What's your greatest clinical success?

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I've been wanting to post about this for awhile, and I figured now was as good of a time as any, to give us a bit of a break from...(gestures broadly around).

So, with no further ado, what do you consider your greatest clinical success(es)? Here's one of mine which I've found interesting:

73 year-old I saw first in 2012 for SBRT for Stage I NSCLC. COPD, so not a surgical candidate. I treated him with SBRT. Did great. Had bilateral recurrence 5 years later, was placed on immunotherapy and nearly died from pneumonitis. Tried chemotherapy, also nearly killed him. So, I just started SBRTing (insert Danny Devito meme here).

We are now in 2025 and I have in total treated 16 separate isocenters across both lungs in 10 courses since 2012. Ten received 50 Gy in 5 fx, two received 54 Gy in 3 fx, and two received 40 Gy in 5 fx due to overlap near the chest wall with prior tx. No change in O2 requirement status, no chest wall pain, no symptoms. Last treatment was last year, and he's been NED since.

Every time I see him and we have to treat, I tell him I really don't know what's going to happen, as we are "off the map". I'm still amazed at how many SBRT treatments his COPD-affected lungs have been able to tolerate. Has anyone heard of anything like this before?

Brag away everyone, I want to hear what we've all been able to get The Healing Rays to achieve.
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That's incredible. Just out of curiosity did you ever have to fight for auth?
 
StealthTech said:
That's incredible. Just out of curiosity did you ever have to fight for auth?
Click to expand...

I can't remember having to fight for auth in his case, but can't 100% rule it out, given the number of times we treated.
 
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90+ year old lady with symptomatic bradycardia with a pacemaker and a 3.5 cm grade 3 Her2+ breast cancer. Poor candidate for surgery and systemic therapy. I treated her with a regimen from Curie Institute, 33 Gy in 5 fx once a week with a 14 Gy in 2 fx boost, also once a week. Some mild wet desquamation, otherwise she does great, NED several years out, some skin dimpling but otherwise cosmesis is fine, she gives me a hug every time I see her.
 
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Two cases:

1. Female patient in her early 30s with an non-resectable diffuse astrocytoma of the brainstem.
She was bed-ridden due to horrible headaches and vertigo.

I ended up doing 59.4/1.8, med onc didn't want to give chemo due to poor PS.

She married, had two kids and can ride the bicycle nowadays.

Funniest thing ever was, when she had the first MRI after she gave birth to her first child and the tumor shrank by half a centimeter out of nowhere.
It was mostly stable on all MRIs before that.
My theory: The pregnancy may have induced some kind of immunosuppressive state and once the baby was born, the immune system finally picked up the tumor. Every single time she get's an MRI, I am super anxious.


2. Male patient in his late 80s with a newly diagnosed stage IIIB NSCLC . Poor PS.

Large chest wall tumor causing pain. Bulky N2 nodes. All histology proven.

It was back in the ages before IO was a thing. Med onc opted for best supportive care.
I ended up giving 5 x 4 Gy to the chest wall tumor only and never following up.

1.5 years later, med onc calls me up. He had a consultation with the patient, who slipped at home and was brought to the ER.
The scan showed a few broken ribs (on the opposite side). The chest wall tumor was gone and the N2 bulky nodes looked a lot smaller.
"Do you want to treat the mediastinum?"
I opted not to.
 
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Have a few goose and pancreas pts still walking around years later post chemoRT to mid 50ish dose. Gives me pause when the topic du jour is to remove us from both of those disease sites.

I've definitely treated and retreated a lot of lung.... The great thing about parallel vs serial tissue once you're away from bronchial tree
 
Very early in my career I got a referral from a family practice guy, who was in my multi-specialty group, for a fellow with an optic nerve sheath glioma. Over a period of a couple years he was slowly losing vision in the affected eye. He was in his mid-50s. He had consulted with a neurosurgeon, but the "captain of his ship" was this neuro-ophth lady in my home state who was SUPER well known and well respected. So I saw the guy, and I recommended RT. I came up with a most beautiful IMRT plan, for the era, giving the visible tumor like 102% of the Rx dose and the nerve like 95-98%... 50.4/28 iirc. BrainLAB ExacTrac IGRT, Varian Linac but with the m3 collimator:
3.jpg


