Benign Disease

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xrt123

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Sorry if this has been discussed but in Germany they seem to treat a large number of patients with joint arthrosis/degenerative joints with what appears to be good results. Has anybody done this and is this covered by insurance or medicare? I have treated the occasional dupytren's but that seems to be a small fraction of what is done for degenerative joints.
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The Germans have even been so kind as to summarize their experience with RT for benign diseases: PMID 25955230. Remarkable that they apparently have an entire cooperative group dedicated to the topic. I also would be curious to hear people's experience with treating and with insurance coverage. The situations that come to mind for me are Dupytren's/Ledderhose, keloids, HO, the occasional very refractory wart, a desmoid in unusual circumstances--anyone done anything else?
 
I have a patient I'm treating for Hidradenitis suppurativa. 6 Gy in 3 fx for her first round, and she did have a good response with 1/2 her disease resolved. I'm going back now and trying 6 Gy in 6 fractions to her residual disease. Some German data (naturally), but dose and fractionation are all over the place, so I'm trying a couple different techniques for her.

The improvement she saw after the first course was the most benefit she's received from any intervention thus far, so I'm encouraged. She has very advanced pelvic disease.
 
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There are a lot of knee and hip replacements going on out there. If there is response rates of 50-80% with 6Gy then potentially a lot of room for benefit with not a lot of down side in the correctly selected patients. I asked my billing folks to look into it just to see if there is any codes the cover XRT with a diagnosis of arthrosis/degenerative disease (still waiting).

There has to be some Radonc who is close to a rheumatologist/ortho surgeon who have had this conversation before.
 
Just scheduled my 3rd arthritis consult for next week.

Will let you know how it goes.

So far it has been patients coming in for cancer f/u (2 prostate pts and a breast) stating they were having painful arthritis. Then I mention low dose XRT for arthritis and every single one has enthusiastically said they are very interested. Now my nurse is asking every patient about arthritis as she walks them to the exam room.

She has also requested I see her husband for same. One of the therapists asked I see her mom when chart rounds were over the other day.

Arthritis is everywhere it seems...
 
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SneakyBooger said:
Just scheduled my 3rd arthritis consult for next week.

Will let you know how it goes.

So far it has been patients coming in for cancer f/u (2 prostate pts and a breast) stating they were having painful arthritis. Then I mention low dose XRT for arthritis and every single one has enthusiastically said they are very interested. Now my nurse is asking every patient about arthritis as she walks them to the exam room.

She has also requested I see her husband for same. One of the therapists asked I see her mom when chart rounds were over the other day.

Arthritis is everywhere it seems...
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send residuals to @xrthopeful
 
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SneakyBooger said:
Just scheduled my 3rd arthritis consult for next week.

Will let you know how it goes.

So far it has been patients coming in for cancer f/u (2 prostate pts and a breast) stating they were having painful arthritis. Then I mention low dose XRT for arthritis and every single one has enthusiastically said they are very interested. Now my nurse is asking every patient about arthritis as she walks them to the exam room.

She has also requested I see her husband for same. One of the therapists asked I see her mom when chart rounds were over the other day.

Arthritis is everywhere it seems...
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Are you running this thought past these patients' PCPs, Orthopedic surgeons, or whoever is managing their arthritis? I'm not saying I'm not on board with the idea, just wondering if it's a unilateral decision you're making or if you're getting buy in from others.

Care to provide the specifics of how you're treating? (CT Sim? Photons vs Electrons? Dose/fractionation?)
 
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SneakyBooger said:
Just scheduled my 3rd arthritis consult for next week.

Will let you know how it goes.

So far it has been patients coming in for cancer f/u (2 prostate pts and a breast) stating they were having painful arthritis. Then I mention low dose XRT for arthritis and every single one has enthusiastically said they are very interested. Now my nurse is asking every patient about arthritis as she walks them to the exam room.

She has also requested I see her husband for same. One of the therapists asked I see her mom when chart rounds were over the other day.

Arthritis is everywhere it seems...
Click to expand...

273506
 
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I think this would be awesome if widely adopted. I am not going to be one of the first people to run a booming arthritis clinic though. He may be dead serious but Booger has engaged in some light message board subterfuge in the past and I'm not ready to take the bait.
 
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To those that have used this treatment, I haven’t reviewed the literature in detail yet on this topic yet but I was curious what one should quote regarding the efficacy and durability of therapy as well as risk(eg secondary malig), efficacy compared to other alternatives, and how this RT may make a joint replacement more difficult in the future within an irradiated field. Also I was curious whether this would be worth discussing to orthos, primaries, rheums through a PowerPoint to gauge interest. Thanks!
 
Last week I approached the senior leadership of the large medical and orthopedic groups and all we very interested.

I have also contacted numerous colleagues with whom I socialize and again the idea was well received.

