Siva Shankar, Jones Gavin, Bressel Mathias, Shaw Mark, Chander Sarat, Chu Julie, Plumridge Nikki, Byrne Keelan, Kothari Gargi, Hardcastle Nicholas, Gaudreault Mathieu, Kron Tomas, Wheeler Greg, MacManus Michael, Hanna Gerard G, Ball David L, David Steven
Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Victoria, Australia.
Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts.
Int J Radiat Oncol Biol Phys. 2022 Dec 1;114(5):862-870. doi: 10.1016/j.ijrobp.2022.05.034. Epub 2022 Jun 22.
Medical operability is prognostic for survival after SABR in primary malignancies. This study investigated the prognostic significance of medical operability and total versus subtotal ablation of all oligometastatic disease sites.
Consecutive patients with 1 to 5 sites of active extracranial oligometastases had medical operability status and presence of subtotal versus total metastatic ablation recorded prospectively in an institutional database. We retrospectively compared overall survival (OS) and progression-free survival (PFS) for medically operable or inoperable patients and patients undergoing total or subtotal metastatic ablation. Secondary endpoints were patterns of failure, high-grade treatment toxic effects (Common Terminology Criteria for Adverse Events version 4.0), and freedom from systemic therapy. The threshold dose per fraction considered ablative was 8 Gy.
A total of 401 patients with 530 treated oligometastases were included, with a median follow-up of 3 years. Three hundred and two and 99 patients had metachronous and synchronous presentations of oligometastatic disease, respectively. Common histologies included prostate (24%), lung (18%), gastrointestinal (19%), and breast (11%). More than 90% of doses delivered were Biologically Effective Dose [BED≥60 Gy. Cumulative incidence at 5 years of local-only failure was 6%, local and distant 2%, and distant-only 58%. The 3- and 5-year OS [95% confidence intervals {CIs}] were 68% [62-73] and 54% [47-61], and PFS was 20% [15-25] and 14% [10-20]. The 3- and 5-year freedom from systemic therapy [95% CIs] were 40% [34-46] and 31% [24-37], respectively. Seventy-six patients were inoperable and 325 were operable. Operability status was not prognostic for OS (adjusted hazard ratio [HR], 1.0; 95% CI, 0.6-1.7; P = .9) or for PFS (adjusted HR, 1.1; 95% CI, 0.8-1.6; P = .5). Total metastatic ablation was prognostic for OS (adjusted HR, 0.8; 95% CI, 0.4-0.9; P = .032) and for PFS (adjusted HR, 0.6; 95% CI, 0.4-0.8; P = .003).
Medical operability was not prognostic in patients with oligometastatic disease treated with SABR. Total metastatic ablation was associated with superior OS and PFS compared with subtotal metastatic ablation. Our data support ablation of all sites of oligometastases wherever feasible.
在原发性恶性肿瘤的立体定向消融放疗（SABR）后，医疗可操作性对生存具有预后价值。本研究调查了医疗可操作性以及所有寡转移病灶的完全消融与次全消融的预后意义。
连续纳入1至5个部位有活动性颅外寡转移的患者，前瞻性地在机构数据库中记录其医疗可操作性状态以及是否进行了次全或完全转移性消融。我们回顾性比较了医疗上可操作或不可操作患者以及接受完全或次全转移性消融患者的总生存期（OS）和无进展生存期（PFS）。次要终点为失败模式、高级别治疗毒性反应（不良事件通用术语标准4.0版）以及无需全身治疗的情况。每分次被视为消融的阈值剂量为8 Gy。
共纳入401例有530处接受治疗的寡转移灶的患者，中位随访时间为3年。分别有302例和99例患者为异时性和同时性寡转移疾病表现。常见组织学类型包括前列腺（24%）、肺（18%）、胃肠道（19%）和乳腺（11%）。超过90%的给予剂量为生物等效剂量[BED≥60 Gy]。仅局部失败的5年累积发生率为6%，局部和远处均失败为2%，仅远处失败为58%。3年和5年总生存期[95%置信区间{CIs}]分别为68%[62 - 73]和54%[47 - 61]，无进展生存期为20%[15 - 25]和14%[10 - 20]。3年和5年无需全身治疗的情况[95% CIs]分别为40%[34 - 46]和31%[24 - 37]。76例患者不可操作，325例可操作。可操作性状态对总生存期（调整后风险比[HR]，1.0；95% CI，0.6 - 1.7；P = 0.9）或无进展生存期（调整后HR，1.1；95% CI，0.8 - 1.6；P = 0.5）无预后价值。完全转移性消融对总生存期（调整后HR，0.8；95% CI，0.4 - 0.9；P = 0.032）和无进展生存期（调整后HR，0.6；95% CI，0.4 - 0.8；P = 0.003）有预后价值。
在接受SABR治疗的寡转移疾病患者中，医疗可操作性无预后价值。与次全转移性消融相比，完全转移性消融与更好的总生存期和无进展生存期相关。我们的数据支持在可行的情况下对所有寡转移部位进行消融。
