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SRS and Neurosurgery consults

SBRTreble

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Has anyone who regularly performs SRS found themselves in a workflow/practice where there is not an automatic referral to Neurosurgery for brain mets (i.e., a 5mm amenable to SRS)? I understand the history of SRS involving Neurosurgery for frame placement, etc., but are people finding there is valuable input regularly being provided in these instances?

Apologies if this has been discussed in this forum recently.
 
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Gfunk6

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There are really two issues at play in involving Neurosurgeons in SRS. The first is on the clinical side (this is much less relevant now then it was 20-30 years ago) and the second is on the camaraderie/teamwork/referral side.

On #1, to the extent that is possible I try to refer all of my SRS patients to a Neurosurgeon. I will freely admit that this can slow down the treatment planning process and is not always useful clinically. However, I find their input indispensable for functional SRS (TGN, AVM) and for resection cavity cases (no one can contour as well as the person who saw the region you are treating intraoperatively).

#2 is as critical if not more so. Neurosurgeons have their own unique billing codes which allows them to rightfully charge for their services. Also, it is human nature to want to reciprocate referrals to those who send patients to you. This is the most important. During supervision of potentially long SRS cases, there is a great opportunity to dialogue with the Neurosurgeon about any number of topics of mutual interest.
 
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SBRTreble

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There are really two issues at play in involving Neurosurgeons in SRS. The first is on the clinical side (this is much less relevant now then it was 20-30 years ago) and the second is on the camaraderie/teamwork/referral side.

On #1, to the extent that is possible I try to refer all of my SRS patients to a Neurosurgeon. I will freely admit that this can slow down the treatment planning process and is not always useful clinically. However, I find their input indispensable for functional SRS (TGN, AVM) and for resection cavity cases (no one can contour as well as the person who saw the region you are treating intraoperatively).

#2 is as critical if not more so. Neurosurgeons have their own unique billing codes which allows them to rightfully charge for their services. Also, it is human nature to want to reciprocate referrals to those who send patients to you. This is the most important. During supervision of potentially long SRS cases, there is a great opportunity to dialogue with the Neurosurgeon about any number of topics of mutual interest.


I agree entirely in regards to postop or preop SRS cases, as well as functional SRS. Sometimes it just feels like additional burden and confusion for the patient to send them to a Neurosurgeon for a couple of subcentimeter brain metastases, where they are clearly going to be receiving SRS for intact lesions. However your #2 point is important and something I probably haven't fully appreciated enough this early in my career - I agree it's important for us to get in the mix for many reasons - otherwise out of sight, out of mind. Thanks for your feedback
 
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BobbyHeenan

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There are really two issues at play in involving Neurosurgeons in SRS. The first is on the clinical side (this is much less relevant now then it was 20-30 years ago) and the second is on the camaraderie/teamwork/referral side.

On #1, to the extent that is possible I try to refer all of my SRS patients to a Neurosurgeon. I will freely admit that this can slow down the treatment planning process and is not always useful clinically. However, I find their input indispensable for functional SRS (TGN, AVM) and for resection cavity cases (no one can contour as well as the person who saw the region you are treating intraoperatively).

#2 is as critical if not more so. Neurosurgeons have their own unique billing codes which allows them to rightfully charge for their services. Also, it is human nature to want to reciprocate referrals to those who send patients to you. This is the most important. During supervision of potentially long SRS cases, there is a great opportunity to dialogue with the Neurosurgeon about any number of topics of mutual interest.

This is a great take.

I didn't fully understand this early in my career, but #2 is important.

For every hassle in getting them to "help" you treat a solitary 8 mm met you could do on your own, there is a train wreck necrosis versus progression case where you need someone to help interpret MRI's (with neuro onc or neuro rads), do biopsies or resections, and just generally help manage even if the patient never was operated on. I have found this very valuable.

It's easier to get team buy in and help in management when the neurosurg was involved in the initial "game plan" regarding what to do with the patient...rather than callling him/her after you've treated and then issues arise.
 
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RadOncMegatron

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This is a great take.

I didn't fully understand this early in my career, but #2 is important.

For every hassle in getting them to "help" you treat a solitary 8 mm met you could do on your own, there is a train wreck necrosis versus progression case where you need someone to help interpret MRI's (with neuro onc or neuro rads), do biopsies or resections, and just generally help manage even if the patient never was operated on. I have found this very valuable.

