RO may have a role in this COVID crisis, but we need a clinical trial.....

[scarbrtj]

COVID-19 pneumonia treated with ultra-low doses of radiotherapy (ULTRA-COVID study): a single institution report of two cases

---

Members don't see this ad.

 

[Palex80]

COVID-19 pneumonia treated with ultra-low doses of radiotherapy (ULTRA-COVID study): a single institution report of two cases

Rather striking...

It took them 5 months to accept it? This is a 2 case report!!!

 

[Mandelin Rain]

I will go on believing that we could have saved literally dozens of thousands of lives in America and likely hundreds of thousands worldwide had we been a bit more forward thinking and aggressive in optimizing low dose XRT early in the pandemic.

Huge failure for our specialty.

EDIT: I understand this belief isn't rooted in overwhelming evidence.

 

[elementaryschooleconomics]

Rather striking...
View attachment 329026

It took them 5 months to accept it? This is a 2 case report!!!

Ralph and David Kirsch probably kept calling and texting the editors with "plz don't publish this, it expands the indications for XRT"

 

[scarbrtj]

I will go on believing that we could have saved literally dozens of thousands of lives in America and likely hundreds of thousands worldwide had we been a bit more forward thinking and aggressive in optimizing low dose XRT early in the pandemic.

Huge failure for our specialty.

EDIT: I understand this belief isn't rooted in overwhelming evidence.

That there's an even 1% chance your theory is true is quite sad... because were it true, this treatment would have the highest reward/risk ratio of any radiotherapeutic treatment ever devised or theorized in the history of mankind

 

[Ray D. Ayshun]

Someone should do a retrospective review and see if the intubated patients who got the obligatory daily bedside CXR to ensure proper ET tube placement did better than those who only got weekly films.

 

[scarbrtj]

Someone should do a retrospective review and see if the intubated patients who got the obligatory daily bedside CXR to ensure proper ET tube placement did better than those who only got weekly films.

Yeah but that's like, what, a tenth of a centigray a day versus 0.1 cGy per week

 

[Mandelin Rain]

Yeah but that's like, what, a tenth of a centigray a day versus 0.1 cGy per week

"Obviously, either intervention yields a 30% treatment induced death rate at 5-years."
-Ralph Weichselbaum, probably

 

[RadOncDoc21]

Yeah but that's like, what, a tenth of a centigray a day versus 0.1 cGy per week

All radiation matters!

 

[Mandelin Rain]

That there's an even 1% chance your theory is true is quite sad... because were it true, this treatment would have the highest reward/risk ratio of any radiotherapeutic treatment ever devised or theorized in the history of mankind

Maybe a close second to vaccination, but yes.

Most, (even here) actively eschewed the possibility of it. If it didn't work? The patient dies of COVID, anyway. If it did? You're the darlings of the country/world. You save thousands and thousands of lives. Acutely. I guarantee APM would be gone for good.

 

[scarbrtj]

"Obviously, either intervention yields a 30% death rate at 5-years."
-Ralph Weichselbaum, probably

I am not a big fan of dragging but Ralph and David should be dragged so so hard for such a silly, wasteful, yelling-fire-in-a-crowded-theater response to this. It hurt my heart!

 

[evilbooyaa]

I will go on believing that we could have saved literally dozens of thousands of lives in America and likely hundreds of thousands worldwide had we been a bit more forward thinking and aggressive in optimizing low dose XRT early in the pandemic.

Huge failure for our specialty.

EDIT: I understand this belief isn't rooted in overwhelming evidence.

C'mon man. This has less evidence than HCQ does in terms of whether it actually helps. I'm not saying that it doesn't help, but just saying we have no idea.

Rather striking...
View attachment 329026

It took them 5 months to accept it? This is a 2 case report!!!

Very slow on the uptake for anything COVID related. This is where pre-print servers should've played a larger role.

