Maintenance Chemotherapy With or Without Local Consolidative Therapy in Treating Patients With Stage IV Non-small Cell Lung Cancer

Inclusion Criteria:

Patients must have the psychological ability and general health that permits completion of the study requirements and required follow up
Women of childbearing potential and men who are sexually active should be willing and able to use medically acceptable forms of contraception during the trial and for up to 180 days after completion of all treatment to prevent pregnancy or fathering a child.
Pathologically proven diagnosis of NSCLC, with metastases (stage IV disease) present prior to registration; this includes patients newly diagnosed with metastatic disease or those initially diagnosed and treated for stage I-III NSCLC who ultimately develop metastases

Appropriate stage for study entry based on the following diagnostic workup:

History/physical examination within 30 days prior to registration
Imaging proof of limited metastatic disease and response to therapy/stable disease, by at least CT chest through the adrenals or PET/CT within 30 days prior to registration
Zubrod performance status 0, 1, or 2 within 30 days prior to registration
Aspartate transaminase (AST) and alanine transaminase (ALT) ≤ 2.5 × upper limit of normal (ULN) or ≤ 5 × ULN with metastatic liver disease
Total bilirubin ≤ 1.5 × ULN
Absolute neutrophil count (ANC) ≥ 500 cells/mm^3
Creatinine clearance ≥ 45 mL/min/1.73 m^2 for patients with creatinine levels above institutional normal
Platelets ≥ 50,000 cells/mm^3
Negative serum pregnancy test within one week prior to registration for females of childbearing potential
Patients must have received first-line/induction chemotherapy (4 cycles) and achieved stable disease or a partial response
Prior systemic chemotherapy as part of concurrent treatment approach for previously diagnosed stage III NSCLC, as adjuvant therapy for previously resected NSCLC, or for other previous cancers is permitted
Prior radiotherapy for patients with brain metastases prior to enrollment is acceptable
Patients must have measurable disease at baseline and 3 or fewer discrete, extracranial metastatic disease sites that are technically amenable to SBRT
For de novo stage IV NSCLC patients (patients with metastatic disease at first presentation), primary disease must be treatable with local therapy in the form of SBRT or hypofractionated radiation; if the primary disease is found in the peripheral or central lung parenchyma without nodal disease for instance, SBRT may be employed; if primary disease is more advanced with involvement of the mediastinum (T4 tumor, N1-N3 disease, etc.), these volumes should be technically treatable with hypofractionated radiation
If primary disease in the thoracic cavity was previously treated with local therapy in the form of surgery, any local/regional disease recurrence should be technically treatable with SBRT or hypofractionated radiation after induction systemic therapy
Patients must be registered within 35 days of administration of the last dose of first-line/induction systemic therapy
The patient or a legally authorized representative must provide study-specific informed consent prior to study entry
Patients with brain metastases are eligible if these lesions have been previously treated and the patients have no clinical or radiographic evidence of progression prior to enrollment

Exclusion Criteria:

Clinical or radiologic evidence of untreated and/or progressive brain metastases
Cutaneous metastasis of NSCLC
Metastatic disease invading the esophagus, stomach, intestines, or mesenteric lymph nodes if not a candidate for surgery for these lesions
Prior invasive malignancy (except non-melanomatous skin cancer, low or intermediate risk prostate cancer, or in situ carcinoma of breast, oral cavity, skin, or cervix) unless disease free for a minimum of one year

Metastases located within 3 cm of previously irradiated (< 3Gy per fraction) structures if if not a candidate for surgery for these lesions and if:

Spinal cord previously irradiated to > 40 Gy
Brachial plexus previously irradiated to > 50 Gy
Small intestine, large intestine, or stomach previously irradiated to > 45 Gy
Brainstem previously irradiated to > 50 Gy
Lung previously irradiated with prior V20 Gy > 35%
Patients receiving targeted therapy (non-cytotoxic systemic therapy) for NSCLC in the first-line setting
If a patient has progressed in previous areas of primary disease that received definitive doses of radiation, these patients would require re-irradiation in previous high dose anatomic areas and are not eligible for this study
Patients with malignant pleural effusions that do not resolve after first-line systemic therapy; patients with pleural effusions that have become too small for thoracentesis at the time of registration would be permitted on study, indicating a significant response to first-line chemotherapy
Patients with more than 3 discrete locations of extra-cranial metastatic disease after first-line systemic therapy requiring more than 3 SBRT plans to cover these distinct metastatic disease entities
Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
Patients who are pregnant or nursing
Participation in any investigational drug study (excluding non-oncology and/or symptom management studies) within 4 weeks prior to registration
Known human immunodeficiency virus (HIV) positive with cluster of differentiation 4 (CD4) count < 200 cells/microliter; note that patients who are HIV positive are eligible, provided they are under treatment with highly active antiretroviral therapy (HAART) and have a CD4 count ≥ 200 cells/microliter within 30 days prior to registration; note also that HIV testing is not required for eligibility for this protocol
For patients who received immunotherapy during induction, patients on chronic steroids or who have active autoimmune disease for which they received systemic treatment in the previous 2 years with corticosteroids, disease modifying agents, or immunosuppressive drugs are not eligible. Replacement therapy (thyroxine, insulin or physiological corticosteroid replacement for adrenal or pituitary insufficiency) is allowed. Patients with active interstitial lung disease or who have a history of pneumonitis for which they had received glucocorticoids are not eligible
Prior bevacizumab therapy or other antiangiogenic therapy in first-line or planned maintenance therapy (due to potential for increased complications from local therapy)