Prostate

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Prostate

  1. 1. Prostate Cancer <ul><li>Understanding the disease </li></ul><ul><li>Treatment options </li></ul><ul><li>Side effects of treatment </li></ul>
  2. 2. Understanding prostate cancer <ul><li>Anatomy </li></ul><ul><li>Importance of Stage </li></ul><ul><li>Importance of the Gleason Score </li></ul><ul><li>Significance of the PSA </li></ul>
  3. 3. The prostate gland has a capsule around it, and cancers arise close to the capsule
  4. 4. The prostate lies along the back of the bladder
  5. 5. Side View of the Prostate, Cancers arise in the peripheral zone , close to the capsule The location of cancer in the prostate is critical for targeting the correct area
  6. 6. Prostate Zones: 80-85% cancers arise from the peripheral zone, 10-15% transitional and 5-10% from the central zone.
  7. 7. The peripheral zone is small at the top (base) of the gland but larger at the bottom (apex)
  8. 8. Cancer occurs along the outside edge of the prostate just under the capsule cancer
  9. 9. Cancer occurs along the outside edge of the prostate just under the capsule, so the radiation field may need to extend slightly outside the capsule cancer cancer
  10. 10. Risk of Extracapsular Spread for T1c, based on Gleason and PSA You can estimate the risk that the cancer has already grown into the capsule , this helps the doctor determine how large an area to treat
  11. 11. Prostate Anatomy…the nerves that can results in impotence are on the side of the gland
  12. 12. There are lymph nodes that may be involved, it is rare to have lymph node spread in low or intermediate risk patients
  13. 13. CT scans and MRI show the anatomy of the prostate quite well
  14. 14. Prostate Cross Section Anatomy Prostate rectum bladder
  15. 15. Cross section anatomy of the male pelvis
  16. 16. Cross section anatomy of the male pelvis
  17. 17. Bladder Prostate Rectum Prostate CT Anatomy
  18. 18. CT Scan = large prostate cancer
  19. 21. MRI showing Cancer Nodule
  20. 22. Prostate Stages
  21. 23. Most men with a low PSA (less than 10) and a low Gleason score (less than 7) have cancer cells in the gland too small to feel or see on CT scans
  22. 24. T1c = too small to feel and biopsied because of an elevated PSA
  23. 25. T2 lesion = big enough to feel
  24. 26. T3 if spread to the seminal vesicles
  25. 27. Stage IV if spread to the lymph nodes or bone
  26. 31. Prostate Cancer Cure Rate After Radical Prostatectomy Based on Pathologic Stage
  27. 32. Prostate Cancer Cure Rate After Radical Prostatectomy Based on PSA Prior to Surgery
  28. 33. PSA (prostate specific antigen) and radiation results PSA Level Relapsed after Radiation 0.1 to 4 4% 4 to 10 7% 10 to 20 22% 20 - 50 48% over 50 67%
  29. 34. Note that the PSA levels slowly decline after completing radiation
  30. 35. Note that the PSA levels slowly decline after completing radiation
  31. 37. Declining PSA After External + Seeds
  32. 38. Prostate Cancer Cure Rate After Radical Prostatectomy Based on Pathologic Grade (i.e. how mutated the cancer cells appear)
  33. 39. Gleason Scoring System From the biopsy, the pathologist grades the appearance of the cells. From least serious (slow growing or Grade 1) to the fastest growing and most dangerous or grade 5). The Gleason score doubles the score So the slowest is a 2 and the fastest is a 10.
  34. 40. The higher the Gleason Score, the lower the cure rates after surgery Gleason Score
  35. 41. The higher the Gleason Score, the lower the cure rates after radiation Gleason Score
  36. 42. Prostate Cancer Risk Groups <ul><li>Low risk : (T1c, T2a Gleason 6, PSA <10) </li></ul><ul><li>Intermediate risk : (T2b, T2c, Gleason 7, PSA 10-20) </li></ul><ul><li>High risk : (T3, Gleason 8-10 or PSA > 20) </li></ul>
  37. 43. What is considered the proper treatment for prostate cancer? <ul><li>Advice from the AUA (American Urologic Association) </li></ul><ul><li>Advice from the NCCN (National Comprehensive Cancer Network) </li></ul>
  38. 44. Treating prostate cancer Surgery? Radiation?
  39. 45. American Urologic Association (AUA) came out with new treatment guidelines for prostate cancer in 2007
  40. 46. AUA: results the same for all three treatment modalities PSA Cure Rates Seeds External Surgery Low risk Intermediate High
  41. 49. RT = radiation therapy. IMRT = intensity modulated radiation therapy, IGRT = image guided RT e.g. Tomotherapy Brachytherapy = seeds
  42. 50. RT = radiation therapy. IMRT = intensity modulated radiation therapy Brachytherapy = seeds Androgen deprivation therapy = Lupron or Zoladex shots
  43. 51. RT = radiation therapy. IMRT = intensity modulated radiation therapy Brachytherapy = seeds Androgen deprivation therapy = Lupron or Zoladex shots
  44. 52. Cure Rates with Radiation versus Surgery for Early Stage Prostate Cancer are the same from the Cleveland Clinic.  Kupelian. JCO Aug 15 2002: 3376-3385
  45. 53. CT scan is obtained at this time CT images are then imported into the treatment planning computer
