BACKGROUND Recognizing the rapidly increasing interest and evidence in using metastasis-directed radiotherapy (MDRT) for oligometastatic disease (OMD), ESTRO and ASTRO convened a committee to establish consensus regarding definitions of OMD and define gaps in current evidence. METHODS A systematic literature review focused on curative intent MDRT was performed in Medline, Embase and Cochrane. Subsequent consensus opinion, using a Delphi process, highlighted the current state of evidence and the limitations in the available literature. RESULTS Available evidence regarding the use of MDRT for OMD mostly derives from retrospective, single-centre series, with significant heterogeneity in patient inclusion criteria, definition of OMD, and outcomes reported. Consensus was reached that OMD is largely independent of primary tumour, metastatic location and the presence or length of a disease-free interval, supporting both synchronous and metachronous OMD. In the absence of clinical data supporting a maximum number of metastases and organs to define OMD, and of validated molecular biomarkers, consensus supported the ability to deliver safe and clinically meaningful radiotherapy with curative intent to all metastatic sites as a minimum requirement for defining OMD in the context of radiotherapy. Systemic therapy induced OMD was identified as a distinct state of OMD. High-resolution imaging to assess and confirm OMD is crucial, including brain imaging when indicated. Minimum common endpoints such as progression-free and overall survival, local control, toxicity and quality-of-life should be reported; uncommon endpoints as deferral of systemic therapy and cost were endorsed. CONCLUSION While significant heterogeneity exists in the current OMD definitions in the literature, consensus was reached on multiple key questions. Based on available data, OMD can to date be defined as 1-5 metastatic lesions, a controlled primary tumor being optional, but where all metastatic sites must be safely treatable. Consistent definitions and reporting are warranted and encouraged in ongoing trials and reports generating further evidence to optimize patient benefits.
Background The COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. Methods For this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. Results In a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. Conclusion This joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.
Purpose Because of the unprecedented disruption of health care services caused by the COVID-19 pandemic, the American Society of Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) identified an urgent need to issue practice recommendations for radiation oncologists treating head and neck cancer (HNC) in a time of limited resources and heightened risk for patients and staff. Methods and Materials A panel of international experts from ASTRO, ESTRO, and select Asia-Pacific countries completed a modified rapid Delphi process. Topics and questions were presented to the group, and subsequent questions were developed from iterative feedback. Each survey was open online for 24 hours, and successive rounds started within 24 hours of the previous round. The chosen cutoffs for strong agreement (≥80%) and agreement (≥66%) were extrapolated from the RAND methodology. Two pandemic scenarios, early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated. The panel developed treatment recommendations for 5 HNC cases. Results In total, 29 of 31 of those invited (94%) accepted, and after a replacement 30 of 30 completed all 3 surveys (100% response rate). There was agreement or strong agreement across a number of practice areas, including treatment prioritization, whether to delay initiation or interrupt radiation therapy for intercurrent SARS-CoV-2 infection, approaches to treatment (radiation dose-fractionation schedules and use of chemotherapy in each pandemic scenario), management of surgical cases in event of operating room closures, and recommended adjustments to outpatient clinic appointments and supportive care. Conclusions This urgent practice recommendation was issued in the knowledge of the very difficult circumstances in which our patients find themselves at present, navigating strained health care systems functioning with limited resources and at heightened risk to their health during the COVID-19 pandemic. The aim of this consensus statement is to ensure high-quality HNC treatments continue, to save lives and for symptomatic benefit.
