How do you approach a peripheral, T1 lung cancer with a positive mediastinal node by EBUS?

I agree with @Dr. First Last's thoughtful response above. Though the idea of SBRT to a small primary is appealing, the clear standard of care here would be to deliver concurrent chemoradiation using standard fractionation (i.e. 60Gy) using standard margins and standard approach to nodal irradiation (i.e. ipsilateral hilum only). Until there's more data to validate novel combinations of conventional RT and SBRT, I don't think one can routinely advocate for this. Doing so would also start complicating many treatment decisions about Stage III disease, since there are many situations where one could conceivably deliver higher-BED radiation to the lung primary than to the nodes. I would think of SBRT primarily as an option if the patient has iso...

Conceptually SBRT for a peripheral T1-2 primary tumor in the setting of N2 disease is attractive, as SBRT is simply another means to deliver tumoricidal radiation and SBRT can reduce the volume of lung exposed to high-dose radiation. It is not approach I have used since (for practical reasons) insurers will not cover SBRT for stage III disease unless there is a compelling reason (i.e. absolutely no way to achieve an acceptable lung V20 with conventional radiation fields). An alternative approach, in the neoadjuvant setting, might be to simply not treat the lung tumor (not something I am advocating, but something I have done in a small number of patients). For definitive chemoradiation, I do make an effort to include the ipsilateral hilum wh...