Benign Disease

[evilbooyaa]

A "good sign" to predict response to treatment is an increase in pain immediately after the first fraction. This is something many you have seen when treating bone mets too, patients describe more pain after the first fraction which then fades off (some use steroids, there was even a randomized trial a while ago looking into that flare phenomenon).

"More pain" after the first fraction for arthritis treatment can be predictive for a durable response. However it's mostly seen in patients with an inflammatory component.


On a side note:

6 x 0.5 Gy has worked in a patient with atypical pain syndrome of the infraorbital nerve. Patient responded and remained pain-free for 2 years.

I was under the impression that 'pain flare' was a concern with high doses of radiation causing RT-induced inflammation compounding with a bone met. Things like 8Gy x 1, or SBRT dosing.

Are you expecting pain flare to be a thing at 0.5Gy?

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[Mandelin Rain]

I was under the impression that 'pain flare' was a concern with high doses of radiation causing RT-induced inflammation compounding with a bone met. Things like 8Gy x 1, or SBRT dosing.

Are you expecting pain flare to be a thing at 0.5Gy?

I'm still unclear on the purported mechanism of action in osteoarthritis. If it is killing pro-inflammatory lymphocytes in the joint space, then yes, likely any cell kill could prompt the local release of cytokines and worsening pain. Lymphocytes and typically radiosensitive, so occurring at a low dose would be possible I'd think.

 

[OTN]

I started 3 patients this week. Just saw 2 this am for their on-treatment visit. Both reported notable pain relief (one in the low back, one in the knees) after only 2 fractions of 60 cGy each. Very encouraging.

 

[Mandelin Rain]

I started 3 patients this week. Just saw 2 this am for their on-treatment visit. Both reported notable pain relief (one in the low back, one in the knees) after only 2 fractions of 60 cGy each. Very encouraging.

What fields/beam arrangement? Just APPA?

 

[OTN]

What fields/beam arrangement? Just APPA?

Yep. Complex planning.

 

[evilbooyaa]

Yep. Complex planning.

We're not contouring OARs and calling this 3D are we?

 

[medgator]

We're not contouring OARs and calling this 3D are we?

I wouldn't think so, I think that defines "complex" planning from an insurance perspective if you aren't having to do those things

 

[OTN]

We're not contouring OARs and calling this 3D are we?

Certainly not

 

[evilbooyaa]

I'm still unclear on the purported mechanism of action in osteoarthritis. If it is killing pro-inflammatory lymphocytes in the joint space, then yes, likely any cell kill could prompt the local release of cytokines and worsening pain. Lymphocytes and typically radiosensitive, so occurring at a low dose would be possible I'd think.

I'm honestly not sure. People who poo-poo it say it's the placebo effect. Two trials that say as much:

Effectiveness of low-dose radiation therapy on symptoms in patients with knee osteoarthritis: a randomised, double-blinded, sham-controlled trial - PubMed

NTR4574.

www.ncbi.nlm.nih.gov

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial - PubMed

NTR4574 (Dutch Trial Register).

www.ncbi.nlm.nih.gov

But then there's the rebuttal:

Low-dose radiotherapy: Mayday, mayday. We’ve been hit! - Strahlentherapie und Onkologie

link.springer.com

I wouldn't think so, I think that defines "complex" planning from an insurance perspective if you aren't having to do those things

I know this is off-topic, but I'm int he process of getting the 'Business of Rad Onc' forum finalized so we can start talking about billing practices behind something resembling a closed door. Because I thought Complex treatment WAS 3D and I've just realized how much I still need to learn about this.

 

[Mandelin Rain]

I always figured that the mechanism of OA was periosteum rubbing on periosteum as in an osteophyte or decreased cartilage, etc... i.e. a structural issue. This is why the pain would worsen throughout the day with activity vs worse in AM as in inflammatory maladies.

I guess if it works it works. Though the same could be said of red light therapy I suppose.

 

[Palex80]

I was under the impression that 'pain flare' was a concern with high doses of radiation causing RT-induced inflammation compounding with a bone met. Things like 8Gy x 1, or SBRT dosing.

Are you expecting pain flare to be a thing at 0.5Gy?

Noone really knows... But it happens often, especially in heel spurs and is considered a "good sign", but that's all of course not evidence based.

 

[scarbrtj]

Noone really knows... But it happens often, especially in heel spurs and is considered a "good sign", but that's all of course not evidence based.

And why do things like this work? Good question too.

I know this is off-topic, but I'm int he process of getting the 'Business of Rad Onc' forum finalized so we can start talking about billing practices behind something resembling a closed door.

This is the biggest weak spot in current residency training. Residents should have to do a two week rotation in the billing & coding department their second and last years of training. And to make sure they get different perspectives they should also have to attend at least one national, legit billing & coding seminar.

