Rad Onc Twitter

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Where I practice, when I am doing dose painting, my fig leaf is the "PTV_eval". It's a beautiful thing. It is essentially me saying which parts of the PTV I actually want covered to rx dose, and allows me to underdose portions near OARs. The physicists love it too, because there is still a true "PTV" volume that they can evaluate to their heart's content. If I am seriously underdosing the PTV because of an OAR (i.e. my PTV_eval has giant bites taken out of it), I usually find some lower dose that is safe to go to the OAR and cover my whole PTV to that dose, thus limiting the chance of a marginal recurrence in the worse possible spot. Everyone wins!
 
elementaryschooleconomics said:
Ah! To continue down Dork River -

Sticking with ICRU again, the CTV to PTV expansion can implicitly include your ITV (as in, you don't have to have an ITV volume and then an additional expansion on top of that to your PTV). The PTV is supposed to represent "geometric uncertainty", which means not only external (setup), but also internal (breathing).

For lung SBRT, I think most people draw a GTV then expand into an ITV based on the 4D/MIP, then expand from there - probably 5mm geometrically? That's what I normally do for vanilla lung SBRT cases anyway.

However, sometimes I'll get like, a 6'4" (1.93m for you Europeans) guy with severe emphysema who has huge lungs and the tumor jumps up and down a crazy amount. Those are the times I do a 7mm/5mm expansion on the PTV because I feel (note: feeling is not evidence based, I know) that there's a higher probability for setup error.


Guilty as charged.

It's actually where my "Mr Clean" joke came from. Really, REALLY early on in residency, on two different services, I watched faculty edit my volumes by taking the eraser to my PTV. Since I was brand new, I had put a lot of effort into those volumes, including looking up why we did a PTV. So, when certain parts were erased (but not others), I was confused and asked them why they did that. I literally was told "because dose shouldn't go there".

Thus, I went on a magical journey of learning and discovery via Google and the disillusionment with RadOnc began to creep in.

I hung out with the physics crew after that.
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To be clear, this is correct approach, but I had already been editing ptvs before overlapping structure optimization was widely used, and didn’t really feel like changing. Source of endless debate in my department at one point and I can assure you for the optic chia am/gbm scenario, lead to identical plans. (I use stupp method of just one plan in gbm). It had got so bad in our department that I was editing ptvs and then regenerating ctv based on inward contraction
 
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TheWallnerus said:
Interesting how boomer might handle optic nerve sheath glioma case where PTV can include/be a portion of the chiasm
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Well the dose utilized is not a GBM Dose, and I haven’t seen many of these but the dose is typically 54 gy, so I would let it get that and minimize hot spots as much as possible, ultimately allowing a max of 55-56
 
I also think about old boomer trials when considering underdosing as well:
pubmed.ncbi.nlm.nih.gov

Long-term observations of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Report by the Radiation Therapy Oncology Group - PubMed

This report details the patterns of tumor recurrence in two prospective randomized studies involving 551 patients with histologically proven unresectable or medically inoperable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Patients were treated according to two...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
50 Gy RT alone to LA-NSCLC wasn't as good as 60 Gy, but LC also wasn't 0%. I don't underdose things just to make the patient have fewer acute side effects, which I have seen. But when I'm bumping into the chiasm, I don't feel guilty modifying the PTV, making a PTV eval, or keeping the PTV and prioritizing the chiasm. It's all the same in the end as far as I can tell.
 
Ray D. Ayshun said:
I also think about old boomer trials when considering underdosing as well:
pubmed.ncbi.nlm.nih.gov

Long-term observations of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Report by the Radiation Therapy Oncology Group - PubMed

This report details the patterns of tumor recurrence in two prospective randomized studies involving 551 patients with histologically proven unresectable or medically inoperable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Patients were treated according to two...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
50 Gy RT alone to LA-NSCLC wasn't as good as 60 Gy, but LC also wasn't 0%. I don't underdose things just to make the patient have fewer acute side effects, which I have seen. But when I'm bumping into the chiasm, I don't feel guilty modifying the PTV, making a PTV eval, or keeping the PTV and prioritizing the chiasm. It's all the same in the end as far as I can tell.
Click to expand...
"The high frequency of brain metastases suggests that, as in small cell carcinoma of the lung, elective irradiation of the brain may be necessary, if not to improve survival to enhance the quality of life of patients with adenocarcinoma and large cell carcinoma."

