Aggressive pancreatic schemes

[RickyScott]

Never heard of bowel perf. Once had a near fatal ulcer when treating (on protocol) with high dose gem 10 years ago.

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[ramsesthenice]

Never heard of bowel perf. Once had a near fatal ulcer when treating (on protocol) with high dose gem 10 years ago.

I haven’t seen one but they (perforations) can happen. I have had one case of a grade 5 non-healing GI bleed. Nothing about the case should have been high risk. 50/25 preop with Xeloda. All dose constraints met. It was a sad reminder that dose constraints predict a low but non zero chance of severe complications. Have yet to see anything major after SBRT or dose escalation.

 

[IRattending2021]

Bowel perforation. I haven't heard of any Grade V unless its bowel perf in this setting.

and we are talking about bowel perforation that cannot be surgical corrected or even managed with drain? Does the pancreatic protocol cause such a hostile environment for surgeons that surgical solution is no longer possiboebin that region?

 

[ramsesthenice]

and we are talking about bowel perforation that cannot be surgical corrected or even managed with drain? Does the pancreatic protocol cause such a hostile environment for surgeons that surgical solution is no longer possiboebin that region?

It’s not that it can’t but there are a few issues. The RT will affect wound healing after surgery. The bigger issues is these folks often have poor functional reserve and are at greater risk of acute mortality from any acute stressor than the general public. Last, a lot of these folks have had vague upper GI discomfort for some time and delays in diagnosis are unfortunately common.

 

[ramsesthenice]

2021 is already looking up. This thread made it page 2 with no mention of the job market. It’s a GD miracle!

 

[StIGMA]

The field needs to be willing to accept more risk for these sorts of treatments (Chris Crane-style), similar to how the field eventually accepted the risks for SBRT. In some settings it may be worthwhile to accept a 5% or more grade 5 toxicity risk. The average absolute risk will vary depending on who is conducting the treatment, similar to how pancreaticobiliary surgeons have different average outcomes. We are holding ourselves back with our complacency.

 

[medgator]

2021 is already looking up. This thread made it page 2 with no mention of the job market. It’s a GD miracle!

Monday is right around the corner

 

[FrostyHammer]

The field needs to be willing to accept more risk for these sorts of treatments (Chris Crane-style), similar to how the field eventually accepted the risks for SBRT. In some settings it may be worthwhile to accept a 5% or more grade 5 toxicity risk. The average absolute risk will vary depending on who is conducting the treatment, similar to how pancreaticobiliary surgeons have different average outcomes. We are holding ourselves back with our complacency.

Unfortunately, our field has too few Chris Cranes and too many Lisa Kachnics...

 

[evilbooyaa]

2021 is already looking up. This thread made it page 2 with no mention of the job market. It’s a GD miracle!

It's just the weekend...

The field needs to be willing to accept more risk for these sorts of treatments (Chris Crane-style), similar to how the field eventually accepted the risks for SBRT. In some settings it may be worthwhile to accept a 5% or more grade 5 toxicity risk. The average absolute risk will vary depending on who is conducting the treatment, similar to how pancreaticobiliary surgeons have different average outcomes. We are holding ourselves back with our complacency.

We as a field are always scared of anything that may approach any toxicity. Many people poo-poo SABR-COMET b/c of the Grade 5 toxicity rate and say that all SBRT is evil. Some are willing to push the envelope. I am willing to let others push the envelope, and if they can show safety (the way I believe Chris Crane has) then I can proceed.

While I am waiting for the right case to try and push dose, I'll probably want fiducials and a good tumor location before I go chasing for 75/25 or 67.5/15. My first one of these I'm probably going to want a body of pancreas tumor invading celiac axis, not nearly anything near head of pancreas. Not to say that folks who are doing it aren't doing it properly (Regardless of academic or PP), but I just don't have a ton of pancreas volume at my current site. I tried to get my GI attending in residency to do it but he was over 60 so he barely was agreeable to 33/5 (lots of 54/30 for unresectable patients after Gem/Abraxane)

 

[IRattending2021]

It’s not that it can’t but there are a few issues. The RT will affect wound healing after surgery. The bigger issues is these folks often have poor functional reserve and are at greater risk of acute mortality from any acute stressor than the general public. Last, a lot of these folks have had vague upper GI discomfort for some time and delays in diagnosis are unfortunately common.

i just find it fascinating that such a common disease is thought to be only treatable by a few, especially when the standard of care seem to be “aggressive palliation”.

