Neuro-oncology fellowship after Rad/Onc residency?

[LeonThePro]

Hey everyone,

I’m a pre-med interested in rad/onc with a quick question.

Would it be possible / would it make sense to do a neuro-oncology fellowship after a rad/onc residency?

I’m really interested in radiosurgery and similar radiotherapy methods in neuro-oncology, such as Gamma Knife.

Is there any way to get substantially involved in radiosurgery, such as Gamma Knife, without first doing a neurosurgery residency?

Some routes I’m curious about:

1. Rad/Onc residency —> Neuro-oncology fellowship

2. IR residency —> Interventional Neuroradiology fellowship

3. Diagnostic radiology residency —> Combined Interventional and diagnostic Neuroradiology fellowship

Any advice appreciated!

---

Members don't see this ad.

 

[medgator]

Or just do rad onc residency alone and join a practice with GK and focus on Neuro/srs

 

[evilbooyaa]

Board certified radiation oncologists without fellowship training are more than capable of doing radiosurgery from the radiation oncologist standpoint.

I'm not sure how much more involved you want to be.

Neuro-oncology AFAIK is only available to neurologists, but the 'fellowship' of neuro-oncology is not involved with radiosurgery.

 

[deleted774703]

Hey everyone,

I’m a pre-med interested in rad/onc with a quick question.

Would it be possible / would it make sense to do a neuro-oncology fellowship after a rad/onc residency?

I’m really interested in radiosurgery and similar radiotherapy methods in neuro-oncology, such as Gamma Knife.

Is there any way to get substantially involved in radiosurgery, such as Gamma Knife, without first doing a neurosurgery residency?

Some routes I’m curious about:

1. Rad/Onc residency —> Neuro-oncology fellowship

2. IR residency —> Interventional Neuroradiology fellowship

3. Diagnostic radiology residency —> Combined Interventional and diagnostic Neuroradiology fellowship

Any advice appreciated!

Pre-meds are getting smarter these days! I didn't even know what SRS or GK was before 3rd yr med school

To answer your question, it would not make sense to do a neuro-onc fellowship after rad onc.

You will receive sufficient training in SRS at any residency. Most use LINAC based radiosurgery while some specifically use Gamma Knife.

If you are at a residency that only uses conventional LINAC based SRS and you REALLY want to learn GKRS, you can take a weekend class (UPitt, Cleveland Clinic, NYU off the top of my head) and become certified on your own

IR is not the route to go if you want to do radiosurgery. That is still the domain of rad onc, with some overlap with neurosurgery

 

[Neuronix]

Actually some neuro oncology fellowships are open to other specialties.

See for example:

Neuro-Oncology Fellowship | Department of Neurology

I would not do this though unless it's a condition of employment and you have a guaranteed job after it. Dedicated CNS jobs in rad onc are pretty rare since CNS is only about 5% of all rad onc treatments. All rad oncs are trained to perform radiosurgery, and it's a part of our board certification.

If you want to do radiosurgery, rad onc is the way to go. Neurosurgery is involved at a superficial level in radiosurgery in my experience.

 

[scarbrtj]

Hey everyone,

I’m a pre-med interested in rad/onc with a quick question.

Would it be possible / would it make sense to do a neuro-oncology fellowship after a rad/onc residency?

I’m really interested in radiosurgery and similar radiotherapy methods in neuro-oncology, such as Gamma Knife.

Is there any way to get substantially involved in radiosurgery, such as Gamma Knife, without first doing a neurosurgery residency?

Some routes I’m curious about:

1. Rad/Onc residency —> Neuro-oncology fellowship

2. IR residency —> Interventional Neuroradiology fellowship

3. Diagnostic radiology residency —> Combined Interventional and diagnostic Neuroradiology fellowship

Any advice appreciated!

