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TREATMENT OF OLIGOMETASTATIC NON-SMALL CELL LUNG CANCER

The oligometastatic disease is a stage between a localized and widespread metastatic disease that continues to be a controversial subject, both in terms of description and therapeutic options. It is characterized by a modest number of metastases with indolent biology, generally one to five. Increasingly effective diagnostic technologies, including positron emission tomography-computed tomography (PET-CT) and magnetic resonance imaging of the brain (MRI of the brain), is leading to an increase in the number of newly diagnosed patients at this stage. 69 Lib Oncol. 2022 ; 50(Suppl 1):1–83 In lung cancer, the oligometastatic disease affects 20 to 50 percent of patients. The brain, contralateral lung, lymph nodes, liver, and adrenal gland are the most common sites of metastasis. Patients with oligometastatic disease have a better long-term prognosis than those with extensive metastatic disease, and they benefit from systemic therapy combined with local therapy (surgery/radiotherapy) at the metastasis site and, in certain situations, at the initial tumor site. The classification of oligometastatic disease is based on the disease’s initial appearance and the use of systemic treatment. The phrase synchronous or de novo refers to the appearance of a small number of metastases at the time of diagnosis, as opposed to the occurrence of new or metachronous metastases (oligo-recurrence) following final treatment of stable locoregional disease. Patients with disseminated disease at the time of diagnosis who partially respond to systemic treatment (disease stabilization) except for the development of a small number of metastases that progress (oligoprogression) or persist (oligoresistance) after systemic treatment are referred to as oligoprogression or oligoresistance. Patients who receive targeted therapy frequently have oligoprogression and oligoresistance. Surgical resection has generally been the primary therapeutic choice for oligometastatic patients, with about 55% of patients receiving surgery. However, in recent years, the use of less invasive ablative procedures, such as stereotactic radiosurgery (SRS) for brain metastases and stereotactic body radiation treatment (SBRT) for various extracranial locations, has expanded dramatically. Which treatment option to choose (surgery or radiotherapy) depends on several factors: age, performance status, comorbidities, time of metastasis in relation to the primary tumor (metachronous metastases have a better prognosis), number of lesions (prognosis is better in patients with single metastases), localization of metastases (prognosis is better for metastases located in the brain, lungs and adrenal glands), size of primary tumor and involvement of mediastinal lymph nodes (better prognosis in stage N0 disease). Numerous studies, including two randomized phase II trials, have shown that local treatment, such as radiotherapy or surgery for the primary tumor and metastasis, improves progression-free survival (PFS) and overall survival (OS) in patients with non-small cell (NSCLC) oligometastatic lung cancer at the time of diagnosis and in those who respond to initial systemic therapy. Immunotherapy and targeted therapy, which are both more efficient and less toxic, have changed the therapeutic paradigm for patients with oligometastatic disease. Local therapy for progressive metastases is similarly linked to a longer PFS and OS in these patients, with the option of continuing the same treatment. Major worldwide clinical recommendations urge a multimodal strategy in the treatment of individuals with oligometastatic disease while awaiting the outcomes of randomized phase III trials. According to current standards, systemic therapy should be used in conjunction with local treatment of metastases and, if necessary, the primary tumor. Treatment options (surgery vs. radiotherapy), with or without systemic treatment must be based on personalized prognostic considerations and considered as part of a multidisciplinary strategy. The availability of molecular or microRNA profiles in the future will aid in the selection of patients who will benefit the most.

oligometastatic disease, radiotherapy, surgery, systemic treatment, multimodal strategy

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