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1509 webinar oligometa lung
- Oligometastatic disease refers to a limited number of metastases that may be amenable to local treatment. - Stereotactic body radiation therapy (SBRT) for lung oligometastases from various primary cancers can achieve high rates of local control with minimal toxicity. - Patient selection is important, with longer disease-free interval, fewer metastatic sites, and controlled primary tumor associated with improved outcomes after aggressive local therapy of oligometastases. - Ongoing clinical trials are investigating SBRT for synchronous and metachronous oligometastatic disease to define optimal patient populations and treatment approaches.
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1509 webinar oligometa lung
- 1. Management of Oligometastatic LungCancer Yong Chan Ahn, MD/PhD Dept. of Radiation Oncology Samsung Medical Center, Sungkyunkwan University School of Medicine
- 2. • Oligometastasis • Oligometastasisin NSCLC • SMC Experience of SBRT for Oligometastasis to Lung • Local Treatment for Oligometastasis • Clinical Studies/Review • Survey • Ongoing Trials • Take Home Messages
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- 4. Nat Rev ClinOncol, 2011
- 5. Oligometastasis • Theory 1stproposed 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
- 6. 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
- 7. Nat Rev ClinOncol, 2011 Single & DFI 36 months Multiple or DFI < 36 months Multiple and DFI < 36 months Lung meta
- 8. Oligometastasis • Oligometastases havelong 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
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- 15. 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.
- 17. SMC Experience ofSBRT for Oligometastasis to Lung
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- 19. SBRT for LungMetastasis • 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
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- 21. Response at 1month: - 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
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- 23. 59.7% 56.2% at 2years at 5 years Acta Oncol, 2012
- 24. Presence of extrathoracicdisease 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
- 25. Conclusion • SBRT forsingle 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
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- 31. 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
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- 33. • Radiation therapyfor 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.
- 34. • Reviews: • SABRfor 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.
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- 36. Am J ClinOncol, 2015
- 37. • 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
- 38. Reasons for adoptingSBRT 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
- 39. Reasons for planningto 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
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- 41. Metachronous meta ≤5 sites NCT01446744 Canada/Netherlands
- 42. DFI 3months ≤ 3 mets in any single organ ≤ 5 total mets NCT01446744 Canada/NetherlandsMetachronous meta ≤ 5 sites
- 43. Arm 1 Lung 8Gy/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/NetherlandsMetachronous meta ≤ 5 sites
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- 46. 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.
- 47. Staging Project 16th WCLCat Denver Paradigm has changed, is changing, and will change!
- 51. Don’t give upeasily! Thank your for your attention!