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T4 lesion (breast cancer)
Julie G
Posted: Monday, September 13, 2010 2:58 PM
Joined: 9/1/2009
Posts: 20


Dr. Medbery: I have a metastatic T4 lesion, posteriorly located, that is just under 2 cm, and which uptakes FDG. I think it occupies about 30% of the vertebral body. I’ve got Stage IV breast cancer, and this lesion is presently becoming somewhat painful. I’m interested in pain palliation, but more importantly, I want to slow the growth of this lesion so I’m not paralyzed re: quality of life. Is it even possible to slow growth in my situation with radiotherapy? I currently have a radiation oncologist who has treated two lesions in my pelvis. He would use M3 to achieve stereotactic radiotherapy, though I don’t know his proposed treatment plan. I believe the device for the M3 is Varian, non-dedicated. Shouldn’t I be looking at CyberKnife for a T4 lesion? What is the difference between M3 and CyberKnife? Isn’t a highly hypofractionated dose what’s required? Would fiducials be necessary? I could travel to Oklahoma, if needed. What modality and approximate treatment plan and schedule would you recommend for a lesion like this? Thank you so much for all your help. Best to you, Julie G
Julie G
Posted: Thursday, September 16, 2010 7:37 PM
Joined: 9/1/2009
Posts: 20


If Dr. Medbery isn't available, could another doctor monitoring the board reply? Thanks so very much. Best, Julie G
radsrus
Posted: Thursday, September 16, 2010 8:38 PM
Joined: 10/10/2008
Posts: 4435


I don't know what M3 is, but CK is probably best for precision, although standard radiation is certainly an option, with CK reserved if there is failure of the standard radiation to control it. We often advise vertebroplasty after the radiation treatment in this situation to stabilize the bone.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Monday, September 20, 2010 3:15 PM
Joined: 9/1/2009
Posts: 20


Thank you so much, Dr. Medbery. Here’s the device the radiotherapy center mentioned for my T4 lesion: http://www.brainlab.com/scripts/website_english.asp?menuDeactivate=1&articleID=1891&articleTypeID=67&pageTypeID=4&article_short_headline=m3%AE As it was explained to me, this M3 device enables configuration of their Varian for a smaller field, yet the normal tissue margin would be 1 cm, which seems pretty big to me. When asked to compare their system to CyberKnife, they did say that CK would be more accurate—though they said they would achieve the same result, same risk. When you say that standard radiation would be an option instead of CK, which would you recommend first--CK or standard? I realize CK can be used after a course of standard radiation, but should it? Isn't CK a better first option? If CK were to be used for my T4 lesion at your facility, what dose and fractionation schedule would you advocate? Best to you, Julie G
radsrus
Posted: Monday, September 20, 2010 9:05 PM
Joined: 10/10/2008
Posts: 4435


For most of the history of our CK, we have used standard radiation first. This was largely to avoid having people think that we just wanted to treat everything with CK. However, I am increasingly coming to the realization that we should consider using CK first since it is more effective. We have not made that our policy yet however. We usually treat with 10 Gy x 3, but often boost the tumor (if there is one visible in the bone) to a higher dose of about 36-39 Gy in 3 fractions (that is done at the same time as the treatment of the entire vertebral body).

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Tuesday, September 21, 2010 7:27 AM
Joined: 9/1/2009
Posts: 20


I thought you might say that. Yes, CK seems like a reasonable first option to me, too, with the goal of tumor control (and palliation) for my T4 lesion. I don't know exactly how close to the cord my lesion is. Is there a margin of proximity to the cord that's a cut-off for being able to use CK? How would you describe the risk if we treated my T4 lesion with CK? What side effects are possible? Again, thanks so much. Best, Julie G
radsrus
Posted: Thursday, September 23, 2010 1:49 PM
Joined: 10/10/2008
Posts: 4435


It would be difficult to talk about risk without having all the details. Suffice it to say that all reported series have shown minimal risk.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Thursday, September 23, 2010 6:21 PM
Joined: 9/1/2009
Posts: 20


Thank you, Dr. Medbery. I understand that it's difficult to quantify or describe risk for a given individual. So that I know if I might even be a candidate, I'm wondering about proximity to the cord. Is there a margin of proximity to the cord that's a cut-off for being able to use CK? Best, Julie
radsrus
Posted: Thursday, September 23, 2010 11:34 PM
Joined: 10/10/2008
Posts: 4435


There is not any real cut-off. THe more room we have the better, but we very frequently treat tumors that are pressing on the cord. It just takes careful planning.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Friday, September 24, 2010 7:33 PM
Joined: 9/1/2009
Posts: 20


Thank you, Dr. Medbery, that's good to know. Can I send you my latest images? Best to you, Julie
radsrus
Posted: Friday, September 24, 2010 10:43 PM
Joined: 10/10/2008
Posts: 4435


It is best to send them to the center where you want to be treated, since they may view things differently. My opinion is not worth much if they disagree.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Wednesday, October 20, 2010 2:24 PM
Joined: 9/1/2009
Posts: 20


Dr. Medbery, I'm pretty sure that I should act fairly quickly to treat this T4 lesion, as it doesn't seem to be responding to my meds and has become increasingly painful. One more question: what is the maximum tumor size (cm) that the cyberknife can treat? Are fiducials required for treatment in this area? Best to you, Julie G
radsrus
Posted: Wednesday, October 20, 2010 6:44 PM
Joined: 10/10/2008
Posts: 4435


No fiducials are needed to treat the spine. I agree that it should be treated in some fashion. THere is no size cut-off, but as tumors get larger it often makes more sense to consider other options.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


radsrus
Posted: Wednesday, October 20, 2010 6:44 PM
Joined: 10/10/2008
Posts: 4435


No fiducials are needed to treat the spine. I agree that it should be treated in some fashion. THere is no size cut-off, but as tumors get larger it often makes more sense to consider other options.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


radsrus
Posted: Wednesday, October 20, 2010 6:44 PM
Joined: 10/10/2008
Posts: 4435


No fiducials are needed to treat the spine. I agree that it should be treated in some fashion. THere is no size cut-off, but as tumors get larger it often makes more sense to consider other options.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Wednesday, October 20, 2010 8:41 PM
Joined: 9/1/2009
Posts: 20


Thank you so much, Dr. Medbery. By other options, do you mean another radiotherapy modality, or do you mean surgery? At this point, I may be refractory to medication for pain palliation and cord preservation. Best, Julie G
radsrus
Posted: Thursday, October 21, 2010 3:52 AM
Joined: 10/10/2008
Posts: 4435


I specifically meant radiation, although there are circumstances in which surgery might be a consideration. You are not refractory to pain medication. It is just a question of finding the right drug and the right dose. I don't know what you mean about cord preservation.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Julie G
Posted: Thursday, October 21, 2010 10:43 AM
Joined: 9/1/2009
Posts: 20


I meant refractory to cancer medication to shrink the tumor, not pain meds. (Pain meds come with a host of difficulties.) By cord preservation, I meant preserving as much function of the cord as possible by controlling the growth of the tumor into it. I'm just trying to retain as much neurogenic function as possible. Thank you, Dr. Medbery, for all your help. Best to you, Julie G
radsrus
Posted: Thursday, October 21, 2010 12:02 PM
Joined: 10/10/2008
Posts: 4435


We should be able to preserve neural function. Get seen and get this treated.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


 

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