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Nguyen TK, Ramadan S, Palma DA, Corkum MT, O' Neil M, Celinski A, Fakir H, Warner A, Hallock A, Correa RJM, Qu XM, Lock M, Lang P, Velker V, Bauman GS. Ablative Radiation Therapy to Restrain Everything Safely Treatable (ARREST): A Phase 1 Study of Stereotactic Ablative Radiation Therapy for Polymetastatic Disease. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02541-0. [PMID: 38986914 DOI: 10.1016/j.ijrobp.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/18/2024] [Accepted: 06/22/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE This phase 1 study aimed to assess the safety and feasibility of SABR therapy delivery to all sites of polymetastatic disease (>10 metastases). METHODS AND MATERIALS A 3 + 3 study design was used with 5 dose levels from 6 Gy (6 Gy × 1) to 30 Gy (6 Gy weekly × 5). Dose-limiting toxicity (DLT) was defined as any grade 4 or 5 toxicity or more than 3 grade 3 toxicities within 6 weeks of treatment. The primary endpoint was the maximal tolerated dose, defined as the dose level where ≥2/6 of patients experienced DLT. Secondary endpoints included quality of life (Functional Assessment of Cancer Therapy - General and European Quality of Life 5 Dimension 5 Level) at 6 weeks posttreatment, progression-free survival, and overall survival. RESULTS Thirteen patients were accrued: 12 Gy (n = 3), 18 Gy (n = 3), 24 Gy (n = 4), and 30 Gy (n = 3), and 207 lesions were treated. Nine patients (69%) had acute toxicity: grade 1 (n = 6, 46%), grade 2 (n = 2, 15%; n = 1 pneumonitis and n = 1 fatigue), and grade 3 (n = 1, 7.7% neutropenia). There were no grade 4 or 5 toxicities. Mean ± SD quality of life (Functional Assessment of Cancer Therapy - General and European Quality of Life 5 Dimension 5 Level health state) was 80.4 ± 21.9 and 77.4 ± 20.9 at baseline versus 76.4 ± 21.8 and 68.0 ± 24.2 at 6-week follow-up, respectively (p = .009 and p = .055, respectively). With a median follow-up of 8.7 months posttreatment (IQR, 2.4-24 months), 8 of 13 patients had disease progression (62%). The median and 12-month progression-free survival were 3.6 months and 11.3%, respectively. The median and 12-month overall survival were 13.8 months and 62%, respectively. CONCLUSIONS In this phase 1 trial, SABR therapy for polymetastatic disease was technically feasible with acceptable acute toxicity at dose levels up to 30 Gy (6 Gy weekly × 5). DLT was not observed.
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Affiliation(s)
- Timothy K Nguyen
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Sherif Ramadan
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Mark T Corkum
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Melissa O' Neil
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Anders Celinski
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Hatim Fakir
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Andrew Warner
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Abhirami Hallock
- Department of Radiation Oncology, Niagara Health, St. Catherine's, Ontario, Canada
| | - Rohann J M Correa
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - X Melody Qu
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Michael Lock
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Pencilla Lang
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Vikram Velker
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Glenn S Bauman
- Division of Radiation Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, Ontario, Canada.
