SBRT : Regarding SBRT and no spaceoar... - Prostate Cancer N...

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SBRT

Sunfire
Sunfire

Regarding SBRT and no spaceoar. Procedure completed today for markers however Spaceoar was tried to be injected but due to prostate space between rectum it was too small a space. Now not sure what to do. RO is considering 28 day IMRT vs SBRT since no protection in place. Incredibly agitated that placement was aborted after 10 sticks! Hoping there is no complication from that alone. Told they have had 4 others they couldn't get it in. RP is not an option on our plate we were considering but not sure IMRT alone gives me enough confidence to use as a monotherapy for G7 3+4. My confidence was in SBRT but complications could be high without protection so RO indicates.

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SpaceOAR is a solution in search of a problem. It reduces only late term rectal injury, but serious late term rectal toxicity is a rare event with SBRT. In my friend's case, it protected part of his cancer from the radiation. Now that part is growing into his rectal wall causing bowel obstruction. I was treated without it and had no rectal problems at all other than some blood on my toilet paper (due to inflamed hemorrhoids) during the first month - my experience is typical.

pcnrv.blogspot.com/2017/01/...

BTW- My RO, who pioneered the use of SBRT for prostate cancer, refuses to use it.

Sunfire
Sunfire
in reply to Tall_Allen

Thank you I will be sure to share this with RO. Interesting article! The RO felt spaceoar was important in protection so we went with it. However unless we go elsewhere now and start all over I'm not confident RO will proceed with SBRT. Will know more after CT/MRI simulation next week. You always come through Tall Allen. Most appreciated.

Tall_Allen
Tall_Allen
in reply to Sunfire

SpaceOAR is no different with SBRT or IMRT. Can you travel for treatment? I highly recommend my RO - Chris King at UCLA. He believes that there is no substitute for careful contouring.

Sunfire
Sunfire
in reply to Tall_Allen

I wish we could! Unfortunately we are in Pennsylvania a long way and still work. Time away is a factor.

Tall_Allen
Tall_Allen
in reply to Sunfire

Anywhere near DC? Sean Collins at Georgetown. I'm pretty sure you can get SBRT at Fox Chase as well.

Sunfire
Sunfire
in reply to Tall_Allen

Yes, currently looking at Fox Chase Philadelphia. Just frustrated because we have SBRT Varian Edge an excellent system locally here. Discussing options after CT/MRI simulation next week with RO and physicists. Fox Chase on my radar though if we don't agree with plan.

Tall_Allen
Tall_Allen
in reply to Sunfire

Everyone has good linacs. That's not a reason to choose one or another.

testr
testr
in reply to Sunfire

Referring to Tall_Allen's post about SpaceOAR:

TA>In my friend's case, it protected part of his cancer from the radiation.

TA>Now that part is growing into his rectal wall causing bowel obstruction.

That's a big deal! That's important information!

So it would seem that SpaceOAR blocks the radiation treatment from getting to some areas that may need it.

I think that's a major concern.

?Is it worth the risk of your radiation treatment missing some of your cancer in order to maybe have less side effects??

?Is that a trade-off that anyone (who wants to try for a cure) would take??

I think this information should be made mandatory before this procedure.

All potential users of SpaceOAR should be made aware of this potentially deadly disadvantage.

Sunfire
Sunfire
in reply to testr

Agreed very good point. No spaceoar here. Start treatment in Feb and we discussed King's protocol at UCLA with RO. Dropping dose at bladder and rectum much like King.

I had good luck with SpaceOar adjunctive to a HDR-Brachy procedure at UCLA, after which I did 25 sessions of IMRT without any SE's. I saw an MRI of the SpaceOar afterwards, and Dr Chang placed it perfectly symmetrical. He has done hundreds of these, and I think a lot of it depends on the skill of the surgeon.

It's questionable that you don't have the space for the implant. There are several steps to creating the space that involve hydrodissection of the the anterior rectal wall and the prostate fascia. The hydrodissection is an interactive process and the space is checked by viewing the needle tip in relation to the prostate and rectum structures. It looks like the surgeon failed in this step.

Here's a description of the process:

urotoday.com/video-lectures...

I'm a smallish 140lbs with a 30cc prostate, and had no issues.

Sunfire
Sunfire
in reply to timotur

Thanks for your feedback. I would tend to agree which lowers our confidence in an experienced RO in our area. He has done others we know. It was not the surgeon rather the RO that does placement. He was definitely more conservative on his approach and the risk after saline was introduced with the smaller space than normal and risk of gel injection into any other area other than where it should after several attempts he chose to abort. Too high a risk. Was that a failure on his part possibly however anatomy varies and Spaceoar reps were called upon before abort.

More muscular here at 200lbs but a larger prostate at 58g. Larger prostate as I understand can inhibit space too.

timotur
timotur
in reply to Sunfire

Here's a good study on it in case you decide to reconsider it...

