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Problem placing the fiducials

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Posted 7/9/2014 7:25 PM (GMT 0)
Went in for the planning CT/MRI and was told 2 of the markers are in the wrong place in the prostate and because of that they cant proceed with the treatment. My options- go back to the Inv Rad to see if he can get them in correctly and go forward with the treatment he estimates this at 50/50. Forget about CK and look for another form of treatment. Has anyone heard of this before? St Luke's uses a through the buttocks placement which no one else has heard of and the idea of this being a problem was never discussed. Has anyone heard of this as an issue?
60 yo, white PSA 14. Positive biopsy after 2 neg.1 positive core Gleason 3+4= 7 Slightly enlarged prostate. MD Anderson Houston did a Pelvic MR shows cancer within the prostate none outside. They thought there was additional cancer in the gland and they re scored Gleason to 4+3= 7
Posted 7/9/2014 8:08 PM (GMT 0)
Sounds like a do-over. Maybe you should request transrectal or transperineal since the transbuttock didn't work.
Posted 7/9/2014 8:34 PM (GMT 0)
Talk about a pain in the ............

Hate to hear of this problem, but TallAllen has a good point. I had never heard of these markers being placed this way. Will they have to remove them?
Posted 7/9/2014 8:59 PM (GMT 0)
They claim the delivery method wasnt the issue but havent really said what it was. Yes a possible do over later this month. I posted on the CK board and look forward to what the docs over there have to say. So far no one ever mentioned this as an issue
Posted 7/9/2014 9:17 PM (GMT 0)
The markers don't have to be in a certain spot, they just have to be visible for the CT scan. I don't know about CK, but for IMRT two of my three markers were so close together they created a starburst on the CT scan. They just did a new radiation plan to account for the mis placement.
Posted 7/9/2014 9:57 PM (GMT 0)
As I recall for my transrectal placement, we watched the needle place the fiducials correctly via ultrasound. So my doctor knew they were correctly placed before I left the room. I had 3 gold fiducials, but some guys get 4, and some guys get 3 pairs. Some places use radio transponders instead of gold fiducials. Some of the newer SBRT machines are so fast that they don't bother with intrafractional tracking, they just use a rectal balloon.

- Allen
Posted 7/9/2014 10:10 PM (GMT 0)
Seems like if they know where they are, then the can calculate the required offset in their planning software and go ahead with the procedures. But then I am not a radiologist.
Posted 7/10/2014 1:29 AM (GMT 0)
I would agree with lapilot that unless they missed the prostate altogether they could still get locked on anywhere they were located. If they missed I would definitely try a new urologist!
Posted 7/10/2014 3:02 AM (GMT 0)
My IMRT radiation treatment did not require the placement of markers. I've been told, having to physically place markers is older technology. I'd want to know why they didn't get the markers placed correctly, as this treatment needs to be precise.
I'd take time to reassess the situation. As far as I'm concerned, you need to get the best care you can, the first time.
Posted 7/10/2014 4:33 AM (GMT 0)
seems to me it is triangualtion.

The only way that would not work is if th ey somehow managed to get the three gold fiducials in a straight line rather than as a triangle.

Even then, inserting one more would surely form at least one triangle as odds of getting 4 into a straight line are infintesimal.

LupronJim
Posted 7/10/2014 12:34 PM (GMT 0)
I have requested a copy of the images and plan to get them to 2-3 other MDs who participate on the CK board. 2 responded saying they didnt think this should be that big of a deal. So we shall see. I also requested a copy of the BC/BS approval letter for me to receive CK at St Luke's in Houston. That way I figure I could use that approval letter to get this treatment where ever I choose to go. I have already spent $14K this year in deductible and out of pocket max and the plan year starts all over in Aug so either I get this done between now and Aug or risk having to start all over on a new insurance plan year.
Posted 7/10/2014 2:25 PM (GMT 0)
I have been following this thread, as CyberKnife is at the top of my list of therapy options. I'm sorry you are dealing with this, dennis h. Every doc I have talked with describes the fiducial placement procedure as no big deal - like a biopsy but with less "clicks."

