Suggested algorithmic approach to management for vertebral bone metastases

VCF: vertebral compression fracture; LE: life expectancy; PS: performance status; EBRT: external beam radiation therapy; VA: vertebral augmentation; SBRT: stereotactic body radiotherapy; CRPC: castration-resistant prostate cancer.
* Assess spine stability using a validated classification system such as the Spine Instability Neoplastic Score (SINS). Refer to UpToDate text.
¶ VA is generally reserved for symptomatic osteolytic spinal metastases with an intact bone cortex and without epidural disease, spinal cord compression, or retropulsion of bone fragments into the spinal cord.
Δ If observation is chosen, consider periodic repeat imaging and treat with EBRT if lesion progresses or there is an impending fracture.
◊ EBRT is the preferred option for most patients. SBRT could be considered for reirradiation or radioresistant malignancy (eg, renal cell sarcoma, melanoma). Refer to UpToDate text.
§ Most of the data on radiopharmaceuticals are in patients with metastatic prostate cancer; they could also be considered for others with diffuse osteoblastic painful metastases versus large-field/hemibody irradiation.