Would you consider repeat SBRT for a hilar in-field recurrence previously treated with SBRT?

This is a very tricky problem that comes up too frequently. It sounds like the patient may have a central or ultracentral recurrent tumor. Although they fall in similar pots based on most published series, they are very different and the worry factor is different. For this situation, I would define ultracentral as the PTV expansion touching the mainstem.

For recurrent SBRT, I think the bar is raised for establishing a diagnosis and staging. Beyond PET, I believe you need broch and EBUS, with confirmation of the primary mass. If they have a treatable mutation, start with that. High PDL-1 staining may also warrant starting with that and seeing how the patient responds. It fits a “Gomez” type approach which establishes oligoprogressive and sys...