Interesting bone case

[Ray D. Ayshun]

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This just walked in the door with partial work-up by ortho

Lesion in left pelvis, 2.7 x 2.7, causing severe pain and debility. Biopsy shows malignant, large cells, not lymphoma. Could be carcinoma, could be sarcoma, pending stains. Metastatic work-up otherwise negative. Wondering what to do. Thinking of treating with 2 Gy fractions with final dose pending final tissue diagnosis. I don't think this burns bridges, could help with pain during the inevitable drawn out outside path consult, etc, particularly if sarcoma. If adeno, presumably metastatic, and no matter what this should get the process of helping the symptom going.

 

[evilbooyaa]

Only site of avidity on PET/CT?

Think it's fine to start at 2Gy/day if patient really can't wait.

 

[Ray D. Ayshun]

Only site of avidity on PET/CT?

Think it's fine to start at 2Gy/day if patient really can't wait.

No PET. Contrasted CT CAP, bone scan, MRI. Worked up in strange manner. If it turns out to be a sarcoma, will keep going. If adeno/something else, may get PET. But there's nothing, even an incidentaloma, on the other scans.

 

[OTN]

I would try to get a stat surgical oncology/orthopedic oncology consult, just to try to get a multi-D opinion on it. If he can't wait, however, due to pain, then your approach seems reasonable and shouldn't burn bridges.

 

[Lamount]

Are they sure it isn't a giant cell tumor, which are benign

Giant Cell Tumor of Bone - An Overview - PMC

Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. Although rarely lethal, benign bone tumors may be associated with a substantial disturbance of the local bony architecture that can be ...

www.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

I would try to get a stat surgical oncology/orthopedic oncology consult, just to try to get a multi-D opinion on it. If he can't wait, however, due to pain, then your approach seems reasonable and shouldn't burn bridges.

This is in the context of a 2 month workup by local ortho.

 

[Ray D. Ayshun]

Are they sure it isn't a giant cell tumor, which are benign

Giant Cell Tumor of Bone - An Overview - PMC

Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. Although rarely lethal, benign bone tumors may be associated with a substantial disturbance of the local bony architecture that can be ...

www.ncbi.nlm.nih.gov

Interesting. do you have any experience with?

 

[Lamount]

Interesting. do you have any experience with?

In the few cases I have seen, the patient underwent resection alone... with a sarcoma surgeon.

 

[Ray D. Ayshun]

In the few cases I have seen, the patient underwent resection alone... with a sarcoma surgeon.

yeah, i see that's the rec. Have called sarcoma surgeon to ask about resectability anyway. waiting to hear back.

not planning on shooting first until next week, so there's time. May start at 1 Gy daily instead, IMRT (jk). Path read does say malignant, but I am no longer at a large academic center of course, this being one of the very rare times that's a bother.

 

[Palex80]

Interesting. do you have any experience with?

I've treated a couple. Two were recurrent ones after surgery, one was a pelvic one, irresectable. 2 out of 3 went well with doses around 54 Gy.

 

[Palex80]

Think it's fine to start at 2Gy/day if patient really can't wait.

I agree.
It looks like a small bowel loop sits directly on top of that lesion. It could be tricky to deliver doses >60 Gy.

 

[evilbooyaa]

No PET. Contrasted CT CAP, bone scan, MRI. Worked up in strange manner. If it turns out to be a sarcoma, will keep going. If adeno/something else, may get PET. But there's nothing, even an incidentaloma, on the other scans.

PSA? Recent colonoscopy?

I guess negative bone scan suggests against prostate but who knows...

I think waiting until path confirms carcinoma vs sarcoma is reasonable before investigating more, and treating at 2Gy/fx in interim.

 

[evilbooyaa]

Are they sure it isn't a giant cell tumor, which are benign

Giant Cell Tumor of Bone - An Overview - PMC

Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. Although rarely lethal, benign bone tumors may be associated with a substantial disturbance of the local bony architecture that can be ...

www.ncbi.nlm.nih.gov

I really, really hate the first line of that abstract:

" Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. "

 

[Ray D. Ayshun]

PSA? Recent colonoscopy?