I received a SCATHING white hot letter of condemnation and damnation from the neuro-ophth lady MD prior to the RT basically warning me I was going to blind the guy, ruin any potential for a surgery, and she would report me for malpractice. Of course, I treated him. His vision improvement was rather remarkable, and he was so happy with his outcome. He brought a newspaper to one visit showing me how he could read small letters he couldn't read before. I saw him for 5 years and then released him. I never heard from neuro-ophth lady, positively or negatively. The patient quit following with her about 6 months after the radiation. (His MRI went to normal, too.)

Most recently, I treated a very active farmer guy with rheumatoid arthritis and really gnarly looking and painful hands interfering with his hay baling. I treated him 3 Gy/6 fx. His improvement was remarkable too, and even visually the hands improved. The patient was most grateful and he weaned off his RA meds. His rheumatologist, per the patient, was very reluctant to credit the RT however. (I treated him for free because we could not get insurance auth for RA.)

Palex80 said:
Male patient in his late 80s with a newly diagnosed stage IIIB NSCLC . Poor PS.

Large chest wall tumor causing pain. Bulky N2 nodes. All histology proven.

It was back in the ages before IO was a thing. Med onc opted for best supportive care.
I ended up giving 5 x 4 Gy to the chest wall tumor only and never following up.

1.5 years later, med onc calls me up. He had a consultation with the patient, who slipped at home and was brought to the ER.
The scan showed a few broken ribs (on the opposite side). The chest wall tumor was gone and the N2 bulky nodes looked a lot smaller.
"Do you want to treat the mediastinum?"
I opted not to.
Click to expand...

pubmed.ncbi.nlm.nih.gov

Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy - PubMed

The aim of palliative thoracic radiotherapy in patients with advanced non-small cell lung cancer (NSCLC) is to alleviate symptoms. This study was designed to determine whether any patients achieved long-term survival after this treatment. In Edinburgh, between 1974 and 1993, 4531 patients were...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Anna Gregor. One of the best rad oncs of which many people have never heard.
 
Last edited:
TheWallnerus said:
Very early in my career I got a referral from a family practice guy, who was in my multi-specialty group, for a fellow with an optic nerve sheath glioma. Over a period of a couple years he was slowly losing vision in the affected eye. He was in his mid-50s. He had consulted with a neurosurgeon, but the "captain of his ship" was this neuro-ophth lady in my home state who was SUPER well known and well respected. So I saw the guy, and I recommended RT. I came up with a most beautiful IMRT plan, for the era, giving the visible tumor like 102% of the Rx dose and the nerve like 95-98%... 50.4/28 iirc. BrainLAB ExacTrac IGRT, Varian Linac but with the m3 collimator:
View attachment 398820

I received a SCATHING white hot letter of condemnation and damnation from the neuro-ophth lady MD prior to the RT basically warning me I was going to blind the guy, ruin any potential for a surgery, and she would report me for malpractice. Of course, I treated him. His vision improvement was rather remarkable, and he was so happy with his outcome. He brought a newspaper to one visit showing me how he could read small letters he couldn't read before. I saw him for 5 years and then released him. I never heard from neuro-ophth lady, positively or negatively. The patient quit following with her about 6 months after the radiation. (His MRI went to normal, too.)

Most recently, I treated a very active farmer guy with rheumatoid arthritis and really gnarly looking and painful hands interfering with his hay baling. I treated him 3 Gy/6 fx. His improvement was remarkable too, and even visually the hands improved. The patient was most grateful and he weaned off his RA meds. His rheumatologist, per the patient, was very reluctant to credit the RT however. (I treated him for free because we could not get insurance auth for RA.)



pubmed.ncbi.nlm.nih.gov

Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy - PubMed

The aim of palliative thoracic radiotherapy in patients with advanced non-small cell lung cancer (NSCLC) is to alleviate symptoms. This study was designed to determine whether any patients achieved long-term survival after this treatment. In Edinburgh, between 1974 and 1993, 4531 patients were...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Anna Gregor. One of the best rad oncs of which many people have never heard.
Click to expand...

