IMRT for esophagus and lung

[radoncgrad2019]

do you guys routinely utilize IMRT for esophageal and stage III lung cancers for patients with private insurance?

If you always do IMRT - do you always submit a 3D comparison plan and what kind of metrics do you make sure to demonstrate to justify IMRT? (v20 percentage drop, etc)

thanks

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[Gfunk6]

Yes, we do routinely use IMRT for both. With EviLcore, it is trickier. V20 is pretty much all they care about so if your 3D plan has an excessively high V20, then they will approve IMRT.

For esophagus, it's more complicated. For CROSS regimen 41.4 Gy is low enough that you don't usually run into dose limiting toxicities. If you treat to 50.4 Gy or higher, then it is the same V20 lung issue you have to prove to justify IMRT.

 

[Pointless]

Oddly enough, Evicore will accept IMRT hands down for esophagus if you are escalating beyond 50.4. Which is obviously absurd that they will approve a good technique only if you are using it to violate the standard of care.

As for lung, the secret password is contralateral. If you can tell them a node is crossing midline, you win.

 

[evilbooyaa]

Yes to both 100% of the time.

Never have issues with esophagus.

Lung I very rarely have to do DVH comparisons (usually gets approved), so I force the 3D plan to have the same coverage (95 of volume getting 100% of dose, rather than standard 95%/95%) which makes V20 worse or spinal cord above tolerance or something and then it's an easy approval.

Lung and esophagus to me are very different than say gastric or pancreas or rectal where maybe I'm OK doing 3D. I am doing IMRT 100% of the time in this scenario and threatening to document the insurance company's refusal in the chart if it is not approved after peer-to-peer with DVH comparison.

 

[scarbrtj]

Oddly enough, Evicore will accept IMRT hands down for esophagus if you are escalating beyond 50.4. Which is obviously absurd that they will approve a good technique only if you are using it to violate the standard of care.

As for lung, the secret password is contralateral. If you can tell them a node is crossing midline, you win.

aka N3

We should do the IMRT just like we do the OTVs. On everyone, always.
Also other secret pass phrase “my V20 above 35% with 3D, lower with IMRT”

 

[Pointless]

aka N3

We should do the IMRT just like we do the OTVs. On everyone, always.
Also other secret pass phrase “my V20 above 35% with 3D, lower with IMRT”

Right, but N3 has staging implications. "Nodes on the other side" is much more nebulous. Not that I would ever attempt to confound one of the illustrious Evicore reviewers.......

 

[Reaganite]

It's actually not nearly as complicated or nebulous as you think. The reviewers are bound to evicore guidelines. Reference Evicore policy word-for-word in your notes, and they will have a difficult time denying.

evicre Lung IMRT policy: "Intensity-Modulated Radiation Therapy (IMRT) is not medically necessary. Exceptions to the IMRT rule will be considered especially in the following situations: a. Where there is disease in the bilateral mediastinum or bilateral hilar regions b. Where there is disease in the para-spinal region c. For superior sulcus tumors d. IMRT will be approved when comparative 3D and IMRT plans demonstrate that a 3D plan does not meet the “Acceptable” normal tissue constraints using standard metrics published by the Radiation Therapy Oncology Group (RTOG)/National Comprehensive Cancer Network (NCCN)."

Your note: "I am recommending IMRT. IMRT is medically necessary for lung cancer per evicore policy xxx when: cite above. My patient meets one of these criteria (spell it out word-for-word). Therefore, per evicore policy, IMRT is medically necessary and should be approved."

 

[PhotonBomb]

You put that in your consult note? It’s easy to do if superior sulcus but like you can’t say in your note ‘IMRT is needed because it dropped the V20 by ten percent compared to the comparison 3D plan’

 

[Reaganite]

You put that in your consult note? It’s easy to do if superior sulcus but like you can’t say in your note ‘IMRT is needed because it dropped the V20 by ten percent compared to the comparison 3D plan’

I bold and underline it in my note. The initial review is mostly done by nurses with no radiation experience. They are instructed to approve and deny based solely on guidelines, and they arent experienced enough to tease out the fine details of rad onc. Your only chance to get in a word with them is through your consult note. Spoon feeding them the guideline word for word in bold goes a long way. Havent had to do a peer to peer with an evicore reviewer in a long while actually.

