Stereotactic body radiotherapy for oligometastases

Overcoming chimeric antigen receptor-T (CAR-T) resistance with checkpoint inhibitors: Existing methods, challenges, clinical success, and future prospects : A comprehensive review

Immune checkpoint blockade is, as of today, the most successful form of cancer immunotherapy, with more than 43 % of cancer patients in the US eligible to receive it; however, only up to 12.5 % of patients respond to it. Similarly, adoptive cell therapy using bioengineered chimeric antigen receptorT (CAR-T) cells and T-cell receptor (TCR) cells has provided excellent responses against liquid tumours, but both forms of immunotherapy have encountered challenges within a tumour microenvironment that is both lacking in tumour-specific T-cells and is strongly immunosuppressive toward externally administered CAR-T and TCR cells. This review focuses on understanding approved checkpoint blockade and adoptive cell therapy at both biological and clinical levels before delving into how and why their combination holds significant promise in overcoming their individual shortcomings. The advent of next-generation checkpoint inhibitors has further strengthened the immune checkpoint field, and a special section explores how these inhibitors can address existing hurdles in combining checkpoint blockade with adoptive cell therapy and homing in on our cancer target for long-term immunity.

Dissecting the Spatial and Single-Cell Transcriptomic Architecture of Cancer Stem Cell Niche Driving Tumor Progression in Gastric Cancer

Despite significant advancements in identifying novel therapeutic targets and compounds, cancer stem cells (CSCs) remain pivotal in driving therapeutic resistance and tumor progression in gastric cancer (GC). High-resolution knowledge of the transcriptional programs underlying the role of CSC niche in driving tumor stemness and progression is still lacking. Herein, spatial and single-cell RNA sequencing of 32 human gastric mucosa tissues at various stages of malignancy, illuminating the phenotypic plasticity of tumor epithelium and transcriptional trajectory from mature gastric chief cells to the CSC state, which is associated with activation of EGFR and WNT signaling pathways, is conducted. Moreover, the CSCs interact with not only the immunosuppressive CXCL13+ T cells and CCL18+ M2 macrophages to evade immune surveillance, but also the inflammatory cancer-associated fibroblasts (iCAFs) to promote tumorigenesis and maintain stemness, which construct the CSC niche leading to inferior prognosis. Notably, it is uncovered that amphiregulin (AREG) derived from iCAFs promotes tumor stemness by upregulating the expression of SOX9 in tumor cells, and contributes to drug resistance via the AREG-ERBB2 axis. This study provides valuable insight into the characteristics of CSC niche in driving tumor stemness and progression, offering novel perspective for designing effective strategies to overcome GC therapy resistance.

1-year efficacy results after MR-guided risk-adapted stereotactic radiotherapy of infra-diaphragmatic oligometastases in a multicenter phase II trial

BACKGROUND AND PURPOSE

The SOFT (Stereotactic ablative radiotherapy of infra-diaphragmatic sOFT tissue metastases) trial assesses the safety and efficacy of risk-adapted MR-guided stereotactic ablative radiotherapy (SABR) of infra-diaphragmatic soft tissue metastasis in patients with oligometastatic disease (OMD) (clinicaltrials.gov ID NCT04407897). This paper reports the one-year efficacy analysis and evaluates associations between local control (LC) and clinical and dosimetric parameters.

MATERIALS AND METHODS

This investigator-initiated, multicenter, single-arm, phase 2 study recruited patients from four MR-linac centers in Denmark and the US. Patients with De novo or recurrent OMD with ≤5 metastases in ≤3 organs and patients with induced OMD or oligoprogressive disease (OPD) with ≤3 metastases were eligible. Fractionation schemes were 45-75 Gy in 3-8 fractions.

RESULTS

The trial included 121 patients with 147 oligometastatic lesions, primarily in the liver (41 %), lymph nodes (35 %), or adrenal glands (14 %). The median follow-up time was 13.0 months, interquartile range (IQR) (11.7,13.7) months. The 1-year LC rate was 89 %, 95 % confidence interval (CI) (83,94 %). We did not observe any statistically significant associations between LC and clinical and dosimetric parameters. The median progression-free survival was 7.1 months, 95 % CI (6.0,9.4). One- and two-year overall survival was 82.6 %, 95 % CI (76.2 %,89.7 %), and 65.1 %, 95 % CI (56.4 %,75.3 %). Sixty-one patients (50 %) were kept off systemic therapy throughout the one-year follow-up.

CONCLUSION

In our study, treatment with risk-adapted, MR-guided SABR resulted in a high one-year local control and survival rate and could keep half of the patients off systemic therapy within the first year of follow-up.

A systematic review of tumour position reproducibility and stability in breath-hold for radiation therapy of the upper abdomen

Background and purpose

Upper abdominal malignancies are relatively rare, and although surgery is considered the primary treatment option, radiation therapy has an emerging role in the management of liver, pancreas, kidney and adrenal gland tumours. Furthermore, stereotactic radiation therapy for the management of upper abdominal metastases is an expanding clinical indication. Breath-hold is one respiratory motion management strategy used in upper abdominal radiation therapy, and the reproducibility, and stability of breath-hold is critical for overall treatment accuracy.

Materials and methods

A systematic review of the literature was conducted in Medline, Embase and Cochrane databases with keyword and vocabulary terms related to radiation therapy, breath-hold and upper abdominal tumours.

Results

Following screening against the selection criteria, 41 studies were included. Breath-hold reproducibility was the most commonly reported outcome and exhale breath-hold was the most common type. Studies were either prospective or retrospective cohort studies, and the mean sample size was 19 participants. The risk of bias of each included study was assessed, and the mean quality assessment score for included studies was 90 % (77-100 %). Median exhale breath-hold cranio-caudal inter-fraction reproducibility was 0.6 mm, (IQR 0.3-1.6 mm), compared to inspiratory breath-hold 0.0 mm (IQR -0.6-2.97 mm). Stability measurements were ≤3 mm in 71 % of studies, irrespective of breath-hold type.

Discussion

Formulating institutional protocols for best clinical practice regarding breath-hold for upper abdominal tumours is challenging, given the significant variation in practices, interventions and definitions observed in the literature. Further investigation to individualise breath-hold strategies and safety margins is warranted.

Treatment of oligometastatic breast cancer: The role of patient selection

Up to 90 % of death from solid tumors are caused by metastases. By 2040, breast cancer (BC) is predicted to increase to over 3 million new cases. Additionally, with the personalization and intensification of BC follow-up, many patients will relapse with oligometastatic disease (OMD). Over the past decades, advances in treatment planning, image guidance, target position reproducibility, and online tracking, along with a compelling radiobiological rationale, have led to the implementation of Stereotactic Body Radiation Therapy (SBRT). This has become a valid ablative treatment option for OMD patients. However, there are still concerns about which patients benefit the most from ablative treatment. In this review, we will analyze the literature regarding SBRT for OMD in BC patients. We aim to present the current data on its effectiveness and define the optimal tailored scenarios for SBRT outcomes.

Metastasis-directed stereotactic radiotherapy and systemic treatment continuation for patients with oligoprogressive metastatic breast cancer

BACKGROUND

About 15-20 % of patients with metastatic breast cancer (mBC) can experience oligoprogressive disease (OPD) in ≤ 5 sites of disease. Patients with OPD may benefit from metastasis-directed stereotactic radiotherapy (SBRT) to all sites of cancer progression while maintaining the same systemic treatment, aiming to prolong the time to next systemic treatment (NEST). This study aims to assess the outcomes provided by this multimodal strategy.

METHODS

Prospective-retrospective, single-center, cohort study including consecutive patients who received SBRT to all extracranial OPD sites (≤ 5), from January 2011 to June 2023, without changing systemic therapy, according to the multidisciplinary tumor board's indication. The primary endpoint was post-radiotherapy progression-free survival (pRT-PFS). A sample size of 130 patients was needed to estimate a median pRT-PFS of 8 months with a 95 % confidence interval (95 %CI) ranging from 5.4 (considered clinically significant) to 10.6 months.

RESULTS

129 patients were included: 99 (77 %) had hormone receptor-positive/HER2-negative (HR+/HER2-) disease, 116 (90 %) had ≤ 2 oligoprogressive lesions, 118 (91 %) presented with non-visceral OPD involving bones or lymph nodes. Patients experienced OPD after a median PFS on systemic therapy (pre-OPD PFS) of 11.3 months (95 % CI, 8.7-13.0). Median pRT-PFS was 11.3 months (95 % CI, 9.1-13.5) and median NEST was 13.6 months (95 % CI, 11.5-15.2). Only 19 (15 %) patients experienced a subsequent PD in the OPD sites treated with SBRT.

CONCLUSION

Patients with oligoprogressive mBC, especially with HR+/HER2- disease and non-visceral OPD after a durable pre-OPD PFS, benefit from OPD-directed SBRT while maintaining the same systemic treatment, suggesting its broader implementation in clinical practice.

