Treatment of Oligometastatic Non-Small Cell Lung Cancer

Publication Date: April 25, 2023
Last Updated: April 27, 2023

Patient/disease characteristics for definitive systemic and local therapies

For patients with oligometastatic NSCLC, treatment decisions should be made using a patient-centered multidisciplinary team approach. (Strong, Expert Opinion)
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For patients with oligometastatic NSCLC, the integration of definitive local therapy is only recommended if technically feasible and clinically safe for all disease sites. (Strong, Moderate)
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For patients with oligometastatic NSCLC, a discussion of definitive local therapy as a component of multimodality treatment approach is recommended irrespective of presence of activating driver mutations. (Strong, Moderate)
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For oligometastatic NSCLC, definitive local therapy is recommended only for patients having up to 5 distant metastases, diagnosed with appropriate imaging. (Strong, Moderate)
Implementation remark:
Despite some prospective trials including patients with up to 5 extracranial metastases, most patients enrolled had 1-2 treated oligometastatic lesions, which should be factored into decision-making.
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For patients with synchronous oligometastatic NSCLC, definitive local therapy to all cancer sites in addition to standard of care systemic therapy is conditionally recommended. (Conditional, Moderate)
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For patients with metachronous oligorecurrent NSCLC, definitive local therapy to all oligorecurrent cancer sites in addition to standard of care systemic therapy is conditionally recommended. (Conditional, Low)
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For patients with induced oligopersistent NSCLC, definitive local therapy to all persistent cancer sites in addition to standard of care systemic therapy is conditionally recommended. (Conditional, Low)
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For patients with induced oligoprogressive NSCLC receiving systemic therapy, definitive local therapy to all progressive cancer sites is conditionally recommended while continuing the current line of systemic therapy. (Conditional, Expert Opinion)
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Local treatment modality selection criteria for oligometastatic NSCLC

For patients with oligometastatic NSCLC, a patient-centered multidisciplinary discussion of the most appropriate local treatment strategy of RT and/or surgery either alone or in combination are recommended. (Strong, Moderate)
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For patients with oligometastatic NSCLC, RT and/or surgery are recommended as definitive local treatment modalities for the locoregional primary and all oligometastases. (Strong, Moderate)
The quality of evidence for RT and surgery as definitive local therapy differs, with implications for multidisciplinary decision-making as described in the narrative text.
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For patients with oligometastatic NSCLC, highly conformal RT approaches and minimally invasive techniques for surgery are recommended to minimize morbidity. (Strong, Moderate)
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For patients with oligometastatic NSCLC, deciding between RT and surgery as the definitive local treatment modality should:
  • Favor RT when multiple organ systems are being treated
  • Favor RT when the clinical prioritization is to minimize breaks from systemic therapy
  • Favor surgery when large tissue sampling is needed for molecular testing, to guide systemic therapy.
(Strong, Expert Opinion)
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Sequencing and timing of treatment therapies for oligometastatic NSCLC

For patients with synchronous oligometastatic NSCLC, ≥3 months of systemic therapy is recommended prior to definitive local therapy. (Strong, Moderate)
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For patients with oligometastatic NSCLC, up-front definitive local treatment for symptomatic lesions should be prioritized. (Strong, Low)
Implementation remark:
Symptomatic disease sites (eg, brain metastases) are treated with up-front definitive local therapy.
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For patients with synchronous oligometastatic NSCLC, the temporary pause of systemic therapy during definitive local therapy versus concomitant treatment should be discussed using a multidisciplinary team approach. (Strong, Expert Opinion)
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For patients with synchronous oligometastatic NSCLC, maintenance systemic therapy is conditionally recommended after completion of definitive local therapy. (Conditional, Low)
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RT dose-fractionation regimens, planning, and delivery techniques for oligometastatic NSCLC

