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Chmura S , Winter KA , Robinson C , Pisansky TM , Borges V , Al-Hallaq H , Matuszak M , Park SS , Yi S , Hasan Y , Bazan J , Wong P , Yoon HA , Horton J , Gan G , Milano MT , Sigurdson ER , Moughan J , Salama JK , White J
Evaluation of Safety of Stereotactic Body Radiotherapy for the Treatment of Patients With Multiple Metastases: Findings From the NRG-BR001 Phase 1 Trial
JAMA Oncol. 2021 Jun 1;7(6) :845-852
PMID: 33885704    PMCID: PMC8063134    URL: https://www.ncbi.nlm.nih.gov/pubmed/33885704
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IMPORTANCE: Stereotactic body radiotherapy (SBRT) for oligometastases is hypothesized to improve survival and is increasingly used. Little evidence supports its safe use to treat patients with multiple metastases. OBJECTIVE: To establish safety of SBRT dose schedules in patients with 3 to 4 metastases or 2 metastases in close proximity to each other. DESIGN, SETTING, AND PARTICIPANTS: This phase 1 trial opened on August 4, 2014, and closed to accrual on March 20, 2018. Metastases to 7 anatomic locations were included: bone/osseous (BO), spinal/paraspinal (SP), peripheral lung (PL), central lung (CL), abdominal-pelvic (AP), mediastinal/cervical lymph node (MC), and liver (L). Six patients could be enrolled per anatomic site. The setting was a consortium of North American academic and community practice cancer centers participating in NRG Oncology trials. Patients with breast, prostate, or non-small cell lung cancer with 3 to 4 metastases or 2 metastases in close proximity (≤5 cm) amenable to SBRT were eligible for this phase 1 study. Statistical analyses were performed from December 31, 2017, to September 19, 2019. INTERVENTIONS: The starting dose was 50 Gy in 5 fractions (CL, MC), 45 Gy in 3 fractions (PL, AP, L), and 30 Gy in 3 fractions (BO, SP). MAIN OUTCOMES AND MEASURES: The primary end point was dose-limiting toxicity (DLT) defined by the Common Terminology Criteria for Adverse Events, version 4.0, as specific adverse events (AEs) of grades 3 to 5 (definite or probable per the protocol DLT definition) related to SBRT within 180 days of treatment. Dose levels were considered safe if DLTs were observed in no more than 1 of 6 patients per location; otherwise, the dose at that location would be de-escalated. RESULTS: A total of 42 patients enrolled, 39 were eligible, and 35 (mean [SD] age, 63.1 [14.2] years; 20 men [57.1%]; 30 White patients [85.7%]) were evaluable for DLT. Twelve patients (34.3%) had breast cancer, 10 (28.6%) had non-small cell lung cancer, and 13 (37.1%) had prostate cancer; there was a median of 3 metastases treated per patient. Median survival was not reached. No protocol-defined DLTs were observed. When examining all AEs, 8 instances of grade 3 AEs, most likely related to protocol therapy, occurred approximately 125 to 556 days from SBRT initiation in 7 patients. CONCLUSIONS AND RELEVANCE: This phase 1 trial demonstrated the safety of SBRT for patients with 3 to 4 metastases or 2 metastases in close proximity. There were no treatment-related deaths. Late grade 3 AEs demonstrate the need for extended follow-up in long-surviving patients with oligometastatic disease. Treatment with SBRT for multiple metastases has been expanded into multiple ongoing randomized phase 2/3 National Cancer Institute-sponsored trials (NRG-BR002, NRG-LU002). TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02206334.
2374-2445 Chmura, Steve Winter, Kathryn A Robinson, Clifford Pisansky, Thomas M Borges, Virginia Al-Hallaq, Hania Matuszak, Martha Park, Sean S Yi, Sun Hasan, Yasmin Bazan, Jose Wong, Philip Yoon, Harold A Horton, Janet Gan, Gregory Milano, Michael T Sigurdson, Elin Ruth Moughan, Jennifer Salama, Joseph K White, Julia U10 CA180822/CA/NCI NIH HHS/United States U10 CA180868/CA/NCI NIH HHS/United States U24 CA180803/CA/NCI NIH HHS/United States UG1 CA189867/CA/NCI NIH HHS/United States Journal Article United States JAMA Oncol. 2021 Apr 22. doi: 10.1001/jamaoncol.2021.0687.