HealingWell
Search Close Search
☰

MET WITH THE 3RD RADIATION ONCOLOGIST TODAY

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
12 3
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 9/21/2016 11:08 PM (GMT 0)
My Salvage radiation will most likely start mid October or early November.
I had a CT planning session set up for early October, but decided to meet with a few more RO's.

I have now talked with 3 different RO's and the one today I feel more comfortable with. The downside is it will require an extra hour commute, half hour each way.

Guy's, any trouble driving because of tiredness after radiation treatments?

He will most likely use a Varian Edge, better for sculpting he said, for most, but use TrueBeam for large areas, such a lymph nodes. Ct before each section and if something does not line up no radiation that day. He will finalize at planning CT.

~70 Gy for prostate bed and ~53-56 for nodes with extra to nodes that 68 Ga PSMA PET/CT detected. Will be done in 35 fractions, or 7 weeks.

Does Hyperfractionated for initial treatment but has not used for salvage/adjuvant. Willing to do 26-28 fractions with reduced Gy's, but suggested he preferred 35.

He suggests 3 years HT and then intermittent, if necessary.

After treatment he will monitor every 3-4 months both the results and SE's. He stated he does 40/50 Adjuvant/Salvage treatments a year with very few patients having long-term SE's.

He gave me his direct line phone number and gets back to everyone within a day or I can contact him on "My Chart Account".

Bobby Mac
Posted 9/21/2016 11:17 PM (GMT 0)
No problem driving. You will have an issue with urinary urgency on the drive home. Have several places that you can stop and pee or have a pee bottle available. Especially if you have to have a full bladder, highly recommended, you will have to pee 10 or 15 minutes after you leave, maybe more often.
Posted 9/21/2016 11:23 PM (GMT 0)
Sounds good! That's a pretty standard plan. There's not a lot of data on hypofractionated salvage, so even apart from the lost profitability, I can certainly see why it's something he doesn't want to experiment with on you. 3 years on HT is a long time, but he's worried that there may be more cells to kill because of your positive LN.

Fiducials in the prostate bed, I assume?

I think an hour extra commute can be tedious after 35 sessions, especially when you're experiencing urinary urgency towards the end. Maybe bring a plastic urinal bottle in the car with you.
Posted 9/21/2016 11:33 PM (GMT 0)
My IMRT was not salvage, but I never ran into tiredness during semi-long So Cal freeway trips. I did have issues with peeing, mainly on the way there as I would try and time my 24 oz liquid consumption to coincide with my arrival at UCLA and wasn't always successful. (And sometimes I'd get there and find they were running late--ARRRGH!)

Good luck to you!
Posted 9/21/2016 11:55 PM (GMT 0)
I had 6 weeks, 140 mile round trip. Tiredness not an issue for me, figuring out how to urinate while driving was the key. That was a huge problem to overcome. mother of invention thing
Posted 9/21/2016 11:57 PM (GMT 0)
John, Michael & Fauntleroy, thank you for the advice-

Tall Allen - thank you for reminding me about those Fiducials - Do they always use them? Can they use the surgical clips instead?

Anyway, I just sent a message to the RO asking him about them.

Bobby Mac

Post Edited (Bobby Mac) : 9/21/2016 6:00:02 PM (GMT-6)

Posted 9/22/2016 12:10 AM (GMT 0)
They do not always use them, but I think they should to help avoid excess toxicity. The fiducials have to be implanted in the prostate bed, so surgical clips won't do. Sometimes ROs say they can use soft tissue, but getting the exact place right on the soft tissue can be problematic. When the pelvic LNs as well as the prostate bed are getting dosed, exact position becomes very important - the motion of the prostate bed is different from the motion of the rest of the pelvic area. The bowels are constantly in motion so things are moving within the radiation field quite a bit. The RO has to be very careful about all this. It may help somewhat if there is more visceral fat. They can use fiducials or transponders but I think they should use one or the other.
Posted 9/22/2016 1:53 AM (GMT 0)
One more thing, cover the seat for the duration. you don't want urine soaking into the car seat.
Posted 9/23/2016 10:50 PM (GMT 0)
Allen -

Received a message from the RO I met with this week regarding Fiducials.

His reply follows:

"You will not need fiducials in the prostate bed since our Edge linear accelerator has a cone-beam CT scanner which enables us to do a CT scan each day prior to treatment to accurately target the prostate bed. We place fiducials when we have an intact prostate gland (i.e., when no surgery has been done) and we are doing very high dose, 5 fraction, SBRT which is stereotactic body radiation therapy. In your case, I would recommend standard fractionation radiation which would be 70 Gy at 2 Gy per fraction over 35 fractions or 7 weeks. I have treated a few postop patients with a hypofractionated technique which delivers 65 Gy at 2.5 Gy per fraction over 26 fractions or 5.2 weeks."

Bobby Mac
Posted 9/24/2016 12:14 AM (GMT 0)
Yes, that's what I was afraid of. Understand that cone beam CT (or stereoscopic X-rays) are used with fiducials or transponders by many ROs doing SRT. They place them in the walls of the prostate bed. That is no guarantee that toxicity will be reduced (ask 142!), but I think it is prudent (just my non-professional opinion), especially because the prostate bed and LNs move separately.

"Total positioning errors >5 mm occurred in 14.1%, 38.7%, and 28.2% of all fractions in the LR, SI, and AP axes, respectively. "
www.redjournal.org/article/S0360-3016(06)03226-3/abstract

To what extent those positioning errors affect toxicity is anyone's guess.

