Benign Disease

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elementaryschooleconomics said:
Hahaha I love this -

Honest to God it doesn't seem like we really know how much radiation we get from any of these things. While a knee treatment is 50cGy per treatment, I would GUESS that a full body CT is 40ish...mGy.

Similar numbers, wrong units.

But I could be totally wrong.

Because we're really bad about this.
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well, i stopped thinking about physics a minute ago, but 40 mJ/kg to 100 kg probably isn't significantly more photons than 50 cJ/kg to 1 kg. Am i totally off here?
 
Ray D. Ayshun said:
well, i stopped thinking about physics a minute ago, but 40 mJ/kg to 100 kg probably isn't significantly more photons than 50 cJ/kg to 1 kg. Am i totally off here?
Click to expand...
But let’s not forget CT kV radiation has a higher RBE than MV linac radiation too 😉
 
elementaryschooleconomics said:
Hahaha I love this -

Honest to God it doesn't seem like we really know how much radiation we get from any of these things. While a knee treatment is 50cGy per treatment, I would GUESS that a full body CT is 40ish...mGy.

Similar numbers, wrong units.

But I could be totally wrong.

Because we're really bad about this.
Click to expand...
100 times less mass in the knee than whole body, so amount of photons- not the dose- may be the same.
 
Ray D. Ayshun said:
Simmed a patient for OA RT to the right hip. 89 yo guy. Ortho doesn't want to do a jt replacement and the patient doesn't seem to either. Here's his right femoral head with avascular necrosis. There's still a component of jt narrowing, OA, and a long history of it including injections. Any reason to treat or not treat this guy at this point?
View attachment 360769View attachment 360770
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I think that bone met needs 30Gy in 10fx
 
what dose do you playas like to use for hydradenitis suppurativa? Been reading about this very interesting.
 
thecarbonionangle said:
what dose do you playas like to use for hydradenitis suppurativa? Been reading about this very interesting.
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I did this once in residency. Woman with severe HS in the peri-vulvar/groin region.

As I recall, we did enface electrons, 20Gy in 5fx.

Worked amazing. I was stunned.

This was back in the "old days", before the bubble crash, and there was minimal interest in benign disease. I couldn't get faculty hype to do a case report, they thought I was being silly.
 
elementaryschooleconomics said:
I did this once in residency. Woman with severe HS in the peri-vulvar/groin region.

As I recall, we did enface electrons, 20Gy in 5fx.

Worked amazing. I was stunned.

This was back in the "old days", before the bubble crash, and there was minimal interest in benign disease. I couldn't get faculty hype to do a case report, they thought I was being silly.
Click to expand...
I've done that scheme before. I've treated a few HS patients, one with the most severe disease her dermatologists had ever seen. RT works and patients were very thankful.
 
elementaryschooleconomics said:
I did this once in residency. Woman with severe HS in the peri-vulvar/groin region.

As I recall, we did enface electrons, 20Gy in 5fx.

Worked amazing. I was stunned.

This was back in the "old days", before the bubble crash, and there was minimal interest in benign disease. I couldn't get faculty hype to do a case report, they thought I was being silly.
Click to expand...
Any published evidence for this that you are aware of? I came across this post on themednet (theMednet - Login) but can't seem to locate a publication for this experience. Everything I can find seems to advocate for lower dosing (PMID: 20178712; PMID: 10897256; Radiotherapy for Non-Malignant Disorders. (2008). Germany: Springer Berlin Heidelberg). It is hard for me to envision much benefit with 6-8 Gy in 1-2 Gy/fx but I've never seen this treated before... German guidelines for treatment of benign diseases (surprisingly) don't seem to mention much regarding hidradenitis.
 
njdamic said:
Any published evidence for this that you are aware of? I came across this post on themednet (theMednet - Login) but can't seem to locate a publication for this experience. Everything I can find seems to advocate for lower dosing (PMID: 20178712; PMID: 10897256; Radiotherapy for Non-Malignant Disorders. (2008). Germany: Springer Berlin Heidelberg). It is hard for me to envision much benefit with 6-8 Gy in 1-2 Gy/fx but I've never seen this treated before... German guidelines for treatment of benign diseases (surprisingly) don't seem to mention much regarding hidradenitis.
Click to expand...
www.karger.com

Radiotherapy for Hidradenitis Suppurativa: A Systematic Review

Abstract. Background: Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis characterized by painful nodules, abscesses, sinus tracts, and scarring mainly in the intertriginous areas. Patients with HS often experience inadequate responses to traditional treatment consisting of...
www.karger.com www.karger.com

The dose is all over the place. There is a case series with 20/5 with up to 90 pct response rate. As you can see, huge range of doses. These patients are miserable and many are not aware this is an option. Make sure your derm/surgical colleagues are aware.
 