For patients with oligometastatic NSCLC, appropriate staging with FDG PET, cranial MRI, and MRI in cases of suspect or proven spine or liver metastases are recommended. (Strong, High)
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For patients with oligometastatic NSCLC, individual assessment of respiratory motion for targets in the lungs and upper abdomen using 4-D CT, fluoroscopy, or MR-cine with appropriate motion compensation is recommended. (Strong, High)
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For patients with oligometastatic NSCLC, highly conformal RT using inverse dose planning, appropriate motion management strategies and image-guided RT delivery are recommended. (Strong, Moderate)
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For patients with oligometastatic NSCLC, a risk adapted approach using stereotactic RT (preferred), hypofractionated RT, or alternatively definitive chemoradiation based on the location and burden of disease is recommended. (Strong, High)
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For patients with oligometastatic NSCLC, definitive local RT should use doses and fractionations which achieve durable local control. (Strong, High)
Implementation remarks:
  • Durable local control defined as minimum 85% local control at 2 years
  • Higher BED10 (typically >75 Gy) with SBRT alone is associated with optimal local control.
  • Lower BED10 (50-75 Gy range) is associated with acceptable local control, typically in the setting of combination systemic therapy and SBRT.
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Indications for additional local therapy on disease progression (after definitive local therapy approach)

In patients previously treated with definitive local therapy for oligometastatic NSCLC who subsequently develop widespread disease progression or recurrence, systemic therapy is recommended as the preferred treatment option. (Strong, Expert Opinion)
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In patients previously treated with definitive local therapy for oligometastatic NSCLC who subsequently develop repeat oligoprogression or recurrence, additional local therapy should be discussed using a multidisciplinary team approach. (Strong, Expert Opinion)
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In patients previously treated with definitive local therapy for oligometastatic NSCLC who subsequently develop repeat oligoprogression or recurrence, local therapy is conditionally recommended. (Conditional, Low)
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In patients previously treated with definitive local therapy for oligometastatic NSCLC who subsequently develop repeat oligoprogression or recurrence at sites previously treated with local therapy, re-treatment is conditionally recommended if systemic treatment options are limited, and local therapy can be delivered with toxicity acceptable to the multidisciplinary team and patient. (Conditional, Expert Opinion)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Treatment of Oligometastatic Non-Small Cell Lung Cancer

Authoring Organization

Publication Month/Year

April 25, 2023

Last Updated Month/Year

February 14, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

This joint guideline by the American Society for Radiation Oncology (ASTRO) and European Society for Radiotherapy and Oncology (ESTRO) was initiated to review evidence and provide recommendations regarding the use of local therapy in the management of extracranial oligometastatic non-small cell lung cancer (NSCLC). Local therapy is defined as the comprehensive treatment of all known cancer – primary tumor, regional nodal metastases, and metastases – with definitive intent.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Radiology services, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant, radiology technologist

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D002289 - Carcinoma, Non-Small-Cell Lung, D008175 - Lung Neoplasms

Keywords

non-small cell lung cancer, NSCLC, oligometastatic, oligometastatic non-small cell lung cancer, oligoprogression

Source Citation

Puneeth Iyengar MD, PhD , Sean All MD , Mark F. Berry MD , Thomas P. Boike MD , Lisa Bradfield BA , Anne-Marie C. Dingemans MD, PhD , Jill Feldman , Daniel R. Gomez MD , Paul J. Hesketh MD , Salma K. Jabbour MD , Melenda Jeter MD, MPH , Mirjana Josipovic PhD , Yolande Lievens MD, PhD , Fiona McDonald MD , Bradford A. Perez MD , Umberto Ricardi MD , Enrico Ruffini MD , Dirk De Ruysscher MD, PhD , Hina Saeed MD , Bryan J. Schneider MD , Suresh Senan MRCP, FRCR, PhD , Joachim Widder MD, PhD , Matthias Guckenberger MD , Treatment of Oligometastatic Non-Small Cell Lung Cancer: An ASTRO/ESTRO Clinical Practice Guideline, Practical Radiation Oncology (2023), doi: https://doi.org/10.1016/j.prro.2023.04.004

Methodology

Number of Source Documents
78
Literature Search Start Date
January 1, 2006
Literature Search End Date
February 1, 2022