As you may know, we have a CK facility here in Austin. If possible, I would recommend a consult with Dr. Paiman Ghafoori with the CK clinic here. He was very helpful and patient with me when I met with him.
Posted 7/10/2014 2:53 PM (GMT 0)
I have talked with Drs Mederry in OKC, Katz in NY, and Simpson in Boulder. I called the Austin clinic and they said a physician would call me back but nobody ever did so now I have a name to use Thanks! I am convinced CK is the right treatment for me but the obstacles can be intimidating. Will keep you in the loop
Posted 7/10/2014 3:50 PM (GMT 0)
Hello Mr. Harrington. We could make a copy of the CT on a CD disc and mail it to you or give it to you at our office. The cyberknife procedure makes automatic, continuous corrections for all 6 types of movement, translations(x, y, z axis), yaw, pitch and roll. In order to make these adjustments during treatment, three fiducials must have minimum spacing of 20mm between them. We had a few other patients who had to return to the hospital radiology department for one or more additional fiducials. Proper spacing is more difficult for small prostates. Response from my doc at St Lukes.
Posted 7/14/2014 10:03 PM (GMT 0)
Anybody have any familiarity with this? "3D acquisition MRI of the prostate, 1.5- 2mm thickness, axial cuts, thru the prostate including the seminal vesicles. Have feet taped together and hands on chest." I will have this sent to Colorado CK center and hopefully get the therapy done there.
Posted 7/15/2014 2:32 AM (GMT 0)
Dennis, Who made this statement that you have in quotes? Very confusing and what does this statement have to do with Colorado CK center?
Posted 7/15/2014 2:35 AM (GMT 0)
This is the MRI Colorado CK asked me to have done and sent to them for the CK planning. It is pretty confusing. Just curious if anyone has had this type of MRI
Posted 7/15/2014 2:43 AM (GMT 0)
I can tell you that if you go to Colorado Cyberknife Center and get your MRI, you won't get your feet taped together. I am speaking from experience. Just had it done out there 3 months ago. I would recommend them highly. I would also get my c-scan and MRI done out there if it was me.
Posted 7/15/2014 4:35 PM (GMT 0)
dennis h, I had an MRI at MD Anderson in June done just that way - feet taped together, hands folded across my chest. It was a 1.5 T machine, with endo-rectal coil. A bit uncomfortable, to say the least. The resulting report seemed to be less accurate than my previous MRI, which was done in March on a 3 T machine with no endo-rectal coil.

Dr. Ghafoori with the local (Austin) CK center was able to read my earlier MRI just fine. He did not say I needed this other type of MRI, although he said the CK procedure would involve a CT scan before the placement of the fiducials.
Posted 7/15/2014 8:48 PM (GMT 0)
Strange farmerboy on the taping the legs because what i posted is direct from Colorado CK. I will ask them before I do it.
Posted 7/15/2014 8:49 PM (GMT 0)
LeftyW- did you see Dr Pugh at MDA? They have a thing for the endorectal coil. I had an MRI done there with it as well
Posted 7/15/2014 9:55 PM (GMT 0)
dennis h - I did not see Dr. Pugh; it was Dr. Chapin who ordered the MRI at MD Anderson with the e-r coil, even though I previously had an MRI done locally with a 3 T machine. As I've discovered, the folks at MD Anderson seem to prefer their own diagnostic testing.
Posted 7/15/2014 10:20 PM (GMT 0)
I had a plastic mold made fitted to my legs - very comfortable! I thought of bringing it home with me but I have no room to store it.

They can't use an e-coil MRI for planning purposes because it changes the shape of the anatomy.Really would be overkill anyway.

- Allen
Posted 7/16/2014 4:29 AM (GMT 0)
Dennis, As I think back on my MRI I do think they put an elastic ring around my feet, which actually helps you relax because you don't have to try to keep your feet and legs tight and stiff to avoid movement. But it didn't involve tape. I think I made the comment to the technician that I had seen tape used and she said that was outdated. It certainly wasn't anything to be concerned about. It was actually kind of relaxing.
Posted 7/16/2014 6:08 PM (GMT 0)
Thanks guys the MR doesnt sound like any big deal especially after the fiducials. So far my expereince with Colorado CK has been excellent. I would like to get them to open a center in Houston I think it would clean up
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