To me a neuro-oncologist is a neurologist who goes on and does a neuro-onc fellowship after neurology residency. E.g., as you can see here, no radiation oncologists in the Dept of Neuro-Onc at MDACC. So no you couldn't do a neuro-onc fellowship after rad onc residency (EDIT see above). At best, 4 years rad onc, 3 years neurology, then a 2 year neuro-onc fellowship. And that sounds 'bout impossible. If we are just talking pure number of arrows in the quiver, neuro-onc (and med onc of course) has more arrows than rad onc. You may not know that the Gamma Knife and Cyberknife were invented by neurosurgeons; but good radiosurgery can be done on "simple" modern linear accelerators that we also use for breast ca, prostate ca, skin ca, etc. Radiation oncologists got involved with radiosurgery because they kind of, regulatory-wise, had to be involved. In my own practice, I don't use a neurosurgeon for linac-based radiosurgery and treat only uncomplicated brain mets, occasionally meningiomas (rarely gliomas) and things of that nature. Overall, the indications for radiosurgery are somewhat sparse (compared to indications of treatments for CNS neoplasms in general) and it would be difficult to be a pure radiosurgeon. And, as you also probably know, radiosurgery is a misnomer... there is no radio, and there is no surgery (ha, and sure as heck no knife)... it's kind of super-amazing and super-boring at the same time. Have you seen one? Your #2 and #3 I won't comment on, but you should go check it out.

 

[LeonThePro]

Thanks guys!

I initially assumed that rad/onc training alone would be more than sufficient, but in my internet search attempts, most of the physicians I find on academic websites who are designated as ‘radiosurgery / gamma knife specialists’ seem to be trained in neurosurgery (with a radiosurgery fellowship or something similar).

So I was curious about the different levels of involvement based on training background.

Good to know that it’s possible to be involved in SRS without going the neurosurgery route

 

[LeonThePro]

To me a neuro-oncologist is a neurologist who goes on and does a neuro-onc fellowship after neurology residency. E.g., as you can see here, no radiation oncologists in the Dept of Neuro-Onc at MDACC. So no you couldn't do a neuro-onc fellowship after rad onc residency (EDIT see above). At best, 4 years rad onc, 3 years neurology, then a 2 year neuro-onc fellowship. And that sounds 'bout impossible. If we are just talking pure number of arrows in the quiver, neuro-onc (and med onc of course) has more arrows than rad onc. You may not know that the Gamma Knife and Cyberknife were invented by neurosurgeons; but good radiosurgery can be done on "simple" modern linear accelerators that we also use for breast ca, prostate ca, skin ca, etc. Radiation oncologists got involved with radiosurgery because they kind of, regulatory-wise, had to be involved. In my own practice, I don't use a neurosurgeon for linac-based radiosurgery and treat only uncomplicated brain mets, occasionally meningiomas (rarely gliomas) and things of that nature. Overall, the indications for radiosurgery are somewhat sparse (compared to indications of treatments for CNS neoplasms in general) and it would be difficult to be a pure radiosurgeon. And, as you also probably know, radiosurgery is a misnomer... there is no radio, and there is no surgery (ha, and sure as heck no knife)... it's kind of super-amazing and super-boring at the same time. Have you seen one? Your #2 and #3 I won't comment on, but you should go check it out.

Awesome, thanks for the detailed reply! So, generally speaking, as a radiation oncologist, is it possible to focus exclusively on neuro, even if radiosurgery etc. is only part of your treatment scope?

 

[OTN]

Awesome, thanks for the detailed reply! So, generally speaking, as a radiation oncologist, is it possible to focus exclusively on neuro, even if radiosurgery etc. is only part of your treatment scope?

Yes, but it's not easy to get that job. You'd be an academic radiation oncologist focusing on neuro-oncology. Not a lot of those running around.

 

[deleted774703]

Awesome, thanks for the detailed reply! So, generally speaking, as a radiation oncologist, is it possible to focus exclusively on neuro, even if radiosurgery etc. is only part of your treatment scope?

These are separate questions

1) Yes you can focus exclusively on CNS -> very difficult to find this job as it is one of the easiest disease sites to tx for us

2) Radiosurgery is so common in rad onc that you don't need to go to a "CNS rad onc" for SRS
-For example brain mets, which is the most common use of SRS in our field, are largely due to lung, breast, RCC, melanoma
-Since we all are trained in SRS during residency, there is little need to transfer your established cancer pt to a "CNS RO specialist" for SRS. In fact, its probably worse for patients since they have to meet a new doctor unnecessary

3) Few things are exclusive to a "CNS Rad Onc"
-Glioma, meningioma, AVM, acoustic neuroma, etc

 

[seper]

Digressing a bit, but I've found that MedOnc-background NeuroOnc attendings are often more sound that those coming from Neurology. Some of the chemo/management issues are too hard for neurologists.

