Need advice if this radiation plan sounds right please

Hi Artie,

Sorry to hear you have some more upcoming radiation, but along with your previous post, I think all told, you're moving in the right direction and it sounds like things are well in hand.  Certainly things around your skull will depend on what the MRI shows, but I am a little surprised to hear the dosing schedule that's been suggested.  Much of what I heard, read, and learned with my own radiation for melanoma experiences (4 rounds of SBRT to various leg bone mets, one round of SBRT to a lung met, and one round of SRS with CyberKnife to the tumor bed of a brain met following craniotomy) has been to "hit it hard and fast", in other words, something in the 30-50 Gy range given in 3-5 fractions on a Mon-Wed-Fri or Tue-Fri schedule.  I'm not sure why that would be different for a met in the skull but outside the brain, definitely something I'd discuss with your radiation oncologist.  Much of the work with melanoma says that melanoma mets respond much better to this approach .  My experience is a small sample size, but even my first two rounds on the leg bone mets were 30-Gy in 5 x 6-Gy fractions, which kept them stable for 2+ years, but they eventually started to grow and required surgery after 2+ years.  But the next two were 30-Gy in 3 x 10-Gy fractions, and they're not only stable but don't even pick up on PET, also about 2+ years later.  Again, I think much will depend on your MRI and if you are dealing with one or several spots.  If it's several, Gamma Knife would seem to be an option unless it is truly reserved for spots inside the brain, but for a single tumor, another form of SBRT like CyberKnife could work as well, I'd think.

For clarification, and again, this is my understanding, the difference between Sand SBRT is just one of semantics, SRS is used to describe stereotactic radiation therapy when it is used on the brain, and SBRT describes the same thing when used anywhere else on the body.  As you describe it, The tumor you're talking about is intracranial but outside the brain, so I don't know which term would officially be used.

You also expressed concern about 90 Gy of total radiation.  I'm not sure where you're coming up with that number, so I'm going to make an assumption, but please correct me if I'm assuming incorrectly.  It sounds like you're adding up the total amount of radiation you'll receive in these three treatments to three different areas (skull, T12, and L2), is that right?  If that's the case, the concern with radiation is the total amount received to a single area, so in this case, adding them together doesn't tell you anything and shouldn't raise a concern — but it's definitely a good question.

It may be worth asking about proton therapy, but I've found that while most think it is a great technology, there are existing (and less expensive) ways of providing the same outcomes with existing methods for many tumors.  But it is appropriate for certain tumor locations.  What proton therapy offers is a way to manage the depth to which the beam maintains its power at which point it drops way off.  While a traditional radiation therapy machine, even SBRT, maintains the intensity of the beam (or multiple beams) pretty much as it enters and exits the body, through any tissues it encounters, proton therapy machines rely on a phenomenon of protons called the "Bragg Peak" that allows the intensity of the beam to intensify and then drop off significantly at a certain distance (preferably the depth of the target tumor), minimizing damage to surrounding tissues, especially those on the "beam exit" side.  That comes at a cost of what is now a very large, expensive machine and planning process.

I hope that helps, let us know how your MRI goes — and so glad to read the encouraging results you're seeing with PD-1.

Best, Joe

Hi Artie,

Sorry to hear you have some more upcoming radiation, but along with your previous post, I think all told, you're moving in the right direction and it sounds like things are well in hand.  Certainly things around your skull will depend on what the MRI shows, but I am a little surprised to hear the dosing schedule that's been suggested.  Much of what I heard, read, and learned with my own radiation for melanoma experiences (4 rounds of SBRT to various leg bone mets, one round of SBRT to a lung met, and one round of SRS with CyberKnife to the tumor bed of a brain met following craniotomy) has been to "hit it hard and fast", in other words, something in the 30-50 Gy range given in 3-5 fractions on a Mon-Wed-Fri or Tue-Fri schedule.  I'm not sure why that would be different for a met in the skull but outside the brain, definitely something I'd discuss with your radiation oncologist.  Much of the work with melanoma says that melanoma mets respond much better to this approach .  My experience is a small sample size, but even my first two rounds on the leg bone mets were 30-Gy in 5 x 6-Gy fractions, which kept them stable for 2+ years, but they eventually started to grow and required surgery after 2+ years.  But the next two were 30-Gy in 3 x 10-Gy fractions, and they're not only stable but don't even pick up on PET, also about 2+ years later.  Again, I think much will depend on your MRI and if you are dealing with one or several spots.  If it's several, Gamma Knife would seem to be an option unless it is truly reserved for spots inside the brain, but for a single tumor, another form of SBRT like CyberKnife could work as well, I'd think.

