Local ablative therapy in oncogenic-driven oligometastatic non-small cell lung cancer: present and ongoing strategies—a narrative review

Abstract

Oligometastatic (OM) disease is defined by a low metastatic tumor spread. OM non-small cell lung cancer (NSCLC) treatment aims to improve the patient's prognosis and quality of life, in an attemptto-cure objective. Oncogenic-driven metastatic NSCLC accounts for about 20-25% of NSCLCs, with an ever-increasing number of potentially druggable molecular alterations. Due to specific targeted therapy, the care and prognosis of mutated NSCLC is quite different from non-oncogenic-driven NSCLC. However, OM-NSCLC treatment guidelines do not specifically discuss oncogenic-driven OM-NSCLC patients.We conducted a narrative review regarding retrospective and prospective studies published from inception to May 2020 dealing with oncogenic-driven OM-NSCLC in order to: (I) describe the specific patterns of metastatic spread of oncogenic-driven NSCLC (i.e., bone and pleural tropism in EGFR mutated NSCLC and serous and brain metastases in ALK NSCLC); (II) review the low level of current evidence for local ablative therapy (LAT) strategies in patients with oncogenic-driven OM-NSCLC, focusing on the benefit/ risk of tyrosine kinase inhibitors (TKI) and LATs combination and (III) present strategies to help to select the best candidate for an attempt-to-cure approach. Finally, the optimal strategy may be to introduce a targeted therapy, then treat all tumor sites with LAT, and finally continue TKI for unknown prolonged duration in an attempt to prolong progression free survival in most patients, improve overall survival for some patients, and potentially lead to a cancer cure for a few patients.

Image‐guided thermal ablation for patients with epidermal growth factor receptor‐mutant nonsmall cell lung cancer

“…Hence, it is particularly important to distinguish between different resistance patterns to guide treatment. Basing on the growth rate and number of growing tumor lesions, the progression of disease during TKI treatment can be generally divided into the following three patterns 32 : (1) intracentral (intracranial) disease progression, (2) development of one or a few distant metastatic sites while the patient remains asymptomatic, or symptomatic disease progression, and (3) systemic metastatic. The first two patterns fall into the general term of oligoprogressive disease.…”

“…Typically, the definition of oligoprogressive disease refers to the presence of fewer than five discrete metastatic sites and not exceeding two organs. Local therapy with continued EGFR-TKIs has been demonstrated to be effective in treating patients with oligoprogressive disease and helped prolong their PFS and OS [32][33][34]. Oligoprogression after targeted drug therapy can also be divided into intracentral and noncentral (extracranial) based on the presence or absence of the central system.…”