Non-biopsied patients: While biopsy should be used whenever possible to confirm malignancy of the tumor, SBRT can be considered for patients who are unable or unwilling to undergo biopsy but have appropriate imaging studies supporting a cancer diagnosis. These cases should be discussed at a multidisciplinary tumor board prior to treatment.

Multiple primary lung cancers (MPLCs)/pneumonectomy patients: Patients with a history of previously resected lung cancers, either singly or multiply, and/or who received a pneumonectomy (which is the surgical removal of a whole lung) for prior lung cancer, and now have a new primary tumor in their remaining lung (or lungs) may be considered for SBRT as a curative-intent treatment option, although lung toxicity rates from SBRT may be higher as a function of the amount of remaining lung tissue.

For the medically inoperable patient, the guideline also outlines how SBRT techniques should be tailored for high-risk scenarios where the tumor abuts critical structures, so that appropriate tumor control can be achieved while minimizing risk to these same structures. Guidelines are as follows:

• Tumors located near mediastinal structures: For tumors that touch the trachea or proximal bronchial tree, or for tumors near the heart and pericardium, SBRT should be delivered in treatment schedules using four or five fractions. For tumors near the esophagus, similar treatment schedules are suggested although data are more limited, and physicians are encouraged to minimize radiation dose to the esophagus with highly conformal techniques. Patients should be counseled on potentially life-threatening toxicities that have been reported in these scenarios.


• Tumors touching or invading the chest wall: For early-stage tumors that touch the chest wall, SBRT is an appropriate treatment option, though patients should be counseled on the risk of grade 1-2 chest wall toxicity. For tumors invading the chest wall (cT3), SBRT is endorsed, since it appears effective without undue increased rates of chest wall toxicity.

Finally, the guideline considers the role of SBRT as salvage therapy for medically inoperable patients with recurrent early-stage disease. Recommendations vary based on treatment history and are as follows:

• Previous conventional radiation therapy: SBRT is conditionally recommended for carefully selected patients, based on limited evidence demonstrating good local control with an acceptable toxicity profile. Patients, however, should be counseled on potentially significant, including fatal, side effects, and the risk of regional and distant failure.


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