SABR + SCOTUS

[scarbrtj]

Never really see the words "stereotactic ablative radiation therapy" in the popular press. A couple things I thought interesting were 1) it took 3 weeks to do the SABR (not "really" 5-or-less-fraction SABR? or did they just do very non-consecutive days?) and 2) they must have been obtaining screening CA 19-9 ("The abnormality was first detected after a routine blood test in early July")? Maybe? It would be a remarkable moment in the history of radiation oncology if SABR thwarted a President's attempt to pick a supreme court justice.


Justice Ruth Bader Ginsburg Treated Again For Cancer

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[FrostyHammer]

Dunno for sure but I guess it was Chris Crane 67.5/15 regimen since it said she was treated at MSKCC. Needless to say, I will be praying for her life.

 

[scarbrtj]

Dunno for sure but I guess it was Chris Crane 67.5/15 regimen since it said she was treated at MSKCC. Needless to say, I will be praying for her life.

(Of note, the ins. co's and Medicare do not, stupidly, consider 15 fx treatments SABR)

 

[BobbyHeenan]

So she possibly had a primary lung and now pancreas?

I was under the assumption she may have a neuro endocrine pancreas cancer diagnosed a while ago.

Who knows, hard to know reading press reports.

If my pancreas needed zapped you bet I’d have Chris Crane do it though. He was a little rough (but fair) as my board examiner but his data is the best there is on pancreatic radiation.

 

[Neuronix]

I don't think 5 fractions to 33 Gy was ever enough. That's why people are doing 5 fractions to 50 Gy.

Using adaptive magnetic resonance image-guided radiation therapy for treatment of inoperable pancreatic cancer - PubMed

Patients treated with dose-escalated MRgRT demonstrated improved OS. Prospective evaluation of high-dose RT regimens with standardized treatment parameters in inoperable pancreatic cancer patients is warranted.

www.ncbi.nlm.nih.gov

ClinicalTrials.gov

clinicaltrials.gov

I think whether you use 5 fractions or 15 fractions to pancreas (or liver) you need to be very careful about how you do it. There are clear OAR constraints that override coverage and strict image guidance and respiratory motion management requirements. I've seen a lot of techniques at various institutions that violate one or both of those safety bounds and the resulting toxicities.

 

[BobbyHeenan]

I don't think 5 fractions to 33 Gy was ever enough. That's why people are doing 5 fractions to 50 Gy.

Using adaptive magnetic resonance image-guided radiation therapy for treatment of inoperable pancreatic cancer - PubMed

Patients treated with dose-escalated MRgRT demonstrated improved OS. Prospective evaluation of high-dose RT regimens with standardized treatment parameters in inoperable pancreatic cancer patients is warranted.

www.ncbi.nlm.nih.gov

ClinicalTrials.gov

clinicaltrials.gov

I think whether you use 5 fractions or 15 fractions to pancreas (or liver) you need to be very careful about how you do it. There are clear OAR constraints that override coverage and strict image guidance and respiratory motion management requirements. I've seen a lot of techniques at various institutions that violate one or both of those safety bounds and the resulting toxicities.

Yeah, this is one area of my practice that I've been too "wimpy" to delve into. I do real-time fiducial tracked (on Truebeam) liver SBRT (sometimes gated, but compliant patients can do really nice breath hold treatments) and have good surgeon buy in for HCC and mets from this - had some excellent outcomes over past 5 years....but I just haven't pulled the trigger on truly ablative dose pancreas treatments.

I can refer out but a lot of my patients just don't have the family or financial support to travel many miles. Would like to be able to offer it at our comprehensive center but just haven't done it yet because some scary case reports out there. I may need to take my physics team on a field trip to somewhere doing a lot of this.

 

[medgator]

I can refer out but a lot of my patients just don't have the family or financial support to travel many miles. Would like to be able to offer it at our comprehensive center but just haven't done it yet because some scary case reports out there. I may need to take my physics team on a field trip to somewhere doing a lot of this.

Yup....still at 50-55 with xeloda myself

 

[thaddeus]

So she possibly had a primary lung and now pancreas?

I was under the assumption she may have a neuro endocrine pancreas cancer diagnosed a while ago.

Who knows, hard to know reading press reports.

If my pancreas needed zapped you bet I’d have Chris Crane do it though. He was a little rough (but fair) as my board examiner but his data is the best there is on pancreatic radiation.