As side note, I remain a little surprised that PCI never became a thing in NSCLC.
 
Ray D. Ayshun said:
50 Gy RT alone to LA-NSCLC wasn't as good as 60 Gy, but LC also wasn't 0%. I don't underdose things just to make the patient have fewer acute side effects, which I have seen. But when I'm bumping into the chiasm, I don't feel guilty modifying the PTV, making a PTV eval, or keeping the PTV and prioritizing the chiasm. It's all the same in the end as far as I can tell.
Click to expand...
There are just so many moving parts to consider and we're rarely comparing apples to apples.

While two trials might have used the exact same targets and expansions, maybe they utilized 3DCRT and margin to block edge was different.

Maybe in other IMRT/VMAT trials, PTV editing was rampant and can't easily be noted on central review. If I do all my Stage III lungs with overlap structures, and you do all your lungs with PTV cropping, are we going to have the same outcomes?

What's an adequate minimum dose? MA20 got away with the 80% coverage. Maybe cropping PTV vs overlap structures doesn't matter when we're already exceeding minimum dose regardless.

I don't necessarily think overlap structures are superior to PTV cropping (or PTV_eval, which I also use). I honestly don't know, and I don't think anyone does, because PTV cropping is rampant and the world hasn't ended.

I do think computers are "dumb" and can only do what we tell them to do. In the mysterious MCO process, a cropped PTV adjacent to a critical OAR will spit out a different plan than an uncropped PTV with an overlap structure assigned a priority. Is the "difference" meaningful? I dunno. But if there are physicists in the jury at my malpractice trial, I know which strategy will win their hearts and minds.
 
PTV_Eval is the way to go, IMO. Similar to an optimization PTV. I would not take an eraser to a PTV. A crop structure, boolean operator, or something else to create a PTV_Eval, sure. This is different from differential expansions. Expanding 5mm everywhere in the brain but 2-3mm along chiasm reasonable if you're doing daily CBCT with rigid mask and therapists are lining up to chiasm/PTV interface.

Whether the overlap between true PTV and OAR PRV requires a separate structure for a minimum dose, IMO, depends on the size of that volume. Big volume? Yes would try to enforce minimum dose and avoid too sharp of fall-off in that area. Small volume? Not necessary and more burdensome for dosimetry and at plan review.
 
evilbooyaa said:
PTV_Eval is the way to go, IMO. Similar to an optimization PTV. I would not take an eraser to a PTV. A crop structure, boolean operator, or something else to create a PTV_Eval, sure. This is different from differential expansions. Expanding 5mm everywhere in the brain but 2-3mm along chiasm reasonable if you're doing daily CBCT with rigid mask and therapists are lining up to chiasm/PTV interface.

Whether the overlap between true PTV and OAR PRV requires a separate structure for a minimum dose, IMO, depends on the size of that volume. Big volume? Yes would try to enforce minimum dose and avoid too sharp of fall-off in that area. Small volume? Not necessary and more burdensome for dosimetry and at plan review.
Click to expand...
Preach.

I wonder if this level of nuance is taught much during residency. I suspect not. I know some programs do Dosimetry rotations, but I don't think that's the norm. Having residents do notes and contour is baked into the system because it makes the attending's job easier, but plan evaluation and review has to be incorporated with thoughtful intent.

"Thoughtful intent" is not a phrase I would use to describe most RadOnc MedEd, though.
 
Nrg nasopharynx protocol literally tells you you can make your PTV 0 as needed near critical structures
 
jondunn said:
Nrg nasopharynx protocol literally tells you you can make your PTV 0 as needed near critical structures
Click to expand...

OK so they're basically telling you to make a PTV_Eval. Multiple ways to skin the cat. I still wouldn't take an eraser tool to it and just freehand. Crop out of the OAR (or out of the PRV) by a certain distance from it if you want.

Lots of old school rad oncs who take erasers to PTVs out there... I don't have the hubris to think I'm as good as Nancy Lee at Nasopharynx...
 
