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medgator said:
With EZ fluence/forward planning, I get plenty of whole breast plans that look great without the need for imrt, even when treating regional nodes. The imrt plans that treat regional nodes can dump plenty of dose into the other breast/cw, even heart if you aren't careful with avoidance structures

Outside of apbi vmat, not really seeing the role for it routinely TBH
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Have heard this before.
Would love to see the data that exceeding the B-51 contralateral breast constraints matter for, especially, 60+ yo women. The biggest risk for developing a contralateral breast cancer is already having had cancer (the biologic argument), which dwarfs the theoretical risk of a late radiation-induced malignancy.
Mean heart dose < 3 Gy easily achievable with VMAT. As opposed to putting a tangent directly through the LAD but still with a beautiful heart mean. What are we trying to achieve?

Unless you have a great reason to treat the medial breast, IMPORT-LOW suggests you don't need to if you are very concerned about contralateral breast dose.

If you need to treat IMNs, the IMRT plans almost always are better than wide tangents, or god forbid electron matches. Yet we have breast-only rad oncs that still claim IMRT is basically malpractice for breast and will instead be totally "cool" with super hot and cold spots with electron/photon plans. There is the basically moral panic of IMRT treating a somewhat variable skin target. Yet, it is standard in anal and vulvar?

Toxicity is way better with inverse planned IMRT even with nitpicky FiF.

I honestly don't get it. We are not treating with 2004's IMRT. It's been 2 decades.
Edit: Glad it's becoming less of an issue with most getting 5 fraction APBI with IMRT. I hate doing whole breast tangents + boost now. Can usually get IMRT approved for PBI or when treating nodes, which is where most of the cases are falling. The 16-20 fraction breast only is pretty rare now.
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medgator said:
Inverse planning has to be a component to bill it as imrt I thought
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Yea again. Take a tool like EZFluence and you can have weird abstract conversations about whether that’s inverse or not.

They know better than to participate in rad onc’s psychopathology. They just help you make nice homogeneous plans that may or may not identify as IMRT.
 
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1708581800099.png


Choosing wisely
 
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Palex80 said:
View attachment 383004

Choosing wisely
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You guys laugh, but can you really treat a right iliac met with SBRT that is 3 cm from bowel with your antiquated non-Reflexion linacs?

And even if you could, the dose fall-off from your non-Reflexion POS is far inferior*

*Does not account for the fact that you have to inject the patient with a whole body radioactive tracer on five consecutive days
 
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Gfunk6 said:
You guys laugh, but can you really treat a right iliac met with SBRT that is 3 cm from bowel with your antiquated non-Reflexion linacs?

And even if you could, the dose fall-off from your non-Reflexion POS is far inferior*

*Does not account for the fact that you have to inject the patient with a whole body radioactive tracer on five consecutive days
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the crazy thing is that this isn't even that automated. You can see the FDG avid lesion, but they clearly contoured more of a "CTV" including the adjacent bone.

Seems like a waste of time for everyone. Rather have a diagnostic PET, contour upfront, and then be there for machine verification on each SBRT Fx (takes 1 minute most of the time).

Only upside would be if the billing for this is much higher than conventional linac-based SBRT. That would be nice, especially if its protected from cuts like protons
 
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radoncftw said:
Only upside would be if the billing for this is much higher than conventional linac-based SBRT. That would be nice, especially if its protected from cuts like protons
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Just don't see it happening. Even big pharma couldn't prevent CMS from starting to negotiate on drug pricing. Used to only be allowed for the VA
 
thesauce said:
This is so crazy stupid
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I almost feel like I'm been gaslighted here. COH must know that every community doc fuses PET (Pylarify, Detectnet or other) to help delineate target when appropriate.

The CTV margins for SBRT non-spine bone are themselves somewhat contentious (just review a consensus paper regarding this).

Where is the value? Collectively, we have gone completely apeS#i! about branding without substance. Do they even believe in what they are doing?
 
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thesauce said:
This is so crazy stupid
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Agreed. You'd have to treat have a million patient trial to demonstrate a benefit here (which is probably 0.0001%)

I'd feel way more confident fusing an MRI of the pelvis than using Reflexion
 
StealthTech said:
Agreed. You'd have to treat have a million patient trial to demonstrate a benefit here (which is probably 0.0001%)

I'd feel way more confident fusing an MRI of the pelvis than using Reflexion
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Haha what is the 0.0001%?

