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Prostate Markers For Radiation Therapy

Stereotactic Body Radiation Therapy

Prostate Cancer Radiation Fiducial Marker and SpaceOAR Gel Procedure ABS Virtual Reality (360 VR)

This technique uses advanced image guided techniques to deliver large doses of radiation to a precise area, such as the prostate. Because there are large doses of radiation in each dose, the entire course of treatment is given over just a few days.

SBRT is often known by the names of the machines that deliver the radiation, such as Gamma Knife, X-Knife, CyberKnife, and Clinac.

The main advantage of SBRT over IMRT is that the treatment takes less time . The side effects, though, are not better. In fact, some research has shown that some side effects might actually be worse with SBRT than with IMRT.

Heres What You Should Know About This Treatment Option

Men who get diagnosed with prostate cancer have several options to choose from for their next step. Many men with slow-growing, low-risk cancer follow active surveillance, a wait-and-see approach that monitors the cancer for changes.

But if the cancer shows higher risk or has already begun to spread, other treatments are recommended. There are two options: surgery to remove the prostate or radiation to destroy the cancer cells.

Studies comparing these two approaches demonstrate no advantage of one over the other with respect to cancer control. Your path will depend on factors like your current health, the specifics of your cancer, and personal preference. Yet for many men, radiation can be the better option.

“Its much more precise than the traditional radiation used for other kinds of cancer, and research also has found that long-term quality of life is often better, with fewer adverse health effects compared to surgery,” says Dr. Anthony DAmico, a radiation oncologist with Harvard-affiliated Dana-Farber Cancer Institute and Brigham and Womens Hospital.

There are two main ways to deliver radiation to the prostate: external beam radiation and brachytherapy.

What Will I Experience During And After The Procedure

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line and when the local anesthetic is injected. Most of the sensation is at the skin incision site when it is anesthetized using local anesthetic.

You may feel some pressure when the pre-loaded needle is inserted, and the area of the needle insertion may possibly feel sore for a few days. If you have significant pain, your doctor may prescribe pain relief medication.

Aftercare instructions vary. However, you generally may remove your bandage one day after the procedure, and you may bathe or shower as normal.

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About Fiducial Markers And Rectal Spacers

Fiducial markers are tiny metal objects . They help your healthcare providers line up the beams of radiation and make sure your radiation therapy is delivered exactly the same way each time. This helps them target the tumor and avoid your nearby healthy tissue. The fiducial markers will stay in your prostate after your treatment.

Youll get a rectal spacer called SpaceOAR hydrogel. It is a gel thats placed between your prostate and rectum to move your rectum away from your prostate. This protects your rectum from radiation and reduces some side effects of radiation therapy. The rectal spacer will stay in place for 3 months. Then, itll be absorbed by your body and come out in your urine.

  • Work in a hospital or nursing home.

Possible Side Effects Of Ebrt

Fiducial Marker Implantation in Prostate Radiation Therapy

Some of the side effects from EBRT are the same as those from surgery, while others are different.

Bowel problems: Radiation can irritate the rectum and cause a condition called radiation proctitis. This can lead to diarrhea, sometimes with blood in the stool, and rectal leakage. Most of these problems go away over time, but in rare cases normal bowel function does not return. To help lessen bowel problems, you may be told to follow a special diet during radiation therapy to help limit bowel movement during treatment. Sometimes a balloon-like device or gel is put between the rectum and the prostate before treatment to act like a spacer to lessen the amount of radiation that reaches the rectum.

Urinary problems: Radiation can irritate the bladder and lead to a condition called radiation cystitis. You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Urinary problems usually improve over time, but in some men they never go away.

Some men develop urinary incontinence after treatment, which means they cant control their urine or have leakage or dribbling. As described in the surgery section, there are different levels and types of incontinence. Overall, this side effect occurs less often with radiation therapy than after surgery. The risk is low at first, but it goes up each year for several years after treatment.

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Vitamins And Dietary Supplements

Many people ask about taking vitamins during treatment. You may take a daily multivitamin, if you wish. Dont take more than the recommended daily allowance of any vitamin. Dont take any other vitamins or any supplements without talking to your doctor. This includes both nutritional and herbal supplements.

Fiducial Markers For Radiation Therapy

Fiducial markers are small metal objects about the size of a grain of rice. Your radiation therapist uses them to find the tumor and treatment area when setting you up for treatment. This makes sure the radiation is delivered to the tumor instead of the nearby healthy tissue. Fiducial markers may be helpful for lining up these parts of your body:

  • Lung or chest wall.
  • Liver, gallbladder, kidney, or pancreas.

The fiducial markers are placed into the soft tissue. They are placed several days before you start your radiation therapy. They will stay in the soft tissue forever. Fiducial markers are used along with your tattoos to get you in the best position possible for treatment.

