Radiotherapy of Motor Deficits From Metastatic Epidural Spinal Cord Compression (SCORE-2)

Radiotherapy of Motor Deficits From Metastatic Epidural Spinal Cord Compression (10 x 3 Gy Versus 5 x 4 Gy)

The primary aim of this randomized multi-center trial is to investigate the efficacy of the radiotherapy regimens 5 x 4 Gy and 10 x 3 Gy with respect to the effect on motor function in patients with metastatic epidural spinal cord compression.

Study Overview

• Status: Completed
• Conditions: Metastatic Epidural Spinal Cord Compression
• Intervention / Treatment: Radiation: radiotherapy

Detailed Description

The primary aim of this randomized multi-center trial is to investigate the efficacy of the radiotherapy regimens 5 x 4 Gy and 10 x 3 Gy with respect to the effect on motor function in patients with metastatic epidural spinal cord compression. The response rate (improvement in motor function or prevention of progression) will be assessed at one month following radiotherapy.

In addition, the following endpoints will be evaluated:

1. Motor function; additional assessments directly and at 3 and at 6 months after radiotherapy
2. Ability to walk; assessment directly and at 1, 3 and 6 months after radiotherapy
3. Sensory function; assessment directly and at 1, 3 and 6 months after radiotherapy
4. Quality of life; evaluation directly and at 1, 3 and 6 months after radiotherapy
5. Pain assessment directly and at 1, 3 and 6 months after radiotherapy
6. Overall survival up to 6 months following radiotherapy
7. Local Progression-free survival up to 6 months following radiotherapy

• Study Type: Interventional
• Enrollment (Actual): 203
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Germany
  • Berlin, Germany, 10117
    • Charite Berlin
  • Bremen, Germany, 28239
    • Center of Radiotherapy and Radiation Oncology
  • Baden-Wutemberg
    • Ravensburg, Baden-Wutemberg, Germany, 88191
      • Oberschwabenklinik Ravensburg
  • Bavaria
    • Bayreuth, Bavaria, Germany, 95445
      • Klinikum Bayreuth
    • Regensburg, Bavaria, Germany, 93053
      • University of Regensburg
    • Würzburg, Bavaria, Germany, 97080
      • University of Würzburg
  • North Rhine Westphalia
    • Bochum, North Rhine Westphalia, Germany, 44801
      • Ruhr University
  • Saxonia
    • Dresden, Saxonia, Germany, 01067
      • Radiotherapy Practice Dresden-Friedrichstadt
  • Schleswig-Holstein
    • Lübeck, Schleswig-Holstein, Germany, 23538
      • University of Lubeck
• Lithuania
  • Vilnius, Lithuania
    • Institute of Oncology, Vilnius University
• Saudi Arabia
  • Khobar, Saudi Arabia
    • Saad Specialist Hospital
• Slovenia
  • Ljubljana, Slovenia
    • Institute of Oncology
• Spain
  • Castellon
    • Valencia, Castellon, Spain
      • Consorcio Hospitalario Provencial de Castellon
  • Vizcaya (Basque Country)
    • Barakaldo, Vizcaya (Basque Country), Spain, 48903
      • Cruces University Hospital
• United States
  • Arizona
    • Scottsdale, Arizona, United States, 85259
      • Mayo Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 85 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Motor deficits of the lower extremities resulting from metastatic epidural spinal cord compression, which have persisted for no longer than 30 days
• Confirmation of diagnosis by magnetic resonance imaging (spinal computed tomography allowed)
• Relatively poor survival prognosis (defined as ≤35 points on the survival score published in Cancer 2008)
• Written informed consent

Exclusion Criteria:

• Prior radiotherapy or surgery of the spinal areas affected by MESCC
• History of symptomatic brain tumor or symptomatic brain metastases
• Metastases of the cervical spine only
• Other severe neurological disorders
• Pregnancy, Lactation
• Indication for decompressive surgery + stabilization of the affected spinal areas

