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Mutsaers A, Akingbade A, Louie AV, Id Said B, Zhang L, Poon I, Smoragiewicz M, Eskander A, Karam I. Stereotactic Body Radiotherapy for Extracranial Oligometastatic Disease from Head and Neck Primary Cancers: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:851. [PMID: 38473213 DOI: 10.3390/cancers16050851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/25/2024] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Stereotactic body radiotherapy (SBRT) is increasingly used to treat disease in the oligometastatic (OM) setting due to mounting evidence demonstrating its efficacy and safety. Given the low population representation in prospective studies, we performed a systematic review and meta-analysis of outcomes of HNC patients with extracranial OM disease treated with SBRT. METHODS A systematic review was conducted with Cochrane, Medline, and Embase databases queried from inception to August 2022 for studies with extracranial OM HNC treated with stereotactic radiotherapy. Polymetastatic patients (>five lesions), mixed-primary cohorts failing to report HNC separately, lack of treatment to all lesions, nonquantitative endpoints, and other definitive treatments (surgery, conventional radiotherapy, and radioablation) were excluded. The meta-analysis examined the pooled effects of 12- and 24-month local control (LC) per lesion, progression-free survival (PFS), and overall survival (OS). Weighted random-effects were assessed using the DerSimonian and Laird method, with heterogeneity evaluated using the I2 statistic and Cochran Qtest. Forest plots were generated for each endpoint. RESULTS Fifteen studies met the inclusion criteria (639 patients, 831 lesions), with twelve eligible for quantitative synthesis with common endpoints and sufficient reporting. Fourteen studies were retrospective, with a single prospective trial. Studies were small, with a median of 32 patients (range: 6-81) and 63 lesions (range: 6-126). The OM definition varied, with a maximum of two to five metastases, mixed synchronous and metachronous lesions, and a few studies including oligoprogressive lesions. The most common site of metastasis was the lung. Radiation was delivered in 1-10 fractions (20-70 Gy). The one-year LC (LC1), reported in 12 studies, was 86.9% (95% confidence interval [CI]: 79.3-91.9%). LC2 was 77.9% (95% CI: 66.4-86.3%), with heterogeneity across studies. PFS was reported in five studies, with a PFS1 of 43.0% (95% CI: 35.0-51.4%) and PFS2 of 23.9% (95% CI: 17.8-31.2%), with homogeneity across studies. OS was analyzed in nine studies, demonstrating an OS1 of 80.1% (95% CI: 74.2-85.0%) and OS2 of 60.7% (95% CI: 51.3-69.4%). Treatment was well tolerated with no reported grade 4 or 5 toxicities. Grade 3 toxicity rates were uniformly below 5% when reported. CONCLUSIONS SBRT offers excellent LC and promising OS, with acceptable toxicities in OM HNC. Durable PFS remains rare, highlighting the need for effective local or systemic therapies in this population. Further investigations on concurrent and adjuvant therapies are warranted.
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Affiliation(s)
- Adam Mutsaers
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
- Division of Radiation Oncology, London Health Sciences, Western University, Toronto, ON M4N 3M5, Canada
| | - Aquila Akingbade
- Division of Radiation Oncology, London Health Sciences, Western University, Toronto, ON M4N 3M5, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Badr Id Said
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Liying Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Martin Smoragiewicz
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, ON M4N 3M5, Canada
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Id Said B, Mutsaers A, Chen H, Husain ZA, Biswas T, Dagan R, Erler D, Foote M, Louie AV, Redmond K, Ricardi U, Sahgal A, Poon I. Outcomes for oligometastatic head and neck cancer treated with stereotactic body radiotherapy: Results from an international multi-institutional consortium. Head Neck 2023; 45:2627-2637. [PMID: 37602655 DOI: 10.1002/hed.27488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND We report the results of an international multi-institutional cohort of oligometastatic (OMD) head and neck cancer (HNC) patients treated with SBRT. METHODS Patients with OMD HNC (≤5 metastases) treated with SBRT between 2008 and 2016 at six institutions were included. Treated metastasis control (TMC), progression-free survival (PFS), and overall survival (OS) were analyzed by multivariable analysis (MVA). RESULTS Forty-two patients with 84 HNC oligometastases were analyzed. The TMC rate at 1 and 2 years were 80% and 66%, with a median time to recurrence of 10.1 months. The median PFS and OS were 4.7 and 23.3 months. MVA identified a PTV point maximum (BED)10 > 100 Gy as a predictor of improved TMC (HR = 0.31, p = 0.034), and a cumulative PTV > 48 cc as having worse PFS (HR = 2.99, p < 0.001). CONCLUSION Favorable TMC and OS was observed in OMD HNCs treated with SBRT.
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Affiliation(s)
- Badr Id Said
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Adam Mutsaers
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Zain A Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Roi Dagan
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
| | - Darby Erler
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Kristin Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
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Stereotactic Body Radiotherapy and Immunotherapy for Older Patients with Oligometastases: A Proposed Paradigm by the International Geriatric Radiotherapy Group. Cancers (Basel) 2022; 15:cancers15010244. [PMID: 36612239 PMCID: PMC9818761 DOI: 10.3390/cancers15010244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 01/03/2023] Open
Abstract
The standard of care for metastatic disease is systemic therapy. A unique subset of patients with limited metastatic disease defined as distant involvement of five anatomic sites or less (oligometastases) have a better chance of remission or improved survival and may benefit from local treatments such as surgery or stereotactic body radiotherapy (SBRT). However, to prevent further spread of disease, systemic treatment such as chemotherapy, targeted therapy, and hormonal therapy may be required. Older patients (70 years old or above) or physiologically frail younger patients with multiple co-morbidities may not be able to tolerate the conventional chemotherapy due to its toxicity. In addition, those with a good performance status may not receive optimal chemotherapy due to concern about toxicity. Recently, immunotherapy with checkpoint inhibitors (CPI) has become a promising approach only in the management of program death ligand 1 (PD-L1)-positive tumors. Thus, a treatment method that elicits induction of PD-L1 production by tumor cells may allow all patients with oligometastases to benefit from immunotherapy. In vitro studies have demonstrated that high dose of radiotherapy may induce formation of PD-L1 in various tumors as a defense mechanism against inflammatory T cells. Clinical studies also corroborated those observations. Thus, SBRT, with its high precision to minimize damage to normal organs, may be a potential treatment of choice for older patients with oligometastases due to its synergy with immunotherapy. We propose a protocol combining SBRT to achieve a minimum radiobiologic equivalent dose around 59.5 Gy to all tumor sites if feasible, followed four to six weeks later by CPI for those cancer patients with oligometastases. All patients will be screened with frailty screening questionnaires to identify individuals at high risk for toxicity. The patients will be managed with an interdisciplinary team which includes oncologists, geriatricians, nurses, nutritionists, patient navigators, and social workers to manage all aspects of geriatric patient care. The use of telemedicine by the team may facilitate patient monitoring during treatment and follow-up. Preliminary data on toxicity, local control, survival, and progression-free survival may be obtained and serve as a template for future prospective studies.
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