 

[RadOncDoc21]

These are separate questions

1) Yes you can focus exclusively on CNS -> very difficult to find this job as it is one of the easiest disease sites to tx for us

2) Radiosurgery is so common in rad onc that you don't need to go to a "CNS rad onc" for SRS
-For example brain mets, which is the most common use of SRS in our field, are largely due to lung, breast, RCC, melanoma
-Since we all are trained in SRS during residency, there is little need to transfer your established cancer pt to a "CNS RO specialist" for SRS. In fact, its probably worse for patients since they have to meet a new doctor unnecessary

3) Few things are exclusive to a "CNS Rad Onc"
-Glioma, meningioma, AVM, acoustic neuroma, etc

I don’t even think you need to be a “CNS Rad Onc” to do those either. Just pay close attention with the CNS, peds and neurosurgery rotations and you will treat a lot of brain, spine etiologies including benign and functional stuff.

 

[Gfunk6]

In case you don't train on a CK/GK during residency and desire to do so - it only takes about a week to do so as a Rad Onc. Typically it is done at a high-volume site.

 

[deleted774703]

I don’t even think you need to be a “CNS Rad Onc” to do those either. Just pay close attention with the CNS, peds and neurosurgery rotations and you will treat a lot of brain, spine etiologies including benign and functional stuff.

Agree, but from the standpoint of an academic center -> they have to give the CNS person something to do lol

 

[RadOncDoc21]

Agree, but from the standpoint of an academic center -> they have to give the CNS person something to do lol

By the way I like your name! Feels like we’re kin.

 

[evilbooyaa]

I think I heard Mayo makes you switch from your primary Rad Onc to a CNS rad onc if you need SRS. That seems bonkers to me.

 

[deleted774703]

I think I heard Mayo makes you switch from your primary Rad Onc to a CNS rad onc if you need SRS. That seems bonkers to me.

Come on, those circles are very hard to contour!

 

[Neuronix]

Yes, but it's not easy to get that job. You'd be an academic radiation oncologist focusing on neuro-oncology. Not a lot of those running around.

I have essentially become this in my job recently. There are probably 2 dozen CNS dedicated rad onc in the country I would guess. Hate away generalists

Anyone Leon it's way too early to think about this at your point in life. Focus on getting into med school. If you still think you wanna do this when you get to MS3 shoot me a PM.

 

[RadOncDoc21]

I have essentially become this in my job recently. There are probably 2 dozen CNS dedicated rad onc in the country I would guess. Hate away generalists

Anyone Leon it's way too early to think about this at your point in life. Focus on getting into med school. If you still think you wanna do this when you get to MS3 shoot me a PM.

I know I’m digressing but I think academic CNS rad onc is more interesting then breast... treat or no treat, nodes or no nodes? Everything else is basically style and preference and a lot of useless mumbo jumbo!

 

[evilbooyaa]

Come on, those circles are very hard to contour!

I mean, in fairness, I've seen attendings who are so anxious about any toxicity from radiosurgery that they routinely prescribe essentially homeopathic doses of radiation. 5Gy x 5, 7Gy x 3, etc. These are the same attendings who will freak out if their plan has over 115% of prescription dose anywhere (avoiding using the term hotspot to avoid the pedanticism over what a hot-spot technically is) and thus can never seem to meet the V12 < 5-10cc that would let somebody be 'comfortable' with single fraction.

SRS isn't about the contours it's about everything else, and I was so shocked when I realized what I had been learning for 1.5 years was just wrong if I just blindly followed what my attendings used to do.

