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High-Dose Single-Fraction Radiotherapy for the Management of Chordomas of the Spine and Sacrum Yoshiya Yamada M.D., Ilya Laufer M.D., Brett W. Cox M.D.,

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Presentation on theme: "High-Dose Single-Fraction Radiotherapy for the Management of Chordomas of the Spine and Sacrum Yoshiya Yamada M.D., Ilya Laufer M.D., Brett W. Cox M.D.,"— Presentation transcript:

1 High-Dose Single-Fraction Radiotherapy for the Management of Chordomas of the Spine and Sacrum Yoshiya Yamada M.D., Ilya Laufer M.D., Brett W. Cox M.D., Michael D. Lovelock M.D., Robert G. Maki M.D. Ph. D., Joan M. Zatcky N.P., Patrick J. Boland M. D., Mark H. Bilsky M.D. Memorial Sloan-Kettering Cancer Center

2 Chordoma treatment Surgery – primary treatment –Goal - En bloc, Wide margin Radiation –Inoperable/intralesional –Previous surgery –Recurrence Chemotherapy –Salvage/palliation

3 Surgical Summary Wide margin – 57% (35-75) Recurrence-free survival – 45% (40-67) –5y – 62% (52-66) –10y – 46% (33-52) Survival –Tumor-related death – 26% (21-47) –5y – 74% (54-97) –10y – 53% (21-71) York 1999, Fourney 2005, Bergh 2000, Fuchs 2005, Boriani 2006, Hanna 2008, Schwab 2009, Ruggieri 2010, Stacchiotto 2010

4 Photon Therapy –Resistant to conventional fractionation Proton Therapy –5y Recurrence – 10% 1, 27% 2, 32% 3, Carbon Therapy –5y Recurrence – 12% 4 Factors –GTV, implants 1 DeLaney Wagner Staab Imai 2011 Radiation Summary

5 Necrosis After SRS L3 chordoma after single-fraction 2400 cGy SRS showing ghost outlines of epitheliod cells and extensive necrosis 2m post- SRS4m post- SRS

6 Single-Fraction Radiation More irreparable damage to DNA Endothelial apoptosis 1 Overcomes stem cell resistance 2 1 Garcia-Barros Chang 2005

7 Hypothesis Single-fraction SRS can be safely administered as a treatment of chordomas in the mobile spine and sacrum with good short-term local control

8 Methods Study design: Retrospective review Study population –Patients with chordomas of the mobile spine and sacrum treated between 2006 and 2010 Inclusion criteria –Single-fraction SRS Exclusion criteria –Follow-up less than 6 months

9 Methods 62F presented with odynophagia secondary to a C3 chordoma

10 Methods 73M presented with bowel incontinence and left foot numbness

11 Methods 59F presented with back pain and high-grade spinal cord compression secondary to chordoma metastasis to T7

12 Methods SRS –Inverse optimized treatment plan –Onboard orthogonal KV and cone beam imaging –Median prescribed dose – 2400 cGy ( cGy) Primary endpoint –Local tumor control Secondary endpoint –Treatment-related toxicity (CTAE v.4)

13 Methods Stratification variables –Histologic subtype –Location –Size –Dose Follow-up –Clinical data and serial MRIs obtained every 3-4 months Data sources –Chart and imaging review

14 Tumor Characteristics All tumorsDe Novo TumorsRecurrent TumorsMetastases N Median follow-up (m)N N N Mobile Cervical Thoracic Lumbar Sacrum / Pelvis Total Tumor volume – 88cc (26-859cc) 2 Dedifferentiated Chordomas

15 Treatment Characteristics All tumorsDe Novo TumorsRecurrent TumorsMetastases N Median follow-up (m)N N N No surgery Initially planned surgery Neoadjuvant Adjuvant V100 – median 95% (72-100%)

16 Local Progression 1 recurrence – 95% local control –11 months after SRS, died of progressive systemic chordoma 5 patients died from chordoma

17 Case Example 62F presented with odynophagia secondary to a C3 chordoma Single-fraction 24 Gy with surgery planned 3 months after SRS Patient elected to defer surgery and 3-year MRI shows decrease in tumor size

18 Post-SRS Tumor Histology LevelTime from SRS (m)Extent of necrosisFollow-up (m) L22conventional chordoma60 L34>90%46 Sacrum4>90%32 Sacrum550%19 Sacrum55%13 Sacrum8>90%40

19 Toxicity Grade 1 skin reaction (temporary erythema) Grade 1 or 2 odynophagia (temporary) Sciatic neuropathy (foot drop and neuropathic pain) –Tumor encased the sciatic nerve Partial vocal cord paralysis (vocal cord augmentation)

20 Limitations Short follow-up Heterogeneous group

21 Conclusions Single-fraction SRS can be safely used to treat patients with chordomas of the mobile spine and sacrum. Single-fraction SRS provides good short-term tumor control. Long term follow-up will be necessary in order to determine if SRS can be used as definitive chordoma therapy or as a neoadjuvant or adjuvant treatment. Single-fraction SRS represents a good treatment option in patients who cannot undergo wide- margin chordoma excision.


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