In my field, if I am sending an IVC filter retrieval or a portal vein recanalization case to a different shop, it’s because we don’t have the laser sheath or intracardiac ultrasound the big shop has. Expertise level certainly play a part, and I refer those people out if I feel that they can truly benefit from a more experienced doc.

is this the same situation with pancreatic RT? Ablative dose cannot be achieved by most without MR Linac? What’s the secret sauce in those high volume centers? Or is it just experience?

could the more ablative pancreatic RT ever become the standard of care? Hypoethically speaking, I feel that many pt might take a 15% shot of living beyond 3-5 years and 5% chance of dying from RT versus essentially no chance of living beyond 2 years without any side effects.

 

[Ray D. Ayshun]

i just find it fascinating that such a common disease is thought to be only treatable by a few, especially when the standard of care seem to be “aggressive palliation”.

In my field, if I am sending an IVC filter retrieval or a portal vein recanalization case to a different shop, it’s because we don’t have the laser sheath or intracardiac ultrasound the big shop has. Expertise level certainly play a part, and I refer those people out if I feel that they can truly benefit from a more experienced doc.

is this the same situation with pancreatic RT? Ablative dose cannot be achieved by most without MR Linac? What’s the secret sauce in those high volume centers? Or is it just experience?

could the more ablative pancreatic RT ever become the standard of care? Hypoethically speaking, I feel that many pt might take a 15% shot of living beyond 3-5 years and 5% chance of dying from RT versus essentially no chance of living beyond 2 years without any side effects.

When I asked the original question, and made reference to the MR Linac, it was sort of tongue-in-cheek. The truth is, ablative doses can't be delivered by most even with an MR-Linac if you have to meet the duodenal constraints (for head lesions). The history of pancreas RT is one of somewhat improved local control in patient's in whom that didn't much matter given poor systemic options. Now, there seems to be better systemic therapy, which makes me think there will be more patients who come in after "passing" (my words) the chemo test, who would live longer if we could kill everything we could see. Is that worth a few severe toxicities? The surgeons seem to think so.

 

[ramsesthenice]

i just find it fascinating that such a common disease is thought to be only treatable by a few, especially when the standard of care seem to be “aggressive palliation”.

In my field, if I am sending an IVC filter retrieval or a portal vein recanalization case to a different shop, it’s because we don’t have the laser sheath or intracardiac ultrasound the big shop has. Expertise level certainly play a part, and I refer those people out if I feel that they can truly benefit from a more experienced doc.

is this the same situation with pancreatic RT? Ablative dose cannot be achieved by most without MR Linac? What’s the secret sauce in those high volume centers? Or is it just experience?

could the more ablative pancreatic RT ever become the standard of care? Hypoethically speaking, I feel that many pt might take a 15% shot of living beyond 3-5 years and 5% chance of dying from RT versus essentially no chance of living beyond 2 years without any side effects.

The role of any RT in unresectable pancreatic cancer is kind of a dumpster fire because as of yet, it doesn’t improve survival. People like me are very quick to point out how horrendous local progression can be for QOL and routinely offer it but I have the luxury of med oncs and surgeons who agree. So that’s the foundational layer. Now you are talking about doing something with a much higher risk of severe complications with an as of yet unproven benefit. For people in situations where they were not regularly doing RT in the first place, this is asking a lot. For those of us treating this disease a lot who appreciate just how ungratifying current SOC is, it can feel like a no brainer. There are lots of reasons for individual practitioners to feel conflicted. As to why the guidelines are written the way they are, see my above post referring to the political motivations of said writers.

