Salvage Stereotactic Body Radiotherapy (SBRT) Following In-Field Failure of Initial SBRT for Spinal Metastases Isabelle Thibault, MD, Mikki Campbell,

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Salvage Stereotactic Body Radiotherapy (SBRT) Following In-Field Failure of Initial SBRT for Spinal Metastases Isabelle Thibault, MD, Mikki Campbell, MRT(T), Chia-Lin Tseng, MD, Eshetu G. Atenafu, MSc, Daniel Letourneau, PhD, Eugene Yu, MD, B.C. John Cho, MD, Young K. Lee, PhD, Michael G. Fehlings, MD, PhD, Arjun Sahgal, MD International Journal of Radiation Oncology • Biology • Physics Volume 93, Issue 2, Pages 353-360 (October 2015) DOI: 10.1016/j.ijrobp.2015.03.029 Copyright © 2015 Elsevier Inc. Terms and Conditions

Fig. 1 Renal cell cancer in a patient with C2 metastases initially treated with 24 Gy in 2 fractions (cord planning organ at risk volume [PRV] Pmax dose 16.0 Gy) for bone-only disease using a donut distribution. (A) T2 magnetic resonance axial image. (B) Dose distribution. Progression with a significant soft tissue component involving the left paraspinal tissues, left C2-C3 neural foramen and ipsilateral bone segment occurred 23 months after first course stereotactic body radiation therapy (SBRT) and salvage second SBRT delivered with 30 Gy in 5 fractions (cord PRV Pmax dose 15.5 Gy). (C) T2 axial image. (D) Dose distribution. The tumor responded with regression. (E) T2 axial image 2 months after salvage second SBRT. International Journal of Radiation Oncology • Biology • Physics 2015 93, 353-360DOI: (10.1016/j.ijrobp.2015.03.029) Copyright © 2015 Elsevier Inc. Terms and Conditions

Fig. 2 Overall survival for the 40 patients after salvage second course spine stereotactic body radiation therapy (SBRT). International Journal of Radiation Oncology • Biology • Physics 2015 93, 353-360DOI: (10.1016/j.ijrobp.2015.03.029) Copyright © 2015 Elsevier Inc. Terms and Conditions

Fig. 3 Cumulative incidence of local recurrence after salvage second course spine stereotactic body radiation therapy for the 56 spinal metastatic segments treated. International Journal of Radiation Oncology • Biology • Physics 2015 93, 353-360DOI: (10.1016/j.ijrobp.2015.03.029) Copyright © 2015 Elsevier Inc. Terms and Conditions