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OBJECTIVE  This study evaluated a large cohort of patients treated with stereotactic body radiation therapy for spinal metastases and investigated predictive factors for local control, local progression-free survival (LPFS), overall survival, and pain response between the different spinal regions.    METHODS  The study was undertaken via retrospective review at a single institution. Patients with a tumor metastatic to the spine were included, while patients with benign tumors or primary spinal cord cancers were excluded. Statistical analysis involved univariate analysis, Cox proportional hazards analysis, the Kaplan-Meier method, and machine learning techniques (decision-tree analysis).    RESULTS  A total of 165 patients with 190 distinct lesions met all inclusion criteria for the study. Lesions were distributed throughout the cervical (19%), thoracic (43%), lumbar (19%), and sacral (18%) spines. The most common treatment regimen was 24 Gy in 3 fractions (44%). Via the Kaplan-Meier method, the 24-month local control was 80%. Sacral spine lesions demonstrated decreased local control (p = 0.01) and LPFS (p   50 cm 3  was also predictive of local failure (p = 0.04). Fewer cervical spine cases had disease with PTV &gt; 50 cm 3  than the thoracolumbar (p = 5.87 × 10 −8 ) and sacral (p = 3.9 × 10 −3 ) cases. Using decision-tree analysis, the highest-fidelity models for predicting pain-free status and local failure demonstrated the first splits as being cervical and sacral location, respectively.    CONCLUSIONS  This study presents a novel risk stratification for local failure and LPFS by spinal region. Patients with metastases to the sacral spine may have decreased local control due to increased PTV, especially with a PTV of &gt; 50 cm 3 . Multidisciplinary care should be emphasized in these patients, and both surgical intervention and radiotherapy should be strongly considered.

Stereotactic body radiation therapy for spinal metastases: a novel local control stratification by spinal region