Split Course Research Articles

Adenocarcinoma of the rectum treated by radical external radiation therapy

To assess the long-term survival and response rates of patients with primary rectal cancer to radical radiation therapy. Between 1978 and 1987, 229 patients were treated at the Princess Margaret Hospital with radical external radiation therapy for adenocarcinoma of the rectum. Patients were treated with radiation either because they were considered to have unresectable tumors, were medically unfit, or refused surgery, or for a combination of these factors. Doses ranged from 40 Gy in 10 fractions by a split course over 6 weeks to 60 Gy in 30 fractions in 6 weeks. The most commonly prescribed treatment was 52 Gy target absorbed dose in 20 daily fractions over 4 weeks. The overall 5-year actuarial survival rate was 27%; for patients with mobile tumors, it was 48%, partially fixed 27%, and fixed tumor 4%. Forty-eight of the 97 patients (50%) with mobile tumors, 11 of the 37 patients (30%) with partially fixed tumors, and 7 of the 77 patients (9%) with fixed tumors had clinically complete tumor regression following radiation. Of these, 18 of the mobile, 6 of the partially fixed, and 5 of the fixed tumors later relapsed locally. Fifty patients had salvage surgery after failing to achieve complete remission or for local relapse, with a 5-year actuarial survival rate of 42% from the time of surgery. Although radiation therapy can cure some patients with mobile or partially fixed rectal adenocarcinomas who refuse or are unsuitable for surgery, local control remains a problem; salvage surgery should be considered in patients who relapse or fail to go into complete remission and who are fit to undergo surgery. For patients with fixed rectal cancers, high-dose external-beam radiation should be part of a planned preoperative regimen or be palliative in intent.

Rapidly alternating combination of cisplatinbased chemotherapy and hyperfractionated accelerated radiotherapy in split course for stage IIIA and stage IIIB non-small cell lung cancer: Results of a phase I-II study by the GOTHA group

The prognosis of stage III non-small cell lung cancer (NSCLC) can be improved by a combination of radiotherapy (RT) and chemotherapy (CT). In this study, the GOTHA group evaluated the feasibility, tolerance, tumour response, pattern of failure and effect on survival of a combination alternating accelerated hyperfractionated (AH) RT and CT in patients with tumour stage III NSCLC. 65 patients received 3 cycles of cisplatin 60 mg/m2 and mitomycin C 8 mg/m2 on day 1, and vindesin 3 mg/m2 on days 1 and 8 in weeks 1-2, 5-6 and 9-10, alternating with AHRT, 2 daily 1.5 Gy fractions, 5 days/week, in weeks 2-3 (30 Gy) and weeks 6-7 (33 Gy). The dose actually delivered was > 98% for RT, and 85-100% for CT. Mean duration before last CT cycle was 9.5 weeks. Toxic effects were leucopenia, nausea and vomiting, mucositis, diarrhoea, alopecia and peripheral neuropathy. 1 patient died of bronchial haemorrhage at the end of RT. 1 of 5 patients, who underwent secondary pulmonary resections, died of acute respiratory distress syndrome. Evaluation of tumour response was hampered by lung condensations in radiation fields. Some long-term survivors had an initial tumour response assessed as partial response or no change. First failures were more frequent outside (34) than within (21) radiation fields. The median survival was 15.7 months and the 5 year survival rate was 15% (95% CI = 6-26%). 1 patient died of bladder cancer and another of myocardial infarction. Alternating CT and AHRT, as used in this study, were well tolerated and allowed full dose delivery within less than 12 weeks. Initial response was not predictive of survival. The survival curve is encouraging and the 5 year survival is superior to the 5% generally observed with conventionally fractionated radiotherapy.

International survey of radiotherapy practice for radical treatment of non-small cell lung cancer

This postal survey was designed to assess the possible agreement or differences in staging, selection criteria and radiation volumes for a curative treatment of non-small cell lung cancer. The questionnaire was sent to 263 radiotherapists from 38 different countries; 114 responses (43%) were received. In this sample, some geographical differences, mainly for staging procedures (the use of brain CT scan or bone scan) and selection criteria (the role of positive mediastinal lymph nodes), were seen. There was a good agreement between radiotherapists in the choice of treatment volumes in the five different clinical scenarios. The clinical and radiobiological findings of the last decade have discredited the routine use of split course or hypofractionation schedules. Further studies are needed to improve the technical basis of thoracic radiotherapy.

