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What leads to decisions concerning stereotactic ablative radiotherapy application, patient selection, and personalized high-quality care for spinal metastases?
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.
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.
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.
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.
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.
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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Accepted for Publication: September 9, 2019.
Published Online: January 2, 2020. doi:10.1001/jamaoncol.2019.5351
Correction: This article was corrected on June 18, 2020, to fix a typographical error in the third paragraph of the Results, where an instance of “local failure” was incorrectly published as “local control.”
Corresponding Author: Fabio Y. Moraes, MD, Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, 25 King St W, Kingston, ON K7L 5P9, Canada (firstname.lastname@example.org).
Author Contributions: Dr Moraes had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Glicksman, Tjong, Neves-Junior, Berlin, Slotman, Shultz, Maldaun, Szerlip, Yamada, Vera-Badillo, Marta, Moraes.
Acquisition, analysis, or interpretation of data: Glicksman, Tjong, Spratt, K. L. M. Chua, Mansouri, M. L. K. Chua, Winter, Dahele, Bilsky, Maldaun, Lo, Marta, Moraes.
Drafting of the manuscript: Glicksman, Tjong, K. L. M. Chua, Mansouri, Winter, Maldaun, Yamada, Marta, Moraes.
Critical revision of the manuscript for important intellectual content: Glicksman, Tjong, Neves-Junior, Spratt, K. L. M. Chua, Mansouri, M. Chua, Berlin, Winter, Dahele, Slotman, Bilsky, Shultz, Maldaun, Szerlip, Lo, Vera-Badillo, Marta, Moraes.
Statistical analysis: Glicksman, K. L. M. Chua, Maldaun, Moraes.
Administrative, technical, or material support: Glicksman, Neves-Junior, K. L. M. Chua, M. L. K. Chua, Winter, Bilsky, Marta, Moraes.
Supervision: Spratt, Berlin, Slotman, Shultz, Maldaun, Lo, Yamada, Vera-Badillo, Moraes.
Conflict of Interest Disclosures: Dr Spratt reported receiving personal fees from Blue Earth and AstraZeneca outside of the submitted work. Dr K. L. M. Chua reported receiving personal fees from AstraZeneca and Varian Medical Systems and travel support from Brainlab. Dr M. L. K. Chua reported receiving personal fees from MSD, Illumina, Astellas Pharma, Inc, and Janssen Pharmaceutica, grants and personal fees from Ferring Pharmaceuticals, personal fees and nonfinancial support from Varian Medical Systems, grants from Sanofi Canada, and nonfinancial support from AstraZeneca, GenomeDx, BioScience, MedLever, and PVMed, Inc, outside the submitted work. Dr Dahele reported receiving research grants from Varian Medical Systems. Dr Lo reported being a member of the Elekta ICON Gamma Knife expert group. No other disclosures were reported.
Funding/Support: This study was supported by Clinician Scientist Award INV/0027/2018 from the National Medical Research Council and the Duke University-NUS Oncology Academic Clinical Programme Proton Research Fund (Dr M. L. K. Chua).
Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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