How would you treat a patient with oligometastatic disease to the lung for whom SBRT/SABR is not feasible?

How would you approach treatment if SBRT was not technically possible? How would you opt to treat if SBRT was instead not covered by insurance, and would this be different than your approach above?

2 Answers

Mednet Member

Radiation Oncology · Michigan Healthcare Professionals, PC

Answered on

I am not sure what this means exactly, as far as not technically feasible. Very old machine? Lack of dosi/physics support? If you can do VMAT with image guidance at your machine, you can probably do SBRT/SRS. You just need to have physics do their thing.

In America, we use a billing definition to call something SBRT/SRS - radiation delivered in 1-5 fractions. I think of SBRT as an ablative dose delivered in a short-ish period of time, with a few other components - strict immobilization, motion management, reduced margins, IGRT - but insurers are only noting the number of fractions (sometimes dose).

So, whether you are asking to just do conventionally if you don't want to do SBRT/SRS-technique, you can do that with a variety of dose-fraction schemes.

But, if you are truly ablating and it is an insurance issue, then the technique is the same regardless of number of fractions. I.e. - for a central lung tumor, at our MDACC affiliate, we gave 70 in 10. This is not SBRT according to insurance companies, but we did 4DCT, image guidance, motion management, tight margins, strict immobilization. This was billed as VMAT/IMRT, but I don't see that it is not SBRT. 60 in 8 is possible, too, but again, the technique is the same as if you were doing 54/3 or 48/4.

If you are doing conventional fractionation (25-30 fx) for a solitary lung met, should strongly consider sending the patient out, even if it requires travel. I believe this to be suboptimal care here.

Mednet Member

Radiation Oncology · Vanderbilt-Ingram Cancer Center

Answered on

If it is not technically possible because your machine does not have the feasibility to do SBRT (say, a machine that only does step and shoot with kVs, without VMAT or CBCT), then I would refer the patient out to a center/machine capable of doing SBRT.

If insurance does not approve it, despite p2ps and appeals, see if they're willing to pay for IMRT with IGRT, and then proceed with another ablative regimen as 60/8 or 70/10, or 70/17 regimen as mentioned by Dr. @Dr. First Last.