On June 8, David wrote:

A meteorite impact at Earth's surface also "happens."

I reckon the consequences of radiation burns (was he more specific?)
could be permanent in a worst-case situation.

In my case, and note that this is purely anecdotal, I had IMRT
(Intensity Modulated Radiation Therapy) 76 Gy to prostate, 50 to seminal
vesicles and 45 to regional lymph nodes. Tx ended October 2004. Had a
couple months of SEs including fecal urgency and urinary frequency,
annoying but bearable. Was already impotent due to preceding
cryosurgery, so cannot testify as to the effect of the IMRT on that.

I reckon the fecal urgency was due to the dreaded rad burns to rectum.
It, er, passed.

Is that tomotherapy, aka IGRT (Image-Guided Radiation Therapy)? I
referred a friend to a rad onc who performs tomotherapy, and he is
delighted with his results. Another friend I referred to that same rad
onc will begin the regimen on June 12. Hope he's satisfied, too, or I'll
have to fall on my sword :-(

What it amounts to is IMRT on steroids. IOW, it's more accurate IMRT.

Well, everyone is different, to cite a cliché. In my case, my IMRT was
accompanied by ADT which extended (with monthly PSAs of ~0.01 ng/mL) for
15 months and which I terminated as of March 21, 2006. This is IADT,
Intermittent Androgen Deprivation Therapy. Awaiting results......

The PCRI website has two-year-old information on tomotherapy at:
http://www.prostate-cancer.org/education/localdis/Chaiken_IMRT.html

Some of what is written there is:
"Currently, a tomotherapy solution to IMRT  includes a real time CT-like
image obtained  nearly synchronously with treatment. Results  from
helical tomotherapy have been reported  based on a CT scanner
modification to deliver  radiation therapy. The authors, Mackie from  
University of Wisconsin and Grigorov et al from  London Regional Cancer
Center, Canada, have  reported experience with this equipment. Since CT
verification is used for all fields with IMRT delivery, this is  an
example of image-guided  radiation therapy (IGRT) with near real-time
verification of  treatment delivery."

Further information can be gained by googling tomotherapy.

Regards,

Steve J

"We have not lost faith, but we have transferred it from God to the
medical profession."
-- George Bernard Shaw

Almost everthing developed in the last 20 year could be called minimum
burning.  My dad had cobalt radiation.  I had EBRT.  Now they are doing
wonderful things with controlling the size and location of the burn.

Dave,

I think there is a substantial survival benefit to RT after RP.
Obviously, so do your doctors.  All you can do is either take their
word for it or read the studies.

If it is tomotherapy he is referring to, see this page
http://www.tomotherapy.com/clinician/casestudies.htm.

We spent a lot of time yesterday in Phoenix with the Tomo doctors. The
system is just like those pictures, except they can pan through the
body and so different parts (prostate bed, bladder, whatever) come in
and out of view as you pan through different levels.  The doctor marks
the areas he wants, and prescribes a dose to each area.  He also marks
areas he does not want irridiated.  The dosimeterist creates the
treatment plan based on that.

IGRT accuracy is in millimeters.  IMRT accuracy is in centimeters.
This could make a big difference, say, if you want your rectum spared
as much as possible.  It is right there where they will be targeting.

They say the two in Texas are in San Antonio and Houston, so I guess
he's not talking about tomo.  Maybe he's talking about cyberknife.
Anyone know anything about it?  I think it is less advanced than tomo.
It uses the skeletal structure as the frame of reference, but tomo uses
the soft tissues, a ct scan immediately prior to the treatment, as the
frame of reference and to adjust so that the tissues get the dose as
prescribed.  Organs and soft tissues can move around in relation to the
skeleton.

