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Radiation for metastases: What to expect

Different radiation techniques are sometimes used to treat metastases in different parts of the body. Two commonly used treatments are called SBRT and Y90. Here are the basics:

SBRT

SBRT stands for stereotactic body radiation therapy. In colorectal cancer, it’s used to treat small metastases in the liver, lungs, lymph nodes and bones. It may also be called the CyberKnife or Gamma Knife, referring to the brands of machines used.

SBRT delivers a high and very precise dose of radiation to small tumors. It’s usually done over 3 to 5 treatments, administered over 1 to 2 weeks. 

It’s important to make sure you understand how SBRT will fit into your overall treatment plan, because it’s not usually possible to receive SBRT twice to the same area, if you experience recurrence.

Most external radiation experiences will be similar to SBRT.

Want more info? Watch this video:

 

Before the procedure

During your initial visit, you’ll meet your radiation oncologist. They will explain your treatment plan, the goals of treatment, and give you an idea of what to expect. They’ll also address any side effects you may experience. They will go over anything you need to do to prepare for your SBRT treatment.

It’s always a good idea to prepare questions in advance and take notes during your appointment, so you can refer back to them later. Sometimes it can be helpful to bring your carepartner or family member for a second set of ears!

Simulation

The purpose of the simulation is to create a detailed treatment plan — so you can maximize effectiveness and minimize damage to healthy tissue surrounding the tumors.

Before your simulation, some treatments require placement of small metal markers (called fiducials) in or near the tumor. This helps the radiation oncologist better locate the tumor during the simulation and treatment. This step is usually performed as an outpatient procedure prior to your SBRT treatment. However, it’s not necessary for most patients receiving SBRT.

During the simulation, your team will use detailed imaging techniques to locate your tumors and track them over time as they move with your breathing cycle. You will be positioned on the table, possibly with a variety of immobilization devices or body molds to help keep you in place. This also makes it easy to get you into the correct position when you come back for treatment. 

During the imaging process, you’ll probably be asked to hold your breath several times. The breath holds usually range from 10 to 30 seconds. If you’re getting treated in a part of your body that moves when you breathe, you may also practice with breathing apparatuses during the simulation. They may go in your mouth — like a snorkel — or may be strapped to your chest.

At the end of your simulation, you will be given your treatment schedule.

Treatment day

SBRT is usually given over 3 to 5 days over the course of 1 to 2 weeks — depending on the size, location and number of tumors being treated. Each treatment will take anywhere from 20 minutes to an hour.

During the procedure, you’ll lie down in the same position you did for the simulation. The machine will rotate around your body several times, delivering beams of radiation to the tumor from different angles. You will not feel or see the beams going into your body. You’ll be asked to hold your breath several times during treatment, just like in the simulation

After the procedure

After you finish treatment, you’ll have regular follow up appointments with your radiation oncologist. You will likely have a CT scan before each appointment, so your team can see how your body is responding to treatment.

Remember that some side effects will continue for a few days or weeks following treatment. Be sure to ask your doctor about what to expect, and report any side effects during your follow-up appointment.

Want to learn more about SBRT? 

Check out this article from UCLA for more information on the procedure and what to expect. 

Today I had my preparation scans for Stereotactic Body Radiation Therapy (SBRT) to my lungs. First, they laid me on my back and put a mouthpiece with a tube in it, plugged my nose, and put special goggles on me so I could see a screen. Using the screen as a guide, they first had me breathe regularly and a red line went up and down, tracking my breathing. Then they introduced a green bar at the top of the screen. After three regular breaths, my job was to inhale to bring my breath line up to the bar and hold it till the bar disappeared, about 20 seconds. They did this 3 times, then asked me to hold as long as I could , which was 27 seconds. I recommend practicing deep diaphragmatic breathing daily a week or so before this procedure, so you know how to breathe in slowly and hold it in your lower belly.

During this, they scrunched up a pillowy thing I was lying on, molding it to my body, and blew air into it to make a personalized immobilization cushion for the actual procedure. 

