Rad Onc Connection at Kentucky Derby

[beamotherapy]

Did anyone else see the Rad Onc connection at the Kentucky Derby? There was a horse named Cyberknife. Here is an article about the story:

The lives of the connections of Derby contender Cyberknife already richer regardless of outcome - NKyTribune

By Jessie Oswald NKyTribune contributor Before thousands of fans sing “My Old Kentucky Home” under the twin spires of Churchill Downs in Louisville and before 20 horses break through the gate in Saturday’s $3 million Kentucky Derby Cyberknife has already made a lot of lives richer. While...

www.nkytribune.com

Apparently it was 4 times slower than it's peers. Other have said that it is a bit of a ... one trick pony. 😆

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[medgator]

Did anyone else see the Rad Onc connection at the Kentucky Derby? There was a horse named Cyberknife. Here is an article about the story:

The lives of the connections of Derby contender Cyberknife already richer regardless of outcome - NKyTribune

By Jessie Oswald NKyTribune contributor Before thousands of fans sing “My Old Kentucky Home” under the twin spires of Churchill Downs in Louisville and before 20 horses break through the gate in Saturday’s $3 million Kentucky Derby Cyberknife has already made a lot of lives richer. While...

www.nkytribune.com

Apparently it was 4 times slower than it's peers. Other have said that it is a bit of a ... one trick pony. 😆

It seemed to go forwards and backwards during the race quite often and finished in 3x the time of everyone else

 

[evilbooyaa]

I heard it defied the laws of gravity and was able to move in 3-dimensions rather than simply in a flat oval around the center of the track. It eventually got the job done and it was cool to look at!

 

[Ray D. Ayshun]

I heard there were also horses named SRS and SBRT there, which all the med oncs in attendance also called CyberKnife.

 

[beamotherapy]

Take it easy on this poor colt named Cyberknife ... let's not beat a dead horse.

 

[salubalu]

Actually brings up a discussion I wanted to have if it has not already…in training I’ve used a Varian linac for srs SBRT. In practice I have a cyberknife and linac. I prefer the cyberknife for most cases ie. No itvs for most lung tumors. Between the different srs/SBRT machines including but not limited to Cyberknife, Gamma knife, Edge etc what has been y’all’s experience pros/cons.

 

[RadOncDoc21]

Actually brings up a discussion I wanted to have if it has not already…in training I’ve used a Varian linac for srs SBRT. In practice I have a cyberknife and linac. I prefer the cyberknife for most cases ie. No itvs for most lung tumors. Between the different srs/SBRT machines including but not limited to Cyberknife, Gamma knife, Edge etc what has been y’all’s experience pros/cons.

I like Linac-based, don’t like the long time it takes for cyberknife treatments and the need for fiducials. I also like the fact of being able to use a CBCT.

 

[salubalu]

I like Linac-based, don’t like the long time it takes for cyberknife treatments and the need for fiducials. I also like the fact of being able to use a CBCT.

Ya a downside of Cyberknife is time though the new model is much faster and I can typically get a treatment done in 20-30 mins. I do have to put fiducials for prostate and liver/pancreas. I do like its flexibility to treat all sites vs a gamma knife. The mlcs in the s7 help.

 

[medgator]

I like Linac-based, don’t like the long time it takes for cyberknife treatments and the need for fiducials. I also like the fact of being able to use a CBCT.

Likewise. Technically CK is a Linac as well though right, just miniaturized and mounted on a robotic arm

 

[OTN]

Cyberknife and Gamma Knife are quite marketable. Great names. Only benefit to either of them I can see.

For example, it took me about 6-7 years to change vocabulary in town from "let's cyberknife that tumor" (the competitor has a CK) to "let's treat it with SBRT/SRS"

 

[evilbooyaa]

Ya a downside of Cyberknife is time though the new model is much faster and I can typically get a treatment done in 20-30 mins. I do have to put fiducials for prostate and liver/pancreas. I do like its flexibility to treat all sites vs a gamma knife. The mlcs in the s7 help.

