Stereotactic body radiation therapy for management of spinal metastases in patients without spinal cord compression: a phase 1-2 trial.

BACKGROUND: Spinal stereotactic body radiation therapy (SBRT) is increasingly used to manage spinal metastases, yet the technique's effectiveness in controlling the symptom burden of spinal metastases has not been well described. We investigated the clinical benefit of SBRT for managing spinal metastases and reducing cancer-related symptoms. METHODS: 149 patients with mechanically stable, non-cord-compressing spinal metastases (166 lesions) were given SBRT in a phase 1-2 study. Patients received a total dose of 27-30 Gy, typically in three fractions. Symptoms were measured before SBRT and at several time points up to 6 months after treatment, by the Brief Pain Inventory (BPI) and the M D Anderson Symptom Inventory (MDASI). The primary endpoint was frequency and duration of complete pain relief. The study is completed and is registered with ClinicalTrials.gov, number NCT00508443. FINDINGS: Median follow-up was 15·9 months (IQR 9·5-30·3). The number of patients reporting no pain from bone metastases, as measured by the BPI, increased from 39 of 149 (26%) before SBRT to 55 of 102 (54%) 6 months after SBRT (p<0·0001). BPI-reported pain reduction from baseline to 4 weeks after SBRT was clinically meaningful (mean 3·4 [SD 2·9] on the BPI pain-at-its-worst item at baseline, 2·1 [2·4] at 4 weeks; effect size 0·47, p=0·00076). These improvements were accompanied by significant reduction in opioid use during the first 6 months after SBRT (43 [28·9%] of 149 patients with strong opioid use at baseline vs 20 [20·0%] of 100 at 6 months; p=0·011). Ordinal regression modelling showed that patients reported significant pain reduction according to the MDASI during the first 6 months after SBRT (p=0·00003), and significant reductions in a composite score of the six MDASI symptom interference with daily life items (p=0·0066). Only a few instances of non-neurological grade 3 toxicities occurred: nausea (one event), vomiting (one), diarrhoea (one), fatigue (one), dysphagia (one), neck pain (one), and diaphoresis (one); pain associated with severe tongue oedema and trismus occurred twice; and non-cardiac chest pain was reported three times. No grade 4 toxicities occurred. Progression-free survival after SBRT was 80·5% (95% CI 72·9-86·1) at 1 year and 72·4% (63·1-79·7) at 2 years. INTERPRETATION: SBRT is an effective primary or salvage treatment for mechanically stable spinal metastasis. Significant reductions in patient-reported pain and other symptoms were evident 6 months after SBRT, along with satisfactory progression-free survival and no late spinal cord toxicities. FUNDING: National Cancer Institute of the US National Institutes of Health.

Decreasing radiation therapy utilization in adult patients with glioblastoma multiforme: a population-based analysis.

BACKGROUND: The purpose of this study was to assess what factors influence radiation therapy (RT) utilization in patients with glioblastoma and to ascertain how patterns of care have changed over time. METHODS: A total of 9103 patients with supratentorial glioblastoma in the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2006 were analyzed. Demographic information was obtained, including age, sex, race, year of diagnosis, and marital status. Treatment characteristics included receipt of RT and surgical resection. RESULTS: In total, 76.8% of patients received RT, whereas 78% received resection. Patients of male sex, who were currently married, who were <65 years old, and who underwent resection were more likely to receive RT. The average annual percentage change in RT utilization in the years 1990-2006 was -0.41% (95% confidence interval [CI], -0.23 to -0.58), whereas for resection it was 0.26% (95% CI, 0.03 to 0.50). This equates to a 6.5% decrease in RT utilization and a 4.2% increase in resection during this time period. Patients treated with RT had a 2-year overall survival of 11.4%, compared with 5.2% in those not treated with RT (P < .00001). Multivariate analysis showed that younger age (continuous; odds ratio [OR], 0.97; P < .0001), marital status (OR, 1.62; P < .0001), surgical resection (OR, 1.72; P < .0001), and year of diagnosis 1998-2006 compared with 1990-1997 (OR, 0.82; P < .0001) were associated with RT utilization, whereas sex, lesion size, and race were not. CONCLUSIONS: SEER data show a decreasing utilization of RT in patients with glioblastoma from 1990 to 2006. Patients who were older, who were unmarried, and who underwent biopsy only were less likely to receive RT.

Ventricular catheter placement with a frameless neuronavigational system: a 1-year experience.

OBJECTIVE: Accurate placement of ventricular catheters decreases the incidence of proximal catheter failure. The use of a frameless, interactive neuronavigational system can optimize catheter placement. METHODS: Thirty-four ventricular catheters were placed using a Medtronic electromagnetic frameless neuronavigational system (Medtronic Navigation, Inc., Louisville, CO) during a 12-month period. The patients ranged in age from 11 months to 79 years; the mean age was 40.8 years. Nineteen male and 12 female patients participated in the study. The indications for ventricular catheter placement included obstructive hydrocephalus, normal pressure hydrocephalus, pseudotumor cerebri, intrathecal therapy, and tumor cyst aspiration. RESULTS: No proximal failures have been reported to date. One infection necessitated shunt removal. Three postoperative deaths occurred because of non-catheter-related events. CONCLUSION: Frameless neuronavigation in the placement of ventricular catheters assures accurate catheter placement, thereby decreasing the incidence of proximal catheter failure. The absence of rigid head fixation allows additional cohorts to benefit from the apparatus. The use of the electromagnetic system provides a safe, simple, and easy adjunct to optimal catheter placement.