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SPINE SBRT: The MSKCC Spine Service IAEA Singapore SBRT Symposium

SPINE SBRT: The MSKCC Spine Service IAEA Singapore SBRT Symposium. Josh Yamada MD FRCPC Mark Bilsky MD Departments of Radiation Oncology and Neurosurgery Memorial Sloan Kettering Cancer Center NY NY USA. Disclosures. Varian Medical Systems Consultant

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SPINE SBRT: The MSKCC Spine Service IAEA Singapore SBRT Symposium

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  1. SPINE SBRT: The MSKCC Spine ServiceIAEA Singapore SBRT Symposium • Josh Yamada MD FRCPC • Mark Bilsky MD • Departments of Radiation Oncology and Neurosurgery • Memorial Sloan Kettering Cancer Center • NY NY USA

  2. Disclosures Varian Medical Systems Consultant Continuing Medical Education Institute Speakers Bureau

  3. MSKCC Spine Service Radiation Oncology Josh Yamada, M.D. Radiology Eric Lis, M.D. George Krol, M.D. Sasan Karimi, M.D. Pierre Gobin, M.D. Athos Patsilides, M.D. Orthopedic Surgery Patrick Boland, M.D. Neurosurgery Mark Bilsky, M.D. Ilya Laufer, M.D. Neurology Edward Avila, D.O. Xi Chen, M.D. Sonia Sandhu, D.O Pain Roma Tickoo, M.D. Kenneth Cubert, M.D. Vinay Puttaniah, M.D. Amitabh Gulati, M.D. Physiatry Michael Stubblefield,M.D. Jonas Sokolof, D.O. Christian Custodio, M.D. PT/OT Nursing Joan Zatcky, NP Cynthia Correa, RN Ruth Gargan-Klinger, NP Jane Yoffe, NP Solange Inglis, NP Marie Marte, NP

  4. Goals of TreatmentMulti-disciplinary Approach • Metastasis • Palliation • Pain Control • Neurology • Oncology • Mechanical Stability

  5. The Spine Service at MSKCC: Multidisciplinary Care • Spine oncology requires multidisciplinary care • Spine conference • All physicians in the hospital bring their spine patient questions for multidisciplinary assessment—meets weekly • Spine clinic • Joint clinic with neurosurgery, interventional radiology and radiation oncology • NOMS assessment

  6. Treatment ConsiderationsNOMS1,2 • Neurologic • Oncologic • Mechanical Stability • Systemic disease • Systemic Therapy • Radiation Therapy • Surgery vs. 1Bilsky MH, Smith M. Surgical approach to epidural spinal cord compression. Hematology/Oncology Clinics of North America.;20(6):1307-1317, 2006 2Bilsky MH, Azeem S. The NOMS framework for decision making in metastatic cervical spine tumors. Current Opinions in Orthopedics 2007;18(3):263-269.

  7. Options for TherapyMulti-disciplinary Approach • Systemic Therapy • Chemo/Immuno-/Hormonal therapy • Targeted Therapy • Radiation Therapy • Conventional EBRT (30 Gy in 10 fractions) • Image-guided intensity modulated RT • Hypofractionated RT (10 Gy x 3) • Single Fraction RT (24 Gy) • Brachytherapy: p32 plaque • Surgery • Percutaneous Cement Augmentation • Open: Anterior, Posterolateral, Combined • En bloc resection for margins

  8. Presentation • Three Predominant Pain Syndromes: • Biologic • Mechanical • Radiculopathy • Myelopathy • Significant treatment implications

  9. Presentation • Biologic pain • Indicative of bone pathology • Predominant pain syndrome (95%) • Night or morning pain that resolves over the course of the day • Mechanism: Diurnal variation in endogenous steroid secretion • Treatment: Steroids/RT

  10. Presentation • Mechanical Pain • Indicative of bone pathology • Movement-related pain • Level dependent • AA: Flexion/extension/rotation • SAC: Flexion/extension • Thoracic: Extension • Lumbar: Mechanical Radiculopathy • Radiographic correlates • Treatment: Surgery or Kyphoplasty followed by RT

