SPINE SBRT: The MSKCC Spine Service IAEA Singapore SBRT Symposium Josh Yamada MD FRCPC Mark Bilsky MD Departments of Radiation Oncology and Neurosurgery Memorial Sloan Kettering Cancer Center NY NY USA

Disclosures Varian Medical Systems Consultant Continuing Medical Education Institute Speakers Bureau

MSKCC Spine Service Radiation Oncology Josh Yamada, M.D. Radiology Eric Lis, M.D. George Krol, M.D. Sasan Karimi, M.D. Pierre Gobin, M.D. Athos Patsilides, M.D. Orthopedic Surgery Patrick Boland, M.D. Neurosurgery Mark Bilsky, M.D. Ilya Laufer, M.D. Neurology Edward Avila, D.O. Xi Chen, M.D. Sonia Sandhu, D.O Pain Roma Tickoo, M.D. Kenneth Cubert, M.D. Vinay Puttaniah, M.D. Amitabh Gulati, M.D. Physiatry Michael Stubblefield,M.D. Jonas Sokolof, D.O. Christian Custodio, M.D. PT/OT Nursing Joan Zatcky, NP Cynthia Correa, RN Ruth Gargan-Klinger, NP Jane Yoffe, NP Solange Inglis, NP Marie Marte, NP

Goals of Treatment Multi-disciplinary Approach Metastasis Palliation Pain Control Neurology Oncology Mechanical Stability

The Spine Service at MSKCC: Multidisciplinary Care Spine oncology requires multidisciplinary care Spine conference All physicians in the hospital bring their spine patient questions for multidisciplinary assessment—meets weekly Spine clinic Joint clinic with neurosurgery, interventional radiology and radiation oncology NOMS assessment

Treatment Considerations NOMS1,2 Neurologic Oncologic Mechanical Stability Systemic disease Systemic Therapy Radiation Therapy Surgery To decide best therapy in this incredibily complicated patient population, 4 fundamental assessments are made that re incorporated into a decision framework referred to as NOMS , Neurologic Oncologic Mechanical Instability, and systemic disease vs. 1Bilsky MH, Smith M. Surgical approach to epidural spinal cord compression. Hematology/Oncology Clinics of North America.;20(6):1307-1317, 2006 2Bilsky MH, Azeem S. The NOMS framework for decision making in metastatic cervical spine tumors. Current Opinions in Orthopedics 2007;18(3):263-269.

Options for Therapy Multi-disciplinary Approach Systemic Therapy Chemo/Immuno-/Hormonal therapy Targeted Therapy Radiation Therapy Conventional EBRT (30 Gy in 10 fractions) Image-guided intensity modulated RT Hypofractionated RT (10 Gy x 3) Single Fraction RT (24 Gy) Brachytherapy: p32 plaque Surgery Percutaneous Cement Augmentation Open: Anterior, Posterolateral, Combined En bloc resection for margins

Presentation Three Predominant Pain Syndromes: Biologic Mechanical Radiculopathy Myelopathy Significant treatment implications

Presentation Biologic pain Indicative of bone pathology Predominant pain syndrome (95%) Night or morning pain that resolves over the course of the day Mechanism: Diurnal variation in endogenous steroid secretion Treatment: Steroids/RT

Presentation Mechanical Pain Indicative of bone pathology Movement-related pain Level dependent AA: Flexion/extension/rotation SAC: Flexion/extension Thoracic: Extension Lumbar: Mechanical Radiculopathy Radiographic correlates Treatment: Surgery or Kyphoplasty followed by RT

Presentation Radiculopathy Indicative of neuroforaminal disease Differentiate from the following: Bone lesion (eg. L3 vs. femur fracture) Neuropathy Brachial/Lumbosacral Plexus Tumor Leptomeningeal Tumor Treatment: Dependent on tumor histology and degree of ESCC, often RT in absence of instability

Presentation Myelopathy: Indicative of high-grade ESCC Spinothalamic tracts (Pinprick) Corticospinal tracts (Motor) Posterior Columns (Proprioception) Autonomic (Bowel and Bladder) Neurogenic vs. other (eg. narcotics) Perineal numbness Conus medullaris or sacrum Other spinal levels: Significant degree of paralysis Treatment: Dependent on the radiosensitivity of the tumor

