Breast RNI and IMN coverage Discussion.... Again. Breast is the worst x 3?

[medgator]

MODERATOR EDIT - Unrelated to rest of thread. Ignore this and read the below posts

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[HolySmokes]

IMRT for nasal ALA is just bad because you can get a beautiful plan with a personalized bolus and skin collimation. That is just lazy. I keep seeing people mention single node RNI. It is acceptable to do RNI in these cases so i don’t quite follow.

I think RNI for N+ breast cancer is pretty reasonable. People can think what they want about endpoints, subgroup analyses, etc but at the end of the day MA.20 showed reduction in DFS. Whether you use Z0011 to justify tangents or MA.20 to justify RNI I don't think either one is necessarily wrong?

 

[RickyScott]

IMRT for nasal ALA is just bad because you can get a beautiful plan with a personalized bolus and skin collimation. That is just lazy. I keep seeing people mention single node RNI. It is acceptable to do RNI in these cases so i don’t quite follow.

Proton centers justify rni including imn to get coverage for breast cancer with single node.

 

[Ray D. Ayshun]

Can we stop with breast? There is no wrong approach.

 

[Tigerstang]

Proton centers justify rni including imn to get coverage for breast cancer with single node.

Photon centers justify rni including imn to get IMRT coverage for breast cancer with a single node

Your point?

 

[RadOncDoc21]

Can we stop with breast? There is no wrong approach.

How dare you… Never ever!!! You call yourself a rad onc!?

 

[deleted1111261]

Photon centers justify rni including imn to get IMRT coverage for breast cancer with a single node

Your point?

100% true on both counts
Lots of t2n0 get RNI

 

[RickyScott]

Photon centers justify rni including imn to get IMRT coverage for breast cancer with a single node

Your point?

Just speculation, but I am not sure they really would radiate imn in these situations and are using it as pretense for proton justification. Similarly, I would bet proton centers may not opt for partial breast with certain insurers for similar reasons.

 

[Ray D. Ayshun]

Isn't inclusion of imn the only prospectively evaluated use of rni. Is there anything beyond retrospective evaluation to justify doing rni without the imms?

 

[Gfunk6]

Can we stop with breast? There is no wrong approach.

 

[RickyScott]

Isn't inclusion of imn the only prospectively evaluated use of rni. Is there anything beyond retrospective evaluation to justify doing rni without the imms?

Yes. My point is that i think some of these docs would not treat the imns if “citing the need to treat imn” was not required to justify protons. Similarly with partial vs whole breast in favorable elderly pts. End up treating more normal tissue just to justify the modality with insurance.

 

[Ray D. Ayshun]

Yes. My point is that i think some of these docs would not treat the imns if “citing the need to treat imn” was not required to justify protons. Similarly with partial vs whole breast in favorable elderly pts. End up treating more normal tissue just to justify the modality with insurance.

Fair enough. I guess I'm just trying to dumb things down enough for me by pretty much always doing imms if I do nodes. In any case, I am still curious about an imrt xrt plan with imms vs a 3d plan without wrt to coverage, hotspots and nt constraints.

 

[deleted1111261]

Fair enough. I guess I'm just trying to dumb things down enough for me by pretty much always doing imms if I do nodes. In any case, I am still curious about an imrt xrt plan with imms vs a 3d plan without wrt to coverage, hotspots and nt constraints.

I reviewed a vmat Vs 3D

The doc sent a vmat plan with 3x heart dose

She did 3D

 

[Ray D. Ayshun]

I reviewed a vmat Vs 3D

The doc sent a vmat plan with 3x heart dose

She did 3D

That clinic doesn't need to be vmatting anything then. Good lord

 

[RadOncDoc21]

View attachment 375982

The secret is to treat without treating!

 

[RickyScott]

The secret is to treat without treating!

That’s basically the mammosite approach.

