Oligometastases revisited

Oligo- and polymetastatic progression in lung metastasis(es) patients is associated with specific microRNAs

RATIONALE

Strategies to stage and treat cancer rely on a presumption of either localized or widespread metastatic disease. An intermediate state of metastasis termed oligometastasis(es) characterized by limited progression has been proposed. Oligometastases are amenable to treatment by surgical resection or radiotherapy.

METHODS

We analyzed microRNA expression patterns from lung metastasis samples of patients with ≤ 5 initial metastases resected with curative intent.

RESULTS

Patients were stratified into subgroups based on their rate of metastatic progression. We prioritized microRNAs between patients with the highest and lowest rates of recurrence. We designated these as high rate of progression (HRP) and low rate of progression (LRP); the latter group included patients with no recurrences. The prioritized microRNAs distinguished HRP from LRP and were associated with rate of metastatic progression and survival in an independent validation dataset.

CONCLUSION

Oligo- and poly- metastasis are distinct entities at the clinical and molecular level.

Volumetric modulated arc therapy with flattening filter free beams for isolated abdominal/pelvic lymph nodes: report of dosimetric and early clinical results in oligometastatic patients

BACKGROUND

SBRT is a safe and efficient strategy to locally control multiple metastatic sites. While research in the physics domain for Flattening Filter Free Beams (FFF) beams is increasing, there are few clinical data of FFF beams in clinical practice. Here we reported dosimentric and early clinical data of SBRT and FFF delivery in isolated lymph node oligometastatic patients.

METHODS

Between October 2010 and March 2012, 34 patients were treated with SBRT for oligometastatic lymph node metastasis on a Varian TrueBeam(TM) treatment machine using Volumetric Modulated Arc Therapy (RapidArc). We retrospectively evaluated a total of 25 patients for isolated lymph node metastases in abdomen and/or pelvis treated with SBRT and FFF (28 treatments). Acute toxicity was recorded. Local control evaluation was scored by means of CT scan and/or PET scan.

RESULTS

All dosimetric results are in line with what published for the same type of stereotactic abdominal lymph node metastases treatments and fractionation, using RapidArc. All 25 FFF SBRT patients completed the treatment. Acute gastrointestinal toxicity was minimal: one patient showed Grade 1 gastrointestinal toxicity. Three other patients presented Grade 2 toxicity. No Grade 3 or higher was recorded. All toxicities were recovered within one week. The preliminary clinical results at the median follow up of 195 days are: complete response in 12 cases, partial response in 11, stable disease in 5, with an overall response rate of 82%; no local progression was recorded.

CONCLUSIONS

Data of dosimetrical findings and acute toxicity are excellent for patients treated with SBRT with VMAT using FFF beams. Preliminary clinical results showed a high rate of local control in irradiated lesion. Further data and longer follow up are needed to assess late toxicity and definitive clinical outcomes.

Stereotactic ablative radiotherapy delivered by image-guided helical tomotherapy for extracranial oligometastases

PURPOSE

To investigate the outcomes and risk factors of patients treated with stereotactic ablative radiotherapy (SABR) delivered by image-guided helical tomotherapy (HT) for extracranial oligometastases.

METHODS

From August 2006 through July 2011, 42 consecutive patients (median age 69 years [range 16-87]) with oligometastases (≤3) received HT to all known cancer sites (lung, n = 28; liver, n = 12; adrenal, n = 2). Prognostic factors were assessed by Cox's proportional hazards regression analysis.

RESULTS

A total of 60 lesions were treated with hypofractionated HT (median dose 39 Gy [range 36-72.5]; median dose per fraction 12 Gy [range 5-20]). Complete or partial response was observed in 40 (54 %) patients. With a median follow-up period of 15 months, 1- and 2-year overall survival (OS) was 84 and 63 %, respectively; and 1- and 2-year local control (LC) was 92 and 86 %, respectively. Four patients had pneumonitis Grade ≥2 and two patients had lower gastrointestinal toxicity Grade ≥2. Only the lack of complete/partial response was associated with higher risk of mortality on univariate (HR = 3.8, P = 0.04) and multivariate (HR = 6.6, P = 0.01) analyses.

CONCLUSIONS

SABR delivered by image-guided HT is well tolerated and offers adequate LC with low acute morbidity in patients with extracranial oligometastatic disease. We found that the response to HT was the only predictor for OS.

