adding ENI for Decipher-high

[A_DeMichele]

Are there any sort of data, however minimal, to support this?

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[Mandelin Rain]

Feels like something you'd do based solely on vibes.

 

[Chartreuse Wombat]

The only evidence to support Decipher score changing radiation technique (dose, fractionation, volume) that i know of is from RTOG 0126 which supports using higher XRT doses in higher risk patients. This is an unplanned subgroup analysis but there was evidence of interaction. Of course most are dose-escalating everyone.

https://www.redjournal.org/article/S0360-3016(23)00371-1/fulltext

 

[RickyScott]

I have given it in borderline cases, but eni could also have been supported by the mskcc nomogram.

 

[sirspamalot]

Adding nodes to a prostate/SV plan is so marginally harmful, and the benefit is so unknown, I am quick to offer it. We don't know what to do for breast RNI either and lots of people do it.. I would suggest that has a greater hazard than doing pelvic nodez.

 

[deleted1168505]

Adding nodes to a prostate/SV plan is so marginally harmful, and the benefit is so unknown, I am quick to offer it. We don't know what to do for breast RNI either and lots of people do it.. I would suggest that has a greater hazard than doing pelvic nodez.

Guy, you are thinking too hard for working in the boonies. The dosimetrist and Jenny Jennison, NP can handle it and some psuedo-academic will rubber stamp it for a couple extra RVUs.

 

[sirspamalot]

 

[evilbooyaa]

Adding nodes to a prostate/SV plan is so marginally harmful, and the benefit is so unknown, I am quick to offer it. We don't know what to do for breast RNI either and lots of people do it.. I would suggest that has a greater hazard than doing pelvic nodez.

Increased GU and GI toxicity. Wouldn't do it for fun. Breast RNI (at least with photons) is WAY less toxic than treating pelvic nodes.

 

[sirspamalot]

I do 68/25 (56/nodes) and my folks are cruisin' without a bruisin'

Half my patients are constipated, so if anything, its a bonus.

 

[SneakyBooger]

I don't do it.
I look at Decipher as telling me whether this patient is more likely to do poorly.
I don't use it to tell me adding ENI will benefit this patient. Those studies aren't done yet.

 

[evilbooyaa]

I do 68/25 (56/nodes) and my folks are cruisin' without a bruisin'

Half my patients are constipated, so if anything, its a bonus.

56/25 to elective nodal basins?

Just completely unnecessary. You wanna do 50/25 fine, whatever, variation in practice, but there is zero reason to go above 45.

 

[deleted1111261]

I’m seeing people treat nodes to get approval for conventional fx

Which is fine but meh

 

[deleted1168505]

56/25 to elective nodal basins?

Just completely unnecessary. You wanna do 50/25 fine, whatever, variation in practice, but there is zero reason to go above 45.

For prostate cancer? I agree that 56/25 is not something I have seen before, but that's a fair argument to be made that even 50.4/28 is not enough to eradicate subclinical disease, which is one of the arguments against ENI at all. How you want to protect the bowel is a different issue, but it's tru that prostate cancer needs a big hammer.

 

[metallica81788]

If you're actually doing 56/25fxGy to elective nodes no way is that not a big deal. Those people should have GI toxicity on a much higher level.

Maybe typo and you meant 46Gy? which is reasonable

 

[deleted1168505]

Or he is just treating mini-pelvis? I've seen that before, kinda like an inbetween the no-ENI ever no matter what zealots and the 45/25 to a huge field crowd in everything but low risk? I personally do 46/23 in salvage, 50.4/28 conventional intact or 44/20 if I am hypofrac intact.

 

[deleted1111261]

No chemo tho

 

[deleted1111261]

No chemo tho

And the rectum / anus isn’t entirely in PTV

 

[metallica81788]

And the rectum / anus isn’t entirely in PTV

True true - just saying it's not minimal extra toxicity
Elective nodes guys certainly have higher rates of bowel problems vs prostate/SV only guys

 

[sirspamalot]

56 Gy for SV, 50 Gy for nodes.

Just making sure you're all awake.

 

[evilbooyaa]

For prostate cancer? I agree that 56/25 is not something I have seen before, but that's a fair argument to be made that even 50.4/28 is not enough to eradicate subclinical disease, which is one of the arguments against ENI at all. How you want to protect the bowel is a different issue, but it's tru that prostate cancer needs a big hammer.

Why?
How many prostate folks are getting 45-50/25 to the nodes and then recurring in those nodes, in-field?

 

[deleted1168505]

Why?
How many prostate folks are getting 45-50/25 to the nodes and then recurring in those nodes, in-field?

I'm not making that argument. I treat nodes in high risk and salvage. I am just saying the anti-ENI guys make that argument, that it's not enough dose. We have data showing stupid amounts of dose escalation in prostate increases LC. So what's the dose needed to control subclinical disease? Well how much is there? It is likely that the regimen we use for squamous cell is inadequate in many clinical scenarios with higher subclinical burdens but doesn't mean it is inadequate for all of them.

