Rad Onc Twitter

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Lamount said:
Also… none of us are <30 and our brains had the benefit of developing prior to the advent of social media.
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Aint that the truth.

There are papers written about oncology social media, it’s literally an academic thing. Lots of societies do the champion slate and I’m not sure it’s job hunt related.

I find it sad that Oncology social media has become a career. It doesn’t seem like a place for real discussion anymore and it seems like that’s a driving factor. Too risky to give a real opinion for so many.

Still has upside for me, but way less than even 2 years ago.
 
communitydoc13 said:
In almost any professional circumstance, giving a controversial opinion on social media is a mistake unless you are already remarkably established.
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I recommend that you do it anonymously.

Though please try not to cyberbully the "leaders" of the American Board of Radiology for failing half a residency class with no repercussions or the president of ASTRO will scold me. 🙄
 
1724059317120.png

Feels a bit like...

1724059357938.png




- Ooops, I dropped a seed.
- Where? On the floor?
- No, in the duodenum.
 
Gfunk6 said:
If only someone developed some way to physically separate the duodenum and pancreatic head . . . like a spacer. We could call it Duodenal perfOAR
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Surgical spacer placement for proton radiotherapy in locally advanced pancreatic body and tail cancers: initial clinical results - PMC

Particle radiotherapy has increasingly gained acceptance for locally advanced pancreatic cancers owing to superior tumor conformity and dosimetry compared to conventional photon radiotherapy. However, the close proximity of the pancreas to the ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Sorry The Hangover GIF
 
Colin Champ is the current chair of radiation oncology?
 
Chartreuse Wombat said:
I think it was red wine. Natch
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It was an untouched glass of red wine, which I intended to reward myself with after finishing.

Not sure whether I got more **** for treating that many brain mets w/ SRS or that virgin glass of wine.

In any case, the patient lasted 2.5 more years, free from having undergone whole brain and a good friend. He was one of our first patients to show response to Boswellia and helped launch the trend.

They passed while I was deployed in Iraq and I was sad to have missed their funeral.
 
fiji128 said:
View attachment 392179
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Maybe he can shut down, the extra unnecessary residency training program in Western PA. Long shot I know. Maybe at least trim spots

But it's good to see some new blood getting into leadership positions finally in this specialty
 
medgator said:
Maybe he can shut down, the extra unnecessary residency training program in Western PA. Long shot I know. Maybe at least trim spots

But it's good to see some new blood getting into leadership positions finally in this specialty
Click to expand...

Last academic year (2023 to 2024) Allegheny had 2 enrolled residents for 4 total positions. This year (2024 to 2025) they have 3 enrolled residents. I doubt anyone gets hired as a chair with a mandate or even the authority to shut down a training program.
 
fiji128 said:
Last academic year (2023 to 2024) Allegheny had 2 enrolled residents for 4 total positions. This year (2024 to 2025) they have 3 enrolled residents. I doubt anyone gets hired as a chair with a mandate or even the authority to shut down a training program.
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Journey of a thousand miles begins with a single step. Lets not forgot the bloodbath thread on this forum and where he came from
 
fiji128 said:
Last academic year (2023 to 2024) Allegheny had 2 enrolled residents for 4 total positions. This year (2024 to 2025) they have 3 enrolled residents. I doubt anyone gets hired as a chair with a mandate or even the authority to shut down a training program.
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I’m sure he has the authority
 
emt409 said:
Not sure whether I got more **** for treating that many brain mets w/ SRS or that virgin glass of wine.
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What type of wine was it?

We treated 65 brain mets the other day with SRS, and we do stuff like that not too infrequently. Haters gonna hate.

Thank you for your service.
 
Neuronix said:
What type of wine was it?

We treated 65 brain mets the other day with SRS, and we do stuff like that not too infrequently. Haters gonna hate.
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seriously.
I treated 9 small brain mets last week for a patient with new brain mets. I did a short interval MR (4 wks) at time of planning, no significant change and no new lesions.
Multiple staff asked me if i felt whole brain was necessary...
 
emt409 said:
It was an untouched glass of red wine, which I intended to reward myself with after finishing.

