GOECP/SEOR clinical recommendations for lung cancer radiotherapy during the COVID-19 pandemic

Table 1 Stereotactic body radiotherapy schemes for stage T1-T2 non-small cell lung cancer

Prescription	BED10	LC (yr)	Distance
			Thoracic wall	Mediastinum
30-34 Gy single fraction	149.6 Gy	94% (3 yr)	> 2 cm	> 2 cm
54 Gy (18 Gy × 3 fx)	151.2 Gy	94% (3 yr)	≥ 2 cm	> 2 cm
48 Gy (12 Gy × 4 fx)	105.6 Gy	85.4% (3 yr)	< 2 cm	NA
50-60 Gy (10-12 Gy × 5 fx)	100-132 Gy	75%-84% (3 yr)	> 2 cm	≤ 2 cm

LC: Local control; Fx: Fraction; BED: Biologically effective dose.

Table 2 Hypofractionated radiotherapy for locally-advanced non-small cell lung cancer

Study	CT	Fx	Dose	Time	EQD-210	HDV	Comments
Soccar trial Randomized, Phase II[41]	Sequential; Concomitant	20 × 2.75 Gy	55 Gy	26 d	58.4 Gy	Lungs-GTV: V20 < 35%; MLD < 18 Gy; Spinal cord: Dmax 44 Gy; Esophagus: D1 cc < 55 Gy; Heart:V30 < 36%; Brachial plexus: Dmax 55 Gy	High concomitant toxicity; CT adjusted dose required; Not compared vs standard (60 Gy); Widely used in United Kingdom
Anderson, Retrospective[42]	Sequential	15 × 3 Gy	45 Gy	19 d	48,7 Gy	Not published	Retrospective comparison; Similar results to standard: 30 × 2 (60 Gy)
Toronto Retrospective[43]; Anderson Randomized, Phase III[45]	Sequential	15 × 4 Gy	60 Gy	19 d	70 Gy	Lungs-GTV: V20 < 30%; V5 < 60%; MLD < 20 Gy; Spinal cord: Dmax 38 Gy; Esophagus: Dmax < 50 Gy; V45 < 10cc; Heart y MBV: Dmax < 63 Gy; V57 < 10 cc; Trachea y MB: Dmax < 63 Gy; V57 < 10 cc; Rib: Dmáx < 63 Gy; V30 < 30 cc; Brachial plexus: Dmax < 50 Gy; Skin < 50 Gy	Used for SBRT; Lack of data in stage III; Phase III RCT; 15 × 4 vs 30 × 2; Final results not published

CT: Computed tomography; Fx: Fraction.

Table 3 Stereotactic body radiotherapy schemes for oligometastatic non-small cell lung cancer

Localisation	Fractions/Total dose
Brain	1 fx: 18-24 Gy; 3 fx: 24-27 Gy; 5 fx: 25-35 Gy
Lung	3 fx: 54 Gy; 4 fx: 48 Gy; 5 fx: 50-60 Gy
Adrenal gland	3 fx: 36-45 Gy; 5 fx: 40-50 Gy
Liver	1 fx: 24-26 Gy; 3 fx: 45-60 Gy; 5 fx: 40-50 Gy; 8 fx: 60 Gy
Bone (spinal column included)	1 fx: 16-24 Gy; 3 fx: 27-30 Gy; 5 fx: 30-40 Gy

Fx: Fraction.

Table 4 Hypofractionated radiotherapy for limited stage small-cell lung cancer

Ref.	Type of study	Total dose (Gy)	Dose per fraction (Gy)	No. fractions	Radiotherapy technique, Dose tolerance
Giuliani et al[90], 2015	Retrospective	40	2.67	15	3DCRT/IMRT; Lung: V20 ≤ 30%, Dmedia 20 Gy, Esophagus: Dmax < 105%
Grønberg et al[91], 2016	Prospective, phase 2 trial	42	2.8

IMRT: Intensity-modulated radiotherapy; CRT: Chemoradiotherapy.

Table 5 Palliative radiotherapy in lung cancer

Clinical indication	Fractionation
Palliative thoracic treatments (VCS, hemoptysis, dyspnea…)	20 Gy/5 fx; 17 Gy/2 fx; 10 Gy/1 fx;
Bone metastases / Spinal cord compression	8 Gy/1 fx
Multiple brain metastases	20 Gy/5 fractions; Omit in patients with poor ECOG

VCS: Vena cava syndrome.

