Benign tumour treatment
Only a robot was able to save me
Diagnosis: Skull base meningioma.
Georgs (63 years), company director (patient's name has been changed):
“I had sudden vertigos and vision went black and then as if doubled in the mornings. A doctor referred me to examinations and a MRI scan revealed meningioma, a benign tumour growing from the meninges. When I met professor and neurosurgeon Igors Aksiks, I was morally prepared for a surgery. But the professor was in doubts and told that it cannot be operated due to very high risk — the meningioma was located very close to the brainstem. Doctor told that a radiosurgery centre is about to be opened in Sigulda and recommended me to wait and go for a treatment there. There was an alternative to take such procedure with CyberKnife in Germany. I decided to wait and be treated in Latvia. I was waiting for two months and I was one of the first patients of the Sigulda Radiosurgery Centre.
The procedure was totally painless, I felt nothing during it. The only thing I had to do while the robot was working — I had to lie still, because I was not allowed to move. In my case I had to undergo three sessions. I continued with my everyday routines, as if nothing had ever happened. Half year later I visited the centre for control — the tumour had already changed its shape. I had a repeated control one year later and meningioma was even smaller in size than during the procedure. Now I don't have vertigos anymore and pain has subsided. Even though only two years have passed, I think that my head is doing well, and as if it had not undergone any treatment.”
The patient was diagnosed with meningioma at the skull base, clivus area. This is one of the most dangerous and most complicated parts of the skull in case of surgeries. Considering the size and location of the tumour near critical nerves and vascular structures of the brain, 3 radiosurgery sessions with the CyberKnife robotic system were offered. The patient was treated with radiosurgery without complications.
The patient started to gradually feel better after the manipulation with CyberKnife. A control MRI scan one and a half years after the radiosurgery procedure with CyberKnife showed reduction in tumour size by 15%. Currently the patient's condition is good.
Result of meningioma treatment 2 years later
Meningioma treatment process
No hole had to be cut in my head
Diagnosis: Acoustic neuroma in the left side.
Astra, 59 years (patient's name has been changed):
“First, there was tingling in ears. I went to all possible doctors, but nobody found anything. When I discovered that hearing a sound was worse with one ear than with other, I went to an otorhinolaryngologist once more, who then recommended to perform a MRI scan of head and I was diagnosed with an acoustic neuroma in the left side. I was consulted by a neurosurgeon who told me that as the tumour grows it would compress nerves leading to impaired movements, droopy side of the face, headache. The doctor also warned me about serious side effects that are possible if acoustic neuroma is removed in a surgery, and recommended to choose operation only when the tumour reaches the size that cannot make me feel any worse. An idea of growing something incomprehensible in my head and waiting for something to happen seemed scary to me, and I started to look for other options, other treatment methods.
I searched internet and found that in Europe such conditions are treated with CyberKnife, and then I found that it is available in Russia and Ukraine, and I was ready to go there, but then I learned that such procedure was available also here, in Latvia. I understood that no hole would have to be cut in my head, because CyberKnife operates with an X-ray beam, and rehabilitation after the radiosurgery is very successful, nevertheless I was rather scared. I must admit that the procedure is not painful at all, and also afterwards I did not have either nausea or coordination disorders.
Two years have passed. All went just as planned, because the tumour was detected in rather early stage and it is a positive aspect. Anyway, now I feel psychologically calm, because I know I have done all I could. I think that such procedure would come as a relief to many, if it were covered from the state budget or at least included in the health insurance.”
Regarding patient's complaints the MRI scan showed acoustic neuroma (neurinoma). Given the type and size of such tumours radiosurgery is one of standard treatment methods. Treatment efficiency: In 97-98% of cases the risk of complications, including facial paralysis, is less than 1%. In this case the patient had one radiosurgery session with the CyberKnife system.
Within 12 months of the radiosurgery, the patient was feeling satisfactory, even though periodically (1-2 times per month) she had general weakness, sometimes also headache, especially during the change of weather. These symptoms were caused by destruction of tumour cells after the radiosurgery and formation of connective tissues. Usually painkillers and also diuretics are prescribed in such cases to make sure that tumour transformation products are driven out of the body as soon as possible. 1 year after the procedure with CyberKnife, acoustic neuroma of the patient had reduced by 2 mm in diameter. Headache subsided.
Result of treatment of acoustic neuroma 12 months later
Process of treatment of acoustic neuroma
I thought that it would suffice with a surgery, but I was wrong
Diagnosis: Acoustic neuroma on the right side. Condition after the surgery (2013). Tumour continues growing (recurrence).
Renārs (46 years), sales specialist in a wholesale company (patient's name has been changed):
“I had acoustic neuroma removed surgically already in January 2013, but almost three years later I was again back in the waiting list for a repeated surgery, because the acoustic neuroma had grown almost as big as before the surgery. Then a friend of my wife told that a new radiosurgery centre has been opened in Sigulda and the most advanced robotic radiosurgery system in the Eastern Europe — CyberKnife — is available there. At the first moment I did not understand what that was. What was she talking about? But a neurosurgeon in the University hospital explained it to me, saying that it might be the only option for me. If a tumour has settled in, literally embraced the trigeminal nerve and bones of the skull base, it cannot be cut out in a surgery therefore it would continue growing bigger. If they cut it, a half of my face could remain paralysed forever. I would not like to live with a still face and not to feel taste in my mouth.
The doctor told that usually such procedures are performed in Germany and I could go there if I wanted to. Costs would be similar, plus travel and accommodation expenses. I thought why I should go somewhere else, if we have wise specialists and the same equipment. My only fear was about my suitability for the procedure due to the large size of the tumour. I received a positive answer and it was helpful from the side of relatives and friends to support me with the financial aspects of the operation. After all it was less expensive than the amount requested in Germany. As a result I had five radiosurgery sessions with CyberKnife. I did not feel very well afterwards, the doctors had already warned me that it can happen in cases like mine. Five months passed and only then I started to feel fine. But one can go through that knowing that it will get better. Two years have passed now, I feel good, continue working.”
Radiosurgery with the CyberKnife system can be used after a surgical interference, if the tumour has not been fully removed or it has a recurrence.
