What radiation dose is appropriate for patients receiving induction chemoradiation prior to surgery for superior sulcus tumors?

RTOG 0229 demonstrated the safety and efficacy of increasing the radiation dose to 61.2 Gy in the trimodality setting. Therefore, current standard concurrent chemoradiation therapy uses 61.2 Gy, which is safe with or without surgical resection, with improved mediastinal nodal clearance rate (63%). 45 Gy, the radiation dose used in S9416/INT-0160 (the clinical trial that established trimodality therapy as standard treatment for superior sulcus NSCLC) is no longer deemed appropriate.

For example, 61.2 Gy is the radiation dose recommended for all patients enrolled into the ongoing trial S1934 (aka NASSIST- ‘NeoAdjuvant chemoradiation +/- immunotherapy before Surgery for Superior Sulcus Tumors: a randomized phase II trial of trimodality +/- Atez...

I peronally take advantage of these cases to directly engage the thoracic surgeon who's planning to do the resection. I agree with Charles that 45 Gy may be too low, and prefer to Rx at least 50 Gy. By getting the surgeon to help contour, we can illustrate how our doses can be painted with SIB techniques to focus them where they need to go. In return, they can show us where they want the doses to be lower (great vessels, mediastinum, proximal bronchi), and where they might not care (ITV, peripheral upper lobe to be resected). Such a collaborative appraoch may help their surgical appraoch as there's less guesswork about where the beams were aimed, and how much dose went where. It also reduces the risk of bomb throwing at radiotherapy if ther...

While the cooperative group data suggest that 45 Gy is reasonable for potentially resectable dx; I prefer to treat to higher doses with hopes of increasing the pCR.

Alternately, it is not unreasonable to consider induction platinum-based combination chemotherapy followed by re-staging and then chemoradiotherapy, for patients with locally advanced dx.

Finally, the last SWOG-led cooperative group trial was not approved by the NCI Lung Steering Comm 4-5 yrs ago; hence there is no open North American trial dedicated for Pancoast (Superior Sulcus) Tumors.