PURPOSE The summary presented herein represents Part II of the two-part series dedicated to Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline discussing prognostic and treatment recommendations for patients with castration-resistant disease. Please refer to Part I for discussion of the management of patients with biochemical recurrence without metastatic disease after exhaustion of local treatment options as well as those with metastatic hormone-sensitive prostate cancer. RESULTS The Advanced Prostate Cancer Panel created evidence- and consensus-based guideline statements to aid clinicians in the management of patients with advanced prostate cancer. Such statements are summarized in figure 1 and detailed herein. MATERIALS AND METHODS The systematic review utilized to inform this guideline was conducted by an independent methodological consultant. A research librarian conducted searches in Ovid MEDLINE (1998 to January Week 5 2019), Cochrane Central Register of Controlled Trials (through December 2018), and Cochrane Database of Systematic Reviews (2005 through February 6, 2019). An updated search was conducted prior to publication through January 20, 2020. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles. CONCLUSIONS This guideline attempts to improve a clinician's ability to treat patients diagnosed with advanced prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to improve the level of care for these patients.
PURPOSE The central nervous system World Health Organization (WHO) grade 4 adult-type diffuse glioma represents one of the most aggressive and challenging primary brain tumors. This guideline aims to provide evidence-based recommendations for the multidisciplinary management of these tumors, focusing on diagnosis, initial treatment, reirradiation, and health disparities, while acknowledging that present literature primarily represents historical histological grade 4 glioblastoma. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on indications for radiation therapy (RT) and/or adjunctive therapies (eg, systemic therapy, alternating electric field therapy), appropriate regimens for external beam RT after initial biopsy/resection including variables such as pretreatment characteristics, target volumes, technique, dose, reirradiation indications and techniques, and health disparities. Recommendations are based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Following maximum safe resection, molecular and pathologic diagnosis, and prognostic stratification of WHO grade 4 adult-type diffuse glioma, concurrent RT with temozolomide followed by adjuvant temozolomide is recommended for eligible patients and incorporation of alternating electric field therapy is conditionally recommended. In elderly patients, hypofractionated RT with concurrent and adjuvant temozolomide is conditionally recommended. In frail patients, supportive and palliative care is conditionally recommended following multidisciplinary, patient-centered discussion. Appropriate reirradiation techniques, with or without additional systemic therapies, can be considered and are conditionally recommended in patients following pathologic or advanced imaging confirmation of WHO grade 4 diffuse glioma recurrence. Health disparities exist in patients with WHO grade 4 adult-type diffuse glioma and attention is necessary to improve outcomes and increase clinical trial enrollment for underserved populations. CONCLUSIONS These evidence-based recommendations and current practice adoption patterns inform best clinical practices on the management of WHO grade 4 adult-type diffuse glioma. Future advancements in personalized medicine, biomarker discovery, and novel therapies are essential to improving outcomes. The integration of multidisciplinary care and participation in future clinical trials, especially in underserved populations, is crucial in addressing the poor outcomes among WHO grade 4 adult-type diffuse glioma.
The Chinese Society for Therapeutic Radiology Oncology, the Chinese Anti-Cancer Association, the Chinese Society of Clinical Oncology, the Head and Neck Cancer International Group, the European Society for Radiotherapy and Oncology, and the American Society for Radiation Oncology collaboratively developed evidence-based guidelines and a comprehensive contouring atlas for neck target volume delineation in nasopharyngeal carcinoma. These guidelines address five key challenges in modern radiotherapy practice: margin design of clinical target volume; nodal target volume delineation after induction chemotherapy; delineation of equivocal nodes evident on imaging; low-risk clinical target volume delineation based on regional stepwise extension patterns; and modifications for anatomical boundaries of lymphatic areas. Developed through a rigorous systematic review and expert appraisal process by a panel of 50 international, multidisciplinary members from 17 countries and regions, these guidelines incorporate the latest advances in nasopharyngeal carcinoma diagnosis and treatment. They reflect contemporary therapeutic concepts and elaborate on current practice variations. These guidelines aim to standardise global practice, substantially improving consistency and reducing variability in nasopharyngeal carcinoma radiotherapy target delineation.
