Outcomes for Spine Stereotactic Body Radiation Therapy and an Analysis of Predictors of Local Recurrence

Bishop, Andrew J.; Tao, Randa; Rebueno, Neal; Christensen, Eva; Allen, Pamela K.; Wang, Xin A.; Amini, Behrang; Tannir, Nizar M.; Tatsui, Claúdio E.; Rhines, Laurence D.; Li, Jing; Chang, Eric L.; Brown, Paul D.; Ghia, Amol J.

doi:10.1016/j.ijrobp.2015.03.037

Cited by 96 publications

(69 citation statements)

References 30 publications

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“…13, 31 Bishop et al reported that patients with a GTV biologically equivalent minimum dose (Dmin) of at least 33.4 Gy had significantly better local control, recommending that, when possible, the GTV Dmin should be maintained above 14 Gy in 1 fraction and 21 Gy in 3 fractions. 1 In addition to excellent survival and acceptable local control, we have shown that these patients with oligometastatic spine disease had extended time intervals before the initiation of or a modification in systemic therapy, with a median time of 41.2 months. Eighteen percent of patients in this series did not develop any subsequent local recurrences or distant metastases at a follow-up of 75 months and never required systemic therapy (except for 1 patient who started leuprolide shortly after SSRS).…”

Section: Discussionmentioning

confidence: 80%

The use of spine stereotactic radiosurgery for oligometastatic disease

Tang

Deegan

et al. 2016

SPI

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OBJECTIVE The authors investigated the outcomes following spine stereotactic radiosurgery (SSRS) for patients with oligometastatic disease of the spine. METHODS The study was a secondary analysis of 38 of 209 patients enrolled in 2 separate institutional Phase I/II prospective protocols and treated with SSRS between 2002 and 2011. Of these 38 patients, 33 (87%) were treated for a solitary spine metastasis, with no other history of metastatic disease. SSRS was prescribed to 24 Gy in 1 fraction (8%), 18 Gy in 1 fraction (18%), 16 Gy in 1 fraction (11%), 27 Gy in 3 fractions (53%), 30 Gy in 5 fractions (8%), or 20 Gy in 5 fractions (3%). Seventeen patients (45%) received prior conventional external beam radiation therapy. RESULTS The median overall survival (OS) was 75.7 months, and the 2- and 5-year OS rates were 84% and 60%, respectively. In multivariate analysis, patients who had prior spine surgery and a better Karnofsky Performance Scale score had an improved OS (HR 0.16, 95% CI 0.05–0.52, p < 0.01, and HR 0.33, 95% CI 0.13%–0.84%, p = 0.02, respectively), and those who had undergone prior radiation therapy had a worse OS (HR 3.6, 95% CI 1.2%–10%, p = 0.02). The 1-, 2-, and 5-year local progression-free survival rates were 85%, 82%, and 78%, respectively. The median time to systemic therapy modification was 41 months. Two patients (5%) experienced late Grade 3–4 toxicity. CONCLUSIONS Patients with oligometastatic disease of the spine treated with SSRS can experience long-term survival and a long time before needing a modification in systemic therapy. In addition, SSRS leads to excellent local control and minimal late toxicity.

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Section: Discussionmentioning

confidence: 80%

The use of spine stereotactic radiosurgery for oligometastatic disease

Tang

Deegan

et al. 2016

SPI

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“…Relevant clinical and dosimetric factors were balanced between the SF and MF groups. Multivariate analysis utilizing a competing risk regression 2 That analysis of 332 metastases included this patient cohort, and using a Cox regression analysis revealed a GTV Dmin goal of ≥ 33.4 Gy (BED) as correlating significantly with LC. This corresponds to a GTV Dmin goal of 14 Gy in SF treatment or 21 Gy in 3-fraction treatment.…”

Section: Discussionmentioning

confidence: 97%

“…13 Improved LC with SF SSRS has correlated with dosimetric factors such as GTV Dmin. 2,20 However, SF SSRS has also been correlated with both acute toxicities such as pain flare 8,27 and increased late toxicities such as vertebral body compression fractures. 3,30,33 No randomized controlled trial exists comparing SF SSRS and MF SSRS to weigh the potential LC benefits of SF against potential toxicities of treatment.…”

Section: Discussionmentioning

confidence: 99%

Single-fraction versus multifraction spinal stereotactic radiosurgery for spinal metastases from renal cell carcinoma: secondary analysis of Phase I/II trials

