PMC6349598_01
Radiographic timeline of patient's 6 lesions. (A) Represents 18F-fluorodeoxyglucose (FDG) positron emission/computed tomography (PET/CT) axial slices of the patient at initial diagnosis. Identified FDG-avid lesions included 2 right upper-lung nodules, station 4R paratracheal and station 7 subcarinal lymph nodes, a left T6 vertebrae metastasis, and a left adrenal gland metastasis. (B) FDG-PET/CT reevaluation 4.5 months after initial diagnosis and 6 total cycles of chemotherapy showing a mixed response. (C) FDG-PET/CT reevaluation 7.5 months after initial diagnosis and 10 total cycles of chemotherapy. The patient completed radiation therapy to the 4 indicated sites 1 month after this scan was performed. (D) Complete radiographic response to all sites 12 months after initial diagnosis.
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Further evaluation included an 18F-fluorodeoxyglucose positron emission/computed tomography (FDG-PET/CT) scan that revealed 2 right upper-lung nodules, 2 enlarged mediastinal lymph nodes, a left adrenal gland lesion, and a lesion involving the left posterolateral elements of the T6 vertebrae (Fig 1A). T6 (Fig 1B). There was no evidence of new metastatic disease. Tumors, version 1.1, and no evidence of new distant disease (Fig 1C). The patient had a total spinal instability neoplastic score (SINS) of 5. The SINS component scores included location (score 1), pain (score 1), bone lesion (score 2), radiographic spinal alignment (score 0), vertebral body collapse (score 0), and posterolateral involvement of spinal elements (score 1). After completing radiation therapy, the patient completed 2 additional cycles of pemetrexed and carboplatin (12 total cycles), followed by reevaluation 12 months after the initial diagnosis; FDG-PET/CT scan showed no evidence of disease (Fig 1D).
Stereotactic spinal radiation surgery (SSRS) plan. Representative sagittal, coronal, and axial slices for the T6 vertebrae lesion plan. SSRS consisted of 24 Gy and 18 Gy in 1 fraction to the high-dose and low-dose clinical target volumes, respectively.
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The patient proceeded with stereotactic body radiation therapy to the right upper-lung nodules (50 Gy in 5 fractions) and left adrenal metastasis (50 Gy in 5 fractions) along with SSRS to the T6 vertebral lesion (24 Gy in 1 fraction; Fig 2).
Vertebral compression fracture at T6. (A) Sagittal computed tomography slices of patient's spine 3 years after diagnosis (2 years after stereotactic spinal radiation surgery [SSRS]), (B) which was the last imaging obtained before his T6 compression fracture 6 years after diagnosis (5 years after SSRS). (C) Sagittal T2-weighted magnetic resonance sequence at 6 years after diagnosis.
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Imaging revealed a compression fracture at T6 (Fig 3).