PURPOSE This guideline provides evidence-based recommendations on the use of postmastectomy radiation therapy (PMRT) in the treatment of breast cancer. PMRT refers to the treatment of the chest wall and ipsilateral regional nodes, including at-risk axillary, supra/infraclavicular, and internal mammary nodes. Updated recommendations detail indications for PMRT in the upfront surgical setting and after neoadjuvant systemic therapy, and provide guidance on appropriate target volumes, dosing, and treatment techniques. METHODS The American Society for Radiation Oncology, American Society of Clinical Oncology, and the Society of Surgical Oncology convened a multidisciplinary task force to address 4 key questions focused on radiation therapy (RT) in patients with breast cancer who undergo mastectomy including (1) indications for PMRT after upfront surgery, (2) indications for PMRT after neoadjuvant systemic therapy followed by surgery, (3) appropriate PMRT treatment volumes and dose-fractionation regimens, and (4) treatment techniques. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation. RESULTS After upfront mastectomy, PMRT is indicated for most patients with node-positive breast cancer and select patients with node-negative disease. PMRT is also recommended after neoadjuvant systemic therapy, both for patients presenting with locally advanced disease and for those with residual nodal disease at the time of surgery. PMRT is conditionally recommended for patients with cT1-3N1 or cT3N0 breast cancer with pathologically negative nodes after neoadjuvant systemic therapy (ypN0). When PMRT is delivered, treatment to the ipsilateral chest wall/reconstructed breast and regional lymphatics is recommended, with moderate hypofractionation preferred, but with conventional fractionation approaches acceptable in rare cases. Computed tomography-based volumetric treatment planning with 3-dimensional conformal RT is recommended, with intensity modulated RT advised when 3-dimensional conformal RT is unable to achieve treatment goals. Deep inspiration breath hold techniques are also recommended for normal tissue sparing. For patients with skin involvement, positive superficial margins, and/or lymphovascular invasion, the use of a bolus is recommended, but the routine use of tissue-equivalent bolus is not recommended. CONCLUSIONS These evidence-based recommendations guide clinical practice on the use of PMRT in patients with breast cancer.
The Chinese Society for Therapeutic Radiology Oncology, the Chinese Anti-Cancer Association, the Chinese Society of Clinical Oncology, Head and Neck Cancer International Group, the European Society for Radiotherapy and Oncology, and the American Society for Radiation Oncology jointly developed evidence-based guidelines and a contouring atlas for primary target volume delineation for radiotherapy in nasopharyngeal carcinoma. The guidelines systematically address three crucial challenges: margin design of clinical target volumes; target volume delineation after induction chemotherapy; and low-risk clinical target volume delineation based on local stepwise extension patterns. Based on a comprehensive systematic review and critical appraisal by an international multidisciplinary panel of 50 nasopharyngeal carcinoma specialists from 17 countries and regions, these guidelines are in keeping with advances in nasopharyngeal carcinoma diagnosis and treatment, embodying contemporary treatment concepts, and elaborating on the differences in practice. These guidelines aim to support global clinical practice in radiotherapy target volume delineation, substantially enhancing homogeneity and reducing variability in nasopharyngeal carcinoma target delineation.
In this study, we examine the frequency and physical drivers of transformations from cool-core (CC) to non-cool-core (NCC) clusters, and vice versa, in a sample of 352 massive galaxy clusters (M_vir = 10^14-15.3 M_sun) from the TNG-Cluster magnetohydrodynamical cosmological simulation of galaxies. By identifying transformations based on the evolution of central entropy and focusing on z<2.5, we find that clusters frequently undergo such events, depending on their assembly and supermassive black hole histories. On average, clusters experience 2 to 3 transformations. Transformations can occur in both directions and can be temporary, but those to higher entropy cores, i.e. in the direction from CC to NCC states, are the vast majority. CC phases are shorter than NCC phases, and thus overall the TNG-Cluster population forms with low-entropy cores and moves towards NCC states with time. We study the role that mergers play in driving transformations, and find that mergers within ~1Gyr prior to a transformation toward higher (but not lower) entropy cores occur statistically more often than in a random control sample. Most importantly, we find examples of mergers associated with CC disruption regardless of their mass ratio or angular momentum. However, past merger activity is not a good predictor for z=0 CC status, at least based on core entropy, even though clusters undergoing more mergers eventually have the highest core entropy values at z=0. We consider the interplay between AGN feedback and evolving cluster core thermodynamics. We find that core transformations are accompanied by an increase in AGN activity, whereby frequent and repeated (kinetic) energy injections from the central SMBHs can produce a collective, long-term impact on central entropy, ultimately heating cluster cores. Whether such fast-paced periods of AGN activity are triggered by mergers is plausible, but not necessary.
