Association of Chemoradiotherapy With Thoracic Vertebral Fractures in Patients With Esophageal Cancer.

Importance: The association of chemoradiotherapy (CRT) with a thoracic vertebral fracture in patients with esophageal cancer is unknown. Objective: To determine whether CRT is associated with thoracic vertebral fractures in patients with esophageal cancer. Design, Setting, and Participants: This retrospective cohort study included patients with clinical stages I to III thoracic esophageal cancer who visited the Kyoto University Hospital, Kyoto, Japan, from January 1, 2007, to December 31, 2013. Data were analyzed from April 6, 2018, to June 4, 2020. Exposures: Chemoradiotherapy (CRT group) or surgery or endoscopic treatment (non-CRT group). Main Outcomes and Measures: The main outcome of this study was the cumulative incidence rate of thoracic vertebral fractures in 36 months. The incidence rate was calculated taking censoring into account. Possible risk factors, including CRT, were explored in the multivariable analysis. The association of irradiated doses with fractured vertebrae was also evaluated. Results: A total of 315 patients (119 for the CRT group and 196 for the non-CRT group) were included. The median age of patients was 65 (range, 32-85) years. Fifty-six patients (17.8%) were female and 259 (82.2%) were male. The median observation time was 40.4 (range, 0.7-124.1) months. Thoracic vertebral fractures were observed in 20 patients (16.8%) in the CRT group and 8 patients (4.1%) in the non-CRT group. The 36-month incidence rate of thoracic vertebral fractures was 12.3% (95% CI, 7.0%-19.1%) in the CRT group and 3.5% (95% CI, 1.3%-7.5%) in the non-CRT group (hazard ratio [HR], 3.41 [95% CI, 1.50-7.73]; P = .003). The multivariable analysis showed that the HR of the thoracic vertebral fracture in the CRT group to non-CRT group was 3.91 (95% CI, 1.66-9.23; P = .002) with adjusting for sex, 3.14 (95% CI, 1.37-7.19; P = .007) with adjusting for age, and 3.10 (95% CI, 1.33-7.24; P = .009) with adjusting for the history of vertebral or hip fractures. The HR of the thoracic vertebral fracture for a 5-Gy increase in the mean radiation dose to the single vertebra was 1.19 (95% CI, 1.04-1.36; P = .009). Conclusions and Relevance: This study found that chemoradiotherapy was associated with thoracic vertebral fractures in patients with esophageal cancers. A reduced radiation dose to thoracic vertebrae may decrease the incidence of fractures.

Analysis of local setup errors of sub-regions in cone-beam CT-guided post-mastectomy radiation therapy.

The purpose of the study was to quantify local setup errors and evaluate the planning target volume (PTV) margins for sub-regions in cone-beam computed tomography (CBCT)-guided post-mastectomy radiation therapy (PMRT). The local setup errors of 20 patients undergoing CBCT-guided PMRT were analysed retrospectively. Image registration between CBCT and planning CT was performed using four sub-regions of interest (ROIs): the supraclavicular area (SROI), ipsilateral chest wall region (CROI), ipsilateral chest wall plus supraclavicular region (SROI + CROI) and vertebral region (TROI). Bland-Altman analysis, correlation, local setup errors and PTV margins among these ROIs were evaluated. There was no significant consistency or correlation for registration results between the TROI and the CROI or SROI regions on any translational axis. When using the SROI + CROI as the ROI, the systematic error (Σ) and random error (σ) of the local setup errors for the CROI region were 1.81, 1.19 and 1.76 mm and 1.84, 2.64 and 3.00 mm along the medial-lateral (ML), superior-inferior (SI) and anterior-posterior (AP) directions, respectively. The PTV margins for the CROI region were 5.80, 4.82 and 6.50 mm. The Σ and σ of the local setup errors for the SROI region were 1.29, 1.15 and 0.77 mm and 1.96, 2.65 and 2.2 mm, respectively, and the PTV margins were 4.59, 4.73 and 3.47 mm. Large setup errors and local setup errors occur in PMRT. The vertebral body should not be a position surrogate for the supraclavicular region or chest wall. To compensate for the local setup errors, different PTV margins are required, even with CBCT guidance.

Difficulties in Treating Postirradiation Kyphosis in Adults: A Series of Five Cases.

