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Failed HDR attempt NEED HELP

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Prostate Cancer
Failed HDR attempt what option is next best choice
Can RP be done after radiation ? - 20.0% - 1 votes
Additional EBRT? - 0.0% - 0 votes
Retry HDR with some else? How long do I have - 80.0% - 4 votes
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Posted 6/29/2018 3:42 PM (GMT 0)
Scheduled for HDR 6-28-18 failed because Anesthesiologists could not insert the tube to do the numbing
claimed never happed to them and had to with my physical attributes?
I had made my mind up that this was the “gold standard “ and way to go.
Now I do not have a clue on what is still possible. Should I try to get it done by someone else ?
Do I have time since I completed the EBRT 6-4-18. Also on HT since dec 17.
Should I go for additional EBRT(not as effective)?
Is RP now an option? Can’t they do an additional kind of anesthesia?

DX 11-6-17
1. Gleason 8...1 sample 75 % of tissue
2. Gleason 7...4+3...3 samples ranging 15,55,65 % of tissue samples
3.Gleason 7...3+4...2 samples ranging from 50, and 70%
4. Gleason 6...3+3...1 sample 15% of sample
5. 6 samples clear

Summary 7 samples with cancer 6 clear. 53 % with.

Recent PSA came in .15 5/18
Posted 6/29/2018 3:57 PM (GMT 0)
Wow...couldn't do the numbing? In my case, I had an epidural to numb me below the waist, is that what they couldn't do? I think the first question is, what are the options if they can't do this? It's not an RO issue as much as it's an anesthesiologist issue. (At least to my thinking it is.)

If facility #1 doesn't have a workaround, I think you could check and see if another facility would. I would also expect your RO to be taking the lead on this rather than leave you hanging! I would also be checking to see if they can add additional EBRT if you can't get the HDR brachy done.

Regarding the time following EBRT, I would not think that would be a big issue at all, although I'm not a doctor. Surgery would not be a good option at this point and I'd also think it's unnecessary since even if you just had EBRT (assuming they could extend it), you have an excellent chance at a cure.

Keep us posted on this!
Posted 6/29/2018 4:15 PM (GMT 0)
I would go for a second try and request another anesthesiologist; perhaps you just had a novice.
I would also ask if another anesthesia method is possible.
Posted 6/29/2018 5:26 PM (GMT 0)
If it were me I'd try another doctor.
Posted 6/29/2018 5:32 PM (GMT 0)
What does your RO say? Seems to me that he/she should be aggressively working to help you decide what to do next. He/she knows the dosage you have had and should be able to help you with a back up plan.

Jim
Posted 6/29/2018 7:14 PM (GMT 0)
Two Anesthesiologists tried a younger one and an older one..both couldn’t get it done. My RO states other
Pain solutions not acceptable because I need to be immobilize for 36 hours as they do 3 spaced treatments over a day and one half.

He wants me to immediately becgin 12 more fractions of EBRT which were originally will tolerated. Of course to continue with HT 6 months so far(not fun) to complete 18 months to 2 years. States I have excellent prognosis with. I do like the doctor. He gives you his cell phone and returns calls.
Posted 6/29/2018 8:08 PM (GMT 0)
Was this due to interference from the pubic arch? They should have known that from the planning/CT scan. Can it be done with LDR brachy (seeds)? Another option is an SBRT boost to the prostate, which is experimental - Here are some places doing it:

/pcnrv.blogspot.com/2016/08/sbrt-boost-therapy.html

You can ask Alan katz in Flushing if he would do it, or Michael Zeldefsky at MSK.

Surgery would be a worst option so soon after IMRT.
Posted 6/29/2018 8:50 PM (GMT 0)
I don't know if this information will help or simply muddy the waters, and clearly, the HDR method differs from LDR, but I'll be undergoing LDR-Brachy myself here in about 90-days, so I've been questioning my RO and his staff about what to expect during the procedure. I've been particularly interested in the anaesthetic aspect of it.

I was told that typically (or historically), they have done either spinal or general anaesthesia. However, they indicated that they no longer do spinals, because they had too many problems with patients being unable to walk afterwards, so apparently, they now do general anaesthesia almost exclusively, which I'm perfectly good with!

