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Iyengar P, All S, Berry MF, Boike TP, Bradfield L, Dingemans AMC, Feldman J, Gomez DR, Hesketh PJ, Jabbour SK, Jeter M, Josipovic M, Lievens Y, McDonald F, Perez BA, Ricardi U, Ruffini E, De Ruysscher D, Saeed H, Schneider BJ, Senan S, Widder J, Guckenberger M. Treatment of Oligometastatic Non-Small Cell Lung Cancer: An ASTRO/ESTRO Clinical Practice Guideline. Pract Radiat Oncol 2023; 13:393-412. [PMID: 37294262 DOI: 10.1016/j.prro.2023.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/07/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE This joint guideline by American Society for Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) was initiated to review evidence and provide recommendations regarding the use of local therapy in the management of extracranial oligometastatic non-small cell lung cancer (NSCLC). Local therapy is defined as the comprehensive treatment of all known cancer-primary tumor, regional nodal metastases, and metastases-with definitive intent. METHODS ASTRO and ESTRO convened a task force to address 5 key questions focused on the use of local (radiation, surgery, other ablative methods) and systemic therapy in the management of oligometastatic NSCLC. The questions address clinical scenarios for using local therapy, sequencing and timing when integrating local with systemic therapies, radiation techniques critical for oligometastatic disease targeting and treatment delivery, and the role of local therapy for oligoprogression or recurrent disease. Recommendations were based on a systematic literature review and created using ASTRO guidelines methodology. RESULTS Based on the lack of significant randomized phase 3 trials, a patient-centered, multidisciplinary approach was strongly recommended for all decision-making regarding potential treatment. Integration of definitive local therapy was only relevant if technically feasible and clinically safe to all disease sites, defined as 5 or fewer distinct sites. Conditional recommendations were given for definitive local therapies in synchronous, metachronous, oligopersistent, and oligoprogressive conditions for extracranial disease. Radiation and surgery were the only primary definitive local therapy modalities recommended for use in the management of patients with oligometastatic disease, with indications provided for choosing one over the other. Sequencing recommendations were provided for systemic and local therapy integration. Finally, multiple recommendations were provided for the optimal technical use of hypofractionated radiation or stereotactic body radiation therapy as definitive local therapy, including dose and fractionation. CONCLUSIONS Presently, data regarding clinical benefits of local therapy on overall and other survival outcomes is still sparse for oligometastatic NSCLC. However, with rapidly evolving data being generated supporting local therapy in oligometastatic NSCLC, this guideline attempted to frame recommendations as a function of the quality of data available to make decisions in a multidisciplinary approach incorporating patient goals and tolerances.
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Affiliation(s)
- Puneeth Iyengar
- Department of Radiation Oncology, UT Southwestern, Dallas, Texas.
| | - Sean All
- Department of Radiation Oncology, UT Southwestern, Dallas, Texas
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Thomas P Boike
- Department of Radiation Oncology, GenesisCare/MHP Radiation Oncology, Troy, Michigan
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Anne-Marie C Dingemans
- Department of Pulmonology, Erasmus Medical Center Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | | | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul J Hesketh
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Melenda Jeter
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Fiona McDonald
- Department of Radiation Oncology, Royal Marsden Hospital, London, United Kingdom
| | - Bradford A Perez
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | | | - Enrico Ruffini
- Department of Thoracic Surgery, University of Torino, Torino, Italy
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO), Maastricht University Medical Centre, Maastricht and Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Hina Saeed
- Department of Radiation Oncology, Baptist Health South Florida, Boca Raton, Florida
| | - Bryan J Schneider
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam University Medical Centers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Shamji FM, Beauchamp G, Maziak DE. Oligometastatic Lung Cancer Defined by Biology, Science, and Secondary Growths. Thorac Surg Clin 2021; 31:337-346. [PMID: 34304843 DOI: 10.1016/j.thorsurg.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Breast cancer was the first malignant tumor for which TNM classification was proposed by the International Union Against Cancer. Volume and distribution of tumor burden were considered clinically important in this cancer. Lung cancer is caused by excessive cigarette smoking. Prognosis is worst in small cell lung cancer and in non-small cell lung cancer measuring over 3 cm in size and having regional lymphatic spread. Metastatic spread from lung cancer is favored by lymphatic spread to the locoregional lymph nodes and blood-borne spread to 5 sites-lung, brain, bone, liver, and adrenal-all of which are unfavorable prognostic indicators.
