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JP2740

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What type of surgery is done by Rad Oncs and how technically proficient do you need to be?
 

Neuronix

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... What?

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Pointless

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Mostly lap choles, coronary bypasses, arthroplasties... you know, the usual.
 
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scarletgirl777

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Maybe he's talking about the gyn procedures that can happen in the OR?
 

LolaGene

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Yeah you may be referring to brachytherapy? Brachytherapy procedures are typically done in an operating room. Some examples are prostate brachytherapy with radioactive seed implants and brachy for head and neck malignancies. I have actually not observed any of these cases myself, so maybe someone else can comment?
 

seper

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some basic surgical skills are needed if you plan to do brachytherapy... I insert implants for cervical HDR all by myself in RadOnc procedure room, so gotta be prepared to stitch up a laceration...
 

davidjones

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Just to clarify: at no institution is SIRSpheres performed by radoncs; the vast majority of the procedure is endovascular and radiation administration involves a couple of syringe pushes. At a very, very few places radonc may be present for the injection component of it, this is primarily due to a historical lack of IRs certified to use y90; and the patients are primarily managed by either IR or HPB surgery. Witjin the past 5 years or so every IR fellow graduating now is certified to use y90 and will likely not want to split the RVUs.

The only place I've heard of where radonc is involvedin y90 therapy was was at Maryland and that was before they got a new section chief who is a bit of a big wig; so I'm not sure what that level of involvement is.
 

temujim

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Just to clarify: at no institution is SIRSpheres performed by radoncs; the vast majority of the procedure is endovascular and radiation administration involves a couple of syringe pushes. At a very, very few places radonc may be present for the injection component of it, this is primarily due to a historical lack of IRs certified to use y90; and the patients are primarily managed by either IR or HPB surgery. Witjin the past 5 years or so every IR fellow graduating now is certified to use y90 and will likely not want to split the RVUs.

The only place I've heard of where radonc is involvedin y90 therapy was was at Maryland and that was before they got a new section chief who is a bit of a big wig; so I'm not sure what that level of involvement is.
At all three places I have practiced, radiation oncology has been involved in SIRSpheres. Maybe rad oncs identify the patients who may benefit after considering all the other potential local options. Or maybe it was the 4 years of training in oncology, radiation delivery, and safety. Perhaps a radiation oncology has a little more to offer than pushing a syringe?
 

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I didn't mean that the rad onc is there just to push the syringe nor to minimize their role in cancer care or level of education. And as you pointed out, the level of involvement varies by institution.

However at the n=4 institutions that I have been at rad onc is not involved , as I have mentioned the vast majority of the procedure and follow up is managed by IR at least at places where a significant number of these are done. Where i have trained are identified by hepatology, oncology, surgery and occasionally IR and brought to tumor board. The best loco regional options are discussed Including TACE and ablation or both. If y90 is chosen the pt goes for arterial mapping. The dose is prepared and they come back for administration which is done endovascularly. Pt is admitted to either IR or surgery. Radiation safety procedures are performed by either IR or Nuc med and pt is followed up with imaging per the tumor board team.

External beam therapy and stereotactic radiation have both been used for liver treatment, and a rad onc certainly brings value to the discussion in tumor board, and certainly no decent discussion about what's best for the patient can occur without them; however once a Percutaneous therapy has been determined to be the best course of action be it y90 or otherwise, I see very little benefit to having a rad onc be involved at that point, particularly since the radiobiology and radiation safety issue are covered by the dept of radiology and the vast majority of complications are not due to radiation but are endovascular in nature .

Again I am not bashing rad onc, and maybe you can tell me how rad onc is involved at the places you have worked?
 

badasshairday

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We have a Nuc Med tech come to the angio suite and they simply hand over the the material to IR and leave.
 

davidjones

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Rads residents in general and IR in particular get very thorough training in radbio and physics, we get ours from the same lecturer as the radoncs.

Here is the current record for who can use y90.

http://pbadupws.nrc.gov/docs/ML1128/ML11284A266.pdf

In "B" it says any user can be trained by an authorized user, in using y90, since IR is the only one currently doing this procedure it is unlikely they will teach or supervise docs from other specialties to do so. Particularly given what happened with a lot PAD work.

