Rad Onc Twitter

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RealSimulD said:
Why would you not include PTV?

ICRU is very, very hard for people.

Of course don’t add CTV, you’re not treating for microscopic disease. But no PTV? That’s why for practical stuff, just read Beriwal’s answer and move on.
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Totally agree. For these patients, who usually do not have long-term survival, GTV plus a PTV margin would suffice for palliation.

I also agree, many awesome contributors on TheMedNet, including Beriwal. Straightforward and to the point. Yours are pretty good too. 😉
 
RealSimulD said:
I gotta say, I hate quad shot (not The Quad Shot). What a pain in the butt- multiple cycles, BID. Not my jam.
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I'm actually a big fan of QS. Used it a lot in training for H&N cancer pt's in which pt couldn't tolerate definitive CRT/RT or had metastatic disease. Was amazing how little side effects I actually saw. Definitely saw value of QS for high QoL. Also worked quite well for HUGE metastatic melanoma lesions too (typically get 50% size reduction). But yes, cumbersome with treatment logistics.
 
RealSimulD said:
I gotta say, I hate quad shot (not The Quad Shot). What a pain in the butt- multiple cycles, BID. Not my jam.
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I have found my feelings toward it have varied based on where I'm practicing.

Giant academic center, downtown, parking garage 20 minutes from department, blah blah - almost never used.

Community setting, non-urban, parking lot 10 feet from entrance? Use it all the time.

I like it for those borderline KPS elderly H&N cases, where they'd probably benefit from something a little stronger than the 1/5/10 fraction palliative regimens. Specifically because you don't HAVE to give multiple cycles. So, I do one two-day cycle, and tentatively schedule follow-up, if they want. If they can make it, great, if not, well, a single cycle is often adequate palliation for someone who can't come back.
 
elementaryschooleconomics said:
I have found my feelings toward it have varied based on where I'm practicing.

Giant academic center, downtown, parking garage 20 minutes from department, blah blah - almost never used.

Community setting, non-urban, parking lot 10 feet from entrance? Use it all the time.

I like it for those borderline KPS elderly H&N cases, where they'd probably benefit from something a little stronger than the 1/5/10 fraction palliative regimens. Specifically because you don't HAVE to give multiple cycles. So, I do one two-day cycle, and tentatively schedule follow-up, if they want. If they can make it, great, if not, well, a single cycle is often adequate palliation for someone who can't come back.
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For someone in really bad shape, typically use 8 gy x 2; otherwise try 250 x20. All of my 8 gy x 2 have gone on to hospice w/out fu.
 
Might get bumped to another thread (palliative h&n among the toughest to get right), but what about symptomatic local recurrence (reirradiation setting, BOT) with low volume mets. Symptomatic on immunotherapy salvage (bleeding). Good KPS.

Go with quadshot for early symptomatic relief (can do 3D to start next day and convert to IMRT)?

Single fraction of 3-4Gy with 3D then try to semi SBRT it to 30-40 Gy in 4-5 additional fractions)?

Moderate hypo with tight margins all the way through> (2.5-3 Gy/fxn to 40-50 Gy)?
 
communitydoc13 said:
Might get bumped to another thread (palliative h&n among the toughest to get right), but what about symptomatic local recurrence (reirradiation setting, BOT) with low volume mets. Symptomatic on immunotherapy salvage (bleeding). Good KPS.

Go with quadshot for early symptomatic relief (can do 3D to start next day and convert to IMRT)?

Single fraction of 3-4Gy with 3D then try to semi SBRT it to 30-40 Gy in 4-5 additional fractions)?

Moderate hypo with tight margins all the way through> (2.5-3 Gy/fxn to 40-50 Gy)?
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medgator said:
Yeah...i prefer 40/15 or 50/20 unless terrible shape, at which point it usually is just hospice
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I totally agree re: thread dedicated to this.

I think all of these regimens have a time and a place depending on the patient. There have been times I preferred quadshot over 15 or 20 fractions and vice versa, or I've just gone with 8/1 or 20/5.

I also like 0/7/21, which I've used because of logistics (neither BID nor daily).

I haven't used 17//2 in head and neck yet, but love it for lung.

0/7/21 is my palliative H&N "semi SBRT" regimen, you can get beautiful dosimetry with properly designed DCAs (and insurance isn't a battle if you do that).
 
I've been pretty impressed with Quadshot since being on my own, despise my initial resistance to the logistics. I've found it more useful than 50/20 for my personal situations so far. Will continue to fine tune, as palliative H&N or H&N in general with older patients is a very fine line.
 