Stereotactic body radiotherapy for metachronous multisite oligo-recurrence: a long-surviving case with sequential oligo-recurrence in four different organs treated using locally radical radiotherapy and a review of the literature

Stereotactic body radiotherapy (SBRT) for oligometastases represents a recent trend in radiation oncology. While abundant data are available regarding the use of SBRT for the treatment of lung or liver oligometastases from various retrospective series and prospective trials, relatively little information has been accumulated for the treatment of oligometastases at sites other than the lungs and liver, particularly for sequential oligometastases in multiple organs. Oligometastases with primary lesions controlled is called “oligo-recurrence.” We describe herein the case of a lung cancer patient who developed repeated oligo-recurrence at multiple sites that were each controlled by radical radiotherapy and achieved long-term survival and discuss the merits of locally aggressive radiotherapy for this type of disease condition with reviewing the literature. Although further investigation should be undertaken to clarify the benefits, objectives, and methods of SBRT for the treatment of oligometastases, we believe utilization of SBRT may be worthwhile for patients with remote metastases who hope for treatment to acquire better local control and possible longer survival.

Feasibility and toxicity of hypofractionated image guided radiation therapy for large volume limited metastatic disease

PURPOSE

Hypofractionated image guided radiation therapy (HIGRT) is increasingly used for limited metastases. Reported studies have mostly treated small volume tumors. Here, we report the toxicity and oncologic outcomes following treatment of large volume metastases.

METHODS AND MATERIALS

HIGRT patients treated from October 2005 to March 2010 were reviewed. Gross tumor volumes (GTV) and planning target volumes (PTV) were obtained from planning software. A metastasis was considered large volume if the treated PTV exceeded 50 cc. Patients were treated with either 10-fraction (4-5 Gy per fraction) or 3-5 fraction (8-14 Gy per fraction) regimens. Toxicity was obtained from both prospectively collected databases and retrospectively from patient charts.

RESULTS

Sixty-four patients with 93 treated lesions >50 cc were identified. The median GTV and PTV volumes were 41 and 119 cc, respectively. The median number of treated large volume lesions was 1, and a maximum of 3 large volume lesions were treated in a single patient. Primary malignancies included non-small cell lung cancer, renal cell, colorectal, breast, bladder, pituitary, small cell lung cancer, sarcoma, head-and-neck cancer, and hepatocellular cancer. Treated sites included lung (n = 33), regional lymph nodes (n = 20), bone (n = 17), adrenal (n = 9), and liver (n = 6). The most frequently used treatment regimen was 50 Gy in 5 Gy fractions. The median follow-up was 27 months for surviving patients. Treated lesion control was 78%. Low rates of acute and late grade 3 or higher toxicity were reported, with 3 and 5 patients experiencing each, respectively.

CONCLUSIONS

HIGRT to large volume oligometastatic disease is tolerable and feasible with promising tumor control. Local radiation therapy should be considered in patients with large volume, limited metastatic disease.

Stereotactic body radiotherapy treatment of extracranial metastases

Radiotherapy is an integral treatment for patients with metastatic cancer, although it is usually reserved for palliation of pain, dyspnoea, oedema, bleeding and neurological symptoms. However, the administration of high-precision radiotherapy, termed stereotactic body radiotherapy (SBRT), has the potential to significantly affect the disease course for some patients with metastatic cancer by delivering high doses of radiation to the secondary tumours with limited high-dose delivery to adjacent healthy tissues. Indeed, such accurate delivery has been firmly established as a therapy for medically inoperable early-stage non-small-cell lung cancer. To date, the technique has demonstrated improvements in controlling metastasis and, in some cases, improved palliation compared with conventionally fractionated radiotherapy. Active areas of research in SBRT include patient selection for curative intent, optimization of SBRT planning techniques, dosing schema and integration of SBRT into systemic therapies. Given the improvements in cytotoxic and targeted therapies over the past decade, studies testing the careful integration of SBRT into standard systemic therapy regimens are needed. Further investigations are also needed to understand the basic biological mechanisms underlying SBRT because they are likely to be different to those mechanisms in conventional radiotherapy.

Salvage stereotactic body radiotherapy for patients with limited prostate cancer metastases: deferring androgen deprivation therapy

BACKGROUND

We investigated whether repeated stereotactic body radiotherapy (SBRT) of oligometastatic disease is able to defer the initiation of palliative androgen deprivation therapy (ADT) in patients with low-volume bone and lymph node metastases.

