IGRT orders by disease site

[Irradi8or]

Hi! I'm working to update some of the policies in my department, and we'd like to standardize most of our IGRT by disease site. It would mainly be a starting point, and physicians can alter those based on preferences, individual patient anatomy, etc. Do any of you like a list of your typical IGRT orders (MV, kV, CBCT, etc and frequency) broken down by disease site? There's a lot of variability but appreciate your input

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[TheWallnerus]

Hi! I'm working to update some of the policies in my department, and we'd like to standardize most of our IGRT by disease site. It would mainly be a starting point, and physicians can alter those based on preferences, individual patient anatomy, etc. Do any of you like a list of your typical IGRT orders (MV, kV, CBCT, etc and frequency) broken down by disease site? There's a lot of variability but appreciate your input

Why not CBCT everything. Every fraction. And kV everything with fiducials, plus CBCT for good measure. (I don’t mean to tell tales out of school but if you have MRgRT or BgRT you get MRIs and PETs on everyone.) I know the insurance won’t pay for all this, but it’s ok to do the IGRT you want and not bill for it. MV is just for those Tomo dudes right?

 

[A_DeMichele]

yes, so long you don't bill anyone, you may as well IGRT every XRT fraction

 

[drowsy12]

yes, so long you don't bill anyone, you may as well IGRT every XRT fraction

are some of you not?

 

[A_DeMichele]

are some of you not?

I don't. try to stick to Evicore rules in IGRT, broadly

 

[evilbooyaa]

You think the misanthropes on SDN, who probably aren't even real Radiation Oncologists, are the best place to get IGRT guidelines in place?

In short - all my IMRT patients get daily CBCT/MVCT imaging.
I don't think there's anything wrong with doing daily images on all 3D patients either.

 

[Mandelin Rain]

You've got the tool. Why not use it?

Hot take: Daily IGRT on every fraction would do more to increase patient safety than direct supervision. Why isn't ASTRO writing letters about that?

 

[drowsy12]

our therapists do daily IGRT always, regardless of whether it is being billed or not. they like it, physics likes it, I like it.

 

[Burt Radnolds]

You've got the tool. Why not use it?

Hot take: Daily IGRT on every fraction would do more to increase patient safety than direct supervision. Why isn't ASTRO writing letters about that?

 

[Irradi8or]

Thanks everyone! Well, I'm taking over clinical leadership of a department that has had really old school boomer Rad Oncs for 30 years - they barely did CBCTs or kv imaging on patients. I'm getting pushback now from the therapists about daily IGRT (esp CBCT imaging), as they just don't have comfort with it and feels like it slows them down. Part of the reason for standardizing the process is to get everyone caught up to more modern tech in the department. Agree with the comments above here - I also tend to IGRT daily (mix/match of kv, CBCT, OSMS, depending on the case) and have much smaller PTV margins than my predecessors - who are now thankfully retired

 

[medgator]

You've got the tool. Why not use it?

Hot take: Daily protons for every fraction would do more to increase patient safety than direct supervision. Why isn't ASTRO writing letters about that?

Ftfy, now they will

 

[A_DeMichele]

Thanks everyone! Well, I'm taking over clinical leadership of a department that has had really old school boomer Rad Oncs for 30 years - they barely did CBCTs or kv imaging on patients. I'm getting pushback now from the therapists about daily IGRT (esp CBCT imaging), as they just don't have comfort with it and feels like it slows them down. Part of the reason for standardizing the process is to get everyone caught up to more modern tech in the department. Agree with the comments above here - I also tend to IGRT daily (mix/match of kv, CBCT, OSMS, depending on the case) and have much smaller PTV margins than my predecessors - who are now thankfully retired

Just a word of caution, old is not always stupid... too tight of a margin in palliation can do harm. I'm thinking orbital apex recurrences after WBRT, multiple myeloma relapse above and and below the field, etc

 

[Irradi8or]

Just a word of caution, old is not always stupid... too tight of a margin in palliation can do harm. I'm thinking orbital apex recurrences after WBRT, multiple myeloma relapse above and and below the field, etc

Yes obviously certain techniques for certain indications. That’s why we all go thru training to make those decisions - though I question the training at some programs and certainly question the value of MOC for some of the older Rad Oncs that still never seemed to keep up with the field. But treating a curative situation with massive margins and palliative field arrangements also isn’t the best use of modern technology.

 

[thecarbonionangle]

Therapists will always argue new tech “slows them down”. It is super annoying.

 

[NotMattSpraker]

Yes obviously certain techniques for certain indications. That’s why we all go thru training to make those decisions - though I question the training at some programs and certainly question the value of MOC for some of the older Rad Oncs that still never seemed to keep up with the field. But treating a curative situation with massive margins and palliative field arrangements also isn’t the best use of modern technology.

The new must learn from the old.

The old are exempt from learning from the new.

Medicine is beautiful 🥲

 

[evilbooyaa]

Just a word of caution, old is not always stupid... too tight of a margin in palliation can do harm. I'm thinking orbital apex recurrences after WBRT, multiple myeloma relapse above and and below the field, etc

Sometimes the old way is fine. But when boomers think that ALL that is old is better, that's the issue.

But in the situations you described:
Orbital apex recurrence gets re-irradiation SBRT, no harm no foul.
Multiple myeloma should be treated, upfront, at a dose that re-RT can be done without any concern. Doing 30/10 or equivalents to MM outside of, POTENTIALLY, spinal cord compression, is stupid.