Benign Disease

[Fpg1245]

Hand osteoarthritis is the lowest hanging fruit, in my humble opinion.
These patients generally suffer for years and treating hands is easier to sell to anyone (patients and other physicians) than a major joint.

You can use photons, one beam 6-MV with a bolus.
If you have an orthovoltage machine, treating from each side with 0.5 Gy works well too, you get about 0.5 Gy in the middle of the joint too (depending on how thick the fingers are and how much kV your machine can deliver, you may need to add/substract a bit of dose).

Who is managing just straight OA these days. I can’t imagine ortho being all that helpful as they’ll probably just replace the joint. Maybe the people that don’t want surgery. Rheum? Primary Care?

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[elementaryschooleconomics]

Everyone doing 0.5Gy x 6 QOD for 2 weeks?

I've done that or 0.6Gy x5 QOD.

It's probably all in my head, but I do think the 0.5Gy is better. However, with the way the calendar/schedule falls, doing 6 instead of 5 fractions has occasionally meant a patient is still "undergoing treatment" for an extra week, and they don't want that (a few friends/family have gotten treatment while visiting on vacation, so I try to be done within 2 weeks for them). In those cases, I'll do 0.6Gy.

I agree. I was the most skeptical of its benefits but truly see some great improvement. The downside is minimal and it is life-changing some of the time.

I'm still really struggling with this too, personally. I think it's just because it's unlike anything we normally do. Honestly, I REALLY struggle with the side effects part. Because there aren't any. And that doesn't make any sense. Because everything else we do has a side effect, right?

But...the only side effect seems to be the uncomfortable linac table.

 

[TheWallnerus]

Because everything else we do has a side effect, right?

Not 26 Gy in 5fx partial breast

(At least not “in clinico”)

 

[RickyScott]

I've done that or 0.6Gy x5 QOD.

It's probably all in my head, but I do think the 0.5Gy is better. However, with the way the calendar/schedule falls, doing 6 instead of 5 fractions has occasionally meant a patient is still "undergoing treatment" for an extra week, and they don't want that (a few friends/family have gotten treatment while visiting on vacation, so I try to be done within 2 weeks for them). In those cases, I'll do 0.6Gy.


I'm still really struggling with this too, personally. I think it's just because it's unlike anything we normally do. Honestly, I REALLY struggle with the side effects part. Because there aren't any. And that doesn't make any sense. Because everything else we do has a side effect, right?

But...the only side effect seems to be the uncomfortable linac table.

The number of photons being absorbed into the body in a course of treatment to an elbow is like half a ct scan- something like that was said in the in the accelerators podcast.

 

[deleted1111261]

I have talked to podiatrists, PCPs and am working on some ortho and rheum. As @OTN says, best market is follow up patients.
Women are more interested than men, in my experience. "What do you have to lose?" is a good argument in support.

I'm moving along nicely with this program. Makes hospital happy as it is capturing revenue we would have never got. We are low volume, so every patient helps. And the staff is here anyway.

I am doing M, W, F x 2 weeks for PF and OA (1 Gy/Fx for PF, 0.5 Gy/Fx for OA)

CT for planning if needed, even if not reimbursed. Clinical set up for hands.

 

[TheWallnerus]

The number of photons being absorbed into the body in a course of treatment to an elbow is like half a ct scan- something like that was said in the in the accelerators podcast.

That would be a neat way to specify dose

Square meters per second (photon flux)

Instead of

Joules per kg (gray)

Of course the sharp eyed reader realizes that the gray is equivalent to photon flux per second (square meters per square seconds) … which in terms of E=mc2 reduces to E/m. (The gray doesn’t make sense without special relativity.)

 

[RickyScott]

That would be a neat way to specify dose

Square meters per second (photon flux)

Instead of

Joules per kg (gray)

Of course the sharp eyed reader realizes that the gray is equivalent to photon flux per second (square meters per square seconds) … which in terms of E=mc2 reduces to E/m. (The gray doesn’t make sense without special relativity.)

I don’t know how you would account for the fact that many of the photons are not absorbed and pass right through?

 

[OTN]

I noticed a marked improvement in response when I changed from 60 cGy QD to QOD, so I do believe the Swiss got it wrong.

My rate of hand arthritis improvement is right in line with that published Spanish data. It works really well.

 

[Palex80]

Who is managing just straight OA these days. I can’t imagine ortho being all that helpful as they’ll probably just replace the joint. Maybe the people that don’t want surgery. Rheum? Primary Care?

Primary Care Physicians and Rheumatologists are our main referring physicians for hand osteoarthritis.

