanoma spinal metastases in 28 patients. METHODS: Thirty-six melanoma spine metastases were treated with a single-session radiosurgery technique (1 cervical, 11 thoracic, 13 lumbar, and 11 sacral) with a follow-up period of 3-43 months (median 13 months). Tumor volume ranged from 4.1 to 153 cm3 (mean 47.6 cm3). Twenty-three of the 36 lesions had received prior external beam irradiation. RESULTS: Maximum tumor dose was maintained at 17.5-25 Gy (mean 21.7 Gy). Spinal cord volume receiving > 8 Gy ranged from 0.0 to 0.7 cm3 (mean 0.26 cm3); spinal canal volume at the cauda equina level receiving > 8 Gy ranged from 0.0 to 3.5 cm3 (mean 0.98 cm3). No radiation-induced toxicity occurred during the follow-up period. Axial and radicular pain improved in 27 of 28 patients (96%) who were treated primarily for pain. Long-term tumor control was seen in 3 of 4 cases treated primarily for radiographic tumor progression. Two patients went on to require open surgical intervention for tumor progression resulting in neurological deficit. CONCLUSIONS: Spinal radiosurgery offers a therapeutic modality for the safe delivery of large dose fractions of radiation therapy in a single fraction for the management of spinal metastases in patients with advanced melanoma that are often poorly controlled with alternative conventional external beam radiation therapy, and is successful even in patients with previously irradiated lesions.

Adult↗
PubMed2006

Spine: minimally invasive techniques.

Minimally invasive spine surgery decompression, arthrodesis, and instrumentation techniques are now being applied in a wide variety of percutaneous, laparoscopic and minimal access procedures. There is currently little longitudinal long-term data on these procedures to document their efficacy, indications, limitations or complications as compared to standard open techniques. Further complicating such direct comparisons is that widely used spine outcomes instruments often do not capture the relative benefits of these new procedures. It is only through randomized trials that the potential benefits of these procedures be substantiated in order to justify the sometimes significant increased costs associated with them.

Cost-Benefit Analysis↗
PubMed2006

Quality of life assessment in patients undergoing nucleoplasty-based percutaneous discectomy.

OBJECT: Nucleoplasty is a minimally invasive surgical procedure for disc decompression developed to treat patients with symptomatic contained herniated discs. Nucleoplasty uses nonheat-driven radiofrequency energy to ablate and coagulate the disc nucleus via a percutaneous "discography" trajectory under fluoroscopic guidance. In this study the authors evaluated pain, functioning, and quality of life (QOL) in patients with radicular leg and back pain who underwent nucleoplasty-based percutaneous disc decompression. METHODS: The study was designed as a prospective nonrandomized longitudinal cohort study in an academic medical center. Sixty-seven patients (mean age 41 years) with primarily radicular pain due to a contained disc herniation underwent nucleoplasty-based decompression in an outpatient setting. Patients completed the Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey, EuroQol 5D (EQ5D), and a visual analog scale (VAS) for pain preoperatively, and at 3 and 6 months after surgery. Postoperative QOL differences were assessed using the Wilcoxon signed-rank test. A surgical probe, the Perc-DLE SpineWand, was placed percutaneously into the disc after application of a local anesthetic or induction of general anesthesia to remove part of the disc (that is, a percutaneous discectomy). Nucleoplasty-treated levels were L2-3 (one case), L3-4 (five cases), L4-5 (44 cases), and L5-S 1 (40 cases); there were 22 multiple treatment levels and 42 bilateral treatments. There were no infections or nerve root injuries associated with the procedure. Compared with preoperative QOL, there was a statistically significant improvement in QOL at 3 months as measured using the SF-36 Physical Component Summary (PCS) scale (mean score improvement 4.4 [p = 0.014]), the EQ5D (mean score improvement 0.22 [p = 0.001]), and the VAS for pain (mean score improvement 0.13 [p = 0.021). Six-month results in 36 patients continued to reflect improvement as measured using the SF-36 PCS (mean score improvement 7.6 [p = 0.002]) and the EQ5D (mean score improvement 0.27 [p = 0.001]). CONCLUSIONS: Nucleoplasty-based percutaneous disc decompression in patients with symptomatic contained disc herniations is safe and improves QOL as measured by the SF-36, EQ5D, and VAS for pain, three generic QOL outcome instruments. Nucleoplasty is an effective minimally invasive surgical treatment alternative in patients with symptomatic contained disc hemiations. Further follow-up evaluation is underway to determine the durability of QOL improvement after nucleoplasty.

