Rad Onc Twitter

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thecarbonionangle said:
What are you hoping to do with it?
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Beats me. At risk of doxing myself, our centre is in the midst of transitioning to a new state-of-the-art facility, and along with the dual energy CTs, we are commissioning two MR-linacs, and an MR-sim as well. There was a considerable amount of money available to modernize our facility (which sees ~5000 consults a year). I personally have not been very involved in the equipment selection process much, other than attending a few of the product demonstrations. Apart from the increased soft tissue definition, once they are available I am going to have to a lot more reading and studying to see how best to leverage the technology. If you asked me right now, I would just say ‘better contouring’ (though better could take longer if one is going back and forth between merged image sets - will still need to see an assess the workflow).
 
thecarbonionangle said:
What i hear from protonists is “next big thing” is arc proton therapy (spread our LET) and FLASH (proton machines currently only are only ones that can deliver standard and flash rates at same time)
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One needs to really know the dose from any given gantry position to meaningfully do arcs. Also start degrading that low dose bath advantage that justifies protons at all in the pediatric population.

Protons are already the best leveraged tech we have. It is not rooted in real clinical value. It is rooted in cost, elitism and visual impressiveness.

I remember Cox and co. giving a talk on protons when I was in med school ~2006-2007. Can't remember the physicist who was talking with him. It was basically "We are going all in. We believe that it is always better." That was 2007.
 
communitydoc13 said:
One needs to really know the dose from any given gantry position to meaningfully do arcs. Also start degrading that low dose bath advantage that justifies protons at all in the pediatric population.

Protons are already the best leveraged tech we have. It is not rooted in real clinical value. It is rooted in cost, elitism and visual impressiveness.

I remember Cox and co. giving a talk on protons when I was in med school ~2006-2007. Can't remember the physicist who was talking with him. It was basically "We are going all in. We believe that it is always better." That was 2007.
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I would be a tool. Proton CSI does not need arcs likely, but there might be a benefit in some situations to spread out LET. Partial arcs would be possible/a consideration. There are papers comparing arc vs other modalities and techniques, you can review to check our assumptions.

JC was wrong about protons (embarrassing editorial) but he also did a lot of “wrong” things. The dude would be absolutely cancelled these days like many from “golden days”
 
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thecarbonionangle said:
I would be a tool. Proton CSI does not need arcs likely, but there might be a benefit in some situations to spread out LET. Partial arcs would be possible/a consideration. There are papers comparing arc vs other modalities and techniques, you can review to check our assumptions.

JC was wrong about protons (embarrassing editorial) but he also did a lot of “wrong” things. The dude would be absolutely cancelled these days like many from “golden days”
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Just having a last name of Cox can almost get you cancelled these days
 
TheWallnerus said:
All the discussions above lend credence to a general idea I have that protons are not as precise as photons. That is to say, the ratio of the prescription isovolume to the PTV is greater in protons than photons. They are a kind of step backward in that regard. That would bother me as I have spent a whole career trying to get that ratio as close as possible to one in every single patient’s case. When you get into protons the first time, is it tough to let this notion go?
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Protons=Precise uncertainty
 
communitydoc13 said:
One needs to really know the dose from any given gantry position to meaningfully do arcs. Also start degrading that low dose bath advantage that justifies protons at all in the pediatric population.

Protons are already the best leveraged tech we have. It is not rooted in real clinical value. It is rooted in cost, elitism and visual impressiveness.

I remember Cox and co. giving a talk on protons when I was in med school ~2006-2007. Can't remember the physicist who was talking with him. It was basically "We are going all in. We believe that it is always better." That was 2007.
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True believers
 
TheWallnerus said:
Totally forgot to think along pediatric lines (as I’m wont to do having never treated a peds case my entire career). On one hand, makes sense to dose the vertebral bodies. But gosh this just reminds me how medieval/antediluvian radiation occasionally/rarely is: because the child is getting CSI, we have to uniformly “torch” the uninvolved, normal vertebral bone-making cells of the child so the child doesn’t grow funny. Re: your thoughts on skepticism (“electively” irradiate the VBs or no), would be a great trial but for a whole host of reasons I see why that trial has never ran.