Precision in Motion Management: Long-Term Local Control and Prognostic Insights in SBRT for Oligometastatic Lung and Liver Metastases

Background/Objectives: Inadequate dosing and respiratory motion contribute to local recurrence for oligometastatic disease (OMD). While short-term LC rates are well-documented, data on long-term LC remain limited. This study investigated long-term LC after stereotactic body radiotherapy (SBRT), using respiratory motion management techniques. Methods: This retrospective study took place at UZ Brussel with follow-up until Oct 2024. It analyzed oligometastatic patients treated with SBRT between Jul 2012 and Feb 2017. Treatment involved delivering 50 Gy in 10 fractions on the 80% isodose line, building on data from a prior prospective study. Lesion movement was managed using internal target volume (ITV) or dynamic tumor tracking (DTT) with marker. The primary endpoint of the study was long-term LC and identifying variables associated with it using a Cox proportional hazards model. Results: A total of 100 patients were treated for a total of 211 metastatic lesions. Lesions were predominantly in the lungs (74%) and treated using ITV (88%). LC rates at 1, 3, 5, and 10 years were 76.5%, 53.8%, 38.1%, and 36.3%, respectively. Improved LC was observed in locations other than lung and liver (HR: 0.309; p = 0.024) and with increasing age (HR: 0.975; p < 0.010). Worse LC was seen in liver lesions (HR: 1.808; p = 0.103) and systemic therapy post-radiotherapy (HR: 3.726; p < 0.001). No significant associations were found with tumor size or tumor motion, nor between the two motion management strategies used (DTT and ITV). Conclusions: Appropriate motion management is key in LC for OMD. No significant difference in LC was found between both techniques. Lesion location, patient age, and systemic therapy post-radiotherapy were prognostic factors for LC.

Effects of maximum dose on local control after stereotactic body radiotherapy for oligometastatic tumors of colorectal cancer

This study aimed to identify radiotherapy dosimetric parameters related to local failure (LF)-free survival (LFFS) in patients with lung and liver oligometastases from colorectal cancer treated with stereotactic body radiotherapy (SBRT). We analyzed 75 oligometastatic lesions in 55 patients treated with SBRT between January 2014 and December 2021. There was no constraint or intentional increase in maximum dose. LF was defined as the progression of the treated lesion until the last follow-up or death. The dose distributions were recalculated using Monte Carlo-based algorithms. The significance of the planning target volume (PTV) biologically effective dose (BED) 10s (D2, D95, D98, Dmean) in LFFS was evaluated using Cox regression, considering sex, age, primary cancer, tumor site, oligometastatic status, multiplicity, and either tumor size or one of the volume parameters. LF occurred in 23.4% of the lesions. Lesions showing LF received significantly lower PTV D2 (146 ± 21 vs. 164 ± 23, p = 0.006). Multivariate analysis revealed that PTV D2 (< 159 Gy10 vs. ≥ 159 Gy10) was the sole dosimetric parameter associated with LFFS. Tumors equal to or larger than the median size/volume yet receiving < 159 Gy10 of PTV D2 showed the lowest LFFS following stratification by median PTV D2 combined with tumor size or volume parameters. The maximum dose (PTV D2) was significantly associated with LFFS after SBRT for lung and liver oligometastases from colorectal cancer. Increasing the maximum dose may be beneficial for managing larger tumors.

Local treatment for oligoprogressive metastatic sites of breast cancer: efficacy, toxicities and future perspectives

Metastatic breast cancer (MBC) is still an incurable disease, which eventually develops resistance mechanisms against systemic therapies. While most patients experience widespread disease progression during systemic treatment (ST), in some cases, progression may occur at a limited number of metastatic sites. Evidence from other malignancies suggests that local treatment with stereotactic ablative radiotherapy (SABR) of oligoprogressive disease (OPD) may allow effective disease control without the need to modify ST. Available evidence regarding local treatment of oligoprogressive breast cancer is limited, mostly consisting of retrospective studies. The only randomized data come from the randomized CURB trial, which enrolled patients with oligoprogressive disease, including both small cell lung cancer and breast cancer patients, and did not show a survival benefit from local treatment in the latter group. However, local treatment of oligoprogressive MBC is still considered in clinical practice, especially to delay the switch to more toxic STs. This review aims to identify patients who may benefit from this approach based on the current available knowledge, focusing also on the potential risks associated with the combination of radiotherapy (RT) and ST, as well as on possible future scenarios.

Prognostic value of circulating tumor cells in oligorecurrent hormone-sensitive prostate cancer patients undergoing stereotactic body radiation therapy

BACKGROUND

Stereotactic body radiation therapy (SBRT) is an effective metastasis-directed therapy for managing oligometastatic prostate cancer patients. However, it lacks reliable biomarkers for risk stratification. Circulating Tumor Cells (CTC) show promise as minimally invasive prognostic indicators. This study evaluates the prognostic value of CTC in oligorecurrent hormone-sensitive prostate cancer (orHSPC).

METHODS

orHSPC patients with 1-3 nodal and/or bone metastases undergoing SBRT were enrolled (N = 35), with a median follow-up time of 42.1 months. CTC levels were measured at baseline (T0), 1 month (T1), and 3 months (T2) post-SBRT using a novel metabolism-based assay. These levels were correlated with clinical outcomes through Cox-regression and Kaplan-Meier analyses.

RESULTS

Median CTC counts were 5 at T0, 8 at T1, and 5 at T2 with no significant variation over time. Multivariate analysis identified high (≥5/7.5 mL) T0 CTC counts (HR 2.9, 95% CI 1.3-6.5, p = 0.01, median DPFS 29.7 vs. 14.0 months) and having more than one metastasis (HR 3.9, 95% CI 1.8-8.6, p < 0.005, median DPFS 34.1 vs. 10.7 months) as independent predictors of distant progression-free survival (DPFS). CTC assessment successfully stratified patients with a single metastasis (HR 3.4, 95% CI 1.1-10.2, p = 0.03, median DPFS 42.1 vs. 16.7 months), but not those with more than one metastasis. Additionally, a combined score based on CTC levels and the number of metastases effectively stratified patients.

CONCLUSION

The study demonstrates that hypermetabolic CTC could enhance risk stratification in orHSPC patients undergoing SBRT, particularly in patients with limited metastatic burden, potentially identifying patients with indolent disease who are suitable for tailored SBRT interventions.

Trabectedin for L-Type Sarcoma: A Retrospective Multicenter Study

(1) Background: Metastatic L-type sarcomas (liposarcoma and leiomyosarcoma) are rare and have a poor prognosis. Trabectedin is an effective agent that can be used after anthracyclines. This study was designed to evaluate the real-life effectiveness and safety of trabectedin. (2) Methods: A retrospective multicenter study was conducted on patients who were treated with trabectedin for metastatic L-type sarcomas at ten tertiary oncology centers between 2015 and 2023. The objective response rate (ORR), disease control rate (DCR), time to treatment failure (TTF), and overall survival (OS) were evaluated in the cohort. Cox regression analysis was used to determine prognostic factors for survival. (3) Results: A total of 98 patients (52% liposarcoma and 48% leiomyosarcoma) were included in the study. The median treatment line was three (range: 1 to 6). Thirteen patients (13.3%) underwent local treatment due to oligoprogression, and dose reduction was required in seventeen patients (17.3%) due to toxicity. The ORR and DCR were 16% and 42%, respectively. The median TTF was 3 months, and the median OS was 10 months. In univariate analysis, a significantly longer median TTF was observed in patients who underwent local treatment (p = 0.008), obtained objective responses (p < 0.001), and underwent dose reduction (p = 0.002). No statistical differences were observed according to the histologic subtype and metastatic site. In the multivariate analysis for OS, it was found that obtaining an objective response was a good prognostic factor (p = 0.003), while the presence of liver metastases was associated with a poor prognosis (p = 0.016). (4) Conclusion: Trabectedin is a suitable option for L-type sarcoma after doxorubicin-based treatments. Survival was not worse in patients who underwent dose reduction. The use of local therapies simultaneously with trabectedin can be effective.

Challenges in the Understanding of Oligometastatic Disease in Clinical Practice

Introduction: There is little data describing oligometastatic disease (OMD) and decision-making. We sought to understand the knowledge gaps and challenges in deciphering and delivering treatments.

MATERIALS AND METHODS

 This is a quality improvement (QI) study conducted via an anonymous survey. Three different clinical scenarios of OMD (oligo-recurrence disease, synchronous de-novo OMD, and oligo-progressive disease) were presented to assess participants' comprehension. A qualitative approach was used, involving four open-ended questions. Summary statistics and descriptive analysis were utilized to describe survey answers.

RESULTS

 The survey was answered by 70 clinicians, 56% (n=39) medical oncologists, 24% (n=17) radiation oncologists, 7% (n=5) surgeons, and the remaining 13% (n=9) from anatomical pathology, radiology, and palliative care. The three clinical cases were correctly identified as oligo-recurrence, de-novo, and oligo-progression disease in 63% (n=44), 94% (n=66), and 76% (n=53) of responses, respectively. Additionally, for each case, the majority of respondents indicated that they would offer local treatment (n=59, 84%; n=57, 81%; n=55, 79%, respectively). Seventy-nine percent (n=49) perceived differences between each modality of local therapies. Physicians perceived challenges including the lack of prospective trial data and unclear approach to OMD. An important determinant in deciding whether patients may benefit from treatment was tumor histology.

CONCLUSION

 The term OMD involves certain difficulties in definition and management. Positive and negative trials have further added uncertainty regarding who would best benefit from local treatment. The discordance in outcome expectations from physicians and patients will need to be addressed to ensure that patient's goals of care are met.

