Bad Wegener's and Lung RT

[evilbooyaa]

Unless this patient has atypical anatomy, the LLL bronchus (or most of its segmental bronchi) are right there.

…would be very careful doing SBRT in this spot in a healthy patient, let alone someone on 3L O2 at rest. Aside from the risk of bronchial hemorrhage (which is higher in this patient due to the vasculitis), you could VERY easily take out most or all of the LLL due to stenosis of the segmental bronchi. Doesn’t sound like this patient can spare a lobe.

Sure, very reasonable. Hard to say on one slice of a low res CT. If that's PBT then danger, will robinson!

I'm primarily just challenging the notion that aortic toxicity is some bogeyman to avoid SBRT in 2023. PBT, sure.

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[TheWallnerus]

Sure, very reasonable. Hard to say on one slice of a low res CT. If that's PBT then danger, will robinson!

I'm primarily just challenging the notion that aortic toxicity is some bogeyman to avoid SBRT in 2023. PBT, sure.

Would you do single shot 34 Gy on this

There’s SBRT and there’s SBRT

 

[Fpg1245]

Would you do single shot 34 Gy on this

There’s SBRT and there’s SBRT

Gotta have balls to do the 34Gy single frac. I remember saying it during a mock oral and the attending was like “you really wanna do that?”

 

[taserlaser]

Gotta have balls to do the 34Gy single frac. I remember saying it during a mock oral and the attending was like “you really wanna do that?”

I spent some time working in a place that routinely gave single frac SBRT, where I had never done any in my training. The other attendings chuckled and called me chicken. They said, once you do one you realize how well tolerated it is and then stop worrying. There is something to be said about convenience for sure, but I would only use it for small peripheral lesions for sure. Because I AM chicken haha.

 

[sirspamalot]

If you had a line of patients needing SBRT out the door... single fx SBRT would be routine.

 

[TheWallnerus]

Gotta have balls to do the 34Gy single frac. I remember saying it during a mock oral and the attending was like “you really wanna do that?”

Balls in rad onc I guess are different than balls in other specialties. I'm reminded of what F. Lee Bailey once told Chris Darden (real quote, really happened)

You, sir, have the balls of a stud field mouse.

American Crime Story (2016) - S01E07 clip with quote You, sir, have the balls of a stud field mouse. Yarn is the best search for video clips by quote. Find the exact moment in a TV show, movie, or music video you want to share. Easily move forward or backward to get to the perfect clip.

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[Lamount]

Single fraction isn't my favorite. I have only done it once or twice... in cases where logistical concerns of 4-5 fx were too difficult to surmount. You lose the safety that fractionation confers regarding setup uncertainties (a little more of an issues with a moving target as compared to brain SRS), and you also likely cause more scarring for the same efficacy, potentially complicating efforts to treat other areas down the road. One abiding principle I employ is: "don't get cute when you don't need to".

 

[Haybrant]

med onc saying no chemo. considering 2.5 x 28 fractions to 70 and trying to push out hot spots to the aorta/PBT. did not see this suggested, anyone with concerns about this regimen

 

[Ray D. Ayshun]

med onc saying no chemo. considering 2.5 x 28 fractions to 70 and trying to push out hot spots to the aorta/PBT. did not see this suggested, anyone with concerns about this regimen

Haven't seen that regimen anywhere but the pelvis, but probably fine. I suspect airways and vessels would tolerate it fine. I generally do 60/15 for ultra-ultracentral/questionable PS.

 

[BobbyHeenan]

med onc saying no chemo. considering 2.5 x 28 fractions to 70 and trying to push out hot spots to the aorta/PBT. did not see this suggested, anyone with concerns about this regimen

Seems reasonable to me. I think anything in that 60/15 or 70/17 range is OK with data to support those fractionation schemes. It shows you gave it thought regarding a "more gentle" approach that still shows good efficacy in a well published series of patients.

 

[RadOncDoc21]

Seems reasonable to me. I think anything in that 60/15 or 70/17 range is OK with data to support those fractionation schemes. It shows you gave it thought regarding a "more gentle" approach that still shows good efficacy in a well published series of patients.

Agree… I’m all about data when it protects me!

 

[TheWallnerus]

Single fraction isn't my favorite. I have only done it once or twice... in cases where logistical concerns of 4-5 fx were too difficult to surmount. You lose the safety that fractionation confers regarding setup uncertainties (a little more of an issues with a moving target as compared to brain SRS), and you also likely cause more scarring for the same efficacy, potentially complicating efforts to treat other areas down the road. One abiding principle I employ is: "don't get cute when you don't need to".

I used to worry about a bad setup with fewer fractions and then, back of envelope like, one day realized if you have bad setup on just one out of five fractions tumor control should be 0%. There is no fractionation safety when trying to cure NSCLC in the 1-5 fraction range… if you believe in a D-zero.

 

[TheWallnerus]

med onc saying no chemo. considering 2.5 x 28 fractions to 70 and trying to push out hot spots to the aorta/PBT. did not see this suggested, anyone with concerns about this regimen

Also good data for 80.5/35; this was my go to before the SBRT era and cured almost everyone

 

[evilbooyaa]

Would you do single shot 34 Gy on this

There’s SBRT and there’s SBRT

Haven't done 34x1 ever. Don't see the draw. Is 5Fx so much more problematic than 1? I also liberally hypofx brain lesions getting SRS.

But, no, this would not be a good candidate for 34Gy x 1 SBRT.

 

[evilbooyaa]

med onc saying no chemo. considering 2.5 x 28 fractions to 70 and trying to push out hot spots to the aorta/PBT. did not see this suggested, anyone with concerns about this regimen

I thought most mens prostates were in their pelvises, not up by their aortas

This might be the equivalent of a Scorigami in the NFL, at least for a definitive lung cancer fractionation scheme.

But it's about the same efficacy as 70Gy in 2Gy Fx, which is fine, and less toxic than 60/15, so it's in the acceptable range I suppose....