Vertebral Compression Fracture Rates after Stereotactic Radiosurgery for Spinal Metastases

Abstract Aim: Stereotactic ablative body radiotherapy (SABR) for spine metastases is associated with a risk of vertebral compression fracture (VCF). The aim of this study was to determine the rate of VCF at one UK institution and evaluate the use of the Spinal Instability Neoplastic Score (SINS) to predict these. Materials and methods: A retrospective analysis of all patients who underwent SABR for spinal metastases between 2014 and 2018 at one UK institution was performed. Basic demographic data were collected, and SINS prior to SABR was calculated. The primary outcome was VCF rate. Secondary outcomes included time to VCF and need for surgical intervention following VCF. Results: A total of 48 oligometastases were treated with a median follow-up of 20·5 months. A maximum of two vertebral bodies were treated. The median baseline SINS was calculated as 3. The median dose was 26 Gy in three fractions. Two patients were reported to have VCF and both were successfully conservatively managed. Findings: SABR for spine oligometastases is being performed safely with low VCF rates which are comparable with those in international publications. This may be as a result of strict adherence to criteria for delivery of SABR with low pre-treatment SINS.

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The impact of decompression with instrumentation on local failure following spine stereotactic radiosurgery

Journal of Neurosurgery Spine ◽

10.3171/2017.3.spine161015 ◽

2017 ◽

Vol 27 (4) ◽

pp. 436-443 ◽

Cited By ~ 3

Author(s):

Jacob A. Miller ◽

Ehsan H. Balagamwala ◽

Camille A. Berriochoa ◽

Lilyana Angelov ◽

John H. Suh ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Competing Risks ◽

Cumulative Incidence ◽

Vertebral Compression Fracture ◽

Compression Fracture ◽

Local Failure ◽

Control Group ◽

Spinal Decompression ◽

Grade 3 ◽

The Impact

OBJECTIVESpine stereotactic radiosurgery (SRS) is a safe and effective treatment for spinal metastases. However, it is unknown whether this highly conformal radiation technique is suitable at instrumented sites given the potential for microscopic disease seeding. The authors hypothesized that spinal decompression with instrumentation is not associated with increased local failure (LF) following SRS.METHODSA 2:1 propensity-matched retrospective cohort study of patients undergoing SRS for spinal metastasis was conducted. Patients with less than 1 month of radiographic follow-up were excluded. Each SRS treatment with spinal decompression and instrumentation was propensity matched to 2 controls without decompression or instrumentation on the basis of demographic, disease-related, dosimetric, and treatment-site characteristics. Standardized differences were used to assess for balance between matched cohorts.The primary outcome was the 12-month cumulative incidence of LF, with death as a competing risk. Lesions demonstrating any in-field progression were considered LFs. Secondary outcomes of interest were post-SRS pain flare, vertebral compression fracture, instrumentation failure, and any Grade ≥ 3 toxicity. Cumulative incidences analysis was used to estimate LF in each cohort, which were compared via Gray’s test. Multivariate competing-risks regression was then used to adjust for prespecified covariates.RESULTSOf 650 candidates for the control group, 166 were propensity matched to 83 patients with instrumentation. Baseline characteristics were well balanced. The median prescription dose was 16 Gy in each cohort. The 12-month cumulative incidence of LF was not statistically significantly different between cohorts (22.8% [instrumentation] vs 15.8% [control], p = 0.25). After adjusting for the prespecified covariates in a multivariate competing-risks model, decompression with instrumentation did not contribute to a greater risk of LF (HR 1.21, 95% CI 0.74–1.98, p = 0.45). The incidences of post-SRS pain flare (11% vs 14%, p = 0.55), vertebral compression fracture (12% vs 22%, p = 0.04), and Grade ≥ 3 toxicity (1% vs 1%, p = 1.00) were not increased at instrumented sites. No instrumentation failures were observed.CONCLUSIONSIn this propensity-matched analysis, LF and toxicity were similar among cohorts, suggesting that decompression with instrumentation does not significantly impact the efficacy or safety of spine SRS. Accordingly, spinal instrumentation may not be a contraindication to SRS. Future studies comparing SRS to conventional radiotherapy at instrumented sites in matched populations are warranted.

