ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO

ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO

1. R ADIATION O NCOLOGY S IMULATION TO E XECUTION ROSE CASE SPINAL SBRT 16-May-24 1 Dr Kanhu Charan Patro MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC Clinical Director, HOD (Radiation Oncology) ISRo - I nstitute of S tereotactic R adiation o ncology Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam [email protected] /M- [phone]/ www.drkanhupatro.com

2. Case scenario 45-year-old female, who has been treated for Her2+ve carcinoma left breast around 2020. She presented to our OPD with c/o backache. The patient was diagnosed with a sclerotic lesion over L1 vertebra.

3. Treatment objectives GOAL OF TREATMENT CHOICE OF TREATMENT DEPENDS ON Achieving maximum pain control Structural and neurological preservation and restoration Prevention of pathological fracture/ skeletal related events Local control of disease Performance status Biology and extent of disease Life expectncy Quality of life

4. Treatment consideration- NOMS N Neurologic assessment O ncologic assessment M echanical assessment S ystemic assessment

5. Neurological Assessment Bilsky Grading system No epidural disease Epidural impingement, No deformation of thecal sac Epidural impingement., Deformation of thecal sac Epidural spinal ord compression , No visible CSF Epidural spinal cord compression, Visible CSF present Deformation of thecalsac, Abutment of spinal cord

6. Oncological assessment Radiation Sensitivity Tumor Histology Sensitive Myeloma Lymphoma Moderately Sensitive Prostate Breast Moderately Resistant Colon NSCLC Highly Resistant Thyroid Renal Sarcoma Melanoma

7. Mechanical assessment SPINE INSTABILITY NEOPLASTIC SCORE SYSTEM (SINS) Tallied score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 13-18 requires surgical stabilization

8. Systemic assessment All treatment decisions are predicted on the patient’s ability to tolerate the treatment based on Systemic co-morbidities General tumor burden [Extraspinal (visceral and bone) metastatic disease] General Frailty Physiological age/ Performance status

9. Current NOMS decision framework

10. Indication for SBRT

11. MODIFIED WEINSTEIN-BORIANI-BAIGINI SYSTEM Sector 1 : V ertebral body S ector 2 : L eft pedicle S ector 3 : L eft transverse process and lamina S ector 4 : S pinous process S ector 5 : R ight transverse process and lamina S ector 6 : R ight pedicle.

12. Contouring guideline

13. MRI

14. GTV

15. CTV Delineation Should contain GTV and invlude bony CTV expansion to account for subclinical spread. Includes abnormal marrow signal suspicious for microscopic invasion. Circumferential CTVs encircling the cord should be avoided except, If vertebral body,bilateral pedicle/ lamina and spinous process are all involved If extensive metastatic disease along the circumference of epidural space present without spinal cord compression

16. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Any portion of the vertebral body 1 1 Include the entire vertebral body

17. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Lateralized within the vertebral body 1 1,2 Include the entire vertebral body and the ipsilateral pedicle/transverse process

18. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Diffusely involves the vertebral body 1 1,2,6 Include the entire vertebral body and the bilateral pedicles/transverse processes

19. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Vertebral body and unilateral pedicle 1,2 1,2,3 Include entire vertebral body, pedicle, ipsilateral transverse process, and ipsilateral lamina

20. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Vertebral body and bilateral pedicles/transverse processes 6,1,2, ± 3, ± 5 1,2,3,5,6 Include entire vertebral body, bilateral pedicles/transverse processes, and bilateral laminae.

21. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description U nilateral pedicle 2 2,3, ± 1 Include pedicle, ipsilateral transverse process, and ipsilateral lamina ± vertebral body.

22. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description U nilateral lamina 3 2,3,4 Include lamina, ipsilateral pedicle/transverse process, and spinous process .

23. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description S pinous process 4 3,4,5 Include entire spinous process and bilateral laminae

24. CTV =GTV+ Include the entire vertebral body

25. PTV Uniform expansion around the CTV (1.5-2.5 mm margin) Should contain entire GTV and CTV. PTV margin adjacent to crtical structures may be modified to allow spacing at discretion of treating physician unless GTV compromised. Never overlap with cord/ cord avoidance structure. To allow for unavoidable underdosing of PTV in close proximity to spinal cord, while maintaining consistency in the treatment prescription PTV-Cord PRV is done

26. PTV =CTV+2mm

27. Dosage

28. Plan Evaluation D100% 103% D98% 104% D95% 105% Dmax 116% V100% 100% V110% 45.4% GTV

29. D100% 97.9% D98% 101.5% D95% 102.3% Dmax 116% V100% 99.85 V110% 35.1% CTV

30. D100% 87.7% D98% 98.3% D95% 99.8% Dmax 116% V100% 94.6% V110% 24.4% Dose given 27Gy/3Fr PTV

31. OAR Dose Coverage Structures Desirable (Gy) Achieved(Gy) Spinal cord 20.3 21 B/L Kidney 16 4.95

32. Conformity Index 0.89 Homogeneity Index 1.2 Target Coverage Isodose lines Pink 100% Isodose Line Green 80% Isodose Line Brown 60% Isodose Line Light blue 40% Isodose Line

33. Isodose lines Volume Radius 100% 26.9cc 1.86cm 80% 52.4cc 2.32cm 60% 88.1cc 2.76cm 40% 205.1cc 3.66cm Gradient Index Equivalent Radius D/b Isodose Line Desirable Achieved 80% and 60% <2mm 4mm 80% and 40% <8mm 13mm

34. BEV REV Beam Arrangements

35. Day 1 Day 2 Day 3

36. PREMEDICATION Tab. Dexamethasone 4mg thrice daily starting day before Tab. Pan 40 once daily starting day before Diabetes care if Taper the steroid over 3 weeks PPI Peri medication 16-May-24 42

37. Response assessment: SPINO ( SPI ne response assessment in N euro- O ncology) Focus on p ain control and imaging based local tumor control Pain response Brief Pain Inventory (BPI) preferred (assessment based on worst pain score) International Consensus Pain Response Endpoints (ICPRE) should be adopted as standard guidelines for pain response Time of assessment: 3 months after SBRT Imaging follow-up frequency - Spine MRI preferred e very 2-3 months for first 12-18 months Every 3-6 months thereafter

38. Imaging-based local tumour response MRI preferred RECIST criteria not optimum Local control Local progression Absence of progression within the treated area on serial imaging (2 or 3 consecutive MRI scans 6-8 weeks apart) Gross unequivocal increase in tumor volume or linear dimension Any new or progressive tumour within the epidural space Neurological deterioration attributable to pre-existing epidural disease with equivocal increased epidural disease dimensions on MRI

39. Pseudoprogression, necrosis: interval imaging, occasionally biopsy needed. Difficulties in interpretation MRI signal changes confined within bone segment (in high-dose volume) without epidural or paraspinal progression. Coincident vertebral compression fracture

40. The superior and inferior extent of CTV is determined by the vertebral levels. (Exception: If GTV involves any part of the S1 ala, CTV commences from the superior aspect of the S1 ala ). At the level of S1–S2 (but occasionally S3), lateral surfaces of the sacrum (alae) can be identified as having an anterior and posterior section due to the fusion of two separate ossification centers during development. Inferiorly (S3–S5), the alae develop from one ossification center. If including the alae prophylactically in the CTV as the adjacent marrow space to the compartment containing the GTV, the ossification line (if visible) can be used to contain the overall size of the CTV Ossification lines are not typical barriers to spread; therefore, if the GTV involves any portion of the ala, it is not advisable to use these lines to limit the CTV volume