Evaluation of a Novel CT-On-Rails or Trilogy Stereotactic Spine Radiotherapy System (SSRS)

CT-On-Rails or Trilogy is a system that places the radiation treatment machine in the same
room as the CT scanner so that the CT scanner can help deliver radiation more precisely.

You will have a MRI of the spine within 1 month of registration on this study. You will also
fill out a health survey (5 minutes), a symptom inventory ( 5 minutes), and a Brief Pain
Inventory (5 minutes) within 1 week of registration.

A pretreatment feasibility study will first be performed to determine the precision,
accuracy, and reproducibility with which the target volume and critical normal structures
(e.g. spinal cord) can be positioned relative to the radiation beams for spine tumors; this
will consist of a CT scan.

Patients will have a CT-simulation. The simulation is like a CT scan where a special body
frame is used to keep the patient from moving during scanning and later treatment.

You will be asked questions about your medical history and have a complete neurological exam
during your first consultation. The neurological exam involves testing upper and lower motor
strength, sensation to light touch, reflexes, mental exam, and way you walk. MRI of the spine
must be performed within 1 month of registration. You will be asked to complete 3
questionnaires to evaluate your symptoms and pain. Each questionnaire will take around 5
minutes to complete, and should be completed within 1 month of being enrolled in the study.

All patients will be treated with radiation therapy that is guided by the CT-on-Rails or
Trilogy procedure. Patients will receive a CT scan immediately before the treatment in the
same room of the treatment using CT-On-Rails or Trilogy. There will be a total of 3
treatments over a period of 2 weeks.

Monitoring of side effects will be focused on neurological, gastrointestinal,
musculoskeletal, and hematological systems. Every attempt will be made to have the patient
complete the prescribed course of radiation to maximize the beneficial effect of treatment.
However, if there is severe side effects, radiation treatment will be stopped and patients
will be taken off study.

You will have follow up visits once a week during radiation treatment, scheduled on the same
day as radiation. After treatment, you will have telephone, mail, or follow-ups per fax
scheduled at 2 and 4 weeks,and 2 months post radiation. You will have follow up visits
scheduled at 3, 6, 9, 12, 18, and 24 months, then every six months for the rest of your life.
At all follow-up visits, you will be asked questions about your medical history, have a
neurological exam, and neurologic function will be evaluated. Any pain medication you are
taking will be noted. You will have an MRI of the spine at 3, 6, 9, 12,18, and 24 months,
then once a year for the rest of your life. You will also be asked to complete 3
questionnaires to evaluate your symptoms and pain. Each questionnaire will take around 5
minutes to complete.

This is an investigational study. The CT-on-rails and Trilogy linear accelerator are
FDA-approved medical devices and are commercially available, however, the way these two
devices are being used is investigational. Up to 150 patients will take part in this study.
All will be enrolled at M. D. Anderson.

Inclusion Criteria:

1. Radiographically documented spine or paraspinal metastasis demonstrated on spine MRI
within 4 wks of registration

2. Maximum of 2 metastatic sites in the spine to be irradiated over a single course of
treatment.

3. Informed consent for irradiation or re-irradiation of spinal or para-spinal tumor (s)

4. Diagnosis cancer including but not limited to lung (non-small cell and small cell),
breast, prostate, renal cell, melanoma, gastrointestinal, germ cell tumors, and
unknown primary tumors

5. Karnofsky performance status of at least 40 (i.e. not requiring active
hospitalization)

6. Maximum of 1 prior course of spine radiotherapy to the current region of interest
allowed.

Exclusion Criteria:

1. Worsening neurological status due to radiographic evidence of spinal cord compression
requiring immediate surgical decompression or emergent conventional external radiation
therapy

2. Delay in initiation of radiation treatment would be potentially detrimental to
neurological outcome

3. Patients already re-treated with radiation as part of this protocol will not be
eligible for additional re-treatment

4. Unstable spine requiring surgical stabilization.

5. Sites outside the spine (eg. lung, liver) are not eligible for treatment

6. Systemic radiotherapy (Sr-89) within 30 days

7. Prior irradiation of the area to be treated within 3 months of registration

8. Patients currently receiving, or who have received chemotherapy within 30 days are not
eligible

9. Inability to tolerate lying flat on treatment couch for greater than 30 minutes.

10. Patient with multiple myeloma

11. Patients unable to undergo MRI of the spine

12. Patients with pacemakers

13. Patients who have previously received maximum cord tolerance of 45 Gy in 5 weeks
conventional fractionation or equivalent dose to the current area to be treated.