Benign Disease

[Ray D. Ayshun]

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.

well, i stopped thinking about physics a minute ago, but 40 mJ/kg to 100 kg probably isn't significantly more photons than 50 cJ/kg to 1 kg. Am i totally off here?

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[TheWallnerus]

well, i stopped thinking about physics a minute ago, but 40 mJ/kg to 100 kg probably isn't significantly more photons than 50 cJ/kg to 1 kg. Am i totally off here?

But let’s not forget CT kV radiation has a higher RBE than MV linac radiation too

 

[hookem19]

I think it’s the effective dose that is lower for 3Gy/6fx to knee (13mSv to 50mSv or so)

Estimation of the carcinogenic risk of radiotherapy of benign diseases from shoulder to heel

To estimate risk on fatal tumour induction in patients by radiotherapy of benign diseases at various body sites, including heterotopic ossification, o…

www.sciencedirect.com

 

[Ray D. Ayshun]

But let’s not forget CT kV radiation has a higher RBE than MV linac radiation too

All's I know is, I hate breast.

 

[RickyScott]

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.

100 times less mass in the knee than whole body, so amount of photons- not the dose- may be the same.

 

[elementaryschooleconomics]

100 times less mass in the knee than whole body, so amount of photons- not the dose- may be the same.

Bro

...bro.

This made my whole day.

 

[evilbooyaa]

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 think that bone met needs 30Gy in 10fx

 

[Ray D. Ayshun]

I think that bone met needs 30Gy in 10fx

Planning on 30 gy in 60 fx

 

[thecarbonionangle]

what dose do you playas like to use for hydradenitis suppurativa? Been reading about this very interesting.

 

[elementaryschooleconomics]

what dose do you playas like to use for hydradenitis suppurativa? Been reading about this very interesting.

I did this once in residency. Woman with severe HS in the peri-vulvar/groin region.

As I recall, we did enface electrons, 20Gy in 5fx.

Worked amazing. I was stunned.

This was back in the "old days", before the bubble crash, and there was minimal interest in benign disease. I couldn't get faculty hype to do a case report, they thought I was being silly.

 

[OTN]

I did this once in residency. Woman with severe HS in the peri-vulvar/groin region.

As I recall, we did enface electrons, 20Gy in 5fx.

Worked amazing. I was stunned.

This was back in the "old days", before the bubble crash, and there was minimal interest in benign disease. I couldn't get faculty hype to do a case report, they thought I was being silly.

I've done that scheme before. I've treated a few HS patients, one with the most severe disease her dermatologists had ever seen. RT works and patients were very thankful.

 

[njdamic]

I did this once in residency. Woman with severe HS in the peri-vulvar/groin region.

As I recall, we did enface electrons, 20Gy in 5fx.

Worked amazing. I was stunned.

This was back in the "old days", before the bubble crash, and there was minimal interest in benign disease. I couldn't get faculty hype to do a case report, they thought I was being silly.

Any published evidence for this that you are aware of? I came across this post on themednet (theMednet - Login) but can't seem to locate a publication for this experience. Everything I can find seems to advocate for lower dosing (PMID: 20178712; PMID: 10897256; Radiotherapy for Non-Malignant Disorders. (2008). Germany: Springer Berlin Heidelberg). It is hard for me to envision much benefit with 6-8 Gy in 1-2 Gy/fx but I've never seen this treated before... German guidelines for treatment of benign diseases (surprisingly) don't seem to mention much regarding hidradenitis.

 

[thecarbonionangle]

Any published evidence for this that you are aware of? I came across this post on themednet (theMednet - Login) but can't seem to locate a publication for this experience. Everything I can find seems to advocate for lower dosing (PMID: 20178712; PMID: 10897256; Radiotherapy for Non-Malignant Disorders. (2008). Germany: Springer Berlin Heidelberg). It is hard for me to envision much benefit with 6-8 Gy in 1-2 Gy/fx but I've never seen this treated before... German guidelines for treatment of benign diseases (surprisingly) don't seem to mention much regarding hidradenitis.

Radiotherapy for Hidradenitis Suppurativa: A Systematic Review

Abstract. Background: Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis characterized by painful nodules, abscesses, sinus tracts, and scarring mainly in the intertriginous areas. Patients with HS often experience inadequate responses to traditional treatment consisting of...

www.karger.com

The dose is all over the place. There is a case series with 20/5 with up to 90 pct response rate. As you can see, huge range of doses. These patients are miserable and many are not aware this is an option. Make sure your derm/surgical colleagues are aware.

