Benign Disease

[Surf Rx]

anyone treated hips- do they respond?

Just treated someone a few months ago who was on high doses of gabapentin and needed a cane to get around. Now pain free and walking around unassisted. Couldn't be happier.

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[dieABRdie]

The German POC study from 2018 states single fraction doses are 0.5 - 1.0 Gy to total doses of 2-8 Gy are being used.

View attachment 373440

The European (mostly Germany) literature in which the prescription practices are described is relatively few. Many used kV therapies. Those that described their MV prescription practices almost entirely prescribe to isocenter. I have only found 1 publication prescribing to a 3D volume.

60 cgy is one of the more common single fraction doses evaluated. I don't know what developments led to the choice of 60 cgy -- maybe it was an "educated guess". If dose is prescribed to the isocenter, that correlates with a lower dose covering the entirety of the joint. If I prescribe 50 cgy to a volume (the joint) the isocenter dose is between 60 to 100 cgy.

My insurers will only pay for 5 fractions. Therefore, I have limited my prescription to 5 fractions which delivers a total dose to the isocenter meeting or exceeding 300 cgy as described by DEGRO.

Regarding dose/fraction, several in vitro studies have shown more beneficial effects on immunomodulators with doses between 30 - 70 cgy compared with higher doses. The most effective dose/fraction (and total dose) are unknown, as far as I can tell. But, it appears to me that the lower the dose/fraction the greater the anti-inflammatory effect. What should the total dose be? I don't know, but suspect the lower the better there also. There are many patients who report significant pain relief within 1 or 2 fractions. Makes me wonder if those patients really need to complete the remainder of their treatments.

I started out treating 5 x 60 cgy. For the past couple years I have been treating with 5 x 50 cgy to a volume (i.e., the joint). I have treated hundreds of joints with this regimen since and haven't noticed a detriment to response rate.

Fortunately, or unfortunately depending on how you look at it, my arthritis practice has taken off as patients return to their PCP's/Ortho's and they see the results. I had to limit the number of arthritis patients I see in a week as it was crowding out my ability to take care of oncology patients. I have arthritis consults commonly booked out 3+ months now. But, it doesn't seem to bother them as they have already been told by their orthopod that it will be 5-6 mos before they can have surgery for their joint anyway. I am currently treating the spouse of one of my top referrers.

When I started this years ago I did not believe it would work. I thought the Europeans were quacks! I am amazed by what I have seen and wish I had started doing this sooner as it can have a tremendous positive impact on a patient's life.

Thanks for that.

I was worried about getting too busy and not having room for cancer patients, but right now I would really like to fill some of these slots....

 

[Surf Rx]

Just treated someone a few months ago who was on high doses of gabapentin and needed a cane to get around. Now pain free and walking around unassisted. Couldn't be happier.

Forgot to mention that I treated this guy for prostate cancer a few years prior. So his previous hip dose didn't adversely affect his outcomes with LDRT, thankfully.

 

[dieABRdie]

Forgot to mention that I treated this guy for prostate cancer a few years prior. So his previous hip dose didn't adversely affect his outcomes with LDRT, thankfully.

I actually just got this question earlier today from a prostate patient....

 

[elementaryschooleconomics]

I'm at the point now where I showed up one day

To find one of my nurses had scheduled a consult with me

For LDRT

Because she's watched my patients come in with canes...then come in for followups without canes.

It's hard to argue with results

I'm running solely off word of mouth at this point, haha.

 

[metallica81788]

For those of you who have treated let's say >50-100 patients...

What would you say the breakdown is of sites? Hip v knee v elbow v shoulder v spine v hand etc?
I just worry once I start rolling with this most of my patients will be hip/spine and that anecdotally has less response and "more risk"

 

[elementaryschooleconomics]

For those of you who have treated let's say >50-100 patients...

What would you say the breakdown is of sites? Hip v knee v elbow v shoulder v spine v hand etc?
I just worry once I start rolling with this most of my patients will be hip/spine and that anecdotally has less response and "more risk"

Knees have DOMINATED for me

Although the bias is on my end, because I don't aggressively pitch LDRT to like, spine in the same way I pitch to shoulder/hands/knee/feet

 

[Palex80]

What would you say the breakdown is of sites? Hip v knee v elbow v shoulder v spine v hand etc?
I just worry once I start rolling with this most of my patients will be hip/spine and that anecdotally has less response and "more risk"

Hands are the most common indication in our hospital.

 

[elementaryschooleconomics]

Hands are the most common indication in our hospital.

What's your preferred setup? Or are you using orthovoltage since you're not in American?

The uh...robust body habitus of my countrymen and narrow megavoltage linac table (and CT scan bore) can mean creative hand setups for me.

