Lhermitte's sign following VMAT-based head and neck radiation-insights into mechanism

Huaising C. Ko, Allison R. Powers, Ren Dih Sheu, Sarah L. Kerns, Barry S. Rosenstein, Stephen C. Krieger, Waleed Fouad Mourad, Kenneth S. Hu, Vishal Gupta, Richard L. Bakst

Research output: Contribution to journalArticle

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Abstract

Purpose/Objectives: We observed a number of patients who developed Lhermitte's sign (LS) following radiation to the head and neck (H/N), since instituting volumetric modulated arc therapy (VMAT). We aimed to investigate the incidence of LS following VMAT-based RT without chemotherapy, and determine the dosimetric parameters that predict its development. We explored whether the role of inhomogeneous dose distribution across the spinal cord, causing a "bath-and-shower" effect, explains this finding. Methods and Materials: From 1/20/2010-12/9/2013, we identified 33 consecutive patients receiving adjuvant RT using VMAT to the H/N without chemotherapy at our institution. Patients' treatment plans were analyzed for dosimetric parameters, including dose gradients along the anterior, posterior, right, and left quadrants at each cervical spine level. Institutional Review Board approval was obtained. Results: 5 out of 33 (15.2%) patients developed LS in our patient group, all of whom had RT to the ipsilateral neck only. LS patients had a steeper dose gradient between left and right quadrants across all cervical spine levels (repeated-measures ANOVA, p = 0.030). Within the unilateral treatment group, LS patients received a higher mean dose across all seven cervical spinal levels (repeated-measures ANOVA, p = 0.046). Dose gradients in the anteriorposterior direction and mean doses to the cord were not significant between LS and non-LS patients. Conclusions: Dose gradients along the axial plane of the spinal cord may contribute to LS development; however, a threshold dose within the high dose region of the cord may still be required. This is the first clinical study to suggest that inhomogeneous dose distributions in the cord may be relevant in humans. Further investigation is warranted to determine treatment-planning parameters associated with development of LS.

Original languageEnglish (US)
Article numbere0139448
JournalPLoS One
Volume10
Issue number10
DOIs
StatePublished - Oct 8 2015

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Intensity-Modulated Radiotherapy
neck
Neck
Head
Radiation
therapeutics
dosage
Chemotherapy
Analysis of variance (ANOVA)
cervical spine
Patient treatment
Spinal Cord
Analysis of Variance
Spine
spinal cord
drug therapy
Drug Therapy
analysis of variance
Research Ethics Committees
Planning

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)
  • Agricultural and Biological Sciences(all)

Cite this

Ko, H. C., Powers, A. R., Sheu, R. D., Kerns, S. L., Rosenstein, B. S., Krieger, S. C., ... Bakst, R. L. (2015). Lhermitte's sign following VMAT-based head and neck radiation-insights into mechanism. PLoS One, 10(10), [e0139448]. https://doi.org/10.1371/journal.pone.0139448

Lhermitte's sign following VMAT-based head and neck radiation-insights into mechanism. / Ko, Huaising C.; Powers, Allison R.; Sheu, Ren Dih; Kerns, Sarah L.; Rosenstein, Barry S.; Krieger, Stephen C.; Mourad, Waleed Fouad; Hu, Kenneth S.; Gupta, Vishal; Bakst, Richard L.

In: PLoS One, Vol. 10, No. 10, e0139448, 08.10.2015.

Research output: Contribution to journalArticle

Ko, HC, Powers, AR, Sheu, RD, Kerns, SL, Rosenstein, BS, Krieger, SC, Mourad, WF, Hu, KS, Gupta, V & Bakst, RL 2015, 'Lhermitte's sign following VMAT-based head and neck radiation-insights into mechanism', PLoS One, vol. 10, no. 10, e0139448. https://doi.org/10.1371/journal.pone.0139448
Ko HC, Powers AR, Sheu RD, Kerns SL, Rosenstein BS, Krieger SC et al. Lhermitte's sign following VMAT-based head and neck radiation-insights into mechanism. PLoS One. 2015 Oct 8;10(10). e0139448. https://doi.org/10.1371/journal.pone.0139448
Ko, Huaising C. ; Powers, Allison R. ; Sheu, Ren Dih ; Kerns, Sarah L. ; Rosenstein, Barry S. ; Krieger, Stephen C. ; Mourad, Waleed Fouad ; Hu, Kenneth S. ; Gupta, Vishal ; Bakst, Richard L. / Lhermitte's sign following VMAT-based head and neck radiation-insights into mechanism. In: PLoS One. 2015 ; Vol. 10, No. 10.
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abstract = "Purpose/Objectives: We observed a number of patients who developed Lhermitte's sign (LS) following radiation to the head and neck (H/N), since instituting volumetric modulated arc therapy (VMAT). We aimed to investigate the incidence of LS following VMAT-based RT without chemotherapy, and determine the dosimetric parameters that predict its development. We explored whether the role of inhomogeneous dose distribution across the spinal cord, causing a {"}bath-and-shower{"} effect, explains this finding. Methods and Materials: From 1/20/2010-12/9/2013, we identified 33 consecutive patients receiving adjuvant RT using VMAT to the H/N without chemotherapy at our institution. Patients' treatment plans were analyzed for dosimetric parameters, including dose gradients along the anterior, posterior, right, and left quadrants at each cervical spine level. Institutional Review Board approval was obtained. Results: 5 out of 33 (15.2{\%}) patients developed LS in our patient group, all of whom had RT to the ipsilateral neck only. LS patients had a steeper dose gradient between left and right quadrants across all cervical spine levels (repeated-measures ANOVA, p = 0.030). Within the unilateral treatment group, LS patients received a higher mean dose across all seven cervical spinal levels (repeated-measures ANOVA, p = 0.046). Dose gradients in the anteriorposterior direction and mean doses to the cord were not significant between LS and non-LS patients. Conclusions: Dose gradients along the axial plane of the spinal cord may contribute to LS development; however, a threshold dose within the high dose region of the cord may still be required. This is the first clinical study to suggest that inhomogeneous dose distributions in the cord may be relevant in humans. Further investigation is warranted to determine treatment-planning parameters associated with development of LS.",
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