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How Should You Prepare For Fiducial Marker Placement

When prepping to have your fiducial markers placed you will be asked to do a few things. They may include:

  • Stopping certain medications. Examples: Aspirin, ibuprofen, steroids, vitamin E, or blood thinners. Make sure your provider is aware of all medications and supplements you are taking.
  • Doing an enema to clean out your bowels the morning of your procedure.
  • On the day of your procedure, you may need to take an antibiotic to prevent infection.
  • You can usually eat and drink like normal on the day of your procedure.

The prep needed depends on where your fiducials markers are being placed. Your provider will talk to you about the specific prep you need to do.

What Happens After Radiotherapy

What to Expect Before Starting Radiation Treatment for Prostate Cancer

After youve finished your radiotherapy, you will have regular check-ups to monitor your progress. This is often called follow-up. The aim is to:

  • check how your cancer has responded to treatment
  • help you deal with any side effects of treatment
  • give you a chance to raise any concerns or ask any questions.

Your follow-up appointments will usually start two or three months after treatment. You will then have appointments every three to six months. After three years, you may have

follow-up appointments less often. Each hospital will do things slightly differently, so ask your doctor or nurse for more details about how often you will have follow-up appointments.

PSA test

The PSA test is a blood test that measures the amount of a protein called prostate specific antigen in your blood. You will usually have a PSA test a week or two before each follow-up appointment, so the results are available at your check-up. This can often be done at your GP surgery. PSA tests are a very effective way of checking how well your treatment has worked.

After treatment, your PSA level should start to drop. Your PSA level wont fall to zero as your healthy prostate cells will continue to produce some PSA. But it could fall to about 1 ng/ml, although every man is different and your medical team will monitor your PSA level closely.

Treatment options after radiotherapy

Looking after yourself after radiotherapy

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What Is Fiducial Marker Placement

Fiducial marker placement is an image-guided procedure often performed by an interventional radiologist in preparation for certain types of radiation therapy, such as stereotactic radiosurgery and stereotactic body radiotherapy , or proton therapy.

Fiducial markers are small metal spheres, coils or cylinders about the size of a grain of rice that are placed in or near a tumor to help guide the placement of radiation beams during treatment.

Prostate Fiducial Marker Placement In Patients On Anticoagulation: Feasibility Prior To Prostate Sbrt

  • 1Department of Radiation Oncology, NYU Winthrop Hospital, Mineola, NY, United States
  • 2Stony Brook University School of Medicine, Stony Brook, NY, United States
  • 3Department of Urology, NYU Winthrop Hospital, Mineola, NY, United States

Background and Purpose: Fiducial marker placement is required in patients undergoing robotic-based Stereotactic Body Radiotherapy or image-guided radiation therapy for prostate cancer. Many patients take antiplatelet or anticoagulant medication due to other medical comorbidities. They are often required to temporarily discontinue these medications prior to invasive medical procedures as they are prone to bleed. Some patients are unable to discontinue therapy due to an elevated risk of thromboembolic events. The purpose of this study is to report this institution’s experience placing fiducial markers in prostate cancer patients who are on chronic antiplatelet or anticoagulant medication.

Results: All 57 patients on antiplatelet or anticoagulant medication who underwent fiducial marker placement were discharged home the same day of the procedure. Four patients experienced persistent bleeding that required a nurse to hold prolonged pressure to the area. No patient experienced significant bleeding the following day or any untoward cardiovascular event.

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What Are The Benefits Vs Risks

  • The use of fiducial markers helps pinpoint the location of a tumor with greater accuracy, enabling a treatment team to deliver the maximum dosage of radiation to the tumor while minimizing the dose delivered to nearby healthy tissue.
  • Fiducial markers may move away from where they were originally implanted. There must be sufficient time between the implantation of markers and treatment in order for the markers to stabilize.
  • Fiducial markers placed in the lung may result in a complication called pneumothorax or collapsed lung, in which air becomes trapped in the space between the lung and the chest wall. This condition may require the insertion of a chest tube to remove the air pocket and re-expand the lung.
  • Any procedure that penetrates the skin carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.

Number And Types Of Fiducial Markers

UroLift as a surrogate for fiducial markers in IGRT planning of ...

FMs exist in a variety of shapes, sizes and materials and are commercially available from a variety of vendors. Gold markers are by far most frequently used for prostate IGRT. This is due to the fact that they are widely available and are visible using MV or kV image guidance. The basic specification for an FM includes radio-opacity for a given imaging modality , that they are readily available and that they are not prohibitively expensive.

This review elicited only one study specifically comparing types of markers. Fonteyne et al35 investigated five different gold FMs. They observed a better correlation between automatic CBCT image-matching results and manual match results for the largest FM, which was 20mm×0.75mm, than for smaller FMs, suggesting that larger markers may result in more consistent setup data when comparing automatic and manual alignment. However, they also state the largest FM resulted in increased image artefact. Artefact created by FMs on CT and CBCT is one of the main disadvantages of using gold or entirely metallic markers and may add to the degree of uncertainty associated with contouring and matching the prostate36 and may also result in inaccurate treatment planning.37 One study suggests that platinum is superior to gold in terms of its visibility on MRI and therefore preferable as an aid for CT/MRI registration.38 This would have the disadvantage of being more expensive than gold.

