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Posted 4/15/2017 3:57 AM (GMT 0)
Anybody care to comment about fiducial marker placement in preparation for SBRT? I'm particularly interested in hearing thoughts and experiences contrasting transrectal placement versus transperineal placement. Thanks.

Post Edited By Moderator (Tudpock18) : 4/17/2017 5:09:17 AM (GMT-6)

Posted 4/15/2017 4:34 AM (GMT 0)
I don't understand why that's even a question -- Why do you want transrectal if you can get transperineal? More accurate placement, and much lower risk of infection.
Posted 4/15/2017 11:37 AM (GMT 0)
I had 3 fiducial markers placed for my primary IGRT, transrectal. No issues from it, rather like the biopsies with which we're all familiar, but only 3 pokes. I never had complications from any of the biopsies done the same way, either.

Just my experience. YMMV...
Posted 4/15/2017 12:33 PM (GMT 0)
TA...... It's a question because my doctor specifically said that that getting someone to do the procedure transperneally, which is her preference, is apparently somewhat of a challenge now because of the way Drs are compensated.
Posted 4/15/2017 3:15 PM (GMT 0)
Tarpon,

Thanks for posting this question. I just "signed up" for SBRT (CyberKnife) at Beth Israel with Dr. Irving Kaplan. Treatment to start in early June. As you know the first step is to have the markers placed. I didn't even realize there were options about the methods for that... so another learning curve.

OT a bit... But I also have questions about the way "The Plan" is created and I know there are lots of options there too. More studying to do. If you have any info or links about "The Plan" I would love to see that too.

Thank you,
Tim
Posted 4/15/2017 6:13 PM (GMT 0)
19tarpon47-

OIC. Well, if transrectal is all that's available, you have to go with that. That's what I had back in the olden days. It is only 3 "stabs" (some get 4) with the 18 gauge needle (the hypodermic goes through the US probe - same used in your biopsy). The fiducials (gold or platinum) are tiny - the size of rice grains. He numbed the rectal area with topical lidocaine, and then did a couple of deeper injections. The first two insertions were painless. But then it was quickly over (whole thing took less than 5 minutes). Let him know if you've taken a lot of any kind of antibiotic in the past. They can swab the rectal area with povidone iodine too.

TimOZ-

Congratulations on making that decision. The best way to learn about your plan is to make an appointment to go over it with Dr Kaplan when it is done. That is the crux of his job and the physicist's, and I'm sure he would love to show it to you and explain it all. Most patients aren't that interested. I find it fascinating, but that's just me.
Posted 4/15/2017 6:34 PM (GMT 0)
TA,
Thank you for your reply. Actually, from what I have learned from Dr. Freeman, you, and reading, I am definitely inclined toward the perineum method and if there is a way to arrange it, that will be what happens. Dr. Freeman indicated that the accuracy is more reliable that way aside from the obvious potential infection issue. However, ultimately I will do whatever is necessary to get this show on the road. I like your answer to Tim about the "plan". The physicist and the Dr will put that together and explain it. While I try to advocate for myself as best I can, there is a limit for me on the technical issues that I can expect to fully grasp in a couple months time. After all, in January, I was fat, dumb and happy....prostate cancer was the furthest thing from my mind and all was cool....or so I thought. Now, I'm just fat and dumb........ smilewinkgrin So in less than three months, I'm in need of learning all that Dr. Freeman knows, all that TA knows, Dr. Katz, Dr. King, etc..........not gonna happen. At some point, I will make at least a few assumptions that the good Dr. has my best interest at heart and go forth hopefully never to look back!
Posted 4/15/2017 6:41 PM (GMT 0)
Hi Allen,

I had mentioned to you how I got to the cusp of making the decision and did hesitate a bit. You told me to take my time.

I think I mentioned that I also decided to skip hormone therapy. I think with my single 7 (albeit a 4+3) I'm not that far over the active surveillance side of things. So I started to think that HT might be overkill. Kaplan agreed with me, which made the decision there simple.

What a difference between 6 months of HT and 44 treatments 2 other RO's recommended vs no HT and 5 treatments. But it isn't only the convenience that made me go that way. It is my belief that for my situation this is the best course with the most effective treatment and fewest side-effects. Only time will tell for sure but I feel fairly confident about this course of action. In no small part due to advice from you and others on this forum. What a great find HW was!

