Abscopal Effect From Low-dose Radiotherapy in Metastatic Cancer Combined With Stereotactic Body Radiotherapy

Abscopal Effect From the Addition of Low-dose Radiotherapy in Metastatic Cancer Patients Receiving Stereotactic Body Radiotherapy: a Multicenter, Randomized Clinical Study

Stereotactic body radiotherapy (SBRT) has been known to enhance the abscopal effect by up to 40% when delivered with immune checkpoint inhibitors (ICIs). Recently, preclinical and clinical studies demonstrate that metastatic lesions treated with non-cytotoxic low-dose radiotherapy (LDRT) significantly were reduced in the condition where SBRT and ICIs were administered together. Given that ICIs are highly expensive and some tumors are beyond the indications of ICIs, novel approaches are required to boost the abscopal effect in the absence of ICIs. Therefore, the investigators design a multicenter, randomized clinical trial that investigates the efficacy and safety of LDRT combined with SBRT in metastatic cancer patients. The primary endpoint is a lesion-specific response of LDRT lesions (i.e., abscopal effect) evaluated three months after radiotherapy.

Subjects will be randomly allocated into two groups (1:1) with the stratification by planning target volume and previous use of ICIs: control group (SBRT in three fractions) or experimental group (SBRT + LDRT in three factions). Unless patients agree with randomization, subjects will participate in a prospective cohort study.

Inclusion Criteria:

• Randomization study: Patients who can provide their written informed consent
• Cohort study: Patients who do not consent to randomization and who are able to consent to a prospective cohort study and provide written informed consent
• Age ≥19 years
• Patients with histologically confirmed primary solid (irrespective of the status of the primary tumor)
• Patients with ECOG performance status 0-2
• Patients planning stereotactic body radiotherapy for extracranial metastases
• Based on RECIST v1.1, patients with at least one extracranial measurable lesion other than SBRT lesions
• Patients with one or more measurable lesions, which are not suitable for SBRT or palliative radiotherapy and can be considered for LDRT (bone metastasis is not indicated for LDRT)
• Patients with hematologic function suitable for radiotherapy (absolute neutrophil count ≥1,500/mm^3, hemoglobin ≥9 g/dL, platelet count ≥100,000/mm^3)
• Patients with a life expectancy of 6 months or more according to the researcher's judgment

Exclusion Criteria:

• Patients participating in other clinical studies that may affect the efficacy/safety of this clinical study
• Patients with brain metastasis
• Patients planning SBRT for all measurable lesions due to oligometastasis
• Patients with a history of radiotherapy for extracranial metastases within 3 months of the enrollment
• Patients unable to cooperate with stereotactic body radiotherapy
• Patients who are pregnant or planning to
• Patients with advanced or multiple malignancies requiring aggressive treatment (excluding skin cancers other than melanoma or intraepithelial cancer)
• Patients who have received systemic steroid therapy or immunosuppressive therapy within 2 weeks of enrollment - Patients with an (e.g. allergic disease, radiation pneumonitis, etc.) active autoimmune disease requiring systemic treatment within the past 2 years, evidence of clinically severe autoimmune disease, or syndrome requiring systemic steroid or immunosuppressive therapy (Patients who need intermittent use of bronchodilators, inhaled steroids, or topical steroid injections, hypothyroid patients on stable hormone replacement therapy, type 1 diabetes patients, or patients recovering from childhood asthma/atopic dermatitis are permitted)
• Patients with active infection requiring systemic treatment