STUDY DESIGN: Clinical case series. OBJECTIVE: To assess objective outcomes of surgical correction of post-external beam radiation therapy (ERBT) kyphosis in a series of five adults. SUMMARY OF BACKGROUND DATA: EBRT is a well-established treatment for many cancers in children and adults. One complication associated with EBRT is postirradiation spine deformity. Scoliosis is the most common deformity, but kyphosis also occurs frequently. Differences in deformity patterns are likely related to the location and intensity of radiation. To our knowledge, no studies have addressed treatment of these deformities in adults, and the most recent case series (of children) was published in 2005. METHODS: We present a series of five adults who underwent surgery for postirradiation kyphosis, with a mean follow-up of 3.8 years (range, 2.5-6.2 years). RESULTS: Surgery improved the kyphotic deformity in all patients. Overall mean kyphotic deformity correction was 56° and was larger for cervical/cervicothoracic deformities (mean, 76°) than for lumbar deformities (mean, 42°) at midterm follow-up. Patients reported significant improvements in pain and self-image. Consistent with prior case series of children, we observed a high rate of complications (mean, 1.4 complications per patient) in adults. Three patients each underwent an unplanned surgical procedure because of a complication. CONCLUSION: The surgical treatment of postirradiation kyphotic spinal deformity is challenging, with common postoperative complications such as infection, instrumentation failure, and pseudarthrosis. However, with modern surgical techniques and spinal instrumentation, excellent deformity correction can be achieved and maintained. We recommend performing a two-stage procedure for cervicothoracic deformity, with anterior release followed by posterior fusion and instrumentation. In thoracolumbar deformities, correction can be achieved through single-stage posterior fusion. Rigid spinopelvic fixation with sacral-alar-iliac screws and second-stage anterior lumbar interbody fusion at L5-S1 is recommended to reduce nonunion risk. Cement augmentation of proximal and distal anchors can help prevent junctional failure. LEVEL OF EVIDENCE: Level IV.

PATIENT DOSES IN COMMON DIAGNOSTIC X-RAY EXAMINATIONS.

A local survey was conducted, to evaluate the radiation dose to adult patients who underwent diagnostic X-ray examinations. Patient-related and technical data were recorded, in 1504 patients, for each of the 11 individual projections, of the 7 most common examinations performed in an X-ray room, with 1 digital radiography system. The patient entrance surface air kerma (ESAK) and the effective dose (ED) were calculated based on the X-ray tube output and the exposure parameters, as well as utilisation of suitable conversion coefficients, respectively. The 75th percentiles of the distribution of the ESAK and kerma area product (KAP) values were also established. The mean, median and 75th percentiles were compared with the national reference levels and the most common values reported at the European level through the DOSE DATAMED II project. The corresponding ED values were also compared with the average values reported for all European countries. The mean ESAK, KAP and ED values along with the uncertainty U values for chest PA, chest LAT, cranium AP, cranium LAT, cervical spine AP, cervical spine LAT, lumbar spine AP, lumbar spine LAT, pelvis AP, abdomen AP, kidneys and urinary bladder (KUB) AP were 0.12 (0.001) mGy, 0.66 (0.023) mGy, 1.01 (0.034) mGy, 0.69 (0.098) mGy, 0.72 (0.014) mGy, 0.63 (0.011) mGy, 4.12 (0.050) mGy, 5.74 (0.082) mGy, 2.57 (0.024) mGy, 1.94 (0.017) mGy, 2.47 (0.073) mGy, and 0.09 (0.001) Gy cm2, 0.38 (0.012) Gy cm2, 0.32 (0.009) Gy cm2, 0.27 (0.052) Gy cm2, 0.17 (0.004) Gy cm2, 0.21 (0.006) Gy cm2, 1.18 (0.018) Gy cm2, 1.86 (0.023) Gy cm2, 1.41 (0.012) Gy cm2, 1.27 (0.010) Gy cm2, 1.28 (0.038) Gy cm2, as well as 0.01 (0.0001) mSv, 0.05 (0.0016) mSv, 0.02 (0.0006) mSv, 0.01 (0.0012) mSv, 0.03 (0.0008) mSv, 0.03 (0.0006) mSv, 0.26 (0.0038) mSv, 0.17 (0.0022) mSv, 0.20 (0.0016) mSv, 0.23 (0.0018) mSv, 0.23 (0.0068) mSv, respectively. The 75th percentiles along with the uncertainty U values for chest PA, chest LAT, cranium AP, cranium LAT, cervical spine AP, cervical spine LAT, lumbar spine AP, lumbar spine LAT, pelvis AP, abdomen AP, kidneys and urinary bladder (KUB) AP were 0.14 (0.006) mGy, 0.88 (0.031) mGy, 1.22 (0.049) mGy, 0.94 (0.098) mGy, 0.93 (0.027) mGy, 0.78 (0.013) mGy, 5.16 (0.073) mGy, 7.24 (0.134) mGy, 2.96 (0.047) mGy, 2.59 (0.036) mGy, 3.07 (0.116) mGy, as well as 0.10 (0.0006) Gy cm2, 0.51 (0.017) Gy cm2, 0.37 (0.020) Gy cm2, 0.33 (0.040) Gy cm2, 0.23 (0.007) Gy cm2, 0.26 (0.011) Gy cm2, 1.50 (0.036) Gy cm2, 2.26 (0.035) Gy cm2, 1.61 (0.023) Gy cm2, 1.67 (0.017) Gy cm2, 1.56 (0.069) Gy cm2, in terms of ESAK and KAP values, respectively. The results were significantly lower compared with the national reference levels, the most common DRL values reported at the European level and other previously reported dose values. Patient dose surveys could contribute towards optimising radiation protection for patients, therefore, highlighting the necessity to increase the awareness and knowledge of the radiation dose in conjunction with the required image quality.