Currently our group is going to treat a small number of patients and see if the response is as presented by the groups in Germany, Austria, Switzerland.

If the results are favorable that will make a more robust case for referrals.

Summary: starting slow.

Planning 0.5 Gy/Fx (+/-) to approximately 3 Gy total. Will be doing CT sims.

Photons for hips, knees, shoulders, elbows, ankles

Consider electrons for thumbs/fingers.

If one is interested in doing this I would strongly suggest subscribing to Strahlentherapie und Onkologie.

I have reviewed every issue of that journal online and read every publication regarding benign disease that I could find. And I did a PubMed search.

One of my partners trained in a program that had a large percentage of patients treated for arthritis (they wrote a book on it), so that helps also - especially when you approach your partners and ask if anyone would consider beginning this "new" chapter in the use of radiotherapy. When another senior member chimes in and says yes with interest it makes it easier for the others to consider it. Turns out the entire group is unanimously interested without hesitation.
 
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5040cGy said:
To those that have used this treatment, I haven’t reviewed the literature in detail yet on this topic yet but I was curious what one should quote regarding the efficacy and durability of therapy as well as risk(eg secondary malig), efficacy compared to other alternatives, and how this RT may make a joint replacement more difficult in the future within an irradiated field. Also I was curious whether this would be worth discussing to orthos, primaries, rheums through a PowerPoint to gauge interest. Thanks!
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We have been doing lots of treatments for arthritis.

Response is variable. The longer the disease has been there, the tougher it may be to produce a good, durable response to RT. We generally say that 80% of patients respond to some degree and around 50% can expect to be pain–free or almost pain–free.

Second malignancy has not been reported in the literature, at least as far as I know. Perhaps it has to do with the low doses used (3–6Gy) and the generally elder patients receiving it.

There is no problem with surgery, since the dose is low.

Good book by one of the German experts:

Radiotherapy for Non-Malignant Disorders
Seegenschmiedt, M.H., Makoski, H.-B., Trott, K.-R., Brady, L.W. (Eds.)


You can use a linac for all indications. We use an orthovoltage machine with 100kV for fingers. If they are really thick, we give 0.5 Gy from both sides ––> 0.5 Gy in the middle.


Last but not least:

Raising interest in your ortho colleagues may give rise to additional referrals. They also see quite few painful heel spurs and heterotopic ossifications certainly.
 
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a
Palex80 said:
We have been doing lots of treatments for arthritis.

Response is variable. The longer the disease has been there, the tougher it may be to produce a good, durable response to RT. We generally say that 80% of patients respond to some degree and around 50% can expect to be pain–free or almost pain–free.

Second malignancy has not been reported in the literature, at least as far as I know. Perhaps it has to do with the low doses used (3–6Gy) and the generally elder patients receiving it.

There is no problem with surgery, since the dose is low.

Good book by one of the German experts:

Radiotherapy for Non-Malignant Disorders
Seegenschmiedt, M.H., Makoski, H.-B., Trott, K.-R., Brady, L.W. (Eds.)


You can use a linac for all indications. We use an orthovoltage machine with 100kV for fingers. If they are really thick, we give 0.5 Gy from both sides ––> 0.5 Gy in the middle.


Last but not least:

Raising interest in your ortho colleagues may give rise to additional referrals. They also see quite few painful heel spurs and heterotopic ossifications certainly.
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Thanks for the thoughtful replies!
 
The Dutch actually performed (recently published) double blinded, sham controlled, RCTs on OA in the knee and hand showing no benefit of low-dose XRT and recommending against it's use. Mechanistically, I can buy XRT for relief in inflammatory conditions, but I don't think it's shrinking osteophytes (yes, I understand there is an inflammatory component to the development of OA).
 
Mandelin Rain said:
The Dutch actually performed (recently published) double blinded, sham controlled, RCTs on OA in the knee and hand showing no benefit of low-dose XRT and recommending against it's use. Mechanistically, I can buy XRT for relief in inflammatory conditions, but I don't think it's shrinking osteophytes (yes, I understand there is an inflammatory component to the development of OA).
Click to expand...

This article has a nice discussion regarding that study:

 
Has XRT treatment for symptomatic degenerative / arthritic disease been reimbursed in US (beside XRT for HO)?
 
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Mandelin Rain said:
The Dutch actually performed (recently published) double blinded, sham controlled, RCTs on OA in the knee and hand showing no benefit of low-dose XRT and recommending against it's use. Mechanistically, I can buy XRT for relief in inflammatory conditions, but I don't think it's shrinking osteophytes (yes, I understand there is an inflammatory component to the development of OA).
Click to expand...

I am out of my depth here, but wouldn't RT be better utilized in RA patients and not OA patients? OA is basically wear and tear, correct? Is it odd that they chose to focus on OA?
 