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Nasser N, Perez BA, Penagaricano JA, Caudell JJ, Oliver DE, Latifi K, Moros EG, Redler G. Technical feasibility of novel immunostimulatory low-dose radiation for polymetastatic disease with CBCT-based online adaptive and conventional approaches. J Appl Clin Med Phys 2024; 25:e14303. [PMID: 38377378 PMCID: PMC11163490 DOI: 10.1002/acm2.14303] [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: 11/07/2023] [Revised: 12/15/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024] Open
Abstract
PURPOSE A workflow/planning strategy delivering low-dose radiation therapy (LDRT) (1 Gy) to all polymetastatic diseases using conventional planning/delivery (Raystation/Halcyon = "conventional") and the AI-based Ethos online adaptive RT (oART) platform is developed/evaluated. METHODS Using retrospective data for ten polymetastatic non-small cell lung cancer patients (5-52 lesions each) with PET/CTs, gross tumor volumes (GTVs) were delineated using PET standardized-uptake-value (SUV) thresholding. A 1 cm uniform expansion of GTVs to account for setup/contour uncertainty and organ motion-generated planning target volumes (PTVs). Dose optimization/calculation used the diagnostic CT from PET/CT. Dosimetric objectives were: Dmin,0.03cc ≥ 95% (acceptable variation (Δ) ≥ 90%), V100% ≥ 95% (Δ ≥ 90%), and D0.03cc ≤ 120% (Δ ≤ 125%). Additionally, online adaptation was simulated. When available, subsequent diagnostic CT was used to represent on-treatment CBCT. Otherwise, the CT from PET/CT used for initial planning was deformed to simulate clinically representative changes. RESULTS All initial plans generated, both for Raystation and Ethos, achieved clinical goals within acceptable variation. For all patients, Dmin,0.03cc ≥ 95%, V100% ≥ 95%, and D0.03cc ≤ 120% goals were achieved for 84.8%/99.5%, 97.7%/98.7%, 97.4%/92.3%, in conventional/Ethos plans, respectively. The ratio of 50% isodose volume to PTV volume (R50%), maximum dose at 2 cm from PTV (D2cm), and the ratio of the 100% isodose volume to PTV volume (conformity index) in Raystation/Ethos plans were 7.9/5.9; 102.3%/88.44%; and 0.99/1.01, respectively. In Ethos, online adapted plans maintained PTV coverage whereas scheduled plans often resulted in geographic misses due to changes in tumor size, patient position, and body habitus. The average total duration of the oART workflow was 26:15 (min:sec) ranging from 6:43 to 57:30. The duration of each oART workflow step as a function of a number of targets showed a low correlation coefficient for influencer generation and editing (R2 = 0.04 and 0.02, respectively) and high correlation coefficient for target generation, target editing and plan generation (R2 = 0.68, 0.63 and 0.69, respectively). CONCLUSIONS This study demonstrates feasibility of conventional planning/treatment with Raystation/Halcyon and highlights efficiency gains when utilizing semi-automated planning/online-adaptive treatment with Ethos for immunostimulatory LDRT conformally delivered to all sites of polymetastatic disease.
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Affiliation(s)
- Nour Nasser
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
- Department of PhysicsUniversity of South FloridaTampaFloridaUSA
| | - Bradford A. Perez
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | | | - Jimmy J. Caudell
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Daniel E. Oliver
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Kujtim Latifi
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Eduardo G. Moros
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - Gage Redler
- Department of Radiation OncologyMoffitt Cancer CenterTampaFloridaUSA
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Lee BM, Chang JS, Koom WS, Byun HK, Kim HS, Beom SH, Oh C, Suh YJ, Ahn JB, Shin SJ, Park BJ, Park SY. Importance of Local Ablative Therapies for Lung Metastases in Patients With Colorectal Cancer. Ann Surg 2023; 278:e173-e178. [PMID: 35837890 DOI: 10.1097/sla.0000000000005466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of local ablative therapy (LAT) on overall survival in patients with lung metastases from colorectal cancer (CRC) compared with patients treated with systemic therapy. SUMMARY BACKGROUND DATA CRC affects approximately 1.4 million individuals worldwide every year. The lungs are commonly affected by CRC, and there is no treatment standard for a secondary lung metastasis from CRC. METHODS This longitudinal, retrospective cohort study (2010-2018) quantified the pulmonary and extrapulmonary tumor burden of 1143 patients by retrospectively reviewing computed tomography images captured at diagnosis. A comprehensive multidisciplinary approach informed how and when surgery and/or stereotactic body radiotherapy was administered. RESULTS Among 1143 patients, 473 patients (41%) received LAT, with surgery first (n = 421) or stereotactic ablative radiation therapy first (n = 52) either at the time of diagnosis (n = 288), within 1 year (n = 132), or after 1 year (n = 53). LAT was repeated in 158 patients (33.4%, 384 total sessions) when new lung metastases were detected. The 5- and 10-year survival rates for patients treated with LAT (71.2% and 64.0%, respectively) were significantly higher than those of patients treated with systemic therapy alone (14.2% and 10.0%, respectively; P <0.001). The overall survival of patients who received LAT intervention increased as the total tumor burden decreased. CONCLUSIONS A high long-term survival rate was achievable in a significant portion of patients with lung metastasis from CRC by the timely administrations of LAT to standard systemic therapy. The tumor burden and LAT feasibility should be included in a discussion during the follow-up period.
