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Is CyberKnife the hope I've been looking for?
Mindy Irby
Posted: Tuesday, December 28, 2010 4:47 PM
Joined: 12/28/2010
Posts: 14


I'm a 47-yr-old mother of 2 (11 & 13), never smoked/drank, nor diabetic or overweight recently (on 11/21/10) diagnosed with stage II/III unrecectable Pancreatic Cancer: The 2.5x2.7 cm hypodense mass abuts the portal splenic confluence and causes a high-grade narrowing of the superior mesentery vein upon its entrance to the portal vein. I've received Chemo (Gemzar & Abraxane) on 12/13 & 12/20 (12/27 was delayed till 1/3/11 due to high grade fever). I've consulted with CyberKnife here in Phoenix (St. Joseph's Barrow Neurological Institute) and told I am a candidate. Here are my questions: My Oncologist and the Radiation Oncologist he referred me to are both vehemently against CK, even though the Radiation Oncologist used to work at St. Joe's operating CK. They both advocate the traditional snail-pace 5-7 wk daily radition, they said "these are tried and true". I argued with both that from what I read the "tried and true" had not been substantially more successful in shrinking pancreatic tumor while one case study from Georgetown University shows a 54-yr old man with identical tumor (down to the size) and unrecectable for the same reason was successfully treated with CK after trying their so-called "tried and true" method. Please assure me that CK is not as "horrific" as they tried to portray... And should I consider flying over to Standford for CK treatment (the birthplace of CK) or stay in Phx? Or even Georgetown University? I'm willing to go anywhere that has the best track record in treating Pancreatic Cancer with CK (how do I know who does?) Thank you for your attention.
youngpatient
radsrus
Posted: Tuesday, December 28, 2010 4:52 PM
Joined: 10/10/2008
Posts: 4435


St. Joseph should be able to do this. SBRT for pancreatic cancer is highly effective in achieving local control, and it is at least as effective and safe as standard treatment. I suspect there is economic bias in the other advice you have been given.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Wednesday, December 29, 2010 1:12 PM
Joined: 12/28/2010
Posts: 14


Thank you Dr. May I ask a few other questions that came to mind? On 11/20 I had an Abdominal CT which found the tumor, on 12/2 I had the PET, both CT showed liver to be clear. But on 12/17, 4 days after my first round of chemo, the Angio CT showed a 13 mm hperdense lesion in the liver. Liver biopsy was done on 12/22, report came back on 12/27 showed no neoplasm identified. Any idea why the liver lesion did not show up in the earlier CT? Could it have grown between 12/2 and 12/17? Or has it always been there just not picked up by the earlier CT? I was told liver metastasis can not be ruled out even though the biopsy result reported negative for cancer. Would this remove me as candidate for CK now?

Mom of 2
Mom of 2
Posted: Wednesday, December 29, 2010 1:16 PM
Joined: 12/28/2010
Posts: 14


Sorry, forgot to add: if CK is able to successfully shrink the tumor, would Whipple still be necessary?

Mom of 2
radsrus
Posted: Thursday, December 30, 2010 3:25 AM
Joined: 10/10/2008
Posts: 4435


We would not recommend surgery after CK for pancreatic cancer.

I think you will just have to wait on the liver abnormality and see what develops. You could go ahead with CK if you wished.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


PCDaughter
Posted: Monday, January 03, 2011 3:40 PM
Joined: 12/19/2010
Posts: 5


Why is surgery not recommended after CyberKnife?  I am confused.  I was under the impression that the only chance for cure was surgery.  The CyberKnife is used to shrink tumors, either as palliation of symptoms or as a means to shrink the tumor enough to possible surgically resect it.  The CyberKnife will not offer a cure.  Am I mistaken?



PCDaughter
PCDaughter
Posted: Monday, January 03, 2011 3:44 PM
Joined: 12/19/2010
Posts: 5


What do you mean by SBRT?  Is that different than "standard" radiation therapy (external beam and internal/brachytherapy)?

 

Are you saying that standard radiation therapy is the most commonly prescribed method for economic reasons - bringing in more revenue to the administering hospital? 