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Radiation-induced vertebral compression fracture following spine stereotactic radiosurgery: clinicopathological correlation

Journal of Neurosurgery Spine ◽

10.3171/2013.2.spine12739 ◽

2013 ◽

Vol 18 (5) ◽

pp. 430-435 ◽

Cited By ~ 56

Author(s):

Ameen Al-Omair ◽

Roger Smith ◽

Tim-Rasmus Kiehl ◽

Louis Lao ◽

Eugene Yu ◽

...

Keyword(s):

Tumor Progression ◽

Stereotactic Radiosurgery ◽

Vertebral Compression Fracture ◽

Compression Fracture ◽

Spinal Tumors ◽

High Dose ◽

Diagnostic Challenge ◽

New Era ◽

Radiation Induced ◽

Dose Radiation

Spine stereotactic radiosurgery (SRS) is increasingly being used to treat metastatic spinal tumors. As the experience matures, high rates of vertebral compression fracture (VCF) are being observed. What is unknown is the mechanism of action; it has been postulated but not confirmed that radiation itself is a contributing factor. This case report describes 2 patients who were treated with spine SRS who subsequently developed signal changes on MRI consistent with tumor progression and VCF; however, biopsy confirmed a diagnosis of radiation-induced necrosis in 1 patient and fibrosis in the other. Radionecrosis is a rare and serious side effect of high-dose radiation therapy and represents a diagnostic challenge, as the authors have learned from years of experience with brain SRS. These cases highlight the issues in the new era of spine SRS with respect to relying on imaging alone as a means of determining true tumor progression. In those scenarios in which it is unclear based on imaging if true tumor progression has occurred, the authors recommend biopsy to rule out radiation-induced effects within the bone prior to initiating salvage therapies.

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Factors Influencing Vertebral Compression Fracture Specific to Renal Cell Carcinoma Spinal Metastases After Stereotactic Body Radiation Therapy: A Multi-institutional Study

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2014.05.470 ◽

2014 ◽

Vol 90 (1) ◽

pp. S83 ◽

Cited By ~ 1

Author(s):

I. Thibault ◽

E.G. Atenafu ◽

E. Chang ◽

S. Chao ◽

A. Al-Omair ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Radiation Therapy ◽

Cell Carcinoma ◽

Renal Cell ◽

Vertebral Compression Fracture ◽

Stereotactic Body Radiation Therapy ◽

Spinal Metastases ◽

Compression Fracture ◽

Stereotactic Body Radiation ◽

Factors Influencing

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Clinical outcome of vertebral compression fracture after single fraction spine radiosurgery for spinal metastases.

Journal of Clinical Oncology ◽

10.1200/jco.2015.33.15_suppl.e13017 ◽

2015 ◽

Vol 33 (15_suppl) ◽

pp. e13017-e13017 ◽

Cited By ~ 1

Author(s):

Isabelle M. Germano ◽

Andrea Carai ◽

Seth Blacksburg ◽

Puneet Pawha ◽

yeh-Chi Lo ◽

...

Keyword(s):

Clinical Outcome ◽

Vertebral Compression Fracture ◽

Spinal Metastases ◽

Compression Fracture ◽

Single Fraction ◽

Spine Radiosurgery

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RADT-10. DEVELOPMENT AND INTERNAL VALIDATION OF A PREDICTIVE SCORE FOR VERTEBRAL COMPRESSION FRACTURE AFTER STEREOTACTIC BODY RADIATION THERAPY FOR SPINAL METASTASES

Neuro-Oncology ◽

10.1093/neuonc/noab196.168 ◽

2021 ◽

Vol 23 (Supplement_6) ◽

pp. vi43-vi43

Author(s):

Roman Kowalchuk ◽

Benjamin Johnson-Tesch ◽

Joseph Marion ◽

Trey Mullikin ◽

William Harmsen ◽

...

