For patients with oligometastatic disease, new and emerging data continue to support the benefits of aggressive ablative therapy to known metastases; however, questions remain regarding the definition and characterization of oligometastatic disease and the role of different treatment modalities.
Plenary 2: Multidisciplinary Approach to the Oligo Paradigm featured a series of state-of-the-art presentations covering the latest research findings and clinical recommendations for the treatment of oligometastatic lung cancer. The live presentation took place on Sunday, August 7, during WCLC 2022. A recording of the session is available on-demand.
ILCN editorial group member Anne-Marie Dingemans, MD, PhD, professor of Thoracic Oncology at Erasmus MC University Medical Center in the Netherlands, opened the presentations with a discussion of the need for a uniform definition of oligometastatic disease.
Dr. Dingemans was a member of a writing group convened in 2019 by the European Organization for Research and Treatment of Cancer (EORTC) to draft a consensus definition for oligometastatic non-small cell lung cancer (NSCLC).
“To define oligo-metastases, we recommended up to five metastases in no more than three organs as the definition,” she said. “This definition is relevant for patients for whom radical treatment is technically feasible with acceptable toxicity, and for whom treatment may modify the course of the disease leading to long-term disease control.”
Matthias Guckenberger, MD, chair of the Department of Radiation Oncology at University Hospital Zürich in Switzerland, further discussed the definition and classification of oligometastatic disease, noting that more evidence and deeper characterization is needed.
“Counting metastases on a PET scan, for example, is not sufficient for including a patient into a clinical trial,” Dr. Guckenberger said. “You need to have a closer look at their medical history, such as the local and systemic treatments to which the patient has been exposed, the prior response pattern, and the progressive pattern at the time you see these metastases on PET imaging.”
John Heymach, MD, PhD, professor and chair of Thoracic and Head and Neck Medical Oncology at MD Anderson Cancer Center in Houston, Texas, discussed the need for a multivariate predictor to determine which patients might benefit from local consolidative therapy (LCT).
“Baseline oligometastatic versus polymetastatic, however it’s defined, does not predict all the patients who are going to benefit from LCT—some with polymetastatic disease will benefit and some with oligometastatic disease won’t,” he said. “Possible determinants could include not only baseline number of metastases but also response to systemic therapy, post-induction tumor volume, percent consolidation, and metastatic propensity. Ultimately, I believe a multivariate predictor will increase the number of patients who can benefit from LCT.”
Looking at the role of systemic therapy in de novo oligometastatic disease, Delphine Antoni, MD, of the ICANS Institut de Cancérologie Strasbourg, France, said that the response to first-line systemic therapy is a key prognostic factor and that ongoing trials will help to establish optimal combinations of local treatment with novel systemic agents.
Mara Antonoff, MD, associate professor of Thoracic and Cardiovascular Surgery at MD Anderson Cancer Center in Houston, Texas, followed with a discussion of the role of surgery in local consolidation for oligometastatic disease.
“There is clearly a potential opportunity for more aggressive local therapy, given the limited disease burden of the oligometastatic state and the distinct tumor biology,” Dr. Antonoff said. “Pulmonary resection for metastatic lung cancer has emerged as a new frontier for thoracic surgery and it provides us with opportunities to help people with advanced disease with surgical intervention.”
Daniel Gomez, MD, director of Thoracic Radiation Oncology at Memorial Sloan Kettering Cancer Center in New York, discussed new and emerging findings demonstrating the role of radiation as ablative therapy in oligometastatic disease.
“Radiation therapy has been shown to be feasible and safe in the de novo oligometastatic, induced oligometastatic, and oligoprogressive states,” Dr. Gomez said. “However, areas in need of exploration are appropriate timing, when to intercede in the oligoresidual disease state, and the effect of radiating the primary lesion alone.”
The appropriate selection of patients for radiation therapy versus other modalities of treatment, he emphasized, should be made in the multidisciplinary setting where input can be regarding the best approach can be maximized.
Looking at interventional radiology (IR) for oligometastatic lung cancer, Mitiadis Krokidis, MD, PhD, associate professor at the Medical School of the National Kapodistrian University of Athens in Greece, said that ablation for lung metastatic disease has been shown to be as effective as surgery in terms of overall survival, the main advantage being repeatability.
Eric Lim, MD, MSc, FRCS, Consultant Thoracic Surgeon at the Royal Brompton Hospital and Professor of Thoracic Surgery at the National Heart and Lung Institute of Imperial College London, discussed multimodality management of induced oligometastatic disease and the need for more clinical trials in this area.
“We need to continue to push for even better outcomes in favorable patient subsets and fully utilize all the treatment modalities to the benefit of our patients,” Dr. Lim said. “At the same time, we must guard patient safety but also take into account quality of life and treatment costs. Now more than ever, we need to work together to evaluate new multimodality combinations so our patients, regardless of stage, can live longer and better.”
In the final presentation of the session, Lavinia Magee, a nurse consultant in thoracic oncology at Royal Papworth Hospital in Cambridge, UK, discussed the patient perspective and the importance of shared decision-making.
“When confronted with their own mortality, it can be very difficult for patients to make decisions,” she said. “The two key things are communication—not only with the patients but among the multidisciplinary teams as well—and time. Patients must be given time to make choices about their treatment.”