Prostate carcinoma- localised and locally advanced

1. MANAGEMENT OF LOCALISED
& LOCALLY ADVANCED
PROSTATE CANCER
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. MODERATORS:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
2

3. LOCALISED CARCINOMA PROSTATE
 Organ confined
disease
 Tumor stage T1, T2
3
Dept
of
Urology,
GRH
and
KMC,
Chennai.

4. NATURAL HISTORY
 May be Indolent
 Highly aggressive – metastasize quickly and death
 One in six men will be diagnosed with prostate cancer in his
lifetime
 Only one in 35 men will die from cancer
4
Dept
of
Urology,
GRH
and
KMC,
Chennai.

5. TREATMENT OPTIONS
Conservative
• Active surveillance
• watchful waiting
Radical prostatectomy
Radiotherapy
Hormonal therapy
Focal therapies 5
Dept
of
Urology,
GRH
and
KMC,
Chennai.

6. CRITERIA TO CONSIDER WHEN SELECTING
APPROPRIATE TREATMENT FOR PCA
 Tumour’s potential aggressiveness
 Patient’s general health/co-morbidities
 Patient’s life expectancy
 QOL preferences of patient
6
Dept
of
Urology,
GRH
and
KMC,
Chennai.

7. TREATMENT STRATEGIES
Favorable risk profiles may opt
for surveillance strategies
Higher risk can be guided
towards a growing array of
interventions, perhaps applied
in combination as appropriate.
7
Dept
of
Urology,
GRH
and
KMC,
Chennai.

8. RISK STRATIFICATION
8
Dept
of
Urology,
GRH
and
KMC,
Chennai.

9. RISK STRATIFICATION - NCCN
9
Dept
of
Urology,
GRH
and
KMC,
Chennai.

10. RISK STRATIFICATION – EAU
LOW INTERMEDIATE HIGH
PSA <10 10 -20 >20
GS <7 =7 >7
cT stage T1 – 2a T2b T2c
10
Dept
of
Urology,
GRH
and
KMC,
Chennai.

11. INTERMEDIATE RISK GROUP
 Gleason 3+4
 % of biopsy core positivity
<50%
 Gleason 4+3
 % of biopsy core positive 50%
or greater
 Multiple intermediate risk
factors (Gleason 7, PSA level
of 10 to 20 ng/mL, cT2b )
FAVOURABLE UNFAVOURABLE
11
Dept
of
Urology,
GRH
and
KMC,
Chennai.

12. 12
Dept
of
Urology,
GRH
and
KMC,
Chennai.

13. NOMOGRAMS IN RISK ASSESSMENT
13
Dept
of
Urology,
GRH
and
KMC,
Chennai.

14. KATTAN’S
NOMOGRAM
14
Dept
of
Urology,
GRH
and
KMC,
Chennai.

15. PARTIN’S TABLES
 Use clinical features
 Gleason score
 Serum PSA
 Clinical stage
 To predict the number of percent with the specified PSA,
stage and GS who would have
 Organ confined disease
 EPE
 SV +
 LN+ 15
Dept
of
Urology,
GRH
and
KMC,
Chennai.

16. CAPRA SCORE
 University of California, San Francisco
Cancer of the Prostate Risk
Assessment (CAPRA) score
 Predicts relative rather than absolute
risk for multiple oncologic outcomes
including surgical pathology, BCR,
metastasis, cancer-specific, and
overall survival.
 The CAPRA score is categorized into
three risk strata:
 0 to 2 indicates low risk
 3 to 5 intermediate risk
 6 to 10 high risk
16
Dept
of
Urology,
GRH
and
KMC,
Chennai.

17. ROACH FORMULA
 EPE = 3/2 X PSA + 10 X (GS-3)
 SV + = PSA + 10 X (GS-6)
 LN + = 2/3 X PSA + 10 (GS-6)
17
Dept
of
Urology,
GRH
and
KMC,
Chennai.

18. BRIGANTI NOMOGRAM
18
Dept
of
Urology,
GRH
and
KMC,
Chennai.

19. IDENTIFICATION OF INDOLENT TUMOR
1. Epstein criteria – for insignificant tumor
 Gleason ≤6
 Tumor volume < 0.2ml
 Organ confined cancer
 PSA density <0.1ng/mL/g
 ≤2 needle cores +ve (minimum 6 total cores)
 <50% in any +ve core
 PSA density 0.1 to 0.15 ng/ml/g & cancer < 3mm on all biopsy sample
 f/t ratio ≥0.15
19
Dept
of
Urology,
GRH
and
KMC,
Chennai.