Keyword(s):

Radiation Therapy ◽

High Risk ◽

Vertebral Compression Fracture ◽

Stereotactic Body Radiation Therapy ◽

Cox Model ◽

Spinal Metastases ◽

Compression Fracture ◽

Predictive Score ◽

Internal Validation ◽

Stereotactic Body Radiation

Abstract PURPOSE Vertebral compression fracture (VCF) is a potential adverse effect following stereotactic body radiation therapy (SBRT) for spinal metastases. In this analysis, we developed and internally validated a risk stratification model for VCF. METHODS From an initial set of 680 treatments, we excluded those with proton therapy, prior surgical intervention, or missing data. The final dataset had 464 treatments in 313 patients. Delineations of VCF and all radiographic components of the spinal instability neoplastic score (SINS) were determined by a radiologist. Recursive partitioning analysis (RPA) was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was used as the criterion for node splitting. RESULTS With a median follow-up of 21 months, we identified 84 VCF (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median 9 months (IQR: 3 – 21) to VCF. From an initial set of 15 candidate variables, six were identified using the backwards selection method, feature importance testing, and a correlation heatmap. Four were then selected in the highest-fidelity RPA models: epidural tumor extension, lumbar location, gross tumor volume > 10 cc, and SINS > 6. One point was assigned to each variable, and the resulting multivariate Cox model had a concordance of 0.760. Each one point increase in score was associated with increasing rates of VCF. Low-risk lesions (score: 0-1, n=273) had 2-year freedom from VCF of 92%, compared to 80% for intermediate-risk (score: 2, n=99) and 56% (score: 3-4, n=92) for high-risk lesions (p < 0.0001). Cumulative incidence curves with death as a competing risk showed increased VCF with higher scores via Gray’s test (p < 0.001). CONCLUSIONS Our internally-validated model identifies a subgroup of patients with high risk for VCF who may benefit from prophylactic surgical stabilization or vertebroplasty.

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Vertebral compression fracture risk after stereotactic body radiotherapy for spinal metastases

Journal of Neurosurgery Spine ◽

10.3171/2011.11.spine116 ◽

2012 ◽

Vol 16 (4) ◽

pp. 379-386 ◽

Cited By ~ 131

Author(s):

Nicholas S. Boehling ◽

David R. Grosshans ◽

Pamela K. Allen ◽

Mary F. McAleer ◽

Allen W. Burton ◽

...

Keyword(s):

