Bone met reirradiation

[Ray D. Ayshun]

Seeing a guy with a rib met from prostate cancer that got 30/10 two years ago who has had progression at the edge of the field. Wondering if people are continuing with standard palliative stuff here or would think so about sbrt, 30/5, etc.

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[fiji128]

I would think with sbrt your chance of rib fracture would go way up compared to conventional fractionation in this scenario.

 

[thecarbonionangle]

chance of fracture probably higher but honestly i would do sbrt. 8-10x3, 12x2

 

[elementaryschooleconomics]

For patients like this, my choice depends on everything else going on with him.

Good KPS, disease otherwise well controlled, etc? Yeah I'd probably do 30/5 (agree about rib fracture risk, but depends on size blah blah). I don't love the 12x2 regimen literally only because I'd want VMAT for that and it's REALLY hard to get insurance approval for palliative VMAT for me. This is more of a local/"my department" issue (I don't get folks knocking on my door if I tell them to shutup and bill 3D for 5 fraction, I will get frantic hand-flapping if I say the same thing about two-fraction schemes though).

Terrible KPS, non-zero chance he goes hospice in the next few months? 8x1 or 20/5.

Some weird scenario where he's doing well but you're worried about adjacent OARs and whatnot with re-irradiation? 39/13 or 45/15 are my "I want something slightly spicy but not SBRT level" favorites.

No wrong choice really.

 

[deleted1111261]

3-5 fx with vmat/sbrt

 

[communitydoc13]

is 35/5 a pretty standard 5 fraction regimen for SBRT bone for you folks? Seems like a reasonable and conservative dose for ribs and the like.

 

[ramsesthenice]

Seeing a guy with a rib met from prostate cancer that got 30/10 two years ago who has had progression at the edge of the field. Wondering if people are continuing with standard palliative stuff here or would think so about sbrt, 30/5, etc.

What is the goal? You already have a good idea of the best case response to 30/10. If you want anything better, might want to do something different. If the same outcome (or similar) is acceptable, no problem just repeating.

 

[OTN]

Is it his only gross site of disease? If so, might make sense to try and dose escalate, but SBRT has a very high chance to cause a rib fx. If he has other sites of disease, I would fractionate, as you're treating for palliation at that point, not increasing survival.

 

[thecarbonionangle]

is 35/5 a pretty standard 5 fraction regimen for SBRT bone for you folks? Seems like a reasonable and conservative dose for ribs and the like.

Yes 6-8 x5 is fine too.

 

[Ray D. Ayshun]

What is the goal? You already have a good idea of the best case response to 30/10. If you want anything better, might want to do something different. If the same outcome (or similar) is acceptable, no problem just repeating.

Exactly

 

[TheWallnerus]

Two years out from a palliative dose of 30 Gy in 10 fx to a painful rib met, a prostate cancer patient has progression. A decision is made to reirradiate. What is the most reasonable option for retreatment.

Just AS PRESENTED with no further elaboration and you were getting the above case vignette on OLA and here are your multiple choices what do you pick for re RT.

A, 30 Gy/10 fx
B. 8 Gy/1 fx
C. 30 Gy/5 fx
D. 24 Gy/2 fx
E. 45 Gy/15 fx

 

[Ray D. Ayshun]

Two years out from a palliative dose of 30 Gy in 10 fx to a painful rib met, a prostate cancer patient has progression. A decision is made to reirradiate. What is the most reasonable option for retreatment.

Just AS PRESENTED with no further elaboration and you were getting the above case vignette on OLA and here are your multiple choices what do you pick for re RT.

A, 30 Gy/10 fx
B. 8 Gy/1 fx
C. 30 Gy/5 fx
D. 24 Gy/2 fx
E. 45 Gy/15 fx

F. all of the above.

 

[thesauce]

Two years out from a palliative dose of 30 Gy in 10 fx to a painful rib met, a prostate cancer patient has progression. A decision is made to reirradiate. What is the most reasonable option for retreatment.

Just AS PRESENTED with no further elaboration and you were getting the above case vignette on OLA and here are your multiple choices what do you pick for re RT.

A, 30 Gy/10 fx
B. 8 Gy/1 fx
C. 30 Gy/5 fx
D. 24 Gy/2 fx
E. 45 Gy/15 fx

C

Somewhat confident

Very applicable

 

[Ray D. Ayshun]

Two years out from a palliative dose of 30 Gy in 10 fx to a painful rib met, a prostate cancer patient has progression. A decision is made to reirradiate. What is the most reasonable option for retreatment.

Just AS PRESENTED with no further elaboration and you were getting the above case vignette on OLA and here are your multiple choices what do you pick for re RT.

A, 30 Gy/10 fx
B. 8 Gy/1 fx
C. 30 Gy/5 fx
D. 24 Gy/2 fx
E. 45 Gy/15 fx

Rest of story is otherwise no progression elsewhere. Also, what if RCC, more definitely SBRT?