I could imagine one patient sometime having PET avid disease that does not yet have a CT correlate but its also not a false positive.

BgRT is gonna be siiiick for that guy!
 
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communitydoc13 said:
Where is the value? Collectively, we have gone completely apeS#i! about branding without substance. Do they even believe in what they are doing?
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Perhaps they are working on these "easy" cases to test the machine. However, if this is the case, they should do this in a trial, due to the apparent novelty. Is this the case?

I could imagine the Reflexxion to hold some potential in HNSCC, (N)SCLC or cervical cancer, when using FGD.
Perhaps delivering some kind of SIB to particularly FDG-avid areas within the tumor?
But it doesn't seem that's what they are planning to do with it...
 
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Palex80 said:
Perhaps they are working on these "easy" cases to test the machine. However, if this is the case, they should do this in a trial, due to the apparent novelty. Is this the case?

I could imagine the Reflexxion to hold some potential in HNSCC, (N)SCLC or cervical cancer, when using FGD.
Perhaps delivering some kind of SIB to particularly FDG-avid areas within the tumor?
But it doesn't seem that's what they are planning to do with it...
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Owning a Reflexion will be a mandatory requirement as part of the ASTRO palliative care network certification.
 
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Palex80 said:
View attachment 383004

Choosing wisely
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New radiation device company dripping with pharma dollars that went through the trouble of getting their own specific (temporary) code. I'm sure they're doing easy stuff right now, likely at the request of their physics team, before trying more complicated things like mobile tumors in the lung, liver, etc, or more experimental stuff like hypoxic dose escalation for HN or what have you. But I don't doubt it's coming.

Sure this is twitter hype for the uninitiated, but that's the audience. If Terry is smart, and I'm sure he is, he'll be parading every rad onc naive hospital admin through over the next 6 months so they can "see the magic". And then hopefully squeeze ever more dollars and resources out of the COH bean counters.

And the almost uniform response of SDN so far is to take a **** on them? This stuff isn't a danger to private practice. My patients aren't gonna get on a plane for this. But if any of reflexion tech ultimately works and we treat more patients because of it, then only good for the field. Or we can turtle up and get buried by systemics in a self-fulfilling prophecy?
 
temujim said:
And the almost uniform response of SDN so far is to take a **** on them?
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I have to be honest. I feel like Rad Onc is taking a **** on me. Just tell me why I should be excited about BgRT like in terms of benefit for patients, or efficiency, really anything other than it is new and pays more than regular SBRT. I've asked the CMO and even invited him on the show. No dice (so far).

Maybe this is asking too much. I dont know.

Maybe I should stand there, covered in ****, and just let a nurse tell me how to treat my patients with lung cancer.
 
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I can barely get 3D covered for bone Mets with extraosseous extension and yet Evicore is ready to approve bgrt?
 
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Can’t wait for the first paper to use reflexion to help outline the lumpectomy cavity
 
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temujim said:
New radiation device company dripping with pharma dollars that went through the trouble of getting their own specific (temporary) code. I'm sure they're doing easy stuff right now, likely at the request of their physics team, before trying more complicated things like mobile tumors in the lung, liver, etc, or more experimental stuff like hypoxic dose escalation for HN or what have you. But I don't doubt it's coming.

Sure this is twitter hype for the uninitiated, but that's the audience. If Terry is smart, and I'm sure he is, he'll be parading every rad onc naive hospital admin through over the next 6 months so they can "see the magic". And then hopefully squeeze ever more dollars and resources out of the COH bean counters.

And the almost uniform response of SDN so far is to take a **** on them? This stuff isn't a danger to private practice. My patients aren't gonna get on a plane for this. But if any of reflexion tech ultimately works and we treat more patients because of it, then only good for the field. Or we can turtle up and get buried by systemics in a self-fulfilling prophecy?
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I'm going to freely take a **** on them because, in marketing their product, they completely misrepresent what we can and do accomplish as radoncs on a daily basis. PET fusion --> treatment has been around for well more than a decade. Yes, this machine could potentially increase throughput for SBRT patients with multiple mets. That's about it as far as I can tell.

It is, in fact, a danger to private practice, because these large, well-reimbursed academic centers who can afford to "invest" in technology such as this will use this machine as yet another marketing tool to suggest community radoncs aren't delivering world-class care. Additionally, instead of national radonc voices and "leaders" working on what would be valuable- improving the media/layperson perspective of radiation, helping other specialties understand where we are being underutilized, expanding indications for benign conditions, working on radiopharm- they're captured by industry and are working for them to market their machine.
 
