Multidisciplinary Management and CNS Surveillance in ROS1-Positive Advanced Non-Small Cell Lung Cancer

The panel reinforces that oligo-progression management in ROS1-positive NSCLC requires careful distinction from strategies used in EGFR-mutated NSCLC. In ROS1-positive disease with intracranial progression on the current drug, continuing the same systemic therapy while locally radiating is inappropriate if the CNS is the primary site of inadequate control; a drug with documented CNS activity against the resistance mechanism is required.

The panel endorses neuro-oncology consultation for patients with CNS involvement, particularly for seizure prophylaxis, symptom management, radiation necrosis prevention, and nuanced MRI interpretation. Radiation oncology expertise including stereotactic radiosurgery and, at some centers, proton therapy is highlighted as an important partner. For patients progressing in the CNS, the panel emphasizes that modern SRS can treat multiple small lesions with high precision and low neurocognitive impact compared to whole brain radiation.

CNS surveillance practices: for patients with baseline brain metastases, brain MRI every 3 months; for those without, every 6 months minimum. Early imaging within 6 weeks of starting a new second-line or later-line systemic agent allows timely intervention if the drug is not achieving CNS control, avoiding a 3-month delay in identifying failure.