After that, they put me in the CT scan machine with my arms overhead for one session of held breath, then took off the mouth, nose, and eye gear and did one last scan. Then the technician put stickers on my body marking the coordinates that will help the radiation oncologist get the tumors precisely. Then I was done! The whole thing took about an hour.

Day 1 of SRBT at [my cancer center] in the bag, for one of my two lung mets. My machine was a TrueBeam. I lay in my handcrafted body mold with my arms over my head, but they did NOT use the breathing apparatus on me —said I didn’t need it. They arranged me, pulled up my shirt to just below my breasts, turned on a big circular plate thing over my chest, and said they’d do some imaging and then the treatment. I could see in a mirrored part of the circular plate that a square over a part of my chest was lit up, with a green line of light through it. Parts of the machine slowly passed over my chest — the circular plate, a square panel, and another square panel. Since French lounge music was playing and the equipment looked so space aged, I felt like I was in a 70s sci fi porn flick. Big Barbarella vibe. I got kind of sleepy. About 15 minutes later they came in and I said, oh, is the imaging done? And they said the whole thing was over, treatment and all. And they stuck a new sticker on me, right over where the met is, and hauled me up and I went home. 5 more to go. But it’s all rather boring! No side effects 3 hours later!

I said I’d blog my SBRT experience, but it was too boring to write about every session. So, I’m done now, having had 3 sessions for a metastasis in my left lobe and 3 for a metastasis in my right lobe, over the course of 2 1/2 weeks (Fri., Tues., Thurs for left lung and Mon., Weds., Fri. for right lung). Each session was very quick, 15 minutes in a Varian TrueBeam, with me lying on my back with my arms overhead, on a special pad that had been contoured to my body. 

I ended up not needing the breathing apparatus, so I breathed normally while a series of mysterious panels rotated over my torso, with a green beam of light coming down over them and through some of them. Music played—a different genre each time, from French lounge music to smooth jazz to Fleetwood Mac. It was relaxing. I had no side effects except fatigue the night of the radiation, when I went to bed early and slept well.

I had a PET scan after treatment #4 for other reasons, and nothing showed in the left lung that had had the full 3 treatments, though the lesion in my right one still showed up as it had had only 1. Hoping for clear chest scans in a couple of months!

Y90/SIRT

For colorectal cancer, Y90 is used to treat liver metastases. It’s a minimally invasive procedure, which involves inserting tiny glass or resin beads that contain the radioactive isotope yttrium 90 into the blood vessels that feed liver tumors.

The radioactive beads are delivered to the tumor through long, thin tubes called cathethers. They cut off the blood flow to the tumor, while sparing healthy tissue as much as possible. Once the beads are lodged in the tumor site, they deliver a high dose of radiation to the tumor, killing cancer cells.

Y90 is not usually intended to “cure” the liver or eliminate tumors entirely, but it can be very effective in controlling tumor progression and extending survival.

Learn more about Y90 here:

 

Before the procedure

You will have an appointment with an interventional radiologist, who will explain the goals of treatment. They’ll also go over how to prepare, what to expect during treatment, and what side effects you might experience.

You should receive detailed instructions about eating, drinking, and taking medication or supplements before the procedure. Come prepared with questions, and take notes to refer back to later.

You’ll need to arrange for someone to drive you to the procedure and pick you up afterwards. And because you’re receiving a high dose of radiation, you will probably be told to limit close contact with other people — particularly children and pregnant women — for a time after the procedure.

Your team will also take blood samples and do an angiogram, which helps them map out the blood vessels that are feeding the tumor. If necessary, they’ll use coils to block the blood vessels feeding other organs, such as the stomach, bowels, and lungs.

Treatment day

Y90 treatment is usually done as an outpatient procedure, although some people may be admitted to the hospital.

You’ll receive an IV sedative, as well as medication to prevent pain, nausea, and infection. A nurse will monitor your vital signs. You’ll receive local anasthesia to numb the area where the catheter is inserted into the blood vessel.

