Gold Markers For Prostate Radiation

Complete A Health Care Proxy Form

If you have not already filled out a Health Care Proxy form, we recommend you do now. If you already filled one out or have any other advance directives, bring them to your next appointment.

A health care proxy is a legal document. It says who will speak for you if you cannot communicate for yourself. This person is called your health care agent.

• For information about health care proxies and other advance directives, read Advance Care Planning.
• For information about being a health care agent, read How to Be a Health Care Agent.
• If you have more questions about filling out a Health Care Proxy form, talk with your healthcare provider.

Overview Of The Gold Seed Procedure

This is a surgical procedure we do in the operating room under anesthetic. Some centers may do this step with local anesthetic only, but we find it is more comfortable to use deep sedation. In the procedure, your legs are placed in footrests and your legs are spread apart and your knees are bent up. We place an ultrasound in the rectum so that we can see the prostate gland in real time during the procedure. We use only needles there is no cutting and no suturing required. The procedure takes about 10 minutes if we are just placing gold markers, and it takes about 20 minutes total if we are also placing SpacOAR.

Many radiation oncologists have a urologist place the gold seeds and SpaceOAR, but I prefer to do it myself. If a urologist places the marker seeds, he may insert the needles through the rectal wall to deposit the seeds. This is not bad and it will work fine, but I believe that you can aim better if the needles are placed through the perineum skin instead of through the rectum, and there will be less chance of infection. It can be finicky injecting the SpaceOAR into the perfect spot, so it is good to have a lot of experience with this.

Patient Preparation And Selection

The study was performed on patients with prostate carcinoma diagnosis who underwent radiotherapy planning at the University Medical Center Utrecht between September and October 2015. The study has been conducted in accordance with regulations from the local ethical committee.

For position verification purposes, each patient received three intraprostatic cylindrical gold FMs measuring 1 mm by 5 mm . The FMs were transperineally implanted under ultrasound guidance by a physician prior to the imaging session using two 18-gauge needles placed with the aid of a template.

Patient positioning at CT scan was conducted simulating the treatment, i.e. using a flat table, knee wedges, positioning arms on the chest and tattooing the patient with the aid of laser alignment.

Patient setup at 3T MR scan was performed using a knee wedge, but without a flat table top, without positioning arms on the chest and without laser-aided positioning. Patients were scanned using anterior and posterior phased array coils . To avoid compression of patients anatomy, two in-house-built coil bridges supported the anterior coil. The location of FMs from CT images was obtained as previously described in . No rectum or bladder preparation protocol was applied before imaging sessions, but the patients were asked to empty their rectum in case rectal filling was noticed being larger than 5 cm during the imaging session.

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Availability Of Data And Materials

The datasets analysed during the current study are not publicly available due to internal policy of the Medical Ethical Commission pertaining to data sharing but are available from the corresponding author upon Medical Ethical Commissions approval. The datasets generated during the inter-observer localisation, e.g. the FM location and the correspondent analysis are available at .

Brachytherapy For Prostate Cancer

This outpatient procedure most often requires spinal anesthesia to numb the patient from the waist down. Upon treatment, an ultrasound probe is placed in the rectum, giving the surgeon a visual of the prostate gland on a monitor and aiding him in positioning the radioactive materials .

Once the prostate is located, between 50 and 100 seeds are implanted into the prostate using several tiny needles that are inserted into the skin between the rectum and the scrotum.

Brachytherapy for prostate cancer can be done with both low-dose and high-dose radiation. The temporary treatment lasts about 30 minutes, after which the doctor removes the radioactive seed. With the permanent method, the seed is left in place and gives off a small amount of radiation for several months. At the end of the procedure, a catheter is placed in the patient’s bladder to help him pass urine during recovery.

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Taking Care Of Your Overall Health

• We encourage all our patients to use this opportunity to improve their overall health.
• We recommend you meet with a dietitian and exercise regularly . The Valley Health and Wellness Center offers an exercise therapy evaluation, which we can refer you to as desired.
• You may also wish to meet with one of our social workers to address issues that can affect your overall health . Social workers can also connect you other Valley cancer support services.

