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Posted 5/2/2018 3:55 PM (GMT 0)
As an update, I am meeting with a HDR Brachy specialist next week to learn whether or not it's an option for me (since one RO who doesn't do Brachy has told me it isn't).

I'm also still waiting on receipt of my second opinion from Johns Hopkins on my biopsy. I'll be surprised if the outcome is changed.

But I'm having a tough time identifying SBRT ROs in the greater Atlanta area. I'm aware of WellStar Kennestone having a CyberKnife, but not having much luck on determining who their guru is for using it on PC. Anyone have recommendations for SBRT docs in Atlanta? I'm also open to traveling to find more preferred SBRT experts as well since this is one of the options that I'm most seriously considering based on my research so far.
Posted 5/2/2018 5:06 PM (GMT 0)
If you can't get a name, I had a thought... Call Debra Freeman in Tampa Bay and ask her if she has a recommendation in the Atlanta area. I think she's pretty plugged in to who's who in the SBRT world.

www.cyberknifetampabay.org/index.php/about-us/physicians/77-dr-debra-freeman
Posted 5/14/2018 8:53 PM (GMT 0)
I'm still waiting for my biopsy 2nd opinion results from Hopkins, but I did meet with a Brachy specialist - turns out the specialty was in LDR-BT, but the Doc I met also has a couple of well-regarded HDR-BT specialists in the same practice group, so I am covered if I opt for BT. They scheduled me for a MRI (but I didn't know to ask at the time whether it's going to be a trans-rectal MRI or not, but since I assume they're seeking the best image possible, I will go in mentally prepared for that temporary "full" feeling.

That leaves SBRT as my next most viable option to investigate. During my consultation with a RP surgeon, I did learn that he firmly prefers that patients who choose a form of external beam radiation treatment select a higher volume, lower dose course of treatment, such as proton or IMRT. He has concerns about the longer term side effects on the rectum and bladder of the higher dose treatments. Says that as a surgeon, he remembers most the "bad" radiation outcomes he had worked on. He also noted anecdotally that he encounters more post-proton issue patients than other forms of EBRT. I personally still consider SBRT a more feasible option for me due to work circumstances than a prolonged course of treatment, but will probably learn more about that too before I finally decide.

A very recent PSA test (from a different lab) revealed a very slightly higher level result, so maybe my PSA is creeping up a bit. At this point, I'm more worried about my own "paralysis through analysis" than actually getting the treatment. I know some philosopher once said something to the effect of "Anxiety is the result of having choices." I'm crawling along toward the treatment decision point, and I will note again, being able to read guys' experiences in this forum has been immensely helpful to me in learning what to expect and what to ask. Thank God I found this forum.
Posted 5/15/2018 12:34 AM (GMT 0)
There is only a possible slight advantage to using an endorectal coil versus an abdominal apron for the MRI. They are extremely painful. Johns Hopkins stopped using them when they got their 3T machines, citing "patient discomfort", and little advantage. Be careful what you ask for.
Posted 5/15/2018 10:42 AM (GMT 0)
I have had 2 MRI's with the endorectal coil no big deal

Larry
Posted 5/15/2018 11:53 AM (GMT 0)
I too had an endorectal coil 3T MRI at the National Cancer Center. No discomfort to speak of, and they were very clear that it adds a lot to the sensitivity of the MRI.

Seems like it did. smile
Posted 5/15/2018 12:43 PM (GMT 0)
Not a fan of the coil. I would take 10 biopsies over that one MRI...
Posted 5/15/2018 5:02 PM (GMT 0)
Studies I've read seem to show that a 3T without endorectal coil is equivalent to a 1.5T with one, and nothing much more is gained by adding the coil on a 3T. Much more important is the experience of the radiologist. Coils distort anatomy, which is only a problem if the image is fused with a CT for radiotherapy later.
Posted 5/15/2018 5:56 PM (GMT 0)
I 'imagine' the physicians at NCI would like to see those studies, Allen.

This from NCBI, in 2017, appears to indicate the added value of the endorectal coil:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5286427/

Their final conclusion from this in-depth study:

In conclusion, the subjectively rated 3-T MR image quality related to the detection, localization and staging of prostate cancer was improved with a dedicated organ coil. In terms of diagnostic performance, the numbers of true cancer foci and of patients with cancer were higher but also that of false positive results.