NOMS Assessment Neurologic Oncologic Mechanical Instability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology Radiation or Chemosensitivity Mechanical Instability Systemic Disease and Medical Co-morbidity

O: Radiation Sensitivity NOMS N: ESCC O: Radiation Sensitivity Radiation Sensitivity Tumor Histology Sensitive Myeloma   Lymphoma Moderately Sensitive Breast Moderately Resistant Colon NSCLC Highly Resistant Thyroid Renal Sarcoma Melanoma 2 3 1

O: Radiation Sensitivity NOMS O: Radiation Sensitivity N: ESCC Radiation Sensitivity Tumor Histology Sensitive Myeloma   Lymphoma Moderately Sensitive Breast Moderately Resistant Colon NSCLC Highly Resistant Thyroid Renal Sarcoma Melanoma 2 3 1 cEBRT 30 Gy in 3 Gy/fraction

O: Radiation Sensitivity NOMS N: ESCC O: Radiation Sensitivity Radiation Sensitivity Tumor Histology Sensitive Myeloma   Lymphoma Moderately Sensitive Breast Moderately Resistant Colon NSCLC Highly Resistant Thyroid Renal Sarcoma Melanoma 2 3 1 SRS

O: Radiation Sensitivity NOMS N: ESCC O: Radiation Sensitivity Radiation Sensitivity Tumor Histology Sensitive Myeloma   Lymphoma Moderately Sensitive Breast Moderately Resistant Colon NSCLC Highly Resistant Thyroid Renal Sarcoma Melanoma 2 3 1 Surgery + SRS

Histologic Classification Radiosensitivity to cEBRT (30 Gy in 10) Lymphoma Seminoma Myeloma Breast Prostate Sarcoma Melanoma GI NSCLC Renal Gilbert F U Maranzano Rades I Katagiri Responses: F-Favorable, I-Intermediate, U-Unfavorable Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and outcomes. Spine 34(22S):S78-92, 2009

Local Control Histology 413 patients Histology 3 Yr Local Control Breast 98% GI H&N 93% Lung Melanoma 90% Unknown 91% Prostate Renal 89% Sarcoma 96% Thyroid 92%

Radiosurgery Recommendations A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of oligometastatic disease and/or radioresistant histology in which no relative contraindications exist. Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and outcomes. Spine 34(22S):S78-92, 2009

Case Solitary T10 RCC

RCC/Melanoma Stereotactic Radiosurgery 80 patients 2004-2008 SSRS 18 to 24 Gy x 1 Imaging and PE q 4 months Radiographic/Symptom Control: 92% Trend towards better control at 24 Gy: 97% vs. 83% Thiagaragan A, et.al. Stereotactic radiosurgery: A new paradigm For melanoma and renal cell carcinoma spine metastases. Presented ASCO, 2010

NOMS Assessment Neurologic Oncologic Mechanical Instability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: RCC Radiation or Chemosensitivity Mechanical Instability Systemic Disease and Medical Co-morbidity

SRS NOMS Assessment Neurologic Oncologic Mechanical Stability: Stable Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression: ESCC 1b Oncologic Tumor Histology: RCC Radiation: Sensitive to SRS Mechanical Stability: Stable Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response SRS

RCC SRS:24 Gy, Cord dMax:14Gy f/u 26 months Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.

SRS:24 Gy, Cord dMax:14Gy f/u 26 months RCC A strong recommendation is made that patients with solid renal cell carcinoma in the absence of epidural disease may benefit from stereotactic radiosurgery as first line therapy rather than en bloc excision. SRS:24 Gy, Cord dMax:14Gy f/u 26 months Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.