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: 5 x 4 Gy in 1 week; radiotherapy with 5 x 4 Gy in 1 week (5 x 4 Gy per week)	Radiation: radiotherapy; external beam radiotherapy (5 x 4 Gy versus 10 x 3 Gy)
Active Comparator: 10 x 3 Gy in 2 weeks; radiotherapy with 10 x 3 Gy in 2 weeks (5 x 3 Gy per week)	Radiation: radiotherapy; external beam radiotherapy (5 x 4 Gy versus 10 x 3 Gy)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants Showing Improvement or no Further Progression of Motor Deficits at 1 Month Following Radiotherapy	Overall response was defined as improvement or no further progression of motor deficits following radiotherapy. Motor function was graded with the following 8-point scale: 0, complete paraplegia; 1, palpable or visible muscle contractions; 2, active movement of the leg without gravity; 3, active movement against gravity; 4, active movement against mild resistance; 5, active movement against intermediate resistance; 6, active movement against strong resistance; and 7, normal strength. Motor function was recorded separately for each leg resulting in total points of 0 to 14. Improvement of motor function was defined as an increase by at least 2 points compared to baseline. No further progression was defined as +/-1 point (i.e. +1 point, +/- 0 points or -1 point).	at 1 month following radiotherapy

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants Who Were Able to Walk at 1 Month Following Radiotherapy	Ambulatory status was assessed using the following scoring system: 0 = Normal strength; = Ambulatory without aid; = Ambulatory with aid; = Not ambulatory A patient with a score equal to or less than 2 is considered "able to walk". Both participants that could and could not walk prior to radiotherapy have been included in this assessment..	at 1 month following radiotherapy
Number of Participants Who Were Alive at 6 Months Following Radiotherapy Without Deterioration of Motor Function During (or Directly Following) Radiotherapy and Freedom From In-field Recurrence of Metastatic Spinal Cord Compression Following Radiotherapy	Local Progression Free Survival (LPFS) was defined as freedom from progression of motor deficits during or one month following radiotherapy and freedom from in-field recurrence of metastatic spinal cord compression (MSCC) following radiotherapy. An in-field recurrence was defined as a recurrence of MSCC associated with motor deficits in the region of the spinal cord that had been previously irradiated for MSCC. In case of clinical suspicion of sich a recurrence, a spinal MRI was performed to confirm the diagnosis. Time to in-field recurrence was calculated from the last day of radiotherapy, and the patients were followed for a maximum of 6 months after the end of radiotherapy. The values of 6-month LPFS were estimated using the Kaplan-Meier method.	6 months following radiotherapy
Number of Participants Who Experienced Relief of Distress at 1 Month Following Radiotherapy Compared to Baseline	Distress (as an indicator of impairment of quality of life) was measured with the distress-thermometer. the patients rated their level of distress on a scale ranging from 0 (no distress) to 10 (extreme distress). Patients rated the distress they experienced during the last week and stated the reasons for distress from a list of items. An improvement (lower score) by 2 points was considered a clinically relevant relief of distress. Patients with baseline-scores of 0-1 points were not included, since improvement by 2 points was not possible.	at 1 month following radiotherapy
Number of Participants Who Experienced Relief of Pain at 1 Month Following Radiotherapy Compared to Baseline	Pain was measured with a numeric self-rating scale ranging from 0 (no pain) to 10 (worst pain). Relief of pain was defined as improvement (=decrease of pain) by at least 2 points without increase of analgesics. Patients with baseline-scores of 0-1 points were not included, since improvement by 2 points was not possible.	at 1 month following radiotherapy
Number of Participants Who Were Alive at 6 Months Following Radiotherapy	Overall Survival (OS) was defined as freedom from death of any cause. Time to death was calculated from the last day of radiotherapy, and the patients were followed for a maximum of 6 months after the end of radiotherapy. The values of 6-month OS were estimated using the Kaplan-Meier method.	6 months following radiotherapy
Number of Participants Showing Improvement of Motor Deficits at 1 Month Following Radiotherapy	Motor function was graded with the following 8-point scale: 0, complete paraplegia; 1, palpable or visible muscle contractions; 2, active movement of the leg without gravity; 3, active movement against gravity; 4, active movement against mild resistance; 5, active movement against intermediate resistance; 6, active movement against strong resistance; and 7, normal strength. Motor function was recorded separately for each leg resulting in total points of 0 to 14. Improvement of motor function was defined as an increase by at least 2 points compared to baseline.	at 1 month following radiotherapy
Number of Participants Experiencing at Least One Grade >=2 Radiotherapy-related Toxicity	Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) (version 4)	during radiotherapy and up to 6 months following radiotherapy