 

[Neuronix]

Don't worry, fractionated stereotactic will save us all. Any PTV margin, any linac setup, any volume of normal brain treated. Just give 9 Gy x 3 or 6 Gy x 5. Watch out for the brainstem and optic structures and you're golden. Just kidding. Sort of. This is basically how all my SRS discussions go with anyone outside the CNS community these days.

But seriously, I see a lot of interesting, non-routine stuff. Plenty of skull base, AVMs, functional, re-treatments, brainstem mets, tough spine cases. Of course the full spectrum of gliomas as well. I have GK and linac options. I enjoy many aspects of it, though there are some tough parts too. Anyway, if I'm going to be stuck in academics I might as well actually be an academic, super specialize, and get some research done.

 

[deleted774703]

I mean, in fairness, I've seen attendings who are so anxious about any toxicity from radiosurgery that they routinely prescribe essentially homeopathic doses of radiation. 5Gy x 5, 7Gy x 3, etc. These are the same attendings who will freak out if their plan has over 115% of prescription dose anywhere (avoiding using the term hotspot to avoid the pedanticism over what a hot-spot technically is) and thus can never seem to meet the V12 < 5-10cc that would let somebody be 'comfortable' with single fraction.

SRS isn't about the contours it's about everything else, and I was so shocked when I realized what I had been learning for 1.5 years was just wrong if I just blindly followed what my attendings used to do.

Agree that there is more to SRS than just contours and that Radoncs may lose their nerve once they become attendings

On the other hand, we all should have learned how to properly irradiate pts using SRS/fSRS

For those who can’t, we can banish them to the “advanced rad onc SRS fellowships”

 

[scarbrtj]

These are the same attendings who will freak out if their plan has over 115% of prescription dose

You're triggering me

 

[medgator]

I think I heard Mayo makes you switch from your primary Rad Onc to a CNS rad onc if you need SRS. That seems bonkers to me.

Doesn't Anderson have a palliative service? I wonder if those docs have to transfer their bone mets there

 

[evilbooyaa]

Agree that there is more to SRS than just contours and that Radoncs may lose their nerve once they become attendings

On the other hand, we all should have learned how to properly irradiate pts using SRS/fSRS

For those who can’t, we can banish them to the “advanced rad onc SRS fellowships”

Completely agree. What is OK for those 20 years into practice should not be OK for those still in residency. Lots of personal reading is necessary for every resident to confirm what your attendings are doing wouldn't be considered malpractice in the opinions of others.

You're triggering me

I tried changing my terminology to avoid the pedantism. It appears I have continued to fail unfortunately.

 

[RadOncDoc21]

Nothing like a good whole brain to treat a glioblastoma... I saw this recently!’

 

[OTN]

These are separate questions

1) Yes you can focus exclusively on CNS -> very difficult to find this job as it is one of the easiest disease sites to tx for us

2) Radiosurgery is so common in rad onc that you don't need to go to a "CNS rad onc" for SRS
-For example brain mets, which is the most common use of SRS in our field, are largely due to lung, breast, RCC, melanoma
-Since we all are trained in SRS during residency, there is little need to transfer your established cancer pt to a "CNS RO specialist" for SRS. In fact, its probably worse for patients since they have to meet a new doctor unnecessary

3) Few things are exclusive to a "CNS Rad Onc"
-Glioma, meningioma, AVM, acoustic neuroma, etc

You don't need to be a CNS radonc to treat the CNS. In the last two years alone I have seen and treated gliomas, meningiomas, AVMs, acoustics, TGN, Rathhke's cleft cysts, skull base chordomas (ok I sent that one off to our proton center), and esthesioneuroblastomas.

Radonc is not so large that you need to be a specialist in anything to treat any site, with the exception of pediatrics.

Edit: changed one year to two years. Don't see more than one esthesioneuroblastoma a year.

 

[LeonThePro]

Wow, thanks to everyone for all the detailed replies.

Disclaimer: I realize that this decision is years away for me but I really enjoy learning about the paths to different potential specialties. Thanks for sharing your experiences.

While I have all these radoncs here, anyone who cares to answer:

1. Are you generally happy with your speciality choice? Best / worst parts of your job compared to similar specialities?

2. What would you recommend for a student interested in radiology, radiosurgery, neuroimaging, treatment of neuro-pathology etc.? Mainly as far as specialty choice

 

[evilbooyaa]

Wow, thanks to everyone for all the detailed replies.

