Benign Disease

[deleted1111261]

I love that, I actually did my most recent hand patient whole hand and had much better success, may have been thinking too oncologically in my initial patients a while back.

Please report back what you hear from our German colleagues! I'd love to know how routinely they treat people in their 40's, if you have the chance to ask

@medgator made the point that we routinely give 15-18 Gy for keloids and that is an aesthetic treatment. I’ve treated people under 40. Waiting to hear from some of our foreign colleagues.

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[OTN]

Case:

40 yo woman with receptor positive early stage breast cancer s/p appropriate treatment who is now on endocrine therapy.

Her hands hurt terribly. ROM decreased. Hard time opening jars. Suffering.

Any one ever treat this type of joint pain / arthropathy with LD RT? Would you consider it?

I've done it before for hormone-therapy induced hand arthropathy. Worked.

I always treat the whole hand. No need to get cute with it.

 

[hookem19]

Regarding field size, some data suggests being more liberal with field size has better response. Probably makes sense to treat whole hand in most cases

The field size matters: low dose external beam radiotherapy for thumb carpometacarpal osteoarthritis : Importance of field size - PubMed

The purpose of this work was to evaluate the efficacy of low-dose radiotherapy (RT) for thumb carpometacarpal osteoarthritis (rhizarthrosis). The responses of 84 patients (n = 101 joints) were analyzed 3 months after therapy (n = 65) and at 12 months (n = 27). Patients were treated with 6...

pubmed.ncbi.nlm.nih.gov

 

[Palex80]

@medgator made the point that we routinely give 15-18 Gy for keloids and that is an aesthetic treatment. I’ve treated people under 40. Waiting to hear from some of our foreign colleagues.

I‘ve treated keloids in younger patients too. Lot‘s of post-piercing scar issues (ears mainly).
We do not have an age threshold for benign conditions. I‘ve treated a 25 year old for heterotopic ossification prophylaxis with 1 x 7 Gy to the hip (car crash injury the year before with lots of ossifications).

 

[SneakyBooger]

Case:

40 yo woman with receptor positive early stage breast cancer s/p appropriate treatment who is now on endocrine therapy.

Her hands hurt terribly. ROM decreased. Hard time opening jars. Suffering.

Any one ever treat this type of joint pain / arthropathy with LD RT? Would you consider it?

1st pt I ever treated for arthritis came in for followup this week.

She is 8.5 yrs out from postmastectomy XRT.

She had miserable knee pain severely aggravated by endocrine therapy.

Now 3.5 yrs out from arthritis XRT and has "no pain whatsoever" in her knees. Still on endocrine therapy.

Treated her husband's hands 2 yrs ago. He is now playing guitar again.

Both are attorneys and extremely grateful.

 

[SneakyBooger]

Regarding field size, some data suggests being more liberal with field size has better response. Probably makes sense to treat whole hand in most cases

The field size matters: low dose external beam radiotherapy for thumb carpometacarpal osteoarthritis : Importance of field size - PubMed

The purpose of this work was to evaluate the efficacy of low-dose radiotherapy (RT) for thumb carpometacarpal osteoarthritis (rhizarthrosis). The responses of 84 patients (n = 101 joints) were analyzed 3 months after therapy (n = 65) and at 12 months (n = 27). Patients were treated with 6...

pubmed.ncbi.nlm.nih.gov

I have also become more liberal with my fields.

I treat whole hand and wrist no matter where the pain is in that area.

 

[dieABRdie]

I've done it before for hormone-therapy induced hand arthropathy. Worked.

I always treat the whole hand. No need to get cute with it.

This is amazing. I would have never thought it would work for endocrine therapy related joint pain. Just today I had a prostate patient who started ADT a few months ago crying in clinic because of joint pain.

 

[medgator]

This is amazing. I would have never thought it would work for endocrine therapy related joint pain. Just today I had a prostate patient who started ADT a few months ago crying in clinic because of joint pain.

