Lutathera

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xrt123

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Just curious if anyone out there is managing the patients and coordinating the care in the Radonc field? Our center has set up the division of labor between NucMed and RadOnc. Is this atypical?
 
We're still getting it together, but in our practice it is going to be 100% radonc-led. Nuclear Medicine docs aren't oncologists, so I don't think it's appropriate for them to be managing patients, coordinating care, etc.
 
OTOH, as an oncologist, I think I can count all the NET patients I've seen in clinic on one hand, maybe one finger. Definitely has been more the realm of Nuc Med than Rad Onc anywhere I've ever been.
 
xrt123 said:
Just curious if anyone out there is managing the patients and coordinating the care in the Radonc field? Our center has set up the division of labor between NucMed and RadOnc. Is this atypical?
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To better answer your question, unsealed source therapy (Spheres, Xofigo, I-131, Bexxar, Octreotide, whatever...) is usually controlled by either nuc med or rad onc (at least in the multiple settings I've encountered). That is not atypical. I've always seen it be the domain of Nuc Med, but it is largely dependent of the history of the departments. Usually the med oncs just tell the nuc med guys what to do and they do it, similar to ordering a PET scan or something. I agree that they are not making independent oncologic decisions, nor should they be. They are really only there as technicians.

If you're starting a new program, it could become a turf war you could fight if you felt passionately about it. I never did, and quite honestly I'd need to re-learn an awful lot of stuff to feel comfortable administering any of it.
 
Hated thyroid requirement in residency, we went to the nuc med dept to get signed off on cases

In practice I do a decent amount of xofigo, while most of the thyroid goes to my partners

The IR guys in town do sirspheres without us since they have radioactive license.

Don't know much about lutathera other than it was fda approved this year.... Is it in widespread usage now? We are within a couple hours of a few major centers so I imagine that's where those cases are going
 
I feel pretty strongly that we should give up as little of this stuff as possible. The Nuc Med guys don't have clinics, can't follow patients after treatment, etc. After the law changed to where IR docs could do Y90, I've seen a decrease in quality of treatment. They almost never do proper contouring for volumes, they routinely try to treat a single lesion with Y90, etc.

Patients with metastatic prostate cancer getting Xofigo frequently need palliative XRT during treatment, so I follow them all pretty closely.

Not as much I-131 being given these days anyway, as the data continues to show most patients don't need it.

As far as lutathera goes, the economics of giving it in a freestanding center don't work yet, but we're working with our hospital to get it done there.
 
We haven't run into any turf war issues as our NucMeds don't really attend tumor board where these patients are presented, do not have significant clinical support, time for monitoring side effects and nursing care to coordinate all the logistics. I think that other similar treatments are in the drug pipeline and we are excited about it.

"As far as lutathera goes, the economics of giving it in a freestanding center don't work yet, but we're working with our hospital to get it done there."

We don't see much reimbursement besides the radioactive administration codes, but we aren't taking any risk on the reimbursement of the drug (the hospital is). Are you losing money on the actual drug when administering at a freestanding center?
 
OTN said:
. After the law changed to where IR docs could do Y90, I've seen a decrease in quality of treatment. They almost never do proper contouring for volumes, they routinely try to treat a single lesion with Y90, etc.
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Probably true in our area too. I could see that happening.

IR guys in our neck of the woods are fairly unscrupulous...they'll get a referral for a lung biopsy and bring the patient in for consult and then go over path at f/u and tell them they should get RFA without consulting us or a surgeon in many cases
 
medgator said:
Probably true in our area too. I could see that happening.

IR guys in our neck of the woods are fairly unscrupulous...they'll get a referral for a lung biopsy and bring the patient in for consult and then go over path at f/u and tell them they should get RFA without consulting us or a surgeon in many cases
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Treating single lesion with Y90 has a place in those certain nonarterially enhancing (which suggest decreased potential response to TACE) but are potentially radiosensitive.

Ablation of small lung lesions have been found to be comparable to surgery. It is entirely possible that a patient expressed sentiment to not want to have surgery to an IR therefore the said IR did not refer to surgery but ablated instead.
 
doctorsdatdo said:
Ablation of small lung lesions have been found to be comparable to surgery. It is entirely possible that a patient expressed sentiment to not want to have surgery to an IR therefore the said IR did not refer to surgery but ablated instead.
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Based on what data? Single institution retrospective studies?

