Prospective evaluation of spinal reirradiation by using stereotactic body radiation therapy

Abstract

BACKGROUND: Stereotactic body radiotherapy for previously irradiated, progressive spinal metastases may be a viable option in selected patients. The authors review a prospective series of spinal metastasis patients reirradiated with stereotactic body radiotherapy. METHODS: A total of 59 patients with 63 tumors of the spine were reirradiated with stereotactic body radiotherapy between 2003 and 2009. Spinal magnetic resonance imaging was performed both before treatment initiation and at regular follow-up intervals. Stereotactic body radiotherapy was delivered to a peripheral dose of 30 grays (Gy) in 5 fractions (6 Gy per fraction), or 27 Gy in 3 fractions (9 Gy per fraction). The National Cancer Institute Common Toxicity Criteria 2.0 and McCormick neurological function system were used to evaluate toxicity and neurologic status, respectively. RESULTS: Mean follow-up was 17.6 months. Actuarial 1-year radiographic local control and overall survival for all patients were both 76%. Of the tumors that progressed after stereotactic body radiotherapy, 13 (81%) of 16 patients had tumors that were within 5 mm of the spinal cord, and 6 of them eventually developed spinal cord compression. Toxicity was most commonly grade 1 or 2 fatigue. Two patients experienced mild to moderate radiation injury (lumbar plexopathy) while remaining independently ambulatory and pain free. Freedom from neurologic deterioration from any cause was 92% at 1 year. CONCLUSIONS: Reirradiation for progressive spinal metastases with stereotactic body radiotherapy results in good local control and limited toxicity. Initial surgery should be considered for tumors within 5 mm of the spinal cord. Radiation dose should be tailored for tumors near or invading the psoas muscle secondary to observed risk of lumbar plexopathy. Cancer 2011;117:3509-

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

“…15,16 The trials were approved by the institutional review board and written informed consent was obtained from trial participants prior to enrollment. Eligibility requirements included diagnosis of cancer, Karnofsky Performance Scale (KPS) score > 40, an MR image identifying spinal or paraspinal metastasis within 4 weeks of enrollment, and no more than 2 metastatic sites in the spine to be irradiated over a single course of treatment.…”

“…Institutional, prospective, single-arm trials have been performed at MD Anderson Cancer Center establishing the safety and efficacy of SSRS for spinal metastases, with 1-year actuarial LC rates of 84% in patients who had not previously undergone radiation therapy at the site of SSRS. 15,16 The optimal dose and fractionation for SSRS is debated without Level-1 data to guide therapeutic recommendations. 18 This is especially pertinent for radioresistant histologies such as RCC, as it is believed that larger fraction sizes are needed to overcome the intrinsic radioresistance of the tumor cells.…”

The use of spine stereotactic radiosurgery for oligometastatic disease

“…4,10,11 Protocol inclusion criteria were a Karnofsky Performance Scale (KPS) score > 40, histopathological confirmation of cancer at our institution, and MRI identifying spinal or paraspinal metastasis < 1 month prior to enrollment. Protocol exclusion criteria were spinal cord compression and unstable spine as determined by multidisciplinary evaluation, cytotoxic chemotherapy within 1 month of enrollment, or EBRT in the prior 3 months to the same site.…”

“…13,23,31 In addition, it has proven to be an effective salvage tool in patients who have progressive spinal metastases who have received prior radiation. 11,13,31 abbreviationS CI = confidence interval; CTV = clinical treatment volume; DFS = disease-free survival; Dmax = dose maximum; Dmin = dose minimum; EBRT = external beam radiation therapy; GI = gastrointestinal; GTV = gross tumor volume; HR = hazard ratio; KPS = Karnofsky Performance Scale; OS = overall survival; SSRS = spine stereotactic radiosurgery; STMFS = systemic therapy modification-free survival. obJective The authors investigated the outcomes following spine stereotactic radiosurgery (SSRS) for patients with oligometastatic disease of the spine.…”

Utilization of laser interstitial thermotherapy guided by real-time thermal MRI as an alternative to separation surgery in the management of spinal metastasis

“…Recent series have demonstrated improvement in local control, pain, and the quality of life of patients treated with this modality. [15][16][17][18]30,37,39,40 Bilsky and Smith 4 have proposed a decision framework (NOMS) based on neurological, oncological, mechanical, and systemic considerations 22 in which the judicious use of surgery and conventional and stereotactic radiation are combined to provide optimal local control, symptomatic relief, and functional preservation for patients suffering from spinal metastasis. 4,5,21,22,28 These authors advocate surgery only in cases with a high degree of spinal cord compression in recognition of the fact that tumoricidal doses of radiation can be delivered with the stereotactic method up to but not including a margin of 2-3 mm around the spinal cord.…”