Dr. Nadim Nasr
speaker
51 appearances
1 recordings
1 series
first heard Oct 2024
last heard Oct 2024
Dr. Nadim Nasr’s voice in public audio — every appearance, attributed to the second.
Trend
recordings per month · last 12 monthsNo recordings in the last 12 months.Older appearances are listed below; set an alert to hear about the next one.
Appearances
So I joined the practice here in 2010, so I've been here for 14 years now. We started out as a small practice of two radiation oncologists. We've now, over the last 14 years, expanded to two centers. They're both hospital-based, community hospital-based, and there's four of us in the group.
I am the one that does the vast majority of the prostate cancers in the group, but I do treat really everything else. We have the full gamut of options for treatment, including external beam, brachytherapy, and SBRT. A significant portion of my training at Georgetown was in SBRT, and so I've got a lot of experience in treating SBRT, especially for prostate cancer.
I think there is. And the main reason is that if you look at the changes in the NCCN guidelines, especially over the last four or five years, what you're seeing is a lot more inclusion of SBRT as opposed to IMRT in the treatment of prostate cancer. And with SBRT, you are using such higher doses per treatment that it's really important to try to spare that anterior rectal wall.
And now with the use of PSMA PET scans to further narrow down which patients are good candidates for prostate-directed therapy, we're really doing more and more of that. And I think that there is really a large need for perirectal spacing in the majority, but not all patients.
Well, I want to agree with Eric. I think that we've mostly moved away from standard fractionation for prostate cancer. If you look at radiobiologic studies, what they actually show is that most prostate cancers respond a lot better to higher doses per treatment. And so I think we're going to see a significant move towards hyperfractionation in almost, you know, most of these cancers.
And again, in my own practice, I can't remember the last time I treated a prostate in nine weeks. Most of my prostates, even the IMRT, are done in the five and a half to six week courses of treatment. And again, in those cases, having a spacer in place really does cut down that docety into your rectal wall.
The only patients that I do hesitate in placing them, and I place my own spacers and fiducials. It's not our urologists that do them. The only patients that I hesitate in are the patients where we suspect some extension outside the prostate on the MRIs that they had before the biopsies. Those are the ones that I do hesitate in putting in spacers.
So there is some data in the radiation oncology literature that suggests that placing a spacer when there is extraprostatic extension could potentially push some of those malignant cells away from the prostate and away from the high-dose region, especially if you're using very conformal techniques like SBRT.
Now, where that is going to end up, and we don't really know, we're going to have to see what the future of the data holds, but Those are the cases where I might hesitate a bit in putting in spacer initially and might consider putting it down the road if my initial dosimetry shows that I'm compromising coverage to spare the rectum.
My experience parallels Eric's in terms of seven or eight years ago, we started using Spacer and You know, we're really doing, I mean, I probably end up doing somewhere between 50 to 100 cases a year. I did try the Baragel. I felt that the entire process of switching the tubes and the needles was a little clunky.
And I never really liked the end result of how the gel separated versus doing the hydrodissection and knowing that, well, you've got a nice space and you can go. The only time that I feel, at least in my experience, that there may have been a slight advantage
is in patients who we are retreating with radiation, where there's a lot of scar tissue in that perirectal space, and it will simply just not hydrodissect with the saline. I have used Baragel in those cases where I knew where the positive nodule was in the prostate to try to get some separation behind it.
But that's really, I mean, I would say, you know, less than three cases that I've done in that. The vast majority that we're doing is Spacor.
There's no prostate, so...
So we have a procedure room in the office and we do it all in the department itself. I would say it's about 50-50 whether we do it with local numbing versus getting anesthesia involved for some sedation for the procedure. I really leave it up to the patients. I mean, from my end, it's really the same procedure. I agree.
I think the vast majority of patients tolerate it very well with really just minimal discomfort. Some men do have about 10 to 15 minutes of some rectal pressure. feeling like they have to have a bowel movement, which dissipates in most of them. And we've had our share of a couple of guys who had a little vagal response and we had to wake them up a little bit.
But, you know, the guys who end up having some light sedation with anesthesia down in our department, by the time they wake up, they really have no symptoms whatsoever from it.
No, and honestly, we do almost a mirror image of what you guys do. We do three days of Cipro leading up to the fiducials and the spacer at the same time. Very similar in terms of setup. They do an enema the morning of before coming in, and we go from there for the actual procedure. And do you do the fiducials first and then the gel? I do the fiducials first.
I did make the mistake once of trying to put the spacer first, and what I didn't realize is that the ultrasound image It's completely distorted once that spacer goes in and you really cannot see where you're going with the fiducials. So I always start out with the fiducials first and then go with the spacer second.
I mean, I tell them that obviously if they're still awake during the procedure, if it's not a sedation procedure, that they're going to have a little discomfort while I'm putting in, you know, numbing them up, putting the markers in, putting the spacer in. And I talk them through it step by step as I'm doing it. And most men honestly tolerate it just fine.
Showing 1–20 of 51 · page 1 of 3
Next →