SubserviantToABR said:
Another reason why Drew Moghanaki is trash:
View attachment 354130
What margins (CTV and PTV) do you use for palliation when using Quad Shot regimen?

Why can't he answer a question straight? This is why he is a complete joke, especially on Twitter with thoracic surgeons. Probably was drinking too much when he was answering this question.

That's the post. Thanks.
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"Months turned into years" then "at the 18 month follow-up" "That's the story. Thanks."
So there is no plurality of years there.
This is the worst campfire story I have ever heard. Thanks.

Stream of consciousness nonsense. I met Drew once. He was rude, arrogant, and miserable.

Which makes this post hilarious, coming from such a famously miserable person..

 
Moonbeams said:
"Months turned into years" then "at the 18 month follow-up" "That's the story. Thanks."
So there is no plurality of years there.
This is the worst campfire story I have ever heard. Thanks.

Stream of consciousness nonsense. I met Drew once. He was rude, arrogant, and miserable.

Which makes this post hilarious, coming from such a famously miserable person..

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His original Post made me think of this speech
1651502199178.png
 
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Moonbeams said:
"Months turned into years" then "at the 18 month follow-up" "That's the story. Thanks."
So there is no plurality of years there.
This is the worst campfire story I have ever heard. Thanks.

Stream of consciousness nonsense. I met Drew once. He was rude, arrogant, and miserable.

Which makes this post hilarious, coming from such a famously miserable person..

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If months turned into years, he may have misjudged original condition of the patient and should have used a longer fractionation schedule. For a variety of reasons, marginal misses are very uncommon in head and neck.
 
RickyScott said:
If months turned into years, he may have misjudged original condition of the patient and should have used a longer fractionation schedule. For a variety of reasons, marginal misses are very uncommon in head and neck.
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He also seems to be confused between the nature of palliative and definitive radiation.
We don't normally act surprised and write a soliloquy when a patient develops progressive tumor 18 months later in an area treated with palliative intent. The success of palliative radiotherapy is not determined by whether there is locally progressive tumor 18 months after treatment. The good news is I hear that there are palliative RT fellowships out there where he could go to hone his skills.
 
RickyScott said:
If months turned into years, he may have misjudged original condition of the patient and should have used a longer fractionation schedule. For a variety of reasons, marginal misses are very uncommon in head and neck.
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This wasn’t just a marginal miss by his description, if by “rim” he means a circular thing

Some sort of perfectly circumferential, uniformly 360 degree miss?

The most beautiful miss of all time; he had to kill the tumor except for a few negative millimeters on its planar edges… that takes skill
 
TheWallnerus said:
This wasn’t just a marginal miss by his description, if by “rim” he means a circular thing

Some sort of perfectly circumferential, uniformly 360 degree miss?

The most beautiful miss of all time; he had to kill the tumor except for a few negative millimeters on its planar edges… that takes skill
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It was an event horizonal miss. The center of the original tumor was so dense it pulled every photon inward and unfortunately there was cancer growing circumferentially at the boundary.
 
TheWallnerus said:
This wasn’t just a marginal miss by his description, if by “rim” he means a circular thing

Some sort of perfectly circumferential, uniformly 360 degree miss?

The most beautiful miss of all time; he had to kill the tumor except for a few negative millimeters on its planar edges… that takes skill
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Maybe he doesn’t recognize a central necrotic recurrence with rolled edges.
 
DM and ET both give me GERD. DM is considered a joke by all thoracic surgeons and probably 25-50% of rad oncs. ET seems to use social media (or at least twitter) SOLELY to post **** that would put him at grounds for dismissal with cause on social media (contouring while drinking, breaking HIPAA by announcing a former patient of his, while simultaneously getting that person in trouble with HIPAA for sending unsecured results through private text).

Just a buncha morans.
 
jondunn said:
actually - @RealSimulD - any chance you all can get Sue Yom on the Accelerators?
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I don’t think she likes me very much.

Astro is not supportive of pretty much anything associated with me and never has been, though ARRO has.

It would have to be something meaningful. I think the journal system is completely broken, I think the RJ has such an opportunity to be better but chooses the worn path rather than new ideas. I say this phrase: “ASTRO / Red Journal says they want diverse voices, but they want them all to sing the same song.” This is the tragedy here - we have a “loyal opposition” that is begging to be involved but gets shunned. If we had her on, I’d want to talk about 1) explaining the shift to becoming a social science journal 2) fees 3) allowing for true diversity of opinions 4) improving the quality of what is published 5) increasing community engagement, even if (especially if) they disagree with party line.

