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Medical Forum / Diseases and Disorders / Prostate Cancer / January 2007Good news on post treatment PSA
In October, my PSA was 13.8. I had 110 iodine seeds implanted on 10/23 and then 35 IMRT's from 11/13 through 1/3 using the AccuLoc system. I went in today for my first post treatment PSA test. This is exactly 3 months after seeding. The doctor told me the PSA should drop in half. I was hoping it would go below 10, maybe down to 6 or 7. He just called me with the results. 3.3!!!!! My doctor is a real artist. He has done over 2300 seedings. I have had zero sexual problems, zero rectal problems and only minor urinary urgency. In fact, I have a bottle of Flomax but I haven't had to take the first one. I couldn't be any happier. John > In October, my PSA was 13.8. I had 110 iodine seeds implanted on 10/23 > and then 35 IMRT's from 11/13 through 1/3 using the AccuLoc system. [quoted text clipped - 8 lines] > urgency. In fact, I have a bottle of Flomax but I haven't had to take > the first one. I couldn't be any happier. Well SCREW YOU, John!!! Oh, wait a minute . . . your success didn't come at my expense; you can't give me back my potence and continence. Well, heck . . . never mind the screw you, and Good On Ya! Turn a few back flips, give your wife a few gasps, take a few relaxed leaks, and enjoy poopy time, all for the rest of us, you lucky dog. I.P. Great news John. I personally believe that radiation is no different from surgery in the need to have a really experienced, competent practitioner. Sounds like you got one. Alan > In October, my PSA was 13.8. I had 110 iodine seeds implanted on 10/23 > and then 35 IMRT's from 11/13 through 1/3 using the AccuLoc system. [quoted text clipped - 3 lines] > was hoping it would go below 10, maybe down to 6 or 7. He just called > me with the results. 3.3!!!!! That's terrific. I don't know what the AccuLoc is but I'm guessing it's that image tracking IMRT. -kh > I don't know what the AccuLoc is but I'm guessing it's that image > tracking IMRT. Exactly. It uses three gold seeds that can be seen using the IMRT head taking port shots. The coordinates are keyed into a computer and the bed moves in three dimensions to insure the beam will hit the exact location the same way for every fraction. They claim sub-millimeter accuracy. Q. What is ACCULOC? A. ACCULOC is a system that includes both hardware and software to provide high precision localization based on three tiny implanted gold markers for an internal reference system. Q. Why can't we continue using skin marks, lasers? A. External markers such as lasers, stereotactic frames and body boxes, and bony anatomy do not indicate the precise location of the internal organ to be treated - only the relative location of the organ. External markers, thus, do not tolerate organ motion. Since ACCULOC uses the treatment beam for alignment, the localization is accurate EVERY TIME! Q. What is the accuracy of ACCULOC? A. Independently verified to be accurate to sub-millimeter precision (0.8mm along sagittal, 0.6mm along axial, and 0.3mm along coronal). Q. Is the accuracy of localization user dependent? A. Since the gold markers are clearly visualizable on standard port films as well as electronic portal imaging devices (EPID), the accuracy of localization by ACCULOC is not user dependent. Q. After acquiring the images of the implanted markers, how do we move the target into position? A. The ISOLOC software outputs both the relative and final couch location information, making quick and exact setup simple and easy to perform. For more info: http://www.nmpe.com/acculoc.aspx John >> I don't know what the AccuLoc is but I'm guessing it's that image >> tracking IMRT. [quoted text clipped - 4 lines] > location the same way for every fraction. They claim sub-millimeter > accuracy. How, and how accurately, do they place the gold markers? I.P. >>> I don't know what the AccuLoc is but I'm guessing it's that image >>> tracking IMRT. [quoted text clipped - 6 lines] > >How, and how accurately, do they place the gold markers? Presumably if the 3 markers are fairly widely separated within the prostate and a 3D prostate map is then generated - after insertion - round those markers, the initial positioning should be non-critical? On Jan 24, 12:01 pm, "I.P. Freely" <fuhgheddabou...@noway.nohow> wrote: >How, and how accurately, do they place the gold markers? I.P. The gold seeds are implanted along with the other 110 iodine seeds during the implant surgery. My doc showed me the gold seeds on the CT scan a week after surgery. They light up like a beacon compared to the other seeds. I read where they can be implanted in a similar way to the way a biopsy needle is used. I guess this is for those who are having EBRT only, without the brachytherapy. >> How, and how accurately, do they place the gold markers? > The gold seeds are implanted along with the other 110 iodine seeds > during the implant surgery. My doc showed me the gold seeds on the CT [quoted text clipped - 4 lines] > needle is used. I guess this is for those who are having EBRT only, > without the brachytherapy. That still leaves me wondering what good sub-millimeter *detection* accuracy