  46. 54. In the simulation process the CT and PET scan images are used to create a computer plan
  47. 55. bladder Radiation zone prostate rectum Goal = radiation zone precisely around the prostate cancer with small margin
  48. 56. The CT scan images are then converted into a 3 dimensional view inside the patient You can actually see inside the man’s body and locate the key organs
  49. 57. IMRT Identify organs and tumor target prostate rectum bladder
  50. 58. IMRT using 7 different beams to target the prostate The computer can determine the optimal number of beams to deliver the radiation dose to hit the target and avoid other structures
  51. 59. IMRT The radiation dose clouds that surround the target bladder prostate rectum
  52. 60. The computer identifies targets and using IMRT techniques applies low doses to some structures (like lymph nodes) and high doses to the main target (prostate)
  53. 61. Even if the prostate has been removed radiation can be used to target the prostate bed (Tomo)
  54. 62. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment
  55. 64. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)
  56. 66. With Tomotherapy the beam can hit the target (nodes) in the upper abdomen and avoid the bladder and small intestine and lower in the pelvis hit the prostate, nodes and seminal vesicles and still avoid the bladder and rectum
  57. 67. With daily image guided with a CT using Tomotherapy, radiation field can be very tight (‘close’) around prostate
  58. 68. Significant movement of the prostate gland based on daily gas in rectum Planned target Rectal gas No Rectal gas Planned target, missed badly if rectal gas pushes the prostate forward
  59. 69. Significant movement of the prostate gland based on daily gas in rectum Initial computer target for prostate (red circle) would have badly missed the target if no adjustments were made based on the amount of rectal gas
  60. 70. Importance of daily CT targeting on Tomotherapy and adjusting the treatment daily Very little bowel gas on initial study and the dose (red) targets the prostate gland closely large bowel gas on later treatment day and the dose (red) will cover half the rectum if an adjustment is Not made
  61. 71. If no adjustment was made Actual treatment on Tomotherapy
  62. 73. Using Tomotherapy to tightly target the prostate with very little radiation hitting the bladder or rectum
  63. 74. Tomotherapy is particularly useful in men with hip replacements
  64. 76. Tampa Bay Cyberknife Center
  65. 77. Cyberknife Radiosurgery
  66. 78. With cyberknife you can use multiple beams from any direction
  67. 79. CyberKnife Multiple beamlets of radiation striking the prostate
  68. 80. bladder prostate rectum Radiation doses are conformed very closely or tightly to prostate avoiding the rectum and bladder
  69. 81. Seed Implants
  70. 82. Prostate Seed Implants
  71. 83. Prostate Seed Implants
  72. 84. Rectal ultrasound used to image the prostate
  73. 85. A grid or template with holes every 5mm are used to line up the needles
  74. 86. The needles are distributed
  75. 87. The Mick ‘Gun’ is used to push the radioactive seeds into the gland
  76. 88. The seeds are left behind, distributed through the gland and slowly radiate the cancer
  77. 89. CT scans of the prostate will show the seeds and the studies will be used to calculate the radiation dose
  78. 90. Side Effects of Prostate Radiation Is related to the size and area of normal structures that are over lapped by the radiation zone…the goal is to keep the radiation zone as small as possible
  79. 91. Side Effects of Prostate Radiation With IMRT and image guided techniques the goal is to shape the radiation zone very precisely , based on the type of cancer (high Gleason might require a larger margin around the gland)
  80. 92. Side Effects of Prostate Radiation The structures that will get radiation irritation: bladder, urethra and rectum Radiation zone
  81. 93. Irritation of bladder, urethra and rectum Radiation zone <ul><li>Urinary frequency (getting up at night very few hours) </li></ul><ul><li>Slight burning or stinging with urination </li></ul><ul><li>Diarrhea or more frequent, softer bowel movements, rectal soreness </li></ul><ul><li>Mild skin irritation </li></ul><ul><li>Fatigue </li></ul>
  82. 94. Long Term Side Effects of Radiation
  83. 95. Typical Radiation Protocols for Low Risk <ul><ul><li>Daily external beam radiation, Monday through Friday for ~ 8weeks </li></ul></ul><ul><ul><li>Seeds (one time) </li></ul></ul><ul><ul><li>Combination: 5 weeks or external radiation then 3-5 weeks later a seed implant </li></ul></ul>
  84. 96. Typical Radiation Protocols for More Advanced Risk Group <ul><ul><li>May start with hormonal therapy (e.g. Zoladex or Lupron) for several months prior to starting radiation </li></ul></ul><ul><ul><li>May need to continue on hormone therapy for up to 2 to 3 years </li></ul></ul>
  85. 97. Radiation prescription for # Diagnosis: # Hormones: # Seeds: # External radiation: #

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