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Affiliation(s)
- Farid M Shamji
- University of Ottawa, Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
| | - Gilles Beauchamp
- Thoracic Surgery Unit, Department of Surgery, Maisonneuve-Rosemount Hospital, University of Montreal, 5415 L'Assomption Boulevard, Montreal, Quebec H1T 2M4, Canada
| | - Donna E Maziak
- University of Ottawa, Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
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Mukai Y, Koike I, Matsunaga T, Yokota NR, Takano S, Sugiura M, Sato M, Miyagi E, Hata M. Radiation Therapy for Uterine Cervical Cancer With Lung Metastases Including Oligometastases. In Vivo 2020; 33:1677-1684. [PMID: 31471423 DOI: 10.21873/invivo.11655] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/13/2019] [Accepted: 07/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIM To investigate the role and outcomes of radiation therapy (RT) for stage IVB uterine cervical cancer (UCC) patients with lung (oligo) metastases due to the lack of recent reports on the subject. PATIENTS AND METHODS The cohort for this retrospective study comprised 23 consecutive patients with UCC (squamous cell carcinoma, n=13) and lung metastases who had received pelvic RT. Ten had lung metastases only, including 7 with oligometastases (≤4 lung metastases); the remaining 13 also had other distant metastases. RESULTS Nine (39.1%) of the 22 patients (95.7%) completed RT without interruption. The 1-year primary progression-free rate was 95.2%. The 1-year overall survival rate was 47.2 % (estimated median survival: 9 months). Significant prognostic factors for survival included: i) ≤4 lung metastases (p=0.035), ii) unilateral lung metastases (p=0.039), iii) primary tumor diameter <100 mm (p<0.001), and iv) ECOG performance status <1 (p=0.015). CONCLUSION RT is safe and effective for stage IVB UCC patients with lung metastases.
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Affiliation(s)
- Yuki Mukai
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Izumi Koike
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tatsuya Matsunaga
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naho Ruiz Yokota
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Syoko Takano
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Madoka Sugiura
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Mizuki Sato
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masaharu Hata
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Kissel M, Martel-Lafay I, Lequesne J, Faivre JC, Le Péchoux C, Stefan D, Barraux V, Loiseau C, Grellard JM, Danhier S, Lerouge D, Chouaid C, Gervais R, Thariat J. Stereotactic ablative radiotherapy and systemic treatments for extracerebral oligometastases, oligorecurrence, oligopersistence and oligoprogression from lung cancer. BMC Cancer 2019; 19:1237. [PMID: 31856742 PMCID: PMC6924047 DOI: 10.1186/s12885-019-6449-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 12/11/2019] [Indexed: 12/25/2022] Open
Abstract
Background Stereotactic irradiation (SBRT) is a standard of care for inoperable stage I lung cancer and brain oligometastases from lung cancer but is controversial for extracranial oligometastases. We assessed outcomes of lung cancer patients with extracranial metastases in oligometastatic, oligorecurrent, oligopersistent and oligoprogressive settings (“oligometastatic spectrum”) under strategies using SBRT +/− systemic treatments. Methods A retrospective multicentric study of consecutive lung cancer adult patients with 1–5 extracranial metastases treated with SBRT was conducted. Results Of 91 patients (99 metastases, median age 63, 64.8% adenocarcinomas, 19.8% molecular alterations), 11% had oligometastases, 49.5% oligorecurrence, 19.8% oligopersistence and 19.8% oligoprogression. Of 36% of patients under systemic treatments at initiation of SBRT, systemic treatment interruption was performed in 58% of them. With median follow up of 15.3 months, crude local control at irradiated metastases was 91%, while median distant progression-free survival (dPFS) and overall survival were 6.3 and 28.4 months (2-year survival 54%). Initial nodal stage and oligometastatic spectrum were prognostic factors for dPFS; age, initial primary stage and oligometastatic spectrum were prognostic factors for survival on multivariate analysis. Patients with oncogene-addicted tumors more frequently had oligoprogressive disease. Repeat ablative irradiations were preformed in 80% of patients who had oligorelapses. Worst acute toxicities consisted of 5.5% and one late toxic death occurred. Conclusion The oligometastatic spectrum is a strong prognosticator in patients undergoing SBRT for extracranial metastases. Median survival was over two years but dPFS was about 6 months. Continuation of systemic therapy in oligoprogressive patients should be investigated.