That seems like a 2-3cm expansion margin though anteriorly. I’d understand maybe a half cm or so. You would not expand anteriorly this much in adult CSI w protons would you due to “robustness”? That would be measurable toxicity inducing robustness?
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Thats a good question, it's not my plan and I don't treat CSI with protons and I now wont be treating with protons at all 🤣

Given how much people talk about "marrow sparing" in a broad range of settings, I'm surprised I basically never see it in practice. Weird.
 
jondunn said:
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She gave me permission, I almost shared to Twitter then decided not to. But since you asked, Ill share it here instead. It's a highly unusual case that her and I hope to turn in to some kind of MedEd post once my life settles down a bit.

It was a high grade pleomorphic sarcoma of the breast "invading" pec muscle (quotes due to indeterminate imaging on that aspect). She had a mastectomy then had post-op RT with protons. I am not a fan of protons for sarcoma, but it was a left sided chest wall field in a young woman who was facing Adria; when in Rome.

During post-op RT she had a small local recurrence (biopsy proven), so I changed to BID. This was based on apprentice training, I am not aware of data supporting that maneuver. The whole "initial" sarcoma field ultimately got 60 Gy equivalent because the path demonstrated very infiltrative behavior. After radiation she got chemotherapy AIM x5. During that she had a recall reaction, and (IMO) combined with aggressive exercise and cancer rehab, her wound opened up. This was closed after chemotherapy completed. As an aside, I have a small handful of "cancer rehab toxicities"; huge fan of the intervention, but no one is really talking about potential toxicity.

Then she was NED for about a year until she developed a solitary lung metastasis. This was removed with wedge resection and she entered a vaccine trial at another institution. She is now 20 months post surgery and remains NED. On my last exam, she has grade 2 late skin toxicity with hyperpigmentation and some fibrosis, but no functional limitation at all and no pain.

In the photo, the dry area where the breast was is the field. She said she has not sweated there in 3 years. The other dry areas are just asymmetric sweat how people normally get with exercise. The field did not extend to the abdomen or around the flank.

Genuinely one of the weirdest cases I have ever treated, but positive and I dont get too many of those with my case mix. I spoke to her today and she said she feels better than she ever has, even before treatment!

EDIT: I added a picture of the plan. This was prior to IMPT availability here, so it was a single passive scatter field. Mean dose to heart was 3.3 Gy.
 

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NotMattSpraker said:
She gave me permission, I almost shared to Twitter then decided not to. But since you asked, Ill share it here instead. It's a highly unusual case that her and I hope to turn in to some kind of MedEd post once my life settles down a bit.

It was a high grade pleomorphic sarcoma of the breast "invading" pec muscle (quotes due to indeterminate imaging on that aspect). She had a mastectomy then had post-op RT with protons. I am not a fan of protons for sarcoma, but it was a left sided chest wall field in a young woman who was facing Adria; when in Rome.

During post-op RT she had a small local recurrence (biopsy proven), so I changed to BID. This was based on apprentice training, I am not aware of data supporting that maneuver. The whole "initial" sarcoma field ultimately got 60 Gy equivalent because the path demonstrated very infiltrative behavior. After radiation she got chemotherapy AIM x5. During that she had a recall reaction, and (IMO) combined with aggressive exercise and cancer rehab, her wound opened up. This was closed after chemotherapy completed. As an aside, I have a small handful of "cancer rehab toxicities"; huge fan of the intervention, but no one is really talking about potential toxicity.

Then she was NED for about a year until she developed a solitary lung metastasis. This was removed with wedge resection and she entered a vaccine trial at another institution. She is now 20 months post surgery and remains NED. On my last exam, she has grade 2 late skin toxicity with hyperpigmentation and some fibrosis, but no functional limitation at all and no pain.

In the photo, the dry area where the breast was is the field. She said she has not sweated there in 3 years. The other dry areas are just asymmetric sweat how people normally get with exercise. The field did not extend to the abdomen or around the flank.

Genuinely one of the weirdest cases I have ever treated, but positive and I dont get too many of those with my case mix. I spoke to her today and she said she feels better than she ever has, even before treatment!

EDIT: I added a picture of the plan. This was prior to IMPT availability here, so it was a single passive scatter field. Mean dose to heart was 3.3 Gy.
Click to expand...
Thanks for sharing all those details! No personal experience with protons here, but I imagine you could get the heart out of field with photon tangents and a good beath hold. 2 questions:

1 - Are you using breath hold (or have the ability to do so) with your modern proton treatments, and
2 - Does it even help with the proton treatments, given the decreased stopping power of the lung anyways?

