Radiation therapy for locally advanced lung cancer

Management for locally advanced non-small cell lung cancer (LANSCLC), which consists of Stage IIIA and IIIB disease, has progressed throughout the decades. While overall survival (OS) remains guarded, advancements in radiotherapy techniques along with the integration of chemotherapy, including targeted therapy, is transforming modern management. LANSCLC was initially treated with definitive radiation therapy (RT) alone. Early trials showed a local control benefit and OS benefit with dose escalation using conventional and altered fractionation. The next phase of management included the addition of chemotherapy. Sequential chemoradiation led to a survival benefit, however, concurrent chemoradiation proved to be a better regimen. While definitive chemoradiation is the standard of care for LANSCLC, neoadjuvant chemoradiation followed by surgical management is reserved for a subset of patients who have low volume single nodal station disease and are eligible for a lobectomy upfront. In terms of techniques, we have progressed from treating elective nodal sites to involved nodal regions. Supplementary technical improvements include three dimensional computed tomography planning, targeting F-18-fluorodeoxyglucose positron emission tomography-computed tomography planning, motion management, use of Intensity Modulated Radiation Therapy (IMRT), and evaluating normal tissue dose volume relationships. We will also discuss ongoing novel techniques such as adaptive RT and use of hypofractionation. Finally, appropriate palliative treatment will be reviewed highlighting the role of dose per fraction, brachytherapy, and use of concurrent chemotherapy. American society for radiation oncology (ASTRO) summary guidelines will be presented at the end of the definitive and palliative section. Here, the advancement of RT for definitive and palliative treatment will be reviewed.