Adult↗
PubMed2005

Single-fraction radiosurgery for the treatment of spinal breast metastases.

BACKGROUND: The spine is the most common site of bony metastases in patients with osseous breast carcinoma metastases. Spine metastases are the source of significant pain and occasionally neurologic deficit in this patient population. Conventional external beam radiotherapy lacks the precision to allow delivery of large single-fraction doses of radiation and simultaneously limit the dose to radiosensitive structures such as the spinal cord. This study evaluated the clinical efficacy of the treatment of spinal breast carcinoma metastases with a single-fraction radiosurgical technique. METHODS: In this prospective cohort evaluation, 68 breast carcinoma metastases to the spine in 50 patients were treated with a single-fraction radiosurgery technique with a follow-up period of 6-48 months, median 16 months. The most common indication for radiosurgery treatment was pain in 57 lesions, as a primary treatment modality in 8 patients, and for radiographic tumor progression, as a postsurgical boost, and for a progressive neurologic deficit in 1 patient each. RESULTS: Tumor volume ranged from 0.8-197 cm3 (mean, 27.7 cm3). Maximum tumor dose was maintained at 15-22.5 Gy (mean, 19 Gy). No radiation-induced toxicity occurred during the follow-up period (6-48 mo). Long-term axial and radicular pain improvement occurred in 55 of 57 (96%) patients who were treated primarily for pain. Long-term radiographic tumor control was seen in all patients who underwent radiosurgery as their primary treatment modality, for radiographic tumor progression, or as a postsurgical treatment. CONCLUSIONS: Spinal radiosurgery was found to be feasible, safe, and clinically effective for the treatment of spinal metastases from breast carcinoma. The results indicate the potential of radiosurgery in the treatment of patients with spinal breast metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.

Adult↗
PubMed2005

Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures.

OBJECT: Patients with symptomatic pathological compression fractures require a stabilization procedure for mechanical control of back pain as well as radiation therapy for the underlying malignant process. In this study the authors evaluated a treatment paradigm of closed fracture reduction and fixation in which kyphoplasty was used, followed by single-fraction spinal radiosurgery performed with the CyberKnife. METHODS: Twenty-six patients (six men and 20 women, mean age 72 years) with histologically confirmed pathological compression fractures (16 thoracic, 10 lumbar) were prospectively evaluated. For inclusion in the study, the patients' presenting symptoms were limited to pain without neurological deficits. Histological findings included 11 lung, nine breast, and four renal carcinomas, one cholangiocarcinoma, and one ocular melanoma. All patients underwent kyphoplasty of the affected vertebral body, for which a percutaneous transpedicular procedure was used. Fiducial markers that allow image guidance for CyberKnife radiosurgery were placed into the pedicles at the adjacent levels at the time of the kyphoplasty procedure. Patients then underwent single-fraction radiosurgery (at a mean of 12 days after kyphoplasty) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy to the 80% isodose line (mean 18 Gy). Treated tumor volume ranged from 12.7 to 37.1 cm3. Axial pain improved in 24 (92%) of 26 patients during the follow-up period of 7 to 20 months. CONCLUSIONS: A combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be safe and clinically effective for patients with pathological fractures without significant spinal canal compromise. This technique combines two minimally invasive surgical procedures, thereby avoiding the morbidity associated with open surgery while providing immediate fracture fixation as well as a single-fraction tumoricidal radiation dose.

Aged↗
PubMed2005

CyberKnife Frameless Radiosurgery for the treatment of extracranial benign tumors.