Do you not need fiducials for Lung SBRT on CK? How are you 'tracking' without an ITV otherwise?

In regards to not needing ITV - there may be a very small subset of patients who would benefit from lower lung volume radiation. However, given how well SBRT is tolerated in appropriately selected patients (perhaps the indications could be wider with CK), idk if there would be a clinical benefit.

 

[thesauce]

Cyberknife and Gamma Knife are quite marketable. Great names. Only benefit to either of them I can see.

For example, it took me about 6-7 years to change vocabulary in town from "let's cyberknife that tumor" (the competitor has a CK) to "let's treat it with SBRT/SRS"

Amen. They advertise it on all local TV channels and the radio. All of my patients ask about it like it is some brand new thing.

 

[thesauce]

Do you not need fiducials for Lung SBRT on CK? How are you 'tracking' without an ITV otherwise?

In regards to not needing ITV - there may be a very small subset of patients who would benefit from lower lung volume radiation. However, given how well SBRT is tolerated in appropriately selected patients (perhaps the indications could be wider with CK), idk if there would be a clinical benefit.

I will save us all the millions of dollars to run this clinical trial: it will show no benefit to CK. Unless of course the trial is run by the Accuray in which case it will increase survival by 50%

 

[salubalu]

Do you not need fiducials for Lung SBRT on CK? How are you 'tracking' without an ITV otherwise?

In regards to not needing ITV - there may be a very small subset of patients who would benefit from lower lung volume radiation. However, given how well SBRT is tolerated in appropriately selected patients (perhaps the indications could be wider with CK), idk if there would be a clinical benefit.

Yes no fiducials for lung SBRT in 95% cases in my clinic as long as the tumor is relatively solid and reasonable size. Cyberknife can track using xsight lung algorithm. Who knows how clinically significant it is but isn’t one principle in our field to minimize dose to normal tissue as much as possible while optimizing tumor coverage. I have both a true beam and ck for stereotactic and prefer the ck in this case. If a fiducial is needed I would prefer not to and just treat with an itv on the truebeam.

 

[salubalu]

I’m curious to see why SBRT toxicity was less in Ck patients vs non in pace b trial.

 

[salubalu]

I went to one center who got an edge and sold it after two years and another center who had an edge and I asked if they treated trigems and they were hesitant to treat to those doses with a frameless technique. Have y’all had any opinions on the Edge? In the end I believe the benefit difference between all the machines is likely marginal and it’s the doc behind the plan and the dosi/physics/therapy team which will make the biggest difference.

 

[salubalu]

Amen. They advertise it on all local TV channels and the radio. All of my patients ask about it like it is some brand new thing.

There’s the science of medicine and the business. It’s real life.

 

[RadOncDoc21]

I’ve treated trigems using Truebeam and an Edge… I’ve trained on gamma knife and worked with a cyberknife and novalis. All have pros and cons but overall, they all got the job done. I think it’s all about what you are comfortable with using and in a lot of cases… marketing.

 

[radoncftw]

my academic attendings have me convinced i won't be able to treat any functional stuff without a gamma knife. "would you feel comfortable placing a 80 Gy shot without GK type precision? "

 

[thesauce]

I went to one center who got an edge and sold it after two years and another center who had an edge and I asked if they treated trigems and they were hesitant to treat to those doses with a frameless technique. Have y’all had any opinions on the Edge? In the end I believe the benefit difference between all the machines is likely marginal and it’s the doc behind the plan and the dosi/physics/therapy team which will make the biggest difference.

I know people that treat trigems on the Edge. It’s no big deal

 

[thesauce]

my academic attendings have me convinced i won't be able to treat any functional stuff without a gamma knife. "would you feel comfortable placing a 80 Gy shot without GK type precision? "

Come on now. Gamma Knife is a 60 year old machine. The resolution of the imaging (CT and/or MRI) is the bottleneck.