To your last point I would bet a lot of money this will become at least “a” SOC once there is randomized data showing superiority to conventional RT schemes.

 

[drewdog1973]

The role of any RT in unresectable pancreatic cancer is kind of a dumpster fire because as of yet, it doesn’t improve survival. People like me are very quick to point out how horrendous local progression can be for QOL and routinely offer it but I have the luxury of med oncs and surgeons who agree. So that’s the foundational layer. Now you are talking about doing something with a much higher risk of severe complications with an as of yet unproven benefit. For people in situations where they were not regularly doing RT in the first place, this is asking a lot. For those of us treating this disease a lot who appreciate just how ungratifying current SOC is, it can feel like a no brainer. There are lots of reasons for individual practitioners to feel conflicted. As to why the guidelines are written the way they are, see my above post referring to the political motivations of said writers.

To your last point I would bet a lot of money this will become at least “a” SOC once there is randomized data showing superiority to conventional RT schemes.

I guess I struck a bit of a nerve. I guess main point is to be very detailed and thorough when doing this. Having seen nightmares of early IMRT (contouring strap muscles as “the neck node”, parotids, and that’s about it) and many reports of poor outcomes, this dose is particularly high and close to critical structures. But, yes, a community doc is very able to do this as good or better than academician. Just make sure someone who does a lot reviews a few cases!

Can you imagine the protocol ? Good lord. They would assume we are all dummies and dumb down everything.

 

[Reaganite]

The field needs to be willing to accept more risk for these sorts of treatments (Chris Crane-style), similar to how the field eventually accepted the risks for SBRT. In some settings it may be worthwhile to accept a 5% or more grade 5 toxicity risk. The average absolute risk will vary depending on who is conducting the treatment, similar to how pancreaticobiliary surgeons have different average outcomes. We are holding ourselves back with our complacency.

I've been on the verge of "pushing the envelope" several times in my career only to receive a call from some referring physician complaining about the mild skin reaction I caused his breast patient. The level of scrutiny our field is under as it pertains to side effects is insane. A patient dies during a high risk surgery, and it's an understood risk. Cause a mild skin reaction as a radonc, and you're the guy/gal who "burns" patients. If I killed even .1% of the pancreas patients sent my way, my referrals would dry up. I'd be the guy who burns and kills patients. I'm not sure how much of the reluctance to push the envelope is complacency vs. the ridiculous standards to avoid toxicity some of us are held to.

 

[metallica81788]

I've been on the verge of "pushing the envelope" several times in my career only to receive a call from some referring physician complaining about the mild skin reaction I caused his breast patient. The level of scrutiny our field is under as it pertains to side effects is insane. A patient dies during a high risk surgery, and it's an understood risk. Cause a mild skin reaction as a radonc, and you're the guy/gal who "burns" patients. If I killed even .1% of the pancreas patients sent my way, my referrals would dry up. I'd be the guy who burns and kills patients. I'm not sure how much of the reluctance to push the envelope is complacency vs. the ridiculous standards to avoid toxicity some of us are held to.

I've heard this mentioned by many people as why they tend to overfractionate things. Some of my colleagues entered hospital or PP jobs with longer term partner telling them not to hypofractionate because "we don't want to burn people they will stop referring", etc

 

[ramsesthenice]

I've been on the verge of "pushing the envelope" several times in my career only to receive a call from some referring physician complaining about the mild skin reaction I caused his breast patient. The level of scrutiny our field is under as it pertains to side effects is insane. A patient dies during a high risk surgery, and it's an understood risk. Cause a mild skin reaction as a radonc, and you're the guy/gal who "burns" patients. If I killed even .1% of the pancreas patients sent my way, my referrals would dry up. I'd be the guy who burns and kills patients. I'm not sure how much of the reluctance to push the envelope is complacency vs. the ridiculous standards to avoid toxicity some of us are held to.

I distinctly remember being taught in medical school that if you do t take out a normal appendix from time to time then you are probably letting some bad things leave the hospital unaddressed. I do think that to an extent our goal is not to never cause a complication, but rather, strike the best balance between toxicity and efficacy.