The quality and breadth of data for rfa is pretty poor compared to sbrt, let alone surgery/lobectomy which is the gold standard of care, and the data that is there suggests poorer local control for lesions above 1-2 cm.

The IR guy should have probably referred him to a pulmonologist for pfts prior to doing anything
 
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It’s one thing to say “we need continued research into this new modality”. It’s another thing to claim people who use the said new modality as bad actors. I agree that more research and data will always benefit the field of medicine as a whole.
 
doctorsdatdo said:
. It’s another thing to claim people who use the said new modality as bad actors.
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Yes making a unilateral decision to treat a patient with rfa without a multidisciplinary evaluation by pulmonary, CT surgery and rad onc is "bad acting" imo and the guidelines would agree
 
IR docs should not be making oncologic decisions. Period. They are not oncologists. That is well beyond the scope of their training. Their role in cancer care should be performing procedures ordered by an oncologist if they deem these procedures safe and potentially efficacious.

And yes, definitive management of a lung cancer qualifies as oncologic decision making.
 
Mandelin Rain said:
IR docs should not be making oncologic decisions. Period. They are not oncologists. That is well beyond the scope of their training. Their role in cancer care should be performing procedures ordered by an oncologist if they deem these procedures safe and potentially efficacious.

And yes, definitive management of a lung cancer qualifies as oncologic decision making.
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$10 says most IR guys have no clue what nccn guidelines are or why they should even know about them
 
medgator said:
$10 says most IR guys have no clue what nccn guidelines are or why they should even know about them
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I am just a med student, but it seems like bad taste to bad mouth other specialities like this. There are IRs present in all the liver tumor conferences I’ve been to. To categorically say that someone have no say in oncological decision making reminds me of infancy of theraputic radiology when all of you guys were supposed to act only on med onc’s direction?
 
doctorsdatdo said:
I am just a med student, but it seems like bad taste to bad mouth other specialities like this. There are IRs present in all the liver tumor conferences I’ve been to. To categorically say that someone have no say in oncological decision making reminds me of infancy of theraputic radiology when all of you guys were supposed to act only on med onc’s direction?
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Do they go to the lung cancer conference? They don't show up to ours

Since when did anyone say we had to act under med oncs direction? We have more oncology training than they do and usually my med oncs will curbside me to discuss cases and get my input before we start treatment
 
I would conjecture that performing RFA on a lung lesion without the patient being seen by a surgeon, medical oncologist or radiation oncologist would be borderline malpractice. Our IR (who come to lung tumor board) would never think about doing this.
 
Mr RADical said:
I would conjecture that performing RFA on a lung lesion without the patient being seen by a surgeon, medical oncologist or radiation oncologist would be borderline malpractice. Our IR (who come to lung tumor board) would never think about doing this.
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The only time I heard this happen, the IR consult note documented that pt is unwilling to consider surgery or radiation therapy despite being explained those modalities and refused referal to those services. Perhaps this was the case here?
 
doctorsdatdo said:
The only time I heard this happen, the IR consult note documented that pt is unwilling to consider surgery or radiation therapy despite being explained those modalities and refused referal to those services. Perhaps this was the case here?
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There's never any reason clinically to do RFA up front for lung cancer. Maybe on recurrence if it's already been treated stereotactically. The data continues to show worse outcomes compared with SBRT.

I agree that it's not great to bash other specialties, but it's important to understand that many radoncs are having to deal with IR docs offering substandard treatments to patients, taking advantage of the fact that they see them for biopsy, without fully explaining all the options to them.

Someone else asked about Lutathera at a freestanding center. Even with the purchasing power of our practice, which is enormous, the economics don't work in an outpatient center, as we would have lost money on the drug.
 
OTN said:
There's never any reason clinically to do RFA up front for lung cancer. Maybe on recurrence if it's already been treated stereotactically. The data continues to show worse outcomes compared with SBRT.