The use of master protocols for efficient trial design to evaluate radiotherapy interventions: a systematic review

The aim of this review was to highlight why the use of master protocols trial design is particularly useful for radiotherapy intervention trials where complex setup pathways (including quality assurance, user training, and integrating multiple modalities of treatment) may hinder clinical advances. We carried out a systematic review according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, reviewing the findings using a landscape analysis. Results were summarized descriptively, reporting on trial characteristics highlighting the benefits, limitations, and challenges of developing and implementing radiotherapy master protocols, with three case studies selected to explore these issues in more detail. Twelve studies were suitable for inclusion (4 platform trials, 3 umbrella trials, and 5 basket trials), evaluating a mix of solid tumor sites in both curative and palliative settings. The interventions were categorized into 1) novel agent and radiotherapy combinations; 2) radiotherapy dose personalization; and 3) device evaluation, with a case study provided for each intervention. Benefits of master protocol trials for radiotherapy intervention include protocol efficiency for implementation of novel radiotherapy techniques; accelerating the evaluation of novel agent drug and radiotherapy combinations; and more efficient translational research opportunities, leading to cost savings and research efficiency to improve patient outcomes. Master protocols offer an innovative platform under which multiple clinical questions can be addressed within a single trial. Due to the complexity of radiotherapy trial setup, cost and research efficiency savings may be more apparent than in systemic treatment trials. Use of this research approach may be the change needed to push forward oncological innovation within radiation oncology.

Hypofractionated stereotactic radiotherapy for brain metastases in lung cancer patients: dose‒response effect and toxicity

BACKGROUND

Lung cancer is a common cause of brain metastases, approximately 40% of patients with lung cancer will develop brain metastases at some point during their disease. Hypofractionated stereotactic radiotherapy (HSRT) has been demonstrated to be effective in controlling limited brain metastases. However, there is still no conclusive on the optimal segmentation of HSRT. The aim of our study was to explore the correlation between the HSRT dosage and its treatment effect and toxicity.

METHODS

A retrospective analysis was conducted on patients with non-small cell lung cancer (NSCLC) brain metastasis at Hangzhou Cancer Hospital from 1 January 2019 to 1 January 2021. The number of brain metastases did not exceed 10 in all patients and the number of fractions of HSRT was 5. The prescription dose ranges from 25 to 40 Gy. The Kaplan-Meier method was used for estimation of the localised intracranial control rate (iLC). Adverse radiation effects (AREs) were evaluated according to CTCAE 5.0. This study was approved by the Institutional Ethics Review Board of the Hangzhou Cancer Hospital (#73/HZCH-2022).

RESULTS

Forty eligible patients with a total of 70 brain metastases were included in this study. The 1-year iLC was 76% and 89% in the prescribed dose ≤ 30 Gy and > 30 Gy group, respectively (P < 0.05). For patients treated with HSRT combined with targeted therapy, immunotherapy and chemotherapy, the 1-year iLC was 89%, 100%, and 45%, respectively. No significant associations were observed between the number, maximum diameter, location, and type of pathology of brain metastases. The rate of all-grade AREs was 33%. Two patients who received a total dose of 40 Gy developed grade 3 headache, the rest of the AREs were grade 1-2.

CONCLUSIONS

Increasing the prescription dose of HSRT improves treatment effect but may also exacerbate the side effects. Systemic therapy might impact the iLC rate, and individualized treatment regimens need to be developed.

Beyond success: unveiling the hidden potential of radiotherapy and immunotherapy in solid tumors

Immunotherapy, particularly with immune checkpoint inhibitors, has significantly transformed cancer treatment. Despite its success, many patients struggle to respond adequately or sustain long-lasting clinical improvement. A growing consensus has emerged that radiotherapy (RT) enhances the response rate and overall efficacy of immunotherapy. Although combining RT and immunotherapy has been extensively investigated in preclinical models and has shown promising results, establishing itself as a dynamic and thriving area of research, clinical evidence for this combination strategy over the past five years has shown both positive and disappointing results, suggesting the need for a more nuanced understanding. This review provides a balanced and updated analysis of the combination of immunotherapy and RT. We summarized the preclinical mechanisms through which RT boosts antitumor immune responses and mainly focused on the outcomes of recently updated clinical trials, including those that may not have met expectations. We investigated the optimization of the therapeutic potential of this combined strategy, including key challenges, such as fractionation and scheduling, lymph node irradiation, and toxicity. Finally, we offered insights into the prospects and challenges associated with the clinical translation of this combination therapy, providing a realistic perspective on the current state of research and potential future directions.

Application and dosimetric comparison of surface-guided deep inspiration breath-hold for lung stereotactic body radiotherapy

Respiratory motion management is the crucial challenge for safe and effective application of lung stereotactic body radiotherapy (SBRT). The present study implemented lung SBRT treatment in voluntary deep inspiration breath-hold (DIBH) with surface-guided radiotherapy (SGRT) system and evaluated the geometric and dosimetric benefits of DIBH to organs-at-risk (OARs), aiming to advising the choice between DIBH technology and conventional free breathing 4 dimensions (FB-4D) technology. Five patients of lung SBRT treated in DIBH with SGRT at our institution were retrospectively analyzed. CT scans were acquired in DIBH and FB-4D, treatment plans were generated for both respiratory phases. The geometric and dosimetry of tumor, ipsilateral lung, double lungs and heart were compared between the DIBH and FB-4D treatment plans. In terms of target coverage, utilizing DIBH significantly reduced the mean plan target volume (PTV) by 21.9% (p = 0.09) compared to FB-4D, the conformity index (CI) of DIBH and FB-4D were comparable, but the dose gradient index (DGI) of DIBH was higher. With DIBH expanding lung, the volumes of ipsilateral lung and double lungs were 2535.1 ± 403.0cm3 and 4864.3 ± 900.2cm3, separately, 62.2% (p = 0.009) and 73.1% (p = 0.009) more than volumes of ipsilateral lung (1460.03 ± 146.60cm3) and double lungs (2811.25 ± 603.64cm3) in FB-4D. The heart volume in DIBH was 700.0 ± 146.1cm3, 11.6% (p = 0.021) less than that in FB-4D. As for OARs protection, the mean dose, percent of volume receiving > 20Gy (V20) and percent of volume receiving > 5Gy (V5) of ipsilateral lung in DIBH were significantly lower by 33.2% (p = 0.020), 44.0% (p = 0.022) and 24.5% (p = 0.037) on average, separately. Double lungs also showed significant decrease by 31.1% (p = 0.019), 45.5% (p = 0.024) and 20.9% (p = 0.048) on average for mean dose, V20 and V5 in DIBH. Different from the lung, the mean dose and V5 of heart showed no consistency between DIBH and FB-4D, but lower maximum dose of heart was achieved in DIBH for all patients in this study. Appling lung SBRT in DIBH with SGRT was feasibly performed with high patient compliance. DIBH brought significant dosimetric benefits to lung, however, it caused more or less irradiated heart dose that depend on the patients' individual differences which were unpredictable.

Colorectal Cancer Pulmonary Metastasectomy: When, Why and How

Colorectal cancer is the third-most-diagnosed cancer in males and in females, representing 8% of estimated new cases, and the third cause of cancer-related death in both sexes, accounting for 9% of cancer deaths in men and 8% in women. About 20% of patients diagnosed with CRC present metastatic disease. Although lung metachronous or synchronous metastatic spread without other involved sites has been reported in only a small proportion of patients, considering that this tumor is frequently diagnosed, the clinical approach to CRC pulmonary metastases represents a major issue for thoracic surgeons and CRC oncologists. Among patients diagnosed with pulmonary metastases from CRC, about 9-12% are eligible for local treatments with radical intent, including surgical resection, SBRT (stereotactic body radiation therapy) and ablation therapy. Due to the lack of randomized controlled trials among different local strategies, there is no definitive evidence about the optimal approach, although surgical resection is considered the most effective therapeutic option in this clinical scenario. Oncological achievement of primary radical resection, the biology of primary tumor and metastatic sites, disease free interval and or progression free survival are independent prognostic factors which make it possible to define a cohort of patients which might significantly benefit from pulmonary metastasectomy.

A Prospective Study Assessing the Efficacy and Toxicity of Stereotactic Body Radiation Therapy for Oligometastatic Bone Metastases

Purpose

Stereotactic body radiation therapy (SBRT) is a promising treatment for oligometastatic disease in bone because of its delivery of high dose to target tissue and minimal dose to surrounding tissue. The purpose of this study is to assess the efficacy and toxicity of this treatment in patients with previously unirradiated oligometastatic bony disease.

Methods and Materials

In this prospective phase II trial, patients with oligometastatic bone disease, defined as ≤3 active sites of disease, were treated with SBRT at Brigham and Women's Hospital/Dana Farber Cancer Center and Beth Israel Deaconess Medical Center between December 2016 and May 2019. SBRT dose and fractionation regimen were not protocol mandated. Local progression-free survival, progression-free survival, prostatic specific antigen progression, and overall survival were reported. Treatment-related toxicity was also reported.

Results

A total of 98 patients and 126 lesions arising from various tumor histologies were included in this study. The median age of patients enrolled was 72.8 years (80.6% male, 19.4% female). Median follow-up was 26.7 months. The most common histology was prostate cancer (68.4%, 67/98). The most common dose prescriptions were 27/30 Gy in 3 fractions (27.0%, 34/126), 30 Gy in 5 fractions (16.7%, 21/126), or 30/35 Gy in 5 fractions (16.7%, 21/126). Multiple doses per treatment regimen reflect dose painting employing the lower dose to the clinical target volume and higher dose to the gross tumor volume. Four patients (4.1%, 4/98) experienced local progression at 1 site for each patient (3.2%, 4/126). Among the entire cohort, 2-year local progression-free survival (including death without local progression) was 84.8%, 2-year progression-free survival (including deaths as well as local, distant, and prostatic specific antigen progression) was 47.5%, and 2-year overall survival was 87.3%. Twenty-six patients (26.5%, 26/98) developed treatment-related toxicities.

Conclusions

Our study supports existing literature in showing that SBRT is effective and tolerable in patients with oligometastatic bone disease. Larger phase III trials are necessary and reasonable to determine long-term efficacy and toxicities.

