1. SRS for spinal metastases

2. Who needs surgical stabilization?

3. Who needs stabilization? FOM – small lesion T7 VC – large lesion involving the vertebral body, lateral and post processes, previously irradiated area

4. Immobilisation and imaging for target definition

5. Technique Custom vaccum bag immobilisation No need for 4D for target -consider if critical adjacent mobile OAR Fused fine resolution T2 MRI, 2mm transverse cuts IMRS CBCT

6. MRI FOR PLANNING 2mm slices T2 +contrast Where is the cord? Where is the tumour?

7. CTV definition

8. CTV-PTV definition FOM – small lesion T7VC – large lesion involving the vertebral body, lateral and post processes, previously irradiated area

9. GTV alone inadequate as CTV Chang et al. 6 Gyx5 or 9 Gyx3 74 tumors 17 (23%) failed Typically, included entire vertebral body excluded posterior elements in PTV Progression adjacent vertebrae one case. Failure of nontreated pedicles and posterior elements (3 of 17) and at epidural space (8 of 17) Spinal cord limit was set at 10 Gy. Chang J Neurosurg Spine 2007;7:151–160.

10. International Spine Radiosurgery Consortium Consensus Guidelines for Target Volume Definition in Spinal Stereotactic Radiosurgery Brett W. Cox et al. IJROBP May 2012 CTV Delineation Orange is average Red=range

11. Which one is better: Uniform dose vs. SIB? Single vs multiple fractions?

12. FOM – oligometastatic breast ca, T7 lesion, IMRT- SIB, 16Gy/1fr whole vertebral body, 24Gy/1fr to the metastasis

13. VC- metastatic oesophageal ca, previously irradiated SRS 18Gy/3 fr to the GTV, 12Gy/3fr to the CTV

14. Spinal cord tolerance

15. Vertebral body collapse

16. Vertebral Compression Fracture VCF MSKCC 27 VCF in (39%) of 71 patients Saghal : 252 patients with 410 lesions from MDAH, Cleveland, Toronto Saghal JCO vol 4 Nov 2013