Patient case: 52-year-old male with Lung cancer. Genetic variant: EML4-ALK Fusion transcript. Other conditions: Hypertension, Osteoarthritis.

Clinical trial: Maintenance Chemotherapy Versus Consolidative Stereotactic Body Radiation Therapy (SBRT) Plus Maintenance Chemotherapy for Stage IV Non-Small Cell Lung Cancer (NSCLC): A Randomized Phase II Trial

Summary: The core hypothesis to be tested is that the use of consolidative SBRT followed by maintenance chemotherapy in patients with less than or equal to 6 metastatic sites (primary + 5) will improve progression free survival (PFS) compared to maintenance chemotherapy alone.

Detailed description: This protocol is a randomized phase II trial of maintenance chemotherapy versus consolidative Stereotactic Body Radiation Therapy (SBRT) plus maintenance chemotherapy for patients with Stage IV non-small cell lung cancer (NSCLC).
  Prior to accrual on the trial, patients with Stage IV NSCLC will be treated with standard first-line chemotherapy. Patients who achieve a partial response or stable disease by imaging criteria with fewer than or equal to six sites of oligometastatic disease will be randomized to maintenance chemotherapy or consolidative SBRT to all sites of disease (followed by maintenance chemotherapy at the medical oncologist's discretion). Choices of first line and maintenance chemotherapy will be determined by the medical oncologist based on clinical appropriateness.

Eligibility: Inclusion Criteria:
  1. Patients must have biopsy proven metastatic NSCLC (Stage IV).
  2. Patients must have received first line chemotherapy, from 4-6 cycles, and achieved stable disease or a partial response.
  3. Patients receiving first-line erlotinib, gefitinib, or crizotinib for EGFR mutant-positive or EML4-ALK positive NSCLC will be excluded.
  4. Age ≥ 18 years
  5. Patients must have measurable disease at baseline.
  6. Patients can have up to only 6 discrete active extracranial lesions (≤3 in the liver and ≤3 in the lung) identified by PET scan and also seen on correlative plain film, CT scan, or MRI within 8 weeks prior to the initiation of SBRT.
  1. For patients who have received prior radiotherapy to the primary site in the lung, residual PET activity is difficult to interpret and will not be considered a site of active disease if the CT appearance is stable or improved over an interval of at least three months
  2. Patients who previously received radiotherapy to the primary site will be ineligible if there is CT evidence of disease progression within the past 3 months.
  3. Patients with previously un-irradiated primary sites will be potentially eligible, but special considerations apply.
  4. Up to 2 contiguous vertebral metastases will be considered a single site of disease.
  7. Patients must have a KPS >60
  8. AST, ALT & Alkaline phosphates must be ≤ 2.5X the upper limit of normal. Total bilirubin must be within the limit of normal.
  9. Patients should have adequate bone marrow function as defined by peripheral granulocyte count of ≥1500/mm³.
  10. Patients should have adequate renal function (serum creatinine ≤1.5 times the ULN).
  11. Females of childbearing potential should have a negative pregnancy test.
  12. Patients who would be receiving SBRT for lung tumors who are known or suspected by the treating radiation oncologist to have compromised lung function must have a documented forced expiratory volume in 1 second (FEV1) ≥ 1L.
  13. Patients must provide verbal and written informed consent to participate in the study.
  14. Total bilirubin: within normal institutional limits
  Exclusion Criteria:
  1. Patients who previously received radiotherapy to the primary site with CT evidence of disease progression at the primary site within 3 months following the initial radiotherapy.
  2. Patients with either untreated brain metastases or brain metastases treated within the past three months are ineligible
  3. Patients with serious, uncontrolled, concurrent infection(s).
  4. Significant weight loss (>10%) in the prior 3 months.
  5. Because the tolerance dose of SBRT to the gastrointestinal tract is not established, patients with metastatic disease invading the esophagus, stomach, intestines, or mesenteric lymph nodes will not be eligible.
  6. Patients with cutaneous metastasis of NSCLC.
  7. Treatment for other carcinomas within the last five years, except cured non-melanoma skin and treated in-situ cancers.
  8. Patients with more than 6 discrete extra-cranial lesions.
  9. Participation in any investigational drug study within 4 weeks preceding the start of study treatment.
  10. Unwillingness to participate or inability to comply with the protocol for the duration of the study.
  11. Patients who are pregnant. Patients with reproductive capability will need to use adequate contraception during the time of participation in the study

Relevance to patient case: not relevant