In this situation patient first had one part of a large acoustic neuroma removed. Usually radiosurgery with CyberKnife is not applied where tumours exceed 4 cm. 3 years after the surgery, remains of the tumour were detected indicating at continued growing. Patient was recommended to undergo 5 sessions with CyberKnife. Treatment of the patient progressed well. 12 months later it was established that the tumour has stopped growing and started to shrink gradually.
Neuroma treatment result after 12 months
Neuroma treatment process
Treatment of arteriovenous malformation
I don't want another stroke
Agnese (30 years), works in financial sector in Lithuania (patient's name has been changed):
“I was hospitalised due to stroke and I was diagnosed with inborn pathological vascular malformation — arteriovenous malformation, which evidently caused the stroke. Doctors told me that if I did not want to go through it one more time only the radiosurgery method could save me. I was told that such procedure was available in neighbouring country Latvia, in Sigulda, so I didn't need to take a long trip. Sure, I did not think for a long time. On 27 April 2016, I came to consultation and the procedure took place already on 29 April. It is amazing — I had to lie only for 40 minutes and that's it. I had no bad sensations, nothing. In Sigulda Hospital I felt professional, understanding and kind attitude and everything was explained and clarified to me. The team working here is wonderful. I was going home and thinking — did it really happen (laughing)?"
The patient was hospitalised with acute condition in Vilnius where after a diagnostic examination an arteriovenous malformation, i.e. pathological netting of arteries and veins, was detected, and it posed a risk of sudden bleeding in brain. After solving of the acute condition the arteriovenous malformation could not be blocked with embolisation therefore Lithuanian neurosurgeons recommended to turn to the Radiosurgery Centre Sigulda were she was referred to radiosurgery with CyberKnife robot. The patient was treated with radiosurgery without complications. Expected results: if volume capacity of arteriovenous malformation is less than 3 ml, there is 80% likelihood that arteriovenous malformation will close completely within 2-3 years thus a risk of repeated bleeding in brain is reduced to minimum. During the first months after the manipulation the patient gradually started feeling better. When performing the control MRI scan two years after the radiosurgery procedure with CyberKnife, location of arteriovenous malformation actually could not be found. Current condition of the patient is good, no complaints and repeated bleeding has been observed for already 2.5 years.
Arteriovenous malformation treatment process
Prostate cancer treatment
5 days instead of 30 days
Diagnosis: Low risk prostate cancer.
Oskars, 65 years (patient's name has been changed):
I am 65 years old and I have always thought of myself as a healthy person. I have been living healthy since young age, and I still continue working. The only exception in my health condition is that I have to get up several times during the night to go to toilet. Sometimes it causes inconvenience, but apart from that, other functions seem to be alright. Besides, a year ago I scheduled a visit to an urologist.
During the examination the treating doctor detected enlarged prostate and that the level of prostate-specific antigen (PSA) has elevated from 5 to 11.
Doctor told that prostate biopsy is needed to specify the diagnosis. Some tumour cells were found in one of samples and it meant that I have prostate cancer in early stage. He explained to me and my wife the examination results, possible treatment options and potential complications. I was offered a prostate surgery. Unfortunately, due to possible side effects about which I read in stories of other patients, I decided to refuse from the offered treatment.
I waited for another six months and then attended the urologist repeatedly, because the PSA level was still elevated, and therefore the urologist recommended radiotherapy. Conventional radiotherapy lasts for six weeks, but due to my work schedule I could not take such treatment and the very disease, according to doctor, was in the early stage. The urologist informed me about possibility to try a new and progressive radiosurgery system, CyberKnife, which was suitable also for my case, and referred me to a consultation to the Radiosurgery Centre in Sigulda. After consultation in Sigulda I was scheduled for five radiotherapy sessions with the CyberKnife system instead of thirty conventional sessions. I attended the procedures three months ago, just as planned.
Treatment process was a real surprise. Both professionalism and technical competence and careful attitude and attention of the staff was very good. The procedures were scheduled in a time convenient for me, on the second half of the day, taking into consideration the busy work schedule that I had. I could completely adapt it to my routine day at work. And, to be honest, I did not feel any discomfort.
Of course, it is too early to say that the cancer has fully disappeared. Doctors told that it would take some time to see if the process is becoming stable. Besides, neither during the treatment nor now I have any of those severe side effects the urologist referred to. Everything seems to work fine and also the PSA level got slightly lower during the first control one month later. During the treatment and also afterwards I carefully comply with the recommendations given by the doctor from the Radiosurgery Centre; so each of us have done their part of the job.
I can recommend patients with urological problems and prostate cancer diagnosis similar to mine to take a consultation and treatment in Sigulda. Staff working in the Centre is competent and treatment with CyberKnife progressed as described in the consultation. I express gratitude to the medical staff for great care and comfortable, almost cosy atmosphere in the Radiosurgery Centre Sigulda. I am grateful to all of them and my only wish is that people suffering from problems similar to mine could afford coming to Sigulda and be treated with CyberKnife. They won't be disappointed for making such a decision.
Patient was diagnosed with low risk of recurrence and a metastasis-forming tumour, however it progressed through gradual increase of PSA level in the blood. In such cases a radical treatment is justified and radiosurgery shows very high efficiency — 5 years of disease control is reported in 97.3% of cases and 10 years of disease control is reported in 93% of cases. Besides recurrence in the treated area (prostate) is reported only in 2% of cases. Patient had slight side effects after the therapy that disappeared few weeks later, allowing literally the same quality of life as before the therapy.
Process of treatment of primary prostate cancer
Process of treatment of primary prostate cancer
If there are alternatives of treatment,I want to know them
Diagnosis: High risk prostate cancer.
Gatis (44), doctor
In October 2016, within the framework of preventive examination, I was detected an elevated prostate-specific antigen (PSA), standing at 11.3 ng/ml (standard threshold up to 4.0 ng/ml). I had no complaints. Control analyses one week later still showed an increased PSA therefore I made an appointment with an urologist.