The doctor will make a small incision, insert the catheter, then use imaging technology to move it into the correct position. Then, they will insert the small radioactive beads through the catheter. The catheter will be removed, the incision will be closed and covered with a small dressing. Then you should be able to go home!

After the procedure

In the 10 to 14 days following the procedure, radioactive material will be released from the beads, into your tumors. The beads lodged in capillaries can also cut off blood supply and help kill the tumors. 

Y90 can cause hyperplasia, or enlargement of the liver. Y90 can be targeted to specific areas in the liver, so it’s possible to receive this treatment multiple times to target different areas. 

Because you’ve received a high dose of radiation, your doctor will probably recommend avoiding close contact with kids and pregnant women, and to avoid extended contact with other family members or pets. This is because the radioactive seeds are implanted in the body, and will continue to release over time. 

You may be asked to schedule a follow up appointment.

Want to learn more about Y90? 

Check out this article by Radiology Info. 

Diagnosed: July 2018

Stage: IV

Type: Colon cancer, metastases in liver

Now this is a story all about how my life got flipped-turned upside down and I’d like to take a minute just sit right there I’ll tell you how I was diagnosed with stage 4 colorectal cancer. My name is Jason, and I was diagnosed stage 4 at age 35 on July 17, 2018. Two weeks prior to this date is when I first experienced any symptoms that were considered red flags. I went to my PCP to get it looked at, mentioning diverticulitis that my mom had several times, and they ordered a CT scan to verify. There was a 5cm sigmoid mass and 14 metastatic lesions in my liver, all but one being 2.5cm in diameter and the last one being 11.5cm x 7cm.

Due to a full blockage via the tumor and the extent of cancer in the liver, I was deemed inoperable and an emergency 10cm titanium SEMS stent was placed to keep the sigmoid colon open and me alive. I began chemotherapy within a week of diagnosis (I’m a lucky guy), and I had 9 cycles of FOLFIRINOX (slightly different than FOLFOXIRI), the big guns to start. 

In November and December 2018, I took a heavy chemo break to have Y90 mapping and 2 Y90 procedures done. I resumed heavy chemo within a month and did 11 cycles of FOLFOX. I stopped this due to it diminishing my platelet counts to the point we were concerned I may need a bone marrow transplant. During the time after my Y90s, I started to see an integrative medicine doctor who helped improve the symptoms and side effects I was experiencing. This allowed me to go back to work in May 2019. 

Scans in August 2019 showed a very good and continued response to chemo and Y90. I also had 5 biopsies (4 colon, 1 liver) performed, with results of no malignancy detected. Scans still showed a few liver spots and one near the colon. October 2019 CT scans showed 2 abnormalities on the lungs. I had an upper respiratory infection at the time when those spots showed up. To be safe, my team put me back on FOLFIRI with Vectibix for 4 cycles. I asked about the possibility of resection surgery for both the colon and liver and was told that it still was not approved by the review board, especially now that those two spots showed up in the lungs. Scans in November 2019 revealed the lung spots were much smaller and labeled as consistent with inflammation or infection, but they could not rule out metastatic disease due to the possibility the chemotherapy was what had shrunk them. I then asked about surgery again and was told no, chemo for life. 

This is when I decided to take the knowledge learned in COLONTOWN, and others, to seek out a second opinion about liver surgery, because what did I have to lose at this point? I wanted to have confirmation by one of the best that I would truly not be a candidate for resection surgery. Learning this information would let me feel confident that I had at least tried to exhaust all options before resigning myself to the chemo for life and inoperable prognosis.

I got my second opinion from a specialist who focuses on only mCRC liver mets. He reviewed it all and explained to me that I was the perfect candidate for his resection surgery. He explained that my right lobe Y90 procedure had worked a bit of overtime and killed off my entire portal vein. It performed its own Portal Vein Embolization (PVE) that [a specialist] uses as a gauge in his two-part surgery. Mine had already shown that the left lobe compensated for the dead part of the right and I would be having surgery with curative intent in a single surgery instead of the 2-phase surgery he normally requires. Best part is his surgery comes with an average of 40-50% curative rate. This is a game changer after being told inoperable beyond palliative reasons. The January lead up CT and PET scans determined the lungs had no lesions and it was infection or inflammation.

