A Prospective Study Using Implanted Fiducial Markers to Assess Treatment Accuracy and Esophageal Toxicity in Spinal Stereotactic Body Radiation Therapy

Study Description

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Brief Summary:

The goal of the first part of this clinical research study is to learn how to deliver more accurate radiation treatment of tumors in the spine. Researchers also want to learn how internal organs might move during radiation treatment.

The goal of the second part of this study is to learn if it is safe to allow slightly more radiation to the normal esophagus when spinal tumors close by are being treated. This may result in better tumor control.

Condition or disease	Intervention/treatment	Phase
Spinal Tumor	Radiation: Spinal SBRT (Standard Dose); Radiation: Spinal SBRT (Higher Dose); Procedure: Gold Seed Implantation; Behavioral: Questionnaires	Not Applicable

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Study Design

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Study Type :	Interventional (Clinical Trial)
Actual Enrollment :	41 participants
Allocation:	Non-Randomized
Intervention Model:	Single Group Assignment
Masking:	None (Open Label)
Primary Purpose:	Treatment
Official Title:	A Prospective Study Using Implanted Fiducial Markers to Assess Treatment Accuracy and Esophageal Toxicity in Spinal Stereotactic Body Radiation Therapy
Actual Study Start Date :	June 2012
Estimated Primary Completion Date :	June 2019
Estimated Study Completion Date :	June 2020

Arms and Interventions

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Arm	Intervention/treatment
Experimental: Hypofractionated Radiation; All patients receive CT-guided spinal SBRT using IMRT to maximize conformality of treatment plan to target volume, while sparing normal structures. Dose given to tumor and number of treatments received determined by patient's doctor. In second stage, characterize tolerance of esophagus to hypofractionated radiation doses through prospective constraint relaxation and toxicity monitoring. Data collected from Group 1 in first stage will give data on dose delivered to esophagus. Second stage of protocol will begin accrual once Group 1 has filled. Dose constraints used for Groups 3 allow higher dose. Dose constraints for Group 4 represent modest increase of esophageal dose maximums.	Radiation: Spinal SBRT (Higher Dose); Group 3 and 4: Higher dose of radiation to esophagus than group before it, if no intolerable side effects were seen. 2 groups of 10 participants enrolled in the second part of study. Only participants who will receive a single spinal SBRT treatment are eligible for second part of study.; Other Name: XRT Procedure: Gold Seed Implantation; 4 gold seeds implanted into bones of spine: 2 gold seeds above and 2 gold seeds below the area of tumor to be treated.; Other Name: Fiducial implantation Behavioral: Questionnaires; Completion of questionnaire before radiation treatment starts, and 1 time a week for the next 4 weeks. It should take about 10 minutes to complete.; Other Name: Surveys
Experimental: ExacTrac Positioning System; Analysis performed of ExacTrac positioning system with and without fiducial guidance. Four dimensional CT datasets for simulation will allow use of data from this portion of protocol to characterize degree to which organ at risk (OAR) motion is relevant at each spinal level. 20 patients accrued in two groups of 10, with 10 patients in each rostral-caudal position in the spine (Group 1: T4-T12, Group 2: L1-L5). Imaging done with fiducial markers for this study will not impact patient management. Patients will treated with standard dose constraints to normal tissues.	Radiation: Spinal SBRT (Standard Dose); Group 1 and 2: Standard doses of radiation therapy to the normal esophagus while treating the tumor. Up to 2 groups of 10 participants enrolled.; Other Name: XRT Procedure: Gold Seed Implantation; 4 gold seeds implanted into bones of spine: 2 gold seeds above and 2 gold seeds below the area of tumor to be treated.; Other Name: Fiducial implantation Behavioral: Questionnaires; Completion of questionnaire before radiation treatment starts, and 1 time a week for the next 4 weeks. It should take about 10 minutes to complete.; Other Name: Surveys

Outcome Measures

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Primary Outcome Measures :

1. Assess Use of Implanted Fiducial Markers in Treatment Planning and Delivery Workflow for Frame-Based Spinal Stereotactic Body Radiation Therapy (Spinal SBRT) [ Time Frame: 1 month ]

   Establish platform and perform analysis of the ExacTrac positioning system with and without fiducial guidance.

