Background: Spinal metastases affect approximately 40% of patients with systemic cancers; metastatic epidural spinal cord compression (MESCC) occurs in up to 20% of cases and leads to potential significant morbidity. Recent advancements in high-dose conformal radiation techniques, such as Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), enable histology-independent ablative treatments, yet optimal dose fractionation remains undetermined. Methods and Results: This case of vertebral metastases with high-grade ESCC exemplifies the model of a comprehensive treatment workflow that emphasizes interdisciplinary collaboration, within the framework of a personalized medicine. The “Hybrid Therapy” combines Separation Surgery, aimed at achieving circumferential spinal cord decompression, with SBRT/SRS. The oncologic resection has been performed in a navigation-assisted technique that is tailored to the SBRT target, pre-operatively defined on the neuronavigation station. Conclusions: This seamless integration during initial planning of surgery with the ideal radio-oncological target is aimed at avoiding delays in referral and limitations in subsequent treatment options. This integrative holistic strategy not only prioritizes functional preservation, minimizing surgical invasiveness, but also promotes tumor control, thus offering potential promising new avenues for patient-centered oncologic care. Future high-quality studies are warranted to validate the widespread potential utility and safety of this approach.

In this study we investigated the repeatability and reproducibility of radiomic features extracted from MRI images and provide a workflow to identify robust features. 2D and 3D T$_2$-weighted images of a pelvic phantom were acquired on three scanners of two manufacturers and two magnetic field strengths. The repeatability and reproducibility of the radiomic features were assessed respectively by intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC), considering repeated acquisitions with or without phantom repositioning, and with different scanner/acquisition type, and acquisition parameters. The features showing ICC/CCC > 0.9 were selected, and their dependence on shape information (Spearman's $\rho$> 0.8) was analyzed. They were classified for their ability to distinguish textures, after shuffling voxel intensities. From 944 2D features, 79.9% to 96.4% showed excellent repeatability in fixed position across all scanners. Much lower range (11.2% to 85.4%) was obtained after phantom repositioning. 3D extraction did not improve repeatability performance. Excellent reproducibility between scanners was observed in 4.6% to 15.6% of the features, at fixed imaging parameters. 82.4% to 94.9% of features showed excellent agreement when extracted from images acquired with TEs 5 ms apart (values decreased when increasing TE intervals) and 90.7% of the features exhibited excellent reproducibility for changes in TR. 2.0% of non-shape features were identified as providing only shape information. This study demonstrates that radiomic features are affected by specific MRI protocols. The use of our radiomic pelvic phantom allowed to identify unreliable features for radiomic analysis on T$_2$-weighted images. This paper proposes a general workflow to identify repeatable, reproducible, and informative radiomic features, fundamental to ensure robustness of clinical studies.