Yea I was guessing pancreatic NET as well based on the history of pancreas cancer diagnosed in 2009 and the prior resection of her lung tumor (presuming mets from pancreas). Then I guess the blood test referred to was Chromogranin A or some such? As far as I am aware, there is not much data for SBRT for NETs, though I suppose same basic principles apply as adeno. Weird thought that the fate of the republic rests in Chris Crane's hands.

 

[RadRadRad]

Yea I was guessing pancreatic NET as well based on the history of pancreas cancer diagnosed in 2009 and the prior resection of her lung tumor (presuming mets from pancreas). Then I guess the blood test referred to was Chromogranin A or some such? As far as I am aware, there is not much data for SBRT for NETs, though I suppose same basic principles apply as adeno. Weird thought that the fate of the republic rests in Chris Crane's hands.

When does the lutathera happen?

 

[BobbyHeenan]

When does the lutathera happen?

Probably waiting on prior auth. Peer to peer family doc denied it based on age so they’re going up the chain.

 

[scarbrtj]

When does the lutathera happen?

I think only in somatostatin receptor positive NETs, and I think a reasonable percent of pancreatic NETs are not positive.

 

[maxxor]

I think only in somatostatin receptor positive NETs, and I think a reasonable percent of pancreatic NETs are not positive.

Yes, this needs SSTR positivity, demonstrated either by path or positive Ga-68-DOTATATE scan.

 

[evilbooyaa]

It's not just Chris Crane - Parag Parikh at Henry Ford now also had published similar outcomes. Can't find the paper right now but Crane mentioned it in a previous MedNet post and it looked similar.

Agree with Neuronix that it's not for the faint of heart and something that I would very very strongly consider referring out given risks of catastrophic toxicity (especially if the patients aren't planned for resection - can't get a duodenal ulcer if the duodenum is out). It also is a fraction of the patient population since you can't really have duodenal invasion or abutment.

 

[Brim]

2) they must have been obtaining screening CA 19-9 ("The abnormality was first detected after a routine blood test in early July")?

Or maybe elevated liver "function" tests. The article did mention that she needed a stent, so she could have presented with hyperbilirubinemia.

 

[OTN]

It's not just Chris Crane - Parag Parikh at Henry Ford now also had published similar outcomes. Can't find the paper right now but Crane mentioned it in a previous MedNet post and it looked similar.

Agree with Neuronix that it's not for the faint of heart and something that I would very very strongly consider referring out given risks of catastrophic toxicity (especially if the patients aren't planned for resection - can't get a duodenal ulcer if the duodenum is out). It also is a fraction of the patient population since you can't really have duodenal invasion or abutment.

I’ve done Chris Crane’s regimen in 10ish patients now, most with unresectable cholangio, and have been very happy with the outcomes, both in terms of local control and toxicity. As long as you use his “PRV+5mm” approach the chance of significant toxicity shouldn’t be too high.

 

[KHE88]

The issue with escalating pancreas to curative doses is yes, you will cure some patients. But you also will kill some. 5-10% iirc.
Not surprising most stick with 50/28 and 33/5.

 

[evilbooyaa]

I’ve done Chris Crane’s regimen in 10ish patients now, most with unresectable cholangio, and have been very happy with the outcomes, both in terms of local control and toxicity. As long as you use his “PRV+5mm” approach the chance of significant toxicity shouldn’t be too high.

I really want to try this when I'm an attending if I feel my equipment and staff are competent enough. Tough to get attendings on board to break their dogma as a resident.

 

[OTN]

I really want to try this when I'm an attending if I feel my equipment and staff are competent enough. Tough to get attendings on board to break their dogma as a resident.

His data is so good for unresectable cholangiocarcinomas in the liver, if you have the technology and staffing to do it, I would consider it borderline unethical not to do so or at least refer out for treatment.

 

[evilbooyaa]

Don't see a ton of unresectable cholangio at my current institution but the locally advanced pancreas stuff is what I'd like to implement.

 

[Neuronix]

The issue with escalating pancreas to curative doses is yes, you will cure some patients. But you also will kill some. 5-10% iirc.

What? Rate of death due to SBRT in pancreas is less than 1% in experienced hands. Grade 3+ toxicity is 5-10%, mostly GI ulcer. Problem is that some patients will develop GI ulcers just from tumor erosion (~50% of the ulcers IMO), but they all get coded as radiation related toxicities.

