Histology-Specific Treatment Strategies and Survival Prediction in Lung Cancer Patients with Spinal Metastases: A Nationwide Analysis.

BACKGROUND/OBJECTIVES: Spinal metastases are a common and severe complication of lung cancer, particularly in small cell lung cancer (SCLC), and are associated with poor survival. Despite advancements in treatment, optimal management strategies remain unclear, with significant differences between non-small cell lung cancer (NSCLC) and SCLC. This study evaluates treatment patterns, survival outcomes, and prognostic factors in lung cancer patients with spinal metastases, integrating deep learning survival prediction models. METHODS: This retrospective cohort study analyzed the National Cancer Database (NCDB) to identify NSCLC and SCLC patients diagnosed with spinal metastases. Demographics and treatment modalities were analyzed and adjusted for age, sex, and comorbidities. Kaplan-Meier analysis and Cox proportional hazards models assessed overall survival (OS). Five advanced survival prediction models estimated 1-year and 10-year mortality, with feature importance determined via permutation analysis. RESULTS: Among 428,919 lung cancer patients, 5.1% developed spinal metastases, with a significantly higher incidence in SCLC (13.6%) than in NSCLC (5.1%). SCLC patients had poorer OS. Radiation therapy alone was the predominant treatment, and stereotactic body radiation therapy (SBRT) predicted better short- and long-term survival compared to other radiation techniques. High-dose radiation (71-150 Gy BED) improved OS in NSCLC, while reirradiation benefited NSCLC but had a limited impact in SCLC. SurvTrace demonstrated the highest predictive accuracy for 1-year and 10-year mortality, identifying age, radiation dose, reirradiation, and race as key prognostic factors. CONCLUSIONS: The management of spinal metastases requires a histology-specific approach. Radiation remains the primary treatment, with SBRT predicting better short- and long-term survival. High-dose radiation and reirradiation should be considered for NSCLC, while the benefits are limited in SCLC. These findings support histology-specific treatment strategies to improve survival of patients with metastatic lung cancer to the spine.