title: Strategies of dose escalation in the treatment of locally advanced non-small cell lung cancer: image guidance and beyond.
abstract: Radiation dose in the setting of chemo-radiation for locally advanced non-small cell lung cancer (NSCLC) has been historically limited by the risk of normal tissue toxicity and this has been hypothesized to correlate with the poor results in regard to local tumor recurrences. Dose escalation, as a means to improve local control, with concurrent chemotherapy has been shown to be feasible with three-dimensional conformal radiotherapy in early phase studies with good clinical outcome. However, the potential superiority of moderate dose escalation to 74 Gy has not been shown in phase III randomized studies. In this review, the limitations in target volume definition in previous studies; and the factors that may be critical to safe dose escalation in the treatment of locally advanced NSCLC, such as respiratory motion management, image guidance, intensity modulation, FDG-positron emission tomography incorporation in the treatment planning process, and adaptive radiotherapy, are discussed. These factors, along with novel treatment approaches that have emerged in recent years, are proposed to warrant further investigation in future trials in a more comprehensive and integrated fashion.
authors.affiliation: Department of Radiation Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Chi
authors.affiliation: The International Geriatric Radiotherapy Group , Tucson, AZ , USA.
authors.forename: Nam Phong
authors.initials: NP
authors.lastname: Nguyen
authors.affiliation: Northern Illinois University Institute for Neutron Therapy at Fermilab , Batavia, IL , USA.
authors.forename: James S
authors.initials: JS
authors.lastname: Welsh
authors.affiliation: Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: William
authors.initials: W
authors.lastname: Tse
authors.affiliation: Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: Manish
authors.initials: M
authors.lastname: Monga
authors.affiliation: Thoracic Surgery, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: Olusola
authors.initials: O
authors.lastname: Oduntan
authors.affiliation: Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Almubarak
authors.affiliation: Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: John
authors.initials: J
authors.lastname: Rogers
authors.affiliation: Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA.
authors.forename: Scot C
authors.initials: SC
authors.lastname: Remick
authors.affiliation: Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago, IL , USA.
authors.forename: David
authors.initials: D
authors.lastname: Gius
keywords: NSCLC; adaptive radiotherapy; image guidance; intensity-modulated radiotherapy; proton therapy