Hypofractionated spinal stereotactic body radiation therapy for high-grade epidural disease

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  • 1 Departments of Neurosurgery,
  • 2 Radiation Oncology,
  • 3 Radiology,
  • 4 Epidemiology and Biostatistics, and
  • 5 Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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OBJECTIVE

To characterize the clinical outcomes when stereotactic body radiation therapy (SBRT) alone is used to treat high-grade epidural disease without prior surgical decompression, the authors conducted a retrospective cohort study of patients treated at the Memorial Sloan Kettering Cancer Center between 2014 and 2018. The authors report locoregional failure (LRF) for a cohort of 31 cases treated with hypofractionated SBRT alone for grade 2 epidural spinal cord compression (ESCC) with radioresistant primary cancer histology.

METHODS

High-grade epidural disease was defined as grade 2 ESCC, which is notable for radiographic deformation of the spinal cord by metastatic disease. Kaplan-Meier survival curves and cumulative incidence functions were generated to examine the survival and incidence experiences of the sample level with respect to overall survival, LRF, and subsequent requirement of vertebral same-level surgery (SLS) due to tumor progression or fracture. Associations with dosimetric analysis were also examined.

RESULTS

Twenty-nine patients undergoing 31 episodes of hypofractionated SBRT alone for grade 2 ESCC between 2014 and 2018 were identified. The 1-year and 2-year cumulative incidences of LRF were 10.4% (95% CI 0–21.9) and 22.0% (95% CI 5.5–38.4), respectively. The median survival was 9.81 months (95% CI 8.12–18.54). The 1-year cumulative incidence of SLS was 6.8% (95% CI 0–16.0) and the 2-year incidence of SLS was 14.5% (95% CI 0.6–28.4). All patients who progressed to requiring surgery had index lesions at the thoracic apex (T5–7).

CONCLUSIONS

In carefully selected patients, treatment of grade 2 ESCC disease with hypofractionated SBRT alone offers a 1-year cumulative incidence of LRF similar to that in low-grade ESCC and postseparation surgery adjuvant hypofractionated SBRT. Use of SBRT alone has a favorable safety profile and a low cumulative incidence of progressive disease requiring open surgical intervention (14.5%).

ABBREVIATIONS CTV = clinical target volume; Dmax = maximum dose; Dmin = minimum dose; D95% = dose to 95% of the target; ECOG = Eastern Cooperative Oncology Group; ESCC = epidural spinal cord compression; GTV = gross tumor volume; LRF = locoregional failure; NSCLC = non–small cell lung carcinoma; OS = overall survival; PTV = planning target volume; SBRT = stereotactic body radiation therapy; SINS = Spinal Instability Neoplastic Score; SLS = same-level surgery.

Supplementary Materials

    • Supplementary Figure 1 (PDF 676 KB)

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Contributor Notes

Correspondence Daniel S. Higginson: Memorial Sloan Kettering Cancer Center, New York, NY. higginsd@mskcc.org.

INCLUDE WHEN CITING Published online July 24, 2020; DOI: 10.3171/2020.4.SPINE20118.

R.J.R. and Y.L. contributed equally to this work.

Disclosures Dr. Lis is in the speakers bureau for Medtronic. Dr. Laufer is a consultant for DePuy/Synthes, Medtronic, Spine Wave, Globus, and Brainlab. Dr. Yamada is a consultant for Vision RT, Brainlab, Varian Medical Systems, and the University of Wollongong. He is also on the medical advisory board for the Chordoma Foundation.

  • 1

    Patchell RA, Tibbs PA, Regine WF, Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643648.

    • Search Google Scholar
    • Export Citation
  • 2

    Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol. 1978;3(1):4051.

    • Search Google Scholar
    • Export Citation
  • 3

    Katagiri H, Takahashi M, Inagaki J, Clinical results of nonsurgical treatment for spinal metastases. Int J Radiat Oncol Biol Phys. 1998;42(5):11271132.

    • Search Google Scholar
    • Export Citation
  • 4

    Maranzano E, Latini P, Perrucci E, Short-course radiotherapy (8 Gy x 2) in metastatic spinal cord compression: an effective and feasible treatment. Int J Radiat Oncol Biol Phys. 1997;38(5):10371044.

    • Search Google Scholar
    • Export Citation
  • 5

    Rades D, Fehlauer F, Schulte R, Prognostic factors for local control and survival after radiotherapy of metastatic spinal cord compression. J Clin Oncol. 2006;24(21):33883393.

    • Search Google Scholar
    • Export Citation
  • 6

    Rades D, Karstens JH, Alberti W. Role of radiotherapy in the treatment of motor dysfunction due to metastatic spinal cord compression: comparison of three different fractionation schedules. Int J Radiat Oncol Biol Phys. 2002;54(4):11601164.

    • Search Google Scholar
    • Export Citation
  • 7

    Rades D, Schild SE, Fehlauer F. Defining the best available treatment for neurocytomas in children. Cancer. 2004;101(11):26292632.

  • 8

    Maranzano E, Bellavita R, Rossi R, Short-course versus split-course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol. 2005;23(15):33583365.

    • Search Google Scholar
    • Export Citation
  • 9

    Barzilai O, Laufer I, Yamada Y, Integrating evidence-based medicine for treatment of spinal metastases into a decision framework: neurologic, oncologic, mechanicals stability, and systemic disease. J Clin Oncol. 2017;35(21):24192427.

    • Search Google Scholar
    • Export Citation
  • 10

    Laufer I, Rubin DG, Lis E, The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist. 2013;18(6):744751.