The urologist performed transrectal ultrasonoscopy with targeted prostate biopsy in order to specify a diagnosis, finding atypical cells in one out of twelve samples. In November 2016, on the basis of biopsy results, the diagnosis —prostate cancer —was confirmed.
In order to decide on further treatment tactics, the urologist recommended performing MRI examination for the prostate. Magnetic resonance imaging exam confirmed new lesion in the left lobe of prostate without extracapsular growth.
It was followed by a question—what to do? Considering all aspects—my age, PSA index, Gleason score 7 and finding from the MRI scan —the urologist offered radical treatment methods like prostatectomy or surgical removal of the prostate. The physician also informed me about possible complications after the surgery, including complete loss of potency and inconsistency of varied severity. Faced with seriousness of the situation and consequences of the surgical treatment, I started to look for tumour treatment alternatives. If I were 80 years old, I would not give a second thought, but if there are alternatives of treatment nowadays, I want to know them.
In spring 2017, in an internet portal I foundan information about robotic stereotactic radiosurgery treatment possibilities in Sigulda. I found out that robotic stereotactic radiosurgery technology CyberKnife treats tumours of various origin and localisation, including primary prostate tumour.
In order to find out more about possibilities to be treated with this method, I made an appointment with a radiation oncologist. According to recommendations of the radiation oncologist I had positron emission tomography (PET) performed with preparation 68Ga-PSMA, which is currently recognised as the most precise diagnostic method for prostate cancer in order to determine possible tumour cells outside the prostate. Thanks to God, the tumour was localised only in one lobe of the prostate and no cells had been spread outside it.
As I learned about radiosurgery treatment possibilities, their benefits and possible complications, I agreed to be treated with that method.Prior to the treatment I read feedback from patients who were treated in Sigulda as well as experience of patients who were treated abroad.
There were several factors to the advantage of my choice: high-precision technology that delivers radiation exactly to a tumour thus saving the surrounding tissues as much as possible, low complication risk, no direct surgical invasion, painless procedure after which one can go home, short five days' course of treatment that is adjusted to patient's routine as well as deep understanding by the radiation oncologist and convincing perspective on my situation andsolutions.
I started treatment in March 2012. Sigulda Hospital is very up-to-date and patient-friendly establishment. In my case I headed for the procedure for five successive days with my car. Each session lasted for approximately one hour and during it I was lying peacefully, thinking over my life and felt no pain. After the session I went home by myself. Even though I had taken a vacation due to the treatment course, I think it would not be problematic to keep working during the treatment.
On a week following the treatment I had slight complaints about which I was already warned. Initially due to oedema I had difficult and more frequent urination, and more frequent elimination due to irritation, because the prostate is located very close to colon. As I observed the recommendations given by the specialists the side effects diminished within few weeks. Three months after the radiosurgery treatment course PSA indexes were back to norm—3.01 ng/ml and two more months later PSA stood at 1.47 ng/ml. At present moment I feel good. Potency is retained, there are no routine complaints about urination, perhaps only more frequent elimination is an issue but I call it nonsense. In dynamics I continue controlling PSA and observe situation on an out-patient's basis at the urologist. I continue communication also with the Radiosurgery Centre's specialists regarding the efficiency of my therapy.
I am grateful to Sigulda Hospital Radiosurgery Centre collective and especially Dr. Maris Mezecklis for being responsive,comprehensive and professional.
In case of Gatis, we primarily applied the most cutting-edge technology in cancer treatment —CyberKnife M6 —five faction radiosurgery procedure during which a maximum radiation dose is targeted a a lesion, yet the very prostate was radiated with conventional radiotherapy doses. In order to be able to apply this method, at first we made PET/CT examination with Ga68-PSMA, which made it possible to rule out local and distant metastases as well as to specify the location of the tumour in the prostate and its size.
Main advantages from the applied methods:
- Destruction of local tumour focus without surgical intervention;
- Possibility to maximally reduce side effects of other radical therapy;
- Decreased impact of therapy on potency and sexual function.
Process of treatment of primary prostate cancer
Treatment of prostate cancer metastases
I could not have received such treatment in Great Britain
Diagnosis: Prostate cancer, ogliometastases in lymph nodes, bones, ribs.
Peter from Great Britain, 70 years (patient's name has been changed):
Letter from the patient's wife to Dr. Maris Mezeckis:
We are more than happy with the treatment we have received from you. Your diligence, speed of response to medical questions and clear communication is the reason we chose to come to Latvia in the first place, rather than Eastern Europe, when we could not afford treatment in the UK. You have been excellent in always responding quickly and efficiently to any situation and we realised just how dedicated you are to your job, when we came for treatment in February. You should be very proud of the work you do and you are a credit to the Sigulda CyberKnife centre and therefore no apology was required. Your kindly manner and our trust in you was the reason we returned for further treatment, and your medical team are also excellent.
We think the problem we noticed is that behind every great doctor in the UK, there is a very highly organised medical secretary, worth their weight in gold, who is highly skilled and deals with all the planning issues to ensure everything runs like clockwork and smoothly and in a timely manner. This part of the equation seems to be sadly lacking in Sigulda this time. We just perceived that you do not seem to get enough support and are left to deal with stuff that you shouldn’t be dealing with as a doctor. We contact you as we know you will respond and deal with everything accordingly but you should have a right hand person, who is as equally efficient and dedicated to take some of the pressure of you.
You mentioned that the Director was looking to expand and find new customers and to do that your support system needs to be much stronger to cope with increasing customer numbers. The other issue is the CT scan and planning for treatment is now done in Sigulda, which frees up more time for you as a doctor, instead of going back and forth to Riga but the MRI still needs to be done in Riga, which seems wrong. We know these machines are very costly but it would make sense to have a top of the range MRI in Sigulda too, so all could be done on site.
As we mentioned the main problem is people in the UK don’t know about CyberKnife. It is not available on the NHS, so NHS oncologists do not tell people about it, as there is nothing worse than being told there is a treatment available but it is out of reach financially to most people in the Uk. The only reason we knew about CyberKnife and the psma test is Peter’s surgeon told him about it and only because he was based at Birmingham University Hospital, which is one of the few NHS hospitals that have a CyberKnife machine. The problem came in that they withdrew CyberKnife treatment at the end of December for state patients, unless used for areas such as brain cancer and now is only available for people with medical health insurance, so Peter missed treatment by a couple of weeks. The issue with prostate cancer is it tends to be diagnosed in men over retirement age and most give up their private medical health insurance when they retire to cut costs, so can’t access CyberKnife now in the UK.
