Radiosurgery- role of the RO and the NS?

[Raygun77]

Hey Guys, I'm Ray. Long time fan (of the website), first time poster.

About me, I'm a going into my 3rd year of a 6 year ugrad medical degree in Aust, and think I'm interested in rad onc and neuro- perhaps specifically where the two fields cross paths.

I'm keen to ask- how is the procedure of radiosurgery organised, and what is the interplay between the neurosurgeon and radiation oncologist? For example, does the scenario unfold like-

pt referred to neurosurgeon after diagnosis of brain lesion -> neurosurgeon decides on radiosurgery as best treatment modality -> neurosurgeon assembles team incl. rad onc -> rad onc assesses radiation dose while the neurosurg pinpoints lesion.

Or is it the vice versa, with the patient being referred to the rad onc, then the rad onc deciding radiosurgery as the best plan of attack? Which physician is the 'primary' physician for the patient, so to speak?

Also on a somewhat similar note, what is the role of the rad onc scrubbed in for something like a gliasite implant? I'd have thought the NS would be very capable of doing that all alone, given the gliasite implant is prepared and calibrated beforehand.

Apologies if this has been covered before. And thanks in advance for responses!

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[medgator]

With regards to body radiosurgery, thats strictly a rad onc run enteprise with no surgeon required.

That is certainly institution-dependent.

 

[Gfunk6]

That is certainly institution-dependent.

Seriously. I know of neurosurgeons, thoracic surgeons, and even general surgeons who do (non-GK) sterotactic radiosurgery without a Rad Onc. Sometimes their complications can be apalling and something that could have been avoided with proper treatment planning. Interstingly, since GK uses radioactive sources it is far more tightly regulated than on-off devices.

 

[medgator]

Seriously. I know of neurosurgeons, thoracic surgeons, and even general surgeons who do (non-GK) sterotactic radiosurgery without a Rad Onc. Sometimes their complications can be apalling and something that could have been avoided with proper treatment planning. Interstingly, since GK uses radioactive sources it is far more tightly regulated than on-off devices.

How does such an arrangement pass the medico-legal sniff test? Doesn't a rad onc have to sign off on the plan?

 

[Raygun77]

Cheers for the responses guys.

Wagy, when you say primary planning, what specifically do you mean? I mean, from a first principles approach I'd say that the two elements to plan are lesion localisation and thus frame placement, as well as radiation dose- the former probably the domain of the NS, while the latter that of the RO. Or does the Rad Onc look at both of those, and the NS simply put them into practice and/or add their adjustments to it once the plan is complete?

 

[medgator]

Cheers for the responses guys.

Wagy, when you say primary planning, what specifically do you mean? I mean, from a first principles approach I'd say that the two elements to plan are lesion localisation and thus frame placement, as well as radiation dose- the former probably the domain of the NS, while the latter that of the RO. Or does the Rad Onc look at both of those, and the NS simply put them into practice and/or add their adjustments to it once the plan is complete?

I honestly think it will vary from place to place. At some places, the rad onc and the neurosurgeon put the frame on together. In some places, the rad onc shows up after everyone has had their frame placed and MRI scan done.

The neurosurgeon and the rad onc contour/reviews contours together in most places i'd imagine. Planning can be done by either of those two individuals (with the other person reviewing the plan at the end) or the physicist.

 

[temujim]

Seriously. I know of neurosurgeons, thoracic surgeons, and even general surgeons who do (non-GK) sterotactic radiosurgery without a Rad Onc. Sometimes their complications can be apalling and something that could have been avoided with proper treatment planning. Interstingly, since GK uses radioactive sources it is far more tightly regulated than on-off devices.

Seriously?? If you know of a situation where no radiation oncologist is involved in the prescription of radiation, it should be reported. To who is the question. Surely AS(T)RO or ACRO would be very interested in these types of stories.

 

[Gfunk6]

Seriously?? If you know of a situation where no radiation oncologist is involved in the prescription of radiation, it should be reported. To who is the question. Surely AS(T)RO or ACRO would be very interested in these types of stories.

I admit that I'm not familiar with the legal requirements to administer radiation treatments. However with certain devices (partial breast irradiation, CyberKnife), I know that non Rad Onc MDs do the irradiation. There is always physics dosimeteric support involved but not always a Rad Onc.

 

[KERMA]

Bs

 

[qwert]

I know of one place that was doing GK w/out RadOnc signing off the plans. When the scheme was uncovered, punishment was swift: the chief of neurosurgery removed, and hospital fined.

I admit that I'm not familiar with the legal requirements to administer radiation treatments. However with certain devices (partial breast irradiation, CyberKnife), I know that non Rad Onc MDs do the irradiation. There is always physics dosimeteric support involved but not always a Rad Onc.

 

[Dimoak]

I know of one place that was doing GK w/out RadOnc signing off the plans. When the scheme was uncovered, punishment was swift: the chief of neurosurgery removed, and hospital fined.

Did they atleast have a MedRad physicist on board?

 

[medgator]

Did they atleast have a MedRad physicist on board?

im sure they had to have one. Who's going to manage the source, help with planning etc.?

 

[IndyXRT]

I know of one place that was doing GK w/out RadOnc signing off the plans. When the scheme was uncovered, punishment was swift: the chief of neurosurgery removed, and hospital fined.

Rules vary by state, but the rules governing radioactive sources are often different than those governing linear accelerators. Thus, non-radiation oncologists may be able to get away with more if they have a cyber knife than if they have a gamma knife.

 

[Gfunk6]

Rules vary by state, but the rules governing radioactive sources are often different than those governing linear accelerators.

I think this is the core of the problem. With radioactive sources (e.g. GK, 60Co, HDR, LDR) the governing body is the NRC, I believe. This is highly regulated as you can imagine given the dangers of unathorized use or theft. Recently, at our institution, all users of radioactive sources needed to undergo fingerprint clearance through the federal government.

With "on-off" machines the rules are much more loose. With devices like Xoft (e.g. electronic brachytherapy), manufacturers are trying to broaden the market beyond just Radiation Oncologists.

As to my statement above re: non-Rad Oncs administering radiation, I base it based on a corporate M&M I attended. I can't reveal too much on a public forum since I signed a non-disclosure agreement but I will say there were cases of non-Rad Oncs MDs performing linac-based RT. Physics was always utilized but I don't know if a Rad Onc signed off on the plan. Given the avoidable complications (e.g. overdosing critical structures) that were presented, I would wager not.

 

[Raygun77]

This is interesting. So there may not be any strict law requiring a rad oncs involvement, and manufacturers are moving to cut out the middle men (ie rad oncs)?
As a rad onc, is this an issue with surgeons encroaching on your scope of practice?