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Metastases to the liver are common, and stereotactic body radiation therapy (SBRT) is a recognized tool for ablation of liver metastases. Colorectal cancers commonly metastasize to the liver, and long-term survival is possible after metastasectomy. However, many patients are not candidates for surgical resection, which opened the door to early studies investigating noninvasive techniques such as liver SBRT. Multiple prospective trials have demonstrated excellent local control with this approach coupled with an excellent safety record. The oligometastatic disease state is now appreciated across many histologies, and treatment of liver metastases as a component of oligometastatic disease management has emerged as a rational and relevant strategy. To this end, recent randomized studies in oligometastatic non-small-cell lung cancer demonstrated improved progression-free survival with consolidative local therapy, and this approach is the topic of ongoing cooperative group studies inclusive of patients with an array of primary histologies. Further, there is a push to explore the role of radiation as a means to enhance the efficacy of immune enabling drugs. Recent prospective data evaluating the safety and response of SBRT with anti-CTLA-4 therapy for patients with lung or liver metastasis demonstrated clinical benefit (out of field immune-related partial response or immune-related stable disease ≥6 months) in about a quarter of enrolled patients. Interestingly, SBRT to liver metastases was found to elicit a greater systemic immune response than SBRT to lung metastases. Classic management paradigms for metastatic disease are rapidly being supplanted by approaches that are improving outcomes for patients previously offered best supportive care or palliation alone. In this article, we will review the established and emerging potential indications for liver SBRT in this new era of oncologic care.

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INTRODUCTION: Guidelines have recommended prophylactic cranial irradiation (PCI) for patients with limited-stage small-cell lung cancer with at least a partial response after thoracic chemoradiation. However, the survival advantage has been small and was observed in an era before magnetic resonance imaging and surveillance. Neurotoxicity also remains a concern, especially in older adults. Thus, patients have a complex value-laden decision to make. We sought to better understand the role physicians play in patient decision making and introduce a patient decision aid (PDA) to potentially facilitate these discussions. MATERIALS AND METHODS: An e-mail survey was sent to International Association for the Study of Lung Cancer members querying their personal perspectives and professional recommendations regarding PCI for limited-stage small-cell lung cancer. RESULTS: We received 295 responses. Most were from the United States (35%) and Europe (35%) and were radiation (45%) or medical (43%) oncologists. Of those responding, 88% and 50% reported they would recommend PCI to a 50- and 70-year-old patient, respectively. Also, 79% reported that they would wish to receive PCI if faced with this decision. The physicians who would have chosen PCI if faced with the decision were 27.6 and 12.9 times more likely to recommend PCI to a 50- and 70-year-old patient, respectively, than were physicians who would not undergo PCI themselves. Most of the respondents had positive responses to the proposed PDA. CONCLUSION: Physician bias appears to play a role in PCI counseling, and most physicians reported that the provided PDA was better than their present method for discussing PCI and would help patients make such value-laden choices.

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PURPOSE: Neuroendocrine cervical cancer is a rare malignancy with a poor prognosis, yet there is a paucity of data to guide treatment decisions when managing patients with this diagnosis. Specifically, there are little data to aid practitioners in deciding if there is added value to brachytherapy given the additional time, cost, discomfort, and toxicity to patients. METHODS AND MATERIALS: We used the National Cancer Data Base to identify women with locally advanced neuroendocrine cervical cancer treated with definitive chemoradiotherapy to determine if the addition of brachytherapy improves outcomes in this disease. We also assessed outcomes based on chemotherapy timing in this cohort. RESULTS: We identified 100 patients with locally advanced nonmetastatic neuroendocrine cervical cancer that were treated with definitive chemoradiotherapy between 2004 and 2012. There was a substantial improvement in overall survival when brachytherapy was administered in addition to external beam radiotherapy. In multivariate analysis, the addition of brachytherapy, compared with external beam radiotherapy alone, was associated with an improved median survival of 48.6 vs. 21.6 months (hazard ratio (HR), 0.475; 95% CI, 0.255-0.883; p = 0.019). We observed no difference in overall survival for patients treated with neoadjuvant chemotherapy compared with the group who received chemotherapy started concurrently with radiation (HR, 0.851; 95% CI, 0.483-1.500; p = 0.578). CONCLUSIONS: Brachytherapy should be considered an essential component of definitive chemoradiotherapy for the treatment of neuroendocrine cervical cancer. Chemotherapy timing, however, does not impact outcome.

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