a b s t r a c tBackground: Nitroglycerin is proposed as an agent to reduce tumour hypoxia by improving tumour perfusion. We investigated the potential of nitroglycerin as a radio-sensitizer in non-small cell lung cancer (NSCLC) and the potential of functional imaging for patient selection. Material and methods: Trial NCT01210378 is a single arm phase II trial, designed to detect 15% improvement in 2-year overall survival (primary endpoint) in stage IB-IV NSCLC patients treated with radical (chemo-) radiotherapy and a Transiderm-Nitro 5 patch during radiotherapy. Patients underwent dynamic contrast-enhanced CTs (DCE-CT) and HX4 (hypoxia) PET/CTs before and after nitroglycerin. Secondary endpoints were progression-free survival, toxicity and the prognostic value of tumour perfusion/hypoxia at baseline and after nitroglycerin. Results: The trial stopped after a futility analysis after 42 patients. At median follow-up of 41 months, two-year and median OS were 58% (95% CI: 44-78%) and 38 months (95% CI: 22-54 months), respectively. Nitroglycerin could not reduce tumour hypoxia. DCE-CT parameters did not correlate with OS, whereas hypoxic tumours had a worse OS (p = 0.029). Changes in high-uptake fraction of HX4 and tumour blood flow were negatively correlated (r = -0.650, p = 0.022). The heterogeneity in treatment modalities and patient characteristics combined with a small sample size made further subgroup analysis of survival results impossible. Toxicity related to nitroglyerin was limited to headache (17%) and hypotension (2.4%). Conclusion: Nitroglycerin did not improve OS of NSCLC patients treated with (chemo-)radiotherapy. A general ability of nitroglycerin to reduce hypoxia was not shown. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Abbreviations: BF, blood flow; BV, blood volume; CI, confidence interval; CoR, coefficient of repeatability; DCE-CT, dynamic contrast-enhanced CT; FHV, fraction of hypoxic volume hypoxic fraction of the GTV; GTV, gross tumour volume; GTVln, gross tumour volume of the lymph nodes; GTVp, gross tumour volume of the primary tumour; HX4, 2-nitroimidazole [ 18 F]-HX4 (flortanidazole, 3-[18F]fluoro-2-(4-((2-nitro-1Himidazol-1-yl)methyl)-1H-1,2,3-triazol-1-yl)-propan-1-ol); HX4-HF, HX4 hypoxic fraction; HX4-HV, HX4 hypoxic volume; INDAR, individualized accelerated radiotherapy; IQR, interquartile range; LRPFS, loco-regional progression free survival; MFS, metastasis-free survival; NO, nitric oxide; NSCLC, non-small cell lung cancer; OS, overall survival; PET, positron emission tomography; SUV max , maximum standardised uptake value; SUV mean , mean standardised uptake value; TTD, total tumour dose; TBR, tumour-to-blood ratio.