Expanding indications for radoncs

[OTN]

Hey all,

I've been placed on a task force in our large private practice, the goal of which is to look at ways to expand the role of us radoncs. Facing reimbursement pressures, hypofractionation, etc, we want to try to find new ways we can treat cancer patients or look to expand treatments or techniques we're not utilizing to their full potential.

There have been some good preliminary discussions on this board before regarding this very issue, so I thought I would pick everyone's brain to see what people think. Nothing at this point is off the table, so go nuts.

I'll start: We do dose to volume, so why not cryoablation for prostate ca failure after definitive XRT?

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[Bequerel]

SRS to the lateral hypothalamic area for weight loss

 

[radiaterMike]

Optune if not already doing it. Conceivable that it will become used for NSCLC brain mets some day.


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[OTN]

Optune if not already doing it. Conceivable that it will become used for NSCLC brain mets some day.


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We've started this already, actually. Interesting tech, but they sure need to find a better way to deliver the electrical current. Probably not possible, though.

 

[RadOncDoc21]

Whole abdomen RT for weight loss

 

[medgator]

Prolia, xgeva, zometa etc for your prostate bone met patients on long term lupron....

 

[BobbyHeenan]

Make sure it's you and not nuc med giving xofigo. We are looking into joining ongoing clinical trials for breast patients with bone mets too getting xofigo.

 

[radtothebone]

Hey all,

I've been placed on a task force in our large private practice, the goal of which is to look at ways to expand the role of us radoncs. Facing reimbursement pressures, hypofractionation, etc, we want to try to find new ways we can treat cancer patients or look to expand treatments or techniques we're not utilizing to their full potential.

There have been some good preliminary discussions on this board before regarding this very issue, so I thought I would pick everyone's brain to see what people think. Nothing at this point is off the table, so go nuts.

I'll start: We do dose to volume, so why not cryoablation for prostate ca failure after definitive XRT?

As for locally recurrent disease after definitive XRT, why use cryo when you stick within our field and use salvage brachytherapy? There are multiple retrospective studies showing reasonable outcomes and toxicity with both HDR and LDR.

Another indication that I think think is intriguing is XRT for plantar fasciitis (I know Medicare will reimburse in the US). I'm amazed about how many people I know who are dealing with this problem.

Prospective Randomized Comparison of the Effectiveness of Radiation Therapy and Local Steroid Injection for the Treatment of Plantar Fasciitis. - PubMed - NCBI
https://www.ncbi.nlm.nih.gov/pubmed/25936814

 

[Palex80]

Another indication that I think think is intriguing is XRT for plantar fasciitis (I know Medicare will reimburse in the US). I'm amazed about how many people I know who are dealing with this problem.

Prospective Randomized Comparison of the Effectiveness of Radiation Therapy and Local Steroid Injection for the Treatment of Plantar Fasciitis. - PubMed - NCBI

Pretty common indication in many parts of Europe too.
We treat more than a dozen patients per year where I work.

 

[Palex80]

Some more:

1. Immunomodulation for metastatic NSCLC (see separate thread).
2. Metastatic prostate cancer: RT to the primary (awaiting results of Stampede and EORTC trials).
3. 2 x 2 Gy for indolent NHL progression (I've been getting a lot of requests for this. Patients on long term Rituximab with focal progressions of individual LNsget focal treatment and don't need to dwitch drugs.)

 

[berag]

The Germans will radiate anything:

Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines

 

[medgator]

The Germans will radiate anything:

Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines

"German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD)"

 

[laserbeams]

WashU is doing a trial of SBRT for cardiac arrhythmia which are treatment refractory using conventional EP ablation. I spoke with one of the rad oncs at ASTRO involved with the project and he was very excited about the results, but noted difficulty in recruiting cardiologists to refer patients. The results thus far are apparently pretty good, and the patients still 'belong' to the cardiologist. If the data pans out, I wouldn't be surprised if we see these sicker, non-ablation candidates come our way for single-fraction treatments.

Phase I/II Study of EP-guided Noninvasive Cardiac Radioablation for Treatment of Ventricular Tachycardia - Full Text View - ClinicalTrials.gov

 

[BobbyHeenan]

WashU is doing a trial of SBRT for cardiac arrhythmia which are treatment refractory using conventional EP ablation. I spoke with one of the rad oncs at ASTRO involved with the project and he was very excited about the results, but noted difficulty in recruiting cardiologists to refer patients. The results thus far are apparently pretty good, and the patients still 'belong' to the cardiologist. If the data pans out, I wouldn't be surprised if we see these sicker, non-ablation candidates come our way for single-fraction treatments.