PHASE III TRIAL

Based on the phase II results, researchers evaluated SpaceOAR in a 3-year, multicenter, randomized, controlled trial of 222 men with stage T1 or T2 prostate cancer (NCT01538628).32 After undergoing CT and MRI-based radiation treatment planning and fiducial marker placement, participants were randomly assigned on a 2:1 basis to the spacer or control (no spacer) arm. Men in the spacer arm had the hydrogel spacer placed under intravenous anesthesia. Patients in both arms then received another set of planning scans followed by dose-escalated (79.2 Gy) IMRT of the prostate (with or without the seminal vesicles) in 44 fractions.32

The results of the phase III trial supported those from the phase II study. Spacer placement increased the perirectal space by a mean of 11.0 mm.32 In the spacer arm, 97.3% of men had at least a 25% decrease in average projected volume of rectal tissue receiving at least 70 Gy (rV70).32 Mean rectal v70 values were 3.3% after spacer placement versus 12.4% at baseline (P < .0001).32 Rates of acute rectal toxicities generally were similar between groups, but men who received the spacer reported significantly less acute rectal pain compared with controls (P = .02).32

From 3 months onward, no patients in the spacer arm and 5.7% of controls developed grade 2 or worse rectal toxicities such as fecal incontinence, proctitis, or bleeding (P = .012).33 Rates of late-onset grade 1 or worse rectal toxicities also favored the spacer arm (2% vs. 9.2% in the control group; P = .028). Men who received the spacer also had a significantly lower rate of grade 1 or worse urinary incontinence (4% versus 15%; P = .046), although rates of grade 2 or worse urinary toxicity were identical (7%) between arms.33

urotoday.com/journal/everyd...

Sunfire
Sunfire
in reply to timotur

Excellent yes that is why we were encouraged to use spaceoar. There are pros and cons either way. Next step is simulation next week and after that we will discuss options with RO and physicists.

tnone
tnone
in reply to Sunfire

Sorry to hear about your SpaceOAR experience. The biggest surprise for me is that you indicate that the spacer was inserted by the RO. My fiducial/spacer procedure was performed by the URO under general anesthesia in an outpatient surgery center. In reviewing my clinical notes from the URO, he very deliberately documents the technique for hydrodissection with saline, the separation between the prostate and rectum, the insertion of the gel, and followup regarding spacer symmetry and overall separation. I'm not sure why, but the SpaceOAR rep was present during my procedure. At the time of my procedure, the URO had completed over a hundred spacer insertions. Also, my RO would not treat PCa on the Cyberknife without it, so I'm guessing that accounts for some the URO's experience level.

I have read where there is sometimes difficulty separating the prostate from the rectum and have wondered if that's just a variable in anatomy from person to person. They do say that some prostate tissue is left behind during surgery on some patients. Could some of remaining tissue be cancerous and the cause for recurrence? That was one factor in my decision to chose radiation over surgery.

I believe I have posted before that my spacer was not covered by my private insurance. It is covered by Medicare though. At my 3-month followup appointment with my RO, he says that the insurance companies are now adamantly refusing to cover the spacer, citing no significant advantage. Reluctantly, he has just started treating PCa patients on the Cyberknife without it. His technique is very tedious and specific, so I'll be interested if he finds any difference in urinary/rectal side effects without the spacer.

Best of luck as you move forward. Let us know how your simulation goes.

Sunfire
Sunfire
in reply to tnone

Yes I am finding it's rather controversial. Actually Spaceoar rep was there during procedure too! That said not exactly sure I'll ever know for sure why it couldn't be placed but I'm a believer everything happens for a reason. That said if we can do it with a lower dose in the area avoiding rectum I'll still do SBRT.

Hmm... I had HDR Brachy and 25 days of IMRT ( this year) without the SpaceOar.

My MSK RO explained that at G9 and no mets, the gel could apply pressure that could release cells elsewhere.

So far, I'm doing just fine

Best

Sunfire
Sunfire
in reply to westof

Wow thank you encouraging feedback there. Glad to hear your doing well!

I had SBRT last August with Dr. King at UCLA. No SpaceOar of course, Dr. King sees no merit in it. I had no problems at all with SBRT. Tall Allen is correct, I too highly recommend Dr King.

Excellent thanks for sharing and glad you had the same awesome results as others with King!

I, too, asked about spaceoar. Was told that, because of multiple biopsies over the years, it was probably not a good idea.

I had 25 IMRT and 39 seed brachytherapy (and ADT). Procedures themselves were uneventful (still anxious mess during them.)

ADT was the awful part for me.

Btw, 3+4, PSA 23, no mets.

Here's hoping.

Good luck.

Edinbaltimore

I also had SBRT with Dr. King at UCLA recently, without SpaceOar. I have no rectal issues at all.

45 IG/IMRT/ARC/Boost treatments last year. No SpaceOar - my RO said that just lets the techs be sloppy.. and he doesn't allow that. He also felt with G9/G10 that "messing about in the area" isn't a good idea. He'd get it done if I wanted it - but recommended against that and the markers (for basically the same regions.)

Sunfire
Sunfire
in reply to Don_1213

Thanks for sharing and glad to hear your doing well! Not happy RO was messing around down there trying to get it placed and failed anyway. Thought it would be brutally sore today but so far minimal soreness. Hopefully he didn't irritate the sleeping bear too much!

Same here, had SBRT without the spaceoar with Dr King at UCLA and no rectal issues so far, I was really pushing for it but he refused. I did enough research to trust him. Treatment was completed 10/2018.

Sunfire
Sunfire
in reply to G_gnn

Quite a few here completed without Spaceoar. Moving forward feel more confident it should be ok for SBRT without gel. Thanks for sharing. Will be interesting after CT/MRI simulation how RO and physicists plan to proceed.

G7 ..140 lbs...45 fractions 81gys..no space oar...no rectal problems..good luck

Sunfire
Sunfire
in reply to fldrifter

Thanks for sharing. Good news and all the best to you on your healing!

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