Limited data exists for the use of radiosurgery for benign extracranial tumors. The purpose of this study was to evaluate the feasibility, toxicity, and local control of patients with benign extracranial lesions treated with the CyberKnife Frameless Radiosurgery System. From September 2001 thru January 2004, 59 benign tumors in 44 patients were treated using the CyberKnife a frameless image-guided radiosurgery system. Of these tumors, there were 21 neurofibromas, ten schwannomas, eight meningiomas, eight hemangioblastomas, seven paragangliomas, two hemangiopericytomas, one pseudotumor, one ependymoma, and one arteriovenous malformation (AVM). The anatomic locations of these tumors were spinal (25 cervical, four thoracic, 14 lumbar, and two sacral), neck (eight), orbital (three), brainstem (one), and foramen magnum (one). All patients were treated in a single fraction except three lesions were treated in a fractionated manner. The median treatment delivery time per fraction was 59 minutes (range 11-194). Twenty three lesions initially underwent surgical resection. Ten lesions received prior external beam radiation with a median dose 48 Gy (range 40-54 Gy), and one lesion received two prior CyberKnife treatments for a total dose of 32 Gy to the 80% isodose line. The median follow-up was eight months (range 1-25 months). Acute and late toxicity was graded using the National Cancer Institute Common Toxicity Criteria (CTC) scale. Symptomatic response was documented as "improved," "stable," or "progression". The median tumor dose delivered was 16.0 Gy to the 80% isodose line (range 10-31 Gy). The median tumor volume was 4.3 cc (range 0.14-98.6 cc). The median spinal cord volume receiving more than 8 Gy was 0.035 cc (range 0-2.5 cc) and the median maximum spinal cord dose 11.5 Gy (range 0-19.8 Gy). There were no patients that suffered a significant (Grade 3, 4, or 5) acute toxicity. There was no observed late toxicity. 78% of patients experienced an improvement of their pre-treatment symptoms while only one patient experienced symptom progression. Of the 26 patients who underwent follow-up imaging, the local control rate was 96%. This study suggests that CyberKnife Radiosurgery is a safe and efficacious treatment modality for benign tumors, even for those patients with recurrent previously irradiated lesions.

Brain Neoplasms↗
PubMed2005

Accuray CyberKnife image-guided radiosurgical system.

Radiosurgery is the application of radiation therapy in an extremely precise manner. These techniques apply large bioequivalent doses of radiation to a small area in order to destroy tumor cells, while sparing surrounding normal tissues. Radiosurgery has been available for intracranial abnormalities since the 1950s but it has only recently become available to treat tumors outside of the brain and skull base. This article outlines the authors experience with CyberKnife in the treatment of spinal and spine-associated abnormalities.

Clinical Trials as Topic↗
PubMed2005

Stereotactic radiosurgery for spinal metastases from renal cell carcinoma.

OBJECT: The role of stereotactic radiosurgery in treating renal cell carcinoma (RCC) metastases to the spine has previously been limited. In this study the authors evaluated the clinical outcome in patients with spinal RCC who underwent single-fraction radiosurgery. METHODS: Forty-eight patients with 60 RCC metastases to the spine (six cervical, 26 thoracic, 18 lumbar, and 10 sacral) were treated with a single-fraction radiosurgery technique and were followed for a period of 14 to 48 months (median 37 months). All patients were successfully treated in an outpatient setting. The tumor volume ranged from 5.5 to 203 cm3 (mean 61.9 cm3). Forty-two of the total 60 lesions had been previously treated with external-beam radiation therapy (EBRT). The maximum tumor dose was maintained at 17.5 to 25 Gy (mean 20 Gy). The volume of the spinal cord exposed to greater than 8 Gy ranged from 0.01 to 3 cm3 (mean 0.64 cm3); the volume of the spinal canal at the cauda equina level exposed to greater than 8 Gy ranged from 0.01 to 2.2 cm3 (mean 0.65 cm3). No radiation-induced toxicity occurred during the follow-up period. Axial and radicular pain improved in 34 (89%) of 38 patients who were treated primarily for pain. Tumor control was demonstrated in seven of eight patients treated primarily for radiographically documented tumor progression. In time six patients required open surgical intervention for tumor progression that had caused neurological dysfunction after radiosurgery. CONCLUSIONS: Spinal radiosurgery can be a successful therapeutic modality for the delivery of large-dose single-fraction radiation to RCC spinal metastases that are often poorly controlled with conventional EBRT modalities.

Aged↗
PubMed2005

Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures.

