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RickyScott said:
probably because you are cis white male. Dont diminish the struggle.
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Struggling Season 2 GIF by Law & Order
 
I’ve put a pt on it in 2014 🙂
good science is hard.

interestingly, that pt had in-field acute inflammation of major airways 1 month after completing 70 Gy. Required admission and was quite sick.
 
FindMeOnTheLinks said:


Time to rekindle this debate?
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Interesting thread. It is okay to read studies and update your ideas on how diseases and treatments work, people should do that more. "This is okay at MY center"... wow.

The one time Ive treated a patient with lung cancer to 70 Gy in independent practice was on RTOG 1308.
 
NotMattSpraker said:
Interesting thread. It is okay to read studies and update your ideas on how diseases and treatments work, people should do that more. "This is okay at MY center"... wow.

The one time Ive treated a patient with lung cancer to 70 Gy in independent practice was on RTOG 1308.
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That tender juicy esophagus. If only we could SBRT it all.

Fear not.. Protonman to the rescue!
 
Palex80 said:


GIF by Achievement Hunter
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"In our hands, contralateral esophagus sparing can be effectively done with 70 Gy/7 weeks but not with 45 Gy/3 weeks."

This makes so much sense. I'm guessing, they try to spare the contralateral esophagus in their qd plans but not the BID plans because it's too much work to find it twice in a day.
 
StIGMA said:
"In our hands, contralateral esophagus sparing can be effectively done with 70 Gy/7 weeks but not with 45 Gy/3 weeks."

This makes so much sense. I'm guessing, they try to spare the contralateral esophagus in their qd plans but not the BID plans because it's too much work to find it twice in a day.
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Haha I was going to ask about that but he clearly explained this is just a quirk of Harvard Hands.
 
Rad oncs are a different breed, it’s no wonder we’re bottom feeders.
 
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StIGMA said:
"In our hands, contralateral esophagus sparing can be effectively done with 70 Gy/7 weeks but not with 45 Gy/3 weeks."

This makes so much sense. I'm guessing, they try to spare the contralateral esophagus in their qd plans but not the BID plans because it's too much work to find it twice in a day.
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I've been effectively sparing the esophagus by giving 60 Gy in 30 fractions.
 
grenz said:
Interesting how convinced proton users are that lymphopenia matters. That’s a variable that surely has a ton of confounders, and to my knowledge the evidence for it is all retrospective
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That was my thought as well. I can't help but think it's just a surrogate for more extensive disease but maybe not. The proton fans for lung love to talk about lymphopenia and proton benefits...

We'll see soon enough with the randomized trial.
 
BobbyHeenan said:
That was my thought as well. I can't help but think it's just a surrogate for more extensive disease but maybe not. The proton fans for lung love to talk about lymphopenia and proton benefits...

We'll see soon enough with the randomized trial.
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Even so, won’t proton fans continue to treat with protons anyway?
 
He's referencing their published shrinking field contralateral esophagus sparing technique. Contralateral Esophagus–Sparing Technique in Locally Advanced Lung Cancer Treated With Chemoradiation

0% G3+ esophagitis going to 70 Gy

2 fields PTV1 built off CTV, PTV2 built off ITV. 44 Gy then shrinks for cone down with 26 Gy for 70 Gy total.

With that design you'd have to come up with something analogous for BID treatment with small cell.

Makes me wonder if this is now a standard approach at Harvard based on a phase I. Not sure how this is being used.

Also interesting throwing a NSCLC study with shrinking fields into a discussion about SCLC.
 
CaesarRO said:
With that design you'd have to come up with something analogous for BID treatment with small cell.
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So what you are saying is that the people who try to wedge every clinical finding into the A/B model and rave about lymphopenia can't figure out a way to do this BID?

CaesarRO said:
He's referencing their published shrinking field contralateral esophagus sparing technique. Contralateral Esophagus–Sparing Technique in Locally Advanced Lung Cancer Treated With Chemoradiation

0% G3+ esophagitis going to 70 Gy

2 fields PTV1 built off CTV, PTV2 built off ITV. 44 Gy then shrinks for cone down with 26 Gy for 70 Gy total.

With that design you'd have to come up with something analogous for BID treatment with small cell.

Makes me wonder if this is now a standard approach at Harvard based on a phase I. Not sure how this is being used.

Also interesting throwing a NSCLC study with shrinking fields into a discussion about SCLC.
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0 G3+ esophagitis in a very small study on a highly selected patient population, further cherry picked for analysis.

"To be analyzable for the primary end point, participants were required to have received concurrently 5 or more cycles of weekly combined carboplatin plus paclitaxel or 2 or more cycles of platinum and pemetrexed or etoposide and to have had 3 or fewer days of unplanned treatment interruption unrelated to esophagitis."

I take this with a giant block of salt, but conceptually most people probably do this technique of sparing the edge of a target along an OAR at least a little bit in some settings where there is more data. I use this all the time in pancreas and spine SBRT.

Palex80 said:
A Phase I, non-randomized trial with 25 patients. Which got published in Jama Oncology (no clue why).
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Because it was done at Harvard.
 
NotMattSpraker said:
So what you are saying is that the people who try to wedge every clinical finding into the A/B model and rave about lymphopenia can't figure out a way to do this BID?



0 G3+ esophagitis in a very small study on a highly selected patient population, further cherry picked for analysis.

"To be analyzable for the primary end point, participants were required to have received concurrently 5 or more cycles of weekly combined carboplatin plus paclitaxel or 2 or more cycles of platinum and pemetrexed or etoposide and to have had 3 or fewer days of unplanned treatment interruption unrelated to esophagitis."