And in an economic sense it doesn't make sense to charge the patient for the presence of an additional MD, radonc or Nuc med, since the presence of either isnt required because any IR performing these at this point is an authorized user. Splitting the revenue doesn't make sense either since the IR does the labor intensive part and takes on all the liability for complications.
 

davidjones

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I think this has turned away from the OP, as the question was what procedures rad oncs do.

But in response to wagy, it is not about money, certainly not in the sense that this is about padding wallets, especially because y90 is notoriously difficult to get reimbursed for because based on current data TACE and even bland embolization (based on data from MSK) work equally well but often have worse side effects.

When you guys do brachytherapy what role do the urologists and gyns serve? What is the benefit of having them there?

When we first stared doing ablations of RCC urology used to come down we would place the probes, monitor the ablation zone and dictate the report, not to mention admit the patient and do pre and post clinic visits. The urologist would then get a piece of the reimbursement.

I should also mention that the vast majority of acute complications are also handled by IR for RCC.

Before I forget radiology does NOT take separate radbio boards, however you do get additional training to do Y90 for it, and as I mentioned before while radiation administration is the goal of the procedure it is the least critical part of the whole procedure.

And believe me I am all for multidisciplinary care; it is good for the patient and mutually beneficial for all docs involved. But you haven't provided a good reason for why radonc should be involved in Y90. Other than its radiation.

If anything radiologist are better suited for it since we administer internal radiation all the time for thyroid ca, metastatic bone ca, zevalin ...
 

temujim

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Rads residents in general and IR in particular get very thorough training in radbio and physics, we get ours from the same lecturer as the radoncs.

Here is the current record for who can use y90.

http://pbadupws.nrc.gov/docs/ML1128/ML11284A266.pdf

In "B" it says any user can be trained by an authorized user, in using y90, since IR is the only one currently doing this procedure it is unlikely they will teach or supervise docs from other specialties to do so. Particularly given what happened with a lot PAD work.

And in an economic sense it doesn't make sense to charge the patient for the presence of an additional MD, radonc or Nuc med, since the presence of either isnt required because any IR performing these at this point is an authorized user. Splitting the revenue doesn't make sense either since the IR does the labor intensive part and takes on all the liability for complications.
The NRC if anything disputes your point. Under "A", that basically includes nuc med and rad onc without additional caveats. IR in of itself cannot be an AU. They need quite a bit of additional training as outlined by the NRC.

Anyway, I've yet to see a long term IR follow-up clinic.

But why fight over that bone? As wagy27 notes, rad onc deals with urologists, gyn oncs, neurosurgeons, etc in the "radio-OR". As a rad onc, it kind of sucks to be at the end of the food chain. If anything IR is another step removed.
 

davidjones

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Actually my point was the extensive additional training that IR has to go through, in addition we have the requesite procedural skills, and perform nearly all of the other loco regional therapies for conditions for which Y90 is an option.

I'm not being the least bit facetious in asking to explain to me the role of other specialties in the OR when you guys are doing your procedures.

When we do combined procedures the other specialty has a critical component, i.e. perc nephrostomy followed by lithotripsy, EVARs at some places, embolization followed by resection.

Having a rad onc present for y90 is just unnecessary, it is basically a syringe push, and I am not sure of what your experience is as far as radonc following these patients but everywhere I've been they are followed by either surgery, hepatology, oncology or IR, or all of them. But again my experience is limited.

Im not sure where you practice but there are indeed long term follow-up IR clinics, just like in rad onc, some people are technicians and some are clinicians, unfortunately IR realized that relatively late in the game, but any IR practice worth going to has a good clinic and dedicated clinic time much more similar to a surgery clinic than something like radonc which requires more long term follow-up.

Also I'm not sure what you mean by IR being further removed than rad onc; both are tertiary referral specialties, both get referrals directly from surgery and oncology; IR also gets self referrals for things like venous ablation and fibroids; in the case of the latter we then refer them to gyn and work with them to make sure the pt gets the best treatment.

If anything the two fields should be working more closely together (not in the angio suite) but in a cancer center type setting. Particularly since they are both susceptible to changes in referral patterns.
 

davidjones

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No one is saying IR is trying to encroach on radiation therapy, in fact the only thing we do with radiation is y90; I used Zevalin/I131 as examples of other internal radiation therapy we get a lot of exposure to in residency.

