3. Lobes Zones

37. GLEASON GRADING It is important to recognize Gleason pattern 4 tumor because tumors with this pattern have a significantly worse prognosis than those with pure Gleason pattern 3 ( McNeal et al, 1990 ). Tumors with Gleason score 4 + 3 = 7 have a worse prognosis than those with Gleason score 3 + 4 = 7 ( Chan et al, 2000 ) GS Gleason’s Pattern Histo. Grade Differentiation 10 yr Progression (%) 2, 3, 4 1, 2 I Well <25 5, 6, 7 3 II Mod. 50 8, 9, 10 4, 5 III Poorly 75

38. TNM STAGING SYSTEM

55. GTV+SV GTV+ SV, PTV, CTV LN GTV P+SV, CTV P+SV CTV P+SV

56. 3DCRT FIELDS ARRANGEMENTS

60. IMRT PHASE

66. RADIOISOTOPES IODINE 125 PALLADIUM 103 IRIDIUM 192 T 1/2 (days) 59.4 16.97 73.83 Energy(keV) 27.4 21 340 Form Seeds Seeds Seeds Implant type Permanent Permanent Temporary Dose rate 8 20 Variable Mean activity/seed 0.42 1.3 Monotherapy dose 145 125 Variable (~600) +EBRT dose 110 100 20-25 TVL(mm) Pb 0.01 0.03 HVL-4.5 mm

72. TRUS GUIDED HDR INTERSTITIAL BRACHYTHERAPY

79. Strategies for Androgen Deprivation

90. Very high : T3b-T4 <10yr >10yr Expectant m/m or RT or RP±PLND RP±PLND or RT Androgen ablation or RT+Androgen ablation Any T, N1 Any T, Any N, M1 Androgen ablation Androgen ablation or RT+Androgen ablation Relapse risk Expected survival Initial T/t LOW : T1, T2a GS 2-6 PSA< 10 <10yr Intermediate : T2b, T2c GS 7 PSA-10-20 Expectant m/m or RT or RP±PLND High : T3a GS 8-10 PSA>20 >10yr Expectant m/m or RT Androgen ablation +RT or RT or RP±PLND

91. THANK YOU

107. Targeted Cryoablation of the Prostate (TCAP) Before Probes Placed Prostate frozen

111. IMRT PLAN SUM