I'm hoping you continued to send the neuro-ophth doc happy updates for years
 
Woman with SCC of the vaginal stump, having had prior brachy to that area iirc. Recurrence touching/invading the sigmoid, with multiple positive nodes going up the PA chain. She said she just wanted to see her son graduate high school next year. Treated with definitive chemoRT and adjuvant pembro. She saw her son graduate high school, college, and get married. Saw grandkids. 8 plus years out now. She still sends me pictures/updates every 6 months with her scans.
 
I have a 58 yo woman with EGFR+ NSCLC on Osi with rapidly enlarging oligoprogressive 8cm LLL/hilar mass that I treated with 15 fx dose painting in 2020 (needed O2 during RT bc the airway was putting pressure on the LLL when she lay flat) -responded by the end of tx and shrunk away to nothing in a few months, one year later SBRTed an iliac lesion, one later treated her sacrum. She’s been disease free on osi since, and just got back from hiking in the SW.

I have a 60ish guy who had refractory VT and had profound agoraphobia because he went down twice while shopping and woke up to AICD shock and EMS… treated him with CRA and has been shock free for 2 years and plays bridge once week now with close friends.


Also have a 35 yo woman with mNEC whom I treated in 2022 with a very large mass in front of her celiac plexus. She had a 2 yo daughter at the time and she was heartbroken that she had too much abdominal pain to sit on the floor with her. Treated it with 15 fx dose painting and it melted. I have since treated her a to a few other spots her abdomen. She evidently told her daughter (now 5) this story I saw her last week and she told me that her daughter made her promise to thank me from her.


Btw, great thread!
 
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Had a guy about 5 years ago who had an in gland recurrence maybe 10 years after prior radiation the essentially replaced the entire prostate with tumor. He couldn’t pee and urology was going to put a suprapubic in. He had been on ADT a couple years but was now castrate resistant. Came to me not wanting a suprapubic. I didn’t want to do Brachy or SBRT with his obstruction but also felt like 30/10 never did anything. Figured I’d give hyperfrac a try and took the prostate to 45/30 BID. In a month, had complete symptom resolution and PSA went form 8 to around 0.2. Stopped ADT and went about 2 years without progression. I SBRTd a new node and we are now 4 years out with biochemical control and still good symptom control. Saw him last week and still going strong. Not sure it’s my singular proudest case, but I tried something pretty creative and got an amazing outcome.
 
I've got a twist on the optic nerve sheath meningioma case.

A pregnant woman in her 30s in the late first trimester presented to emergency with progressive monocular vision loss. Workup including MRI without contrast concluded that the only reasonable diagnosis was ONSM, likely fueled by hormones of pregnancy.

She came to me via my chairman and discussed the options. We decided to proceed with MRI with contrast to best define the target and intensity modulated proton radiation. Physics best calculations and simulations indicated less than 1 mSv to fetus from neutron scatter and daily kV for matching.

Her vision improved with treatment and has stayed 20/20 ever since. She had a full term baby boy without defects who is developing normally.

I've had some other interesting proton wins. Proton craniospinal was a battle between my department and I as leadership didn't want to do it, but therapy, physics, and I did. I was told at one point to never do it again for LMD, and I kept doing it anyway. Did I mention I've never had a good relationship with administrators?

Well anyway... I was referred a patient in her 30s with young children and leptomeningeal disease with cranial neuropathies from triple positive breast cancer. The therapy team affectionately calls her "the fainting goat" due pressure waves that caused her to pass out every so often somewhat randomly. We got her through proton craniospinal somehow. She improved somewhat after that, the pressure waves subsided, though she was stuck with cranial neuropathies and imbalance.

My experience with proton CSI is that some patients crash and burn regardless and some surprise you. Well, this patient is still alive years later. I stabilized her enough to start a clinical trial a few months later that has worked and she is still with us. Even my therapy team can't believe that one.

