Stereotactic Body Radiation Therapy For Early-Stage Non-Small Cell Lung Cancer

Publication Date: October 1, 2017
Last Updated: March 14, 2022

Recommendations

When is SBRT appropriate for patients with T1-2, N0 NSCLC who are medically operable?

Any patient with operable stage I NSCLC being considered for SBRT should be evaluated by a thoracic surgeon, preferably in a multidisciplinary setting, to reduce specialty bias. (Strong, Moderate)
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For patients with “standard operative risk” (ie, with anticipated operative mortality of <1.5%) and stage I NSCLC, SBRT is not recommended as an alternative to surgery outside of a clinical trial. Discussions about SBRT are appropriate, with the disclosure that long-term outcomes with SBRT >3 years are not wellestablished. For this population, lobectomy with systematic mediastinal lymph node evaluation remains the recommended treatment, though a sublobar resection may be considered in select clinical scenarios. (Strong, High)
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For patients with “high operative risk” (ie, those who cannot tolerate lobectomy, but are candidates for sublobar resection) stage I NSCLC, discussions about SBRT as a potential alternative to surgery are encouraged. Patients should be informed that while SBRT may have decreased risks from treatment in the short term, the longer term outcomes >3 years are not well-established. (Conditional, Moderate)
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When is SBRT appropriate for medically inoperable patients with T1-2, N0 NSCLC:

• With centrally located tumors
• With tumors N5 cm in diameter
• Lacking tissue confirmation
• With synchronous primary or multifocal tumors
• Who underwent pneumonectomy and now have a new primary tumor in their remaining lung?

For patients with centrally located tumors?

SBRT directed toward centrally located lung tumors carries unique and significant risks when compared to treatment directed at peripherally located tumors. The use of 3-fraction regimens should be avoided in this setting. (Strong, High)
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SBRT directed at central lung tumors should be delivered in 4 or 5 fractions. Adherence to volumetric and maximum dose constraints may optimize the safety profile of this treatment. For central tumors for which SBRT is deemed too high risk, hypofractionated radiation therapy utilizing 6 to 15 fractions can be considered. (Conditional, Moderate)
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For patients with tumors >5 cm in diameter?

SBRT is an appropriate option for tumors >5 cm in diameter with an acceptable therapeutic ratio. Adherence to volumetric and maximum dose constraints may optimize the safety profile of this treatment. (Conditional, Low)
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For patients lacking tissue confirmation?

Whenever possible, obtain a biopsy prior to treatment with SBRT to confirm a histologic diagnosis of a malignant lung nodule. (Strong, High)
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SBRT can be delivered in patients who refuse a biopsy, have undergone nondiagnostic biopsy, or who are thought to be at prohibitive risk of biopsy. Prior to SBRT in patients lacking tissue confirmation of malignancy, patients are recommended to be discussed in a multidisciplinary manner with a consensus that the lesion is radiographically and clinically consistent with a malignant lung lesion based on tumor, patient, and environmental factors. (Strong, Moderate)
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For patients with synchronous primary or multifocal tumors?

Multiple primary lung cancers (MPLCs) can be difficult to differentiate from intrathoracic metastatic lung cancer and pose unique issues for parenchymal preservation; therefore, it is recommended that they are evaluated by a multidisciplinary team. (Strong, Moderate)
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Positron emission tomography/ computed tomography and brain magnetic resonance imaging are recommended in patients suspected of having MPLC to help differentiate from intrathoracic metastatic lung cancer. Invasive mediastinal staging should be addressed on a case-by-case basis. (Strong, Moderate)
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SBRT may be considered as a curative treatment option for patients with synchronous MPLC. SBRT for synchronous MPLC has equivalent rates of local control and toxicity, but decreased rates of overall survival compared with those with single tumors. (Conditional, Low)
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SBRT is recommended as a curative treatment option for patients with metachronous MPLC. SBRT for metachronous MPLC has equivalent rates of local control and toxicity and overall survival compared with those with single tumors. (Strong, Moderate)
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For patients who underwent pneumonectomy and now have a new primary tumor in their remaining lung?