It's easier to get team buy in and help in management when the neurosurg was involved in the initial "game plan" regarding what to do with the patient...rather than callling him/her after you've treated and then issues arise.

I'm not a big fan of invoking neurosurgery for these cases. They don't consult us upfront, so why should we consult them if we don't need their help. If we need their help we consult, save $ for the patients, and reduce visits (esp. right now during COVID).

We have to stop this quid pro quo referral process. I have a great relationship with my neurosurgeon and there are no issues.
 
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Neuronix

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Has anyone who regularly performs SRS found themselves in a workflow/practice where there is not an automatic referral to Neurosurgery for brain mets (i.e., a 5mm amenable to SRS)? I understand the history of SRS involving Neurosurgery for frame placement, etc., but are people finding there is valuable input regularly being provided in these instances?

Apologies if this has been discussed in this forum recently.

I have gotten zero helpful input for linac SRS. Most of our neurosurgeons just want to sign off on the plan (which still generates some revenue I believe) and put their name on the chart so that they get called if there is ever a neurosurgical issue down the road. They do not come to the treatments.

For GK SRS it depends on the case. Usually not, but there are rare cases when the feedback can be helpful. Our neurosurgeons mostly put on the frame (even this is mostly the resident's doing) and leave the area immediately, so it's not really much of a networking opportunity either.

That's not to say that neurosurgeons aren't a valuable part of the team. We review cases in tumor board. They're also happy to discuss cases or see patients quickly for consideration of surgery.

A neurosurgeon once told me: "You don't come into the OR and tell me how to operate; why would I tell you how to give radiation?"
 
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BobbyHeenan

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I'm not a big fan of invoking neurosurgery for these cases. They don't consult us upfront, so why should we consult them if we don't need their help. If we need their help we consult, save $ for the patients, and reduce visits (esp. right now during COVID).

We have to stop this quid pro quo referral process. I have a great relationship with my neurosurgeon and there are no issues.

Part of the necessity on my end is frame for GK.

However, I also frame less fractionate some cases (typically larger lesions). These are the complex cases anyway, so neurosurgery help (ie should they have surgery or not...after treatment is it necrosis or not, etc). So I think it's helpful.

Also - the majority of hte neurosurgeons in our program DO in fact involve me up front. We very often look at pre-op resection cases together prior to surgery...and I greatly appreciate that.
 
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BobbyHeenan

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I have gotten zero helpful input for linac SRS. Most of our neurosurgeons just want to sign off on the plan (which still generates some revenue I believe) and put their name on the chart so that they get called if there is ever a neurosurgical issue down the road. They do not come to the treatments.

For GK SRS it depends on the case. Usually not, but there are rare cases when the feedback can be helpful. Our neurosurgeons mostly put on the frame and leave the area immediately, so it's not really much of a networking opportunity either.

I know you know this, but GK programs can vary WILDLY regarding the participation/interest of neurosurgeons. Some places like UVA and UPMC have very involved, interested neurosurgeons, and other places (to some degree) the neurosurgeons are not real interested, but for simple cases just put a frame on and duck out. Even in my half dozen neurosurgeons that do GK with me, the majority are very interested and involved, while one or two just want to put a frame on and that's about it.

I have some very "radiation friendly" neurosurgeons though that are interested in active management and I have found their assistance really helpful, so I'm glad to have them involved in cases.

I don't think it helps my volume one way or another - I'm going to get the small brain met cases no matter what.
 
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Neuronix

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100% true for GK SRS. There are rad onc driven places and neurosurgery driven places for sure.

We're very rad onc driven here. It was kind of scary when I was a new attending and didn't get any hand holding on most cases. Now that I've done hundreds of GK cases, I just want everyone out of my way :laugh:
 
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scarbrtj

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Has anyone who regularly performs SRS found themselves in a workflow/practice where there is not an automatic referral to Neurosurgery for brain mets (i.e., a 5mm amenable to SRS)? I understand the history of SRS involving Neurosurgery for frame placement, etc., but are people finding there is valuable input regularly being provided in these instances?