I'm not a doctor, so I have no clue, but wouldn't general anaesthesia be applicable for someone like the OP in this case?
Posted 6/30/2018 2:09 AM (GMT 0)
RO states they don’t and wouldn’t do general anesthesia because there procedure requires 3 deliveries HDR
over 2 days which requires the patient to lay flat on there back for a total of 36 hours. In as much as you have this catheter in you you cannot move at all during period of time. Claims this anesthesia is the only way to assure this.
Posted 6/30/2018 2:17 AM (GMT 0)

JGB said...
Anesthesiologists could not insert the tube to do the numbing
claimed never happed to them and had to with my physical attributes?.......................Two Anesthesiologists tried a younger one and an older one..both couldn’t get it done. My RO states other
Pain solutions not acceptable because I need to be immobilize for 36 hours as they do 3 spaced treatments over a day and one half.

He wants me to immediately becgin 12 more fractions of EBRT which were originally will tolerated. Of course to continue with HT 6 months so far(not fun) to complete 18 months to 2 years. States I have excellent prognosis with. I do like the doctor. He gives you his cell phone and returns calls.

JGB: what tube are you referring to? Not uncommonly there is difficulty inserting the airway tube for general anesthesia. Is that what they are talking about? If so, there is always a way to get that done what with devices such a a Glide Scope (allows you to see around the curve with ease) or various awake ( but sedated) intubation techniques. It is very helpful when you expect it to be very difficult in advance and thus have every piece of whiz bang hi tech gear handy when you first try to place the tube.

Or, are they/you talking about inability to place a spinal or epidural needle/catheter used to make you numb for regional anesthesia? In this case, if super difficult(can't get past/between the bones, too much fat so can't feel the bones, etc), the can use imaging ( C arm ) to allow them to see exactly where to put the needle, usually can get almost anyone done by using the x-ray vision approach.

Or, are they talking about something else? Either way, I'm surprised they say it has never happened to either one of them. Sooner or later, every one has a tube they just can't get in. Though that is becoming far more uncommon what with Glidescopes, imaging, etc. I would think that some one can get er done, though they might struggle. EDIT: I see from a newer post that it is not general anesthesia. So must be spinal, or more likely epidural? Ask them if they can use C Arm imaging to get the epidural catheter in.

Post Edited (BillyBob@388) : 6/29/2018 8:24:59 PM (GMT-6)

Posted 6/30/2018 2:41 AM (GMT 0)
Also, unless this is a small institution, there are probably far more than 2 anesthesia providers there, both MD and CRNA. Most likely, there is one guy- or maybe 2 or 3- who are known to have the magic hands and the vast experience with epidurals. There might be one guy or gal there who has done many thousands of epidurals because they used to work on the labor and delivery ward(childbirth) for a long time. See if you can get one of these guys, and see if you can get them to use the c arm imaging. It can be like magic.
Posted 6/30/2018 1:21 PM (GMT 0)
I can’t mess around with this anymore. Going to go with plan “b”...additional EBRT.
Appreciate all the help and comments.
Posted 6/30/2018 6:48 PM (GMT 0)
Good decision, based on the info provided
Posted 7/4/2018 11:03 AM (GMT 0)
Hello JGB

I was diagnosed recently with PC and as one of the treatment options I consider HDR. Here is the link
to process description and this process is performed under General Anesthesia. The Interval between two sessions is 4-6 hours. I do not understand why your provider wants to use spine anesthesia and wait 36 hours? I would bring this print-out and ask them this question.

https://www.mskcc.org/cancer-care/patient-education/high-dose-rate-brachytherapy-treatment-prostate
Posted 7/4/2018 11:33 AM (GMT 0)
SergeFL,