Furthermore to elaborate o, the radiation delivery component, and that is it is more than just radiation delivery, it is also the emboliization part, and while we are embolizing we are making sure there is no a/v shunt, no dissection, no vasospasm etc. and let's be honest the additional training we get for just y90 is more than sufficient. The success of y90 therapy depends on dose delivery parameters like making sure there is no av shunt in the tumor, subselecting the correct vessel, etc in a way the radiation dose is almost incidental. Additionally these pts are not followed by rad onc after, so what exactly are they contributing?

What role do the surgeons play in your OR cases? Do they do exposures for you? Or help with placement in a surgical capacity? Or do they stand on the sidelines and clai
They need to be there because you're working within their domain?

If it's the latter I would argue they don't need to be there. If its the former than tne role they play it is critical to the success of the procedure.

As I have said previously IR clinic is closer to surgery clinic than Radonc which is primarily outpatient. Many of the procedures we do for cancer therapy are all we can offer the patient, and after the therapy is completed we can't retreat and they get better or die. There are exceptions but much of what we treat has a defined end point.

Since we are talking about y90: the therapy consists of arterial mapping, and as many therapy sessions as there are arteries feeding tumor, usually 2. This is spaced over 1 to 3 months. Pts then get follow up imaging and have follow up appointments about q3 months, within 3 to 6 months we can determine if their doing well and can have a transplant. If tumor recurrs or more often grows, as is the case more often then not then the pt is usually out of options. Our patients are different then rad onc pts, the ones that can be cured our cured with transplant we bridge to that. The ones that can't are there for palliation. How long is the oncologic follow up for your palliative patients?

There are are conditions which require long term f/up like PAD, complex AVMs, fibroids.

When a pt is done with radiation therapy do you continue to follow them?

And as a final note Nuc med is a section of radiology , in very few places are they an independent entity, no DR does I131 or Zevalin outside of fellowship trained nucs people .
 

bix

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As I have said previously IR clinic is closer to surgery clinic than Radonc which is primarily outpatient. Many of the procedures we do for cancer therapy are all we can offer the patient, and after the therapy is completed we can't retreat and they get better or die. There are exceptions but much of what we treat has a defined end point.

Radiation Oncology is anatomically based, local therapy. We try to control local disease to improve symptoms or survival. We have lots of ways we can do this but there are a lot of parallels to surgery.

Rad Onc is also involved in Y90 at our institution and we do calculate the normal liver volume and tumor volume and order the dose of radiation as well as "push the syringe." We also follow the patients long term with IR and have a very good relationship. IR also does a lot of TACE and RFA at our institution and we do SBRT.

There is a lot of variability in who does specific procedures such as Y90, prostate or Gyn brachy, I-131, etc. In some institutions the Rad Onc does prostate or gyn brachy by themselves, and in some the urologist or gyn oncologist is involved. The bottom line is we are here to do the best for the patient. As long as the team or individual that is doing the procedure is trained well (ie qualified and licensed to do it), has experience doing it that way, and follows their outcomes the composition doesn't matter that much and will vary.
 

scarletgirl777

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No one is saying IR is trying to encroach on radiation therapy, in fact the only thing we do with radiation is y90; I used Zevalin/I131 as examples of other internal radiation therapy we get a lot of exposure to in residency.

Furthermore to elaborate o, the radiation delivery component, and that is it is more than just radiation delivery, it is also the emboliization part, and while we are embolizing we are making sure there is no a/v shunt, no dissection, no vasospasm etc. and let's be honest the additional training we get for just y90 is more than sufficient. The success of y90 therapy depends on dose delivery parameters like making sure there is no av shunt in the tumor, subselecting the correct vessel, etc in a way the radiation dose is almost incidental. Additionally these pts are not followed by rad onc after, so what exactly are they contributing?

What role do the surgeons play in your OR cases? Do they do exposures for you? Or help with placement in a surgical capacity? Or do they stand on the sidelines and clai
They need to be there because you're working within their domain?

If it's the latter I would argue they don't need to be there. If its the former than tne role they play it is critical to the success of the procedure.