Carboplatin plus epirubicin plus VP-16, concurrent ‘split course’ radiotherapy and adjuvant surgery for limited small cell lung cancer

Thirty-three patients with limited small cell lung cancer (SCLC) received carboplatin, epirubicin and VP-16 chemotherapy, concurrent ‘split course’ thoracic radiotherapy, followed by surgery for patients achieving an objective response (OR). High-risk patients and those staged T4-N3 (IIIB) at diagnosis, were excluded from surgery. After induction chemoradiotherapy we obtained 90.9% OR, with 63.3% obtaining complete response (CR). Ten patients (30.3%) were eligible for surgery after induction therapy. Five patients (15.1%) were subjected to surgery and five additional patients refused. Of the five patients who were subjected to surgery, four had a complete response (CR), (three pathological confirmations), and one had a partial response (PR), (unresectable). The median survival time for all patients was 16 months with 12.1% of the long-term survivors still living after 2 years and 9% still living after 3 and 4 years. Toxicity consisted mainly of myelosuppression. This study shows a high activity of the chemotherapy and the chemoradiotherapeutic regimen employed but a low feasibility for adjuvant surgery in SCLC.

Curative radiotherapy for technically operable stage I nonsmall cell lung cancer

Purpose : Retrospective study of patients with Stage I nonsmall cell lung cancer (NSCLC) unable to undergo surgery or refusing surgery. Methods and Materials : Between 1984 and 1990, 47 patients with technically operable Stage I NSCLC received hypofractionated radiotherapy. The total dose varied from 32 Gy in six fractions (two fractions/week) or 40 Gy split course in ten fractions (low-dose schedules) to 48 Gy in 12 fractions or 56 Gy in 20 fractions (high-dose schedules). The mean age of the patients was 75 years. Three patients refused surgery and 44 patients were inoperable due to their medical condition. Severe associated disease was present in 34 patients (72.3%). Results : The intrathoracic recurrence rate was 25.5%. In a multivariate analysis, tumor size was identified as the only significant factor predictive for intrathoracic failure ( p < 0.001). Disease-specific survival was 90, 53, and 32% at 1, 3, and 5 years, respectively. In Cox's proportional hazards analysis, only tumor size was predictive for disease-specific survival. Overall survival (all causes) was 70, 33, and 15% at 1, 3, and 5 years, respectively. In Cox's proportional hazards analysis, only the presence of severe associated disease was predictive for overall survival ( p < 0.01), while tumor size did not attain statistical significance ( p = 0.08). There were no severe acute or late side-effects. Conclusion : Radiotherapy can effectively control small nonsmall cell tumors. The reported results are comparable to those achieved with more fractionated radiation schedules. In patients of advanced age or in poor medical condition, hypofractionated radiotherapy can be given with curative intent, with minimal burden to the patient.

Salvage split course brachytherapy for tonsil and soft palate carcinoma: Treatment techniques and results

From December 1981 to October 1990, 28 patients with prior irradiation of the oropharynx underwent salvage brachytherapy for a squamous cell carcinoma of the tonsil and/or the soft palate. The patients were free of cervical nodes and without metastatic disease. There were 4 immediate failures of radiotherapy, 14 local recurrences, and 10 new malignancies. The mean size of the lesion was 2.7 +/- 1.7 cm (range, 0.5 to 7 cm). The initial irradiation had delivered 40 to 80 Gy (mean, 69 Gy) to the oropharynx with a mean interval between external therapy and salvage treatment of 22 +/- 28 months. Salvage brachytherapy consisted of two split course implants done 1 month apart, delivering 35 and 30 Gy, respectively. Fifteen patients (46.5%) were clinically disease-free before the second implant and 23 (82%) were clinically disease-free at the end of treatment. Five local failures have been observed without any influence of the tumor size, the topographic site of the tumor, or the histological differentiation. Of the 4 patients who previously had failed with external beam therapy, 3 were disease-free after salvage brachytherapy. Among the 23 patients in complete remission, 4 (17%) presented a local recurrence within a mean time of 5 months. The overall local control rate was 68% with a mean follow-up of 41 +/- 29 months. The overall actuarial survival was 25% and 19% at 2 and 5 years, respectively; it was 30% at 5 years for the patients presenting with lesions less than or equal to 3 cm. Tolerance was acceptable. Among the 23 patients who achieved complete remission, subsequent soft-tissue necrosis was observed in 4 cases. For these 4 patients, the interval between previous radiation therapy and salvage treatment was short (mean, 7 months). Interstitial split course brachytherapy offers an effective and reasonable option for salvage therapy in patients with recurrent and second cancers occurring in the tonsillar region and in the soft palate, even when the tumor arises in a zone that has previously received high-dose irradiation.

