Christien Kluwe

A patient came to me last month with a “rotator cuff tear” scheduled for surgery. His exam told a different story. He canceled the operation. Here’s the uncomfortable truth about shoulder pain: imaging isn’t always a reliable witness in the room. By age 60, more than half of asymptomatic adults have partial rotator cuff tears on imaging. The tear on the scan and the pain in the shoulder are often two unrelated facts. Sorting them out is a physical exam skill and it determines whether the right answer is a scalpel, a steroid, or a linear accelerator. Three conditions. Three exams. Three answers. 1. Glenohumeral osteoarthritis: the stiff shoulder. Passive AND active range of motion are both lost. When I move the arm for the patient and it still won’t externally rotate, the joint surface itself is the problem. Imaging confirms: joint space narrowing, osteophytes. This is prime LDRT territory with synovial inflammation as a major pain driver. 2. Calcific tendinitis / cuff tendinopathy: the painful shoulder that still moves. Passive motion preserved. Painful arc at 60–120°. Positive Neer and Hawkins. Imaging shows calcium in the supraspinatus or tendon thickening with intact fibers. Decades of European data support LDRT here and arguably one of its most established periarticular indication. 3. True rotator cuff tear: the weak shoulder. This is the one exam finding that changes everything: weakness, not just pain-limited effort. Drop-arm sign. External rotation lag. MRI showing full-thickness tear with retraction and fatty infiltration. The surgical lane is narrow and clear: acute traumatic full-thickness tear, younger active patient, retraction, progressive weakness. Send that patient to orthopedics the same week. The LDRT lane is wider than most physicians realize: degenerative disease where inflammation drives the pain. The 68-year-old with OA and an incidental partial tear. The calcific tendinitis patient on her third steroid injection. The cuff tendinopathy patient who failed PT and isn’t a surgical candidate. My patient? Full passive motion. No true weakness but just pain inhibition. His pain was inflammatory. Treat the patient, not just the picture. The exam still decides.

ROADS trial added to rad onc tables Our department met with the device rep who answered a lot of our questions and was able to provide data not in the abstract The results are impressive - a little difficult to believe - but the trial was rigorous and well designed

Not every arthritic knee is a good candidate for low dose radiotherapy. The ones that respond best usually show a specific pattern, on imaging and on exam. On MRI, I'm looking for signs of active inflammation, not just wear and tear: → Bone marrow edema → Synovitis → Effusion These suggest the joint still has an inflammatory driver we can influence. LDRT works on inflammation, not on bone that has simply worn away. On physical exam, I'm ruling out mechanical causes of pain first: → Meniscal tears with locking or catching → Ligamentous instability → Significant malalignment driving focal overload If the pain is mechanical, radiation isn't going to fix that. That patient needs a different conversation, sometimes ortho, sometimes PT, sometimes both. Patient selection is the difference between a treatment that works and a treatment that just gets tried. The more precise we get about who responds, the more we can honestly say LDRT belongs earlier in the disease course, not as a last resort before joint replacement. That's the work right now. Getting the selection criteria right, and being honest when the answer is "not you."

Erling Haaland has returned to Norway, and it looks like he brought home a $750 Whiskey Raccoon from Wild Bill's Western Store in Dallas, Texas. What an authentic piece of American culture.

All attendings/residents should actually read the ct scan instead of trusting what the radiologist says at face value. The radiologist doesn't always know what you're looking for and don't have the context of the physical exam.

@TylerSbrt TNM staging/prognos was derived from data using DRE. So that’s the tech correct answer. Imaging influences treatment decisions still, but I’ve seen too many FIR guys started on ADT based on “concern for ECE” on report off 1cm capsular contact. So “cTx with clear ___ by imaging”

Clear SVI on MRI and PSMA PET (image above). How do you document #ProstateCancer stage?

Clear SVI on MRI and PSMA PET. How do you document stage? Poll 👇🏼

⏳ New editorial out on late GU SE after #PCa SBRT in PACE-B trial ⚡️ Congrats to @DrMedo58935306 on leading this insightful collaboration. Curious? 📖 Read it for the clinical takeaways tau.amegroups.org/article/view/1… @banu_atalar @alison_tree @nickva1 @EmmaHall71 @DrAndrewLoblaw

1/ New in Radiotherapy & Oncology: ESTRO consensus recommendations on how to focal boost the intraprostatic tumour in prostate cancer. The practical question: now that FLAME is positive, who gets a boost, how do we contour it, and what dose do we prescribe? Why it matters: focal boosting is about to become a lot more common.