Pointless said:
I am out of my depth here, but wouldn't RT be better utilized in RA patients and not OA patients? OA is basically wear and tear, correct? Is it odd that they chose to focus on OA?
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I think the issue is the inflammation, not the autoimmunity. Wear and tear wouldn't be so bad if the body didn't "over-react" with inflammation. E.g., plantar fasciitis; theoretically the RT works by blunting the inflammatory response. Is there an inflammatory response with RA? Sure but I guess there you also have some increased radiation sensitivity too.
SneakyBooger said:
This article has a nice discussion regarding that study:

Is it time to redefine the role of low-dose radiotherapy for benign disease? | Annals of the Rheumatic Diseases
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Gonna be pretty ironic if there are successful radiation oncologists who never treat cancer. Wait! Maybe there already are. What will we call these chaps; not radiation oncologists. How will one introduce oneself? "Hi. I'm a Radiation."
 
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SneakyBooger said:
This article has a nice discussion regarding that study:

Click to expand...
To be completely pedantic, "those" studies.

The history of radiation oncology is littered with denying/spinning of evidence that goes against our preconceived beliefs ("Protons cause more skin toxicity, but is that a good thing?"). We have exactly 2 RTC to draw conclusions from and they both indicate that radiation doesn't work. Like at all. They also seem to show that there is roughly a 50% placebo effect from getting on and off the treatment couch which makes retrospectively analyzed physician reported responses of 70% seem less great.
 
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scarbrtj said:
I think the issue is the inflammation, not the autoimmunity. Wear and tear wouldn't be so bad if the body didn't "over-react" with inflammation. E.g., plantar fasciitis; theoretically the RT works by blunting the inflammatory response. Is there an inflammatory response with RA? Sure but I guess there you also have some increased radiation sensitivity too.
Click to expand...

Again, I'm a bit out of my depth as well, but plantar fasciitis isn't OA. My undestanding is it's microtrauma to the fascia causing a brisk inflammatory response that actually delays it's healing. Kill the recruited lymphocytes, pain gets better and tears heal. I get that. But OA is a different beast. Once the joint degeneration has occurred, and the cartilage is gone, and the osteophytes have formed, what is a low dose of XRT going to do?
 
Mandelin Rain said:
They also seem to show that there is roughly a 50% placebo effect from getting on and off the treatment couch
Click to expand...


This just keeps getting better. Can we offer and bill for sham radiation? Its win win, no radiation exposure, and 50% response rate! Seems like a slam dunk for any insurance company.
 
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The incidence of herpetic zoster is about the same incidence as cancer. I always thought going to the med oncs and the PCPs and being like "hey I can treat shingles" would be a good use of low dose RT too. You just irradiate the affected dorsal root ganglia with a few gray.

ASTRO: Low-Dose Radiation Numbs Lengthy Post-Shingles Pain
 
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SneakyBooger said:
You are overflowing with wonderful ideas!
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Always thought the wee bit of elitism in rad onc prevented a rad onc from ever (gasp) putting a center in a large primary care office just treating benign stuff. Like, when people play Monopoly, they salivate for the greens of Pacific Avenue and the blues of Boardwalk. I go after the Baltic Avenue and Oriental Avenue properties and the railroads. Not sexy, but a proven strategy. In rad onc, I don't think anyone has (yet) tried a similar strategy.
 
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scarbrtj said:
Always thought the wee bit of elitism in rad onc prevented a rad onc from ever (gasp) putting a center in a large primary care office just treating benign stuff. Like, when people play Monopoly, they salivate for the greens of Pacific Avenue and the blues of Boardwalk. I go after the Baltic Avenue and Oriental Avenue properties and the railroads. Not sexy, but a proven strategy. In rad onc, I don't think anyone has (yet) tried a similar strategy.
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Wally world produced a few billionaires.... Afaik, Sam Walton drove the same pickup truck til the end of his life
 
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My current pickup is only 20 years old - still a long way to go for ol' reliable.

My previous pickup I finally had to get rid of when the floor boards rusted out.
 
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scarbrtj said:
Always thought the wee bit of elitism in rad onc prevented a rad onc from ever (gasp) putting a center in a large primary care office just treating benign stuff. Like, when people play Monopoly, they salivate for the greens of Pacific Avenue and the blues of Boardwalk. I go after the Baltic Avenue and Oriental Avenue properties and the railroads. Not sexy, but a proven strategy. In rad onc, I don't think anyone has (yet) tried a similar strategy.
Click to expand...

I just spend all my time in jail. It’s a lot cheaper and safer for me.
 
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How much time did you spend doctoring this photograph? :laugh:
 
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scarbrtj said:
Gonna be pretty ironic if there are successful radiation oncologists who never treat cancer. Wait! Maybe there already are. What will we call these chaps; not radiation oncologists. How will one introduce oneself? "Hi. I'm a Radiation."
Click to expand...
Funny that you say so. In german speaking countries our profession is not called "Radiation Oncology" it's called "Strahlentherapie und Radioonkologie", which translates to "Radiation Therapy and Radiation Oncology". This covers both.
 