Apologies if this has been discussed in this forum recently.
Short answer: no clinical shame in the game of not albatrossing yourself with a NSG referral "just because that's how it's done" especially in the clinical scenario you describe. Know what else is neat when things are running like a top? Identify the met/get referral for met on day #1, sim them and plan them that day, and bring them in for treatment the next day. 24-hour turnaround for a "brain surgery." The med oncs captaining most these folks' ships can get pretty impressed by this and you can get farther in life by keeping med oncs' biscuits buttered versus those NSGs. Best outcome: NSG says "stop sending me these people."

Now that I've done hundreds of GK cases, I just want everyone out of my way :laugh:
Video of the routine-NSG-referral-for-SRS process...
 
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BobbyHeenan

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100% true for GK SRS. There are rad onc driven places and neurosurgery driven places for sure.

We're very rad onc driven here. It was kind of scary when I was a new attending and didn't get any hand holding on most cases. Now that I've done hundreds of GK cases, I just want everyone out of my way :laugh:

Where I trained we kind of had an "intermediate" interest from neurosurgeons. Was definitely rad onc driven.

Out in practice I didn't know what to expect, but was pretty excited when I put on a 20 Gy to 50% isodose Rx on a small met and the neurosurgeon said (in jest) "you wimp, they went higher than that on RTOG 90-05." I was pumped he was actually interested in dosing and knew something.
 
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BobbyHeenan

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Short answer: no clinical shame in the game of not albatrossing yourself with a NSG referral "just because that's how it's done" especially in the clinical scenario you describe. Know what else is neat when things are running like a top? Identify the met/get referral for met on day #1, sim them and plan them that day, and bring them in for treatment the next day. 24-hour turnaround for a "brain surgery." The med oncs captaining most these folks' ships can get pretty impressed by this and you can get farther in life by keeping med oncs' biscuits buttered versus those NSGs. Best outcome: NSG says "stop sending me these people."


Video of the routine-NSG-referral-for-SRS process...

I got the "stop sending me these" vibes at times (especially pre COVID), so I started texting the neurosurgeon, we look at images and I say something like "I'm planning on fractionating (27 in 3) without a frame - do you want to be involved in this?" If they're busy with stuff they will decline. But some of then want to be involved.

I certainly don't mind if they decline on cases where I feel like I don't have to have them involved.
 
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evilbooyaa

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Currently, we have one neurosurgeon who likes to come down and look at the plan if he is already involved in the case (consulted previously, former patient, whatever) so he can bill the relevant charge. Other 2 don't really give a crap, and I'm definitely not calling them for intact cases. I may call them if I'm anxious about something specific on a post-op case, but even that is exceedingly rare.

If people want to do the quid pro quo call NSG on every single SRS case then whatever, but it's just as bad as the community hospitalist who consults his specialist buddies to come do easy consults on the inpatients with stable medical co-morbidities (consult for: PKTY, h/o COPD, as an example).

I call NSG when I have a question for them. I don't need their approval or blessing to pick a radiation dose or fractionation scheme. I will involve them as a courtesy if they were the ones who did the surgery (for a post-op case).

We don't do hardly any pre-op SRS here, but I suppose if I was routinely doing that, then sure, get the NSG involved.
 
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In Europe this is hardly the case.

We basically get referrals by whoever sees the patient: either med onc who finds the metastasis on imaging or the emergency department docs when the patient comes in symptomatic. All cases are presented at a tumor board (if no emergency procedure is necessary) where both a rad onc and a neurosurgeon are present, leading to a treatment recommendation. I'd say that most of the patients get SRS or SFRT for solitary cases (about 70% would be my guess). Neurosurgeons may sometimes send us a case they pick up during follow up of patients they resected on. We rarely ask them if they can operate, practically only in posterior fossa tumors with edema or in post-SRS cases progressing or showing necrosis.
 
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FrostyHammer

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I'm not a big fan of invoking neurosurgery for these cases. They don't consult us upfront, so why should we consult them if we don't need their help. If we need their help we consult, save $ for the patients, and reduce visits (esp. right now during COVID).

We have to stop this quid pro quo referral process. I have a great relationship with my neurosurgeon and there are no issues.
Very well put and I agree. IMHO, involving neurosurgery for any "smaller" / asymptomatic brain met case that doesn't require resection is a waste. Yeah, I can see the argument for some post-op cases but the intact cases...useless.
 
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evilbooyaa

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Has anyone had success involving Pulm/Thoracic for SBRT? They supposedly also have codes.

