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This treatment combines the best aspects of Radioactive Seed Implantation and External Beam Radiation Therapy (EBRT)
Radioactive seed implants allow us to attack the tumor with very high doses of radiation. By approaching the prostate and cancer internally we can minimize injury to normal tissue surrounding the prostate.
External Beam Radiation Therapy (EBRT) allows a wide field of radiation and treats areas where tumor might have spread. These areas are not easily reached except by radiation, and beyond what can be removed by surgery.
If you choose this treatment, the entire procedure requires a number of steps to accomplish.
Consultation
Consultation and review with Dr. Tokita or associate
Dr Tokita will then consult and conference with your Urologist and Family Practitioner (If needed).
If you and your doctors agree that this treatment is appropriate for you, the process will begin.
Prostate Measurement
Gland measurement: We will first measure your prostate with Transrectal ultrasound (US). Many of you have already had an ultrasound, and wonder why measure again? We will be using a very extensive study (which is not usually done or needed by your Urologist at the time of your prostate biopsy.)
Gland Size: A prostate over 40 grams (gm) or cubic centimeters (cc) is too large for safe treatment, and also glands under 40gms have a higher cure rate.
If your prostate is over 40 gms, Dr Tokita may request your Urologist to place you on a male hormone blocker or a combination of these prescription medications to shrink the gland. Commonly used drugs are Lupron, Zoladex, Casodex, and Flutamide. This can be considered the first part of your cancer treatment.
Nice positive side effects of these medications:
· Tumor Growth: abruptly stops the growth of the cancer
· Shrink the prostate
· Improved Cure Rate: we feel actually enhances the overall cure rate.
Unfortunately, there are several other not so nice side effects
· Hot flashes: (say “hello to your wife”, she’s not alone);
· Weakness: after a month or two some weakness and tiredness
(if you block male hormone, which is an anabolic steroid,
your muscle mass will decrease temporarily);
· Intercourse: for many, a complete although temporary, inability
to have erections and intercourse.
This hormone treatment can go on for months. After the hormones are started, Dr Tokita will measure the prostate each month. Once the prostate size is acceptable (<40 gms ideally), we can start radiation planning and treatment.
Treatment Planning
Dr Tokita will use multiple modalities to get as perfect a 3D configuration and treatment plan as possible. The Cancer Center is truly state of the art in these areas, having introduced several of these procedures to Orange County.
Pelvic CT scan for 3-dimensional holographic reconstruction of your pelvis and prostate, to facilitate computer planning
Ultrasounds for CT-Ultrasound image fusion, to as perfectly as possible visualize and plan your implant.
Computer dosimetry and formal plan of site and position of each plastic (Flexiguide) catheter to be placed at implantation surgery by Dr Tokita and your Urologist.
Scheduling Implant
Schedule and plan the first of two Temporary Iridium HDR Prostate implants. They will be done in an operating room with an Urologist and Dr Tokita.
All of this is elective and not an emergency procedure. We do not want to take any possible risks and will require a very comprehensive pre-op evaluation.
This will require:
· Pre-op clearance for surgery by your family physician, or internist.
· Test:
Electrocardiogram,
Chest X-ray,
Blood tests
Blood count,
Chemistries (to check your kidney function, liver,
Cholesterol, bone metabolism, etc) finally,
Protime: to check your clotting ability
· Note: If you are on blood thinners Heparin, Coumadin etc., or anti-inflammatories such as Aspirin, Advil, Ibuprofen, Aleve etc.; they need to be stopped several days before surgery.
Surgery #1 first Implant
Surgery #1: You will come to the surgery center about 2 hours early. At surgery, Dr Tokita and your Urologist will perform a surgery called Transperineal Ultrasound and fluoroscopically guided implantation of plastic (flexiguide) afterloading catheters into the prostate. The actual surgery in the operating room takes about an hour followed by an hour of recovery time.
After recovery you will be transferred to Radiation Therapy at the Cancer Center: Once recovered from anesthesia, you will be allowed to eat and drink, but be kept flat, although you can roll from side to side about 30 degrees. You cannot sit with all the instruments in your bottom. If you have pain, let the nurses know, and they will give you medicine prescribed by Dr. Tokita.
Once at the Radiation Department of the Cancer Center
CT: you will first be taken directly to the CT room. This CT will confirm the accurate positioning of the HDR catheters. If not perfect, Dr Tokita can adjust them.