I won’t hold my breath
 
evilbooyaa said:
DM and ET both give me GERD. DM is considered a joke by all thoracic surgeons and probably 25-50% of rad oncs. ET seems to use social media (or at least twitter) SOLELY to post **** that would put him at grounds for dismissal with cause on social media (contouring while drinking, breaking HIPAA by announcing a former patient of his, while simultaneously getting that person in trouble with HIPAA for sending unsecured results through private text).

Just a buncha morans.
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ET has been part of some good research, DM not so much.
 
I mean DM is doing VALOR, so I give him credit. only thing is he's made himself such a clown that people are going to think he rigged the results, like certain politicians
 
RickyScott said:
ET has been part of some good research, DM not so much.
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I suppose ET has been a (small) PART of some good research given the Fiveash-lead VMAT (Rapid and now HyperArc) VMAT for SRS planning of multiple mets with iso, but he's almost always been a bridesmaid, rarely the bride (one 1st author pub back in 2014, everything else is middle author)... I'm happy for him he's parlayed it into a CNS job at OSU and he definitely seems knowledgable about SRS in general given his focus on it during residency, but not sure if 'research' is his strongest suit.

DM for all the grief he causes, is still the PI of the VALOR trial, isn't he?
*Find out why Thoracic Surgeons HATE DM*
Yes a fair portion of his other research life is served as a middle author on VA stuff including the VA database work, but he does have first and senior author pubs.
 
a modality to treat a disease that's probably most common amongst people who, in addition to living in denial, live way out in the sticks and would never travel far to a proton center, and couldn't afford to in the first place. Fortunately for this exact group in the sticks of MN, there is one. It probably is better, but my one or two yearly inflammatory breast patients don't strike my as folks who would go to anyone but me, if that.
 
jondunn said:
The word is case CLOSED - protons seen as SOC per the thought leaders


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4/19 patients were right sided

4/19 patients had rib fractures. I think I’ve seen 1 rib fracture in my entire career for breast ca. it’s like we are back in the cobalt era

1/19 had fistula requiring coverage with flap. Don’t think I’ve ever seen this

Most patients had only grade 1 dermatitis? Hard to believe
 
RadRadRad said:
4/19 patients were right sided

4/19 patients had rib fractures. I think I’ve seen 1 rib fracture in my entire career for breast ca. it’s like we are back in the cobalt era

1/19 had fistula requiring coverage with flap. Don’t think I’ve ever seen this

Most patients had only grade 1 dermatitis? Hard to believe
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20% rib fracture rate after only 24 months of median follow up? That’s going to continue to go up with time.

A big concern I have with left sided protons is the same high RBE distal edge that’s causing the rib fractures could be dumping high RBE dose on the LAD if you’re not thoughtful with your planning.
 
grenz said:
20% rib fracture rate after only 24 months of median follow up? That’s going to continue to go up with time.

A big concern I have with left sided protons is the same high RBE distal edge that’s causing the rib fractures could be dumping high RBE dose on the LAD if you’re not thoughtful with your planning.
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Or brainstem radionecrosis for medulloblastoma/ependymoma…oh wait that already happened and study had to be paused
 
RadRadRad said:
Or brainstem radionecrosis for medulloblastoma/ependymoma…oh wait that already happened and study had to be paused
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The list could really go on because so many sites use just a few beams. If proton arc therapy becomes a thing, that should fix the problem, but that’s far from sure.
 
grenz said:
The list could really go on because so many sites use just a few beams. If proton arc therapy becomes a thing, that should fix the problem, but that’s far from sure.
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For sure
I believe that Peds protocol was amended to use multiple angles all with non overlapping distal edges
 
jondunn said:
The word is case CLOSED - protons seen as SOC per the thought leaders


Click to expand...


Getting dangerously close to that 1 patient: 1 author ratio and for a paper in Green Journal.... 19:14. 21% Rib fracture in IBC (or really any breast cancer treatment) is considered OK ('toxicity is favorable, modest increase in rib fracture' per the highlights)? Why would anyone use a therapy that has not shown to be oncologically more effective when it is clearly more toxic? And this is with IMPT. The cadillac of proton therapy. In contemporary patients treated within the past 6 years. Way better than passive scattering, which is like the beat up crown-vic of proton therapy. And still. Still has 21% of rib fracture. Is this considered advancing the field? Is the conclusion not "Oh, man, lots of rib fractures, maybe this isn't the best idea"? If not, why not?
 
I tell you (as a non proton user), they don’t know where that proton (biologically effective) dose is going and the type of tissue matters a lot. This is physics/radbio.

Great modality for en face Retinoblastoma treatment.
 
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