Sad thing is someone else will come in and offer spine sbrt, and no one will ever know how poorly it’s being done. Well maybe simul when they try to sneak in an sbrt charge for 20/5
Funny you say thatSad thing is someone else will come in and offer spine sbrt, and no one will ever know how poorly it’s being done. Well maybe simul when they try to sneak in an sbrt charge for 20/5
Old iXs can't upgrade to rapidarc/vmat, but they still have cbct. No cbct in 2023 takes some real talent i thinkno CBCT
My nurses are now doing BED calcs bc the GD skin cancer guidelines changed to pure BED.
Interesting thought.Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
In many centers this is routine. For patient comfort as much as anything else. I never treat patients on a “breast board” either. Just in vac locs. Not because I’m smart, or stupid. It’s just that’s how I was trained.Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
Serious question, because I don’t treat breast but I cover my colleagues as needed. When treating nodes and the breast, how is CBCT better? I feel like often the body surface contour of the breast and the chest wall (etc) don’t deform in a uniform way and aligning to one takes you a little off on the other. I feel like personally, I would make sure to align to chest wall and use more flash to make sure the whole breast is treated. Breast is one place where often, I feel like port films show me what I need to know better than most other sites. I am sincerely curious from folks who do a lot of breast what the advantages are of CBCT for UNIlLATERAL non VMAT breast imaging? (Bilateral comprehensive plans are somewhat self explanatory).Interesting thought.
i assume back in the old days, both arms were up to have reproducable positioning with skin markings?
But nowadays with surface guidance and CBCT…
Serious question, because I don’t treat breast but I cover my colleagues as needed. When treating nodes and the breast, how is CBCT better? I feel like often the body surface contour of the breast and the chest wall (etc) don’t deform in a uniform way and aligning to one takes you a little off on the other. I feel like personally, I would make sure to align to chest wall and use more flash to make sure the whole breast is treated. Breast is one place where often, I feel like port films show me what I need to know better than most other sites. I am sincerely curious from folks who do a lot of breast what the advantages are of CBCT for UNIlLATERAL non VMAT breast imaging? (Bilateral comprehensive plans are somewhat self explanatory).
And I am seriously surprised I am curious about breast. It is the WORST 😛
Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
I just follow NSABP B-51, which is 7 mm for chest wall and 5 mm for nodes. Those are also cropped in various ways as per protocol. It's complicated and weird bc breast is the worst, but I've had 0 LRRs in 4 yrs....Entirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
Entirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
5-7 mmEntirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
If you're willing to advance an argument like that, a rejoinder is, contra arm down, they're less likely to develop one.Banner told us that Houston does both arms up and I ended up asking why.
The reason I was told ... "In case they develop a contra cancer, it will be easier to treat"
That's ... a reason.
6mmEntirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
I can only think of one thing worse than not giving RNI in patients with 1-3+ LNs that a rad onc can do, and that is downcoding.
This means you must give ENI to T1N0, or at least it’s now a supportable standard of care. I definitely could not see that one coming.
Breast Cancer Mortality down 1.6%.
I can't even get a surgeon to perform a SLNBx in cN0 patients. Now, you want me radiating all the LNs in all these patients?This means you must give ENI to T1N0, or at least it’s now a supportable standard of care. I definitely could not see that one coming.
Also I feel bad for all the women radiation killed prior to the 1990s.
And you sure can’t get them to dissect an axilla in a SLN+ patient (and we know positive lymph nodes are left behind in the patient from not dissecting). We didn’t even need a meta-analysis to know that not dissecting out those left behind positive nodes actually doesn’t affect outcomes at all. BUT… this meta-analysis says we can affect outcomes if we irradiate the axilla, sclav, and IMNs. Which in and of itself is not a new finding, but saying it affects survival for a single node positive patient kind of is new. And saying it improves survival in N0 is really new; that actually does conflict with previous trial outcomes (the “power” of meta-analysis finds things trials didn’t).I can't even get a surgeon to perform a SLNBx in cN0 patients. Now, you want me radiating all the LNs in all these patients?
Sounds reasonable.
Tripple negative, 1.9 cm, G3, Ki67 80%, upper inner quadrant with extensive LVI, cN0 pNx?I'm not doing RNI for T1N0 patients.. ever.
What do you mean by pNx? I would definitely not do if CR to chemo; those triple negative patients do great long term. But, no, I will not do ENI for any cN0/pN0 patient. AFAIK, there is no cN0/pN0 presentation for which the NCCN would recommend ENI. We don't mention that the most significant differences between ENI and no ENI in MA20 and EORTC were in side effects. (Woops, just mentioned it.) Axillary lymph nodes are not waystations to distant metastasis, especially in your hypothetical case.Tripple negative, 1.9 cm, G3, Ki67 80%, upper inner quadrant with extensive LVI, cN0 pNx?
I meant no SLNB performed.What do you mean by pNx? I would definitely not do if CR to chemo; those triple negative patients do great long term. But, no, I will not do ENI for any cN0/pN0 patient. AFAIK, there is no cN0/pN0 presentation for which the NCCN would recommend ENI. We don't mention that the most significant differences between ENI and no ENI in MA20 and EORTC were in side effects. (Woops, just mentioned it.) Axillary lymph nodes are not waystations to distant metastasis, especially in your hypothetical case.
Now, take everything I'm saying with a grain of salt given this "compelling" recent meta-analysis. For if you want ENI for a T1cN0 triple negative, you would want ENI for T1cN0 ER+... it would just logically follow, based on this fused, melded, data (as long as you discard some of the old data).
If you look at the subgroup analyses from this meta-analysis, the benefit from RNI was lost when the IM nodes were not irradiated. Maybe it’s really the IMNs that matter the most for RNI. DBCG would support thatAxillary lymph nodes are not waystations to distant metastasis, especially in your hypothetical case.
Most probably this is the case. Anyone know of any good case series supporting this? It's of recent interest again for my partners & dosimetry team
A persistent delusion maintained by many rad oncsalmost certain it’s clearance of imn seeding distant disease.
Well planned VMAT, yes. Unfortunately lots of folks accepting crap plans out there using VMAT for RNI and accepting MHD of > 4-5Gy for R sided and MHD > 8-10 Gy for L sided.