This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) focuses on the principles of radiation therapy (RT), which include the following: (1) general principles for early-stage, locally advanced, and advanced/metastatic NSCLC; (2) target volumes, prescription doses, and normal tissue dose constraints for early-stage, locally advanced, and advanced/palliative RT; and (3) RT simulation, planning, and delivery. Treatment recommendations should be made by a multidisciplinary team, including board-certified radiation oncologists who perform lung cancer RT as a prominent part of their practice.

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    HowladerNNooneAMKrapchoM. SEER Cancer Statistics Review 1975-2011 based on November 2013 SEER data submission posted to the SEER web site April 2014. Bethesda, MD: National Cancer Institute; 2014. Available at: http://seer.cancer.gov/csr/1975_2011/. Accessed November 24 2014.

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    HowladerNNooneAKrapchoM. SEER Cancer Statistics Review 1975-2009 (Vintage 2009 Populations) based on November 2011 SEER data submission. Bethesda, MD: National Cancer Institute; 2012. Available at: http://seer.cancer.gov/csr/1975_2009_pops09/. Accessed November 24 2014.

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    AlbergAJBrockMVFordJG. Epidemiology of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest2013;143:e1S29S.

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    AlbergAJFordJGSametJMAmerican College of Chest P. Epidemiology of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest2007;132:29S55S.

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    The Health Consequences of Smoking: A Report of the Surgeon General. (ed 2010/07/30). Atlanta (GA): U.S. Department of Health and Human Services. Centers for Disease Control and Prevention (US); 2004.

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    The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. (ed 2010/07/30). Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2006.

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    DarbySHillDDeoH. Residential radon and lung cancer—detailed results of a collaborative analysis of individual data on 7148 persons with lung cancer and 14,208 persons without lung cancer from 13 epidemiologic studies in Europe. Scand J Work Environ Health2006;32(Suppl 1):183.

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    ThunMJCarterBDFeskanichD. 50-year trends in smoking-related mortality in the United States. N Engl J Med2013;368:351364.

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    LeoneFTEvers-CaseySTollBAVachaniA. Treatment of tobacco use in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest2013;143:e61S77S.

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    JhaPRamasundarahettigeCLandsmanV. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med2013;368:341350.

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    TaoLWangRGaoYTYuanJM. Impact of postdiagnosis smoking on long-term survival of cancer patients: the Shanghai cohort study. Cancer Epidemiol Biomarkers Prev2013;22:24042411.

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    HaysJTEbbertJO. Adverse effects and tolerability of medications for the treatment of tobacco use and dependence. Drugs2010;70:23572372.

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  • 40

    CarneyDN. Lung cancer—time to move on from chemotherapy. N Engl J Med2002;346:126128.

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    National Lung Screening Trial Research TeamAberleDRBergCD. The National Lung Screening Trial: overview and study design. Radiology2011;258:243253.

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    National Lung Screening Trial Research TeamAberleDRAdamsAM. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med2011;365:395409.

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    National Lung Screening Trial Research TeamAberleDRAdamsAM. Baseline characteristics of participants in the randomized national lung screening trial. J Natl Cancer Inst2010;102:17711779.

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    SmithRABrooksDCokkinidesV. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin2013;63:88105.

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    MoyerVAForce USPST. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med2014;160:330338.

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    TravisWDBrambillaENoguchiM. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol2011;6:244285.

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  • 49

    Effects of postoperative mediastinal radiation on completely resected stage II and stage III epidermoid cancer of the lung. The Lung Cancer Study Group. N Engl J Med1986;315:13771381.

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  • 50

    KellerSMAdakSWagnerH. A randomized trial of postoperative adjuvant therapy in patients with completely resected stage II or IIIA non-small-cell lung cancer. Eastern Cooperative Oncology Group. N Engl J Med2000;343:12171222.

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  • 51

    DouillardJYRosellRDe LenaM. Impact of postoperative radiation therapy on survival in patients with complete resection and stage I, II, or IIIA non-small-cell lung cancer treated with adjuvant chemotherapy: the adjuvant Navelbine International Trialist Association (ANITA) Randomized Trial. Int J Radiat Oncol Biol Phys2008;72:69701.

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  • 52

    BradleyJDPaulusRGrahamMV. Phase II trial of postoperative adjuvant paclitaxel/carboplatin and thoracic radiotherapy in resected stage II and IIIA non-small-cell lung cancer: promising long-term results of the Radiation Therapy Oncology Group—RTOG 9705. J Clin Oncol2005;23:34803487.