Continuous split course irradiation for stage I and II Hodgkin's disease: 20 year experience at the Medical College of Wisconsin

Between January 1970 and December 1989, 153 consecutive patients with stage I or 11 Hodgkin's disease were treated at the Medical College of Wisconsin Affiliated Hospitals. Eighty-eight patients were clinically staged and 65 patients underwent staging laparotomy. Ninety-nine patients were treated using continuous split course irradiation (CSCI) technique. Overall survival (OS) at 5, 10, and 15 years was 89%, 79%, and 68%, respectively. Disease-free survival (DFS) at 5, 10, and 15 years was 75%, 72%), and 68%, respectively. No significant differences were found in OS or DFS when comparing pathologically and clinically staged patients or when comparing patients treated using CSCI with those treated with the standard technique. Patients treated using CSCI tended to complete therapy in a shorter time, without increased morbidity.

HYPERFRACTIONATED SPLIT-COURSE THORACIC RADIATION-THERAPY PLUS CHEMOTHERAPY IN LOCALLY ADVANCED NONSMALL CELL LUNG-CANCER

Hyperfractionated split course radiotherapy combined with carboplatin, etoposide and mitomycin C was administered to 76 patients with stage III non-small cell lung cancer. Grade 4 leukopenia occurred in 5 patients; 4 toxic deaths were observed. The overall response rate was 45%, including a 9% rate of complete responses, which lasted > 12 months in four cases. The median survival was 13 months, 2-year progression-free survival 17%, actuarial 2-year survival rate 22%. Age > 65, performance status > 1, no response to prior treatment were predictors of poor outcome. Our treatment plan, particularly because of the long lasting complete responses, warrants further investigation.

Dose, fractionation and overall treatment time in radiation therapy — the effects on local control for cancer of the larynx

The effect of total tumor dose, split course treatment and overall treatment time on local control was analysed in a retrospective series of 997 patients with carcinoma of the larynx, treated with megavoltage radiotherapy only. Primary tumors were classified by site (glottis and supraglottis) and T-stage. Continuous course (CC, n = 594) treatment was given primarily to small tumors. Split course radiation (SC, n = 403) was generally given to patients with larger field sizes, Total doses of irradiation ranged from 50 to 79 Gy, with a mean of 64 Gy in CC and 66 Gy in SC. Most of the treatments were given with fraction sizes between 2.0 and 2.1 Gy (91%). Overall treatment times ranged between 25 and 60 days in the CC group (mean, 45 days) and between 45 and 120 in the SC group (mean, 76 days). A local recurrence was observed in 256 patients. T-stage was the only tumor characteristic strongly related to local failure, Corrected for T-stage, no difference in local relapse rate was observed between glottic and supraglottic tumors, or between node-negative ( n = 886) and node-positive patients ( n = 111), After correction for T-stage the local failure rate of SC-treated tumors was 2.1 (95% confidence limits: 1.4–3.1) times higher than of CC-treated tumors. However, this effect could not be explained as an effect of the overall treatment time (OTT) itself, as no effect of OTT was found within the SC and the CC group, even though the variation in OTT's was considerable in the SC group. A higher tumor dose was associated with a lower local failure rate in the CC group ( p = 0,005), but not in the SC group ( p = 0.56).

Radiation-induced lung damage in rats: The influence of fraction spacing on effect per fraction

