OUTCOMES OF INTRAOPERATIVE RADIOTHERAPY (IORT) FOR SPINAL TUMOURS

Authors

  • Sheikh Muhammad Ebad Ali Dr. Ruth K.M. Pfau Civil Hospital Karachi
  • Ahmed Nadeem Abbasi Aga Khan University Hospital, Karachi
  • Naila Zahoor Baqai Medical University

DOI:

https://doi.org/10.55519/JAMC-01-9230

Keywords:

palliation, intraoperative radiotherapy, IORT, spinal tumors, vertebral metastasis

Abstract

Background: The spinal column is a major site of neoplastic proliferation where decisions regarding surgical or radiotherapeutic intervention are based upon spinal instability neoplastic score (SINS). A novel technique named ‘Intraoperative radiotherapy (IORT) was proposed where surgery and radiotherapy were performed in the same session. During our literature search, we found no published systematic review or meta-analysis regarding the outcomes of IORT for spinal tumors. This review aims to provide the knowledge regarding the outcomes of IORT for spinal tumors to assist surgeons and radiologists. Methods: PubMed, Google Scholar, Cochrane library for trials reporting the outcomes of IORTin spinal tumors. The search terms were “outcomes”, “Intraoperative radiotherapy”, “IORT”, “spine neoplasia” and “spine metastasis” in different combinations. Standardized mean difference (SMD) in VAS for pain relief while proportionality for neurological improvement, local progression, and toxicities were plotted on forest plots, respectively. Results: Eight studies comprising 610 patients were included with two conference proceedings. SMD for VAS was -1.715 while proportionality for neurological improvement, local progression, and toxicities were 0.9 (90%), 0.03 (3%), and 0.121 (12.1%), respectively. Conclusion: Pain relief was evident by a decrease in VAS scores in the majority of patients. The majority showed neurological improvement and regained motor and sensory functions while an overwhelming population showed local tumor control with lesser patients developing tumor progression and radiation-induced toxicities. Short follow-ups and the absence of randomized trials advocates the need for further clinical researches to confirm the outcomes of IORT in spinal tumors.

References

Tafti D, Cecava ND. Spinal Hemangioma. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2020.

Unni KK, Inwards CY. Dahlin’s Bone Tumours: General Aspects and Data on 10,165 Cases. Wolters Kluwer Health/Lippincott Williams & Wilkins 2010.

Kurisunkal V, Gulia A, Gupta S. Principles of Management of Spine Metastasis. Indian J Orthop 2020;54(2):181–93.

Guo Y, Ngo-Huang AT, Fu JB. Perspectives on Spinal Precautions in Patients Who Have Cancer and Spinal Metastasis. Phys Ther 2020;100(3):554–63.

Ziu E, Viswanathan VK, Mesfin FB. Cancer, Spinal Metastasis. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC; 2020.

Fiorini F, Lavrador JP, Vergani F, Bhangoo R, Gullan R, Reisz Z, et al. Primary lumbar paraganglioma: clinical, radiological, surgical and histopathological characteristics from a case series of 13 patients. World Neurosurg 2020;142:e66–72.

Tang S, Zuo J, Zhang H, Wu Z, Liang B. The spinal metastatic melanoma with unknown primary lesions presenting as radiculopathy:Case report and literature review. World Neurosurg 2020;140:320–4.

Roser S, Maharaj MM, Taylor MA, Kuru R, Hansen MA, Ferch R. Vertebrectomy in metastatic spinal tumours: A 10 year, single-centre review of outcomes and survival. J Clin Neurosci 2019;68:218–23.

Boussios S, Cooke D, Hayward C, Kanellos FS, Tsiouris AK, Chatziantoniou AA, et al. Metastatic Spinal Cord Compression: Unraveling the Diagnostic and Therapeutic Challenges. Anticancer Res 2018;38(9):4987–97.

Pennington Z, Ahmed AK, Westbroek EM, Cottrill E, Lubelski D, Goodwin ML, et al. SINS Score and Stability: Evaluating the Need for Stabilization Within the Uncertain Category. World Neurosurg 2019;128:e1034–47.

Masuda K, Ebata K, Yasuhara Y, Enomoto A, Saito T. Outcomes and Prognosis of Neurological Decompression and Stabilization for Spinal Metastasis: Is Assessment with the Spinal Instability Neoplastic Score Useful for Predicting Surgical Results? Asian Spine J 2018;12(5):846–53.

Pontes MDS, Pires BPF, Albuquerque FP, Herrero C. Assessment of the posterior approach for surgical treatment of spinal metastatic breast cancer. Acta Ortop Bras 2020;28(1):22–5.

Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 2010;35(22):E1221–9.

Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T. Surgical strategy for spinal metastases. Spine 2001;26(3):298–306.

Tokuhashi Y, Matsuzaki H, Toriyama S, Kawano H, Ohsaka S. Scoring system for the preoperative evaluation of metastatic spine tumour prognosis. Spine 1990;15(11):1110–3.

Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine 2010;13(3):324–8.

Wenz F, Schneider F, Neumaier C, Kraus-Tiefenbacher U, Reis T, Schmidt R, et al. Kypho-IORT--a novel approach of intraoperative radiotherapy during kyphoplasty for vertebral metastases. Radiat Oncol 2010;5:11.