Thanks in advance
 
It appears the stopping power does change with breathing per my reading. As lungs inflate they have more air and are less dense. As lungs deflate in full expiration they are denser/less air. The answer might actually be to treat with gating in full expiration in some of these cases. Just an outloud thought.
 
taserlaser said:
Thanks for sharing all those details! No personal experience with protons here, but I imagine you could get the heart out of field with photon tangents and a good beath hold. 2 questions:

1 - Are you using breath hold (or have the ability to do so) with your modern proton treatments, and
2 - Does it even help with the proton treatments, given the decreased stopping power of the lung anyways?

Thanks in advance
Click to expand...

1- Yes, now we have the ability. At that time it was not available. I think you imagine correctly regarding proton versus photon with breath hold. This was discussed extensively in the consult and there was a desire to reduce integral dose to all tissues including the heart. The patient is very well read and had a sophisticated understanding of all the issues. Since protons was available across the hall and was approved, that's what we decided to use together.

2- Im not sure how to answer! That is a fantastic question.
 
NotMattSpraker said:
She gave me permission, I almost shared to Twitter then decided not to. But since you asked, Ill share it here instead. It's a highly unusual case that her and I hope to turn in to some kind of MedEd post once my life settles down a bit.

It was a high grade pleomorphic sarcoma of the breast "invading" pec muscle (quotes due to indeterminate imaging on that aspect). She had a mastectomy then had post-op RT with protons. I am not a fan of protons for sarcoma, but it was a left sided chest wall field in a young woman who was facing Adria; when in Rome.

During post-op RT she had a small local recurrence (biopsy proven), so I changed to BID. This was based on apprentice training, I am not aware of data supporting that maneuver. The whole "initial" sarcoma field ultimately got 60 Gy equivalent because the path demonstrated very infiltrative behavior. After radiation she got chemotherapy AIM x5. During that she had a recall reaction, and (IMO) combined with aggressive exercise and cancer rehab, her wound opened up. This was closed after chemotherapy completed. As an aside, I have a small handful of "cancer rehab toxicities"; huge fan of the intervention, but no one is really talking about potential toxicity.

Then she was NED for about a year until she developed a solitary lung metastasis. This was removed with wedge resection and she entered a vaccine trial at another institution. She is now 20 months post surgery and remains NED. On my last exam, she has grade 2 late skin toxicity with hyperpigmentation and some fibrosis, but no functional limitation at all and no pain.

In the photo, the dry area where the breast was is the field. She said she has not sweated there in 3 years. The other dry areas are just asymmetric sweat how people normally get with exercise. The field did not extend to the abdomen or around the flank.

Genuinely one of the weirdest cases I have ever treated, but positive and I dont get too many of those with my case mix. I spoke to her today and she said she feels better than she ever has, even before treatment!

EDIT: I added a picture of the plan. This was prior to IMPT availability here, so it was a single passive scatter field. Mean dose to heart was 3.3 Gy.
Click to expand...
I also bid when pts recurr or tumor grows during xrt. 1.5 bid?
 
NotMattSpraker said:
She gave me permission, I almost shared to Twitter then decided not to. But since you asked, Ill share it here instead. It's a highly unusual case that her and I hope to turn in to some kind of MedEd post once my life settles down a bit.

It was a high grade pleomorphic sarcoma of the breast "invading" pec muscle (quotes due to indeterminate imaging on that aspect). She had a mastectomy then had post-op RT with protons. I am not a fan of protons for sarcoma, but it was a left sided chest wall field in a young woman who was facing Adria; when in Rome.

During post-op RT she had a small local recurrence (biopsy proven), so I changed to BID. This was based on apprentice training, I am not aware of data supporting that maneuver. The whole "initial" sarcoma field ultimately got 60 Gy equivalent because the path demonstrated very infiltrative behavior. After radiation she got chemotherapy AIM x5. During that she had a recall reaction, and (IMO) combined with aggressive exercise and cancer rehab, her wound opened up. This was closed after chemotherapy completed. As an aside, I have a small handful of "cancer rehab toxicities"; huge fan of the intervention, but no one is really talking about potential toxicity.

Then she was NED for about a year until she developed a solitary lung metastasis. This was removed with wedge resection and she entered a vaccine trial at another institution. She is now 20 months post surgery and remains NED. On my last exam, she has grade 2 late skin toxicity with hyperpigmentation and some fibrosis, but no functional limitation at all and no pain.