Not sure whether I got more **** for treating that many brain mets w/ SRS or that virgin glass of wine.

In any case, the patient lasted 2.5 more years, free from having undergone whole brain and a good friend. He was one of our first patients to show response to Boswellia and helped launch the trend.

They passed while I was deployed in Iraq and I was sad to have missed their funeral.
Click to expand...

Optics are unfortunately more important than the reality of a situation. But all of us make mistakes from time to time, all we can do is learn from them. Welcome back!
 
radoncftw said:
seriously.
I treated 9 small brain mets last week for a patient with new brain mets. I did a short interval MR (4 wks) at time of planning, no significant change and no new lesions.
Multiple staff asked me if i felt whole brain was necessary...
Click to expand...

I've been an attending since 2016. When I was in residency, I had attendings telling me that SRS for any number of brain mets was dumb because "they're just going to die anyway" (one particularly vocal attending ran a related ASTRO committee). Certainly more than four was considered crazy, and many thought these patients should all get WBRT on top of the SRS (NCCTG trial came along around that time to dispel that one).

I fought other attendings in my institution back then to treat even five brain mets with SRS alone. When I first started, I had a breast cancer patient who had 10 small mets that I did GK. Insurance and other attendings thought I was crazy. She never developed a new brain met, went disease free for 6 years, and eventually passed away this year (8 years later) of liver metastases.

I had to fight insurance once in a protracted battle that I eventually won because a patient with esophageal cancer and no systemic disease had a cerebellar met then developed another one three months later and they wanted WBRT. That patient never developed another met brain or otherwise after that second SRS and is still NED 7 years later.

So many battles over the years... Oh boy they thought I was crazy here when I told them that SCLC PCI was useless after the Japanese trial. We've had plenty of people even here on SDN disagree with me about this. We're one of the top accruers on MAVERICK with my heartfelt hope that it will kill PCI for good. I fought like hell to start doing proton CSI for LMD in a public battle with my chair. Nobody did re-irradiation to the spine at any dose level, and now I'm doing SBRT on SBRT and third course re-re-irradiations.

I like neuro rad onc because it moves fast, but it creates a lot of controversy sometimes.
 
Ray D. Ayshun said:
I thought the main issue with the contouring post wasn't the number of mets or wine, but the doing it in public. Guess I'm misremembering.
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We can't contour in public? When I'm in the audience at ASTRO it seems like half the audience is contouring.
 
Neuronix said:
We can't contour in public? When I'm in the audience at ASTRO it seems like half the audience is contouring.
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I suppose you can do whatever you want. Guess I wouldn't want my wife's case contoured in public, so, I don't contour any case in public. If that Twitter post did show that happening and the patient felt like looking into it, would be a pretty straightforward HIPAA issue. AKA, a fireable offense.
 
Ray D. Ayshun said:
I suppose you can do whatever you want. Guess I wouldn't want my wife's case contoured in public, so, I don't contour any case in public. If that Twitter post did show that happening and the patient felt like looking into it, would be a pretty straightforward HIPAA issue.
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Would have to have PHI in that screenshot. And it didn’t have any.
 
TheWallnerus said:
Would have to have PHI in that screenshot. And it didn’t have any.
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Not sure about that. There is a picture of PHI being visible on a bar table. It would easily support the idea that it's visible to bar patrons in a public location. Essentially, it's a picture of a HIPAA violation.
 
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radoncftw said:
seriously.
I treated 9 small brain mets last week for a patient with new brain mets. I did a short interval MR (4 wks) at time of planning, no significant change and no new lesions.
Multiple staff asked me if i felt whole brain was necessary...
Click to expand...
Biologically, in most cases, much of the metastatic spread happens at once (before the primary is treated)... so it is just a question of whether there are more subclincial mets -but it is likely that, in many cases, there isn't. It's hard to know for any given patient, but I am always a fan of giving patients the benefit of the doubt and assuming the disease is controllable -you usually don't lose anything by being a little more aggressive so long as its safe.
 
