Hypofractionation for vertebral metastasis

[Kroll2013]

Dear collegues, what do you recommend as an alternative schedule for treating lombar vertebra metastasis ? 5*4 Gy ? 4*5 Gy?

Thank you

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[Palex80]

Any fractionation schedule that respects dose constraints to the spinal cord is appropriate.

With good planning nowadays, including IMRT, very few patients experience toxicity even with high doses in the area.
I still remember how it was 10 years ago with patients vomitting and having diarrhea when a single pa field or an ap/pa field pair were used.
This does not happen nowadays.

I tend to use 1 x 8 Gy in patients who have a bad prognosis and when my only goal is to control pain and not induce remineralisation/stability of the bone. Besides that 3 x 6 Gy, 4-5 x 5 Gy, 5-6 x 4 Gy, 8 x 3.5 Gy, 10 x 3 Gy are all excellent choices and probably lead to the same result.

 

[xrthopeful]

When are people not doing ap/pa for non-srs palliative spine? What?

 

[radiaterMike]

When are people not doing ap/pa for non-srs palliative spine? What?

Palex is not in the US so insurers are not telling him what to do (although I think reimbursements are the same no matter what technique you use but I may be wrong ). 2D for bone mets or brain mets is unacceptable in my view. Why not use 3D for field in field (for brain) or multi field bone mets treatment. In think insurers / CMS should have a "simple 3D" code for all palliation and reimburse at an appropriate rate as they do for "simple IMRT".


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[medgator]

Palex is not in the US so insurers are not telling him what to do (although I think reimbursements are the same no matter what technique you use but I may be wrong ). 2D for bone mets or brain mets is unacceptable in my view. Why not use 3D for field in field (for brain) or multi field bone mets treatment. In think insurers / CMS should have a "simple 3D" code for all palliation and reimburse at an appropriate rate as they do for "simple IMRT".


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How do you define that? I think most people in this day and age contour a volume on a planning CT and critical oar's. Don't see the point of going with anything fancier than appa for someone in severe pain that can barely lay still got 5-10 mins secondary to multi level spinal mets

 

[radiaterMike]

How do you define that? I think most people in this day and age contour a volume on a planning CT and critical oar's. Don't see the point of going with anything fancier than appa for someone in severe pain that can barely lay still got 5-10 mins secondary to multi level spinal mets

I would think that contouring and prescribing to a volume is 3D. Obviously insurers don't agree.

Using non opposing beams (i.e. Posterior obliques or 3 field to treat a spine) with optimal weighting/beam energy of each beam is not really more time consuming for the patient than APPA. Clearly it is less complex than a 3D definitive plan but more complex than an open field (or simple blocking) APPA or PA 2d plan.


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[medgator]

I would think that contouring and prescribing to a volume is 3D. Obviously insurers don't agree.

Using non opposing beams (i.e. Posterior obliques or 3 field to treat a spine) with optimal weighting/beam energy of each beam is not really more time consuming for the patient than APPA. Clearly it is less complex than a 3D definitive plan but more complex than an open field (or simple blocking) APPA or PA 2d plan.


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Sometimes those multi field plans help and the patient can tolerate the extra table time, in other situations, you want to get them on and off as quickly as possible. I would hope no one is doing "2D" treatment a la slapping fields on an xray and calling it a day.

I also run into problems with insurers not wanting to pay for 3D for bone mets despite the contouring and dvh evaluation. Cigna comes to mind. They also don't want to pay for igrt or more than 10 fractions

 

[Palex80]

IMRT pays a bit more than 3D here, around 10% more.
Doing ap/pa is not good treatment in my view. It's more toxic, especially for bowel.
I also have the impression of less esophagitis in many IMRT plans nowadays for thoracic vertebral mets.

I'm just curious, but: would the insurer reimburse you for 2D/3D in the US if you did IMRT instead?

 

[medgator]

IMRT pays a bit more than 3D here, around 10% more.
Doing ap/pa is not good treatment in my view. It's more toxic, especially for bowel.
I also have the impression of less esophagitis in many IMRT plans nowadays for thoracic vertebral mets.

I'm just curious, but: would the insurer reimburse you for 2D/3D in the US if you did IMRT instead?

Nope, would be considered fraudulent. Upcharging or downcharging a patient is frowned upon.