 

[evilbooyaa]

Isn't inclusion of imn the only prospectively evaluated use of rni. Is there anything beyond retrospective evaluation to justify doing rni without the imms?

Effect of Elective Internal Mammary Node Irradiation on Disease-Free Survival in Women With Node-Positive Breast Cancer: A Randomized Phase 3 Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT04803266.

pubmed.ncbi.nlm.nih.gov

May only be useful to treat IMNs in patients with central/medial tumors with + Axillary LNs. In patients with pN1a dz and outer quadrant tumor I wouldn't routinely recommend IMN treatment.

Also - moved this to it's own thread...

Breast is the worst... again.

 

[Ray D. Ayshun]

Effect of Elective Internal Mammary Node Irradiation on Disease-Free Survival in Women With Node-Positive Breast Cancer: A Randomized Phase 3 Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT04803266.

pubmed.ncbi.nlm.nih.gov

May only be useful to treat IMNs in patients with central/medial tumors with + Axillary LNs. In patients with pN1a dz and outer quadrant tumor I wouldn't routinely recommend IMN treatment.

Also - moved this to it's own thread...

Breast is the worst... again.

Thanks. I remember this one. Now that you posted it. I think there was also a paper where IMNs were treated on right and not left-sided, and those with right sided breast cancer had better dfs. In this paper too, was numerically superior, though not statistically superior.

 

[evilbooyaa]

Right - prospective but not randomized (obviously) in support of IMN RT: https://ascopubs.org/doi/10.1200/JCO.22.00044

 

[deleted1111261]

It’s not randomized but it’s very strong IMO

 

[gmsquid]

It’s not randomized but it’s very strong IMO

With a distant met reduction better than adding paclitaxel to AC and also seen on ma20 and poortmans

 

[mheat3]

French randomized study showing no benefit with older techniques: Ten-year survival results of a randomized trial of irradiation of internal mammary nodes after mastectomy - PubMed

 

[deleted1111261]

Yeh, they did something crazy like a photon field

 

[RadOncDoc21]

I love the title of this thread!!! I have nothing more to add to breast cancer.

 

[grenz]

Best data re: IMN treatment IMO

Effect of Elective Internal Mammary Node Irradiation on Disease-Free Survival in Women With Node-Positive Breast Cancer: A Randomized Phase 3 Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT04803266.

pubmed.ncbi.nlm.nih.gov

 

[TheWallnerus]

Best data re: IMN treatment IMO

Effect of Elective Internal Mammary Node Irradiation on Disease-Free Survival in Women With Node-Positive Breast Cancer: A Randomized Phase 3 Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT04803266.

pubmed.ncbi.nlm.nih.gov

Best data like… don’t do IMN RT?

Or best data like… this data shows IMN RT works?

Blue dress? Gold dress?

 

[RadOncDoc21]

Best data like… don’t do IMN RT?

Or best data like… this data shows IMN RT works?

Blue dress? Gold dress?

 

[grenz]

Best data like… don’t do IMN RT?

Or best data like… this data shows IMN RT works?

Blue dress? Gold dress?

You have support to drop it for lateral or low T stage. Medial and central you should really try

 

[RickyScott]

You have support to drop it for lateral or low T stage. Medial and central you should really try

Does anyone think that a single node for an UOQ L breast cance deserves RNI including imn?

 

[Palex80]

Does anyone think that a single node for an UOQ L breast cance deserves RNI including imn?

Depends on histology and patient factors, I would say.

72yo, luminal A

42yo, triple negative

 

[Bequerel]

I think it does if the patient’s anatomy is bad and an imrt plan is better than 3dcrt plan and you forget to draw the imn’s down to the 3rd intercostal space and accept 80% coverage. I hate insurance companies btw

 

[deleted1111261]

Well

The luminal A - LRF is much more important than distant failure, while opposite is true for triple negative.

So, based on the old 4:1 rule, where the ratio is lower for luminal A and higher for triple negative, wouldn’t it be the opposite ?