Phase I/II Study of EP-guided Noninvasive Cardiac Radioablation for Treatment of Ventricular Tachycardia - Full Text View - ClinicalTrials.gov

Really interesting. Thanks for posting.

 

[thesauce]

The Germans will radiate anything:

Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines

You say they'll radiate anything and then post a link where a group thoughtfully outlines what benign conditions they do and do not recommend it for and why?

I don't think you're making your point...

 

[thesauce]

WashU is doing a trial of SBRT for cardiac arrhythmia which are treatment refractory using conventional EP ablation. I spoke with one of the rad oncs at ASTRO involved with the project and he was very excited about the results, but noted difficulty in recruiting cardiologists to refer patients. The results thus far are apparently pretty good, and the patients still 'belong' to the cardiologist. If the data pans out, I wouldn't be surprised if we see these sicker, non-ablation candidates come our way for single-fraction treatments.

Phase I/II Study of EP-guided Noninvasive Cardiac Radioablation for Treatment of Ventricular Tachycardia - Full Text View - ClinicalTrials.gov

I saw this. Remarkable. Huge demand. Cardiologists in our area would definitely refer.

 

[seper]

Does anyone know what the target is? How do they manage motion?

Really interesting. Thanks for posting.

 

[OTN]

This is all great stuff, everyone, thanks for sharing. I'll keep you updated with how things move forward with the committee. If WashU is having trouble recruiting patients, I wonder if they'd like to partner with a large private practice group to get some numbers...

 

[Palex80]

The Germans will radiate anything:

Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines

And most of the times it works!

I have irradiated all kinds of benign stuff.

Arthrosis, arthritis, tendinitis, heterotopic ossifications, psoriasis of the skin, fibromatosis (hands, feet, penis).

 

[medgator]

I saw this. Remarkable. Huge demand. Cardiologists in our area would definitely refer.

sounds like it would be more interesting to do than coronary brachytherapy too. I had no idea about it, did cardiologists in your area ask about it?

 

[thesauce]

sounds like it would be more interesting to do than coronary brachytherapy too. I had no idea about it, did cardiologists in your area ask about it?

No but we brought it up to them. We have a close relationship with them and they will send us patients.

 

[medgator]

No but we brought it up to them. We have a close relationship with them and they will send us patients.

Interesting. I probably interact least with Cardiology, Rheum, and Optho. ID and ortho also very little, but they do send the occasional kaposi's/HO prophlyaxis pt.

 

[evilbooyaa]

Interesting. I probably interact least with Cardiology, Rheum, and Optho. ID and ortho also very little, but they do send the occasional kaposi's/HO prophlyaxis pt.

Cardiology is just to ask about pacemakers if necessary, sometimes echos. Rheum is essentially 0. Never seen a consult from a rheumatologist, and I've never directly consulted or even spoken to a rheumatologist. ID we send ORN consults sometimes for Abx length discussion, but no consults from them, and ortho we work with closely b/c of extremity sarcoma volume

 

[jigglypuff2]

see in pigs: Dose-escalation study for cardiac radiosurgery in a porcine model. - PubMed - NCBI
see in humans: http://assets.cureus.com/uploads/case_report/pdf/2533/1493842872-20170503-1769-14g5jy5.pdf

See in pigs: Radiosurgical Ablation of the Renal Nerve in a Porcine Model: A Minimally Invasive Therapeutic Approach to Treat Refractory Hypertension
See in humans: see the pattern?

psychosurgery: Stereotactic lesioning for mental illness. - PubMed - NCBI, Gamma-knife subcaudate tractotomy for treatment-resistant depression and target characteristics: a case report and review

overall I find the general topic of functional radiosurgery so fascinating. Mesial temporal lobe epilepsy, etc etc?

Essentially the theme is, is there a surgery for it? could there be a role for radiation in some cases (patients too sick for surgery)?

I'm loving the potential for these indications for radiation as a growing therapeutic modality. We'll have to be careful in how it is pioneered but I think there's plenty of potential there. We'll have to continue to reach out to other fields and educate them.

 

[medgator]

overall I find the general topic of functional radiosurgery so fascinating. Mesial temporal lobe epilepsy, etc etc?

Essentially the theme is, is there a surgery for it? could there be a role for radiation in some cases (patients too sick for surgery)?

I'm loving the potential for these indications for radiation as a growing therapeutic modality. We'll have to be careful in how it is pioneered but I think there's plenty of potential there. We'll have to continue to reach out to other fields and educate them.

Reminds me of the CNN spotlight a decade ago....