 

[SneakyBooger]

Orthopod just called me.

Had a pt in a boot with achilles tendinitis with pre-RT pain of 8/10.

She completed 300 cGy in 5 fractions a few weeks ago.

He had her in the office now and her pain is "less than 1/10" and wanted to know what I did to her.

Said he will be sending me many more patients.

 

[scarbrtj]

Orthopod just called me.

Had a pt in a boot with achilles tendinitis with pre-RT pain of 8/10.

She completed 300 cGy in 5 fractions a few weeks ago.

He had her in the office now and her pain is "less than 1/10" and wanted to know what I did to her.

Said he will be sending me many more patients.

Will as many Americans get achilles tendinitis in 2020 as will get cancer? I think so?

 

[SneakyBooger]

Just saw a patient who is being treated to bilateral knees.

Pain preRT was 8/10.

after 4 fractions states pain is 2/10. He is extremely pleased.

When he told his PCP what he was doing his PCP said "Whaaaat?!", and to go for it.

He said he can't wait to tell his PCP how well his pain has responded.

There's something going on here...

 

[Krukenberg]

Did you treat with opposed lats? What were your field borders?

 

[SneakyBooger]

Knee - appa

ankle - opp lat

small fields - roughly 10x10

 

[SneakyBooger]

Hold your horses.

Just saw a thumb that had no response.

Still could respond in the coming weeks to months. And retreatment is an option. We'll see what happens with this one...

 

[OTN]

Do you have any marketing materials you would be willing to share?

 

[hockyfan]

Hold your horses.

Just saw a thumb that had no response.

Still could respond in the coming weeks to months. And retreatment is an option. We'll see what happens with this one...

FWIW, Data for hand OA was weaker and showed less effectiveness than some of the other sites you've had success with

 

[SneakyBooger]

Do you have any marketing materials you would be willing to share?

No marketing.

I discuss with current patients in followup when they mention their arthritis is the main issue bothering them. Approximately 85% of those patients want to proceed.

If I marketed it we would need to double our vaults.

 

[OTN]

No marketing.

I discuss with current patients in followup when they mention their arthritis is the main issue bothering them. Approximately 85% of those patients want to proceed.

If I marketed it we would need to double our vaults.

That's exactly what I've been doing thus far- talking only to my follow ups about it. 75-85% is what I've seen as well.

I also haven't marketed, as it would overwhelm our capacity.

 

[w00tz]

Thanks for keeping us updated on this. Is there an age where you would feel uncomfortable treating?

 

[SneakyBooger]

Not an issue thus far, but since I just finished treating a trio of keloids in a 31YO female I don't think so.

 

[taserlaser]

A Long Term Results of External Beam Radiation Therapy in Hemophilic Arthropathy of the Ankle in Children

Bleeding into joint space is critical to develop hemophilic arthropathy. To reduce the frequency of bleeding in the ankle joint of children with hemophilic arthropathy, low dose external beam irradiation was performed for 37 patients. Among them, 35 patients ...

www.ncbi.nlm.nih.gov

Short followup (mean 87 months), higher doses. No 2nd malignant events seen.

Have a patient (20s) referred to me for RA/chronic synovitis from ortho. Ortho doesn't want to do total synovectomy as they think high risk of recurrence. Just reviewed MRI with rads, unlikely to be PVNS. Have to do my own due diligence and lit review on RA radiotherapy literature still, but probably will be treating lower dose (eg 20/10) and go with that.

 

[medgator]

That's exactly what I've been doing thus far- talking only to my follow ups about it. 75-85% is what I've seen as well.

I also haven't marketed, as it would overwhelm our capacity.

The future of Radiation isn't oncology I guess....

 

[Krukenberg]

A Long Term Results of External Beam Radiation Therapy in Hemophilic Arthropathy of the Ankle in Children

Bleeding into joint space is critical to develop hemophilic arthropathy. To reduce the frequency of bleeding in the ankle joint of children with hemophilic arthropathy, low dose external beam irradiation was performed for 37 patients. Among them, 35 patients ...

www.ncbi.nlm.nih.gov

Short followup (mean 87 months), higher doses. No 2nd malignant events seen.

Have a patient (20s) referred to me for RA/chronic synovitis from ortho. Ortho doesn't want to do total synovectomy as they think high risk of recurrence. Just reviewed MRI with rads, unlikely to be PVNS. Have to do my own due diligence and lit review on RA radiotherapy literature still, but probably will be treating lower dose (eg 20/10) and go with that.

do you mean 20 gy in 10 fractions?

 

[taserlaser]

do you mean 20 gy in 10 fractions?

Yes, sorry that wasn’t clear.

