Post on 26-Mar-2015
SPINE SBRT: The MSKCC Spine Service
IAEA Singapore SBRT Symposium
Josh Yamada MD FRCPCMark Bilsky MDDepartments of Radiation Oncology and NeurosurgeryMemorial Sloan Kettering Cancer CenterNY NY USA
Disclosures
Varian Medical Systems Consultant
Continuing Medical Education Institute Speakers Bureau
Radiation OncologyJosh Yamada, M.D.
RadiologyEric Lis, M.D.
George Krol, M.D.Sasan Karimi, M.D.Pierre Gobin, M.D.
Athos Patsilides, M.D.
Orthopedic Surgery
Patrick Boland, M.D.
PhysiatryMichael
Stubblefield,M.D.Jonas Sokolof, D.O.Christian Custodio,
M.D.PT/OT
NursingJoan Zatcky, NP
Cynthia Correa, RNRuth Gargan-Klinger,
NPJane Yoffe, NP
Solange Inglis, NPMarie Marte, NP
NeurosurgeryMark Bilsky, M.D.Ilya Laufer, M.D.
NeurologyEdward Avila, D.O.
Xi Chen, M.D.Sonia Sandhu, D.O
PainRoma Tickoo, M.D.
Kenneth Cubert, M.D.Vinay Puttaniah, M.D.Amitabh Gulati, M.D.
MSKCC Spine Service
Goals of TreatmentMulti-disciplinary Approach
• MetastasisMetastasis
• PalliationPalliation
Pain ControlPain Control
NeurologyNeurology
OncologyOncology
Mechanical StabilityMechanical Stability
The Spine Service at MSKCC: Multidisciplinary Care
•Spine oncology requires multidisciplinary care
•Spine conference
•All physicians in the hospital bring their spine patient questions for multidisciplinary assessment—meets weekly
•Spine clinic
• Joint clinic with neurosurgery, interventional radiology and radiation oncology
•NOMS assessment
Treatment ConsiderationsNOMS1,2
•Neurologic
•Oncologic
•Mechanical Stability
•Systemic disease
• Systemic Therapy
• Radiation Therapy
• Surgery
vs.
1Bilsky MH, Smith M. Surgical approach to epidural spinal cord compression. Hematology/Oncology Clinics of North America.;20(6):1307-1317, 2006
2Bilsky MH, Azeem S. The NOMS framework for decision making in metastatic cervical spine tumors. Current Opinions in Orthopedics 2007;18(3):263-269.
Options for TherapyMulti-disciplinary Approach
• Systemic Therapy• Chemo/Immuno-/Hormonal therapy• Targeted Therapy
• Radiation Therapy• Conventional EBRT (30 Gy in 10
fractions)• Image-guided intensity modulated RT
o Hypofractionated RT (10 Gy x 3)o Single Fraction RT (24 Gy)
• Brachytherapy: p32 plaque
• Surgery– Percutaneous Cement Augmentation • Open: Anterior, Posterolateral,
Combined• En bloc resection for margins
Presentation
•Three Predominant Pain Syndromes:
Biologic
Mechanical
Radiculopathy
•Myelopathy
•Significant treatment implications
Presentation
•Biologic pain
•Indicative of bone pathology
•Predominant pain syndrome (95%)
•Night or morning pain that resolves over the course of the day
•Mechanism: Diurnal variation in endogenous steroid secretion
•Treatment: Steroids/RT
Presentation
•Mechanical Pain•Indicative of bone pathology•Movement-related pain•Level dependent
AA: Flexion/extension/rotationSAC: Flexion/extensionThoracic: ExtensionLumbar: Mechanical Radiculopathy
•Radiographic correlates•Treatment: Surgery or Kyphoplasty followed
by RT
Presentation
•Radiculopathy
•Indicative of neuroforaminal disease
•Differentiate from the following:Bone lesion (eg. L3 vs. femur fracture)NeuropathyBrachial/Lumbosacral Plexus TumorLeptomeningeal Tumor
•Treatment: Dependent on tumor histology and degree of ESCC, often RT in absence of instability