 

[drewdog1973]

I've heard this mentioned by many people as why they tend to overfractionate things. Some of my colleagues entered hospital or PP jobs with longer term partner telling them not to hypofractionate because "we don't want to burn people they will stop referring", etc

Totally. If the cancer comes back because you underdosed, no big deal, because cancer comes back. But if you 'overdose'/push envelope and it leads to toxicity, you will lose referrals. This is very true. Hence the guys that still use 1.8s for everything...

 

[Reaganite]

Totally. If the cancer comes back because you underdosed, no big deal, because cancer comes back. But if you 'overdose'/push envelope and it leads to toxicity, you will lose referrals. This is very true. Hence the guys that still use 1.8s for everything...

My first week of practice nearly a decade ago a rad onc friend quoted me exactly this...Nobody stresses if a cancer comes back because that's what cancer does, but cause a toxicity and they'll remember that forever. Would never under-dose, but I'd give pause to push the envelope with aggressive schemes that could kill 5% of patients. As for the dosing, I definitely have referring doctors who specifically call me and say "don't ever do that 'HYPERfractionating' stuff or whatever you call it on my patients." I have one referring doctor convinced 'hyperfractionation' causes leukemia in breast cancer patients.

 

[medgator]

Totally. If the cancer comes back because you underdosed, no big deal, because cancer comes back. But if you 'overdose'/push envelope and it leads to toxicity, you will lose referrals. This is very true. Hence the guys that still use 1.8s for everything...

The breast hypofx data suggests better outcomes though. Outside of that, would agree

 

[FrostyHammer]

Totally. If the cancer comes back because you underdosed, no big deal, because cancer comes back. But if you 'overdose'/push envelope and it leads to toxicity, you will lose referrals. This is very true. Hence the guys that still use 1.8s for everything...

1.8s = yuck.
Sorry Reaganite for your horrendous referring docs... That ain't normal

 

[RadOncDoc21]

1.8s = yuck.
Sorry Reaganite for your horrendous referring docs... That ain't normal

Sounds like my environment. Just got blamed for “multi focal pneumonitis” on a patient with stage III lung on durvalumab with consolidation in both lungs, radiation didn’t even go to the other side but I have to take it like a champ (chump). Recently got blamed for causing a seroma on a breast patient after one fraction (Do I dare blame the only breast surgeon in the community?).

Unfortunately, I’m fighting against big time groups with well established referral chains so I’m extremely vulnerable. These are the things they don’t teach you in residency but definitely should in order to survive.

 

[BobbyHeenan]

Sounds like my environment. Just got blamed for “multi focal pneumonitis” on a patient with stage III lung on durvalumab with consolidation in both lungs, radiation didn’t even go to the other side but I have to take it like a champ (chump). Recently got blamed for causing a seroma on a breast patient after one fraction (Do I dare blame the only breast surgeon in the community?).

Unfortunately, I’m fighting against big time groups iwith well established referral chains so I’m extremely vulnerable. These are the things they don’t teach you in residency but definitely should in order to survive.

Reminds me of when the plastic surgeon blamed me for an implant infection the patient got mid way through radiation. By what mechanism of action does radiation put staph in a patient?

His notes all say "radiation induced infection" or something like that.

 

[RadOncDoc21]

Reminds me of when the plastic surgeon blamed me for an implant infection the patient got mid way through radiation. By what mechanism of action does radiation put staph in a patient?

His notes all say "radiation induced infection" or something like that.

Oh I have stories for days on stuff like this... just put the words “radiation induced” in front of it and that’s the answer!

I hear radiation induced staph infections are the worst!

 

[Ray D. Ayshun]

Oh I have stories for days on stuff like this... just put the words “radiation induced” in front of it and that’s the answer!

I hear radiation induced staph infections are the worst!

How do you think that **** became resistant to methicillin?

 

[RadOncDoc21]

How do you think that **** became resistant to methicillin?

Lol makes sense!

 

[medgator]

How do you think that **** became resistant to methicillin?

The same mechanism that the radioactive spider had on Peter parker?

