Local Ablative Therapy for Oligometastatic Non-small Cell Lung Cancer with Actionable Mutations: A Consensus from Hong Kong

Survey Instructions

Thank you for taking the time to participate in this survey. Our goal is to assess the level of agreement among consensus panel members regarding the revised recommendations developed in March 2025. These recommendations are based on the latest literature and the expert opinions expressed during the recent voting meeting you were unable to attend.

In this survey, you will find the revised statements for your review. We kindly invite you to share your insights and indicate your level of agreement with each statement. Your feedback is invaluable to our process and will greatly contribute to our collective efforts.

Please indicate your level of agreement according to the following guidance:

1. Accept completely: The statement is fully endorsed without any concerns. It is considered highly relevant, evidence-based, and applicable to the target population.
2. Accept with some reservation: The statement is generally supported, but there are minor concerns or conditions that need to be addressed. Experts may see some aspects that require further clarification or adaptation.
3. Accept with major reservation: While there is some acceptance of the statement, significant concerns exist that could impact its implementation. Major revisions may be necessary for it to be deemed suitable.
4. Reject with reservation: The statement is largely rejected, but some elements might be useful if modified. Experts recognise some value but believe the overall approach is flawed.
5. Reject completely: The statement is entirely dismissed. It is viewed as irrelevant, lacking evidence, or inappropriate for the target population. No elements are considered acceptable.
6. Abstain: The expert does not feel they have the appropriate expertise to vote on this statement.

We greatly appreciate your expertise and look forward to your valuable input.

Statement 1

Oligometastatic disease is defined as the presence of up to 5 extra-cranial metastases, which can be de novo (at the time of primary diagnosis) or induced (after systemic treatments).

Statement 2

Oligoresidual disease is defined as the presence of up to 5 residual extra-cranial metastases that remained active after a brief duration of systemic treatments, typically at least 3 months, in the context of other metastatic sites under effective control.

Statement 3

Oligoprogressive disease is defined as the presence of up to 5 extra-cranial metastases that are progressing during systemic treatments.

Statement 4

Comprehensive imaging including at least contrast CT whole body (preferably 18FDG PET-CT) and brain imaging (preferably MRI) should be used define oligometastatic status, and exclude the presence of malignant pleural effusion, pericardial effusion, peritoneal and leptomeningeal metastases.

Statement 5

Local ablative therapy should be considered for patients with good performance status (i.e. ECOG PS ≤2).

Statement 6

Local ablative therapy should be considered if all disease sites, including primary sites if present, are feasible for LAT.

Statement 7

Potential prognosticators of survival including initial disease load, number of active disease sites or response of systemic treatment should also be considered when offering LAT.

Statement 8

Patient selection and choice of local ablative therapy should preferably be discussed in the MDT setting.

Statement 9

SBRT or hypofractionated IGRT are the recommended RT modality in oligometastatic disease.

Statement 10

For oligometastatic NSCLC with actionable mutations, LAT may be considered prior to, or as consolidation after, or upon progression with targeted therapy.

Statement 11

For patients with polymetastatic disease, LAT may be considered if patients have oligoresidual or oligoprogression after initiation of targeted therapy.

Statement 12

The optimal modality of LAT should preferably be a joint decision made in a multidisciplinary meeting, considering the patient’s preference.

Statement 13

For oligometastatic NSCLC with an actionable mutation, a brief pause of targeted therapy before and after SBRT should be considered, depending on location.

Statement 14

For patients with oligometastatic NSCLC, if a brief pause is not feasible, the concurrent use of EGFR-TKI and thoracic radiotherapy should be with caution and be individualised.

Statement 15

For oligometastatic NSCLC with an actionable mutation, a brief pause of targeted therapy before and after other LAT (e.g., surgery, RFA) will depend on type of TKI and clinician’s judgment.

Statement 16

For patients with oligometastatic NSCLC with an actionable mutation who have received SBRT in conjunction with targeted therapy, the same systemic treatment should be continued.

Statement 17

The optimal dose and fractionation are undefined and should be individualised based on the location and characteristics of the oligometastases.

Statement 18

A high biologically effective dose translates into excellent local control in early-stage NSCLC, but it can be challenging in oligometastatic setting, e.g., multiple lesions in the same organ or close to vulnerable organs-at-risk (OARs). A fine balance between local control, technical feasibility and patients' tolerability is required.

Statement 19

An OAR-prioritisation approach is recommended to avoid high grade toxicities.

Statement 20

Minimising treatment volume should be attempted whenever possible. This includes efforts in minimising margins by tight and reproducible immobilisation, tumour motion control, intrafraction motion monitoring, image guidance and online correction of patients positioning etc.

Statement 21

Tumour motion management (breath hold, 4D-CT, gating or tumour tracking) should be performed in treating targets whose position is potentially affected by respiration.

Statement 22

For patients with NSCLC harbouring actionable mutation presenting with 4 or fewer brain metastases treated with targeted agents with uncertain CNS efficacy, local ablative therapy in addition to standard-of-care systemic therapies should be considered upfront.

Statement 23

For patients with NSCLC harbouring actionable mutation presenting with 4 or fewer asymptomatic to mildly symptomatic brain metastases, if targeted agents with good CNS efficacy can be offered upfront, local ablative therapy may be delayed.

Statement 24

For patients with oligoprogressive brain metastases having been treated with local ablative therapy, the same systemic therapy may be continued if extracranial control remains stable.

Statement 25

Building a prediction nomogram can help identify the most suitable subjects for LAT and maximise the therapeutic window.