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Risk of infections from fiducial placement

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Posted 1/31/2016 6:15 PM (GMT 0)
As someone who got a UTI from fiducial placement, I can bear witness to this problem. Fluoroquinolone (e.g., Cipro) resistance is on the rise, and anytime a needle penetrates the rectum, resistant E. coli may be injected into the blood and the prostate. Of course this is true of transrectal biopsies as well. One good solution is transperineal placement instead - but that will probably involve some kind of anesthesia. If you're headed for external beam radiation (primary or salvage) that involves fiducial or Calypso placement, it's a good idea to discuss this with your doctor first.

Risk for infection(s) from fiducial marker placement

- Allen
Posted 1/31/2016 6:28 PM (GMT 0)
Great article Tall Allen as I approach the starting gate myself.Would this also apply to HDR-RT as that procedure penetrates that area also ? Thanks Again,0311
Posted 1/31/2016 7:00 PM (GMT 0)
0311,

Brachytherapy (HDR and LDR) does not penetrate that area. The implants are transperineal (through the perineum), not transrectal (through the rectum). There is a much lower risk of infection with transperineal placement because there is no fecal matter, and it's easier to sterilize the skin. As I said in the article, fiducials can be placed for SBRT transperineally as well.

- Allen
Posted 1/31/2016 11:43 PM (GMT 0)
As I re-read the 21 questions that Tall Allen suggested that we ask or ROs about SBRT,and # 10 says:
Do you use fiducials or Calipyso transponders ? Do you use transperineal placement of them ? Now I see the connection from your post above. I vote for transperineal placement to avoid any chance of infection even if I need sedation.

Also question # 10 a&b which are important:What system do you use for inter-fractional tracking? And what system do you use for intra-fractional tracking ? As you stated in previous post intra is more precise.

Question #11:What dose restraints do you put on "organs at risk' ?
Question 11b: what dose will my penile bulb receive ? Geez,my penis bulb !!!
All the questions are good as I had asked 2 ROs all 21.And they answered them all but as of today I really didnt consider #10 a big deal, now I do.

Yes this is a complicated cancer as for which treatment to do to start .Then we get into these specifics of each of them. Tall Allen, thank you again for your continued support , and always having the time to answer our questions.When do you sleep ?.And I thank everyone else for their knowledge and support as well. SemperFi
Posted 2/1/2016 6:41 AM (GMT 0)
Placement is sometimes done by a urologist (not the RO), so you might have to find one willing and able to do transperineal. I think even a swab of the rectum for a culture to see if there are any resistant bacteria would be a wise precaution.

There are some SBRT ROs who think a rectal balloon is enough to hold the prostate in place and lift away most of the rectal wall, and so they don't need intra-fractional tracking with fiducials. I'd like to see that proven in a clinical trial first. Tomotherapy may not need fiducials.

The penile bulb is the hidden end that extends into the pelvis. Some (but not all) think that too high a radiation dose there can contribute to ED. For IMRT the mean dose to 95% of it should be under 50 Gy, or under 20 Gy for SBRT. But, depending on individual anatomy, that may not be possible without sacrificing dose to the nearby prostate apex. As you've noticed, there is often not a single "right" answer, just stuff that must be considered.

I know it makes me feel more comfortable just knowing that the doctor considered all these specifics, even when there are judgement calls that are controversial.

- Allen
Posted 2/2/2016 3:09 AM (GMT 0)
Good information, thank you.
0311-have you made a decision as to which path you would like to take? We are heading to Sloan on March 1st to see Dr. Zelefsky. Hopefully all will go well.
Am I correct in thinking the discussion about inter(the daily setup?) and intra(patient motion happening during test?)-fraction tracking has to do with SBRT or any IMRT therapy? How can any doc think a rectal balloon is the only thing you need. To me it makes no logical sense just to have that.
0311-on a side note. Did you have to get ALL your medical paperwork, slides, and scans on CD sent to the docs you visited ahead of each visit? I know you met with a few in a very short time. How did you shuffle your slides and the other things from 1 to the next? We were told we could not make an appt with our next possible doc til all those things are in his possession. When I asked our original hospital if we can carry the slides back from NYC to our home so we could take them to the next doc visit they said unfortunately they have to go back to the original hospital and then a request has to be made to send them to the next doc. This is what we are up against and right now slides are at Sloan til we get there March 1st. Hubby is a bit anxious we can't get all our visits in so we have a bit of time to discuss the options offered us. How do people do this so quickly?
Posted 2/2/2016 4:13 AM (GMT 0)
IO-
Intra-fractional motion tracking is not done with IMRT, only SBRT. With the many light doses of IMRT, a little bit of miss within the treatment doesn't matter as much, as long as the set-up is accurate.

Proton is typically done with a rectal balloon.

It's a good idea to keep all the records you can in your own possession. My hospital charges me $15 for a copy of my MRI/CT scan. Most hospitals accept Epstein or Bostwick as the gold standard, but I know MSKCC prefers to do their own. I ask for copies of everything, preferably online, or I scan them in. Then I can just forward the files to the next doctor.

- Allen
Posted 2/2/2016 5:16 AM (GMT 0)
Thank you for all the clarification Tall Allen. We should have done that from the beginning. Actually all that we are missing in our possession is the medical record. Tomorrow I will call and see about getting that sent to us. I did not realize that about Epstein 2nd opinion. I'll let my hubby know this all. Cheers.
Posted 2/2/2016 5:31 AM (GMT 0)
InquisitiveOne,Im meeting with my 2nd Cyberkife Dr. this Wed.I talked to Dr.Debra Freeman in Tampa,one of the best in SBRT and she recommended Dr.Arica Hirsch out by me in Chicagoland.I also have a visit scheduled for Dr.Alvero Martinez,HDB,the following Wed. in Michigan.Thats a 5 hr. drive.But we are to do a phone consul before the visit so if I decide to go with HDB I will just go there and get it done.I will make the final decision soon.As Tall Allen said,its a coin toss.Ive done enough I think.6 visits,5 phone consults with great Drs.Its about due dilligence for me,make the best shot count.

As far as records go I have a master set about 15 pages that I fax over to the new Drs.before the visits or phone consuls.The Mri disk,bone scan disk they say to bring along.A few ROs that I visited put the MRI disk on the computer in the office and looked at it there..One RO that was talking to me about HDB wants to get his Pathologist at Loyola university to read my slides before HDB to see if I need IMRT along with the HDB.The slides are kept at the 1st pathologys office,which is Quest.For example my prolaris test,the prolaris company had to get the slides from quest then return them.Same as John Hopkins.JH had to get them from Quest,read them and return them to Quest.Keep me posted,thanks,0311

Post Edited (0311) : 2/3/2016 9:35:17 AM (GMT-7)

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