Disclaimer: I realize that this decision is years away for me but I really enjoy learning about the paths to different potential specialties. Thanks for sharing your experiences.

While I have all these radoncs here, anyone who cares to answer:

1. Are you generally happy with your speciality choice? Best / worst parts of your job compared to similar specialities?

2. What would you recommend for a student interested in radiology, radiosurgery, neuroimaging, treatment of neuro-pathology etc.? Mainly as far as specialty choice

I'm going to nip the answer to #1 in the bud. This has been a great thread, let's not ruin it. The answer to #1, OP, is in a multitude of other threads within this forum. Honestly, most other threads in this forum. Check out the first page of 'med students entering the match' as a first glimpse into this rabbit hole.

2. Get into, ideally, a US MD school and do well in medical school. Spend time evaluating things that interest you, either by shadowing or doing rotations.

 

[radoncgrad2019]

In places that do GKRS it’s very common for the CNS team to take over brain mets. For obvious reasons.

Why do you people get mad about everything

 

[medgator]

In places that do GKRS it’s very common for the CNS team to take over brain mets. For obvious reasons.

Plenty of places are transitioning away from GK. UAB got rid of theirs a few years ago iirc and do their functional stuff on a Varian edge now.

Not that hard for most of us to do linac srs srt these days.

 

[Neuronix]

Plenty of places are transitioning away from GK. UAB got rid of theirs a few years ago iirc and do their functional stuff on a Varian edge now.

On a research protocol with a highly specialized setup that's almost exclusive to them. But sure, easy peasy.

 

[medgator]

On a research protocol with a highly specialized setup that's almost exclusive to them. But sure, easy peasy.

For most mets though, a linac is fine, which is way more bread and butter rad onc imo

 

[taserlaser]

On a research protocol with a highly specialized setup that's almost exclusive to them. But sure, easy peasy.

To be fair my residency program did linac srs, and my new centre has a cyberknife. We did functional treatments on the linac (first time I saw 150 Gy to a point was something else...) Both academic programs. Easy I think is up to the physics support to say haha

 

[xrt123]

I mean, in fairness, I've seen attendings who are so anxious about any toxicity from radiosurgery that they routinely prescribe essentially homeopathic doses of radiation. 5Gy x 5, 7Gy x 3, etc. These are the same attendings who will freak out if their plan has over 115% of prescription dose anywhere (avoiding using the term hotspot to avoid the pedanticism over what a hot-spot technically is) and thus can never seem to meet the V12 < 5-10cc that would let somebody be 'comfortable' with single fraction.

SRS isn't about the contours it's about everything else, and I was so shocked when I realized what I had been learning for 1.5 years was just wrong if I just blindly followed what my attendings used to do.

Are you going to higher doses then these traditional fractionation schemes? I haven’t seen much data to suggest that control is significantly better than 9Gyx3 . Are you pushing doses a lot higher than this? (I have no radionecrosis anxiety but also no true reason to push higher)

 

[scarbrtj]

To be fair my residency program did linac srs, and my new centre has a cyberknife. We did functional treatments on the linac (first time I saw 150 Gy to a point was something else...) Both academic programs. Easy I think is up to the physics support to say haha

This takes me back. I used to have an m3. Not this kind of M3; this kind of an m3.* I do ~80Gy Rx dose for trigem; always used a frame. My max dose is never really as high as 150 but 120 certainly. And by the time you're doing that you've got a treatment with 24,000+ monitor units. Had a young eager physicist and this was one of his first really high dose cases; he could not fathom that number of monitor units. He was nervous the whole day and the whole case and ran his calcs a million times. The next day the physicist asked me how the patient was because it was the first time we had done a trigem in this center (I had done them before). I said, "Unfortunately, I just found out this morning he was rushed to the hospital and died last night." As a joke of course. NEVER to this day have I seen a more frightened face on a physicist. Good times, good times.