SBRT may be considered a curative treatment option for patients with metachronous MPLC in a postpneumonectomy setting. While SBRT for metachronous MPLC appears to have equivalent rates of local control and acceptable toxicity compared to single tumors, SBRT in the postpneumonectomy setting might have a higher rate of toxicity than in patients with higher baseline lung capacity. (Conditional, Low)
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For medically inoperable early-stage lung cancer patients, how can SBRT techniques be individually tailored to provide an adequate dose for tumor eradication with minimal risk to normal structures in “high-risk” clinical scenarios, including:

• Tumors with intimal proximity/involvement of mediastinal structures (bronchial tree, esophagus, heart, etc.)
• Tumors abutting or invading the chest wall?

For tumors with intimal proximity/involvement of mediastinal structures (bronchial tree, esophagus, heart, etc.)?

For tumors in close proximity to the proximal bronchial tree, SBRT should be delivered in 4 to 5 fractions. Physicians should endeavor to meet the constraints that have been utilized in prospective studies given the severe toxicities that have been reported. (Strong, Low)
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For tumors in close proximity to the esophagus, physicians should endeavor to meet the constraints that have been utilized in prospective studies or otherwise reported in the literature given the severe esophageal toxicities that have been reported. (Strong, Low)
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For tumors in close proximity to the heart and pericardium, SBRT should be delivered in 4 to 5 fractions with low incidence of serious toxicities to the heart, pericardium, and large vessels observed. Adherence to volumetric and maximum dose constraints utilized in prospective trials or reported in the literature may optimize the safety profile of this treatment. (Strong, Low)
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For tumors abutting or invading the chest wall?

SBRT is an appropriate option for treatment and should be offered for T1-2 tumors that abut the chest wall. Grade 1 and 2 chest wall toxicity is a common occurrence post SBRT that usually resolves with conservative management. Patients with peripheral tumors approximating the chest wall should be counseled on the possibility of this common toxicity. (Strong, High)
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SBRT may be utilized in patients with cT3 disease due to chest wall invasion without clear evidence of reduced efficacy or increased toxicity compared to tumors abutting the chest wall. (Conditional, Low)
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In medically inoperable patients, what is the role of SBRT as salvage therapy for earlystage lung cancer that recurs:

• After conventionally fractionated radiation therapy
• After SBRT
• After sublobar resection?

After conventionally fractionated radiation therapy?

The use of salvage SBRT after primary conventionally fractionated radiation may be offered to selected patients due to reported favorable local control and survival. (Conditional, Low)
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Patients treated with salvage SBRT after primary conventionally fractionated radiation should be informed of significant (including fatal) toxicities. (Strong, Low)
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Patient selection for salvage SBRT after primary conventionally fractionated radiation is a highly individualized process. Radiation oncologists should assess evidence-based patient, tumor, and treatment factors prior to treatment initiation. (Strong, Low)
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Patient selection for salvage SBRT after previous SBRT is a highly individualized process. Radiation oncologists should assess evidence-based patient, tumor, and treatment factors before treatment initiation. (Strong, Low)
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After sublobar resection

Patient selection for salvage SBRT after prior sublobar resection is a highly individualized process. Radiation oncologists should assess evidence-based patient, tumor, and treatment factors before treatment initiation. (Strong, Low)
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Recommendation Grading

Overview

Title

Stereotactic Body Radiation Therapy For Early-Stage Non-Small Cell Lung Cancer

Authoring Organization

American Society for Radiation Oncology

Publication Month/Year

October 1, 2017

Last Updated Month/Year

December 5, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline presents evidence-based recommendations for stereotactic body radiation therapy (SBRT) in challenging clinical scenarios in early-stage non-small cell lung cancer (NSCLC).

Target Patient Population

Patients with early-stage non-small cell lung cancer

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D013903 - Thoracic Surgery, D018787 - Radiation Oncology, D011827 - Radiation, D013238 - Stereotaxic Techniques

Keywords

non-small cell lung cancer, radiation therapy, Non Small Cell Lung Cancer, non_small_cell_lung_cancer, Adjuvant Radiation Therapy