Thank you,
Tim
Posted 4/15/2017 9:51 PM (GMT 0)
FWIW, Cleveland Clinic, Dr. Eric Klein, Chief of Urology, installs the markers transrecal. They give you 750 mg tablet of LevoFLoxacin and an injection to the butt of 40 ml of gentamicin. The worst part of the procedure was the anxiety prior to.
Posted 4/16/2017 12:14 AM (GMT 0)
19 - As I mentioned before, my Fiducials were inserted through the perineum. My RO felt that this gave them better visibility of the insertion locations, and was their preferred means of insertion. If your doc does them trans-rectally, and they do lots of them, then why worry? Yes, there may be more risk of infection, but when all is said and done, if your doc uses the procedure that they are familiar with, you can expect their usual good result.

Was the insertion fun? I've had root canals that I enjoyed more. But. . . the root canals always took a while to settle down and stop hurting. This did not. I was back at my normal activities, other than driving (due to the meds), within the hour. No pain or discomfort afterward. In fact, I actually felt better after, because we had done something concrete toward getting my treatment started.

Hang in there. Soon enough you will be like the rest of your SBRT brothers who finish their treatment, then ask "Is that IT?"
Posted 4/16/2017 12:41 AM (GMT 0)
Hey 19......I am a ditto to Redwing57`s post ..........easy pesey....worked for me .......David
Posted 4/16/2017 2:29 AM (GMT 0)
Paxton,
I remember that discussion and actually u r the only person who has related to me a personal experience with the perineum method. I can do it either way as far as I'm concerned, however, my RO would much prefer the way you did it. She said the placement accuracy is much better. That's really the main issue. However, she also indicated, as I said, that fewer Dr's are doing the perineum method because apparently they frequently don't get compensated as well for the time and effort required.
Posted 4/16/2017 7:38 PM (GMT 0)
19 - Maybe I'm the goofy one, but I've always felt that if MY doctor has a preference but my insurance balks at it, I'll volunteer to pay any reasonable difference in cost just to get what I/we want. It is possible that if you offer, they will negotiate a rate so that the difference is minimal and your doc gets what they feel is best. The other path to take is to seek pre-approval and appeal if denied. (That's probably more common.)
Posted 4/16/2017 10:32 PM (GMT 0)
Don't know much about biology ...don't know much about theology...but what I do know is...the title of this thread...makes me think of the many financial advisors here...in-stead....

Tell me I ain't on to something full of wonder....
Posted 4/17/2017 2:51 AM (GMT 0)
Paxton...... You are not goofy at all. That is exactly the approach I took with Dr Freeman. If the doc can't make enough $ for what's required to do the process through the perineum, then I'll pay the difference. We'll see what she runs into after my scans are done and we can actually move forward. She plans to call my Mayo urologist and ask if he will do that type of marker placement. When Dr Freeman discussed the marker placement being more accurate when done through the perineum, that's all I needed to know. Less chance of infection is just a bonus.

Bololidat..... Unbelievable! Very perceptive. I never noticed that typo. Actually, it's pretty funny. I suppose there is no way for the OP to edit the subject after the first post???
Posted 4/17/2017 3:10 AM (GMT 0)
There probably is...but I don't know how...nor do I want to...there are no coincidences...life is an arrangement of notes...so I take notice...it gives me meaning... I like meaning....good luck with your treatments...
Posted 4/17/2017 11:09 AM (GMT 0)
19T...I fixed it for you.

Jim
Posted 4/17/2017 12:17 PM (GMT 0)
BTW, 19 - TA mentioned that his fiducial placement was ". . . only 3 stabs." Well, with any luck, yours will be only 2. Most docs now use "threaded" fiducials, where pairs of markers are connected together with short lengths of fine surgical thread of some sort. That way, they can implant 4 markers with only 2 pokes.

That is, unless you're a bit unlucky as was I. The doc got the first pair right where he needed them to be, but when he inserted the needle carrying the second pair, it was off target, so he had to pull back and re-insert it. Even with that, it was over in less time than the biopsy took - maybe 10 minutes including positioning the ultrasound probe.
Posted 4/17/2017 1:29 PM (GMT 0)
TUD.....Thank you. I presume that can only be done by a moderator and not the OP

Paxton.....Thanks for the info. And that's something I never heard. Another bit of information for my ongoing education about this subject. This place is an absolute wealth of information and experiences. I wish I could wave a magic wand and cure everybody on this forum and turn it into a fishing forum....that would be great!
Posted 4/17/2017 3:41 PM (GMT 0)
Someone at the gym a couple of days ago showed me the 'infamous' tarpon grab for the guy on the docks arm...that was interesting...pitbull kine...Im not sure why they just didn't kill it rather than wrestle it away..
tho it did happen quickly...stunned... shocked
Posted 4/17/2017 6:26 PM (GMT 0)
I like to eat fish, but I don't like to have to chase them around. I learned that when some friends and I caught a bunch of catfish many years ago. Nasty buggers, but they sure taste good.
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