Cancer Therapy and Research Center
7979 Wurzbach Road
San Antonio, TX 78229

The Methodist HospitalThe Methodist Hospital
6565 Fannin
Houston, TX 77030
713-790-3311

Cyberknife info from cksociety.org

    Dedicated to Clinical & Academic Exchange of Information

Prostate Cancer
Table of Contents
·     An overview of prostate cancer
·     What are the symptoms of prostate cancer?
·     How is prostate cancer diagnosed?
·     What are the treatment options for prostate cancer? What factors
influence treatment choice?
·     What is CyberKnife radiotherapy and how might it help prostate
cancer patients?
·     What is the patient process for CyberKnife® treatment of prostate
cancer?
·     What are the side effects of CyberKnife radiotherapy?
·     Can the Cyberknife be used to treat prostate cancer?

An overview of prostate cancer
According to the 2004 American Cancer Society report, approximately
230,000 cases of prostate cancer are diagnosed each year in the U.S.
and about 30,000 deaths result from the disease annually. Cancer of the
prostate is the second most common cause of cancer death among American
men after lung cancer. Although 1 in 6 men will develop prostate
cancer, only 1 in 32 will die from this disease.

There is no single direct cause of prostate cancer. However, there are
several known risk factors. These include: age, race (African American
men have a higher risk for unknown reasons), nationality (Asian men for
example have a lower risk), diet (red meat and dairy products have been
implicated), lack of exercise, and family history of prostate cancer.
Several studies have suggested that some dietary supplements such as
vitamin E and Lycopene can perhaps reduce the chance of developing
prostate cancer.

Over the past decade, better understanding of the complex biology of
prostate cancer has led to an earlier diagnosis, and advances in
technology have resulted in improvements in treatments such as
radiotherapy. While many areas within the field of prostate cancer
remain controversial and several questions are still unanswered,
standard therapies such as surgery or radiation therapy for localized
disease are the benchmark against which all other novel treatment
modalities must be compared to. Patients who want further reading
should go to the American Cancer Society website at www.cancer.org.

The following is a brief overview of some of the important facts
relating to the diagnosis and therapeutic options for patients with
newly diagnosed localized prostate cancer.

What are the symptoms of prostate cancer?
For the most part, prostate cancer has no warning symptoms in its
earliest stages. Older men may experience urinary frequency, but this
is more likely due to enlargement of the prostate gland known as BPH
(benign prostatic hypertrophy) rather than prostate cancer. Pain or
bleeding is also not commonly associated with the early stages of
prostate cancer.

How is prostate cancer diagnosed?
Prostate cancer is commonly suspected if there is either an elevated
PSA (prostate specific antigen) level in the blood or an abnormal
finding, such as a nodule, on digital rectal exam (DRE). However, the
diagnosis of prostate cancer can only be confirmed by a positive
biopsy.

Prostate biopsies are typically performed by a urologist on an
outpatient basis. During this procedure a trans-rectal ultrasound probe
is used to guide a needle gun that removes several small tissue samples
from different regions of the prostate gland. In the typical patient 10
to 12 samples are taken.

Based upon microscopic examination of the biopsy samples, the
pathologist assigns a tumor grade using the Gleason scoring system. The
Gleason score provides a measure of the potential aggressiveness of the
tumor which is an index of how fast the tumor is likely to grow. The
Gleason score consists of two numbers, each one ranging between 1
(nearly normal) and 5 (most abnormal). The grades of the two most
common cell patterns in the cancer are added together to form the
Gleason 'sum' (e.g. 3+4 = Gleason sum of 7). The higher the Gleason sum
(which ranges from 2 to 10) the more aggressive the cancer. A Gleason
sum of 6 or lower is sometimes referred to as 'low grade', a sum of 7
referred to as 'intermediate grade', and a sum of 8 or higher referred
to as 'high grade'.

A Gleason sum of 6 or lower is sometimes referred to as 'low grade', a
sum of 7 referred to as 'intermediate grade', and a sum of 8 or higher
referred to as 'high grade'. In addition to the biopsy, other factors
that are used to assess or stage patients include the PSA level and the
DRE findings, which are assigned a T-stage.