 

[communitydoc13]

Two years out from a palliative dose of 30 Gy in 10 fx to a painful rib met, a prostate cancer patient has progression. A decision is made to reirradiate. What is the most reasonable option for retreatment.

Just AS PRESENTED with no further elaboration and you were getting the above case vignette on OLA and here are your multiple choices what do you pick for re RT.

A, 30 Gy/10 fx
B. 8 Gy/1 fx
C. 30 Gy/5 fx
D. 24 Gy/2 fx
E. 45 Gy/15 fx

They're going for B. Answer how they want you to. NCIC-SC20

 

[madchemist89]

I would treat conventionally. There was no reason to believe that the original course would definitively treat the area. I wouldn't consider this a failure. Palliative rt worked just fine the first time. It should work again, and I would be cognizant about avoiding toxicity. This is all assuming that palliation was the original and currently intended goal.

 

[TheWallnerus]

Seeing a guy with a rib met from prostate cancer that got 30/10 two years ago who has had progression at the edge of the field. Wondering if people are continuing with standard palliative stuff here or would think so about sbrt, 30/5, etc.

Rest of story is otherwise no progression elsewhere.

The "Rest of the Story" was my favorite radio show. But your vignette, and often times multiple choice questions, don't give that.

No progression elsewhere implies: there is disease elsewhere.

The initial 30/10 implied: palliation was the initial goal. And no "rest of story" gave this test-taker a hint that palliation was still the goal.

 

[TheWallnerus]

They're going for B. Answer how they want you to. NCIC-SC20

Without judging anyone else's approaches, I obviously designed the question along those lines: "Answer how they want you to."

 

[radiaterMike]

I would refer to a practice within the national network of palliative radiation therapy providers

 

[deleted1111261]

Two years out from a palliative dose of 30 Gy in 10 fx to a painful rib met, a prostate cancer patient has progression. A decision is made to reirradiate. What is the most reasonable option for retreatment.

Just AS PRESENTED with no further elaboration and you were getting the above case vignette on OLA and here are your multiple choices what do you pick for re RT.

A, 30 Gy/10 fx
B. 8 Gy/1 fx
C. 30 Gy/5 fx
D. 24 Gy/2 fx
E. 45 Gy/15 fx

There is not a great study on re-RT with SBRT doses.
That would be interesting and useful.

After 30/10 or 20/5 and pain has returned - randomize to 8/1 3D vs idk 24/3

 

[ramsesthenice]

I would treat conventionally. There was no reason to believe that the original course would definitively treat the area. I wouldn't consider this a failure. Palliative rt worked just fine the first time. It should work again, and I would be cognizant about avoiding toxicity. This is all assuming that palliation was the original and currently intended goal.

Can't agree more and that is why I said what I said above. If you were happy with the control you got before and would be happy with a similar result this time around then don't make things more complicated than you have to. It was never supposed to be curative or permanent in the first place.

 

[deleted1116990]

I would refer to a practice within the national network of palliative radiation therapy providers

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

 

[deleted1111261]

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

Wow

 

[jondunn]

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

holy

 

[Mandelin Rain]

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

Sounds like malpractice to me

 

[TheWallnerus]

Anybody seen any pubic ramus fractures after prostate proton therapy? I have.

 

[Mandelin Rain]

Anybody seen any pubic ramus fractures after prostate proton therapy? I have.

Protons really hate bones.

 

[metallica81788]

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

Sounds like they chose wisely

 

[medgator]

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

Financial and clinical toxicity ftw

 

[Mandelin Rain]

Did they give like 12 Gy x 5? To a bone met?

Because in all honestly, that sounds malpractice-y.

 

[thecarbonionangle]

Just finished palliating a patient from one of these expert centers who left a crater in the sternum with 60 GyE proton therapy for a bone met. Of course metted all around it and in field too.

In how many fractions?

 

[jondunn]

In how many fractions?

i was assuming 60 Gy/30, which is just nuts.

 

[deleted1116990]

In how many fractions?

10.

Guess what I did? 20 Gy in 5 fractions with a super tight VMAT plan abutting the proton field. Worked GREAT. Patient's pain GONE. NO CRATER. (all this was in a prior breast tangent field too BTW).

 

[Mandelin Rain]

I saw a couple early stage lung patients who were treated decades ago with 6Gy x 10 with 2 or 3-field technique on protocol. They had non healing skin ulcers, front and back.

 

[Mandelin Rain]

10.

Guess what I did? 20 Gy in 5 fractions with a super tight VMAT plan abutting the proton field. Worked GREAT. Patient's pain GONE. NO CRATER. (all this was in a prior breast tangent field too BTW).

 

[thecarbonionangle]

10.

Guess what I did? 20 Gy in 5 fractions with a super tight VMAT plan abutting the proton field. Worked GREAT. Patient's pain GONE. NO CRATER. (all this was in a prior breast tangent field too BTW).

Damn thats a lot of dose for a bone met. “Experts”, voila!

 

[TheWallnerus]

I saw a couple early stage lung patients who were treated decades ago with 6Gy x 10 with 2 or 3-field technique on protocol. They had non healing skin ulcers, front and back.

