Delivering a third course of radiation to spine metastases using image-guided, intensity-modulated radiation therapy

Clinical article

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The objective of this study was to investigate the feasibility and safety of delivering a third course of radiation to patients with multiply recurrent metastatic disease to the spine.


Between 2009 and 2011, 10 patients received a third course of radiation to spinal metastases at Memorial Sloan–Kettering Cancer Center using image-guided intensity-modulated radiation therapy (IMRT). Patient and tumor characteristics, dosimetry details, and outcomes were obtained using retrospective chart review. Spinal imaging was performed prior to treatment and at regular follow-up intervals. The cumulative biologically effective dose (BED) to the spinal cord and cauda equina was calculated and was normalized to 2 Gy equivalents (Gy2/2). Toxicity and local control were assessed.


The median time between the first and second courses of radiation was 18.5 months and the median time between the second and third courses was 11.5 months. The median follow-up from the third course of radiation was 12 months and the median overall survival was 13 months. Pain or neurological symptoms were improved in 80% of patients. The median spinal cord maximum dose normalized BED (nBED) for the whole cohort was 70.73 Gy2/2 (range 51.9–101.7 Gy2/2). The median dose to 5% of the spinal cord D05 nBED for the entire cohort was 59.4 Gy2/2. Acute toxicity was most commonly fatigue and dermatitis, with 1 patient experiencing Grade 3 fatigue and 1 patient Grade 3 dermatitis. Late toxicity was limited to 2 cases of Grade 1 dysphagia. There was 1 case of Grade 1 neuropathy and 1 case of Grade 2 neuropathy. The crude rate of local control was 80% with 1 in-field failure and 1 marginal failure.


In this cohort of patients, a third course of IMRT to the spine was well tolerated with no significant late toxicities. Used as salvage therapy for select patients, a third course of radiation is a safe and effective treatment strategy.

Abbreviations used in this paper:BED = biologically effective dose; D05 = dose to 5% of the target; D80 = dose to 80% of the target; Dmax = maximum dose; IMRT = intensity-modulated radiation therapy; nBED = normalized BED; PTV = planning target volume; SBRT = stereotactic body radiation therapy.

Article Information

Address correspondence to: Evangelia Katsoulakis, M.D., Department of Radiation Oncology, Memorial Sloan–Kettering Cancer Center, 1275 York Avenue, New York, New York 10065. email:

Please include this information when citing this paper: published online October 26, 2012; DOI: 10.3171/2012.9.SPINE12433.

© AANS, except where prohibited by US copyright law.



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    Case 1. Radiation treatment plan for leiomyosarcoma treated using 3 courses of image-guided IMRT with overlap at T-9. The first, second, and third courses involved the T9–11 (A), T8–10 (B), and T9–11 (C) levels, respectively. Isodose curves are shown with a corresponding legend for percentages (C), which is applicable to all 3 treatment plans. Both PTV (red) and spinal cord (green) are outlined.


  • 1

    Damast SWright JBilsky MHsu MZhang ZLovelock M: Impact of dose on local failure rates after image-guided reirradiation of recurrent paraspinal metastases. Int J Radiat Oncol Biol Phys 81:8198262011

  • 2

    Gagnon GJNasr NMLiao JJMolzahn IMarsh DMcRae D: Treatment of spinal tumors using cyberknife fractionated stereotactic radiosurgery: pain and quality-of-life assessment after treatment in 200 patients. Neurosurgery 64:2973072009

  • 3

    Garg AKWang XSShiu ASAllen PYang JMcAleer MF: Prospective evaluation of spinal reirradiation by using stereotactic body radiation therapy: The University of Texas MD Anderson Cancer Center experience. Cancer 117:350935162011

  • 4

    Gerszten PCBurton SAOzhasoglu CWelch WC: Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 32:1931992007

  • 5

    Gibbs ICPatil CGerszten PCAdler JR JrBurton SA: Delayed radiation-induced myelopathy after spinal radiosurgery. Neurosurgery 64:2 SupplA67A722009

  • 6

    Katagiri HTakahashi MInagaki JKobayashi HSugiura HYamamura S: Clinical results of nonsurgical treatment for spinal metastases. Int J Radiat Oncol Biol Phys 42:112711321998

  • 7

    Kirkpatrick JPvan der Kogel AJSchultheiss TE: Radiation dose-volume effects in the spinal cord. Int J Radiat Oncol Biol Phys 76:3 SupplS42S492010

  • 8

    Laufer IHanover ALis EYamada YBilsky M: Repeat decompression surgery for recurrent spinal metastases. Clinical article. J Neurosurg Spine 13:1091152010

  • 9

    Lovelock DMHua CWang PHunt MFournier-Bidoz NYenice K: Accurate setup of paraspinal patients using a noninvasive patient immobilization cradle and portal imaging. Med Phys 32:260626142005

  • 10

    Nieder CGrosu ALAndratschke NHMolls M: Proposal of human spinal cord reirradiation dose based on collection of data from 40 patients. Int J Radiat Oncol Biol Phys 61:8518552005

  • 11

    Patchell RATibbs PARegine WFPayne RSaris SKryscio RJ: Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366:6436482005

  • 12

    Rades DRudat VVeninga TStalpers LJHoskin PJSchild SE: Prognostic factors for functional outcome and survival after reirradiation for in-field recurrences of metastatic spinal cord compression. Cancer 113:109010962008

  • 13

    Rades DSchild SE: Is stereotactic radiosurgery the best treatment option for patients with spinal metastases?. Nat Clin Pract Oncol 4:4004012007

  • 14

    Sahgal ABilsky MChang ELMa LYamada YRhines LD: Stereotactic body radiotherapy for spinal metastases: current status, with a focus on its application in the postoperative patient. A review. J Neurosurg Spine 14:1511662011

  • 15

    Sahgal ALarson DAChang EL: Stereotactic body radiosurgery for spinal metastases: a critical review. Int J Radiat Oncol Biol Phys 71:6526652008

  • 16

    Sahgal AMa LGibbs IGerszten PCRyu SSoltys S: Spinal cord tolerance for stereotactic body radiotherapy. Int J Radiat Oncol Biol Phys 77:5485532010

  • 17

    Sahgal AMa LWeinberg VGibbs ICChao SChang UK: Reirradiation human spinal cord tolerance for stereotactic body radiotherapy. Int J Radiat Oncol Biol Phys 82:1071162012

  • 18

    Wang JCBoland PMitra NYamada YLis EStubblefield M: Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. J Neurosurg Spine 1:2872982004

  • 19

    Wang PYShen WCJan JS: MR imaging in radiation myelopathy. AJNR Am J Neuroradiol 13:104910581992

  • 20

    Wong DAFornasier VLMacNab I: Spinal metastases: the obvious, the occult, and the impostors. Spine (Phila Pa 1976) 15:141990




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