Todays blog is going to start the discussion about the use of Cyberknife to treat prostate cancer. Because this is such a new and interesting modality to treat prostate cancer, I am going to break up the discussion into at least two sessions. The first will introduce the method of treatment and the particulars of the treatment itself. Further discussion will take place about my experience with Cyberknife in terms of its side effects, complications and results.

Cyberknife Stereotactic Radiosurgery (CKSRS) is one of the newest and fastest growing radiation treatment options for localized prostate cancer. While Cyberknife is being offered at a small handful of hospitals in Maryland, there is no question that Sinai Hospital of Baltimore has the largest experience with this exciting technology. There are multiple uses for Cyberknife, but given my specialty and this forum, we will only address its use in the treatment of localized prostate cancer. I am not aware of any other hospital locally that is offering CKSRS for prostate cancer, although this may have changed over the last few months.

Our group, Advanced Urology Associates, has by far, the largest experience of any urology group in the Mid-Atlantic region. As of the writing of this blog, it is my understanding that our group has the only urologists locally that are credentialed to perform CKSRS. In the last year, Drs. O’Reilly and I have treated over fifty men using CKSRS at Sinai Hospital. And while long term treatment success is impossible to gauge at this time, PSA results have followed that of seed implantation and the side effect panel has been minimal. In the interest of full disclosure, I do not own any portion of the Cyberknife machine nor do I own stock in the company which makes it. Finally, I am not an employee of Sinai Hospital. I became interested in Cyberknife as an alternative to seed implantation in the patient with significant voiding dysfunction putting them at higher risk of complications from my standard treatment.

CKSRS for prostate cancer is performed as an outpatient. It is similar to the high dose radiation model of seed implantation rather than the low dose multiple treatment model of external beam radiation or IMRT/IGRT. Typically each patient receives five one hour treatments given on a daily or every other day basis.

Typically my pre-surgical evaluation of the patient is limited to an initial consultation followed by a urinary flow test and measurement of post void residual urine. In those men in whom it is indicated, cystoscopy will be performed. After the patient has undergone consultation with the radiation oncologist they will be scheduled for placement of fiducial markers. These are four gold marker seeds that are placed at the base and the apex of the prostate on both the left and the right side under ultrasonic guidance. This procedure is done under a light sedative similar to what is used for colonoscopy. A small bowel preparation the day before the procedure insures an empty rectum and excellent ultrasonography allowing for precise placement of the gold fiducial markers.

Approximately one week after placement of the gold fiducial markers the patient undergoes a pelvic CT scan and MRI. Following these studies, the CT and MRI are merged by the Radiation Physicist at Sinai Hospital. The urologist then pulls up the studies and “contours” the prostate. Essentially, we create a three dimensional image of the prostate based upon the merged CT and MRI. The previously placed gold fiducial markers act as grid points allowing us the merge the two studies. Once the prostate and critical structures such as the bladder, rectum and urethra are contoured the Cyberknife computer generates a treatment plan for the radiation. The patient comes in for his five one hour treatments, again given either daily or every other day, and thus completes his treatment regimen.

As with seed implantation, an antibiotic is given prior to placement of the gold fiducial markers. In addition, I start all of my CKSRS patients on either Flomax or Uroxatrol to help with urination during the period of treatment and typically for a couple of months afterward. I have not had to use the steroid dose pack as I have done with the seed patients and post procedure pain has been handled with either a non-steroidal such as motrin or a very light narcotic such as hydrocodone.

In our next discussion I will go over treatment results in terms of side effects and short term PSA results.

I would be remiss if I did not mention how proud I was of my Baltimore Ravens this past weekend. To go into New England and lay the beating they did on the Patriots was nothing short of amazing. For all the criticism of the Ravens and their coaching staff this year, I think we can safely say that at a minimum this team has a lot of character. And that starts with the head coach, John Harbaugh. Kudos to the team on an impressive victory. Now go exorcise the demons of the Mayflower past, go into Indy and beat the tar out of the Colts. Go Ravens.

I realize that it has been awhile since my last post but now that the new year has started, my goal is to post a couple of times a month. Today the health discussion is more on a spiritual level than physical level.

On the 10th of November my mother Sylvia “Mickey” Leventhal Weinberg suffered a massive cerebellar stroke. Three weeks later she was buried to rest alongside my father who died when I was a young man of 18.

My mother was a few months shy of 90 when she died. She was your typical old Jewish lady. She was as parsimonious as they came, but was generous with her time. She volunteered at the Weinberg center where she lived for years before she lived there. She was a member of the Golden Rule Guild and used to volunteer at Spring Grove and Rosewood. When my brother asked her why she was a volunteer at age 88 she gave him an answer that stays with me now and will all my life. She said, “ Because I can, and they can’t and as long as I can, I will.” That was the essence of my mother may she rest in peace.

Since my father died when I was young and our family was not observant, this shiva period was the first I have experienced in the Orthodox community. The outpouring of support was incredible. We had people here to help me make a minyan that I had never met before. The women of our shul made sure that all of our meals during shiva were accounted for. I essentially was not left alone for the whole week of shiva.

Having now finished shaloshim (the first 30 days of mourning), I have had a chance to sit back and reflect on the importance of community during this time. It is trite to say, but there is no good time to die. It follows then that there is no good time to lose a parent. And finally, once you lose both parents, you are an orphan even at age 48 as I am. And you realize that you are an orphan despite being a grown adult with children of your own.

Our community in the Orthodox enclave is very tight knit when it comes to things like the loss of a loved one. I now understand why it is so important that my wife invariably is making food for 15 instead of our typical five a couple of times a month. It was a comforting feeling physically, emotionally, and spiritually when I needed it most. Every community has its ups and downs. Every community has its drawbacks and the Orthodox community of Baltimore is no exception. But when it comes to support in times of need, the Orthodox community has no peer, at least in my myopic view.

This is an open letter expressing my sincerest thanks to all of the people who helped me through one of the most difficult times of my life. To my business partners who covered for me while my mother was ill and after her death, to the hundreds of my patients who sent me condolence cards, to all of the people of all races and religions who stopped by my home during the week of shiva to be “menachem avel,” I thank you from the depths of my heart.

Back to urology next time. Until then, have a happy New Year and a fulfilling week ahead.