One more thing briefly, I used to have docs in my department including administration as well as insurance fight me on radiosurgery cases for patients with many or rapidly progressive brain mets. I was told I had to do whole brain. Several of those patients were managed with SRS alone and lived or have lived several years without any neurologic side effects. Most recently was a guy who years ago transferred care to another cancer center for some chemo trial who was told there he had LMD based on MRI and needed to go hospice. He came back to me and I treated his something like 20 cerebellar brain mets with SRS and he never developed a new brain met. He's still out riding his motorcycle.
 
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Palex80 said:
1. Female patient in her early 30s with an non-resectable diffuse astrocytoma of the brainstem.
She was bed-ridden due to horrible headaches and vertigo.

I ended up doing 59.4/1.8, med onc didn't want to give chemo due to poor PS.
Click to expand...

Wow! How long out is she? I've had similar situations, but improvements this dramatic are uncommon and they usually recur in around a year.
 
Id' have to think about this more, but off the top of my head...

I had been meaning to update this, but I asked for help on this board on this case (esophageal/GE Jxn mediastinal failure)...my man is still alive NED ECOG1 working full time traveling and doing great.
s/p carbo/taxol CROSS 2018 --> esophagectomy . Solitary nodal failure tx'd with 60/15 2000. Then other upper mediastinal nodal /sclv failures treated with long course compreshensive xrt with xeloda then 1 year of immunotherapy 2022.

B

Thread 'Esophageal nodal failure -'

Hello. Looking for any input on this challenging case.

58 yo male, obese. neoadj chemo (carbo/taxol)-XRT (50.4 Gy total dose as 41.4 then boost gross disease) for cT3N0 GE junction adeno completed 7/2018. Ivor Lewis Esophagectomy 10/2018 with 4mm residual disease ypT1bN2 (4 nodes + out of 18 submitted).

1 year later (11/2019) on imaging he has a high level 4R mediastinal node look slightly larger. It is above his anastomosis (at carina) and above his prior radiation. It's hot on PET (no other sites of disease); EUS biopsy + for adeno, Her2 (-). He completes...
  • Like

I have an active Trigeminal practice as well. And though some days are better than others, I see some end of ht eline literally suicidal people with so much pain. I had a grandma tell me yesterday at her 90 days post gamma knife she played in the cold wind and snow with her grandkids for the first time and it was the best winter she's ever had. Off all meds, no pain. Doesn't always happen that way but that's a big win.
 
BobbyHeenan said:
Id' have to think about this more, but off the top of my head...

I had been meaning to update this, but I asked for help on this board on this case (esophageal/GE Jxn mediastinal failure)...my man is still alive NED ECOG1 working full time traveling and doing great.
s/p carbo/taxol CROSS 2018 --> esophagectomy . Solitary nodal failure tx'd with 60/15 2000. Then other upper mediastinal nodal /sclv failures treated with long course compreshensive xrt with xeloda then 1 year of immunotherapy 2022.

B

Thread 'Esophageal nodal failure -'

Hello. Looking for any input on this challenging case.

58 yo male, obese. neoadj chemo (carbo/taxol)-XRT (50.4 Gy total dose as 41.4 then boost gross disease) for cT3N0 GE junction adeno completed 7/2018. Ivor Lewis Esophagectomy 10/2018 with 4mm residual disease ypT1bN2 (4 nodes + out of 18 submitted).

1 year later (11/2019) on imaging he has a high level 4R mediastinal node look slightly larger. It is above his anastomosis (at carina) and above his prior radiation. It's hot on PET (no other sites of disease); EUS biopsy + for adeno, Her2 (-). He completes...
  • Like

I have an active Trigeminal practice as well. And though some days are better than others, I see some end of ht eline literally suicidal people with so much pain. I had a grandma tell me yesterday at her 90 days post gamma knife she played in the cold wind and snow with her grandkids for the first time and it was the best winter she's ever had. Off all meds, no pain. Doesn't always happen that way but that's a big win.
Click to expand...
Trigems are great.

And @Neuronix I should have said optic nerve sheath meningioma, as it probably was, but I am rather sure through the fog of history through which I now look he came to me styled as a glioma.
 
BobbyHeenan said:
Id' have to think about this more, but off the top of my head...

