NSCLC - solitary brain met; ?management of thoracic burden?

[BobbyHeenan]

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Looking for further input, as I've struggled with these cases in the past....

I've had different variations on this, but looking for what people do in these cases. Let's say you have a fit patient with T4 (small mediastinal invasion)N0M1 squamous cell of lung with a brain met. Asymptomatic from chest disease. Symptomatic from met. Met is being managed with surgery followed by radiosurgery (or in a very small met managed with SRS)...

How do you manage the chest? Chemo (full dose) --> restaging ..> radiation? Or do you do concurrent chemoXRT then adjuvant IO/chemo?

I've had good luck with either way in some cases, but at the same time I've done these chemo/XRT concurrent then the next scan has new distant mets and I'm thinking I should have pushed for full dose systemic therapy first instead. Then in other cases I"ve had patients get too sick from their chemo and not much response and wishing maybe we'd gone first with chemo-XRT concurrent.

Any input is appreciated.

 

[thecarbonionangle]

I think both approaches are reasonable. Hopefully one day we will have molecular data to guide some of these decisions. The patients who likely benefit from immediate radiation to the chest are on the oligomet paradigm, good biology, less likely to develop widely disseminated bony/visceral disease. Benefits of chemo first approach is allowing biology to “declare” itself and then choose the patients with good response to follow with chemoxrt/IO.

 

[scarbrtj]

I don't fault anyone for treating the chest like the patient is M0. Although in practice we don't get to do it that often because the other docs don't let us lay hands on the newly-diagnosed M1s. But the solitary brain met M1b patient is unique; can have very measurable 5y survival probabilities. When 5y survival in M1 solitary brain met NSCLC has been reported it's almost always been with some sort of "aggressive" (hate that word) local chest approach up front and early. I don't think you can predict who will be the "mets out" vs "doesn't met out" patients, nor is it easy to predict who will/won't do well with upfront high dose chemo only. So in general, in high PS patients, when I get a say, I try to be "aggressive" in the chest and treat as Stage III, or II, or rarely I (the T1N0M1b solitary brain met patient does happen... they are probably the longest lived M1b NSCLC patients). At the same time I'm doing that try to send for craniotomy or do SRS in the head. No whole brain.

 

[BobbyHeenan]

I don't fault anyone for treating the chest like the patient is M0. Although in practice we don't get to do it that often because the other docs don't let us lay hands on the newly-diagnosed M1s. But the solitary brain met M1b patient is unique; can have very measurable 5y survival probabilities. When 5y survival in M1 solitary brain met NSCLC has been reported it's almost always been with some sort of "aggressive" (hate that word) local chest approach up front and early. I don't think you can predict who will be the "mets out" vs "doesn't met out" patients, nor is it easy to predict who will/won't do well with upfront high dose chemo only. So in general, in high PS patients, when I get a say, I try to be "aggressive" in the chest and treat as Stage III, or II, or rarely I (the T1N0M1b solitary brain met patient does happen... they are probably the longest lived M1b NSCLC patients). At the same time I'm doing that try to send for craniotomy or do SRS in the head. No whole brain.

Thanks.

Yes, fortunately for whatever reason we've had a run on these cases and med onc is on board for "aggressive" thoracic treatment, so I usually see these patients up front.

We're all just sitting around at thoracic tumor board and no one can agree about chemo-->xrt or concurrent. Everyone agrees to give thoracic radiation, but how to sequence is always debated.

Definitely agree on the brain management. My particular recent case had a 4 cm brain met, so this went for GTR. I plan to treat the operative bed.

 

[Neuronix]

I don't know any data that indicates one way or another. Both seem reasonable. We've been doing chemo followed by consolidation RT to full dose assuming response to chemo.

 

[seper]

I've always felt that some sort of chemo or immunotherapy supersedes radiation due to the presence of micrometastatic disease.
It's a very common situation so chances are we'll get good data, eventually.

 

[BobbyHeenan]

I've always felt that some sort of chemo or immunotherapy supersedes radiation due to the presence of micrometastatic disease.
It's a very common situation so chances are we'll get good data, eventually.

This is my thinking as well, but as you know we get imprinted with anecdotes so hearing others takes has been helpful.

 

[medgator]

I think nccn endorsees srs to the met and standard 6-7 weeks of chemo rt which is what we do.

They would likely benefit from adjuvant durva but it would not be an on label usage so our med oncs don't give it

 

[Mandelin Rain]

I've had a couple handfuls of single brain met patients live 3-5+ years with "aggressive" thoracic treatment. Is that just tumor biology? Probably. But it makes me feel better about behaving aggressively upfront.

