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The role of stereotactic radiosurgery in the treatment of intramedullary spinal cord neoplasms: a systematic literature review

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Abstract

Advances in imaging technology and microsurgical techniques have made microsurgical resection the treatment of choice in cases of symptomatic intramedullary tumors. The use of stereotactic radiosurgery (SRS) for spinal tumors is a recent development, and its application to intramedullary lesions is debated. We conducted a literature search through PubMed’s MeSH system, compiling information regarding intramedullary neoplasms treated by SRS. We compiled histology, tumor location and size, treatment modality, radiation dose, fractionation, radiation-induced complications, follow-up, and survival. Ten papers reporting on 52 patients with 70 tumors were identified. Metastatic lesions accounted for 33 %, while 67 % were primary ones. Tumor location was predominantly cervical (53 %), followed by thoracic (33 %). Mean volume was 0.55 cm3 (95 % confidence interval (CI), 0.26–0.83). Preferred treatment modality was CyberKnife® (87 %), followed by Novalis® (7 %) and linear particle accelerator (LINAC) (6 %). Mean radiation dose was 22.14 Gy (95 % CI, 20.75–23.53), with mean fractionation of 4 (95 % CI, 3–5). Three hemangioblastomas showed cyst enlargement. Symptom improvement or stabilization was seen in all but two cases. Radionecrotic spots adjacent to treated areas were seen at autopsy in four lesions, without clinical manifestations. Overall, clinical and radiological outcomes were favorable. Although surgery remains the treatment of choice for symptomatic intramedullary lesions, SRS can be a safe and effective option in selected cases. While this review suggests the overall safety and efficacy of SRS in the management of intramedullary tumors, future studies need randomized, homogeneous patient populations followed over a longer period to provide more robust evidence in its favor.

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Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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Authors and Affiliations

  1. Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA

    Silvia Hernández-Durán, Simon Hanft, Ricardo J. Komotar & Glen R. Manzano

  2. Department of Neuroanatomy, University of Costa Rica School of Medicine, San José, Costa Rica

    Silvia Hernández-Durán

Authors
  1. Silvia Hernández-Durán
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  2. Simon Hanft
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  3. Ricardo J. Komotar
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  4. Glen R. Manzano
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Correspondence to Glen R. Manzano.

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Comments

Mikhail Chernov, Tokyo, Japan

Introduction of stereotactic radiosurgery (SRS) into clinical practice revolutionized treatment of patients with various intracranial diseases, and it currently represents an approved technique for management of newly diagnosed, residual, and recurrent neoplasms, being used either separately or in combination with other treatment modalities. Further progress of technology for stereotactic irradiation and dose planning led to the development of spinal radiosurgery, and nowadays, it is widely applied in many centers, particularly in cases of metastatic disease of the spine [2]. Moreover, during the last decade, there is an increasing number of reports on the use of SRS for management of spinal cord tumors and vascular malformations [1, 3].

The authors of the presented systematic review collected data on radiosurgical treatment of 52 patients with 70 intramedullary spinal cord neoplasms, which were reported in ten articles published between 1998 and 2012. Their analysis suggests that SRS provides both efficacy and safety and may be considered as a reasonable treatment option in such cases. This information seems very important for clinical practitioners treating patients with spinal cord tumors.

Nevertheless, as it is clearly marked by the authors themselves, the present review is mainly based on the retrospective and uncontrolled clinical series with limited number of included cases. Therefore, the evidence of the presented data corresponds at best to level IV according to Oxford Centre for Evidence-Based Medicine or levels II–3 according to the US Preventive Services Task Force, which does not support high-grade clinical recommendations. Of note, extrapolation of the beneficial results of intracranial radiosurgery on management of intraparenchymal spinal cord tumors is hardly possible, particularly due to different radiosensitivities of the brain and spinal cord. Therefore, before the wide acceptance of SRS for management of spinal cord neoplasms, its benefits and risks require further evaluations, and at present, such treatment should be applied with caution, preferably according to strict clinical protocols, and in the radiosurgical centers with sufficient expertise and experience.

Reference

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3. Park HK, Chang JC (2013) Review of stereotactic radiosurgery for intramedullary spinal lesions. Korean J Spine 10: 1-6

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Hernández-Durán, S., Hanft, S., Komotar, R.J. et al. The role of stereotactic radiosurgery in the treatment of intramedullary spinal cord neoplasms: a systematic literature review. Neurosurg Rev 39, 175–183 (2016). https://doi.org/10.1007/s10143-015-0654-y

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