Summary Background This study investigated the clinical benefit of using hypofractionated stereotactic body radiotherapy (SBRT) to manage spinal metastases in patients with cancer and to reduce cancer-related symptoms. Methods Cancer patients (n=149) with mechanically stable, non–cord-compressing, spinal metastases (n=166) were treated by SBRT in a phase I/II study. Patients received a total dose of 27–30 Gy, typically in three fractions. Symptoms were measured repeatedly by the Brief Pain Inventory (BPI) and the M. D. Anderson Symptom Inventory (MDASI). The primary endpoint was to establish the safety, feasibility, and efficacy of using a CT-on-Rails or Trilogy Stereotactic Spine Radiation Therapy system to treat spinal and paraspinal tumors and to document pain relief and toxicity associated with such treatment. Symptom outcomes were estimated according to protocol using descriptive analysis and ordinal regression modeling. This is the final report for the completed enrollment and follow-up. Findings The median follow-up time was 15·9 (interquartile range 9·5–30·3) months and the mean was 20·9 (SD=17·1) months. The actuarial tumor progression-free survival rates at one year and two years post-SBRT were 80·5% and 72·4%, respectively. Patients reported significant MDASI pain reduction (p=0·00003) during the six months post-SBRT. Patients reporting no pain from bone metastases on the BPI increased from 39/149 (26·2%) before SBRT to 55/102 (53·9%) six months post-SBRT (p<0·0001). BPI pain reduction from baseline to four weeks post-SBRT was clinically meaningful (effect size=0·47, p<0·01). These improvements were accompanied by significant reduction in opioid use during the six months post-SBRT (p<0·05) and a significant reduction in MDASI symptom interference with daily life (p<0·01).. Only a few instances of nonneurological grade 3 toxicities occurred (one report each of nausea, vomiting, diarrhea, fatigue, dysphagia, neck pain, diaphoresis, two reports of pain associated with severe tongue edema and trismus, and 3 reports of noncardiac chest pain). No grade 4 toxicities occurred. Interpretation SBRT is an effective primary or salvage treatment of mechanically stable spinal metastasis. Significant reduction in patient-reported pain and other symptoms was evident six months post-SBRT, along with satisfactory progression-free survival and no late spinal cord toxicities.

BACKGROUND The current retrospective study was undertaken to evaluate the treatment outcomes of patients with meningeal hemangiopericytoma (M‐HPC), to define the role of radiotherapy in the management of the disease, and to report on the patterns of failure. METHODS The medical records of 29 patients with nonmetastatic M‐HPC treated at The University of Texas M. D. Anderson Cancer Center (Houston, TX) between August 1979 and March 1999 were reviewed. Fifteen patients (52%) underwent macroscopic total resection (‘gross total resection’ [GTR]), 10 (34%) underwent subtotal resection (STR), and 4 (14%) had unknown extent of surgery. Ten of 24 patients received adjuvant radiotherapy. RESULTS The 5, 10, and 15‐year overall survival rates were 85%, 68%, and 43%, respectively. The local control rates at 5 and 10 years were 68% and 22%, respectively. Two patients experienced disease recurrence at another intracranial site. Sixteen patients (55%) developed extraneural metastases. Four patients (14%) developed spinal metastases. The 5‐, 10‐, and 15‐year distant metastasis–free survival rates were 80%, 46%, and 21%, respectively. The 5‐year local control rates for patients treated with GTR and STR were 84% and 38%, respectively (P = 0.003). Of the 15 patients treated with GTR, 3 received adjuvant radiotherapy as part of their initial treatment. Malignant disease did not recur locally in these three patients. However, the effect of the adjuvant radiotherapy on local control was not statistically significant. CONCLUSIONS M‐HPCs can recur locally or distantly in the neural axis or as extraneural distant metastases. Based on literature review and the patterns of failure in the current series, attempting to perform GTR followed by limited‐field radiotherapy appeared to represent a reasonable approach for the initial management of M‐HPC. Cancer 2004;100:1491–7. © 2004 American Cancer Society.

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In recent decades, there has been substantial growth in our understanding of the immune system and its role in tumor growth and overall survival. A central finding has been the cross-talk between tumor cells and the surrounding environment or stroma. This tumor stroma, comprised of various cells, and extracellular matrix (ECM), has been shown to aid in suppressing host immune responses against tumor cells. Through immunosuppressive cytokine secretion, metabolic alterations, and other mechanisms, the tumor stroma provides a complex network of safeguards for tumor proliferation. With recent advances in more effective, localized treatment, radiation therapy (XRT) has allowed for strategies that can effectively alter and ablate tumor stromal tissue. This includes promoting immunogenic cell death through tumor antigen release to increasing immune cell trafficking, XRT has a unique advantage against the tumoral immune evasion mechanisms that are orchestrated by stromal cells. Current studies are underway to elucidate pathways within the tumor stroma as potential targets for immunotherapy and chemoradiation. This review summarizes the effects of tumor stroma in tumor immune evasion, explains how XRT may help overcome these effects, with potential combinatorial approaches for future treatment modalities.