 

[FrostyHammer]

IMRT should be standard for both cancer types, and anything less is inadequate. For lung, one can cite Chun et al JCO 2017 as randomized evidence that IMRT reduces the G3+ pneumonitis rates.

 

[PhotonBomb]

I bold and underline it in my note. The initial review is mostly done by nurses with no radiation experience. They are instructed to approve and deny based solely on guidelines, and they arent experienced enough to tease out the fine details of rad onc. Your only chance to get in a word with them is through your consult note. Spoon feeding them the guideline word for word in bold goes a long way. Havent had to do a peer to peer with an evicore reviewer in a long while actually.

So do you just put a standard number in your note? ‘For this patient the IMRT plan dropped the V20 by ten percent ?’

 

[evilbooyaa]

I bold and underline it in my note. The initial review is mostly done by nurses with no radiation experience. They are instructed to approve and deny based solely on guidelines, and they arent experienced enough to tease out the fine details of rad onc. Your only chance to get in a word with them is through your consult note. Spoon feeding them the guideline word for word in bold goes a long way. Havent had to do a peer to peer with an evicore reviewer in a long while actually.

But say the patient doesn't meet the criteria you referenced - how do you put in your consult note that the V20 is only acceptable using IMRT planning, since you haven't done CT sim yet?

The bit about para-spinal disease is interesting - will have to start putting that on applicable cases if I run into EvilCore out in practice.

 

[Reaganite]

IMRT should be standard for both cancer types, and anything less is inadequate. For lung, one can cite Chun et al JCO 2017 as randomized evidence that IMRT reduces the G3+ pneumonitis rates.

So this is not the best way to get IMRT approved. Reviewers are instructed to strictly adhere to the plan guideline. They don't have to approve IMRT because you quote a study. The idea is that the guideline already incorporates these data and has teased out the specifics of the trials. (i.e. IMRT will be approved if certain DVH criteria are met).

So do you just put a standard number in your note? ‘For this patient the IMRT plan dropped the V20 by ten percent ?’

Every health plan guideline is different. The blues are very specific and have the "drop by 10%" whereas Evicore uses a more generic "does not meet 'acceptable' constraints." I quote the relevant guideline in my note. I also always put this section at the end of my note in a separate paragraph so it doesn't confuse my referring doctors.

If I do ever get called for a peer-to-peer, by the way, I always exchange pleasantries, and I start by quoting the guideline. "Mr rad onc reviewer, so nice to meet you. How's the biryani in your neck of the woods? So sorry there has been this confusion. I'm not sure why they are wasting your time with this p2p. I reviewed the healthplan guidelines and they say IMRT should be covered when these criteria are met. My patient meets this criteria as I detailed in my consult note." Even the ones looking to deny are going to have a hard time dealing with those lines.

But say the patient doesn't meet the criteria you referenced - how do you put in your consult note that the V20 is only acceptable using IMRT planning, since you haven't done CT sim yet?

The bit about para-spinal disease is interesting - will have to start putting that on applicable cases if I run into EvilCore out in practice.

Verify pre-cert not required for 3D conformal treatment then do CT sim and IMRT vs. 3D comparison. Add addendum to initial consult note and submit along with comparison plans to healthplan.


Anyone interested in joining my MSO, shoot me a PM

 

[Lamount]

IMRT should be standard for both cancer types, and anything less is inadequate. For lung, one can cite Chun et al JCO 2017 as randomized evidence that IMRT reduces the G3+ pneumonitis rates.

We routinely look at IMRT/VMAT for lung cases, but sometimes DCA is just as good (particularly when the PTV is convex and you aren't too worried about a hot spot).

 

[evilbooyaa]

We routinely look at IMRT/VMAT for lung cases, but sometimes DCA is just as good (particularly when the PTV is convex and you aren't too worried about a hot spot).

You're doing DCA for stage III NSCLC?

 

[Lamount]

You're doing DCA for stage III NSCLC?

I wouldn't for most N2 disease (4R, 4L, 7) because the hotspot would likely be right in the esophagus. I have had a few recent cases where the metrics were just as good. Most are T2-3 N1, but one case comes to mind where it was "N2" (level 6) but was more a suprahilar node.

