1. Rarer Bone Tumors Thomas F. DeLaney, M.D. Co-Director: Sarcoma Program
Medical Director: F. H. Burr Proton Center
Massachusetts General Hospital

2. Survival-Advanced Inoperable Chondrosarcoma (Picci et al),2 ,4 ,6 ,8 1 12 24 36 48 60 72 84 96
108
120
months
Overall survival for all 171 pts was:
48% at 1 year
24% at 2 years
12% at 3 years
6% at 4 years
2% at 5 years
Median time to death was 11 months-
Useful benchmark for future studies

3. OS and stage of inoperable disease1
local only
local + lung ,8
lung only
multiple sites ,6
Cum. Survival ,4 ,2 12 24 36 48 60 72 84 96
108
120
months
P-Value

4. OS and Medical Treatment (all pts),2 ,4 ,6 ,8 1 12 24 36 48 60 72 84 96
108
120
months
Cum. Survival (YES)
Cum. Survival (NO)
Cum. Survival
OS and Medical Treatment
(all pts)
P-Value ,2 ,4 ,6 ,8 1 12 24 36 48 60
months
Cum. Survival
Cum. Survival (YES)
Cum. Survival (NO)
Pts with metastasis only
(local & local + met excluded)
P-Value

5. OS and Radiotherapy (Local only)
OS and Radiotherapy (all pts)
OS and Radiotherapy (Local + met) ,2 ,4 ,6 ,8 1 12 24 36 48 60 72 84 96
108
120
months
P-Value
0.1052 ,2 ,4 ,6 ,8 1 12 24 36 48 60 72 84 96
108
120
months
P-Value
0.1063
Cum. Survival (YES)
Cum. Survival (YES)
Cum. Survival (NO)
Cum. Survival (NO)
OS and Radiotherapy (Local only)
P-Value 1 ,8 ,6
Cum. Survival ,4 ,2
Cum. Survival (YES)
Cum. Survival (NO) 12 24 36 48 60 72 84 96
108
120
months

6. 24 pts (21 1º tumors) rx’ed with single-fraction SRS
High-Dose Single-Fraction RT for the Management of Chordomas of the Spine and Sacrum (Yamada et al)
24 pts (21 1º tumors) rx’ed with single-fraction SRS
Median follow-up 24 months
SRS was administered as definitive (10), neoadjuvant (6) or adjuvant (8) treatment
95% control rate-High rates of LC in 1º chordomas
Radical surg, surg (en bloc) + high dose RT, definitive RT+/- TKI
Limited toxicity (to date)
1 sciatic neuropathy -1 vocal cord paralysis
Will need longer follow-up on this regimen
Neuropathies are late events→H. Suit: “Late events occur late”
How to do phase 1 studies in Radiation Oncology- ? Surrogate endpoints?

7. IG-SRS for Spine Sarcoma(Folkert et al, MSKCC)
Conventional RT of spine sarcomas: prolonged RT course
Conventional doses ~ 50 Gy not effective
High doses ~ Gy by sophisticated techniques/particles effective for 1º tumors->~85% LC
Hypofx and single-fx image-guided stereotactic RT (IG-SRS) may be more convenient/cost effective Rx
33% pts 1º and 66% pts met tumors Rx’ed since 2005
Myelogram-CT simulation and inverse RT planning
Image-guided Rx: KV imaging/cone-beam CT scan.
117 patients/147 lesions Rx’ed with hypofx (3-6 fx; n=49, 33.3%) or single-fx IG-SRS (n=98, 66.7%)
88% local control with single-fraction IG-SRS.
A Phase II clinical trial is being developed to use single-fx IG-SRS in the definitive management of sarcoma.
Exercise caution for 1º tumor pts at risk for late effects

8. Local progression-free survival and overall survival, full cohort.
Outcomes, IG-SRS
Single
24 months
Local Progression-Free Survival (LPFS) 
Full Cohort
82.6%
(95% CI %)
Metastatic lesions
80.6%
(95% CI %)
Primary lesions
88%
(95% CI %)
Hypofractionated IG-SRS
68.2%
(95% CI %)
Single-fraction IG-SRS
88.2%
(95% CI %)
Overall Survival (OS)
51%
(95% CI %)
Metastatic patients
39%
(95% CI %)
Primary patients
77.1%
(95% CI %)
Hypofractionated IG-SRS patients
42.7%
(95% CI %)
Single fraction IG-SRS patients
54.4%
(95% CI %)
P=.005
Hypo
P=.020
24Gy x1
Hypo
Local progression-free survival and overall survival, lesions treated with single-fraction and hypofractionated IG-SRS
Local progression-free survival and overall survival, full cohort.
Multivariate analysis: single-fraction IG-SRS retained its significance in terms of reduction in local recurrence (P=.002): HR (95% CI: ).