Patient Diagnosis: LESION 1, PIRADS v2 Score: 5, Size: 1.9 x 1.0 cm
Location: Right, anterior, base, peripheral and transition zone * Extracapsular extension: Possible extensive extension.
Seminal vesicle invasion: None.
Adjacent organ invasion: None.
Gleason 7 (3+4)
On December 22nd, I completed five SBRT treatments on the MSK Precise MR Linec at Memorial Sloan Kettering in NYC. Because the experiences of my former journeymen here on PCN has been so helpful, I offer up my humble documentation for those you who are following down this road.
I have learned that MSK provides more than one type of radiation treatment that’s called MSK Precise. Where others in this group have talked about needing to have a full bladder before treatment, I was required to have mine empty. When I asked about this the Radiation Therapist said there’s different machines doing SBRT. So mine is called the MRI Linec. It’s a big selling point as it offers realtime monitoring and extremely precise (hence the name) pinpoint application of radiation.
The process is as follows: You're in an MRI tube for approximately an hour. A full scan of the prostate area is taken for the first 40 minutes, the RO reviews the scan, makes adjustments, and then the radiation treatment is applied for the final 15 minutes. For all of that time, you are are held in place by a custom molded truss around your midsection, with your arms on your chest holding onto a ring. You are told to not move. This is tedious but not painful. Each day of the treatment starts with an enema. The prep was the first two hours, where-as the scans and treatment are approximate an hour to ninety minutes directly following prep. Here’s how it played out for me:
December 13, 2021
9 AM, I arrived at the Memorial Sloane Kettering David Koch Center for Cancer Care, a beautiful facility filled with kind, and highly qualified professionals. This certainly made the experience easier. I was shown from the waiting room into a private changing area. I put my clothes and belongings in a locker and changed into a gown and a pair of hospital socks. After about 15 minutes the nurse came in and took me into an adjacent room. This small connecting exam room was where the enema was administered. This was required before each of my five treatments. Jenna (the nurse) set up the reclining chair to make me comfortable, covering me in a blanket, and lifted only the area of the blanket where the business at hand needed to be conducted. We chatted for the requisite five minutes (patient receiving an enema is supposed to retain the liquid for as much as five minutes to build up maximum pressure), I said goodbye and off I went to the bathroom to purge. In my case, not only did the bladder need to be empty, but the lower intestine as well. This was the process every day of my treatment, between the hours of 9 AM and about 12 noon. Certainly a nuisance, but not painful. If you have any squeamishness about being given an enema by a young nurse, best to forget about that. Classic male dignity has little place here.
About 10:30 AM I was brought into the radiation theater, a very clean, white futuristic facility, placed on my back on the metal bed which is fairly firm, measured, bolted in, covered, headphone supplied, and slid into the tube like a torpedo. You have a little button where you can communicate with the technician if needed, and they will play music if you like, which I found helpful, as it distracted me away from the noise. The Linec is fairly noisy.
You lie quietly in the tube and you do every thing in your power to not move. This is harder than it sounds. There are no symptoms, although your hands and feet can fall asleep, and after a while I found my back starting to ache. The staff do not speak much. They did tell me the difference between the taking of images (the first 40 minutes) and the actual radiation treatment (last 15). When the session was complete, I went back into the dressing room, dressed and went home. I did feel some swelling in my prostate by the time I got home and noticed not long after that my urine flow was reduced by about 20 or 30%. I was still able to go but the flow was definitely more limited and mildly uncomfortable.
December 15 9 AM
Same routine as Monday except today the treatment was longer as there was some delay between the taking of images and the treatment. I do not know why. The information was not volunteered, but it seemed like I sat in the tube for an additional thirty minutes, and I found this frustrating. I asked what the delay was and I was told that the doctor was making adjustments. My back hurt a lot by this point, and my arms and legs were completely asleep, so it took me longer to get up and move around when the session was over. When I got home I felt the same discomfort in my prostate and it was becoming more difficult to urinate. So I called Dr. Zelefsky‘s office and asked if I could take Advil. The assistant said this was a great idea and that she recommended that or Aleve, but not Tylenol as she said it was less effective. They also prescribed a medication to increase the urine flow called Alfuzosin. I started taking the Alfuzosin after a few days as the restricted flow and associated discomfort was relentless. I felt like I needed to be all the time.
December 17 9 AM
Today was pretty easy. The morning routine was as usual except that I decided to take two Advil at eight in the morning to see if I felt better during the treatment. The answer was an emphatic yes. The back pain from lying in the tube unable to move, was reduced by 30%. There were no delays. The whole process for me from arrival to departure has distilled down to about three hours. I arrive at nine and was often out the door by noon.
December 20 9 AM
Today the Linac broke down and had to be rebooted. That added an extra twenty minutes to the treatment. Note to self: No big deal. Just breath and go with the flow. Everyone is doing their best.
I was scheduled to see Dr. Zelefsky after this treatment and again, when treatment was complete I was in some discomfort. It does get worse as the treatments progress. Again, not painful, but uncomfortable.
The office visit with Dr. Z and his assistant Maria was pleasant and relaxed. I asked all the questions I could think of, most importantly: “ So Doc, how did we do?” The answer was “I’m very pleased, everything lined up perfectly. You have a 95% chance of not seeing this again”. From his mouth to G*d’s ears as they say. I also heard that I could expect the discomfort to last for a few months and was advised to continue to take the Alfuzosin for a month and see how it goes. Continue the Advil as needed.
December 22, 9AM
Last day and am I excited. Last enema, bye bye Nurse Jenna. The procedure today was on time, uneventful, and without disruption. I said goodbye to the technicians who had been utterly professional. We said we would meet again on a beach in Hawaii, but never again in the MR Linec. I dressed, walked out of the radiation wing and into the main waiting room. I found the bell and rang it (it is customary to ring a bell or hit a gong when treatment is complete). The whole floor started to applaud. It was a very satisfying moment. A young receptionist ran over to me and said “Congratulations!” with much enthusiasm. I said “I love you all and hope to never see any of you again” We all had a laugh.
One Month Post Treatment:
I am mostly comfortable. I continue to use the Alfuzosin to help with urine flow. I did try and stop it a few days ago and found that the urge to urinate returned along with discomfort, so started it again. Sex is doable, but not yet enjoyable. There are no ED issues that didn’t occur before treatment (I am 65 and can no longer claim to be the stud I once was :-). There is discomfort during orgasm. I was told that is to be expected for some time, so I will try again in a few weeks to see if the sensation if more pleasant. I have gone back to the gym. My life is pretty normal now and it’s a great relief to have this behind me.
First PSA check will be in March and again in June. I was told there will most likely be another Biopsy in two years to make sure all the cancer cells are gone.
And so now I can get on with my life. Please don’t hesitate to reach out to me should you have any questions.
WP
SBRT #4
Started MRI Guided SBRT at MSK
My 22 month psa after radiation treatment (SBRT) is 1.25. What should my nadir be? Less than 0.5?
SBRT and supplements 
