Stereotactic body radiation therapy for spinal metastases: a novel local control stratification by spinal region

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  • 1 Radiosurgery Center, Riverside Regional Medical Center (in partnership with University of Virginia Health System), Newport News;
  • 2 Departments of Radiation Oncology and
  • 4 Neurosurgery, University of Virginia Health System, Charlottesville; and
  • 3 Department of Neurosurgery, Riverside Regional Medical Center, Newport News, Virginia
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OBJECTIVE

This study evaluated a large cohort of patients treated with stereotactic body radiation therapy for spinal metastases and investigated predictive factors for local control, local progression-free survival (LPFS), overall survival, and pain response between the different spinal regions.

METHODS

The study was undertaken via retrospective review at a single institution. Patients with a tumor metastatic to the spine were included, while patients with benign tumors or primary spinal cord cancers were excluded. Statistical analysis involved univariate analysis, Cox proportional hazards analysis, the Kaplan-Meier method, and machine learning techniques (decision-tree analysis).

RESULTS

A total of 165 patients with 190 distinct lesions met all inclusion criteria for the study. Lesions were distributed throughout the cervical (19%), thoracic (43%), lumbar (19%), and sacral (18%) spines. The most common treatment regimen was 24 Gy in 3 fractions (44%). Via the Kaplan-Meier method, the 24-month local control was 80%. Sacral spine lesions demonstrated decreased local control (p = 0.01) and LPFS (p < 0.005) compared with those of the thoracolumbar spine. The cervical spine cases had improved local control (p < 0.005) and LPFS (p < 0.005) compared with the sacral spine and trended toward improvement relative to the thoracolumbar spine. The 36-month local control rates for cervical, thoracolumbar, and sacral tumors were 86%, 73%, and 44%, respectively. Comparably, the 36-month LPFS rates for cervical, thoracolumbar, and sacral tumors were 85%, 67%, and 35%, respectively. A planning target volume (PTV) > 50 cm3 was also predictive of local failure (p = 0.04). Fewer cervical spine cases had disease with PTV > 50 cm3 than the thoracolumbar (p = 5.87 × 10−8) and sacral (p = 3.9 × 10−3) cases. Using decision-tree analysis, the highest-fidelity models for predicting pain-free status and local failure demonstrated the first splits as being cervical and sacral location, respectively.

CONCLUSIONS

This study presents a novel risk stratification for local failure and LPFS by spinal region. Patients with metastases to the sacral spine may have decreased local control due to increased PTV, especially with a PTV of > 50 cm3. Multidisciplinary care should be emphasized in these patients, and both surgical intervention and radiotherapy should be strongly considered.

ABBREVIATIONS BED = biologically effective dose; KPS = Karnofsky Performance Status; LPFS = local progression-free survival; PTV = planning target volume; SBRT = stereotactic body radiation therapy.

Supplementary Materials

    • Supplemental Figs. 1–3 (PDF 1.51 MB)

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Contributor Notes

Correspondence Roman O. Kowalchuk: Riverside, Radiosurgery Center, Newport News, VA. roman.kowalchuk@rivhs.com; okowal17@gmail.com.

INCLUDE WHEN CITING Published online October 23, 2020; DOI: 10.3171/2020.6.SPINE20861.

Disclosures The wife of Dr. Kowalchuk is a senior technical product manager at GE Healthcare.

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