I guess negative bone scan suggests against prostate but who knows...

I think waiting until path confirms carcinoma vs sarcoma is reasonable before investigating more, and treating at 2Gy/fx in interim.

God performed a prostatectomy on her preconception. TBH, I'm really liking this giant cell tumor dx. It's very well circumscribed, solitary, and grew pretty fast. If a met, would expect something systemically in something that has progressed so quickly.

 

[scarbrtj]

God performed a prostatectomy on her preconception. TBH, I'm really liking this giant cell tumor dx. It's very well circumscribed, solitary, and grew pretty fast. If a met, would expect something systemically in something that has progressed so quickly.

I like GCT too. Purt rare. As an aside some people say females have prostates.

 

[knuckles]

Increase narcotics while waiting for path. Not an oncologic emergency needing to start tx.

 

[Ray D. Ayshun]

I like GCT too. Purt rare. As an aside some people say females have prostates.

Yes. they're called radiologists who use a template for their pelvic imaging.

With regards to not being an oncologic emergency, I don't disagree. OTOH, in doing an expected value calculation, I'm not sure what waiting, potentially weeks, gets me. Feels like -EV, so long as I explain the situation for litigious reasons. It feels like there's enough info to treat it as a met, sarcoma, lymphoma, or gct, which RT would be appropriate for. Path says malignancy fwiw.

 

[Haybrant]

General principal is that it’s Better to wait and know what you’re getting into so you can have an appropriate multiD discussion with consensus before you start; pain can be controlled w narcotics in the meantime; if it’s bad enough it’s going to fracture anyway with or without RT.

 

[Carotenoid]

so what did this end up being?

 

[Ray D. Ayshun]

so what did this end up being?

Metastatic adeno. Ihc consistent with pancreas primary. Ca 19-9 normal, cea 162. Given that and normal ct cap, presuming colon or ovary? Pet is pending. She missed one Thursday as daughter having surgery. Only symptom anywhere was pain, so I sbrted it. Was doing better two days after treatment ended.

Kinda weird that this is it. Well, so far.

 

[scarbrtj]

Metastatic adeno. Ihc consistent with pancreas primary. Ca 19-9 normal, cea 162. Given that and normal ct cap, presuming colon or ovary? Pet is pending. She missed one Thursday as daughter having surgery. Only symptom anywhere was pain, so I sbrted it. Was doing better two days after treatment ended.

Kinda weird that this is it. Well, so far.

How easy or hard was it to get insurance to Ok SBRT for that

 

[Carotenoid]

Metastatic adeno. Ihc consistent with pancreas primary. Ca 19-9 normal, cea 162. Given that and normal ct cap, presuming colon or ovary? Pet is pending. She missed one Thursday as daughter having surgery. Only symptom anywhere was pain, so I sbrted it. Was doing better two days after treatment ended.

Kinda weird that this is it. Well, so far.

Thanks for sharing, great case.

 

[Ray D. Ayshun]

How easy or hard was it to get insurance to Ok SBRT for that

Haha, I'm not sure I know yet. She was/is in the midst of medicaid approval.

 

[Ray D. Ayshun]

Final update since I came back to it was a lung primary, probably. Kinda in the right hilum, intensely avid, and with no lesion in the lung. There were a couple other very tiny bone mets, a pelvic node, and an inguinal node. Still doesn't totally make sense, but she's no longer using a walker and not on narcotics after 7 Gy x 5. Glad they didn't see anything else on the initial scans, as it allowed me to get away with doing the right thing for the patient.

 

[BobbyHeenan]

Final update since I came back to it was a lung primary, probably. Kinda in the right hilum, intensely avid, and with no lesion in the lung. There were a couple other very tiny bone mets, a pelvic node, and an inguinal node. Still doesn't totally make sense, but she's no longer using a walker and not on narcotics after 7 Gy x 5. Glad they didn't see anything else on the initial scans, as it allowed me to get away with doing the right thing for the patient.