 

[Ray D. Ayshun]

The same mechanism that the radioactive spider had on Peter parker?

Exactly. Sometimes radiation makes good mutants, sometimes bad.

 

[xrt123]

I go to a bunch of tumor boards and when ever there is a complication prior to therapy I call it pre-radiation induced. I think it drives home the point to not blame me for everything.

 

[drewdog1973]

That is awesome

 

[GI_RadOnc]

This is an excellent thread! I think the recipe to deliver ablative radiation therapy to pancreas is well described in this article, as mentioned by @drewdog1973 Ablative radiation therapy for locally advanced pancreatic cancer: techniques and results. Fiducials make it easier for your team to align the patient; and breath hold is important to be able to review the duodenum offline. I followed the instructions here, with a call to Dr. Reyngold for my first case, and have used this a few times when the patient is not a MR-linac 50 Gy / 5 fraction candidate. Those patients are not doing better than or worse than my other radiation patients.

I don't think this is 'just' for academic centers; and obviously in a community practice one needs to select the correct patients and referring physician team to offer aggressive therapy to. I think, if something went awry, you would have a good choice of 'expert witnesses' who would be happy to point out that you didn't give ineffective chemoradiation (Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial - PubMed) or an SBRT regimen that closed early for borderline resectable pancreatic cancer patients (Combination Chemotherapy With or Without Hypofractionated Radiation Therapy Before Surgery in Treating Patients With Pancreatic Cancer - Full Text View - ClinicalTrials.gov).

I don't know if ablative pancreas radiation is going to be the 'answer' that moves the radiation needle for pancreatic cancer, which is bereft of positive evidence. But the preliminary data is promising; and combined with the strong negative data from standard approaches, it merits using in the correct patient... or sending them to someone (academic/private/community whatever) who would consider it.

 

[Ray D. Ayshun]

In order to not start a new panc thread I'll revive this one. Different scenario being BR panc cancer with plans for whipple. Wondering if people are doing preopanc regimen (though perhaps modified as most patients who are fit are starting with folfirinox now), but the RT part, 3 weeks of gemRT. Otherwise, classic long course? In the event that surgery is aborted, I'm wondering what it's better to have given.

Edit: 1 answer: from Crane:

"Low dose small-volume SBRT should not be used in the preoperative setting for pancreatic cancer. It was never a good idea to begin with. Due to very tight margins of 2-5 mm on the GTV, it has resulted in 30-50% marginal miss resulting in local recurrences outside of the treated volume now reported in 2 studies from the US and 1 from China. This should never happened with any neoadjuvant treatment. Furthermore, an interim analysis of a randomized trial from the Alliance which was evaluating neoadjuvant chemotherapy followed by low dose small-volume SBRT versus chemotherapy alone has been performed that showed futility of the SBRT to improve outcomes in the arm was discontinued. Taken with other negative radiation therapy trials in pancreatic cancer, this is an ominous result for the the acceptance of a standard use of radiation in general for BRPC, an indication which seemed to be an obvious benefit based on the results showing reduced positive margin rate.

It is hard to understand why anyone would even think this would be an advance over standard 3-D conformal radiation. Shrinking the volume and a preoperative setting is not an acceptable trade-off for this slight amount of convenience that it allows.

The use of low-dose small-volume SBRT in the preoperative setting has become so common that medical oncologist and surgeons do prefer the convenience of a one-week regimen. For this reason we have shortened our course of preoperative treatment from the standard 50.4Gy in 28# to 36Gy in 12# treating wide margins on the tumor and the regional lymphatics. Results from our treatment with 30Gy in 10# at M.D. Anderson showed similar results to 50.4Gy with less than 10% margin positive rate and overall local tumor control rate of 80% for both groups. We selected the more favorable patients without gross tumor near the arterial margins to receive 30Gy, so there was some selection. For this reason, we have increased to 36Gy. If there is a lot of stomach volume or if the whole duodenum needs to be treated for an extensive tumor, we use 35Gy in 14 #."

but still curious what others think.