If only ASTRO hasn't facilitated bundling the OTV code with the orthovoltage code to fight DermRads and effectively kill the orthovoltage market in the USA...

 

[deleted1111261]

What's your preferred setup? Or are you using orthovoltage since you're not in American?

The uh...robust body habitus of my countrymen and narrow megavoltage linac table (and CT scan bore) can mean creative hand setups for me.

If only ASTRO hasn't facilitated bundling the OTV code with the orthovoltage code to fight DermRads and effectively kill the orthovoltage market in the USA...

Every patient gets a direct electron field, 20Mev

And Port Huron ain’t skinny town

 

[elementaryschooleconomics]

Every patient gets a direct electron field, 20Mev

And Port Huron ain’t skinny town

Are you having them stand next to the table with a clinical setup for that?

I've experimented with several setups and don't feel like I've found the "default" version yet.

 

[deleted1111261]

Are you having them stand next to the table with a clinical setup for that?

I've experimented with several setups and don't feel like I've found the "default" version yet.

Exactly

 

[Palex80]

What's your preferred setup? Or are you using orthovoltage since you're not in American?

The uh...robust body habitus of my countrymen and narrow megavoltage linac table (and CT scan bore) can mean creative hand setups for me.

If only ASTRO hasn't facilitated bundling the OTV code with the orthovoltage code to fight DermRads and effectively kill the orthovoltage market in the USA...

Orthovoltage works well.

Otherwise, single 6 MV photon field with a 5mm bolus.

 

[sirspamalot]

Someone really needs to do a sham treatment vs. real and long term followup. I mean, I want to believe but..

 

[elementaryschooleconomics]

Someone really needs to do a sham treatment vs. real and long term followup. I mean, I want to believe but..

Low-dose RaDiation therapy for patients with KNee osteoArthritis (LoRD-KNeA): a protocol for a sham-controlled randomised trial | BMJ Open

 

[elementaryschooleconomics]

Low-dose RaDiation therapy for patients with KNee osteoArthritis (LoRD-KNeA): a protocol for a sham-controlled randomised trial | BMJ Open

The only downside to this trial is 0.3Gy (30cGy) is still within the realm of the in vitro doses showing effect.

I'm very curious about the trial regardless.

 

[sirspamalot]

Well, as long as they aren't trying to sell some random bogus stuff.. lol..

Google: Knee-Grow

 

[SneakyBooger]

For those of you who have treated let's say >50-100 patients...

What would you say the breakdown is of sites? Hip v knee v elbow v shoulder v spine v hand etc?
I just worry once I start rolling with this most of my patients will be hip/spine and that anecdotally has less response and "more risk"

Knees and hands. Then feet, hips. Then shoulders.

 

[SneakyBooger]

Knees have DOMINATED for me

Although the bias is on my end, because I don't aggressively pitch LDRT to like, spine in the same way I pitch to shoulder/hands/knee/feet

I am unaware of any publications regarding spines. I have done a few and have seen a small response in some. Is there any data out there on spines?

 

[elementaryschooleconomics]

I am unaware of any publications regarding spines. I have done a few and have seen a small response in some. Is there any data out there on spines?

I don't think so - I've done a few based on anecdote from others who have seen results.

Mechanistically it makes sense, but because of the lack of reports, I don't actively pitch it (they come to me based on word of mouth, I tell them basically that - "the spine doesn't have the same level of data" - but even with the disclaimer, people are just eager to try anything that isn't surgery)

 

[SneakyBooger]

people are just eager to try anything that isn't surgery)

100%!

 

[Ray D. Ayshun]

How are y'all simming bilateral hands? Just hands flat above head, single field? Have an old lady that may or may not be able to do that.

 

[evilbooyaa]

How are y'all simming bilateral hands? Just hands flat above head, single field? Have an old lady that may or may not be able to do that.

You talkin' about CT Sim? supine hands above head? Or prone bilateral superman?

I think most aren't CT simming hands, doing clinical set up with patient sitting/standing with hands on table

 

[TheWallnerus]

How are y'all simming bilateral hands? Just hands flat above head, single field? Have an old lady that may or may not be able to do that.

Have her sit in a chair and place her hands on the table. Extended SSD would be fine. You could do one beam hands up, one beam hands down.

Hands down... this will work!

 

[OTN]

I've done both prone with hands above head and supine with hands at sides

 

[Ray D. Ayshun]

I've done both prone with hands above head and supine with hands at sides

I was thinking supine with hands above head for the sake of a single field. She's an old rectal patient who had an apr so no prone stuff. Supine at the side is fine but would have to do 2 fields. I'm not crazy about clinical setups in general, though seated would be cool. She's probably not a great stander. You all just treating whole hand? I've been relying on field design from the red journal article with slight mods when appropriate.