I like this for times where there is a bulky necrotic primary without any embeded bronchus or major/medium sized vessels... in these cases, I think the hotspot could be beneficial. Plus, if the patient is symptomatic, it is much easier to turn around a DCA plan quickly.

Edit: in all cases, the node was adjacent to the primary, so the PTV was convex. DCA can't be comforal for concave targets.

 

[evilbooyaa]

I wouldn't for most N2 disease (4R, 4L, 7) because the hotspot would likely be right in the esophagus. I have had a few recent cases where the metrics were just as good. Most are T2-3 N1, but one case comes to mind where it was "N2" (level 6) but was more a suprahilar node.

I like this for times where there is a bulky necrotic primary without any embeded bronchus or major/medium sized vessels... in these cases, I think the hotspot could be beneficial. Plus, if the patient is symptomatic, it is much easier to turn around a DCA plan quickly.

Edit: in all cases, the node was adjacent to the primary, so the PTV was convex. DCA can't be comforal for concave targets.

Interesting. I have not considered DCA for anything outside of brain SRS, as I do care about hot-spots in lung treatment, both stage III NSCLC and SBRT, given tumor motion. I suppose almost all the stage III NSCLCs we treat are N2 or in close proximity to prox. bronchial tree/mediastinum where this would not even be a consideration. Something to keep in the back of my mind though. Thanks for the explanation

 

[deleted1002574]

What on God's green earth is DCA?

 

[evilbooyaa]

Dynamic Conformal Arcs - Imagine VMAT but without MLC motion. I think it has slightly different billing than VMAT as it's technically not 'intensity-modulated' but it's not really 3D-CRT either.

We use it frequently for small convex lesions in the brain getting SRS. Some places also consider it for certain SBRT cases where the focus is just conformity without a specific care for 'carving' dose out of or away from OARs.

 

[deleted1002574]

ah. conformal arcs. yah, we use that. good for palliative cases, too. no qa necessary and don't need imrt approval, and nice conformal plans.

 

[scarbrtj]

Dynamic Conformal Arcs - Imagine VMAT but without MLC motion. I think it has slightly different billing than VMAT as it's technically not 'intensity-modulated' but it's not really 3D-CRT either.

We use it frequently for small convex lesions in the brain getting SRS. Some places also consider it for certain SBRT cases where the focus is just conformity without a specific care for 'carving' dose out of or away from OARs.

How can you have conformal arcs without MLC motion. Surely to goodness it’s 3D.

 

[scarbrtj]

I wouldn't for most N2 disease (4R, 4L, 7) because the hotspot would likely be right in the esophagus. I have had a few recent cases where the metrics were just as good. Most are T2-3 N1, but one case comes to mind where it was "N2" (level 6) but was more a suprahilar node.

I like this for times where there is a bulky necrotic primary without any embeded bronchus or major/medium sized vessels... in these cases, I think the hotspot could be beneficial. Plus, if the patient is symptomatic, it is much easier to turn around a DCA plan quickly.

Edit: in all cases, the node was adjacent to the primary, so the PTV was convex. DCA can't be comforal for concave targets.

When I think of “DCA” and a Stage II or greater lung plan, I can only envision a very crappy looking plan. Would enjoy seeing some screen shots.

 

[evilbooyaa]

How can you have conformal arcs without MLC motion. Surely to goodness it’s 3D.

1. Have a circular PTV
2. Place MLCs around PTV
3. Don't have MLCs move as the arc moves
4. ???
5. Profit!

 

[evilbooyaa]

ah. conformal arcs. yah, we use that. good for palliative cases, too. no qa necessary and don't need imrt approval, and nice conformal plans.

I have not ever considered conformal arcs for palliation. I can't really explain why I've never even considered it, besides the fact that most palliatve cases:
1. Aren't circular
2. Don't want huge heterogeneity like with what is seen in SRS planning given some proximity to OARs.

What percentage of palliative cases are you using conformal arcs?

 

[scarbrtj]

1. Have a circular PTV
2. Place MLCs around PTV
3. Don't have MLCs move as the arc moves
4. ???
5. Profit!

Never seen the “circular” T3N1 lung case myself. I’m ready to learn! But the MLCs have to move *a little* unless the target is perfectly spherical (“circular”).