Neuronix said:
I had attendings telling me that SRS for any number of brain mets was dumb because "they're just going to die anyway"
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This is the most infuriating line of logic and should have been abandoned circa 2008.

The attendings should have been telling you..."avoid WBRT at all costs, because they are going to die anyway".

I reserve whole brain for rare circumstances. It often facilitates death IMO.

There may be issues with cost/benefit for some of these CNS interventions in systemic patients. That being said, the cost per month for novel systemic therapy is uniformly absurd.

Neuronix said:
I told them that SCLC PCI was useless after the Japanese trial
Click to expand...
I'm assuming this references extensive stage disease only? Are you not giving PCI for young limited stage patients presently?

Neuronix said:
I fought like hell to start doing proton CSI for LMD in a public battle with my chair.
Click to expand...
Well....usually a crazy thing to do.
 
rymd said:
I was guilty of this. And now I won't even consider offering it unless they're randomized to PCI on MAVERICK...
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There is a difference between SCLC LD and SCLC ED.
PCI is not useless.
 
communitydoc13 said:
I'm assuming this references extensive stage disease only? Are you not giving PCI for young limited stage patients presently?
Click to expand...

Short answer: No.

Long answer: Why would I? In what trial was addition of PCI positive in LS-SCLC? I'm happy to discuss data, but using data before the adoption of MRIs is suspect and using meta-analyses of small and old studies with varying RT techniques is doubly suspect.

communitydoc13 said:
Well....usually a crazy thing to do.
Click to expand...

Until there was an overall survival benefit in a randomized trial. Anecdotally, I have a good percentage of patients with LMD who live way longer than expected, and I am sure it's the proton CSI.
 
Neuronix said:
Short answer: No.

Long answer: Why would I? In what trial was addition of PCI positive in LS-SCLC? I'm happy to discuss data, but using data before the adoption of MRIs is suspect and using meta-analyses of small and old studies with varying RT techniques is doubly suspect.



Until there was an overall survival benefit in a randomized trial. Anecdotally, I have a good percentage of patients with LMD who live way longer than expected, and I am sure it's the proton CSI.
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That proton csi vs photon involved field trial was an interesting one. Can’t do proton csi up here, best we can do is vmat which is still good, but it’s hard to say how much the marrow toxicity adds up compared to a proton plan. This is a situation I can absolutely see protons having an edge for reducing toxicity in a sick pt population.
 
thesauce said:
I’m sure he has the authority
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Discussed on SDN in the past. No RO chair has authority to shut down a smallish program. It’s the biggest local supplier of labor and thus profits on the professional side. Specifically, AGH went as far as sponsoring a visa for an FMG recently, in order to keep their program from disappearing - success
 
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communitydoc13 said:
This is the most infuriating line of logic and should have been abandoned circa 2008.

The attendings should have been telling you..."avoid WBRT at all costs, because they are going to die anyway".

I reserve whole brain for rare circumstances. It often facilitates death IMO.
Click to expand...
Seems a bit over the top no? Esp now with HA wbrt
 
taserlaser said:
That proton csi vs photon involved field trial was an interesting one. Can’t do proton csi up here, best we can do is vmat which is still good, but it’s hard to say how much the marrow toxicity adds up compared to a proton plan. This is a situation I can absolutely see protons having an edge for reducing toxicity in a sick pt population.
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Bone marrow toxicity is very likely higher with photon CSI vs. proton CSI.

- Does that mean that photon CSI is not feasible in most patients with LMD? Questionable.
- Does that mean that patients with proton CSI will be able to undergo more intensive systemic treatment than those with photon CSI? Perhaps.
- Will the ability to receive more cytotoxic systemic treatment enhance the survival of patients with LMD? Questionable.
 
Palex80 said:
Bone marrow toxicity is very likely higher with photon CSI vs. proton CSI.