PATIENTS AND METHODS

Patients with up to 3 synchronous metastases (bone and/or lymph nodes) diagnosed on positron emission tomography, following biochemical recurrence after local curative treatment, were treated with (repeated) SBRT to a dose of 50 Gy in 10 fractions. Androgen deprivation therapy-free survival (ADT-FS) defined as the time interval between the first day of SBRT and the initiation of ADT was the primary end point. ADT was initiated if more than 3 metastases were detected during follow-up even when patients were still asymptomatic or in case of a prostate specific antigen elevation above 50 ng/mL in the absence of metastases. Secondary end points were local control, clinical progression-free survival, and toxicity. Toxicity was scored using the Common Terminology Criteria for Adverse Events.

RESULTS

We treated 24 patients with a median follow-up of 24 months. Ten patients started with ADT resulting in a median ADT-FS of 38 months. The 2-year local control and clinical progression-free survival was 100% and 42%, respectively. Eleven and 3 patients, respectively, required a second and third salvage treatment for metachronous low-volume metastatic disease. No grade 3 toxicity was observed.

CONCLUSION

Repeated salvage SBRT is feasible, well tolerated and defers palliative ADT with a median of 38 months in patients with limited bone or lymph node PCa metastases.

[The conceptual oligometastatic non-small cell lung cancer and therapeutic strategies]

非小细胞肺癌是发病率及致死率最高的恶性肿瘤之一。约20%-50%会发生远处转移，最常见的转移部位为脑、骨、肝及肾上腺。寡转移状态是一段肿瘤生物侵袭性较温和的时期，存在于局限性原发灶与广泛性转移之间的过渡阶段，转移瘤数目有限并且转移器官具有特异性。“寡转移”来源于微转移，肿瘤细胞已具有器官特异性，但尚不具备全身播散的遗传倾向。治疗寡转移状态的关键是局部控制，需要兼顾预防远处转移、治疗隐匿性转移灶、治疗寡转移灶和全身治疗结束后清除残留癌灶四个方面。本文旨在对“寡转移”概念在非小细胞肺癌常见转移脏器治疗中的应用作一综述。

Oligometastatic disease at presentation or recurrence for nonsmall cell lung cancer

Oligometastatic Non-Small Cell Lung Cancer (NSCLC) presents a unique opportunity for potential curative therapy. Improved cancer staging using PET/CT, MRI, and future cellular and molecular staging with circulating tumor cells and/or molecular markers will identify more patients with truly oligometastasis disease that will benefit from definitive local treatment. Recent development of noninvasive local ablative therapy such as stereotactic radiotherapy makes it possible to eradicate multiple local diseases with minimal side effect. Novel systemic therapy may also control systemic spread and therefore make it possible to improve survival by eliminating local diseases. More research, particularly prospective studies, is ideally randomized studies are needed to validate the concept of oligometastasis.

Review and uses of stereotactic body radiation therapy for oligometastases

In patients with proven distant metastases from solid tumors, it has been a notion that the condition is incurable, warranting palliative care only. The term "oligometastases" was coined to refer to isolated sites of metastasis, whereby the entire burden of disease can be recognized as a finite number of discrete lesions that can be potentially cured with local therapies. Stereotactic body radiation therapy (SBRT) is a novel treatment modality in radiation oncology that delivers a very high dose of radiation to the tumor target with high precision using single or a small number of fractions. SBRT is the result of technological advances in patient and tumor immobilization, image guidance, and treatment planning and delivery. A number of studies, both retrospective and prospective, showed promising results in terms of local tumor control and, in a limited subset of patients, of survival. This article reviews the radiobiologic, technical, and clinical aspects of SBRT for various anatomical sites.

