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Posted 1/14/2016 4:20 PM (GMT -5)
Hello All,I know Cyberknife SBRT requires the placement of markers (fiducials) in the prostate.Then you wait a week for them to seat.Now Im looking at Varian Trubeam,and Tomotherapy as another choice as those machines dont need fiducials implanted.Is this a better option as to not going thru the CyberKnife with the implants?Less invasion? I know its who is behind the machine,the expertise of the RO setting doses etc.But the more advanced the machine makes up a little for experience ?
Posted 1/14/2016 6:24 PM (GMT -5)
Gosh 0311, I thought you would get more traffic on this topic. Hopefully with this one it will give you the info you are looking for in order to make a better decision. Any help out there?

For my hubby and I, if we don't find any more answers we are going to base our opinion on the fact that Cyberknife is older technology so therefore not as good(??) as the newer technology.

Everybody must be so tired from worrying about the Powerball, they are all taking a break. (wink, wink)
Posted 1/14/2016 6:44 PM (GMT -5)
I just completed salvage IMRT/IGRT using the Varian Trilogy system. I asked the same question and the radiation oncologist and latter the radiation technicians said they used to use fiduciary markers. They said they moved away from invasive markers due to the risk of infection, discomfort during the implantion, and costs for the patient. With Image Guided Radiation Therapy, I had 3 extremely small tattoos, on on each hip and one about 5 inches below the belly button.

The process is I get on the table, they used the tattoos to primarily get me fairly closely lined up with the lasers in the x,y,z axis. The tattoos about the size of a period at the end of the this sentence was done during the planning stage when you had the original CT done. Prior to each treatment the system's conebeam CT (CBCT) arms swing out and takes a 3D CT image which is used to precisely align my body to the exact coordinates required (within about 1mm in the x,y,z axis.) The daily CBCT is then overlayed on the original CT that was utilized to plan your treatment. Within a minute the table you are laying on automatically moves in the x,y,z axis to the precise location. Then the radiation treatment starts. The entire process from laying on the table to completion of the treatment takes about 5 minutes.
Posted 1/14/2016 6:54 PM (GMT -5)
Geez,I was pretty close to Cyberknife.Today I just called a place that did Tomo and they said they now have the newer Varian Trubeam that also dont use the gold markers (fidiculs).Yes ,how about the learning curve on any newer piece of machinery that was discussed in posts past ? When I look at these hospitals that do any of these I always look at the Bio of the Drs.Where they were educated,how long doing this etc.I asked few of the secretarys for patient referrels and they said they dont give that info out.One said HIPPA rules or laws.I remember Tall Allen stating even if some ROs did give some names ,they could be the ones with the most positive outcomes.But in the end look at the 9 yr. study that Tall Allen posted recently about SBRT.I hope to hang my hat there soon.
Posted 1/14/2016 8:01 PM (GMT -5)
Vero appears to be the real state of the art for SBRT.
Posted 1/14/2016 8:26 PM (GMT -5)
Cleveland Clinic used the Varian Edge for Steve's SBRT. He had fiducials and tattoos and also a mold for the lower half of his body. All of these were used to align his body with the pre-planning scan. They also did a rectal balloon prior to each treatment.

Our first scheduled treatment was cancelled because our RO felt things were NOT aligned to his satisfaction. They tried three times but we were eventually sent home. One of the technicians told us our RO was an absolute perfectionist about the alignment. I'm sure that was an expensive morning for the Clinic because no treatment meant no billing to insurance. While we were extremely disappointed about the delay, this experience confirmed that we made the right choice with our RO.
Posted 1/14/2016 8:46 PM (GMT -5)
I was treated using Truebeam and RapidArc with fiducial markers. I know that Tomotherapy doesn't need them because it uses the "waste" X-rays for imaging.

Here's a dosimetry study that compares VMAT (like RapidArc), Tomo, and Robotic (CyberKnife):
Stereotactic Body Radiation Therapy (SBRT) for Low-Risk Prostate Cancer: A 3 Way Comparison Between Modulated Arc, Helical Tomotherapy, and Robotic Radiosurgery Plans

They're all pretty good, arc was a bit better in that study.

Unless you're using Tomo (who is using Tomo for SBRT?), I would caution against trying to do it without fiducials or Calypso. SBRT is just too high dose rate to be anything but absolutely precise, and the best way to get that precision is by using implanted markers and continually checking position throughout the treatment. I know that some have argued that a rectal balloon is enough to ensure reduced prostate motion and reduce the risk of rectal injury when using a very fast arc machine. I'm dubious - I'd like to see that proven.

There are several manufacturers of arc systems - Novalis and Elekta are probably the two biggest. Vero is an arc system with an extra dimension, but it is a rarity. The precision is a product of both the X-ray delivery system and the on-board imaging system - both have to be really good for SBRT. All of them are good systems, as long as the RO and physicist are expert at getting the best plans out of them.

- Allen
Posted 1/14/2016 9:52 PM (GMT -5)
Upstate has Tomo , but don't consider using it for SBRT due to its' lack of positioning precision in particular in light of the fact that they do have Vero, which they like because of said precision.

Of course they need to pay for the Vero machine.....there is that.
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