Stereotactic Body Radiotherapy Boost After Palliative Radiotherapy for Spinal Cord Compression
Stereotactic Body Radiotherapy Boost After Palliative Radiotherapy for Spinal Cord Compression
Spinal cord compression (SCC) is a devastating complication of advanced malignancy, and can
 cause significant deterioration in function and quality of life (QoL). The goal of treatment
 is to improve functional status and symptoms, but the optimal treatment regimen for these
 patients has not been thoroughly established. Many patients with SCC present with
 uncontrolled systemic disease and poor performance status, and are not eligible for standard
 surgical resection. They are generally treated with 3D conformal palliative RT (3DCRT) alone,
 however recent trials suggest that less than 70% of patients are ambulatory, that the
 re-establishment of ambulation in non-ambulatory patients is poor, and the duration of
 improvement is guarded with radiotherapy alone.

 Recently, stereotactic body radiotherapy (SBRT) used alone or after previous radiotherapy to
 treat spinal metastasis has demonstrated superior results in pain control, tumour response
 and durability. SBRT requires time for careful planning, and many patients with neurologic
 symptoms must be treated immediately to prevent progression. Therefore the role of SBRT is
 still unclear in this patient population, although it seems to be a potential alternative to
 surgical decompression in patient not suitable for surgery. The investigators propose a
 feasibility study to investigate the potential benefits of dose escalation with a sequential
 SBRT boost to urgent 3D CRT in the setting of SCC. This regimen will allow inoperable
 patients to receive urgent 3DCRT while simultaneously creating the opportunity for superior
 outcomes with SBRT. The investigators also aim to characterize the effect on motor function
 and ambulation, pain and QoL. This study could stimulate further multi-center randomized
 trials in this area, improve motor function and patient-reported QoL, and contribute to
 improving oncology care in Canada in a meaningful way.
Inclusion Criteria:

 1. Diagnosis of metastatic malignancy (radiologic or pathologic)

 2. Evidence of disease in vertebral body with epidural component such that Bilsky
 radiologic score is 1c-2 on MRI (abuts spinal cord without cord compression (1c), or
 spinal cord compression but with visible CSF (2)

 3. Motor function (MF) of 3 or greater

 Exclusion Criteria:

 1. Surgical candidate

 2. Instability of vertebral bodies with or without bony retropulsion requiring surgical
 intervention or hardware placement

 3. Previous radiotherapy course to same region of spine with overlapping fields (prior to
 phase I course) at discretion of treating radiation oncologist

 4. No CT or MRI within previous 3 months

 5. Life expectancy estimated <3 months

 6. Performance status KPS<40

 7. On active chemotherapy or targeted therapy or immunotherapy (must be stopped for at
 least one week prior to and following)

 8. Pregnant or lactating

 9. Contraindications to radiotherapy (eg. active autoimmune disease requiring medication)

 10. Inability to lie flat comfortably for at least 20 minutes

 11. Age < 18