Empiric Radiotherapy for Lung Cancer Collaborative Group Multiinstitutional Evidence-Based Guidelines for the Use of Empiric Stereotactic Body Radiation Therapy for Non-Small Cell Lung Cancer Without Pathologic Confirmation

Abigail T. Berman; Salma K. Jabbour; Anil Vachani; Cliff Robinson; J. Isabelle Choi; Pranshu Mohindra; Ramesh Rengan; Jeffrey Bradley; Charles B. Simone II

Disclosures

Transl Lung Cancer Res. 2019;8(1) 

In This Article

Abstract and Introduction

Abstract

The standard of care for managing early stage non-small cell lung cancer (NSCLC) is definitive surgical resection. Stereotactic body radiation therapy (SBRT) has become the standard treatment for patient who are medically inoperable, and it is increasingly being considered as an option in operable patients. With the growing use of screening thoracic CT scans for patients with a history of heavy smoking, as well as improved imaging capabilities, the discovery of small lung nodes has become a common dilemma. As a result, clinicians are increasingly faced with managing lung nodules in patients in whom diagnostic biopsy is not safe or feasible. Herein, we describe the scope of the problem, tools available for predicting the probability that a lung nodule is a malignancy, staging procedures, benefits of pathology-proven and empiric SBRT, considerations of safety based on location of the lesion of concern, and overall efficacy of SBRT.

Introduction

The standard treatment of early-stage non-small cell lung cancer (NSCLC) has been surgical resection when feasible. However, in patients who are surgically or medically inoperable or by patient preference, stereotactic body radiation therapy (SBRT) has become established as an effective definitive modality to treat stage I NSCLC,[1] and it is emerging as a viable modality for medically operable patients.[2] Many patients treated with SBRT have poor pulmonary reserve and significant co-morbidities and are, therefore, also at significant risk of developing complications from biopsy. While a historical resolute mantra of cancer care is that no therapy is administered without pathologic proof of malignancy, clinicians are increasingly faced with the challenge of considering SBRT to be performed empirically for patients with radiographic findings consistent with early-stage lung cancer. We performed a thorough literature search and formed the Empiric Radiotherapy for Lung Cancer Collaborative Group to report the evidence regarding empiric SBRT and guidelines for physicians to consider. Herein, we provide an expert commentary on how to apply "rationalism to empiricism," or when it is appropriate to treat a patient with SBRT without pathologic confirmation.

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