Kypho-IORT--a novel approach of intraoperative radiotherapy during kyphoplasty for vertebral metastases

Frederik Wenz, Frank Schneider, Christian Neumaier, Uta Kraus-Tiefenbacher, Tina Reis, René Schmidt, Udo Obertacke, Frederik Wenz, Frank Schneider, Christian Neumaier, Uta Kraus-Tiefenbacher, Tina Reis, René Schmidt, Udo Obertacke

Abstract

Background: Instable and painful vertebral metastases in patients with progressive visceral metastases present a common therapeutic dilemma. We developed a novel approach to deliver intraoperative radiotherapy (IORT) during kyphoplasty and report the first treated case.

Methods/results: 60 year old patient with metastasizing breast cancer under chemotherapy presented with a newly diagnosed painful metastasis in the 12th thoracic vertebra. Under general anaesthesia, a bipedicular approach into the vertebra was chosen with insertion of specially designed metallic sleeves to guide the electron drift tube of the miniature X-ray generator (INTRABEAM, Carl Zeiss Surgical, Oberkochen, Germany). This was inserted with a novel sheet designed for this approach protecting the drift tube. A radiation dose of 8 Gy in 5 mm distance (50 kV X-rays) was delivered. The kyphoplasty balloons (KyphX, Kyphon Inc, Sunnyvale) were inflated after IORT and polymethylmethacrylate cement was injected. The whole procedure lasted less than 90 minutes.

Conclusion: In conclusion, this novel, minimally invasive procedure can be performed in standard operating rooms and may become a valuable option for patients with vertebral metastases providing immediate stability and local control. A phase I/II study is under way to establish the optimal dose prescription.

Figures

Figure 1
Figure 1
Coronal CT scan of the vertebral metastasis.
Figure 2
Figure 2
Specially designed guiding sleeves were inserted using a bipendicular approach.
Figure 3
Figure 3
X-ray control of guiding sleeve position.
Figure 4
Figure 4
The INTRABEAM system is inserted into the guiding sleeves while the drift tube is protected by a novel sheet.
Figure 5
Figure 5
The INTRABEAM system in treatment position.
Figure 6
Figure 6
Dose distribution for localization in the center of the vertebra. Please note that the spinal cord is touched by the 1 Gy isodose.
Figure 7
Figure 7
The 8 Gy isodose reaches the spinal cord after placement of the radiation source in the dorsal part of the vertebra.
Figure 8
Figure 8
PMMA cement is injected after inflation of the kyphoplasty balloons to stabilize the vertebra.

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Source: PubMed

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