This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Macbeth, F. Articles by Hoskin, P. Search for Related Content PubMed PubMed Citation Articles by Macbeth, F. Articles by Hoskin, P. Social Bookmarking                            What's this?

Radiation Dose in Spinal Cord Compression

Velindre Hospital, Cardiff, United Kingdom
Medical Research Council Clinical Trials Unit, London, United Kingdom
Mount Vernon Cancer Centre, Northwood, United Kingdom

To the Editor:

We were surprised that the editorial by Kwok, Regine, and Patchell¹ perpetuated the myth that single fractions of 8 Gy are hazardous to the spinal cord, and that this is not a standard schedule. Single fractions of 8 Gy and 10 Gy and hypofractionated regimens of 16 Gy or 17 Gy in two fractions have been investigated widely in clinical trials for the management of painful bone metastases, symptomatic lung cancer, and metastatic spinal cord compression (MSCC) for almost 20 years. The risk of radiation myelopathy (RM) for such schedules appears minimal. For example, no cases of RM were reported by the Radiation Therapy Oncology Group² (455 patients receiving 8 Gy x 1 for painful bone metastases), Sundstrom et al³ (143 patients receiving 17 Gy x 2 for advanced non–small-cell lung cancer [NSCLC]), Kramer et al⁴ (149 patient receiving 16 Gy x 2 for advanced NSCLC), Rades et al⁵ (261 patients receiving 8 Gy x 1 for MSCC) or Rades et al⁶ (34 patients receiving re-irradiation of 8 Gy x 1 for in-field recurrence). In addition, the Medical Research Council⁷ reviewed the risk of RM in three large randomized trials of palliative radiotherapy for NSCLC, and reported no cases in 114 patients receiving 10 Gy x 1, but three cases in 524 patients receiving 17 Gy x 2, although two further cases were reported in 153 patients receiving 39 Gy x 13.

Consequently, single and hypofractionated schedules are used widely in Europe and to belittle the trial by Maranzano et al⁸ by implying it might be regarded as "a randomized phase II study, rather than a true phase III study" because the schedules were not "standard" is therefore inappropriate. It is undoubtedly an important trial in the management of MSCC and its results need to be treated seriously. Whereas Kwok, Regine, and Patchell¹ feel it is conceivable that the 13 patients who progressed to paraplegia without in-field recurrence may have suffered from late radiation-induced toxicity, we would argue that, in fact, this is inconceivable.

Although we accept that a trial of dose escalation may be appropriate for a highly selected group of better-prognosis patients with MSCC, given the low risk of RM with single and hypofractionated schedules we were surprised that a schedule (45 to 48 Gy/15 to 16 fractions) with a predicted RM rate as high as 5% is contemplated by Kwok, Regine, and Patchell.¹ We agree with the conclusions of the analysis by Rades et al⁵ that it is still appropriate to test the utility of short fraction regimens in the majority of patients with MSCC who do have a poor prognosis and for whom a prolonged period of hospitalization may be inappropriate.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Kwok Y, Regine WF, Patchell RA: Radiation therapy alone for spinal cord compression: Time to improve upon a relatively ineffective status quo. J Clin Oncol 23:3308-3310, 2005[Free Full Text]

2. Hartsell WF, Scott CB, Bruner DW, et al: Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 97:798-804, 2005[Abstract/Free Full Text]

3. Sundstrom S, Bremnes R, Aasebo U, et al: Hypofractionated palliative radiotherapy in advanced non-small cell lung carcinoma is comparable to standard fractionation for symptom control and survival: A national phase III study. J Clin Oncol 22:801-810, 2004[Abstract/Free Full Text]

4. Kramer G, Wanders S, Noordijk E, et al: Results of the Dutch National Study of the palliative effect of irradiation using two different treatment schedules for non-small cell lung cancer. J Clin Oncol 23:2962-2970, 2005[Abstract/Free Full Text]

5. Rades D, Stalpers LJ, Veninga T, et al: Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. J Clin Oncol 23:3366-3375, 2005[Abstract/Free Full Text]

6. Rades D, Stalpers LJ, Veninga T, et al: Spinal reirradiation after short-course RT for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys, Jun 3, 2005 (epub ahead of print)

7. Macbeth FR, Wheldon TE, Girling DJ, et al: Radiation myelopathy: Estimates of risk in 1048 patients in three randomized trials of palliative radiotherapy for non-small cell lung cancer. Clin Oncol 8:176-181, 1996

8. Maranzano E, Bellavita R, Rossi R, et al: Short-course versus split-course radiotherapy in metastatic spinal cord compression: Results of a phase III randomised, muticenter trial. J Clin Oncol 23:3358-3365, 2005[Abstract/Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Macbeth, F. Articles by Hoskin, P. Search for Related Content PubMed PubMed Citation Articles by Macbeth, F. Articles by Hoskin, P. Social Bookmarking                            What's this?