Purpose: When the linear-quadratic model is used to predict fractionated treatments which are isoeffective, it is usually assumed that each (equal size) treatment fraction has an equal effect, independent of the time at which it was delivered during a course of treatment. Previous work by our group has indicated that this assumption may not be valid in the context of radiation-induced lung damage in rats. Consequently we tested directly the validity of the assumption that each fraction has an equal effect, independent of the time it is delivered. Methods and Materials: An experiment was completed in which fractionated irradiation was given to whole thoraces of Sprague-Dawley rats. All treatment schedules consisted of eleven equal dose fractions in 36 days given as a split course, with some groups receiving the bulk of the doses early in the treatment schedule, before a 27-day gap, and others receiving most of the dose toward the end of the treatment schedule, after the time gap. To monitor the incidence of radiation-induced damage, breathing rate and lethality assays were used. Results: The maximum differences in the LD 50s and breathing rate ED 50s for the different fractionation schedules were 4.0% and 7.7% respectively. The lethality data and breathing rate data were consistent with results expected from modelling using the linear-quadratic model with the inclusion of an overall time factor, but not the generalized linear-quadratic model which accounted for fraction spacing. Conclusion: For conventional daily fractionation, and within the range of experimental uncertainties, the results indicate that the effect of a treatment fraction does not depend on the time at which it is given (its position) in the treatment. The results indicate no need to extend isoeffect formulae to consider the effect of each fraction separately for radiation-induced lung damage.

Treatment of advanced carcinoma of the vulva with chemoradiotherapy - can exenterative surgery be avoided?

Thirty-seven patients with advanced FIGO stage (17 stage III, 20 stage IV) carcinoma of the vulva whose extent of disease would have required extenterative surgery were treated with chemoradiotherapy (CRT). Radiotherapy was given as a split course (2500 cGy mid-plane dose in 10 daily fractions, repeated 1 month later) to the first seven patients. Subsequently radiotherapy was given as a continuous course (4500 cGy mid-plane dose in 20-25 daily fractions). Chemotherapy included mitomycin c as an intravenous bolus and 5 fluorouracil as a continuous intra-venous infusion over 4-5 days, with variations in timing and dose according to the type of radiotherapy course. Fifteen (47%) complete and 11 (34%) partial responses were seen at 3 months after completion of treatment. Of the 15 patients with complete response, 10 remained disease-free for a median of 24 months (range 6-36 months). The median sur-vival for complete and partial responding patients was 15 and 11 months, respectively (range 2-37 months). Acute toxicity included moist perineal desquamation, diarrhea and myelosupression. One death secondary to neutropaenic sepsis occurred in the split course group. WHO grade 3 radiation enteritis occurred in one patient (14%) in the split course and two patients (6%) in the continuous CRT groups. Using CRT, very high response rates have been obtained with relatively low toxicity. There is a useful role for CRT in the treatment of patients with locally advanced recurrent disease although its place in the management of extensive primary disease requires further evaluation.

Increased chronic bowel complications with split-course pelvic irradiation

Purpose : To assess the possible impact of various treatment factors including split-course versus continuous course treatment on the incidence of chronic bowel complications in patients receiving adjuvant pelvic radiotherapy. Methods and Materials : A retrospective review was performed of records of 153 patients treated with adjuvant external beam pelvic radiation therapy without brachytherapy for endometrial and colorectal carcinomas. Continuous course radiotherapy was administered in 91 patients (59%) and 62 patients (41%) received split course treatment with a planned 2; week mid-treatment break. Mean pelvic dose and daily fraction size were 51.4 and 1.71 Gray, respectively. Multiple patient and treatment variables were assessed for their possible relationship to chronic bowel complications. Univariate and multivariate statistical analyses were carried out. Results : Twenty-seven patients (18%) developed chronic bowel complications at a median interval of 12 months after radiotherapy. Of all factors analyzed, only the use of split course technique was associated with a significantly higher rate of chronic bowel injury and decreased complication-free survival ( p = 0.009). Conclusion : This study supports earlier suggestions that the use of split course rather than continuous course pelvic radiotherapy can. increase late intestinal complication rates. Possible pathophysiologic mechanisms are discussed.

Dose, fractionation and overall treatment time in radiation therapy—The effects on local control for cancer of the larynx

The effect of total tumor dose, split course treatment and overall treatment time on local control was analysed in a retrospective series of 997 patients with carcinoma of the larynx, treated with megavoltage radiotherapy only. Primary tumors were classified by site (glottis and supraglottis) and T-stage. Continuous course (CC, n = 594) treatment was given primarily to small tumors. Split course radiation (SC, n = 403) was generally given to patients with larger field sizes. Total doses of irradiation ranged from 50 to 79 Gy, with a mean of 64 Gy in CC and 66 Gy in SC. Most of the treatments were given with fraction sizes between 2.0 and 2.1 Gy (91%). Overall treatment times ranged between 25 and 60 days in the CC group (mean, 45 days) and between 45 and 120 in the SC group (mean, 76 days). A local recurrence was observed in 256 patients. T-stage was the only tumor characteristic strongly related to local failure. Corrected for T-stage, no difference in local relapse rate was observed between glottic and supraglottic tumors, or between node-negative (n = 886) and node-positive patients (n = 111). After correction for T-stage the local failure rate of SC-treated tumors was 2.1 (95% confidence limits: 1.4-3.1) times higher than of CC-treated tumors. However, this effect could not be explained as an effect of the overall treatment time (OTT) itself, as no effect of OTT was found within the SC and the CC group, even though the variation in OTT's was considerable in the SC group. A higher tumor dose was associated with a lower local failure rate in the CC group (p = 0.005), but not in the SC group (p = 0.56).