In the following, read the section "Image-guided radiotherapy."
/www.ncbi.nlm.nih.gov/pmc/articles/PMC4646477/

This gets more complex when the pelvic LN area is simultaneously treated with the prostate bed. I know this is controversial and many believe that soft-tissue alignment is adequate. Maybe worth hearing from a few different ROs.
Posted 9/24/2016 1:19 AM (GMT 0)
Driving shouldn't be a problem. Unlike many I had no fatigue from SRT. But as Tall Allen point s out, urinary urgency did become a problem after week five or so when getting out of car and first standing up. I was able to will my way through and the urgency would pass in a minute or so, but there was sometimes doubt if I would overcome the urge in time. Fortunately I always did and managed to never risk arrest for lewd conduct in a parking garage.
Jim
Posted 9/24/2016 3:42 PM (GMT 0)
I've completed 32 of 33 IMRT sessions and I'm having no fatigue issues. My commute to the clinic is only 10 minutes, so no urinary problems, except the time my bladder was overfilled and I got caught in huge traffic jam crossing the Mississippi River into New Orleans for my daily treatment at Tulane Cancer Center. I was able to make it, barely!
Posted 9/24/2016 5:25 PM (GMT 0)
@ Allen -

I hear what you saying about Fiducials and I am concerned.

As I said I have talked with three RO's and this guy impresses me the most. He was trained at a top ten cancer hospital, per US News, and is at a top hospital in Florida now.

My RO is using Varian Edge - does that make a difference?? It is much more precise than Varian's TrueBeam.

@NolaVette - Is your RO using Fiducials for your salvage radiation? What equipment is he using?

@SRT's/ART's Did your RO's use Fiducials or Transponders?

Bobby Mac

Bobby Mac
Posted 9/24/2016 6:39 PM (GMT 0)
Precision doesn't help if the prostate bed and PLN area has deformed since the planning study, which all of our organs do - they are not rigid. The beam will precisely land in the wrong place. The question is, will it make a detectable difference in toxicity? I don't know the answer to that. Salvage IMRT often uses wide margins (e.g., 1 cm) because the location of microfoci of cancer is uncertain. And the dose per treatment is low, typically 1.8-2.0 Gy, so a few misses here or there won't make a big impact.

The most deformable area is where the small bowel abuts the pelvic LNs. Gas, peristalsis, and food digestion move that area quite a bit (even during a single treatment), and the enteric tissue is vulnerable to a late response to radiation that may not show up for years. I don't think there's anyplace nearby to stick a fiducial. So maybe his fast, accurate linac will make a difference in that area at least. I would think it's especially important to use tight margins there, yet full coverage is essential.

I would talk to a few ROs and hear their opinions. It seems that UCSF does use them - maybe set up a phone interview with Mack Roach to get his opinion. I'm not sure what a poll tells you, but if you want to hear how HWers were treated, maybe start a new thread with a poll: Those who had whole pelvic salvage radiation, did you have fiducials/transponders in place? Yes or No.
Posted 9/24/2016 6:53 PM (GMT 0)
BTW - You may wish to discuss the following new study with your RO. There will be a trade-off between increasing coverage and increasing toxicity.

Patterns of Lymph Node Failure after Dose-escalated Radiotherapy: Implications for Extended Pelvic Lymph Node Coverage
Posted 9/24/2016 8:06 PM (GMT 0)
Allen -

Thank you for that study!

Bobby Mac
Posted 9/24/2016 9:15 PM (GMT 0)
Bobby Mac,

The drive home shouldn't be a problem. I had the same SRT (70.2 grays, 39 treatments) and I had zero problems. I had a full bladder through the IMRT/IGRT and then I would pee prior to driving home which is about 30 minutes from the radiation center. As per my RO, I never changed my diet and I had zero GI or urgency problems. I might have had a little fatigue (hard to tell) towards the latter half of radiotherapy and for a short time afterwards.
Posted 9/25/2016 6:37 PM (GMT 0)
@NolaVette - Is your RO using Fiducials for your salvage radiation? What equipment is he using?

Bobby Mac: No fiducials, just the 3 tattoo marks. One on each side and one in the pubic area for alignment. They do an imaging sequence for every treatment before the actual radiation is administered to make sure the bladder is full and the rectum is empty of solids and gas (my biggest problem).

As far as the machinery being used: I've seen the brand name "Trilogy" in a large logo sorta thing on the unit.

Sorry Bobby Mac....I just realized I was replying to you instead of Tall Allen. I fixed it with an edit.
Posted 9/25/2016 6:55 PM (GMT 0)

NolaVette said...
@NolaVette - Is your RO using Fiducials for your salvage radiation? What equipment is he using?

RO has informed me he does not use Fiducials for SRT-

He will use Varian Edge for the bed and possibly Varian TrueBeam for nodes.

Have not had official SRT planning session yet!

Bobby Mac
Posted 9/25/2016 8:33 PM (GMT 0)
Hey Bobby Mac, if you show your RO that study post what his response is.
Posted 9/25/2016 8:34 PM (GMT 0)
If he is not familiar with it and wants to stick to his plan..what is your next move? Keeping in mind that it is a single study, of course. :)
Posted 9/25/2016 8:45 PM (GMT 0)
Do you guys asking for treatment suggestions on HW tell your docs what a guy called "Tall Allen" says? If so what response do you get?
Posted 9/25/2016 8:59 PM (GMT 0)
I sent him the study - and ask if he is willing to act on it - I'll wait and see what he says-

I do not mention any names from Healing Well-

Bobby Mac
Posted 9/25/2016 9:17 PM (GMT 0)
the question was what you will do if he will NOT act on it. Do you mention HW in general?
Posted 9/25/2016 9:24 PM (GMT 0)
I will have to see what he says before I can decide what to do if he says no - Also, I sent the study to another RO that I met with -

I do not mention HW -

Why do you ask that question?

Bobby Mac
✚ New Topic ✚ Reply
123