Stereotactic Body Radiation Therapy

After our planning and testing period, you will start your radiation therapy.

For stereotactic body radiation therapy at Valley, we use the Varian TrueBeam platform combined with the BrainLab ExacTrac Dynamic system. This system allows us to visualize your internal anatomy before and during treatment.

This visualization allows us to see whether your bladder is filled appropriately, that there isnt too much gas in your rectum, and that your prostate is aligned correctly for treatment.

During treatment:

• During treatment, you will lie on the table in your fixation device. You should not feel any discomfort as the treatment is happening.
• Once treatment begins, the BrainLab ExacTrac Dynamic system monitors the surface of your body and the implanted fiducials in your prostate for any movement.
• If your prostate moves, the machine will stop the radiation beam automatically and adjust your position. It will then restart treatment.

Treatment length:

• TrueBeam is much faster than other linear accelerators , which means there is less time for the prostate to move.
• For the Think Five approach, you will have five treatments spread out over approximately 10 days. Each treatment will last 30 45 min, which includes all the time for changing, set up, position verification, and treatment.
• Alternatively, you may be recommended to receive 28 treatmentsfive days a week for five to six weeks. Each treatment will last 15 20 minutes.

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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.

What Are The 4 Stages Of Prostate Cancer

Prostate cancer stages range from 1 through 4.

• Stage 1 prostate cancer.
• Stage 2 prostate cancer means the cancer remains confined to the prostate gland.
• Stage 3 prostate cancer means the cancer is locally advanced.
• Stage 4 prostate cancer means the cancer has spread to lymph nodes or to other parts of the body.

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Fiducial Markers And Spaceoar

For prostate stereotactic body radiation therapy at Valley, we first implant fiducial markers and SpaceOAR hydrogel.

These are implanted in one 30-minute procedure. The implantation is performed under general anesthesia in our same-day surgical center within the cancer center.

• Fiducial markers are tiny gold markers that we implant in your prostate. Fiducials guide our delivery of radiation by enhancing our ability to detect subtle changes in prostate position. Because the markers show up on imaging, we are able to deliver radiation more accurately and consistently at each session.
• SpaceOAR is a semi-solid gel that creates space between your prostate and rectum. This extra space protects your rectum from radiation and reduces radiation side effects.

How to Prepare for Fiducial and SpaceOAR Implantation

You will need to have additional tests to be cleared for the implantation procedure.

Nurses in our office will walk you through the scheduling process for the procedure and the tests you need. You will leave your first visit with us with an appointment for the implantation procedure.

We will also give you information about how to prepare for your procedure. This will include instructions to:

• Take an antibiotic for five days starting one day before the procedure
• Perform an enema at home following instructions we will provide
• Not eat or drink after midnight the night before the procedure

Fiducial and SpaceOAR Implantation

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.

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Arrange For Someone To Take You Home

You must have a responsible care partner take you home after your procedure. A responsible care partner is someone who can help you get home safely. They should be able to contact your care team if they have any concerns. Make sure to plan this before the day of your procedure.

If you dont have a responsible care partner to take you home, call one of the agencies below. Theyll send someone to go home with you. Theres a charge for this service, and youll need to provide transportation. Its OK to use a taxi or car service, but you still need a responsible care partner with you.

Psa Tests After Treatment

After treatment ends, you will follow up with your urologist to resume prostate-specific antigen surveillance. We recommend:

• You have your first PSA test three months later
• Then you have one every six months for the first three to five years
• After that, you have yearly exams

PSA typically declines over time. However, it is common to experience a PSA bounce within the first couple of years after treatment. This is normal.

Please discuss any concerns you have over your PSA value with your radiation oncologist.

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Displacement Of Prostate Centroid

The clinical characteristics of the patients who participated in this study are shown in .