- Does that mean that photon CSI is not feasible in most patients with LMD? Questionable.
- Does that mean that patients with proton CSI will be able to undergo more intensive systemic treatment than those with photon CSI? Perhaps.
- Will the ability to receive more cytotoxic systemic treatment enhance the survival of patients with LMD? Questionable.
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So many questions! The ones you pose are right on the nose. There has been a small shift to using more vmat csi in the LMD patients here. Some hypofrac. Not sure if we have had enough pts yet though to do a good audit of our outcomes. Anecdotally, my last pt I treated this way a month ago had an early symptomatic response which we were happy about. But the marrow toxicity had yet to drop :/

This image is quite something, and this is just treating the thorax x.com
 
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seper said:
Discussed on SDN in the past. No RO chair has authority to shut down a smallish program. It’s the biggest local supplier of labor and thus profits on the professional side. Specifically, AGH went as far as sponsoring a visa for an FMG recently, in order to keep their program from disappearing - success
Click to expand...

Whether they can or will are 2 different things. I know of at least 1 program that shut down because the chair said so
 
Neuronix said:
What type of wine was it?

We treated 65 brain mets the other day with SRS, and we do stuff like that not too infrequently. Haters gonna hate.

Thank you for your service.
Click to expand...

A joe phelps Insignia I think.....

Props to you on using SRS like it's supposed to be. Unbelievable it's 2024 and we still have ppl whole braining a handful of mets.
 
Neuronix said:
I've been an attending since 2016. When I was in residency, I had attendings telling me that SRS for any number of brain mets was dumb because "they're just going to die anyway" (one particularly vocal attending ran a related ASTRO committee). Certainly more than four was considered crazy, and many thought these patients should all get WBRT on top of the SRS (NCCTG trial came along around that time to dispel that one).

I fought other attendings in my institution back then to treat even five brain mets with SRS alone. When I first started, I had a breast cancer patient who had 10 small mets that I did GK. Insurance and other attendings thought I was crazy. She never developed a new brain met, went disease free for 6 years, and eventually passed away this year (8 years later) of liver metastases.

I had to fight insurance once in a protracted battle that I eventually won because a patient with esophageal cancer and no systemic disease had a cerebellar met then developed another one three months later and they wanted WBRT. That patient never developed another met brain or otherwise after that second SRS and is still NED 7 years later.

So many battles over the years... Oh boy they thought I was crazy here when I told them that SCLC PCI was useless after the Japanese trial. We've had plenty of people even here on SDN disagree with me about this. We're one of the top accruers on MAVERICK with my heartfelt hope that it will kill PCI for good. I fought like hell to start doing proton CSI for LMD in a public battle with my chair. Nobody did re-irradiation to the spine at any dose level, and now I'm doing SBRT on SBRT and third course re-re-irradiations.

I like neuro rad onc because it moves fast, but it creates a lot of controversy sometimes.
Click to expand...
In your practice, does WBRT + HA have a role?
 
emt409 said:
A joe phelps Insignia I think.....

Props to you on using SRS like it's supposed to be. Unbelievable it's 2024 and we still have ppl whole braining a handful of mets.
Click to expand...
Sorry not sorry. Sclc with 10+ Mets? Nope

Maybe it's easier when you are carrying 10-15 CNS pts at an academic mothership I guess when these pts invariably relapse. Dealing with one now over the last several months.

Never heard of HA-WBRT?
 
Radonky said:
In your practice, does WBRT + HA have a role?
Click to expand...

Sure. Over 15 mets we always consider whether it would be better to do HA-WBRT.

Below 15 it's less likely unless the patient can't keep coming back or doesn't want to come back for SRS.

I always used to hear that WBRT was better for patients with poor prognosis, but a 1-5 fraction zap of SRS for palliation is better than 10 fractions for a hospitalized patient you'd like to get to discharge or an otherwise poor prognosis patient.

Also, if it's looking like lepto or might become lepto, I'd like to hold the WBRT for the CSI.

Our practice started out with these 15+ met cases only in patients who had prior WBRT and progressed, but it worked so well we started doing it even in patients without WBRT. Exactly which patients deserve SRS vs WBRT with large numbers of Mets is still something we're all debating both here and internationally. CE.7 will help with this question.
 
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