I agree that it's not great to bash other specialties, but it's important to understand that many radoncs are having to deal with IR docs offering substandard treatments to patients, taking advantage of the fact that they see them for biopsy, without fully explaining all the options to them.

Someone else asked about Lutathera at a freestanding center. Even with the purchasing power of our practice, which is enormous, the economics don't work in an outpatient center, as we would have lost money on the drug.
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We had the same problem with Quadramet back in the day...
 
doctorsdatdo said:
The only time I heard this happen, the IR consult note documented that pt is unwilling to consider surgery or radiation therapy despite being explained those modalities and refused referal to those services. Perhaps this was the case here?
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Why is IR explaining those options to begin with? They have no oncology training.... Moreover, in addition to having less data to support this less efficacious treatment, RFA carries a not insignificant risk of pneumothorax, something which is unheard of in SBRT.

Do your think IR is explaining that to the patient? Or surgical options like lobectomy VS segmentectomy VS wedge etc?
 
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doctorsdatdo said:
The only time I heard this happen, the IR consult note documented that pt is unwilling to consider surgery or radiation therapy despite being explained those modalities and refused referal to those services. Perhaps this was the case here?
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Makes total sense. I think that's what that urologist told me about all the high risk prostate cancer he was cryoing too. They all refused after a thorough discussion of the available standard of care options.

Also, curious about "that one time" that IR RFA'd a tumor without consulting other services and you had the opportunity to review their consult note. Sounds like they must have recurred and ended up in front of tumor board again?
 
radmonckey said:
Makes total sense. I think that's what that urologist told me about all the high risk prostate cancer he was cryoing too. They all refused after a thorough discussion of the available standard of care options.

Also, curious about "that one time" that IR RFA'd a tumor without consulting other services and you had the opportunity to review their consult note. Sounds like they must have recurred and ended up in front of tumor board again?
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Nope. Did not hear it from tumor board.
 
IR has a growing role in oncology with a fair number of interventionists now with sub specialization in the treatment of oncologic conditions primarily related to the liver, kidney, lung and bone.

As far as the lung, it is an option for patients with oligo metastatic disease and in patient's with limited options (ie not surgical candidate or SBRT candidate).

I think that in the setting of lung cancer, it should be considered in front of a tumor board type setting given the uncertain efficacy of RFA for limited lung cancer. I think PFTs, performance status, patient desires all should be considered. PET scanning, mediastinoscopy, Lobectomy/segmentectomy/SBRT etc should be considered. In more advanced stages we tend to pursue either definitive chemo/rt or neoadjuvant chemo/rt with potential surgery if downstage. Also with the different receptors especially in certain ethnicities and nonsmokers with more advanced disease. EGFR,ALK,ROS, BRAF,PD1 should be evaluated. It can be done with local anesthesia and mild sedation in a similar fashion to the biopsy.

Interventional radiologists have a significant role in the management of hepatocellular cancer with TACE/Y90/Ablation/portal vein embolization etc including in the setting of curative treatment and bridge to transplant .

We have a growing presence in palliative pain interventions in the oncology population including nerve blocks/ablative techniques /cementoplasty and screw fixation for osseous lesions.

Always impressed by the strong foundation of evidence based medicine that radiation oncology brings to the table of cancer care. This is something that interventional physicians really need to employ if they are to provide true advances in oncologic care. The field of Interventional radiology is at a crossroads much like radiation oncology was when they had ultimately left diagnostic radiology to become a "clinical" discipline.
 
irwarrior said:
IR has a growing role in oncology with a fair number of interventionists now with sub specialization in the treatment of oncologic conditions primarily related to the liver, kidney, lung and bone.

As far as the lung, it is an option for patients with oligo metastatic disease and in patient's with limited options (ie not surgical candidate or SBRT candidate).

I think that in the setting of lung cancer, it should be considered in front of a tumor board type setting given the uncertain efficacy of RFA for limited lung cancer. I think PFTs, performance status, patient desires all should be considered. PET scanning, mediastinoscopy, Lobectomy/segmentectomy/SBRT etc should be considered. In more advanced stages we tend to pursue either definitive chemo/rt or neoadjuvant chemo/rt with potential surgery if downstage. Also with the different receptors especially in certain ethnicities and nonsmokers with more advanced disease. EGFR,ALK,ROS, BRAF,PD1 should be evaluated. It can be done with local anesthesia and mild sedation in a similar fashion to the biopsy.