Presentation
•Myelopathy:
• Indicative of high-grade ESCCSpinothalamic tracts (Pinprick)Corticospinal tracts (Motor)Posterior Columns (Proprioception)Autonomic (Bowel and Bladder)
Neurogenic vs. other (eg. narcotics)
Perineal numbness
Conus medullaris or sacrum
Other spinal levels: Significant degree of paralysis
Treatment: Dependent on the radiosensitivity of the tumor
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology
• Radiation or Chemosensitivity
•Mechanical Instability
•Systemic Disease and Medical Co-morbidity
NOMS N: ESCC
0
2 3
1Radiation Sensitivity
Tumor Histology
Sensitive Myeloma LymphomaModerately Sensitive BreastModerately Resistant Colon NSCLCHighly Resistant Thyroid
RenalSarcomaMelanoma
O: Radiation Sensitivity
NOMS N: ESCC
0
2 3
1Radiation Sensitivity
Tumor Histology
Sensitive Myeloma LymphomaModerately Sensitive BreastModerately Resistant Colon NSCLCHighly Resistant Thyroid
RenalSarcomaMelanoma
O: Radiation Sensitivity
cEBRT30 Gy in 3 Gy/fraction
NOMS N: ESCC
0
2 3
1Radiation Sensitivity
Tumor Histology
Sensitive Myeloma LymphomaModerately Sensitive BreastModerately Resistant Colon NSCLCHighly Resistant Thyroid
RenalSarcomaMelanoma
O: Radiation Sensitivity
SRS
NOMS N: ESCC
0
2 3
1Radiation Sensitivity
Tumor Histology
Sensitive Myeloma LymphomaModerately Sensitive BreastModerately Resistant Colon NSCLCHighly Resistant Thyroid
RenalSarcomaMelanoma
O: Radiation Sensitivity
Surgery + SRS
Histologic ClassificationRadiosensitivity to cEBRT (30 Gy in 10)
LymphomaSeminomaMyeloma
Breast Prostate Sarcoma Melanoma GINSCL
CRenal
Gilbert F F U U U U U U
Maranzano F F F U U U U U
Rades F I I I U I U I
Rades F F F U U U U U
Katagiri F F F U U U U U
Maranzano F F F U U U U U
Rades F I I I U I U I
Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and
outcomes. Spine 34(22S):S78-92, 2009
Responses: F-Favorable, I-Intermediate, U-Unfavorable
Local Control Histology
Histology3 Yr Local Control
Breast 98%
GI 98%
H&N 93%
Lung 98%
Melanoma 90%
Unknown 91%
Prostate 98%
Renal 89%
Sarcoma 96%
Thyroid 92%
413 patients
Radiosurgery Recommendations
A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over
conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of
oligometastatic disease and/or radioresistant histology in which no relative contraindications exist.
Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and
outcomes. Spine 34(22S):S78-92, 2009
CaseSolitary T10 RCC
RCC/MelanomaStereotactic Radiosurgery
•80 patients •2004-2008•SSRS 18 to 24 Gy x 1•Imaging and PE q 4 months•Radiographic/Symptom Control: 92%•Trend towards better control at 24 Gy: 97% vs. 83%
Thiagaragan A, et.al. Stereotactic radiosurgery: A new paradigmFor melanoma and renal cell carcinoma spine metastases. Presented
ASCO, 2010
NOMS Assessment
•Neurologic
• Myelopathy• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
•Mechanical Instability
•Systemic Disease and Medical Co-morbidity
NOMS Assessment
•Neurologic
•Myelopathy
•Functional Radiculopathy
•Degree of epidural spinal cord compression: ESCC 1b
•Oncologic
•Tumor Histology: RCC
•Radiation: Sensitive to SRS
•Mechanical Stability: Stable
•Systemic Disease and Medical Co-morbidity
SRS
RCC
Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.