* Emory did a patient rotator technique for SRS with the patient sitting upright; kept gantry stationary and the patient spun about the vertical axis. The patient sat in a literally spinning chair on a motorized turntable. It was the leather racing seat from a BMW M3. Only time in known history patients have been irradiated sitting in seats from cars.

 

[taserlaser]

This takes me back. I used to have an m3. Not this kind of M3; this kind of an m3.* I do ~80Gy Rx dose for trigem; always used a frame. My max dose is never really as high as 150 but 120 certainly. And by the time you're doing that you've got a treatment with 24,000+ monitor units. Had a young eager physicist and this was one of his first really high dose cases; he could not fathom that number of monitor units. He was nervous the whole day and the whole case and ran his calcs a million times. The next day the physicist asked me how the patient was because it was the first time we had done a trigem in this center (I had done them before). I said, "Unfortunately, I just found out this morning he was rushed to the hospital and died last night." As a joke of course. NEVER to this day have I seen a more frightened face on a physicist. Good times, good times.

* Emory did a patient rotator technique for SRS with the patient sitting upright; kept gantry stationary and the patient spun about the vertical axis. The patient sat in a literally spinning chair on a motorized turntable. It was the leather racing seat from a BMW M3. Only time in known history patients have been irradiated sitting in seats from cars.

Our major case was for an ablative case for severe, refractory OCD. As I understand, unfortunately they did kill themselves soon after treatment, so we didn’t find out how it worked...

 

[RadOncDoc21]

I've done more stereotactic CNS cases after residency, including a lot of functional diseases. At first it's scary but you soon realize that as long as you have good data and a good team to help with planning, anything is possible. It's definitely some scary stuff to play around with those doses in such critical locations, but there is nothing more fulfilling then improving someone's quality of life when nothing else was working.

 

[FrostyHammer]

I mean, in fairness, I've seen attendings who are so anxious about any toxicity from radiosurgery that they routinely prescribe essentially homeopathic doses of radiation. 5Gy x 5, 7Gy x 3, etc. These are the same attendings who will freak out if their plan has over 115% of prescription dose anywhere (avoiding using the term hotspot to avoid the pedanticism over what a hot-spot technically is) and thus can never seem to meet the V12 < 5-10cc that would let somebody be 'comfortable' with single fraction.

SRS isn't about the contours it's about everything else, and I was so shocked when I realized what I had been learning for 1.5 years was just wrong if I just blindly followed what my attendings used to do.

This message is absolutely on point. Sorry if I'm shaming others, but I'm tired of people using worthless doses under the guise of fractionated SRS because they don't feel like having a normal brain constraint. Sounds like to me that their brain is too constrained for this type of higher order thinking...

 

[RadOncDoc21]

Digressing a bit, but I've found that MedOnc-background NeuroOnc attendings are often more sound that those coming from Neurology. Some of the chemo/management issues are too hard for neurologists.

Temodar with ppx antibiotics, check labs.. if that doesn’t work, give Avastin, unless you’re worried about active bleeding...check labs. Go home, tell all your neurology colleagues how much better life became!

Extrapolate to Gyn Onc... carbo/taxol for everybody, however they still do surgery. Last one urologist.. give everyone casodex for life, never ever admit you can’t “get it all.”

 

[evilbooyaa]

Are you going to higher doses then these traditional fractionation schemes? I haven’t seen much data to suggest that control is significantly better than 9Gyx3 . Are you pushing doses a lot higher than this? (I have no radionecrosis anxiety but also no true reason to push higher)

I said 7Gy x 3 for fractionated. I do 9Gy x 3 for my fractionated cases based on Minitti data. It's not a randomized trial but if outcomes are as good as they are I'm hard pressed to escalate further.

As always, also matters what isodose line you're prescribing to/ what max heterogeneity you are accepting. 9Gy x 3 as point dose to isocenter is different than 9Gy x 3 to 80% IDL (which is generally what I prefer for simple linac-based plans) although I will accept higher if dosimetry feels it leads to a more conformal plan with improvements in V18 (for a 3-fraction regimen).

 

[Neuronix]

I recommend for MLC based linac treatments not prescribing to an IDL. The most important metrics are conformity and dose fall off (gradient index), and prioritizing prescription IDL can worsen those parameters.