 

[metview]

If surgery is aborted, then I think long course (50.4 Gy) is better than the 30/10 or 35/14 because of the higher dose which would have better LC. However, if pt's are undergoing surgery, then they are equivalent in terms of R0 resection rates.

If surgical status is uncertain, then doing something like 40 Gy in 5 fractions or 50.4 Gy (w/ 8 Gy boost) in 1.8s make more sense. If there is a very good chance of the Whipple, then 33 Gy/5 or the fractionation (10-15 fx) mentioned by Crane but making sure to cover draining LN regions regardless of what you choose.

 

[Krukenberg]

If surgery is aborted, then I think long course (50.4 Gy) is better than the 30/10 or 35/14 because of the higher dose which would have better LC. However, if pt's are undergoing surgery, then they are equivalent in terms of R0 resection rates.

If surgical status is uncertain, then doing something like 40 Gy in 5 fractions or 50.4 Gy (w/ 8 Gy boost) in 1.8s make more sense. If there is a very good chance of the Whipple, then 33 Gy/5 or the fractionation (10-15 fx) mentioned by Crane but making sure to cover draining LN regions regardless of what you choose.

If the surgery is aborted, the patient is screwed with or without 50.4

 

[salubalu]

If the surgery is aborted, the patient is screwed with or without 50.4

I have an 80 yo patient who had a whipple 9 months ago with positive margins and 6/20 positive nodes had 6 cycles of xeloda and gemzar. Post chemo ct shows a 3 cm local recurrence in the region of the pancreatic body abutting the stomach and compressing the portal confluence. No distant Mets on pet.
She was referred for SBRT and I do pancreas SBRT routinely but she’s refusing fiducials and I am hesitant on its proximity to stomach. She lives 2 hours away from any radiation center and doesn’t prefer a 5-6 week course of rt. I haven’t done a crane approach. What would y’all do?

 

[Palex80]

Edit: 1 answer: from Crane:

"Low dose small-volume SBRT should not be used in the preoperative setting for pancreatic cancer. It was never a good idea to begin with. Due to very tight margins of 2-5 mm on the GTV, it has resulted in 30-50% marginal miss resulting in local recurrences outside of the treated volume now reported in 2 studies from the US and 1 from China. This should never happened with any neoadjuvant treatment.

Although I do understand the concern, this still is pancreatic cancer... My feeling is that patients will experience recurrences and I am not aware of any good data showing lower recurrence rates with larger margins and ENI or smaller margins without ENI in pancreatic cancer. There is even some quite good data pointing out that "traditional" large-volume RT including ENI is not beneficial at all in irresectable pancreatic cancer,
I do see the rational in SBRT, targetting for dose painting to the area where the surgeons have most problems achieving a clear margin (--> vessels) and the fact that probably only small volume short-course targetted radiotherapy (--> SBRT) is feasible if one opts for an FOLFIRINOX-based induction therapy.

My feeling is that a proper neoadjuvant strategy should include:
a) PREOPANC-style chemoradiotherapy or
b) FOLFIRINOX +/- small-volume RT (which may be SBRT and reserved for those patients were doubts exist concerning achieving clear resection margins).

 

[medgator]

If the surgery is aborted, the patient is screwed with or without 50.4

Disagree... esp with 54-56. Have seen some long-term durable responses, 1-2 years on average, certainly better than doing nothing.

 

[salubalu]

Disagree... esp with 54-56. Have seen some long-term durable responses, 1-2 years on average, certainly better than doing nothing.

Or after an interstitial boost

 

[ramsesthenice]

Although I do understand the concern, this still is pancreatic cancer... My feeling is that patients will experience recurrences and I am not aware of any good data showing lower recurrence rates with larger margins and ENI or smaller margins without ENI in pancreatic cancer. There is even some quite good data pointing out that "traditional" large-volume RT including ENI is not beneficial at all in irresectable pancreatic cancer,
I do see the rational in SBRT, targetting for dose painting to the area where the surgeons have most problems achieving a clear margin (--> vessels) and the fact that probably only small volume short-course targetted radiotherapy (--> SBRT) is feasible if one opts for an FOLFIRINOX-based induction therapy.

