Sunday, December 6, 2009


DR.MAHADEV Senior Consultant, Radiation Oncology

71 Yrs old Mr.Birendra Singh from Gopalganj, Bihar was devastated when he was diagnosed to have Prostate cancer. He had gone to his urologist for just a routine checkup because he was having difficulty in passing urine for the last couple of months. A routine PSA done was in the range of 15ng/ml. A transrectal biopsy revealed grade 2 adenocarcinoma of the prostate gland with a Gleason’s score of 3+4.

Mr.Singh went to Delhi for an opinion. He consulted various doctors which included several urologists, surgical oncologists and radiation oncologists.The options given to him included wait and watch, bilateral orchidectomy(removal of both testis), Radical prostatectomy, Brachytherapy(seed /HDR implant).The opinions were so varied that the family could not take a decision for 3 months.

Patient also consulted Apollo Hospitals at Ranchi in Jharkhand where he was advised to go to Apollo Speciality Hospital Chennai as all the treatment options were available there and he was also told that a full team of doctors decide on a treatment in the tumor board.

Mr Birendra Singh’s nephew who lives in the United States, meanwhile contacted his uncle from there and told him about a new treatment called the cyberknife which he had read on the internet. His nephew was very impressed by what he had read on the net- outpatient treatment, non-invasive, very precise radiation delivered robotically and just 5 sittings with practically no side effects. He asked his uncle to come to US for treatment as he thought it was unlikely that this treatment option would be available in India.

After going through all the treatment options Mr.Birendra Singh decided he would go in for Cyberknife as he found that to be the best treatment modality in his opinion. He visited Chennai in March 2009 to take a final decision. We had just then started using Cyberknife and we told him that the latest version of Cyberknife is now available here. He was told that the cost of cyberknife would be around 40,000 US dollars in US. We told him that the cost of treatment here would be Rs 400,000.

As we had just started Cyberknife Mr Singh was anxious about our technical capability. But when he came to know that the entire team was trained at the Stanford University, California, where actually the cyberknife was invented, he immediately decided to have the treatment here.

The first step in the treatment process was counselling him about the various treatment aspects.This included explaining to him the various stages of the treatment preparation ,planning and execution.The expected benefits and the various side effects that can be expected was explained to him in detail.The side effects that are normally seen with this treatment can be increased frequeny of micturition and bowel movemens.Very rarely, rectal bleeding can be seen as a late effect of radiotherapy.

The second step was placing 5 gold fiducials into the prostate gland transperinealy under transrectal guidance which took about half an hour. These fiducials are necessary for the machine to track the prostate gland during the entire course of treatment. Normally, we have to wait for a week after placing the fiducials for doing the planning CT scan. This is necessary because in the first couple of days, the seeds can migrate.

The third step in his planning was the making of a special type of bed called Vacloc for immobilization of the patient during treatment. Vacloc is a vacuum bed which takes the shape of the patient so that daily reproducibility of the patient in the same position can be achieved easily. This took about 10 minutes following which a CT scan was done with the patient lying in the vacloc in the treatment position.

Next, the Radiation oncologist contours the prostate gland, bladder and rectum. Then, the medical physicist puts on the treatment beams. The treatment plan was ready the next day and was reviewed by the oncologist and urologist.The treatment plan was finalized and the patient was asked to come for treatment the following day which happened to be a Tuesday. Patient was asked to have a light breakfast before 8 am and report for treatment at 10am.He was also asked to take a laxative the previous night and antacids.This preparation is a very important part of the treatment as improper bowel evacuation and gas in the bowel can interfere with the accuracy of the treatment.As cyberknife can achieve submillimeter target accuracy and continuously tracks the target while treatment ,it is absolutely essential that patients follow this preparatory regimen very carefully.Mr Singh was prescribed 5 treatment sittings on consecutive days.

Each treatment lasted for about 45-50 minutes and Mr.Birendra Singh completed his treatment on schedule on Saturday.He had initially booked his tickets for Sunday but as he did not have any side effects he preponed his journey to Saturday night.He was advised to have a PSA after 3 months which confirmed that the PSA had come down to normal values.


Mr.Singh Reported back to us in the first week of December. His PSA which was repeated was less that 1ng/ml which shows excellent response to treatment. There were practically no side effects during and after the treatment.