Laser Interstitial Thermal Ablation and Stereotactic Radiosurgery for Patients With Spine Metastases

Primary Objectives:

• Documenting rate of local control in patients who have received this combined treatment and
• Documenting safety of MRI compatible hardware for MRI based image guidance
• Determining the accuracy of the MRI-based image guidance

Secondary Objectives:

• To determine local control at 1, 3, 6, 9, 18, and 24 months, and to compare to a historical control where patients received only SSRS at these time points and at 12 months.
• To document the extent of epidural tumor regression at 1, 3, 6, 9, 12, 18 and 24 months

• Calculate decrease in epidural tumor volume (by volumetric measurements using Brain Lab Elements software)
• Calculate increase in thecal sac patency (by volumetric measurements using Brain Lab Elements software and according to Bilsky method
• To determine overall survival at 6, 12, 18, and 24 months.
• To assess changes in muscle strength, location and severity of spinal-related pain, sensory function, ability to ambulate, and neurological grading at 1, 3, 6, 9, 12, 18, and 24 months compared with pretreatment baselines.
• To assess the effect of treatment on quality of life, measured at 1 month and every 3 months after with validated outcome measure tools
• To describe adverse side effects after treatment and to descriptively correlate those effects with radiographic findings, pain control, and quality of life.

Inclusion criteria

• Age > 18 years old. (The indication for this technique is controversial in skeletally immature patients.)
• Histologic diagnosis of solid malignant tumor (not one of the more radiosensitive histologic subtypes, see Exclusion Criteria), including but not limited to non-small cell lung cancer, breast, prostate, renal cell, melanoma, gastrointestinal, sarcoma, thyroid, head and neck primary, and unknown primary tumors.
• Quantification of the degree of epidural spinal cord compression as grade 1C, 2, or 3 by MRI, with and without contrast sequences. Axial T2 sequence is encouraged but not required.
• The vertebral body site to be treated must be located from T2 to L1
• No more than 3 contiguous or dis-contiguous vertebral levels involved with metastasis in the spine to be irradiated in a single session or 3 sessions.
• Motor strength ≥4 out of 5 in extremity or extremities affected by the level of the spinal cord compression (see section 4 for grading method).
• ECOG performance status <2 or Karnofsky performance status (KPS) >50
• Life expectancy >3 months.
• Inoperable disease because of patient refusal, neurosurgical evaluation, or any other medical reasons.
• Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) before study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately.
• Prior conventional radiation to the same site is allowed as long as there is a greater than 3 months interval.
• Signed informed consent.

Exclusion criteria

• Requires open spinal procedure or a percutaneous procedure without the use of image guidance.
• Primary tumors of radiosensitive histology (lymphoma, multiple myeloma, small cell carcinoma, germ cell tumors), as conventional radiation is likely to be effective in such cases.
• Unable to tolerate general anesthesia and prone position.
• Unable to undergo MRI scan of the spine.
• Inability to lie flat on a treatment table for >60 minutes.
• Pregnant. (Urine testing must be done no more than 10 days prior to surgery.)
• Prior conventional irradiation of the spine site and level to be treated with an interval shorter than 3 months.
• Frank cord compression or cord compression from bone components or configuration and acute neurological deficits (defined as motor strength <4/5 in extremity or extremities affected by the level of the spinal cord compression)