Vertebroplasty with Radiation Therapy for Spine Metastatic Cancer Patients with Indeterminate Lesion (SINS Criteria)

Not Applicable

Recruiting

• Conditions: Metastatic Malignant Neoplasm in the Spine; Hematopoietic and Lymphoid Cell Neoplasm; Malignant Solid Neoplasm
• Interventions: Other: Immunotherapy; Radiation: Stereotactic Radiosurgery; Procedure: Vertebroplasty

• Registration Number: NCT05178472
• Lead Sponsor: Ohio State University Comprehensive Cancer Center

Brief Summary

This clinical trial studies the side effects of stereotactic radiosurgery and how well it works with or without vertebroplasty, separation surgery, or immunotherapy in patients with cancer that is radiation resistant and has spread to the spine (spinal metastases). Spinal metastases are rapidly progressive, have poor prognosis, are extremely difficult to treat, and can effect patient quality of life and overall health. Immunotherapy is a type of standard of care therapy to boost or restore the ability of the immune system to fight cancer. Stereotactic radiosurgery is a type of external radiation therapy that uses special equipment to position the patient and precisely give a single large dose of radiation to a tumor. A vertebroplasty is a procedure used to repair a bone in the spine that has a break caused by cancer, osteoporosis, or trauma. The purpose of this trial is to test different combinations of immunotherapy, stereotactic radiosurgery, and surgery to improve overall survival and quality of life in patients with spinal metastases.

Detailed Description

PRIMARY OBJECTIVE:

I. To determine the overall efficacy and safety of stereotactic radiosurgery (SRS) with or without vertebroplasty or separation surgery in patients with radiation resistant histologies metastatic to the spine with or without concurrent immunotherapy with PD1 blockade.

SECONDARY OBJECTIVES:

I. To assess 6 month vertebral compression fracture (VCF) rate. II. To assess local control (LC) and distant disease control rates. III. To assess the progression free survival (PFS). IV. To assess the overall survival (OS). V. To assess potential vertebral compression fracture (VCF) risk in cancer patients with spinal metastases (SM).

VI. To assess changes in pain from baseline with patient reported measures, medication changes, and quality of life (QoL) measures.

EXPLORATORY OBJECTIVES:

I. To assess changes in immune-stimulatory effect via Trex1 relative to radiation dose.

II. To evaluate whether changes in Trex1 correlates with PD-L1 expression. III. To validate known molecular signatures predicting metastatic potential and molecular mechanisms that have previously been documented.

IV. To develop novel molecular biomarker signatures that predict local spinal metastasis control.

V. To evaluate molecular signatures at the time of spinal metastasis, and potentially define the "molecular evolution" of a tumor after treatment.

OUTLINE:

INDETERMINATE COHORT: Patients are randomized to 1 of 2 arms.

ARM I: Patients undergo vertebroplasty 2-4 weeks later, undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies in the absence of disease progression or unacceptable toxicity.

ARM II: Patients undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for 1 year.

Study Timeline

• Study First Submitted: 2021-12-16
• Study First Submitted QC: 2021-12-16
• Study First Posted: 2022-01-05
• Study Start: 2023-03-27
• Status Verified: 2025-02
• Last Update Submitted: 2025-03-13
• Last Update Posted: 2025-03-17
• Primary Completion: 2026-12-31
• Study Completion: 2026-12-31

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 200

Inclusion Criteria

• At least 18 years of age and older with indeterminate Spine Metastasis.
• All patients with metastatic radiation resistant histologies to the spine (such as Non-small cell Lung cancer, Melanoma, Colorectal, Sarcoma, head and neck, Esophageal, Gallbladder, Liver, Pancreatic, Prostate, Breast, Thyroid, Renal Cell Carcinoma)
• Eastern Cooperative Oncology Group (ECOG) performance status =< 2
• Disease visualized by CT or MRI
• Prior radiation therapy will be allowed at the discretion of the Radiation Oncologist based on current standard operating procedures.
• Tumor tissue from the core biopsy or resected site of disease will be collected, if available for biomarker analyses.
• Four or less consecutive spinal segments involved by tumor. Or four or less separate spinal tumor targets with a minimum of one vertebral body separation
• Patient is able (i.e. sufficiently fluent) and willing to complete the quality of life questionnaire in either English or Spanish. The baseline assessment must be completed within required timelines. Inability (illiteracy in English or Spanish, loss of sight, or other equivalent reason) to complete the questionnaires will not make the patient ineligible for the study. However, ability but unwillingness to complete the questionnaires will make the patient ineligible

Exclusion Criteria

• Patients < 18 years of age
• Inability to get a standard MRI or CT myelogram for radiation treatment target delineation
• Patients with prior radiation to the spinal segment to be treated may be included if the radiation dose can be delivered safely, per the treating radiation oncologist.
• Patients with symptomatic spinal cord compression requiring emergent surgery
• Pregnant or lactating women
• Systemic therapy or immunosuppressive medications, excluding immunotherapy, within 3-14 days of radiation treatment, at the discretion of the treating radiation oncologist .
• Patients with stable or unstable lesions based on SINS criteria

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm II (no vertebroplasty)	Immunotherapy	Patients receive standard of care immunotherapy IV every 2 weeks for up to 6 months and undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies in the absence of disease progression or unacceptable toxicity.
Arm I (vertebroplasty)	Vertebroplasty	Patients undergo vertebroplasty and, 2-4 weeks later, undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies. Patients also receive standard of care immunotherapy IV every 2 weeks for up to 6 months in the absence of disease progression or unacceptable toxicity.
Arm II (no vertebroplasty)	Stereotactic Radiosurgery	Patients receive standard of care immunotherapy IV every 2 weeks for up to 6 months and undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies in the absence of disease progression or unacceptable toxicity.
Arm I (vertebroplasty)	Immunotherapy	Patients undergo vertebroplasty and, 2-4 weeks later, undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies. Patients also receive standard of care immunotherapy IV every 2 weeks for up to 6 months in the absence of disease progression or unacceptable toxicity.
Arm I (vertebroplasty)	Stereotactic Radiosurgery	Patients undergo vertebroplasty and, 2-4 weeks later, undergo SRS over 1-3 fractions depending upon the number of affected vertebral bodies. Patients also receive standard of care immunotherapy IV every 2 weeks for up to 6 months in the absence of disease progression or unacceptable toxicity.

Primary Outcome Measures

Name	Time	Method
Vertebral compression fracture (VCF) rate	At 6 months	Will be summarized for all patients overall and by each cohort. The confidence interval of the overall VCF rate within 6 months will be calculated using binomial exact test for each cohort.
Local control	At 6 months	Will be summarized for all patients overall and by each cohort. Will be summarized using Kaplan-Meier survival analysis.

Secondary Outcome Measures

Name	Time	Method
Objective response rate	Up to 1 year	Will be summarized for all patients overall and by each cohort.
Overall survival	Up to 1 year	Will be summarized for all patients overall and by each cohort. Will be summarized using Kaplan-Meier survival analysis.
Abscopal effects	Up to 1 year	Will be summarized for all patients overall and by each cohort.
Progression-free survival	Up to 1 year	Will be summarized for all patients overall and by each cohort. Will be summarized using Kaplan-Meier survival analysis.
Change in health-related quality of life	Baseline up to 1 year	Will be summarized for all patients overall and by each cohort and estimated using the linear mixed model for repeated measures for each group and overall.

Trial Locations

Locations (1)

Ohio State University Comprehensive Cancer Center; 🇺🇸 Columbus, Ohio, United States