Surgery With or Without Internal Radiation Therapy Compared With Stereotactic Body Radiation Therapy in Treating Patients With High-Risk Stage I Non-Small Cell Lung Cancer

DISEASE CHARACTERISTICS:

   - Lung nodule suspicious for non-small cell lung cancer (NSCLC)

      - Biopsy confirmation is strongly recommended but not required; if biopsy is
      attempted and non-diagnostic, if the patient refuses biopsy, or if the risk of
      biopsy is considered too high, patients may be enrolled if the mass is suspicious
      for NSCLC based on two or more of the following criteria:

         - Positive smoking history

         - Absence of benign calcifications within suspicious nodule

         - Activity on PET greater than normal tissue

         - Evidence of growth compared to previous imaging

         - Presence of spiculation

   - Tumor ≤ 4 cm maximum diameter, clinical stage IA or selected IB (i.e., with visceral
   pleural involvement) by PET/CT scan of the chest and upper abdomen performed within 60
   days prior to registration

   - All clinically suspicious mediastinal N1, N2, or N3 lymph nodes (> 1 cm short-axis
   dimension on CT scan and/or positive on PET scan) confirmed negative for involvement
   with NSCLC by one of the following methods: mediastinoscopy, anterior mediastinotomy,
   endoscopic and/or endobronchial ultrasonography (EUS/EBUS)-guided needle aspiration,
   CT-guided, or video-assisted thoracoscopic or open lymph node biopsy

   - Tumor verified by a thoracic surgeon to be in a location that will permit sublobar
   resection

   - Tumor located peripherally within the lung, defined as not touching any surface within
   2 cm of the proximal bronchial tree in all directions

      - Patients with non-peripheral (central) tumors are NOT eligible

   - No evidence of distant metastases

PATIENT CHARACTERISTICS:

   - ECOG performance status (PS) 0, 1, or 2

   - Patient at high-risk for surgery by meeting a minimum of one major criteria or two
   minor criteria as described below:

      - Major criteria

         - FEV1 ≤ 50% predicted

         - DLCO ≤ 50% predicted

      - Minor criteria

         - Age ≥ 75 years

         - FEV1 51-60% predicted

         - DLCO 51-60% predicted

         - Pulmonary hypertension (defined as a pulmonary artery systolic pressure
         greater than 40 mm Hg) as estimated by echocardiography or right heart
         catheterization

         - Poor left ventricular function (defined as an ejection fraction of 40% or
         less)

         - Resting or exercise arterial pO2 ≤ 55 mm Hg or SpO2 ≤ 88%

         - pCO2 > 45 mm Hg

         - Modified Medical Research Council (MMRC) Dyspnea Scale ≥ 3

   - Not pregnant or nursing

   - Negative urine or serum pregnancy test

   - Fertile patients must use effective contraception

   - No prior invasive malignancy, unless disease-free for ≥ 3 years prior to registration
   (except non-melanoma skin cancer, in-situ cancers).

PRIOR CONCURRENT THERAPY:

   - No prior intra-thoracic radiotherapy

      - Prior radiotherapy as part of treatment for head and neck, breast, or other
      non-thoracic cancer is permitted

   - Prior chemotherapy or surgical resection for the lung cancer being treated on this
   protocol is NOT permitted