He brought on board another surgeon to perform my anterior resection surgery, stent removal, and ileostomy placement. I had a 9 hour long surgery on February 25, 2020 and had 30cm of colon including my stent removed, my entire right liver lobe removed, gallbladder removed, and ileostomy placed.

My pathology report came back two weeks later to reveal that I had a rare, near complete pathological response to the 30 cycles of chemotherapy and two Y90s; with <1% of total tumor remaining from date of diagnosis, 99% was tumor necrosis, the remaining tumor was removed well within the margins, and 5 microscopic lesions on the left lobe were ablated successfully. Of the 31 lymph nodes removed during surgery, all were negative for metastatic cancer! My surgeon was glowing with excitement at the report and basically called me his unicorn patient. WOW, I am a lucky dude to hear that from one of the best at what he does. The other surgeon was impressed at the colon as well, minus the whole stent part (about to get to that), and he is a very good CRC surgical oncologist that had just came from [a great cancer center]. I fully recovered from that massive surgery successfully and had my ileostomy reversed on May 19, 2020. Not one bit leading up to that surgery was easy though.

Three weeks prior to my liver/colon surgery, my friendly lifesaving stent decided to flip the tables and try and kill me by fracturing and perforating my bowels. If I had emergency surgery here in Kansas to remove the colon and stent, it would have taken the curative liver surgery off the table- a surgery I was told I would NEVER have prior to this. Sorry, not having it, I had come too far to not try and tough it out. I have three children, one that was born just two hours after my 8th chemo cycle, and my wonderful wife, who was 6 months pregnant at diagnosis — so I decided to tough it out and make it to the surgery in California come hell or high water.

Those three weeks were extremely difficult for me, because I basically lived in a hot shower, could not eat or drink more than a few cups of water or liquids at a time, and had to have a heating pad on me constantly. I was taking 6-10 showers per day for 20-30 mins at a time to fight off the hunger pangs and the tremendous pain of the stent not wanting to pass much stool (and then when it managed to pass something, it felt like razor blades). I was away from my family, suffering in my parent’s basement, not able to sleep for more than a few hours at a time- tired, scared, lonely, doped up on pain meds, just ready for the day to come when I would become chopped liver, desperately hoping the stent would not get infected or fail my body, even though it had perforated my bowel. 

My stomach was making noises from antibiotics that were not from this world, starting to swell a little bit due to inflammation. I had previously managed to get off the opioid pain meds for a long time due to not having any pain, but I had to have them those three weeks, it hurt so badly. If I had to describe a feeling I was going through, it was dying. I lost an additional 35 lbs. to the already 75 lbs. lost in the year and a half prior due to cancer. Losing 35 lbs. in 3 weeks was very taxing on my body in that short time before surgery. I wish this feeling upon no one. 

Considering what I had just gone through, getting to the surgery was a major accomplishment in my cancer experience, and my medical oncologist now is over the moon about the results of the liver surgery. However, in October of 2020 my CT scan revealed a spot near my coccyx and my rectum as well as a positive Signatera test (88 mtm/ml) and we started me back on 4 more cycles of FOLFIRI and Vectibix before more scans. The day after my last chemo infusion I discovered I had COVID-19 and it delayed my treatments and scans for a full month. Once I was able to get scanned again, the tumor board decided that to get me to a surgical state again that I would need to have 28 chemoradiation sessions to my entire pelvic region. This happened in February and March of 2021 and it caused me some considerable side effects, especially with LARS symptoms and specifically clustering and tenesmus. I was spending upwards of 2 hours on the toilet, and it was not a fun time but my tumor did show response to both the chemo and chemoradiation we threw at it. 

My scans prior to surgery revealed that the tumor had infiltrated my coccyx bone and I had a full abdominal perineal (APR) resection surgery on June 4th, 2021 with an en block coccygectomy, where they remove the entire tailbone and, in my case, also 1cm of sacrum. I lost my entire rectum and anus in the procedure too and was stitched up from behind like a Ken/Barbie doll and got a permanent colostomy bag. 