Yet you say what you call it matters. My only point is it doesn’t matter. But to think it’s wrong to do it, when ultimately you’re going to be setting your patient up at that critical OAR interface doesn’t make sense to me.

Multiple ways to skin the cat is the exact point

In my experience, the people afraid to shave a PTV or don’t understand that ultimately all that matters is the iso dose lines is peak boomer.

I was taught in residency ‘never shave a PTV’ by some older attendings and once I knew enough realized how silly
That seemed, to me, and clearly many others
 
jondunn said:
In my experience, the people afraid to shave a PTV or don’t understand that ultimately all that matters is the iso dose lines is peak boomer.
Click to expand...
Except the isodose lines aren't real. For a 2-arc Stage III lung I currently have on beam (treating with VMAT):

The MU calcs prior to starting:
1650646679148.png


The portal dosimetry after starting:
1650646655640.png


The QA for the other arc is a little worse but within acceptable limits. I'm sure there's day-to-day variation, but to what degree is anyone's guess. Tolerance of gamma pass rates vary by institution, but current TG recommendation is that pass rates should be ≥95% using 3%/2mm tolerance and 10% threshold

The final treatment plan I approved look great. The isodose lines fell where I wanted them to fall. However, those isodose lines were born from an algorithm using voxels from the AVG sequence of a 4D CTSIM. In order for those to be "real":

Patient needs to be set up exactly as they were at time of sim
Breathing cycle/pattern needs to be the exact same at time of sim
Linac needs to spit out radiation precisely as the algorithm calculated
The radiation needs to interact with matter within the patient precisely as the algorithm calculated

The probability of all that happening simultaneously is very low, which is why the PTV margin exists. The volume within the PTV margin represents the probability that your CTV receives the prescribed dose. Shaving the PTV margin to make the treatment plan look better on review is only reducing the probability that your CTV receives the desired dose.

Again, is it clinically significant? Most of the time, probably not. But the isodose lines you're approving aren't real.
 
TheWallnerus said:
"The high frequency of brain metastases suggests that, as in small cell carcinoma of the lung, elective irradiation of the brain may be necessary, if not to improve survival to enhance the quality of life of patients with adenocarcinoma and large cell carcinoma."

As side note, I remain a little surprised that PCI never became a thing in NSCLC.
Click to expand...
RTOG 0214
Prophylactic Cranial Irradiation vs Observation in Patients With Locally Advanced Non–Small Cell Lung Cancer
 
elementaryschooleconomics said:
Except the isodose lines aren't real. For a 2-arc Stage III lung I currently have on beam (treating with VMAT):

The MU calcs prior to starting:
View attachment 353744

The portal dosimetry after starting:
View attachment 353743

The QA for the other arc is a little worse but within acceptable limits. I'm sure there's day-to-day variation, but to what degree is anyone's guess. Tolerance of gamma pass rates vary by institution, but current TG recommendation is that pass rates should be ≥95% using 3%/2mm tolerance and 10% threshold

The final treatment plan I approved look great. The isodose lines fell where I wanted them to fall. However, those isodose lines were born from an algorithm using voxels from the AVG sequence of a 4D CTSIM. In order for those to be "real":

Patient needs to be set up exactly as they were at time of sim
Breathing cycle/pattern needs to be the exact same at time of sim
Linac needs to spit out radiation precisely as the algorithm calculated
The radiation needs to interact with matter within the patient precisely as the algorithm calculated

The probability of all that happening simultaneously is very low, which is why the PTV margin exists. The volume within the PTV margin represents the probability that your CTV receives the prescribed dose. Shaving the PTV margin to make the treatment plan look better on review is only reducing the probability that your CTV receives the desired dose.