O: Radiation Sensitivity NOMS N: ESCC O: Radiation Sensitivity Radiation Sensitivity Tumor Histology Sensitive Myeloma   Lymphoma Moderately Sensitive Breast Moderately Resistant Colon NSCLC Highly Resistant Thyroid Renal Sarcoma Melanoma 2 3 1 Surgery + SRS

SRS and High-Grade ESCC 7 local failures received <15 Gy to small percentage of PTV Currently, dMax Cord <14 Gy with 10% per mm falloff: Cytotoxic tumoral dose risks overdosing the spinal cord Subtherapeutic dose that spares spinal cord tolerance risks epidural tumor progression Resolution of soft tissue disease can take months: No effective decompression of epidural disease Caveat: SRS for RT-sensitive disease (Median 16Gy)1 Under-dosed sub-volume Cord Tumor (gross target volume) Tumor (gross target volume) Prescription isodose 28 1Ryu S., et.al Radiosurgical decompression of metastatic epidural compression. Cancer 116(9): 2250, 2010

Neurologic Oncologic Assessment Prospective randomized trial Solid tumors HG-ESCC with myelopathy Surgery + cEBRT vs. cEBRT alone Exclusion criteria RT-sensitive tumors ie. Hematologic malignancies and GCT Multi-level disease Systemic contraindications to surgery The best evidence that patients with high-grade spinal cord compression are best served with surgical decompression comes from a prospective randomized trial from Roy Patchell and Tibbs from U of K published in Lancet 2005 RA Patchell, et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 366: 643, 2005

Results Surgery Radiation Significance Overall Ambulation 84% (42/50) 57% (29/51) p=.001 Duration 122 days 13 days p=.003 Recover Ambulation 62% (10/16) 19% (3/16) p= .012 Continence 155 days 17 days p=.016 Narcotics (MSO4) .4mgs 4-8 mgs p=.002 Survival Time 126 days 100 days p=.033 RA Patchell, et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 366: 643, 2005

Evidence-based Recommendations (GRADE methodology) : Results Surgery Radiation Significance Overall Ambulation 84% (42/50) 57% (29/51) p=.001 Duration 122 days 13 days p=.003 Recover Ambulation 62% (10/16) 19% (3/16) p= .012 Continence 155 days 17 days p=.016 Narcotics (MSO4) .4mgs 4-8 mgs p=.002 Survival Time 126 days 100 days p=.033 Evidence-based Recommendations (GRADE methodology) : A strong recommendation is made for patients with high-grade spinal cord compression due to solid tumor malignancy undergo surgical decompression and stabilization followed by RT.1 Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease. Spine 34(22S): S101-S107, 2009

Radiosurgery Recommendations A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of oligometastatic disease and/or radioresistant histology in which no relative contraindications exist. Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and outcomes. Spine 34(22S):S78-92, 2009

Postoperative Adjuvant Radiation 101 patients/106 metastases operated between1977 to 1996 Surgery: Posterolateral: 79% Anterior: 12% Combined Anterior/Posterior: 9% Partial (48%) or Complete Resection (43%): 91% Adjuvant Treatment: 100% Local Control: 40% @ 6 months 30% @ 1 year 4% @ 4 years Significant Predictors of Recurrence: Ambulation, Tumor Histology, Completeness of Resection Klekamp J, Samii. Surgical results for spinal metastases. Acta Neurochir (Wien) 140 (9):957-967, 1998

Postoperative Adjuvant Radiation MSKCC Data: 21 patients RT-resistant tumors: 100% Melanoma Renal Cell Carcinoma Sarcoma Colorectal Carcinoma Surgical Indication: High Grade ESCC (Grade 2 or 3): 96% Mechanical Radiculopathy: 4% SRS Single Fraction: 18 to 24 Gy GTV contoured to the preoperative tumor volume Myelogram/CT Moulding, et.al. Local disease control after decompressive surgery and high-dose single fraction radiation for spine metastases. J Neurosurg Spine 13(1): 87-93, 2010

Local Control Surgery + SRS LD:40% HD:94% Moulding, et.al. Local disease control after decompressive surgery and adjuvant high-dose single fraction radiation for spine metastases. J Neurosurg Spine 13(1): 87-93, 2010

Local Control Separation Surgery + SRS 192 pts. SRS: 90% Hypo LD:78% Hypo HD: 95.8%