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Affiliation(s)
- Manon Kissel
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France. .,Institut Gustave Roussy, radiotherapy department, 114 Rue Edouard Vaillant, 94800, Villejuif, France.
| | - Isabelle Martel-Lafay
- Centre de lutte contre le cancer Léon Bérard, radiotherapy department, 28 Promenade Léa et Napoléon Bullukian, 69008, Lyon, France
| | - Justine Lequesne
- Centre de lutte contre le cancer François Baclesse, clinical research department, 3 avenue du Général Harris, 14000, Caen, France
| | - Jean-Christophe Faivre
- Institut de Cancérologie de Lorraine, radiotherapy department, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
| | - Cécile Le Péchoux
- Institut Gustave Roussy, radiotherapy department, 114 Rue Edouard Vaillant, 94800, Villejuif, France
| | - Dinu Stefan
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
| | - Victor Barraux
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
| | - Cédric Loiseau
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
| | - Jean-Michel Grellard
- Centre de lutte contre le cancer François Baclesse, clinical research department, 3 avenue du Général Harris, 14000, Caen, France
| | - Serge Danhier
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
| | - Delphine Lerouge
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
| | - Christos Chouaid
- CHI de Créteil, pneumology department, 40 Avenue De Verdun, 94000, Créteil, France
| | - Radj Gervais
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
| | - Juliette Thariat
- Centre de lutte contre le cancer François Baclesse/ ARCHADE, radiotherapy department, 3 avenue du Général Harris, 14000, Caen, France
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Comparison of Clinical Characteristics and Outcomes in Relapsed Versus De Novo Metastatic Non-Small Cell Lung Cancer. Am J Clin Oncol 2019; 42:75-81. [PMID: 30211724 DOI: 10.1097/coc.0000000000000483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To compare the clinical characteristics and outcomes between relapsed and de novo metastatic non-small cell lung cancer (NSCLC). MATERIALS AND METHODS We reviewed all NSCLC diagnoses between January 1999 and December 2013 in the institutional Glans-Look Lung Cancer Database, which contains demographic, clinical, pathologic, treatment, and outcome information. Patients with distant metastasis at diagnosis (American Joint Committee on Cancer [AJCC] eighth edition, stage IV), the "de novo" cohort, were compared with the "relapsed" cohort, consisting of patients diagnosed with early stage disease (stage I/II) undergoing curative intent treatment and subsequently experiencing metastatic relapse. Survival analysis, along with univariate and multivariable analysis was performed. RESULTS A total of 185 relapsed and 3039 de novo patients were identified. Significantly different patterns of smoking history, histology, systemic therapy use, and disease extent were observed between the relapsed and de novo cohorts. Median overall survival from time of metastasis was significantly longer in relapsed than in de novo disease (8.9 vs. 3.7 mo, P<0.001). Relapsed patients demonstrated significant improvements in outcomes over time. In multivariate analysis, de novo metastatic disease continued to bode a worse prognosis (adjusted hazard ratio [HR], 1.4) as did male sex (HR, 1.2), never-smoking history (HR, 1.2), and presence of extrapulmonary metastases (HR, 1.3). Systemic therapy receipt conferred better outcome (HR, 0.4), although the impact of relapsed versus de novo disease on outcomes persisted regardless of systemic therapy receipt. CONCLUSIONS Relapsed and de novo patients represent significantly different subpopulations within metastatic NSCLC with the latter exhibiting poorer survival. This information facilitates discussions about prognosis with patients and supports screening initiatives aimed at reducing de novo disease.