In the photo, the dry area where the breast was is the field. She said she has not sweated there in 3 years. The other dry areas are just asymmetric sweat how people normally get with exercise. The field did not extend to the abdomen or around the flank.

Genuinely one of the weirdest cases I have ever treated, but positive and I dont get too many of those with my case mix. I spoke to her today and she said she feels better than she ever has, even before treatment!

EDIT: I added a picture of the plan. This was prior to IMPT availability here, so it was a single passive scatter field. Mean dose to heart was 3.3 Gy.
Click to expand...
Really appreciate the anecdote, thanks for sharing the story.
 
Pancreatic cancer is not that uncommon. Twenty years ago, a reasonable performance status non-met pancreatic cancer patient is getting chemoRT 90 percent of the time or more. The med oncs, as always, were the impetus for the rad onc referrals.

They’re losing their desire to refer. Quite a big change in a short period of time.

 
TheWallnerus said:
Pancreatic cancer is not that uncommon. Twenty years ago, a reasonable performance status non-met pancreatic cancer patient is getting chemoRT 90 percent of the time or more. The med oncs, as always, were the impetus for the rad onc referrals.

They’re losing their desire to refer. Quite a big change in a short period of time.

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Still treating plenty... last I checked, chemo wasn't curative in solid tumors.
 
TheWallnerus said:
Pancreatic cancer is not that uncommon. Twenty years ago, a reasonable performance status non-met pancreatic cancer patient is getting chemoRT 90 percent of the time or more. The med oncs, as always, were the impetus for the rad onc referrals.

They’re losing their desire to refer. Quite a big change in a short period of time.

Click to expand...


And yet the MD PhD brain trust recruited to rad onc a decade ago couldn’t figure out how to reverse the decline, there really isn’t much hope here. If I see a LA panc it’s because they already got chemo and haven’t metted out and Haven’t seen many of those. If med onc loses faith really doesn’t matter what you publish in the red journal.
 
jondunn said:
which of you is this person 5 UTR?

ridiculous tweets

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Only partly. Hasn't been proven more toxic as far as I know. Hasn't been proven equally toxic, though. Is it ridiculous to believe that 27/5 is significantly more toxic than 26/5? Of all the ridiculous claims, I'd put that one up there.
 
Ray D. Ayshun said:
Only partly. Hasn't been proven more toxic as far as I know. Hasn't been proven equally toxic, though. Is it ridiculous to believe that 27/5 is significantly more toxic than 26/5? Of all the ridiculous claims, I'd put that one up there.
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I believe 5 fraction whole breast is likely more toxic than moderately hypo whole breast based on the published studies. Reasons include excess really bad outcomes by blinded analysis, which are included in the appendix from FAST-FORWARD.

Mild to moderate toxicity is exceptionally hard to meaningfully study. In the 10 year update of FAST they did an analysis regrading 5 year toxicity and looking for concordance as there was marked disparity between toxicity assignment at 2 and 5 years. This is in the appendix of the 10 year update. There is very little correlation between assignment of low or intermediate grade toxicity by different reviewers. This tells me that their analysis of low and intermediate grade toxicity is not very meaningful.

In their own words:

In summary, although the observed agreement between the original scores and the rescores for mild and marked changes was higher than would be expected by chance, it was decided to use the rescores for all analyses presented in this article, as the level of agreement overall was only moderate. The number of patients with mild/marked change in photographic breast appearance at 2 years reported here is less than in the 2011 article, but conclusions regarding differences between the fractionation schedules are as before.9

Picking and choosing.
 
voxveritatisetlucis said:
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“My institution had an open position that they were debating whether or not to fill, and I literally overheard an attending state "a warm body is a warm body."

Matches the same info i have gotten from hellpits in the way these match SOAP meetings went in recent cycle. Direct quote from a source “we just have to make sure we match anyone”. These places were freaking out they did not have anyone to do the work, clearly a hellpit where residents are just cheap labour. Hellpits will always hellpit.
 
RealSimulD said:
Whoever is UTR is making ROs look bad.
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Interesting. Typically the people trying to win the MedTwitter popularity contest of showing how much they care do it behind their real name. Usually avatars are only used when someone is saying something that would ostracize them from the cliques. I don't have Twitter so I can't read past the first 10 posts or so before the site locks me out, but it's pretty clear this could be any random account from the clique saying all the right things.

The fact that this individual is ripping on 5 fraction breast makes it even more bizarre. Is it the fact that it pretty much kills the observation option for most eligible patients that's worked him/her all up?
 
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