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Palex80 said:
Funny that you say so. In german speaking countries our profession is not called "Radiation Oncology" it's called "Strahlentherapie und Radioonkologie", which translates to "Radiation Therapy and Radiation Oncology". This covers both.
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I've always thought the more obsolete term here in the US was more appropriate: "therapeutic radiologist".

Now all the patients (and some physicians!) who call us "radiologists" won't have to be corrected anymore
 
We are oncologists. We have Oncology specific training. Any attempt to remove the word Oncology from our field is a self-own IMO and takes us away from the table with med oncs and surgeons and with our patients as well. We are oncologists.

I’m all for doing other things in our scope including benign conditions, cardiac arrhythmias etc, but there’s no need to change the name and take away from the vast majority of what we do.
 
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xrthopeful said:
We are oncologists. We have Oncology specific training. Any attempt to remove the word Oncology from our field is a self-own IMO and takes us away from the table with med oncs and surgeons and with our patients as well. We are oncologists.

I’m all for doing other things in our scope including benign conditions, cardiac arrhythmias etc, but there’s no need to change the name and take away from the vast majority of what we do.
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Fair point.
 
Palex80 said:
Strahlentherapie also picked up that recent literature with some critical comments.
www.ncbi.nlm.nih.gov

Low-dose radiotherapy: Mayday, mayday. We've been hit! - PubMed

Low-dose radiotherapy: Mayday, mayday. We've been hit!
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
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So radiation is okay as long as the patients aren't fat nor have had pain for a few years.

All that acute onset OA in skinny people in America, may still be fair game based mainly on the opinion of the author. Though largely refuted by the best evidence available.

Cancer or no cancer, I'm all for helping anyone in pain that I think I can probably help. This ain't it chief.
 
Palex80 said:
Funny that you say so. In german speaking countries our profession is not called "Radiation Oncology" it's called "Strahlentherapie und Radioonkologie", which translates to "Radiation Therapy and Radiation Oncology". This covers both.
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Thanks. Never knew that; but I did know it (Strahlentherapie) was a good journal. I guess this is why X-strahl is called... X-strahl.
xrthopeful said:
We are oncologists. We have Oncology specific training. Any attempt to remove the word Oncology from our field is a self-own IMO and takes us away from the table with med oncs and surgeons and with our patients as well. We are oncologists.

I’m all for doing other things in our scope including benign conditions, cardiac arrhythmias etc, but there’s no need to change the name and take away from the vast majority of what we do.
Click to expand...
Michael Jordan never had to say "I'm a guard." People just knew. For the radiation oncologist of the future who might be only treating heart, or other benign things exclusively... it will be odd to keep the oncologist moniker. Today's oncologist is tomorrow's maybe-something-different. Whatever we do, it will involve radiation of some sort. It may or may not involve cancer. Perhaps it might be the better part of valor to focus on the "radiation" part to protect our turf, keep our niche well carved out; perhaps it may not. Today I stand side by side with you as a brother* in radiation oncology. Ouch! As I stood I had sharp pain in my knee. Maybe some radiation would help with that; better see an oncologist :)
*name
 
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xrthopeful said:
We are oncologists. We have Oncology specific training. Any attempt to remove the word Oncology from our field is a self-own IMO and takes us away from the table with med oncs and surgeons and with our patients as well. We are oncologists.

I’m all for doing other things in our scope including benign conditions, cardiac arrhythmias etc, but there’s no need to change the name and take away from the vast majority of what we do.
Click to expand...

Well the other side of the coin is that if we restrict ourselves to "Oncology" we may appear less appealing to both patients who don't suffer from cancer and to other physicians that do not want to refer their patients to an "oncologist" (even if it's "only" a radiation oncologist).

It's the argument that I have heard from neurosurgeons that bought a Gammaknife to treat benign diseases in their departments:
Otherwise healthy, not-cancer patients, prefer to be treated by a neurosurgeon for their condition (pituitary tumor, AVM, neuralgia) than in the hands of a radiation oncologist. After all, they don't suffer from cancer...
 
Well here in the US, the neurosurgeons need rad oncs to use the GK.....
 
Mandelin Rain said:
So radiation is okay as long as the patients aren't fat nor have had pain for a few years.

All that acute onset OA in skinny people in America, may still be fair game based mainly on the opinion of the author. Though largely refuted by the best evidence available.

Cancer or no cancer, I'm all for helping anyone in pain that I think I can probably help. This ain't it chief.
Click to expand...
"Mayday, mayday.* We've been hit!" Ha! What a great title. Had to be Germans :) Makes we wanna see Wings again.
*technically you're supposed to say it three times.
 
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