 

[Palex80]

Someone should do a retrospective review and see if the intubated patients who got the obligatory daily bedside CXR to ensure proper ET tube placement did better than those who only got weekly films.

Maybe fractionation plays a role?

 

[cancer_doc]

A small (target n=22) prospective randomize trial from a Switzerland team (1Gy LD-RT vs sham radiation) just finished accrual about 1 month ago. Really curious about results when they publish or announce.....

 

[cancer_doc]

COVID-19 pneumonia treated with ultra-low doses of radiotherapy (ULTRA-COVID study): a single institution report of two cases

sigh.... 2 cases.....

 

[Mandelin Rain]

sigh.... 2 cases.....

It's ULTRA!

 

[scarbrtj]

TITANS OF NUCLEAR: MOHAMMAD KHAN

Bret Kugelmass
This drives me. This drives me crazy because we were in I mean, the whole world was in emergency mode. You know, when this you know last spring, and it seemed to me, just like as an average citizen, hey, let's try everything. I don't care how out there it is like, it doesn't have to work. People are dying anyway. So let's just throw every drug at the wall, every therapy at the wall. And yeah, some of them might seem silly or seem stupid. But if people are dying anyway, especially as they get to a certain progression in disease, like we already have precedents for allowing doctors to try random things on people who are about to die, right?

Mohammad Khan
Yeah, that's correct.

Bret Kugelmass
And yet there was still resistance?

Mohammad Khan
Oh, a huge amount of resistance against radiation. Oh, my God. People thought using radiation was the craziest idea ever. They thought people were nuts to even think about it. You know and partly because people forgot history, people didn't realize that radiation was used for pneumonia, and then they find reasons to sort of discount radiation because they said oh that's with bacterial pneumonia. This is viral. This is ARDS, this is inflammatory, this is very different, and they’re afraid and say you might actually make things worse and kill patients. So basically, they found a reason to not want to champion radiation, something that can help. And it really took different kinds of individuals, I would say, radiation heroes, to champion this in a time when there was plenty of doctors again saying they don't believe that radiation will help COVID-19 patients.

...

Bret Kugelmass
Why is that? Is that a function of the review board’s procedures or function of how hard it is to access the equipment? Why is it so much easier to use drugs rather than radiation?

Mohammad Khan
Because it's just inherent bias. It's just an inherent biasing. It has to be a drug, it has to be an antiviral, it has to be this and that's why remdesivir was easy to get into trials. The hydroxychloroquine was easy to get into trials, many, many other things, they use lopinavir, ritonavir also came back negative that was also easy to get into trials there was no issues with getting those approved. You know, because it's an inherent bias, it has to be a drug. And it cannot be radiation that is just that's just the nature of what people believe.

 

[Mandelin Rain]

The funny (sad) part is that the inherent bias against radiation was so strong amongst those that get paid to deliver radiation.

We are truly a self loathing specialty.

 

[RadOncDoc21]

The funny (sad) part is that the inherent bias against radiation was so strong amongst those that get paid to deliver radiation.

We are truly a self loathing specialty.

 

[Palex80]

Here's an update from Emory.

Response to Whole-Lung Low-Dose Radiation Therapy (LD-RT) Predicts Freedom from Intubation in Patients Receiving Dexamethasone and/or Remdesevir for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS)

Background Phase I/II clinical trials have explored whole-lung low-dose radiotherapy (LD-RT) as a potential treatment for patients with COVID-19-related acute respiratory distress syndrome (ARDS). Initial findings require reproduction. Concomitant LD-RT administration with existing therapies...

www.medrxiv.org

20 patients matched to 20 controls. It's a pre-print.

Astonishingly is however this:

Excuse me, but how does that exactly "work"?
Provided, LD-RT is shown to be the "game changer" in a randomized trial in the future and becomes standard of care, will we have to pay Dr. Hess and Dr. Khan in order to deliver it?

