Case Based Challenges in Radiotherapy for Locally Advanced NSCLC-Recording

Video Transcription

Video Summary

The webinar “Radiotherapy Challenges in Locally Advanced NSCLC in the Neoadjuvant Era” focused on staging and treatment decision-making when integrating radiotherapy with modern perioperative systemic therapy.<br /><br />Dr. Shankar Siva discussed mediastinal staging for radiotherapy planning, emphasizing limitations of PET/CT alone and the value of systematic EBUS-TBNA. In a case where systematic EBUS found PET-occult contralateral nodal disease (upstaging to N3), standard PET/CT-based radiotherapy fields would have missed gross disease. Data from the multinational SEISMIC trial showed PET–EBUS discordance in 37% of patients, with 12% upstaged and 25% downstaged (some redirected to surgery). Among upstaged patients receiving radiotherapy, target undercoverage was common. To improve consistency, an IASLC project will evaluate synoptic EBUS reporting (documenting key nodal stations, size, sampling, and results) to reduce variability and better guide radiotherapy volumes.<br /><br />Dr. Paul Martin-Petoro addressed the frequent real-world scenario where patients receiving planned neoadjuvant chemoimmunotherapy do not proceed to surgery (15–20%). With limited evidence and no guidelines, an IASLC expert panel outlined pragmatic approaches by scenario: for local progression or patient refusal, treat with curative-intent concurrent chemoradiotherapy followed by consolidation (often durvalumab), “as if surgery were not planned.” For distant progression, prioritize systemic therapy; metastasis-directed treatment is approached cautiously. If performance status declines or toxicities occur, optimize supportive care and de-escalate (sequential CRT, RT alone) only if necessary.<br /><br />Dr. Cécile Lepageux reviewed postoperative radiotherapy (PORT) after neoadjuvant chemoimmunotherapy and surgery. PORT reduces mediastinal relapse (as shown in LungART/PORT-C), but survival benefit is unclear and cardiopulmonary toxicity is a concern. In the immunotherapy era—where distant relapse falls more than locoregional relapse—PORT may have a role for selected high-risk patients (residual disease, extracapsular extension, uncertain/positive margins, heavy nodal burden). A randomized trial (RESCUE) is underway to define PORT’s value in patients with residual pathologic disease.

Keywords

locally advanced NSCLC

neoadjuvant chemoimmunotherapy

radiotherapy planning

mediastinal staging

EBUS-TBNA

PET/CT discordance

SEISMIC trial

IASLC synoptic EBUS reporting

concurrent chemoradiotherapy with durvalumab consolidation

postoperative radiotherapy (PORT) and RESCUE trial