Humeral head tolerance

[Treat]

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Once again seeking the combined wisdom of the forum...

Am contemplating giving a high dose to a mass sitting just in front of the humeral head.

Tried looking for humeral head tolerances but coming up empty.

Do you use the QUANTEC femoral head tolerances?

Appreciate your input!

 

[Gfunk6]

Maybe use femoral head constraints? V30 < 50%, V50 < 5%, Vmax 52

 

[seper]

I would let humerus get prescription dose if you're treating with definitive intent.

 

[napoleondynamite]

I would let humerus get prescription dose if you're treating with definitive intent.

I agree 100%. It's not weight bearing, I wouldn't skimp on tumor coverage to spare it.

 

[Gfunk6]

Well, it depends on what you are treating . . .

 

[Palex80]

This is palliative, right?

 

[Treat]

50 year old good performance status,
1.5cm peripheral lung primary adenocarcinoma
6cm Met at the coracoid, just adjacent to the humeral head
Nothing else on PET and MRI brain
Surgeons won't operate on the mass

 

[RadOncDoc21]

you should be fine then... unless you're doing some crazy dose and fractionation like 60 Gy in 47 fx or 50 Gy in 1 fx... considering we agree this is for palliation. I would personally go for 30 Gy/10 fx.

That is one huge met by the way- you sure that's not something else.

 

[Treat]

The met was biopsied.

At the risk of sounding pedantic, 30 Gy/10 fx runs the risk of exceeding the tolerances quoted by gfunk.

Would anyone be concerned?

 

[medgator]

The met was biopsied.

At the risk of sounding pedantic, 30 Gy/10 fx runs the risk of exceeding the tolerances quoted by gfunk.

Would anyone be concerned?

No. The guy is kinda screwed either way. Median survival for Stage IV NSCLC (AdenoCa) vs how/when you expect he will get toxicity from 30/10 to the humeral head?

 

[Treat]

No. The guy is kinda screwed either way. Median survival for Stage IV NSCLC (AdenoCa) vs how/when you expect he will get toxicity from 30/10 to the humeral head?

Yeah... just wondering if there is any concern for that tiny chance that he'll live long enough for the toxicity to come back to haunt me.

Given that it's the only site of spread and he may turn out to be suitable for EGFR TKIs, I did toy with the idea of going even higher than 30/10. Other circumstances have put that idea to rest, but was just wondering if there are other worrywarts like me...

 

[medgator]

Yeah... just wondering if there is any concern for that tiny chance that he'll live long enough for the toxicity to come back to haunt me.

Given that it's the only site of spread and he may turn out to be suitable for EGFR TKIs, I did toy with the idea of going even higher than 30/10. Other circumstances have put that idea to rest, but was just wondering if there are other worrywarts like me...

Wouldn't concern me at all. If he's in good shape with limited disease, I'd probably even do 37.5/15. I've treated the humerus before for painful mets with that regimen

 

[Palex80]

Extrapolating tolerance doses from the femur to the humerus is a bit risky. The humerus probably tolerates more.
Most of us have treated patients with soft tissue sarcoma or ewings sarcoma in the humerus / shoulder region, giving doses (way) beyond 50/2 and personally I've never seen necrosis there. Plus those patients actually had partial destruction of the humerus quite some times due to the tumor and received surgery additionally. A mass not invading the humerus and no surgery probably mean even less long term toxicity.
What may happen is slight lymphedema though, if you push for doses higher than 50/2, but yet again this is something usually tolerable and manageable.

 

[RadOncDoc21]

The met was biopsied.

At the risk of sounding pedantic, 30 Gy/10 fx runs the risk of exceeding the tolerances quoted by gfunk.

Would anyone be concerned?

Not going to lie, I had to look up pedantic... My vocab is extremely limited.

 

[Gfunk6]

The met was biopsied.

At the risk of sounding pedantic, 30 Gy/10 fx runs the risk of exceeding the tolerances quoted by gfunk.

Would anyone be concerned?

V30 for bone mets is only relevant in the setting of IMRT to definitive doses. Otherwise, V50 or V52 is a far more relevant metric. The latter will not be exceeded with 30/10.

 

[Phantom1]

No. The guy is kinda screwed either way. Median survival for Stage IV NSCLC (AdenoCa) vs how/when you expect he will get toxicity from 30/10 to the humeral head?

Keytruda was FDA approved 2 days ago for NSCLC refractory to other therapies. Some patients can have durable responses to immunotherapy. Not that I would be concerned at all about 30Gx10... hopefully Low dose lung cancer screening and immunotherapy can make a real impact in lung cancer and reduce mortality. To jump on the soapbox... I think as Rad Onc's we should really be advocates and promote low dose CT lung cancer screening. #1 because approx 70% of patients present with advanced stage disease which is rarely curable, and #2 because we have an excellent non-invasive treatment for early stage lung cancer (SBRT)... Lung cancer is the number 1 cancer killer primarily because patients present only when they develop symptoms! Think of prostate cancer prior to PSA with patients presenting with Stage IV due to bone pain...

 

[medgator]

I do bring up LDCT when mentioning other screening exams like colonoscopy, mammo etc.

Medicare has pretty strict guidelines though about paying for it so I think that limits the number of places doing it. Patients need smoking cessation counseling and the CT facility has to maintain registry

 

[Treat]

As always, I appreciate all the replies!

Not going to lie, I had to look up pedantic... My vocab is extremely limited.

We all learn from each other!