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Affiliation(s)
- Byung Min Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Radiation Oncology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Gyeonggi-do, Republic of Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Han Sang Kim
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung-Hoon Beom
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Caleb Oh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Joo Suh
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joong Bae Ahn
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Joon Shin
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Jo Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Korpics MC, Onderdonk BE, Dadey RE, Hara JH, Karapetyan L, Zha Y, Karrison TG, Olson AC, Fleming GF, Weichselbaum RR, Bao R, Chmura SJ, Luke JJ. Partial tumor irradiation plus pembrolizumab in treating large advanced solid tumor metastases. J Clin Invest 2023; 133:162260. [PMID: 37183819 PMCID: PMC10178837 DOI: 10.1172/jci162260] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 03/24/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUNDWe previously demonstrated the safety of stereotactic body radiotherapy followed by pembrolizumab (SBRT+P) in patients with advanced solid tumors. This phase I clinical trial was expanded to study the safety of partial tumor irradiation (partial-Rx). We assessed irradiated local failure (LF) and clinical outcomes with correlations to biomarkers including CD8+ T cell radiomics score (RS) and circulating cytokines.METHODSPatients received SBRT to 2-4 metastases and pembrolizumab for up to 7 days after SBRT. Tumors measuring up to 65 cc received the full radiation dose (complete-Rx), whereas tumors measuring more than 65 cc received partial-Rx. Landmark analysis was used to assess the relationship between tumor response and overall survival (OS). Multivariable analysis was performed for RS and circulating cytokines.RESULTSIn the combined (expansion plus original) cohort, 97 patients (219 metastases) were analyzed and received SBRT+P. Forty-six (47%) patients received at least 1 partial-Rx treatment. There were 7 (7.2%)dose-limiting toxicities (DLTs). 1-year LF was 7.6% overall, and 13.3% and 5.4% for partial-Rx and complete-Rx tumors, respectively (HR 2.32, 95% CI 0.90-5.97, P = 0.08). The overall, unirradiated, and irradiated objective response rates were 22%, 12%, and 34%, respectively. Irradiated tumor response to SBRT+P was associated with prolonged OS; 1-year OS was 71% (responders), 42% (mixed-responders), and 0% (nonresponders) (P < 0.01). High-RS was significantly associated with improved LF, progression-free survival (PFS), and OS. Elevated circulating IL-8 was independently associated with inferior PFS and OS.CONCLUSIONSBRT+P is safe in patients with large, advanced solid tumors. Additional studies are warranted to assess noninferiority of complete versus partial irradiation of tumors in the setting of immunotherapy.TRIAL REGISTRATIONClinicaltrials.gov NCT02608385FUNDINGMerck Investigator Studies Program; Hillman Fellows for Innovative Cancer Research Program; NIH grants UM1CA186690-06, P50CA254865-01A1, P30CA047904-32, and R01DE031729-01A1.
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Affiliation(s)
- Mark C Korpics
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois, USA
| | - Benjamin E Onderdonk
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois, USA
| | - Rebekah E Dadey
- UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jared H Hara
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois, USA
| | - Lilit Karapetyan
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yuanyuan Zha
- Human Immunological Monitoring Core, Biological Sciences Division
| | | | - Adam C Olson
- UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gini F Fleming
- Department of Medicine, Section of Hematology/Oncology, and
| | - Ralph R Weichselbaum
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois, USA
- Ludwig Center for Metastasis Research, The University of Chicago, Chicago, Illinois, USA
| | - Riyue Bao
- UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois, USA
| | - Jason J Luke
- UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Santos PMG, Li X, Gomez DR. Local Consolidative Therapy for Oligometastatic Non-Small Cell Lung Cancer. Cancers (Basel) 2022; 14:3977. [PMID: 36010969 PMCID: PMC9406686 DOI: 10.3390/cancers14163977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/30/2022] Open
Abstract
In the last 20 years, significant strides have been made in our understanding of the biological mechanisms driving disease pathogenesis in metastatic non-small cell lung cancer (NSCLC). Notably, the development and application of predictive biomarkers as well as refined treatment regimens in the form of chemoimmunotherapy and novel targeted agents have led to substantial improvements in survival. Parallel to these remarkable advancements in modern systemic therapy has been a growing recognition of "oligometastatic disease" as a distinct clinical entity-defined by the presence of a controlled primary tumor and ≤5 sites of metastatic disease amenable to local consolidative therapy (LAT), with surgery or stereotactic ablative body radiotherapy (SABR). To date, three randomized studies have provided clinical evidence supporting the use of LAT/SABR in the treatment of oligometastatic NSCLC. In this review, we summarize clinical evidence from these landmark studies and highlight ongoing trials evaluating the use of LAT/SABR in a variety of clinical contexts along the oligometastatic disease spectrum. We discuss important implications and caveats of the available data, including considerations surrounding patient selection and application in routine clinical practice. We conclude by offering potential avenues for further investigation in the oligometastatic disease space.
