Efficacy and Safety of Metastasis Directed Stereotactic Radiotherapy in NSCLC Patients Progressing Under Targeted- or Immunotherapy.

Abstract

BackgroundMetastasis directed treatment (MDT) is increasingly performed with the attempt to improve outcome in non-small cell lung cancer (NSCLC) patients receiving targeted- or immunotherapy (TT/IT). This study aimed to assess the safety and efficacy of metastasis directed stereotactic radiotherapy (SRT) concurrent to TT/IT in NSCLC patients.MethodsA retrospective multicenter cohort of stage IV NSCLC patients treated with TT/IT and concurrent (≤30 days) MDT was established. 56% and 44% of patients were treated for oligoprogressive disease (OPD) or polyprogressive disease (PPD) under TT/IT, polyprogressive respectively. Survival was analyzed using Kaplan-Meier and log rank testing. Toxicity was scored using CTCAE v4.03 criteria. Predictive factors for overall survival (OS), progression free survival (PFS) and time to therapy switch (TTS) were analyzed with uni- and multivariate analysis.ResultsMDT of 192 lesions in 108 patients was performed between 07/2009 and 05/2018. Concurrent TT/IT consisted of EGFR/ALK-inhibitors (60%), immune checkpoint inhibitors (31%), VEGF-antibodies (8%) and PARP-inhibitors (1%). 2y-OS was 51% for OPD and 25% for PPD. After 1 year, 58% of OPD and 39% of PPD patients remained on the same TT/IT. Second progression after MDT was oligometastatic (≤5 lesions) in 59% of patients. Severe acute and late toxicity was observed in 5.5% and 1.9% of patients. In multivariate analysis, OS was influenced by the clinical metastatic status (p=0.002, HR 2.03, 95% CI 1.30-3.17). PFS was better in patients receiving their first line of systemic treatment (p=0.033, HR 1.7, 95% CI 1.05-2.77) and with only one metastases-affected organ (p=0.023, HR 2.04, 95% CI 1.10-3.79). TTS was 6 months longer in patients with one metastases-affected organ (p=0.031, HR 2.53, 95% CI 1.09-5.89). Death was never therapy-related.ConclusionsMetastases-directed SRT in NSCLC patients can be safely performed concurrent to TT/IT with a low risk of severe toxicity. To find the ideal sequence of the available multidisciplinary treatment options for NSCLC and determine what patients will benefit most, a further evaluated in a broader context within prospective clinical trials is needed continuation of TT/IT beyond progression combined with MDT for progressive lesions appears promising but requires prospective evaluation.Trial registrationretrospectively registered

18F FDG PET/CT and Novel Molecular Imaging for Directing Immunotherapy in Cancer

“…Reporting of mixed response and multi-disciplinary assessment is thus increasingly important, with studies suggesting concomitant administration of localised therapies, e.g. stereotactic radiotherapy, ablative therapies or surgery, may successfully treat isolated progressive lesion(s) and improve patient survival [40,41].…”