Question about prostate fiducial markers

[iradi8u]

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I have recently joined a private practice where they don't use fiducials for prostate IMRT, and I am not comfortable with this. We don't have transrectal US available and I'd like to convince the urologists to place the gold seeds.

Does anyone have any information about the costs/reimbursements for obtaining and placing them so I can pass this on to the local urologists? Thanks.

 

[Reaganite]

I ran into the same issue when I joined my practice. We actually did have BAT, but I had never used it before, and honestly I wasn't at all comfortable with the images, so I had to convince my local uros to place fiducials. They were okay with doing it, but they don't rush my patients in either. I usually have to wait several weeks for medicare/ppo patients, and sometimes a month or more for HMO patients. We pay about 80 dollars for a pack of 3 and give them to the uros. Reimbursement is **** for the placement (a little over $100 I believe) so you pretty much have to supply them.

 

[Neuronix]

We place fiducials here as a resident. This leads me to two questions:

1) If not using fiducials, what are you guys using for image guidance? Are there still a lot of practices out there not using image guidance? I'd be curious about dose and margins in that case, though I don't think I would feel comfortable doing it.

2) What are some other barriers to putting in your own fiducials in private practice? Is this primarily a training issue--i.e. not all residents learn how to place their own fiducials? It seems like an ultrasound unit for this indication would be cost effective, or am I mistaken?

 

[Palex80]

We place fiducials here as a resident. This leads me to two questions:
1) If not using fiducials, what are you guys using for image guidance? Are there still a lot of practices out there not using image guidance? I'd be curious about dose and margins in that case, though I don't think I would feel comfortable doing it.

We don't use fiducials. CTV->PTC-margin is 0.7cm posteriorly, 1 cm in all other directions. Daily cone beam CT.

 

[deleted4401]

Same as Palex, but 0.7cm all around. Soft tissue match is fine.

 

[medgator]

I have recently joined a private practice where they don't use fiducials for prostate IMRT, and I am not comfortable with this. We don't have transrectal US available and I'd like to convince the urologists to place the gold seeds.

Does anyone have any information about the costs/reimbursements for obtaining and placing them so I can pass this on to the local urologists? Thanks.

If you have Cone beam CT, just use the prostate as a fiducial. The reimbursement on fiducial placement isn't great especially since the actual gold seeds themselves eat up a big chunk of it.

I never placed them as a resident, but quickly learn to do so in private practice (along with giving my own ADT, but that's another topic altogether). If you are using just orthogonal imaging, I would not use bony anatomy alone without fiducials for IGRT

We place fiducials here as a resident. This leads me to two questions:

1) If not using fiducials, what are you guys using for image guidance? Are there still a lot of practices out there not using image guidance? I'd be curious about dose and margins in that case, though I don't think I would feel comfortable doing it.

2) What are some other barriers to putting in your own fiducials in private practice? Is this primarily a training issue--i.e. not all residents learn how to place their own fiducials? It seems like an ultrasound unit for this indication would be cost effective, or am I mistaken?

A lot of places use CBCT for IGRT. I know myself and many others didn't learn to place fiducials as residents. This was typically done by a urologist or a radiologist.

We don't use fiducials. CTV->PTC-margin is 0.7cm posteriorly, 1 cm in all other directions. Daily cone beam CT.

Same as Palex, but 0.7cm all around. Soft tissue match is fine.

Yeah CBCT is great, but if the OP doesn't have it, he/she is going to need to use fiducials.

 

[Neuronix]

A lot of places use CBCT for IGRT. I know myself and many others didn't learn to place fiducials as residents. This was typically done by a urologists or a radiologist.

Totally agreed that this is a perfectly acceptable way to do it! I thought the first few posts might have been implying that there was no other image guidance available at their practices, either in the past or currently, outside of BAT which I understand does not work on obese patients of which we see many.

Is there any drawback to CBCT? I have seen CBCT used in practice for prostate at one facility, and their docs had to check every CBCT every day before the therapists could push the button to beam on. Is that typical?

 

[Gfunk6]

I also do not routinely use fiducials. CBCT for IGRT, 7 mm around prostate except 5 mm posterior. CBCT also prevents you from treating patient who has an empty bladder or a largely distended rectum which deforms prostate anatomy. With fiducials, I still use CBCT but reduce margins to 5 mm (3 mm).

In my practice, the MDs have created consensus guidelines to guide therapists when to call us to the machine console prior to prostate treatment.

 

[Palex80]

In my practice, the MDs have created consensus guidelines to guide therapists when to call us to the machine console prior to prostate treatment.

Precisely.
I'd say we get called in around 15% of all cases.