 

[medgator]

prioritizing prescription IDL can worsen those parameters.

Ditto for prioritizing hotspot reduction

 

[scarbrtj]

These are the same attendings who will freak out if their plan has over 115% of prescription dose anywhere

9Gy x 3 as point dose to isocenter is different than 9Gy x 3 to 80% IDL (which is generally what I prefer for simple linac-based plans)

In an ideal world, the TPS would not show >100% IDLs. You would put on beams, and treatment ("block," even cone) margins for the lesion(s), there would be IDLs made from that plan, and you'd pick the IDL that just covers the lesion(s). (At that point, if one's unhappy with the IDL coverage... say it was 60% e.g.... you got kinda one main first choice and that's homogenize the plan by distancing penumbras from lesion surfaces.) This is how it used to be in BrainLAB planning. I imagine old GKRS and even CK planning too. You can become acutely aware rather quickly that dose spillage&conformity/block margin (or cone size)/beam number&DOFs (to some extent)/IDL coverage (where 100% is always max) all have an actually easy to understand push/pull relationship. This is NOT so easy to understand when you have a TPS where IDL percentages float all over the place (looking at you Eclipse). I would NOT let a resident learn how to do SRS using Eclipse if I could avoid it, or at least disavow them of the notion that >100% IDLs exist.

9Gyx3 as a point dose to iso is different than 9Gyx3 to 80% IDL by exactly 6.75 Gy And I could use an 80% IDL for linac SRS the rest of my life and prob be OK with it; never higher, never lower.

 

[evilbooyaa]

LINAC-based SRS is the future and current residents need to have the mental flexibility to speak in whatever 'language' of SRS the institution they are 1) currently at and 2) will end up at use.

You can say that you're prescribing 9Gy x 3 to 80% IDL at PTV or you can say you're prescribing 9Gy x 3 to PTV with max heterogeneity of 125% of prescription dose. Outside of pedantism, those are essentially the same thing (a reminder that 1/0.8 = 125%).

To be so caught up in the 'traditional' way of SRS dose delineation that is not done in 95% of radiation oncology (outside of electrons) is to be inflexible without a clinical reason for doing so.

 

[scarbrtj]

LINAC-based SRS is the future and current residents need to have the mental flexibility to speak in whatever 'language' of SRS the institution they are 1) currently at and 2) will end up at use.

You can say that you're prescribing 9Gy x 3 to 80% IDL at PTV or you can say you're prescribing 9Gy x 3 to PTV with max heterogeneity of 125% of prescription dose. Outside of pedantism, those are essentially the same thing (a reminder that 1/0.8 = 125%).

To be so caught up in the 'traditional' way of SRS dose delineation that is not done in 95% of radiation oncology (outside of electrons) is to be inflexible without a clinical reason for doing so.

Now we are getting somewhere re: "language." On the surface, it seems entirely logical to argue that if two ways of saying something have the same meaning, it doesn't matter which way you say it. And to impose one way in favor or disfavor of the other seems fascist! Or, in this instance here regarding the lingo of radiosurgery, antediluvian.

I think there is a clinical reason for using different "languages" at different times and that is only to generate better clinicians. You and I are fully formed; but what of the inchoate radiosurgery learner? For him or her, I think the Sapir-Whorf hypothesis needs to be taken into account. Why can the average 5yo Chinese child count to 40 but the average 5yo American child only count to 12 or 13? The reason is language. In Chinese, the way numbers are said is very logical and step-wise; in English, it's relatively a jumble. Language literally makes math easier for Chinese children. It makes certain concepts easier to fathom. An entire short story was based on this premise: "The Story of Your Life." It was also made into a movie.

In radiosurgery, as opposed to other radiotherapeutic pursuits, inhomogeneity of dose is sought after versus shunned. In a language where inhomogeneity doesn't exist, this makes such a thought process easier to obtain. Were I a teacher of radiosurgery, this would only be clinically important for my learners. Language shapes thought. It's important to have the right thoughts; I couldn't care less about the language.

 

[Neuronix]