Hypofractionated Boost before Chemotherapy and Radiation Therapy in Treating Patients with Stage II or III Non-small Cell Lung Cancer That Cannot Be Removed by Surgery

Inclusion Criteria

• All prior treatment-related toxicities must be Common Terminology Criteria for Adverse Events (CTCAE) (version 4.0) =< grade 1 (except alopecia) at the time of enrollment
• Absolute neutrophil count >= 1.5 x 10^9/L, obtained within 30 days of study registration
• Hemoglobin >= 9 g/dL, obtained within 30 days of study registration
• Platelets >= 100 x 10^9/L, obtained within 30 days of study registration
• Total bilirubin =< 1.5 x upper limit of normal (ULN), obtained within 30 days of study registration
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN, obtained within 30 days of study registration
• Creatinine < 1.5 mg/dl, obtained within 30 days of study registration or
• Calculated creatinine clearance >= 50 mL/min (calculated by the Cockcroft-Gault formula), obtained within 30 days of study registration, or
• 24-hour urine creatinine clearance >= 50 mL/min, obtained within 30 days of study registration
• Non-small cell lung cancer (NSCLC), histologically and/or cytologically proven
• Clinical American Joint Committee on Cancer (AJCC) stage IIA-IIIB NSCLC (T1-4N0-3M0)
• Patients must be considered unresectable or medically-inoperable
• Patients must have primary tumor =< 10 cm as defined by computed tomography (CT) largest axial dimension
• Within 60 days of registration: patients must have fludeoxyglucose F 18 (FDG)-positron emission tomography (PET)-CT scan (or CT chest/abdomen/pelvis with IV contrast), and magnetic resonance imaging (MRI) brain with IV contrast (preferred) or CT scan of the brain with contrast; non-contrast MRI scans of the chest/abdomen/pelvis or brain are permitted for workup if patient has allergy to CT contrast or renal insufficiency
• Within 30 days of registration: patients must have vital signs, history/physical examination, laboratory studies (complete blood count panel [CBCP] with differential, chemistries including liver function tests, creatinine clearance [CrCl] assessment; pregnancy test if needed within 14 days of registration)
• If a pleural effusion is present and visible on both CT scan AND chest x-ray, the investigator should exclude malignant disease by pleurocentesis to confirm cytologically-negative pleural fluid; if fluid is exudative or cytologically positive for tumor cells, patient is excluded * Patients with effusions that are minimal (i.e. not visible on chest x-ray) and that are too small to safely tap are eligible
• Life expectancy of at least 12 weeks in the opinion of investigator
• Patient has an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1 within 30 days of registration
• Patients must have a measurable primary tumor (undetectable NSCLC primary tumor is ineligible)
• Patients must be a minimum of 3 weeks from thoracotomy (if performed) and well-healed before starting treatment
• Ability to provide written informed consent obtained prior to participation in the study and any related procedures being performed
• Women of child-bearing potential (WOCBP) must have a negative pregnancy test within 14 days of registration; urine human gonadotropin (HCG) is an acceptable pregnancy assessment
• Nursing women may participate only if nursing is discontinued
• Women/men of reproductive potential must be counseled on contraception/abstinence while receiving the study treatment
• Must be able and willing to undergo two MRI scans, before study treatment begins and shortly after first dose of radiation (only mandatory for first 10 patients who have no contra-indications for MRI
• Patient is suitable to receive standard chemotherapy with radiation during weeks 2-7 (e.g. cisplatin+ etoposide or carboplatin+paclitaxel)

Exclusion Criteria

• Patients with contralateral hilar involvement (greater than 1.5 cm on short axis or positive on PET scan, or biopsy-proven)
• Documented or pathologically-proven metastatic disease
• Presence of nodules considered neoplastic in the same lobe or other ipsilateral lobe as the primary tumor (stage T3-4), unless the nodule can be encompassed in the stereotactic boost (gross tumor volume [GTV]boost) without exceeding a total GTVboost size of 10 cm as defined by the sum of the largest CT axial dimensions of each nodule
• Presence of nodules considered neoplastic in contralateral lobes (M1a)
• Patients with history of pneumonectomy
• Prior cytotoxic chemotherapy or molecularly-targeted agents (e.g. erlotinib, crizotinib), unless > 2 years prior
• Any concurrent malignancy other than non-melanoma skin cancer, non-invasive bladder cancer, or carcinoma in situ of the cervix; patients with a previous malignancy without evidence of disease for >= 3 years will be allowed to enter the trial
• History of active connective tissue disease (scleroderma) or idiopathic pulmonary fibrosis
• History of previous radiation therapy which would result in overlapping radiation fields
• Uncontrolled neuropathy grade 2 or greater, regardless of cause
• Subjects who are breast-feeding and plan to continue breast-feeding during therapy, or have a positive pregnancy test will be excluded from the study; should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately
• If patient elects to have two research MRIs, medical contraindication to MR imaging (e.g. pacemakers, metallic implants, aneurysm clips, known contrast allergy to gadolinium contrast, pregnancy, nursing mothers, weight greater than 350 pounds) or severe anxiety/claustrophobia related to MR imaging despite medications to relieve anxiety/claustrophobia
• Any serious and/or unstable pre-existing medical disorder (aside from malignancy exception above), psychiatric disorder, or other conditions that could interfere with subject’s safety, obtaining informed consent or compliance to the study procedures, in the opinion of the investigator; this could include severe, active co-morbidities such as: * Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months * Transmural myocardial infarction within the last 6 months * Acquired immune deficiency syndrome (AIDS) based upon the current Centers for Disease Control (CDC) definition; note, however, that human immunodeficiency virus (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 * Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy within 30 days of registration * Hepatic insufficiency resulting in jaundice and/or coagulation defects