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Affiliation(s)
| | | | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Diplas BH, Santos PMG, Shahrokni A, Warner A, Iyengar P, Yang JT, Gomez DR, Palma DA, Tsai CJ. The Role of Ablative Radiotherapy in Older Adults With Limited Metastatic Disease. Semin Radiat Oncol 2022; 32:135-141. [PMID: 35307115 PMCID: PMC10898514 DOI: 10.1016/j.semradonc.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from recently published and ongoing randomized studies are helping to define the appropriate contexts for effective intervention with stereotactic ablative body radiotherapy (SABR) in the oligometastatic setting. Importantly, older adults represent a significant portion of patients with oligometastatic disease, yet often comprise a minority of patients in clinical trials. Moreover, older adults of the same chronologic age may have variable degrees of fitness and frailty. In this review, we highlight the specific challenges and considerations for the use of radiotherapy for older adults with oligometastatic disease-noting the importance of geriatric assessments in clinical decision-making about the appropriateness of SABR and other metastasis-directed therapies in this population. We then review data from existing trials, including a subset analysis of adverse events and survival estimates among older adults enrolled in the landmark SABR-COMET trial. Finally, we discuss future directions for research, including the need for focused clinical trials in older adult cohorts. Ultimately, a multidisciplinary approach is critical when carefully balancing the potential risks and benefits of this emerging treatment paradigm in the older adult population.
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Affiliation(s)
- Bill H Diplas
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Armin Shahrokni
- Department of Medicine, Geriatrics Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Puneeth Iyengar
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
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Stereotactic Ablative Radiotherapy for Oligometastatic Disease: A Tale of Emperor's New Clothes or New Standard of Care? Clin Oncol (R Coll Radiol) 2022; 34:318-324. [DOI: 10.1016/j.clon.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/24/2022] [Accepted: 02/10/2022] [Indexed: 12/19/2022]
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8
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Nicosia L, Franceschini D, Perrone-Congedi F, Casamassima F, Gerardi MA, Rigo M, Mazzola R, Perna M, Scotti V, Fodor A, Iurato A, Pasqualetti F, Gadducci G, Chiesa S, Niespolo RM, Bruni A, Alicino G, Frassinelli L, Borghetti P, Di Marzo A, Ravasio A, De Bari B, Sepulcri M, Aiello D, Mortellaro G, Sangalli C, Franceschini M, Montesi G, Aquilanti FM, Lunardi G, Valdagni R, Fazio I, Corti L, Vavassori V, Maranzano E, Magrini SM, Arcangeli S, Valentini V, Paiar F, Ramella S, Di Muzio NG, Livi L, Jereczek-Fossa BA, Osti MF, Scorsetti M, Alongi F. A multicenter LArge retrospectIve daTabase on the personalization of Stereotactic ABlative Radiotherapy use in lung metastases from colon-rectal cancer: the LaIT-SABR study. Radiother Oncol 2021; 166:92-99. [PMID: 34748855 DOI: 10.1016/j.radonc.2021.10.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/14/2021] [Accepted: 10/31/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION stereotactic ablative radiotherapy (SABR) has been shown to increase survival in oligometastatic disease, but local control of colorectal metastases remains poor. We aimed to identify potential predictive factors of SBRT response through a multicenter large retrospective database and to investigate the progression to the polymetastatic disease (PMD). MATERIAL AND METHODS the study involved 23 centers, and was approved by the Ethical Committee (Prot. Negrar 2019-ZT). 1033 lung metastases were reported. Clinical and biological parameters were evaluated as predictive for local progression-free survival (FLP). Secondary end-point was the time to the polymetastatic conversion (tPMC). RESULTS Two-year FLP was 75.4%. Two-year FLP for lesions treated with a BED <100 Gy, 100-124 Gy, and ≥125 Gy was 76.1%, 70.6%, and 94% (p=0.000). Two-year FLP for lesion measuring ≤10 mm, 10-20 mm, and >20 mm was 79.7%, 77.1%, and 66.6% (p=0.027). At the multivariate analysis a BED ≥125 Gy significantly reduced the risk of local progression (HR 0.24, 95%CI 0.11-0.51; p=0.000). Median tPMC was 26.8 months. Lesions treated with BED ≥125 Gy reported a significantly longer tPMC as compared to lower BED. The median tPMC for patients treated to 1, 2-3 or 4-5 simultaneous oligometastases was 28.5, 25.4, and 9.8 months (p=0.035). CONCLUSION The present is the largest series of lung colorectal metastases treated with SABR. The results support the use of SBRT in lung oligometastatic colorectal cancer patients as it might delay the transition to PMD or offer relatively long disease-free period in selected cases. Predictive factors were identified for treatment personalization.