Huge range in case series for these things. Just have to pick one. I’m finishing up treatment for someone with Hailey-Hailey disease, and these patients all talk on their support forums. She asked for a RO referral from her derm. Some small improvement so far, using 16 Gy / 8 fr EOD from a recent Danish paper (so very gentle) but most of the improvement comes after. Fingers crossed. Others have used 4-8 Gy/fr, 20 Gy, etc.
 
Yeah I think that single case series is all that's published.

My attending at the time chose it because it was a "standard" palliative regimen.

I didn't like it, but I was a wee junior resident at the time. No one cared what I thought then (or now...).
 
Ray D. Ayshun said:
Simmed a patient for OA RT to the right hip. 89 yo guy. Ortho doesn't want to do a jt replacement and the patient doesn't seem to either. Here's his right femoral head with avascular necrosis. There's still a component of jt narrowing, OA, and a long history of it including injections. Any reason to treat or not treat this guy at this point?
View attachment 360769View attachment 360770
Click to expand...

I am a rad, not a radonc but I would be wary of that. It would be very easy to blame the radiation (whether or not it is the cause).

I would assume you are giving a lot more photons than a CT, because none of my cancer patients would have MSK pain if we were giving similar amounts of radiation.
 
What workup do you guys do before treating? Plain films? Nothing? Typically, patients here have XRs in ortho office that never get formally read and I can't access.
 
I gotta say, there is something just so different about treating OA.

It is not adjuvant breast - where they have no cancer (or microscopic) and you are preventing a recurrence. They may be grateful, but they don't really understand why to be thankful.

A prostate patient is asymptomatic before you treat them, has to come to you for 4-9 weeks daily, they get some mild side effects and then have to see you forever. 80% (more?) would be fine without treatment.

But, someone in pain with QOL issues that gets treated and has relief - man, they just love you.

Add it to your practice - you will have these small victories that add happiness to the world.

(I am feeling particularly "nice" today)
 
Clean7795 said:
I am a rad, not a radonc but I would be wary of that. It would be very easy to blame the radiation (whether or not it is the cause).

I would assume you are giving a lot more photons than a CT, because none of my cancer patients would have MSK pain if we were giving similar amounts of radiation.
Click to expand...
“Bit more”
“Slightly more”
“Skosh more”
Of course it’s not just the photon count, it’s their wavelength too
RealSimulD said:
I gotta say, there is something just so different about treating OA.

It is not adjuvant breast - where they have no cancer (or microscopic) and you are preventing a recurrence. They may be grateful, but they don't really understand why to be thankful.

A prostate patient is asymptomatic before you treat them, has to come to you for 4-9 weeks daily, they get some mild side effects and then have to see you forever. 80% (more?) would be fine without treatment.

But, someone in pain with QOL issues that gets treated and has relief - man, they just love you.

Add it to your practice - you will have these small victories that add happiness to the world.

(I am feeling particularly "nice" today)
Click to expand...
sounds like an ad to make someone want to go to med school!
 
RealSimulD said:
I gotta say, there is something just so different about treating OA.

It is not adjuvant breast - where they have no cancer (or microscopic) and you are preventing a recurrence. They may be grateful, but they don't really understand why to be thankful.

A prostate patient is asymptomatic before you treat them, has to come to you for 4-9 weeks daily, they get some mild side effects and then have to see you forever. 80% (more?) would be fine without treatment.

But, someone in pain with QOL issues that gets treated and has relief - man, they just love you.

Add it to your practice - you will have these small victories that add happiness to the world.

(I am feeling particularly "nice" today)
Click to expand...