Evolution of Liver Transplantation Indications: Expanding Horizons

Liver transplantation (LT) has significantly transformed the prognosis of patients with end-stage liver disease and hepatocellular carcinoma (HCC). The traditional epidemiology of liver diseases has undergone a remarkable shift in indications for LT, marked by a decline in viral hepatitis and an increase in metabolic dysfunction-associated steatotic liver disease (MASLD), along with expanded indications for HCC. Recent advancements in surgical techniques, organ preservation and post-transplant patients' management have opened new possibilities for LT. Conditions that were historically considered absolute contraindications have emerged as potential new indications, demonstrating promising results in terms of patient survival. While these expanding indications provide newfound hope, the ethical dilemma of organ scarcity persists. Addressing this requires careful consideration and international collaboration to ensure equitable access to LT. Multidisciplinary approaches and ongoing research efforts are crucial to navigate the evolving landscape of LT. This review aims to offer a current overview of the primary emerging indications for LT, focusing on acute-on-chronic liver failure (ACLF), acute alcoholic hepatitis (AH), intrahepatic and perihilar cholangiocarcinoma (i- and p-CCA), colorectal liver metastasis (CRLM), and neuroendocrine tumor (NET) liver metastases.

Machine-learning prediction of treatment response to stereotactic body radiation therapy in oligometastatic gynecological cancer: A multi-institutional study

BACKGROUND AND PURPOSE

We aimed to develop and validate different machine-learning (ML) prediction models for the complete response of oligometastatic gynecological cancer after SBRT.

MATERIAL AND METHODS

One hundred fifty-seven patients with 272 lesions from 14 different institutions and treated with SBRT with radical intent were included. Thirteen datasets including 222 lesions were combined for model training and internal validation purposes, with an 80:20 ratio. The external testing dataset was selected as the fourteenth Institution with 50 lesions. Lesions that achieved complete response (CR) were defined as responders. Prognostic clinical and dosimetric variables were selected using the LASSO algorithm. Six supervised ML models, including logistic regression (LR), classification and regression tree analysis (CART) and support vector machine (SVM) using four different kernels, were trained and tested to predict the complete response of uterine lesions after SBRT. The performance of models was assessed by receiver operating characteristic curves (ROC), area under the curve (AUC) and calibration curves. An explainable approach based on SHapley Additive exPlanations (SHAP) method was deployed to generate individual explanations of the model's decisions.

RESULTS

63.6% of lesions had a complete response and were used as ground truth for the supervised models. LASSO strongly associated complete response with three variables, namely the lesion volume (PTV), the type of lesions (lymph-nodal versus parenchymal), and the biological effective dose (BED10), that were used as input for ML modeling. In the training set, the AUCs for complete response were 0.751 (95% CI: 0.716-0.786), 0.766 (95% CI: 0.729-0.802) and 0.800 (95% CI: 0.742-0.857) for the LR, CART and SVM with a radial basis function kernel, respectively. These models achieve AUC values of 0.727 (95% CI: 0.669-0.795), 0.734 (95% CI: 0.649-0.815) and 0.771 (95% CI: 0.717-0.824) in the external testing set, demonstrating excellent generalizability.

CONCLUSION

ML models enable a reliable prediction of the treatment response of oligometastatic lesions receiving SBRT. This approach may assist radiation oncologists to tailor more individualized treatment plans for oligometastatic patients.

Stereotactic body radiation therapy for bone oligometastases

Stereotactic body radiation therapy is effective for the local management of oligometastases (at most five metastases) with a benefit in survival and local control. Most studies on the management of oligometastases focus on all oligometastatic sites in primary cancer and very few focus on a single oligometastatic site. In particular, there are few data on bone oligometastases, which represent one of the preferred sites for secondary cancer locations. This article focuses on the benefit of stereotactic radiotherapy for bone oligometastases of all cancers by histological types, and reviews the results of major studies in this field.

Yttrium-90 Transarterial Radioembolization of Primary Lung Cancer Metastases to the Liver

PURPOSE

To assess whether yttrium-90 transarterial radioembolization (TARE) is safe and effective in the treatment of primary lung cancer metastases to the liver (LCML).

METHODS AND METHODS

This retrospective study included 57 patients with LCML who were treated with 79 TARE treatments. Histology included non-small cell lung cancer (NSCLC) (n = 27), small cell lung cancer (SCLC) (n = 17), and lung carcinoid (LC) (n = 13). Survival was calculated using Kaplan-Meier method; differences between groups were estimated using log rank test. Cox proportional hazards model was used to determine factors influencing survival. Adverse events were graded using the Society of Interventional Radiology Adverse Events Classification.

RESULTS

Median overall survival (OS) was as follows: NSCLC, 8.3 months (95% confidence interval [CI], 6.3-16.4 months); SCLC, 4.1 months (95% CI, 1.9-6.6 months); and LC, 43.5 months (95% CI, 7.8-61.4 months). For NSCLC, presence of bilobar vs unilobar disease (hazard ratio [HR], 5.24; 95% CI, 1.64-16.79; P = .002); more tumors, 2-5 vs 1 (HR, 4.88; 95% CI, 1.17-20.37; P = .003) and >5 vs 1 (HR, 3.75; 95% CI, 0.95-6.92; P = .05); and lobar vs segmental treatment (HR, 2.56; 95% CI, 0-NA; P = .002) were negative predictors of OS. For SCLC, receipt of >2 lines of chemotherapy vs ≤2 lines (HR, 3.16; 95% CI, 0.95-10.47; P = .05) was a negative predictor of OS. For LC, tumor involvement of >50% was a negative predictor of OS (HR, 3.77 × 1015; 95% CI, 0-NA; P = .002). There were 11 of 79 severe or life-threatening adverse events within 30 days (abdominal pain, altered mental status, nausea/vomiting, acalculous/aseptic cholecystitis, hyponatremia, pancreatitis, renal failure, and death from pneumonia).

CONCLUSIONS

TARE has an acceptable safety profile for the treatment of LCML, with survival benefits best seen in LC tumors.

PSMA PET for Detection of Recurrence

Prostate cancer (PC) is a significant health concern worldwide, with high incidence and mortality rates. Early and accurate detection and localization of recurrent disease at biochemical recurrence (BCR) is critical for guiding subsequent therapeutic decisions and improving patient outcomes. At BCR, conventional imaging consisting of CT, MRI, and bone scintigraphy are recommended by US and European guidelines, however, these modalities all bear certain limitations in detecting metastatic disease, particularly in low-volume relapse at low prostate-specific antigen (PSA) levels. Molecular imaging with PET/CT or PET/MRI using prostate-specific membrane antigen (PSMA) targeting radiopharmaceuticals has revolutionized imaging of PC. Particularly at BCR PC, PSMA PET has shown better diagnostic performance compared to conventional imaging in detecting local relapse and metastases, even at very low PSA levels. The most recent version of the National Comprehensive Cancer Network (NCCN) guideline has included PSMA-targeted PET/CT or PET/MRI for the localization of BCR PC. There are several different PSMA-targeting radiopharmaceuticals labeled with different radioisotopes, each with slightly different characteristics, but overall similar high sensitivity and specificity for PC. PSMA-targeted PET has the potential to significantly impact patient care by guiding personalized treatment decisions and thus improving outcomes in BCR PC patients.

Aggressive Local Ablative Radiotherapy Mitigates Progression Risk in Oligometastatic Lung Adenocarcinoma

PURPOSE

This study aimed to determine the role of local ablative radiotherapy (LART) in oligometastatic/oligoprogressive lung adenocarcinoma.

MATERIALS AND METHODS

Patients (n=176) with oligometastatic lung adenocarcinoma treated with LART were identified, and those treated with LART at the initial diagnosis of synchronous oligometastatic disease (OMD group) or treated with LART when they presented with repeat oligoprogression (OPD group) were included.

RESULTS

In the OMD group (n=54), the 1- and 3-year progression-free survival (PFS) were 50.9% and 22.5%, respectively, whereas the 1- and 3-year overall survival in the OPD group were 75.9% and 58.1%, respectively. Forty-one patients (75.9%) received LART at all gross disease sites. Tyrosine kinase inhibitor (TKI) use and all-metastatic site LART were significant predictors of higher PFS (p=0.018 and p=0.046, respectively). In patients treated with TKIs at the time of LART (n=23) and those treated with all-metastatic site LART, the 1-year PFS was 86.7%, while that of patients not treated with all-metastatic site LART was 37.5% (p=0.006). In the OPD group (n=122), 67.2% of the patients (n=82) maintained a systemic therapy regimen after LART. The cumulative incidence of changing systemic therapy was 39.6%, 62.9%, and 78.5% at 6 months, 1 year, and 2 years after LART, respectively.

CONCLUSION

Aggressive LART can be an option to improve survival in patients with oligometastatic disease. Patients with synchronous oligometastatic disease receiving TKI and all-metastatic site LART may have improved PFS. In patients with repeat oligoprogression, LART might potentially extend survival by delaying the need to change the systemic treatment regimen.

Long-term outcomes of metastasis-directed stereotactic body radiation therapy in metastatic nasopharyngeal carcinoma

BACKGROUND

The study aims to evaluate the outcomes of metastasis-directed stereotactic body radiation therapy (SBRT) in metastatic nasopharyngeal carcinoma (mNPC).

METHODS

We reviewed all SBRT conducted in patients with mNPC in our institution between 2013 and 2022. Systemic therapy was performed with chemotherapy with or without anti-programmed death-1 (PD-1) therapy. Local treatment delivered with ablative purpose in stereotactic setting with dose/fraction ≥5 Gy was evaluated. Kaplan-Meier analyses were used to determine the rates of local control (LC), progression-free survival (PFS), and overall survival (OS). Univariate and multivariate analyses were performed by Cox regression.