Interventional radiologists have a significant role in the management of hepatocellular cancer with TACE/Y90/Ablation/portal vein embolization etc including in the setting of curative treatment and bridge to transplant .

We have a growing presence in palliative pain interventions in the oncology population including nerve blocks/ablative techniques /cementoplasty and screw fixation for osseous lesions.

Always impressed by the strong foundation of evidence based medicine that radiation oncology brings to the table of cancer care. This is something that interventional physicians really need to employ if they are to provide true advances in oncologic care. The field of Interventional radiology is at a crossroads much like radiation oncology was when they had ultimately left diagnostic radiology to become a "clinical" discipline.
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When would an IR procedure ever be preferred over stereo XRT for a lung lesion?
 
RickyScott said:
When would an IR procedure ever be preferred over stereo XRT for a lung lesion?
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The risk of pneumothorax is way too high for what is an inferior alternative to sbrt.

The pneumothorax risk is the same reason why many patients don't even undergo CT-guided biopsies of nodules anymore, let alone doing RFA to them. ENB is highly effective and carries a much lower risk of ptx
 
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If radiation has been exhausted or recurrence post SBRT occurs, RFA/cryo/microwave are options. The pneumothorax rate requiring chest tube rate is low.

CT guided biopsies of the lung have showcased an increase surge at our facility due to the lung cancer screening protocol and all of the new systemic agents that are available.
 
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Gfunk6 said:
For SBRT recurrence, you can still SBRT again.


Sent from my iPhone using SDN
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recurrences are very rare, and most of these pts have bad and copd and few years out from primary sbrt. there would be excedingly few pts eligible for rfa
 
In general I agree that in the lung SBRT seems to be the way to go and percutaneous ablative therapy(RFA) seems to have a limited role. In fact given the noninvasive nature and good local control, I have sent some of my own patients with solitary pulmonary metastases for SBRT with good results.
 
Irwarrior,

I have a patient who I treated with SBRT for a T2N0 aca of the lung (not surg candidate) 2 years ago adjacent to the chest wall, and he's now recurred. (He recurred in the mediastinum/hilum last year, and we salvaged with chemoRT). I'm hesitant to retreat him with XRT, as I'm worried chest wall toxicity could be high. Is there an upper bound to the size of the recurrent lesion you could treat with RFA? Any chance of chest wall toxicity?
 
Not knowing the specifics of this case. I would advocate for cryoablation for chest wall lesions . The heat based technology(RFA/microwave) has more potential at the pleural surface to cause bronchopleural fistulas. The cryoablation can cover a 4 or 5 cm territory reasonably well and can be visually monitored by the size of the iceball. But, the probes have to be placed strategically and things to protect the skin should be utilized (ie subcutaneous fluid infiltration/warming gel etc). The other thing to consider is the freeze thaw cycles should be adjusted depending on site and pathologic condition.

But, without knowing the specifics of this case, this sounds like an ideal location and scenario for cryoablation. Also, on top of potential local control it does provide palliative pain control for chest wall lesions.
 
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We're getting a little off topic, but it's a good discussion.

I think IR doing Y-90/TACE for liver mets or even primary HCC is fine without rad onc input (would favor surgeon input unless patient adamantly against surgery), although a comparison of Y-90 vs SBRT (for solitary liver met or primary HCC) would be ideal, IMO, to give some data to refute the results of that JCO NCDB that "proved" RFA is better than SBRT (link to SDN thread provided above).

I think IR unilaterally doing RFA for a pulmonary lesion without evaluation with either a surgeon OR a radiation oncologist is borderline malpractice.

I have no experience with lutathera at my institution. We do Xofigo along with nuc-med. I'm not sure who is doing lutathera, probably nuc-med at my institution; we do see a fair number of PNETs FWIW.
 
At our institution, this is administered by NucMed while using a specially shielded chemo chair. MedOnc views it almost like chemotherapy, but NucMed/NucRad (me) will consent and administer.
 
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