Chest wall pain/injury from SBRT

[Mandelin Rain]

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Have a lady I treated 2 years ago for a large-ish NSCLC that involved the chestwall to 60 Gy in 8 fx (7.5Gy per) who has had terrible chestwall pain and 3 broken ribs since. About a year after treatment it looked like she had coagulative necrosis on an MRI. It has since improved on imaging and there is no concern for tumor progression. Pain remains awful though. Wrapping around her ribs.

What do you do? I've tried the Vit E/Trental. Typical narcs. Sent her to pain for nerve blocks. She doesn't live close so not sure about HBO.

 

[RickyScott]

Have a lady I treated 2 years ago for a large-ish NSCLC that involved the chestwall to 60 Gy in 8 fx (7.5Gy per) who has had terrible chestwall pain and 3 broken ribs since. About a year after treatment it looked like she had coagulative necrosis on an MRI. It has since improved on imaging and there is no concern for tumor progression. Pain remains awful though. Wrapping around her ribs.

What do you do? I've tried the Vit E/Trental. Typical narcs. Sent her to pain for nerve blocks. She doesn't live close so not sure about HBO.

high dose neurontin/lyrica, intermittent steroids and nerve block . never tried HBO. vit e and trental cant hurt

 

[Mandelin Rain]

yes. done the gabapentin thing too. 🙁

 

[seper]

Palliative resection, chest wall reconstruction? I saw a similar case presentation by Timmerman 10 years ago.

 

[w00tz]

I second the nerve block.

 

[evilbooyaa]

If you already sent her for nerve blocks I'd get her set-up with pain management for pain control. They know more about neurontin/lyrica and the neuropathic aspect of pain than we do. Can sprinkle some Vit E/trental but it's probably homeopathic.

Just for curiosity can you provide some Dmax, V15-60 (in increments of 5Gy as cc of chest wall) data points for her dosimetry? I don't mean to call you out in anyway, but we truly have no good idea of constraints for 60/8 and it'd be nice to hear anecdotally what at least CAN cause this level of chest wall toxicity.

 

[Pointless]

That is unfortunate. If it was directly invasive into chest wall at presentation, that's likely what set her up for this. I would think HBO would be my next step since she is refractory to everything else.

FWIW, I have been using 60/15 for these types of large, non-SBRT type peripheral tumors, particularly in elderly patients, and so far so good.

 

[Burt Radnolds]

FWIW, I have been using 60/15 for these types of large, non-SBRT type peripheral tumors, particularly in elderly patients, and so far so good.

Watch out, the BED shamers are lurking! (I also use this fractionation at times, has served me well!)

 

[PhotonBomb]

Watch out, the BED shamers are lurking! (I also use this fractionation at times, has served me well!)

he said non-SBRT type.

 

[Pointless]

Watch out, the BED shamers are lurking! (I also use this fractionation at times, has served me well!)

I think I can only get in trouble with them if this fractionation made more money for me... which, come to think of it, it might? Nah, I don't think so. I'm safe.

 

[Burt Radnolds]

he said non-SBRT type.

Yes, exactly! I promise I only use it in non-SBRT type situations and that my definition of non-SBRT type is exactly what you have in mind 😉.

 

[Burt Radnolds]

My partner had a similar case and the patient seemed to improve with hyperbaric. However it seems the process has stabilized in your case and that pain is the main problem here. Hyperbaric may still be worth a shot but aggressive nerve blocking seems to make the most sense to me and it sounds like you have already referred her in that direction.