How do you approach a NSCLC case with extensive nodal disease that results in a radiation plan that cannot meet normal tissue constraints?

When treating a NSCLC with extensive bilateral mediastinal disease +/- supraclavicular nodes, would you recommend exceeding certain tissue constrains such as lung, heart, or esophagus? Or dropping the total dose? Decreasing your CTV/PTV margins? Neoadjuvant chemotherapy would likely not help as the involved nodal stations will be treated regardless of chemotherapy response.

Answer from: Radiation Oncologist at Academic Institution

This is an interesting question as there are multiple, complementary approaches that can be taken: If using > 60 Gy, drop the dose down to 60 Gy in 2 Gy fractions. Some practitioners continue to use > 60 Gy in the post-RTOG 0617 era, which is not unreasonable based on retrospective data and f...

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Radiation Oncologist at Angelina Radiation Oncology Associates
Of course, the unspoken alternative is to recogniz...

Answer from: Radiation Oncologist at Community Practice

One can consider neoadjuvant chemo (debulk) or protons.

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Radiation Oncologist at UCLA | VA Greater Los Angeles Healthcare System
Agree. Treat with a stage IV regimen and come back...

Radiation Oncologist at Hollings Cancer Center, Medical University of South Carolina
Is there any prospective data to guide this approa...

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How do you approach a NSCLC case with extensive nodal disease that results in a radiation plan that cannot meet normal tissue constraints?

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