The guideline first addresses the appropriateness of SBRT as an alternative to surgery for different subsets of medically operable patients with early-stage NSCLC (e.g., T1-2, N0). Recommendations differ for patients at "high" versus "standard" risk for surgery-related mortality and are as follows:
For medically inoperable patients, recommendations vary based on tumor location, size and type, as well as treatment history. Guidelines are as follows:
- Centrally located tumors: SBRT for central lung tumors is appropriate, but the associated risks of toxicity are dependent on the total dose and fractionation schedule; SBRT therefore should be delivered usually in four or five fractions as a function of the total dose. In addition to the fractionation chosen, appropriate consideration should be given to the use of stereotactic treatment for centrally located lung tumors close to or involving specific critical structures, such as the airways, heart and esophagus, given the risk for rare but potentially severe adverse events following high-dose treatment in their vicinity. Patients should be informed about alternative regimens using a higher number of lower-dose fractions, as deemed appropriate by the clinical presentation.
- Large tumors: SBRT is conditionally recommended for tumors larger than five centimeters that are not suitable for surgical resection, although patients should be counseled about the subsequent risk of locoregional and distant failure.