 

[medgator]

I know people that treat trigems on the Edge. It’s no big deal

I know that's what they do at UAB.... Frameless iirc, still would make me nervous without a frame bolted to someone's head

 

[RadOncDoc21]

I know that's what they do at UAB.... Frameless iirc, still would make me nervous without a frame bolted to someone's head

They also use a “virtual cone” but great results. We still use physical cones to plan.

@radoncftw I know academics centers that use protons for breast. Those same people will claim by using photons, we are killing pregnant women… again much of what we do is based on marketing.

 

[thesauce]

I know that's what they do at UAB.... Frameless iirc, still would make me nervous without a frame bolted to someone's head

Yes - frameless with OSMS gating

 

[thesauce]

I will save us all the millions of dollars to run this clinical trial: it will show no benefit to CK. Unless of course the trial is run by the Accuray in which case it will increase survival by 50%

I’m curious to see why SBRT toxicity was less in Ck patients vs non in pace b trial.

It was funded by Accuray

 

[Gfunk6]

Guys, it is great fun to **** over RO marketing and the relative similarity of different systems. Lord knows I have done the same on this forum with protons - which at times feels more like a cult than a modality.

However consider that we have more Rad Oncs than we need, private practice is dying, academic centers/hospital systems are employing Rad Oncs, and in high-demand areas of the country people are building vaults left and right. These vaults have to be filled by any means possible. What do you have left in this situation where administrators hold all the power except marketing?

We can all poke fun at the silly cancer center ads we see on our local interstate. However, when a patient walks in and tells you, "I came here because you have the latest and greatest technology," what are you going to do? Thank your lucky stars or say "actually that ad campaign is all hype, you will do just as well with that 10 year old accelerator down the street."

 

[evilbooyaa]

I personally wouldn't feel great about functional SRS on a linac without using cones. I know UAB is pioneering virtual cones... I'm just not there yet.

I have no beef with CK users. It's less damaging to the specialty than proton shills, that's for sure!

 

[Neuronix]

my academic attendings have me convinced i won't be able to treat any functional stuff without a gamma knife. "would you feel comfortable placing a 80 Gy shot without GK type precision? "

Reply like this

"The head frame can move too..."

and cite:

Spatial shifts in frame-based Gamma Knife radiosurgery: A case for cone beam CT imaging as quality assurance using the Gamma Knife® Icon™ - PMC

Cone beam CT (CBCT) imaging has been integrated into the most recent version of the Leksell Gamma Knife for the primary purpose to facilitate fractionated therapy. This case study presents three patients where the CBCT system of the Gamma Knife Icon ...

www.ncbi.nlm.nih.gov

Linac radiosurgery with well calibrated Winston-Lutz (CBCT and isocenter) and real-time position monitoring of some type should be good to the 1 mm accuracy level. There are end to end testing papers demonstrating this. Put 80-95 Gy Dmax with a high precision setup close to Meckel's cave and you've still got a millimeter to play with.

 

[Neuronix]

I personally wouldn't feel great about functional SRS on a linac without using cones. I know UAB is pioneering virtual cones... I'm just not there yet.

I have no beef with CK users. It's less damaging to the specialty than proton shills, that's for sure!

Virtual cone is just a 3D arc configuration as far as I'm aware. Anyone can do it today.

We've done some plans like this. The limiting factor is MLC width compared to whatever cone diameter you're trying to mimic.

 

[TheWallnerus]

I’ve treated trigems using Truebeam and an Edge… I’ve trained on gamma knife and worked with a cyberknife and novalis. All have pros and cons but overall, they all got the job done. I think it’s all about what you are comfortable with using and in a lot of cases… marketing.

my academic attendings have me convinced i won't be able to treat any functional stuff without a gamma knife. "would you feel comfortable placing a 80 Gy shot without GK type precision? "

I've treated trigems with a 2100c and an m3 😗 pts did fine

 

[salubalu]

I've treated trigems with a 2100c and an m3 😗 pts did fine

I've used Crouton therapy...gets a little greasy.