Hitting the target

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TTaylor
Regular Member


Date Joined Nov 2010
Total Posts : 102
   Posted 2/2/2011 1:30 PM (GMT -6)   
I am scheduled for RT in the not to distant future. Something that concerns me is how do radiation therapist radiate the exact target without the possibility of destroying other tissue. My concern is that my bladder is now in the area of my prostate, referred to as the prostate bed, and that is where the Dr thinks my gleason 8 adipose tissue invasion is located. He can't be absolutely positive but he thinks so. Given that knowledge what is there to keep the radiation from damaging the bladder and or urether. Unless he can guarantee me there will be no secondary ill effects I am doubtful if I want to chance it. Would appreciate any thoughts you may have on this condition.
TTaylor

Kongo
Regular Member


Date Joined May 2010
Total Posts : 36
   Posted 2/2/2011 1:48 PM (GMT -6)   

TTaylor,

I had radiation (CyberKnife) as a primary treatment for my Gleason 6, stage T1c prostate cancer in July.  While deciding on a treatment I researched several different types of radiation.  The answer to your question is complex.  There are a variety of different technologies used to administer salvage radiation treatments and some can deliver the necessary dosage more accurately than others.

 Some forms of IMRT (one of the most common salvage methods) use fiducial implants which the delivery system uses as a reference point in guiding the radiation.  While it's possible that some radiation may hit the bladder, the system is designed so that dozens of multiple beams are shot into the body and they converge on the exact area targeted by the radiologist.  This method allows real time adjustment of the radiation beams and can compensate for organ movement within the body.  The beams that pass through surrounding tissue are not focused and result in much less dosage below the levels that cause harm.  Other systems place your body in a mold to hold your pelvic region immobile during treatment and they position the system each day.  While less accurate, they still deliver most of the radiation to the desired area.  There are variations of these types of radiation techniques in IGRT, Calypso, and so forth. 

 To answer your question, you really need to know the exact type of equipment being used in your individual case and what the radiation plan for your specific treatment is.  Without that knowledge, you're just guessing or making generalizatons.

 Not sure what secondary ill effects you mean.  Typically, a small percentage of men may feel a sense of urgency following their treatment but not incontinence.  This usually passes within a few weeks to a month and can be treated with OTC drugs like Advil or Flomax (which of course also has side effects).  IMRT also has a small percentage of men with some degree of rectal toxicity (blood in the stools) but this too passes relatively quickly.  The risk of a secondary cancer caused by radiation years after treatment is very rare with the modern types of dose administration although should it occur, it is easily treatable as well.

From what my doctors have told me and from the research I have done there are a few generalizations that can be made about post RT side effects.  Those are that if you have urinary issues before treatment, you will likely have them following treatment.  If your have a potency or ED issue before treatment, you will probably have a similar or worse condition afterward.  The good news about ED is that should you experience a loss of function some time after RT, drugs like Viagra are quite effective in restoring potency.

 After my radiation treatment I have experienced zero side effects, either with urinary function, erectile ability, or rectal toxicity.  Every man is different and there are no absolutes in any of this as I'm sure you realize from your previous experiences with PCa.   If you're really wanting a "guarantee," I don't think you're going to get one.

 I would recommend sharing your concerns with your radiology team and ask them to show you how their equipment works, how they develop a radiation plan, how they minimize radiation to other parts of the body, and what side effects are likely and what are not.

 Good luck to you.


