When should we use our hammer of ablative radiotherapy to treat oligometastatic non-small cell lung cancer?1Vitzhum LK Pollom EL Diverging roads in the management of metastatic EGFR mutated non small cell lung cancer: Ablate all, none, or some?.Intl J Radiat Oncol Bio Phys. 2023; 116: 479-480Google Scholar In our clinical practice, patients with ≤3 metastases would be considered for this. We would weigh the risks and benefits of adding radiation therapy to osimertinib for each of these lesions, and for the patient overall. Given that she has pain from her acetabular metastasis, we would recommend upfront palliation with 35 Gy in 5 fractions, provided there is no evidence of fracture. There is a paucity of evidence to guide us; extrapolation from Canadian Clinical Trials Group SC.24 suggests ablative radiotherapy (biologically effective dose [BED10] ≥ 50 Gy) may confer better pain and local control at the treated site, compared with conventional radiotherapy.2Sahgal A Myrehaug SD Siva S et al.Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: An open-label, multicentre, randomised, controlled, phase 2/3 trial.Lancet Oncol. 2021; 22: 1023-1033Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar We would not irradiate the other tumors upfront. As the brain metastasis is small, asymptomatic, and expected to respond to osimertinib, we would observe this lesion with serial magnetic resonance imaging scans and treat with stereotactic radiosurgery on progression. Randomized evidence for this scenario is pending (NCT03769103). After 3 months of osimertinib and no evidence of progression, we would consolidate the lung primary with 50 Gy in 5 fractions to prolong progression-free survival, as demonstrated by the Gomez trial.3Gomez DR Tang C Zhang J et al.Local consolidative therapy vs. maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer: Long-term results of a multi-institutional, phase II, randomized study.J Clin Oncol. 2019; 37: 1558-1565Crossref PubMed Scopus (645) Google Scholar Some may argue for upfront ablation of all lesions. We note that SINDAS (NCT02893332) excluded patients with brain metastases and was not conducted in the era of third-generation epidermal growth factor receptor inhibitors. Ultimately, not all nails need the same hammer at the same time; we must thoughtfully leverage our oncologic armamentarium to care for each patient.

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