Cortical Thinning and Structural Bone Changes in Non-Human Primates after Single-Fraction Whole-Chest Irradiation.

Stereotactic body radiation therapy (SBRT) is associated with an increased risk of vertebral compression fracture. While bone is typically considered radiation resistant, fractures frequently occur within the first year of SBRT. The goal of this work was to determine if rapid deterioration of bone occurs in vertebrae after irradiation. Sixteen male rhesus macaque non-human primates (NHPs) were analyzed after whole-chest irradiation to a midplane dose of 10 Gy. Ages at the time of exposure varied from 45-134 months. Computed tomography (CT) scans were taken 2 months prior to irradiation and 2, 4, 6 and 8 months postirradiation for all animals. Bone mineral density (BMD) and cortical thickness were calculated longitudinally for thoracic (T) 9, lumbar (L) 2 and L4 vertebral bodies; gross morphology and histopathology were assessed per vertebra. Greater mortality (related to pulmonary toxicity) was noted in NHPs <50 months at time of exposure versus NHPs >50 months ( P = 0.03). Animals older than 50 months at time of exposure lost cortical thickness in T9 by 2 months postirradiation ( P = 0.0009), which persisted to 8 months. In contrast, no loss of cortical thickness was observed in vertebrae out-of-field (L2 and L4). Loss of BMD was observed by 4 months postirradiation for T9, and 6 months postirradiation for L2 and L4 ( P < 0.01). For NHPs younger than 50 months at time of exposure, both cortical thickness and BMD decreased in T9, L2 and L4 by 2 months postirradiation ( P < 0.05). Regions that exhibited the greatest degree of cortical thinning as determined from CT scans also exhibited increased porosity histologically. Rapid loss of cortical thickness was observed after high-dose chest irradiation in NHPs. Younger age at time of exposure was associated with increased pneumonitis-related mortality, as well as greater loss of both BMD and cortical thickness at both in- and out-of-field vertebrae. Older NHPs exhibited rapid loss of BMD and cortical thickness from in-field vertebrae, but only loss of BMD in out-of-field vertebrae. Bone is sensitive to high-dose radiation, and rapid loss of bone structure and density increases the risk of fractures.

Intraoperative radiation exposure in spinal scoliosis surgery for pediatric patients using the O-arm® imaging system.