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Affiliation(s)
- L Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center.
| | - D Franceschini
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - F Perrone-Congedi
- Department of Radiation Oncology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | | | - M A Gerardi
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - M Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center
| | - R Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center
| | - M Perna
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - V Scotti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - A Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Iurato
- Radiation Oncology, Campus Bio-Medico University, Via A. del Portillo, 21, 00128, Rome, Italy
| | - F Pasqualetti
- Radiation Oncology Unit, Pisa University Hospital, Via Roma 67, 56123, Pisa, Italy
| | - G Gadducci
- Radiation Oncology Unit, Pisa University Hospital, Via Roma 67, 56123, Pisa, Italy
| | - S Chiesa
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - R M Niespolo
- Department of Radiation Oncology, Azienda Ospedaliera S. Gerardo, Monza, Italy
| | - A Bruni
- Radiotherapy Unit, University Hospital of Modena, Modena, Italy
| | - G Alicino
- Radiotherapy Unit, University Hospital of Modena, Modena, Italy
| | - L Frassinelli
- Radiotherapy Unit, University Hospital of Modena, Modena, Italy
| | - P Borghetti
- Radiation Oncology Department, ASST Spedali Civili di Brescia - Brescia University, Brescia, Italy
| | - A Di Marzo
- Radiation Oncology Centre, S. Maria Hospital, Terni, Italy
| | - A Ravasio
- Radiotherapy Unit, Humanitas Gavazzeni, Bergamo
| | - B De Bari
- Radiation Oncology Department, University Hospital of Besançon, Besançon, France; Radiation Oncology Department, Neuchâtel Hospital Network, la Chaux-de-Fonds, Switzerland
| | - M Sepulcri
- Radiation Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - D Aiello
- Radiotherapy Unit, Casa di Cura Macchiarella, Palermo, Italy
| | - G Mortellaro
- Department of Radiation Oncology, ARNAS Ospedale Civico, Palermo, Italy
| | - C Sangalli
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - M Franceschini
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - G Montesi
- Radiotherapy Unit ULSS5, Rovigo, Italy
| | - F M Aquilanti
- Radiotherapy Marrelli Hospital, Marrelli Hospital, Crotone, Italy
| | - G Lunardi
- Medical Analysis Laboratory, IRCCS Sacro Cuore Don Calabria Hospital
| | - R Valdagni
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Department of Oncology and Haematology-Oncology, University of Milan
| | - I Fazio
- Radiotherapy Unit, Casa di Cura Macchiarella, Palermo, Italy
| | - L Corti
- Radiation Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - V Vavassori
- Radiotherapy Unit, Humanitas Gavazzeni, Bergamo
| | - E Maranzano
- Radiation Oncology Centre, S. Maria Hospital, Terni, Italy
| | - S M Magrini
- Radiation Oncology Department, ASST Spedali Civili di Brescia - Brescia University, Brescia, Italy
| | - S Arcangeli
- Department of Radiation Oncology, Azienda Ospedaliera S. Gerardo, Monza, Italy
| | - V Valentini
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - F Paiar
- Radiation Oncology Unit, Pisa University Hospital, Via Roma 67, 56123, Pisa, Italy
| | - S Ramella
- Radiation Oncology, Campus Bio-Medico University, Via A. del Portillo, 21, 00128, Rome, Italy
| | - N G Di Muzio
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - L Livi
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - B A Jereczek-Fossa
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - M F Osti
- Department of Radiation Oncology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - M Scorsetti
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy
| | - F Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center; University of Brescia, Brescia, Italy
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9
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Tchelebi LT, Goodman KA. Mature Experiences Using Local Therapy for Oligometastases. Semin Radiat Oncol 2021; 31:180-185. [PMID: 34090644 DOI: 10.1016/j.semradonc.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cancer is a heterogeneous disease, consisting of a spectrum of disorders ranging from local-only disease to those that are widely metastatic from their onset. The oligometastatic state, in which tumors harbor a limited number of metastases, may be curable in a subset of patients. The early success of surgical resection of hepatic metastases from colorectal cancer led to investigations into metastatectomy of other sites and, more recently, into the use of stereotactic ablative radiotherapy (SABR) for oligometastatic disease. This article reviews the data establishing the role of surgery for managing limited metastatic disease. Further, we review recent experiences using alternative local therapies, such as SABR, for oligometastases. This review also discusses ongoing trials evaluating local therapies for patients with a limited burden of metastatic cancer.