  • 11

    Cox BW, Spratt DE, Lovelock M, International Spine Radiosurgery Consortium consensus guidelines for target volume definition in spinal stereotactic radiosurgery. Int J Radiat Oncol Biol Phys. 2012;83(5):e597e605.

    • Search Google Scholar
    • Export Citation
  • 12

    Chan MW, Thibault I, Atenafu EG, Patterns of epidural progression following postoperative spine stereotactic body radiotherapy: implications for clinical target volume delineation. J Neurosurg Spine. 2016;24(4):652659.

    • Search Google Scholar
    • Export Citation
  • 13

    Redmond KJ, Sciubba D, Khan M, A phase 2 study of post-operative stereotactic body radiation therapy (SBRT) for solid tumor spine metastases. Int J Radiat Oncol Biol Phys. 2020;106(2):261268.

    • Search Google Scholar
    • Export Citation
  • 14

    Tseng C-L, Soliman H, Myrehaug S, 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). Int J Radiat Oncol Biol Phys. 2018;102(3):499507.

    • Search Google Scholar
    • Export Citation
  • 15

    Barzilai O, Amato M-K, McLaughlin L, Hybrid surgery-radiosurgery therapy for metastatic epidural spinal cord compression: a prospective evaluation using patient-reported outcomes. Neurooncol Pract. 2018;5(2):104113.

    • Search Google Scholar
    • Export Citation
  • 16

    Barzilai O, McLaughlin L, Amato M-K, Predictors of quality of life improvement after surgery for metastatic tumors of the spine: prospective cohort study. Spine J. 2018;18(7):11091115.

    • Search Google Scholar
    • Export Citation
  • 17

    Moussazadeh N, Laufer I, Yamada Y, Bilsky MH. Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals. Cancer Contr. 2014;21(2):168174.

    • Search Google Scholar
    • Export Citation
  • 18

    Bishop AJ, Tao R, Rebueno NC, Outcomes for spine stereotactic body radiation therapy and an analysis of predictors of local recurrence. Int J Radiat Oncol Biol Phys. 2015;92(5):10161026.

    • Search Google Scholar
    • Export Citation
  • 19

    Bilsky MH, Laufer I, Fourney DR, Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324328.

    • Search Google Scholar
    • Export Citation
  • 20

    Fehlings MG, Nater A, Tetreault L, Survival and clinical outcomes in surgically treated patients with metastatic epidural spinal cord compression: results of the prospective multicenter AOSpine study. J Clin Oncol. 2016;34(3):268276.

    • Search Google Scholar
    • Export Citation
  • 21

    Alghamdi M, Sahgal A, Soliman H, Postoperative stereotactic body radiotherapy for spinal metastases and the impact of epidural disease grade. Neurosurgery. 2019;85(6):E1111E1118.

    • Search Google Scholar
    • Export Citation
  • 22

    Al-Omair A, Masucci L, Masson-Cote L, Surgical resection of epidural disease improves local control following postoperative spine stereotactic body radiotherapy. Neuro Oncol. 2013;15(10):14131419.

    • Search Google Scholar
    • Export Citation
  • 23

    Bate BG, Khan NR, Kimball BY, Stereotactic radiosurgery for spinal metastases with or without separation surgery. J Neurosurg Spine. 2015;22(4):409415.

    • Search Google Scholar
    • Export Citation
  • 24

    Harel R, Emch T, Chao S, Quantitative evaluation of local control and wound healing following surgery and stereotactic spine radiosurgery for spine tumors. World Neurosurg. 2016;87:4854.

    • Search Google Scholar
    • Export Citation
  • 25

    Laufer I, Iorgulescu JB, Chapman T, Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine. 2013;18(3):207214.

    • Search Google Scholar
    • Export Citation
  • 26

    Puvanesarajah V, Lo SL, Aygun N, Prognostic factors associated with pain palliation after spine stereotactic body radiation therapy. J Neurosurg Spine. 2015;23(5):620629.

    • Search Google Scholar
    • Export Citation
  • 27

    Silva SR, Gliniewicz A, Martin B, Oligometastatic disease state is associated with improved local control in patients undergoing three or five fraction spine stereotactic body radiotherapy. World Neurosurg. 2019;122:e342e348.

    • Search Google Scholar
    • Export Citation
  • 28

    Tao R, Bishop AJ, Brownlee Z, Stereotactic body radiation therapy for spinal metastases in the postoperative setting: a secondary analysis of mature phase 1-2 trials. Int J Radiat Oncol Biol Phys. 2016;95(5):14051413.

    • Search Google Scholar
    • Export Citation
  • 29

    Sahgal A, Chang JH, Ma L, Spinal cord dose tolerance to stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys. 2019;pii:S0360-3016(19)33862-3.

    • Search Google Scholar
    • Export Citation
  • 30

    Benedict SH, Yenice KM, Followill D, Stereotactic body radiation therapy: the report of AAPM Task Group 101. Med Phys. 2010;37(8):40784101.

    • Search Google Scholar
    • Export Citation
  • 31

    Katsoulakis E, Jackson A, Cox B, A Detailed dosimetric analysis of spinal cord tolerance in high-dose spine radiosurgery. Int J Radiat Oncol Biol Phys. 2017;99(3):598607.

    • Search Google Scholar
    • Export Citation
  • 32

    Kim DWN, Medin PM, Timmerman RD. Emphasis on repair, not just avoidance of injury, facilitates prudent stereotactic ablative radiotherapy. Semin Radiat Oncol. 2017;27(4):378392.

    • Search Google Scholar
    • Export Citation

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