Jackson Christopher B, Boe Lillian A, Zhang Lei, Apte Aditya, Jackson Andrew, Ruppert Lisa M, Haseltine Justin, Mueller Boris A, Schmitt Adam M, Vaynrub Max, Newman William Christopher, Lis Eric, Barzilai Ori, Bilsky Mark H, Yamada Yoshiya, Higginson Daniel S
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, 10065, USA.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, 10065, USA.
Int J Radiat Oncol Biol Phys. 2025 Jun 16. doi: 10.1016/j.ijrobp.2025.05.078.
Spine stereotactic body radiation therapy (SBRT) outperforms conventional radiation therapy in preventing local failure (LF). Data comparing dose-fractionation schemes on the likelihood of LF and vertebral compression fracture (VCF) are limited.
This is a retrospective cohort study of 1838 patients (2702 lesions) treated between 2014 and 2023 at a single institution with de novo spine SBRT. LF was defined as progressive disease on magnetic resonance imaging. VCF was defined as progressive or new fracture on magnetic resonance imaging without LF. Death was considered a competing risk.
Median follow-up after SBRT for surviving patients was 25 months (IQR 13-43 months). Eleven hundred ninety-seven lesions (44%) received 27 Gy in 3 fractions, 931 (34%) received 30 Gy in 3 fractions, and 574 lesions (21%) received 24 Gy in 1 fraction. Three hundred nine treatment courses involved separation surgery (11%), and 311 lesions (11%) were epidural spinal cord compression score 2 to 3. For lesions treated with 24 Gy in 1 fraction, 30 Gy in 3 fractions, and 27 Gy in 3 fractions, 2-year LF rates (95% CI) were 7% (5%-9%), 11% (9%-13%), and 17% (15%-20%), respectively (P < .001). Two-year VCF rates (95% CI) requiring stabilization were 10% (8%-13%; 24 Gy in 1 fraction), 2% (1%-3%; 27 Gy in 3 fractions), and 3% (2%-5%; 30 Gy in 3 fractions) (P < .001). For the 3-fraction regimens specifically, 30 Gy was associated with a higher overall VCF rate (P = .022) and lower LF rate (P < .001), but there was no significant difference in the risk of VCF requiring intervention (P = .15). Univariable and multivariable regression revealed histologic-based differences in LF: 2-year LF rates were 8.6% (95% CI, 6.4%-11%) for class A lesions (prostate and breast cancers), 26% (95% CI, 20%-32%) for class C lesions (cholangio-, hepatocellular, and colorectal carcinoma), and 13% (95% CI, 12%-15%) for class B lesions (other histologies) (P < .001). For class B to C, epidural spinal cord compression 2 to 3 lesions (n = 261), surgery plus SBRT reduced LF compared to SBRT alone (7.9 vs 20% at 2 years, P = .051), though this did not reach statistical significance.
The preferred hypofractionated SBRT regimen-even for class A histologies-is 30 Gy in 3 fractions, offering superior local control with similar risk of VCF requiring intervention, compared to 27 Gy. For class B to C lesions with high-grade epidural disease, separation surgery prior to SBRT may improve local control.
脊柱立体定向体部放射治疗（SBRT）在预防局部失败（LF）方面优于传统放射治疗。关于不同剂量分割方案对LF和椎体压缩骨折（VCF）发生可能性影响的数据有限。
这是一项回顾性队列研究，纳入了2014年至2023年在单一机构接受初治脊柱SBRT的1838例患者（2702个病灶）。LF定义为磁共振成像显示的疾病进展。VCF定义为磁共振成像显示的进展性或新发骨折且无LF。死亡被视为竞争风险。
存活患者SBRT后的中位随访时间为25个月（四分位间距13 - 43个月）。1197个病灶（44%）接受了27 Gy分3次照射，931个（34%）接受了30 Gy分3次照射，574个病灶（21%）接受了24 Gy单次照射。309个疗程涉及分期手术（11%），311个病灶（11%）的硬膜外脊髓压迫评分为2至3分。对于单次照射24 Gy、分3次照射30 Gy和分3次照射27 Gy的病灶，2年LF率（95%置信区间）分别为7%（5% - 9%）、11%（9% - 13%）和17%（15% - 20%）（P <.001）。需要进行稳定治疗的2年VCF率（95%置信区间）分别为10%（8% - 13%；单次照射24 Gy）、2%（1% - 3%；分3次照射27 Gy）和3%（2% - 5%；分3次照射30 Gy）（P <.001）。具体对于3次分割方案，30 Gy与总体VCF率较高（P =.022）和LF率较低（P <.001）相关，但在需要干预的VCF风险方面无显著差异（P =.15）。单变量和多变量回归显示LF存在基于组织学的差异：A类病灶（前列腺癌和乳腺癌）的2年LF率为8.6%（95%置信区间，6.4% - 11%），C类病灶（胆管癌、肝细胞癌和结直肠癌）为26%（95%置信区间，20% - 32%），B类病灶（其他组织学类型）为13%（95%置信区间，12% - 15%）（P <.001）。对于B类至C类、硬膜外脊髓压迫2至3分病灶（n = 261），与单纯SBRT相比，手术加SBRT降低了LF（2年时分别为7.9%和20%，P =.051），尽管未达到统计学显著性。
优选的低分割SBRT方案——即使对于A类组织学类型——是分3次给予30 Gy，与27 Gy相比，能提供更好的局部控制，且需要干预的VCF风险相似。对于伴有高级别硬膜外病变的B类至C类病灶，SBRT前进行分期手术可能改善局部控制。