 

[taserlaser]

Found some data to suggest that injection radiation synovectomy is estimated to be about 25 Gy external beam, though responses required ”about half” that dose. Stuck with the 20 Gy prescription.

Repeat 8 Gy didn’t induce any response in the hemarthrosis like it did after the first treatment, sadly. Just more localized swelling and a bit more stiff of a knee :/

 

[deleted573262]

Radiotherapy for osteoarthritis of the ankle and tarsal joints—analysis of 66 joints - Strahlentherapie und Onkologie

Purpose Osteoarthritis of the ankle and tarsal joints is less common than osteoarthritis of the knee or hip, but the associated disability is at least as severe as that of the other major joints of the lower limb. The results for total arthroplasty are still not satisfactory. For this reason...

link.springer.com

 

[deleted947887]

Effectiveness of low-dose radiation therapy on symptoms in patients with knee osteoarthritis: a randomised, double-blinded, sham-controlled trial - PubMed

NTR4574.

www.ncbi.nlm.nih.gov

CONCLUSIONS: We found no substantial beneficial effect on symptoms and inflammatory signs of LDRT in patients knee OA, compared with sham treatment. Therefore, based on this RCT and the absence of other high-quality evidence, we advise against the use of LDRT as treatment for knee OA.

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial - PubMed

NTR4574 (Dutch Trial Register).

www.ncbi.nlm.nih.gov

CONCLUSIONS: We were unable to demonstrate a substantial beneficial effect of LDRT on symptoms and inflammation in patients with hand OA, compared to sham treatment. Although a small effect can not be excluded, a treatment effect exceeding 20% is very unlikely, given the confidence interval. Therefore, in the absence of other high-level evidence, we advise against the use LDRT as treatment for patients with hand OA.

 

[scarbrtj]

Alzheimer's may soon be treated with low dose radiation therapy

 

[OTN]

Effectiveness of low-dose radiation therapy on symptoms in patients with knee osteoarthritis: a randomised, double-blinded, sham-controlled trial - PubMed

NTR4574.

www.ncbi.nlm.nih.gov

CONCLUSIONS: We found no substantial beneficial effect on symptoms and inflammatory signs of LDRT in patients knee OA, compared with sham treatment. Therefore, based on this RCT and the absence of other high-quality evidence, we advise against the use of LDRT as treatment for knee OA.

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial - PubMed

NTR4574 (Dutch Trial Register).

www.ncbi.nlm.nih.gov

CONCLUSIONS: We were unable to demonstrate a substantial beneficial effect of LDRT on symptoms and inflammation in patients with hand OA, compared to sham treatment. Although a small effect can not be excluded, a treatment effect exceeding 20% is very unlikely, given the confidence interval. Therefore, in the absence of other high-level evidence, we advise against the use LDRT as treatment for patients with hand OA.

Several problems with that trial, most notably that doses less than 1 Gy seem to work better than the 1 Gy / tx dose used in that trial.

 

[OTN]

Several problems with that trial, most notably that doses less than 1 Gy seem to work better than the 1 Gy / tx dose used in that trial.

Meant to add: the German ARTHRORAD trial should help answer the question, as it’s testing the German protocol of 0.6 Gy x 5 (2-3x/week I believe) and has slightly more refined inclusion criteria.

 

[CaesarRO]

Several problems with that trial, most notably that doses less than 1 Gy seem to work better than the 1 Gy / tx dose used in that trial.

Low-dose radiotherapy: Mayday, mayday. We’ve been hit! - Strahlentherapie und Onkologie

link.springer.com

Nice Green Journal summary of the German take on the two negative RCTs. Also highlights some principles for better patient selection based on their clinical experience.

For us, the two Dutch studies were not convincing enough to change clinical practice in Germany, but they clearly brought the level of clinical trials using LDRT to a higher level than before and have opened the door for improved design and performance of future randomized trials. We summarize that future randomized trials should include patients with less advanced joint osteoarthrosis, with shorter pain intervals, longer follow-up evaluation (at least 1 year), and with a higher patient number and a reduced response difference estimate between the two or three randomized groups

Sent from my Pixel 2 XL using Tapatalk

 

[Mandelin Rain]

Said it in another thread about rectal cancer; I'm not sure why we bother doing randomized trials anymore.

Unless they confirm what we do, we just find some reason to ignore them.

 

[OTN]

Said it in another thread about rectal cancer; I'm not sure why we bother doing randomized trials anymore.

Unless they confirm what we do, we just find some reason to ignore them.

In the Germans’ defense, it didn’t really test what they do.

 

[evilbooyaa]

Said it in another thread about rectal cancer; I'm not sure why we bother doing randomized trials anymore.