Holding Area: you will then be taken back to a recovery room, where your family or others can sit with you.
Plan Recheck: During this time, the physicist and Dr Tokita will be rechecking the entire implant by computer.
Checklist: Also, the technicians and Dr Tokita, will go through an extensive checklist and finally
Program the HDR Computer
Actual HDR Treatment
HDR Room: You will be placed on a special mechanical couch and brought to the HDR Room, which houses the Nucletron HDR Remote Afterloader. The HDR machine has many outlets, and one outlet will be attached to each after-loading flexiguide catheter.
Treatment #1: Once attached and approved by Dr Tokita, everyone will leave the room, and the computer driven HDR machine will first insert a test wire into one catheter and then follow it with the actual treatment wire. You will feel the wires going in and out of each catheter. We will be in constant contact by video monitor and sound system.
Occasionally, the test wire will find a flaw, requiring us to enter the room and clear the problem. This is a fail-safe mechanism to protect you.
When completed, you will be taken back to the holding area (recovery room) and await the second HDR insertion.
Treatment #2: 4-6 hours later, the HDR insertion procedure will be repeated.
After the second insertion, the catheters and holding template and Foley (urine catheter) will be removed. You will be encouraged to move about
You will be discharged home, after you are able to urinate.
Between the two implants, you may notice some bladder irritation, tiredness, and tenderness in your bottom. It can be quite uncomfortable for some but most do well enough to go back to almost normal activity. If Not, please let Dr Tokita know.
An area of ‘black and blue” on your bottom and scrotum is normal.
Second Surgical Catheter Implant
If all goes as planned, the surgery to implant the plastic flexiguide catheters, and 2 HDR insertions with treatments #3 and #4 are repeated about a week later.
Normally, one does not need another pre-op clearance, EKG, chest x-ray and blood tests.
You may experience some short-term effects of the radiation implants. These may include burning upon urination, frequency in urination, the need to urinate at night, loose bowels, and/or diarrhea. You may also experience some discomfort in the bladder, rectum, and urethra commonly referred to as the “sunburn effect”.
The most serious potential side effect is deep venous thrombosis (blood clots in the legs) that can lead to pulmonary embolism (PE or clots to the lungs). This can be fatal. In Dr Tokita’s 16 years doing temporary LDR and HDR implants, he has had one patient with a PE, which was not fatal but frightening. This led to adding Lovenox to the previously used support hose and pressure hoses. Also he encourages anti-inflammatory medication such as Advil, Aleve, or Aspirin to decrease the post-op clotting after the second surgery.
The other is infection in the prostate or pneumonia.
Phase 2: When does the External Beam Radiation (EBRT) begin?
Before leaving the department after the second insertion, you will be given an appointment to start the EBRT (IMRT). If we forget to schedule, you will need to call the Cancer Center to schedule your appointments.
We would like to begin your treatments within one week post implant.
You will first be scheduled by the Radiation Technologists for a confirmatory film taken on the IMRT machine. This film will be taken on the Linear Accelerator (IMRT) and confirms the perfection of the simulation.
You will be scheduled to return the next day or two to begin treatment. Each day in the treatment room, X-ray films called port films will be taken to verify once again that the area “mapped” out is the area that is being targeted for treatment. Fine, milimeter adjustments will be made daily before actual treatment.
We have been asked in the past; "If I have been tattooed, why do we need to take daily films?" In fact, no matter how precisely we set you up, the skin can move, and your rectum can have more or less gas or stool. Any of these factors will change the position of the prostate in relation to the tattoos.
We spent countless hours working out immobilization devices, molds, casts etc. The only sure way we found is to target the prostate daily by the use of the gold fiducials. There is only one or two centers in the US, we know of, who go through this much care for each treatment delivery.
Your treatments will be scheduled Monday through Friday for approximately 5 weeks. This means you will make approximately 25-28 visits to see us for treatment.
Symptoms and Complications of External Beam Radiation Therapy (EBRT)
Acutely: During treatment
Energy: About the third week of treatment, you will notice some tiredness. You will feel fine when you awake, but notice you tire easily (no stamina)
Bowels: You will get some looseness of your bowels and can proceed to diarrhea. The technicians will instruct you on a low fiber diet; stopping coffee, tea, alcohol; and Dr Tokita may prescribe medications (Lomotil or Imodium).