 

[xrt123]

Now that we have PSMA scans I have seen at least 5 of cases of recurrence everywhere but in the elective nodal volume that got around 50Gy.

 

[deleted1168505]

Now that we have PSMA scans I have seen at least 5 of cases of recurrence everywhere but in the elective nodal volume that got around 50Gy.

I believe you, but there are many that are still treating the prostate bed to 70 Gy because they don't believe that 64 Gy is enough to eradicate microscopic disease in the prostate bed (FWIW I only go to 70 if there is a positive margin and I can't identify gross disease on MRI or PSMA)

So, that's a pretty wide gap between 45 is enough for microscopic disease in the nodes but 64 is not enough for microscopic disease in the bed. Conceptually, I see the discordance there.

With IMRT, you could easily dose-escalate the nodal volumes higher while dose-painting the areas adjacent to bowel back to 45-50 (if you wanted to).

 

[SneakyBooger]

I could see someone saying the bed is more hypoxic than the LN.

 

[evilbooyaa]

I believe you, but there are many that are still treating the prostate bed to 70 Gy because they don't believe that 64 Gy is enough to eradicate microscopic disease in the prostate bed (FWIW I only go to 70 if there is a positive margin and I can't identify gross disease on MRI or PSMA)

So, that's a pretty wide gap between 45 is enough for microscopic disease in the nodes but 64 is not enough for microscopic disease in the bed. Conceptually, I see the discordance there.

With IMRT, you could easily dose-escalate the nodal volumes higher while dose-painting the areas adjacent to bowel back to 45-50 (if you wanted to).

Because people still recur, in the bed, even after salvage RT. That being said, globally treating people to 64 rather than 70Gy is supported by SAKK trial

Hypoxia changes of post-op scenario and the discrepancy of likelihood of microscopic disease is also a consideration (similar to how we think about high-risk microscopic vs intermediate risk microscopic when doing 50/60/70 for H&N volumes...

 

[RickyScott]

45-50 gy clears micrsopic disease 95% according to Fletcher?

 

[TheWallnerus]

Now that we have PSMA scans I have seen at least 5 of cases of recurrence everywhere but in the elective nodal volume that got around 50Gy.

Reminds one of breast where ENI sterilizes LN stations but ultimately doesn’t change the overall natural history or OS. I bet, as currently practiced in rad onc across all sites, ENI is not helpful more often than it is helpful. Head/neck guy Sher just irradiated something like 70 head/neck patients with tight PTVs and no ENI and recorded zero percent neck relapses.

 

[deleted1168505]

I could see someone saying the bed is more hypoxic than the LN.

Prostate cancer is relatively hypoxic to begin with. If the dose required to eradicate microscopic nodal disease is coincidentally just below bowel tolerance and the same as other histologies that's great. But if not then we are irradiating bowel for no reason. I still treat nodes as I don't find the evidence not to compelling, but this is the argument, and I will concede it has some merit.

 

[RickyScott]

Reminds one of breast where ENI sterilizes LN stations but ultimately doesn’t change the overall natural history or OS. I bet, as currently practiced in rad onc across all sites, ENI is not helpful more often than it is helpful. Head/neck guy Sher just irradiated something like 70 head/neck patients with tight PTVs and no ENI and recorded zero percent neck relapses.

I have radiated a few head and neck cancer ma without eni (elderly poor performance). Like with lung, you still end up delivering significant doses to nodes most at risk inadvertently. Try giving 70 gy to a tonsil withou giving dose to a junctional level 2 node

 

[TheWallnerus]

I have radiated a few head and neck cancer ma without eni (elderly poor performance). Like with lung, you still end up delivering significant doses to nodes most at risk inadvertently. Try giving 70 gy to a tonsil withou giving dose to a junctional level 2 node

One of the great known unknowns in rad onc: how much does “unintentional” ENI work. New thymic carcinoma ABS consensus statements are out in JAMA Onc. I saw where one recommended regimen in one clinical scenario was 16 Gy/8 fx adjuvant hemithorax RT to sterilize microscopic disease. As much as we never use this dose anywhere else for microscopic disease, one still has to admit even just 16 Gy has cancer killing potential.

 

[sirspamalot]

I have radiated a few head and neck cancer ma without eni (elderly poor performance). Like with lung, you still end up delivering significant doses to nodes most at risk inadvertently. Try giving 70 gy to a tonsil withou giving dose to a junctional level 2 node

Let me tell you the good word is upon us.

Have you met our lord and savior Jesus Protons?

 

[Fpg1245]

Let me tell you the good word is upon us.

Have you met our lord and savior Jesus Protons?

I’m honestly getting to the point where you should just say f it and just get protons. Just blow the whole operation up and get them. Put all patients on it and call it a day

 

[deleted1111261]

I’m honestly getting to the point where you should just say f it and just get protons. Just blow the whole operation up and get them. Put all patients on it and call it a day

This is the way