 

[TheWallnerus]

I noticed a marked improvement in response when I changed from 60 cGy QD to QOD, so I do believe the Swiss got it wrong.

My rate of hand arthritis improvement is right in line with that published Spanish data. It works really well.

I vote QD too

 

[jondunn]

I vote QD too

I think OTN was saying qod was better?

would want to know which is better, thinking about offering it soon

 

[deleted1111261]

I vote QD too

Wait - sounds like OTN saying from QD to QOD?

 

[OTN]

Wait - sounds like OTN saying from QD to QOD?

QOD better yep

 

[TheWallnerus]

Ha yep I misread. I stand by QD!

 

[Palex80]

The Germans generally recommend treatment 2-3 times per week. Small joints are preferably treated 2 times per week. Evidence concerning 2 or 3 times per week is scarce. The dose can be increased from 0.5 Gy to 1.0 Gy if symptoms are of chronic nature (duration > 3 months).

 

[deleted1111261]

Ha yep I misread. I stand by QD!

Oh you don’t like patients getting better ?

 

[Ray D. Ayshun]

Oh you don’t like patients getting better ?

Therapists will start getting pissed when you have 15 mwf patients on treatment

 

[deleted1111261]

Therapists will start getting pissed when you have 15 mwf patients on treatment

😂
We are on our way

 

[DrZap]

I have talked to podiatrists, PCPs and am working on some ortho and rheum. As @OTN says, best market is follow up patients.
Women are more interested than men, in my experience. "What do you have to lose?" is a good argument in support.

I'm moving along nicely with this program. Makes hospital happy as it is capturing revenue we would have never got. We are low volume, so every patient helps. And the staff is here anyway.

I am doing M, W, F x 2 weeks for PF and OA (1 Gy/Fx for PF, 0.5 Gy/Fx for OA)

CT for planning if needed, even if not reimbursed. Clinical set up for hands.

What is your follow-up schedule for these patients? Any guidance on retreatment?

 

[Ray D. Ayshun]

😂
We are on our way

My first patient's husband picked up a bunch of my cards for their church members as her hip pain is already way better s/p 2 of a planned 3 Gy. We'll see about this. I did start with a two jointer as if this works 60%-80% of the time, there's only a 4%-16% I'll go 0fer.

 

[deleted1111261]

What is your follow-up schedule for these patients? Any guidance on retreatment?

I'm going to do 1 month follow up, then 3 month, offer re-RT at 6 months.

 

[deleted1111261]

My first patient's husband picked up a bunch of my cards for their church members as her hip pain is already way better s/p 2 of a planned 3 Gy. We'll see about this. I did start with a two jointer as if this works 60%-80% of the time, there's only a 4%-16% I'll go 0fer.

Church, YMCA, Rotary Club, walking around Meijer.

 

[thecarbonionangle]

Are you guys using arthritis as a billing code?

 

[deleted1111261]

Are you guys using arthritis as a billing code?

yes

 

[Palex80]

I'm going to do 1 month follow up, then 3 month, offer re-RT at 6 months.

You could offer retreat at 6-8 weeks. We do this all the time and it is in European guidelines.

 

[elementaryschooleconomics]

Currently, I have them scheduled to come back at 12 weeks with potential sim to immediately follow.

My rationale is based on that recent German paper which showed excellent response but a decent chunk of people needed a second course. So, if they're happy at 12 weeks, I'm happy. If they're not happy, it's time for Round 2.

 

[hookem19]

I think huge criticism of Minten et el in addition to dose was no retreatment allowed. In Spanish study above, 63% of patients needed retreatment

 

[deleted1111261]

An homage to y’all and particularly @OTN - one of the true Builders we have in this field. Great work!

 

[dieABRdie]

I have absolutely lost count of the number of patients who I've seen in follow up that have said "Now... if you could just do something about this knee!!!"

I'm pretty busy as is... so I'm treading lightly. And very grateful for the insights!

 

[DrZap]

You could offer retreat at 6-8 weeks. We do this all the time and it is in European guidelines.

Thank you 😄

 

[Palex80]

Thank you 😄

Actually, I have heard the argument that you should retreat at 6-8 weeks and not wait for a substantially longer time.

We only have little understanding of the radiobiology of benign diseases. It could be that patients achieving only a partial pain response after a first course of treatment reach a certain immunomodulation that only for a short time frame and should receive re-treatment rather early before they actually progress with more symptoms. These conditions arise from chronic inflammation and if that chronic inflammation comes back at 6 months (even because the patients may have stressed their joints more than they did before, because they had partial pain response!) as full blown inflammation, it may be more difficult to reach a pain-free state with a second course.

So many unknowns...