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Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine, Hershey, PA.
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
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10
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Mehrens D, Unterrainer M, Corradini S, Niyazi M, Manapov F, Westphalen CB, Froelich MF, Wildgruber M, Seidensticker M, Ricke J, Rübenthaler J, Kunz WG. Cost-Effectiveness Analysis of Local Treatment in Oligometastatic Disease. Front Oncol 2021; 11:667993. [PMID: 34211842 PMCID: PMC8239286 DOI: 10.3389/fonc.2021.667993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/31/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In certain malignancies, patients with oligometastatic disease benefit from radical ablative or surgical treatment. The SABR-COMET trial demonstrated a survival benefit for oligometastatic patients randomized to local stereotactic ablative radiation (SABR) compared to patients receiving standard care (SC) alone. Our aim was to determine the cost-effectiveness of SABR. MATERIALS AND METHODS A decision model based on partitioned survival simulations estimated costs and quality-adjusted life years (QALY) associated with both strategies in a United States setting from a health care perspective. Analyses were performed over the trial duration of six years as well as a long-term horizon of 16 years. Model input parameters were based on the SABR-COMET trial data as well as best available and most recent data provided in the published literature. An annual discount of 3% for costs was implemented in the analysis. All costs were adjusted to 2019 US Dollars according to the United States Consumer Price Index. SABR costs were reported with an average of $11,700 per treatment. Deterministic and probabilistic sensitivity analyses were performed. Incremental costs, effectiveness, and cost-effectiveness ratios (ICER) were calculated. The willingness-to-pay (WTP) threshold was set to $100,000/QALY. RESULTS Based on increased overall and progression-free survival, the SABR group showed 0.78 incremental QALYs over the trial duration and 1.34 incremental QALYs over the long-term analysis. Treatment with SABR led to a marginal increase in costs compared to SC alone (SABR: $304,656; SC: $303,523 for 6 years; ICER $1,446/QALY and SABR: $402,888; SC: $350,708 for long-term analysis; ICER $38,874/QALY). Therapy with SABR remained cost-effective until treatment costs of $88,969 over the trial duration (i.e. 7.6 times the average cost). Sensitivity analysis identified a strong model impact for ongoing annual costs of oligo- and polymetastatic disease states. CONCLUSION Our analysis suggests that local treatment with SABR adds QALYs for patients with certain oligometastatic cancers and represents an intermediate- and long-term cost-effective treatment strategy.
