A Study of Local Ablative Therapy (LAT) in People With Non-Small Cell Lung Cancer (NSCLC)

Participant Inclusion Criteria (both Part I and Part II)

Monitoring Phase

Stage IV NSCLC. Note that patients are eligible for the study if they have received definitive treatment for early stage disease, presuming that they remain candidates for local ablative therapy (LAT).
AJCC 8th Edition Stage IV disease
Up to four cycles of standard first-line systemic therapy, defined as: a) platinum-doublet chemotherapy, b) ICI, or c) platinum-doublet chemotherapy + ICI.

Ten or less metastatic lesions (Note that this criterion includes lesions, not sites: 3 brain metastases = 3 lesions).

° Imaging defining extent of disease should be performed within 4 weeks of ctDNA blood draw

All lesions amenable to LAT.
At least one site of measurable disease
Detectable ctDNA
ECOG Performance status 0 - 2.
Age ≥ 18 years.
The participant, or their legally authorized representative (LAR) are able to provide informed consent.
Female subjects must either be of non-reproductive potential (i.e. post-menopausal by history: >/= 60 years old and no menses for 1> year without an alternative medical cause; OR history of hysterectomy, OR history of bilateral tubal ligation, OR history of bilateral oophorectomy) or must have a negative pregnancy test (serum) within 2 weeks or a urine pregnancy test the day of treatment.
Adequate baseline organ function to allow SBRT to all relevant targets, as determined by the treating radiation oncologist based on lesion location, lesion size, and proximity to relevant organs at risk.

Therapeutic Phase

Has received at least 2 cycles of treatment, remains on first-line therapy

No evidence of radiographic RECIST 1.1* progression (as defined above), as measured through the following imaging modalities:

1) PET/CT scan or CT scan of the chest/abdomen/pelvis within 4 weeks of blood draw for ctDNA analysis
2) MRI or CT scan of the brain at baseline, AND within 4 weeks of blood draw for ctDNA analysis
NR-VAF within 4 weeks of enrollment

All active lesions amenable to LAT

° Note that patients who receive local therapy (radiation, surgery, or RFA) prior to enrollment for palliative purposes or to CNS lesions are eligible for enrollment if:

a) all other eligibility criteria are met and b) at least one other lesion is amenable to LAT and is RECIST evaluable. All lesions treated for palliative purposes will also be counted towards the total number of lesions.

Note that patients can either be: a) enrolled on the Monitoring Phase, followed by the Therapeutic Phase, or b) enrolled directly on to the Therapeutic Phase if they present for enrollment at the time that the therapeutic phase would be delivered and retrospectively would have met all of the criteria of the monitoring phase.

Example: If a patient has received 2 cycles of systemic therapy and has NR-VAF, then presents to the clinic for enrollment, they can be enrolled on to the Therapeutic Phase if they meet all of the criteria in the Therapeutic Phase and upon evaluating their prior ctDNA/imaging results would have also met the criteria for the Monitoring Phase.
This allowance will substantially increase accrual, as many patients will present after undergoing baseline ctDNA analysis, and does not affect the scientific question that the study addresses.

Exclusion Criteria:

Complete response radiographically (no lesions to target)
Patients with CNS-only disease (due to limited capacity of peripheral blood ctDNA to detect CNS lesions)
Patient to be treated by targeted agents (e.g. tyrosine kinase inhibitors) or patient not a candidate for systemic therapy
Serious medical co-morbidities precluding radiotherapy or ablation, determined at the discretion of the treating investigator.
Pregnant or lactating women.
Physical limitation to undergo stereotactic radiotherapy.
Other active malignancy within the last year except for basal cell carcinoma of the skin and in situ malignancy even if without evidence of disease.