I had been meaning to update this, but I asked for help on this board on this case (esophageal/GE Jxn mediastinal failure)...my man is still alive NED ECOG1 working full time traveling and doing great.
s/p carbo/taxol CROSS 2018 --> esophagectomy . Solitary nodal failure tx'd with 60/15 2000. Then other upper mediastinal nodal /sclv failures treated with long course compreshensive xrt with xeloda then 1 year of immunotherapy 2022.

B

Thread 'Esophageal nodal failure -'

Hello. Looking for any input on this challenging case.

58 yo male, obese. neoadj chemo (carbo/taxol)-XRT (50.4 Gy total dose as 41.4 then boost gross disease) for cT3N0 GE junction adeno completed 7/2018. Ivor Lewis Esophagectomy 10/2018 with 4mm residual disease ypT1bN2 (4 nodes + out of 18 submitted).

1 year later (11/2019) on imaging he has a high level 4R mediastinal node look slightly larger. It is above his anastomosis (at carina) and above his prior radiation. It's hot on PET (no other sites of disease); EUS biopsy + for adeno, Her2 (-). He completes...
  • Like

I have an active Trigeminal practice as well. And though some days are better than others, I see some end of ht eline literally suicidal people with so much pain. I had a grandma tell me yesterday at her 90 days post gamma knife she played in the cold wind and snow with her grandkids for the first time and it was the best winter she's ever had. Off all meds, no pain. Doesn't always happen that way but that's a big win.
Click to expand...
I’ve got 2 of these > 5 years out now and I agree completely! Both distal tumors that had solitary supraclav recurrences we treated with SBRT instead of chemo. In both cases, our super reasonable oncologist (who sadly since retired) figured he would start chemo when they progressed further (which has yet to happen) instead of worsening their neuropathy upfront. EAC is definitely a bad idea, but the idea that failures can’t be salvaged is false. Just throwing up your hands and only doing palliative systemic therapy may be selling some of these folks short.
 
I'll add another one - Back in 2012 I saw a very impoverished patient with an oral tongue primary from a very small town. She tried to go see a large, internationally-known cancer center which tries to Make Cancer History, only to be told they needed $30,000 up front to even see her. To her it might as well have been $30 billion.

How a state-funded institution can deny care to its own citizens is beyond me, but she eventually made my way to our clinic, and we treated her with definitive chemoradiation therapy (it was way too advanced for resection) 100% for free. No cost to her. I felt really privileged to have a practice that had the resources to help her and a culture which encourages it. We're now 13 years out and every several months I get an electronic request for an Evoxac refill. Makes me smile every time I see it.
 
TheWallnerus said:
Very early in my career I got a referral from a family practice guy, who was in my multi-specialty group, for a fellow with an optic nerve sheath glioma. Over a period of a couple years he was slowly losing vision in the affected eye. He was in his mid-50s. He had consulted with a neurosurgeon, but the "captain of his ship" was this neuro-ophth lady in my home state who was SUPER well known and well respected. So I saw the guy, and I recommended RT. I came up with a most beautiful IMRT plan, for the era, giving the visible tumor like 102% of the Rx dose and the nerve like 95-98%... 50.4/28 iirc. BrainLAB ExacTrac IGRT, Varian Linac but with the m3 collimator:
View attachment 398820

I received a SCATHING white hot letter of condemnation and damnation from the neuro-ophth lady MD prior to the RT basically warning me I was going to blind the guy, ruin any potential for a surgery, and she would report me for malpractice. Of course, I treated him. His vision improvement was rather remarkable, and he was so happy with his outcome. He brought a newspaper to one visit showing me how he could read small letters he couldn't read before. I saw him for 5 years and then released him. I never heard from neuro-ophth lady, positively or negatively. The patient quit following with her about 6 months after the radiation. (His MRI went to normal, too.)