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Affiliation(s)
- Dirk Mehrens
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | | | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim-University of Heidelberg, Mannheim, Germany
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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11
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Corkum MT, Fakir H, Palma DA, Nguyen T, Bauman GS. Can Polymetastatic Disease Be ARRESTed Using SABR? A Dosimetric Feasibility Study to Inform Development of a Phase 1 Trial. Adv Radiat Oncol 2021; 6:100734. [PMID: 34278053 PMCID: PMC8267486 DOI: 10.1016/j.adro.2021.100734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/21/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Phase 2 randomized trials suggest that stereotactic ablative radiation therapy improves progression-free and overall survival in patients with oligometastatic cancer, with phase 3 trials currently testing stereotactic ablative radiation therapy in up to 10 metastases. Whether stereotactic radiation therapy could provide similar benefits in polymetastatic disease (>10 metastases) is unknown. We sought to evaluate the dosimetric feasibility of using stereotactic radiation therapy in polymetastatic disease in preparation for a phase 1 trial. Methods and Materials Five craniospinal computed tomography simulations were used to simulate 24 metastatic targets (n = 2 patients), 30 targets (n = 2 patients), and 50 targets (n = 1 patient) that were not present on the initial scan. Creation of radiation therapy plans was attempted for doses up to 30 Gy in 5 fractions, with de-escalation to 24 Gy/4, 18 Gy/3, 12 Gy/2, or 6 Gy/1 if not feasible based on standardized dose constraints. Plans were created using Raystation for delivery on linear accelerators using volumetric modulated arc therapy and validated using Mobius 3D. Results A stereotactic radiation therapy treatment plan was generated for each simulated patient. Dose constraints were met to a dose of 30 Gy in 5 fractions for the patients with 24 and 30 lesions. For the patient with 50 targets, dose de-escalation to 12 Gy in 2 fractions was required to meet lung constraints. Estimated beam-on time varied between 18 and 29 minutes per fraction of 6 Gy. Median D95 planning target volume dosimetry ranged from 96.6% to 97.7% of the prescription dose. The conformity index (R100) range was 0.89 to 0.95, and R50 range was 6.84 to 8.72. Conclusions Stereotactic radiation therapy treatment plans meeting standardized dose constraints could be created in the setting of 24 to 50 metastatic lesions using volumetric modulated arc therapy. This safety of this approach is being evaluated in a phase 1 trial (NCT04530513).
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Affiliation(s)
- Mark T Corkum
- Division of Radiation Oncology, Department of Oncology
| | - Hatim Fakir
- Department of Medical Biophysics, London Health Sciences Centre, London, Ontario, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology
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12
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Bauman GS, Corkum MT, Fakir H, Nguyen TK, Palma DA. Ablative radiation therapy to restrain everything safely treatable (ARREST): study protocol for a phase I trial treating polymetastatic cancer with stereotactic radiotherapy. BMC Cancer 2021; 21:405. [PMID: 33853550 PMCID: PMC8048078 DOI: 10.1186/s12885-021-08020-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/10/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients with polymetastatic cancer are most often treated with systemic therapy to improve overall survival and/or delay progression, with palliative radiotherapy reserved for sites of symptomatic disease. Stereotactic ablative radiotherapy (SABR) has shown promise in the treatment of oligometastatic disease, but the utility of SABR in treating all sites of polymetastatic disease has yet to be evaluated. This study aims to evaluate the maximally tolerated dose (MTD) of SABR in patients with polymetastatic disease. METHODS Up to 48 patients with polymetastatic cancer (> 10 sites) will be enrolled on this phase I, modified 3 + 3 design trial. Eligible patients will have exhausted (or refused) standard systemic therapy options. SABR will be delivered as an escalating number of weekly fractions of 6 Gy, starting at 6 Gy × 2 weekly fractions (dose level 1). The highest dose level (dose level 4) will be 6 Gy × 5 weekly fractions. Feasibility and safety of SABR will be evaluated 6 weeks following treatment using a composite endpoint of successfully completing treatment as well as toxicity outcomes. DISCUSSION This study will be the first to explore delivering SABR in patients with polymetastatic disease. SABR will be planned using the guiding principles of: strict adherence to dose constraints, minimization of treatment burden, and minimization of toxicity. As this represents a novel use of radiotherapy, our phase I study will allow for careful selection of the MTD for exploration in future studies. TRIAL REGISTRATION This trial was prospectively registered in ClinicalTrials.gov as NCT04530513 on August 28, 2020.