Post Edited (garyi) : 5/15/2018 12:00:48 PM (GMT-6)

Posted 5/15/2018 7:11 PM (GMT 0)
garyi-

Then show these to those physicians:

"Non-endorectal coil 3.0 T MRI provides prostate images that are natural in shape and that have comparable image quality to those obtained at 1.5 T with an endorectal coil, but not superior diagnostic performance."

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4355101/

"The 3.0-T phased-array MRI is equivalent to the 1.5-T endorectal MRI in evaluating local staging accuracy for prostate cancer without significant loss of imaging quality."

/journals.lww.com/jcat/Abstract/2007/07000/Comparison_of_Phased_Array_3_0_T_and_Endorectal.7.aspx

"For T2WI and DWI performed at 3T index PCa lesion identification and evaluation did not differ significantly with both coil setups. Patients preferred MRI without an ERC. Therefore, the use of an ERC may be omitted in a prostate cancer detection setting."

/www.ejradiology.com/article/S0720-048X(16)30090-0/fulltext

"In terms of diagnostic accuracy and comfort of patients, the use of ERC-MRI did not significantly improve the staging of prostate cancer and presented several complications. Therefore, phased-array coil MRI is a better alternative considering comorbidity."

/link.springer.com/article/10.1007%2Fs00345-010-0579-6

"The development of the endorectal coil, much to the rue of our patients, resulted in the 10-fold improvement in SNR over transabdominal phased-array acquisition. With current gradient performance at 3.0 T, however, it is controversial how much value the endorectal coil still adds."

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4266765/

NCCN currently writes, "Furthermore, a high-quality mpMRI requires a 3.0 T magnet; the need for an endorectal coil remains controversial."

If it adds little, if anything, I can't "imagine" why a man would put himself through that. An mpMRI can take over an hour.
Posted 5/15/2018 7:48 PM (GMT 0)
Still being on the learning curve, I assume it is appropriate for me to ask in advance what type of MRI I will be given, and if it's the endorectal (of perhaps dubious value and apparently somewhat barbarian), then it's probably my option to pass on that type of imaging as well. Do we patients have the ability to override the RO on something like this issue?
Posted 5/15/2018 7:48 PM (GMT 0)

Tall Allen said...
garyi-

If it adds little, if anything, I can't "imagine" why a man would put himself through that. An mpMRI can take over an hour.

Well, I didn't have a choice, it was the clinical trial protocol, is was no big deal, and I trust the judgement of the National Cancer Institute physicians.

cool
Posted 5/15/2018 8:07 PM (GMT 0)
Boosted-

An mpMRI is only necessary to help guide a confirmatory biopsy if you were going for AS. You can certainly ask for a 3T without endorectal coil if the institution has a 3T machine and a radiologist with good experience. You could also have just another 12-core TRUS biopsy, or a 30+ core template-mapping biopsy. That should be negotiable, but some programs follow a strict "my way or the highway" protocol.

If you decide on radiation treatment of some kind, the RO will probably want an ordinary MRI (T1 or T2) and a CT scan after fiducials are placed. The images are fused. They are needed to create the radiation plan, and is necessary for image guidance. The ordinary kind of pelvic MRI only takes about 15 minutes and does not require an endorectal coil. It's not something you'd want to refuse because it improves the accuracy of the beams or seed placement.
Posted 5/16/2018 12:36 PM (GMT 0)
Thank you, TA. My MRI is scheduled to help the RO evaluate my Brachytherapy options. At this point, I am leaning towards either HDR Brachy or SBRT. Fortuitously, I had planned a nice vacation booked long before my diagnosis, so I will have a couple of weeks to put all of this aside and give myself a break from agonizing over what treatment will suit me best. I'll interview the SBRT RO when I return and then make a decision.
Posted 5/16/2018 12:44 PM (GMT 0)
I had the coil with MRI and I think they injected me with some kind of contrast medium, made me feel awful for several hours. My urologist at the da Vinci console said in the follow-up appointment the imaging was a significant help when he was removing the prostate. At least that helped me feel like the pain was worth the gain.
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