 

[deleted1111261]

We do standing

Sitting good, too. Drop table and beam on

 

[Fpg1245]

We do standing

Sitting good, too. Drop table and beam on

How is insurance coverage with this. Any Evicore pushback. Doing any IGRT? Or just sim on table?

Who is referring or are you just pushing it to patients already on treatment?

 

[evilbooyaa]

How is insurance coverage with this. Any Evicore pushback. Doing any IGRT? Or just sim on table?

Who is referring or are you just pushing it to patients already on treatment?

My goodness, need an FAQ or sticky about this somewhere. There's 11 pages of discussion on this. These exact questions have likely been asked and answered in this thread previously.

Insurance is fine. It is in most insurance company's guidelines. No IGRT. Clinical set-up vs CT sim depends on location. Bill complex, not 3D.

Some places (mostly non-academic places) have robust referral patterns already set-up. Some busier places just are offering to their F/Us.

 

[OTN]

My goodness, need an FAQ or sticky about this somewhere. There's 11 pages of discussion on this. These exact questions have likely been asked and answered in this thread previously.

Insurance is fine. It is in most insurance company's guidelines. No IGRT. Clinical set-up vs CT sim depends on location. Bill complex, not 3D.

Some places (mostly non-academic places) have robust referral patterns already set-up. Some busier places just are offering to their F/Us.

My experience is the same.

I have not advertised to anyone outside my own follow-up patients, as I am as busy as I can be at the moment.

 

[Fpg1245]

My goodness, need an FAQ or sticky about this somewhere. There's 11 pages of discussion on this. These exact questions have likely been asked and answered in this thread previously.

Insurance is fine. It is in most insurance company's guidelines. No IGRT. Clinical set-up vs CT sim depends on location. Bill complex, not 3D.

Some places (mostly non-academic places) have robust referral patterns already set-up. Some busier places just are offering to their F/Us.

Rough estimate of reimbursement if billing as you described? I know it’s payor dependent

 

[TheWallnerus]

Doing any IGRT?

No IGRT.

 

[Palex80]

We do standing

Sitting good, too. Drop table and beam on

Don't do VMAT with the patient standing or sitting next to the LINAC.

 

[Ray D. Ayshun]

I was thinking of doing supine with hands on knees and knocking out a few joints at once.

 

[evilbooyaa]

Rough estimate of reimbursement if billing as you described? I know it’s payor dependent

CPT codes are in the business forum. I will no longer spoon feed you information that has previously been posted.

 

[deleted1111261]

DAMN. I hear you though. We all keep writing the same things over and over. Same phone calls. Same emails.

 

[Ray D. Ayshun]

We have this, and a separate thread where we threw some dude under the bus for having TORS. Hardly benign.

 

[Ray D. Ayshun]

Anyone have Any fingernail issues with hand rt?

 

[taserlaser]

Anyone have Any fingernail issues with hand rt?

We block them for our dupuytrens cases. Haven’t done any LDRT for OA though.

 

[Palex80]

Anyone have Any fingernail issues with hand rt?

Nope. The dose is too low. In case of retreatment in a short interval, I've seen colleagues block them out.

 

[Ray D. Ayshun]

Nope. The dose is too low. In case of retreatment in a short interval, I've seen colleagues block them out.

Patient I'm about to treat lost em with chemo for rectal cancer a couple years ago. I suspect dose remains too low, but wondered if she might be a special case.

 

[Palex80]

Patient I'm about to treat lost em with chemo for rectal cancer a couple years ago. I suspect dose remains too low, but wondered if she might be a special case.

I haven’t faced this issue.

Do you need to treat the DIPs? Or is the pain in the PIPs and MCPs? If no involvement of DIPs, simply spare nails and nail beds out.

 

[RickyScott]

I haven’t faced this issue.

Do you need to treat the DIPs? Or is the pain in the PIPs and MCPs? If no involvement of DIPs, simply spare nails and nail beds out.

Just treated first case for hypertrophic pulmonary osteoarthropathy but didn’t consider nails.

 

[maruchan]

What dose/fractionation/schedule are you guys using for keloids?

 

[RickyScott]

What dose/fractionation/schedule are you guys using for keloids?

5gy x 3

 

[medgator]

5gy x 3

4-6 Gy x 3 is what I've seen. Some data suggests 12/3 may not be enough dose

 

[metallica81788]

6 x 3

 

[radoncftw]

6 x 3

7 x 3

 

[thecarbonionangle]

7 x 3

This is the way

 

[SneakyBooger]

Anyone have Any fingernail issues with hand rt?

Haven't seen it.