  11. Presentation • Radiculopathy • Indicative of neuroforaminal disease • Differentiate from the following: • Bone lesion (eg. L3 vs. femur fracture) • Neuropathy • Brachial/Lumbosacral Plexus Tumor • Leptomeningeal Tumor • Treatment: Dependent on tumor histology and degree of ESCC, often RT in absence of instability

  12. Presentation • Myelopathy: • Indicative of high-grade ESCC • Spinothalamic tracts (Pinprick) • Corticospinal tracts (Motor) • Posterior Columns (Proprioception) • Autonomic (Bowel and Bladder) • Neurogenic vs. other (eg. narcotics) • Perineal numbness • Conus medullaris or sacrum • Other spinal levels: Significant degree of paralysis • Treatment: Dependent on the radiosensitivity of the tumor

  13. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology • Radiation or Chemosensitivity • Mechanical Instability • Systemic Disease and Medical Co-morbidity

  14. NOMS O: Radiation Sensitivity 0 1 N:ESCC 2 3

  15. NOMS O:Radiation Sensitivity 0 1 N: ESCC 2 3 cEBRT 30 Gy in 3 Gy/fraction

  16. NOMS O: Radiation Sensitivity 0 1 N:ESCC 2 3 SRS

  17. NOMS O: Radiation Sensitivity 0 1 N:ESCC 2 3 Surgery + SRS

  18. Histologic ClassificationRadiosensitivity to cEBRT (30 Gy in 10) Responses: F-Favorable, I-Intermediate, U-Unfavorable Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and outcomes. Spine 34(22S):S78-92, 2009

  19. Local Control Histology 413 patients

  20. Radiosurgery Recommendations A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of oligometastatic disease and/or radioresistant histology in which no relative contraindications exist. Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and outcomes. Spine 34(22S):S78-92, 2009

  21. CaseSolitary T10 RCC

  22. RCC/MelanomaStereotactic Radiosurgery • 80 patients • 2004-2008 • SSRS 18 to 24 Gy x 1 • Imaging and PE q 4 months • Radiographic/Symptom Control: 92% • Trend towards better control at 24 Gy: • 97% vs. 83% Thiagaragan A, et.al. Stereotactic radiosurgery: A new paradigm For melanoma and renal cell carcinoma spine metastases. Presented ASCO, 2010

  23. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: RCC • Radiation or Chemosensitivity • Mechanical Instability • Systemic Disease and Medical Co-morbidity

  24. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression: ESCC 1b • Oncologic • Tumor Histology: RCC • Radiation: Sensitive to SRS • Mechanical Stability: Stable • Systemic Disease and Medical Co-morbidity SRS

  25. RCC SRS:24 Gy, Cord dMax:14Gy f/u 26 months Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.

  26. RCC A strong recommendation is made that patients with solid renal cell carcinoma in the absence of epidural disease may benefit from stereotactic radiosurgery as first line therapy rather than en bloc excision. SRS:24 Gy, Cord dMax:14Gy f/u 26 months Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.

  27. NOMS O: Radiation Sensitivity 0 1 N:ESCC 2 3 Surgery + SRS

  28. SRS and High-Grade ESCC 7 local failures received <15 Gy to small percentage of PTV Currently, dMax Cord <14 Gy with 10% per mm falloff: Cytotoxic tumoral dose risks overdosing the spinal cord Subtherapeutic dose that spares spinal cord tolerance risks epidural tumor progression Resolution of soft tissue disease can take months: No effective decompression of epidural disease Caveat: SRS for RT-sensitive disease (Median 16Gy)1 Under-dosed sub-volume Cord Tumor (gross target volume) Tumor (gross target volume) Prescription isodose 1Ryu S., et.al Radiosurgical decompression of metastatic epidural compression. Cancer 116(9): 2250, 2010

  29. Neurologic Oncologic Assessment • Prospective randomized trial • Solid tumors • HG-ESCC with myelopathy • Surgery + cEBRT vs. cEBRT alone • Exclusion criteria • RT-sensitive tumors ie. Hematologic malignancies and GCT • Multi-level disease • Systemic contraindications to surgery RA Patchell, et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 366: 643, 2005