Risk Factors ◽

Median Time ◽

Stereotactic Body Radiotherapy ◽

Vertebral Compression Fracture ◽

Significant Risk ◽

Spinal Metastases ◽

Compression Fracture ◽

Time To Progression ◽

Average Pain

Object The aim of this study was to identify potential risk factors for and determine the rate of vertebral compression fracture (VCF) after intensity-modulated, near-simultaneous, CT image–guided stereotactic body radiotherapy (SBRT) for spinal metastases. Methods The study group consisted of 123 vertebral bodies (VBs) in 93 patients enrolled in prospective protocols for metastatic disease. Data from these patients were retrospectively analyzed. Stereotactic body radiotherapy consisted of 1, 3, or 5 fractions for overall median doses of 18, 27, and 30 Gy, respectively. Magnetic resonance imaging studies, obtained at baseline and at each follow-up, were evaluated for VCFs, tumor involvement, and radiographic progression. Self-reported average pain levels were scored based on the 11-point (0–10) Brief Pain Inventory both at baseline and at follow-up. Obesity was defined as a body mass index ≥ 30. Results The median imaging follow-up was 14.9 months (range 1–71 months). Twenty-five new or progressing fractures (20%) were identified, and the median time to progression was 3 months after SBRT. The most common histologies included renal cancer (36 VBs, 10 fractures, 10 tumor progressions), breast cancer (20 VBs, 0 fractures, 5 tumor progressions), thyroid cancer (14 VBs, 1 fracture, 2 tumor progressions), non–small cell lung cancer (13 VBs, 3 fractures, 3 tumor progressions), and sarcoma (9 VBs, 2 fractures, 2 tumor progressions). Fifteen VBs were treated with kyphoplasty or vertebroplasty after SBRT, with 5 procedures done for preexisting VCFs. Tumor progression was noted in 32 locations (26%) with 5 months' median time to progression. At the time of noted fracture progression there was a trend toward higher average pain scores but no significant change in the median value. Univariate logistic regression showed that an age > 55 years (HR 6.05, 95% CI 2.1–17.47), a preexisting fracture (HR 5.05, 95% CI 1.94–13.16), baseline pain and narcotic use before SBRT (pain: HR 1.31, 95% CI 1.06–1.62; narcotic: HR 2.98, 95% CI 1.17–7.56) and after SBRT (pain: HR 1.34, 95% CI 1.06–1.70; narcotic: HR 3.63, 95% CI 1.41–9.29) were statistically significant predictors of fracture progression. On multivariate analysis an age > 55 years (HR 10.66, 95% CI 2.81–40.36), a preexisting fracture (HR 9.17, 95% CI 2.31–36.43), and baseline pain (HR 1.41, 95% CI 1.05–1.9) were found to be significant risks, whereas obesity (HR 0.02, 95% CI 0–0.2) was protective. Conclusions Stereotactic body radiotherapy is associated with a significant risk (20%) of VCF. Risk factors for VCF include an age > 55 years, a preexisting fracture, and baseline pain. These risk factors may aid in the selection of which spinal SBRT patients should be considered for prophylactic vertebral stabilization or augmentation procedures. Clinical trial registration no.: NCT00508443.

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Evaluation of predictive factors of vertebral compression fracture after conventional palliative radiotherapy for spinal metastasis from colorectal cancer

Journal of Neurosurgery Spine ◽

10.3171/2017.6.spine17282 ◽

2018 ◽

Vol 28 (3) ◽

pp. 333-340 ◽

Cited By ~ 4

Author(s):

Jeongshim Lee ◽

Woo Joong Rhee ◽

Jee Suk Chang ◽

Sei Kyung Chang ◽

Woong Sub Koom

Keyword(s):

Colorectal Cancer ◽

Vertebral Compression Fracture ◽

De Novo ◽

Spinal Metastasis ◽

Multivariable Analysis ◽

Spinal Metastases ◽

Compression Fracture ◽

Palliative Radiotherapy ◽

Spinal Instability ◽

Spinal Segments

OBJECTIVEDelayed consequences of spinal radiotherapy (RT), including vertebral compression fracture (VCF), are critical complications. However, the predisposing factors that contribute to VCF after conventional RT are unclear. The aim of this study was to assess the incidence of VCF and to determine the predictors of VCF following conventional spinal RT specific to colorectal cancer (CRC).METHODSThe authors retrospectively reviewed 237 spinal segments (147 metastatic and 90 nonmetastatic) in 53 patients with CRC who underwent RT with a median total dose of 30 Gy in 10 fractions between January 2007 and December 2014. The primary end point was the development of a VCF following RT, either de novo VCF or the progression of a baseline VCF. VCFs were assessed using the spinal instability neoplastic score (SINS) criteria.RESULTSAmong all 237 spinal segments, 22 VCFs (9.3%) were observed following RT, including 13 de novo and 9 progressive fractures, and the median time to VCF was 4 months. All VCFs developed in metastatic spines. Among 147 metastatic spinal segments, 22 fractures were observed, with a 12-month cumulative incidence of VCF of 14.8%. Results of multivariable analysis indicated sex (p = 0.023) and SINS class II/III (p < 0.001) as risk factors related to development of a VCF in metastatic spinal segments. Among the SINS criteria, a lytic tumor and the presence of a baseline VCF were identified as predictors of VCF in metastatic spinal segments.CONCLUSIONSIn osteolytic or mixed lesions that were predominant in spinal metastases of CRC, the incidence of VCF was not negligible, even in patients treated with conventional spinal RT. This was especially evident in patients with spinal metastases with a SINS score ≥ 7. Presence of a baseline VCF after spinal RT is a predictor of VCF development and should be observed carefully.

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