Combined 5-FU, cisplatin and accelerated split course irradiation for invasive transitionnal-cell carcinoma of the bladder

Combined 5-FU, cisplatin and accelerated split course irradiation for invasive transitionnal-cell carcinoma of the bladder

Continuous split course irradiation for stage I and II hodgkin's disease: 20 year experience at the medical college of Wisconsin

Continuous split course irradiation for stage I and II hodgkin's disease: 20 year experience at the medical college of Wisconsin

“Compensated” Split-Course Versus Continuous Radiation Therapy of Carcinoma of the Tonsillar Fossa

The Radiation Therapy Oncology Group conducted a prospective comparison of a compensated split course radiotherapy technique (300 cGy x 10, 3 weeks rest, 300 cGy x 10), versus continuous radiotherapy (200-220 cGy up to 6000-6600 cGy), in 137 evaluable patients. The complete response (CR) was 57% in 63 patients, treated with the split-technique vs 61% in 74 patients submitted to continuous course radiotherapy. The completion of therapy as planned was better in the split-technique, but acute and late tissue reactions were the same. Locoregional control of tumor at 5 years was 25% for split and 28% for continuous therapy. At 7 years this was 25% and 24%, respectively. Absolute survival in the split-course patients tended to be lower than in the continuous group, but when the sample of patients was enlarged by the addition of cases from similar trials of nasopharynx and base of tongue lesions, the survival difference was eliminated. On the basis of the results of this study we conclude that the stated compensated split-course technique gives equal clinical results as conventional continuous therapy, with the advantage of requiring fewer radiation fractions, and less burden on the patient and therapy facilities.

Radiation and simultaneous cisplatin in non-small cell lung cancer

Purpose: Phase III non-small cell lung cancer trials comparing radiation and simultaneous single agent cisplatinradiation, as well as, Phase II trials of cisplatin containing combination regimens and concurrent thoracic radiation used as preoperative or as definitive therapy in stage III non-small cell lung cancer are reviewed. Methods and Materials: The prognostic significance of the new international staging system with respect to clinical Stage III disease is described and discussed in this review because it has important implications for clinical trials. The results of four randomized Phase III trials and one Phase II trial which evaluated radiation therapy and single agent cisplatin are reviewed. The data from studies of combination chemotherapy and concurrent thoracic radiation observed in two consecutive Rush University Phase II trials and in a randomized Phase II Mayo Clinic trial are described. Eight phase two studies in which thoracic radiation and simultaneous cisplatin containing combination chemotherapy were given as preoperative treatment are compared. Results: Studies evaluating the prognostic significance of the new staging system (IIIa vs IIIb) have shown conflicting results. In Rush University trials there has been a significant difference for IIIa versus IIIb and in particular the tumors which are invading the mediastinum or chest wall without obvious mediastinal lymph node metastases appear to have the best prognosis. Similarly randomized trials evaluating curative doses of thoracic radiation therapy with or without current single agent cisplatin have shown contradictory results. One of the four randomized trials have shown superior survival with patients treated with radiation and simultaneous daily cisplatin. Toxicity with cisplatin combination chemotherapy regimens and split course radiation has been acceptable. In Phase II nonsurgical trials preoperative treatment consisting of cisplatin containing combination regimens given simultaneously with thoracic radiation have shown that this type of combined modality therapy is feasible and that the rates of resectability appear to be higher than would be expected with surgery alone. Survival results from six of these studies appear to be superior to results reported for radiation or surgery alone. Conclusion: Additional data are needed to determine the prognostic significance of the new staging system for clinical Stage III non-small cell lung cancer patients. Similarly, additional Phase III trials will be required to determine the role of thoracic radiation and concurrent single agent cisplatin, as well as, concurrent cisplatin combination regimens. Treatment with preoperative radiation and concurrent cisplatin containing combination therapies is feasible and relatively safe. Phase III trials are needed to determine the impact of neoadjuvant chemoradiation therapy and surgery in Stage III patients.