 

[taserlaser]

Huge range in case series for these things. Just have to pick one. I’m finishing up treatment for someone with Hailey-Hailey disease, and these patients all talk on their support forums. She asked for a RO referral from her derm. Some small improvement so far, using 16 Gy / 8 fr EOD from a recent Danish paper (so very gentle) but most of the improvement comes after. Fingers crossed. Others have used 4-8 Gy/fr, 20 Gy, etc.

 

[elementaryschooleconomics]

Yeah I think that single case series is all that's published.

My attending at the time chose it because it was a "standard" palliative regimen.

I didn't like it, but I was a wee junior resident at the time. No one cared what I thought then (or now...).

 

[Clean7795]

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 am a rad, not a radonc but I would be wary of that. It would be very easy to blame the radiation (whether or not it is the cause).

I would assume you are giving a lot more photons than a CT, because none of my cancer patients would have MSK pain if we were giving similar amounts of radiation.

 

[Mandelin Rain]

What workup do you guys do before treating? Plain films? Nothing? Typically, patients here have XRs in ortho office that never get formally read and I can't access.

 

[deleted1111261]

What workup do you guys do before treating? Plain films? Nothing? Typically, patients here have XRs in ortho office that never get formally read and I can't access.

I do a lot of plain films unless past ones show DJD / OA.

If negative, I haven’t been treating.

 

[thesauce]

I do a lot of plain films unless past ones show DJD / OA.

If negative, I haven’t been treating.

Same. Need some radiographic backup to verify diagnosis. Plain film should be adequate.

 

[deleted1111261]

I gotta say, there is something just so different about treating OA.

It is not adjuvant breast - where they have no cancer (or microscopic) and you are preventing a recurrence. They may be grateful, but they don't really understand why to be thankful.

A prostate patient is asymptomatic before you treat them, has to come to you for 4-9 weeks daily, they get some mild side effects and then have to see you forever. 80% (more?) would be fine without treatment.

But, someone in pain with QOL issues that gets treated and has relief - man, they just love you.

Add it to your practice - you will have these small victories that add happiness to the world.

(I am feeling particularly "nice" today)

 

[TheWallnerus]

I am a rad, not a radonc but I would be wary of that. It would be very easy to blame the radiation (whether or not it is the cause).

I would assume you are giving a lot more photons than a CT, because none of my cancer patients would have MSK pain if we were giving similar amounts of radiation.

“Bit more”
“Slightly more”
“Skosh more”
Of course it’s not just the photon count, it’s their wavelength too

I gotta say, there is something just so different about treating OA.

It is not adjuvant breast - where they have no cancer (or microscopic) and you are preventing a recurrence. They may be grateful, but they don't really understand why to be thankful.

A prostate patient is asymptomatic before you treat them, has to come to you for 4-9 weeks daily, they get some mild side effects and then have to see you forever. 80% (more?) would be fine without treatment.

But, someone in pain with QOL issues that gets treated and has relief - man, they just love you.

Add it to your practice - you will have these small victories that add happiness to the world.

(I am feeling particularly "nice" today)

sounds like an ad to make someone want to go to med school!

 

[Sheldor]

I gotta say, there is something just so different about treating OA.

It is not adjuvant breast - where they have no cancer (or microscopic) and you are preventing a recurrence. They may be grateful, but they don't really understand why to be thankful.

A prostate patient is asymptomatic before you treat them, has to come to you for 4-9 weeks daily, they get some mild side effects and then have to see you forever. 80% (more?) would be fine without treatment.

But, someone in pain with QOL issues that gets treated and has relief - man, they just love you.

Add it to your practice - you will have these small victories that add happiness to the world.

(I am feeling particularly "nice" today)

I've had patients walk without a cane for the first time in 15 years. Had another call it "life changing!" I agree Simul, it is so nice to work that into our usual patient mix!

 

[NotMattSpraker]

Has anyone radiated arthritis precipitated by hormone therapy yet?

The pathophysiology seems unclear but medical oncologists describe it similar to osteoarthritis in the literature I've seen.

 

[OTN]

Has anyone radiated arthritis precipitated by hormone therapy yet?

The pathophysiology seems unclear but medical oncologists describe it similar to osteoarthritis in the literature I've seen.

Yes. Works. Haven't been able to get much buy in from medoncs for whatever reason, but I've been successful in treating it.

