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Repeat Reirradiation Of The Spinal Cord: Multi-national Expert Treatment Recommendations

C. Nieder, L. Gaspar, D. Ruysscher, M. Guckenberger, M. Mehta, C. Rusthoven, A. Sahgal, E. Gkika
Published 2018 · Medicine

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BackgroundImproved survival of patients with spinal bone metastases has resulted in an increased number of referrals for retreatment and repeat reirradiation.MethodsA 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 2‑Gy fractions [EQD2] for spinal cord [alpha/beta 2 Gy] 75 Gy). Expert recommendations were tabulated with the aim of providing guidance.ResultsFive 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.ConclusionsThe 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.ZusammenfassungHintergrundAls Folge längerer Überlebenszeiten werden Patienten mit spinalen Knochenmetastasen immer öfter zu einer Rebestrahlung oder sogar zweiten Rebestrahlung vorgestellt.MethodenEine Expertengruppe aus Radioonkologen (RO) wurde etabliert, die Empfehlungen zur Rezidivbehandlung erarbeiten sollte. Ausgangspunkt war der Fall eines Patienten mit T5-Metastase, die bereits zweimal bestrahlt worden war (Intervall >12 Monate, angenommene kumulative biologisch äquivalente Dosis in 2‑Gy-Fraktionen [EQD2] für das Rückenmark [alpha/beta-Wert 2 Gy] 75 Gy). Die Empfehlungen wurden in Tabellen verglichen und eine Strategie wurde ausgearbeitet.ErgebnisseFünf der 7 RO würden eine dritte Strahlentherapieserie anbieten, bevorzugt mit hochkonformaler Technik, wie der stereotaktischen Behandlung. Allerdings wurden heterogene Fraktionierungskonzepte vorgeschlagen (3–20 Fraktionen), die teilweise auch Rücksicht auf bestimmte systemische Therapien nahmen. Alle 5 RO würden eine Unterdosierung des Zielvolumens akzeptieren, wenn die Rückenmarksdosis dadurch sinkt. Die Definition des Rückenmarks-PRV („planning organ at risk volume“) war unterschiedlich. Alle 5 RO hielten die EQD2 für das Rückenmark niedrig. Zwei Empfehlungen gingen über eine EQD2 von 12,5 Gy hinaus, wobei die höchste akzeptierte Dosis bei 19 Gy lag.SchlussfolgerungDie Zunahme der Publikationen zu Knochenmetastasen und einer Rebestrahlung des Rückenmarks hat einige RO-Experten ermutigt, bei palliativen Rebestrahlungen eine EQD2 von mehr als 75 Gy zu akzeptieren. Allerdings besteht darüber kein 100 %iger Konsensus. Es werden Strategien zur Harmonisierung der klinischen Praxis und zur Entwicklung evidenzbasierter Dosisgrenzen diskutiert.
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