Chapters Transcript Video Metastatic Disease: Panel Discussion and Case Studies Alright, I think we have a quick case to discuss here again. We're a little bit behind time, but I think we can, uh, go over the case while we're putting the case up. Um, how many in the room of the clinicians actually still believe in consolidated radiation and radiation for oligo progressive disease? So consolidated radiation, you still do it? Radiation for oligo progressive disease. We're still doing it it's so good to see that we're not data driven it's. I mean I don't know how many more negative studies we need to have to say. OK, Doctor Kumar, from where you're sitting actually here use the microphone, um, she's kind enough to provide us with another case. Can you hear me? Yeah, yeah, OK, so hospice is your patient. Um, so 66-year-old male presented with right-sided rib pain and a CT of the chest showed a right fourth rib destructive lesion and a left hilar mass, and you can see the left hilar mass. It's on the PET. Um, so EBIS and IR guided biopsy showed both sites had poorly differentiated non-small cell lung cancer, lymph nodes were negative, MRI brain negative, PET negative for other disease, uh, stages of T1CN1M1B. Um, so we got 4 cycles of carbapempem, and he had a good response with just the residual mass right there and the right 4th rib mass. And so he came to me, uh, and he got 60,000 and 15 fractions to both of those sites, and you can see the radiation plan here. It's pretty good, um. And so, uh, he went on to receive maintenance Pen Pen, but he did well, but then he developed some dysphagia and a CT showed an enlarging subcrial lymph node, and that was confirmed by PET. And so we treated him because this was a level 7 lymph node, we treated him with concurrent chemo rods. Um, I felt like doing it with 6000, 30 fractions with concurrent chemo would possibly mitigate some of the esophageal toxicity rather than doing 15 fractions. I was just worried because so much of the esophagus was involved, um, and so that's what we ended up doing. He did get esophagitis, but he's better now. OK. Um, so he did well. He did well for several months, uh, and then he developed a right supraclavicular mass. Um, the CT showed an enlarged right supraclavicular lymph node. He initially went on a study, a Nevo Ram study, um, but it continued to grow, um, and a PET showed that this was larger and hypermetabolic, and the IR guided biopsy confirmed, uh, the same disease, non-small cell with no driver mutations. And so we treated this with adaptive radiation, which I, I use, uh, sometimes in, uh, patients that have had a lot of prior radiation, um, or if it's close to the esophagus. Um, so we did 6000, 15 fractions. This dose in fractionation worked before. If it's not broke, don't fix it, so we did that and he's doing well. He's been on active surveillance. He hasn't been on any systemic therapy. He's doing well. He's, you know, 1 year and 10 months out. He doesn't have any major side effects. He fishes a lot. He's doing great. Corey, you sounded like you were suspicious. Yeah, you want the microphone. I've long argued that our um non-med on colleagues are the secret ingredient for long term survival in these patients. Uh, this is exactly what we would have done, uh, more or less, um, probably would have given some additional chemo each time you gave, uh, uh, radiation would have dropped the checkpoint inhibitor during the radiation because of the lessons we've learned now from Pacific 2 from, uh, uh, 5181. Uh, uh, all the studies where checkpoint inhibitors seem to for some reason interact negatively with, uh, definitive radiation. Um, I have patients like this. I mean, we had a, uh, study, uh, where we used a JAK inhibitor. I, I connect it with, uh, uh, Pembro and 50% or higher PDL1 expression. And we're seeing this pattern that I don't think I saw previously of often isolated oligoro progression or maybe two sites of oligoprogression. Uh, that will judiciously radiate. Uh, one gentleman had axillary nodes, retroperineal nodes, 3 nodes total, all individually radiated. We resumed his Pembroke, did fine for 2 years, then developed submental and, um, cervical nodes, treated him as if he had neck cancer, continued the Pembroke. Finally, after about 4.5, 5 years, we stopped the Pembroke, so he's an observation as well. He doesn't fish, but he does other things, so, um. Uh, you know, it's another era. I, I thinking back to the pre-IO era, I don't remember folks having these, uh, areas of sort of isolated either thoracic and nodal progression. Usually when they had progression it was everywhere. It was fulminant and it was, uh, unrelenting and it was, uh, you know, treatment, uh, uh, resistant. So, um, no, this is, uh, we're, we're doing this sometimes with ablations as well. If you run out of real estate that you can radiate, uh, we get the, uh, interventional radiologists involved. So I think creat creativity to some extent is secret to longevity. Sure, that thing. This one Is it on? I definitely agree with how the patient was treated and with what Corey said, but this is the space where If you're looking for a very high level of evidence, you need to be fishing a lot. So, so a lot of individualization is needed, and I think the more isolated the progression event or the residual tumor is, the more likely local therapy will be successful, and we're building on. Long history of isolated brain, adrenal metastasis, we always take a definitive approach in those, right? So extending some of that cautiously based on the promising but not definitive information we have is reasonable. But I think consolidation radi radiation is an option and not the standard of care. So I think for each and every patient you have to look at it, the, the is it the right, right match for that specific patient. Long disease free interval in isolated sites of progression makes a lot of sense. OK, thanks. I think I just want to add quickly, maybe with a quick joke here. Uh, when I was a fellow, one of our co-fellows was presenting a case and he said that it's a lung cancer patient with oligometastatic disease in the liver, oligometastatic disease in the adrenal gland, oligometastatic disease in the bone. Uh, uh, so I think let's have, uh, NRGU 002 defined their patients. Uh, so it was not truly oligome metastatic. I really like that point that earlier studies that included maybe truly liga metastatic cases, uh, showed a significant benefit. Uh, so, yeah, thank you. Yeah, thanks. Was there a comment or a question? Yeah, uh, uh, a question for, um, what's the working theory for the development of oligometastatic disease? Was it there from the beginning? Or is it from the uh less than well-treated primary? Go ahead, you can make a comment. You want me to comment? Oh boy. I have no idea. I mean, the presumption is that when Mets appear, they've probably been there right along. I, I guess the question is can metastasis metastasize, but my understanding and others correct me or weigh in differently. Is that anything that pops up was probably seeded a long time ago and it was suppressed. I mean the only way I can explain is that these are the, these are sites where specific clones are becoming resistant to whatever treatment you're using. Uh, so whatever treatment we were using was just scial, not, um, you know, getting rid of them, and then eventually they develop a mutation that allows them to grow and that's what you get these all like a metastatic, uh, presentations. We never lose an opportunity to biopsy sites, but by and large they're usually identical to the original tumor. Um, if they're wild type, they haven't developed new oncogenes. I mean, occasionally we'll find something that we didn't know about before, uh, but, uh, you don't have, it's not the, um, evolution you see with EGFR where you have the typical mechanisms of resistance. Uh, I have had two patients who had non-small cell, non-small cell, and then transformed to small cell, whether it's transformation or just a brand new tumor, but they're sort of following this, uh, uh, pattern of oligo oligo and then. Blossomed and you, you can't assume it's gonna be the same astrology. You really should, uh, biopsy responding now to atoposide platinum and of course checkpoint inhibitor. The patient never been without a checkpoint inhibitor. Um, in the interest of time, I think I'm gonna thank our speakers and our panelists. Thank you so much for your wonderful presentations and move on to the next stage. Created by Related Presenters Randi Cohen, MD, MS Director of Radiation Oncology, Fox Chase Cancer Center – East Norriton,Associate Professor, Department of Radiation Oncology, Fox Chase Cancer Center