 

[evilbooyaa]

Never seen the “circular” T3N1 lung case myself. I’m ready to learn! But the MLCs have to move *a little* unless the target is perfectly spherical (“circular”).

Same here.

If the MLCs twitch at all it's VMAT though!

If doing co-planar arcs it can also be cylindrical.

 

[deleted1002574]

I have not ever considered conformal arcs for palliation. I can't really explain why I've never even considered it, besides the fact that most palliatve cases:
1. Aren't circular
2. Don't want huge heterogeneity like with what is seen in SRS planning given some proximity to OARs.

What percentage of palliative cases are you using conformal arcs?

Nice for vertebral mets, nodal disease in the SCV pushing on nerve causing pain, for example.

The volume doesn't have to be a circle or a sphere. But, the dose will be spherical around it. As long as somewhat symmetric in two dimensions, it can be a candidate. Not amazing, but surprising nice conformal plans. But don't let those MLCs twitch!!

 

[evilbooyaa]

Nice for vertebral mets, nodal disease in the SCV pushing on nerve causing pain, for example.

I guess my response to that is, what's wrong with AP/PA (or 3-field if in L-S spine) for both of those scenarios?

What's your IGRT in that situation? For our DCA SRS we do daily CBCT

 

[deleted1002574]

Take it a step further with what you're saying...

What about just AP?
Maybe skip the MLCs and do isodose complex?

In my opinion, conformal arcs are a way to treat tumor, decrease dose to adjacent tissues, improve conformality, and not feel slimy by charging IMRT rates.

 

[scarbrtj]

Same here.

If the MLCs twitch at all it's VMAT though!

If doing co-planar arcs it can also be cylindrical.

Re: the twitch. No. I don’t know who invented dynamic conformal arcs. But BrainLAB was doing it with the m3 in the 1990s. (And prior to the noun “IMRT” being in existence.) Just because it’s an arc and the MLCs track the outside of the target that’s no different than static beams at different angles that also track the target. Intensity modulation specifically means putting something in between the beam path and target (a dot decimal block, an electronic wedge, an MLC leaf that causes partial temporal occlusion) to cause the beam path (a “path” is arbitrary here) intensity to fall somewhere between 0 and 100%. Conformal arcs limit all beam paths (at different angles) to either 0 and 100% intensity. No in betweens. If that makes sense. There’s a method to my madness.

 

[Lamount]

The difference between DCA and VMAT is as follows:

With DCA, the MLCs conform to the peripheral of the target from every angle in the arc (i.e. the BEV from every angle looks as though it is from a 3D plan. -so the MLCs DO move...)

With VMAT, the beam is intensity is modulated (i.e. the BEV from some or all angles has MLCs that are blocking some part of the target).

So for DCA, the center of the tumor is always unobstructed, resulting in hot spots (i.e. the beam profile through the target would look like a mountain). And since there is no modulation, the high dose isodose lines cannot hug sharp corners, but rather form a circle/oval that encompasses the target's shape. In terms of planning, our dosimetrists will use this in conjuction with static conformal fields to achieve more oblong dose distributions, if needed. It's certinaly not as conformal as IMRT/VMAT, but often significantly more conformal than static 3D.

With VMAT, the modulation allows you to have more homogenious dose in the target (i.e. the beam profile would look like a plateau), and the isodose lines can better hug a concave target. Additionally, you can create asymetric dose gradients so that dose will fall off rapidly on one side of the target (e.g. near an OAR).

We bill DCA as 3D, and I have certainly used this in palliative cases (especially in the lung, treating large peri-hilar masses)... it's nice because you can turn around a fairly conformal plan very quickly without the need for QA. And you can sometimes get away with a bit of a higher dose of on a palliative case than you would ordinarily be able to achieve with static 3D because the dose falloff around the target is much tighter.

 

[evilbooyaa]

I was mistaken in my previous posts, re: the twitch. Thanks for the explanations.

What sort of hotspots are you getting extracranially with this technique? I'd be wary of a 120% hotspot in anything that's not SRS

 

[deleted1002574]

La Mount said what I wanted to say, but better. Must be the fellowship

 

[Lamount]

I was mistaken in my previous posts, re: the twitch. Thanks for the explanations.