Timmerman has those slides

 

[deleted1116990]

Damn thats a lot of dose for a bone met. “Experts”, voila!

I SBRT bone mets all the time and up to 50 in 5 and have never seen anything like that. I guess they were worried about heart dose in this patient with metastatic breast cancer or something?

 

[salubalu]

Protons

 

[thesauce]

I would refer to a practice within the national network of palliative radiation therapy providers

Agreed. I for one would not feel comfortable treating this patient off clinical trial

 

[Lamount]

I SBRT bone mets all the time and up to 50 in 5 and have never seen anything like that. I guess they were worried about heart dose in this patient with metastatic breast cancer or something?

I would worry about 50/5 to sternum… very close to the surface.

 

[Mandelin Rain]

I would worry about 50/5 to sternum… very close to the surface.

If only there was another particle that could treat areas very close to the surface before stopping in tissue.

 

[Lamount]

If only there was another particle that could treat areas very close to the surface before stopping in tissue.

There are plenty... of various electrical charges. Administering any of them (or photons for that matter) to a dose of 50 Gy in 5 fractions to the sternum where PTV has significant overlap with skin is a good way to see what a sternum actually looks like.

 

[TheWallnerus]

If only there was another particle that could treat areas very close to the surface before stopping in tissue.

There are plenty... of various electrical charges. Administering any of them (or photons for that matter) to a dose of 50 Gy in 5 fractions to the sternum where PTV has significant overlap with skin is a good way to see what a sternum actually looks like.

I'm picturing a PA proton beam whose Bragg Liberty peak is in the sternum, ~zero skin dose. Would be a neat plan. Prob unsafe but sternal skin would look wonderful.

 

[Mandelin Rain]

There are plenty... of various electrical charges. Administering any of them (or photons for that matter) to a dose of 50 Gy in 5 fractions to the sternum where PTV has significant overlap with skin is a good way to see what a sternum actually looks like.

No doubt. Ditto 60 Gy in 10. Especially in the reirradiation setting, which this was.

60Gy in 10 via protons feels very much like a, "let's see if we can get away with this," type regimen rather than any kind of thoughtful regimen based on weighing pros and cons (including cost) for the patient. Meanwhile, you can't be in this institution's Palliative Care Network unless you're prescribing 8Gy x 1 via 2D setup same day see, sim, and treat while eating the reimbursement on multiple codes.

Seems legit.

 

[evilbooyaa]

standard palliation (30/10, 20/5, 8/1) or SBRT (30-35/5) depending on whether patient requires palliation or something more aggressive. If doing SBRT counsel on rib fx.

2-years for 30/10 is pretty good all things ocnsidered.

Anyone giving 60 in 10 to a bone met should get sued regardless of whether it is within protons or not. But, doubly so if given with protons.

 

[deleted1116990]

I would worry about 50/5 to sternum… very close to the surface.

Just saw a follow-up patient I did 50/5 to a small met in the (deep) clavicular head for. Skin dose constrained. Excellent response to treatment, no skin issues.

I have always wondered about the standard of giving sub-ablative doses (30-35 in 5) when doing SBRT for oligiomets. Are people really seeing myositis as a complication? If superficial doses can be kept <30, Is that the concern for dose-reducing in soft tissue and bones vs. blasting away mets in lung, liver, etc? We do 50 in 5 for lung lesions abutting ribs all the time without blinking an eye.

 

[BobbyHeenan]

Just saw a follow-up patient I did 50/5 to a small met in the (deep) clavicular head for. Skin dose constrained. Excellent response to treatment, no skin issues.

I have always wondered about the standard of giving sub-ablative doses (30-35 in 5) when doing SBRT for oligiomets. Are people really seeing myositis as a complication? If superficial doses can be kept <30, Is that the concern for dose-reducing in soft tissue and bones vs. blasting away mets in lung, liver, etc? We do 50 in 5 for lung lesions abutting ribs all the time without blinking an eye.

I have one SBRT myositis patient and it's been a problem for the patient but he's alive and doing well.

This was a kidney SBRT case (poor lung function, not an operative candidate) and the way the bowel/tumor/kidney were I spilled dose into the chest/abd wall/oblique musculature. I think I did 42 in 3 like the Australians. . He's had a really firm flank for a couple of years now. acutely flaired up a few months after treatment. Now just rock hard but not too bothersome. He's three years out from treatment, NED, good renal function, with a rock hard CV angle.

IT's crazy though because I've definitely done "riskier" treatments on chest walls, etc and gotten away with it.

The older I get the more I realize how variable tolerance is to what we do...protoplasm and all that...and underlying genes.

 

[deleted1116990]

I am betting the 60 GyE/10 crater proton therapy left above the sternum would not have happened with IMRT. Wild speculation. Dumping high dose per fraction bragg peaks all around superficial tissues seems... not ideal.

 

[taserlaser]

Have seen steroid responsive myosotis to a large sarcoma which got 30-35/5 in a young teen. Heavily pretreated and ++chemo was a cofactor I think