  30. Results RA Patchell, et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 366: 643, 2005

  31. Results Evidence-based Recommendations (GRADE methodology) : A strong recommendation is made for patients with high-grade spinal cord compression due to solid tumor malignancy undergo surgical decompression and stabilization followed by RT.1 Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease. Spine 34(22S): S101-S107, 2009

  32. Radiosurgery Recommendations A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of oligometastatic disease and/or radioresistant histology in which no relative contraindications exist. Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and outcomes. Spine 34(22S):S78-92, 2009

  33. Postoperative Adjuvant Radiation • 101 patients/106 metastases operated between1977 to 1996 • Surgery: • Posterolateral: 79% • Anterior: 12% • Combined Anterior/Posterior: 9% • Partial (48%) or Complete Resection (43%): 91% • Adjuvant Treatment: 100% • Local Control: 40% @ 6 months • 30% @ 1 year • 4% @ 4 years • Significant Predictors of Recurrence: • Ambulation, Tumor Histology, Completeness of Resection Klekamp J, Samii. Surgical results for spinal metastases. Acta Neurochir (Wien) 140 (9):957-967, 1998

  34. Postoperative Adjuvant Radiation • MSKCC Data: 21 patients • RT-resistant tumors: 100% • Melanoma • Renal Cell Carcinoma • Sarcoma • Colorectal Carcinoma • Surgical Indication: • High Grade ESCC (Grade 2 or 3): 96% • Mechanical Radiculopathy: 4% • SRS Single Fraction: 18 to 24 Gy • GTV contoured to the preoperative tumor volume • Myelogram/CT Moulding, et.al. Local disease control after decompressive surgery and high-dose single fraction radiation for spine metastases. J Neurosurg Spine 13(1): 87-93, 2010

  35. Local Control Surgery + SRS LD:40% HD:94% Moulding, et.al. Local disease control after decompressive surgery and adjuvant high-dose single fraction radiation for spine metastases. J Neurosurg Spine 13(1): 87-93, 2010

  36. Local Control Separation Surgery + SRS 192 pts. SRS: 90% Hypo LD:78% Hypo HD: 95.8%

  37. “Separation Surgery” + SRS 86 year old Papillary thyroid ASIA C Absent proprioception N: HG ESCC O: RT-resistant M: Stable S: Tolerable

  38. “Separation Surgery” + SRS

  39. RCCEn bloc excision • Published literature: • 6 case series:15 patients • Operative times: 8 to 12 hours • Transfusion data: Melcher • - PRBC-15.7units/FFP-20units • No complications reported • Recurrences:13% • Median follow-up 16 months Bilsky M, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009. 2

  40. “Separation Surgery” + SRS • SST post RT/Chemo • Tumor progression with instability • T3 vertebral body • Massive brachial plexus • N: ESCC 2 Radiculopathy/plexopathy • O: Resistant • M: Unstable • S: Tolerate an operation

  41. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: RCC • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity

  42. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: RCC • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity

  43. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: RCC • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity • High-dose steroids • Embolization

  44. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: RCC • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity • Posterolateral decompression • Instrumentation /SRS + /- p32 plaque

  45. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: Lymphoma • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity

  46. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: Lymphoma • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity • High-dose steroids • cEBRT (30 Gy in 10 fractions)

  47. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: Unknown • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity

  48. NOMS Assessment • Neurologic • Myelopathy • Functional Radiculopathy • Degree of epidural spinal cord compression • Oncologic • Tumor Histology: Unknown • Radiation or Chemosensitivity • Mechanical Stability • Systemic Disease and Medical Co-morbidity • High-dose steroids • Establish RT-sensitive: RT • No Dx: Surgery

  49. NOMechanical InstabilityS • Recognition of instability as an indication for surgery or percutaneous cement augmentation prior to RT • Spine Oncology Study Group (SOSG) created a scoring system Spine Instability Neoplastic Score or SINS1 -Integrates systematic literature review with expert opinion -Reliable: High inter and intra-relater reliability2 -Valid: Substantial agreement between SINS score and expert opinion2 1Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine. 2010;35(22):E1221-9. 2Fourney DR, et al. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol 2011;29(22):3072-71 .

  50. Spine Instability Neoplastic Score (SINS) Tallied Score from 6 components Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

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