RESULTS

A total of 54 patients with 76 metastatic sites receiving SBRT were analyzed. Median follow-up was 49 months. The 3-year LC, PFS, and OS rates were 89.1%, 29.4%, and 57.9%, respectively. Adding a PD-1 inhibitor to SBRT tended to prolong median OS (50.1 vs. 32.2 months, p = 0.068). Patients receiving a biological effective dose (BED, α/β = 10) ≥ 80 Gy had a significantly longer median OS compared to those who received a lower dose (not reached vs. 29.5 months, p = 0.004). Patients with oligometastases (1-5 metastases) had a better median OS (not reached vs. 29.5 months, p < 0.001) and PFS (34.3 vs. 4.6 months, p < 0.001). Pretreatment EBV-DNA and maintenance therapy were also significant predictors for OS.

CONCLUSIONS

Metastatic NPC patients could benefit from metastases-directed SBRT in combination with systemic therapy.

Optimizing Treatment Strategy for Oligometastases/Oligo-Recurrence of Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer, and nearly half of CRC patients experience metastases. Oligometastatic CRC represents a distinct clinical state characterized by limited metastatic involvement, demonstrating a less aggressive nature and potentially improved survival with multidisciplinary treatment. However, the varied clinical scenarios giving rise to oligometastases necessitate a precise definition, considering primary tumor status and oncological factors, to optimize treatment strategies. This review delineates the concepts of oligometastatic CRC, encompassing oligo-recurrence, where the primary tumor is under control, resulting in a more favorable prognosis. A comprehensive examination of multidisciplinary treatment with local treatments and systemic therapy is provided. The overarching objective in managing oligometastatic CRC is the complete eradication of metastases, offering prospects of a cure. Essential to this management approach are local treatments, with surgical resection serving as the standard of care. Percutaneous ablation and stereotactic body radiotherapy present less invasive alternatives for lesions unsuitable for surgery, demonstrating efficacy in select cases. Perioperative systemic therapy, aiming to control micrometastatic disease and enhance local treatment effectiveness, has shown improvements in progression-free survival through clinical trials. However, the extension of overall survival remains variable. The review emphasizes the need for further prospective trials to establish a cohesive definition and an optimized treatment strategy for oligometastatic CRC.

Enhancement of Radiation Sensitivity by Cathepsin L Suppression in Colon Carcinoma Cells

Cancer is one of the main causes of death globally. Radiotherapy/Radiation therapy (RT) is one of the most common and effective cancer treatments. RT utilizes high-energy radiation to damage the DNA of cancer cells, leading to their death or impairing their proliferation. However, radiation resistance remains a significant challenge in cancer treatment, limiting its efficacy. Emerging evidence suggests that cathepsin L (cath L) contributes to radiation resistance through multiple mechanisms. In this study, we investigated the role of cath L, a member of the cysteine cathepsins (caths) in radiation sensitivity, and the potential reduction in radiation resistance by using the specific cath L inhibitor (Z-FY(tBu)DMK) or by knocking out cath L with CRISPR/Cas9 in colon carcinoma cells (caco-2). Cells were treated with different doses of radiation (2, 4, 6, 8, and 10), dose rate 3 Gy/min. In addition, the study conducted protein expression analysis by western blot and immunofluorescence assay, cytotoxicity MTT, and apoptosis assays. The results demonstrated that cath L was upregulated in response to radiation treatment, compared to non-irradiated cells. In addition, inhibiting or knocking out cath L led to increased radiosensitivity in contrast to the negative control group. This may indicate a reduced ability of cancer cells to recover from radiation-induced DNA damage, resulting in enhanced cell death. These findings highlight the possibility of targeting cath L as a therapeutic strategy to enhance the effectiveness of RT. Further studies are needed to elucidate the underlying molecular mechanisms and to assess the translational implications of cath L knockout in clinical settings. Ultimately, these findings may contribute to the development of novel treatment approaches for improving outcomes of RT in cancer patients.

Oligometastatic Disease (OMD): The Classification and Practical Review of Prospective Trials

Oligometastatic disease (OMD) is currently known as an intermediate state of cancer, characterized by a limited number of systemic metastatic lesions for which local ablative therapy could be curative. Indeed, data from multiple clinical trials have illustrated an increase in overall survival (OS) for cancer patients when local ablative therapy was included in the systemic adjuvant therapy. Given that no driver and somatic mutations specific to OMD are currently established, the diagnosis of OMD is mainly based on the results of X-ray studies. In 2020, 20 international experts from the European Society for Radiotherapy and Oncology (ESTRO) and the European Organization for Research and Treatment of Cancer (EORTC) developed a comprehensive system for the characterization and classification of OMD. They identified 17 OMD characteristics that needed to be assessed in all patients who underwent radical local treatment. These characteristics reflect the tumor biology and clinical features of the disease underlying the development of OMD independently of the primary tumor type and the number of metastatic lesions. In particular, the system involves the characteristics of the primary tumor (e.g., localization, histology, TNM stage, mutational status, specific tumor markers), clinical parameters (e.g., disease-free interval, treatment-free interval), therapies (e.g., local, radical or palliative treatment, the numbers of the therapeutic regimens), and type of OMD (e.g., invasive). Based on the aforementioned criteria, an algorithm was introduced into the clinic to classify OMDs collectively according to their nomenclature. A history of polymetastatic disease (PMD) prior to OMD is used as a criterion to delineate between induced OMD (previous history of PMD after successful therapy) and genuine OMD (no history of PMD). Genuine OMD is divided into two states: recurrent OMD (i.e., after a previous history of OMD) and de novo OMD (i.e., a first newly diagnosed oligometastatic disease). de novo OMD is differentiated into synchronous and metachronous forms depending on the length of time from the primary diagnosis to the first evidence of OMD. In the case of synchronous OMD, this period is less than 6 months. Lastly, metachronous and induced OMD are divided into oligorecurrence, oligoprogression, and oligopersistence, depending on whether OMD is firstly diagnosed during an absence (oligo recurrence) or presence (oligoprogression or oligopersistence) of active systemic therapy. This classification and nomenclature of OMD are evaluated prospectively in the OligoCare study. In this article, we present a practical review of the current concept of OMD and discuss the available prospective clinical trials and potential future directions.

MRI feature-based radiomics models to predict treatment outcome after stereotactic body radiotherapy for spinal metastases

OBJECTIVE

This study aimed to extract radiomics features from MRI using machine learning (ML) algorithms and integrate them with clinical features to build response prediction models for patients with spinal metastases undergoing stereotactic body radiotherapy (SBRT).

METHODS

Patients with spinal metastases who were treated using SBRT at our hospital between July 2018 and April 2023 were recruited. We assessed their response to treatment using the revised Response Evaluation Criteria in Solid Tumors (version 1.1). The lesions were categorized into progressive disease (PD) and non-PD groups. Radiomics features were extracted from T1-weighted image (T1WI), T2-weighted image (T2WI), and fat-suppression T2WI sequences. Feature selection involved intraclass correlation coefficients, minimal-redundancy-maximal-relevance, and least absolute shrinkage and selection operator methods. Thirteen ML algorithms were employed to construct the radiomics prediction models. Clinical, conventional imaging, and radiomics features were integrated to develop combined models. Model performance was evaluated using receiver operating characteristic (ROC) curve analysis, and the clinical value was assessed using decision curve analysis.

RESULTS

We included 194 patients with 142 (73.2%) lesions in the non-PD group and 52 (26.8%) in the PD group. Each region of interest generated 2264 features. The clinical model exhibited a moderate predictive value (area under the ROC curve, AUC = 0.733), while the radiomics models demonstrated better performance (AUC = 0.745-0.825). The combined model achieved the best performance (AUC = 0.828).

CONCLUSION

The MRI-based radiomics models exhibited valuable predictive capability for treatment outcomes in patients with spinal metastases undergoing SBRT.

CRITICAL RELEVANCE STATEMENT

Radiomics prediction models have the potential to contribute to clinical decision-making and improve the prognosis of patients with spinal metastases undergoing SBRT.

KEY POINTS

• Stereotactic body radiotherapy effectively delivers high doses of radiation to treat spinal metastases. • Accurate prediction of treatment outcomes has crucial clinical significance. • MRI-based radiomics models demonstrated good performance to predict treatment outcomes.

Metabolic factors associated with the prognosis of oligometastatic patients treated with stereotactic body radiotherapy

Over the past two decades, it has been established that cancer patients with oligometastases, i.e., only a few detectable metastases confined to one or a few organs, may benefit from an aggressive local treatment approach such as the application of high-precision stereotactic body radiotherapy (SBRT). Specifically, some studies have indicated that achieving long-term local tumor control of oligometastases is associated with prolonged overall survival. This motivates investigations into which factors may modify the dose-response relationship of SBRT by making metastases more or less radioresistant. One such factor relates to the uptake of the positron emission tomography tracer 2-deoxy-2-[18F]fluoro-D-glucose (FDG) which reflects the extent of tumor cell glycolysis or the Warburg effect, respectively. Here we review the biological mechanisms how the Warburg effect drives tumor cell radioresistance and metastasis and draw connections to clinical studies reporting associations between high FDG uptake and worse clinical outcomes after SBRT for oligometastases. We further review the evidence for distinct metabolic phenotypes of metastases preferentially seeding to specific organs and their possible translation into distinct radioresistance. Finally, evidence that obesity and hyperglycemia also affect outcomes after SBRT will be presented. While delivered dose is the main determinant of a high local tumor control probability, there might be clinical scenarios when metabolic targeting could make the difference between achieving local control or not, for example when doses have to be compromised in order to spare neighboring high-risk organs, or when tumors are expected to be highly therapy-resistant due to heavy pretreatment such as chemotherapy and/or radiotherapy.