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    FeigenbergSJHanlonALLangerC. A phase II study of concurrent carboplatin and paclitaxel and thoracic radiotherapy for completely resected stage II and IIIA non-small cell lung cancer. J Thorac Oncol2007;2:287292.

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  • 54

    JaklitschMTHerndonJE2ndDeCampMMJr. Nodal downstaging predicts survival following induction chemotherapy for stage IIIA (N2) non-small cell lung cancer in CALGB protocol #8935. J Surg Oncol2006;94:599606.

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  • 55

    McAvoySCiuraKWeiC. Definitive reirradiation for locoregionally recurrent non-small cell lung cancer with proton beam therapy or intensity modulated radiation therapy: predictors of high-grade toxicity and survival outcomes [published online ahead of print September 11, 2014]. Int J Radiat Oncol Biol Phys. doi: 10.1016/j.ijrobp.2014.07.030.

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    Expert Panel on Radiation Oncology-Brain MetastasesLoSSGoreEM. ACR Appropriateness Criteria® pre-irradiation evaluation and management of brain metastases. J Palliat Med2014;17:880886.

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    Expert Panel on Radiation Oncology-Bone MetastasesLoSSLutzST. ACR Appropriateness Criteria® spinal bone metastases. J Palliat Med2013;16:919.

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  • 58

    Expert Panel On Radiation Oncology-Bone MetastasesLutzSTLoSS. ACR Appropriateness Criteria® non-spine bone metastases. J Palliat Med2012;15:521526.

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  • 59

    PatelSHRobbinsJRGoreEM. ACR Appropriateness Criteria® follow-up and retreatment of brain metastases. Am J Clin Oncol2012;35:302306.

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  • 60

    ChangJYKestinLLBarrigerRB. ACR Appropriateness Criteria® nonsurgical treatment for locally advanced non-small-cell lung cancer: good performance status/definitive intent. Oncology (Williston Park)2014;28:706710712714passim.

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  • 61

    RosenzweigKEChangJYChettyIJ. ACR Appropriateness Criteria® nonsurgical treatment for non-small-cell lung cancer: poor performance status or palliative intent. J Am Coll Radiol2013;10:654664.

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  • 62

    DoningtonJFergusonMMazzoneP. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest2012;142:16201635.

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  • 63

    GregoireVMackieTR. State of the art on dose prescription, reporting and recording in intensity-modulated radiation therapy (ICRU report No. 83). Cancer Radiother2011;15:555559.

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  • 64

    TeohMClarkCHWoodK. Volumetric modulated arc therapy: a review of current literature and clinical use in practice. Br J Radiol2011;84:967996.

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  • 65

    ChenABNevilleBASherDJ. Survival outcomes after radiation therapy for stage III non-small-cell lung cancer after adoption of computed tomography-based simulation. J Clin Oncol2011;29:23052311.

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  • 66

    LiaoZXKomakiRRThamesHDJr. Influence of technologic advances on outcomes in patients with unresectable, locally advanced non-small-cell lung cancer receiving concomitant chemoradiotherapy. Int J Radiat Oncol Biol Phys2010;76:775781.

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  • 67

    TerasawaTDvorakTIpS. Systematic review: charged-particle radiation therapy for cancer. Ann Intern Med2009;151:556565.

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    TaremiMHopeADaheleM. Stereotactic body radiotherapy for medically inoperable lung cancer: prospective, single-center study of 108 consecutive patients. Int J Radiat Oncol Biol Phys2012;82:967973.

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  • 69

    TimmermanRPaulusRGalvinJ. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA2010;303:10701076.

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    AmbrogiMCFanucchiOCioniR. Long-term results of radiofrequency ablation treatment of stage I non-small cell lung cancer: a prospective intention-to-treat study. J Thorac Oncol2011;6:20442051.

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  • 71

    HowingtonJABlumMGChangAC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest2013;143:e278S313S.

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  • 72

    BilalHMahmoodSRajashankerBShahR. Is radiofrequency ablation more effective than stereotactic ablative radiotherapy in patients with early stage medically inoperable non-small cell lung cancer?Interact Cardiovasc Thorac Surg2012;15:258265.

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  • 73

    ShirvaniSMJiangJChangJY. Comparative effectiveness of 5 treatment strategies for early-stage non-small cell lung cancer in the elderly. Int J Radiat Oncol Biol Phys2012;84:10601070.

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  • 74

    GewanterRMRosenzweigKEChangJY. ACR Appropriateness Criteria: nonsurgical treatment for non-small-cell lung cancer: good performance status/definitive intent. Curr Probl Cancer2010;34:228249.