PURPOSE: The O-arm® navigation system allows intraoperative CT imaging that can facilitate highly accurate instrumentation surgery, but radiation exposure is higher than with X-ray radiography. This is a particular concern in pediatric surgery. The purpose of this study is to examine intraoperative radiation exposure in pediatric spinal scoliosis surgery using O-arm. METHODS: The subjects were 38 consecutive patients (mean age 12.9 years, range 10-17) with scoliosis who underwent spinal surgery with posterior instrumentation using O-arm. The mean number of fused vertebral levels was 11.0 (6-15). O-arm was performed before and after screw insertion, using an original protocol for the cervical, thoracic, and lumbar spine doses. RESULTS: The average scanning range was 6.9 (5-9) intervertebral levels per scan, with 2-7 scans per patient (mean 4.0 scans). Using O-arm, the dose per scan was 92.5 (44-130) mGy, and the mean total dose was 401 (170-826) mGy. This dose was 80.2% of the mean preoperative CT dose of 460 (231-736) mGy (P = 0.11). The total exposure dose and number of scans using intraoperative O-arm correlated strongly and significantly with the number of fused levels; however, there was no correlation with the patient's height. CONCLUSIONS: As the fused range became wider, several scans were required for O-arm, and the total radiation exposure became roughly the same as that in preoperative CT. Use of O-arm in our original protocol can contribute to reduction in radiation exposure.

Radiation Dose to the Thoracic Vertebral Bodies Is Associated With Acute Hematologic Toxicities in Patients Receiving Concurrent Chemoradiation for Lung Cancer: Results of a Single-Center Retrospective Analysis.

PURPOSE: To test the hypothesis that increasing radiation therapy (RT) dose to the thoracic vertebral bodies (TVBs) contributes to the development of hematologic toxicities (HTs) in patients with lung cancer. METHODS AND MATERIALS: Cases of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) treated with definitive chemoradiation with concurrent platinum-based doublet chemotherapy at our institution from 2007 to 2016 were identified. Mean TVB dose and the volume of TVBs receiving at least 5 to 60 Gy (V5-V60) were retrospectively recorded. Logistic regression was used to test associations between grade ≥3 HT (HT3+) and dosimetric/clinical parameters. Normal tissue complication probability was evaluated using the Lyman-Kutcher-Burman (LKB) model for HT3+, and receiver operating characteristics analysis was used to determine dosimetric cut-points. RESULTS: We identified 201 patients, the majority having NSCLC (n=162, 81%) and stage III to IV disease (n=179, 89%). All patients received either cisplatin/etoposide (n=107, 53%) or carboplatin/paclitaxel (n=94, 47%). Median RT dose was 60 Gy (range, 60-70 Gy). The rate of HT3+ was 49% (n=99). Increasing mean TVB dose (per Gy) was associated with higher odds of developing HT3+ (odds ratio 1.041, 95% confidence interval 1.004-1.080, P=.032), as were increasing TVB V5 to V20. These dosimetric correlates to HT3+ persisted on multivariate analysis. Constrained optimization of the LKB model for HT3+ yielded the parameters: n=1, m=1.79, and TD50=21.4 Gy. Optimal cut-points identified were V5=65%, V10=60%, V20=50%, and mean dose=23.5 Gy. Patients with values above these cut-points had an approximately 2-fold increased risk of HT3+. CONCLUSIONS: We found that mean TVB dose and low-dose parameters (V5-V20) were associated with HT3+ in chemoradiation for lung cancer. Per the LKB model, bone marrow behaves like a parallel organ (n=1), implying that mean TVB dose is a useful predictor for toxicity. These data suggest that efforts to spare dose to the TVBs may reduce rates of severe HT.

Repeat reirradiation of the spinal cord: multi-national expert treatment recommendations.

BACKGROUND: Improved survival of patients with spinal bone metastases has resulted in an increased number of referrals for retreatment and repeat reirradiation. METHODS: A consortium of expert radiation oncologists (RO) has been established with the aim of providing treatment recommendations for challenging clinical scenarios for which there are no established guidelines. In this case, a patient developed local progression of a T5 vertebral lesion after two prior courses of palliative radiotherapy (time interval >12 months, assumed cumulative biologically equivalent dose in 2­Gy fractions [EQD2] for spinal cord [alpha/beta 2 Gy] 75 Gy). Expert recommendations were tabulated with the aim of providing guidance. RESULTS: Five of seven RO would offer a third course of radiotherapy, preferably with advanced techniques such as stereotactic radiotherapy. However, the dose-fractionation concepts were heterogeneous (3-20 fractions) and sometimes adjusted to different options for systemic treatment. All five RO would compromise target volume coverage to reduce the dose to the spinal cord. Definition of the spinal cord planning-organ-at-risk volume was heterogeneous. All five RO limited the EQD2 for spinal cord. Two were willing to accept more than 12.5 Gy and the highest EQD2 was 19 Gy. CONCLUSIONS: The increasing body of literature about bone metastases and spinal cord reirradiation has encouraged some expert RO to offer palliative reirradiation with cumulative cord doses above 75 Gy EQD2; however, no consensus was achieved. Strategies for harmonization of clinical practice and development of evidence-based dose constraints are discussed.

