Easy does it.

Many of us have become comfortable with lung hypofractionation by working backwards with challenging SBRT cases. At the same time, we’ve reached a bit of an impasse with conventional dose escalation for stage III disease. So what about moderate hypofractionation for stage III? In this retrospective analysis, 42 patients with stage III NSCLC were treated with 60 Gy in 15 fractions. The majority underwent induction chemo for de novo disease (though 10% were post-op recurrences). They had to have <7 cm post-chemo tumor burden to be eligible and couldn’t have extensive abutment of the esophagus. Importantly, they did not receive concurrent chemo. The target was post-chemo primary and nodal gross disease (accounting for intra-fraction movement) with a direct 5-10 mm PTV margin. Unfortunately, over a third of patients didn’t receive the intended 60 Gy dose, mainly due to toxicity. Grade 3+ pneumonitis was seen in 14% (including two grade 5 events), and grade 3+ esophagitis was seen in 14%. TBL: Exercise caution and careful patient selection if considering hypofractionation for stage III NSCLC. | Kong, Int J Radiat Oncol Biol Phys 2020