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Suzawa K, Soh J, Takahashi Y, Sato H, Shien K, Yamamoto H, Kanazawa S, Kiura K, Miyoshi S, Toyooka S. Clinical outcome of patients with recurrent non-small cell lung cancer after trimodality therapy. Surg Today 2019; 49:601-609. [PMID: 30734881 DOI: 10.1007/s00595-019-1774-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/15/2019] [Indexed: 12/25/2022]
Abstract
PURPOSES The purpose of this study was to review the clinical course of patients with recurrence after induction chemoradiotherapy followed by surgery (trimodality therapy) for locally advanced non-small cell lung cancer (LA-NSCLC) and to identify the factors associated with favorable clinical outcome after recurrence. METHODS We analyzed the records of 140 patients with LA-NSCLC who were treated with trimodality therapy between 1999 and 2014. RESULTS Recurrence developed after trimodality therapy in 48 patients. A yp-N positive status was associated with a high risk of recurrence (HR, 2.05; P = 0.048). Of the 45 of these patients able to be assessed retrospectively, 18 had oligometastatic recurrence and 20 underwent local treatment with curative intent. Local treatment was most frequently given to patients with oligometastatic recurrence (P < 0.001). The median post-recurrence survival (PRS) was 41.4 months, and the 2-year PRS rate was 62%. Patients who received local treatment showed better PRS (P = 0.009). The presence of liver metastasis (P = 0.008), bone metastasis (P = 0.041), or dissemination (P < 0.0001) were associated with worse PRS. CONCLUSION The survival of patients who received aggressive local treatment for postoperative recurrence after trimodality therapy for LA-NSCLC was better than that of patients who did not.
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Affiliation(s)
- Ken Suzawa
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Junichi Soh
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuta Takahashi
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Hiroki Sato
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazuhiko Shien
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Hiromasa Yamamoto
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Susumu Kanazawa
- Department of Radiology, Okayama University Hospital, Okayama, Japan
| | - Katsuyuki Kiura
- Department of Respiratory Medicine, Okayama University Hospital, Okayama, Japan
| | - Shinichiro Miyoshi
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Shinichi Toyooka
- Department of Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan.
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Shibahara I, Kanamori M, Watanabe T, Utsunomiya A, Suzuki H, Saito R, Sonoda Y, Jokura H, Uenohara H, Tominaga T. Clinical Features of Precocious, Synchronous, and Metachronous Brain Metastases and the Role of Tumor Resection. World Neurosurg 2018; 113:e1-e9. [DOI: 10.1016/j.wneu.2017.10.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 01/10/2023]
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Jensen GL, Yost CM, Mackin DS, Fried DV, Zhou S, Court LE, Gomez DR. Prognostic value of combining a quantitative image feature from positron emission tomography with clinical factors in oligometastatic non-small cell lung cancer. Radiother Oncol 2018; 126:362-367. [DOI: 10.1016/j.radonc.2017.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/31/2017] [Accepted: 11/13/2017] [Indexed: 01/24/2023]
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Yap TA, Macklin-Doherty A, Popat S. Continuing EGFR inhibition beyond progression in advanced non-small cell lung cancer. Eur J Cancer 2016; 70:12-21. [PMID: 27866095 DOI: 10.1016/j.ejca.2016.10.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/29/2016] [Accepted: 10/18/2016] [Indexed: 01/31/2023]
Abstract