OBJECT: Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and irradiation for the underlying malignant process. The authors evaluated a treatment paradigm of closed fracture reduction and fixation involving kyphoplasty and subsequent spinal radiosurgery. METHODS: Twenty-six patients (six men and 20 women, mean age 72 years) with pathological compression fractures (16 thoracic and 10 lumbar) were prospectively evaluated. Histological diagnoses included 11 lung, nine breast, four renal, one cholangiocarcioma, and one ocular melanoma. Seven lesions had received prior external-beam radiation therapy. All patients underwent kyphoplasty that involved the percutaneous transpedicular technique. Fiducial markers allowing for image guidance during CyberKnife treatment were placed, at time of the kyphoplasty, in the pedicles at adjacent levels. Patients underwent single-fraction radiosurgery (mean time after kyphoplasty 12 days) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy (mean 18 Gy) to the 80% isodose line. The treated tumor volume ranged from 12.7 to 37.1 cm3. No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (range 11-24 months, median 16 months). Axial pain improved in 24 (92%) of 26 patients. CONCLUSIONS: The combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be clinically effective in patients with pathological fractures; there was no significant spinal canal compromise. In this technique two minimally invasive surgical procedures are combined to avoid the morbidity associated with open surgery while providing both immediate fracture fixation and administering a single-fraction tumoricidal radiation dose.

Aged↗
PubMed2004

Cyberknife radiosurgery for metastatic spine tumors.

Metastatic spine tumors affect a large number of patients each year, resulting in significant pain,destruction of the spinal column causing mechanical instability, and neurologic deficits. Standard therapeutic options include surgery and fractionated external beam radiotherapy. The first option can be associated with significant morbidity and limited local tumor control. Conversely, radiotherapy may provide less than optimal pain relief and tumor control, because the total dose is limited by the tolerance of adjacent tissues, such as the spinal cord. The emerging technique of spinal radiosurgery represents a logical extension of the current state-of-the-art radiation therapy. It has the potential to significantly improve local control of cancer of the spine, which could translate into more effective palliation and potentially longer survival. Spinal radiosurgery might offer improved pain control and a longer duration of pain control by giving larger radiobiologic doses.This technique also allows for the treatment of lesions previously irradiated using external beam radiation. Another advantage to the patient is that irradiation can be completed in a single day rather than several weeks, which is not inconsequential for patients with a limited life expectancy. In addition, cancer patients may have difficulty with access to a radiation treatment facility for prolonged daily fractionated therapy. This technique allows for the treatment of lesions previously irradiated using external beam radiation.Finally, the procedure is minimally invasive compared with open surgical techniques and can be performed in an outpatient setting. Similar to intracranial radiosurgery, stereo-tactic radiosurgery now has a feasible and safe delivery system available for the treatment of spinal metastatic lesions. The major potential benefit of radiosurgical ablation of spinal lesions is a relatively short treatment time in an outpatient setting combined with potentially better local control of the tumor with minimal risk of side effects. CyberKnife spinal radiosurgery offers a new and important alternative therapeutic modality for the treatment of spinal metastases in medically inoperable patients, previously irradiated sites, and for lesions not amenable to open surgical techniques or as an adjunct to surgery. Spinal radiosurgery is likely to become an essential part of any neurosurgical spine center that treats a large number of patients with spinal metastases.

Humans↗
PubMed2004

Rotational and transpositional flaps for the treatment of spinal wound dehiscence and infections in patient populations with degenerative and oncological disease.

OBJECT: Wound-related complications following complex posterior spine procedures may result in the need for serial debridements and may place the instrumentation at risk. Numerous treatments have been advocated for this problem, but each has limitations. In this article the authors discuss the experience from two large teaching institutions at which rotational and transpositional flaps were used in the management of deep wound infections and dehiscences. METHODS: The authors generated a list of patients treated via posterior or posterolateral approaches for metastatic tumors or complex degenerative disorders in whom wound complications subsequently developed. Data were obtained from the medical records and reviewed retrospectively. Thirty-seven patients were treated with rotational or transpositional flaps at the two institutions during the study period. Patients underwent a mean of 1.3 procedures for the treatment of wound healing problems, and cultures were positive in 70%. In three patients (8%) this treatment failed due to protrusion of hardware through the skin or repeated dehiscence requiring reclosure. Spinal instrumentation was salvaged in 97% of the cases. CONCLUSIONS: The use of local tissue flaps is advantageous for treatment of posterior wound complications due to spine surgery. In this procedure highly vascularized tissue is used to increase healing, accelerate clearance of bacteria, and fill any dead space.

