Radiation Oncology 2025 Updates-Recording

Video Transcription

Video Summary

The webinar, moderated by Dr. Luis Reyes, reviewed evolving strategies combining radiation with systemic therapy in non–small cell lung cancer (NSCLC), plus consolidation approaches for metastatic disease and tumor treating fields (TTF) for brain metastases.

Dr. Jeffrey Bradley summarized the established benefit of consolidation durvalumab after chemoradiation in unresectable stage III NSCLC (PACIFIC), and noted similar benefit in limited-stage small cell lung cancer with post-chemoradiation durvalumab (ADRIATIC). However, several recent trials adding immunotherapy <em>concurrently</em> with chemoradiation or SBRT were negative (e.g., PACIFIC-2, NRG LU005, KEYNOTE-867) and showed higher early toxicity, especially pneumonitis. He highlighted “estimated dose to immune cells” (EDIC)—irradiating large blood volumes may impair outcomes—and discussed emerging concepts such as sparing lymphatics/nodes, using sub-ablative SBRT (e.g., 8 Gy ×3) to prime immune response, and neoadjuvant chemo-immunotherapy followed by radiation to residual disease.

Dr. Puneet Inigar reviewed the rationale for local consolidative therapy (LCT) in oligometastatic NSCLC: most failures occur at original gross disease sites even in the immunotherapy era. Earlier phase II trials suggested PFS/OS gains, but the modern immunotherapy-era NRG-LU002 trial did not improve PFS/OS with LCT, despite better local control and delayed new lesions, likely due to increased pneumonitis leading to reduced maintenance immunotherapy. He emphasized better biologic/predictive selection is needed; NORTHSTAR (EGFR-mutant on osimertinib with consolidation) showed benefit, suggesting genomics may guide LCT value.

Dr. Erin (Eric) Leeper presented the phase III METIS trial: after SRS for 1–2 NSCLC brain metastases, adding TTF delayed intracranial and distant brain progression without worsening quality of life; benefit appeared stronger with concurrent immune checkpoint inhibitors. The Q&A discussed future trial designs, toxicity mitigation (e.g., nodal avoidance, dose strategies), and potential roles for proton therapy to reduce toxicity and preserve immunotherapy delivery.

Keywords

non–small cell lung cancer (NSCLC)

chemoradiation

consolidation durvalumab

PACIFIC trial

concurrent immunotherapy with radiation

radiation pneumonitis toxicity

estimated dose to immune cells (EDIC)

local consolidative therapy (LCT) oligometastatic NSCLC

NRG-LU002 trial

tumor treating fields (TTF) brain metastases METIS trial