Imaging-Based Outcomes for 24 Gy in 2 Daily Fractions for Patients with de Novo Spinal Metastases Treated With Spine Stereotactic Body Radiation Therapy (SBRT)

Tseng, Chia‐Lin; Soliman, Hany; Myrehaug, Sten; Lee, Young Kyung; Ruschin, Mark; Atenafu, Eshetu G.; Campbell, Mikki; Maralani, Pejman; Yang, Victor X. D.; Yee, Albert; Sahgal, Arjun

doi:10.1016/j.ijrobp.2018.06.047

Cited by 86 publications

(70 citation statements)

References 25 publications

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“…15 Cunha et al and Thibault et al 10,28 also found that doses per fraction of ≥20Gy were associated with higher VCF rates in their analyses. These data are consistent with the 39% rate of VCF with high-dose single-fraction SBRT by Rose et al and the modest 8.5% rate of VCF with 24Gy in 2 fractions by Tseng et al 19,25 The benefit of high-dose singlefraction radiotherapy is higher rates of local control, especially with tumours considered radio-resistant such as renal cell carcinoma. 34,35 However, there has not been a published randomised trial assessing the efficacy and adverse effect profile of varying SBRT fractionations for spine metastases.…”

Section: Relationship Between Sbrt and Vcfsupporting

confidence: 86%

“…The 15 studies identified are listed in Table 2 with the relevant findings. 10,19,20,[22][23][24][25][26][27][28][29][30][31][32][33] The majority involved patients with diverse primary tumour locations or histologies. Thibault et al focused specifically on patients with renal cell carcinoma (RCC) metastases, and Yoo et al only reported lesions from hepatocellular carcinoma (HCC) origin.…”

Section: Resultsmentioning

confidence: 99%

“…Ling et al and Tseng et al employed a consistent approach, being 16Gy in 1 fraction and 24Gy in 2 fractions, respectively. 24,25 SBRT delivered in a single fraction was the most common method in 7 studies. Four primarily involved SBRT in three fractions and 3 reports mainly used a two fraction approach.…”

Section: Sbrt Regimensmentioning

confidence: 99%

“…Boehling et al 26 Boyce-Fappiano et al 27 Cunha et al 28 Germano et al 29 Jawad et al 23 Patient ( Lee et al 30 Ling et al 24 Mehta et al 31 Rose et al 19 Saghal et al Lee et al 30 Ling et al 24 Mehta et al 31 Rose et al 19 Saghal et al 20 Risk factors on MVA (HR or P-value) 32 Thibault et al 10 Thibault et al 33 Tseng et al 25 Yoo et al…”

Section: Treatment Outcomesmentioning

confidence: 99%

“…30 Within SINS, lytic vertebral lesions, pre-existing VCF and spinal malalignment were identified on multivariable analyses across multiple studies as independent risk factors for VCF. 4,20,25,28 The reliability of SINS in relation to therapeutic decision-making has been assessed in various independent reports. Fourney et al showed that total SINS scores demonstrated strong intra-and inter-observer reliability in defining the three states of stability, potential instability and mechanical instability.…”

Section: Predictive and Protective Factors For Post-sbrt Vcfmentioning

confidence: 99%

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Vertebral fractures following stereotactic body radiotherapy for spine metastases

et al. 2020

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Stereotactic body radiotherapy has emerged as one of the preferred treatments for patients with spine metastases, with the potential for long-term control from lesion irradiation. Post-treatment vertebral compression fractures are a known complication of this therapy, contributing to worsening pain and reduced quality of life, sometimes requiring surgical intervention. This review explores the current knowledge of post-radiotherapy fractures, in terms of the rates and associated predictive factors. A search of databases including Medline, Embase and the Cochrane Library was conducted using keywords such as 'vertebral compression fracture', 'stereotactic body radiotherapy' and 'spine metastases'. The search was limited to published studies up to March 2019, reporting clinical outcomes including both the post-treatment fracture rate and statistical identification of associated risk factors. Rates of post-treatment fractures ranged from 4 to 39%. A variety of factors were found to increase the risk, including the appearance of lytic vertebral disease, degree of pre-existing compression, spinal malalignment, increased dose per fraction and a Spinal Instability Neoplastic Score >6. This knowledge can enable clinicians to counsel patients when considering management options for spine metastases, maintaining the balance between local tumour control and the risk of subsequent fracture.

