Lung cancer with brain metastasis has a poor prognosis and has always been treated with palliative intent in the past. We report a case of good response to two courses of whole brain irradiation (WBI) and one course of hypofractionated stereotactic radiotherapy (HSRT) over a nine-year period, with no significant neurotoxicity. We present the case of a 43-year-old non-smoker female with biopsy-proven adenocarcinoma of right lower lobe lung, stage T1N2M0, positive for anaplastic lymphoma kinase (ALK). She received concurrent 60-Gy chemoradiation in 30 fractions in 2010. She had no local recurrence, but biopsy confirmed distant metastases in neck lymph nodes nine months later. As a result of a 3-cm brain metastasis in the right cerebellum on computed tomography (CT), she received 20-Gy WBI in five fractions. We did not treat any other distant metastases with radiation. She only received systemic tyrosine kinase inhibitors (TKIs). Four years after the first WBI, she developed headaches and balance problem. MRI showed at least nine metastatic lesions in the brain. She had a craniotomy to remove the largest 4-cm lesion in the right cerebellum followed by 21-Gy WBI in seven fractions. Her symptoms disappeared, and she went back to her normal life. Another MRI three years after the second WBI showed progression of the largest brain metastases in the right cerebellum. We offered her 20-Gy HSRT in five fractions every other day. She tolerated HSRT very well, with no neurotoxicity. She was able to walk without a walker or cane. She could manage all her daily activities. On examination, there was no neurological deficit. CT scan nine months after HSRT showed excellent local control. Stage 4 non-small cell lung cancer with positive ALK can have a good response to TKI, and long survival is possible even with multiple brain metastases. Not all patients will have severe neurotoxicity after multiple courses of WBI. HSRT can be a good alternative treatment to symptomatic brain metastases if craniotomy is not desirable. The acute and late toxicities can be reasonably tolerated. Long-term local control and good quality of life are achievable.

Extensive stage small cell lung cancer (ES-SCLC) with symptomatic brain metastasis (BM) carries very poor prognosis with a median survival of only three to four months. This case shows the potential benefit of offering aggressive multimodality treatment to achieve the best quality of life and to improve survival. A complete response (CR) was achieved following craniotomy, whole brain irradiation (WBI), palliative chemotherapy, and palliative consolidative thoracic radiotherapy (CTRT) for ES-SCLC with large symptomatic BM. There was no residual cancer or further metastasis seen on CT imaging. The patient remains cancer free and asymptomatic nine years after the initial diagnosis.

The gold standard treatment of stage I non-small cell lung cancer (NSCLC) is surgical resection. For medically inoperable patients, stereotactic body radiation therapy (SBRT) can provide comparable local control (LC) and overall survival (OS). The objectives of this study are to determine the three-year LC and OS for SBRT compared to early-stage NSCLC patients treated with alternative radiation modalities at our institution. This retrospective study included a total of 139 consecutive patients who were diagnosed with stage I (T1-2 N0 M0) NSCLC and treated with radiation therapy at our institution between 2015 and 2020. Patient demographics and clinical data were obtained from chart reviews. Treatment subgroups were: SBRT (48Gy/4 or 60Gy/8), hypofractionation (60Gy/15), conventional fractionation (60Gy/30 or 50Gy/20), and palliative radiation (20Gy/5, 30Gy/10, or 40Gy/15). Kaplan-Meier curves were plotted for LC and OS. We also performed Cox’s proportional hazard regression analysis. The median patient age was 74 (range 52-91). The numbers of patients in each treatment subgroup were: SBRT (44), hypofractionation (78), conventional fractionation (8), and palliative (9). Differences in age, gender, and histopathological cell type between subgroups were not statistically significant. Metastatic progression was the most common outcome amongst treatment failures, followed by local recurrence and regional spread. Median post-treatment follow-up in months for each subgroup was: SBRT (20.2), hypofractionated (20.7), conventional fractionation (13.9), and palliative (14.4). Post-treatment three-year LC was found to be significantly better with SBRT (94%) versus hypofractionation (71%), conventional fractionation (80%), and palliative (71%). OS at three years were SBRT (67%), hypofractionation (59%), conventional fractionation (66%), and palliative (44%). As a whole, 72% (100/139) of patients had biopsy-proven NSCLC. Analysis showed biopsy status had no statistical significance with regards to LC or OS. Every 20 years of age had a 3.2x risk of death (95% CI: 1.425-7.268). Concerning the treatment modalities, there were significant differences for the hazard of death compared to SBRT: hypofractionation had 2.58x increased risk while palliative had 5.83x increased risk. The proportion of patients who experienced post-treatment radiation pneumonitis or dermatitis were: SBRT (7%, 2%), hypofractionation (8%, 3%), conventional fractionation (13%, 25%), and palliative (0%, 0%), respectively. No patients who experienced grade III or higher toxicities were observed as defined by Common Terminology Criteria for Adverse Events (CTCAE). Our experience confirms SBRT can provide durable three-year local control with a comparable rate of post-treatment complications versus other radiation modalities for early-stage NSCLC. SBRT appears to be non-inferior to hypofractionation with regards to three-year LC.