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Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them?

ABSTRACT: Systematic literature review.To summarize the risks of 3 key complications of stereotactic body radiotherapy (SBRT) for spinal metastases, that is, radiation myelopathy (RM), vertebral compression fracture (VCF), and epidural disease progression, and to discuss strategies for minimizing them.RM, VCF and epidural disease progression are now recognized as important risks following SBRT for spine metastases. It is unclear at this stage exactly how large these risks are and what strategies can be employed to minimize these risks.A systematic review of the literature using MEDLINE and a review of the bibliographies of reviewed articles on SBRT for spinal metastases were conducted.The initial literature search revealed a total of 376 articles, of which 38 were pertinent to the study objectives. The risk of RM following SBRT was found to be dependent on the maximum dose to the spinal cord and estimated to be ?5% if the recommended published thecal sac dose constraints are adhered to. The crude risk of VCF was 13.7% (range: 0.7%-40.5%), and, on average, 45% were surgically salvaged. It has been shown that the risk of VCF is dependent on several anatomic and tumor-related factors including the SBRT dose per fraction. The crude risk of local failure at 1 year was 21.4% (range: 12%-27%) of which 67% (range: 38%-96%) occurred within the epidural space. The grade of epidural disease has been shown to be associated with the risk of local failure.The risk of RM after spinal SBRT is low in particular if recommended dose metrics are adhered to. There is a significant risk of both VCF and epidural disease progression after spinal SBRT. These risks can potentially be minimized by identifying the risk factors for these complications, and performing careful radiotherapy and surgical planning.2.

SUBMITTER: Chang JH

PROVIDER: S-EPMC5552170 | biostudies-literature | 2016 Oct

REPOSITORIES: biostudies-literature

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Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them?

Chang Joe H JH Shin John H JH Yamada Yoshiya J YJ Mesfin Addisu A Fehlings Michael G MG Rhines Laurence D LD Sahgal Arjun A

Spine 20161001

<h4>Study design</h4>Systematic literature review.<h4>Objectives</h4>To summarize the risks of 3 key complications of stereotactic body radiotherapy (SBRT) for spinal metastases, that is, radiation myelopathy (RM), vertebral compression fracture (VCF), and epidural disease progression, and to discuss strategies for minimizing them.<h4>Summary of background data</h4>RM, VCF and epidural disease progression are now recognized as important risks following SBRT for spine metastases. It is unclear at ...[more]

PMID: 27488294

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Project description:To report overall survival and local control for patients identified in the RSSearch® Patient Registry with metastatic cancer to the lung treated with SBRT.Seven hundred two patients were identified with lung metastases in the RSSearch® Registry. Of these patients, 577 patients had SBRT dose and fractionation information available. Patients were excluded if they received prior surgery, radiation, or radiofrequency ablation to the SBRT treated area. Between April 2004-July 2015, 447 patients treated with SBRT at 30 academic and community-based centers were evaluable for overall survival (OS). Three hundred four patients with 327 lesions were evaluable for local control (LC). All doses were converted to Monte Carlo equivalents and subsequent BED Gy10 for dose response analysis.Median age was 69 years (range, 18-93 years). Median Karnofsky performance status (KPS) was 90 (range 25/75% 80-100). 49.2% of patients had prior systemic therapy. Median metastasis volume was 10.58 cc (range 25/75% 3.7-25.54 cc). Site of primary tumor included colorectal (25.7%), lung (16.6%), head and neck (11.4%), breast (9.2%), kidney (8.1%), skin (6.5%) and other (22.1%). Median dose was 50 Gy (range 25/75% 48-54) delivered in 3 fractions (range 25/75% 3-5) with a median BED of 100Gy10 (range 25/75% 81-136). Median OS for the entire group was 26 months, with actuarial 1-, 3-, and 5-year OS of 74.1%, 33.3, and 21.8%, respectively. Patients with head and neck and breast cancers had longer median OS of 37 and 32 months respectively, compared to colorectal (30 months) and lung (26 months) which corresponded to 3-year actuarial OS of 51.8 and 47.9% for head and neck and breast respectively, compared to 35.8% for colorectal and 31.2% for lung. The median LC for all patients was 53 months, with actuarial 1-, 3-, and 5-year LC rates of 80.4, 58.9, and 46.3%, respectively. There was no difference in LC by primary histologic type (p?=?0.49). Improved LC was observed for lung metastases that received SBRT doses of BED ?100Gy10 with 3-year LC rate of 77.1% compared to 45% for lung metastases treated with BED?<?100Gy10 (p?=?0.01). Smaller tumor volumes (<11 cc) had improved LC compared to tumor volumes?>?11 cc. (p?=?0.005) Two-year LC rates for tumor volumes?<?11 cc, 11-27 cc and?>?27 cc were 72.9, 64.2 and 45.6%, respectively. This correlated with improved OS with 2-year OS rates of 62.4, 60.9 and 46.2% for tumor volumes?<?11 cc, 11-27 cc and?>?27 cc, respectively (p?=?0.0023). In a subset of patients who received BED ?100Gy10, 2-year LC rates for tumor volumes?<?11 cc, 11-27 cc and?>?27 cc were 82.8, 58.9 and 68.6%, respectively (p?=?0.0244), and 2-year OS rates were 66.0, 58.8 and 28.5%, respectively (p?=?0.0081).Excellent OS and LC is achievable with SBRT utilizing BED ?100Gy10 for lung metastases according to the RSSearch® Registry data. Patients with small lung metastases (volumes?<?11 cc) had better LC and OS when using SBRT doses of BED ?100Gy10. Further studies to evaluate a difference, if any, between various tumor types will require a larger number of patients.

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Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them?

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Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them?

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