What is the recommended management approach for patients with oligometastatic non-small cell lung cancer (NSCLC)?

From the Guidelines

The recommended management approach for patients with oligometastatic non-small cell lung cancer (NSCLC) involves a multimodal strategy combining systemic therapy with local ablative treatments, with local radical therapy (LRT) in addition to systemic treatment recommended to increase progression-free survival (PFS) and overall survival (OS) 1.

Key Considerations

• Patients with oligometastatic NSCLC should be staged with FDG PET/CT and brain imaging to accurately assess the extent of disease 1.
• The choice of LRT, including radiation therapy (RT) or surgery, should be discussed in a multidisciplinary team (MTB) setting, as both options are safe and effective 1.
• Solitary lesions in the contralateral lung should be considered as synchronous second primary tumors and treated with curative-intent therapy, if possible 1.

Systemic Therapy

• Systemic therapy should be tailored to the individual patient's disease characteristics, including the presence of actionable mutations (e.g., EGFR, ALK, ROS1) or PD-L1 status 1.
• Immunotherapy (e.g., pembrolizumab, nivolumab, atezolizumab) with or without chemotherapy (e.g., platinum-based doublets) may be considered based on PD-L1 status and histology.

Local Ablative Treatments

• Stereotactic body radiation therapy (SBRT) delivering high-dose radiation to metastatic lesions may be used to achieve local control 1.
• Surgical resection or other ablative techniques like radiofrequency ablation may be considered for selected patients with oligometastatic disease.

Rationale

• The aggressive approach of combining systemic and local therapies is justified by evidence showing improved PFS and OS in oligometastatic NSCLC patients compared to systemic therapy alone 1.
• Oligometastatic disease represents an intermediate biological state between localized and widely metastatic cancer, where eliminating all visible disease sites may significantly impact disease progression and potentially lead to long-term disease control or even cure in select patients.

From the Research

Management Approach for Oligometastatic NSCLC

The management of oligometastatic non-small cell lung cancer (NSCLC) involves a multidisciplinary approach, considering the patient's overall health, tumor biology, and treatment goals. Key aspects of management include:

• Local therapy, such as radiation or surgery, to control the primary tumor and metastases
• Systemic therapy, including chemotherapy, targeted therapy, or immunotherapy, to address microscopic disease
• Integration of local and systemic therapies, with consideration of sequencing and timing

Local Therapy Options

Local therapy options for oligometastatic NSCLC include:

• Radiation therapy, such as stereotactic body radiotherapy (SBRT) or stereotactic ablative radiotherapy (SABR)
• Surgery, which may be considered for patients with limited metastases and favorable tumor biology
• Other ablative methods, such as radiofrequency ablation or cryoablation, which may be used in select cases

Recommendations for Local Therapy

Recommendations for local therapy in oligometastatic NSCLC include:

• Definitive local therapy should be considered for patients with 5 or fewer distinct metastatic sites 2
• Radiation and surgery are the primary definitive local therapy modalities recommended for use in the management of patients with oligometastatic disease 2
• Sequencing recommendations should be provided for systemic and local therapy integration 2

Systemic Therapy Considerations

Systemic therapy considerations for oligometastatic NSCLC include:

• Chemotherapy, targeted therapy, or immunotherapy may be used to address microscopic disease
• The choice of systemic therapy should be based on tumor biology, patient performance status, and other factors
• Integration of systemic therapy with local therapy should be considered, with attention to sequencing and timing 3, 4

Future Directions

Future directions for the management of oligometastatic NSCLC include:

• Further research on the role of local therapy in improving overall survival and progression-free survival
• Investigation of molecular or microRNA profiles to improve treatment selection and patient outcomes 3, 5
• Evaluation of the efficacy of combination therapies, such as immunotherapy and SABR, in oligometastatic NSCLC 6