 

[Palex80]

Well

The luminal A - LRF is much more important than distant failure, while opposite is true for triple negative.

So, based on the old 4:1 rule, where the ratio is lower for luminal A and higher for triple negative, wouldn’t it be the opposite ?

If you have a look at subgroup analyses of the trials, patients with more aggressive tumors and of younger age, seemed to have benefitted more from RNI.

For instance:

MA20

DBCG-IMN

I do not believe in the old 4:1 rule. I think the ratio strongly depends on biology.

 

[deleted1111261]

Well you’re just being reality-based

(I don’t believe 4:1 rule either; otherwise prime should show survival benefit lol)

 

[TheWallnerus]

I want some of the psychedelics a lot of you hype RNI/hype IMN guys take

Catch the new psychedelics episode on the latest Accelerators podcast!

 

[TheWallnerus]

You have support to drop it for lateral or low T stage. Medial and central you should really try

 

[Ray D. Ayshun]

80% covering 90%, or whatever the acceptable imn constraints are, is kind of "trying."

 

[dieABRdie]

I reviewed a vmat Vs 3D

The doc sent a vmat plan with 3x heart dose

She did 3D

For current residents lurking and reading this thread:

DO NOT LEAVE RESIDENCY WITHOUT DOING A DOSIMETRY ROTATION (or at least take the time to learn how an IMRT plan is done)

You might end up at one of these aforementioned clinics.

 

[RadOncDoc21]

For current residents lurking and reading this thread:

DO NOT LEAVE RESIDENCY WITHOUT DOING A DOSIMETRY ROTATION (or at least take the time to learn how an IMRT plan is done)

You might end up at one of these aforementioned clinics.

All 4,000 of you residents! Next year, we’ll be up to 20,000!

 

[madchemist89]

For current residents lurking and reading this thread:

DO NOT LEAVE RESIDENCY WITHOUT DOING A DOSIMETRY ROTATION (or at least take the time to learn how an IMRT plan is done)

You might end up at one of these aforementioned clinics.

I agree learn as much dosi as possible. I have to plan all my breast vmat cases.

 

[HolySmokes]

For current residents lurking and reading this thread:

DO NOT LEAVE RESIDENCY WITHOUT DOING A DOSIMETRY ROTATION (or at least take the time to learn how an IMRT plan is done)

You might end up at one of these aforementioned clinics.

Learning how to do my own planning has probably been the most beneficial thing I've done as an attending

 

[CaesarRO]

Okay, now I've gotta ask.

How much time do the self-planners spend on planning their own cases?

I have great dosi. I know enough to talk to them and point out specifics for how I want them to tweak plans.

Simple palliative stuff? Sure I'll do it myself. Sometimes faster that way.

But I'm not actually sitting there running optimizations myself and tweaking the objective values for IMRT plans.

 

[deleted1111261]

I’ve never done a plan in 13 years

So surprised people do it

So time consuming

 

[Ray D. Ayshun]

Okay, now I've gotta ask.

How much time do the self-planners spend on planning their own cases?

I have great dosi. I know enough to talk to them and point out specifics for how I want them to tweak plans.

Simple palliative stuff? Sure I'll do it myself. Sometimes faster that way.

But I'm not actually sitting there running optimizations myself and tweaking the objective values for IMRT plans.

Yeah, this is a bridge too far, however much I like planning. Particularly IMRT breast/nodes. There's all sorts of tricks with virtual bolus, etc, that I don't have time for in addition to trying to locate records, coordinate care, etc.

 

[madchemist89]

Okay, now I've gotta ask.

How much time do the self-planners spend on planning their own cases?

I have great dosi. I know enough to talk to them and point out specifics for how I want them to tweak plans.

Simple palliative stuff? Sure I'll do it myself. Sometimes faster that way.

But I'm not actually sitting there running optimizations myself and tweaking the objective values for IMRT plans.