is, particularly for RT, if "placement" is achieved by a guy using an ultrasound wand to stick pellets in moving, flexible, meat. There's still something basic I'm not following. I.P. >That still leaves me wondering what good sub-millimeter *detection* > accuracy is, particularly for RT, if "placement" is achieved by a guy > using an ultrasound wand to stick pellets in moving, flexible, meat. > There's still something basic I'm not following. My doc said sub-millimeter is not that important for the prostate. It is important for other treatments like a brain tumor. For the prostate, they are just trying to compensate for the normal movement of the prostate within the prostate bed. If you go to http://www.nmpe.com/acculoc.aspx, you can see a diagram captioned: "CT studies performed one week apart clearly illustrate a prostate shift with respect to setup marks. Prostate displacement is 15 mm, 5 mm, and 3 mm, respectively, in the AP, SI, and RL axes." By compensating for these shifts, the IMRT dose can be increased and they don't worry about an overdose to the urethra and the rectum. As you said, the prostate is flexible, so they want you to arrive everyday at the same time in the same condition, ie empty bladder, empty rectum. That way you put minimal pressure on the gland and cause minimal distortion. John > "CT studies performed one week apart clearly illustrate a prostate > shift with respect to setup marks. Prostate displacement is 15 mm, 5 > mm, and 3 mm, respectively, in the AP, SI, and RL axes." And to think the rectum is just 2mm from the prostate. Spooky. I.P. Actually, the better of the diagrams are here: http://www.nmpe.com/extra2.htm Interesting stuff indeed in theory. I was a sub-millimeter in choosing this myself, although the IMRT version in 2004. I opted for robotic surgery for a true pathology of the disease with negative margins and organ confined confirmation along with real Gleason numbers. But that's just me. B.A. > That still leaves me wondering what good sub-millimeter *detection* > accuracy is, particularly for RT, if "placement" is achieved by a guy > using an ultrasound wand to stick pellets in moving, flexible, meat. > There's still something basic I'm not following. I'm sure it's the sequence of events. First they implant the three gold targets using an ultrasound for aiming. Close enough here is good enough. Second, they take either an MRI or a CAT-scan an image the prostate in relation to the gold targets. Third step is to digitize the prostate's co-ordinates relative to the gold targets. This is probably done by hand and I'd guess takes an hour offline. Fourth, download these co-ordinates to the radiation planning software and generate the treatment plan. Fifth, treatment, each day, put the patient on the platform. Use an X-ray to locate the three targets and align the platform to the linear accelerator's beam head. Software sees the targets. Sixth, having acquired the targets and loaded the treatment protocol from the database, energize the linear accelerator, manipulate the lead shutters to outline the prostate. Move the beamhead to orbit the patient. This is all done with software. In a 270 (?) degree orbiting beampath, only a tiny, tiny, tiny percentage of the 70-odd Grays will "spill" to adjacent tissue. During the treatment (possibly, I didn't see that in the text), software checks and rechecks the alignment, manipulating the shutters, and moving the platform to maintain alignment. Probably not that much of an improvement for the prostate, which is a relatively large, non-critical, target. Think about treating cancer near the spinal cord or in brain. When I heard about it, I picked up a pencil, laid it across my finger, and rotated the pencil to orbit my finger. They can peel cancer off a body part with this thing. Sub-millimeter alignment? Not much damage to adjacent organs. As a software engineer, I see amazing possibilities. As the doc at INOVA said, "This toy of ours has lots of tricks in it." He was smiling. -kh >> That still leaves me wondering what good sub-millimeter *detection* >> accuracy is, particularly for RT, if "placement" is achieved by a guy [quoted text clipped - 12 lines] > gold targets. This is probably done by hand and I'd guess takes an > hour offline. Gotcha; NOW it makes sense. Measure with a rubber band, slap the fiduciary gold beads in the right vicinity, measure *their* relation to the prostate with a laser, at which point nothing else matters as long as the beads dance with the meat. Cool! I.P. >.Gotcha; NOW it makes sense. Measure with a rubber band, slap the > fiduciary gold beads in the right vicinity, measure *their* relation to > the prostate with a laser, at which point nothing else matters as long > as the beads dance with the meat. Cool! I think (not sure here, I found a video about the Trilogy in December) that they do the prostate to gold beads measurement/location with "something like" a Photoshop software ruler. I don't think this is THAT much of an advance for prostate cancer treatment. The improvement is probably down in the few percent, but hey, if it moves the odds a little, that's worth it. That is, until they get more data. This thing is a researcher's dream. If