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Section: Relationship Between Sbrt and Vcfsupporting

confidence: 86%

Section: Resultsmentioning

confidence: 99%

Section: Sbrt Regimensmentioning

confidence: 99%

Section: Treatment Outcomesmentioning

confidence: 99%

Section: Predictive and Protective Factors For Post-sbrt Vcfmentioning

confidence: 99%

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Vertebral fractures following stereotactic body radiotherapy for spine metastases

et al. 2020

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Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases

et al. 2020

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IMPORTANCERising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application.OBJECTIVE To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies. EVIDENCE REVIEWThe MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases.RESULTS Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease.CONCLUSIONS AND RELEVANCE These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.

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Development and Assessment of a Predictive Score for Vertebral Compression Fracture After Stereotactic Body Radiation Therapy for Spinal Metastases

et al. 2022

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IMPORTANCEVertebral compression fracture (VCF) is a potential adverse effect following treatment with stereotactic body radiation therapy (SBRT) for spinal metastases.OBJECTIVE To develop and assess a risk stratification model for VCF after SBRT. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study conducted at a high-volume referral center included 331 patients who had undergone 464 spine SBRT treatments from December 2007 through October 2019. Data analysis was conducted from November 1, 2020, to August 17, 2021. Exclusions included proton therapy, prior surgical intervention, vertebroplasty, or missing data.EXPOSURES One and 3 fraction spine SBRT treatments were most commonly delivered. Single-fraction treatments generally involved prescribed doses of 16 to 24 Gy (median, 20 Gy; range, 16-30 Gy) to gross disease compared with multifraction treatment that delivered a median of 30 Gy (range, 21-50 Gy). MAIN OUTCOMES AND MEASURESThe VCF and radiography components of the spinal instability neoplastic score were determined by a radiologist. Recursive partitioning analysis was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was the criterion for node splitting. RESULTSOf the 331 participants, 88 were women (27%), and the mean (IQR) age was 63 (59-72) years. With a median follow-up of 21 months (IQR, 11-39 months), we identified 84 VCFs (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median of 9 months (IQR, 3-21 months) to developing a VCF. From 15 candidate variables, 6 were identified using the backward selection method, feature importance testing, and a correlation heatmap. Four were selected via recursive partitioning analysis: epidural tumor extension, lumbar location, gross tumor volume of more than 10 cc, and a spinal instability neoplastic score of more than 6. One point was assigned to each variable, and the resulting multivariable Cox model had a concordance of 0.760. The hazard ratio per 1-point increase for VCF was 1.93 (95% CI, 1.62-2.30; P < .001). The cumulative incidence of VCF at 2 years (with death as a competing risk) was 6.7% (95% CI, 4.2%-10.7%) for low-risk (score, 0-1; 273 [58.3%]), 17.0% (95% CI, 10.8%-26.7%) for intermediate-risk (score, 2; 99 [21.3%]), and 35.4% (95% CI, 26.7%-46.9%) for high-risk cases (score, 3-4; 92 [19.8%]) (P < .001). Similar results were observed for freedom from VCF using stratification. CONCLUSIONS AND RELEVANCEThe results of this cohort study identify a subgroup of patients with high risk for VCF following treatment with SBRT who may potentially benefit from undergoing prophylactic spinal stabilization or vertebroplasty.

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Imaging-Based Outcomes for 24 Gy in 2 Daily Fractions for Patients with de Novo Spinal Metastases Treated With Spine Stereotactic Body Radiation Therapy (SBRT)

Cited by 86 publications

References 25 publications

Vertebral fractures following stereotactic body radiotherapy for spine metastases

Vertebral fractures following stereotactic body radiotherapy for spine metastases

Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases

Development and Assessment of a Predictive Score for Vertebral Compression Fracture After Stereotactic Body Radiation Therapy for Spinal Metastases

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