Stereotactic body radiation therapy for metastasis in the lung: an undervalued treatment option with future prospects

SUMMARY The lung is a common site of metastatic disease from solid tumors. Most cancers can develop lung metastases, and sarcoma and epithelial (especially colorectal) malignancies are prone to metastasize to the lung. In particular, the International Registry of Lung Metastases describes 5206 cases of lung metastasectomy, of which 43% were epithelial and 42% were sarcomatoid. Common presenting symptoms include cough, hemoptysis, shortness of breath, chest pain and back pain. Data in the literature suggest the existence of an oligometastatic state, where metastases are limited in number and location. For selected patients with lung oligometastases, local therapy such as surgery, stereotactic body radiotherapy (SBRT) and radiofrequency ablation may potentially yield prolonged survival. Data from retrospective series and prospective trials on the use of SBRT for lung metastases are emerging, showing promising results. Most studies show high local control rates rivaling those found in studies of surgical management (the usual treatment of choice) for lung metastases, while SBRT also has the benefit of low rates of significant toxicities. This review will provide an overview of the utilization of SBRT in the management of lung oligometastases.

Potentially curative stereotactic body radiation therapy (SBRT) for single or oligometastasis to the lung

BACKGROUND

To analyze the treatment outcomes of a potentially curative therapy, stereotactic body radiation therapy (SBRT), for patients with single or oligometastasis to the lungs.

MATERIAL AND METHODS

Sixty-seven metastatic lung lesions in 57 patients were treated with SBRT between September 2001 and November 2010. All patients had single or oligo-metastasis to the lungs following a meticulous clinical work-up, including PET-CT scans. The lungs were the most common primary organ (33 lesions, 49.3%), followed by the head and neck (11 lesions, 16.4%), the liver (nine lesions, 13.5%), the colorectum (seven lesions, 10.4%), and other organs (seven lesions, 10.4%). Three different fractionation schedules were used: 50 Gy/5 fractions to four lesions (6.0%); 60 Gy/5 fractions to 44 lesions (65.7%); and 60 Gy/4 fractions to 19 lesions (28.3%).

RESULTS

Local tumor progression occurred in three lesions (4.5%). The three-year actuarial local control rate was 94.5%. Tumors larger than or equal to 2.5 cm showed poorer local control (98.3% vs. 77.8%, p <0.01). Metastatic tumors from the liver and colorectum showed lower local control rates than those from other organs (77.8%, 85.7%, and 100%, p =0.04). The two-year overall survival rate was 57.2%. Patients with tumors smaller than 2.5 cm had more favorable survival rates (64.0% vs. 38.9% at two-year, p =0.032). Patients with extrathoracic disease had poorer survival rates (66.1% vs. 0% at two-year, p =0.003). Patients with disease-free intervals longer than two years showed a trend toward good prognosis (71.1% vs. 51.1% at two-year, p =0.106). Grade 2 lung toxicity occurred in four patients (6.0%). One patient experienced Grade 5 lung toxicity following SBRT.

CONCLUSION

SBRT for single or oligo-metastasis to the lung seems quite effective and safe. Tumor size, disease-free interval, and presence of extrathoracic disease are prognosticators for survival.

Prognostic impact of radiation therapy to the primary tumor in patients with non-small cell lung cancer and oligometastasis at diagnosis

PURPOSE

We investigated prognostic factors associated with survival in patients with non-small cell lung cancer (NSCLC) and oligometastatic disease at diagnosis, particularly the influence of local treatment to the primary site on prognosis.

METHODS AND MATERIALS

From January 2000 through June 2011, 78 consecutive patients with oligometastatic NSCLC (<5 metastases) at diagnosis underwent definitive chemoradiation therapy (≥45 Gy) to the primary site. Forty-four of these patients also received definitive local treatment for the oligometastases. Survival outcomes were estimated using the Kaplan-Meier method, and risk factors were identified by univariate and multivariate analyses.

RESULTS

Univariate Cox proportional hazard analysis revealed better overall survival (OS) for those patients who received at least 63 Gy of radiation to the primary site (P=.002), received definitive local treatment for oligometastasis (P=.041), had a Karnofsky performance status (KPS) score >80 (P=.007), had a gross tumor volume ≤124 cm³ (P=.002), had adenocarcinoma histology (P=.002), or had no history of respiratory disease (P=.016). On multivariate analysis, radiation dose, performance status, and tumor volume retained significance (P=.004, P=.006, and P<.001, respectively). The radiation dose also maintained significance when patients with and without brain metastases were analyzed separately.

CONCLUSIONS

Tumor volume, KPS, and receipt of at least 63 Gy to the primary tumor are associated with improved OS in patients with oligometastatic NSCLC at diagnosis. Our results suggest that a subset of such patients may benefit from definitive local therapy.