Skin: You may get red skin in the areas of treatment. The skin thinks it is getting sun, and reacts accordingly. These areas include the lower abdomen, around the anus and between the buttock crease. Again the technicians will train you on skin care and if needed, may ask Dr Tokita to give you a “cortisone” cream to help the red skin.
Bladder and Urethral Irritation: From the radiation hitting part of the bladder and prostate, you will get irritation and this leads to urinary frequency, nocturia (increased urination at night), urgency (have to get to the bathroom…quick!) and occasional burning on urination (dysuria). These symptoms are all mild; time limited and will go away, after treatment.
With the normal male aging process, men may develop impotence or urinary obstruction. The various treatments offered to patients with prostate cancer such as Surgery, External Radiation or Radioactive Seed Implants might hasten these problems.
Even though long term side effects are not common, they could appear after a period of three months to a year. As the prostate tumor cells are killed and the gland shrinks, urinary obstruction may become a problem. Also the rectum is immediately behind the prostate and can get sunburned.
Rectum: Severe injury to the rectum can occur. This is severe radiation sunburn of the anterior rectum. This can lead to intermittent diarrhea, mucous drainage and cramping. These symptoms can be variable from none or mild, to severe. In a worse case scenario, it can lead to a colostomy to divert stool off of the rectum, or even a fistula (an abnormal opening) between the bladder and the rectum. This would allow urine to flow out of the rectum and fecal material to get into the bladder. Fortunately, this is rare, and to date none of Dr Tokita’s patients over the last 14 years have had severe problems.
Statistically, 75% have no rectal symptoms, 15% mild rectal symptoms, 7% moderate rectal symptoms (requiring care from Dr Tokita for 3-4 months) and 3 % severe rectal symptoms, requiring longer care (medications and possibly other treatments to help healing). We have had very few severe injuries to the rectum and are very proud of this record, but they certainly can occur.
Small Bowel: There is a risk to the small bowel (intestines). This injury potential is enhanced If there is a significant amount of small bowel trapped in the pelvis from previous surgeries or infections. This is better known as adhesions. This trapped bowel is at increased risk from the radiation. Normally, Dr Tokita can rely on normal intestinal motion to allow different sections of bowel to move in and out of the radiation field, giving no one area too much radiation. However with adhesions, radiation may injure (severely scar) the trapped bowel and lead to contraction, possible obstruction and rarely require surgical removal of that diseased and injured bowel. Again, this is rare but possible. With the newer treatment set-ups and computer planning, this is rarely seen. Dr Tokita has not seen such an injury since 1978.
Urinary Obstruction: After radiation, occasionally, there is enough increased narrowing and enhanced scarring of the prostatic urethra (urine tube running through the prostate) that the urethra narrows and closes. This usually occurs in patients who have had previous surgery, such as a TURP or other manipulations. This is very rare but serious. If it requires surgery to open, it can lead to permanent incontinence (inability to control one’s urine flow). This is also rare, but if it happens, Dr. Tokita must work closely with your urologist to avoid procedures that enhance the risks of surgery and incontinence. Be sure that Dr Tokita knows if you are having a problem!
Again, to date, Dr Tokita has never seen permanent incontinence in any of his patients.
Impotence: As we get older, we all face the prospects of losing our ability to have adequate intercourse. Even without cancer treatment, 20% of men at 60, 40-45% at age 70 cannot perform and on and on. Any manipulation of our sexual organs can enhance this deterioration. Most men who are able to have intercourse before the start of radiation, will get return of function. However, it may be weaker or not as satisfying, and some may lose their ability to erect well. There are good aids available today, although not perfect. A number of our patients are actually better after treatment, with these aids. Be that as it may, you must be prepared for the risk of losing that function or require medications (such as Viagra, Cialis, etc.) or mechanical or injectable aids.
Finally, we hope every patient we treat will be cured. Realistically, that is not possible. Patients, who are candidates for radiation, in general are reasonable candidates for cure. But under the best of circumstances, the overall cure rate will vary dramatically with the grade (Gleason’s score) and stage (Extent of tumor). That means many of you will be cured and live to hopefully enjoy a longer healthy life. Unfortunately some will not be cured, and we will explore other salvage techniques when possible and work to keep you comfortable if we are not able to offer you an alternative chance for cure. Since cancer of the prostate is often slow growing, non-cure is not an immediate death sentence for most. A large number live many more comfortable productive years, with a slow growing cancer.