Potential of Proton Therapy to Reduce Acute Hematologic Toxicity in Concurrent Chemoradiation Therapy for Esophageal Cancer.

PURPOSE: Radiation therapy dose escalation using a simultaneous integrated boost (SIB) is predicted to improve local tumor control in esophageal cancer; however, any increase in acute hematologic toxicity (HT) could limit the predicted improvement in patient outcomes. Proton therapy has been shown to significantly reduce HT in lung cancer patients receiving concurrent chemotherapy. Therefore, we investigated the potential of bone marrow sparing with protons for esophageal tumors. METHODS AND MATERIALS: Twenty-one patients with mid-esophageal cancer who had undergone conformal radiation therapy (3D50) were selected. Two surrogates for bone marrow were created by outlining the thoracic bones (bone) and only the body of the thoracic vertebrae (TV) in Eclipse. The percentage of overlap of the TV with the planning treatment volume was recorded for each patient. Additional plans were created retrospectively, including a volumetric modulated arc therapy (VMAT) plan with the same dose as for 3D50; a VMAT SIB plan with a dose prescription of 62.5 Gy to the high-risk subregion within the planning treatment volume; a reoptimized TV-sparing VMAT plan; and a proton therapy plan with the same SIB dose prescription. The bone and TV dose metrics were recorded and compared across all plans and variations with respect to PTV and percentage of overlap for each patient. RESULTS: The 3D50 plans showed the highest bone mean dose and TV percentage of volume receiving ≥30 Gy (V30Gy) for each patient. The VMAT plans irradiated a larger bone V10Gy than did the 3D50 plans. The reoptimized VMAT62.5 VT plans showed improved sparing of the TV volume, but only the proton plans showed significant sparing for bone V10Gy and bone mean dose, especially for patients with a larger PTV. CONCLUSIONS: The results of the present study have shown that proton therapy can reduced bone marrow toxicity.

Bone mineral density loss in thoracic and lumbar vertebrae following radiation for abdominal cancers.

PURPOSE: To investigate the relationship between abdominal chemoradiation (CRT) for locally advanced cancers and bone mineral density (BMD) reduction in the vertebral spine. MATERIALS AND METHODS: Data from 272 patients who underwent abdominal radiation therapy from January 1997 to May 2015 were retrospectively reviewed. Forty-two patients received computed tomography (CT) scans of the abdomen prior to initiation and at least twice after radiation therapy. Bone attenuation (in Hounsfield unit) (HU) measurements were collected for each vertebral level from T7 to L5 using sagittal CT images. Radiation point dose was obtained at each mid-vertebral body from the radiation treatment plan. Percent change in bone attenuation (Δ%HU) between baseline and post-radiation therapy were computed for each vertebral body. The Δ%HU was compared against radiation dose using Pearson's linear correlation. RESULTS: Abdominal radiotherapy caused significant reduction in vertebral BMD as measured by HU. Patients who received only chemotherapy did not show changes in their BMD in this study. The Δ%HU was significantly correlated with the radiation point dose to the vertebral body (R=-0.472, P<0.001) within 4-8 months following RT. The same relationship persisted in subsequent follow up scans 9 months following RT (R=-0.578, P<0.001). Based on the result of linear regression, 5 Gy, 15 Gy, 25 Gy, 35 Gy, and 45 Gy caused 21.7%, 31.1%, 40.5%, 49.9%, and 59.3% decrease in HU following RT, respectively. Our generalized linear model showed that pre-RT HU had a positive effect (ß=0.830) on determining post-RT HU, while number of months post RT (ß=-0.213) and radiation point dose (ß=-1.475) had a negative effect. A comparison of the predicted versus actual HU showed significant correlation (R=0.883, P<0.001) with the slope of the best linear fit=0.81. Our model's predicted HU were within ±20 HU of the actual value in 53% of cases, 70% of the predictions were within ±30 HU, 81% were within ±40 HU, and 90% were within ±50 HU of the actual post-RT HU. Four of 42 patients were found to have vertebral body compression fractures in the field of radiation. CONCLUSIONS: Patients who receive abdominal chemoradiation develop significant BMD loss in the thoracic and lumbar vertebrae. Treatment-related BMD loss may contribute to the development of vertebral compression fractures. A predictive model for post-CRT BMD changes may inform bone protective strategies in patients planned for abdominal CRT.