What exactly is "LD-RT technogy"? Is it the technique? I always thought one can patent a device or a very special procedure that hasn't been done before. The technique does not sound complicated, does it?
"A single treatment of 1.5 Gy to the bilateral whole lungs with 15 megavoltage photons on a linear accelerator, utilizing a 2-dimensional therapeutic radiation technique, an anterior-posterior beam configuration, and standard dose rates (600 MU/min)."


EDITED to be more specific.

 

[elementaryschooleconomics]

Here's an update from Emory.

Response to Whole-Lung Low-Dose Radiation Therapy (LD-RT) Predicts Freedom from Intubation in Patients Receiving Dexamethasone and/or Remdesevir for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS)

Background Phase I/II clinical trials have explored whole-lung low-dose radiotherapy (LD-RT) as a potential treatment for patients with COVID-19-related acute respiratory distress syndrome (ARDS). Initial findings require reproduction. Concomitant LD-RT administration with existing therapies...

www.medrxiv.org

20 patients matched to 20 controls. It's a pre-print.

Astonishingly is however this:

View attachment 331405

Excuse me, but how does that exactly "work"?
Provided, LD-RT is shown to be the "game changer" in a randomized trial in the future and becomes standard of care, will we have to pay Dr. Hess and Dr. Khan in order to deliver it?

"LD-RT technogy" surely sounds complicated, no wonder it's patented...
"A single treatment of 1.5 Gy to the bilateral whole lungs with 15 megavoltage photons on a linear accelerator, utilizing a 2-dimensional therapeutic radiation technique, an anterior-posterior beam configuration, and standard dose rates (600 MU/min)."


I've never seen that before...

Man, I don't know if this is a precedent we want to set, potential court battles coming in 3...2...1...

 

[TheWallnerus]

I tried to patent alopecia-preventing whole brain (IM)RT once. Couldn't do it. But I wasn't at Emory lol.

 

[elementaryschooleconomics]

Found (marginally) more info from this site:

So it seems like it's equipment, not the technique itself, which makes WAY more sense.

 

[cancer_doc]

Found (marginally) more info from this site:

View attachment 331416
So it seems like it's equipment, not the technique itself, which makes WAY more sense.

My bet is some orthovoltage X-ray machine on wheels...

K

 

[Palex80]

My bet is some orthovoltage X-ray machine on wheels...

Indeed.

However it will not be trivial to deliver the 1.5 Gy WLI with an orthovoltage machine resulting in a homogeneous dose distribution in the lung. Even you go for 200-300kV with a.p./p.a.-fields, you still have something like 25+ cm of lung to irradiate through. Dose distribution will not be nice.

 

[evilbooyaa]

Indeed.

However it will not be trivial to deliver the 1.5 Gy WLI with an orthovoltage machine resulting in a homogeneous dose distribution in the lung. Even you go for 200-300kV with a.p./p.a.-fields, you still have something like 25+ cm of lung to irradiate through. Dose distribution will not be nice.

Maybe it's like an iron lung that uses MV beams... like a SBRT version of Zap-X?

 

[TheWallnerus]

Maybe it's like an iron lung that uses MV beams... like a SBRT version of Zap-X?

Oh lordy. That'd be over-over-engineered for ~1 Gy to the lungs. (But I wouldn't put it past Mo Khan lol.) Just use something like this right here...

The unit might cost a couple hundred bucks to manufacture (add wheels, and a motor to go extended SSD), then just get a cobalt source... whatever that costs. And Bob's your uncle. (Well, this would be *my* solution!)

 

[LoudChicken]

You'd never know from the tweet that 20% of the radiation treated group died, compared to 0% of controls.

 

[Radonc90]

@LoudChicken,

Do you work at Emory and have data?
I am just curious who to believe, the authors on medrvix.org or an anonymous whistle-blower?

 

[LoudChicken]

@LoudChicken,

Do you work at Emory and have data?
I am just curious who to believe, the authors on medrvix.org or an anonymous whistle-blower?

