Hippocampal avoidance WBRT

[Ray D. Ayshun]

If you can see it on an MRI and can do so safely why not hit it? Sib to 40/10 too with 10 fx

I do wonder though if someone here is thinking, “hmmmm if sdn thinks i can bill APBI as SBRT, maybe i should bill this too!”

30/5 would get billed as sbrt post op. I saw a trial that did 50/10 sib. Seems risky off trial.

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[thecarbonionangle]

Since someone admitted to trying to get paid for sbrt for 25/5 rectum, i nominate same person to try to get paid for HA-WBRT with sib to 30/5 as SBRT. You heard it here first!

 

[jondunn]

Since someone admitted to trying to get paid for sbrt for 25/5 rectum, i nominate same person to try to get paid for HA-WBRT with sib to 30/5 as SBRT. You heard it here first!

Throw a cone down in, a couple of 1.8s, baby you got yourself a stew!

 

[Palex80]

 

[taserlaser]

In training I was asked how much I was actually sparing at the 20 Gy level for HA-WBRT - answer is probably not much. Much more difference in dose levels at 30 Gy and I agree with the commentary here about performance status and prognosis - so many patients just pass regardless of treatment and WBRT would have just made their end days ****tier, and so patient selection is huge imo, esp when we have SRS.

For those that SIB, how often are you coming back for any salvage therapy like SRS? I know it’s possible and we have done it here, but after taking with the local SRS guy here, I have been a bit reluctant off trial to do so due to (anecdotal?) concerns of increased necrosis risk later on since they had higher dose up front. Thoughts?

 

[evilbooyaa]

For those that SIB, how often are you coming back for any salvage therapy like SRS? I know it’s possible and we have done it here, but after taking with the local SRS guy here, I have been a bit reluctant off trial to do so due to (anecdotal?) concerns of increased necrosis risk later on since they had higher dose up front. Thoughts?

That's kinda my worry about it - if we say SRS after regular WBRT is fine in terms of cumulative dose, and we say 20/5 is functionally equivalent to 30/10, then is it safe to SRS at normal doses (which are already not ablative due to being in the brain) in a SIB'd area? I think doing 20/5 with SIB actually makes more sense because the likelihood patient is coming back for SRS is lower since you've already somewhat internally assessed (at least based on responses here) their prognosis... vs 30/10 with SIB to 40 is kinda shooting yourself in the foot for future SRS assuming they are a good player (no LMD, no exploding extracranial disease, bonus points if EGFR/ALK mutated NSCLC or have immunotherapy options, newly diagnosed or at leas tnot on 5th line hail mary systemic therapy, etc. etc.)

 

[TheWallnerus]

View attachment 353591

Or, about as good, not electively irradiating radiographically normal-appearing supratentorial CNS tissue

 

[thecarbonionangle]

90-05 had heavily pretreated patients. One of patchell studies went to 50gy WBRT.
Alpha beta 3 eqd2 for 40/10 is 56 gy
Alpha beta 10 eqd2 for 40/10 is 46 gy

 

[evilbooyaa]

90-05 had heavily pretreated patients. One of patchell studies went to 50gy WBRT.
Alpha beta 3 eqd2 for 40/10 is 56 gy
Alpha beta 10 eqd2 for 40/10 is 46 gy

Patchell patients weren't getting SRS... I suppose 1/3rd did have primary brain tumors that got a median dose of 60Gy initially (on re-check of the final 9005 pub Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05) but the median dose for brain met patients was 30Gy

 

[Palex80]

While most of us question the value of WBRT, some people test if a second course of WBRT may be the answer...

ClinicalTrials.gov

clinicaltrials.gov

The primary endpoint is great...


Primary Outcome Measures :
1. Toxicity [ Time Frame: 3 months ]
The primary endpoint is toxicity according to CTCAE after whole brain radiotherapy.

 

[elementaryschooleconomics]

The primary endpoint is great...


Primary Outcome Measures :
1. Toxicity [ Time Frame: 3 months ]
The primary endpoint is toxicity according to CTCAE after whole brain radiotherapy.

 

[TheWallnerus]

While most of us question the value of WBRT, some people test if a second course of WBRT may be the answer...

ClinicalTrials.gov

clinicaltrials.gov

View attachment 353878

The primary endpoint is great...


Primary Outcome Measures :
1. Toxicity [ Time Frame: 3 months ]
The primary endpoint is toxicity according to CTCAE after whole brain radiotherapy.

View attachment 353883

Ed Shaw was a believer. He was one of the first people to look at doing it (1996 paper); 20 Gy/10fx was the usual go-to. I have done it a few times many, many years ago. And then I stopped. Lackluster results as far as I could tell. Private practice guy Jay Loeffler wrote some papers on it too. Maybe it's like PULSAR? But fractionated

Analysis of outcome in patients reirradiated for brain metastases​

 

[Ray D. Ayshun]

I don't understand the need to treat every single brain met, particularly with reRT. It's either SRS all of em or whole brain. Why not srs the big symptomatic one and do nothing to the others in certain situations? If someone needs repeat whole brain, they probably really need LC at 1 or 2 sites, and if not, they're probably QUARTZers.

 

[Palex80]

 

[TheWallnerus]

View attachment 353894

 

[elementaryschooleconomics]