Fractures of thoracic vertebrae in patients with locally advanced non-small cell lung carcinoma treated with intensity modulated radiotherapy.

PURPOSE: To report on the incidence of vertebral fractures in patients treated with Intensity Modulated Radiotherapy (IMRT) for locally advanced non-small cell lung carcinoma (NSCLC) and to analyse the association with clinical and dosimetric parameters. PATIENTS AND METHODS: Between 2007 and 2012, 524 patients treated with ⩾51 Gy were retrospectively analysed for the incidence of vertebral fractures (VF). Clinical parameters were assessed. In addition, a case control study in 50 patients was performed to study the association between the radiotherapy dose and fractured vertebrae. RESULTS: Three hundred and thirty-six patients were eligible for analyses. Twenty-eight patients (8%) were observed with VF at a median follow up of 12 months. Age was significantly higher in the group with VF (p<0.01). After balancing age, the mean vertebrae dose was most significantly associated with fractures of the vertebrae (p<0.01). CONCLUSION: VF was observed in 8% of the patients with locally advanced NSCLC. RT dose was associated with the occurrence of thoracic vertebral fractures.

EFFECTIVE DOSE TO PATIENTS FROM THORACIC SPINE EXAMINATIONS WITH TOMOSYNTHESIS.

The purposes of the present work were to calculate the average effective dose to patients from lateral tomosynthesis examinations of the thoracic spine, compare the results with the corresponding conventional examination and to determine a conversion factor between dose-area product (DAP) and effective dose for the tomosynthesis examination. Thoracic spine examinations from 17 patients were included in the study. The registered DAP and information about the field size for each projection radiograph were, together with patient height and mass, used to calculate the effective dose for each projection radiograph. The total effective doses for the tomosynthesis examinations were obtained by adding the effective doses from the 60 projection radiographs included in the examination. The mean effective dose was 0.47 mSv (range 0.24-0.81 mSv) for the tomosynthesis examinations and 0.20 mSv (range 0.07-0.29 mSv) for the corresponding conventional examinations (anteroposterior + left lateral projection). For the tomosynthesis examinations, a conversion factor between total DAP and effective dose of 0.092 mSv Gycm(-2) was obtained.

RETROSPECTIVE ESTIMATION OF PATIENT DOSE-AREA PRODUCT IN THORACIC SPINE TOMOSYNTHESIS PERFORMED USING VOLUMERAD.

The aim of this study was to evaluate the use of a recently developed method of retrospectively estimating the patient dose-area product (DAP) of a chest tomosynthesis examination, performed using VolumeRAD, in thoracic spine tomosynthesis and to determine the necessary field-size correction factor. Digital imaging and communications in medicine (DICOM) data for the projection radiographs acquired during a thoracic spine tomosynthesis examination were retrieved directly from the modality for 17 patients. Using the previously developed method, an estimated DAP for the tomosynthesis examination was determined from DICOM data in the scout image. By comparing the estimated DAP with the actual DAP registered for the projection radiographs, a field-size correction factor was determined. The field-size correction factor for thoracic spine tomosynthesis was determined to 0.92. Applying this factor to the DAP estimated retrospectively, the maximum difference between the estimated DAP and the actual DAP was <3 %. In conclusion, the previously developed method of retrospectively estimating the DAP in chest tomosynthesis can be applied to thoracic spine tomosynthesis.

Thoracic Vertebral Body Irradiation Contributes to Acute Hematologic Toxicity During Chemoradiation Therapy for Non-Small Cell Lung Cancer.