Radiotherapy plus immune checkpoint inhibitor in prostate cancer

The immune checkpoint inhibitor (ICI) is a promising strategy for treating cancer. However, the efficiency of ICI monotherapy is limited, which could be mainly attributed to the tumor microenvironment of the "cold" tumor. Prostate cancer, a type of "cold" cancer, is the most common cancer affecting men's health. Radiotherapy is regarded as one of the most effective prostate cancer treatments. In the era of immune therapy, the enhanced antigen presentation and immune cell infiltration caused by radiotherapy might boost the therapeutic efficacy of ICI. Here, the rationale of radiotherapy combined with ICI was reviewed. Also, the scheme of radiotherapy combined with immune checkpoint blockades was suggested as a potential option to improve the outcome of patients with prostate cancer.

Updated Review and Clinical Recommendations for the Diagnosis and Treatment of Patients with Retroperitoneal Sarcoma by the Spanish Sarcoma Research Group (GEIS)

Soft tissue sarcomas (STS) are an uncommon and biologically heterogeneous group of tumors arising from mesenchymal cells. The incidence is estimated at five cases per 100,000 people per year. Retroperitoneal sarcomas (RPS) account for 10-15% of all STS, and their management depends on their anatomical characteristics and histotype. Due to their very low incidence, it is recommended that RPS be treated in reference centers and evaluated by an experienced multidisciplinary team (MDT). In Spain, the Spanish Group for Research in Sarcomas (GEIS) brings together experts from various specialties to promote research on sarcomas and improve treatment results. This paper summarizes the GEIS recommendations for the diagnosis, treatment, and follow-up of patients with RPS.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer (mCRC), published in late 2022, were adapted in December 2022, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with mCRC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with mCRC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian countries. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with mCRC across the different countries of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation, coupled with a disparity in the drug approvals and reimbursement strategies, between the different countries.

Design, Synthesis and Anticancer Evaluation of Nitroimidazole Radiosensitisers

The role of hypoxic tumour cells in resistance to radiotherapy, and in suppression of immune response, continues to endorse tumour hypoxia as a bona fide, yet largely untapped, drug target. Radiotherapy innovations such as stereotactic body radiotherapy herald new opportunities for classical oxygen-mimetic radiosensitisers. Only nimorazole is used clinically as a radiosensitiser, and there is a dearth of new radiosensitisers in development. In this report, we augment previous work to present new nitroimidazole alkylsulfonamides and we document their cytotoxicity and ability to radiosensitise anoxic tumour cells in vitro. We compare radiosensitisation with etanidazole and earlier nitroimidazole sulfonamide analogues and we identify 2-nitroimidazole and 5-nitroimidazole analogues with marked tumour radiosensitisation in ex vivo assays of surviving clonogens and with in vivo tumour growth inhibition.

Automated detection, delineation and quantification of whole-body bone metastasis using FDG-PET/CT images

Non-small cell lung cancer (NSCLC) patients with the metastatic spread of disease to the bone have high morbidity and mortality. Stereotactic ablative body radiotherapy increases the progression free survival and overall survival of these patients with oligometastases. FDG-PET/CT, a functional imaging technique combining positron emission tomography (PET) with 18 F-fluorodeoxyglucose (FDG) and computer tomography (CT) provides improved staging and identification of treatment response. It is also associated with reduction in size of the radiotherapy tumour volume delineation compared with CT based contouring in radiotherapy, thus allowing for dose escalation to the target volume with lower doses to the surrounding organs at risk. FDG-PET/CT is increasingly being used for the clinical management of NSCLC patients undergoing radiotherapy and has shown high sensitivity and specificity for the detection of bone metastases in these patients. Here, we present a software tool for detection, delineation and quantification of bone metastases using FDG-PET/CT images. The tool extracts standardised uptake values (SUV) from FDG-PET images for auto-segmentation of bone lesions and calculates volume of each lesion and associated mean and maximum SUV. The tool also allows automatic statistical validation of the auto-segmented bone lesions against the manual contours of a radiation oncologist. A retrospective review of FDG-PET/CT scans of more than 30 candidate NSCLC patients was performed and nine patients with one or more metastatic bone lesions were selected for the present study. The SUV threshold prediction model was designed by splitting the cohort of patients into a subset of 'development' and 'validation' cohorts. The development cohort yielded an optimum SUV threshold of 3.0 for automatic detection of bone metastases using FDG-PET/CT images. The validity of the derived optimum SUV threshold on the validation cohort demonstrated that auto-segmented and manually contoured bone lesions showed strong concordance for volume of bone lesion (r = 0.993) and number of detected lesions (r = 0.996). The tool has various applications in radiotherapy, including but not limited to studies determining optimum SUV threshold for accurate and standardised delineation of bone lesions and in scientific studies utilising large patient populations for instance for investigation of the number of metastatic lesions that can be treated safety with an ablative dose of radiotherapy without exceeding the normal tissue toxicity.

Magnetic resonance-guided stereotactic body radiation therapy (MRgSBRT) for oligometastatic patients: a single-center experience

PURPOSE

Stereotactic body radiotherapy is increasingly used for the treatment of oligometastatic disease. Magnetic resonance-guided stereotactic radiotherapy (MRgSBRT) offers the opportunity to perform dose escalation protocols while reducing the unnecessary irradiation of the surrounding organs at risk. The aim of this retrospective, monoinstitutional study is to evaluate the feasibility and clinical benefit (CB) of MRgSBRT in the setting of oligometastatic patients.

MATERIALS AND METHODS

Data from oligometastatic patients treated with MRgSBRT were collected. The primary objectives were to define the 12-month progression-free survival (PFS) and local progression-free survival (LPFS) and 24-month overall survival (OS) rate. The objective response rate (ORR) included complete response (CR) and partial response (PR). CB was defined as the achievement of ORR and stable disease (SD). Toxicities were also assessed according to the CTCAE version 5.0 scale.

RESULTS

From February 2017 to March 2021, 59 consecutive patients with a total of 80 lesions were treated by MRgSBRT on a 0.35 T hybrid unit. CR and PR as well as SD were observed in 30 (37.5%), 7 (8.75%), and 17 (21.25%) lesions, respectively. Furthermore, CB was evaluated at a rate of 67.5% with an ORR of 46.25%. Median follow-up time was 14 months (range: 3-46 months). The 12-month LPFS and PFS rates were 70% and 23%, while 24-month OS rate was 93%. No acute toxicity was reported, whereas late pulmonary fibrosis G1 was observed in 9 patients (15.25%).

CONCLUSION

MRgSBRT was well tolerated by patients with reported low toxicity levels and a satisfying CB.

Stereotactic body radiotherapy for mediastinal lymph node with CyberKnife®: Efficacy and toxicity

PUPRPOSE

Stereotactic body radiotherapy is more and more used for treatment of oligometastatic mediastinal lymph nodes. The objective of this single-centre study was to evaluate its efficacy in patients with either a locoregional recurrence of a pulmonary or oesophageal cancer or with distant metastases of extrathoracic tumours.

PATIENTS AND METHODS

Patients with oligometastatic mediastinal lymph nodes treated with CyberKnife from June 2010 to September 2020 were screened. The primary endpoint was to assess local progression free survival and induced toxicity. Secondary endpoints were overall survival and progression free survival. The delay before introduction of systemic treatment in the subgroup of patients who did not receive systemic therapy for previous progression was also evaluated.

RESULTS

Fifty patients were included: 15 with a locoregional progression of a thoracic primary tumour (87% pulmonary) and 35 with mediastinal metastasis of especially renal tumour (29%). Median follow-up was 27 months (6-110 months). Local progression free survival at 6, 12 and 18 months was respectively 94, 88 and 72%. The rate of local progression was significantly lower in patients who received 36Gy in six fractions (66% of the cohort) versus other treatment schemes. Two grade 1 acute oesophagitis and one late grade 2 pulmonary fibrosis were described. Overall survival at 12, 18 and 24 months was respectively 94, 85 and 82%. Median progression free survival was 13 months. Twenty-one patients were treated by stereotactic body irradiation alone without previous history of systemic treatment. Among this subgroup, 11 patients (52%) received a systemic treatment following stereotactic body radiotherapy with a median introduction time of 17 months (5-52 months) and 24% did not progress.

CONCLUSION

Stereotactic body irradiation as treatment of oligometastatic mediastinal lymph nodes is a well-tolerated targeted irradiation that leads to a high control rate and delay the introduction of systemic therapy in selected patients.

Clinical and pathological characterization of 158 consecutive and unselected oligometastatic breast cancers in a single institution

PURPOSE

Data about incidence, biological, and clinical characteristics of oligometastatic breast cancer (OMBC) are scarce. However, these data are essential in determining optimal treatment strategy. Gaining knowledge of these elements means observing and describing large, recent, and consecutive series of OMBC in their natural history.

METHODS

We collected data retrospectively at our institution from 998 consecutive patients diagnosed and treated with synchronous or metachronous metastatic breast cancer (MBC) between January 2014 and December 2018. The only criterion used to define OMBC was the presence of one to five metastases at diagnosis.