My feeling is that a proper neoadjuvant strategy should include:
a) PREOPANC-style chemoradiotherapy or
b) FOLFIRINOX +/- small-volume RT (which may be SBRT and reserved for those patients were doubts exist concerning achieving clear resection margins).

I’ll second your thoughts on ENI. I’ll treat gross nodes and I always end up with some ENI but nothing like the traditional volumes. Isolated nodal failures are just not that common.

I have an 80 yo patient who had a whipple 9 months ago with positive margins and 6/20 positive nodes had 6 cycles of xeloda and gemzar. Post chemo ct shows a 3 cm local recurrence in the region of the pancreatic body abutting the stomach and compressing the portal confluence. No distant Mets on pet.
She was referred for SBRT and I do pancreas SBRT routinely but she’s refusing fiducials and I am hesitant on its proximity to stomach. She lives 2 hours away from any radiation center and doesn’t prefer a 5-6 week course of rt. I haven’t done a crane approach. What would y’all do?

I am honestly not sure why you would feel much better about this in that situation. It’s more fractionated but the high dose expansions still depend on good target and avoidance localization. I do both under MRI or fiducials.

 

[Palex80]

I have an 80 yo patient who had a whipple 9 months ago with positive margins and 6/20 positive nodes had 6 cycles of xeloda and gemzar. Post chemo ct shows a 3 cm local recurrence in the region of the pancreatic body abutting the stomach and compressing the portal confluence. No distant Mets on pet.
She was referred for SBRT and I do pancreas SBRT routinely but she’s refusing fiducials and I am hesitant on its proximity to stomach. She lives 2 hours away from any radiation center and doesn’t prefer a 5-6 week course of rt. I haven’t done a crane approach. What would y’all do?

I thought the "Crane approach" was actually for patients presenting with unresectable primary disease not recurrent tumors. The entire anatomy is totally different. The patient you describe is a) 80 years old b) presenting with a local recurrence 6 months after surgery.
My feeling: this is pure palliation. Either irradiate now or later (when symptomatic) with a palliative dose. 36/3, 25/5 are common regimes, don't push it.
I woulnd't use MRI or fiducials for that. Just sim and treat with an empty stomach.

 

[RickyScott]

I thought the "Crane approach" was actually for patients presenting with unresectable primary disease not recurrent tumors. The entire anatomy is totally different. The patient you describe is a) 80 years old b) presenting with a local recurrence 6 months after surgery.
My feeling: this is pure palliation. Either irradiate now or later (when symptomatic) with a palliative dose. 36/3, 25/5 are common regimes, don't push it.
I woulnd't use MRI or fiducials for that. Just sim and treat with an empty stomach.

Would go as high as anatomy allows.

 

[StIGMA]

I have an 80 yo patient who had a whipple 9 months ago with positive margins and 6/20 positive nodes had 6 cycles of xeloda and gemzar. Post chemo ct shows a 3 cm local recurrence in the region of the pancreatic body abutting the stomach and compressing the portal confluence. No distant Mets on pet.
She was referred for SBRT and I do pancreas SBRT routinely but she’s refusing fiducials and I am hesitant on its proximity to stomach. She lives 2 hours away from any radiation center and doesn’t prefer a 5-6 week course of rt. I haven’t done a crane approach. What would y’all do?

Tumor grew through chemo and is abutting stomach and jejunum at anastomosis in area of positive margin. You are up against tolerances- which is palliative SBRT (<=33 Gy; lower here (5x5) advisable as Palex suggested in this case b/c bowel) or palliative fractionated - but can't go anything close to definitive dose. Choice of treatment is really patient-driven with a goals of care discussion.

