Local recurrence from NSCLC

[Gfunk6]

Woman in 70s with prior history of heavy smoking with Stage IIIA pulmonary adenocarcinoma. Evaluated by CT surgery but declined. We treated with CRT to 60 Gy in 30 fractions.

Patient was disease for about on year then developed oligometastatic bone recurrence. Performed SBRT on x1 painful bone lesion which resolved pain. Tumor was PDL-1 amplified so was salvaged with immunotherapy.

Pt progressed on immunotherapy so was switched to carboplatin + pemetrexed. Had disease remission x 8 months.

Now has FDG-avid recurrence in hilar region which was site of original XRT 2 years prior. Under normal circumstances would consider SBRT but this is in Timmerman exclusion zone so bad idea. Any other ideas to salvage this with a more gentle fractionation? Perhaps 4 Gy x 10 or 3.5 Gy x 15?

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[RickyScott]

Phase I Study of Accelerated Conformal Radiotherapy for Stage I Non–Small-Cell Lung Cancer in Patients With Pulmonary Dysfunction: CALGB 39904
calgb regimen also reasonable

 

[evilbooyaa]

Proximity to proximal bronchial tree? How about proximity to Aorta? I'd look at the papers regarding BED and risk of Aortic toxicity (primarily a concern in the re-irradiation setting, I've looked at Evans et al 2013 in Green Journal) if proximal bronchial tree is not an issue. Patient declined surgery before - is she agreeable now for possible salvage resection if radiation is going to have higher risk? If proximal bronchial tree is > 1cm away (also depends on what dose it got previously) could take a look and see if you could meet cumulative dose constraints with a reasonable dose schedule.