NOMS Framework  

Posted bythespinebookadminPosted inTopics, Tumor

Background 

  • NOMS Framework – A tool/ framework used to determine the optimal therapy for patients with spinal metastases (20% of Ca pt have mets, 10% have compression) 
  • Goals of Care: 
    • Pain relief 
    • Maintain vs recover neurologic function 
    • Local durable tumour control 
    • Spinal stability 
    • QoL 
  • Considers 4 sentinel decision points 
    • Neurologic – degree of ESCC (myelopathy/ radiculopathy) 
    • Oncologic – expected tumour response to the treatment options 
    • Mechanical – path fractures 
    • Systemic – pt ability to: tolerate treatment/ expected survival based on extent of disease 
  • Management using 
    • Conventional External Beam Therapy (cEBRT) 
    • Stereotactic RadioSurgery (SRS) 
    • MIS and Open 
    • Systemic therapy 

Neurologic Assessment 

  • Radiographic ESCC (Bilsky et al. Classification) 
    • T2 Weighted Axial Images at the site of most compression to described ESCC (6 grades) 
    • Bilsky Classification 
      • Grade 0 – bone only 
      • Grade 1 – epidural space invaded 
        • A – no deformation of sac 
        • B – deformed sac not abutting cord 
        • C – abutting cord (but not compressing) 
      • Grade 2 – compressing cord CSF visible 
      • Grade 3 – compressing cord CSF not visible 
    • Treatment 
      • Gr 1AB – radiation 
      • Gr 1C – unclear 
      • Gr 23 – decompression before rads 
  • Clinical assessment 
    • Myelopathy 
    • Radiculopathy 

Oncologic Assessment 

  • Considers the responsiveness of a tumour to currently available treatments 
    • Rads most effective, least invasive therefore the most important part is to determine sensitivity to rads 
    • ALL SPINAL METS GET Rads 
      • Sens – CEBRT 
      • Res- SRS 
  • cEBRT response (1 or 2 beams no conformal techniques) 
    • Fraction dose limited by amount of cord in the field (radiation toxicity to cord) 
  • IGRT (image guided radiation therapy) – SRS delivered via IGRT platform (single or multiple fractions) 
  • Tumour Histology is Key to determining cEBRT response 
  • Radiosensitivity – responds to 50 Grays in 1.2 Gy fractions 
    • 5% pr of complication in 5 years 
    • CEBRT – if radiosensitive 
    • SRS – if radioresistant 
  • Radiosensitive – NOMS LBP (in bold CEBRT regardless of ESCC) 
    • Neuroendocrine 
    • Ovarian 
    • Myeloma 
    • Seminoma 
    • Lymphoma 
    • Breast 
    • Prostate 
  • Radioresistant (SRS +/- separation surgery) SMRT CA 
    • Sarcoma 
    • Melanoma 
    • RCC 
    • Thyroid 
    • Colorectal 
    • Adenocarcinoma Lung (NSCLC) 
  • Radiosensitive – CEBRT 
  • Radioresistant Gr <2 – IGRT only 
  • Radioresistant Gr 2 3 – surgery then IGRT (Patchell et al 2005), Separation surgery of 2mm (Benzel and Angelov) 

Mechanical Stability 

  • Independent assessment irrespective of Neurologic or Oncologic 
  • SINS (Spinal Instability Neoplastic Score) 
    • Location 
      • Junctional 3 
      • Mobile 2  
      • Semirigid 1 
      • Rigid 0 
    • Pain 
      • Always 3 
      • Not mechanical 1 
      • Pain free 0 
    • Bone lesion 
      • Lytic (95%) 2 
      • Mixed 1 
      • Blastic (5%) – Breast Prostate 0 
    • Alignment 
      • Subluxation/ translation 4 
      • De novo deformity 2  
      • Normal 0  
    • Vertebral Body Collapse 
      • >50 – 3 
      • <50 2 
      • No Collapse but >50 body 1  
      • None 0  
    • PL Involvement 
      • Bilateral 3 
      • Unilateral 1 
      • None 0 
    • Total 
      • Stable 0-6 
      • Indeterminate 7-12 
      • Unstable 13-18 

Systemic Assessment 

  • ECOG 
    • 0 full active no resti 
    • 1 resitrcted strenus 
    • 2 ambulateor 
    • 3 limited self care 
    • 4 bedridden 
  • Tokuhasi 

5 Complications of Radiation around Cord 

  • Rads Myelopathy 
  • Vertebral Compression Fractures 
  • Pain flair (2 point increase VAS) – treated with steroids 
  • Esophageal toxicity 
  • Rads plexopathy and radiculopathy