 

[elementaryschooleconomics]

Actually, I have heard the argument that you should retreat at 6-8 weeks and not wait for a substantially longer time.

We only have little understanding of the radiobiology of benign diseases. It could be that patients achieving only a partial pain response after a first course of treatment reach a certain immunomodulation that only for a short time frame and should receive re-treatment rather early before they actually progress with more symptoms. These conditions arise from chronic inflammation and if that chronic inflammation comes back at 6 months (even because the patients may have stressed their joints more than they did before, because they had partial pain response!) as full blown inflammation, it may be more difficult to reach a pain-free state with a second course.

So many unknowns...

Hmmm...I might alter my practice then. Good point.

 

[deleted1116990]

It would be funny if you all got together and published on OA. I could see that really pissing off many in academics with a publication coming out of SDN from anonymous misanthropes expanding indications for RT. Would be hilarious.

 

[DrZap]

Actually, I have heard the argument that you should retreat at 6-8 weeks and not wait for a substantially longer time.

We only have little understanding of the radiobiology of benign diseases. It could be that patients achieving only a partial pain response after a first course of treatment reach a certain immunomodulation that only for a short time frame and should receive re-treatment rather early before they actually progress with more symptoms. These conditions arise from chronic inflammation and if that chronic inflammation comes back at 6 months (even because the patients may have stressed their joints more than they did before, because they had partial pain response!) as full blown inflammation, it may be more difficult to reach a pain-free state with a second course.

So many unknowns...

Thank you. Do you offer more than two courses to the same site?

 

[Ray D. Ayshun]

do those of you retreating resim, or just reuse the old plan?

 

[Palex80]

Thank you. Do you offer more than two courses to the same site?

I have never offered more than two courses over a short time frame.
So if there is little / no pain response at 6-8 weeks and I retreat and 6-8 weeks later there is still no pain response, I do not treat again.
I am not aware if people do that, perhaps there are case reports of patients with clinical improvement.

I have however treated the same site with multiple courses over longer time frames. I have had patients who have received 4-5 courses over a time period of several years, yes.

do those of you retreating resim, or just reuse the old plan?

This is a good question.
I guess it depends on a) methods of immobilization, b) type of plan you used and c) whether or not you think you may have missed the target.

a) if you use one of those fancy pillows that you form any way you want with heat, water or by sucking the air out, then you can certainly put that pillow in a storage bin and have it in place if the patients needs a second course 6-8 weeks later.
b) if you use a simple photon field with open leaves at a gantry of 0° to treat a hand on the linac couch, with the patient standing next to the couch, you can obviously use that plan during the second course.
c) if you are treating a painful heel spur, but the patient comes back 6 weeks later with pain in the achilles tendon, then you may have missed some of the target during the first course.

 

[OTN]

Dupuytren's contracture: Has anyone ever treated it? If so, for volumes, have you contoured just the nodule? Any recommendations?

 

[deleted1111261]

Dupuytren's contracture: Has anyone ever treated it? If so, for volumes, have you contoured just the nodule? Any recommendations?

And do people do 30 Gy split course into 15 Gy? Or other dose?

Here is a paper with some pictures: https://dupuytrens.org/DupPDFs/2012_Seegenschmiedt.pdf

Seems like generous margin on nodules.

 

[RO28]

So I have treated several on my own and learned the technique in residency. I use a overhead projector transparency and draw out the hand outline, nodules and cords as well as any distinct lines on the hand so that the transparency can be aligned (akin to a map). This allows the therapist to cut out an electron block. Clinical set up and I treat the patient standing. 6 MeV, usually to 90%, but I suppose if the patient had very large hands that could change. I treat the whole palm most of the time, as the patients have had several nodules in distinct areas. I do 30 Gy split course, separated by 8 weeks.

 

[TheWallnerus]

So I have treated several on my own and learned the technique in residency. I use a overhead projector transparency and draw out the hand outline, nodules and cords as well as any distinct lines on the hand so that the transparency can be aligned (akin to a map). This allows the therapist to cut out an electron block. Clinical set up and I treat the patient standing. 6 MeV, usually to 90%, but I suppose if the patient had very large hands that could change. I treat the whole palm most of the time, as the patients have had several nodules in distinct areas. I do 30 Gy split course, separated by 8 weeks.

And do people do 30 Gy split course into 15 Gy? Or other dose?

Here is a paper with some pictures: https://dupuytrens.org/DupPDFs/2012_Seegenschmiedt.pdf

Seems like generous margin on nodules.

In reality, you really need a 2cm block margin with 6 MeVs (no matter the disease or site) because the "usable" dose constricts in so much from the block edges at surface. Given electrons, you really need "generous" margins per the physics. Seegenschmiedt uses a lot of kV, and the penumbra is very sharp for that, but even then the man himself says 2cm margins.