 

[CptCrunch]

It depends on the med onc that sees them, but we've mostly been treating the thoracic disease with concurrent chemoRT to 60-66 Gy then immunotherapy.

 

[medgator]

It depends on the med onc that sees them, but we've mostly been treating the thoracic disease with concurrent chemoRT to 60-66 Gy then immunotherapy.

I've wondered about the immunotherapy. Not sure why pembro wouldn't get paid for in adjuvant setting for any stage IV pt

 

[FrostyHammer]

Based on the most recent thoughts and protocols, I'd give immunotherapy provided the PDL1 is not 0, then restage, and provided no progression, consolidation chest RT. Dose has been debated here before but my two cents are for 45/15.

 

[Palex80]

Our treatment algorithm calls for solitary (or few) brain mets and adrenal mets in NSCLC that we will treat the NSCLC according to the locoregional stage as if the met was never there. The met will be treated either before or after completion of the chest treatment (adrenal mets are always treated after, but a brain met may be treated before if it's big or symptomatic). We will of course "check" a bit more often during treatment to rule out any further disease progression at distant sites, which will eliminate the curative intent of such an approach.

 

[BobbyHeenan]

I think nccn endorsees srs to the met and standard 6-7 weeks of chemo rt which is what we do.

They would likely benefit from adjuvant durva but it would not be an on label usage so our med oncs don't give it

Yes, NCCN gives both options and doesn't seem to endorse either one.

You can do systemic therapy, restage, then treat the chest; or just go straight to chemo-XRT.

Either way I agree I think (esp if PDL1+) some form of IO should be included. If giving concurrent chemo-XRT in my experience the stage IV patients went on adjuvant keytruda (rather than durvalumab), but otherwise was like PACIFIC with a swap of the immunotherapy on the back end.

 

[CptCrunch]

I've wondered about the immunotherapy. Not sure why pembro wouldn't get paid for in adjuvant setting for any stage IV pt

Yes, from what I've observed they've been able to get pembro approved.

 

[medgator]

Based on the most recent thoughts and protocols, I'd give immunotherapy provided the PDL1 is not 0, then restage, and provided no progression, consolidation chest RT. Dose has been debated here before but my two cents are for 45/15.

I like 45/15 or 50/20 in my poorer PS patients

 

[evilbooyaa]

Anything for the thoracic disease is fine IMO, whether you do chemoRT vs 45/15 or other hypofractionated RT alone regimens, and whether to do it after or prior to systemic therapy.

In this situation I would favor surgical resection with SRS (either pre-op or post-op) especially if easily accessible, to maximize local control for the brain met. For a solitary brain met patient. Some would argue Resection + WBRT based on trial data but I wouldn't want to put this person through that personally.

 

[OTN]

Brain: Surgical resection --> postop cavity SRS vs definitive SRS, depending on location
Thorax: SBRT (maybe 10-fraction, modified Dutch regimen if close to esophagus)
Systemic: Immunotherapy post-thoracic SBRT if indicated based on molecular analysis.

I treat NSCLC aggressively if disease burden is limited, and I've seen incredible long-term survival with this strategy. Saw a patient this week in follow-up this week, now at 8 years out (!!) after being diagnosed and treated for NSCLC with a solitary brain met. I've treated her brain a few times over that time period and her lung for oligometastatic progression. NED now.

 

[BobbyHeenan]

Brain: Surgical resection --> postop cavity SRS vs definitive SRS, depending on location
Thorax: SBRT (maybe 10-fraction, modified Dutch regimen if close to esophagus)
Systemic: Immunotherapy post-thoracic SBRT if indicated based on molecular analysis.

I treat NSCLC aggressively if disease burden is limited, and I've seen incredible long-term survival with this strategy. Saw a patient this week in follow-up this week, now at 8 years out (!!) after being diagnosed and treated for NSCLC with a solitary brain met. I've treated her brain a few times over that time period and her lung for oligometastatic progression. NED now.

This one case is too big for SBRT and has mediastinal invasion, but I've definitely done SBRT for the rare T1/2N0M1 patient...and as scrabtj mentions above, I suspect those series of prolonged survival patients are skewed by this cohort, becuase I too have had some really long term survivors with SRS to brain, then SBRT/chemo (or in mordern era chemo/IO) for systemic disease.

I've also seen the T3's shrink down to SBRT targets after systemic therapy, so I've gone that route too.

 

[PhotonBomb]

I've always felt that some sort of chemo or immunotherapy supersedes radiation due to the presence of micrometastatic disease.
It's a very common situation so chances are we'll get good data, eventually.

agree.

I think the most important thing in these patients is immunotherapy so any approach that precludes IO does not seem like the best approach