The majority of patients with epidermal growth factor receptor (EGFR) mutant non-small cell lung cancer (NSCLC) respond to first-line EGFR tyrosine kinase inhibitors (TKIs), but nearly all inevitably acquire resistance and develop disease progression. Conventional practice would be to switch treatments to second-line therapy. However, continuing TKIs beyond progression is becoming increasingly commonplace in patients with indolent, small volume asymptomatic growth, who may potentially continue to derive ongoing clinical benefit and to avoid a 'withdrawal tumour flare'. Nevertheless, there are limitations to our current criteria for assessing disease response, which are based on radiological assessments without considering symptomatic benefit, or the complex molecular and clinical heterogeneity of tumour growth and drug response patterns. In this article, we review the rationale for continuing EGFR inhibitors in patients with EGFR mutant NSCLC beyond disease progression and discuss strategies that have been pursued in the context of molecularly and clinically heterogeneous populations of tumour growth depending on the different clinical scenarios encountered. We discuss the management of systemic disease progression, including continuing EGFR TKIs alone, introducing a drug holiday, or combining TKIs with chemotherapy or other molecularly targeted agents. We also focus on approaches in managing patients with indolent, small volume asymptomatic growth (non-CNS oligometastatic disease progression) and those with oligometastatic EGFR mutant NSCLC with involvement of the central nervous system. We envision future precision medicine strategies through the use of next generation sequencing strategies of serial tumour rebiopsies and circulating plasma DNA to individualise the management for such patients during disease progression.
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Affiliation(s)
- Timothy A Yap
- Department of Medicine, Royal Marsden Hospital, London, UK; Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | | | - Sanjay Popat
- Department of Medicine, Royal Marsden Hospital, London, UK; Section of Genomic Medicine, National Heart and Lung Institute, Imperial College, London, UK.
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Campo M, Al-Halabi H, Khandekar M, Shaw AT, Sequist LV, Willers H. Integration of Stereotactic Body Radiation Therapy With Tyrosine Kinase Inhibitors in Stage IV Oncogene-Driven Lung Cancer. Oncologist 2016; 21:964-73. [PMID: 27354669 DOI: 10.1634/theoncologist.2015-0508] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/18/2016] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED : Genotype-based selection of patients for targeted therapies has had a substantial impact on the treatment of non-small cell lung cancers (NSCLCs). Tyrosine kinase inhibitors (TKIs) directed at cancers driven by oncogenes, such as epidermal growth factor receptor mutations or anaplastic lymphoma kinase rearrangements, often achieve dramatic responses and result in prolonged survival compared with chemotherapy. However, TKI resistance invariably develops. Disease progression can be limited to only one or a few sites and might not be symptomatic, raising the important question of whether this type of oligoprogression warrants a change in systemic therapy or consideration of local treatment. Recent clinical observations suggest a growing role for stereotactic body radiation therapy (SBRT) in the treatment of oligoprogressive and perhaps even oligopersistent disease (primary and/or metastases) in oncogene-driven NSCLC. SBRT might allow patients to continue with existing TKI treatments longer and delay the need to switch to other systemic options. We review the current data with regard to the use of SBRT for metastatic NSCLC and particularly oncogene-driven disease. Although there is great promise in the marriage of targeted therapies with SBRT, prospective data are urgently needed. In the meantime, such strategies are being used in carefully selected patients, with risk-adapted SBRT dose-fractionation regimens used to optimize the therapeutic index. IMPLICATIONS FOR PRACTICE Stereotactic body radiation therapy (SBRT) or SBRT-like treatments are increasingly being used for oligoprogression in patients with oncogene-driven non-small cell lung cancer. This approach allows patients to extend the duration of tyrosine kinase inhibitor therapy and has the potential to prolong survival times. Careful patient selection and risk-adapted radiation dosing is of critical importance to minimize toxicity and preserve patient quality of life.
