Palliative radiotherapy is widely used in stage IV non-small cell lung cancer (NSCLC). Radiotherapy dose fractionation studies have shown its utility in symptom control with improved survival at higher doses. Recent advances in radiotherapy planning and delivery offer dose escalation while reducing toxicity. However, there are no studies testing palliative radiotherapy in combination with modern systemic therapies and trials are needed to test timing, dose and fractionation in that context.

Background and purpose The use of Magnetic Resonance imaging (MRI) for radiotherapy (RT) planning for locally advanced non-small cell lung cancer (LA NSCLC) could improve RT precision due to its superior soft tissue definition compared to computed tomography (CT). However, thoracic oncologists have limited experience of identifying thoracic structures on MRI. The aim of this study was to provide recommendations for MR sequences for thoracic organ at risk (OAR) contouring and present an atlas and descriptive instructions for delineation of thoracic OARs in the setting of MRI-guided radiation treatment planning and guidance. Materials and methods MRI scans were acquired in nine patients with early-stage lung cancer on a diagnostic 1.5 Tesla system. MRI sequences included T1-weighted and T2-weighted imaging techniques, each optimised for visualisation of particular OARs. OAR delineations were carried out and reviewed by an international panel of thoracic oncologists and MR radiologists. Results Thoracic MRI OAR contouring recommendations and atlas were developed by multi-institutional collaboration of six radiation oncologists and two MR radiologists. The atlas and contouring recommendations are described alongside high-resolution contoured MR images. Conclusions This consensus MRI contouring atlas has a variety of potential applications, from integration of MRI within the standard CT-based workflow in order to improve the contouring accuracy of challenging structures such as the brachial plexus, to forming the foundation of an MRI-only workflow for use in MRI-guided treatment machines. This guideline should provide a useful reference for education and will facilitate uniformity in MRI-based contouring of OARs.

Background and purpose The use of Magnetic Resonance imaging (MRI) for radiotherapy planning and guidance for locally advanced non-small cell lung cancer (LA NSCLC) is novel. The superior soft tissue definition of MRI compared to CT, may facilitate more accurate gross tumour volume (GTV) definition, with the goal of improving radiotherapy precision. This work aims to develop GTV contouring recommendations for NSCLC on MRI. Materials and methods Two international training workshops on GTV delineation for LA NSCLC were attended by thoracic radiation oncologists and MR radiologists. Thoracic radiation oncology experts contoured nine cases of LA NSCLC, firstly, on mid-position 4D-CT with PET-CT guidance, and secondly on non-contrast MRI, registered with the CT and PET-CT. Consensus contours generated on CT and MRI were discussed and finalised during two international meetings. Results Recommendations on GTV delineation for LA NSCLC for both the primary tumour and individual lymph node stations using thoracic MRI were produced and are provided in this document. Consensus contours generated on CT and MRI for specific clinical scenarios were demonstrated and challenges addressed. Conclusions We provide the first set of consensus recommendations on GTV contouring on MRI for LA NSCLC through an international collaborative process between international experts in thoracic radiation oncology and MR radiology. This work provides an initial step towards standardisation of lung GTV delineation on MRI which is necessary prior to any meaningful assessment of the benefits of MRI in GTV definition compared to current practice.

Background: There is an unmet need in patient monitoring between the end of radiotherapy and the first follow-up appointment during which patients may experience severe side effects. Personalised follow-up has the potential to tailor healthcare to individual needs. ePROMs enable remote monitoring and identification of those needing earlier intervention. Purpose: To assess the feasibility of integrating ePROMs into personalised follow-up of patients after radiotherapy. Materials and Methods: Patients with lung or head and neck (HN) cancer were enrolled. ePROMs questionnaires, comprising EQ-5D-5L and 14 lung or 19 HN cancer-specific questions adapted from CTCAE v5.0, were sent to patients at eight timepoints: pre-radiotherapy, mid-radiotherapy, end of radiotherapy, weekly for four weeks post-treatment, and first face-to-face follow-up appointment. Upon completion, automated advice was provided based on responses. Grade 2 or above symptoms were escalated to clinicians. Patient feedback was obtained through structured interviews. Results: Over two months, 19 eligible patients (10 lung, 9 HN) were recruited: 13 received concurrent chemoradiotherapy, and six received radiotherapy alone. ePROMs completion rate was 69.1%, ranging from 47.4% to 89.5% at each timepoint. Three patients reported grade 3 or above symptoms on 5 instances during and after radiotherapy. Fourteen patients participated in the interviews: all 14 reported ePROMs were easy to complete, took an acceptable amount of time, and made them feel better supported. Conclusion: Integrating ePROMs into personalised follow-up is feasible and acceptable to patients. ePROMs provide insights into patients’ symptoms during and after radiotherapy, highlighting the need for a tailored approach.

Purpose:Stereotactic ablative radiation therapy (SABR) is a standard of care for early-stage lung cancer and thoracic oligometastatic or oligoprogressive disease. However, ultracentral lesions remain challenging because of their proximity to critical mediastinal structures and the associated risk of severe toxicity. Stereotactic magnetic resonance-guided adaptive radiation therapy (SMART) allows for daily plan adaptation and real-time tracking in breath-hold, enhancing target coverage while improving sparing of adjacent organs compared to conventional SABR. Methods and Materials:This retrospective study analyzed outcomes of SMART-based SABR for ultracentral metastatic lesions in patients with histologically confirmed non-small cell lung cancer (NSCLC). Ultracentral lesions were defined by planning target volume overlapping with the proximal bronchial tree, esophagus, or pulmonary vessels. Endpoints included grade ≥ 3 SMART-related toxicity, freedom from local progression, progression-free survival, and overall survival. Results:Between 2020 and 2023, 11 patients with 18 ultracentral NSCLC lesions underwent SMART. All treatments were delivered in breath-hold. The median dose was 40 Gy (range, 30-60 Gy) in 5 to 8 fractions. Online plan adaptation was performed for 100% of the 78 delivered fractions. No grade ≥ 3 toxicities were observed. Rates of grade 1 to 2 acute and late toxicities were 54% and 18%, respectively. At a median follow-up of 28 months (range, 5-41 months), 66.7% of patients were alive. One-year freedom from local progression was 93%. Median progression-free survival was 5.8 months (range, 1-39 months), and median overall survival was 20 months (range, 5-41 months). Conclusions:SMART with daily online adaptation achieved excellent local control and a favorable safety profile in ultracentral NSCLC, comparable to conventional non-adaptive SABR, but without severe toxicity.

Virtual clinical trials use computer simulations (e.g. radiation physics and radiobiology) and/or real-world data (e.g. patient anatomy and tissue characteristics) to model radiation oncology treatments, addressing limitations of traditional clinical trials. They aim to enhance subsequent trial design, improve patient selection, and reduce risk of unsuccessful trials. AI promises to boost their precision, enabling faster, more efficient research that keeps pace with evolving technologies and better reflects real-world clinical practice. Note: Many different terms are used in the literature to describe computer-simulated research approaches, including virtual clinical trials, simulated trials, and in silico trials. In this paper, we have chosen to use the term virtual clinical trials for consistency and clarity.