Post Edited (Kongo) : 2/2/2011 11:55:28 AM (GMT-7)


F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3838
   Posted 2/2/2011 2:01 PM (GMT -6)   
 >>Unless he can guarantee me there will be no secondary ill effects I am doubtful if I want to chance it.<<
 
i'd be more leery if he gave you the guarantee.  there are risks to all procedures.
 
ed
age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

TTaylor
Regular Member


Date Joined Nov 2010
Total Posts : 102
   Posted 2/2/2011 2:14 PM (GMT -6)   
Thanks guys for your response. My Dr says they will use adjuvent radiation and I do plan to ask questions before I go ahead with the RT. With all I have been through RP, anastamosis and now nerve damage the thought of having RT gives me the willies.
TTaylor
Age 67. Robotic prostatectomy 10/26/2010, due for RT in Janury 0f 2011. Eight of 12 lobes positive. Gleason Score 4+4=8, Margin envolvement was present with adipose tissue invasion and perineural invasion, glandular and stromal hyperplasia present,pT3 pNO and no evidence of metastatic adenocarcinoma. 1st psa after surgery Nov. 24, 2010 was .3
HT started Nov. 24, 2010.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3787
   Posted 2/2/2011 2:28 PM (GMT -6)   
I am being treated (SRT) on one of the more advanced machines..Varian Novalis Rapid Arc..

In the beginning, you get a detailed, high-resolution CAT scan that your R-doc uses to formulate your treatment plan. You are then put on a table identical to the treatment table, A leg and or a hip mold is made, and four tiny tattoos are carefully placed using a laser surveying system.

Then, during treatment, you are positioned on the table exactly the same everyday..The first pass the machine makes is a low-power CAT scan to verify your position and the position of the treatment target. These images are compared to that first master image. You will feel the table make some tiny corrections in position. The CAT scan arms fold back, the "gantry" positions itself, the beam is activated and the gantry rotates around you, the beam focused on the desired area..But since the beam is in constant motion, only the focal-point gets the full dose, the other tissue is exposed to the moving beam for a MUCH shorter period of time. I get two passes, right to left then left to right..

So far, the only effect I have noticed is increased urinary frequency and to lesser extent, urgency..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT NOW

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 2/2/2011 3:09 PM (GMT -6)   
taylor:

keep asking your radiation doctor those kinds of questions. i am the one that suffered extreme damage from salvage radiation. I had 39 treatments totalling 72 gys of IMRT, which ended November of 2009. To make a long story short, the radiation was delievred with an empty bladder and with a suprapubic catheter in place. I questioned the doctor about not having a full bladder and her response was "I got that covered. I started experiencing radiation burns on the 4th treatment and it got progressively worse. It was a horrible ordeal, and then I spent almost a full year post radiation in severe pain, unable to eliminate the catheter. Was on pain pills the entire time. In the end, it was determined that my bladder and bladder neck were severely damaged by the radiation. In the end, I needed the ileial conduit surgery which left me with a urostom (stoma) for life, and a bladder that has been perm. disconnected and damaged.

while my story might be rare, i tell it to you because bad things can happen with radiation treatments. i was on modern state of the art equipment at the time, and a national brand radiation clinic at the time.

no doctor can guarantee you safety through the radiation process, he/she would be a fool to do so. good luck as you come to a full decision. most men get through it without all the issues and drama that happened to me, but it can go sour. there is a risk factor, like in all of our treatments.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

TTaylor
Regular Member


Date Joined Nov 2010
Total Posts : 102
   Posted 2/2/2011 3:17 PM (GMT -6)   
David
My thanks for your response. I was hoping to hear from you because I am aware of your condition, and quite frankly this is what prompts my concern. I had an anastamosis after surgery and whether or not it has healed to the original condition prior to surgery I will never know. I have questions of the Dr but I understand what you are saying, and will hopefully make the right decision.
TTaylor
Age 67. Robotic prostatectomy 10/26/2010, due for RT in Janury 0f 2011. Eight of 12 lobes positive. Gleason Score 4+4=8, Margin envolvement was present with adipose tissue invasion and perineural invasion, glandular and stromal hyperplasia present,pT3 pNO and no evidence of metastatic adenocarcinoma. 1st psa after surgery Nov. 24, 2010 was .3
HT started Nov. 24, 2010.

