Management of oligometastatic non-small cell lung cancer patients: Current controversies and future directions

Abstract

Oligometastatic non-small cell lung cancer (NSCLC) describes an intermediate stage of NSCLC between localized and widely-disseminated disease. This stage of NSCLC is characterized by a limited number of metastases and a more indolent tumor biology. Currently, the management of oligometastatic NSCLC involves radical treatment (radiotherapy or surgery) that targets the metastatic lesions and the primary tumor to achieve disease control. This approach offers the potential to achieve prolonged survival in patients who, in the past, would have only received palliative measures. The optimal therapeutic strategies for the different scenarios of oligometastatic disease (intracranial vs extracranial disease, synchronous vs metachronous) remain undefined. Given the lack of head-to-head studies comparing radiotherapy to surgery in these patients, the decision to apply surgery or radiotherapy (with or without systemic treatment) must be based on prognostic factors that allow us to classify patients. This classification will allow us to select the most appropriate therapeutic strategy on an individualized basis. In the future, the molecular or microRNA profiles will likely improve the treatment selection process. The objective of the present article is to review the most relevant scientific evidence on the management of patients with oligometastatic NSCLC, focusing on the role of radiotherapy and surgery. We also discuss areas of controversy and future directions.

Keywords: Non-small cell lung cancer, Metastasectomy, Oligometastases, Stereotactic ablative radiotherapy, Stereotactic body radiation therapy, Radiosurgery

Core tip: In recent years, numerous studies, including two randomized phase II trials, have demonstrated that local treatment, either radiotherapy or surgery, of the primary tumor and metastases improves progression-free survival and overall survival in patients who present with oligometastatic non-small cell lung cancer at diagnosis and in those who respond to the initial systemic therapy. As we await the results of ongoing randomized phase III trials, the main international clinical guidelines recommend a multimodal strategy to manage this subgroup of oligometastatic patients. Current guidelines recommend systemic therapy combined with local treatment of the metastases and, if applicable, the primary tumor.