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Affiliation(s)
- Glenn S Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6C 1K1, Canada.
| | - Mark T Corkum
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6C 1K1, Canada
| | - Hatim Fakir
- Department of Medical Biophysics, London Health Sciences Centre, London, Ontario, Canada
| | - Timothy K Nguyen
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6C 1K1, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, 790 Commissioners Rd. E, London, Ontario, N6C 1K1, Canada
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13
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Mazzola R, Jereczek-Fossa BA, Antognoni P, Di Muzio N, Nicosia L, Lancia A, Fazio I, Chiesa S, Osti MF, Pergolizzi S, Franceschini D, Gentile P, Triggiani L, Alongi F. OLIGO-AIRO: a national survey on the role of radiation oncologist in the management of OLIGO-metastatic patients on the behalf of AIRO. Med Oncol 2021; 38:48. [PMID: 33761017 DOI: 10.1007/s12032-021-01493-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/09/2021] [Indexed: 12/15/2022]
Abstract
In the last years, several evidences demonstrated the role of stereotactic body radiotherapy (SBRT) in the oligometastatic disease and the possibility to increase survival in selected patients. In 2020 the study group "biology and treatment of the oligometastatic disease" of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) conducted a survey evaluating the attitude of physicians in treating the oligometastatic disease and the definition of it. An electronic questionnaire was administered online to the society members. 105 questionnaires were returned. 78% responders considered as oligometastatic a disease with ≤ 5 metastases. The majority of the responders (77%) treated > 50 patients in the last year, and 89% responders agreed in considering every oligometastatic tumor susceptible to local treatments. Regarding the clinical management of the oligometastatic disease, the majority of the responders (66%) suggested an interdisciplinary discussion. When choosing a treatment option for fit patients with a single oligometastatic focus, 52% of the responders agreed in proposing only SBRT. In the case of unfit patients with a single oligometastatic lesion the agreement was in favor of the SBRT alone (89%). In the oligoprogressive setting, 41% responders opted to continue the current systemic treatment and to add SBRT, while in the case of oligoresidual disease, 70% responders was in favor of adding SBRT and continuing the current systemic treatment. In conclusions, the survey illustrated the current agreement and prescribing attitude for oligometastatic patients in Italy. The non-homogenous agreement in some clinical scenarios suggest the need of more robust evidence.
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Affiliation(s)
- Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Paolo Antognoni
- Radiation Oncology Centre, Ospedale di Circolo e Fondazione Macchi, ASST Dei Sette Laghi, Varese, Italy
| | - Nadia Di Muzio
- Department of Radiotherapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Luca Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - Andrea Lancia
- Radiation Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ivan Fazio
- Radiation Therapy Unit, Casa di Cura Macchiarella, Palermo, Italy
| | - Silvia Chiesa
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Mattia F Osti
- Radiotherapy Oncology, Department of Medicine and Surgery and Translational Medicine, Sapienza University of Rome, S. Andrea Hospital, Rome, Italy
| | | | - Davide Franceschini
- Department of Radiotherapy, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Piercarlo Gentile
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, Brescia University, Piazza Spedali Civili,1, 25100, Brescia, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
- University of Brescia, Brescia, Italy
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14
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Reply to: The course of lung oligometastatic colorectal cancer may be a reflection of selection for treatment rather than an effect of stereotactic body radiotherapy. Strahlenther Onkol 2020; 197:76-78. [PMID: 33242139 DOI: 10.1007/s00066-020-01710-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 10/22/2022]
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15
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Metastasis-directed therapy for oligometastasis and beyond. Br J Cancer 2020; 124:136-141. [PMID: 33204024 PMCID: PMC7782796 DOI: 10.1038/s41416-020-01128-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/19/2020] [Accepted: 09/22/2020] [Indexed: 12/25/2022] Open
Abstract
Metastasis-directed therapy (MDT)-local therapy that is intended to eradicate specific metastatic lesions-has hitherto been used with varying degrees of clinical efficacy and acceptance as a meaningful therapy for metastatic disease. Over the past 25 years, however, the momentum for using MDT to manage patients with metastatic solid tumours has increased, driven by several factors. Among these factors is the recognition that patients with limited metastatic burden could potentially derive survival benefits from MDT. Furthermore, although current systemic therapies are increasingly effective, they are infrequently curative. In addition, technological advances have broadened the spectrum of metastatic lesions that can be treated with ablative intent. Here we aim to briefly review the status of evidence for the clinical benefit of MDT based on current data mainly from trials in patients with oligometastatic disease, discuss the myriad of clinical states that might fall under and beyond the definition of oligometastasis, review technological advances in MDT and their applications beyond oligometastasis, and discuss the need for the continued co-evolution of MDT and systemic therapy as we seek to understand which patients with metastatic cancer can achieve durable remission and how to optimally manage those who cannot.
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