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  • 75

    RodriguesGVideticGMSurR. Palliative thoracic radiotherapy in lung cancer: an American Society for Radiation Oncology evidence-based clinical practice guideline. Pract Radiat Oncol2011;1:6071.

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  • 76

    RodriguesGMacbethFBurmeisterB. Consensus statement on palliative lung radiotherapy: third international consensus workshop on palliative radiotherapy and symptom control. Clin Lung Cancer2012;13:15.

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  • 77

    ChenABCroninAWeeksJC. Palliative radiation therapy practice in patients with metastatic non-small-cell lung cancer: a Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study. J Clin Oncol2013;31:558564.

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  • 78

    LallyBEZeltermanDColasantoJM. Postoperative radiotherapy for stage II or III non-small-cell lung cancer using the surveillance, epidemiology, and end results database. J Clin Oncol2006;24:29983006.

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  • 79

    MartinsRGD’AmicoTALooBWJr. The management of patients with stage IIIA non-small cell lung cancer with N2 mediastinal node involvement. J Natl Compr Canc Netw2012;10:599613.

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  • 80

    WederWCollaudSEberhardtWE. Pneumonectomy is a valuable treatment option after neoadjuvant therapy for stage III non-small-cell lung cancer. J Thorac Cardiovasc Surg2010;139:14241430.

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    AlbainKSSwannRSRuschVW. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet2009;374:379386.

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  • 82

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  • 83

    ShahAABerryMFTzaoC. Induction chemoradiation is not superior to induction chemotherapy alone in stage IIIA lung cancer. Ann Thorac Surg2012;93:18071812.

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  • 84

    CerfolioRJBryantASJonesVLCerfolioRM. Pulmonary resection after concurrent chemotherapy and high dose (60Gy) radiation for non-small cell lung cancer is safe and may provide increased survival. Eur J Cardiothorac Surg2009;35:718723; discussion 723.

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  • 85

    KwongKFEdelmanMJSuntharalingamM. High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival. J Thorac Cardiovasc Surg2005;129:12501257.

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  • 86

    SonettJRSuntharalingamMEdelmanMJ. Pulmonary resection after curative intent radiotherapy (>59 Gy) and concurrent chemotherapy in non-small-cell lung cancer. Ann Thorac Surg2004;78:12001205; discussion 1206.

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    RuschVWGirouxDJKrautMJ. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol2007;25:313318.

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  • 88

    BradleyJGrahamMVWinterK. Toxicity and outcome results of RTOG 9311: a phase I-II dose-escalation study using three-dimensional conformal radiotherapy in patients with inoperable non-small-cell lung carcinoma. Int J Radiat Oncol Biol Phys2005;61:318328.

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  • 89

    KongFMTen HakenRKSchipperMJ. High-dose radiation improved local tumor control and overall survival in patients with inoperable/unresectable non-small-cell lung cancer: long-term results of a radiation dose escalation study. Int J Radiat Oncol Biol Phys2005;63:324333.

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  • 90

    ZhaoLWestBTHaymanJA. High radiation dose may reduce the negative effect of large gross tumor volume in patients with medically inoperable early-stage non-small cell lung cancer. Int J Radiat Oncol Biol Phys2007;68:103110.

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  • 91

    WangLCorreaCRZhaoL. The effect of radiation dose and chemotherapy on overall survival in 237 patients with stage III non-small-cell lung cancer. Int J Radiat Oncol Biol Phys2009;73:13831390.

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  • 92

    RosenmanJGHalleJSSocinskiMA. High-dose conformal radiotherapy for treatment of stage IIIA/IIIB non-small-cell lung cancer: technical issues and results of a phase I/II trial. Int J Radiat Oncol Biol Phys2002;54:348356.

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  • 93

    SchildSEMcGinnisWLGrahamD. Results of a phase I trial of concurrent chemotherapy and escalating doses of radiation for unresectable non-small-cell lung cancer. Int J Radiat Oncol Biol Phys2006;65:11061111.

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  • 94

    BradleyJDMoughanJGrahamMV. A phase I/II radiation dose escalation study with concurrent chemotherapy for patients with inoperable stages I to III non-small-cell lung cancer: phase I results of RTOG 0117. Int J Radiat Oncol Biol Phys2010;77:367372.

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  • 95

    BradleyJDPaulusRKomakiR. A randomized phase III comparison of standard-dose (60 Gy) versus high-dose (74 Gy) conformal chemoradiotherapy with or without cetuximab for stage III non-small cell lung cancer: results on radiation dose in RTOG 0617 [abstract]. J Clin Oncol2013;31(Suppl 15):Abstract 7501.