Thanks for the information. I have asked similar type questions in the past. His answer has been that this is the way they do it. Needs to immobilize the lower body because of the 3 treatments over 36 hours. If epidural not done right or general anesthesia used potentially could result in complications. In any event I feel like too much time has passed and committed to plan “B” which has already began.
Posted 7/4/2018 1:05 PM (GMT 0)
JGB, out of curiosity, where were you having this done? Other guys on this forum who did HDR had two outpatient visits 2 days apart. Your docs seem to be following a different--and unusual protocol.
Posted 7/4/2018 7:39 PM (GMT 0)
JGB, Thank you for update. I am not sure why 3 treatments is required. All information I was able to find require two treatments max for HDR. I understand that keeping you for two days in hospital has more financial benefits, then 2 treatments 4 hours apart and you released the same day. If this is the way they do it then plan "B" is the right choice.
Posted 7/4/2018 7:54 PM (GMT 0)
HUMC or Hackensack Medical Center.
Posted 7/4/2018 8:23 PM (GMT 0)
Everyone has different protocols. Some do only one insertion, some do two with about 6 hours in between, this one does 3. There is no right or wrong way - they just follow their approved protocols.
Posted 7/5/2018 5:35 PM (GMT 0)
I understand part about protocol, but there must be some sort of standard or guideline set by insurance company or/and research medical institution. In my personal "uneducated" opinion having 3 treatments may be overkill, unless it required due to specific medical condition like size of prostate, type of radioactive material used in treatment, etc. When my dad had prostate cancer 8 years ago, the treatment center did not make any decisions. All his information was sent to John Hopkins Medical Institution and they assigned treatment process. If someone claims this is the way they do it without explaining it, I would consider other options.
Posted 7/5/2018 5:50 PM (GMT 0)
Inasmuch as have restarted EBRT treatments an additional 12..(8 left).for a total of 45...which they state is an equivalent treatment(?) not sure that I could/should proceed with HDR at another institution.

Do not know if it is medically possible and if it is if I should proceed. PSA when just started treatments .15 from the HT and som EBRT treatments.

Thank you for the input.
P.S. he did state that this is how they do it after asking why he does it.
Posted 7/5/2018 7:14 PM (GMT 0)
SergeFL-
All protocols have similar 'bioequivalent' doses of radiation. The number of fractions impact bioequivalence in a non-linear way. So a boost dose of 16 Gy in 2 fractions is bioequivalent to a boost dose of 19.5 Gy in 3 fractions. But the dose will depend upon how much radiation was given via external beam. The individual institution will do the protocol(s) they are most accustomed to doing.
Posted 7/6/2018 12:54 PM (GMT 0)
Hello Tall Allen,
I am sorry for confusion. I was under impression from original post that HDR was consider as mono therapy without using external beam radiation. I understand that if two different radiation sources are used it must be balanced to correct total amount of radiation. This may require 3 fractions.
However, If we talk about HDR as mono therapy then 3 treatments over 36 hours period may be too much. I only refer to LOW Risk PC.
Posted 7/6/2018 3:59 PM (GMT 0)
SergefL-

You still seem to misunderstand. The HDR-BT is in addition to external beam, but that's not why 3 fractions are required. There is no set number of fractions required for monotherapy or as part of multi-modal therapy. It is based on the desired biologically effective dose, and is a matter of protocol.
Posted 7/6/2018 7:55 PM (GMT 0)
JGB

If you are having a full course of 45 EBRT fractions you would not also have HDRBT. That would be too much radiation at the presentation time. And you would not split clinics as there has to be one integrated radiation plan that is followed. You have moved from a combination of EBRT and HDRBT to a mono-therapy of EBRT only. You will receive the same radiation equivalent, just all delivered externally.

SergeFL

There are several different protocols to deliver HDRBT. Mine was two fractions/procedures one week apart. That has become a very standard method. This eliminates the overnight stay but requires two insertions of the catheters. As TA explained the key is the total radiation that is delivered to provide the maximum dose for cancer control but not so much to be overly toxic. When you add EBRT to the combination the two methods have to be coordinated to provide the optimum dose.

There is a minimum total dose required to be effective at killing the cancer. That dose is delivered by either very many small fractions or very few large fractions. Treatment experience shows the large doses with few fractions are a more effective for prostate cancer control. That is why HDRBT is favored over permanent seeds and SBRT is favored over traditional EBRT. However, many providers have not moved to the larger dose fewer fractions methods.

And if one is truly low risk they would normally pursue AS rather than radiation or surgical treatment.
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