 

[Tanner]

CBCT image resolution quality diminishes as the patient's pelvic girth increase. In those cases, I would place fiducials to augment CBCT image-guidance. Otherwise, I usually do not feel the need to place fiducials.

 

[Gfunk6]

CBCT image resolution quality diminishes as the patient's pelvic girth increase. In those cases, I would place fiducials to augment CBCT image-guidance. Otherwise, I usually do not feel the need to place fiducials.

Very true. And hip replacements can be a nightmare as well.

 

[medgator]

Very true. And hip replacements can be a nightmare as well.

that was one situation where I really liked having a tomo unit. MvCT masks that type of artifact really well.

It's interesting that some people use fiducials + CBCT. never understood the need for both unless perhaps the CBCT went down or something periodically or I guess the situation discussed above with increased pelvic girth.

 

[OTN]

I ran into the same issue when I joined my practice. We actually did have BAT, but I had never used it before, and honestly I wasn't at all comfortable with the images, so I had to convince my local uros to place fiducials. They were okay with doing it, but they don't rush my patients in either. I usually have to wait several weeks for medicare/ppo patients, and sometimes a month or more for HMO patients. We pay about 80 dollars for a pack of 3 and give them to the uros. Reimbursement is **** for the placement (a little over $100 I believe) so you pretty much have to supply them.

Careful with this - I believe ASTRO sent a missive out the other day suggesting that giving fiducials to urologists to place is considered an illegal "kickback". Might want to look into it.

 

[medgator]

I ran into the same issue when I joined my practice. We actually did have BAT, but I had never used it before, and honestly I wasn't at all comfortable with the images, so I had to convince my local uros to place fiducials. They were okay with doing it, but they don't rush my patients in either. I usually have to wait several weeks for medicare/ppo patients, and sometimes a month or more for HMO patients. We pay about 80 dollars for a pack of 3 and give them to the uros. Reimbursement is **** for the placement (a little over $100 I believe) so you pretty much have to supply them.

Careful with this - I believe ASTRO sent a missive out the other day suggesting that giving fiducials to urologists to place is considered an illegal "kickback". Might want to look into it.

I had heard something similar from other rad oncs I've spoken with. never saw anything in writing though. Would you happen to have a link?

 

[Lois123]

Palex and Gfunk-
Just wondering what kind of guidelines you give your therapists so that you on't get called to check CBCT daily? We have urologists place fiducials, but surprisingly, they miss the prostate more often than you'd think. In those cases, we do CBCT daily and get called to check it before each treatment. Boy does that get old!

 

[Palex80]

Palex and Gfunk-
Just wondering what kind of guidelines you give your therapists so that you on't get called to check CBCT daily? We have urologists place fiducials, but surprisingly, they miss the prostate more often than you'd think. In those cases, we do CBCT daily and get called to check it before each treatment. Boy does that get old!

After auto-matching of images, if the computer recommends a shift greater than 7mm we get called in. The same applies if the therapists see a quite empty bladder or a quite full rectum.

Another point to be taken into account is WHERE you match using your CBCT. I've seen clinics, where the therapists matched to the bone and rarely had to call in a physician. They didn't look at prostate matching at all and did just bone matching. 😱 That's pretty much what we did with 2D imaging of bony landmarks in the pre-fiducial era, only it's automated and 3D.

 

[user_name]

Use the prostate/rectal interface as the rectum is your biggest and closest OAR. If you draw your seminal vesicles, even if not treating them, the therapists have another easy to see "fiducial" that helps them know their sup/inf location.

 

[iradi8u]

Thanks, everyone. I'm at a small practice without CBCT, so it looks like I'll either have to find out if it's legal to supply fiducials or suck it up and buy an US. I like the idea of contouring SVs as a surrogate fiducial.

I think this is going to take a lot of time to build up trust in my therapists before I can do any tight margins, which stinks.

 

[medgator]

Thanks, everyone. I'm at a small practice without CBCT, so it looks like I'll either have to find out if it's legal to supply fiducials or suck it up and buy an US. I like the idea of contouring SVs as a surrogate fiducial.

I think this is going to take a lot of time to build up trust in my therapists before I can do any tight margins, which stinks.

In my area, we have an ultrasound company that goes to different practices. Perhaps something like that exists where you are?' Or perhaps hospital based radiology might be willing to do it for you?

 

[iradi8u]

In my area, we have an ultrasound company that goes to different practices. Perhaps something like that exists where you are?' Or perhaps hospital based radiology might be willing to do it for you?

I didn't know this - I'll check into it. The hospital is another good thought. Thanks!