In addition to the biopsy results, other factors are used to assess or
'stage' patients, such as PSA level and DRE findings. Together,
these findings are assigned a T-stage.

The T-stage is defined as follows:

   - T1c: the prostate gland feels normal on DRE (ie. no nodule) but
the PSA level is elevated

   - T2a, b or c: a nodule is felt on DRE (the letter a or b is given
if the nodule is on one side of the gland, c if it is felt on both
sides)

   - T3: there is suspicion of cancer spread outside of the prostate
capsule based upon DRE

Sometimes, additional diagnostic tests such as a bone scan, CT, or MRI
are performed depending on the physician's estimate of risk.

Risk Groups
Using all information available, the risk of extra-prostatic disease
(either by direct extension of cancer through the prostate 'capsule',
or by the spread of the cancer to skeleton or other organs) can be
estimated. Although in reality there is a continuous spectrum of risk,
assigning specific risk groups allows us to think more clearly about
the best medical management for an individual patient. A common
classification scheme used is as follows:

   * Low Risk: T1c or T2, PSA<10, Gleason sum of 6 or lower
   * Intermediate Risk: T1c or T2, PSA 10-20, Gleason sum of 7
   * High Risk: T3 or PSA>20 or Gleason sum of 8 or higher

What treatment options are available? What factors influence treatment
choice?
The treatment options available to patients with prostate cancer depend
upon their risk group. The principal options include: surgery, external
beam radiation, and brachytherapy (alone or in combination with
external beam radiotherapy). What follows is a very brief outline of
these individual options.

Surgery
Surgery, otherwise known as radical retropubic prostatectomy, refers to
the surgical removal of the entire prostate gland and possible sampling
of nearby lymph nodes. This operation typically lasts 3 to 4 hours,
requires general anesthesia, and a 3-day hospital stay. Recovery at
home usually lasts several weeks, the first two weeks of which a Foley
catheter (inserted through the urethra into the bladder) is used.
Potential long-term side-effects include a low risk of urinary
incontinence and erectile dysfunction.

External beam radiotherapy
External beam radiotherapy consists of daily doses of radiation given
on an outpatient basis for a total of 7-8 weeks. Each daily dose lasts
about 15 minutes. Modern external beam radiotherapy is usually referred
to as 3-dimensional (3D) conformal or intensity-modulated radiotherapy
(IMRT). IMRT utilizes beam-shaping to dynamically reshape the outlines
and intensity of the radiation field, thereby allowing the dose of
radiation to be sculpted (conformed) to a target much better than with
conventional radiation techniques. By limiting irradiation of normal
tissues, injury to these structures is lessened and it becomes possible
to increase (escalate) the dose of radiation administered to a tumor.
Potential side-effects include the temporary symptoms of rectal and
urinary irritation, and long-term erectile dysfunction.

Brachytherapy
Brachytherapy (permanent seeds) consists of a closed procedure under
general or spinal anesthesia whereby radioactive seeds are placed
within the prostate gland. Long needles are inserted through the area
of skin between the legs into the prostate under the guidance of a
trans-rectal ultrasound. A temporary Foley catheter is rarely needed.
Patients are usually discharged home on the same day. Potential
side-effects include symptoms of urinary irritation which can last for
6 months, and long-term erectile dysfunction.

It is important to realize that there are currently no randomized
trials comparing one treatment option to any other, and therefore there
is no conclusive data favoring any specific therapy. However, based
upon a multitude of retrospective published series, all of the
treatment options are currently thought to be equivalent in terms of
cure rates. These treatments differ primarily in terms of their
technical nature and potential side effects. Patients who are eligible
for all of these options have an important personal decision to make
with the help of their physicians.

Based upon the patient's risk group, there are some generally accepted
recommendations regarding optimal treatment for a given situation. The
following provide only general guidelines - a full recommendation
depends on many more factors and can only be made in conjunction with a
physician.