Aside: I (really the patient loses in all this at the end of the day) lost a peer to peer and an appeal on a solitary bone met at L4 from head/neck cancer this week. Only 30 Gy in 10 "complex isodose" would be approved.

Made me really sad for all involved. They wouldn't take SABR comet data, they wouldn't take the new canadian trial randomized data (24 gy in 2 which is what I was planning). I can do a 3rd party appeal but she's in too much pain to wait. So 30/10 it is then we'll appeal later for maybe an SBRT course if it doesn't work.

*Yes, I thought of 8 GY X 1 but I think her prognosis is pretty good and re-treatment likely.

 

[Ray D. Ayshun]

Aside: I (really the patient loses in all this at the end of the day) lost a peer to peer and an appeal on a solitary bone met at L4 from head/neck cancer this week. Only 30 Gy in 10 "complex isodose" would be approved.

Made me really sad for all involved. They wouldn't take SABR comet data, they wouldn't take the new canadian trial randomized data (24 gy in 2 which is what I was planning). I can do a 3rd party appeal but she's in too much pain to wait. So 30/10 it is then we'll appeal later for maybe an SBRT course if it doesn't work.

Its not even just the sabr comet stuff. Its the simple fact that we can treat things with extreme precision, but are discouraged from doing so.

 

[scarbrtj]

Aside: I (really the patient loses in all this at the end of the day) lost a peer to peer and an appeal on a solitary bone met at L4 from head/neck cancer this week. Only 30 Gy in 10 "complex isodose" would be approved.

Its not even just the sabr comet stuff. Its the simple fact that we can treat things with extreme precision, but are discouraged from doing so.

They (Evicore) are teaching us. Slowly, but surely, I have learn't. You miss 100% of the shots you never take; a less known saying is you get approved for 100% of the dumbed down treatments you prescribe that you know won't get denied by Evicore. "We can treat things with extreme precision, but are discouraged from doing so." It's a classic look but don't touch. OTOH, doing SBRT on a solitary bone met was considered nigh malpractice or at least tantamount to radiotherapeutic graft ~10 years ago. I've proudly held my head high in shame... if that even makes sense... against self-righteous, erstwhile anti-SBRT-bone-met colleagues a few times.

 

[Neuronix]

I'm 2 for 2 on evicore appeals to the insurer last week. Just saying...

 

[BobbyHeenan]

I'm 2 for 2 on evicore appeals to the insurer last week. Just saying...

Im usually very successful. I can’t even remember my last L. Definitely took one on this case.

Maybe I can get you to facetime in with me on my next one 🙂

 

[Mandelin Rain]

Contrary to what well known chairmen will tell you, giving 2 Gy to the pelvis will cause no toxicity (after child bearing age). Discuss that ideally you'd have final path but they called it "malignant" (ie cancer) on preliminary and given his symptoms you'd recommend proceeding with XRT if he felt comfortable doing so. Document this conversation. If it comes back something benign-ish like GCT that can be treated with surgery alone, he'll be happy enough to not care about the fraction or two you gave him.

EDIT: Didn't read the whole thread prior to posting. There was a conclusion. A long time ago. Just in general, the above is my approach to such situations.

 

[Ray D. Ayshun]

Contrary to what well known chairmen will tell you, giving 2 Gy to the pelvis will cause no toxicity (after child bearing age). Discuss that ideally you'd have final path but they called it "malignant" (ie cancer) on preliminary and given his symptoms you'd recommend proceeding with XRT if he felt comfortable doing so. Document this conversation. If it comes back something benign-ish like GCT that can be treated with surgery alone, he'll be happy enough to not care about the fraction or two you gave him.

EDIT: Didn't read the whole thread prior to posting. There was a conclusion. A long time ago. Just in general, the above is my approach to such situations.

Your proposal was what I was on the verge of doing. My feeling regarding pain is that the resolution of the pain is related to the start date in a given patient. As in, if we compared the same patient and started treatment exactly one week earlier, they'd feel better exactly one week earlier. In turn, like to start ASA is reasonable. Turned out SBRT was reasonable in this setting, and in hindsight, waiting for a tissue diagnosis probably helped resolve things even quicker. Live and learn.