Table 6 Summary of recommendations of the main clinical guidelines and of the GOECP/SEOR for lung cancer radiotherapy during the coronavirus disease 2019 pandemic

	ESTRO-ASTRO	MSKCC	Yale radiation oncology	GOECP/SEOR
Stage I NSCLC	SBRT: 45-54 Gy in 3 fx, 48 Gy in 4 fx; Maximum hypofractionation supported, 30-34 Gy 1 fx	SBRT; Peripheral lesions: 34 Gy, 1 fx; Central tumours: 10 Gy × 5 fx; Ultracentral tumours: 7.5 Gy × 8 fx	SBRT; Peripheral lesions: 30-34 Gy, 1 fx (first option). -45 Gy in 3 fx; Central tumours: 45 Gy in 3 fx (first option); -50 Gy/5 fx; Ultracentral or very large tumours: 60-72 Gy in 15-18 fx vs 60 Gy in 8 fx	SBRT; Safe Zone: -30-34Gy, 1 fx (first option). -54 Gy in 3 fx; Peripheral Lesions: 48 Gy in 4 fx (first option); Central Tumour: 50-60 Gy in 5 fx vs 60 Gy in 8 fx
Stage III NSCLC	CRT 60-66 Gy in 30-33 fx	CRT 55 Gy in 20 fx	CRT 60 Gy in 30 fx	CRT 60-66 Gy in 30-33 fx
Stage III NSCLC; Radiotherapy Alone/sequential	60 Gy in 15 fx (33%); 60 Gy in 20 fx (27%); 60-66 Gy in 24-30 fx (2.2-2.75 Gy/d) (23%) 24; 55 Gy in 20 fx (13%)	45 Gy in 15 fx (or more hypofractionated)	52.5-60 Gy in 15 fx	55 Gy in 20 fx1 (first option); 45 Gy in 15 fx
PORT NSCLC	50-60 Gy over 5-6 wk	50 Gy in 25 fx	Delay treatment	Delay treatment
LS-SCLC	CRT 60-66 Gy in 30-33 fx over 6-6.5 wk, or 45 Gy in 30 fx over 3 wk using BID fractions of 1.5 Gy	-45 Gy in twice daily 1.5 Gy (first option); -66-70 Gy in 33-35 daily fx; -45 Gy in 15 daily fx	40-42 Gy in 15 daily fx	CRT 60-66 Gy in 30-33 fx over 6-6.5 wk, or 45 Gy in 30 fx over 3 wk using BID fractions of 1.5 Gy1
PCI; SCLC	LS-SCLC: 25 Gy in 10 fx over 2 wk	LS-SCLC: 25 Gy in 10 fx; ES-SCLC: 20 Gy in 5 fractions or MRI surveillance	Delay treatment	LS-SCLC: 25Gy in 10 fx; ES-SCLC: MRI surveillance (if available)
Palliative	Preferred fractionation schedule: 20 Gy in 5 fx (30%); 17 Gy in 2 fx (37%); 8-10 Gy in 1fx (33%)	-20 Gy in 5 fx; -17 Gy in 2 fx; -10 Gy in 1fx	Pain or bony lesion: 8 Gy × 1 fx; Bleeding: 10 Gy × 1 fx; If single fraction not possible, hypofractionate dose to extent possible; Brain metastases can be deferred per algorithm, and treated with single fraction radiosurgery; Endobronchial obstruction: Consider 8 Gy × 1 or 17 Gy in 2 weekly fractions	Pain or bony lesion: 8 Gy × 1 fx; Bleeding: 10 Gy x 1 fx, 20 Gy × 5fx; If single fraction not possible, hypofractionate dose to extent possible; Multiple brain metastases: 20 Gy × 5 fx (in favourable subgroup); MSCC: 8 Gy × 1fx

¹Selected cases, if there are resource limitations in the radiotherapy department, consider hypofractionated radiotherapy administered sequentially after chemotherapy. CRT: Chemoradiotherapy; Fx: Fraction; NSCLC: Non-small cell lung cancer; SCLC: Non-small cell lung cancer; LS: Limited stage; ES: Extensive stage; MSCC: Malignant spinal cord compression; MSKCC: Memorial sloan-kettering cancer center; PCI: Prophylactic cranial irradiation; PORT: Postoperative radiotherapy; GOECP: Oncologic Group for the Study of Lung Cancer; SEOR: Spanish Society of Radiation Oncology; SBRT: Stereotactic body radiotherapy.