This to me makes even less sense than getting a NSG's 'approval' of an intact SRS case. Maybe the rare scenario if it was a local recurrence after previous surgery to assist with distinguishing post-surgical change from tumor.

People calling them for lung oligomets too or just stage I NSCLC?
 
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scarbrtj

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This to me makes even less sense than getting a NSG's 'approval' of an intact SRS case. Maybe the rare scenario if it was a local recurrence after previous surgery to assist with distinguishing post-surgical change from tumor.

People calling them for lung oligomets too or just stage I NSCLC?
Reasons neurosurgery got somehow yoked to the radiosurgical process were all essentially strictly procedural and historical. It was a neurosurgeon who developed the first radiosurgery device and coined the word "radiosurgery." We didn't really see the advent of non-gamma knife radiosurgery until the 1990s when only a few centers in the world began publishing on experiences with linac-based radiosurgery. And everything up until that point in time required a headframe, and most times the neurosurgeons would take patients to the OR to place it under general anesthesia. (When of course the frame can be placed with a bit of local anesthesia in an exam room but I digress.) Because neurosurgeons are, well, neurosurgeons, they wanted to hang around with the rad onc in the planning process. And every single radiosurgery vendor would practically require a neurosurgeon to be a part of the initial dog and pony shows and subsequent trainings on the equipment. Let's be honest. If one thinks this is an era of less-than-aggressive radiation oncologists now, in the 90's radiation oncologists were great supine protoplasmic invertebrate jellies. Thus neurosurgeons ran the show.

Fast forward to the present: frameless radiosurgery, yada yada yada, and the neurosurgeon now shouldn't be a part of radiosurgery IMHO. I know all there is to know about (linac based) radiosurgery, I can place my own frames if I had to, I always removed them myself when they were placed, and it's my ass on the line not the neurosurgeon's (at least in my own heart and mind) if something goes wrong. The code for the pulmonologist or CT surgeon for lung SBRT can be used in any thoracic SBRT case. It was an attempt by Varian (who lobbied for the code) to sort of ape my first paragraph above. It's as "silly" to get a CT surgeon involved in lung SBRTs as it is to get NSG involved in brain SRSs... YMMV of course.
 
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BobbyHeenan

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[/QUOTE]
this looks to be worth 4 wRVU's! I surprised no one had success with Pulm or Thoracic taking the bait.

I may be wrong here, but I *think* those codes aren't universally paid for the way neurosurgery codes are. When we were running prostate radiosurgery trials years ago there were some unlisted codes we tried to get urology to bill for to get them involved and rarely were they paid. Not sure if that's the case for pulm or not. Someone let us know.

Like Scarbrtj is saying...I'm not sure neurosurg would be as intimately involved if we started at square 1 linac frameless SRS. I have a Gamma Knife, so involvement is mandated, but when I fractionate cases I get them involved...partially intertia from GK, partially due to improvement in patient care by having them involved.
 
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Gfunk6

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To echo and reinforce what others are saying about pulmonary or thoracic surgery involvement in SBRT:

1. There are codes, but they are relatively new. Many payors are not very familiar with them and the reimbursement is low.
2. As scarbtj noted above, there are long and deep historical precedents for Neurosurgical involvement in SRS. SRS is a facet of Neurosurgical residency. Pulmonary/Thoracic surgery has neither of these things.

Personally, I've tried to involve pulmonary/thoracic surgery but it never went anywhere so I dropped it.
 
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Has anyone had success involving Pulm/Thoracic for SBRT? They supposedly also have codes.

Why? I interviewed at a place that had the thoracic surgeon circle the tumor for all SBRT cases. It was frankly insulting to me.
I'd be shocked if any of these were otherwise operable.
 
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scarbrtj

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Why? I interviewed at a place that had the thoracic surgeon circle the tumor for all SBRT cases.
So you're saying that thoracic surgeons can perform the main therapeutic functional role of a radiation oncologist sans radiation oncology residency?!
Please don't ever say stuff like this again.
/snark
 
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scarbrtj

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I thought CT vendors had algorithms for that...
Ha well AI auto-segmentation already "outperform[ing] humans" in many sites

AI tumor volume contouring very rapidly appearing on the horizon.
Radiation oncologists need to prepare for a time which will be soon when we will be spending MUCH less time on contouring.

 
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