I take this with a giant block of salt, but conceptually most people probably do this technique of sparing the edge of a target along an OAR at least a little bit in some settings where there is more data. I use this all the time in pancreas and spine SBRT.



Because it was done at Harvard.
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"The patients that did great are reported in this analysis. we excluded the ones where the tumor was touching their esophagus and they needed a 1 week break for esophagitis"

I liked this report and have integrated the principles into my dosimetry ...but come on. How many massive level VII nodes (that move a ton) have we all had that caused major esophagitis? It's really really hard to prevent that...even in a Boston zip code.
 
NotMattSpraker said:
So what you are saying is that the people who try to wedge every clinical finding into the A/B model and rave about lymphopenia can't figure out a way to do this BID?



0 G3+ esophagitis in a very small study on a highly selected patient population, further cherry picked for analysis.

"To be analyzable for the primary end point, participants were required to have received concurrently 5 or more cycles of weekly combined carboplatin plus paclitaxel or 2 or more cycles of platinum and pemetrexed or etoposide and to have had 3 or fewer days of unplanned treatment interruption unrelated to esophagitis."

I take this with a giant block of salt, but conceptually most people probably do this technique of sparing the edge of a target along an OAR at least a little bit in some settings where there is more data. I use this all the time in pancreas and spine SBRT.



Because it was done at Harvard.
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have been sparing the esophagus for 15 years w/imrt. Harvard or not, dose can only fall off 4-5% per mm when constrained by a 10-15% hot spot. Any esophagus/or paraesophagus that is 1cm from ptv, we often optimize to 50-60% of the dose. multiple centers have been doing years.
 
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RickyScott said:
have been sparing the esophagus for 15 years w/imrt. Harvard or not, dose can only fall off 4-5% when constrained by a 10-15% hot spot. Any esophagus/or paraesophagus that is 1cm from ptv, we often optimize to 50-60% of the dose. multiple centers have been doing years.
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When esophagus is deflated, I restrict PTV(eval) expansion on CTV to 3 mm (rather than 5 mm) in the esophagus + 5 mm zone. Usually knocks a bit off mean and significantly decreases region of esophagus getting Rx dose. I do this for both SCLC and NSCLC where there is a lot of disease flanking the esophagus. truth is, it really doesn’t impact coverage all that much.
 
Another example of rad oncs trying hard to separate themselves from one another. If a country bumpkin rad onc uses appropriate volumes and dose constraints, I guarantee you the esophagitis experienced will be the same as that of the ol so prestigious Haaavard rad onc who is able to see two esophaguessieses (plural form?) or as I like to call it, the oesophagus because I’m even more fancier.
 
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That tender juicy esophagus doesn't always stay still. Especially if accompanied by a small (or large) hernia. We just make up stuff and keep our fingers crossed, lets be real.
 
sirspamalot said:
That tender juicy esophagus doesn't always stay still. Especially if accompanied by a small (or large) hernia. We just make up stuff and keep our fingers crossed, lets be real.
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Hey, you could always do online adaptation with MRI guidance.


I can already feel the SDN rad onc forum branded tomatoes getting thrown at me for suggesting this.
 
sirspamalot said:
Can anyone actually confirm this? For reals? Holy crap if so. Every single day another planning charge? Hello standard course my old friend..good bye hypofrac.
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Im not sure the actual rules, if there are rules, but you have to justify the new plan. So if you start the adaptive workflow and the DVH looks the same, you don't adapt. We used to have to document what constraints broke and/or if coverage improved with a new plan.

I wish I knew more about this but I have never had adaptive RT and a financially honest department at the same time, so have no idea beyond that at least for SBRT, a new plan is billed each fraction.
 
NotMattSpraker said:
Im not sure the actual rules, if there are rules, but you have to justify the new plan. So if you start the adaptive workflow and the DVH looks the same, you don't adapt. We used to have to document what constraints broke and/or if coverage improved with a new plan.

I wish I knew more about this but I have never had adaptive RT and a financially honest department at the same time, so have no idea beyond that at least for SBRT, a new plan is billed each fraction.
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As with the IRS, you can submit whatever you want.. the question is.. will the payor/CMS pay it?

And what will happen (if) when FLASH becomes a reality? "But sir, you can just treat him in a single fraction, you can use your old machine with a small upgrade, and we all know E&M doesn't pay. As such.."

Al Pacino Money GIF
 
sirspamalot said:
Can anyone actually confirm this? For reals? Holy crap if so. Every single day another planning charge? Hello standard course my old friend..good bye hypofrac.
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People have to recall that in the not long ago past CPT 77014 was CT simulation billed with 77290 at sim. Then vendors *cough* *Varian* *cough* said we are going to glom a CT scanner onto the linac. And then everyone said “you know what, I am gonna bill a CT simulation code EVERY day.” Because there were no rules one way or the other. And as of now there are no guardrails at the payor level, either insurance or Medicare, to keep more than 2 or 3 CPT 77301’s being billed per course of treatment. (Just like there were no 77014 guardrails back then… some were quite “freaked” to bill daily CT scan charges.) Try it… 77301 multiples. On any patient. One will see I am correct. A similar current tale can be told of the the derms and daily 77280 with superficial RT. We think derms would be satisfied with $25 a day for the superficial RT treatment code alone?
 
dieABRdie said:
Our most senior partner as the ViewRay rep reviews their process for daily adaptation

(i.e..... standing at the console contouring every day....)


GIF by Giphy QA
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Not really though anymore. Our attendings didn’t put up with being chained to the machine for very long. Pretty easy to train the therapists to contour stomach, bowel and duo. Page attending after it’s done. Check gtv. Reoptimization takes 15-20 seconds. Approve plan. Literally at the machine for 3mins these days
 
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