Very few hospitals in the US function as a system. The majority are fragmented healthcare delivery facilities with a free-for-all mindset barely kept together by a few internal champions who build multi-disciplinary clinical teams to support coordinated care.

@ChadTangMD @jryckman3 Operating with the power of the sun! Suns out, guns out bro! 😀

@jryckman3 Omg is this the ortho clinic 😜. Didn’t know there were this many guns outside of Texas.

Feeling very fortunate to have had a chief resident and medical student rotate with me over the past two months, along with our new #RadOnc APP, Justin Hasley, joining the team last month. Grateful for the opportunity to teach, learn, and grow alongside others. Wishing @jchrisknothmd and Nate Dunham all the best as they begin their careers in practice! #RadOnc @WVUCancer

Excited to share the results of the #ARTO trial. After a median f-up of 53 months, Adding SBRT to abiraterone + ADT significantly improved overall survival (HR 0.55). @dicataldovanes1 @BarbaraJereczek @Ric_Campi @ChadTangMD @TheLancetOncol @ESTRO_RT authors.elsevier.com/a/1nM825EIIgXF…

Pleased to share an outstanding collaborative review by @UrogerliMD @LauraBukavinaMD @CanDAydogdu @EUplatinum Each histological subtype of bladder cancer behaves differently and deserves its own approach, not a one-size-fits-all approach. Here we synthesize the latest data on this topic @PGrivasMDPhD @SpiessPhilippe @apolo_andrea @lianchengmd @AndreaNecchi et al Full Text: authors.elsevier.com/c/1nL8w14kpm4a… 🧵 @IBCG_BladderCA

pCR at cystectomy have reached levels not seen before after neoadjuvant therapy and are increasingly being proposed as a surrogate endpoint for clinical trials, but ... does improving pCR reliably predict improving overall survival? In our collaborative study in @EurUrolOncol we analyzed 12 prospective neoadjuvant trials (3,119 patients) using a formal two-step trial-level surrogacy framework. @Pietro9609 @AndreaNecchi @drenriquegrande @BenjaminPradere @DrShariat @AlisonBirtle @OncoBellmunt @MRoupret @ThoSeisen @laconss @slusarczyk_alek @UroMoschini 🧵

“England historically has struggled here in Massachusetts” — #WorldCup announcer on Fox 👀

@umbreite @huntsmancancer @uofutah @UTHSAUro

Excited to announce my move to @HuntsmanCancer / @UofUtah this fall. Grateful for my time at UT Helath San Antonio @UTHSAUro — the patients, trainees, and colleagues made it exceptional. Looking forward to the next chapter in Salt Lake. Onwards and Upwards.

New in #practicalRO: MRI-based Atlas for Prostate Bed Recurrence after Radical Prostatectomy: Consistency of CTV Delineation with 7 Contouring Guidelines. tinyurl.com/probottero

Pretreatment MRI findings including extraprostatic extension and seminal vesicle invasion were independently prognostic for recurrence, metastasis, and mortality after radical prostatectomy. #ProstateCancer ja.ma/3QUYFxU

Want to hear more from radiation oncologist Charles Thomas, MD? Check out the full interview in RadOnc Student Scan Issue 8: zurl.co/INyyH #RadOnc #RadiationOncology #CancerCare #MedStudent

New in Advances in Radiation Oncology: Wallach et al. propose “curative oligometastatic radiotherapy” (CORT) as a distinct treatment-intent category for carefully selected patients with oligometastatic disease when cure, or exceptionally durable disease control, may be attainable. The concept goes beyond metastasis-directed therapy alone: all known disease, including the primary when needed, is addressed with curative intent. Proposed favorable features include limited metastatic burden, favorable disease biology or effective systemic options, controlled extracranial disease, good performance status, low tumor markers or favorable ctDNA, and a long disease-free interval. The nuance: this is a terminology and clinical framework, not a validated prognostic model. CORT may improve communication, shared decision-making, trial design, and data collection, but selection must remain individualized and disease-specific. A useful reminder that metastatic disease does not automatically make every course of radiotherapy palliative. #radonc #OligometastaticDisease #OncTwitter

Dupuytren disease (DD), a benign fibroproliferative disorder, affects an estimated 12% to 29% of individuals aged 55 to 75 years in Western countries. 1 It is more common and severe in men around the age of 50. A Systematic Review of Clinical Outcomes and Adverse Effects: zurl.co/0jTts #ProstateCancer #RadiationOncology #Brachytherapy #RadOnc #MensHealthMonth #MHM26