   Patients monitored at each follow-up visit, with MRI of the spine performed at each follow-up time point during the first year. Treated lesions will be classified as progressive (defined as > 25% increased volume), stable (defined as radiographically unchanged), or smaller, and spinal tumor progression-free survival (PFS) will be calculated.

Secondary Outcome Measures :

1. Esophageal Tolerance to Hyperfractionation [ Time Frame: 1 month ]

   Characterize tolerance of esophagus to hypofractionated radiation doses through prospective constraint relaxation and toxicity monitoring.

   Specific esophageal toxicity endpoints monitored include: dyspepsia, dysphagia, fistula, hemorrhage, necrosis, obstruction, pain, perforation, stenosis, ulcer, varices and esophagitis.

Eligibility Criteria

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Ages Eligible for Study:	18 Years and older (Adult, Senior)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

1. STAGE 1: >/= 18 years old
2. STAGE 1: Pathologically confirmed diagnosis of cancer, including, but not limited to non-small cell lung cancer, breast, prostate, renal cell, melanoma, gastrointestinal, sarcoma, thyroid, head and neck primary, and carcinoma of unknown primary
3. STAGE 1: Signed informed consent
4. STAGE 2: 1-3 above, and Patients undergoing single fraction spinal SBRT

Exclusion Criteria:

1. STAGE 1: Patient with radiosensitive histologies (lymphoma, multiple myeloma, small cell carcinomas, germ cell tumors)
2. STAGE 1: Extensive (> 50%) height loss of the involved vertebral body
3. STAGE 1: Inability to tolerate lying flat on treatment table for greater than 30 minutes
4. STAGE 1: Pregnancy
5. STAGE 2: Prior irradiation of the spine site and level to be treated
6. STAGE 2: Patients with primary disease arising in the posterior elements of the VB in question
7. STAGE 2: History of Barrett's esophagus, esophageal webbing, stricture, or fistula
8. STAGE 2: Prior radiation to the esophagus

Contacts and Locations

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Locations

United States, Texas
University of Texas MD Anderson Cancer Center
Houston, Texas, United States, 77030

Sponsors and Collaborators

M.D. Anderson Cancer Center

Investigators

Principal Investigator:	Amol J. Ghia, MD	M.D. Anderson Cancer Center

More Information

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Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information

Additional Information:

University of Texas MD Anderson Cancer Center Website 

Responsible Party:	M.D. Anderson Cancer Center
ClinicalTrials.gov Identifier:	NCT01624220 History of Changes
Other Study ID Numbers:	2012-0190; NCI-2012-01244 ( Registry Identifier: NCI CTRP )
First Posted:	June 20, 2012
Last Update Posted:	March 6, 2018
Last Verified:	March 2018

Keywords provided by M.D. Anderson Cancer Center:

Spinal tumor; Tumor of the mid or lower spine; Non-small cell lung cancer; Breast cancer; Prostate cancer; Renal cell cancer; Melanoma; Gastrointestinal cancer; Sarcoma	Thyroid cancer; Head and neck primary cancer; Carcinoma of unknown primary; Fiducial markers; Gold seed markers; Spinal stereotactic body radiation therapy; Spinal SBRT; Stereotactic Radiotherapy

Additional relevant MeSH terms:

Spinal Cord Neoplasms; Spinal Neoplasms; Central Nervous System Neoplasms; Nervous System Neoplasms; Neoplasms by Site; Neoplasms; Spinal Cord Diseases	Central Nervous System Diseases; Nervous System Diseases; Bone Neoplasms; Bone Diseases; Musculoskeletal Diseases; Spinal Diseases