A pilot study of stereotactic boost for malignant epidural spinal cord compression: clinical significance and initial dosimetric evaluation

Elysia K Donovan, Jeffrey Greenspoon, Kara L Schnarr, Timothy J Whelan, James R Wright, Crystal Hann, Anthony Whitton, Tom Chow, Sameer Parpia, Anand Swaminath, Elysia K Donovan, Jeffrey Greenspoon, Kara L Schnarr, Timothy J Whelan, James R Wright, Crystal Hann, Anthony Whitton, Tom Chow, Sameer Parpia, Anand Swaminath

Abstract

Purpose: Metastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced malignancy, which can result in neurologic complications and significant deterioration in overall function and quality of life. Most patients are not candidates for optimal surgical decompression and as a result, receive urgent 3D conformal radiotherapy (3DCRT) to prevent or attempt to reverse neurologic progression. Multiple trials indicate that response and ambulatory rates after 3DCRT are inferior to surgery. The advent of stereotactic body radiation therapy (SBRT) has created a method with which a "radiosurgical decompression" boost may facilitate improve outcomes for MESCC patients.

Methods: We are conducting a pilot study to investigate SBRT boost after urgent 3D CRT for patients with MESCC. The aim of the study is to establish feasibility of this two-phase treatment regimen, and secondarily to characterize post-treatment ambulation status, motor response, pain control, quality of life and survival.

Discussion: We describe the study protocol and present a case report of one patient. A quality assurance review was conducted after the first seven patients, and resultant dose-constraints were revised to improve safety and feasibility of planning through more conservative organ at risk constraints. There have been no severe adverse events (grade 3-5) to date. We have illustrated clinical and dosimetric data of an example case, where a patient regained full strength and ambulatory capacity.

Conclusions: Our study aims to determine if SBRT is a feasible option in addition to standard 3DCRT for MESCC patients, with the goal to consider future randomized trials if successful. Having a robust quality assurance process in this study ensures translatability going forward if future trials with multicenter and increased patient representation are to be considered.

Trial registration: clinicaltrials.gov; registration no. NCT03529708; https://ichgcp.net/clinical-trials-registry/NCT03529708 ; First posted May 18, 2018.

Keywords: Palliative radiation; Spinal cord compression; Stereotactic radiotherapy.

Conflict of interest statement

EKD was funded by an Accuray Incorporated fellowship grant to conduct this research. There are no other conflicts of interest.

Figures

Fig. 1
Fig. 1
Baseline T1 (left) MRI sequences showing soft tissue metastasis at T6 with epidural soft tissue component and edema and extension to spinal cord in Patient A
Fig. 2
Fig. 2
Phase II Cyberknife plan for Patient A, Isodose distribution (topand radiotherapy target and organ at risk doses (bottom) are displayed
Fig. 3
Fig. 3
Composite plan for Patient A. Composite distribution (top), dose volume histogram and accumulated estimated phase I and II doses (bottom) displayed
Fig. 4
Fig. 4
Phase II Cyberknife plan for Patient B treated after revision of dose constraints. Phase II distribution (top) and radiotherapy target/organ at risk doses (bottom) are displayed
Fig. 5
Fig. 5
T2 (right) MRI sequence at 3 months showing excellent response to phase II boost treatment in Patient A

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