Appa works when you're giving palliative doses like 30/10, 20/5 etc. And I don't find it to be very toxic. It's needed at times esp around the kidneys. Sometimes PA only just won't cut it

 

[xrthopeful]

Using IMRT for a conventional palliative spine treatment seems pretty out there to me.

AP/PA is pretty darn standard and is what is being done in most academic institutions for non-radiosurgery treatments. Of course you throw blocks on using MLC, so that makes it 3D by definition.

Not sure where you get the idea that AP/PA is toxic?

 

[nkmiami]

I also use 4 x5, 5 x4 6 x3 etc. I have not used AP/PA in many years. When treating the spine with hyofractionation try to avoid hitting the esophagus. Contour it and then use oblique posterior fields to minimize hitting it with field in a field technique. Sometimes, depending location of tumor in the vertebrae, may also change ptv to minimize dose to esophagus,

AP/PA spinal cord treatment often causes side effects- use techniques to avoid radiation to mucosal structures

 

[nkmiami]

There was an article in medical dosimetry several years ago about optimal technique to treat the spine at different levels and avoid mucosal structure. In training, I can't tell you the amount of patients who got esophagitis or other issues in the palliative setting because dosimetrist wast too lazy to spend the extra 10 minutes

C spine- laterally oriented fields
T1/T2 can sometimes do angled down laterally oriented fields( couch kick)
T3-L2 posterior angled obliques with field with in field
L3-spine laterals and posterior field or posterior angled obliques

Don need to make someone who is there for "palliation" feel ****ty with esophagitis and diarrhea,

Very really need to do ap/pa in radiation- even for a site like femur - angle the fields off each other a little bit and less likely to have skin reaction (and use high energy)

 

[BraggPeak]

I very rarely see anyone do anything but AP-PA for palliative spine and femur treatments-- with the exception being c-spine where everyone uses laterals. Although obliques look good on the plan, it also spreads low dose throughout the lungs, or other tissues. I have never used field in field for whole brain.

I feel like I'm really missing something here...

 

[nkmiami]

negligible dose of radiation to the lung is the trade off for esophagitis, which can be bad especially when patients are getting chemo for their metastatic disease.

 

[BraggPeak]

I've had very few patients complain about anything more than mild esophagitis.

Also-- skin reaction for femur treatment?? Never had that be an issue and never done anything other than AP-PA.

 

[xrthopeful]

Agree, braggpeak. Feel like I'm taking crazy pills or missing something as well. Maybe nkmiami is also not from the U.S.?

 

[Palex80]

Using IMRT for a conventional palliative spine treatment seems pretty out there to me.

AP/PA is pretty darn standard and is what is being done in most academic institutions for non-radiosurgery treatments. Of course you throw blocks on using MLC, so that makes it 3D by definition.

Not sure where you get the idea that AP/PA is toxic?

Well if you are going to treat L1-L5 in an obese patient with ap/pa, you are going t have considerable amounts of bowel within the high dose region and dependent on how you weight the fields, this may very well be the 90% isodose the bowel will be in. It will definetely be the 80% isodose.

Here's an example I found online:

This is toxic. It will cause nausea, it will cause diarrhea, it will cause lots of fatigue.
That's my experience.

Around the kidneys, I also use VMAT. In order to protect the kidneys, you can allow two limited arcs (150-210 degrees and 340-20 degrees),it works well.

Oblique fields are also very good, we switcherd to them around 8 years ago instead of ap/pa and then went to VMAT 2 years ago.

 

[Reaganite]

Well if you are going to treat L1-L5 in an obese patient with ap/pa, you are going t have considerable amounts of bowel within the high dose region and dependent on how you weight the fields, this may very well be the 90% isodose the bowel will be in. It will definetely be the 80% isodose.

Here's an example I found online:

This is toxic. It will cause nausea, it will cause diarrhea, it will cause lots of fatigue.
That's my experience.

Around the kidneys, I also use VMAT. In order to protect the kidneys, you can allow two limited arcs (150-210 degrees and 340-20 degrees),it works well.

Oblique fields are also very good, we switcherd to them around 8 years ago instead of ap/pa and then went to VMAT 2 years ago.