Dosi can do all the easy plans. It's when they tell you they can't meet constraints you have to step in. When things get complicated, you have to think about drawing planning structures to optimize dose. In my experience, most dosimetrists will take your target volumes and go straight to optimization. That works fine for easy plans. Once you have target overlap with OARs and other complicating issues, that's when they need help.

 

[HolySmokes]

Even when they're good, most don't have the physics background to really understand what the machine is doing and how to structure the optimizer to make it most efficient. That's where it helps for me to have a good understanding so I can either guide them by recommending ways to do things or just take over and do it myself since I know exactly what I'm looking for and how to get there

Once you get familiar it's really not all that time consuming. Most plans can be done in ~30-40 minutes and half that time is waiting on the optimizer while I'm doing other things (clinic notes, seeing patients, contouring other plans, etc)

 

[SneakyBooger]

In addition to doing all of the dosimetry for our center (145+ pts under beam per day, 15-30 SBRT/SRS's, and a heavy HDR service) I also do all the physics QA. I am currently commissioning 2 new linacs and commissioning my friend's linac 2 hrs away. I take all the call for rad onc, Gyn Onc, and med onc. I run the ICU's and ER at the Level I trauma center at our hospital. Sometimes I have to do minor surgeries such as abdominal explorations in MVA pts. I want to do more but with only 7 days in a week I just can't find the time. I am pretty sure my children have graduated college and have families of their own but haven't seen them or my spouse in 28 yrs except when they drop by the department during the holidays for a brief family photo. Usually they don't recognize me and vice versa. Sometimes we see each other when they get admitted to one of the floors I am covering. My spouse and I were able to celebrate our 32nd wedding anniversary together while having dialysis before their transplant. I performed the transplant. Then it's right back to work. I just did a craniotomy as I was typing this.

 

[communitydoc13]

I’ve never done a plan in 13 years

So surprised people do it

So time consuming

Agree, there is a big difference between doing a plan yourself and knowing how to establish exactly what your expectations are with your dosimetry crew. The latter is what I would expect from a good doc. The most sophisticated example of the latter is a doc drawing out substructures to guide coverage, direct hotspots and allow for adequate regions for falloff to meet critical OAR constraints.

A doc calcing their own 3D plan is saving the clinic very little time, especially when dosi is still responsible for submitting any med necessity forms for your signature.

A doc tweaking segments on a breast plan for 105% isodose line aesthetics? Bad use of time.

I have good dosimetrists, and they do take the initiative to look into advances in planning techniques. In recent years, this often means learning about protocolized beam arrangements for certain indications (like vertex implementation for HC sparing whole brain) or splitting fields for large field pelvic plans.

IMO, GEUD is largely a strategy for optimization that in practice emphasizes volumetric constraints and de-emphasizes dose uniformity or meaningless hot spots. Useful for large volume lung cases. What you often get is a plan that "looks less pretty" but "makes more sense".

 

[CaesarRO]

Dosi can do all the easy plans. It's when they tell you they can't meet constraints you have to step in. When things get complicated, you have to think about drawing planning structures to optimize dose. In my experience, most dosimetrists will take your target volumes and go straight to optimization. That works fine for easy plans. Once you have target overlap with OARs and other complicating issues, that's when they need help.

Oh, I've definitely used Eval structures and for complex cases I'll create optimization structures to guide dosi.

To me, that just makes for clearer communication and faster planning. It should be the doc not the dosimetrist deciding what to do at coverage/constraint interfaces.

 

[temujim]

Okay, now I've gotta ask.

How much time do the self-planners spend on planning their own cases?

I have great dosi. I know enough to talk to them and point out specifics for how I want them to tweak plans.

Simple palliative stuff? Sure I'll do it myself. Sometimes faster that way.

But I'm not actually sitting there running optimizations myself and tweaking the objective values for IMRT plans.

How do you know you have great dosimetrists? Ever bench mark them?

Hear this a lot, but for most MDs it's just a feeling.