RESULTS

Of 998 MBC, 15.8% were classified OMBC. Among these, 88% had one to three metastases, and 86.7% had only one organ involved. Bone metastases were present in 52.5% of cases, 20.9% had progression to lymph nodes, 14.6% to the liver, 13.3% to the brain, 8.2% to the lungs, and 3.8% had other metastases. 55.7% had HR+/HER2- OMBC, 25.3% had HER2+OMBC, and 19% had HR-/HER2- OMBC. The HR+/HER2- subtype statistically correlated with bone metastases (p = 0.001), the HER2+subtype with brain lesions (p = 0.001), and the HR-/HER2- subtype with lymph node metastases (p = 0.008). Visceral metastases were not statistically associated with any OMBC subtypes (p = 0.186). OMBC-SBR grade III was proportionally higher than in the ESME series of 22,109 MBC (49.4% vs. 35.1%, p < 0.001).

CONCLUSION

OMBC is a heterogeneous entity whose incidence is higher than has commonly been published. Not an indolent disease, each subgroup, with its biological and anatomical characteristics, merits specific management.

Prognostication for Patients Receiving Palliative Radiation Therapy

Estimation of patient prognosis plays a central role in guiding decision making for the palliative management of metastatic disease, and a number of statistical models have been developed to provide survival estimates for patients in this context. In this review, we discuss several well-validated survival prediction models for patients receiving palliative radiotherapy to sites outside of the brain. Key considerations include the type of statistical model, model performance measures and validation procedures, studies' source populations, time points used for prognostication, and details of model output. We then briefly discuss underutilization of these models, the role of decision support aids, and the need to incorporate patient preference in shared decision making for patients with metastatic disease who are candidates for palliative radiotherapy.

The oligometastatic setting in HNSCC: A critical review by the Rete Oncologica Piemonte e Valle d'Aosta multidisciplinary team

INTRODUCTION

The oligometastatic disease is a low burden metastatic disease that might still benefit from curable treatment. Squamous cell carcinoma of the head and neck (HNSCC) is a complex group of malignancies, with high rates of loco-regional recurrences. Distant metastases are less frequent, and a single or few deposits are often observed (oligometastatic disease). The optimal management of oligometastatic HNSCC remains to be defined.

MATERIALS AND METHODS

Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used.

RESULTS

This paper contains a narrative report and a critical discussion of the available evidence on the management of oligometastatic HNSCC patients, with a focus on metastasis-directed therapy (MDT), particularly stereotactic ablative radiotherapy (SABR).

CONCLUSIONS

in line with literature data, the multidisciplinary evaluation emerged as the key element in the management of oligometastatic HNSCC patients.

Outcome of patients with biochemical recurrence of prostate cancer after PSMA PET/CT-directed radiotherapy or surgery without systemic therapy

BACKGROUND

Radiotherapy (RT) and surgery are potential treatment options in patients with biochemical recurrence (BCR) following primary prostate cancer treatment. This study examines the value of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT)-informed surgery and RT in patients with BCR treated without systemic therapy.

METHODS

This is a post-hoc subgroup analysis of a prospective clinical trial. Inclusion criteria were: histologically proven prostate cancer at initial curative-intent treatment, BCR after primary treatment with curative intent, having five or fewer lesions identified on [¹⁸F]DCFPyL PET/CT, and treatment with either PET/CT-directed RT or surgery without systemic therapy. The biochemical progression-free survival after PSMA ligand PET/CT-directed RT and surgery was determined. Uni- and multivariate Cox regression analyses were performed for the association of patients' characteristics, tumor-specific variables, and PSMA PET/CT imaging results with biochemical progression at the last follow-up.

RESULTS

Fifty-eight patients (30 in surgery and 28 in radiotherapy groups) met the inclusion criteria. A total of 87 PSMA-positive lesions were detected: 16 local recurrences (18.4%), 54 regional lymph nodes (62.1%), 6 distant lymph nodes (6,8%), and 11 osseous lesions (12.7%). A total of 85.7% (24 of 28) and 70.0% (21 of 30) of patients showed a ≥ 50% decrease in prostate-specific antigen (PSA) levels after RT and surgery, respectively. At a median follow-up time of 21 months (range, 6-32 months), the median biochemical progression-free survival was 19 months (range, 4 to 23 months) in the radiotherapy group, as compared with 16.5 months (range, 4 to 28 months) in the surgery group. On multivariate Cox regression analysis, the number of PSMA positive lesions (2-5 lesions compared to one lesion), and the anatomic location of the detected lesions (distant metastasis vs. local relapse and pelvic nodal relapse) significantly correlated with biochemical progression at the last follow-up, whereas other clinical, tumor-specific, and imaging parameters did not.

CONCLUSIONS

This study suggests that RT or surgery based on [¹⁸F]DCFPyL PET/CT are associated with high PSA response rates. The number and site of lesions detected on the PSMA PET/CT were predictive of biochemical progression on follow-up. Further studies are needed to assess the impact of targeting these sites on patient relevant outcomes.

TRIAL REGISTRATION

Registered September 14, 2016; NCT02899312; https://clinicaltrials.gov/ct2/show/NCT02899312.

Predictive model based on DCE-MRI and clinical features for the evaluation of pain response after stereotactic body radiotherapy in patients with spinal metastases

OBJECTIVE

To investigate the correlation of conventional MRI, DCE-MRI and clinical features with pain response after stereotactic body radiotherapy (SBRT) in patients with spinal metastases and establish a pain response prediction model.

METHODS

Patients with spinal metastases who received SBRT in our hospital from July 2018 to April 2022 consecutively were enrolled. All patients underwent conventional MRI and DCE-MRI before treatment. Pain was assessed before treatment and in the third month after treatment, and the patients were divided into pain-response and no-pain-response groups. A multivariate logistic regression model was constructed to obtain the odds ratio and 95% confidence interval (CI) for each variable. C-index was used to evaluate the model's discrimination performance.

RESULTS

Overall, 112 independent spinal lesions in 89 patients were included. There were 73 (65.2%) and 39 (34.8%) lesions in the pain-response and no-pain-response groups, respectively. Multivariate analysis showed that the number of treated lesions, pretreatment pain score, Karnofsky performance status score, Bilsky grade, and the DCE-MRI quantitative parameter K^trans were independent predictors of post-SBRT pain response in patients with spinal metastases. The discrimination performance of the prediction model was good; the C index was 0.806 (95% CI: 0.721-0.891), and the corrected C-index was 0.754.

CONCLUSION

Some imaging and clinical features correlated with post-SBRT pain response in patients with spinal metastases. The model based on these characteristics has a good predictive value and can provide valuable information for clinical decision-making.

KEY POINTS

• SBRT can accurately irradiate spinal metastases with ablative doses. • Predicting the post-SBRT pain response has important clinical implications. • The prediction models established based on clinical and MRI features have good performance.

Systemic treatment with or without ablative therapies in oligometastatic breast cancer: A single institution analysis of patient outcomes

PURPOSE

Local ablative treatment (LAT) is increasingly combined with systemic therapy in oligometastatic breast cancer (OMBC), without a high-level evidence to support this strategy. We evaluated the addition of LAT to systemic treatment in terms of progression-free survival (PFS) and overall survival (OS). Secondary endpoints were local control (LC) and toxicity. We sought to identify prognostic factors associated with longer OS and PFS.

METHODS AND MATERIALS

We identified consecutive patients treated between 2014 and 2018 for synchronous or metachronous OMBC (defined as ≤ 5 metastases). LAT included stereotactic body radiation therapy (SBRT) and volumetric modulated arc therapy (VMAT), surgery, cryotherapy and percutaneous radiofrequency ablation (PRA). PFS and OS were calculated, and Cox regression models analyzed for potential predictors of survival.

RESULTS

One hundred two patients were included (no-LAT, n = 62; LAT, n = 40). Sixty-four metastases received LAT. Median follow-up was 50.4 months (95% CI [44.4; 53.4]). One patient experienced grade 3 toxicity in the LAT group. Five-year PFS and OS were 34.75% (95% CI [24.42-45.26]) and 63.21% (95% CI [50.69-73.37]) respectively. Patients receiving both LAT and systemic therapy had longer PFS and OS than those with no-LAT ([HR 0.39, p = 0.002]) and ([HR 0.31, p = 0.01]). The use of LAT, HER2-positive status and hormone-receptor positivity were associated with longer PFS and OS whereas liver metastases led to worse PFS.

CONCLUSIONS

LAT was associated with improved outcomes in OMBC when added to systemic treatment, without significantly increasing toxicity. The prognostic factors identified to extend PFS and OS may help guide clinicians in selecting patients for LAT.

Accelerated Hypofractionated Radiotherapy for Centrally Located Lung Tumours Not Suitable for Stereotactic Body Radiotherapy or Chemoradiotherapy

AIMS

Accelerated hypofractionated radiotherapy is used at our institution for non-small cell lung cancer (NSCLC) patients not eligible for stereotactic body radiotherapy or chemoradiotherapy. The purpose of this study was to report clinical outcomes of delivering 60 Gy in 15 fractions for these patients.

MATERIALS AND METHODS

All NSCLC patients who received 60 Gy in 15 fractions were reviewed. Outcomes of interest were local failure, regional failure, distant progression, overall survival and treatment-associated toxicities.

RESULTS

In total, 111 patients were included. The median age was 78.8 years and most tumours were adenocarcinoma (n = 55, 49.6%). Sixty-five patients (58.6%) were N0. The cumulative incidence of local failure at 12 and 24 months in the N0 cohort was 5.2% and 14.2%, respectively, compared with 11.5% and 14.8% for N+ patients. Tumour size >35 mm predicted for local failure (hazard ratio 2.706, 95% confidence interval 1.002-7.307, P = 0.0494). Distant progression at 12 and 24 months in N0 patients was 13.7% and 24.3% compared with 24.6% and 33.5% in N+ patients. In N0 patients, larger tumour size was associated with increased risk of distant progression. The median overall survival was 38.1 months in N0 patients versus 31.7 months in N+ patients. The most common toxicity was radiation pneumonitis (n = 6, 6.4%). The incidence of any grade 3 toxicity was 10.3% at ≥1 year. There were no deaths or hospitalisations attributed to treatment.