PURPOSE: To determine the relationships between radiation doses to the thoracic bone marrow and declines in blood cell counts in non-small cell lung cancer (NSCLC) patients treated with chemoradiation therapy (CRT). METHODS AND MATERIALS: We included 52 patients with NSCLC treated with definitive concurrent carboplatin-paclitaxel and RT. Dose-volume histogram (DVH) parameters for the thoracic vertebrae (TV), sternum, scapulae, clavicles, and ribs were assessed for associations with changes in blood counts during the course of CRT. Linear and logistic regression analyses were performed to identify associations between hematologic nadirs and DVH parameters. A DVH parameter of Vx was the percentage of the total organ volume exceeding x radiation dose. RESULTS: Grade ≥ 3 hematologic toxicity including neutropenia developed in 21% (n=11), leukopenia in 42% (n=22), anemia in 6% (n=3), and throbocytopenia in 2% (n=1) of patients. Greater RT dose to the TV was associated with higher risk of grade ≥ 3 leukopenia across multiple DVH parameters, including TV V20 (TVV) (odds ratio [OR] 1.06; P=.025), TVV30 (OR 1.07; P=.013), and mean vertebral dose (MVD) (OR 1.13; P=.026). On multiple regression analysis, TVV30 (ß = -0.004; P=.018) and TVV20 (ß = -0.003; P=.048) were associated with white blood cell nadir. Additional bone marrow sites (scapulae, clavicles, and ribs) did not affect hematologic toxicity. A 20% chance of grade ≥ 3 leukopenia was associated with a MVD of 13.5 Gy and a TTV30 of 28%. Cutoff values to avoid grade ≥ 3 leukopenia were MVD ≤ 23.9 Gy, TVV20 ≤ 56.0%, and TVV30 ≤ 52.1%. CONCLUSIONS: Hematologic toxicity is associated with greater RT doses to the TV during CRT for NSCLC. Sparing of the TV using advanced radiation techniques may improve tolerance of CRT and result in improved tolerance of concurrent chemotherapy.

Radiation-induced camptocormia and dropped head syndrome: Review and case report of radiation-induced movement disorders.

BACKGROUND: In recent years, camptocormia and dropped head syndrome (DHS) have gained attention as particular forms of movement disorders. Camptocormia presents with involuntary forward flexion of the thoracolumbar spine that typically increases during walking or standing and may severely impede walking ability. DHS is characterized by weakness of the neck extensors and a consecutive inability to extend the neck; in severe cases the head is fixed in a "chin to chest position." Many diseases may underlie these conditions, and there have been some reports about radiation-induced camptocormia and DHS. METHODS: A PubMed search with the keywords "camptocormia," "dropped head syndrome," "radiation-induced myopathy," "radiation-induced neuropathy," and "radiation-induced movement disorder" was carried out to better characterize radiation-induced movement disorders and the radiation techniques involved. In addition, the case of a patient developing camptocormia 23 years after radiation therapy of a non-Hodgkin's lymphoma of the abdomen is described. RESULTS: In total, nine case series of radiation-induced DHS (n = 45 patients) and-including our case-three case reports (n = 3 patients) about radiogenic camptocormia were retrieved. Most cases (40/45 patients) occurred less than 15 years after radiotherapy involving extended fields for Hodgkin's disease. CONCLUSION: The use of wide radiation fields including many spinal segments with paraspinal muscles may lead to radiation-induced movement disorders. If paraspinal muscles and the thoracolumbar spine are involved, the clinical presentation can be that of camptocormia. DHS may result if there is involvement of the cervical spine. To prevent these disorders, sparing of the spine and paraspinal muscles is desirable.

Clinical curative effect of percutaneous vertebroplasty combined with 125I-seed implantation in treating spinal metastatic tumor.

This paper selected and studied 15 in-hospital patients to analyze and discuss the clinical curative effect of percutaneous vertebroplasty (PVP) combined with (125)I-seed implantation in treating spinal metastatic tumor. The evaluation of clinical curative effects was based on the observation of several factors, namely recovery conditions of vertebral body's leading edge and middle section before and after surgery, improvements of kyphosis Cobb angle, visual analog scale (VAS), and Barthel Index (BI). The paper found significant difference between preoperative VAS and postoperative VAS, and the same situation occurred to BI. However, compared to the loss rate of vertebral body's leading edge and middle section and the improvement of Cobb angle before operative, postoperative loss rate and Cobb angle did not show statistical difference. Thus the conclusion is that PVP combined with (125)I-seed implantation is a minimally invasive surgery for effectively treating spinal metastatic tumor, which does well in rapidly releasing pains, improving patients' daily life activities and life qualities.

