Congrats to new ASTRO President..is this the first time that the President is on SDN?

[deleted1168505]

Grade 5 in lung cancer is probably more frequent than any other site. It is the only site where patients actually die from our treatment. I get the feeling that fatal pneumonitis is under reported.

That's interesting. Med onc seems to think we can just SBRT probably-benign lung nodules without a tissue dx ad infinitum without a problem.
I have pointed out that 54 Gy in 3 fractions to a bunch of 10cc volumes in somebody whose medical status/lung function isn't good enough for even a biopsy isn't trivial and we should at least try and make sure it is cancer first and basically have been called an assshole

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[CaesarRO]

Grade 5 in lung cancer is probably more frequent than any other site. It is the only site where patients actually die from our treatment. I get the feeling that fatal pneumonitis is under reported.

I thought most G5 in the literature is actual hemoptysis, not pneumonitis.

Pneumonitis death is confounded imho by poor baseline pulmonary function (ILD/COPD exacerbation) and immunotherapy-induced pneumonitis

 

[RickyScott]

I thought most G5 in the literature is actual hemoptysis, not pneumonitis.

Pneumonitis death is confounded imho by poor baseline pulmonary function (ILD/COPD exacerbation) and immunotherapy-induced pneumonitis

Fatal pneumonitis was seen by anyone who treats a lot of lung prior to io. Hemoptysis with 60-70 gy conventional fraction is very rare.

 

[medgator]

Grade 5 in lung cancer is probably more frequent than any other site. It is the only site where patients actually die from our treatment. I get the feeling that fatal pneumonitis is under reported.

How many of them die from surgery for stage 3?

 

[RickyScott]

How many of them die from surgery for stage 3?

have no idea, but our field is more risk adverse and less tolerant

 

[evilbooyaa]

Do you think there is value in lower mean heart dose in NSCLC? I do.

Sure, and if there's a NSCLC patient with disease wrapping around the heart such that MHD is over 10-20Gy and protons can reduce that, then maybe that can be an acceptable metric for someone to get protons. What percntage of stage III lung cancer patients meet that? Or are you suggesting that MHD should be < 4Gy similar to how it is for breast cancer, and thus basically ANY PTV co-planar with heart means protons should be auto approved?

Isn't LAD dose even a better metric?

There are multiple types of heart failure. LAD and other coronaries probably increase ischemic risk at certain thresh-holds (v15 >10%). There is growing data about constraints for other cardiac substructures like the atrium. I predict in the future you will have more validated constraints (left atrium V60 <25.6%,pericardium D30% <18.9 Gy, and right atrium V55 <19.5%). Cardio-oncology is also a growing field. more advanced cardiac imaging (i. Myostrain etc) along with medical optimization will have a growing role.

The most robust data currently is MHD. Proponents of other constraints should work on proving that they matter clinically and (more importantly) that they are BETTER than MHD as currently outlined.

 

[evilbooyaa]

That's interesting. Med onc seems to think we can just SBRT probably-benign lung nodules without a tissue dx ad infinitum without a problem.
I have pointed out that 54 Gy in 3 fractions to a bunch of 10cc volumes in somebody whose medical status/lung function isn't good enough for even a biopsy isn't trivial and we should at least try and make sure it is cancer first and basically have been called an assshole

I don't like SBRTing the lung more than 2 separate lobes at once, and more than 4 separate lobes of the lung lifetime.

Most nodules not convincing can simply be watched for 3 months and allowed to declare themselves. SBRTing every 5-10mm thing that pops without giving it a chance to stick around and/or show PET avidity.... no bueno.

 

[deleted1168505]

Most nodules not convincing can simply be watched for 3 months and allowed to declare themselves. SBRTing every 5-10mm thing that pops without giving it a chance to stick around and/or show PET avidity.... no bueno.

If you want to work here, you zap what med onc says to zap.
Most nodules picked up in high risk patients are not cancer.
Alternate facts. Zap boy.

 

[evilbooyaa]

If you want to work here, you zap what med onc says to zap.
Most nodules picked up in high risk patients are not cancer.
Alternate facts. Zap boy.

Oof. If I couldn't tell my local surgeons/med-oncs to go kick rocks once in a blue moon I'm not sure I'd still be at this job.

Most of my time is spent trying to convince them that 'hey, I could treat that with radiation, and then you could, ya know, keep the patient on their 4th line chemo!' or 'radiation toxicities have improved greatly over the past 20 years with the advent of contemporary techniques'

 

[medgator]

If you want to work here, you zap what med onc says to zap.
Most nodules picked up in high risk patients are not cancer.
Alternate facts. Zap boy.

Completely disagree with this. Don't be an invertebrate at your tumor board

 

[RadOncDoc21]

Completely disagree with this. Don't be an invertebrate at your tumor board

After awhile you get used to it… I just pretend I’m just a cheap prostitute.

 

[deleted1168505]

I'm actually amazed insurance never puts up a fight about treating a who-knows-what-this-is lung nodule with SBRT but throws a fit about a few extra fractions of IMRT or IGRT here or there.

 

[sirspamalot]

We are all subject to forces we cannot master. Grasshopper, you must find peace within yourself, meditate over the hum of the Linac and find inner peace with the lotus and the photon.