The modified Newcastle Ottawa scale for cross sectional studies. [Internet]. [cited 2021 Feb 2021]. Available from: https://storage.googleapis.com/plos-corpus-prod/10.1371/journal.pone.0136065/1/pone.0136065.s004.pdf?

Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17(1):1–12.

Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969;7(3):179–92.

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7(3):177–88.

Ellis PD. EFFECT SIZE EQUATIONS. [Internet]. 2009. [cited 2021 Feb 2021]. Available from: https://www.polyu.edu.hk/mm/effectsizefaqs/effect_size_equations2.html

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327(7414):557–60.

Bludau F, Welzel G, Reis T, Schneider F, Sperk E, Neumaier C, et al. Phase I/II trial of combined kyphoplasty and intraoperative radiotherapy in spinal metastases. Spine J 2018;18(5):776–81.

Chen K, Huang L, Cai Z, Shi J, You K, Shen H. Micro-invasive surgery combined with intraoperative radiotherapy for the treatment of spinal metastasis. Eur Spine J 2017;26(7):1893–901.

Sugita S, Hozumi T, Yamakawa K, Goto T, Kondo T. Risk factors for surgical site infection after posterior fixation surgery and intraoperative radiotherapy for spinal metastases. Eur Spine J 2016;25(4):1034–8.

Kondo T, Hozumi T, Goto T, Seichi A, Nakamura K. Intraoperative radiotherapy combined with posterior decompression and stabilization for non-ambulant paralytic patients due to spinal metastasis. Spine 2008;33(17):1898–904.

Saito T, Kondo T, Hozumi T, Karasawa K, Seichi A, Nakamura K. Results of posterior surgery with intraoperative radiotherapy for spinal metastases. Eur Spine J 2006;15(2):216–22.

Seichi A, Kondoh T, Hozumi T, Karasawa K. Intraoperative Radiation Therapy for Metastatic Spinal Tumours. Spine (Phila Pa 1976) 1999;24(5):470–3.

Gandhi S, Latefi A, Molina FD, Chen Y, Ghaly M. SURG-28. Kypho-IORT: a new treatment paradigm for pathological fractures. Int J Radiat Oncol Biol Phys 2017;99(2):E520.

Rana ZH, Gogineni E, Mark DJ, Vempati P, Molina FD, Chen Y, et al. Outcomes of a Prospective Trial Utilizing Kypho-IORT. Int J Radiat Oncol Biol Phys 2019;105(1):E590–1.

Oishi T, Nishida M, Takebayashi K, Nasu K, Narahara H. Small-Cell Carcinoma of the Uterine Cervix Discovered With Quadriplegia Caused by Cervical Spine Metastasis. Clin Med Insights Case Rep 2020;13:1179547620920170.

Khawaja SN, Scrivani SJ. Utilization of neurolysis in management of refractory head and neck cancer related pain in palliative patients: A retrospective review. J Oral Pathol Med 2020;49(6):484–9.

Lage DE, El-Jawahri A, Fuh CX, Newcomb RA, Jackson VA, Ryan DP, et al. Functional Impairment, Symptom Burden, and Clinical Outcomes Among Hospitalized Patients With Advanced Cancer. J Natl Compr Canc Netw 2020;18(6):747–54.

Ballatori E. Unsolved problems in evaluating the quality of life of cancer patients. Ann Oncol 2001;12(Suppl 3):S11–3.

Buhmann Kirchhoff S, Becker C, Duerr HR, Reiser M, Baur-Melnyk A. Detection of osseous metastases of the spine: comparison of high resolution multi-detector-CT with MRI. Eur J Radiol 2009;69(3):567–73.

Fribourg D, Tang C, Sra P, Delamarter R, Bae H. Incidence of subsequent vertebral fracture after kyphoplasty. Spine 2004;29(20):2270–7.

Kim SI, Ha KY, Cho YS, Kim KW, Oh IS. Delayed Height Loss After Kyphoplasty in Osteoporotic Vertebral Fracture with Severe Collapse: Comparison with Vertebroplasty. World Neurosurgery 2018;119:e580–8.

Chang CW, Fu TS, Lin DY, Lai PL, Chiu PY, Kao FC, et al. Percutaneous Balloon Kyphoplasty and Short Instrumentation Compared with Traditional Long Instrumentation for Thoracolumbar Metastatic Spinal Cord Compression. World Neurosurgery 2019;130:e640–7.

Laufer I, Bilsky MH. Advances in the treatment of metastatic spine tumours: the future is not what it used to be. J Neurosurgery Spine 2019;30(3):299–307.

Abbouchie H, Chao M, Tacey M, Lim Joon D, Ho H, Guerrieri M, et al. Vertebral fractures following stereotactic body radiotherapy for spine metastases. J Med Imaging Radiat Oncol 2020;64(2):293–302.

Ozdemir Y, Torun N, Guler OC, Yildirim BA, Besen AA, Yetisken AG, et al. Local control and vertebral compression fractures following stereotactic body radiotherapy for spine metastases. J Bone Oncol 2019;15:100218.

Chang JH, Shin JH, Yamada YJ, Mesfin A, Fehlings MG, Rhines LD, et al. Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them? Spine 2016;41(Suppl 20):S238–45.

Downloads

Published

2022-01-01