SRS:24 Gy,
Cord dMax:14Gy
f/u 26 months
RCC
SRS:24 Gy, Cord dMax:14Gy f/u 26
months
A strong recommendation is made that patients with solid
renal cell carcinoma in the absence of epidural disease
may benefit from stereotactic radiosurgery as first line
therapy rather than en bloc excision.
Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.
NOMS N: ESCC
0
2 3
1Radiation Sensitivity
Tumor Histology
Sensitive Myeloma LymphomaModerately Sensitive BreastModerately Resistant Colon NSCLCHighly Resistant Thyroid
RenalSarcomaMelanoma
O: Radiation Sensitivity
Surgery + SRS
Tumor (gross target
volume)
SRS and High-Grade ESCC
•7 local failures received <15 Gy to small percentage of PTV
•Currently, dMax Cord <14 Gy with 10% per mm falloff:
Cytotoxic tumoral dose risks overdosing the spinal cord
Subtherapeutic dose that spares spinal cord tolerance risks epidural tumor progression
•Resolution of soft tissue disease can take
months:
No effective decompression of epidural disease
•Caveat: SRS for RT-sensitive disease
(Median 16Gy)1
Tumor (gross target
volume)
Prescription isodose
Cord
Under-dosed sub-volume
1Ryu S., et.al Radiosurgical decompression of metastatic epidural compression. Cancer 116(9):
2250, 2010
Neurologic Oncologic Assessment
•Prospective randomized trial
•Solid tumors•HG-ESCC with myelopathy•Surgery + cEBRT vs. cEBRT alone
•Exclusion criteria• RT-sensitive tumors ie.
Hematologic malignancies and GCT
• Multi-level disease
• Systemic contraindications to surgeryRA Patchell, et al., Direct decompressive surgical resection in the treatment of
spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 366: 643, 2005
ResultsSurgery Radiation Significance
Overall Ambulation
84% (42/50)
57% (29/51) p=.001
Duration 122 days 13 days p=.003
Recover Ambulation
62% (10/16)
19% (3/16) p= .012
Continence 155 days 17 days p=.016
Narcotics (MSO4) .4mgs 4-8 mgs p=.002
Survival Time 126 days 100 days p=.033
RA Patchell, et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by
metastatic cancer: a randomized trial. Lancet 366: 643, 2005
ResultsSurgery Radiation Significance
Overall Ambulation
84% (42/50)
57% (29/51) p=.001
Duration 122 days 13 days p=.003
Recover Ambulation
62% (10/16)
19% (3/16) p= .012
Continence 155 days 17 days p=.016
Narcotics (MSO4) .4mgs 4-8 mgs p=.002
Survival Time 126 days 100 days p=.033
Evidence-based Recommendations (GRADE methodology) : A strong recommendation is made for patients with high-grade spinal cord compression due to solid tumor malignancy undergo
surgical decompression and stabilization followed by RT.1
Bilsky M,, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease. Spine 34(22S): S101-S107,
2009
Radiosurgery Recommendations
A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over
conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of
oligometastatic disease and/or radioresistant histology in which no relative contraindications exist.
Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: What are the options, indications, and
outcomes. Spine 34(22S):S78-92, 2009
Postoperative Adjuvant Radiation
Klekamp J, Samii. Surgical results for spinal metastases.Acta Neurochir (Wien) 140 (9):957-967, 1998
•101 patients/106 metastases operated between1977 to 1996•Surgery:Posterolateral: 79%Anterior: 12%Combined Anterior/Posterior: 9%Partial (48%) or Complete Resection (43%): 91%•Adjuvant Treatment: 100%•Local Control: 40% @ 6 months 30% @ 1 year 4% @ 4 years•Significant Predictors of Recurrence: Ambulation, Tumor Histology, Completeness of Resection
Postoperative Adjuvant Radiation
Moulding, et.al. Local disease control after decompressive surgery and high-dose single fraction radiation for spine metastases. J Neurosurg Spine 13(1): 87-93, 2010
•MSKCC Data: 21 patients• RT-resistant tumors: 100%Melanoma Renal Cell CarcinomaSarcomaColorectal Carcinoma
•Surgical Indication: High Grade ESCC (Grade 2 or 3): 96%Mechanical Radiculopathy: 4%
•SRS Single Fraction: 18 to 24 Gy GTV contoured to the preoperative tumor volume Myelogram/CT
Local Control Surgery + SRS
HD:94%
LD:40%
Moulding, et.al. Local disease control after decompressive surgery and adjuvant high-dose single fraction radiation for spine metastases.
