Re-irradiation spine stereotactic body radiotherapy following high-dose conventional radiotherapy for metastatic epidural spinal cord compression: a retrospective study

Abstract

Purpose: We aimed to evaluate the efficacy and safety of re-irradiation stereotactic body radiation therapy (SBRT) in patients with metastatic epidural spinal cord compression (MESCC) following high-dose conventional radiotherapy.

Materials and methods: Twenty-one patients met the following eligibility criteria: with an irradiation history of 50 Gy₂ equivalent dose in 2-Gy fractions (EQD2) or more, diagnosed MESCC in the cervical or thoracic spines, and treated with re-irradiation SBRT of 24 Gy in 2 fractions between April 2018 and March 2023. Prior treatment was radiotherapy alone, not including surgery. The primary endpoint was a 1-year local failure rate. Overall survival (OS) and treatment-related adverse events were assessed as the secondary endpoints. Since our cohort includes one treatment-related death (TRD) of esophageal perforation, the cumulative esophageal dose was evaluated to find the dose constraints related to severe toxicities.

Results: The median age was 68, and 14 males were included. The primary tumor sites (esophagus/lung/head and neck/others) were 6/6/7/2, and the median initial radiotherapy dose was 60 Gy₂ EQD2 (range: 50-105 Gy₂, 60-70/ > 70 Gy₂ were 11/4). Ten patients underwent surgery followed by SBRT and 11 SBRT alone. At the median follow-up time of 10.4 months, 17 patients died of systemic disease progression including one TRD. No radiation-induced myelopathy or nerve root injuries occurred. Local failure occurred in six patients, with a 1-year local failure rate of 29.3% and a 1-year OS of 55.0%. Other toxicities included five cases of vertebral compression fractures (23.8%) and one radiation pneumonitis. The cumulative esophageal dose was recommended as follows: D_max < 203, D_{0.035 cc} < 187, and D_1cc < 167 (Gy₃ in biological effective dose).

Conclusion: Re-irradiation spine SBRT may be effective for selected patients with cervical or thoracic MESCC, even with high-dose irradiation histories. The cumulative dose assessment across the original and re-irradiated esophagus was recommended to decrease the risk of severe esophageal toxicities.

Keywords: Re-irradiation; Spinal cord compression; Spinal metastases; Stereotactic radiotherapy.

Fig. 1

Algorithm for management of progressive or recurrent spinal cord compression received by the initial conventional radiotherapy. MESCC metastatic epidural spinal cord compression, EBRT external beam radiation therapy, SBRT stereotactic body radiation therapy, fx fractions, SINS spinal instability neoplastic score

Fig. 2

Local failure rate and overall survival in the entire cohort

Fig. 3

The images of diagnostic CT of radiation-induced esophageal perforation. A The diagnostic image. The patient was urgently hospitalized 18 days before death due to a fever and developed paraplegia 12 days before death. The image shows esophageal perforation, mediastinitis, and spinal cord compression due to an epidural abscess. B Dose distribution of re-irradiation SBRT on the fused-CT image (same CT as Fig. 2A). C Dose distribution of initial EBRT on the fused-CT image (same CT as Fig. 2A). CT computed tomography, SBRT stereotactic body radiation therapy, EBRT external beam radiation therapy

Fig. 4

A Dose volume histogram for cumulative esophageal dose (equivalent dose at 2 Gy with the α/β ratio of 2). Red line shows a histogram of the patient died of radiation-induced esophageal perforation (grade 5), and Black lines show those of the other patients