Definitely another aspect of AI therapy as well that doesn't get talked about enough and a big qol hit for some patients

 

[Sheldor]

Definitely another aspect of AI therapy as well that doesn't get talked about enough and a big qol hit for some patients

Had a patient that hadn't worked out in a years because her joints were so sore she couldn't get to the gym. Hard to compare apples to oranges, but hard to think that the benefit of working out daily for a few years could conceivably be as high, or higher, than the benefit of the AI.

 

[thesauce]

This is different then cancer data. I agree that the treatment is atoxic so very little to no clinical downside to treatment.

But... for example it is claimed that "there are strong data to suggest a benefit of LDRT in plantar fasciitis, with about 80% efficacy in pain reduction." Ok plantar fasciitis is caused by micro tears in the plantar aponeurosis due to mechanical stress. Not sure it even has anything to do with inflammation from what I've read. Almost all cases will resolve over 6 to 12 months. So is any of this due to RT effect or just time.

Then why does it respond to steroid injections?

 

[fiji128]

Then why does it respond to steroid injections?

If you read about it, it technically doesn’t and it’s not recommended treatment. I did a deep dive on the condition a few months back. It’s name is a misnomer as it implies an inflammatory issue but its underlying pathology is micro tears in the facia.

 

[deleted1111261]

If you read about it, it technically doesn’t and it’s not recommended treatment. I did a deep dive on the condition a few months back. It’s name is a misnomer as it implies an inflammatory issue but its underlying pathology is micro tears in the facia.

The studies with RT require bone spurs to treat. I am not treating the whole sole of the foot. Maybe talking past each other? RT doesn’t fix PF. It does appear to help patients that have bone spurs.

 

[fiji128]

The studies with RT require bone spurs to treat. I am not treating the whole sole of the foot. Maybe talking past each other? RT doesn’t fix PF. It does appear to help patients that have bone spurs.

I was just responding to the question that thesauce asked regarding steroid injections. A lot of the stuff you see on treating benign conditions with RT cite planter fasciitis as indication. Having previously done a deep dive into the literature on the condition, I’m just saying I have my doubts RT is really doing anything in this one instance beyond a placebo effect. Not a comment on anyones individual practice or treatment for other causes of foot pain.

 

[taserlaser]

I was just responding to the question that thesauce asked regarding steroid injections. A lot of the stuff you see on treating benign conditions with RT cite planter fasciitis as indication. Having previously done a deep dive into the literature on the condition, I’m just saying I have my doubts RT is really doing anything in this one instance beyond a placebo effect. Not a comment on anyones individual practice or treatment for other causes of foot pain.

The one doc here that does a lot of Dupuytrens, also treats the odd Leserhosen, especially in patients where they have both. As I understand from them, they respond quite well to each.

 

[Sheldor]

What is everyone quoting for durability of response? I loved hearing the story above of 3+ year response! I have been quoting "Up to 12+ months of response." Curious what everyone else is seeing and telling patients.

 

[SneakyBooger]

What is everyone quoting for durability of response? I loved hearing the story above of 3+ year response! I have been quoting "Up to 12+ months of response." Curious what everyone else is seeing and telling patients.

Approx 60-65% at 1 yr
Approx 50% at 2 yrs
Approx 33% at 3 yrs

 

[SneakyBooger]

I also advise that a second course is required in 30-40% of pts to achieve a response.

The vast majority of my pts that have undergone a 2nd course have had pain improvement.

 

[TheWallnerus]

I was just responding to the question that thesauce asked regarding steroid injections. A lot of the stuff you see on treating benign conditions with RT cite planter fasciitis as indication. Having previously done a deep dive into the literature on the condition, I’m just saying I have my doubts RT is really doing anything in this one instance beyond a placebo effect. Not a comment on anyones individual practice or treatment for other causes of foot pain.