 

[Ray D. Ayshun]

Yes. Works. Haven't been able to get much buy in from medoncs for whatever reason, but I've been successful in treating it.

Do you do anything to confirm "arthritis?" Plain films etc. Or you just do it?

 

[NotMattSpraker]

Do you do anything to confirm "arthritis?" Plain films etc. Or you just do it?

Well it's not osteoarthritis. The med oncs call it AIMSS, AI associated musculoskeletal syndrome. And as far as I can tell in the literature, a patient report of arthritis plus the presence of the drug secures the diagnosis enough to treat.

 

[Ray D. Ayshun]

Well it's not osteoarthritis. The med oncs call it AIMSS, AI associated musculoskeletal syndrome. And as far as I can tell in the literature, a patient report of arthritis plus the presence of the drug secures the diagnosis enough to treat.

Is there anything we can use to justify treatment? As far as I can tell, the only diagnostic codes that fit this are for oa and psoriatic arthritis. Technically, this may fall under the auspices of degenerative musculoskeletal disorder but I'm wondering how to get it through insurance

 

[OTN]

Is there anything we can use to justify treatment? As far as I can tell, the only diagnostic codes that fit this are for oa and psoriatic arthritis. Technically, this may fall under the auspices of degenerative musculoskeletal disorder but I'm wondering how to get it through insurance

Good question - I can't remember what I used to be honest. I think there's a generalized arthritis code I may have used.

 

[TheWallnerus]

Good question - I can't remember what I used to be honest. I think there's a generalized arthritis code I may have used.

Osteoarthritis is a medical term for pain coming from a joint that is inflamed.

Given that we don’t have a blood test or scan that is highly specific for inflammation in a painful joint that is otherwise normal by physical exam and not complicated by other issues (like autoimmune), “you have a painful joint that is inflamed” seems like a reasonable diagnosis for, well, pain in a joint. Aka “OA.” Been a long time since I had to think general doctor thoughts!

 

[evilbooyaa]

Yeah I think that single case series is all that's published.

My attending at the time chose it because it was a "standard" palliative regimen.

I didn't like it, but I was a wee junior resident at the time. No one cared what I thought then (or now...).

Doesn't matter what you're palliating... cancer or a benign condition.... use the 'standard' palliative regimen.

Woof, not the best thought process, me thinks. Similar to indiscriminate use of 'standard' palliative radiation doses for run of the mill palliation of multiple myeloma.... and then we wonder why heme/onc doesn't want to send their patients to Rad Onc before they get hospitalized

 

[elementaryschooleconomics]

Doesn't matter what you're palliating... cancer or a benign condition.... use the 'standard' palliative regimen.

Woof, not the best thought process, me thinks. Similar to indiscriminate use of 'standard' palliative radiation doses for run of the mill palliation of multiple myeloma.... and then we wonder why heme/onc doesn't want to send their patients to Rad Onc before they get hospitalized

Completely agree.

I found that to be a common sentiment. If the patient was deemed "palliative", then we had to go with 30/10, 20/5, 8/1.

Obviously...I immediately abandoned that way of practicing the second I was free of the institution.

 

[Palex80]

Obviously...I immediately abandoned that way of practicing the second I was free of the institution.

Everyone get's 20 x 2 Gy now?

 

[elementaryschooleconomics]

Everyone get's 20 x 2 Gy now?

Don't forget my 1.8Gy x 3 cone down requiring a repeat CTSIM.

 

[evilbooyaa]

Completely agree.

I found that to be a common sentiment. If the patient was deemed "palliative", then we had to go with 30/10, 20/5, 8/1.

Obviously...I immediately abandoned that way of practicing the second I was free of the institution.

I'm a big fan of 2.5 x 15 for large soft tissue mets. Simul, don't @ me.

 

[medgator]

I'm a big fan of 2.5 x 15 for large soft tissue mets. Simul, don't @ me.

Evilcore is too

 

[deleted1111261]

I'm a big fan of 2.5 x 15 for large soft tissue mets. Simul, don't @ me.

You'll be surprised at what I do if patient is in fairly good shape...

3.5 x 15 to GTV, 3 x 15 to PTV

SIB. WITH IMRT. AND IGRT.

Yah...

 

[Bequerel]

Just had a plantar fasciitis patient show up for consult. I’m reading through this thread. 0.5/Gy or 1Gy per fraction x 6 QOD? I see both in here? What’s the target?