Clearly once we knew about CyberKnife and then found we could no longer get it on the NHS and could not afford to pay for it privately in the UK, we researched countries where we could afford it, hence our trip to Latvia but we were the exception. If you go to the oncologist now, they will not tell you about a treatment they cannot offer, as that will only upset people. There Is a big problem that each country has CyberKnife but the majority of people of that country cannot afford to access it. We are not sure what the solution is but it seems very wrong, as I am sure the cost of treatment in Latvia is doable for us but not for the majority of people of Latvia.
Thank you again for the treatment and we hope that all teething problems are ironed out, as we would highly recommend you to anyone thinking of having treatment. We hope you have a great holiday and a well deserved rest.
Peter and Marry
Thanks to your letter and situation described in it, we have added some employees to our team, which considerably reduces the load of our specialists allowing them to focus on patient care as much as possible. Our team is supplemented with Customer Consultants, Regional Representatives and Customer Service Manager, who must take care of logistics and administrative issues relevant to our customers and comfort of our customers during the treatment.
Unfortunately magnetic resonance imaging is not yet available in Sigulda, but we hope to introduce it in nearest future. Within the framework of the radiosurgery procedure, with a view to ensure maximum comfort to our patients, we offer transfer from Sigulda to Riga and back to Sigulda to take all the necessary medical manipulations and diagnostic services.
Patients from UK (for treatment received in Latvia, including Sigulda) can recover the expenses from NHS. Please ask our consultants for more detail or visit the website of our Regional Consultant at http://medrefund.co.uk/en/
Patient had a recurrence of disease after the radical prostatectomy and PET-CT showed tumour seeding in pelvic lymph nodes and bones. However the number of foci was not that big, therefore the hormonal therapy was supplemented with radiosurgery, giving a break to the hormonal therapy and implementing so-called intermittent hormonal therapy. This approach can reduce side effects of hormonal therapy and, possibly, delay formation of resistance to it. Besides, so-called abscopal effect can be observed regarding many tumours, including prostate cancer; it means that when destroying one lesion with radiation, lesions elsewhere in the body and tumour cells circulating in the body are oppressed by the immune system. It is because when tumour cells divide in the body their protein is released into bloodstream and this allows the immune system resisting other tumour cells.
Process of treatment of primary prostate cancer
Treatment of prostate cancer metastases in thorax
It seemed to be a nonsense or a problem in size of a chestnut
Diagnosis: oligometastatic prostate cancer
Andris (62 years) IT engineer
I was diagnosed with a prostate cancer in spring 2013. Since my work covers an insurance package, once a year I undergo something I call "technical check-up", so I also gave blood test for PSA, which I am taking since I was 55, following my family physician's recommendations. Until 2013,everything was fine, but in spring of 2013 PSA slightly exceeded the threshold. There were no prominent symptoms, the only thing was that I had to go to a toilet more frequently during nights; nevertheless I did not perceive it as a crucial problem. I made an appointment with an urologist, he did a biopsy of the prostate and discovered a cancer; unfortunately the worst scenario happened.
Doctors told me then —if a prostate cancer is detected in early stage, there are good chances and itcan be treated completely. Quoting the patient himself —a problem in size of a chestnut.However, it turned out to be different.
Initially doctors determined stage II. In June 2013 I had a surgery. In October I had PSA control and everything looked good; very good indicator, as my physician told me, and he thought we're through with that. Unfortunately, a year later PSA levels started to increase once again. I was referred to radiotherapy, 30 sessions in total; they radiated the entire pelvis. The mostparticular side effect was that haemorrhoids started to swell. I was warned that I would have nausea, but that did not apply to my case. I am rather well trained, my body is strong. I practice cross-country cycle race and cycling tourism. I had cycled almost 1,000 km along the mountains of Spain in spring of that year.
After radiotherapy PSA levels dropped, but not so much as initially, after the surgery. A year later PSA increased again. Physicians made a decision regarding further tactics; since the radiotherapy was already applied, the next step was the hormonal therapy.
Before taking this step I made inquiries as to what other options are available. I wanted to postpone the hormonal therapy and start it at the latest phase possible, because, according to what specialists told me, a resistance would develop against it and there are also side effects such as putting on weight, reduction of muscle mass. Upon my initiative I decided to try out new technologies that had just entered Latvia —PET or positron emission tomography and CyberKnife in the Radiosurgery Centre ofthe Sigulda Hospital, about which I learned from the printed mass media. So far I have not started the hormonal therapy, even though it was already scheduled for me.
Dr. Maris Mezeckis from the Radiosurgery Centre at Sigulda Hospital considered my caseand recommended starting with PET examination. The examinations detected 3 cancer metastases in pelvis —near major blood vessels and also near the bladder.
I showed PET opinion to the surgeon who had operated me and asked whether these new technologies introduced any corrections in the conventional treatment plan. His opinion remained the same —hormonal therapy and also chemotherapy are required as soon as possible. There was not a single word from the physicians regarding the new possibilities. I understood that the tumour board complies with the regular guidelines and does not risk recommending me the new therapy.
I decided to try out the modern technologies of radiosurgery, because I can start hormonal therapy at any time.
In January 2017, together with Dr. Mezeckis from the Radiosurgery Centre we planned the course of the therapy and necessary preparatory work. I had special gold markers placed in the lesions before the procedure. It was not painful, just a slightly unpleasant. Now I have gold in my stomach, because 2 out of 3 markers were gilded. Coordinates of the third reference point were taken, following the spinal vertebra. I had also CT and MRI scan to see the lesions during the procedure, and a vacuum bag was prepared that would keep mein a fixed position during the radiosurgery.