Collaborators and Investigators

• Sponsor: Prof. Dirk Rades, MD
• Investigators: Study Chair: Dirk Rades, MD, Department of Radiation Oncology, University of Lubeck, Germany

Publications and helpful links

General Publications

• Koswig S, Budach V. [Remineralization and pain relief in bone metastases after after different radiotherapy fractions (10 times 3 Gy vs. 1 time 8 Gy). A prospective study]. Strahlenther Onkol. 1999 Oct;175(10):500-8. doi: 10.1007/s000660050061. German.
• Steenland E, Leer JW, van Houwelingen H, Post WJ, van den Hout WB, Kievit J, de Haes H, Martijn H, Oei B, Vonk E, van der Steen-Banasik E, Wiggenraad RG, Hoogenhout J, Warlam-Rodenhuis C, van Tienhoven G, Wanders R, Pomp J, van Reijn M, van Mierlo I, Rutten E. The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study. Radiother Oncol. 1999 Aug;52(2):101-9. doi: 10.1016/s0167-8140(99)00110-3. Erratum In: Radiother Oncol 1999 Nov;53(2):167. Leer, J [corrected to Leer, JW]; van Mierlo ,T [corrected to van Mierlo, I].
• Maranzano E, Latini P. Effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial. Int J Radiat Oncol Biol Phys. 1995 Jul 15;32(4):959-67. doi: 10.1016/0360-3016(95)00572-g.
• Sorensen S, Borgesen SE, Rohde K, Rasmusson B, Bach F, Boge-Rasmussen T, Stjernholm P, Larsen BH, Agerlin N, Gjerris F, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer. 1990 Apr 1;65(7):1502-8. doi: 10.1002/1097-0142(19900401)65:73.0.co;2-d.
• Helweg-Larsen S, Sorensen PS, Kreiner S. Prognostic factors in metastatic spinal cord compression: a prospective study using multivariate analysis of variables influencing survival and gait function in 153 patients. Int J Radiat Oncol Biol Phys. 2000 Mar 15;46(5):1163-9. doi: 10.1016/s0360-3016(99)00333-8.
• Leviov M, Dale J, Stein M, Ben-Shahar M, Ben-Arush M, Milstein D, Goldsher D, Kuten A. The management of metastatic spinal cord compression: a radiotherapeutic success ceiling. Int J Radiat Oncol Biol Phys. 1993 Sep 30;27(2):231-4. doi: 10.1016/0360-3016(93)90232-k.
• Rades D, Blach M, Bremer M, Wildfang I, Karstens JH, Heidenreich F. Prognostic significance of the time of developing motor deficits before radiation therapy in metastatic spinal cord compression: one-year results of a prospective trial. Int J Radiat Oncol Biol Phys. 2000 Dec 1;48(5):1403-8. doi: 10.1016/s0360-3016(00)01408-5.
• Rades D, Heidenreich F, Bremer M, Karstens JH. Time of developing motor deficits before radiotherapy as a new and relevant prognostic factor in metastatic spinal cord compression: final results of a retrospective analysis. Eur Neurol. 2001;45(4):266-9. doi: 10.1159/000052141.
• Rades D, Heidenreich F, Karstens JH. Final results of a prospective study of the prognostic value of the time to develop motor deficits before irradiation in metastatic spinal cord compression. Int J Radiat Oncol Biol Phys. 2002 Jul 15;53(4):975-9. doi: 10.1016/s0360-3016(02)02819-5.
• Arcangeli G, Giovinazzo G, Saracino B, D'Angelo L, Giannarelli D, Arcangeli G, Micheli A. Radiation therapy in the management of symptomatic bone metastases: the effect of total dose and histology on pain relief and response duration. Int J Radiat Oncol Biol Phys. 1998 Dec 1;42(5):1119-26. doi: 10.1016/s0360-3016(98)00264-8.
• Niewald M, Tkocz HJ, Abel U, Scheib T, Walter K, Nieder C, Schnabel K, Berberich W, Kubale R, Fuchs M. Rapid course radiation therapy vs. more standard treatment: a randomized trial for bone metastases. Int J Radiat Oncol Biol Phys. 1996 Dec 1;36(5):1085-9. doi: 10.1016/s0360-3016(96)00388-4.
