COMMENTARY

Managing Oligometastasis or Oligoprogression in Lung Cancer

Mark G. Kris, MD

Disclosures

March 07, 2019

This transcript was edited for clarity.

Hello. I'm Mark Kris from Memorial Sloan Kettering, continuing discussions on the growing need to develop our skills in multimodality therapy, and to think about doing it in the care of every person with lung cancer.

More and more, we have learned that there is virtually no patient who, in the course of an illness, receives only one modality now. We are always at least considering other modalities if not administering them. The other issue that is becoming plain is that for people who have a longer treatment course, we need to make many decisions, and each of those decision points requires that consideration for multimodality care.

I'm not saying that every patient will receive multimodality care. Many of them will still receive a single modality, but it should be the best choice for that patient based on a discussion among experts in their care, choosing what the best modality is going to be for them, and whether it will be one, two, three, or even more modalities. An issue that really brings us to a head is the growing acceptance and understanding of the presence of unique patient situations, either oligometastasis or oligoprogression.

Oligometastasis is a situation where, at the time of diagnosis, there are a finite number of metastatic sites in addition to the primary tumor. They can be different sites in the same organ or in different organs. Generally, most people [agree that] five or fewer sites of disease are potentially candidates for an oligometastatic approach. That means that in addition to systemic therapy, there is a consideration for a local therapy for each of the five lesions that you found. There is fairly good evidence, [including some randomized data], demonstrating that this can be useful for select patients.

A rare group of patients have these oligometastases. I think the most common patients that have been described are those with metastases to the brain, to other parts of the lungs, and also to the adrenal gland. There is good evidence that, in addition to systemic therapy, treating these other sites as a way of controlling all disease is a useful approach for a rare group of patients. This approach needs to be carefully selected and is not right for everybody. Generally, my rule of thumb is that we need to have some demonstration of control of the systemic disease before we go after each of the sites.

The second situation that comes up—oligoprogression—is slightly different. At some point during care of patients with multiple metastatic sites who have control of their disease by systemic therapy, such as chemotherapy, targeted therapy, or a checkpoint inhibitor, a single metastatic site or two adjacent sites exhibit evidence of progression while the rest of the cancer remains under control. In a growing number of patients, applying a local therapy to those single or nearby sites of progression leads to additional long-term benefit for that patient, generally resuming the systemic therapy after the local therapy is given.

We have seen this often with patients with EGFR-mutant cancers, and we see it more and more with patients on checkpoint inhibitors. I also urge that you, again, keep an open mind. It's very, very important to analyze the pathologic materials that you remove.

We recently had a case of oligoprogression in an EGFR-mutant case. At surgery, the patient had a small cell transformation that gave us a new direction [for therapy]. As it turned out, this particular patient was a candidate for both chemotherapy and radiation. It was a fit patient and both modalities made sense.

That result would not have been found on a blood test—you needed tissue. Obtaining the surgical specimen led to not only a surgery, which controlled the existing disease, but also information that contributed to a better systemic therapy. [Selected patients] represent a good example of the need for multimodality approaches for targeting oligometastases and oligoprogression.

Be very careful in evaluating these patients because it is not for everyone. It's probably for a small minority of patients, but it can make a huge difference for them. Make sure that there is systemic control of the majority of disease sites and that the sites that you choose for treatment of oligometastases or oligoprogression can be effectively managed by local therapy.

This brings new options to patients, but it requires more discussion with our multimodality teams. What is the best multimodality approach? Is it surgery? Is it radiation? If so, what kind of radiation? Is it an ablative procedure, cryoablation, or radiofrequency ablation? All of these are options for patients.

Multimodality care and multimodality teams bring more options and a better way of controlling cancer in our patients. You won't use this approach in all patients, but I urge you to at least consider it. When it feels right for that individual patient, make it happen.

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