In total it took 6 sessions during one and a half weeks in Sigulda Radiosurgery Centre. My case was special, because I have a hip prosthesis due to which they could not radiate all 3 metastases at once. Initially during 3 sessions first two nodules were treated with radiation and then the position was adjusted to have other 3 sessions for the remaining tumour node. If not the hip prosthesis, 3 sessions had been sufficient during which all 3 metastases would beradiated concurrently. It was my individual case.
I went to Sigulda at the end of a working day. It was 40 minutes' procedure during which one must lie still. The ambience was pleasant —polite nurses, very encouraging management of the Centre, during the procedure there were bird songs and music in the background, apple-tree blossom video projections in the ceiling while hi-tech equipment does its work. Of course, it is completely contrary to the university hospital where also the equipment is not verynew.
Immediately after the operation I drove my car back to Riga without facing any side effects and restrictions. There was no dizziness or anything like that. One more nuance was that the bladder had to be full during the procedure for CyberKnife tobetter detect and reach the tumour's nodules. I had to drink a certain volume of water a certain while before the procedure. In the first time it was a little bit more difficult, but then I got used to it.
For a comparison I can say that the recovery after the surgical operation in the hospital was longer. Back then I spent two weeks in the hospital and for one more month I had a catheter inserted in the urethra, because one of two ureteric orifices are destroyed as the prostate is removed, therefore I had to live with the catheter for a long while and it was not comfortable. Also radiotherapy was much longer —30 sessions.
Now, looking retrospectively, I wonder whether I could have started with the modern technologies and avoided surgical operation in the very beginning, when the tumour was localized in the prostate. These technologies were not available in Latvia then.
Now I feel very well, I am 63 and I have just retired. It seems that there is so much to experience in future and I do not want to think of disease. I was thinking before the procedure —have the advanced technologies succeeded or I'd have to go back to the operating surgeon and humbly start the hormonal therapy. I hoped that it would be alright. Now, three moths after the radiosurgery my PSA level has dropped from 7.3 to 1.3. Eight months after the therapy PSA has reduced down to 0.3. So far, so good. On 3 September,I joined the Cycling Trip of the Union. Now I am expecting my trip to Spain. And the we'll see whether or not the advancedtechnologies have helped me. I hope that it is going to be alright.
Patient is a man aged 63, who was diagnosed with a prostate cancer in 2013.In the University Hospital he had a surgery —prostatectomy. A year after removal of the prostate PSA level unfortunately started to raise again and the patient was referred to conventional radiotherapy with 30 sessions where areaof former prostatewas radiated, because a recurrence was suspected there.
When the analyses showed an elevated PSA level once again, the patient took an initiative and approached us in the Radiosurgery Centre at Sigulda Hospital as he was looking for alternative treatment options. We performed PET-CT scan of the patient. It detected three metastases in pelvic lymph nodes —one between aorta and spine, other —where aorta splits into two pelvic arteries, and third —in front of the bladder. Initially we planed to remove two pelvic metastases in a surgery and to radiate only one —the one that was located at the spine. If a metastasis is located close to the spine, CyberKnife can track it very well and a precise radiosurgery needs no external markers to be placed in the body. However the surgeons refused to perform a surgery being afraid that they would not be able to find pelvic lymph nodes’ metastases accurately and there is a high risk to have a serious damage of blood vessels. We decided to place markers and treat all three metastases with CyberKnife.In case of this particular patient we had another challenge —the patient had ahip prosthesis that forced us to adapt the technology. Beams used to control patient's position are falling at angle of 45 degrees and the lesion turned out to be located in a place where the prosthetics is obstructing the beams while thepatient lies on his back. Therefore entire planning and therapy was especially accustomed to his case.
In case of ogliometastases and on the basis of the clinical research, our tactics is as follows: three months later we perform PSA analysis and see if there are any changes. Six months later we repeat PSA analysis and, if needed, we perform PET-CT to make sure that the radiated lesions are inactive and no new lesion has appeared. The first and the simplest indicator is blood count with a focus on PSA. Therapy is efficient if the number decreases and is even 0. If the level of PSA does not decrease, a PET-CT scan can be repeated half year later and test whether the tumour is active in the same region and in such case it would mean that tumour cells have not reacted fully or a new point has activated.Result of the patient in question was evaluated three months later. His PSA level had decreased from 7.3 to 1.3. Eight months after the therapy it was merely 0.3.
The very method of therapy itself is local:CyberKnife radiates only those nodules that can be seen in that moment both in the prostate and places where it has seeded. It does not rule out circulation of tumour cells in bloodstream, and theoretically they can seed in a new location. Advantage of the method is that this radiosurgery procedure can be repeated.
Process of treatment of prostate cancer metastases in pelvis
Treatment of metastases
I thought it was a stroke, but they turned out to be metastases
Diagnosis: Renal cancer, condition after nephrectomy. Metastases (3) in brain.
Aurimas (53 years), works in a bank in Lithuania (patient's name has been changed):
“I was hospitalised with symptoms similar to those in case of a stroke — speech and movement disorders. After a MRI scan they found two metastases in my head. It turned out that they have formed from the renal cancer, treated three years ago. I thought I was completely healed, because doctors told so after the kidney surgery. Alas, the disease made its comeback.
Neurosurgeons recommended a surgery, but since it was difficult previous time, I decided to refuse. Doctors told: if you don't want a head surgery, you can be saved only by radiosurgery. They told that such procedure is available in neighbouring country Latvia, in Sigulda, so I don't need to take a long trip. Sure, I did not think for a long time. In May 2016, I came for a consultation and already few days later I had that procedure done. During it I had to lay for 60 minutes, while the robot did its work. I had no bad sensations after the procedure. I was going home and thinking — did it really happen? Because it was painless and without anaesthesia. Did they do anything at all? Almost 2 years have passed and I don't have a stroke and the metastases have also disappeared, but for now I have to take medicines to prevent new metastases from forming.”
The patient had three renal cancer metastases found in brain. Renal cancer and also melanoma are tumours creating the most radioresistant metastases. Radiation of whole brain in these cases usually has low efficiency. Radiosurgery with CyberKnife is an efficient treatment method in such cases, because it ensures high radiation dose. This patient was treated with CyberKnife twice: in 2016 and 2017. In the first time 2 metastases were radiated and they started to decrease after the treatment — it was noticeable in MRI scans 3 and 6 months later. During this examination another new metastasis was detected, and it was also treated with the radiosurgery system CyberKnife in 2017. Currently patient's condition is satisfactory, 2 small metastases have almost disappeared.