As for treatment of cholangio and pancreas, I strongly recommend fiducials, as does the NRG protocol for 15 fraction liver. If you synchronize the fiducials to the respiratory management system, you're much of the way there. I've seen a lot of centers refuse to do this because it's complicated. I wouldn't do those treatments without these steps (or MRI guidance).

 

[BobbyHeenan]

What? Rate of death due to SBRT in pancreas is less than 1% in experienced hands. Grade 3+ toxicity is 5-10%, mostly GI ulcer. Problem is that some patients will develop GI ulcers just from tumor erosion (~50% of the ulcers IMO), but they all get coded as radiation related toxicities.

As for treatment of cholangio and pancreas, I strongly recommend fiducials, as does the NRG protocol for 15 fraction liver. If you synchronize the fiducials to the respiratory management system, you're much of the way there. I've seen a lot of centers refuse to do this because it's complicated. I wouldn't do those treatments without these steps (or MRI guidance).

Agree on fiducials. In some HCC cases s/p TACE (or lipoiodal) you have great "fiducials" with the lipoiodal, but otherwise I get IR to do liver fiducials.

I've had less enthusiasm on pancreas fiducials from interventional GI, but if I dive into the pancreas ablative dose realm I think it's absolutely necessary with real-time tracking.

 

[KHE88]

What? Rate of death due to SBRT in pancreas is less than 1% in experienced hands. Grade 3+ toxicity is 5-10%, mostly GI ulcer. Problem is that some patients will develop GI ulcers just from tumor erosion (~50% of the ulcers IMO), but they all get coded as radiation related toxicities.

As for treatment of cholangio and pancreas, I strongly recommend fiducials, as does the NRG protocol for 15 fraction liver. If you synchronize the fiducials to the respiratory management system, you're much of the way there. I've seen a lot of centers refuse to do this because it's complicated. I wouldn't do those treatments without these steps (or MRI guidance).

No, I mean with the ablative treatment. You have a non-trivial risk of killing people with doses that high.

 

[xrthopeful]

No, I mean with the ablative treatment. You have a non-trivial risk of killing people with doses that high.

I think this is what Neuronix was saying ‘what?’ to

 

[evilbooyaa]

No, I mean with the ablative treatment. You have a non-trivial risk of killing people with doses that high.

Even in the worst series (like the stanford 34x1 stuff) the death rate likely wasn't 5-10%. Extraordinary claims require extraordinary evidence.

 

[scarbrtj]

R.I.P. Justice Ginsburg

Justice Ruth Bader Ginsburg dead at 87

Supreme Court Justice Ruth Bader Ginsburg died on Friday due to complications of metastatic pancreas cancer, the court announced. She was 87.

www.cnn.com

 

[thecarbonionangle]

R.I.P. Justice Ginsburg

Justice Ruth Bader Ginsburg dead at 87

Supreme Court Justice Ruth Bader Ginsburg died on Friday due to complications of metastatic pancreas cancer, the court announced. She was 87.

www.cnn.com

somewhere in Kentucky, the turtle sits in its shell and sticks head out hesitantly, then lets out an evil laugh, and I ain’t talking about a rad onc, or maybe I am? The worst of times and best of times are yet to come.

 

[radOresident]

Sad day for the country. McConnell will undoubtedly have this seat filled before January. Republicans have neither morals nor shame.

 

[Chartreuse Wombat]

Sad day for the country. McConnell will undoubtedly have this seat filled before January. Republicans have neither morals nor shame.

Very much doubt that. Murkowski already said no vote and Collins will surely follow.

 

[medgator]

Very much doubt that. Murkowski already said no vote and Collins will surely follow.

Not sure Mitt will play ball either to give 45 another lifetime appointment

 

[FrostyHammer]

So sad right now. That brave heroine fought to her very last breath. I'm very sorry, mods, for getting into politics but I can't imagine what ungodly evil schadenfreude is going on in the minds of Moscow Mitch and Trump the Chump. Nevertheless...RIP our dear RBG.

 

[thecarbonionangle]

As RO moribundly limps into jan 2021, Trump crony Azar and Hahn will be waiting to finish it off over their next four years. Hope you guys are saving some money!

 

[Haybrant]

She shoulda stepped down during Obama’s term. But 100% they’ll figure out a way to get someone on that seat before Jan 1.