Again, is it clinically significant? Most of the time, probably not. But the isodose lines you're approving aren't real.
Click to expand...
Everything you said is true, but if there is going to be random error in the location of the 100% IDL, I would prefer that random error be centered around the target I want.
 
of course they aren't completely real and change on a day to day and second to second basis while the patient is moving a mm which is why ultimately it's sort of a 'dose cloud' that you are aligning the patient to, which is why the idea of you trying to force some dose into a pretend structure you made up so you can say your 'PTV_eval' is covered to a lower dose is less important, IMO

The feathering that is happening is what makes any of what we do work, which is why I also don’t believe in caring about a PTV MIN dose

I don't get the point you are making

Ultimately this is a philosophical difference/practice preference
 
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elementaryschooleconomics said:
Again, is it clinically significant? Most of the time, probably not. But the isodose lines you're approving aren't real.
Click to expand...
“A deviation of ≥7% in cumulative dose was noted in 7 of 36 (19%) for breast cancer patients. In prostate cancer patients, a ≥7% deviation was noted in 6 of 29 (21%) and 8 of 19 (42%) during initial and boost irradiation, respectively.”

Why did we not pursue real time in vivo dosimetry? Did people not care that real world doses were so off when checked? Whatever happened to Charles Scarantino?
 
I should add that if there is a big difference of what you are shaving then sure there’s a purpose to having a PTV eval to make sure it gets dose. I’m assuming this conversation is about shaving a few mm to get your isotropic 3-5 mm PTV out of a chiasm, which has no business getting tumoricidal doses unless it’s an optic Glioma or meningioma

Okay done. There was a Twitter thread about lung SBRT parameters people look at, interesting to see how different people view differnt things and what they give priority to
 
jondunn said:
Yet you say what you call it matters. My only point is it doesn’t matter. But to think it’s wrong to do it, when ultimately you’re going to be setting your patient up at that critical OAR interface doesn’t make sense to me.

Multiple ways to skin the cat is the exact point

In my experience, the people afraid to shave a PTV or don’t understand that ultimately all that matters is the iso dose lines is peak boomer.

I was taught in residency ‘never shave a PTV’ by some older attendings and once I knew enough realized how silly
That seemed, to me, and clearly many others
Click to expand...

Yes because words matter. PTV is something that has a definition. You may disagree with that definition but you will get confused and confuse others when you have discussions with them.

You unilaterally changing the definition of PTV (to PTV_Eval, or zPTV, or optimizing PTV) is wrong. You may not feel like it is, but it is.

Those who say never shave a PTV are technically (the best kind of) correct. You are shaving PTV_Eval, or zPTV, or whatever you want to call it. You apparently call it PTV. But that's not the definition of PTV anyone else has. And again, having differential expansions is OK because you're thinking about what you're aligning to. But, if you do your expansion and then using the eraser tool to your PTV, and adamantly say it's the PTV and not a PTV_Eval, I can't get on board with that.

I was going to say before I wrote this post that ESE was turning into Wallnerus... and I here I find myself shouting from the mountains of pedantry within Radiation Oncology.

gather one of us GIF by South Park


Transformation complete.
army smith GIF
 
evilbooyaa said:
Yes because words matter. PTV is something that has a definition. You may disagree with that definition but you will get confused and confuse others when you have discussions with them.

You unilaterally changing the definition of PTV (to PTV_Eval, or zPTV, or optimizing PTV) is wrong. You may not feel like it is, but it is.

Those who say never shave a PTV are technically (the best kind of) correct. You are shaving PTV_Eval, or zPTV, or whatever you want to call it. You apparently call it PTV. But that's not the definition of PTV anyone else has. And again, having differential expansions is OK because you're thinking about what you're aligning to. But, if you do your expansion and then using the eraser tool to your PTV, and adamantly say it's the PTV and not a PTV_Eval, I can't get on board with that.

I was going to say before I wrote this post that ESE was turning into Wallnerus... and I here I find myself shouting from the mountains of pedantry within Radiation Oncology.

gather one of us GIF by South Park


Transformation complete.
army smith GIF
Click to expand...
YES WARM YOURSELF BY THE FIRE...

Mr...Anderson...
 
TheWallnerus said:
“A deviation of ≥7% in cumulative dose was noted in 7 of 36 (19%) for breast cancer patients. In prostate cancer patients, a ≥7% deviation was noted in 6 of 29 (21%) and 8 of 19 (42%) during initial and boost irradiation, respectively.”

