Page 10 - ARNM-2-2

Advances in Radiotherapy
& Nuclear Medicine CFR-PEEK: A systematic review

mechanical stability, systemic disease burden, and was conducted and reported according to the applicable
psychosocial factors. Surgical indications are typically Preferred Reporting Items for Systematic Reviews and
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palliative with the focus centered on preserving neurologic Meta-Analyses (PRISMA).
function, obtaining local tumor control, achieving
mechanical stability, alleviating pain, and overall improving 2.2. Study selection
quality of life. Postoperative follow-up with imaging of the Studies were included if they met the following
spine plays an important role in the longitudinal care of criteria: (1) Reported primary clinical data with CFR-
these patients to evaluate for recurrent metastases. PEEK instrumentation in patients with both primary
Given the importance of multidisciplinary care, the and metastatic spinal tumors; (2) evaluated surgical
focus of innovation in the surgical management of spinal complications around implementation of CFR-PEEK
oncology has been on reducing the surgical footprint hardware; (3) reported postoperative outcomes pertaining
allowing patients to proceed more quickly and safely to to hardware. Exclusion criteria were non-English studies,
radiation and chemotherapy while facilitating adequate abstracts only, cadaveric studies, phantom studies,
surveillance. Titanium-based surgical constructs produce experimental studies, case reports, review articles, and
significant imaging artifact, creating challenges in radiation systematic reviews. Abstracts were screened independently
planning and surveillance for progression. Carbon fiber- for relevance by two authors (J.W., S.W.). Potential articles
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reinforced polyetheretherketone (CFR-PEEK) is a type of were extracted for full-text evaluation. Full-text evaluation
composite material combining the strength and stiffness was performed independently for relevance by two authors
of carbon fiber with the biocompatibility and resistance (J.W., S.W.).
to corrosion of PEEK. It has been used in various medical 2.3. Data extraction
and surgical applications, including as an alternative to
traditional titanium instrumentation in spine surgery. Data included study characteristics (publication year,
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CFR-PEEK does not create the same artifact on advanced study design, sample size, number of screws placed),
imaging as titanium hardware and thus could play an demographics (age, sex, type of cancer), procedure
integral role in adjuvant therapy planning. Compared to characteristics (hardware use [Titanium vs. CFR-PEEK],
conventional radiotherapy, stereotactic body radiotherapy levels fused, inclusion of anterior reconstruction, and
(SBRT) has been shown to provide excellent local tumor total number of screws), procedure-related and late
control for both primary and metastatic bone tumors. complications (spinal fluid leak, wound complications,
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CFR-PEEK hardware allows for more precise contouring screw loosening, hardware failure, epidural hematoma,
of the spinal cord and at-risk organs for patients requiring incidental durotomy, and pulmonary embolism), and
adjuvant therapy and may allow for more efficient use late complications (pseudoarthrosis, revision surgery
of SBRT where it has previously been avoided, such as needed, screw pull-out, screw loosening, and screw
cases where poor visualization compromises dosimetry. breakage) in studies reporting a follow-up period of
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The purpose of this systematic review is to evaluate and at least 1-year. A full-text evaluation was conducted
describe the overall effectiveness and safety of CFR- independently by two authors to screen the collected
PEEK instrumentation in spine oncology through data to ensure validity.
analysis of previously published data around surgical
outcomes including complications, hardware failure, and 3. Results
postoperative local tumor control. In addition, we hope to 3.1. Study identification and demographics
explore literature surrounding the cost of care differences
between these treatment modalities. The search and review process used to identify and select
articles for the meta-analysis according to the study
2. Methods inclusion and exclusion criteria is shown in the PRISMA
flow chart (Figure 1). A total of 322 articles were identified
2.1. Literature search from PubMed and Embase. After duplicate articles were
A literature search was performed using Embase (Elsevier) removed, abstracts were screened, and full-text articles
and PubMed (National Library of Medicine) databases were reviewed; in total, 15 studies met the inclusion
from inception to January 18, 2023, to identify studies criteria. Of these 15 studies, 9 studies were full-text articles
evaluating the use of CFR-PEEK in spinal oncology. Search that assessed CFR-PEEK use in spinal oncology cases, 5,9-16
terms were compiled to “[Spine] AND [[CFR-PEEK] 4 studies were abstracts only, and 4 studies used CFR-PEEK
OR [Carbon Fiber]] AND [[oncology] OR [proton] OR in settings other than instrumentation placement for spinal
[metastasis] OR [radiation] OR [tumor]]”. This study oncology. 6,17-19 Only the full-text articles were included in

Volume 2 Issue 2 (2024) 2 doi: 10.36922/arnm.3130