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Review
. 2021 Feb 1;109(2):352-364.
doi: 10.1016/j.ijrobp.2020.08.025. Epub 2020 Aug 13.

Use of Multi-Site Radiation Therapy for Systemic Disease Control

Affiliations
Review

Use of Multi-Site Radiation Therapy for Systemic Disease Control

Roshal R Patel et al. Int J Radiat Oncol Biol Phys. .

Abstract

Metastatic cancer is a heterogeneous entity, some of which could benefit from local consolidative radiation therapy (RT). Although randomized evidence is growing in support of using RT for oligometastatic disease, a highly active area of investigation relates to whether RT could benefit patients with polymetastatic disease. This article highlights the preclinical and clinical rationale for using RT for polymetastatic disease, proposes an exploratory framework for selecting patients best suited for these types of treatments, and briefly reviews potential challenges. The goal of this hypothesis-generating review is to address personalized multimodality systemic treatment for patients with metastatic cancer. The rationale for using high-dose RT is primarily for local control and immune activation in either oligometastatic or polymetastatic disease. However, the primary application of low-dose RT is to activate distinct antitumor immune pathways and modulate the tumor stroma in efforts to better facilitate T cell infiltration. We explore clinical cases involving high- and low-dose RT to demonstrate the potential efficacy of such treatment. We then group patients by extent of disease burden to implement high- and/or low-dose RT. Patients with low-volume disease may receive high-dose RT to all sites as part of an oligometastatic paradigm. Subjects with high-volume disease (for whom standard of care remains palliative RT only) could be treated with a combination of high-dose RT to a few sites for immune activation, while receiving low-dose RT to several remaining lesions to enhance systemic responses from high-dose RT and immunotherapy. We further discuss how emerging but speculative concepts such as immune function may be integrated into this approach and examine therapies currently under investigation that may help address immune deficiencies. The review concludes by addressing challenges in using RT for polymetastatic disease, such as concerns about treatment planning workflows, treatment times, dose constraints for multiple-isocenter treatments, and economic considerations.

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Conflict of interest statement

Conflict of interest:

All other authors declare no relevant conflicts of interest.

Figures

Figure 1.
Figure 1.
Average single-cell polyfunctional activated topology principal component analysis (PAT-PCA). Polyfunctionality is defined as 2+ cytokines secreted per cell. PSI, or Polyfunctional Strength Index, is defined as the percentage of polyfunctional cells in the sample, multiplied by the intensities of the secreted cytokines.
Figure 2.
Figure 2.
Low-dose RT to a 5.5 cm peritoneal lesion. A) CT with contrast before RT. B) Low-dose RT treatment plan (axial). C) CT with contrast after RT.
Figure 3.
Figure 3.
Low-dose RT to nearly the whole liver. A) CT with contrast before RT. B) Low-dose RT treatment plan (coronal). C) CT with contrast after RT.
Figure 4.
Figure 4.
Low-dose RT to previously irradiated neck lymph nodes. A) Initial prophylactic neck irradiation treatment plan. B) PET-CT before RT. C) Low-dose RT treatment plan (axial). D) PET-CT after RT. Red arrow identifies site of cervical lymph node.
Figure 5.
Figure 5.
Schematic illustration of a hypothesis-generating treatment approach in patients with metastatic disease, incorporating concepts of disease burden and immune function as well as therapeutic strategies under investigation.

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