Process of treatment of renal cancer metastases
Result of treatment of renal cancer metastases in brain 2 years later
How confidence in myself, CyberKnife and physiotherapy got me back on my feet
Diagnosis: Renal cancer with a metastasis in the tenth thoracic vertebrae.
Viktors, 68 years (patient's name has been changed):
My renal cancer was discovered accidentally in 2015. When I was working in Russia, I met a familiar doctor (general practitioner) and she asked me: “When was the last time you visited a doctor?” I told that 20 years ago and that I have noticed — the less I go to them, the less frequently I become ill. She offered to examine me with medical ultrasound. During examination the doctor told she did not like what she was seeing. She organised a consultation with a professor immediately. I went to the consultation and I was told that I have a kidney cancer. From where? No idea. I had no symptoms. I don't know. I have been to many business trips and, as you know, in business trips there is no regular eating and sleeping is disturbed.
I don't have any chronic illness. I played beach volleyball, also tennis, swam 2-3 km in the sea. I could play volleyball 3 to 4 hours in a row. Then my blood pressure was 120/60. And then suddenly — that's it. I have no idea where did the cancer come from. I have always been optimistic, a good fellow, and then it came as out of the blue. It was unexpected also for the family.
I immediately returned to Latvia to have a surgery in Hospital Gailezers. In autumn 2015, they removed my right kidney. Doctors told that the surgery was successful and the cancer was found in early stage. They did not refer me to additional therapy, the only control was blood tests. I controlled it, and it was fine.
However, it turned out that the disease goes on. In October 2016, I went to Smolensk with my friends and felt pain in the back. I know that I have lumbar osteochondrosis (spondylosis, to speak in proper medical terms) therefore, as usually in such cases, I applied some painkilling ointment. Initially the pain subsided. But then gradually it became worse and worse, until my feet could no longer feel. I could not walk across the room. I was hospitalised in a Russian clinic. Doctors asked what my complaints were. I said that I have lumbar osteochondrosis (spondylosis). I had MRI scan performed in the lumbar region of the spine, but they found nothing and it got even worse. Then they decided to examine the entire spine and found out that I have tumour metastases in the spine, tenth vertebrae and also around the spinal cord. The cancer had grown around the spinal cord. It was then it dawned on me that the renal cancer can create metastases inside the spine.
Russian doctors referred me to radiotherapy for the spine. I was treated for several weeks, but there was no improvement, it got only worse. On 28 December I was discharged from the hospital semi-paralysed and lying.
In order to seek help, my friends and acquaintances sent my MRI scans to several hospitals. Minsk was responsive and told to bring me to them and they would try to do something. In the beginning of January I was brought to a hospital in Minsk and had a surgery performed to remove the metastasis. But they managed to do it only partially — they removed it from the vertebrae, but not from the spinal cord, because the wound started to bleed heavily. They closed the wound and told that I needed also radiotherapy, but since I had it already done in Russia, there was no use in repeating it.
In Minsk they told me that the recent generation radiosurgery with so-called cyberknife is available in Sigulda Hospital, in Latvia, and in comparison to conventional radiotherapy it radiates the tumour with higher accuracy and does not damage surrounding tissue. Doctors from Minsk had met specialists from Latvia in a conference and knew about this possibility. I come from Latvia! Of course I decided to go there. Doctors made phone calls and agreed that I could come. I was taken with a minivan from Belarus to Sigulda.
At that point I was lying and capable of moving only the big toes. Specialists of Sigulda Radiosurgery Centre got acquainted with my case, assessed previous treatment and the dose of radiotherapy that I had already received in Russia and considered whether a further treatment is possible. They also performed the positron emission tomography (PET) scan to make sure that metastases are located only in the spine and have not spread elsewhere.
Specialists from Sigulda made a decision about further treatment and addressed the task.
They did all the necessary preparation procedures and then I had three radiosurgery sessions with CyberKnife. At first I felt even worse. On the day of the procedure and day after I felt tired, sickened, apathetic. Then energy and force came back to me. My condition gradually improved after the radiosurgery sessions. I started to get up and move. Before and after the procedure I actively worked out in the Rehabilitation Department of Sigulda Hospital. I gradually did all what specialists recommended — exercised at the wall bars, I was riding a gym bike. I did not stop at what they offered and took an initiative to ask for additional courses and training.
I am a naturally born optimist. I see different people in the Rehabilitation Department, they tend to work five minutes on the gym bike and then they are tired. I overcome myself all the time — I can, I can, I can! I pedal 6 km forwards and 6 km backwards. Doctors are asking where I am going. I tell them — to Riga! Doctors laugh that it is dangerous to approach me. I come by myself, see a free gym bike and have additional pedalling workout. Gradually. They also say that it is too much, it is enough.
I can say that confidence in myself, CyberKnife and physiotherapy got me back on my feet.
In 2015, the patient was diagnosed with a renal cancer. A surgery, nephrectomy (damaged kidney was removed), was scheduled. After the surgery he was monitored by an oncologist. No other therapies were recommended.
In the end of 2016, the patient felt weakness in legs. He was referred to spinal examination — MRI scan during which a metastasis in T10 was found. Weakness in legs intensified prominently. Patient was offered conventional radiotherapy with linear accelerator in the Oncology Centre, but few sessions later patient's condition worsened considerably and he could not move legs anymore. Lower paraplegia developed. Radiotherapy was discontinued. He had an urgent surgery (decompression laminectomy) to prevent the spinal cord from being compressed. Unfortunately due to bleeding it was not possible to detach metastasis completely. Movements in legs were somewhat restored. But the metastasis was still found during post-operative examinations. It meant that the metastasis was still compressing the spinal cord.