“Separation Surgery” + SRS 86 year old Papillary thyroid ASIA C Absent proprioception N: HG ESCC O: RT-resistant M: Stable S: Tolerable

“Separation Surgery” + SRS

RCC En bloc excision Published literature: 6 case series:15 patients Operative times: 8 to 12 hours Transfusion data: Melcher - PRBC-15.7units/FFP-20units No complications reported Recurrences:13% Median follow-up 16 months Bilsky M, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009. 2

“Separation Surgery” + SRS SST post RT/Chemo Tumor progression with instability T3 vertebral body Massive brachial plexus N: ESCC 2 Radiculopathy/plexopathy O: Resistant M: Unstable S: Tolerate an operation

NOMS Assessment Neurologic Oncologic Mechanical Stability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: RCC Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response

NOMS Assessment Neurologic Oncologic Mechanical Stability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: RCC Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response

NOMS Assessment Neurologic Oncologic Mechanical Stability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: RCC Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response High-dose steroids Embolization

Posterolateral decompression Instrumentation /SRS + /- p32 plaque NOMS Assessment Neurologic Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: RCC Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response Posterolateral decompression Instrumentation /SRS + /- p32 plaque

NOMS Assessment Neurologic Oncologic Mechanical Stability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: Lymphoma Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response

cEBRT (30 Gy in 10 fractions) NOMS Assessment Neurologic Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: Lymphoma Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response High-dose steroids cEBRT (30 Gy in 10 fractions)

NOMS Assessment Neurologic Oncologic Mechanical Stability Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: Unknown Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response

Establish RT-sensitive: RT NOMS Assessment Neurologic Myelopathy Functional Radiculopathy Degree of epidural spinal cord compression Oncologic Tumor Histology: Unknown Radiation or Chemosensitivity Mechanical Stability Systemic Disease and Medical Co-morbidity Needle biopsy revealed mutliple myeloma. The NOMS assess changes to RT sensitive and appropriately this patient was irradiated. With cEBRT with an excellent response High-dose steroids Establish RT-sensitive: RT No Dx: Surgery

NOMechanical InstabilityS Recognition of instability as an indication for surgery or percutaneous cement augmentation prior to RT Spine Oncology Study Group (SOSG) created a scoring system Spine Instability Neoplastic Score or SINS1 -Integrates systematic literature review with expert opinion -Reliable: High inter and intra-relater reliability2 -Valid: Substantial agreement between SINS score and expert opinion2 Part of our failure to recognize instability in the neoplastic setting is that it is very different from the traumatic setting. 1Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine. 2010;35(22):E1221-9. 2Fourney DR, et al. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol 2011;29(22):3072-71 .

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

Spine Instability Neoplastic Score (SINS) SINS Component Description Score Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S1) Mobile (C3-6, L2-4) Semirigid (T3-10) Rigid (S2-5) 3 2 1 Pain Yes* Occasional non-mechanical pain No Bone Lesion Lytic Mixed Blastic Alignment Subluxation / translation De novo deformity Normal 4 Vertebral Body >50% collapse <50% collapse No collapse with >50% VB involved None of above Posterolateral Involvement Bilateral Unilateral None Tallied Score from 6 components Stable Potentially Unstable Unstable 0-6 7-12 13-18 The points alloted were contributions to instabiity Location: Junctional areas were considered significantly more unstable than rigid spines Pain: Mechanical pain is axial load or movement related . Non-mechanical pain is biologic pain that is night or morning pain that resolves over the course of the day and is responsive to steroids, but does not denote instability. Bone lesions lytic disease is impacts instabiity significantly more than sclerotic bone disease. Alignment: subluxation translation had the highest point total veretbral body was degree of collapse and involvement of the vertebral bdoy, posterior elements included joints, pedicle and ribs. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9, 2010

SRS NOMS Algorithm

Summary NOMS provides a comprehensive approach to the multidisciplinary management of spine metastases Metastatic cancer patients are a unique cohort Integration of new technologies and therapeutic options Most effective and low impact = best palliatiion NOMS provides a vehicle for surgeons, medical and radiation oncologists to speak a common language