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levels said:
Can’t wait for the first paper to use reflexion to help outline the lumpectomy cavity
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Don't forget the sequel paper(s) where a group of authors (all with relevant COI people choose to ignore) do some crazy voodoo math where they invoke the cost of recurrence (inpatient stay, OR time, time off from work due to stress, etc) and arrive at the conclusion that ACTUALLY, IF YOU DO THE MATH, THE INCREASED COST OF BGRT FOR ROUTINE BREAST TREATMENT IS TOTALLY WORTH IT YOU GUYS.
 
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Ray D. Ayshun said:
can I bill for bgRT if I match the sclerotic bone metastasis on CBCT to the slerotic bone metastasis on planing scan daily?
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Forget about doing a cone beam, I can’t even bill for 3D to treat a sclerotic bone met, so I’m going to go with no. I’m surprised we can even still ct sim them at this point.
 
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Reflexion allows for the PET signal to be monitored in real time and for radiation to be directed at it. How that benefits the patient (vs Cyberknife or other real-time monitoring or adaptive planning systems that actually account for day to day changes) I don’t know.
 
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radiaterMike said:
Reflexion allows for the PET signal to be monitored in real time and for radiation to be directed at it. How that benefits the patient (vs Cyberknife or other real-time monitoring or adaptive planning systems that actually account for day to day changes) I don’t know.
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Theoretically you could get definitive doses to mobile tumors with limiting OARs eg, pancreas? The strategy now is basically to accept under dosing at the margins to ablate the center of the tumor. Ie, marginal miss because you have no choice. If the tech could wait until the tumor was a favorable location before beam on, then I could see a benefit. Bone Mets tend to be uh pretty easy to localize.
 
radiaterMike said:
Reflexion allows for the PET signal to be monitored in real time
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Fabulous tool for basic research then. I have no idea what real time PET signal means in an actively irradiated target.

Spatial resolution of PET typically quoted around 4-5 mm. Is this notably different on the reflexion? (All practicing radoncs will note the slice thickness they employ at CT sim and fused MRI when doing SBRT presently).
 
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The mere fact that they tweeted about doing this to a bone met is in-line with something that they think will ultimately impress patients and annoy SDN/serve no purpose.
 
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MidwestRadOnc said:
Theoretically you could get definitive doses to mobile tumors with limiting OARs eg, pancreas? The strategy now is basically to accept under dosing at the margins to ablate the center of the tumor. Ie, marginal miss because you have no choice.
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What is the best imaging modality to look at a soft tissue interface between two organs? Not PET.

MidwestRadOnc said:
If the tech could wait until the tumor was a favorable location before beam on, then I could see a benefit. Bone Mets tend to be uh pretty easy to localize.
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So, gating?

I feel like a chump for trying to pretend this about clinical medicine. Im sitting here wondering what this is good far when the answer is right there on Jordan's spreadsheet.

MidwestRadOnc said:
Theoretically you could get definitive doses to mobile tumors with limiting OARs eg, pancreas? The strategy now is basically to accept under dosing at the margins to ablate the center of the tumor. Ie, marginal miss because you have no choice. If the tech could wait until the tumor was a favorable location before beam on, then I could see a benefit. Bone Mets tend to be uh pretty easy to localize.
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I dont actually agree that this is the advantage of OTA for pancreas. This is pure hypothesis, but I think the cumulative CTV coverage is MUCH higher than if you just did your safe offline sim plan and delivered that with the PTV undercoverage/PRV uncertainty. When I would cover these cases, most would have substantial increases in coverage, like 50-->75%. This is obviously anecdotal.

It also kind of idiot proofs the RT planning and IGRT/delivery. Sometimes in my current practice I might be a little less aggressive on my CTV coverage because the patient is less stable or the set up might be more challenging.

They dont really have dose accumulation software yet that is ready for prime time, so we dont really know quantitatively.

Its also not like the primary method of failure is marginal local recurrence in these cases.

I was very hyped about the phase III adaptive trial for pancreas but was not very confident it would be a positive trial. I am not sure. I guess now it doesnt matter. COH has already declared the Viewray lifesaving and no one is going to run that trial.
 
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