The number one tranche of procedures in podiatry offices is related to toenails, and the second most common is injecting cortisone in the foot for plantar fasciitis. Podiatrists seem to think doing the steroid works; they would be resistant to being told it’s all placebo, that steroids don’t work for micro-tears, etc. They would also argue with you that plantar fasciitis is always just microtears. In addition, heel spurs can happen and the patient not complain of PF, and a patient can have PF and not have a heel spur. RT doesn’t regress heel spurs, but it helps PF. If you think it doesn’t help PF and it’s all placebo, I would suggest treating 10 patients with >1 year complaints of PF refractory to conservative treatments and steroid injections. Then report back here…

 

[thesauce]

The studies with RT require bone spurs to treat. I am not treating the whole sole of the foot. Maybe talking past each other? RT doesn’t fix PF. It does appear to help patients that have bone spurs.

There’s actually a study comparing those with bone spurs to those without, and there was no difference in the response rate.

 

[Ray D. Ayshun]

The one doc here that does a lot of Dupuytrens, also treats the odd Leserhosen, especially in patients where they have both. As I understand from them, they respond quite well to each.

Just had a great plantar fibromatosis response last week.

 

[fiji128]

The number one tranche of procedures in podiatry offices is related to toenails, and the second most common is injecting cortisone in the foot for plantar fasciitis. Podiatrists seem to think doing the steroid works; they would be resistant to being told it’s all placebo, that steroids don’t work for micro-tears, etc. They would also argue with you that plantar fasciitis is always just microtears. In addition, heel spurs can happen and the patient not complain of PF, and a patient can have PF and not have a heel spur. RT doesn’t regress heel spurs, but it helps PF. If you think it doesn’t help PF and it’s all placebo, I would suggest treating 10 patients with >1 year complaints of PF refractory to conservative treatments and steroid injections. Then report back here…

Ok I guess you can’t express doubts because such and such swears that it works in there own personal experience.

 

[deleted1111261]

Ok I guess you can’t express doubts because such and such swears that it works in there own personal experience.

Out of curiosity, have you tried it ?

 

[hookem19]

What is everyone quoting for durability of response? I loved hearing the story above of 3+ year response! I have been quoting "Up to 12+ months of response." Curious what everyone else is seeing and telling patients.

Per German guidelines, states that "even after >5 years, sustained pain relief can be achieved in more than half of these patients".

Another recent retrospective study from Germany of alomst 300 joints treated (Radiotherapy for osteoarthritis-an analysis of 295 joints treated with a linear accelerator - PubMed) showed most had durable response at 2 years. I added their figure to show pain scores.

Seems like for those who initially benefit the responses are durable.

 

[TheWallnerus]

Out of curiosity, have you tried it ?

Anecdote time!

I was treating a guy for prostate cancer many many years ago. Pretty healthy younger guy and in an OTV he was going on and on about very chronic plantar fasciitis. After about the third week of complaining to me I don’t remember why I remembered that I once had read about radiation and PF in Brady and Perez. It was almost like a fleeting dirty thought in my brain and I was thinking “am I hallucinating that RT can work for this.” So during the OTV with him I went back to my office and opened up my textbook and then brought it in the exam room and showed him the section where it said RT could help. I was like “it sounds kind of crazy but you’re already coming to see me every day so I’m willing to try it if you are.” (These were the days of black and white TVs and MSKCC telling everyone in the world that 45 IMRT fraction prostate was the superior RT schedule.) I had no hope one way or the other. Of course I wouldn’t be telling this story if the guy wasn’t pleased with the outcome; an outcome I wrought that other doctors he had seen hadn’t.

 

[SneakyBooger]

The number one tranche of procedures in podiatry offices is related to toenails, and the second most common is injecting cortisone in the foot for plantar fasciitis. Podiatrists seem to think doing the steroid works; they would be resistant to being told it’s all placebo, that steroids don’t work for micro-tears, etc. They would also argue with you that plantar fasciitis is always just microtears. In addition, heel spurs can happen and the patient not complain of PF, and a patient can have PF and not have a heel spur. RT doesn’t regress heel spurs, but it helps PF. If you think it doesn’t help PF and it’s all placebo, I would suggest treating 10 patients with >1 year complaints of PF refractory to conservative treatments and steroid injections. Then report back here…

I have had some excellent responses with PF.

I think there may be an argument that XRT may have an effect on the natural history of heel spurs. Albeit, currently a weak one, but possibly an argument to be made. Less inflammation -----> less spur formation -- seems plausible.