Phase II study of helical tomotherapy in the multidisciplinary treatment of oligometastatic colorectal cancer

Background

Complete metastasectomy provides a real chance for long-term survival in patients with oligometastatic colorectal cancer (CRC). For inoperable patients, we evaluated in this study intensity-modulated and image-guided radiotherapy (IMRT-IGRT) by helical tomotherapy.

Methods

Twenty-four CRC patients with ≤ 5 metastases were enrolled, receiving a dose of 50 Gy in fractions of 5 Gy. No limitations concerning dimension or localization of the metastases were imposed. Whole body PET-CT was performed at baseline and 3 months after the initiation of RT to evaluate the metabolic response rate according to PET Response Criteria in Solid Tumors (PERCIST) version 1.0.

Results

A total of 53 metastases were treated. Seventeen patients (71%) received previously ≥ 1 line of chemotherapy for metastatic disease, displaying residual (n = 7) or progressive (n = 10) metabolic active oligometastatic disease at time of inclusion. Most common sites were the lung, liver and lymphnodes. One patient (4%) experienced grade 3 dysphagia. Twenty-two patients were evaluated by post-treatment PET-CT. Twelve patients achieved a complete (n = 6) or partial (n = 6) metabolic response, resulting in an overall metabolic response rate of 55%. At a median follow-up of 10 months, 7 patients (29%) are in remission, of which 5 received previous chemotherapy with residual oligometastatic disease at time of inclusion. The actuarial 1-year local control, progression-free survival, and overall survival were 54%, 14% and 78%.

Conclusions

Helical tomotherapy delivering 10 fractions of 5 Gy resulted in a metabolic response rate of 55%, and appeared to be attractive as consolidation of inoperable oligometastatic disease after effective chemotherapy.

Trial registration

Eudract 2008-008300-40; NCT00807313

High dose stereotactic body radiotherapy using three fractions for colorectal oligometastases

BACKGROUND AND OBJECTIVES

This study evaluated the treatment result of high dose stereotactic body radiation therapy (SBRT) for colorectal oligometastases.

METHODS

Between 2003 and 2009, 41 patients with 50 lesions confined to one organ from colorectal cancer (CRC) and treated with high dose SBRT ≥45 Gy were retrospectively reviewed. Lymph nodes (LNs) (18 patients) were the most frequent sites followed in order by lung (12) and liver (11). SBRT doses ranged from 45 to 60 Gy in three fractions (median 48 Gy). The cumulative gross tumor volume (GTV) ranged from 2 to 123 ml (median 13 ml).

RESULTS

The median follow-up period from the SBRT date was 28 months (range, 6-65 months). The 3-year local control and overall survival rates were 64 and 60%, and the respective 5-year rates were 57 and 38%. Cumulative GTV and SBRT dose were statistically significant prognostic factors for local control. The grade 3 or 4 complications occurred in three patients (7%).

CONCLUSIONS

High dose SBRT for colorectal oligometastases was found to produce results comparable with surgical series. To improve local control, dose higher than 48 Gy are recommend when possible, but further study will be required to define the optimal normal tissue constraints and acceptable toxicity.

Strong YB-1 expression is associated with liver metastasis progression and predicts shorter disease-free survival in advanced gastric cancer

BACKGROUND

The most significant cause of gastric cancer (GC) death is metastasis, although the underlying mechanisms remain obscure. Y-box binding protein-1 (YB-1) is associated with tumor aggressiveness and poor prognosis in various cancers. In this study we investigated the relationship between YB-1 expression and the clinicopathologic features and metastasis-associated epithelial-mesenchymal transition (EMT) phenotype in advanced GC patients.

PATIENTS AND METHODS

Immunohistochemistry (IHC) was used to analyze YB-1, E-cadherin, and vimentin expression in 98 advanced GC cases.

RESULTS

Twenty-nine (29.6%) cases of GC exhibited strong YB-1 immunoreactivity. Strong YB-1 staining occurred more often in patients with intestinal or non-scirrhous cancer, and demonstrated a significant correlation with vascular invasion (VI), liver metastasis, and shorter disease-free survival (DFS). However, we observed no relationship between YB-1 expression and EMT phenotype or overall survival. Logistic regression analysis revealed that strong staining for YB-1 was the only predictive factor for liver metastasis.

CONCLUSIONS

Our results indicate that YB-1 plays a role in the process of GC metastasis, and that the immunohistochemical detection of this protein potentially delivers valuable insight regarding the prediction of liver metastasis and shorter DFS in patients undergoing curative resection for advanced GC.