He was offered a radiosurgery with CyberKnife M6 to destroy remains of the metastasis in T10. Three sessions were scheduled. Patient's condition improved significantly after the radiosurgery and was followed by rehabilitation treatment course in Sigulda Hospital. The patient started walking again. Of course, in order to strengthen the spine, another surgery was offered half year after the treatment with CyberKnife. During the surgery the damaged vertebrae was removed and replaced with a fixation system. It was established during a histological examination that there were no more “living” tumour cells in the removed vertebrae (good result after radiosurgery with CyberKnife M6). The Patient went to the medical oncologist and was referred to chemotherapy to prevent progression of the disease and formation of new metastases.
Process of treatment of renal cancer metastases in spine
Quick and painless — cancer can be treated with CyberKnife!
Diagnosis: Renal cancer, metastases in lungs, head.
Anna, 58 years (patient's name has been changed):
In 2013, a tumour was found in my right kidney — clear cell carcinoma — therefore the kidney had to be removed. Doctor promised that everything would going to be alright and I have to come to examinations on a yearly basis. In spring 2015, I did all the examinations, but in August a cough appeared — dry, very disturbing and unceasing. I went to a pulmonologist who instantly referred me to an X-ray and CT scan. Unfortunately it showed two lesions in lungs. I was referred to further examinations in the Centre of Tuberculosis and Lung Diseases. One lesion was located in the upper lobe whereas the other — in the mediastinum of lung with almost no access to it. I was offered two solutions — to monitor lesions initially or to remove in a surgery, at least the available one.
In October I had a surgery and they found out what that lesion was — it turned out to be a malignant lesion: a metastasis of clear cell renal carcinoma. Doctors automatically assumed that the lesion in mediastinum is of the same origin. It was inaccessible, and conventional radiotherapy or chemotherapy was not an option. Later on, when contacting my oncologist, I was prescribed a medicine for further use. It turned out to be chemotherapy in a form of a pill. In the beginning I took one pill a day and it seemed to be alright. But on the fifth day, as I drank lukewarm tea, it felt as if I had drunk a boiling liquid. It was the first out of countless side effects: blood pressure fluctuations, constant diarrhoea, bleeding... I was hospitalised due to these side effects and I was given additional medicines to calm down side effects. My treating doctor prescribed alternative medicines, but unfortunately they also had side effects: constant diarrhoea, stomach bloating, extremely high blood pressure. My vision became worse, hair fell out, I was weak and had pain in heart region. Since I felt so bad, I searched for information about other treatment options. But nobody could offer me such opportunity. Soon I had another CT scan performed, and they established that another lesion has appeared in lungs... At that moment I was so desperate, it seemed that there is no hope left. Until I read an article in journal IEVA: " If someone had said earlier that a tumour in head can be defeated with a precisely targeted beam, it would sound like a sci-fi". It was the first time I heard about so-called cyberknife, but one month later I read about it in greater detail in journal Ievas Veseliba. I immediately contacted the radiation oncologist of Sigulda Hospital, Maris Mezeckis, and we made an appointment. Having heard my story, the doctor recommended additional examinations, for example positron emission tomography (PET) scan at the Nuclear Medicine Clinic and computed tomography. Luckily, the examinations showed that the second lesion is not malignant. It was possible to treat the malignant tumour with the CyberKnife, and there was a hope to destroy it.
I had to do some preparatory works before the procedure — markers had to be placed near the tumour. These are small, tiny, microscopic spirals made of gold that remain in the body. They were placed during a bronchoscopy under anaesthesia. Several days later I had preparation for the procedure scheduled. Before the very procedure I had to put on a vest with attached device helping the system to track the breathing rhythm. When I lied down in my fixing bag, I had to lie still, but in case of sudden cough or sneezing, I had to raise my right hand and doctors came to me. The robot adjusts to breathing in order to catch the right angle where the tumour is and then it “shoots”. You cannot feel the “shot”. After the procedures I could stand up and had no vertigo.
Patient was diagnosed with renal tumour ogliometastases and she had combined therapy — resection of lung segment and treatment of one metastasis with fractioned radiosurgery. Unfortunately the patient had prominent intolerance to chemotherapy (targeted therapy) medications prescribed in treatment, therefore local treatment methods, including radiosurgery is the only way to delay progression and further seeding of the tumour. Unfortunately a likelihood of formation of new metastases increases without additional chemotherapy and patient had 3 solitary lesions in brain treated with short interval between all sessions. However, the therapy was efficient and had relatively mild side effects, allowing the patient to continue living.
Process of treatment of renal cancer metastasis in lung
Result of treatment of renal cancer metastasis in lung 6 months later
I am ready to fight until victory.
Diagnosis: colon cancer, metastasis in scapula.
Maris, 61 years (patient's name has been changed):
Even though I am a doctor, I can comment on my disease that it is important to listen to your heart and body. First signs indicating at symptoms of the disease were unpleasant feelings in toilet and changing bowel movements. I thought that haemorrhoids are to be blamed, therefore I did not pay so much attention to it, because the work and needs of others always seemed more important. But, when it was followed by rectal bleeding, I understood that I finally have to go to see a doctor. And then it started: surgery to remove a section of the large intestine, a repeated surgery, creation of stoma. Several chemotherapy treatment courses before and after the surgeries, finding and removal of metastasis in lungs, regular examinations, including PET-CT scan and genetic testing of tissue sample, immunity boosting after chemotherapies and virotherapy. To put it simple, I did all I could to defeat my “crab” and continue living like before.
I came to Sigulda after a repeated PET scan, which showed a suspicious lesion in the right scapula — most probably a metastasis form my “old crab” I talked to my surgeon, had a consultation in Germany, but nobody really took a risk to operate a location so difficult to reach, because they assured I would not be able to play golf after the surgery. I started looking for alternatives and found information in internet about CyberKnife that treats tumours and their metastases in locations hard-to-access in a surgery in any place of the body. It was clear at once that there are no other alternatives. I contacted specialists from Sigulda, went to a consultation and two weeks later I was ready to take the treatment course. The treatment itself was not complicated, because I almost did not have to do anything, I was only asked to lie down. I must admit that the radiated area was rather aching in the evening after the session, but a good cognac made them go away. Almost two years have passed. Process in the scapula has stopped and no significant activity can be spotted in PET scans. I still play golf and try to do it as often as possible. I know that the tumour is still sleeping inside of me and occasionally reminds me of it, but I am ready to fight until victory.