PURPOSE With the results of several recently published clinical trials, this guideline focused update provides evidence-based recommendations for the indications and dose-fractionation regimens for neoadjuvant radiation therapy (RT), optimal sequencing of RT and systemic therapy in the context of total neoadjuvant therapy (TNT), and considerations for selective omission of RT and surgery for rectal cancer. METHODS The American Society for Radiation Oncology convened a multidisciplinary task force to update 3 key questions that focused on the role of RT for patients with operable rectal cancer. The key questions addressed (1) indications for neoadjuvant RT, (2) selection of neoadjuvant regimens, and (3) indications for consideration of a nonoperative management (NOM) or local excision approach after definitive/preoperative chemoradiation. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation. RESULTS For patients with stage II-III rectal cancer, neoadjuvant RT was strongly recommended; however, among patients deemed at lower risk of locoregional recurrence, consideration of omission of neoadjuvant RT was conditionally recommended in favor of neoadjuvant chemotherapy with a favorable treatment response or upfront surgery. For patients with T3-T4 and node positive rectal cancer undergoing neoadjuvant RT, a TNT approach was strongly recommended. Among patients with higher risk of locoregional recurrence, TNT with chemotherapy before or after long-course chemoradiation was strongly recommended, whereas TNT with short-course RT followed by chemotherapy was conditionally recommended. For patients with rectal cancer for whom NOM is a priority, concurrent chemoradiation followed by consolidation chemotherapy was strongly recommended. Selection of RT dose-fractionation regimen, sequencing of therapies, and consideration of NOM should be determined by multidisciplinary consensus, and based on disease extent, disease location, patient preferences, and quality of life considerations. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of RT for rectal cancer with strong emphasis on multidisciplinary care. Future studies should focus on further addressing optimal treatment regimens to allow for more personalized recommendations based on individual risk stratification and patient priorities regarding quality of life.
PURPOSE Adaptive radiation therapy (ART) is the latest topic in a series of white papers published by the American Society for Radiation Oncology addressing quality processes and patient safety. ART widens the therapeutic index by improving precision of radiation dose to targets, allowing for dose escalation and/or minimization of dose to normal tissue. ART is performed via offline or online methods; offline ART is the process of replanning a patient's treatment plan between fractions, whereas online ART involves plan adjustment with the patient on the treatment table. This is achieved with in-room imaging capable of assessing anatomical changes and the ability to reoptimize the treatment plan rapidly during the treatment session. Although ART has occurred in its simplest forms in clinical practice for decades, recent technological developments have enabled more clinical applications of ART. With increased clinical prevalence, compressed timelines and associated complexity of ART, quality and safety considerations are an important focus area. METHODS ASTRO convened an interdisciplinary task force to provide expert consensus on key workflows and processes for ART. Recommendations were created using a consensus-building methodology and task force members indicated their level of agreement based on a 5-point Likert scale, from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters selecting "strongly agree" or "agree" indicated consensus. Content not meeting this threshold was removed or revised. SUMMARY Establishing and maintaining an adaptive program requires a team-based approach, appropriately trained and credentialed specialists as well as significant resources, specialized technology, and implementation time. A comprehensive quality assurance program must be developed, using established guidance, to make sure all forms of ART are performed in a safe and effective manner. Patient safety when delivering ART is everyone's responsibility and professional organizations, regulators, vendors, and end-users must demonstrate a clear commitment to working together to deliver the highest levels of quality and safety.
