Transcript The Role of Stereotactic Radiosurgery in the

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
Physiatry
Michael
Stubblefield,M.D.
Jonas Sokolof, D.O.
Christian Custodio, M.D.
PT/OT
Nursing
Joan Zatcky, NP
Cynthia Correa, RN
Pain
Ruth Gargan-Klinger, NP
Jane Yoffe, NP
Roma Tickoo, M.D.
Solange Inglis, NP
Kenneth Cubert, M.D.
Marie Marte, NP
Vinay Puttaniah, M.D.
Amitabh Gulati, M.D.
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
• Systemic Therapy
• Oncologic
• Radiation Therapy
• Mechanical Stability
• Surgery
• 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
o Hypofractionated RT (10 Gy x 3)
o 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
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal
cord compression
• Oncologic
• Tumor Histology
• Radiation or
Chemosensitivity
• Mechanical Instability
• Systemic Disease and
Medical Co-morbidity
NOMS
0
ESCC
N:
1
O: Radiation Sensitivity
Radiation Tumor
Sensitivity Histology
Sensitive
2
3
Myeloma
Lymphoma
Moderately
Sensitive
Breast
Moderately
Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma
NOMS
0
N: ESCC
O: Radiation Sensitivity
1
Radiation Tumor
Sensitivity Histology
Sensitive
2
3
cEBRT
30 Gy in 3 Gy/fraction
Myeloma
Lymphoma
Moderately
Sensitive
Breast
Moderately
Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma
NOMS
0
N: ESCC
1
O: Radiation Sensitivity
Radiation Tumor
Sensitivity Histology
Sensitive
2
3
SRS
Myeloma
Lymphoma
Moderately
Sensitive
Breast
Moderately
Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma
NOMS
0
N: ESCC
O: Radiation Sensitivity
1
Radiation Tumor
Sensitivity Histology
Sensitive
2
3
Surgery + SRS
Myeloma
Lymphoma
Moderately
Sensitive
Breast
Moderately
Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma
Histologic Classification
Radiosensitivity to cEBRT (30 Gy in 10)
Lymphoma
Seminoma
Myeloma
Breast Prostate
Sarcoma
Melanoma
GI
NSCL
C
Renal
Gilbert
F
F
U
U
U
U
U
U
Maranzano
F
F
F
U
U
U
U
U
Rades
F
I
I
I
U
I
U
I
Rades
F
F
F
U
U
U
U
U
Katagiri
F
F
F
U
U
U
U
U
Maranzano
F
F
F
U
U
U
U
U
Rades
F
I
I
I
U
I
U
I
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
98%
H&N
93%
Lung
98%
Melanoma
90%
Unknown
91%
Prostate
98%
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
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal
cord compression
• Oncologic
• Tumor Histology: RCC
• Radiation or
Chemosensitivity
• Mechanical Instability
NOMS
Assessment
• Neurologic
• 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
SR
S
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.
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.
NOMS
0
N: ESCC
O: Radiation Sensitivity
1
Radiation Tumor
Sensitivity Histology
Sensitive
2
3
Surgery + SRS
Myeloma
Lymphoma
Moderately
Sensitive
Breast
Moderately
Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma
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:
Under-dosed
sub-volume
No effective decompression of epidural disease
• Caveat: SRS for RT-sensitive disease
(Median 16Gy)1
Cord
Tumor
(gross
Tumor
(gross
target
volume)
target
volume)
1Ryu
S., et.al Radiosurgical decompression of metastatic
epidural compression. Cancer 116(9): 2250, 2010
Prescription
isodose
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
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
Overall Ambulation
Duration
Surgery
Radiation
Significance
84%
(42/50)
57% (29/51)
p=.001
13 days
p=.003
19% (3/16)
p= .012
122 days
Recover
Ambulation
62%
(10/16)
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
Results
Overall Ambulation
Duration
Surgery
Radiation
Significance
84%
(42/50)
57% (29/51)
p=.001
13 days
p=.003
19% (3/16)
p= .012
122 days
Recover
Ambulation
62%
(10/16)
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
Klekamp J, Samii. Surgical results for spinal metastases.
Resection
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/FFP20units
•No complications
reported
Bilsky M, et.al. Shifting Paradigms in the Treatment of Metastatic
Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.
•Recurrences:13%
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
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord
compression
• Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
• Mechanical Stability
NOMS
Assessment
• Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord
compression
• Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
• Mechanical Stability
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
High-dose steroids
Embolization
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
Posterolateral
decompression
Instrumentation /SRS + /p32 plaque
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
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
High-dose steroids
cEBRT (30 Gy in 10 fractions)
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
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
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
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
3
1
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
None
3
1
0
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
None
3
1
0
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
None
3
1
0
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
None
3
1
0
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
None
3
1
0
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
None
3
1
0
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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, L5S1)
Mobile (C3-6, L2-4)
Semirigid (T3-10)
Rigid (S2-5)
3
2
1
0
Yes*
Occasional non-mechanical pain
No
3
1
0
Bone Lesion
Lytic
Mixed
Blastic
2
1
0
Alignment
Subluxation / translation
De novo deformity
Normal
4
2
0
Vertebral Body
>50% collapse
<50% collapse
No collapse with >50% VB involved
None of above
3
2
1
0
Posterolateral
Involvement
Bilateral
Unilateral
3
1
Pain
Tallied Score from 6 components
Stable
0-6
Potentiall Unstable
y Unstable
7-12
13-18
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