PCDaughter
radsrus
Posted: Monday, January 03, 2011 4:42 PM
Joined: 10/10/2008
Posts: 4435


You are mistaken. The CK is primarily used with curative intent, although there are times when it can be used for palliative benefit. It is generally used instead of surgery.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


radsrus
Posted: Monday, January 03, 2011 4:44 PM
Joined: 10/10/2008
Posts: 4435


SBRT is stereotactic Body Radiation Therapy. It is the same thing as stereotactic radiosurgery, except the latter term is now conventionally reserved for tumors in the head, while SBRT is conventionally used for tumors elsewhere.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Monday, January 10, 2011 2:48 PM
Joined: 12/28/2010
Posts: 14


As I mentioned in earlier posting, I wanted to know if I should travel to Stanford or even Georgetown University to receive best CK treatment. Both Stanford and Dr. Medbery suggested my local St. Joseph's in Phoenix should be adequate. I found out last week that I in fact will be St. Joseph's very first Pancreatic Cancer patient they will be treating with CK, apparently all previous patients with PC they have seen had been Stage IV, too advanced for CK.  I've gone for MRI on Saturday, 1/8 and just got back from CT this morning, the first CK treatment is being planned for next Tuesday, 1/18.  I am anxious and nervous about being their very first PC patient, I know I've invested too much money and time to be asking this, but: should I have chosen to go to Stanford or Georgetown afterall?  For more experience and reassurance?  St. Joseph's in Phoenix did have almost 10 yrs expereince in using CK, just not on PC patients.

Mom of 2
radsrus
Posted: Tuesday, January 11, 2011 11:10 AM
Joined: 10/10/2008
Posts: 4435


I guess I am a little surprised they had not treated pancreatic cancer, but the most important thing is that they just take the time and care to do it right.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Tuesday, March 22, 2011 11:48 AM
Joined: 12/28/2010
Posts: 14


8 wks post CK. Had MRI Saturday, 3/19. Got result yesterday, was disappointed to hear no shrinkage of tumor.  Was really hoping for the optimal result of complete eradication, at the very least some amount of shrinkage.  Am I asking/expecting too much?

One bit of good news is, the tumor marker has been dropping.

CA19-9 was 4000 on 11/20 and 4923 on 11/30. CA19-9 was 3375 on 1/7 (after 1st 3 rounds of chemo: 12/13, 12/30, 1/3). CA19-9 was 2000 on 2/4 (after CK: 1/19, 1/21, 1/24).

Most recently, CA19-9 on 3/14 was 727 (after 4 rounds of chemo: 2/7, 2/14, 2/21, 3/7). 

I had chemo 3/14 following CA19-9 test, and again yesterday, 3/21.  Hoping that's enough to bring CA19-9 down to normal range (0-37)?!?

Question again: Should I be concerned that tumor has not shrunk after 2 months post CK? Or is it more important that CA19-9 is dropping consistently? 

And if the last 2 rounds of chemo, 3/14, 3/21 is enough to bring CA19-9 to normal range, would I need additional chemo ("to play it safe")? I was initially told chemo was been planned for 6 cycles total, into June.  I'm 3 cycles in/down. 

Thanks again for your consideration... anxious for your response...



Mom of 2
radsrus
Posted: Wednesday, March 23, 2011 3:51 AM
Joined: 10/10/2008
Posts: 4435


You don't need to be unduly concerned. We frequently find that masses just sit there and become scar tissue. That dropping tumor marker is a good sign. I will leave the chemo question to those who do it for a living. I have not done so since 1984 - not exactly up to date


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Tuesday, April 05, 2011 10:57 AM
Joined: 12/28/2010
Posts: 14


Had a CA19-9 test on Friday, 4/1, was disappointed (and devastated) to see that it went up, from 727 to 754.  Doc wants me back on chemo for one more cycle (3 more treatments) and he's scheduled PET Scan on 4/25. If PET Scan confirms that cancer is confined to the pancreas, he will consult with the surgeon to see if he can surgically remove the remaining tumor, even though the post-CK MRI shows "The mass encases and obliterates the pancreas portion of the superior mesenteric vein.  There is redemonstration of prominent splenic venous collaterals."