As I have said previously IR clinic is closer to surgery clinic than Radonc which is primarily outpatient. Many of the procedures we do for cancer therapy are all we can offer the patient, and after the therapy is completed we can't retreat and they get better or die. There are exceptions but much of what we treat has a defined end point.

Since we are talking about y90: the therapy consists of arterial mapping, and as many therapy sessions as there are arteries feeding tumor, usually 2. This is spaced over 1 to 3 months. Pts then get follow up imaging and have follow up appointments about q3 months, within 3 to 6 months we can determine if their doing well and can have a transplant. If tumor recurrs or more often grows, as is the case more often then not then the pt is usually out of options. Our patients are different then rad onc pts, the ones that can be cured our cured with transplant we bridge to that. The ones that can't are there for palliation. How long is the oncologic follow up for your palliative patients?

There are are conditions which require long term f/up like PAD, complex AVMs, fibroids.

When a pt is done with radiation therapy do you continue to follow them?

And as a final note Nuc med is a section of radiology , in very few places are they an independent entity, no DR does I131 or Zevalin outside of fellowship trained nucs people .

One thing that surprised me about rad onc that I didn't realize until I did a rotation is that there is a lot of potential to do significant follow-up with patients. I've seen docs that were following patients 10+ years out post-treatment. I think that this gives the specialty a little less of a totally procedural feel like something like IR. Since you don't have to be there at every single treatment session, maybe there is less pressure to kick people out of clinic who are "only" there for follow-up.
 

davidjones

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Do you guys follow them for surveillance? (when you're talking about follow up years out?) which malignancies? Just for my own education?

when I said IR is more like surgery, what I meant was the things we do have more significant short term consequences and complications, our cancer pts don't require long term follow up because of the nature of the therapy, much like when a surgeon cuts snip merging out, they follow into no further surgical intervention is required and then the pt goes to their oncologist. Long term follow happens for the groups of pts I listed above.

Bix do you guys do SBRT for liver? Or did you mean in general?
 
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Why in the world would rad-oncs want to be involved with Y90? It pays terrible and it seemed not satisfying or cerebral at all. Seemed like technician work to me.

Gyn brachy we do alone, the gyn onc only places the sleeve in the OR mid treatment during EBRT without our assistance, then I do all the implants myself. Prostate brachy the urologists places the US in the rectum and contours the prostate on the US, which we subsequently completely ignore. If they are late, we can do that part. Then we put in the needles and the seeds. They don't do post tx cysto, either. They do provide conversation and support, however, and it is appreciated. I don't know how the billing breaks out, but I presume they get something, because they show up.
 

medgator

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Why in the world would rad-oncs want to be involved with Y90? It pays terrible and it seemed not satisfying or cerebral at all. Seemed like technician work to me.

Gyn brachy we do alone, the gyn onc only places the sleeve in the OR mid treatment during EBRT without our assistance, then I do all the implants myself. Prostate brachy the urologists places the US in the rectum and contours the prostate on the US, which we subsequently completely ignore. If they are late, we can do that part. Then we put in the needles and the seeds. They don't do post tx cysto, either. They do provide conversation and support, however, and it is appreciated. I don't know how the billing breaks out, but I presume they get something, because they show up.

In a lot of practices, and where I trained, for prostate brachy the urologists would place the needles (sometimes under our direction) and we would place the seeds either with a Mick applicator or we would drop them if the needles were pre-loaded with stranded seeds. Post-brachy cysto seemed to be completely urologist-dependent. Some would do it, some wouldn't
 

bix

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Do you guys follow them for surveillance? (when you're talking about follow up years out?) which malignancies? Just for my own education?

We tend to follow patients indefinitely after we treat them (this does vary some and some Rad Oncs may not see a prostate after 10 yrs of fu and undectable psa). This is shorter for GBM/pancreas than breast or prostate. All procedures (including surgery) can have long term complications and you won't know if you don't follow your patients.

Bix do you guys do SBRT for liver? Or did you mean in general?

Yes. We do SBRT liver.

For prostate brachy we do intraoperative planning with linked seeds. While urology inserts needles we contour and then plan (we also give guidance on where we want the needles). We then adjust the contours and plan after the needles are inserted. We then create the links of sources and drop them. We can adjust the plan on the go if needed.
 
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