Non cms avm

[Reaganite]

Anybody treated an avm outside the cns? Have a guy with a 6cm lower extremity avm who has failed previous embolization, etc. Very limited data on doses outside cns. Wondering what you guys would do? Actually decent distance between femur and lesion and patient is pretty thick in the leg...20 x 1 or hypofractionate?

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[Palex80]

Any specific reason why the surgeons wont simply operate on this patients? If he hasn't seen a specialized vascular surgeon, I would suggest to send him to one first.

 

[BobbyHeenan]

Agree with Palex - I'd want vascular surgeon or ortho oncology to weigh in.

I actually wouldn't be as worried about the femur as I would radiation induced myositis treating a 6 cm target to 20 Gy. I've seen this in a patient that got hypofractionated (don't remember exact dosage, I think something pretty aggressive like 50 Gy in 15 Fx's) curative intent proton therapy for a sacral recurrence of rectal cancer. Was not my patient but I saw it presented at tumor board. Significant edema/FLAIR change on MRI right in the moderate to high dose distribution on the gluteal musculature up to 9-12 months after treatment. When you put the ~70% isodose line on it it was remarkable the correlation between imaging change and dose. Had a path CR on biopsy but major myositis/myopathy. Patient had pretty profound muscle aches, weakness, discomfort, and fatigue but good control of his recurrence.

*IF* everyone says no surgery and this guy has bled before, then I think it's just as reasonable as observation to treat this guy. Obviously in a data-free zone. I'd probably put him on prophylactic Trental/Vit E...not sure if that would decrease embolization rate, but may help with preventing fibrosis. You at least have phase III data for fractionated breast cancer that says it helps with fibrosis.

For me personally, I'd send him to the academic center a few hours away before I turned the beam on unless he out right refuses to go see them.

 

[Reaganite]

Can't send out for insurance reasons and was already evaluated by every possible non rad onc specialist...

 

[RadOncDoc21]

Can't send out for insurance reasons and was already evaluated by every possible non rad onc specialist...

I'm going to play devil's advocate here and ask the question "why not treat?"

I understand the argument for toxicity, data, uncertainties, etc; but how are we ever suppose to grow as a field and expand our knowledge if we don't attempt to step outside the box every once in awhile?

Timmerman did and see what happened to our field, I say consent the patient, tell him he may die and present your results!

 

[BobbyHeenan]

Can't send out for insurance reasons and was already evaluated by every possible non rad onc specialist...

Tough case then. If it's bled before I'd probably treat it.

If it's never bled before then I'd wonder how it was caught and ask about the consequences of this thing bleeding...is it life threatening like a stroke or just limb-threatening? I'm no expert on AVM's, but especially extra cranial AVM's. Like if it bleeds will he die, or will he get compartment syndrome or something but it's likely to stop the bleeding and maybe lose the leg?

 

[Palex80]

I'm going to play devil's advocate here and ask the question "why not treat?"

I understand the argument for toxicity, data, uncertainties, etc; but how are we ever suppose to grow as a field and expand our knowledge if we don't attempt to step outside the box every once in awhile?

Timmerman did and see what happened to our field, I say consent the patient, tell him he may die and present your results!

There is a slight difference between an NSCLC and an AVM.

I do however understand your point.

 

[Newquagmire]

We offered treatment for a symptomatic neuroforaminal AVM based on these papers, but patient chose surgery.
Multisession CyberKnife radiosurgery for intramedullary spinal cord arteriovenous malformations. - PubMed - NCBI
Stereotactic radiosurgery for intramedullary spinal arteriovenous malformations. - PubMed - NCBI

 

[seper]

I treated one patient just like that, 6 Gy X 5. Good response.