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 2/2/2011 3:21 PM (GMT -6)   
A full blader apparently helps drop it down and protects it from the rays.
While filling your bladder ahead of each session MAY have been mentioned to me among 2,328,934 other things, I think they SHOULD HAVE MADE SURE THAT I UNDERSTOOD THE BLADDER SHOULD BE FULL!

Please, make sure to have this discussion with your dr!

And best of luck, my prayers and thioughts are with you, all.

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3794
   Posted 2/2/2011 3:44 PM (GMT -6)   
Full bladder and empty bowel is what my rad-onc instructed me. Then, while you are on the table just hold your breath for about 10 minutes!

I normally drank a 12 ounce bottle of water on my way to the center. I would have a 15 minute wait at the center and then under the ray. Once off the table I was ready to empty my bladder but wasn't in dire need.

My system rotated around me and stopped in nine different positions and delivered 5-9 doses in each position as the beam changed with each dose. The machine buzzed when delivering the radiation. As the gantry moved to the next position I was able to take a little breath being careful not to move. As Fairwind describes, the latest machine does not stop moving around you and takes a little less time to deliver the total treatment.

Overall my side effects were minimal. If you are not 100% comfortable with the doc, staff, or equipment....then go see another one and compare.

TTaylor
Regular Member


Date Joined Nov 2010
Total Posts : 102
   Posted 2/2/2011 4:07 PM (GMT -6)   
Thanks guys for your response. Quite frankly I'm more concerned with the RT than I am with the cancer. May sound difficult for some to understand but having had so many difficulties post surgery Iam concerned about everything from here on out.
TTaylor
Age 67. Robotic prostatectomy 10/26/2010, due for RT in Janury 0f 2011. Eight of 12 lobes positive. Gleason Score 4+4=8, Margin envolvement was present with adipose tissue invasion and perineural invasion, glandular and stromal hyperplasia present,pT3 pNO and no evidence of metastatic adenocarcinoma. 1st psa after surgery Nov. 24, 2010 was .3
HT started Nov. 24, 2010.

kuls
Regular Member


Date Joined Mar 2010
Total Posts : 57
   Posted 2/5/2011 1:43 AM (GMT -6)   
Boy....how to even TRY to answer this satisfactorily???? (especially after having had a couple of glasses of wine)!! tongue
 
The rationale for delivering a fractionated course (i.e. over numerous, equal dose treatments) of radiation therapy, is to eradicate the harmful cells while "sparing" the healthy surrounding tissue.  Because the radiation is delivered externally, of course the healthy surrounding tissue DOES receive a portion of the dose.  When optimizing a patient's individualized "treatment plan", every possible precaution is taken to ensure that the maximum dose is delivered to the target volume without compromising the critical surrounding structures.  Different tissues and organs in the body have different "tolerance doses". 
 
Cancer cells are "rogue" cells that have, for some reason, changed in ways that they no longer follow the "normal" pattern of what their function is supposed to be....they ignore the rules.  A cancer grows by cell division  (i.e. you start out with one bad cell, it divides, then you have two--then four---then eight....etc.)  What the radiation does (to both bad cells and to healthy cells) is to cause damage to the cellular DNA that makes the cell capable of dividing (reproducing).   Fortunately, healthy cells are better able to repair the radiation damage than the bad cells, so the healthy cells are able to repair themselves and do their job, while the bad cells are not as capable of repairing the damage.  By delivering the course of radiation in equal daily doses over a number of treatments, it allows time for the healthy cells to repair some of the damage. When the cells reach the end of their normal cell life cycle, the healthy cells divide as they are supposed to, but the bad cells just die off (ideally).
 
This is also the reason why side effects from treatment do not generally appear immediately.....it takes time for the radiation effects on both the healthy and the bad tissue to manifest.  Side effects to different tissue occur at different times during the course of treatment, depending on the radiosensitivity of the tissue.
 
As with any curative treatment, no doctor can EVER give you a guarantee that you will not experience acute and/or long-term side effects.  All they can do is give you the statistics.  It is impossible to predict who will experience side effects, or to what degree of severity they will experience them. 
 
