If you have commercial insurance IMRT for routine whole breast is seldom going to get through unless the commercial policy doesn’t require prior auth
But you can still probably get protons (thank them for that too!!)
If I do imrt I do breath hold fwiw. I pretty much always do imrt for rni. In any case, I think wallnerus discussed this in a separate thread.
That “expert” very likely does not understand imrt.
1) Fake news that IMRT more dangerous, more failures, more low dose spray, more pneumonitis (that one’s a howler)
In modern rad onc, you’ve gotta be an IMRT expert before you can be an anything else expert
How do you image if you're doing breath hold IMRT?
I can't. Cone beam beforehand. Physics feels comfortable enough the setup.
Same. Setup has been remarkably consistent.
Let’s say setup was not consistent, why would breast imrt be worse than 3d?
Not sure why folks don't get this. In today's era, your forward planned breast plan may be segmented to a very high degree. E-comp plans are in fact inverse planned and include dynamic MLC movements.
Can't tell exactly what you're asking, but by remarkably consistent, I mean soft tissue, cavity, imns, etc are pretty much dead on. obviously, setup wouldn't be better or worse if 3d. In that vain, hotspots are better, toxicities have been fewer, and I'm able to forget all the kick the couch vs single iso mental masturbation that comes with 3d rni. I do arcs wherever I can, and do breath hold in breast as opposed to lung because I haven't the slightest idea how to feel comfortable doing a 4d breast sim, which as someone noted, we do in pancreas and lung and incorporate motion into our volumes. Sure, I can expand my ptv outside the body, which can be accounted for with tangents, but not arcs.
Every boob I’ve ever watched seemed to sit there, did very little dancing around
Yup. And that's why we treat nodes. [ducks]Wait. By 3D, do you mean FiF, I.e. IMRT?
We are all Todd now
Are you talking about IMRT with arcs or static fields?
We are adding flash to our vmat plans. Heats up the superficial tissues a smidge but as I understand it is more robust.
I
i doubt it matters. We treat with vmat and add a fake bolus or body. If anterior most breast tissue which is 5 mm below surface recieves 90% of dose, I can’t imagine their would be clinical consequences. (Absent inflam or skin involvement)
I agree. That feedback was given to me by my planners, but if it’s an effect I haven’t really noticed it in what has been presented to me.
Just tell them it’s partial
Would be be ok to do what you say? Call it “partial” because you are skimping a bit medially and laterally? Would this be “legal”? A grift is another man’s MO?
This has been a struggle... I'd like to hear others input b/c I this this could be just our planners. (I assume you are meaning including the IMN)
I'm around 3 Gy mean on most of these if treating IM's. I do some partial arc, some static IMRT.
I think I made that. Man, it is really good.
Again, covering top 3 intercostal spaces (to the top of the 4th rib) is ABOVE the heart.
Thanks. I had forgotten who had originally did it up, and it found its way into my memes folder. It’s a classic
Wide tangents?
Ok, only wide tangents or do you add an old-school ap electron/photon field for the IM?
Just wide
I think I'm like many folks who will open tangents superiorly to cover first 3 intercostal interspaces for IM nodes with trimming inferiorly. Will also sim flat and push ISO as superiorly as reasonable to reduce lung dose from Sclav. Coverage to 45 or even 40 Gy often accepted.
This may have already been mentioned but I think ma20 allowed imn to be covered by 80% idl