Boris Schmidt, Stefano Bordignon, A. Metzner
et al.
BACKGROUND: Ablation strategies for patients with symptomatic atrial fibrillation and isolated pulmonary veins vary and their effects on arrhythmia recurrence remain unclear. A prospective randomized German multicenter trial sought to compare 2 ablation strategies in this patient cohort. METHODS: Patients with atrial fibrillation despite durable pulmonary vein isolation were randomly assigned at 7 centers to undergo low-voltage area ablation using 3-dimensional mapping and irrigated radiofrequency current ablation (group A) or empirical left atrial appendage isolation (LAAI) using the cryoballoon followed by staged interventional left atrial appendage closure (group B). The primary end point was freedom from atrial tachyarrhythmias between 91 and 365 days after index ablation. The study was powered for superiority of LAAI compared with low-voltage area. RESULTS: Patients (40% women; mean age, 68.8±8 years) with paroxysmal (32%) or persistent atrial fibrillation (68%) were randomized to undergo low-voltage area ablation (n=79) or cryoballoon-guided LAAI (n=82). After a planned interim analysis, enrollment was halted for futility on January 10, 2023. In the LAAI group, 77 of 82 left atrial appendages were successfully isolated with subsequent left atrial appendage closure in 57 patients. Procedure-related complications occurred in 4 (5%) and 11 (13.5%) patients in group A and B, respectively (P=0.10). The median follow-up was 367 days (interquartile range, 359–378). The Kaplan-Meier point estimate for freedom from atrial tachyarrhythmias was 51.7% (CI, 40.9%–65.4%) for group A and 55.5% (CI, 44.4%–69.2%; P=0.8069) for group B. CONCLUSIONS: The current study did not detect superiority of cryoballoon-guided LAAI over low-voltage area ablation in patients with atrial fibrillation despite durable PVI. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04056390.
Intraoperative radiotherapy (IORT) is considered a de‐escalating adjuvant treatment for breast cancer low‐risk patients. However, the broader criteria applied by the Taiwan IORT Study Cooperative Group led to an increased rate of locoregional recurrence (LRR) among patients receiving only IORT. Consequently, we revised the criteria for sole IORT treatment to include patients who meet the American Society for Radiation Oncology (ASTRO) eligibility standards. This study aims to investigate how aligning treatment strategies with ASTRO guidelines impacts oncological outcomes in patients receiving IORT.
Past scholars noted that one of the challenges is education in relation to tourism particularly the aspects of training and curriculum design. Existing literature has explored challenges of customer services education in tourism and suggest measures such as retraining and improving the curricula as a remedy to match the skills needed in the post pandemic for the hospitality and tourism industry. Conversely, there is less attention on other forms of tourism like astro-tourism. Hence, this paper’s aim is to expand literature on education in tourism with the main objective of exploring astro-tourism and education in tourism. Guided by the behaviorist learning theory, the specific objective is to explore the forms of astro-tourism and training programs from the perspective of Kenya and Tanzania. A systematic literature review supplemented by integrative literature review is deployed as a research methodology. A total of 16 papers from journals, conferences and newsflash deemed sufficient for descriptive statistics and literature analysis to avail findings. The findings indicate that although various forms of astro-tourism exist, these are not fully complemented with training programs. Very few public institutions or private enterprises offer astro-tourism programs like astro tour guide. The findings suggest that both higher education institutions and the private sector should continue promoting tourism education that includes training programs aligned with the growing trends in astro-tourism.
