Investigator Decision

Current dose escalation regimens with and without chemotherapy have failed to achieve improved local control and overall survival over standard of care therapy to date. Difficulties with dose escalation have been largely due to dose limiting toxicities of surrounding normal organs, in particular to the normal lung parenchyma, and esophagus. Real time, online adaptive planning using magnetic resonance imaging (MRI) could achieve significant volume reduction of primary lung disease over the course of therapy, thereby reducing dose to normal structures, and providing a mechanism in which to dose escalate safely, and more effectively with accurate target delineation.

The investigators hypothesize that MRI based adaptive planning will provide a novel method to dose escalate safely with acceptable organ at risk doses. In addition, further improvements in radiotherapy targeting accuracy, normal tissue avoidance, and conformality of target-tissue coverage will be achieved through the use of 4D real-time tracking which is derived by deformably registering daily MR and planning MR (MRsim) and Computed Tomography Simulator (CTsim) with advanced non-rigid image-registration tools.

This study is a single-arm phase II study of adaptive radiotherapy using ViewRay MRI based imaging in locally Advanced non-small cell lung cancer patients. Randomization is not applicable.

Inclusion Criteria:

1. Patient must have primary lung tumor identified on MRI, histologically proven to be NSCLC.

2. Patients must be clinical AJCC stage IIIA or IIIB (AJCC 7th ed) with non-operable disease; evaluated by a multidisciplinary treatment team including at least 1 thoracic surgeon within 8 weeks prior to registration.

3. Patients with multiple, ipsilateral pulmonary nodules (T3, or T4) are eligible

4. Minimum diagnostic workup to include:

   • History/physical examination, including documentation of weight, within 8 weeks prior to registration (2 weeks optimal)

   • Diagnostic CT scan for staging and RT plan within 4 weeks prior to registration;

   • CT scan or sim CT of chest and upper abdomen (IV contrast is recommended unless medically contraindicated) within 6 weeks prior to registration;

   • CT scan of the brain (contrast is recommended unless medically contraindicated) or MRI of the brain within 6 weeks prior to registration

   • Able to tolerate repeated MRI imaging

   • Pulmonary function tests, including diffusing capacity of the lung for carbon monoxide (DLCO), within 6 weeks prior to registration; patients must have forced expiratory volume in one second (FEV1) ≥ 1.2 Liter or ≥ 50% predicted without bronchodilator;

   • Zubrod Performance Status 0-1 within 2 weeks prior to registration

   • Age ≥ 18;

   • Complete blood count (CBC)/differential obtained no more than 8 weeks prior to registration on study, with adequate bone marrow function defined as follows:

     • White blood cell (WBC) ≥ 4000/ml
     • Absolute neutrophil count (ANC) ≥1,800 cells/mm
     • Platelets ≥100,000 cells/mm
     • Hemoglobin ≥ 10.0 mg/dl (Note: the use of transfusion or other intervention to achieve this level is acceptable)

   • Serum creatinine, blood urea nitrogen, alanine aminotransferase (ALT), aspartate aminotransferase (AST), Alk Phos, total bilirubin, serum electrolytes (eg. Sodium, potassium, chloride, bicarbonate, calcium), glucose, total protein, albumin will be drawn no greater than 8 weeks prior to enrollment.

     • Serum creatinine of 1.5mg or less; serum bilirubin of 2.0mg or less; creatinine clearance of 60ml/min or greater no more than 4 weeks prior to registration (Note: calculated creatinine clearance is permissible. If the creatinine clearance is greater than 60ml/min, then a serum creatinine of up to 1.8mg is allowable at the discretion of the PI

   • Serum pregnancy test for female patients of childbearing potential, ≤8 weeks prior to enrollment; women of childbearing potential and male participants must practice adequate contraception on trial

   • Patients must be able to provide study-specific informed consent prior to study entry

   • Patients must agree to have their biopsy tissue and blood banked for future molecular studies

Exclusion Criteria:

1. Patients with any component of small cell lung carcinoma are excluded

2. Evidence of distant metastases.

3. Patients with evidence of a malignant pleural or pericardial effusion.

4. Previous systemic chemotherapy (for any cancer) or pelvic radiation therapy

5. A prior or concurrent malignancy of any other site or histology unless the patient has been disease free for greater than or equal to five years except for nonmelanoma skin cancer and/or stage T1a prostate cancer or carcinoma in situ of the uterine cervix.

6. Prior radiotherapy that would result in overlap of radiation fields

7. Patients taking drugs with potential nephrotoxicity or ototoxicity (such as aminoglycosides)

8. Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the treatment involved in this study may be significantly teratogenic

9. Prior allergic reaction to the study drug(s) involved in this protocol

10. Patients with T4 disease with radiographic evidence of invasion of a large pulmonary artery and tumor causing significant narrowing and destruction of that artery are excluded.

11. Severe active co-morbidity:

    • Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months
    • Transmural myocardial infarction within the last 6 months
    • Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
    • Chronic Obstructive Pulmonary Disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of registration
    • Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects (Note: laboratory tests for liver function and coagulation parameters are not required for entry into this protocol)
    • Acquired Immune Deficiency Syndrome (AIDS) based upon current Centers for Disease Control and Prevention (CDC) definition (Note: HIV testing is not required for entry into this protocol) The need to exclude patients with AIDS from this protocol is necessary because the treatments involved in this protocol may be significantly immunosuppressive. Protocol-specific requirements may also exclude immune-compromised patients