Non small cell lung cancer

Indications

Stage IIB (T3,N0) IIIA, B and C

Performance status

0-2

Pulmonary functions

FEV1 and TLCO>40% and/or adequate functional status

Note: As per RCR guidelines, pulmonary function tests are a guidance and these should be assessed alongside with patient's functional status

Dose

55Gy/20 or 60-66Gy/30-33

Chemotherapy/SACT 

(see SACT pathway and local SACT protocols for administration and dosing details)

Option 1

Cisplatin with vinorelbine given either as:

• Cisplatin D1 and vinorelbine D1+8, 3 weekly with radiotherapy 60-66Gy/30-33
• Aim for 3-4 cycles with radiotherapy starting ideally before Cycle 2 day 1.
• In combination with vinorelbine, cisplatin should be first choice, however in the event of renal impairment/other contra-indication, carboplatin can be considered as per local protocol. 

Or alternatively

• SOCCAR regimen with cisplatin 20mg/m2 per day over 4 days, weeks 1 and 4 during radiotherapy 55Gy/20

Option 2

Carboplatin with paclitaxel

•  Weekly for 6 weeks concurrent with 60-66Gy/30-33
• Aim to start within the first 3 days of starting radiotherapy
• Followed by 1-2 cycles of 3 weekly consolidation  carboplatin and paclitaxel 

Concurrent NSCLC SACT pathway

Both options acceptable and should take individual patient factors into account. 

Final cycle may need to be omitted if intending to move to durvalumab maintenance.

Indications

Stage IIB (T3,N0), IIIA, B and C

Performance status

0-2

May be considered in those with good PS but larger tumours unable to meet OAR dose constraints, PTV size, comorbidities, uncertainty about stage, PS, lung function and volume, position of primary and extent of nodal involvement.

Pulmonary function

Preferred FEV≥1l and DLCO>40% but can consider at lower values if functional status deemed adequate

Dose

55Gy/20/4 weeks

Chemotherapy

2-4 cycles prior to radiotherapy using platinum based doublet.

See sequential NSCLC SACT pathway for treatment options

Indications

Stage I-IIIC

T1-3,N0 patients only if unsuitable for SABR

Performance status

0-3

Pulmonary function

Preferred FEV≥1l and DLCO>40% but can consider at lower values if functional status deemed adequate

Dose

55Gy/20/4w, 60-66Gy/30-33/6w, 54Gy/36/12days

Indications

Surgical margin <1mm

Performance status

0-2

Pulmonary function

Functionally adequate/recovered from surgery

Dose

50-55Gy/20/4w (55Gy if macroscopic residual)

Indications

• Locally advanced disease not amenable to radical radiotherapy
• Consolidation after chemotherapy when radical not feasible

Can be considered if required for symptom control in metastatic setting if low volume metastases

Performance status

0-3

Dose

36Gy/12 or 39Gy/13,  consider 30Gy/10 if large field

Indications

For symptom control, focal site amenable to radiotherapy

Poor PS and/or short life expectancy (but >6 w)

Performance status

0-4

Dose

8-10Gy/1 or 20Gy/4-5 fractions for lung primary

17Gy/2 fractions a week apart

8Gy/1 for bony metastases or cord compression

10Gy/1 for lung tumour poor PS but if large field/SVCO consider 20Gy/5   

Indications

• MDT diagnosis of NSCLC based on findings of positive histology or a positive PET scan when predictive models (e.g. Herder, Brock) indicate a > 70% risk of malignancy (Callister et al BTS guidelines) 
• Clinical stages of T1 N0 M0 or T2 (< 5cm) No Mo or a subset of T3 (by virtue of chest wall invasion only) (< 5cm) 
• Not suitable for surgery because of medical co-morbidity, lesion is technically inoperable or patient declines surgery after surgical assessment (or option of assessment) 
• Peripheral lesions, defined as outside the IASLC ‘central’ zone  
• Age > 18 years 

Performance status

0-3

Pulmonary function

No absolute constraints for FEV1 or DLCO, but patients with interstitial lung disease or established lung fibrosis should be treated with caution.

Relative contraindications

Target motion due to respiration ≥ 1cm despite techniques to reduce tumour motion

Presence of pulmonary fibrosis (consider and consent for increased risk of significant toxicity) - NOTE in which case referral to respiratory physicians to discuss convenience of treatment and enhanced measures/follow up from their department strongly encouraged.

PS3 (due to reason for poor PS being co-morbidities rather than disease)

Exclusion

• Any tumour not clinically definable on the treatment planning CT scan e.g. surrounded by consolidation or atelectasis.
• Tumour with respiratory motion ≥ 1cm, only proceed with treatment if target delineation is reliable and suggested normal tissue and tumour planning constraints can be achieved.
• Previous radiotherapy within the planned treatment volume; SABR may be offered in selected cases after consideration of potential risks of re-treatment.
• Chemotherapy administered within previous 6 weeks or < 6 weeks following SABR.
• Pregnant or lactating females
• Inability to obtain consent or comply with treatment requirements

Dose

54Gy/3/5-8d                     Peripheral lesion, T1, no OAR issues
55Gy/5/10-14d                 T2 or close to chest wall
50Gy/5/10-14d                 Abut or overlap central area
 60Gy/8/17-19d                PTV close to great vessels or can’t meet OAR
(Fractionations here given 2-3 times per week)