Dr. Nadim Nasr
speaker
51 appearances
1 recordings
1 series
first heard Oct 2024
last heard Oct 2024
Dr. Nadim Nasr’s voice in public audio — every appearance, attributed to the second.
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Appearances
I warn them that once that spacer goes in, they will have feeling of rectal fullness, feeling like they have to have a bowel movement. I remind them that they just had an enema a little while ago and there's really nothing to come out. and so that tends to relax them.
Once we finish the procedure, we tend to get their legs down, tend to get their legs to bend their knees up a bit, and I think that helps them a little bit with that sensation, and it generally goes away within a few minutes. I do warn them that they may see a little bit of blood in the urine or stool for a day or so after treatment.
Obviously, most of these gentlemen have had a prostate biopsy not too long before, and so they're pretty familiar with that. And that's really about it for the side effects. I mean, I prepped them and most of our talk obviously is on the side effects of the radiation, not necessarily this.
Because we're moving to so much SBRT now, all of those patients, and we have a CyberKnife as well. That's our main SBRT unit. All of those patients are planned with both CT and MRI imaging. When we do our treatment planning, we're doing a CT simulation in our department And then they're going straight to radiology for an MRI right away in the same day.
And then we fuse those images based on the fiducial markers. And so you get a nice registration of the two images. And you can see that hydrogel very nicely on those MRIs. And where will there be a benefit using the spacer view? There was a short time period where we were doing a lot of spacer and we were still doing a lot of IMRT that was purely CT based for planning.
And I did use it for a brief amount of time there. But again, now that most of what we're doing is based on both CT and MRI imaging, I don't really use it anymore.
So we're a little bit different. I mean, we're a hospital-based group in the sense that we contract out to the hospital to do all their radiation professional services, but the technical fees still go to the hospital, including a lot of the technical fees for the equipment, the medications, the gels, and things like that. So that's a loop through the hospital process.
But we're, of course, conscious of that. Where our challenges come in are some of the insurers in the area will not cover a spacer, or at least not initially. And so in those cases, what we've started doing is placing the fiducial markers, planning the patient, and then if it looks like there's absolutely a need for spacing because of compromise on either coverage or
or rectal dose, then we'll go ahead and make a request to put in the spacer. So those are the challenges that we face on our end.
You know, with SBRT, generally from the time of fiducial and spacer placement till treatment is about at most three to four weeks in our practice. And my experience is the spacers really held its shape and integrity very well. I've not had any problems with that. And even back when we were doing longer courses of IMRT, I didn't even see any issues even up to about two months out.
at least with spacer. So my experience has really been that it does maintain its integrity and shape.
Large prostates, it absolutely matters. But again, it matters on the particular anatomy. Is it a large prostate with some separation between the prostate and the rectum, or is it one of those prostates where the rectum is draped across the backside and on top of the prostate? Obviously, if somebody has a large prostate or they have higher risk disease, we are putting them on ADT.
And again, if they're having a lot of urinary symptoms or they have a large prostate, I will put them on ADT for a couple months before treating them versus if they don't really have any of that, we'll go ahead and start ADT and then within a few weeks treat them.
I have not had an issue with re-spacing. I have had the issue of having to re-scan and re-simulate for planning just to confer. And I think the longest we had was about a three-month gap, and it still looked very good. I mean, I think it was a little bit small. I compared it back to what we had seen before.
I think the spacing was a little bit less, but it wasn't so much as I would have considered re-spacing. I think they were perfectly fine proceeding with treatment. Luckily, though, they had good anatomy as well. And that was three months after original placing? Three months after placement, whereas usually we'll scan usually about two weeks after spacing.
This is a big reason why we're the ones that are putting a lot of these spacers and fiducials in and not the urologists that send them to us. A lot of the urology groups that we get patients from have standing stentors. They're their own practices, and I think they're very happy not dealing with it, honestly.
I mean, that's exactly what I tell them is, you know, the gel will dissolve. I think they will end up with a lot less perirectal scarring in that area. And, you know, I've gotten some feedback from the gastroenterologists that we work with, really just for my own curiosity as to what they're seeing on colonoscopies on some of these patients, you know, routine colonoscopies. And
They do tell me that they're seeing a lot less telangiectasias in that anterior rectal wall. They're seeing a lot less post-radiation changes. I mean, they're still there. I don't think it's going to go away. We're still getting a decent dose of that anterior rectal wall, but it's certainly not something that I think has long-term consequences.
When we first started doing the spacer back in, I think it was 2016, 2017, when it first came out, most of the data was on external beam and IMRT. And there was actually very little data on SBRT. So we had some residents rotating through that put together some of our data for us. And essentially what we did was we did a comparison of rectal dosimetry for CyberKnife between patients that...
had spacer versus ones who did not have spacer and we tried to match patients up based on prostate size which was the one factor that we we thought would equal things out and essentially what we saw was anywhere between a 50 to 70 percent decrease in dose to the interior rectal wall and specifically a lot of the higher dose points, not just sort of the average lower dose, but the higher doses.
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