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RADIATION ONCOLOGY SIMULATION TO EXECUTION
ROSE CASE SPINAL SBRT
5/16/2024 1
Dr Kanhu Charan Patro
MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC
Clinical Director, HOD (Radiation Oncology)
ISRo- Institute of Stereotactic Radiation oncology
Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam
drkcpatro@gmail.com /M- +91-9160470564/ www.drkanhupatro.com
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.
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
Treatment consideration- NOMS
• NNeurologic assessment
• Oncologic assessment
• Mechanical assessment
• Systemic assessment
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
Oncological assessment
Radiation Sensitivity Tumor Histology
Sensitive  Myeloma
 Lymphoma
Moderately Sensitive  Prostate
 Breast
Moderately Resistant  Colon
 NSCLC
Highly Resistant  Thyroid
 Renal
 Sarcoma
 Melanoma
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
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
Current NOMS decision framework
Indication for SBRT
MODIFIED WEINSTEIN-BORIANI-BAIGINI SYSTEM
Sector 1: Vertebral body
Sector 2: Left pedicle
Sector 3: Left transverse
process and lamina
Sector 4: Spinous process
Sector 5: Right transverse
process and lamina
Sector 6: Right pedicle.
Contouring guideline
MRI
GTV
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
GTV involvement ISRC GTVanatomic
classification
ISRC bony CTV
recommendation
CTV description
Any portion of the
vertebral body
1 1 Include the entire
vertebral body
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
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
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
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.
GTV involvement ISRC GTVanatomic
classification
ISRC bony CTV
recommendation
CTV description
Unilateral pedicle 2 2,3,±1 Include pedicle,
ipsilateral transverse
process, and
ipsilateral lamina
±vertebral body.
GTV involvement ISRC GTVanatomic
classification
ISRC bony CTV
recommendation
CTV description
Unilateral lamina 3 2,3,4 Include lamina,
ipsilateral
pedicle/transverse
process, and spinous
process.
GTV involvement ISRC GTVanatomic
classification
ISRC bony CTV
recommendation
CTV description
Spinous process 4 3,4,5 Include entire spinous
process and bilateral
laminae
CTV=GTV+ Include the entire vertebral body
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
PTV=CTV+2mm
Dosage
Plan Evaluation
D100% 103%
D98% 104%
D95% 105%
Dmax 116%
V100% 100%
V110% 45.4%
GTV
D100% 97.9%
D98% 101.5%
D95% 102.3%
Dmax 116%
V100% 99.85
V110% 35.1%
CTV
D100% 87.7%
D98% 98.3%
D95% 99.8%
Dmax 116%
V100% 94.6%
V110% 24.4%
Dose
given
27Gy/3Fr
PTV
OAR Dose Coverage
Structures Desirable (Gy) Achieved(Gy)
Spinal cord 20.3 21
B/L Kidney 16 4.95
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
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
BEV
REV
Beam Arrangements
Day 1
Day 2
Day 3
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
5/16/2024 42
Response assessment: SPINO (SPIne response
assessment in Neuro-Oncology)
• Focus on pain 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 every 2-
3 months for first 12-18 months
• Every 3-6 months thereafter
• 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
• 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
• 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
ROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATRO

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ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO

  • 1. RADIATION ONCOLOGY SIMULATION TO EXECUTION ROSE CASE SPINAL SBRT 5/16/2024 1 Dr Kanhu Charan Patro MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC Clinical Director, HOD (Radiation Oncology) ISRo- Institute of Stereotactic Radiation oncology Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam drkcpatro@gmail.com /M- +91-9160470564/ 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 • NNeurologic assessment • Oncologic assessment • Mechanical assessment • Systemic 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.
  • 9. 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
  • 11.
  • 13. MODIFIED WEINSTEIN-BORIANI-BAIGINI SYSTEM Sector 1: Vertebral body Sector 2: Left pedicle Sector 3: Left transverse process and lamina Sector 4: Spinous process Sector 5: Right transverse process and lamina Sector 6: Right pedicle.
  • 15.
  • 16. MRI
  • 17. GTV
  • 18. 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
  • 19. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Any portion of the vertebral body 1 1 Include the entire vertebral body
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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.
  • 24. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Unilateral pedicle 2 2,3,±1 Include pedicle, ipsilateral transverse process, and ipsilateral lamina ±vertebral body.
  • 25. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Unilateral lamina 3 2,3,4 Include lamina, ipsilateral pedicle/transverse process, and spinous process.
  • 26. GTV involvement ISRC GTVanatomic classification ISRC bony CTV recommendation CTV description Spinous process 4 3,4,5 Include entire spinous process and bilateral laminae
  • 27. CTV=GTV+ Include the entire vertebral body
  • 28. 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
  • 31. Plan Evaluation D100% 103% D98% 104% D95% 105% Dmax 116% V100% 100% V110% 45.4% GTV
  • 32. D100% 97.9% D98% 101.5% D95% 102.3% Dmax 116% V100% 99.85 V110% 35.1% CTV
  • 33. D100% 87.7% D98% 98.3% D95% 99.8% Dmax 116% V100% 94.6% V110% 24.4% Dose given 27Gy/3Fr PTV
  • 34. OAR Dose Coverage Structures Desirable (Gy) Achieved(Gy) Spinal cord 20.3 21 B/L Kidney 16 4.95
  • 35. 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
  • 36. 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
  • 37.
  • 38.
  • 41.
  • 42. 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 5/16/2024 42
  • 43. Response assessment: SPINO (SPIne response assessment in Neuro-Oncology) • Focus on pain 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 every 2- 3 months for first 12-18 months • Every 3-6 months thereafter
  • 44.
  • 45. • 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
  • 46. • 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
  • 47.
  • 48.
  • 49. • 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