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Review
January 2, 2020

Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases: A Review

Author Affiliations
  • 1Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil
  • 3Department of Radiation Oncology, University of Michigan, Ann Arbor
  • 4Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
  • 5Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
  • 6Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
  • 7Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
  • 8Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
  • 9Department of Neurosurgery, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
  • 10Division of Neurosurgery, Hospital Sírio-Libanês, São Paulo, Brazil
  • 11Department of Neurosurgery, University of Michigan, Ann Arbor
  • 12Department of Radiation Oncology, University of Washington School of Medicine, Seattle
  • 13Department of Radiation Oncology, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
  • 14Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
  • 15Division of Radiation Oncology, Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
  • 16Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
JAMA Oncol. Published online January 2, 2020. doi:10.1001/jamaoncol.2019.5351
Key Points

Question  What leads to decisions concerning stereotactic ablative radiotherapy application, patient selection, and personalized high-quality care for spinal metastases?

Findings  In this review of 5655 patients who underwent SABR for spinal metastases in 59 unique studies, optimal patient selection and stereotactic ablative radiotherapy were associated with high rates of local tumor control with moderate rates of adverse effects.

Meaning  This study suggests that spinal stereotactic ablative radiotherapy is an effective treatment option for well-selected patients with spinal metastases; future studies might explore the potential for broader applications of spinal stereotactic ablative radiotherapy and enhanced personalization of care.

Abstract

Importance  Rising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application.

Objective  To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies.

Evidence Review  The MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases.

Results  Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease.

Conclusions and Relevance  These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.

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