Combining stereotactic body radiotherapy with immunotherapy in stage IV non-small cell lung cancer

The optimal stereotactic body radiotherapy dose with immunotherapy for pulmonary oligometastases: a retrospective cohort study

Background

Stereotactic body radiotherapy (SBRT) is a precise and effective treatment for pulmonary oligometastases, offering high local control (LC) rates. However, the optimal SBRT dose when combined with immunotherapy remains unclear, and there is a lack of comprehensive studies focusing on dose optimization in this setting. This study addresses this knowledge gap by exploring different SBRT dose regimens and their impact on progression-free survival (PFS), overall survival (OS), and LC in patients receiving concurrent immunotherapy, offering novel insights into the synergistic effects of these treatments.

Methods

A retrospective cohort study was conducted of 101 patients with 141 pulmonary oligometastases treated from April 2018 to April 2022. Inclusion criteria included patients with a maximum of five lung metastases and an Eastern Cooperative Oncology Group performance status of ≤2. Patients received SBRT with doses ranging from 50-70 Gy in 5-10 fractions. Follow-up was performed quarterly, and the best dose was determined by comparing survival outcomes across different dose groups. The patients received SBRT with doses ranging from 50-70 Gy in 5-10 fractions. Patient demographics, tumor characteristics, treatment details, and outcomes were collected. The Kaplan-Meier method was used for the survival analysis, and Cox regression models were used to identify prognostic factors for LC, PFS, and OS.

Results

The median follow-up for the 101 patients was 22.4 months (range, 1-58 months). The cohort comprised 82.2% male patients with a median age of 64 years (range, 36-81 years). The majority of the patients (64.4%) had primary tumors originating from non-lung sites, with adenocarcinoma being the predominant histological subtype (47.5%). The median tumor size was 13.5 mm. Across the entire cohort, the median OS was 39 months, and the median PFS was 11 months. Pre-treatment with immunotherapy significantly improved outcomes: the PFS increased to 13 months compared to 7 months for those who did not receive immunotherapy [P=0.02, hazard ratio (HR) = 0.523, 95% confidence interval (CI): 0.302-0.906], and the OS was also significantly improved (P=0.008, HR =0.411, 95% CI: 0.214-0.792). The SBRT regimen of 60 Gy in 10 fractions provided the best outcomes, with a median OS of 39 months, a median PFS of 10 months, and a LC rate of 92.4%, with relatively low toxicity compared to other regimens.

Conclusions

SBRT is a potent, minimally invasive option for managing pulmonary oligometastases, especially when preceded by immunotherapy. The 60 Gy in 10 fractions regimen demonstrated significant efficacy in terms of OS and LC, while maintaining manageable toxicity. Although the retrospective nature of the study introduces some selection bias, this dose regimen appears to offer a promising therapeutic option for pulmonary oligometastases. Further validation through well-designed prospective studies would help confirm the optimal SBRT dose and clarify the role of immunotherapy in this setting.

Next-Generation Immunotherapy: Advancing Clinical Applications in Cancer Treatment

Next-generation immunotherapies have revolutionized cancer treatment, offering hope for patients with hard-to-treat tumors. This review focuses on the clinical applications and advancements of key immune-based therapies, including immune checkpoint inhibitors, CAR-T cell therapy, and new cancer vaccines designed to harness the immune system to combat malignancies. A prime example is the success of pembrolizumab in the treatment of advanced melanoma, underscoring the transformative impact of these therapies. Combination treatments, integrating immunotherapy with chemotherapy, radiation, and targeted therapies, are demonstrating synergistic benefits and improving patient outcomes. This review also explores the evolving role of personalized immunotherapy, guided by biomarkers, genomic data, and the tumor environment, to better target individual tumors. Although significant progress has been made, challenges such as resistance, side effects, and high treatment costs persist. Technological innovations, including nanotechnology and artificial intelligence, are explored as future enablers of these therapies. The review evaluates key clinical trials, breakthroughs, and the emerging immune-modulating agents and advanced delivery systems that hold great promise for enhancing treatment efficacy, reducing toxicity, and expanding access to immunotherapy. In conclusion, this review highlights the ongoing advancements in immunotherapy that are reshaping cancer care, with future strategies poised to overcome current challenges and further extend therapeutic reach.