For clarification, and again, this is my understanding, the difference between Sand SBRT is just one of semantics, SRS is used to describe stereotactic radiation therapy when it is used on the brain, and SBRT describes the same thing when used anywhere else on the body.  As you describe it, The tumor you're talking about is intracranial but outside the brain, so I don't know which term would officially be used.

You also expressed concern about 90 Gy of total radiation.  I'm not sure where you're coming up with that number, so I'm going to make an assumption, but please correct me if I'm assuming incorrectly.  It sounds like you're adding up the total amount of radiation you'll receive in these three treatments to three different areas (skull, T12, and L2), is that right?  If that's the case, the concern with radiation is the total amount received to a single area, so in this case, adding them together doesn't tell you anything and shouldn't raise a concern — but it's definitely a good question.

It may be worth asking about proton therapy, but I've found that while most think it is a great technology, there are existing (and less expensive) ways of providing the same outcomes with existing methods for many tumors.  But it is appropriate for certain tumor locations.  What proton therapy offers is a way to manage the depth to which the beam maintains its power at which point it drops way off.  While a traditional radiation therapy machine, even SBRT, maintains the intensity of the beam (or multiple beams) pretty much as it enters and exits the body, through any tissues it encounters, proton therapy machines rely on a phenomenon of protons called the "Bragg Peak" that allows the intensity of the beam to intensify and then drop off significantly at a certain distance (preferably the depth of the target tumor), minimizing damage to surrounding tissues, especially those on the "beam exit" side.  That comes at a cost of what is now a very large, expensive machine and planning process.

I hope that helps, let us know how your MRI goes — and so glad to read the encouraging results you're seeing with PD-1.

Best, Joe

Hi Artie,

Sorry to hear you have some more upcoming radiation, but along with your previous post, I think all told, you're moving in the right direction and it sounds like things are well in hand.  Certainly things around your skull will depend on what the MRI shows, but I am a little surprised to hear the dosing schedule that's been suggested.  Much of what I heard, read, and learned with my own radiation for melanoma experiences (4 rounds of SBRT to various leg bone mets, one round of SBRT to a lung met, and one round of SRS with CyberKnife to the tumor bed of a brain met following craniotomy) has been to "hit it hard and fast", in other words, something in the 30-50 Gy range given in 3-5 fractions on a Mon-Wed-Fri or Tue-Fri schedule.  I'm not sure why that would be different for a met in the skull but outside the brain, definitely something I'd discuss with your radiation oncologist.  Much of the work with melanoma says that melanoma mets respond much better to this approach .  My experience is a small sample size, but even my first two rounds on the leg bone mets were 30-Gy in 5 x 6-Gy fractions, which kept them stable for 2+ years, but they eventually started to grow and required surgery after 2+ years.  But the next two were 30-Gy in 3 x 10-Gy fractions, and they're not only stable but don't even pick up on PET, also about 2+ years later.  Again, I think much will depend on your MRI and if you are dealing with one or several spots.  If it's several, Gamma Knife would seem to be an option unless it is truly reserved for spots inside the brain, but for a single tumor, another form of SBRT like CyberKnife could work as well, I'd think.

For clarification, and again, this is my understanding, the difference between Sand SBRT is just one of semantics, SRS is used to describe stereotactic radiation therapy when it is used on the brain, and SBRT describes the same thing when used anywhere else on the body.  As you describe it, The tumor you're talking about is intracranial but outside the brain, so I don't know which term would officially be used.

You also expressed concern about 90 Gy of total radiation.  I'm not sure where you're coming up with that number, so I'm going to make an assumption, but please correct me if I'm assuming incorrectly.  It sounds like you're adding up the total amount of radiation you'll receive in these three treatments to three different areas (skull, T12, and L2), is that right?  If that's the case, the concern with radiation is the total amount received to a single area, so in this case, adding them together doesn't tell you anything and shouldn't raise a concern — but it's definitely a good question.

It may be worth asking about proton therapy, but I've found that while most think it is a great technology, there are existing (and less expensive) ways of providing the same outcomes with existing methods for many tumors.  But it is appropriate for certain tumor locations.  What proton therapy offers is a way to manage the depth to which the beam maintains its power at which point it drops way off.  While a traditional radiation therapy machine, even SBRT, maintains the intensity of the beam (or multiple beams) pretty much as it enters and exits the body, through any tissues it encounters, proton therapy machines rely on a phenomenon of protons called the "Bragg Peak" that allows the intensity of the beam to intensify and then drop off significantly at a certain distance (preferably the depth of the target tumor), minimizing damage to surrounding tissues, especially those on the "beam exit" side.  That comes at a cost of what is now a very large, expensive machine and planning process.

I hope that helps, let us know how your MRI goes — and so glad to read the encouraging results you're seeing with PD-1.

Best, Joe