Current radiotherapy techniques in NSCLC: challenges and potential solutions

ABSTRACT

Introduction: Radiotherapy is an important therapeutic strategy in the management of non-small cell lung cancer (NSCLC). In recent decades, technological implementations and the introduction of image guided radiotherapy (IGRT) have significantly increased the accuracy and tolerability of radiation therapy.

Area covered: In this review, we provide an overview of technological opportunities and future prospects in NSCLC management.

Expert opinion: Stereotactic body radiotherapy (SBRT) is now considered the standard approach in patients ineligible for surgery, while in operable cases, it is still under debate. Additionally, in combination with systemic treatment, SBRT is an innovative option for managing oligometastatic patients and features encouraging initial results in clinical outcomes. To date, in inoperable locally advanced NSCLC, the radical dose prescription has not changed (60 Gy in 30 fractions), despite the median overall survival progressively increasing. These results arise from technological improvements in precisely hitting target treatment volumes and organ at risk sparing, which are associated with better treatment qualities. Finally, for the management of NSCLC, proton and carbon ion therapies and the recent development of MR-Linac are new, intriguing technological approaches under investigation.

KEYWORDS:

• NSCLC
• radiotherapy
• technology
• sbrt
• protons
• imrt
• mr-Linac

Article highlights

• Radiotherapy represents an important oncological strategy in the management of NSCLC

• Stereotactic body radiotherapy (SBRT) is the standard approach in inoperable or unfit early stage NSCLC. In operable early stage NSCLC, SBRT is still under investigation despite initial experiences demonstrating encouraging results in terms of clinical outcomes.

• In locally advanced NSCLC, the radiation dose prescription is still considered 60 Gy in 30 fractions. Nevertheless, median overall survival is constantly increasing due to technological improvements, new systemic therapies and better pre-treatment molecular/radiological imaging in clinical practice.

• The role of proton therapy is progressively increasing in the management of NSCLC, demonstrating important results from initial clinical trials. Carbon ion experiences are very limited and it still unclear its role in the management of NSCLC

• MR-Linac is an innovative technology under investigation that could potentially impact the treatment of NSCLC.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper received no funding.