J Neurosurg Spine 13(1): 87-93, 2010
SRS: 90% Hypo LD:78%
Hypo HD: 95.8%
Local Control Separation Surgery + SRS
192 pts.
“Separation Surgery” + SRS
N: HG ESCCO: RT-resistant
M: StableS: Tolerable
86 year oldPapillary thyroid
ASIA CAbsent
proprioception
“Separation Surgery” + SRS
2
Bilsky M, et.al. Shifting Paradigms in the Treatment of Metastatic Spine Disease .Spine. 34(22S) Supplement:S101-S107, 2009.
• Published literature:• 6 case series:15 patients•Operative times: 8 to 12 hours•Transfusion data: Melcher - PRBC-15.7units/FFP-20units•No complications reported•Recurrences:13%•Median follow-up 16 months
RCCEn bloc excision
• SST post RT/Chemo
• Tumor progression with instability
• T3 vertebral body
• Massive brachial plexus
• N: ESCC 2
Radiculopathy/plexopathy
• O: Resistant
• M: Unstable
• S: Tolerate an operation
“Separation Surgery” + SRS
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
High-dose steroidsEmbolization
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: RCC
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
Posterolateral decompression
Instrumentation /SRS + /- p32 plaque
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: Lymphoma
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: Lymphoma
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
High-dose steroidscEBRT (30 Gy in 10
fractions)
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: Unknown
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
NOMS Assessment
•Neurologic
• Myelopathy
• Functional Radiculopathy
• Degree of epidural spinal cord compression
•Oncologic
• Tumor Histology: Unknown
• Radiation or Chemosensitivity
•Mechanical Stability
•Systemic Disease and Medical Co-morbidity
High-dose steroidsEstablish RT-sensitive: RT
No Dx: Surgery
NOMechanical InstabilityS
•Recognition of instability as an indication for surgery or percutaneous cement augmentation prior to RT
•Spine Oncology Study Group (SOSG) created a scoring system Spine Instability Neoplastic Score or SINS1
-Integrates systematic literature review with expert opinion
-Reliable: High inter and intra-relater reliability2
-Valid: Substantial agreement between SINS score and expert opinion2
.
1Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine
Oncology Study Group. Spine. 2010;35(22):E1221-9. 2Fourney DR, et al. Spinal instability neoplastic score: an analysis of reliability
and validity from the spine oncology study group. J Clin Oncol 2011;29(22):3072-71
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
SINS Component Description Score
Location Junctional (Occ-C2, C7-T2, T11-L1, L5-S1)Mobile (C3-6, L2-4)Semirigid (T3-10)Rigid (S2-5)
3210
Pain Yes*Occasional non-mechanical painNo
310
Bone Lesion LyticMixedBlastic
210
Alignment Subluxation / translationDe novo deformityNormal
420
Vertebral Body >50% collapse<50% collapseNo collapse with >50% VB involvedNone of above
3210
Posterolateral Involvement
BilateralUnilateralNone
310
Stable Potentially Unstable
Unstable
0-6 7-12 13-18
Fisher CG, et al. A novel classification system for spinal
instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 35(22):E1221-9,
2010
Spine Instability Neoplastic Score (SINS)
Tallied Score from 6 components
NOMS Algorithm
SR
S
Summary
•NOMS provides a comprehensive approach to the multidisciplinary management of spine metastases
•Metastatic cancer patients are a unique cohort
•Integration of new technologies and therapeutic options
•Most effective and low impact = best palliatiion
•NOMS provides a vehicle for surgeons, medical and radiation oncologists to speak a common language