Thoughts on Calypso

Folks:

I'm investigating my adjuvant or salvage radiation options. Had surgery a month ago and came back with a relatively huge positive surgical margin (1.2 cm).

Spoke yesterday with an oncologist that recommended the Calypso system.

http://www.calypsomedical.com/

Apparently the big deal is that it's real time tracking of your prostate bed during the entire radiation treatment, as opposed to a CT scan at the beginning of the procedure.

Does anyone have an opinion on this?

Is it markedly better than say the gold implants system, where they use those as markers and then give you a CT before each treatment?

On their website they list one study showing supposedly markedly better side effects results, but the size of the study (less than 100 men) seems awfully small to me. Doesn't necessarily invalidate it, but I'm wondering if there's more info out there.

Montiman:

Thank you.

I'm having a really hard time determining what criteria to use to determine skill levels of the doctor and techs.

The guy I'm looking at currently has done about 250 adjuvant or salvage radiation treatments (and presumeably considerably more done as primary treatment without surgery), and 80 of those have been specifically using Calypso.

Just dang near impossible for me to determine what makes a skilled oncologist....

His receptionist is pretty hot, but it's not like I could do anything about that currently anyway....

John:

How much SRT experience would you consider adequate?

This particular oncologist has done about 250 prostate salvage therapies (specifically salvage, not radiation as a primary therapy)

I'm having a terrible time determining what a 'good' radiation oncologist is.

I went with a surgeon that had a ton of procedures under his belt (over 1000) and I still ended up with a massive positive surgical margin.

And from what I can see there aren't really statistics on a 'good' outcome from SRT, as it's far less clearcut than a surgical result where you know if you have positive margins, etc.

Aachen

I think John is correct that Calypso or gold fiducial won't matter as much for SRT. I've seen a comparison and Calypso looks good. The important thing is to avoid dosing the rectum and bladder, penile bulb, femurs, etc. -- either image guidance technique is good at that. Because your positive margins were posterior and at the bladder neck, I think that IGRT with tracking during treatment (intrafractional) is particularly important for you.

I think the radiologist learning curve is a lot less steep than for surgery. My understanding is that the manufacturer (e.g., Accuray, Varian, Electra) trains and certifies the radiologist. The human part is mostly done in the planning stage - they set such parameters as the target volume and its dose and the dose to organs at risk. So, for example, how deeply will the 70 Gy penetrate into the prostate bed, what will be the maximum dose to the penile bulb, etc. These involve trade-offs that the radiologist will use his experienced judgment on. The software creates a 3D plan based on your anatomy (from the MRI/CT you'll have after fiducial or transponder placement). The radiologist may play with the plan parameters to find the best plan for you - that's where his expertise comes in.

Once the plan is accepted, it guides the computer that runs the RT machine. Because organs move naturally, the image guidance is used to re-align you with the plan. Image guidance may be done just at the start of each treatment or throughout the treatment as well, which would increase accuracy and reduce toxicity. It's not all about image-guidance, however. The speed of the machine plays a role too. A really fast machine like Varian's Truebeam with RapidArc will complete each treatment in under 5 minutes, so there is less chance of organ displacement and greater accuracy.

I was told by a radiologist that only a couple of hundred patients counts for good experience, but I haven't seen any studies in that regard.

The surgical positive margin is partly due to the surgeon's skill level. If his average positive margin rate approaches 10%, that's about as good as it gets. For the remaining 10%, the cancer has moved out of the prostate and no amount of skill will get it all -- only radiation can do that.

You're right that the outcome of SRT is less clearcut than a path report. Can the SRT get all of what was left behind? Because we currently don't have a good way to detect microscopic bits of cancer in the prostate fossa or elsewhere -- it's impossible to know. All we can do is closely monitor PSA progression.

Tall Allen:

Thank you. Excellent summary.

Do you know how the TrueBeam's speed compares to older Varian models?

One oncologist I talked to uses the Varian 600N, which I can't seem to find much info on other than it dates back to 2004.

I've asked his office to clarify, but haven't gotten anything much in return.

I assume it's the first generation in this, but I don't know that for sure

http://www.novalis-radiosurgery.com/about-us/novalis-radiosurgery-family/

So TrueBeam cuts even the NovalisTX system time in half?

That's pretty impressive.

How much movement is there in prostate salvage radiation? I assume a lot, since the bladder and such is right there, and we have to breathe.

I'm not sure but I think the 600N is the original Varian. Not even sure it uses RapidArc at all.

If anybody could clarify that would be great.

Good evening, gentlemen.

I have participated in other threads of this forum, but this seems fitting at this juncture.

First, a summary of my status:

60 years old
Health otherwise: Excellent
April 2013 PSA: 5.7
Traditional biopsy in May 2013: Results benign
Urologists suspected prostatitis and subscribed 30-day regimen of Cipro
October 2013: PSA 5.3; active surveillance begins
December 2013: PSA still 5.3; patient inists on MRi;
January 2013: 3D MRI at Massey Cancer Center in Richmond, VA, shows suspicious area in transitional zone
Mid-January 2013: Final pathology report concludes there is only one tumor, moderate in size, Stage 2, located in the transitional zone at the right apex; Gleason Score: 7 (3+4), favorable intermediate risk

I have ruled out surgery for various reasons, chief of which it is not necessary given the parameters of my diagnosis. But now I am frankly in angst as to whether to go with IGRT/IMRT or the Calypso method for radiation.

Your thoughts?

Thanks --

Windsor11

Windsor,

You ask:

But now I am frankly in angst as to whether to go with IGRT/IMRT or the Calypso method for radiation.

You don't. The RT is IGRT (IMRT is older). The Calypso is a control that monitors your proper position while IGRT is being delivered. You move, it sees it, and things shut down instead of nuking innocent tissue.

Calypso is an Add-on to make IGRT more precise.

Mine was denied for the scan fee of $165 per day, but because the clinic did it on a "providers pre-certify or else" plan in which they asked for power of attorney to pursue payment, they had to eat the cost.

Interestingly enough, insurance did not flinch about paying the cost of implanting the markers or the cost of the markers. Just the daily scan fee.

Can't say here who my insurance is with, but very large national company.

It was denied as "experimental". Likewise they would not cover proton RT, calling it "experimental"

My primary RT series IGRT by IMRT, done on a Varian Trilogy with RapidArc. It measured my three gold fiducial markers for alignment targets by 2 quick x-rays at the start of the treatment. The techs aligned the machine to those implanted targets. Then the 2 treatment sweeps happened. Each one was less than one minute long, first one way then the reverse.

I think even more important than whether you have Calypso markers (tiny RFID pellets), or gold fiducials, is to have consistent bladder and rectal conditions at the start of every treatment. Full bladder, empty rectum, during the initial CT planning session and at every treatment session. No carbonated beverages, no gassy foods. Stable and predictable is the most important thing.

I had no real side effects from the RT series. No skin burns, no bleeding from anywhere, just an increase in urinary urgency (worst period was 6-7 potty trips a night). Down to 1 or maybe 2 at night now, 6 months later.

If you're interested, I posted a video of one of my treatment sessions from start to finish. Not terribly dynamic visually, but it is a real first person point of view video of a real session. I captioned it here and there so you can know what's happening throughout.

Here's a link to my thread about it:
www.healingwell.com/community/default.aspx?f=35&m=2878923

And a direct link to the video (on youtube):

http://youtu.be/AMEEBZDQSNo