There is also a risk of secondary malignancies arising from EBRT.  Again, statistics are all one has to go by when determining their best course of action regarding treatment.  It is definitely a case of risk vs. benefit. 
 
The best advice I could give anyone is to BE YOUR OWN ADVOCATE!!  There is absolutely NOTHING wrong with bringing in a list of questions when you consult with your doctor.  At least once you have had the opportunity to ask your questions (even if you don't get the precise answers you'd like to hear), you will be making a more informed decision regarding your treatment.
 
As far as daily positioning for treatment, there are numerous ways positioning can be verified for day-to-day reproducability.  External marks such as tattoos are often used to give the therapists a "starting point" for daily positioning.  Distances and measurements are often confirmed with the use of an ODI (optical distance indicator).  When images are taken, they can be overlaid and compared with the images provided from the original treatment plan, by use of fiducial markers implanted within the prostate (e.g. gold seeds) or by matching bony anatomical structures such as the symphisis pubis and the obturator foramen.  Adjustment to positioning can then be made, if necessary, depending on the numerical results of the image matching.
 
One thing to point out is that the TIME it takes to verify positioning can vary GREATLY from day to day.  Some days a person can lie down almost perfectly and positioning verification can be done very quickly.  Other days, it takes much fiddling around and adjusting to get everything lining up just right.  This really has NOTHING to do with how experienced the therapists are.....it is basically the fact that we are living, breathing human beings, with mobile skin and bones.....we are not a bunch of bricks that can just be plopped onto the treatment couch in the exact same position from day to day, without changing shape, gaining/losing weight, retaining fluid, etc., etc., etc.
 
Again, it certainly doesn't hurt to ask what system your treatment centre uses.
 
I'm tired, wined-out, and ready for bed!! tongue    I'll probably read this post in the morning and realize that it doesn't make any sense at all!!!  Oh well.....I tried!! blush
 

Post Edited (kuls) : 2/4/2011 11:59:39 PM (GMT-7)


billye
Regular Member


Date Joined Nov 2009
Total Posts : 24
   Posted 2/5/2011 4:03 PM (GMT -6)   
go to a first rate cancer center, in phila, its fox chase, in texas, its anderson, in ohio, its the cleveland clinic-------------------do not go to your local hospital unless its world class.  note that this is you, no replacements, you and your family deserve the best. w

TTaylor
Regular Member


Date Joined Nov 2010
Total Posts : 102
   Posted 2/5/2011 4:39 PM (GMT -6)   
My sincere thanks to all you great guys for your response. Kuls if you are not a Dr you may have missed your calling. What knowledge and to think I kept you from a glass of wine. Still have not healed from surgery and currently going through pain therapy so I still have time to hopefully make the right decision.
TTaylor
Age 67. Robotic prostatectomy 10/26/2010, due for RT in Janury 0f 2011. Eight of 12 lobes positive. Gleason Score 4+4=8, Margin envolvement was present with adipose tissue invasion and perineural invasion, glandular and stromal hyperplasia present,pT3 pNO and no evidence of metastatic adenocarcinoma. 1st psa after surgery Nov. 24, 2010 was .3
HT started Nov. 24, 2010.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3787
   Posted 2/5/2011 7:27 PM (GMT -6)   
Ask your R-doc to explain to you EXACTLY how radiation kills cancer cells but does not cause severe damage to healthy tissue..That is what R-docs are paid $500K a year to do...To make that happen...

kuls
Regular Member


Date Joined Mar 2010
Total Posts : 57
   Posted 2/5/2011 7:48 PM (GMT -6)   
For anyone who REALLY wants to learn the nitty gritty about radiation effects on tissue, and on the technical aspects of radiation therapy, you could curl up with some basic  Radiobiology, Radiation Physics, and Radiation Therapy textbooks!! confused    Pretty dry reading, but certainly educational!!
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