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What Are The Limitations Of Fiducial Markers

Fiducial markers are inert elements that typically do not react with the body or result in any imaging artifacts. They typically do not set off airport scanners. There is a small risk that fiducial markers may be misplaced during placement or may migrate to other areas potentially causing adverse events. This risk is very rare.

Before Your Marker Placement

  • Tell your doctor if you take any medications to thin your blood. We have listed some below, but there are others.
  • Nonsteroidal anti-inflammatory drugs such as:

If you take aspirin because youve had a problem with your heart or youve had a stroke, be sure to talk with your doctor before you stop taking it. For more information, review the resource Common Medications Containing Aspirin, Other Nonsteroidal Anti-inflammatory Drugs , or Vitamin E. It includes important information about medications youll need to avoid before your procedure and what medications you can take instead.

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Quantitative Evaluation Of Fms Visibility And Associated Artefacts

For volumetric X-ray scans , a region of interest for each marker was defined as the box containing 3 FM with 3mm isotropic inner margin . Air bubbles were also removed from this ROI. Using high resolution segments, the FMs in each box were contoured using the Eclipse treatment planning system using the automatic thresholding tool. The maximum HU threshold defining the FM was set as the highest HU value inside box ROI. The minimum value for the threshold was determined in Eclipse by manually adjusting the window level to view the FM only. This way an approximate low threshold value was obtained for each marker. Contouring was performed on CT scans with 0.625mm slice thickness and then transferred to other datasets with different slice thicknesses .

To quantitatively evaluate the visibility of the FM, the contrast-to-noise ratio was also calculated . For each FM, the mean HU and standard deviation were compared to background and standard deviation . The background HU values were determined from the two boxes with gel only . CNR for each FM was then calculated using the equation:

The higher the CNR the more visible the object .

To quantify the severity of streak artefact, firstly an artefact volume was defined for each FM by subtracting the FM structure from the box ROI and this artefact volume was then used in the analysis. Similar to the analysis by Huang et al. , streak artefact index was calculated for each ROI. The SI is defined as

Frequent Urination Burning With Urination And Difficulty Urinating

Radiation therapy for prostate cancer: What to expect

These are the most common complaints. Occasionally the urinary stream will weaken. Generally these symptoms are managed with medications to help the bladder function better or eliminate burning. Rarely, your doctor may order a urine test. Symptoms will resolve after the end of treatment. Contact your doctor if you see blood in your urine or if you are unable to urinate.

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Questions To Ask Your Radiation Oncologist

Before your appointment, its helpful to write down the questions you want to ask your radiation therapy care team. Examples of questions you can ask are listed below. Write down the answers during your appointment so you can review them later.

What kind of radiation therapy will I get?

How many radiation treatments will I get?

What side effects should I expect during my radiation therapy?

Will these side effects go away after I finish my radiation therapy?

What kind of late side effects should I expect after my radiation therapy?

Diarrhea Flatulence Or Painful Defecation

These symptoms usually occur after the second or third week of treatment. Symptoms will resolve after the treatment ends. During radiation, dietary modification usually helps reduce the frequency and severity of diarrhea. Try to avoid or reduce fried foods, greasy foods and highly spiced foods. Reduce foods with insoluble fiber, such as lettuce and cauliflower, and increase low-fiber and soluable-fiber foods, such as bananas, mashed potatoes, applesauce, white rice, canned or cooked fruits and vegetables.

Maintain your intake of lean proteins, such as turkey, chicken and fish, and increase your fluid intake to avoid dehydration. Using moist toilet paper, baby wipes or sitz baths may help relieve rectal irritation. Your doctor may recommend anti-diarrheal medications. Contact your doctor if you see blood in your stool, if the diarrhea worsens or if you become light-headed or dizzy.

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Are You A Candidate

Whether your doctor recommends radiation depends on various factors, including your age, health, and personal preferences. The type of radiation is often dictated by your risk group and whether the cancer is localized or has spread.

Sometimes hormone therapy is given before radiation or along with it. ADT reduces levels of male hormones, called androgens, which can slow or even stop the cancers growth. Studies have found this one-two punch leads to higher survival rates than radiation alone among men with localized prostate cancer and a Gleason score of 7 or higher.

If you opt for surgery, your doctor may suggest radiation afterward, called adjuvant radiation therapy. “You have surgery to remove cancer, and then radiation to eliminate any remaining tumor deposits to keep cancer from returning,” says Dr. Anthony DAmico, a radiation oncologist with Harvards Dana-Farber Cancer Institute. Cancer that has grown beyond the prostate also may require post-surgery radiation.

After youve had radiation, youll have a prostate-specific antigen test every three to six months for five years and then annually after that to check for recurrence of the cancer. “If your PSA ever rises above 2, then imaging tests are done, and if needed, additional radiation or other appropriate treatment is given,” says Dr. DAmico.

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