Ghia

Chang

Bishop

et al. 2016

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OBJECTIVE The objective of this study was to compare fractionation schemes and outcomes of patients with renal cell carcinoma (RCC) treated in institutional prospective spinal stereotactic radiosurgery (SSRS) trials who did not previously undergo radiation treatment at the site of the SSRS. METHODS Patients enrolled in 2 separate institutional prospective protocols and treated with SSRS between 2002 and 2011 were included. A secondary analysis was performed on patients with previously nonirradiated RCC spinal metastases treated with either single-fraction (SF) or multifraction (MF) SSRS. RESULTS SSRS was performed in 47 spinal sites on 43 patients. The median age of the patients was 62 years (range 38–75 years). The most common histological subtype was clear cell (n = 30). Fifteen sites underwent surgery prior to the SSRS, with laminectomy the most common procedure performed (n = 10). All SF SSRS was delivered to a dose of 24 Gy (n = 21) while MF regiments were either 27 Gy in 3 fractions (n = 20) or 30 Gy in 5 fractions (n = 6). The median overall survival duration for the entire cohort was 22.8 months. The median local control (LC) for the entire cohort was 80.6 months with 1-year and 2-year actuarial LC rates of 82% and 68%, respectively. Single-fraction SSRS correlated with improved 1- and 2-year actuarial LC relative to MF SSRS (95% vs 71% and 86% vs 55%, respectively; p = 0.009). On competing risk analysis, SF SSRS showed superior LC to MF SSRS (subhazard ratio [SHR] 6.57, p = 0.014). On multivariate analysis for LC with tumor volume (p = 0.272), number of treated levels (p = 0.819), gross tumor volume (GTV) coverage (p = 0.225), and GTV minimum point dose (p = 0.97) as covariates, MF SSRS remained inferior to SF SSRS (SHR 5.26, p = 0.033) CONCLUSIONS SSRS offers durable LC for spinal metastases from RCC. Single-fraction SSRS is associated with improved LC over MF SSRS for previously nonirradiated RCC spinal metastases.

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“…For example, Choi et al 19 reported superior local control rates when the prescribed dose was greater than a single session equivalent dose of 15 Gy. Bishop et al 20 reported an association with better local control when the minimum dose in the gross target volume was at least a biologically effective dose (BED) of 33.4 Gy. Whether or not the choice of fractionation scheme can enhance local control is also debatable, and some have reported an association with more favorable local control rates with high-dose per fraction regimens such as 18 to 24 Gy in 1 to 2 fractions, as compared to more fractionated approaches.…”

Section: Discussionmentioning

confidence: 99%

Stereotactic Body Radiotherapy for Spinal Metastases

Chang

Shin

Yamada

et al. 2016

Spine

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Study Design Systematic literature review. Objectives To summarize the risks of 3 key complications of stereotactic body radiotherapy (SBRT) for spinal metastases, that is, radiation myelopathy (RM), vertebral compression fracture (VCF), and epidural disease progression, and to discuss strategies for minimizing them. Summary of Background Data RM, VCF and epidural disease progression are now recognized as important risks following SBRT for spine metastases. It is unclear at this stage exactly how large these risks are and what strategies can be employed to minimize these risks. Methods A systematic review of the literature using MEDLINE and a review of the bibliographies of reviewed articles on SBRT for spinal metastases were conducted. Results The initial literature search revealed a total of 376 articles, of which 38 were pertinent to the study objectives. The risk of RM following SBRT was found to be dependent on the maximum dose to the spinal cord and estimated to be <5% if the recommended published thecal sac dose constraints are adhered to. The crude risk of VCF was 13.7% (range: 0.7%- 40.5%), and, on average, 45% were surgically salvaged. It has been shown that the risk of VCF is dependent on several anatomic and tumor-related factors including the SBRT dose per fraction. The crude risk of local failure at 1 year was 21.4% (range: 12%–27%) of which 67% (range: 38%–96%) occurred within the epidural space. The grade of epidural disease has been shown to be associated with the risk of local failure. Conclusion The risk of RM after spinal SBRT is low in particular if recommended dose metrics are adhered to. There is a significant risk of both VCF and epidural disease progression after spinal SBRT. These risks can potentially be minimized by identifying the risk factors for these complications, and performing careful radiotherapy and surgical planning.

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Outcomes for Spine Stereotactic Body Radiation Therapy and an Analysis of Predictors of Local Recurrence

Cited by 96 publications

References 30 publications

The use of spine stereotactic radiosurgery for oligometastatic disease

The use of spine stereotactic radiosurgery for oligometastatic disease

Single-fraction versus multifraction spinal stereotactic radiosurgery for spinal metastases from renal cell carcinoma: secondary analysis of Phase I/II trials

Stereotactic Body Radiotherapy for Spinal Metastases

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