Unless they confirm what we do, we just find some reason to ignore them.

It's kinda one of those things that I can't explain why maybe 0.5Gy/fx works better than 1Gy/fx but the believers in it will say "you don't do what we do". Maybe it is all just a placebo effect.

 

[Mandelin Rain]

Yes. Why would 0.6 Gy work better than 1.0 Gy? Preclinical data? Proposed mechanism of action? Any rationale at all? Anything?

 

[taserlaser]

Yes. Why would 0.6 Gy work better than 1.0 Gy? Preclinical data? Proposed mechanism of action? Any rationale at all? Anything?

I mean who knows? Killing off sensitive lymphocytes without provoking longer term sucblinical fibrosis which could mask treatment effect, having a narrow therapeutic window of dose? We're not used to treating with such low doses per fraction so I don't know if one can say one way or another. FWIW, as above, I am using 2 Gy/fr right now for a rheumatoid case. I'll see her next week and see how she's done with the first half of treatment.

 

[Mandelin Rain]

I reread the German response and they do offer some rationale.

 

[Palex80]

New articles!!!


Interesting article on re-irradiation for osteoarthritis

Re-irradiation for osteoarthritis—retrospective analysis of 217 joints - Strahlentherapie und Onkologie

Purpose Osteoarthritis is a common disease with a prevalence of approximately 8.9% among the average population. One treatment option is low-dose radiotherapy. Some authors mention that they apply a second or third course of radiation for recurrent pain or partial or no response to the initial...

link.springer.com

And a large patient collection with all kinds of benign skeletal disorders

Radiotherapy for painful benign skeletal disorders - Strahlentherapie und Onkologie

Purpose The aim of this retrospective clinical quality assessment was to evaluate the efficacy of low-dose radiotherapy (RT) for painful benign skeletal disorders. Methods Patients with different painful benign skeletal disorders (arthrosis and enthesopathies) were recruited for this...

link.springer.com

 

[SneakyBooger]

Nice graph:

 

[Krukenberg]

Have any of these groups that treat benign joints looked at arthroplasty complication rates for patients who go into get a joint replacement. The thing that would make me nervous about this is if there’s no published data about whether it increases the risk of prosthesis failure.

or if an orthopedic surgeon would be more likely to decline to do a joint replacement because they hear the patient had radiation. They get graded on their outcomes so wouldn’t surprise me if they’re very careful about patient selection

 

[OTN]

Have any of these groups that treat benign joints looked at arthroplasty complication rates for patients who go into get a joint replacement. The thing that would make me nervous about this is if there’s no published data about whether it increases the risk of prosthesis failure.

or if an orthopedic surgeon would be more likely to decline to do a joint replacement because they hear the patient had radiation. They get graded on their outcomes so wouldn’t surprise me if they’re very careful about patient selection

3 Gy in 5 fractions won't do anything. You should be able to reassure the referring orthopods that operating in a field with such small a dose should be fine.

 

[medgator]

3 Gy in 5 fractions won't do anything. You should be able to reassure the referring orthopods that operating in a field with such small a dose should be fine.

Orthopods send for more dose with HO prophylaxis before surgery

 

[SneakyBooger]

Have any of these groups that treat benign joints looked at arthroplasty complication rates for patients who go into get a joint replacement. The thing that would make me nervous about this is if there’s no published data about whether it increases the risk of prosthesis failure.

or if an orthopedic surgeon would be more likely to decline to do a joint replacement because they hear the patient had radiation. They get graded on their outcomes so wouldn’t surprise me if they’re very careful about patient selection

FWIW, I have not seen any studies regarding this issue, but have seen the comment in several publications that RT does not have any effect on surgical outcomes.

However, that doesn't mean that an orthopod won't blame RT for every complication that subsequently occurs anyway.

 

[OTN]

FWIW, I have not seen any studies regarding this issue, but have seen the comment in several publications that RT does not have any effect on surgical outcomes.

However, that doesn't mean that an orthopod won't blame RT for every complication that subsequently occurs anyway.

As is tradition

 

[evilbooyaa]

FWIW, I have not seen any studies regarding this issue, but have seen the comment in several publications that RT does not have any effect on surgical outcomes.

However, that doesn't mean that an orthopod won't blame RT for every complication that subsequently occurs anyway.

Is one truly a radiation oncologist if not getting blamed for other specialties complications?

 

[Krukenberg]

However, that doesn't mean that an orthopod won't blame RT for every complication that subsequently occurs anyway.

this is my worry. That without any evidence we don’t affect surgical outcomes they will either blame us or turn down patients that really need a joint replacement out of a fear of complications. We can tell them all we want that we wouldn’t expect this dose to make a difference but we’re not the ones doing the surgery and managing the complications