Spinal Irradiation and BED

Radiation treatments, palliative or curative, which include target areas of the spine are
common in our everyday practice; however, re-irradiation to these areas of the spine or
overlapping regions are not as common and can pose risks to the patient. Read the attached
article by Nieder et al as found HERE. Discuss your thought process for treatment
planning for the following scenario.

A patient, diagnosed with intramedullary astrocytoma of the thoracic spine, received a

curative course of spinal irradiation to T4-T9 back in 2013, 50.4 Gy in 28 fractions. The
patient returned in 2018 with recurring issues, requiring an additional round of radiation
to the same area. Using your knowledge of BED, give an example of a fractionation
regimen that could be used to deliver around 30 Gy to the same area, while limiting the
total BED (past and present radiation) to less than 150 Gy? What are the risks to the
patient if the BED is not taken into consideration?

Spinal Irradiation and BED

The concept of biologically effective dose (BED) is used for isoeffective dose fractionation
calculations and to measure true biological dose.1 The calculation of BED is based on dose per
fraction, total dose to a particular tissue and α/β tissue ratio. The equation for BED is
d
BED = nd(1 + )
α⁄β
n= the number of fraction
d= the dose per fraction (Gy)
α/β=the repair capacity
According to Nieder et al2, cervical and thoracic cord have a α/β of 2 and lumbar cord has a α/β
of 4.

In 2013, a patient with a diagnosis of intramedularry astrocytoma of the thoracic spine was
treated with 50.4 Gy in 28 fractions. An α/β of 2 will be used for this calculation.
28 Gy
BED = 28 x 1.8 Gy (1 + )
2
= 96 Gy2
In 2018, the same patient returned requiring radiation treatment of 30 Gy to the same area while
limiting the total BED to less than 150 Gy. Knowing previous treatment is necessary to
determine the best fractionation regimen for second treatment. To know the new BED for second
treatment, subtract 150 Gy from 96 Gy. The remaining value of 54 Gy is used to evaluate the
new regimen to meet the total BED less than 150 Gy. A few parameters are needed to find the
best and safe fractionation.
Trial 1: 30 Gy (3.0 Gy x 10 fractions)
3.0 Gy
BED = 10 x 3.0 Gy (1 + ) = 75 Gy2
2

Trial 2: 30 Gy (2.5 Gy x 12 fractions)

2.5 Gy
BED = 12 x 2.5 Gy (1 + ) = 67.5 Gy2
2

Trial 3: 30 Gy (1.5 Gy x 20 fractions)

1.5 Gy
BED = 20 x 1.5 Gy (1 + ) = 52.5 Gy2 → the best parameter
2

By looking at these trials, one can determine that 1.5 Gy given in 20 fractions produces the best
fractionation regiment as 96 Gy + 53 Gy is 149 Gy and within tolerance.

Reirradiating spinal cord must apply the rule to keep the dose as low as reasonably achievable
while maintaining adequate local control. Spinal cord irradiation can cause toxicity and the most
adverse effect is radiation induced myelopathy and radiation injury to cauda equina.3 Nieder et
al2 suggested to maintain the total BED below 135.5 Gy2 and the retreatment interval to more
than 6 months to prevent the risk of radiation myelopathy. The risk of radiation myelopathy was
also small when the initial BED was below 98 Gy2.

References:
1. Jones B, Dale RG, Deehan C, Morgan DA. The role of biologically effective dose (BED)
in clinical oncology. Clin Oncol. 2001;13(2):71-81. PMID: 11373882. Accessed October
18, 2018.
2. Nieder C, Grosu A, Andratschke N, Molls N. Update of human spinal cord reirradiation
tolerance based on additional data from 38 patients. Int J Radiation Oncol Biol Phys.
2006;66(5):1446-1449. http://dx.doi:10.1016/j.ijrobp.2006.07.1383.x. Accessed October
18, 2018.
3. Suzuki G, Yamazaki H, Aibe N, et al. Clinical outcome of patients treated with re-
irradiation for spine or pelvic bone metastasis: a multi institutional analysis of 98
patients. Mol and Clin Oncol. 2017;6(6):871-875.
http://dx.doi.org/10.3892/mco.2017.1245. Accessed October 18, 2018.