I don't work at Emory, but I do have data (i.e., the study itself):

"Sixteen of 20 irradiated patients (80%) experienced rapid decline in CRP levels over ≤3 days following LD-RT and were classified as LD-RT responders. The remaining four (20%) experienced rise in CRP and were classified as non-responders (Figure S3, bottom right pane)... Of 4 non-responders, 2 required intubation, 3 died by day 28 (1 refused intubation), and the 4th died on day 33... Contrary to expectations based on known mortality rates, none of the 20 blindly selected controls died. No other toxicity, airway emergencies, or adverse events were observed following LD-RT."

"No other toxicity, airway emergencies, or adverse events were observed." You know, other than the 20% mortality. To get around this, they classify those who ended up dying as "non-responders", and compare all the controls against the "responders." The study is an absolute joke.

 

[StIGMA]

"No other toxicity, airway emergencies, or adverse events were observed." You know, other than the 20% mortality. To get around this, they classify those who ended up dying as "non-responders", and compare all the controls against the "responders." The study is an absolute joke.

18% decreased risk of being intubated balanced by 20% mortality in LDRT group vs. 0% mortality standard of care.

Theory is that some hyperactivated immune phenomenon is leading to increased need for intubations/death... so preventing this hyperimmune phenomenon to prevent intubation would be beneficial.

Could it be that in some subset... the immune response is actually protective against virus, and LDRT could be causative in some of the deaths? Well, no: Authors conclusion paragraph, second sentence "The addition of LD-RT to drug therapies appears safe."

 

[TheWallnerus]

Back of envelope calcs: 4/20 vs 0/20 is not statistically significant.

 

[Palex80]

You'd never know from the tweet that 20% of the radiation treated group died, compared to 0% of controls.

A "40-patient study" is also not the correct term, bearing in mind that 20 patients were matched controls and not study participants.
This is actually a 20-patient study, i.e. only 20 patients ever consented and treated.

Otherwise, I can enroll one patient in a trial, match another 99 patients from my hospital records and also call it a "100-patient study".

 

[RadRadRad]

Indeed.

However it will not be trivial to deliver the 1.5 Gy WLI with an orthovoltage machine resulting in a homogeneous dose distribution in the lung. Even you go for 200-300kV with a.p./p.a.-fields, you still have something like 25+ cm of lung to irradiate through. Dose distribution will not be nice.

What would the skin dose be if tried to deliver 1 gy whole lung with ortho voltage?

 

[TheWallnerus]

What would the skin dose be if tried to deliver 1 gy whole lung with ortho voltage?

Assuming ~300 kV and 0.5 Gy from the AP and 0.5 Gy from the PA to a 12 cm depth, the entrance doses would be about 2.5 Gy. The exit doses would be about 0.1 Gy. So in the neighborhood of 2.5-3.0 Gy on the skin. More interesting to me would be the doses in the lung as the x-rays enter and travel to the midplane prescription point. But even with 6 MV x-rays AP/PA, the pleural surface entrance doses will be twice that of the prescription dose. Really the ideal energy if you want to be more homogenous would be >20 MV x-rays; of course one could say this about any AP/PA prescription in radiotherapy.

 

[Mandelin Rain]

As a big proponent of trying this out, I will say....that data is underwhelming at best and conclusions seem wholly inappropriate.

"Among the people the radiation worked on, it worked in 100% of them."

No need to patent this one or work on developing a mobile unit.

 

[evilbooyaa]

You'd never know from the tweet that 20% of the radiation treated group died, compared to 0% of controls.

The COI is strong in this one. Time to poo-poo again!

 

[Radonc90]

I was at the local grocery store and saw "EXTRA Virgin Olive Oil" for $7.50/Liter.
I got so excited and bought it.
Normally, it is $20-$30/L for this extra virgin stuff.

Only after I got home, then I realized it is ONLY 20% Extra Virgin Olive Oil, the rest (80%) is Sunflower Oil...lol.
The 20% Olive Oil is written in small font below the big letter of "EXTRA Virgin Olive Oil".

