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Wahid Hanna



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    PD01 - Poster Discussion Session (ID 4)

    • Event: NACLC 2019
    • Type: Poster Discussion Session
    • Track:
    • Presentations: 1
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      PD01.14 - Stereotactic Modulating Radiation Therapy (SMRT) for Oligo-Metastatic Non-Small Cell Lung Cancer (ID 65)

      15:45 - 16:45  |  Author(s): Wahid Hanna

      • Abstract

      Background:
      Patients with oligometastatic non-small cell lung cancer (PD1>50%) are now treated with a PD1 inhibitor as single agent therapy. Patients with (PD1<50%) are now treated with platinum doublet chemotherapy concurrent with a PD1 inhibitor. Stereotactic body radiotherapy (SBRT) has improved outcomes in oligometastatic non-small cell lung cancer with two recent randomized clinical trials showing improvement in progression free survival and overall survival. As a result, immunotherapy combined with SBRT or chemo-immuno-SBRT is emerging as a new standard of care for select patients with oligometastatic non-small cell lung cancer. High doses of stereotactic ablative radiotherapy (SABR) are safe and effective and are commonly used to treat lung cancer. At moderate doses, radiation can increase interferon expression resulting in an increase in Th1 T-Helper cell differentiation with a resulting increase in CD8+ anti-tumor cytotoxic T- Lymphocytes (CTL). We propose the term stereotactic modulating radiation therapy (SMRT) to describe the moderate doses of SBRT. We hypothesize that moderate dose SMRT therapy will improve outcomes in oligometastatic lung cancer compared to higher dose SABR therapy. We have initiated a phase II clinical trial to test SABR and SMRT radiotherapy in combination with immunotherapy or chemo-immunotherapy.


      Method:
      Oligometastatic NSCLCa (< 5 sites of disease) are treated with three cycles of systemic therapy. Tumors with PDL1>50% receive immunotherapy. Patients with PDL1<50% receive platinum doublet chemotherapy with immunotherapy. After three cycles patients are evaluated for response and randomized to SMRT or SABR. SMRT cohort 6-8Gy x 3-5 = 24-30Gy. SABR cohort 10-24G x 1-5 = 24-60Gy. Patients with tumor > 5cm or residual adenopathy after cycle 3 receive hypofractionated radiation (2.5Gy x 20 = 50Gy) concurrent with cycle 4 and then randomize to SMRT or SABR. All patients receive maintenance therapy.


      Results:
      The primary end point is toxicity of immunotherapy or chemo-immunotherapy with SMRT or SABR by CTCAE v 4.03. Secondary endpoints are response rate by RECIST v 1.1 and iRECIST, patient reported quality or life, DFS, and OS. Exploratory endpoints investigate the immune response and cytokine levels in tumor microenvironment and peripheral blood prior to systemic therapy, after cycle 3, and after SBRT.


      Conclusion:
      The widespread adoption of immunotherapy and chemo-immunotherapy makes it crucial to understand the interaction between radiation therapy and PD1 inhibitors. This study investigates high dose stereotactic ablative radiotherapy (SABR) compared to moderate dose stereotactic modulating radiotherapy (SMRT) in an effort to identify patients most likely to benefit from this combination.