The only promise, warranty, or assurance we can give, is to promise the finest treatment available today. Our experience and record speak for themselves.
APPENDIX
Measurement of the Prostate Gland
The prostate gland is measured using a transrectal ultrasound probe. The size and shape of the prostate gland is recorded on film. The Radiation Oncologist and Medical Radiation Physicist determine how many catheters may be implanted and the desired radiation to be delivered to each catheter.
Gland Size
When the prostate gland is less than 40cc(gms), the patient is scheduled for surgery following the initial CT, ultrasound measurement and Computer Treatment Plan.
Here are samples of the transrectal ultrasound films:
The prostate gland, in the transverse view, has been outlined for you in the film on the right. The films show a template grid overlying the prostate gland. The Radiation Oncologist and Urologist use this grid at the time of surgery to guide the hollow catheter/needles into place.
Transperineal ultrasound and fluoroscopically guided HDR Iridium-192 temporary seed implants are done in the surgery department on an outpatient basis. The patient is admitted the morning of the surgery, transferred to the Cancer Center where he is treated and goes home that same evening.
The ultrasound probe is inserted into the rectum during surgery. Attached to the top of the probe is a template with holes to guide the insertion of the catheters into the prostate. These catheters will hold the iridium-192 wire, which will be remotely inserted, at the Cancer Center.
This is a diagram of the Ultrasound probe inserted in the rectum with the template attached to the probe:
The diagram above shows a single catheter through the template. Up to 20 catheters may be used during an implant. The average is 17 catheters.
The smaller inset diagram on the right highlights the grid printed on the template.
Using the preplanned computer grid, the entire prostate gland will be embedded with catheters to predetermined locations.
Below is a more graphic cut-out diagram of a patient in stirrups, having the hollow flexiguides being inserted into the prostate.
Insertion of Iridium-192 Source
The radioactive iridium-192 will be loaded into hollow catheters. These catheters are inserted into the template and prostate with ultrasound guidance.
With the use of the grid and the ultrasound guidance, all the catheters are inserted evenly covering the prostate gland and in some cases the seminal vesicles. The hollow needle is left in place, for later insertion of Iridium-192 with the Remote Afterloading HDR Machine. The diagram inset on the left highlights the “dwell” points or the place where the iridium source will be held. The amount of time it will “dwell” there to deliver the radiation will be prescribed by Dr Tokita and programmed by the Physicist. Also shown are spaces within the catheter between the dwell points, where the Iridium will not stop.
Special Note:
Dr. Tokita uses the above sequence of steps in his treatment of the prostate gland using temporary Iridium-192 seed implantation and external radiation. If you have other resources that differ with this information, please keep in mind that there are several different methods of treating prostate cancer with these modalities and this is what we have found to be the best for our patients.
The consultation, review and this pamphlet are meant to enhance your understanding of these procedures. If there are areas of confusion, possible areas of inadequate understanding or questions, it is critical that you ask before we start your treatment!
Note; Dr Tokita will review the most common risks with you. Unfortunately, it is impossible to be 100% comprehensive of all possible risks. We must warn all patients, that other very serious events can occur. Any time we use surgery, radiation, anesthesia or any surgical procedure, rare but serious events such as infections, pneumonia, blood clots in the leg, blood clots to the lung, etc. can occur. These can lead to long unexpected hospitalizations, debility and under very rare situation, death. To date, we have been extremely fortunate in avoiding these problems, but as we treat cancer patients, we realize that these can occur anytime. We apologize for scaring you, but it is certainly a good thing for all patients to have as full a picture of the risks and benefits as possible.
It is a major mistake to hold back at this important time. Now is the time to ask questions and seek second opinions. Dr Tokita is more than happy to answer your questions and even help you to obtain good second opinions.
For more information, call:
The Cancer Center of Irvine
Kenneth M.Tokita, M.D.
16100 Sand Canyon Avenue, Suite 130
Irvine, California 92618
Phone; 949-417-1100 Fax: 949-417-1165
Copyright © 2004 Cancer Center of Irvine. All rights reserved Disclaimer