The shift in the prostate centroid due to marker matching was highest along the AP-axis and lowest along the LR-axis . The shift due to bone matching was highest along the AP-axis . When comparisons were made between marker and bone matching, the shift in the prostate centroid was lower in the LR- and AP-axes when marker matching was used. Overall, the 3D displacement was significantly lower for marker matching than for bone matching .

Shift in prostate centroid: marker matching compared with bone matching values are given as the mean ± SD

How Do They Put Markers In For Prostate Radiation

To effectively treat prostate cancer, doctors need an accurate view of the prostate gland during radiation therapy. To help improve this view, doctors may insert gold markers called fiducials into the prostate by placing hollow gold needles through the rectum and moving a fiducial through each needle.

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How Will I Know If My Procedure Was Successful

After an X-ray, your doctor should be able to determine that the markers were inserted correctly into the body. Once your first course of radiation is scheduled, the markers will be used by your radiation oncologist to plan your treatment.

If you have any questions or concerns about your upcoming radiation treatment or your fiducial markers, your care team is always there to help.

Expert cancer care

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.

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How To Prepare For Your Procedure

If youre scheduled to have fiducial markers inserted before starting radiation, your care team will let you know exactly how to prepare.

Before your fiducial marker insertion:

• Inform your care team about any allergies or medical conditions you have and all prescription and over-the-counter medicines and supplements you take. Due to the risks of radiation, be sure to tell your doctor if theres a possibility that youre pregnant.
• Your care team may ask you to temporarily stop taking certain prescription and over-the-counter medications the week before the procedure, such as blood thinners, aspirin and ibuprofen.
• You may be prescribed an antibiotic to take on the day of the procedure. This is intended to help lower your chance of infection.
• You can go about your day normally and eat meals, because fasting isnt required for this procedure.
• Its a good idea to arrange for someone to take you home after the procedure.

When you arrive, youll be asked to remove your jewelry, glasses and clothing and change into a hospital gown, as this prevents interference with the X-ray machines.

The Fiducial Markers Procedure

Fiducial markers are placed with an image-guided procedure. Under anesthesia, your doctor will gently insert a probe into your rectum. The probe uses ultrasound to show your doctor images of your prostate to guide fiducial marker placement. Using the ultrasound probe for guidance, your doctor will use a thin needle to implant the fiducial markers into your prostate. The procedure will take around 15 minutes.1

Your doctors office will give you all preparation and aftercare instructions prior to your fiducial markers placement.

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How Should I Prepare

Prior to your procedure, your blood may be tested to determine how well your kidneys are functioning and whether your blood clots normally.

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials containing iodine . Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs or blood thinners for a specified period of time before your procedure.

Also inform your doctor about recent illnesses or other medical conditions.

Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.

You will receive specific instructions on how to prepare, including any changes that need to be made to your regular medication schedule. Other than medications, you may be instructed to not eat or drink anything for several hours before your procedure.

You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, eye glasses and any metal objects or clothing that might interfere with the x-ray images.

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.

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Imaging And Position Matching

A computed tomography scan was taken 1 month after LDR brachytherapy and used as a reference image. Axial CT images of the pelvic area were taken at 3-mm thickness and 3-mm intervals. Additional CT scans were performed weekly for 45 weeks during the irradiation period. The immobilization device was not used for CT scans. These weekly images were taken immediately after irradiation, so they could be considered nearly the same condition as the actual treatment. In this study, all imaging information was transferred to a treatment planning system . The prostate was contoured based on each CT scan by a radiation oncologist, and the prostate centroid was the calculated 3D center of mass of each patients prostate. The relative position error of the prostate centroid was calculated and analyzed based on the reference CT scan. Gold marker matching aligned the upper and lower points of each gold marker on the left and right . Pelvic bone matching was conducted by aligning with the pelvic bony anatomy as shown in . For a total of 175 CT images in 38 patients, the setup error was measured by the average values of the relative position displacement of the prostate centroid at the time of gold marker matching and pelvic bone matching. Then, the setup error between gold marker matching and pelvic bone matching was compared using the Wilcoxon signed-rank test. Rotational corrections were not included in the analyses. Analyses were carried out using SPSS version 22.0 .