The new new careers - (4) - Business 2.0

 

[CaesarRO]

see in pigs: Dose-escalation study for cardiac radiosurgery in a porcine model. - PubMed - NCBI
see in humans: http://assets.cureus.com/uploads/case_report/pdf/2533/1493842872-20170503-1769-14g5jy5.pdf

See in pigs: Radiosurgical Ablation of the Renal Nerve in a Porcine Model: A Minimally Invasive Therapeutic Approach to Treat Refractory Hypertension
See in humans: see the pattern?

psychosurgery: Stereotactic lesioning for mental illness. - PubMed - NCBI, Gamma-knife subcaudate tractotomy for treatment-resistant depression and target characteristics: a case report and review

overall I find the general topic of functional radiosurgery so fascinating. Mesial temporal lobe epilepsy, etc etc?

Essentially the theme is, is there a surgery for it? could there be a role for radiation in some cases (patients too sick for surgery)?

I'm loving the potential for these indications for radiation as a growing therapeutic modality. We'll have to be careful in how it is pioneered but I think there's plenty of potential there. We'll have to continue to reach out to other fields and educate them.

Not yet clinical, but maybe one day?

A New Use for an Old Treatment: Radiation Therapy and Alzheimer's Disease

Authors: George D. Wilson; Brian Marples

Pmid: 27092764
Doi: 10.1667/RR14367.1

Article

 

[thesauce]

Interesting. I probably interact least with Cardiology, Rheum, and Optho. ID and ortho also very little, but they do send the occasional kaposi's/HO prophlyaxis pt.

I don't interact with them much professionally, but we've become friends in a social setting

 

[thesauce]

see in pigs: Dose-escalation study for cardiac radiosurgery in a porcine model. - PubMed - NCBI
see in humans: http://assets.cureus.com/uploads/case_report/pdf/2533/1493842872-20170503-1769-14g5jy5.pdf

See in pigs: Radiosurgical Ablation of the Renal Nerve in a Porcine Model: A Minimally Invasive Therapeutic Approach to Treat Refractory Hypertension
See in humans: see the pattern?

psychosurgery: Stereotactic lesioning for mental illness. - PubMed - NCBI, Gamma-knife subcaudate tractotomy for treatment-resistant depression and target characteristics: a case report and review

overall I find the general topic of functional radiosurgery so fascinating. Mesial temporal lobe epilepsy, etc etc?

Essentially the theme is, is there a surgery for it? could there be a role for radiation in some cases (patients too sick for surgery)?

I'm loving the potential for these indications for radiation as a growing therapeutic modality. We'll have to be careful in how it is pioneered but I think there's plenty of potential there. We'll have to continue to reach out to other fields and educate them.

Agreed. Our bottleneck is neurosurgery support.

 

[radiaterMike]

Reminds me of the CNN spotlight a decade ago....

The new new careers - (4) - Business 2.0

Wait a minute. I went through college, 4 years of medical school and 5 years of residency and I could have done it all in a 3 week training course ???!'nn


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[medgator]

Wait a minute. I went through college, 4 years of medical school and 5 years of residency and I could have done it all in a 3 week training course ???!'nn


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To be fair they mention you have to be a bc rad onc (implying the above) when taking that course...

 

[napoleondynamite]

SRS to the lateral hypothalamic area for weight loss

Is this tongue in cheek or for real? If you're serious, I'm curious to see data if you know of some. Honestly, I don't know if you're joking!

 

[BobbyHeenan]

Is this tongue in cheek or for real? If you're serious, I'm curious to see data if you know of some. Honestly, I don't know if you're joking!

The baromodulatory effect of gamma knife irradiation of the hypothalamus in the obese Zucker rat.

It's real.

I'm not aware of any human trials though this did create some buzz at the gamma knife meetings a decade ago, given the obesity epidemic, etc.

 

[radtothebone]

Another potential indication to take from Neurosurgery. Plus, who doesn't want to say they have given 100 Gy in a single fraction? Not many out there that can say they have done that.

Radiosurgical third ventriculostomy: Technical note

 

[Krukenberg]

The baromodulatory effect of gamma knife irradiation of the hypothalamus in the obese Zucker rat.

It's real.

I'm not aware of any human trials though this did create some buzz at the gamma knife meetings a decade ago, given the obesity epidemic, etc.

Really cool but hard to imagine it could result in as much weight loss as gastric bypass. And it could never cure diabetes like bypass can.


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[evilbooyaa]

Really cool but hard to imagine it could result in as much weight loss as gastric bypass. And it could never cure diabetes like bypass can.


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Sure, but there will always be medically inoperable people out there. Also, it doesn't have to work as well as a gastric bypass (which has it's own host of possible complications) to still be a reasonable option. I think if it actually works it could be offered as a potential alternative to gastric bypass to people who don't want the possible complications of the surgery, especially for something like a roux-en-y.