From a PET-CT scan the patient was early diagnosed with several metastases and they were successfully removed in a surgery. A metastasis in the scapula was difficult, because surgery options are very restricted due to small dimensions and complicated shape of the bone. Therefore radiosurgery was chosen. Growth of the metastasis was stopped and it was later also reassured in biopsy data, when an increased glucose metabolism in the area treated with CyberKnife was observed.
Treatment process of colon cancer metastasis
The most important thing –I have redeemed the Big Hope!
Diagnosis: salivary gland tumour recurrence.
Livija (49 years) a teacher and poet in her leisure time
Soon I will be fifty. I have been to many and different doctors, hospitals since childhood, and my relatives have been ill. I don’t think that situation with medical staff in Latvia is very bad, like they say in public and media. But specialists, whom I met at the Radiosurgery Centre of Sigulda Hospital, deserve to be invited on the stage and granted with the Medical Award of the Year at least once.
“In 2010, I had one malignant tumour resected. Bad things happen... It was followed by radiotherapy so that everything, already removed by professional surgery and with a reserve, could be ‘eaten’ also with beams. However, every successive year I had to lie on the operation table... Also when after the last surgery (January 2015) I was told that they unfortunately had to remove one of jaw joints to access deeply located recurring tumour, I was still thinking: it is alright, I am alive, and this is going to (will!) be the last time. But when I found out in April this year that there is an extensive recurrence, it was clear to me –surgery is not possible... But to go through the hell of conventional radiotherapy once more... I had said to myself NO a long time ago.
But good people told me about possibilities offered bythe Radiosurgery Centre at Sigulda Hospital.
Radiotherapy performed in 2010 was so torturing and negative in my memories that recommendations from many good persons regarding novelties in this area in Sigulda stirred up only extreme lack of faith and fear. Nevertheless, putting together all pros and cons, and going through the most varied spectrum of emotions and mostly thanks to my family and friends, I had to make a decision –to try, because I had nothing to lose except my life...
To be honest, I was very sceptical when I went to the first visit in Sigulda (even though I had read the clear and promising information in their website). While listening and wondering whether doctor Dace Saukuma could offer me anything positive, I was constantly captured by aclue of tears.
Besides, since nobody had ever given me any guarantees (because oncology is an unpredictable field) and that it is only my choice, the load on my nerves was too huge to allow me making a choice as if it was a regular deal.However, everything developed quickly, simply and self-evidently and I just let myself be carried away by that stream. I was warned about side effects which I won’t be able to prevent. The scariest notion was “long healing” and possibly even “non-healing” ulcers...
I was explained that my malignant lesion is covered only with a layer of skin, several millimetres thick, from the outside and also in oral cavity, therefore no matter how accurate the smart beams are in destroying the object, it would be better to have more flesh around the tumour.
Therefore things were pretty bad after the CyberKnife procedure, but thanks to the doctors we managed that. I continue treatment and understand that it won’t get worse.
The most important thing –I have redeemed the Big Hope!Now I am able to open my mouth –there is no pain anymore. A lesion in my temple, which caused severe pain and grew almost daily during June, has reduced so much that it seems –it has not been there at all. Magnetic resonance imaging, performed several months later, will show the true picture, but I hope that it will be very gratifying. Doctors say: radiosurgery will be repeated if it is necessary. And I will consent to it without doubts and fears.
Since the first phone conversation with administrator IvetaI had a feeling that I was approached by a representative of a special mission, who cares for my pain and my issue. I felt like the most important, the only patient and that the place has been built, equipped and arranged especially for me.
You are welcome here! No slightest emotional discomfort at any moment. Besides everything is being explained. Answers are provided with patience, understanding, sincerity and apologies for making me wait for a short while.
I can say the same about every doctor. Both already mentioned Dace Saukuma and Maris Mezeckis. About specialists who do all the preparatory things at the table before each radiation session... The same recognition can be attributed to every employee at Sigulda Hospital: each one of them made me feel like a VIP and I do not exaggerate.
And I have not told yet what does the radiosurgery room where the smart robot “eats” the evil cells look like... Cherry blossom in the blue sky above the head. Scenes of GaujaValley at the walls. Even if you don’t see it (I kept my eyes closed) –I could listen to the gentle songs of the birds.... and to think only good thoughts.
Diagnosis: Salivary gland cancer. Condition after repeated surgery, externalbeam therapy (2010).In 2010, the patient was diagnosed with salivary gland cancer. The tumour was surgically removed in the Oncology Center of Latvia and patient was referred to external beam radiotherapy. Unfortunately in 2016 the patient had recurrence. Repeated conventional radiotherapyin area of recurrence, given the previous radiation, posed a high risk of complications and was dangerous. Tumour board (oncologist, radiation oncologist, oncosurgeon from the Head and Neck Departmentof Oncology Center of Latvia) made a decision to refer the patient to radiosurgerysessions with CyberKnife in Sigulda for5 re-radiation sessions.
Treatment progressed well, however few weeks after the treatment with CyberKnife the expected inflammatory reactions appeared in oral cavity near salivary glands in the side of the tumour. Such reactions can be seen in re-radiation cases and they indicate at destruction of tumour cells. Since our doctors were prepared for such reactions, the patient was admitted into Sigulda Hospital, and she received anti-inflammatory and restorative treatment course.
After the treatment when inflammatory and post-radiation reactions subsided, the patient continuedbeing under supervision of the oncologist and also doctors from Sigulda Hospital RadiosurgeryCentre. In the beginning of 2018, a control examination was performed (2 years after the radiosurgery) and decrease in tumour mass was detected and it showed no active tumour cells in the area radiated with CyberKnife.
Unfortunately the tumour has progressed in other partsof the skulland metastases have appeared.The patient was consulted by our medical oncologist. It was recommended to perform molecular genetic testing with OncoDNAtests. On the basis of results of OncoDNA analyses, the medical oncologist referred chemotherapy preparations that are suitable for that type of tumour, metastases have stopped growing and have started to reduce.