The margins were clear, albeit very close (1mm), but clear and I was determined to be NED on the follow up scans and pathology report. The same pathology report showed 0 of 11 lymph nodes positive for cancer too. I took a Signatera test before surgery and after surgery as well and both came back negative, but we will continue to use that and standard monitoring tools to watch for reoccurrence and on an accelerated schedule of 2 months instead of 3. The permanent colostomy bag is very easy too, I spend less than 5 minutes per day messing with it most days which is great compared to the 2 hours I was spending on the porcelain throne. We opted to not do any more chemo or radiation, even though 5 sessions of SBRT was offered if I wanted to be overcautious and I am okay with that and being aggressive with the monitoring.

I have my own maintenance routine as well, taking a few supplements that have shown some preventative measures for CRC that were recommended by my oncologist and surgeon- Vitamin D and low dose aspirin. I also take one that is repurposed but under the direction of my integrative medicine doctor, which is an immunomodulatory, but that is for another discussion. Mental health, diet, and exercise have been important, with a largely Mediterranean style, high fiber diet. I cannot stress enough how important it is to take care of your mind during this cancer experience as well as just your physical well-being. Easier said than done, but if you can see a therapist to talk or find a meditation that works for you, then please do it, and don’t hold back. There is no shame in any of this, none of us deserve this and it can really help to talk to a professional. I see a therapist every week to talk about so many things, but it has helped get me through many of the harder to process emotions than I can do on my own. 

I cannot tell you the feelings and emotions that come with going from a situation of not having much hope with a bad prognosis… desperate, scared… and having that flipped completely around and being NED. It has been positively life changing and very emotional at the same time. I have a lot of survivor’s guilt, so I try to cope by providing help to others. I try to help them find their own voice in their cancer experience or try to point people in the right direction (which may prove to be beneficial to their situation). No one in my family will ever understand it either, no matter how much I explain it to them, that’s why COLONTOWN is also my family; we all understand the depth of it all here and there is comfort in that.

I know exactly where some of you all are. It isn’t fun, hearing things that make you go to dark places, things that add layers of stress to an already stressful world that is life-changing, life-impacting nonsense that no one deserves. I’ve had about 6 surgeries including a fistula surgery, 34 chemo treatments, 2 Y90s and mappings, 28 chemo radiations, countless other procedures along the way, 5 colonoscopies, a chemo leak from the take home pump that caused severe chemical burning, had to learn to self-catheterize when my tumor had blocked me from urinating, many ER trips, and so much more. I want to provide some hope, love, support, and encouragement for those who too may feel lost and hopeless at stage 4 and that even something as simple as knowledge of a new procedure or drug protocol your oncologist may not know about that you may learn here, or if you seek a second opinion, or as many as you need, that it can change the whole trajectory of your prognosis, maybe not, but worth pursuing.

One of the first things my integrative medicine doctor told me the first time I met him, after looking me straight in the eyes, was: “Jason, I want you to keep your eyes on the prize, and never take them off. Set a goal, plan a vacation, an upcoming event, anything to look forward to and to keep your eyes on the prize. When you reach your goal, immediately set a new one and remember to always keep your eyes on the prize”. What he said stuck with me, and I never looked back no matter what was going on.

Want to learn more about radiation?

Join one of our COLONTOWN Facebook groups:

  • Corner Cupboard is a place to discuss treatment side effects and management
  • In Liver Lover’s Lane we talk all about liver metastases.
    Join us in Lungston for all things related to lung metastases
  • In Legoland, we discuss bone metastases
  • Come join us in The Attic to learn about brain metastases
  • If you want more information about distant lymph node metastases, join us in In the Distance
  • The Mighty Y-90 neighborhood has the answers to all of your questions about Y-90 treatment
  • If you’re suffering from late or long-lasting side effects related to treatment, check out The Late Show

Want to join? Fill out the registration form here.