Why did we not pursue real time in vivo dosimetry? Did people not care that real world doses were so off when checked? Whatever happened to Charles Scarantino?
Click to expand...
Didn't he create a company? That went nowhere afaik...
 
TheWallnerus said:
“A deviation of ≥7% in cumulative dose was noted in 7 of 36 (19%) for breast cancer patients. In prostate cancer patients, a ≥7% deviation was noted in 6 of 29 (21%) and 8 of 19 (42%) during initial and boost irradiation, respectively.”

Why did we not pursue real time in vivo dosimetry? Did people not care that real world doses were so off when checked? Whatever happened to Charles Scarantino?
Click to expand...
Wasn’t 21st century oncology doing this with iMRT and essentially billing a daily OLSD (77331) for their dose checking algorithm. A google search comes up with so many false claims settlements against them that I can’t seem to find this.

Edit - found it —. United States Settles False Claims Act Allegations Against 21st Century Oncology for $34.7 Million
 
1650721551786.png

1650721574273.png

1650721598844.png


Several things to unpack here, but two immediately leap to mind:

1) I'm not sure what the abbreviation "HD" stands for. Does he mean HDR brachy? Am I just being dense? Regardless, while it's good (perhaps necessary) to be exposed to the uncommon cases and procedure-based treatments, I think we're past the point where we can stop pretending like doing a couple T&O (+/- interstitial) cases over the entire course of residency makes it OK for you to go out into the world and do it independently. For the uncommon-to-rare/high risk treatments requiring a level of procedural skill (so, most brachy that isn't skin or cylinder), we should be moving towards ACGME-accredited fellowships with separate board certification. Pediatrics should go that way as well. However, I have read papers in the Red Journal from literally 40 years ago calling for the exact same thing, and clearly nothing happened...so I guess we can continue pretending. Because "doing" 8 instead of 6 cervix cases over 4 years was definitely the missing link.

2) As always...you don't get to throw your opinion out into the universe on a public platform and request discourse only from certain individuals. That's not how any of this works. Because, to flesh out Ken's last Tweet:

"Here I am as faculty at a well-known institution with opinions on the classic/traditional side of academic RadOnc, on a platform (Twitter) with a razor-thin edge for any sort of debate devolving into chaos, and I am only going to engage with people who are not anonymous, knowing full well that dissenting opinions from traditional RadOnc on Twitter (or elsewhere) carries high personal/career risk for the person(s) dissenting, as this is a very small field where everyone knows everyone and it's very easy to blacklist people from seeking employment in an entire geographic region".

I don't think many of us are willing to openly debate the Elder RadOnc Faction and risk White Knighting/Radical Candor/"plz don't cancel me miscreants" editorials/etc.

Elder RadOncs are going to do what they want on whatever timeline they want until they retire at age 82, and the rest of us are just left here to languish and hope medical students seek gainful employment elsewhere.
 
KO is annoying but on this front I don't have a lot to criticize. These changes are good. We can argue all day about how there should be more changes, or that maybe the changes can't be enforced or that programs will find a way to skirt around them. but that doesn't change the fact that any change is better than no change.
 
jondunn said:
KO is annoying but on this front I don't have a lot to criticize. These changes are good. We can argue all day about how there should be more changes, or that maybe the changes can't be enforced or that programs will find a way to skirt around them. but that doesn't change the fact that any change is better than no change.
Click to expand...
Sure, I think the changes are "good". I remain very skeptical about enforcement. Of the programs that "shut down" in recent memory, I believe they were mostly internal/financial.

Cornell seems to be the only program "forcefully" shut down due to deficiencies. I remember hearing about/being warned about Cornell RadOnc like, 10-15 years before it happened. So while the changes sound good/a step in the right direction, for now this is all talk.

If standards are enforced, and there are consequences...I will be signing a different tune.
 
In regards to the 1.5:1 core faculty to resident ratio - this isn't going to hold. My current program is already planning on including attendings at satellites who we never work with and attendings who don't see patients (research/lab MDs) as "core faculty" to meet this requirement. Without this, our program would need to decrease resident spots but they wont allow that to happen.

