Interstitial Lung disease SBRT vs Cryo?

[Mandelin Rain]

Older guy with small, peripheral lesion. Respiratory status up and down with interstitial lung disease with obvious scarring on CT. Not operable. You doing SBRT or referring for cryo?

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[OTN]

SBRT all day

 

[Palex80]

I'd say it depends on your DVH metrics. However, if the lesion is small and peripheral, I would go for SBRT.
RFA / Cryotherapy or whatever surely bears less of a risk for pneumonitis than SBRT; however I feel that the risk with SBRT is very small in lesions like that.

 

[evilbooyaa]

SBRT toxicity is a concern in ILD patients but for a small peripheral lesion would treat. Minimize low-dose wash through lung.

 

[thecarbonionangle]

50/5 or 60/5, keep your V20 low, maybe <5 if possible

 

[radiaterMike]

A pneumothorax in a patient with severe ILD can be fatal.

 

[Mandelin Rain]

Pretty much all the same thoughts as everyone. Thanks.

 

[Palex80]

50/5 or 60/5, keep your V20 low, maybe <5 if possible

Do you think the V20 is more important in ILD than for instance perhaps the V5?

 

[thecarbonionangle]

Do you think the V20 is more important in ILD than for instance perhaps the V5?

i think looking at the V5 is totally fine as well, but i do not routinely do it. I look at R50 as well

 

[Lamount]

During residency, I saw 2 patients with ILD rapidly decline and die of respiratory failure within months following de novo SBRT to a small peripheral lesion. Broadly, I don't have a great sense of how safe it is, but anecdotally, ILD terrifies me.

 

[FrostyHammer]

I can't say if with ILD the V20 or V5 is more important but it might be worth just evaluating conformity index as a good gauge and clamping down on that if needed, because trying to clamp down on V20 often means letting V5 rise. I'm not sure I could compromise on either for an ILD patient so the CI would be important...no data though, just a random thought.

 

[OTN]

During residency, I saw 2 patients with ILD rapidly decline and die of respiratory failure within months following de novo SBRT to a small peripheral lesion. Broadly, I don't have a great sense of how safe it is, but anecdotally, ILD terrifies me.

I’ve treated a few and they’ve done fine.

I’d tighten up the margins to avoid as much normal lung as possible.

 

[Burt Radnolds]

During residency, I saw 2 patients with ILD rapidly decline and die of respiratory failure within months following de novo SBRT to a small peripheral lesion. Broadly, I don't have a great sense of how safe it is, but anecdotally, ILD terrifies me.

This is my experience as well. Have seen some catastrophic outcomes. The handful of fatal pneumonitis cases I've observed (residency, colleagues, my own) have all had evidence of ILD. These plans typically had intense lung sparing too. It is no joke and in anyone with a hint of ILD on CT scan I document that I observed it and counseled them on the risk of treatment related death well beyond the normal population.

A brief literature search will confirm that this is not just anecdotal and that ILD is probably the single biggest predictor of severe pneumonitis.

 

[medgator]

This is my experience as well. Have seen some catastrophic outcomes. The handful of fatal pneumonitis cases I've observed (residency, colleagues, my own) have all had evidence of ILD. These plans typically had intense lung sparing too. It is no joke and in anyone with a hint of ILD on CT scan I document that I observed it and counseled them on the risk of treatment related death well beyond the normal population.

A brief literature search will confirm that this is not just anecdotal and that ILD is probably the single biggest predictor of severe pneumonitis.

Damned if you do, damned if you don't. @radiaterMike comment is very on point and these are pts that almost no surgeon wants to touch

 

[Burt Radnolds]

Damned if you do, damned if you don't. @radiaterMike comment is very on point and these are pts that almost no surgeon wants to touch

I largely agree with most of what's been said otherwise. Radiation still likely many of these patients best option and I still typically offer treatment as I wouldn't want to withhold a chance at curative therapy.

 

[RadOncMegatron]

i think looking at the V5 is totally fine as well, but i do not routinely do it. I look at R50 as well

R50 love the metric when I get it, HATE it when I can't. For healthier lungs it seems a lot easier to obtain, but with these ILD guys (or anyone with really paper thin crappy lungs) I know R50 is going to be "variation acceptable" at best. Anyone else have similar experience? I think I read somewhere (forgot source) where those with poor lungs basically have far less build up than healthy lungs, thus higher R50. Could be wrong, but that's my understanding. Love to hear what other's say.

 

[Palex80]

Protons FTW!

 

[thecarbonionangle]

Protons FTW!

would consider proton sbrt to avoid “low dose bath”, get beautiful gorgeous V5. I would make sure to use robust optimization in multiple phases to account for the interplay effect. If tons of movement on 4dct, avoid protons.