Could heel spurs regress? I think that might also be possible, but I am unaware of any studies indicating such. I am open minded at this point.

 

[Palex80]

Could heel spurs regress? I think that might also be possible, but I am unaware of any studies indicating such. I am open minded at this point.

Sure, SBRT it with a 200 BED. That should cause osteonecrosis and regression.
Oh, wait…

 

[taserlaser]

Can’t have heel spurs if you don’t have a heel *taps head*

 

[TheWallnerus]

Can’t have heel spurs if you don’t have a heel *taps head*

Fallout

 

[SneakyBooger]

This is how it happens...

Just saw a nurse practitioner who works in an urgent care center who self referred for XRT to his hands after hearing about it from one of my other referrers.

He said he researched it himself and is anxious to get started.

Since having concluded his research, he stated for every patient that comes through the urgent care center that puts arthritis on their medical history that he immediately submits an order for an outpatient consult with me. So far he states 10 consults have been requested.

He stated he understood that he may not benefit but regardless he is convinced it is a better treatment than the others that are available.

The snowball is rolling on...

 

[deleted1111261]

Booger (if that’s reallly your name) - what a great anecdote. Just passed on to my CEO who will let our ED docs know.

 

[evilbooyaa]

This is how it happens...

Just saw a nurse practitioner who works in an urgent care center who self referred for XRT to his hands after hearing about it from one of my other referrers.

He said he researched it himself and is anxious to get started.

Since having concluded his research, he stated for every patient that comes through the urgent care center that puts arthritis on their medical history that he immediately submits an order for an outpatient consult with me. So far he states 10 consults have been requested.

He stated he understood that he may not benefit but regardless he is convinced it is a better treatment than the others that are available.

The snowball is rolling on...

 

[deleted1111261]

Got some word that Cigna is rejecting.

Will follow

 

[medgator]

Got some word that Cigna is rejecting.

Will follow

They are usually the worst of the commercials in my experience although uhc has been making strides lately with Optum

 

[elementaryschooleconomics]

Yeah I've seen some ridiculous stuff this week.

Actually, now that I'm typing this...it's the first week of October, isn't it?

Isn't this when new OMFS fee schedules are adopted and/or proposed? I've personally gotten a few denials that haven't happened all year, and I've had some friends get some absolutely whacky denials. Nothing to do with OA/benign stuff though.

Is this like, the "start of the school year", but for insurance?

 

[Ray D. Ayshun]

Simmed a patient for OA RT to the right hip. 89 yo guy. Ortho doesn't want to do a jt replacement and the patient doesn't seem to either. Here's his right femoral head with avascular necrosis. There's still a component of jt narrowing, OA, and a long history of it including injections. Any reason to treat or not treat this guy at this point?

 

[OTN]

Simmed a patient for OA RT to the right hip. 89 yo guy. Ortho doesn't want to do a jt replacement and the patient doesn't seem to either. Here's his right femoral head with avascular necrosis. There's still a component of jt narrowing, OA, and a long history of it including injections. Any reason to treat or not treat this guy at this point?
View attachment 360769View attachment 360770

I would feel comfortable treating

 

[deleted1111261]

Me too

 

[Ray D. Ayshun]

I'm not uncomfortable with risk to patient, though we always get blamed. I got blamed for xerostomia in a patient who got RNI recently. In any case, my main concern is that this is futile.

 

[TheWallnerus]

I'm not uncomfortable with risk to patient, though we always get blamed. I got blamed for xerostomia in a patient who got RNI recently. In any case, my main concern is that this is futile.

Futility can mean many different things to different physicians. You think an orthopod worries about the futility of a steroid injection here. For *elective* procedures with essentially zero complication risk, futility has a very high bar; and in rad onc this is such a different mode of thinking.

 

[deleted1111261]

This is an atoxic treatment that is very inexpensive.
We do far more invasive things with even less data.
It seems worth a try.

Out of curiosity - what is the risk you are thinking about?