American here, and I personally agree. I've never understood why we aren't more mindful of acute toxicity in palliative cases. I have a few contracts where my pay for imrt vs 3d is same and I still palliate many of the spine cases near esophagus and bowel with imrt to avoid excess acute morbidity. I love IMRT for treatment of extensive lumbosacral spine mets. In fact, I've even been able to get palliative IMRT approved for this scenario with commercial insurers with honest comparative plans/DVHs. We often miss the acute toxicity phase of 30 in 10 since it happens during that 2 week window between treatment completion and post treatment follow up.

 

[Gfunk6]

Although I've seen esophagitis with AP/PA fields in T-spine infrequently, I've very rarely seen diarrhea for L/S spine. Most patient are on narcotic pain medications anyway which can be very constipating; XRT to bowel "evens them out." YMMV.

 

[deleted18755]

Well if you are going to treat L1-L5 in an obese patient with ap/pa, you are going t have considerable amounts of bowel within the high dose region and dependent on how you weight the fields, this may very well be the 90% isodose the bowel will be in. It will definetely be the 80% isodose.

Here's an example I found online:

This is toxic. It will cause nausea, it will cause diarrhea, it will cause lots of fatigue.
That's my experience.

Around the kidneys, I also use VMAT. In order to protect the kidneys, you can allow two limited arcs (150-210 degrees and 340-20 degrees),it works well.

Oblique fields are also very good, we switcherd to them around 8 years ago instead of ap/pa and then went to VMAT 2 years ago.

How the heck do you get this authorized/approved by insurers?
I can only get AP/PA and believe it or not if performance status is on the lower end I'm starting to get grief for doing 10 fractions (they literally won't even pay for 3Gy x 10 AP/PA and want me to treat 8Gy x 1 to the lumbar spine ... if I tried IMRT or VMAT they would laugh in my face!)

 

[medgator]

How the heck do you get this authorized/approved by insurers?
I can only get AP/PA and believe it or not if performance status is on the lower end I'm starting to get grief for doing 10 fractions (they literally won't even pay for 3Gy x 10 AP/PA and want me to treat 8Gy x 1 to the lumbar spine ... if I tried IMRT or VMAT they would laugh in my face!)

Correct. Even Medicare, which is arguably the easiest to deal with, does not have bone mets on its general list for imrt approval. I've had denials before from Medicare and had to send in letters of medical necessity because a pt had previous xrt at an adjacent site which is why I didn't do 3D in the first place.

The practices doing imrt for bone mets routinely are probably on the short list for a Medicare audit at some point.

And yes, Cigna, and now even blue cross lately, won't pay for more than 10 fractions and if the pt isn't ECOG 0-2, they want you to do it in 1 fraction. Without IGRT in either situation. I've even had cigna refuse to pay for 3D for an iliac crest lesion, let alone IGRT.

I think 3D/appa is very reasonable for palliation.... those multi-field oblique and imrt (outside of maybe vmat) plans are going to keep the pt on the table for a long time, some are in too much pain to tolerate that and as gfunk alluded to, many are on multiple narcotics and probably could use a little xrt enteritis.

Once we go to bundled payments, this may become a non issue and create a situation closer to what Palex80 experiences as imrt right now still pays a lot more in the U.S.

 

[nkmiami]

without insulting anyone- we are talking about hypo fractionation here, often in patients who have recently received chemo - there are simple 3 d solutions for every spinal level that won't make your patient sick and doesn't require imrt. 2000 cGy in a week to multiple thoracic levels in close proximity to chemo (because they are metastatic after all) can easily cause esophagitis. same is true for nausea in the abdomen.

 

[medgator]

20 Gy in a week is a textbook palliative dose in my practice in people with a lower ecog than what would be appropriate for 2-3 weeks of palliation.

It may be hypofractionated but it's palliative and certainly not what people are using for srs/sbrt.

I rarely use 20/5, usually it's 30/10 and I'll echo many others on this thread who don't see excessive toxicity with appa arrangements. In a thin pt, I will try to go with PA only when I can

 

[xrthopeful]

without insulting anyone- we are talking about hypo fractionation here,

You say this as if you would ever NOT hypofrac someone with spine mets? Like what are you actually talking about?


30/10, 20/5 are standard.

 

[nkmiami]

You say this as if you would ever NOT hypofrac someone with spine mets? Like what are you actually talking about?


30/10, 20/5 are standard.

 

[nkmiami]

patients do get side effects from "palliative" like diarrhea and esophagitis, usually after completing treatment.

 

[nkmiami]