What sort of hotspots are you getting extracranially with this technique? I'd be wary of a 120% hotspot in anything that's not SRS

The bigger the volume, the smaller the hotspot. I am looking at one of my DCA plans for a T2N1 NSCLC patient with a hotspot of 12%... but I only went to 60 Gy and the 110% isodose line is on my ITV (i.e. kinda like an SIB to 66).

For smaller volumes, it is a bit more like SRS with hotspots of 120%.... which I am okay with when using SABR for early stage NSCLC away from medium sized vessels/bronchi. Consider that many landmark SABR trials like Hasbeek prescribed to 80% isodose line. Another benefit in DCA for SABR is that the treatment is much quicker than VMAT since you are blocking less of your beam.

 

[BobbyHeenan]

Related to this, I just got an IMRT denial for a bladder case. First denial for Imrt in a while.

rectal and small bowel were way worse with 3D but “not bad enough.”
They were using prostate constraints on the rectum and quantec small bowel constraints to make the call though. I’m not e en sure they were taking into account hypofractionation either even on my peer to peer.

I am going 55gy in 20 on a 90 year old T2N0 woth no chemo. Taking whole bladder to 41.25 then boosting to 55-60.

I’d be lying if Ididn’t contemplate saying, OK then, we’re going 66.6 at 1.8.

Alas, 3D it is. I’m at least appealing to get IMRT boost.

 

[scarbrtj]

Related to this, I just got an IMRT denial for a bladder case. First denial for Imrt in a while.

rectal and small bowel were way worse with 3D but “not bad enough.”
They were using prostate constraints on the rectum and quantec small bowel constraints to make the call though. I’m not e en sure they were taking into account hypofractionation either even on my peer to peer.

I am going 55gy in 20 on a 90 year old T2N0 woth no chemo. Taking whole bladder to 41.25 then boosting to 55-60.

I’d be lying if Ididn’t contemplate saying, OK then, we’re going 66.6 at 1.8.

Alas, 3D it is. I’m at least appealing to get IMRT boost.

You will not get the IMRT for the boost either. Been there done that. Evicore won’t brook IMRT for any bladder situation. There’s good data eg for IG-IMRT DART-lite for bladder. They won’t hear of it.

 

[BobbyHeenan]

You will not get the IMRT for the boost either. Been there done that. Evicore won’t brook IMRT for any bladder situation. There’s good data eg for IG-IMRT DART-lite for bladder. They won’t hear of it.

Good to know. I had previously found some evicore things *gasp* reasonable and even when I “lost” a rare PTP I felt most of time it wasn’t terrible.

but I’m staring at a 3D plan with a sigmoid with full circumferential dose through it, a pocket of low small bowel in there...versus a beautiful VMAT plan. He’s quoting me dvh constraints to meet and we’re just not seeing eye to eye when he’s quoting me constraints from prostate .

 

[Reaganite]

You will not get the IMRT for the boost either. Been there done that. Evicore won’t brook IMRT for any bladder situation. There’s good data eg for IG-IMRT DART-lite for bladder. They won’t hear of it.

Agree, not gonna happen for bladder. Evicore policy gives no option for imrt. Even if you somehow magically got it pre certed they would probably deny payment on the back end.

 

[seper]

I haven't kept up with data, but at this point V5 is pretty much irrelevant? Even in preop cases?

 

[FrostyHammer]

Here's

I haven't kept up with data, but at this point V5 is pretty much irrelevant? Even in preop cases?

Here's how I feel about V5... What's the V5 (or V10) of a peds WLI case? I rest my case.

 

[seper]

I hear you... That's one way to think about it.
It is clear, though, that adult smokers slated for VATS have lower lung tolerance.

Here's how I feel about V5... What's the V5 (or V10) of a peds WLI case? I rest my case.

 

[Lamount]

Here's

Here's how I feel about V5... What's the V5 (or V10) of a peds WLI case? I rest my case.

I really wish I believed that low dose metrics like V5 didn’t matter... but I am afraid the Peds literature isn’t that comforting. Do kids who get WLI live as long as healthy kids?...

The adult data from the transplant literature is less reassuring. Prediction and prevention of transplant-related mortality from pulmonary causes after total body irradiation and allogeneic stem cell transplantation

 

[evilbooyaa]

I haven't kept up with data, but at this point V5 is pretty much irrelevant? Even in preop cases?

