Stereotactic Body Radiotherapy (SBRT) for Spinal/Para-Spinal Metastases (Spine SBRT)

• To determine prospective pain and functional outcome data using the Brief Pain Inventory questionnaire [ Time Frame: 5 years ] [ Designated as safety issue: No ]
• To prospectively document quality of life outcomes for patients post-SBRT using the validated EORTC QLQ - BM22 and C-15 PAL [ Time Frame: 5 years ] [ Designated as safety issue: No ]
• To determine pain flare prospective data by using the Pain Diary for first 10 days after radiation. [ Time Frame: 5 years ] [ Designated as safety issue: No ]
• To prospectively evaluate neurologic outcomes using the ASIA questionnaire [ Time Frame: 5 years ] [ Designated as safety issue: No ]
• To evaluate acute and late toxicity of RT using NCIC Common Toxicity Criteria v. 3.0 [ Time Frame: 5 years ] [ Designated as safety issue: No ]

Spine SBRT is currently being practiced as an alternative to conventional wide-field radiation in the up-front management of spinal metastases, in the re-irradiation scenario, and in the post-operative setting. This study proposes to treat patients with a uniform spine SBRT approach, and collect prospective outcome data as a basis for future randomized trial design. Preliminary evaluation of our technique has yielded acceptable accuracy in treatment delivery as compared to the literature, and our practice follows current standards in major university hospitals performing this technique. Furthermore, preliminary data also suggest efficacy and safety for patients treated with SBRT for spinal metastases in a previously radiated field. However, well defined prospective outcomes are lacking in this patient group.

There a 3 cohorts for this study each with a target accrual of 30 patients. Cohort 1: patients with spinal metastases and no prior radiation. These patients will be treated with either 20-24 Gy in one fraction (recommended); 20-24 Gy in two fractions; or 20-24 Gy in three fractions. Cohort 2: patients with spinal metastases with a history of previous radiation to the affected spinal segment. These patients will be treated with either 20-24 Gy in one fraction (recommended), or 20-24 Gy in two fractions, or 20-24 Gy in three fractions. Cohort 3: post-operative patients with spinal metastases with or without a history of previous radiation to the affected spinal segment. These patients will be treated with either 20-24 Gy in one fraction (recommended) or 20-24 Gy in two fractions, or 20-24 Gy in three fractions. There is also and optional imaging component of this study.

• Experimental: Radiotherapy Alone
  Intervention: Radiation: Stereotactic Body Radiotherapy (SBRT)
• No Intervention: No Radiotherapy
• Experimental: Radiotherapy plus Surgery
  Intervention: Radiation: Stereotactic Body Radiotherapy (SBRT)
• No Intervention: Surgery Alone

Inclusion Criteria:

• Solitary or oligometastatic spine disease (maximum 5 sites of metastases), or bone only metastatic disease (regardless of the number) in otherwise high performance status patients, or patients with diffuse metastatic disease where the patient survival is expected to be at least 6 months
• Maximum of 2 consecutive spinal segments involved by tumor for treatment otherwise a maximum of 3 sites within the spine to be treated in a single session
• Previously irradiated: up to one course where the maximum BED previously delivered is no more than 100 Gy2 (50 Gy2/2) and >5 month interval from prior radiation to planned SBRT (Cohort 2) or first part of cohort 3
• Patient refusal or medical co-morbidities precluding surgery
• Karnosfky Performance Status >60
• Had an MRI or CT documented spinal tumor and MRI of full spine no more than 3 weeks prior to SBRT (if patients cannot have a MRI then a CT myelogram is required)
• Had a histological confirmation of neoplastic disease
• Expected to have survival of > 3 months regardless of the number of metastases
• Able to lie still and in a supine position on the treatment couch for up to 1 hour
• Age >18
• Able to provide written informed consent
• Adequate Bowel or urinary function

Exclusion Criteria:

• A Pacemaker such that MRI cannot be performed or the treatment cannot be delivered safely
• Scleroderma or connective tissue disease as a contra-indication to radiotherapy
• Unable to lie supine (i.e. tolerate treatment)
• Previously treated with 89Sr or systemic chemotherapy within 30 days prior to SBRT
• Had external beam radiotherapy to the same area less than 5 months prior to SBRT and/or a course of radiation previously delivered >100 Gy2 (50 Gy2/2)
• Significant or progressive neurologic deficit
• Malignant epidural spinal cord compression or cauda equina syndrome
• Spine instability, or neurological deficit resulting from bony compression of neural structures
• Receiving chemotherapy for at least 1 week prior to SBRT and chemotherapy for one week following SBRT
• Expected patient survival < 3 months