I've had patients walk without a cane for the first time in 15 years. Had another call it "life changing!" I agree Simul, it is so nice to work that into our usual patient mix!
 
Has anyone radiated arthritis precipitated by hormone therapy yet?

The pathophysiology seems unclear but medical oncologists describe it similar to osteoarthritis in the literature I've seen.
 
NotMattSpraker said:
Has anyone radiated arthritis precipitated by hormone therapy yet?

The pathophysiology seems unclear but medical oncologists describe it similar to osteoarthritis in the literature I've seen.
Click to expand...

Yes. Works. Haven't been able to get much buy in from medoncs for whatever reason, but I've been successful in treating it.
 
Ray D. Ayshun said:
Do you do anything to confirm "arthritis?" Plain films etc. Or you just do it?
Click to expand...

Well it's not osteoarthritis. The med oncs call it AIMSS, AI associated musculoskeletal syndrome. And as far as I can tell in the literature, a patient report of arthritis plus the presence of the drug secures the diagnosis enough to treat.
 
NotMattSpraker said:
Well it's not osteoarthritis. The med oncs call it AIMSS, AI associated musculoskeletal syndrome. And as far as I can tell in the literature, a patient report of arthritis plus the presence of the drug secures the diagnosis enough to treat.
Click to expand...
Is there anything we can use to justify treatment? As far as I can tell, the only diagnostic codes that fit this are for oa and psoriatic arthritis. Technically, this may fall under the auspices of degenerative musculoskeletal disorder but I'm wondering how to get it through insurance
 
Ray D. Ayshun said:
Is there anything we can use to justify treatment? As far as I can tell, the only diagnostic codes that fit this are for oa and psoriatic arthritis. Technically, this may fall under the auspices of degenerative musculoskeletal disorder but I'm wondering how to get it through insurance
Click to expand...
Good question - I can't remember what I used to be honest. I think there's a generalized arthritis code I may have used.
 
OTN said:
Good question - I can't remember what I used to be honest. I think there's a generalized arthritis code I may have used.
Click to expand...
Osteoarthritis is a medical term for pain coming from a joint that is inflamed.

Given that we don’t have a blood test or scan that is highly specific for inflammation in a painful joint that is otherwise normal by physical exam and not complicated by other issues (like autoimmune), “you have a painful joint that is inflamed” seems like a reasonable diagnosis for, well, pain in a joint. Aka “OA.” Been a long time since I had to think general doctor thoughts!
 
elementaryschooleconomics said:
Yeah I think that single case series is all that's published.

My attending at the time chose it because it was a "standard" palliative regimen.

I didn't like it, but I was a wee junior resident at the time. No one cared what I thought then (or now...).
Click to expand...

Doesn't matter what you're palliating... cancer or a benign condition.... use the 'standard' palliative regimen.

Woof, not the best thought process, me thinks. Similar to indiscriminate use of 'standard' palliative radiation doses for run of the mill palliation of multiple myeloma.... and then we wonder why heme/onc doesn't want to send their patients to Rad Onc before they get hospitalized
 
evilbooyaa said:
Doesn't matter what you're palliating... cancer or a benign condition.... use the 'standard' palliative regimen.

Woof, not the best thought process, me thinks. Similar to indiscriminate use of 'standard' palliative radiation doses for run of the mill palliation of multiple myeloma.... and then we wonder why heme/onc doesn't want to send their patients to Rad Onc before they get hospitalized
Click to expand...
Completely agree.

I found that to be a common sentiment. If the patient was deemed "palliative", then we had to go with 30/10, 20/5, 8/1.

Obviously...I immediately abandoned that way of practicing the second I was free of the institution.
 
elementaryschooleconomics said:
Completely agree.

I found that to be a common sentiment. If the patient was deemed "palliative", then we had to go with 30/10, 20/5, 8/1.

Obviously...I immediately abandoned that way of practicing the second I was free of the institution.
Click to expand...

I'm a big fan of 2.5 x 15 for large soft tissue mets. Simul, don't @ me.
 
Just had a plantar fasciitis patient show up for consult. I’m reading through this thread. 0.5/Gy or 1Gy per fraction x 6 QOD? I see both in here? What’s the target?
 