These are all good ideas, but no one is going to enforce it. It's all talk at this point.
 
jondunn said:
KO is annoying but on this front I don't have a lot to criticize. These changes are good. We can argue all day about how there should be more changes, or that maybe the changes can't be enforced or that programs will find a way to skirt around them. but that doesn't change the fact that any change is better than no change.
Click to expand...
KO won't discuss or debate anything with you unless he knows who you are and where your institution is. Makes total sense. 🤡🤡 As usual
 
elementaryschooleconomics said:
View attachment 353767
View attachment 353768
View attachment 353769

Several things to unpack here, but two immediately leap to mind:

1) I'm not sure what the abbreviation "HD" stands for. Does he mean HDR brachy? Am I just being dense? Regardless, while it's good (perhaps necessary) to be exposed to the uncommon cases and procedure-based treatments, I think we're past the point where we can stop pretending like doing a couple T&O (+/- interstitial) cases over the entire course of residency makes it OK for you to go out into the world and do it independently. For the uncommon-to-rare/high risk treatments requiring a level of procedural skill (so, most brachy that isn't skin or cylinder), we should be moving towards ACGME-accredited fellowships with separate board certification. Pediatrics should go that way as well. However, I have read papers in the Red Journal from literally 40 years ago calling for the exact same thing, and clearly nothing happened...so I guess we can continue pretending. Because "doing" 8 instead of 6 cervix cases over 4 years was definitely the missing link.

2) As always...you don't get to throw your opinion out into the universe on a public platform and request discourse only from certain individuals. That's not how any of this works. Because, to flesh out Ken's last Tweet:

"Here I am as faculty at a well-known institution with opinions on the classic/traditional side of academic RadOnc, on a platform (Twitter) with a razor-thin edge for any sort of debate devolving into chaos, and I am only going to engage with people who are not anonymous, knowing full well that dissenting opinions from traditional RadOnc on Twitter (or elsewhere) carries high personal/career risk for the person(s) dissenting, as this is a very small field where everyone knows everyone and it's very easy to blacklist people from seeking employment in an entire geographic region".

I don't think many of us are willing to openly debate the Elder RadOnc Faction and risk White Knighting/Radical Candor/"plz don't cancel me miscreants" editorials/etc.

Elder RadOncs are going to do what they want on whatever timeline they want until they retire at age 82, and the rest of us are just left here to languish and hope medical students seek gainful employment elsewhere.
Click to expand...
I think HD is Hodgkins disease?
 
medgator said:
KO won't discuss or debate anything with you unless he knows who you are and where your institution is. Makes total sense. 🤡🤡 As usual
Click to expand...
look if I was him I wouldn't engage with you or RickyScott's twitter accounts either, to be fair.
 
I’ll restate what I’ve said before on these changes. The changes will make it more difficult to open up new programs and for weak programs to expand, which of course is good. I don’t really see any current programs folding or cutting residents because of them.
 
I’m regards to KO, I will say that I’ve had a couple patients see him for second opinion and unlike the majority of academics he reassured the patient that our plan was what he would do rather than trying to steal them (looking at you mdacc, mskcc )
 
RadRadRad said:
I’m regards to KO, I will say that I’ve had a couple patients see him for second opinion and unlike the majority of academics he reassured the patient that our plan was what he would do rather than trying to steal them (looking at you mdacc, mskcc )
Click to expand...
Just in the interest of being nice on the internet (a rarity), I will say that I've had very positive experiences with MSKCC when my patients have seen them, with no attempts at theft (though I haven't had a case where our opinions were drastically different).

I do wish they'd steal my prostate re-irradiation cases though. Come on guys, please? Please?
 
Radiation is as good as lung surgery? Such a hopeless stand to die for
 
For small peripheral t1s maybe. Segmentectomy had better os, presumably bc more lung removed is worse. Segmentectomy had lr on par with sbrt, and sbrt is even less surgery. The thoracic surgeon on Twitter suggested surgery is superior given the ability to stage better, which is why I wonder how many of these patients (tiny peripheral tumors), properly staged, had n+ disease. Typically, if the pets negative in this population, it's an extremely high npv, ~95%, generally obviating the need for bronch. Is it hard to think that even better imaging, if that's even necessary, could obviate the need for surgery in this population?
 
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