My Oncologist said, even though my CA19-9 had been dropping consistently, from the high of 4923 to the current 754, he sees no possible chance with continuing chemo to bring it down to normal level, surgery is my last remaining hope.

I was previously warned/advised by the surgeon that there's a chance they may need to remove the entire pancreas, rendering me diabetic.  So: cancer or diabetes?  I think the choice is clear... except I'm in the same boat I was before treatment started (chemo or CK): unresectable with tumor wrapped around major vein.

P.S. my Gastroenterologist said with my CA19-9 almost at 5,000 it's the highest he's ever seen, he said most that he's seen before had been in the 700 range, and I saw some other postings in this forum talking about CA19-9 in the tens and hundreds, does this imply my tumor is exceptionally aggressive?  And hence incurable?

I am quickly losing hope and feeling spent...



Mom of 2
radsrus
Posted: Thursday, April 07, 2011 11:21 AM
Joined: 10/10/2008
Posts: 4435


I am not sure that the tumor marker correlates well with the aggressiveness of the disease, more with the amount that is present. A change from 727 to 754 is pretty small and may not be all that significant

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Friday, April 08, 2011 11:38 AM
Joined: 12/28/2010
Posts: 14


Earlier chemo treatments seemed to be successful in bringing down the CA19-9, significantly, but last 2 (3/14 & 3/21) did not seem to move the needle much, any reason I should worry that subsequent treatments may/will have ceased being useful?

My doc said the elevated CA19-9 could be caused by elevated WBC or an infection and in fact my WBC on 4/1 was quite high: 16.5 (normal 4 - 11), do you agree with that assessment?  Why would high WBC cause CA19-9 to go up as well?



Mom of 2
radsrus
Posted: Friday, April 08, 2011 12:23 PM
Joined: 10/10/2008
Posts: 4435


i frankly don't know why an elevated WBC would cause the CA 19-9 to increase. I will take their word for it. Tumors almost always become resistant to chemotherapy, usually not just to the agents being given, but also to other agents.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Saturday, April 09, 2011 10:16 PM
Joined: 12/28/2010
Posts: 14


Thanks Doc... but this is not very encouraging, I'm scheduled to return on Monday for more chemo, how do I know if I'm just suffering the side effects of chemo needlessly, if my tumor may have, like you said, become resistant to treatment? What are my options? I'm so confused... when should I/can I say enough is enough? I had reached that point couple of treatments back, when I needed to get daily neuprogen injections, I was ready to give up, except I thought the next couple more treatments will finally get my CA19-9 to normal... Please help me understand...

Mom of 2
radsrus
Posted: Sunday, April 10, 2011 5:29 AM
Joined: 10/10/2008
Posts: 4435


That is not a very big rise in the CA 19-9. You might want to get one more cycle and see what it does. THese things tend to wax and wane somewhat

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Tuesday, May 03, 2011 8:09 AM
Joined: 12/28/2010
Posts: 14


PET Scan from 4/25 says “The site of the primary malignancy seen previously is no longer metabolically active.  Imaging through the remainder of the abdomen and pelvis is unremarkable with no other areas worrisome for metastatic disease”. 

My CA19-9 is now 170 (dropped from 727 on 3/14) but because it's still elevated, my Oncologist said to continue chemo, indefinitely until surgery can be scheduled.  He will be requesting EUS to see if tumor has shrunk, away from SMV.  But he also said even if I'm now resectable, the surgeon had indicated to him that he's never done a Whipple on a CK patient and may not be willing to risk it.

So now my Oncologist is in the process of looking for a surgeon for me who will operate.

Do you know of any surgeon who has such experience?  I am willing to travel anywhere to get the ultimate cure and stop the dreaded chemo, which is now making me sicker than the disease itself.   Thank you.