Adolescent↗
PubMed2004

CyberKnife frameless stereotactic radiosurgery for spinal lesions: clinical experience in 125 cases.

OBJECTIVE: The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. Its use for the treatment of spinal lesions has been limited by the availability of effective target-immobilizing devices. Conventional external beam radiotherapy lacks the precision to allow delivery of large doses of radiation near radiosensitive structures such as the spinal cord. The CyberKnife (Accuray, Inc., Sunnyvale, CA) is an image-guided frameless stereotactic radiosurgery system that allows for the radiosurgical treatment of spinal lesions. This study evaluated the feasibility and effectiveness of the treatment of spinal lesions with a single-fraction radiosurgical technique using the CyberKnife. METHODS: The CyberKnife system uses the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator with six degrees of freedom that guides the therapy beam to the intended target without the use of frame-based fixation. Real-time imaging allows the tracking of patient movement. Cervical spine lesions were located and tracked relative to cranial bony landmarks; lower spinal lesions were tracked relative to fiducial bone markers. In this prospective cohort evaluation of a spine radiosurgery technique, 125 spinal lesions in 115 consecutive patients were treated with a single-fraction radiosurgery technique (45 cervical, 30 thoracic, 36 lumbar, and 14 sacral). There were 17 benign tumors and 108 metastatic lesions. All dose plans were calculated on the basis of computed tomographic images acquired from 1.25-mm slices with an inverse treatment planning technique. Radiosurgical circular cones ranging in diameter from 5 to 40 mm were used. RESULTS: Tumor volume ranged from 0.3 to 232 cm(3) (mean, 27.8 cm(3)). Seventy-eight lesions had received external beam irradiation previously. Tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean, 14 Gy); canal volume receiving more than 8 Gy ranged from 0.0 to 1.7 cm(3) (mean, 0.2 cm(3)). No acute radiation toxicity or new neurological deficits occurred during the follow-up period (range, 9-30 mo; median, 18 mo). Axial and radicular pain improved in 74 of 79 patients who were symptomatic before treatment. CONCLUSION: This is the first large prospective evaluation of this frameless image-guided spinal radiosurgery system. The CyberKnife system was found to be feasible, safe, and effective. The major potential benefits of radiosurgical ablation of spinal lesions are short treatment time in an outpatient setting with rapid recovery and symptomatic response. This technique offers a successful therapeutic modality for the treatment of a variety of spinal lesions as a primary treatment or for lesions not amenable to open surgical techniques, in medically inoperable patients, in lesions located in previously irradiated sites, or as an adjunct to surgery.

Adult↗
PubMed2003

Evidence-based review of the surgical management of vertebral column metastatic disease.

OBJECT: Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease. METHODS: A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods. CONCLUSIONS: Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.

Combined Modality Therapy↗
PubMed2003

CyberKnife frameless single-fraction stereotactic radiosurgery for tumors of the sacrum.

OBJECT: The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. The experience with radiosurgery for the treatment of spinal and sacral lesions is more limited. Sacral lesions should be amenable to radiosurgical treatment similar to that used for their intracranial counterparts. The authors evaluated a single- fraction radiosurgical technique performed using the CyberKnife Real-Time Image-Guided Radiosurgery System for the treatment of the sacral lesion. METHODS: The CyberKnife is a frameless radiosurgery system based on the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the intended target without the need for frame-based fixation. All sacral lesions were located and tracked for radiation delivery relative to fiducial bone markers placed percutaneously. Eighteen patients were treated with single-fraction radiosurgery. Tumor histology included one benign and 17 malignant tumors. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographically documented tumor volume with no margin. Tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 15 Gy). Tumor volume ranged from 23.6 to 187.4 ml (mean 90 ml). The volume of the cauda equina receiving greater than 8 Gy ranged from 0 to 1 ml (mean 0.1 ml). All patients underwent the procedure in an outpatient setting. No acute radiation toxicity or new neurological deficits occurred during the mean follow-up period of 6 months. Pain improved in all 13 patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging. CONCLUSIONS: Stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of both benign and malignant sacral lesions. The major potential benefits of radiosurgical ablation of sacral lesions are relatively short treatment time in an outpatient setting and minimal or no side effects. This new technique offers a new and important therapeutic modality for the primary treatment of a variety of sacral tumors or for lesions not amenable to open surgical techniques.

Adult↗