[Staging and systemic treatment of ocular and periocular metastases]

Metastases of malignant diseases are the most frequent tumors diagnosed in the human eye. They occur in approximately 5-10% of patients with solid tumors during the course of the disease. Their frequency is particularly high in patients with breast and lung cancer. Many highly sensitive periorbital tissues can be affected by the localization of the metastatic lesions and pose a number of clinical challenges. The main goal of the therapy of ocular metastases consists of the control of tumor growth (including the control of other possible manifestations throughout the body), the preservation of the affected eye and the minimization of potential iatrogenic damage to adjacent tissues. Overall, the purpose of this strategy is also to maintain the quality of life and especially the eyes and vision of the patient. Furthermore, pain should be avoided or at least alleviated. Of special importance is the differentiation between a curative or palliative situation. Patients with ocular metastases usually undergo systemic treatment appropriate for the underlying tumor entity, which is often accompanied by concomitant or sequential radiotherapy. In addition to classical chemotherapy, targeted treatment, treatment with monoclonal antibodies and antibody-drug conjugates as well as immunotherapy with checkpoint antibodies are currently available for many cancer types. This review article gives an overview of the currently available treatment options for patients with ocular metastases of solid tumors.

A Clinical Analysis of Anti-Programmed Death-Ligand 1 (PD-L1) Immune Checkpoint Inhibitor Treatments Combined with Chemotherapy in Untreated Extensive-Stage Small-Cell Lung Cancer

Real-world clinical experience of using anti-programmed death-ligand 1 (PD-L1) immune checkpoint inhibitors (ICIs) combined with chemotherapy in the first-line treatment of extensive-stage small-cell lung cancer (SCLC) patients has rarely been reported. In this study, we aimed to perform a retrospective multicenter clinical analysis of extensive-stage SCLC patients receiving first-line therapy with anti-PD-L1 ICIs combined with chemotherapy. Between November 2018 and March 2022, 72 extensive-stage SCLC patients receiving first-line atezolizumab or durvalumab in combination with chemotherapy, according to the cancer center databases of Linkou, Chiayi, and Kaohsiung Chang Gung Memorial Hospitals, were retrospectively included in the analysis. Twenty-one patients (29.2%) received atezolizumab and fifty-one (70.8%) received durvalumab. Objective response (OR) and disease control (DC) rates of 59.7% and 73.6%, respectively, were observed with first-line ICI plus chemotherapy. The median progression-free survival (PFS) was 6.63 months (95% confidence interval (CI), 5.25-8.02), and the median overall survival (OS) was 16.07 months (95% CI, 15.12-17.0) in all study patients. A high neutrophil-to-lymphocyte ratio (NLR; >4) and a high serum lactate dehydrogenase (LDH) concentration (>260 UL) were identified as independent unfavorable factors associated with shorter OS in the multivariate analysis. Regarding safety, neutropenia was the most common grade 3 treatment-related adverse event (AE), but no treatment-related deaths occurred in the study patients. First-line anti-PD-L1 ICIs combined with chemotherapy are effective and safe for male extensive-stage SCLC patients. Further therapeutic strategies may need to be developed for patients with unfavorable outcomes (e.g., baseline high NLR and serum LDH level).

Differences between Survival Rates and Patterns of Failure of Patients with Lung Adenocarcinoma and Squamous Cell Carcinoma Who Received Single-Fraction Stereotactic Body Radiotherapy

We investigated the survival and patterns of failure in adenocarcinoma (ADC) and squamous cell carcinoma (SCC) in early stage non-small cell lung cancer (NSCLC) treated with single-fraction stereotactic body radiation therapy (SF-SBRT) of 27-34 Gray. A single-institution retrospective review of patients with biopsy-proven early stage ADC or SCC undergoing definitive SF-SBRT between September 2008 and February 2023 was performed. The primary outcomes were overall survival (OS) and disease-free survival (DFS). The secondary outcomes included local failure (LF), nodal failure (NF), and distant failure (DF). Of 292 eligible patients 174 had adenocarcinoma and 118 had squamous cell carcinoma. There was no significant change in any outcome except distant failure. Patients with ADC were significantly more likely to experience distant failure than patients with SCC (p = 0.0081). In conclusion, while SF-SBRT produced similar LF, NF, DFS, and OS, the higher rate of distant failure in ADC patients suggests that ongoing trials of SBRT and systemic therapy combinations should report their outcomes by histology.