How do you manage a stage I LLL medically inoperable lung cancer in close proximity to the stomach?

This is a rare but not uncommon problem (or maybe unusual but not infrequent...). There’s a couple ways to approach this, depending on the tools in your department‘s toolkit. These low lying LLL lesions are ones that I always treat with breath hold (or gated if you have that). You could also look at abdominal compression. Anything to minimize the ITV. Generally speaking I‘m not a fan of those approaches since it complicates the IGRT and slows treatment time but this scenario warrants it. The next, perhaps less obvious approach is to sim, and then subsequently treat, the patient NPO for 4-6 hours. It doesn’t always help but a Taco Bell burrito box (ie any food or drink) can increase the stomach volume both at time of sim and at treatment, wh...

Agree with the prior recommendations of Drs. Olivier and Stephans. Two other potential tips:

1) Oral simethicone to break up gas bubbles 4-6 hrs prior to the sim and each daily treatment, and then NPO

2) Gravity may be your friend with the mobile stomach. NPO for 4-6 hrs and then a sip of oral contrast at the time of the simulation with the patient in a body cast in the right lateral decubitus position. Unless the tumor is in the extreme posterior/inferior LLL the stomach may drop away from your GTV increasing the distance between gastric mucosa and higher isodose lines.