This study will look at treatment for patients that have already been diagnosed with cancer, but develop a new tumor(s) in the spine. Patients who are not recommended for surgery are usually treated with 5-10 sessions of radiotherapy to manage symptoms. For patients with a longer life expectancy (\>6 months), it is better to give a higher dose of treatment to potentially improve the duration of pain relief, cancer control and potentially survival. Higher doses of radiotherapy, however, may also cause worse toxicity and side effects. This study will look at delivering higher doses of radiation in 2 sessions rather than 5-10, using a more modern, targeted technique called image-guided Stereotactic Ablative Body Radiotherapy (SABR). This method requires special equipment and expertise compared to the traditional radiotherapy and this has limited availability in Ireland. This study aims to find out the highest dose that is safe to be given to patients and carefully examine the side effects. These results will help create national and international guidelines to benefit all cancer patients. Patients will be monitored closely during treatment and for 2 years afterwards. Patients have been involved in developing the treatment protocol and the patient information leaflet. Patients will also be asked to fill in quality of life (QOL) questionnaires at certain timepoints during the study. It is anticipated that this study will support the delivery of high quality SABR to all cancer patients in Ireland, resulting in potentially better quality of life, symptom and tumor control.
Written informed consent obtained prior to any study-related procedures
≥ 18 years of age
Life expectancy > 6 months
ECOG (Eastern Cooperative Oncology Group) performance status (PS) 0-2
Previous radiotherapy or surgery to the proposed SABR treatment site which is likely to interfere with treatment or assessment of outcomes (for radiotherapy, this includes prior thoracic radiotherapy to the lung or oesophagus which would result in overlap of fields if a T spine lesion will be treated)
Patients with symptomatic spinal cord compression or cauda equina syndrome, resulting in bony compression or epidural compression of the spinal cord or cauda equine, respectively
Patients with syndromes or conditions associated with increased radiosensitivity
Patients with radiosensitive histologies, e.g. myeloma or lymphoma
Parallel
Radiation: image guided dose escalated SABR using a simultaneous integrated boost (SIB)
RadiationTreatment will consist of image guided dose escalated SABR using a simultaneous integrated boost (SIB) delivered in two fractions adhering to organ at risk dose-volume histogram constraints. There will be three dose levels delivered to the Planning Target Volume\_1 (PTV\_1) in each treatment arm as follows: 28 Gy (14 Gy per fraction), 30 Gy (15 Gy per fraction) and 32 Gy (16 Gy per fraction). A lower dose of 20 Gy (10 Gy per fraction) will be delivered to the PTV\_2 which will be defined according to international consensus guidelines (Cox et al., 2012). The dose to PTV\_2 will remain the same through all dose levels. All doses are prescribed to the target volume.
The establishment of the MTD of 2-fraction spine SABR in patients with oligometastatic or oligoprogressive solid tumor metastases of the spine, by the number of patients experiencing DLTs within six months after treatment.
DLT rate will be calculated as the proportion of evaluable patients (along with the 95% CI) experiencing a DLT, among the total evaluable patients. All evaluable patients will be used in the DLT analysis which will be performed after they have been potentially followed for the 6-months observation period. Patients not evaluable will be reported separately. For each such patient, the reason for exclusion, protocol treatment received, and toxicities reported during the first year will be listed.
Estimate local progression-free survival at 1 and 2 years post-treatment, using Magnetic Resonance Imaging (MRI).
Post treatment response and outcomes using MRI at 3, 6, 9, 12, 15, 18, and 24 months post-RT will be evaluated. The same patients used for DLT analysis will be used in these analyses. Radiation site (treated per study protocol) PFS (i.e. local PFS) at 1 year will be considered the key efficacy endpoint. Local progression is progression within the radiation site treated per study protocol, as identified on serial imaging. When local progression is suspected, two or three MRI scans 6-8 weeks apart are recommended per Investigator discretion (in line with international consortium (SPINO guidelines) (Thibault et al., 2015)). * Local control may be defined as the absence of progression within the radiation site treated per study protocol on serial imaging (MRI). * Any new or progressive tumor within the epidural space * Neurological deterioration attributable to pre-existing epidural disease with equivocal increased epidural disease dimensions on MRI
Estimate 6-month, 1-year and 2-year post-treatment overall survival rates.
The Kaplan-Meier method will be used to estimate overall survival at each dose level. Cox proportional hazards regression will be used to characterise overall survival rate as a function of dose. Overall survival will be measured from the date of study registration until the date of death due to any cause or censoring.
Estimate the pain flare incidence 1 week post-treatment (i.e. 1 week after 2nd SABR fraction) using the Numeric Pain Rating Scale (NPRS) 0-10.
Pain score (including acute pain flare) at the radiation site treated per study protocol (assessed by numerical pain rating score, 0-10) (time frame: 1 week post treatment). \[with secondary endpoint 4:\] The changes in raw scores and percent change will be assessed over time using the Wilcoxon Signed rank test.
Pain score at radiation site (treated per study protocol) at 4 weeks, 3 months, 6 months, 1 year and 2 years post-treatment, using the NPRS.
Pain score (including acute pain flare) at the radiation site treated per study protocol (assessed by numerical pain rating score, 0-10) (time frame: 1 week post treatment). The changes in raw scores and percent change will be assessed over time using the Wilcoxon Signed rank test.
Estimate median time to onset of post-SABR ≥ Grade 2 VCF and rates of post-SABR ≥ Grade 2 VCF at 1 and 2 years. VCF is assessed via MRI.
Time-to-event analyses will be conducted for time to onset of ≥ Grade 2 VCF. Kaplan-Meier curves will be presented and median point estimates (with 95% Cis) will be reported. Patients free of an event at the time of analysis will be censored at last available assessment. Cox proportional hazards regression will be used to assess baseline demographic or clinical variables as risk factors for post-SABR VCF and to develop a nomogram to estimate risk of VCF for future studies.
Type of intervention (surgery or kyphoplasty) in the setting of post-SABR VCF at 1 and 2 years.
Up to 2 years post-treatment
QoL outcomes at 6-months and 1-year post SABR (compared to baseline) using EORTC QLQ-BM22 (EORTC Quality of Life Questionnaire for Patients with Bone Metastases (22 questions)).
The mean and standard deviation (SD) of the overall and domain- and symptom-specific QoL outcomes at 6-months and 1-year post SABR (compared to baseline) using EORTC QLQ-BM22 scores at baseline and 6 months' post treatment will be reported. Scoring will be performed in accordance with the published guidelines.
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