 

[TheWallnerus]

Did peak rad onc cause aggressive pancreas schemes? "I have conquered the SAT. I conquered the MCAT. I dominated med school. I got into the most competitive specialty in all of medicine, rad onc. And look at you, pancreas. Sitting there with your awful survivals and horrible local controls. What a loser. You've never seen the likes of a physician such as myself. I will outthink you. I will outmaneuver you. There is no radiation dose I am not willing to beam into you. I have a dial here attached to a powerful computer only I can understand that I can turn and turn and turn. I will defeat you." And pancreas is like Casey in "Loki" sitting there with all the infinity stones in his desk drawer.

 

[Neuronix]

Apparently we should just freeze all rad onc technology development or any attempts to treat pancreas cancer any more aggressively because that is futile and the cancer will win anyway. So spoke TheWallnerus.

PS: We're treating 50/5 more generously and the lymph node basins with 5 fraction high dose now too. Come at me bro. Enroll on SMART trial when we can.

 

[TheWallnerus]

Apparently we should just freeze all rad onc technology development or any attempts to treat pancreas cancer any more aggressively because that is futile and the cancer will win anyway. So spoke TheWallnerus.

PS: We're treating 50/5 more generously and the lymph node basins with 5 fraction high dose now too. Come at me bro. Enroll on SMART trial when we can.

AGGRESSIVE. Grrr. If I saw a guy using a hammer on a screw I wouldn’t call him aggressive.

 

[Palex80]

Pancreatic cancer is something special for every radiation oncologist.

It is the ONLY cancer where in the setting of M0-disease:
a) the role of adjuvant radiation therapy is questionable, even after marginal (R1) resections
b) the role of definitive radiation therapy is quesionable in unresectable tumors

I am aware that radiation oncologists in the US treat alot more pancreatic cancer than we do over here in Europe.
However, I cannot think of any other (common) tumor, where both these principles apply. Perhaps hepatocellular carcinoma is an exception, although this is probably because other non-surgical options exist for that tumor (if RFA/TACE/MW-ablation didn't exist, RT would be the preferred non-surgical option).

Can you think of any other tumor?

 

[TheWallnerus]

Pancreatic cancer is something special for every radiation oncologist.

It is the ONLY cancer where in the setting of M0-disease:
a) the role of adjuvant radiation therapy is questionable, even after marginal (R1) resections
b) the role of definitive radiation therapy is quesionable in unresectable tumors

I am aware that radiation oncologists in the US treat alot more pancreatic cancer than we do over here in Europe.
However, I cannot think of any other (common) tumor, where both these principles apply. Perhaps hepatocellular carcinoma is an exception, although this is probably because other non-surgical options exist for that tumor (if RFA/TACE/MW-ablation didn't exist, RT would be the preferred non-surgical option).

Can you think of any other tumor?

So you’re saying radiation is questionable 😁

That there is no known dose of ionizing radiation that will not kill a eukaryotic cell is a... seductive fact.

 

[Neuronix]

AGGRESSIVE. Grrr. If I saw a guy using a hammer on a screw I wouldn’t call him aggressive.

It's a good thing we're not working on screws.

I get that it's a metaphor. I don't think it's a good one for this situation.

That there is no known dose of ionizing radiation that will not kill a eukaryotic cell is a... seductive fact.

This is a pretty silly statement considering how many H&N cancers are cured by RT alone.

 

[TheWallnerus]

It's a good thing we're not working on screws.

I get that it's a metaphor. I don't think it's a good one for this situation.

Again with the Loki reference... I speak in metaphors. It makes me seem super smart.

Rad oncs. Getting mad when someone throws shade on pancreatic irradiation since the Time Variance Authority was founded.

DEFINE_ME

 

[TheWallnerus]

It's a good thing we're not working on screws.

I get that it's a metaphor. I don't think it's a good one for this situation.



This is a pretty silly statement considering how many H&N cancers are cured by RT alone.

And the fact that so many head and cancers are cured by RT alone is even more seductive!

 

[communitydoc13]

And pancreas is like Casey in "Loki" sitting there with all the infinity stones in his desk drawer.

From the best radiation series (MSKCC ablative doses): LC at 1 year 82%, Median PFS after XRT just 6.3 mos. Just a competing risk story, simple as that. Each infinity stone is a metastatic pathway.