CONCLUSIONS

Accelerated hypofractionated radiotherapy is well tolerated and resulted in favourable clinical outcomes in various stages of NSCLC patients.

Two-institution results of Stereotactic Body Radiation Therapy (SBRT) for treating adrenal gland metastases from liver cancer

OBJECTIVE

Stereotactic Body Radiation Therapy (SBRT) has been found beneficial for adrenal gland metastases (AGMs) with a high local control rate and low toxicity. The role of SBRT for AGMs in patients with liver cancer has not been well-discussed before. We, therefore, report our two-institution experience to further elaborate on the feasibility and effectiveness of SBRT in the treatment of AGMs from liver cancer.

METHODS

A total of 23 liver cancer patients (19 males, 4 females) with 24 AGMs treated by SBRT from July 2006 to April 2021 were retrospectively included in this study. Toxicity was assessed based on clinical adverse events using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The effectiveness was assessed based on local control (LC), progression-free survival (PFS), and overall survival (OS), which were calculated using the Kaplan-Meier method. Univariate analyses were compared by log-rank test. The relevant covariates were evaluated using Cox proportional hazards models.

RESULTS

The median dose was 40 Gy in 5 fractions, with the corresponding median biological effective dose (BED10, α/β = 10 Gy) of 72 Gy. The median overall follow-up time was 15.4 months (range: 4.2-70.6 months). The complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD) rates were 25.0%, 20.8%, 33.3%, and 20.8%, respectively. All 6 patients with AGMs accompanying symptoms had varying degrees of alleviation after SBRT. The 0.5-, 1-year and 2-year LC rates were 87.5%, 77.8%, and 77.8%, respectively. The 0.5-, 1-year and 2-year OS rates were 95.5%, 66.8%, and 41.1%, respectively. The treatments were all tolerated with only one patient reporting a grade-3 hepatic injury. The univariate analysis concluded that only gross tumor volume (GTV) < 34.5 ml (p = 0.039) was associated with a favorable LC rate. After multivariate analysis, favorable predictors correlated with OS were GTV < 34.5 ml (p = 0.043), systemic therapy (p = 0.017), and without additional organ metastasis after SBRT (p = 0.009).

CONCLUSION

Our results suggest that SBRT is a safe and effective technique to treat AGM from liver cancer, especially for small GTV (< 34.5ml). Moreover, the small metastatic lesion volume, fewer metastatic lesions, and intervention of systemic therapy are more likely to improve OS.

Stereotactic body radiation therapy in the treatment of cancer patients with oligometastatic disease: a real world study

PURPOSE

Stereotactic body radiation therapy (SBRT) is a treatment modality with curative intent for oligometastatic cancer patients, commonly defined by a low-burden metastatic disease with 1-5 systemic metastases. Better knowledge of the clinical profile and prognostic factors in oligometastatic cancer patients could help to improve the selection of candidates who may obtain most benefits from SBRT. The objective of this study was to describe the clinical data and outcome in term of overall survival (OS) of patients with oligometastatic disease treated with SBRT over a 6-year period.

METHODS

From 2013 to 2018, 284 solid tumor cancer patients with 1-5 oligometastases underwent SBRT at a large university-affiliated oncological center in Barcelona, Spain. Variables related to the patient profile, tumor, oligometastatic disease, and treatment were evaluated.

RESULTS

A total of 327 metastatic tumors were treated with SBRT. In 65.5% of cases, metachronous tumors were diagnosed at least 1 year after diagnosis of the primary tumor. The median age of the patients was 73.9 years and 66.5% were males. The median follow-up was 37.5 months. The most common primary tumors were lung and colorectal cancer, with lung and bone as the most commonly treated metastatic sites. Ninety-three percent of patients showed a Karnofsky score (KPS) between 80 and 100. Adenocarcinoma was the most common histological type. The median overall survival was 53.4 months, with 1-, 2- and 5-year survival rates of 90.5%, 73.9% and 43.4%, respectively. Overall survival rates of breast (67.6 months, 95% CI 56.4-78.9), urological (63.3 months, 95% CI 55.8-70.8), and colorectal (50.8 months, 95% CI 44.2-57.4) tumors were higher as compared with other malignancies (20 months, 95% CI 11.2-28.8 months) (p < 0.001). Patients with Karnofsky score (KPS) of 90 and 100 showed a significantly better survival than those with impaired performance status (p = 0.001).

CONCLUSION

SBRT appears to be well tolerated and safe approach in oligometastatic patients. Patients with good performance status and with primary breast, urological and colorectal cancer have higher OS compared with other malignancies. More studies are necessary to evaluate the prognostic factors in oligometastatic disease (OMD) in order to select patients who could benefit more from this therapeutic approach.

Stereotactic radiotherapy of nodal oligometastases from prostate cancer: a prisma-compliant systematic review

Androgen deprivation therapy (ADT) is the standard treatment of metastatic prostate cancer (PCa). However, metastases-directed therapies can delay the initiation or switch of systemic treatments and allow local control (LC) and prolonged progression-free survival (PFS), particularly in patients with lymph nodes (LN) oligometastases. We performed a systematic review on stereotactic body radiotherapy (SBRT) in this setting. Papers reporting LC and/or PFS were selected. Data on ADT-free survival, overall survival, and toxicity were also collected from the selected studies. Fifteen studies were eligible (414 patients), 14 of them were retrospective analyses. A high heterogeneity was observed in terms of patient selection and treatment. In one study SBRT was delivered as a single 20 Gy fraction, while in the others the median total dose ranged between 24 and 40 Gy delivered in 3-6 fractions. LC and PFS were reported in 15 and 12 papers, respectively. LC was reported as a crude percentage in 13 studies, with 100% rate in seven and 63.2-98.0% in six reports. Five studies reported actuarial LC (2-year LC: 70.0-100%). PFS was reported as a crude rate in 11 studies (range 27.3-68.8%). Actuarial 2-year PFS was reported in four studies (range 30.0-50.0%). SBRT tolerability was excellent, with only two patients with grade 3 acute toxicity and two patients with grade 3 late toxicity. SBRT for LN oligorecurrences from PCa in safe and provides optimal LC. However, the long-term effect on PFS and OS is still unclear as well as which patients are the best candidate for this approach.

Multidisciplinary Treatment of Liver Metastases from Intracranial SFTs/HPCs: A Report of Three Consecutive Cases

In the 2016 WHO classification of tumors of the central nervous system, hemangiopericytomas (HPCs) and solitary fibrous tumors (SFTs) were integrated into a new entity (SFT/HPC). Metastases to bone, liver, lung, and abdominal cavity are of concern. Only 37 cases of patients with liver metastases due to intracranial SFTs/HPCs have been reported. Herein, we present our experience in the management of patients with liver metastases from intracranial SFTs/HCPs. All consecutive patients who were treated for liver metastases from intracranial SFTs/HPCs from January 2014 to December 2020 were enrolled. Overall, three patients were treated for liver metastasis from SFTs/HPCs with curative intent. Two patients with bilobar metastases at presentation required surgical resection, transarterial embolization, stereotactic radiofrequency ablation (SRFA) and systemic therapy. One patient with a singular right liver lobe metastasis was treated with SRFA alone. This patient shows no evidence of liver metastases 39 months following diagnosis. Of the two patients with bilobar disease, one died 89 months following diagnosis, while one is still alive 73 months following diagnosis. Long-term survival can be achieved using a multimodal treatment concept, including surgery, loco-regional and systemic therapies. Referral to a specialized tertiary cancer center and comprehensive long-term follow-up examinations are essential.

Evaluation of treatment results of stereotactic body radiotherapy for spinal metastases: A single center experience

Aim: To assess oncological outcomes and adverse events of patients receiving single or multi-fraction stereotactic body radiotherapy (SBRT) for spine metastases. Material and Method: Patients with any pathologically proven solid tumor histology who had SBRT to the spine for recurrent or metastatic disease between the years 2010 and 2021 at our department were identified from institutional database. Patient, tumor and treatment characteristics, and follow-up medical records were retrospectively reviewed. Local control (LC) and overall survival (OS) rates were calculated, and adverse events were evaluated. Results: A total of 47 patients were treated to 50 spine metastases. Median age was 53 years for all patients. Histologies included breast cancer (45%), non-small cell lung cancer (NSCLC; 21%), prostate cancer (15%) and other types (19%). Median follow-up was 16 months for all patients. Of 47 patients, six (13%) developed local failure and 15 (32%) died without local failure. One and two-year actuarial LC rates were 90.1% and 83.6%, respectively. One and two-year OS rates were 75.1% and 62.7%, respectively. Twenty-two (47%) patients had pain before SBRT. Fifteen (68%) of them had complete or partial pain response at 3 months after SBRT. Vertebral compression fracture, which was grade 1 in severity according to the Common Terminology Criteria for Adverse Events (CTCAE [v.4.03]), was observed in only one (2%) patient and it occurred 46 months after SBRT. No cases of treatment-related radiation myelopathy or any≥grade 3 RT induced acute or late toxicities occurred. Conclusion: This study supports that SBRT to the spine results in high LC without any significant toxicity. The results of ongoing phase 3 trials will highlight whether this high LC benefit reflects to survival in oligometastatic disease.