Spine SABR - Dose-escalated Stereotactic Ablative Body Radiotherapy (SABR) for Solid Tumour Spine Metastases

Overview

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.

Interventions

• Radiation Radiation: image guided dose escalated SABR using a simultaneous integrated boost (SIB)
  Treatment 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 accordi

Primary outcome measures

• 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. [Time frame: From start of treatment to 6 months post treatment]

Secondary outcome measures (7)

• Estimate local progression-free survival at 1 and 2 years post-treatment, using Magnetic Resonance Imaging (MRI). [Time frame: Up to 2 years post treatment]
• Estimate 6-month, 1-year and 2-year post-treatment overall survival rates. [Time frame: Up to 2 years post treatment]
• 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. [Time frame: 1 week post treatment]
• 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. [Time frame: Up to 2 years post-treatment]
• Acute toxicity profiles of ≥Grade 2 toxicities at 1- and 4-weeks post treatment, and at 3 months post-treatment using NCI CTCAE V5 [Time frame: Up to 3 months post-treatment]
• Late toxicity profiles of ≥Grade 2 toxicities and DLTs at 6, 9, 12, 15, 18 and 24 months post-treatment using NCI CTCAE V5. [Time frame: Up to 2 years post-treatment]
• Estimates of time to onset of ≥ Grade 2 and ≥ Grade 3 acute toxicities. [Time frame: Up to 3 months post-treatment]

Eligibility criteria

Inclusion criteria

• 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
• Histological diagnosis of malignant primary disease (excluding haematologic, seminomatous or small cell subtype)
• Diagnosis of oligometastatic disease (OMD) or oligoprogressive disease (OPD) defined as:

• OMD where there are 1 to 5 metastatic lesions, with a controlled primary tumor being optional, but where all metastatic sites must be safely treatable (can be synchronous or metachronous to primary tumor diagnosis) with curative intent OR
• OPD with 1 to 5 lesions progressing on a background of widespread but stable metastatic disease OR
• Systemic therapy-induced OMD where there are 1 to 5 persistent lesions after systemic therapy, all safely treatable with SABR
• Single spinal level from C1 to L5 to be treated for the purpose of the study (co-existing lesion(s) on non-consecutive spinal level(s) may receive RT at Investigator discretion, if deemed unlikely to interfere with study treatment and assessment of outcomes).
• Stable spine assessed by Spinal Instability Neoplastic Score (SINS) (SINS 0-6, or SINS 7-12 and not for surgical intervention).
• Bilsky Grade 0-1a (i.e. minimal (epidural impingement, without deformation of thecal sac) or no epidural disease) as confirmed by Radiation Oncologist
• Able to lie flat in the treatment position for radiotherapy for up to 60 minutes
• Females of childbearing potential must not be pregnant or lactating, and must be prepared to take adequate contraception methods during treatment. Males whose female partners are of childbearing potential must be prepared to take adequate contraception methods during treatment. Examples of effective contraception methods are a condom or a diaphragm with spermicidal jelly, or oral, injectable or implanted birth control

Exclusion criteria

• 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
• Contraindication to MRI, e.g. MRI-incompatible personal pacemaker in situ
• Patients with pre-existing osteoporotic fractures of the spine
• Prior treatment with any radionuclide within 30 days prior to registration
• Patients who have received chemotherapy within 1 week prior to administration of protocol RT or who are expected/planned to receive chemotherapy during RT or within 1 week after completing protocol RT
• Uncontrolled intercurrent illness that is likely to interfere with treatment or assessment of outcomes, or psychiatric illness/social situations that would limit compliance with study requirements
• Evidence of any other significant clinical disorder or laboratory finding that makes it undesirable for the patient to participate in the study, or if it is felt by the research / medical team that the patient may not be able to comply with the protocol and follow-up schedule due to psychological, familial, sociological or geographical conditions
• Significant or progressive neurological deficit such that emergency surgery or radiation required

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Non-randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Ireland · 3 centers

• Bon Secours/UPMC — Cork
• St Luke's Radiation Oncology Network (SLRON) at Beaumont Hospital — Dublin
• Beacon Hospital — Dublin

Identifiers

NCT: NCT06078813 · CTRIAL-IE 20-03

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