   * For Low Risk patients, all treatment options are available (ie.
surgery, external beam radiation, or brachytherapy).
   * For Intermediate Risk patients, the only difference from what was
described above is the possible addition of 4 months of hormone therapy
prior to and throughout radiotherapy. Brachytherapy is also less likely
to be recommended to such patients.
   * For High Risk patients surgery is generally not an option.
Hormone therapy is added to external beam radiation therapy, including
a prolonged course after irradiation. Moreover, in such patients the
fields of radiation are expanded to include the pelvic lymph nodes.
Brachytherapy is not recommended.

What is CyberKnife radiotherapy and how might it help prostate cancer
patients?
The CyberKnife belongs to a new class of radiotherapy techniques called
IGRT (image-guided radiotherapy). The CyberKnife is unique in that it
uses a compact linear accelerator (LINAC) mounted on an image-guided
robotic arm to deliver multiple beams of high energy x-rays to a
target. (For more information on the CyberKnife, see CyberKnife
Overview). The ability of the CyberKnife to shape the profile of
radiation to conform to the patient's individual anatomy allows for
maximum sparing of surrounding normal tissues. The CyberKnife
accomplishes this by accurately cross-firing approximately 150 beams of
radiation at the target from multiple directions.
CyberKnife cross firing beams

The CyberKnife technology represents an improvement upon the most
advanced conventional radiation therapy techniques, Intensity Modulated
Radiotherapy (IMRT). Similar to IMRT, the CyberKnife can produce a
highly conformal dose distribution which 'matches' the shape of the
prostate and spares adjacent normal anatomy (bladder and rectum).
CyberKnife Scan     IMRT Scan

However, the CyberKnife differs from IMRT significantly in that it is
much more spatially precise in delivering radiation. Because of such
accuracy the CyberKnife enables a course of radiotherapy to be
'hypofractionated'.

Hypofractionation
Hypofractionation refers to a course of radiation during which the
number of treatments is reduced while simultaneously increasingly the
size of the daily dose. A conventional course of external beam
radiotherapy for the prostate consists of 37 daily treatments, each of
200 cGy (a cGy is a measure of radiation dose) delivered over a period
of two months. This regimen is standard and is used for nearly all
cancers. It is based upon the fact that normal tissues are more
sensitive to the size of the daily dose than are tumor cells. Thus, in
order to minimize damage to normal tissues, the size of the daily dose
is chosen to be small. This is true of all tumors with the exception of
prostate cancer where the situation is reversed: prostate tumor cells
are more sensitive to the size of the daily dose relative to normal
tissues. This unique biologic response to radiation for prostate cancer
has only recently been understood and has led to the conclusion that
hypofractionated radiotherapy would be a more effective way to deliver
radiation. Indeed, using a hypofractionated course of radiation (with
daily doses of around 500 to 700 cGy) would: a) yield higher cure
rates, b) produce fewer acute side effects, and c) keep the late side
effects at the same level as conventional radiotherapy regimens.

What are the side effects of CyberKnife radiotherapy?
The potential side effects of CyberKnife radiosurgery for prostate
cancer are similar to those experienced with standard courses of
radiation therapy using conventional techniques. However, because one
can minimize the physical margins of radiation to the target (ie.
prostate) with the CyberKnife and thus spare more adjacent healthy
tissue, the occurrence and severity of side effects from CyberKnife
radiotherapy should be reduced compared to conventional radiation
techniques.

What are the side effects of conventional radiation therapy for
prostate cancer?
The symptoms following conventional prostate radiation treatment are
classified into early and late side effects.

  1. Early (acute) side effects are those experienced during the first
few months after treatment. They include: urinary urgency and
frequency, nighttime urination, mild burning with urination, rectal
urgency, increased frequency of bowel movements, or irritation of
hemorrhoids. These are usually temporary and resolve gradually once
treatment is completed.
  2. Late side effects are those that may persist for months or may
even be permanent. These include erectile dysfunction.