Radiation myelitis after hypofractionated radiotherapy with concomitant gefitinib.

We describe the case of a 71-year-old Caucasian female with primary disseminated non-small cell cancer of the lung, presented for palliative radiotherapy of metastatic spread to the 9th and 11th thoracic vertebrae without intramedullary growth. Palliative radiotherapy with daily fractions of 3 Gy and a cumulative dose of 36 Gy to thoracic vertebrae 8-12 was performed. The patient received concomitantly 250 mg gefitinib daily. After a latent period of 16 months, the patient developed symptoms of myelitis. Magnetic resonance imaging (MRI) did not reveal any bony or intraspinal tumor progression, but spinal cord signal alteration. No response to steroids was achieved. The neurological symptoms were progressive in August 2013 with the right leg being completely plegic. The left leg was incompletely paralyzed. Deep and superficial sensitivity was also diminished bilaterally. The patient was completely urinary and anally incontinent. Contrary to the clinical findings, a follow-up MRI (July 2013) showed amelioration of the former signal alterations in the spinal cord. The diagnosis of paraneoplastic myelopathy was refuted by a negative test for autologous antibodies. At the last clinical visit in May 2014, the neurological symptoms were stable. The last tumor-specific treatment the patient is receiving is erlotinib 125 mg/d.We reviewed the literature and found no reported cases of radiation myelopathy after the treatment in such a setting. The calculated probability of such complication after radiotherapy alone is statistically measurable at the level of 0.02%. We suppose that gefitinib could also play a role in the development of this rare complication.

Fat composition changes in bone marrow during chemotherapy and radiation therapy.

PURPOSE: To quantify changes in bone marrow fat fraction and determine associations with peripheral blood cell counts. METHODS AND MATERIALS: In this prospective study, 19 patients received either highly myelotoxic treatment (radiation therapy plus cisplatin, 5-fluorouracil mitomycin C [FU/MMC], or cisplatin/5-FU/cetuximab) or less myelotoxic treatment (capecitabine-radiation therapy or no concurrent chemotherapy). Patients underwent MR imaging and venipuncture at baseline, midtreatment, and posttreatment visits. We performed mixed effects modeling of the mean proton density fat fraction (PDFF[%]) by linear time, treatment, and vertebral column region (lumbar [L]4-sacral [S]2 vs thoracic [T]10-L3 vs cervical[C]3-T9), while controlling for cumulative mean dose and other confounders. Spearman rank correlations were performed by white blood cell (WBC) counts versus the differences in PDFF(%) before and after treatment. RESULTS: Cumulative mean dose was associated with a 0.43% per Gy (P=.004) increase in PDFF(%). In the highly myelotoxic group, we observed significant changes in PDFF(%) per visit within L4-S2 (10.1%, P<.001) and within T10-L3 (3.93%, P=.01), relative to the reference C3-T9. In the less myelotoxic group, we did not observe significant changes in PDFF(%) per visit according to region. Within L4-S2, we observed a significant difference between treatment groups in the change in PDFF(%) per visit (5.36%, P=.04). Rank correlations of the inverse log differences in WBC versus the differences in PDFF(%) overall and within T10-S2 ranged from 0.69 to 0.78 (P<.05). Rank correlations of the inverse log differences in absolute neutrophil counts versus the differences in PDFF(%) overall and within L4-S2 ranged from 0.79 to 0.81 (P<.05). CONCLUSIONS: Magnetic resonance imaging fat quantification is sensitive to marrow composition changes that result from chemoradiation therapy. These changes are associated with peripheral blood cell counts. This study supports a rationale for bone marrow-sparing treatment planning to reduce the risk of hematologic toxicity.

Stability of spinal bone metastases in breast cancer after radiotherapy: a retrospective analysis of 157 cases.

PURPOSE: This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system. METHODS: The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated. RESULTS: Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years. CONCLUSION: The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.