Purpose Radiotherapy (XRT) for spine sarcomas is constrained by spinal cord, nerve, and viscera tolerance. Negative surgical margins are uncommon; hence, doses of ≥ 66 Gy are recommended. A Phase II clinical trial evaluated high dose photon/proton XRT for spine sarcomas. Materials/Methods Eligible patients had non-metastatic, thoracic, lumbar, and/or sacral spine/paraspinal sarcomas. Treatment included pre- and/or post-op photon/proton XRT +/- radical resection; patients with osteosarcoma and Ewing's sarcoma received chemotherapy. Shrinking fields delivered 50.4 cobalt Gray equivalent (GyRBE) to subclinical disease, 70.2 GyRBE to microscopic disease in the tumor bed, and 77.4 GyRBE to gross disease at 1.8 GyRBE q.d. Doses were reduced for radiosensitive histologies, concurrent chemoradiation, or when diabetes or autoimmune disease present. Spinal cord dose was limited to 63/54 GyRBE to surface/center. Intra-operative boost doses of 7.5-10 Gy could be given by dural plaque. Results 50 patients (29 chordoma, 14 chondrosarcoma, 7 other) underwent gross total (n=25) or subtotal (n=12) resection or biopsy (n=13). With 48 month median follow-up, five-year actuarial local control, recurrence-free survival, and overall survival are: 78%, 63%, and 87% respectively. Two of 36 (5.6%) patients treated for primary versus 7/14 (50%) for recurrent tumor developed local recurrence, p<0.001. Five patients developed late radiation-associated complications; no myelopathy developed but three sacral neuropathies appeared following 77.12-77.4 GyRBE. Conclusions Local control with this treatment is high in patients radiated at the time of primary presentation. Spinal cord dose constraints appear to be safe. Sacral nerves receiving 77.12-77.4 GyRBE are at risk for late toxicity.

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Forty-four patients were treated using the BSD-1000 Annular Phased Array between April 1983 and December 1986. There were 32 pelvic, nine abdominal, two extremity, and one thoracic sites treated. Mean tumour volume was 646 cc. Thirty-nine patients had concurrent radiation therapy, receiving a mean dose of 38 Gy. Mean average temperature was 41.0 +/- 1.4 degrees C. Most patients experienced local or systemic toxicity, requiring temporary treatment interruption in 33 patients, and termination of treatment in eight. Chronic complications were seen in four, but these were in patients receiving high total radiation doses as well. There were six complete and five partial responses. Among the 32 patients with pelvic tumours, mean tumour volume was 317 cc, mean radiation dose was 42 Gy, and mean average temperature was 41.3 +/- 1.2 degrees C. There were five complete and four partial responses. Achieving tumour temperatures greater than or equal to 42 degrees C with the annular array is difficult, due to both systemic and local toxicity. To improve clinical hyperthermia for thoracic, abdominal, and pelvic tumours, new technologies such as steerable phased array microwave systems; scanned, focused ultrasound; and permanently implantable thermoregulating ferromagnetic seeds, or new approaches such as using drugs to alter blood flow, or combining hyperthermia with antineoplastic drugs or biological agents, will be necessary.

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