Livi breast experience

[evilbooyaa]

Yah I think that sounds reasonable ?

But, I would argue, is it necessary in the setting of such good outcomes already without large evidence of marginal recurrences (meaning we're just barely missing and need the beam to be more accurate) or excessive toxicity (meaning we'd really stand to benefit from aggressive shrinkage of PTV like in lung cancer). This is the downside of early stage breast - patients do so well (and so many of them will do well even without the RT) that identifying incremental approaches in improving accuracy lead to (IMO) relevant questions of whether it's worth the extra cost.

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[deleted1111261]

Well

It’s iterative right? Each little step since Bernie and Melvin with B6 have gotten us to a point where instead of mastectomies for stage I disease, doing Lump + SLN bx + 5fx APBI - they barely look like they have had any treatment.

Each little step.. but yah this one thing not going to change much.

 

[deleted1111261]

For people that are considering daily treatment, their experience is in Practical. I had said that they had switched to daily, but I think people waiting for data.

Grade 1 toxicity was 16%. Nothing higher than that seen.

DEFINE_ME

 

[RickyScott]

For people that are considering daily treatment, their experience is in Practical. I had said that they had switched to daily, but I think people waiting for data.

Grade 1 toxicity was 16%. Nothing higher than that seen.

DEFINE_ME

I respect you a lot and have a great experience with a few pts, but will try to hold off on adopting this for as long as possible.

 

[deleted1111261]

I respect you a lot and have a great experience with a few pts, but will try to hold off on adopting this for as long as I can.

16-20 to whole breast remains the standard of care!

 

[deleted1111261]

Getting paid on wRVU / professional fees leads to weird outcomes. Another thread mentioned it - 3D with image guidance can end up being financially beneficial to the physician, while providing less overall revenue to the hospital. People have done that with prostate and treated the pelvis with a box and then boost the prostate with IMRT.

In the case of VMAT 5 fx APBI + daily IGRT, with commercial payors, the total revenue generated can be higher than with 3D 16 fx to whole breast without image guidance. The wRVUs will be lower for APBI. If we contract for some percentage of total revenue (tech + prof), the incentives change.

 

[OTN]

I want to thank everyone here for their help/experience with Livi. I've finally had some non-oncoplastic lumpectomy patients filter in, and you were all most correct, Livi works great. No more SAVI for my patients, ever.

 

[TheWallnerus]

I respect you a lot and have a great experience with a few pts, but will try to hold off on adopting this for as long as possible.

widespread adoption could be "RT center killers" and actually harm patient access to care

 

[RickyScott]

widespread adoption could be "RT center killers" and actually harm patient access to care

Techs wouldn’t get 40 hrs and we would lose them

 

[deleted1111261]

Techs wouldn’t get 40 hrs and we would lose them

This is a huge problem.

 

[medgator]

I want to thank everyone here for their help/experience with Livi. I've finally had some non-oncoplastic lumpectomy patients filter in, and you were all most correct, Livi works great. No more SAVI for my patients, ever.

My experience has been that savi is very surgeon driven... Great if they are willing to let you steer that ship

 

[OTN]

My experience has been that savi is very surgeon driven... Great if they are willing to let you steer that ship

Oh don't worry I cleared it with them before going to Livi. No need to unbutter bread.

 

[medgator]

Oh don't worry I cleared it with them before going to Livi. No need to unbutter bread.

Your physicists and staff must be so much happier as well... Savi is such a time suck, esp when you consider reimbursement vs 1-4 weeks of ebrt

 

[metallica81788]

Oh don't worry I cleared it with them before going to Livi. No need to unbutter bread.

Once you get 30/5 going, there is no need for Savi unless you're a money grubbing surgeon. It's better in literally every aspect.

 

[Ray D. Ayshun]

anybody use a skin constraint? or find it's never really an issue with cropping and arcs

 

[deleted1111261]

This is a good question.

Some of the cavities are close to skin and you can’t / shouldn’t crop it out. Occasionally people even use bolus. But, as far as skin dose - I don’t know - I haven’t used.

 

[Palex80]

anybody use a skin constraint? or find it's never really an issue with cropping and arcs

Nope, we don't. We haven't used bolus.

 

[evilbooyaa]

This is a good question.

Some of the cavities are close to skin and you can’t / shouldn’t crop it out. Occasionally people even use bolus. But, as far as skin dose - I don’t know - I haven’t used.

Would not use bolus

anybody use a skin constraint? or find it's never really an issue with cropping and arcs

Max point dose < 31.5Gy, shoot for V30 < 5-10cc. PTV frequently includes the skin (we crop 3mm from an external contour to create a PTV_Eval)

Not necessary but goal is to avoid spraying skin with Rx dose outside of the PTV region.