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Affiliation(s)
- Meghan Campo
- Hematology/Oncology Fellowship Program, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Hani Al-Halabi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Melin Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alice T Shaw
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lecia V Sequist
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Stereotactic ablative radiotherapy for pulmonary oligometastases and oligometastatic lung cancer. J Thorac Oncol 2015; 9:1426-33. [PMID: 25170641 DOI: 10.1097/jto.0000000000000317] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
An increasing body of experience suggests that oligometastasis represents a minimal metastatic state with the potential for cure or prolonged survival in selected patients treated with radical local therapy to all identified sites of disease. The main clinical scenarios managed by thoracic oncology specialists are pulmonary oligometastases from primary malignancies of other anatomic sites and primary lung cancer with oligometastases to lung or other organs. Surgery has been a mainstay of treatment in these situations, with remarkably favorable outcomes following pulmonary metastasectomy in well-selected patient cohorts. As with early stage lung cancer in patients who are medically inoperable, stereotactic ablative radiotherapy is emerging as a prominent local treatment option for oligometastatic disease. We review the role and clinical experience of stereotactic ablative radiotherapy for pulmonary oligometastases and oligometastatic lung cancer.
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12
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Yano T. Evaluating the utility of local therapy for oligometastatic lung cancer. Lung Cancer Manag 2014. [DOI: 10.2217/lmt.14.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY In patients with metastatic non-small-cell lung cancer, limited metastases are identified as ‘oligometastases’, and such patients are expected to be long-term progression-free, or possibly curable by local control of those lesions. Especially for oligometastatic recurrence after complete resection of the original primary tumor, local treatment should be taken into consideration as a choice of treatment. Oligoprogression after the administration of EGF receptor tyrosine kinase inhibitors for EGFR-mutated non-small-cell lung cancer might also be indicated for local treatment while continuing the EGF receptor tyrosine kinase inhibitor treatment. Since stereotactic radiotherapy delivery is now available, its potential for local control is nearly comparable to that of surgery. These two major modalities of local therapy should be selected for the treatment of oligometastases after carefully considering both the oligometastatic status (organs, number) and patient status.
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Parikh RB, Cronin AM, Kozono DE, Oxnard GR, Mak RH, Jackman DM, Lo PC, Baldini EH, Johnson BE, Chen AB. Definitive primary therapy in patients presenting with oligometastatic non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2014; 89:880-7. [PMID: 24867533 DOI: 10.1016/j.ijrobp.2014.04.007] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 03/17/2014] [Accepted: 04/03/2014] [Indexed: 12/28/2022]
Abstract
PURPOSE Although palliative chemotherapy is the standard of care for patients with diagnoses of stage IV non-small cell lung cancer (NSCLC), patients with a small metastatic burden, "oligometastatic" disease, may benefit from more aggressive local therapy. METHODS AND MATERIALS We identified 186 patients (26% of stage IV patients) prospectively enrolled in our institutional database from 2002 to 2012 with oligometastatic disease, which we defined as 5 or fewer distant metastatic lesions at diagnosis. Univariate and multivariable Cox proportional hazards models were used to identify patient and disease factors associated with improved survival. Using propensity score methods, we investigated the effect of definitive local therapy to the primary tumor on overall survival. RESULTS Median age at diagnosis was 61 years of age; 51% of patients were female; 12% had squamous histology; and 33% had N0-1 disease. On multivariable analysis, Eastern Cooperate Oncology Group performance status ≥ 2 (hazard ratio [HR], 2.43), nodal status, N2-3 (HR, 2.16), squamous pathology, and metastases to multiple organs (HR, 2.11) were associated with a greater hazard of death (all P<.01). The number of metastatic lesions and radiologic size of the primary tumor were not significantly associated with overall survival. Definitive local therapy to the primary tumor was associated with prolonged survival (HR, 0.65, P=.043). CONCLUSIONS Definitive local therapy to the primary tumor appears to be associated with improved survival in patients with oligometastatic NSCLC. Select patient and tumor characteristics, including good performance status, nonsquamous histology, and limited nodal disease, may predict for improved survival in these patients.