Preoperative concomitant cisplatin/VP16 and radiotherapy in stage III non-small cell lung cancer

Purpose : To evaluate the therapeutic effectiveness of a combined chemoradiotherapy program, followed by surgery in selected cases, in Stage III non-small cell lung cancer. Methods and Materials : Between August 1988 and February 1990, 43 patients Staged IIIa-b (UICC 1987, 58% IIIb) have been treated with concomitant chemotherapy (cisplatin 15 mg/m2 and VP16 75 mg/m2, 5 days a week on week 1 and 5) and radiotherapy (40 Gy split course, 2 Gy/day on week 1, 2, 5, and 6), followed by attempted curative thoracotomy or more cycles of full dose chemotherapy with the same two drugs. Results : Planned chemoradiotherapy has been given to 91% of patients; 13/43 patients have been operated, with 12 complete resections and three (7%) pathological complete responses. Toxicity was significant, with two post-operative deaths and two fatal radiation pneumonitis. Crude progression-free survival rate is 21% at 30 months, with nine patients (21%) alive and free from progression at follow-up times ranging from 31 to 49 months. Subset survival analysis showed a possibly greater therapeutic effect for non-squamous histology as compared to squamous carcinoma. Conclusion : These results are encouraging in a coohort of patients with quite advanced disease (58% Stage IIIb).

Flow cytometric DNA analysis does not predict the radiochemoresponsiveness of esophageal cancer

The relationship between the DNA pattern and the responsiveness to chemotherapy or chemoradiotherapy has been evaluated in 30 patients with squamous cell carcinoma of the esophagus. In 24 patients polychemotherapy with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1,000 mg/m2/24 h, continuous infusion of 120 h) every 3 weeks, was performed. Six other patients received chemoradiotherapy with cisplatin 80 mg/m2 on day 1 and 18.5 Gy (split course). Before treatment, at least three endoscopic biopsies were taken from each tumor and frozen at -85 degrees C. Five patients were excluded from the evaluation, three because of interrupted treatment and two due to unsuitable biopsy material obtained endoscopically. The response rate to the cytoreductive treatment was 40% (10/25). DNA content was analyzed with flow cytometry. Out of 25 evaluable patients, a diploid and aneuploid tumor was present in 8 (32.0%) and 17 (68.0%) patients, respectively. According to the DNA pattern, a major response was observed in 4 of 8 patients with a diploid tumor and in 6 of 17 patients with an aneuploid tumor (P = 0.5). No relationship between the percentage of cells in the S-phase and the response to the cytoreductive treatment was evident. Although a slightly higher percentage of major responses was found in euploid tumors, there is no evidence that flow-cytometric DNA analysis can be helpful in the selection of patients for chemotherapy or chemoradiotherapy.

Hypofractionated radiation therapy in unresectable stage iii non-small cell lung cancer

Hypofractionation is the current choice for radiation therapy for patients with unresectable non-small cell lung cancer (NSCLC) at the authors' institute. In this nonrandomized study, three hypofractionated radiation schedules (40-Gy split course; 30-32 Gy in 6 fractions and 24 Gy in 3 fractions) are evaluated in 301 patients with unresectable Stage III NSCLC: Patients with Stage IIIA disease treated with a 40-Gy split course had longer survival (P < 0.005) and a lower local relapse rate (P < 0.01), but a higher distant failure rate (P < 0.01) than those receiving 24-32 Gy. Survival for patients with Stage IIIA disease treated with 40 Gy at 1, 2, and 5 years was 47%, 22%, and 7%, respectively. For patients with Stage IIIB disease, the radiation scheme used did not correlate with survival and relapse rates. Survival at 1, 2, and 5 years was 30%, 9%, and 2%, respectively. The hypofractionated radiation schemes were well tolerated, and no severe complications were recorded. In patients with Stage IIIA disease, 40-Gy split-course radiation therapy yields survival rates comparable to those achieved with conventional radiation therapy. In patients with Stages IIIB and IV NSCLC, 24 Gy in 3 weekly fractions yields survival rates comparable to those achieved with higher total doses given in more fractions.