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Minimal Acute Toxicities Following High-Dose Proton Therapy for Spinal Tumors
Jennifer Jefferis,
1CDH
1
RN ;
William Hartsell,
1
MD ;
John Chang,
1
MD ;
Vinai Gondi,
1,2
MD
Proton Center, Warrenville, IL; 2Cadence Brain Tumor Center, Warrenville, IL
Purpose
Figure 1. 63 year old M p/w grade I
myxopapillary ependymoma from
T9 to sacral nerve roots, status
post biopsy. Treated with postop
proton beam therapy from T9sacral nerve roots to 45 CGyE,
followed by sequential boost from
below the spinal cord termination
to sacral nerve roots for
cumulative dose of 59.4 CGyE.
Two oblique posterior proton
beams were utilized, with distal
range positioned in the middle of
the vertebral body. With zero dose
delivered to the anterior visceral
compartment, the patient reported
no toxicities, except for grade 1
erythema.
 Using posterior proton beams and positioning distal range
anterior to spinal target volume limits dose to anterior
visceral structures, including esophagus, stomach, bowel
and bladder
 Objective: Assess whether this dosimetric advantage of
proton therapy impacts clinical outcomes in terms of
acute toxicities in patients treated to >50 CGyE.
Materials and Methods
 Patients treated to >50 CGyE for spinal tumors at a single
proton center, consecutively enrolled on the PCG
Registry
 Exclusion criteria: concurrent cranial irradiation or
chemotherapy prior or during treatment
 Treated in supine or prone Position
 Treatments were delivered at 1.8 CGyE/Fraction
 Weekly physician evaluations with physician-assessed
toxicities graded using CTCAE v4.0
Results
19 patients received proton therapy for spinal tumors. Median age
was 49 (range 12-74). 5 patients had chordoma/chondrosarcoma
(dose range 70.4-75.8 CGyE); 1 patient had sarcoma (66.3 CGyE);
5 patients had a WHO grade II ependymoma (54.2-59.6 CGyE); 4
patients had a WHO grade I myxopapillary ependymoma (52.3-59.6
CGyE); 3 patients had benign or malignant peripheral nerve sheath
tumor (57.9-59.8 CGyE); and, 1 patient had hemangioma (50.5
CGyE). 16 patients developed grade 1 dermatitis. Grade 2
desquamation was observed in 2 patients (11%) treated to 72
CGyE, and grade 3 desquamation was observed in 1 patient (5%),
treated to 75.8 CGyE. Aside from desquamation, no grade ≥2
acute toxicities were observed. 2 patients (11%) treated to ≥72
CGyE, developed grade 1 diarrhea. 2 patients (11%) treated to
≥72 CGyE developed grade 1 urinary frequency. 2 patients (11%)
reported grade 1 fatigue.
0.01
Table 1. Acute Toxicities
Grade 1
Hyperpigmentation
Erythema
GI Toxicity
GU Toxicity
Fatigue
Grade 2
Desquamation
Grade 3
Desquamation
Dose Scale
4
21.05%
12
2
1
2
63.16%
10.53%
5.26%
10.53%
2
10.53%
1
5.26%
59.4
Conclusion
Proton therapy to >50 CGyE for spinal tumors is well tolerated,
with no grade ≥2 non-dermatologic acute toxicities and grade 1
acute GI and GU toxicities only in patients treated to ≥72
CGyE. Dermatologic toxicities were observed in all patients,
but severe only in patients treated to ≥72 CGyE.