Oligometastases treated with stereotactic body radiotherapy: long-term follow-up of prospective study

PURPOSE

To analyze the long-term survival and tumor control outcomes after stereotactic body radiotherapy (SBRT) for metastases limited in number and extent.

METHODS AND MATERIALS

We prospectively analyzed the long-term overall survival (OS) and cancer control outcomes of 121 patients with five or fewer clinically detectable metastases, from any primary site, metastatic to one to three organ sites, and treated with SBRT. Freedom from widespread distant metastasis (FFDM) was defined as metastatic disease not amenable to local therapy (i.e., resection or SBRT). Prognostic variables were assessed using log-rank and Cox regression analyses.

RESULTS

For breast cancer patients, the median follow-up was 4.5 years (7.1 years for 16 of 39 patients alive at the last follow-up visit). The 2-year OS, FFDM, and local control (LC) rate was 74%, 52%, and 87%, respectively. The 6-year OS, FFDM, and LC rate was 47%, 36%, and 87%, respectively. From the multivariate analyses, the variables of bone metastases (p = .057) and one vs. more than one metastasis (p = .055) were associated with a fourfold and threefold reduced hazard of death, respectively. None of the 17 bone lesions from breast cancer recurred after SBRT vs. 10 of 68 lesions from other organs that recurred (p = .095). For patients with nonbreast cancers, the median follow-up was 1.7 years (7.3 years for 7 of 82 patients alive at the last follow-up visit). The 2-year OS, FFDM, and LC rate was 39%, 28%, and 74%, respectively. The 6-year OS, FFDM, and LC rate was 9%, 13%, and 65%, respectively. For nonbreast cancers, a greater SBRT target volume was significantly adverse for OS (p = .012) and lesion LC (p < .0001). Patients whose metastatic lesions, before SBRT, demonstrated radiographic progression after systemic therapy experienced significantly worse OS compared with patients with stable or regressing disease.

CONCLUSIONS

Select patients with limited metastases treated with SBRT are long-term survivors. Future research should address the therapeutic benefit of SBRT for these patients.

MicroRNA expression characterizes oligometastasis(es)

BACKGROUND

Cancer staging and treatment presumes a division into localized or metastatic disease. We proposed an intermediate state defined by ≤ 5 cumulative metastasis(es), termed oligometastases. In contrast to widespread polymetastases, oligometastatic patients may benefit from metastasis-directed local treatments. However, many patients who initially present with oligometastases progress to polymetastases. Predictors of progression could improve patient selection for metastasis-directed therapy.

METHODS

Here, we identified patterns of microRNA expression of tumor samples from oligometastatic patients treated with high-dose radiotherapy.

RESULTS

Patients who failed to develop polymetastases are characterized by unique prioritized features of a microRNA classifier that includes the microRNA-200 family. We created an oligometastatic-polymetastatic xenograft model in which the patient-derived microRNAs discriminated between the two metastatic outcomes. MicroRNA-200c enhancement in an oligometastatic cell line resulted in polymetastatic progression.

CONCLUSIONS

These results demonstrate a biological basis for oligometastases and a potential for using microRNA expression to identify patients most likely to remain oligometastatic after metastasis-directed treatment.

Does Radiotherapy Have Curative Potential in Metastatic Patients? The Concept of Local Therapy in Oligometastatic Breast Cancer

In 1995, Hellmann and Weichselbaum defined for the first time the term oligometastases which is used to describe limited metastasis with a maximum of 3-4 clinically detectable metastases. It is assumed that these patients have a better prognosis and that local treatment of the metastases plays a significant part in the further development of the disease. Therefore, these patients could benefit from a curative local therapy of the manifested metastases. Local therapy measures include mainly radiotherapeutic methods alongside invasive ablative processes, such as surgical resection and radiofrequency ablation. Patients subjected to radiation therapy benefit especially from the usage of modern precision technology as it reduces the radiation exposure to the normal tissue, and because short radiation sessions with escalating doses are possible (e.g. radiation surgery, image-assisted radiation therapy, stereotactic radiation). Initial clinical studies show very good local tumor control rates which are on a par with resection and ablative methods, but with very few side effects and risks. This article summarizes the integration of the concept of oligometastases in the radiotherapy of limited metastatic breast cancer.