What is the patient process for CyberKnife treatment of prostate
cancer?

After an initial physician consultation, the following steps would
ensue:

  1. Placement of fiducials
  2. CT scan of the abdomen and pelvis about one week later
  3. CyberKnife treatment beginning about one week after the CT scan

Fiducial placement
Three tiny gold seeds, also known as fiducials Fiducialsare placed in
the prostate gland during an outpatient procedure by the urologist
using trans-rectal ultrasound. These fiducials are readily visible with
a pelvic x-rays. The CyberKnife's image-guidance system uses these gold
seeds to precisely localize and track the spatial position of the
prostate at the start of and throughout each daily radiation treatment.
Once implanted, these seeds will remain in the prostate permanently.

The procedure to place fiducials is very well tolerated and similar to
a prostate biopsy. In fact, patients typically report less discomfort
with placement of these seeds than with the biopsy procedure itself. An
x-ray of the pelvis in a patient who has had these gold seeds placed
within the prostate is shown below from both a left and right
perspective.
Plevis Left     Pelvis Right

CT Scan
Following placement of the fiducials, the patient will return about one
week later. A custom body mold (called an 'alpha cradle') is fitted
to each patient so as to minimize movement during CyberKnife treatment.
While lying in the body mold, a patient will next undergo a CT scan.
The CT information is then downloaded to the CyberKnife computer where
it is used by physicians and medical physicists to develop a customized
treatment plan based on the patient's specific anatomy. The treatment
plan establishes the number, intensity, and direction of radiation
beams the CyberKnife will administer to the prostate gland.

CyberKnife Treatment
Once treatment planning is completed, the patient is scheduled to
return for 5-8 daily CyberKnife treatments. Each day the patient lies
comfortably on the treatment table in the body mold while the
CyberKnife delivers the appropriate dose of radiation. After each daily
treatment which lasts around 30-40 minutes, the patient returns home.

Can the Cyberknife be used to treat prostate cancer?
Yes. At a meeting of Cyberknife users, there was general agreement that
use of the Cyberknife to provide a boost before or after conventional
radiation therapy was not experimental and should be made available by
those centers having the interest and expertise to perform that type of
treatment.

Use of Cyberknife as sole treatment for prostate cancer holds great
promise because of the peculiar nature of prostate cancer and the
non-invasive nature of Cyberknife treatment. However, such treatment at
the present time is early in its development. Institutionally approved
studies are available at several centers. Stanford has been treating on
their protocol for about 15 months. St. Anthony Hospital in Oklahoma
City has written a protocol and have begun patient treatments. Naples
(FL) has a similar protocol and is treating patients. Others centers
may be adopting this approach. Early experience is very promising.

Has anyone else heard of this minimal burning? Or know how much the rad
actually helps?
Thanks
David

=====
hi david - you might want to look at proton beam radiation.  it is the
only one that fires a proton into the body and they can control the
depth of the beam into the body.  this might be able to a better job of
controlling damage of the colon.

you will have to look up where the proton beam units are located in the
country in order to get treatment.

hope this helps,

~ curtis

knowledge is power - growing old is mandatory - growing wise is optional    
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
http://community.webtv.net/PALMER_ENT/doc

I believe that you will find that Dr. Bradley Prestidge in San Antonio and
Dr. Brian Butler in Houston. Both were in Air Force together at Radiation
Oncologists and are best friends. Prestidge speciality is Brachy and
Butler's is IMRT. In fact he helped to develop the Peacock. Uses a water
filled rectal balloon to minimize burn.

I was treated by both and have no problems.

Good luck.

This was one of the reasons my rad onc advised surgery rather than rad
for my initial tx. Guess I'll have fewer choices next go-round.

I.P.