• 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up. Bone Pain Trial Working Party. Radiother Oncol. 1999 Aug;52(2):111-21.
• Rades D, Stalpers LJ, Veninga T, Schulte R, Hoskin PJ, Obralic N, Bajrovic A, Rudat V, Schwarz R, Hulshof MC, Poortmans P, Schild SE. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. J Clin Oncol. 2005 May 20;23(15):3366-75. doi: 10.1200/JCO.2005.04.754.
• Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE, Shank B, Solin LJ, Wesson M. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys. 1991 May 15;21(1):109-22. doi: 10.1016/0360-3016(91)90171-y.
• Barendsen GW. Dose fractionation, dose rate and iso-effect relationships for normal tissue responses. Int J Radiat Oncol Biol Phys. 1982 Nov;8(11):1981-97. doi: 10.1016/0360-3016(82)90459-x. No abstract available.
• Rades D, Dunst J, Schild SE. The first score predicting overall survival in patients with metastatic spinal cord compression. Cancer. 2008 Jan 1;112(1):157-61. doi: 10.1002/cncr.23150.
• Tomita T, Galicich JH, Sundaresan N. Radiation therapy for spinal epidural metastases with complete block. Acta Radiol Oncol. 1983;22(2):135-43. doi: 10.3109/02841868309134353.
• Maranzano E, Bellavita R, Rossi R, De Angelis V, Frattegiani A, Bagnoli R, Mignogna M, Beneventi S, Lupattelli M, Ponticelli P, Biti GP, Latini P. Short-course versus split-course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol. 2005 May 20;23(15):3358-65. doi: 10.1200/JCO.2005.08.193. Epub 2005 Feb 28.
• Rades D, Segedin B, Conde-Moreno AJ, Ferrer-Albiach C, Metz M, Polat B, Badakhshi H, Schreiber A, Nitsche M, Cacicedo J, Schild SE. Patient-Reported Outcomes-Secondary Analysis of the SCORE-2 Trial Comparing 4 Gy x 5 to 3 Gy x 10 for Metastatic Epidural Spinal Cord Compression. Int J Radiat Oncol Biol Phys. 2019 Nov 15;105(4):760-764. doi: 10.1016/j.ijrobp.2019.08.002. Epub 2019 Aug 12.
• Rades D, Segedin B, Conde-Moreno AJ, Garcia R, Perpar A, Metz M, Badakhshi H, Schreiber A, Nitsche M, Hipp P, Schulze W, Adamietz IA, Norkus D, Rudat V, Cacicedo J, Schild SE. Radiotherapy With 4 Gy x 5 Versus 3 Gy x 10 for Metastatic Epidural Spinal Cord Compression: Final Results of the SCORE-2 Trial (ARO 2009/01). J Clin Oncol. 2016 Feb 20;34(6):597-602. doi: 10.1200/JCO.2015.64.0862. Epub 2016 Jan 4.

Study record dates

Study Major Dates

• Study Start: July 1, 2010
• Primary Completion (Actual): July 1, 2015
• Study Completion (Actual): July 1, 2015

Study Registration Dates

• First Submitted: July 7, 2014
• First Submitted That Met QC Criteria: July 10, 2014
• First Posted (Estimate): July 14, 2014

Study Record Updates

• Last Update Posted (Actual): March 5, 2020
• Last Update Submitted That Met QC Criteria: February 18, 2020
• Last Verified: February 1, 2020

More Information

Terms related to this study

• Keywords: pain; quality of life; overall survival; toxicity; motor function; metastatic epidural spinal cord compression; ambulatory status; local control
• Additional Relevant MeSH Terms: Central Nervous System Diseases; Nervous System Diseases; Wounds and Injuries; Spinal Cord Diseases; Spinal Cord Injuries; Spinal Cord Compression
• Other Study ID Numbers: ARO 200901

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No