I respect lung V5 in esophageal cancer patients being planned for surgery.

I would consider it for a lung cancer patient being planned for pre-operative (rare scenario that I don't treat often anymore).

In definitive lung or esophageal cancer patients I don't care about V5, as my more important priorities are lung V20 and mean heart dose.

 

[Pointless]

I really wish I believed that low dose metrics like V5 didn’t matter... but I am afraid the Peds literature isn’t that comforting. Do kids who get WLI live as long as healthy kids?...

The adult data from the transplant literature is less reassuring. Prediction and prevention of transplant-related mortality from pulmonary causes after total body irradiation and allogeneic stem cell transplantation

Get your point, but i would attribute most of the long term toxicity in those patients to the massive quantities of chemotherapy that they have received.

 

[RadOncDoc21]

I respect lung V5 in esophageal cancer patients being planned for surgery.

I would consider it for a lung cancer patient being planned for pre-operative (rare scenario that I don't treat often anymore).

In definitive lung or esophageal cancer patients I don't care about V5, as my more important priorities are lung V20 and mean heart dose.

Got a few cases I’m treating with disease in a lot of areas, T3-4N3,with horrible V20’s. I’ve considered doing upfront chemo vs re-planning but wanted to get some insight. If the majority of the cancer takes up one lung, does V20 matter as much as sparing the other lung?

 

[FrostyHammer]

Got a few cases I’m treating with disease in a lot of areas, T3-4N3,with horrible V20’s. I’ve considered doing upfront chemo vs re-planning but wanted to get some insight. If the majority of the cancer takes up one lung, does V20 matter as much as sparing the other lung?

Great question and one can certainly make an argument for it based on the mesothelioma literature, where post-EPP cases have no remaining ipsilateral lung and hence just the contralateral is constrained.

 

[Palex80]

Even some comprehensive RNI-plans for breast cancer end up with V5 >60% for the ipsilateral lung if you deliver it with IMRT/VMAT and the patient has a less than ideal anatomy.

 

[Lamount]

Got a few cases I’m treating with disease in a lot of areas, T3-4N3,with horrible V20’s. I’ve considered doing upfront chemo vs re-planning but wanted to get some insight. If the majority of the cancer takes up one lung, does V20 matter as much as sparing the other lung?

It’s the N3 that will get you. I have two cases recently with T0-1N3 where I had to move heaven and earth to meet V20 <35%

 

[seper]

A few cases like that I wound up sending for indefinite Keytruda, instead of radiation. Chance of complete remission with XRT at 5 years is dismal, anyway.

It’s the N3 that will get you. I have two cases recently with T0-1N3 where I had to move heaven and earth to meet V20 <35%

 

[evilbooyaa]

Got a few cases I’m treating with disease in a lot of areas, T3-4N3,with horrible V20’s. I’ve considered doing upfront chemo vs re-planning but wanted to get some insight. If the majority of the cancer takes up one lung, does V20 matter as much as sparing the other lung?

Agree that N3 is the driving factor of really bad V20s most of the time. That and location of primary. Contralateral mediastinal (or worse, SCV) disease with a lower lobe primary is almost always a dosimetric disaster.

Guidelines are guidelines. I think you do what you can. A dose or two of induction chemo is not unreasonable although it is unlikely to make a monumental shift in NSCLC (different story sometimes with extent of rapid tumor shrinkage in SCLC). I think if you've really tried to lower V20 as much as possible it's a discussion with patient and proceed with definitive therapy.

I would not send a patient with curable disease for non-curative therapy just because of a V20 as mentioned above, although it could be a factor in certain patients who are borderline candidates for tolerability anyways (borderline chemo tolerance, bad COPD/PFTs, etc.)

Sometimes in really complex plans we'll vector out certain aspects of the VMAT plan (say the beams entering through the contralateral lung) or do half-arcs and accept a less homogenous plan. See if your V20 is really pooching significantly into contralateral lung and try to minimize that with vectoring as feasible. Depending on projected non-cancer lifespan, might relax the heart constraint in order to allow lung.

Can consider respiratory gating (although it's a pain for 30 fractions) if main issue is primary tumor motion.