Evaluation of Definitive Stereotactic Body Radiotherapy and Outcomes in Adults With Extracranial Oligometastasis
Authors: Ian Poon, Darby Erler, Roi Dagan, Kristin J. Redmond, Matthew Foote, Serena Badellino, Tithi Biswas, Alexander V. Louie, Young Lee, Eshetu G. Atenafu, Umberto Ricardi, Arjun Sahgal
Journal: JAMA Network Open (2020)

<h3>Importance</h3> The outcomes and factors that influence survival in patients with oligometastasis (OM) are not well understood and have not been well described in large-scale studies. <h3>Objective</h3> To evaluate overall progression-free survival (PFS), widespread progression (WSP) outcomes, and survival factors from a pooled data set of 1033 patients with OM treated with stereotactic body radiotherapy (SBRT). <h3>Design, Setting, and Participants</h3> Case series from January 1, 2008, to December 31, 2016. The dates of analysis were April 2019 to May 2020. The setting was multi-institutional tertiary care hospitals. Participants were consecutive patients with 5 or fewer extracranial OMs whose primary tumor was treated curatively. <h3>Exposure</h3> Definitive SBRT. <h3>Main Outcomes and Measures</h3> Overall survival (OS), progression-free survival, rate of WSP, patterns of failure, and factors altering OS. <h3>Results</h3> In the largest international OM case series to date (1033 participants) (mean age, 68.0 years [range, 18.0-94.3 years]; 601 [58.2%] men), 1416 SBRT courses were delivered to patients with 1 OM (596 [57.7%]), 2 OMs (245 [23.7%]), 3 OMs (105 [10.2%]), 4 OMs (55 [5.3%]), and 5 OMs (32 [3.1%]). The median follow-up was 24.1 months (range, 0.3-104.7 months), and the median OS was 44.2 months (95% CI, 39.2-48.8 months). The median PFS was 12.9 months (95% CI, 11.6-14.2 months), and the median time to WSP was 42.5 months (95% CI, 36.8-53.5 months). The OS rates were 84.1% (95% CI, 81.7%-86.2%) at 1 year, 56.7% (95% CI, 53.0%-60.2%) at 3 years, and 35.2% (95% CI, 30.1%-40.3%) at 5 years. The 3-year OS, PFS, and WSP rates were 56.7% (95% CI, 53.0%-60.2%), 23.0% (95% CI, 20.2%-25.9%), and 45.2% (95% CI, 41.4%-48.9%), respectively. The 5-year OS, PFS, and WSP rates were 35.2% (95% CI, 30.1%-40.3%), 14.8% (95% CI, 11.9%-17.9%), and 54.5% (95% CI, 49.8%-59.2%), respectively. At the time of first progression, 342 patients (33.1%) had recurrence of OM disease, and 230 patients (22.3%) underwent subsequent ablative therapies to all known metastatic sites. Multivariable analyses identified primary tumor type (hazard ratio [HR], 3.73; 95% CI, 1.75-7.94;<i>P</i> &lt; .001 for breast; 5.75; 95% CI, 2.88-11.46;<i>P</i> &lt; .001 for colorectal; 4.67; 95% CI, 2.12-10.31;<i>P</i> &lt; .001 for kidney; 10.61; 95% CI, 5.36-20.99;<i>P</i> &lt; .001 for lung; and 12.00; 95% CI, 6.06-23.76;<i>P</i> &lt; .001 for other [with prostate being the reference group]), metachronous OM presentation more than 24 months since initial diagnosis (HR, 0.63; 95% CI, 0.49-0.80;<i>P</i> &lt; .001), metastases confined to the lung only (HR, 0.58; 95% CI, 0.48-0.72;<i>P</i> &lt; .001), and nodal or soft-tissue metastases only (HR, 0.49; 95% CI, 0.26-0.90;<i>P</i> = .02) as survival factors. Sixty-six (6.4%) grade 3 or higher toxic effects were observed, including 1 (0.1%) grade 5 event. <h3>Conclusions and Relevance</h3> This study found favorable long-term OS and WSP rates associated with extracranial OM ablated with SBRT; however, modest PFS rates were observed. A substantial proportion of patients with OM developed progressive disease and were treated with local ablation. Factors that can inform clinical decision-making and clinical trial design include primary tumor type, a metachronous presentation more than 24 months since diagnosis, and the site of OM presentation.