20. 2.Kattan nomogram – to identify indolent ca
 Based on 20% of low-risk PCa group had “indolent disease” -
 Point system from 0 to 200 and includes 7 variables } higher score = indolent PCa
 1) pre-treatment PSA
 2) clinical stage
 3) primary Gleason score
 4) secondary Gleason score
 5) U/S volume of prostate
 6) mm of cancer
 7) mm of non-cancer
20
Dept
of
Urology,
GRH
and
KMC,
Chennai.

21. Kattan criteria for indolent PCa
 organ confined
 <0.5mL tumour volume
 Gleason ≤6
21
Dept
of
Urology,
GRH
and
KMC,
Chennai.

22. EVALUATING LIFE EXPECTANCY &
HEALTH STATUS
• G8 screening tool
• CALE
22
Dept
of
Urology,
GRH
and
KMC,
Chennai.

23. G8
SCREENING
TOOL
23
Dept
of
Urology,
GRH
and
KMC,
Chennai.

24. 24
Dept
of
Urology,
GRH
and
KMC,
Chennai.

25. CALE
25
Dept
of
Urology,
GRH
and
KMC,
Chennai.

26. 26
Dept
of
Urology,
GRH
and
KMC,
Chennai.

27. TREATMENT OPTIONS
27
Dept
of
Urology,
GRH
and
KMC,
Chennai.

28. TREATMENT OPTIONS
Conservative
• Active surveillance
• watchful waiting
Radical prostatectomy
Radiotherapy
Hormonal therapy
Focal therapies 28
Dept
of
Urology,
GRH
and
KMC,
Chennai.

29. ACTIVE SURVEILLANCE
 Delayed primary therapy until there is evidence of progression
 Intent to cure persists
 Goal is to distinguish clinically insignificant PCa from life-threatening PCa
 Avoid overRx while administering curative Rx
“Active surveillance aims to avoid unnecessary treatment in men with
clinically localised PCa who do not require immediate treatment, but at
the same time achieve the correct timing for curative treatment in those
who eventually do.”
29
Dept
of
Urology,
GRH
and
KMC,
Chennai.

30. PATIENT SELECTION FOR ACTIVE SURVEILLANCE
 Low – intermediate risk (favourable)
 PSA < 10
 Life expectancy >10 years
 Upto T2a
30
Dept
of
Urology,
GRH
and
KMC,
Chennai.

31. CANDIDATES NOT SUITABLE FOR AS
 Family history of Ca – P
 African - American men
- High risk for disease progression
- Worse clinico pathological features
 Men With BRCA mutation
- Advanced tumor stage at presentation
- High gleason
- Shorter median survival 31
Dept
of
Urology,
GRH
and
KMC,
Chennai.

32. FOLLOW UP IN ACTIVE SURVEILLANCE
 Semi annual
 PSA
 DRE
 Annual
 Biopsy 32
Dept
of
Urology,
GRH
and
KMC,
Chennai.

33. RECLASSIFICATION CRITERIA FOR TREATMENT IN AS
 Disease progression
 Gleason pattern 4 or 5
 3 or more biopsy core +ve
 >50% of the core +ve
 Increase in disease extent
 Stage migration
 Patient preference 33
Dept
of
Urology,
GRH
and
KMC,
Chennai.

34. Untoward consequence of AS
 Need multiple biopsies
 Infection / Erectile dysfunction
 May complicate subsequent attempt of NS surgery
 Delay treatment until window of opportunity for cure had closed
% of curable ca at the time of progression – 30 -90%
34
Dept
of
Urology,
GRH
and
KMC,
Chennai.

35. WATCHFUL WAITING
 Monitoring until progression that requires palliative treatment
 No intent to cure
 Goal is to limit morbidity from disease & therapy
“Watchful waiting refers to conservative management for patients deemed
unsuitable for curative treatment right from the outset, and patients are ‘watched’
for the development of local or systemic progression with (imminent) disease-
related complaints, at which stage they are then treated palliatively according to
their symptoms, in order to maintain QoL.”
35
Dept
of
Urology,
GRH
and
KMC,
Chennai.

36. CANDIDATES FOR WATCHFUL WAITING
 Any T
 Any PSA
 Gleason < 7
 Life expectancy < 10 years
36
Dept
of
Urology,
GRH
and
KMC,
Chennai.

37. ACTIVE
SURVEILLANCE
WATCHFUL WAITING
Treatment intent Curative Palliative
Follow up Predefined schedule Patient specific
Assessment/markers
used
DRE, PSA, re-biopsy,
mpMRI
Not predefined
Life expectancy >10 years < 10 years
Aim Minimise treatment
related toxicity without
compromising survival
Minimise treatment
related toxicity
Comments Low risk patients Can apply to patients
with all stages 37
Dept
of
Urology,
GRH
and
KMC,
Chennai.