Most recently, I treated a very active farmer guy with rheumatoid arthritis and really gnarly looking and painful hands interfering with his hay baling. I treated him 3 Gy/6 fx. His improvement was remarkable too, and even visually the hands improved. The patient was most grateful and he weaned off his RA meds. His rheumatologist, per the patient, was very reluctant to credit the RT however. (I treated him for free because we could not get insurance auth for RA.)



pubmed.ncbi.nlm.nih.gov

Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy - PubMed

The aim of palliative thoracic radiotherapy in patients with advanced non-small cell lung cancer (NSCLC) is to alleviate symptoms. This study was designed to determine whether any patients achieved long-term survival after this treatment. In Edinburgh, between 1974 and 1993, 4531 patients were...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Anna Gregor. One of the best rad oncs of which many people have never heard.
Click to expand...
Did the Neuro-Opth MD ever say anything to you afterwards?
 
87 y/o with recurrent Merkel cell after initial resection of pre-auricular lesion (deferred adjuvant XRT), and re-resection at first recurrence with adjuvant IMRT. Second recurrence widespread through dermal lymphatics (Merkel does this) and covered nearly half of the face.

Placed wet wash cloths on half of face and treated wide field 30/10, ensuring dose to skin throughout volume. Complete response without recurrence for years. Stopped f/u due to senescence.

Delivered 3 courses of XRT for multiply recurrent GBM....got 5 years and made it to son's wedding. Patient in mid 70's.

Have never delivered more than about 5 courses of thoracic SBRT. @OTN case is inspirational.
 
Gfunk6 said:
Did the Neuro-Opth MD ever say anything to you afterwards?
Click to expand...
Nothing! Rad onc is a little bit like aviation: referring MDs take all the incredible tech for granted, don’t know details on our intense culture of safety, and never say thank you for the almost boringly routine safe landings.
 
TheWallnerus said:
Very early in my career I got a referral from a family practice guy, who was in my multi-specialty group, for a fellow with an optic nerve sheath glioma. Over a period of a couple years he was slowly losing vision in the affected eye. He was in his mid-50s. He had consulted with a neurosurgeon, but the "captain of his ship" was this neuro-ophth lady in my home state who was SUPER well known and well respected. So I saw the guy, and I recommended RT. I came up with a most beautiful IMRT plan, for the era, giving the visible tumor like 102% of the Rx dose and the nerve like 95-98%... 50.4/28 iirc. BrainLAB ExacTrac IGRT, Varian Linac but with the m3 collimator:
View attachment 398820

I received a SCATHING white hot letter of condemnation and damnation from the neuro-ophth lady MD prior to the RT basically warning me I was going to blind the guy, ruin any potential for a surgery, and she would report me for malpractice. Of course, I treated him. His vision improvement was rather remarkable, and he was so happy with his outcome. He brought a newspaper to one visit showing me how he could read small letters he couldn't read before. I saw him for 5 years and then released him. I never heard from neuro-ophth lady, positively or negatively. The patient quit following with her about 6 months after the radiation. (His MRI went to normal, too.)

Most recently, I treated a very active farmer guy with rheumatoid arthritis and really gnarly looking and painful hands interfering with his hay baling. I treated him 3 Gy/6 fx. His improvement was remarkable too, and even visually the hands improved. The patient was most grateful and he weaned off his RA meds. His rheumatologist, per the patient, was very reluctant to credit the RT however. (I treated him for free because we could not get insurance auth for RA.)



pubmed.ncbi.nlm.nih.gov

Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy - PubMed

The aim of palliative thoracic radiotherapy in patients with advanced non-small cell lung cancer (NSCLC) is to alleviate symptoms. This study was designed to determine whether any patients achieved long-term survival after this treatment. In Edinburgh, between 1974 and 1993, 4531 patients were...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Anna Gregor. One of the best rad oncs of which many people have never heard.
Click to expand...
I have never met a neurosurgeon who cared abt prior xrt complicating surgery.
 
1 gbm lady. Hige, unresectable, butterfly gbm 6 years out chemo xrt ned. All my other stories are widespread mets getting palliative xrt hoping to live long enough to make some graduation... ended up on some of the early immuno trials and now ned a decade later.
 
About 1994.....7 y.o. with stage 4 Hodgkins and lung mets. Failed everything including BMT. Gave TNI and whole lung radiation. I saw her last at age 12, NED and playing full court basketball at a high level. I have several other miracles, but they are all in older patients.

Used cerrobend thin lung blocks FYI...HA!
 
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