For patients needing re-treatment to the spine, it is important to consider the biologically

effective dose (BED). The BED takes into account the dose that is given to the patient as
well as the fractionation and is important in determining late effects that may
occur. According to Nieder et al1 the risk of radiation myelopathy appears to be small
with doses less than or equal to 135.5Gy; however, a cumulative spinal cord BED in the
range of 130-150 Gy is justified in order to achieve tumor control. To determine the BED
the following formula can be used:

BED= n x d x (1 + d/(α/β))

n = number of fractions
d = dose per fraction
α/β= dose in Gy (3 Gy for late effects & 10 Gy for acute reactions and tumor
response).2Largerα/βimplies decreased sensitivity to changes in fraction size while a
small α/β suggests changes in fraction size have a dramatic effect on tissue response.2

In the case of a patient who received 50.4Gy in 28 fractions in 2013 and is now returning
in 2018 for additional radiation to the thoracic spine, it would be important to determine
the total BED to ensure that it is limited to less than 150Gy with the addition of the 30Gy
the physician is prescribing. According to Sminia et al,3 the α/β ratio for the thoracic
spine is 2, so the formula to determine the BED of the original prescription would be:

BED = 28 x 1.8Gy x (1+(1.8Gy/2))

BED = 95.76 or 96 Gy

Because the original prescription has already delivered a BED of 96Gy, the new
prescription must have a BED of 54 Gy or less to be at the maximum allowed BED of
150 Gy.

A prescription of 30 Gy in 10 fractions would result in an unacceptable total BED.

BED = 10 x 3 x (1 + (3/2))
BED = 75 Gy

The dose per day must be limited and the fractions spread out to try and achieve a BED
within the acceptable range. Dropping the dose to 2Gy a day and delivering 30Gy in 15
fractions still does not provide a low enough BED.

BED = 15 x 2 x (1 + (2/2))
BED = 60 Gy

Extending the fractionation further to deliver 1.5 Gy a day over the course of 20
treatments provides a total BED under 150 Gy and would be safer for this patient.

BED = 20 x 1.5 x (1+ (1.5/2))

 BED = 52.5

(Original BED) 96 + (BED of the new prescription) 52.5 = 148.5 total BED

Patients who receive irradiation of the spine are at risk to develop radiation myelopathy.
Studies have been done that show limiting the BED can greatly reduce a patient’s
chances of developing this condition. Because of this, it is important that we consider the
total BED when planning these patients.

1. Nieder C, Grosu AL, Andratschke NH, Molls M. Update of human spinal cord
reirradiation tolerance based on additional data from 38 patients. Int J Radiat
Oncol Biol Phys.2006;66(5):1446-
1449. https://doi.org/10.1016/j.ijrobp.2006.07.1383
2. Werts ED. The Radiation Biology of Dose Fractionation: Determinants of Effect.
[Powerpoint].
3. Sminia P, Oldenburger F, Slotman BJ, Schneider CJ, Hulshof MC. Re-irradiation of the
human spinal cord. Strahlenther Onkol.2002;178(8):453-6.
http://dx.doi.org/10.1007/s00066-002-0948-1