Mom of 2
radsrus
Posted: Tuesday, May 03, 2011 5:12 PM
Joined: 10/10/2008
Posts: 4435


I am not sure why you would want surgery. THere is no metabolically active tumor. Surgery is risky, and recovery is prolonged. Stanford data shows about 85-90% control with CK alone, and that is very good compared with a Whipple procedure.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Wednesday, May 04, 2011 4:27 PM
Joined: 12/28/2010
Posts: 14


Because I can not tolerate 6 more months (or longer) of chemo which is what I was told if surgery is not performed (this is even with a dead tumor!).  My Oncologist went even further and said chemo may need to be continued indefinitely until surgery is possible.   I was told repeatedly that only surgery/Whipple is a sure cure, anything less than that is risking a recurrence of cancer.

Went and saw Mayo surgeon yesterday, he ordered CT Angio today and I'll have an EUS next Friday to make sure the tumor has broken away from the SMV enough for surgery to proceed.



Mom of 2
radsrus
Posted: Wednesday, May 04, 2011 5:42 PM
Joined: 10/10/2008
Posts: 4435


Surgery does not mean no chemo, or vice versa. If you can't tolerate chemo, then don't take, although I personally think it is a good idea. The risk is metastatic disease more than local recurrence

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


radsrus
Posted: Wednesday, May 04, 2011 5:46 PM
Joined: 10/10/2008
Posts: 4435


Whipple is not a sure cure by any means. Only about 20% of patients are candidates, and only about 20% of that 20% are alive at five years. I don't mean to alarm or depress you, or to say that surgery is worthless, but just think it needs to be clearly stated that surgery is not a cure-all even if "successful", and with no viable tumor on the current PET scan, it is hard for me to see a role for the procedure

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Friday, May 06, 2011 3:48 PM
Joined: 12/28/2010
Posts: 14


Thank you Sir. Your objection to surgery turns out to be quite comforting to me, considering your advice I was not as devastated when I got the CT Angio report yesterday.  

This is what the report says: "Since the exam of 12/17/2010, the pancreatic low-density mass has increased slightly in size measuring 28 x 27 x 23 mm previously 27 x 25 x 19 mm.  There is now complete focal obstruction between SMV, splenic vein and portal vein, with the confluence completely obliterated.  However, through collaterals, these veins otherwise remain patent." 

From reading the report, I'm guessing those veins are still involved and I won't get my surgery after all.

My question is: has my Cyberknife treatment, concluded on 1/24, stopped working?  Or can I expect it to continue working, in conjunction with chemo, to help shrink even my dead tumor? Would a dead tumor shrink?  Or is it scar tissue now?



Mom of 2
radsrus
Posted: Saturday, May 07, 2011 11:13 AM
Joined: 10/10/2008
Posts: 4435


I don't think you can know right now what is happening. The best evidence you have is the negative PET scan

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Mom of 2
Posted: Monday, May 09, 2011 8:33 AM
Joined: 12/28/2010
Posts: 14


All the doctors, from the Gastroenterologist, to the Oncologist, to the surgeon all advised me to pursue surgery, if not now, then in the future (after tumor shrinks?).

Even my CK doc does not object to surgery (I'm his first Pancreatic Cancer patient, he had cautioned me even as I was being prepp'd for CK that CK is still considered experimental).

Should I seek advice from Stanford, or Georgetown, facilities that have more experience with CK treatments?  Would I be able to send them my CT/MRI scans alone or would I have to make appt and visit in person?



Mom of 2
Mom of 2
Posted: Monday, May 09, 2011 9:46 AM
Joined: 12/28/2010
Posts: 14


What I'm saying is... no one around me seems to have much experience treating a CK patient like myself, not even my CK doctor (as I said, I'm his first), I feel like I need to meet/consult with ones that have more expertise both in advising in surgical removal of a pancreatic tumor (dead or alive) as well as ongoing chemo treatment after a dead tumor...

Mom of 2
radsrus
Posted: Monday, May 09, 2011 6:32 PM
Joined: 10/10/2008
Posts: 4435


YOu might want to get a consultation from one of those places and see what they say.

 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Capt.Stoney
Posted: Wednesday, September 21, 2016 2:49 PM
Joined: 5/9/2011
Posts: 2


I'm 74YO and have had PC for 6 yrs with NO treatments. It has been stable but now has recently shown some small growth. It is under 4 cm and I'm looking into Cyber Knife, can I get some input.

Fair Winds and Clear Skies

Capt. Stoney


 

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