Brachy boost before or after EBRT

Mine was done two thirds of the way through IMRT.

if you do brachy first they out the markers I need an additional then so u don't need and additional procedure

For what its worth, I've recently come from the first, truly thorough consultation that I've yet to have with a qualified radiation oncologist, and he has proposed the following (approximate) schedule for me:

Casodex (for 4-weeks prior to Lupron): 6/15/18 - 7/15/18
Lupron: 7/15/18-01/15/19 (6-mo. dosage, administered 8-10 weeks prior to seeds, for a continuous total of 26-weeks) **
Permanent LDR (Pd-103 = Palladium-103) Seeds: 09/15/18
IMRT: 10/15/18 ~ 12/01/18 (5-6 weeks in duration and 1-month after seeds)

** Note that he is suggesting a cessation of ADT/HT after only a 6-month period (not 2-3 years as often proposed)

As I've said, this has just been proposed to me very recently, and I am still researching and evaluating whether this is the best overall course of action for me personally, given my 'high-risk' Dx, but at this point, its very likely to be the approach that will be taken in my case (i.e., seeds first, followed by IMRT, followed by continued, but short duration ADT/HT).

And lastly, I should close by clarifying that whether or not doing seeds before or after IMRT was even an option (or a viable approach?), was never really discussed. So this is something that I will need to discuss with him and continue to research on my own before agreeing to move forward with it.

Tall Allen said...
It sounds like a good plan and a good doctor - was this Dr. Lee? i'm sure he has his own protocol that works well for him.

Tall Allen,

Thank you, and yes, in fundamental terms, it seems like a pretty good approach, although this buisness about 'timing' or 'sequence' of 'beam then seeds' vs. 'seeds then beam' is definitely something I need to consider, and I wish I had asked him that key question. The only thing I know with certainty at this point, is that he felt the Lupron (before seeds) would sensitize the prostate to the subsequent effects of radiation (sseds and/or IMRT), and that the seeds themselves would likely 'aggravate' things including swelling of the prostate to the point of relatively severe urethral constriction in some cases, but I failed to ask him about whether reversing the order from 'seeds then IMRT' to 'IMRT then seeds' might make more sense. Definitely something I'd like to get resolved before proceeding.

WifeofPie said...
My husband's ROs said it didn't matter at all as far as efficacy, but since the HDR brachytherapy boost is invasive, the RO was able to place the fiducial markers for his subsequent IMRT during the boost procedure...so he did the BT boost first (if he'd reversed the order, he'd have just needed an extra appointment to put the markers).

Thank you. That's a great point, and I had not thought much about that, although I'm not yet sure that I fully understand the whole "fiducial marker" thing. If I understood my RO correctly, he'll be using ultrasound (presumably what's called TRUS?) to guide him in the placement of the actual Palladium-103 "seeds", but I don't yet know what (if anything) that has to do with "fiducial seeds" or seeds made of gold? Maybe they're altogether different approaches or techniques? No clue. Hence, much more research yet to come!

I think I already explained why EBRT then seeds is the usual order. Don't worry about it - the doctor has done it many times and has his own protocol.

different doctors have different approaches. mine did HT, seeds and then IGRT. my doctor also used cesium seeds. so far it has worked.

What is the reasoning behind the different Radioactive Isotopes?

It's mostly a matter of the personal preference of the brachytherapist, but the size of the prostate is one factor. They can't use high dose rate isotopes on very small prostates because if they insert enough seeds for adequate coverage, it will overdose the organs at risk. The higher dose rate isotopes offer an advantage in the therapeutic ratio because the cancer-killing dose is just as high, but the total dose is lower, so toxicity may not be as high.

Balladeer-

The reason he doesn't recommend HDR brachy is probably because he has little or no experience with it. It requires specialized equipment and training. in many parts of the country, it may be hard to find an expert practitioner. Brachy boost with either kind of brachytherapy seems to do equally well.