you can avoid hitting the colon, what happens if you crank up the dose? Could you improve the treatment success? Or, the converse. If the beam is that much better controlled, maybe you'll miss cancer that has escaped the capsule but is still in the bed. I've imagined that a failing of surgery was that it was too precise. In some small percentage of cases, perhaps micro-tendrals extend a few mm beyond the capsule. IMRT mops these up. Surgery doesn't. No way to know. This is a gamble. We take our chances and hope for the best. -kh seize every opportunity, especially if it's blond and giggles. > If you can avoid hitting the colon, what happens if you crank up the > dose? Could you improve the treatment success? [quoted text clipped - 6 lines] > In some small percentage of cases, perhaps micro-tendrals extend a few > mm beyond the capsule. IMRT mops these up. Surgery doesn't. The way I understand it, the two areas they want to avoid are the urethra and the rectum. Judging from the plots I've seen, they do radiate most of the prostate bed outside the prostate. They plan the dose like a donut shape with the urethra going through the donut hole. If they can hit the entire area pretty hard and spare the urethra and the rectum, they can get the cancer with minimum side effects. The problem with the older method of using tattoos on the body for daily alignment was the internal shift of the prostate. Now, that is no longer an issue. John > ... > If you can avoid hitting the colon, what happens if you crank up the > dose? Could you improve the treatment success? I've seen some literature indicating that the IMRT, and presumably the IGRT, practitioners have in fact cranked up the dose and have increased treatment success as compared with earlier 3DCRT - which used higher doses than the earlier 2D technique. This dose escalation is said to be the primary reason why outcomes of radiation have improved in recent years. > Or, the converse. If the beam is that much better controlled, maybe > you'll miss cancer that has escaped the capsule but is still in the [quoted text clipped - 3 lines] > In some small percentage of cases, perhaps micro-tendrals extend a few > mm beyond the capsule. IMRT mops these up. Surgery doesn't. This is one of the arguments for radiation. The Sloan Kettering prostate nomograms show a slightly higher success rate for radiation than for surgery as PSA and Gleason go up. I don't know if they're right or wrong, but you aren't alone in thinking this is an advantage. There are also nomograms that predict the likelihood of extra- prostatic extensions based on PSA and Gleason score. The likelihood goes up significantly with higher risk disease. It is my understanding that, as you speculate, these extensions are in fact often in the first 4 millimeters around the prostate. Unfortunately, I can't remember my source for that. However I'm not sure that surgeons can't get these extensions too. I don't know if surgeons can see them or not. I presume that, if they can, they can cut them out. Maybe someone knows more about this and can tell us. On the other hand, I'm sure the surgeons could not see very small or microscopic extensions or islands of cancer cells. But the radio beams would get them. > No way to know. This is a gamble. We take our chances and hope for > the best. > > -kh seize every opportunity, especially if it's blond and giggles. Alan John...How many port shots are taken over all fractions and what is the additional radiation dose from each shot? I've always wondered about this, having gone through it perhaps you know the answer...Best wishes and good health, ron > John...How many port shots are taken over all fractions and what is the > additional radiation dose from each shot? I've always wondered about > this, having gone through it perhaps you know the answer...Best wishes > and good health, ron Ron, They take one shot over the belly and another from the side. From these, they can triagulate the position of the prostate and move the bed accordingly. They said the radiation dose is less than a dental xray. They can do a very small dose because the gold seeds don't need much radiation to be visible. After they adjust the bed, they take one more shot to make sure they are "spot on". On a couple of occasions they repeated the process. I guess they just wanted to fine tune the position. The staff was extremely meticulous. John >> I don't know what the AccuLoc is but I'm guessing it's that image >> tracking IMRT. [quoted text clipped - 36 lines] > >John John - excellent news on your superb result. From what I've very roughly gathered from your description of ACCULOC - it's ingenious. (funny, putting that in caps makes me feel like i'm bolstering an advertising campaign... the only thing missing is 'TM') Great News John! > In October, my PSA was 13.8. I had 110 iodine seeds implanted on 10/23 > and then 35 IMRT's from 11/13 through 1/3 using the AccuLoc system. [quoted text clipped - 5 lines] > > John Congratulations, John! And that AccuLoc system sounds pretty neat; makes me feel better about discussing radiation with folks who ask for my advice about treatment options. --charlie |
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