Bequerel said:
Just had a plantar fasciitis patient show up for consult. I’m reading through this thread. 0.5/Gy or 1Gy per fraction x 6 QOD? I see both in here? What’s the target?
Click to expand...
I do 1 Gy x 6
Todd does something different

If the heel hurts, I treat the calc + margin

If sole hurts, heel + sole

Whole foot probably fine, too, if diffuse

CT planning
 
Bequerel said:
Just had a plantar fasciitis patient show up for consult. I’m reading through this thread. 0.5/Gy or 1Gy per fraction x 6 QOD? I see both in here? What’s the target?
Click to expand...
There is one randomized trial on heel spurs
pubmed.ncbi.nlm.nih.gov

Radiation therapy for painful heel spurs: results of a prospective randomized study - PubMed

RT is an effective treatment option for the management of inflammatory heel spurs. The dose for an RT course should not exceed 3.0 Gy.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 


I continue to think that what you guys are observing is the placebo effect. It’s been under-appreciated here how powerful it can be. Surprised I’m hearing talk of billboards going up.
 
grenz said:


I continue to think that what you guys are observing is the placebo effect. It’s been under-appreciated here how powerful it can be. Surprised I’m hearing talk of billboards going up.
Click to expand...

I mean, millions of dollars have been spent on TTF and SpaceOAR, so billboards are a drop in the bucket!

(Editor's note: Lumping in TTF with SpaceOAR is done for comedic effect)
 
grenz said:


I continue to think that what you guys are observing is the placebo effect. It’s been under-appreciated here how powerful it can be. Surprised I’m hearing talk of billboards going up.
Click to expand...

I'll bite, because what you are saying is a bunch of your colleagues are doing something sketchy.

Just a few questions

1) Have you tried it? Like a reasonable number of patients, let's say 5-10

2) Have you reviewed the literature in detail?

3) Have you spoken to international experts that have treated 100s to 1000s of cases?

Placebo is wonderful and has it's uses. I don't know how I can get someone's hands to start opening jars or people to be able to function - recently, was told by my patient could finally walk his dog outside. If they were waiting for someone to shoot x-rays that don't work at their hands/back to be able to open jars or spend time with Fido .. well, that's something.

If it is pure placebo, then this is very important to study further, because it means our fundamental understanding of osteoarthritis is incorrect. If placebo can help you improve function, then there may be a psychiatric component to OA. And that would be super interesting!
 
Last edited by a moderator:
Ray D. Ayshun said:
Either way, we should at least be honest with our patients and tell them that they probably still hurt just as bad as before, regardless of what they think.
Click to expand...
While a placebo response is possible, seems unlikely if pt has failed multiple other therapies, then recieves the xrt and has substantial improvement for an extended period.
 
RickyScott said:
While a placebo response is possible, seems unlikely if pt has failed multiple other therapies, then recieves the xrt and has substantial improvement for an extended period.
Click to expand...
Technically speaking, if these patients became prolific meditators or something, to the degree that they could ignore the pain, it would be placebo. My point is, if a patient sees me because they're hurting, and XRT lessens or resolves it, I really couldn't care less what biological process someone wants to ascribe it to.
 
I’ve had very good objective response in patients with dupuytrens …cording nearly resolved and better function
Have limited number of plantar fasciitis patients but not much success (n too small to say anything for sure)
I’ve done 3 gy in 6 for plantar fasciitis based on paper listed in above pots
 
RadRadRad said:
I’ve had very good objective response in patients with dupuytrens …cording nearly resolved and better function
Have limited number of plantar fasciitis patients but not much success (n too small to say anything for sure)
I’ve done 3 gy in 6 for plantar fasciitis based on paper listed in above pots
Click to expand...
Plantar I've done 6 Gy in 6 Fx.

That was the dose in the 6 Gy vs 0.6 Gy study and there is dramatic difference between arms.
 
I read a story in the National Enquirer once about how a little boy with a brain tumor pictured Star Wars spaceships shooting lasers at his tumor... and he did this every day. Without fail. Especially during each daily radiotherapy session. And lo, said the Enquirer, he cured himself with the power of his own mind. The doctors were astounded.
 
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