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Stereotactic body radiotherapy for spine metastases: a review of 24 Gy in 2 daily fractions

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Abstract

Purpose

Stereotactic body radiotherapy (SBRT) has proven to be a highly effective treatment for selected patients with spinal metastases. Randomized evidence shows improvements in complete pain response rates and local control with lower retreatment rates favoring SBRT, compared to conventional external beam radiotherapy (cEBRT). While there are several reported dose-fractionation schemes for spine SBRT, 24 Gy in 2 fractions has emerged with Level 1 evidence providing an excellent balance between minimizing treatment toxicity while respecting patient convenience and financial strain.

Methods

We provide an overview of the 24 Gy in 2 SBRT fraction regimen for spine metastases, which was developed at the University of Toronto and tested in an international Phase 2/3 randomized controlled trial.

Results

The literature summarizing global experience with 24 Gy in 2 SBRT fractions suggests 1-year local control rates ranging from 83-93.9%, and 1-year rates of vertebral compression fracture ranging from 5.4-22%. Reirradiation of spine metastases that failed prior cEBRT is also feasible with 24 Gy in 2 fractions, and 1-year local control rates range from 72-86%. Post-operative spine SBRT data are limited but do support the use of 24 Gy in 2 fractions with reported 1-year local control rates ranging from 70-84%. Typically, the rates of plexopathy, radiculopathy and myositis are under 5% in those series reporting mature follow up, with no cases of radiation myelopathy (RM) reported in the de novo setting when the spinal cord avoidance structure is limited to 17 Gy in 2 fractions. However, re-irradiation RM has been observed following 2 fraction SBRT. More recently, 2-fraction dose escalation with 28 Gy, with a higher dose constraint to the critical neural tissues, has been reported suggesting improved rates of local control. This regimen may be important in those patients with radioresistant histologies, high grade epidural disease, and/or paraspinal disease.

Conclusion

The dose-fractionation of 24 Gy in 2 fractions is well-supported by published literature and is an ideal starting point for centers looking to establish a spine SBRT program.

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Data availability

The datasets generated and analysed during the current study are available from the corresponding author on request.

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The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada

    Eric K. Nguyen, Mark Ruschin, Beibei Zhang, Hany Soliman, Sten Myrehaug, Jay Detsky, Hanbo Chen, Arjun Sahgal & Chia-Lin Tseng

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  1. Eric K. Nguyen
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  2. Mark Ruschin
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Contributions

All authors contributed to the study conception and design. Literature search, article review, data abstraction and analysis were performed by EKN and CLT. The first draft of the manuscript was written by EKN and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Chia-Lin Tseng.

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MR owns intellectual property related to the image-guidance component on the Elekta Gamma Knife system. HS has travel and education grants from Elekta. SM has research support and honoraria from AAA/Novartis and Ipsen. AS is an advisor/consultant with Abbvie, Merck, Roche, Varian, Elekta, BrainLAB and VieCure, is a board member of the International Stereotactic Radiosurgery Society, has had past educational seminars with Elekta, Accuray Inc., Varian, BrainLAB, Medtronic Kyphon, received research grants with Elekta and Travel accommodations/expenses by Elekta, Varian, BrainLAB and belongs to the Elekta MR Linac Research Consortium, Elekta Spine, Oligometastases and Linac Based SRS Consortia. CLT is an advisor/consultant with Abbvie and Sanofi, has received travel accommodations/expenses & honoraria for past educational seminars by Elekta and belongs to the Elekta MR-Linac Research Consortium.

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Nguyen, E.K., Ruschin, M., Zhang, B. et al. Stereotactic body radiotherapy for spine metastases: a review of 24 Gy in 2 daily fractions. J Neurooncol 163, 15–27 (2023). https://doi.org/10.1007/s11060-023-04327-1

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