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  • 96

    BradleyJPaulusRKomakiR. A randomized phase III comparison of standard-dose (60 Gy) versus high-dose (74 Gy) conformal chemoradiotherapy +/- cetuximab for stage IIIa/IIIb non-small cell lung cancer: preliminary findings on radiation dose in RTOG 0617 [abstract]. Presented at the 53rd Annual Meeting of the American Society of Radiation Oncology; October 2–6, 2011; Miami, Florida. Abstract LBA2.

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  • 97

    BradleyJDBaeKGrahamMV. Primary analysis of the phase II component of a phase I/II dose intensification study using three-dimensional conformal radiation therapy and concurrent chemotherapy for patients with inoperable non-small-cell lung cancer: RTOG 0117. J Clin Oncol2010;28:24752480.

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    Prescribing Recording and Reporting Photon Beam Therapy (Report 50). Bethesda, MD: International Commission on Radiation Units and Measurements; 1993. Available at: http://www.icru.org/home/reports/prescribing-recording-and-reporting-photon-beam-therapy-report-50. Accessed November 25 2014.

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  • 99

    Prescribing Recording and Reporting Photon Beam Therapy (Report 62) (Supplement to ICRU Report 50). Bethesda, MD: ICRU; 1999. Available at: http://www.icru.org/home/reports/prescribing-recording-and-reporting-photon-beam-therapy-report-62. Accessed November 25 2014.

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  • 100

    Prescribing Recording and Reporting Intensity-Modulated Photon-Beam Therapy (IMRT) (ICRU Report 83). Available at: http://www.icru.org/testing/reports/prescribing-recording-and-reporting-intensity-modulated-photon-beam-therapy-imrt-icru-report-83. Accessed November 25 2014.

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  • 101

    GroupIDWHolmesTDasR. American Society of Radiation Oncology recommendations for documenting intensity-modulated radiation therapy treatments. Int J Radiat Oncol Biol Phys2009;74:13111318.

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  • 102

    KongFMRitterTQuintDJ. Consideration of dose limits for organs at risk of thoracic radiotherapy: atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Int J Radiat Oncol Biol Phys2011;81:14421457.

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  • 103

    KongFMPanCEisbruchATen HakenRK. Physical models and simpler dosimetric descriptors of radiation late toxicity. Semin Radiat Oncol2007;17:108120.

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  • 104

    GrahamMVPurdyJAEmamiB. Clinical dose-volume histogram analysis for pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys1999;45:323329.

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  • 105

    KongFMHaymanJAGriffithKA. Final toxicity results of a radiation-dose escalation study in patients with non-small-cell lung cancer (NSCLC): predictors for radiation pneumonitis and fibrosis. Int J Radiat Oncol Biol Phys2006;65:10751086.

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  • 106

    HernandoMLMarksLBBentelGC. Radiation-induced pulmonary toxicity: a dose-volume histogram analysis in 201 patients with lung cancer. Int J Radiat Oncol Biol Phys2001;51:650659.

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  • 107

    KimTHChoKHPyoHR. Dose-volumetric parameters for predicting severe radiation pneumonitis after three-dimensional conformal radiation therapy for lung cancer. Radiology2005;235:208215.

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  • 108

    WangSLiaoZWeiX. Analysis of clinical and dosimetric factors associated with treatment-related pneumonitis (TRP) in patients with non-small-cell lung cancer (NSCLC) treated with concurrent chemotherapy and three-dimensional conformal radiotherapy (3D-CRT). Int J Radiat Oncol Biol Phys2006;66:13991407.

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  • 109

    RoseJRodriguesGYaremkoB. Systematic review of dose-volume parameters in the prediction of esophagitis in thoracic radiotherapy. Radiother Oncol2009;91:282287.

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  • 110

    HallWHGuiouMLeeNY. Development and validation of a standardized method for contouring the brachial plexus: preliminary dosimetric analysis among patients treated with IMRT for head-and-neck cancer. Int J Radiat Oncol Biol Phys2008;72:13621367.

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  • 111

    MarksLBYorkeEDJacksonA. Use of normal tissue complication probability models in the clinic. Int J Radiat Oncol Biol Phys2010;76:S1019.

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  • 112

    MarksLBBentzenSMDeasyJO. Radiation dose-volume effects in the lung. Int J Radiat Oncol Biol Phys2010;76:S7076.

  • 113

    Werner-WasikMYorkeEDeasyJ. Radiation dose-volume effects in the esophagus. Int J Radiat Oncol Biol Phys2010;76:S8693.

  • 114

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