 

[deleted1111261]

Just had a plantar fasciitis patient show up for consult. I’m reading through this thread. 0.5/Gy or 1Gy per fraction x 6 QOD? I see both in here? What’s the target?

I do 1 Gy x 6
Todd does something different

If the heel hurts, I treat the calc + margin

If sole hurts, heel + sole

Whole foot probably fine, too, if diffuse

CT planning

 

[Palex80]

Just had a plantar fasciitis patient show up for consult. I’m reading through this thread. 0.5/Gy or 1Gy per fraction x 6 QOD? I see both in here? What’s the target?

There is one randomized trial on heel spurs

Radiation therapy for painful heel spurs: results of a prospective randomized study - PubMed

RT is an effective treatment option for the management of inflammatory heel spurs. The dose for an RT course should not exceed 3.0 Gy.

pubmed.ncbi.nlm.nih.gov

 

[grenz]

I continue to think that what you guys are observing is the placebo effect. It’s been under-appreciated here how powerful it can be. Surprised I’m hearing talk of billboards going up.

 

[elementaryschooleconomics]

I continue to think that what you guys are observing is the placebo effect. It’s been under-appreciated here how powerful it can be. Surprised I’m hearing talk of billboards going up.

I mean, millions of dollars have been spent on TTF and SpaceOAR, so billboards are a drop in the bucket!

(Editor's note: Lumping in TTF with SpaceOAR is done for comedic effect)

 

[deleted1111261]

I continue to think that what you guys are observing is the placebo effect. It’s been under-appreciated here how powerful it can be. Surprised I’m hearing talk of billboards going up.

I'll bite, because what you are saying is a bunch of your colleagues are doing something sketchy.

Just a few questions

1) Have you tried it? Like a reasonable number of patients, let's say 5-10

2) Have you reviewed the literature in detail?

3) Have you spoken to international experts that have treated 100s to 1000s of cases?

Placebo is wonderful and has it's uses. I don't know how I can get someone's hands to start opening jars or people to be able to function - recently, was told by my patient could finally walk his dog outside. If they were waiting for someone to shoot x-rays that don't work at their hands/back to be able to open jars or spend time with Fido .. well, that's something.

If it is pure placebo, then this is very important to study further, because it means our fundamental understanding of osteoarthritis is incorrect. If placebo can help you improve function, then there may be a psychiatric component to OA. And that would be super interesting!

 

[Ray D. Ayshun]

Either way, we should at least be honest with our patients and tell them that they probably still hurt just as bad as before, regardless of what they think.

 

[RickyScott]

Either way, we should at least be honest with our patients and tell them that they probably still hurt just as bad as before, regardless of what they think.

While a placebo response is possible, seems unlikely if pt has failed multiple other therapies, then recieves the xrt and has substantial improvement for an extended period.

 

[Ray D. Ayshun]

While a placebo response is possible, seems unlikely if pt has failed multiple other therapies, then recieves the xrt and has substantial improvement for an extended period.

Technically speaking, if these patients became prolific meditators or something, to the degree that they could ignore the pain, it would be placebo. My point is, if a patient sees me because they're hurting, and XRT lessens or resolves it, I really couldn't care less what biological process someone wants to ascribe it to.

 

[deleted1111261]

maybe RT helps patients reach jhana

 

[RadRadRad]

I’ve had very good objective response in patients with dupuytrens …cording nearly resolved and better function
Have limited number of plantar fasciitis patients but not much success (n too small to say anything for sure)
I’ve done 3 gy in 6 for plantar fasciitis based on paper listed in above pots

 

[Ray D. Ayshun]

I just read the study that was cited in the tweet. It was comparing using a placebo vs possessing a placebo.

 

[deleted1111261]

I’ve had very good objective response in patients with dupuytrens …cording nearly resolved and better function
Have limited number of plantar fasciitis patients but not much success (n too small to say anything for sure)
I’ve done 3 gy in 6 for plantar fasciitis based on paper listed in above pots

Plantar I've done 6 Gy in 6 Fx.

That was the dose in the 6 Gy vs 0.6 Gy study and there is dramatic difference between arms.

 

[TheWallnerus]

I read a story in the National Enquirer once about how a little boy with a brain tumor pictured Star Wars spaceships shooting lasers at his tumor... and he did this every day. Without fail. Especially during each daily radiotherapy session. And lo, said the Enquirer, he cured himself with the power of his own mind. The doctors were astounded.