 

[Palex80]

So I have treated several on my own and learned the technique in residency. I use a overhead projector transparency and draw out the hand outline, nodules and cords as well as any distinct lines on the hand so that the transparency can be aligned (akin to a map). This allows the therapist to cut out an electron block.

We use a photocopier. We draw everything on the patient's hand, the patient puts the hand onto the glass surface, we close the cover and make a copy of the hand.

And yes, we actually still have a photocopier in the department...

 

[OTN]

Great tips, thanks all!

 

[Ray D. Ayshun]

Does anyone retreat Palmar fibromatosis? Time from initial treatment? New nodule only? Different fractionation/modality? Other options?

 

[CaesarRO]

And do people do 30 Gy split course into 15 Gy? Or other dose?

Here is a paper with some pictures: https://dupuytrens.org/DupPDFs/2012_Seegenschmiedt.pdf

Seems like generous margin on nodules.
View attachment 356928

I prefer 21 Gy in 7 fractions to avoid split course. Works great

Radiotherapy optimization in early-stage Dupuytren's contracture: first results of a randomized clinical study - PubMed

Both prophylactic RT concepts have been well accepted and tolerated by patients. Within the first year, they were equally effective to prevent further disease progression of DC and obtain considerable symptomatic improvement. Although 1-year results suggest similar response rates for both...

pubmed.ncbi.nlm.nih.gov

 

[deleted1111261]

Does anyone retreat Palmar fibromatosis? Time from initial treatment? New nodule only? Different fractionation/modality? Other options?

Don’t like eponyms, bro? I had to look that up!

 

[Ray D. Ayshun]

Don’t like eponyms, bro? I had to look that up!

Having trouble remembering how to spell Dupuytren, who was probably racist/mysoginist etc and needs to be forgotten.

 

[deleted1111261]

Having trouble remembering how to spell Dupuytren, who was probably racist/mysoginist etc and needs to be forgotten.

Yah. Shoot. He probably did a racism and got cancelled.

 

[Ray D. Ayshun]

Yah. Shoot. He probably did a racism and got cancelled.

There seems to be a suggestion that he was an ahole on wiki. It did mention that his most important published work was "treatise on artificial anus," which I think was the subtitle of "art of the deal."

 

[SneakyBooger]

Inflammation:

Low Dose Radiation Therapy Induces Long-Lasting Reduction of Pain and Immune Modulations in the Peripheral Blood – Interim Analysis of the IMMO-LDRT01 Trial​

Frontiers | Low Dose Radiation Therapy Induces Long-Lasting Reduction of Pain and Immune Modulations in the Peripheral Blood – Interim Analysis of the IMMO-LDRT01 Trial

The treatment of chronic inflammatory and degenerative diseases by low dose radiation therapy (LDRT) is promising especially for patients who were refractory...

doi.org

Low-Dose Radiotherapy Leads to a Systemic Anti-Inflammatory Shift in the Pre-Clinical K/BxN Serum Transfer Model and Reduces Osteoarthritic Pain in Patients​

Frontiers | Low-Dose Radiotherapy Leads to a Systemic Anti-Inflammatory Shift in the Pre-Clinical K/BxN Serum Transfer Model and Reduces Osteoarthritic Pain in Patients

Osteoarthritis (OA) is the leading degenerative joint disease in the western world and leads, if left untreated, to a progressive deterioration of joint func...

doi.org

 

[Palex80]

Inflammation:

Low Dose Radiation Therapy Induces Long-Lasting Reduction of Pain and Immune Modulations in the Peripheral Blood – Interim Analysis of the IMMO-LDRT01 Trial​

Frontiers | Low Dose Radiation Therapy Induces Long-Lasting Reduction of Pain and Immune Modulations in the Peripheral Blood – Interim Analysis of the IMMO-LDRT01 Trial

The treatment of chronic inflammatory and degenerative diseases by low dose radiation therapy (LDRT) is promising especially for patients who were refractory...

doi.org

Low-Dose Radiotherapy Leads to a Systemic Anti-Inflammatory Shift in the Pre-Clinical K/BxN Serum Transfer Model and Reduces Osteoarthritic Pain in Patients​

Frontiers | Low-Dose Radiotherapy Leads to a Systemic Anti-Inflammatory Shift in the Pre-Clinical K/BxN Serum Transfer Model and Reduces Osteoarthritic Pain in Patients

Osteoarthritis (OA) is the leading degenerative joint disease in the western world and leads, if left untreated, to a progressive deterioration of joint func...

doi.org

But what about COVID?