Live and learn, I guess I can fry some chicken with this oil...not good enough for salad dressing lol...
So, people, read the "small fonts" when reading a scientific article of RT vs Covid...
Don't get me wrong, I love science and I am all for clinical trials, even with RT to lung for Covid.
But I don't like it when the data is being massaged...

 

[RickyScott]

I was at the local grocery store and saw "EXTRA Virgin Olive Oil" for $7.50/Liter.
I got so excited and bought it.
Normally, it is $20-$30/L for this extra virgin stuff.

Only after I got home, then I realized it is ONLY 20% Extra Virgin Olive Oil, the rest (80%) is Sunflower Oil...lol.
The 20% Olive Oil is written in small font below the big letter of "EXTRA Virgin Olive Oil".

Live and learn, I guess I can fry some chicken with this oil...not good enough for salad dressing lol...
So, people, read the "small fonts" when reading a scientific article of RT vs Covid...
Don't get me wrong, I love science and I am all for clinical trials, even with RT to lung for Covid.
But I don't like it when the data is being massaged...

Just learned that olive oil industry is full of fraud. Apparently high end olive oil should have slightly burn on back of palate.

 

[fiji128]

Pretty sure there is a vaccine now

 

[RadOncDoc21]

Great News: Johnson & Johnson Vaccine Chart Looks Like a Dick — VICE

This vaccine efficacy chart from the FDA sure looks familiar.

apple.news

 

[TheWallnerus]

Great News: Johnson & Johnson Vaccine Chart Looks Like a Dick — VICE

This vaccine efficacy chart from the FDA sure looks familiar.

apple.news

The author of that article sure has seen some scary lookin' d***s.

 

[TheWallnerus]

Stop the presses!

SDN people publish stuff. Wait. "The Mob" publishes stuff.

Conclusions​

Whole-lung LDRT failed to improve clinical outcomes in critically ill patients requiring mechanical ventilation for COVID-19 pneumonia.

 

[Mandelin Rain]

Yeah. This one is dead.

I can sleep better knowing that I wasn't retrospectively negligent in my duty to sick patients.

I respect the hustle at Emory, but don't forget to turn out the lights.

 

[Chartreuse Wombat]

Stop the presses!

SDN people publish stuff. Wait. "The Mob" publishes stuff.

Conclusions​

Whole-lung LDRT failed to improve clinical outcomes in critically ill patients requiring mechanical ventilation for COVID-19 pneumonia.

The obvious explanation is that they didn’t do it right Need the Emory patented device

 

[cancer_doc]

Stop the presses!

SDN people publish stuff. Wait. "The Mob" publishes stuff.

Conclusions​

Whole-lung LDRT failed to improve clinical outcomes in critically ill patients requiring mechanical ventilation for COVID-19 pneumonia.

All the intensivists are breathing a sigh of relief now that they don't have to freak out over the prospect of devising a workflow to transport intubated patients to a linac vault....

I think this gives validity to not offer LDRT to those who are already sick to the bone and intubated. With the details from Emory U where 4/20 nonintubated pts in LDRT arm died, one will need a Hail Mary from the multi-institutional group trial to change the role (or apparently lack of) for LD-RT IMO....


....sigh...

 

[RadOncDoc21]

Just need to open up the proton trials now.

 

[Mandelin Rain]

Just need to open up the proton trials now.

Rib sparing IMPT whole-lung radiation

 

[RadOncDoc21]

Rib sparing IMPT whole-lung radiation

I’m going to patent my SIB IGRT-IMPT DIBH dragonfly technique. Keep 0.03 cc of rib less than 0.001 cGy to avoid 0% risk of long term toxicity in 100 years.

 

[Palex80]

I’m going to patent my SIB IGRT-IMPT DIBH dragonfly technique. Keep 0.03 cc of rib less than 0.001 cGy to avoid 0% risk of long term toxicity in 100 years.

Ralph would be proud of you.