Local control and toxicity outcomes of stereotactic radiosurgery for spinal metastases of gastrointestinal origin

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OBJECTIVE

Colorectal cancer (CRC) and other gastrointestinal (GI) cancers are believed to have greater radioresistance than other histologies. The authors report local control and toxicity outcomes of stereotactic radiosurgery (SRS) to spinal metastases from GI primary cancers.

METHODS

A retrospective single-center review was conducted of patients with spinal metastases from GI primary cancers treated with SRS from 2004 to 2017. Patient demographics and lesion characteristics were summarized using medians, interquartile ranges (IQRs), and proportions. Local failure (LF) was estimated using the cumulative incidence function adjusted for the competing risk of death and compared using Gray’s test for equality. Multivariable analyses were conducted using Cox proportional hazard models, adjusting for death as a competing risk, on a per-lesion basis. Patients were stratified in the Cox model to account for repeated measures for clustered outcomes. Median survival was calculated using the Kaplan-Meier method.

RESULTS

A total of 74 patients with 114 spine lesions were included in our analysis. The median age of the cohort was 62 years (IQR 53–70 years). Histologies included CRC (46%), hepatocellular carcinoma (19%), neuroendocrine carcinoma (13%), pancreatic carcinoma (12%), and other (10%). The 1- and 2-year cumulative incidence rates of LF were 24% (95% confidence interval [CI] 16%–33%) and 32% (95% CI 23%–42%), respectively. Univariable analysis revealed that older age (p = 0.015), right-sided primary CRCs (p = 0.038), and single fraction equivalent dose (SFED; α/β = 10) < 20 Gy (p = 0.004) were associated with higher rates of LF. The 1-year cumulative incidence rates of LF for SFED < 20 Gy10 versus SFED ≥ 20 Gy10 were 35% and 7%, respectively. After controlling for gross tumor volume and prior radiation therapy to the lesion, SFED < 20 Gy10 remained independently associated with worse LF (hazard ratio 2.92, 95% CI 1.24–6.89, p = 0.014). Toxicities were minimal, with pain flare observed in 6 patients (8%) and 15 vertebral compression fractures (13%).

CONCLUSIONS

Spinal metastases from GI primary cancers have high rates of LF with SRS at a lower dose. This study found that SRS dose is a significant predictor of failure and that prescribed SFED ≥ 20 Gy10 (biological equivalent dose ≥ 60 Gy10) is associated with superior local control.

ABBREVIATIONS BED = biological equivalent dose; CI = confidence interval; CRC = colorectal cancer; EBRT = external beam radiation therapy; ECOG = Eastern Cooperative Oncology Group; GI = gastrointestinal; GTV = gross tumor volume; GTV Dmin = minimum dose to GTV; HR = hazard ratio; IQR = interquartile range; LF = local failure; PTV = planning tumor volume; RTOG = Radiation Therapy Oncology Group; SBRT = stereotactic body radiotherapy; SFED = single fraction equivalent dose; SINS = Spine Instability Neoplastic Score; SRS = stereotactic radiosurgery; VCF = vertebral compression fracture.
Article Information

Contributor Notes

Correspondence Erqi L. Pollom: Stanford Cancer Institute, Stanford, CA. erqiliu@stanford.edu.INCLUDE WHEN CITING Published online March 6, 2020; DOI: 10.3171/2020.1.SPINE191260.Disclosures Dr. D. T. Chang reports direct stock ownership in ViewRay, Inc., and clinical or research support for this study from Varian Medical Systems, Inc. Dr. Gibbs reports receiving honoraria from Accuray, Inc. Dr. Li reports being a consultant for Medtronic, being on the speakers bureau for Synthes, and receiving clinical or research support for this study from Bristol-Myers Squibb.
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