1509 webinar oligometa lung
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Transcript of 1509 webinar oligometa lung
Management of Oligometastatic
Lung Cancer
Yong Chan Ahn, MD/PhD Dept. of Radiation Oncology
Samsung Medical Center, Sungkyunkwan University School of Medicine
• Oligometastasis
• Oligometastasis in NSCLC
• SMC Experience of SBRT for
Oligometastasis to Lung
• Local Treatment for Oligometastasis
• Clinical Studies/Review
• Survey
• Ongoing Trials
• Take Home Messages
Oligometastasis
• Theory 1st proposed by Hellman and
Weichselbaum in 1995.
• Along spectrum of locally confined to widely
metastatic cancer, there exists intermediate
“oligometastatic state” where metastases are
limited in number and location.
Paradigm Stages
Old Early vs Metastatic
New Early ~ Oligometastatic ~ Systemic
Nat Rev Clin Oncol, 2011
Oligometastasis
• Eradication of “oligometastases” with local
ablative Tx could be curative in select patients.
• Cure is achieved following curative surgical
resection in:
– Liver metastases from colon cancer
– Lung metastases from various sites
– Adrenal metastases from lung cancer
Nat Rev Clin Oncol, 2011
Nat Rev Clin Oncol, 2011
Single & DFI 36 months
Multiple or DFI < 36 months
Multiple and DFI < 36 months
Lung meta
Oligometastasis
• Oligometastases have long been recognized as
potentially curable, but were considered rare
exceptions to cancer metastasis paradigm.
• Oligometastatic state, however, is becoming
more frequently identified with more
sensitive methods.
• Clinicians will be able to limit ablative local
Tx to only those with true oligometastases.
Nat Rev Clin Oncol, 2011
Lung Cancer, 2013
Conclusion
• Patient selection is key determinant:
– Definitive Tx of primary tumor
– Long disease-free interval
– Lack of intra-thoracic nodal metastasis
• These should be utilized to guide clinical
decision making and design of future studies.
SBRT for Lung Metastasis
• SBRT to 57 patients, 67 metastatic lesions
• Sep. 2001~Nov. 2010
• Lung toxicity:
– Grade 2 in 4 patients (6.0%)
– Grade 5 in 1
Acta Oncol, 2012
Response at 1 month:
- CR in 17 (25%)
- PR in 40 (60%)
- SD in 10 (15%)
Local progression in 3 (5%)
94.5% at 3 years Acta Oncol, 2012
Presence of extrathoracic disease was
the only significant factor (p=0.049)
on multivariate analysis.
64.0% vs 38.9%
at 3 years
66.1% vs 0%
at 3 years 71.1% vs 51.1%
at 3 years
Acta Oncol, 2012
Conclusion
• SBRT for single or oligo-metastasis seems
quite effective and safe.
• Tumor size, disease-free interval, and presence
of extrathoracic disease are prognosticators for
survival.
Acta Oncol, 2012
Clinical Practice Points
• Select oligometastatic NSCLC Pts might benefit
from aggressive Tx to all disease sites:
– Pts with controlled primary lung cancer are
most likely to experience long-term survival.
– Pts with metachronous meta experienced the
longest survivals.
– Pts with synchronous meta and N1-2 disease
had the poorest survivals.
Clinical Lung Cancer, 2014
• Radiation therapy for oligometastatic non-small cell lung cancer. Salama JK, Schild SE. Cancer Metastasis Rev. 2015;34(2):183-93.
• Stereotactic body radiation therapy for oligometastases to the lung: a
phase 2 study. Nuyttens JJ et al. Int J Radiat Oncol Biol Phys. 2015;91(2):337-43.
• Stereotactic body radiotherapy for oligometastatic disease. Hanna GG et
al. Clin Oncol (R Coll Radiol). 2015;27(5):290-7.
• Predictive factors for local control in primary and metastatic lung
tumours after four to five fraction stereotactic ablative body
radiotherapy: a single institution's comprehensive experience. Thibault
I et al. Clin Oncol (R Coll Radiol). 2014;26(11):713-9.
• Outcomes and toxicities of stereotactic body radiation therapy for
non-spine bone oligometastases. Owen D et al. Pract Radiat Oncol.
2014;4(2):e143-9.
• Management of pulmonary oligometastases by stereotactic body
radiotherapy. Gamsiz H et al. Tumori. 2014;100(2):179-83.
• Radical treatment of synchronous oligometastatic non-small cell
lung carcinoma (NSCLC): patient outcomes and prognostic factors. Griffioen GH et al. Lung Cancer. 2013;82(1):95-102.
• Reviews:
• SABR for aggressive local therapy of metastatic cancer: A new
paradigm for metastatic non-small cell lung cancer. Westover KD et al.
Lung Cancer. 2015;89(2):87-93.
• Stereotactic ablative radiotherapy for pulmonary oligometastases
and oligometastatic lung cancer. Shultz DB et al. J Thorac Oncol.
2014;9(10):1426-33.
• 25-question survey • 1,007 respondents from 43
countries
• SBRT users:
• Length of practice
• # patients treated
• Organs treated
• Primary reason
• Dose schedules
• Future intentions
• SBRT non-users:
• Reason for not using SBRT
• Future intentions
83%
>1/3
Am J Clin Oncol, 2015
Reasons for adopting SBRT to treat OM
84%
• Commonly treated organs: lung (90%), liver
(75%), and spine (70%).
• Most would offer second SBRT to new OM.
• 99% planned to continue and 66% planned to
increase SBRT use.
Various dose schedules!
Am J Clin Oncol, 2015
Reasons for planning to adopt SBRT
• The most common reasons for not using SBRT were lack of
clinical efficacy (48%) and/or lack of necessary image guidance
equipment (34%). need for prospective clinical trials!
• Of those not using SBRT, 59% plan to start soon.
Am J Clin Oncol, 2015
DFI 3 months
≤ 3 mets in any single organ
≤ 5 total mets
NCT01446744
Canada/Netherlands Metachronous meta ≤ 5 sites
Arm 1
Lung 8 Gy/1 Fx; 20 Gy/5 Fx’s; 30 Gy/10 Fx’s
Bone 8 Gy/1 Fx; 20 Gy/5 Fx’s; 30 Gy/10 Fx’s
Brain 20 Gy/5 Fx’s; 30 Gy/10 Fx’s
Liver 20 Gy/5 Fx’s
NCT01446744
Canada/Netherlands Metachronous meta ≤ 5 sites
Take Home Messages
• Proportion of patients with OM has been increasing.
• Management of OM has become challenging.
• Patients selection is very important:
– Controlled primary
– Long DFI (metachronous >> synchronous)
– Initially low cN stages
• Consider high dose aggressive local RT (SBRT,
IMRT, IGRT, Particle…) to favorable subgroups.