 

[RadRadRad]

Have those if you with experience in arthritis radiation had joints with this degree of arthritis get improvement ? Agree that downside risk is minimal just wondering about odds of success

 

[deleted1111261]

Futility can mean many different things to different physicians. You think an orthopod worries about the futility of a steroid injection here. For *elective* procedures with essentially zero complication risk, futility has a very high bar; and in rad onc this is such a different mode of thinking.

The sheer number of GBM and unresectable pancreas patients that have been treated with curative intent all of these decades ...

Yet, we worry about futility in this setting. I don't know. Not argumentative - just interesting perspectives.

 

[TheWallnerus]

Have those if you with experience in arthritis radiation had joints with this degree of arthritis get improvement ? Agree that downside risk is minimal just wondering about odds of success

You cannot predict who will or won’t get improvement. I think we need an A.I. (not really joking)

 

[Ray D. Ayshun]

This is an atoxic treatment that is very inexpensive.
We do far more invasive things with even less data.
It seems worth a try.

Out of curiosity - what is the risk you are thinking about?

No real risk. Perceived risk. As in, irradiating a hip with avascular necrosis, and where blame might go if he has a fracture. Given the safety, it's worth a shot. Given the likelihood of it helping in a litigious society, it might not be. Trying to do an expected value calculation in the setting of avascular necrosis, which I think changes the math, particularly if this is significantly less likely to help. I have no worries about this harming him in reality, but it's been a minute since I visited.

 

[OTN]

No real risk. Perceived risk. As in, irradiating a hip with avascular necrosis, and where blame might go if he has a fracture. Given the safety, it's worth a shot. Given the likelihood of it helping in a litigious society, it might not be. Trying to do an expected value calculation in the setting of avascular necrosis, which I think changes the math, particularly if this is significantly less likely to help. I have no worries about this harming him in reality, but it's been a minute since I visited.

If you consent the patient fully and document the consent, medicolegally there will be no issue. I don't think RT doses at the level we use for arthritis would increase the chance of AVN.

I strongly, strongly agree with the sentiment that treating arthritis requires a significant change in thinking compared with how we approach our cancer patients.

 

[elementaryschooleconomics]

1) I would definitely treat

2) I would be a little less optimistic in this particular case, but still better than 50/50 there's at least some improvement. I'd have to dig into my notes, but there have been some studies from the last decade indicating that really longstanding arthritis is more refractory than disease present for 1-2 years.

Regarding getting blamed for things...well, the fact that this guy is even on your radar means you're going to get blamed, even without treatment!

"This patient's name was said within 25 yard of the Radiation Oncology department. Therefore, this acute sinusitis is clearly a late effect of XRT..."

 

[hookem19]

One big criticism of Dutch trial was 45% had OA for greater than 5 years in treatment arm which as mentioned might be thought more refractory. That being said, DEGRO guidelines suggest it may not matter duration of symptoms but degree of OA based the Kellgren Lawrence stage for OA (radiographic scoring).

 

[RickyScott]

AS i understand the number of photons in a knee treatment is less than that delivered in a full body CT?

 

[TheWallnerus]

No real risk. Perceived risk. As in, irradiating a hip with avascular necrosis, and where blame might go if he has a fracture. Given the safety, it's worth a shot. Given the likelihood of it helping in a litigious society, it might not be. Trying to do an expected value calculation in the setting of avascular necrosis, which I think changes the math, particularly if this is significantly less likely to help. I have no worries about this harming him in reality, but it's been a minute since I visited.

I gotcha. Fracture risk from AVN is real; you would just have to hold your ground very firmly if someone tried to blame low dose RT for exacerbating that risk.

AS i understand the number of photons in a knee treatment is less than that delivered in a full body CT?

don’t even know if this is true or not but I’m going to start saying it

 

[elementaryschooleconomics]

AS i understand the number of photons in a knee treatment is less than that delivered in a full body CT?

Hahaha I love this -

Honest to God it doesn't seem like we really know how much radiation we get from any of these things. While a knee treatment is 50cGy per treatment, I would GUESS that a full body CT is 40ish...mGy.

Similar numbers, wrong units.

But I could be totally wrong.

Because we're really bad about this.