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Affiliation(s)
| | | | - David E Kozono
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Geoffrey R Oxnard
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Raymond H Mak
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - David M Jackman
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Peter C Lo
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth H Baldini
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Bruce E Johnson
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Aileen B Chen
- Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts.
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Gandara DR, Li T, Lara PN, Kelly K, Riess JW, Redman MW, Mack PC. Acquired resistance to targeted therapies against oncogene-driven non-small-cell lung cancer: approach to subtyping progressive disease and clinical implications. Clin Lung Cancer 2013; 15:1-6. [PMID: 24176733 DOI: 10.1016/j.cllc.2013.10.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 09/30/2013] [Accepted: 10/08/2013] [Indexed: 01/18/2023]
Abstract
In the emerging era of targeted therapy for advanced-stage non-small-cell lung cancer, it is becoming increasingly important to anticipate underlying driver oncogene alterations at the time of initial diagnosis and tumor-tissue acquisition, so that patients can be selected in a timely fashion for first-line tyrosine kinase inhibitor (TKI) therapy if their cancers are found to harbor tyrosine-kinase-activating mutations in the epidermal growth factor receptor gene or gain-of-function rearrangements in the anaplastic lymphoma kinase gene. However, despite the clear benefits of TKI therapy over chemotherapy in these settings, the eventual emergence of acquired resistance and progressive disease (PD) is universal. How to best approach oncogene-driven non-small-cell lung cancer at the time of acquired resistance to initial TKI therapy is an increasingly complex question because of variability in mechanisms of resistance, extent of PD, and inter- and intrapatient tumor heterogeneity. Here we propose an approach to subtyping PD in the setting of acquired resistance as well as subsequent clinical implications.
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Affiliation(s)
- David R Gandara
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA.
| | - Tianhong Li
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA
| | - Primo N Lara
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA
| | - Karen Kelly
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA
| | - Jonathan W Riess
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA
| | | | - Philip C Mack
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA
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15
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Yano T, Okamoto T, Haro A, Fukuyama S, Yoshida T, Kohno M, Maehara Y. Local treatment of oligometastatic recurrence in patients with resected non-small cell lung cancer. Lung Cancer 2013; 82:431-5. [PMID: 24113550 DOI: 10.1016/j.lungcan.2013.08.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/30/2013] [Accepted: 08/07/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVES We previously reported a retrospective study indicating the prognostic impact of the local treatment of oligometastatic recurrence after a complete resection for non-small cell lung cancer (NSCLC). In the present study, we prospectively observed postoperative oligometastatic patients and investigated the effects of local treatment on progression-free survival (PFS). METHODS Using a prospectively maintained database of patients with completely resected NSCLC treated between October 2007 and December 2011, we identified 52 consecutive patients with postoperative recurrence, excluding second primary lung cancer. Of these patients, 31 suffering from distant metastases alone without primary site recurrence were included in this study. According to the definition of 'oligometastases' as a limited number of distant metastases ranging from one to three, 17 patients had oligometastatic disease. Of those 17 patients, four patients with only brain metastasis were excluded from the analysis. RESULTS The oligometastatic sites included the lungs in five patients, bone in four patients, the lungs and brain in two patients, the adrenal glands in one patient and soft tissue in one patient. Eleven of the 13 patients first received local treatment. Three patients (lung, adrenal gland, soft tissue) underwent surgical resection, and the remaining eight patients received radiotherapy. The median PFS was 20 months in the oligometastatic patients who received local treatment. There were five patients with a PFS of longer than two years. The metastatic sites in these patients varied, and one patient had three lesions. On the other hand, the two remaining patients first received a systemic chemotherapy of their own selection. The PFS of these two patients was five and 15 months, respectively. CONCLUSION Local therapy is a choice for first-line treatment in patients with postoperative oligometastatic recurrence.
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Affiliation(s)
- Tokujiro Yano
- Department of Thoracic Surgery, National Hospital Organization Beppu Medical Center, Japan.
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