Oncological outcomes and safety after spinal reirradiation with stereotactic body radiotherapy

Spinal metastases pose a significant challenge in oncology, with incidence rates increasing alongside improved survival rates. Radiation therapy (RT) has played a crucial role in managing spinal disease progression and reducing associated neurological morbidity. However, management of spinal metastases for which prior RT failed is challenging, and there are limited data regarding the safety and efficacy of stereotactic body radiotherapy (SBRT) for reirradiation. The authors present the largest series to date of patients undergoing SBRT for reirradiation of spinal metastases.

The medical records of patients treated with spine SBRT for reirradiation at a target that overlapped or abutted a previous radiation field between 2010 and 2021 were retrospectively reviewed. The cumulative constraint to the neural avoidance structures was a biologically effective dose with an α/β value of 3 of 75 Gy (above the conus) or 106 Gy (below the conus), accounting for 25% repair at 6 months and 50% repair at 1 year following the first course of RT. Radiographic local recurrence was defined according to Spine Response Assessment in Neuro-Oncology criteria as progressive disease in the treatment volume or at the margin of the treatment field on CT or MRI compared with imaging studies before SBRT. Cumulative incidence of local recurrence was reported with death as a competing event, and overall survival was estimated using Kaplan-Meier analysis. Toxicity grades were determined according to National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0.

A total of 224 vertebral segments from 89 lesions treated with SBRT reirradiation in 83 patients were included in this analysis. The median age at SBRT reirradiation was 63 years, with a median follow-up of 8.0 months. The most common primary cancer types were non-small cell lung cancer (18%), gastrointestinal cancer (16%), renal cell carcinoma (15%), and prostate cancer (15%). Lesions predominantly occurred in the thoracic spine (52%). The median time between initial RT and SBRT reirradiation was 15.4 months. Prior radiation techniques included 3D or 2D conformal RT (52%), SBRT (43%), and intensity-modulated radiotherapy (4%). Reirradiation SBRT prescription doses varied by fractionation, with a median planning target volume of 179.1 cm3. Immunotherapy use was associated with improved local control and, notably, no increase in toxicity. No cases of radiation myelopathy were observed.

SBRT reirradiation for progressive or recurrent spinal metastases appears to be a safe and effective treatment option, offering durable local control and pain relief with low toxicity. Future prospective and multi-institutional studies are warranted to validate these findings.