Stereotactic Radiosurgery for Postoperative Spine Malignancy: A Systematic Review and International Stereotactic Radiosurgery Society Practice Guidelines

Abstract

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Neoadjuvant Arterial Embolization of Spine Metastases Associated With Improved Local Control in Patients Receiving Surgical Decompression and Stereotactic Body Radiotherapy

“…A 1-year LC rate of 94% with the addition of preoperative embolization exceeds the rates previously reported by studies demonstrating the benefits of SBRT after surgical decompression. 9,11-16 The significantly enhanced LC remained durable at 24 months postoperatively.…”

“…With the development of SBRT, LC rates have significantly improved compared with treatment with conventional radiation therapy with estimates claiming that SBRT with surgery achieves 1-year LC rates as high as 85% to 90%. 9,11-16 Blakaj and Palmer et al 2 identified the ideal timing for adjuvant SBRT for spine metastases observing improved LC among patients receiving SBRT within 40 days postoperatively. Incidentally, in a multivariate analysis, preoperative embolization was associated with enhanced LC among patients treated with surgical decompression and adjuvant SBRT.…”

“…Surgery in conjunction with postoperative radiation is an established treatment paradigm that decreases neurological morbidity and improves LC compared with radiation alone. 1,2,9,[11][12][13][14][15][16] Currently, preoperative embolization of spine metastases is considered a surgical adjunct to mitigate blood loss in spine metastases from hypervascular primary malignancies. However, recent multivariate analysis elucidated an association between preoperative spinal embolization and enhanced LC in patients treated with surgical decompression and adjuvant SBRT.…”

“…Finally, the 94% 1-year LC observed in our study surpasses that of previously reported surgery plus SBRT studies suggesting a synergistic response. 9,[11][12][13][14][15][16]…”

30 Gy in 4 Stereotactic Body Radiotherapy Fractions for Complex Spinal Metastases: Mature Outcomes Supporting This Novel Regimen

“…Fractionated SBRT is also more common in the postoperative spine SBRT literature as a strategy to limit toxicity and wound breakdown because a large surgical bed is typically incorporated in the clinical target volume (CTV). [17][18][19] Reducing the dose per fraction also mitigates the risk of vertebral compression fracture (VCF) 20 ; however, to maintain the ablative treatment intent, the total dose is escalated as the number of fractions increases. Finally, patients undergoing reirradiation may also be at an increased risk of radiation-induced myelopathy (RM) after 1-to 2-fraction SBRT, given that the risk of late adverse effects increases with the dose per fraction; therefore, more fractionated courses of SBRT are typically applied in these situations.…”