How would you treat an endobronchial NSCLC abutting a hiatal hernia in a patient who is medically inoperable?

Rates of G5 toxicity (hemorrhage primarily) with even 8 fraction SBRT from the HILUS trial are unacceptably high. The hiatal hernia adds another layer of complexity and the increased risk for tox with stereotactic approaches. If the patient can get chemo, I’d favor concurrent conventionally fraction...

If it's a large lesion invading the mediastinum or other bad disease, I'd probably just use IMRT to 60 Gy c concurrent chemo at standard fractionation.

OTOH, if it was a smaller lesion, and/or the patient couldn't tolerate chemotherapy, I'd probably use an SBRT plan c breath hold treating the center...