The redshifted 21cm signal from the Cosmic Dawn is expected to provide unprecedented insights into early Universe astrophysics and cosmology. Here, we briefly summarize how decaying dark matter can heat the intergalactic medium before the first galaxies, leaving a distinctive imprint on the 21cm power spectrum. We discuss the first Fisher matrix forecasts on the sensitivity of the Hydrogen Epoch of Reionization Array telescope (HERA) and argue that HERA can improve by up to three orders of magnitude previous cosmology constraints. In these proceedings, we project these future bounds in the plane of the Axion like particles (ALP) coupling to photons as a function of the ALP mass. We focus on the ALP mass range between $\sim$ 10 keV and 1 MeV where the 21cm signal power spectrum probes are expected to improve on any other current dark matter searches. This illustrates how 21cm cosmology can be expected to help in probing uncharted regions of the dark matter parameter space beyond the reach of existing astro-particle and cosmology experiments.
We present a framework that for the first time allows Bayesian model comparison to be performed for field-level inference of cosmological models. We achieve this by taking a simulation-based inference (SBI) approach using neural likelihood estimation, which we couple with the learned harmonic mean estimator in order to compute the Bayesian evidence for model comparison. We apply our framework to mock Stage IV cosmic shear observations to assess its effectiveness at distinguishing between various models of dark energy. If the recent DESI results that provided exciting hints of dynamical dark energy were indeed the true underlying model, our analysis shows Stage IV cosmic shear surveys could definitively detect dynamical dark energy. We also perform traditional power spectrum likelihood-based inference for comparison, which we find is not able to distinguish between dark energy models, highlighting the enhanced constraining power for model comparison of our field-level SBI approach.
I take a reflection of the mathematical method of integration applied in physics and astrophysics in the research. I examine the theoretical premise of integration entailed in its applications in the fields, and with qualitative comparative analysis, regard the inconsistency of the mathematical method in physical and astrophysical theories. I seek to uncover the formal science’s affinity to the natural sciences in the research, and assert that number theory and set theory are better substitutes in modern physics and astrophysics. With a relativistic (astro-)physics perspective, I discuss and compare the representations of causality, capacities for deviations, and error tolerance with the methodological approach. I discuss the implications with the example of the Cosmic Microwave Background, and conclude with the teleology of the (astro-)physical sciences.
PURPOSE To develop a radiation therapy summary of recommendations on the management of locally advanced non-small cell lung cancer (NSCLC) based on the Management of Stage III Non-Small Cell Lung Cancer: American Society of Clinical Oncology Guideline, which was endorsed by the American Society for Radiation Oncology (ASTRO). METHODS The American Society of Clinical Oncology, ASTRO, and the American College of Chest Physicians convened a multidisciplinary panel to develop a guideline based on a systematic review of the literature and a formal consensus process, that has been separately published. A new panel consisting of radiation oncologists from the original guideline as well as additional ASTRO members was formed to provide further guidance to the radiation oncology community. A total of 127 articles met the eligibility criteria to answer 5 clinical questions. This summary focuses on the 3 radiation therapy questions (neoadjuvant, adjuvant, and unresectable settings). RESULTS Radiation-specific recommendations are summarized with additional relevant commentary on specific questions regarding the management of preoperative radiation, postoperative radiation, and combined chemoradiation. CONCLUSIONS Patients with stage III NSCLC who are planned for surgical resection, should receive either neoadjuvant chemotherapy or chemoradiation. The addition of neoadjuvant treatment is particularly important in patients planned for surgery in the N2 or superior sulcus settings. Postoperatively, patients who did not receive neoadjuvant chemotherapy should be offered adjuvant chemotherapy. The use of postoperative radiation for completely resected N2 disease is not routinely recommended. Unresectable patients with stage III NSCLC should ideally be managed with combined concurrent chemoradiation using a platinum-based doublet with a standard radiation dose of 60 Gy followed by consolidation durvalumab in patients without progression after initial therapy. Patients who cannot tolerate a concurrent chemoradiation approach can be managed either by sequential chemotherapy followed by radiation or by dose-escalated or hypofractionated radiation alone.