38. 2.RADICAL PROSTATECTOMY
 Complete removal of prostate, seminal vesicle with PLND
 Still - gold standard treatment for Ca P
- HT / CT Never curative
- Not All Ca cells eradicated by RT
- If gland remain in situ – possibility of new Ca from retained
epithelium
38
Dept
of
Urology,
GRH
and
KMC,
Chennai.

39.  Possibility of cure with minimal
collateral damage
 More accurate pathological
staging
 If treatment failure – Curative
salvage RT
 Significantly reduces tumor
progression, mets, Ca specific
mortality than WW
 Possibility of incomplete resection
- if not performed properly
- If tumor not confined to gland
 Risk of erectile dysfunction
 Risk of Urinary incontinence
Advantage Disadvantage
39
Dept
of
Urology,
GRH
and
KMC,
Chennai.

40. Patient Selection:
 Good GC
 Life expectancy >10yrs
 Tumor biologically significant and completely resectable
40
Dept
of
Urology,
GRH
and
KMC,
Chennai.

41. TRIFECTA
Priorities of Patients with Ca P
 Want to survive – Tumor Clearance
 Want to remain continent
 Want to preserve their potency
41
Dept
of
Urology,
GRH
and
KMC,
Chennai.

42. APPROACH - A. PERINEAL
 Acceptable approach
Advantage
 Less bleeding
 Shorter operative time than
retropubic approach
Disadvantage
- No access for PLND
- High rate of rectal injury and
post op fecal incontinence
- Difficult to spare Cavernosal N
42
Dept
of
Urology,
GRH
and
KMC,
Chennai.

43. 2.RETROPUBIC
 Wide exposure
 Able to perform PLND / Preserve Cavernosal N
 Less chance of rectal injury
 Less risk of +ve tumor margin
43
Dept
of
Urology,
GRH
and
KMC,
Chennai.

44. 3.LAPAROSCOPIC
 Better visualisation
 Less bleeding / Need of postop analgesics
 Early recovery / Less hospital stay
Disadvantage
 High risk of vascular, ureteric, bowel injury while PLND
 Hemostasis in NVB – difficult without thermal injury
 Emergency / readmision – more common
44
Dept
of
Urology,
GRH
and
KMC,
Chennai.

45. 4.ROBOTIC
 Easy to tie sutures and vesicourethral anastomosis
 3D vision
 Increased / Enhanced dexterity
Disadvantage
 Availabilty / Cost
 Increase rate of incisional hernias 45
Dept
of
Urology,
GRH
and
KMC,
Chennai.

46. Complications
 Sexual dysfunction (20- 100%)
 Urinary Incontinence (4-70%)
 Stricture (0-12%)
 Mortality (<1%)
46
Dept
of
Urology,
GRH
and
KMC,
Chennai.

47. RADIATION THERAPY
 EBRT
 Heavy Particle Beams
 IMRT
 IGRT
 3D CRT
 Sterotactic
 BRACHYTHERAPY
 Low Dose BT
 High Dose BT 47
Dept
of
Urology,
GRH
and
KMC,
Chennai.

48. DOSAGE
 Currently doses of 76 to 80 Gy or more - improve cancer control
 Low-risk patients - 70 to 72 Gy
 Intermediate-risk patients - 75 to 76 Gy
 High-risk patients - 80 Gy or more
 Doses above 80 Gy - not beneficial. 48
Dept
of
Urology,
GRH
and
KMC,
Chennai.

49. EBRT
 beams of gamma radiation, usually photons, directed at the prostate and
surrounding tissues through multiple fields
3D-CRT
 To minimize radiation injury to the bladder and rectum, in which a computer alters
the radiation beams to focus the radiation dose to the region of the prostate gland
IMRT
 provide localization of the radiation dose to geometrically complex fields
IGRT
 imaging techniques are used to guide IMRT to the target area
49
Dept
of
Urology,
GRH
and
KMC,
Chennai.

50. RADICAL EBRT
 Age<70 yrs
 Stage T1b, T2, T3
 LN involvement detected by nodal sampling
 Risk of LN involvement ≥ 15%
 Documented SVI
 Gleason score ≥6
 PSA ≥ 20 ng/ml 50
Dept
of
Urology,
GRH
and
KMC,
Chennai.

51. RT – SIDE EFFECTS
 Injury to the microvasculature of the bladder, rectum, striated
sphincter muscle, and urethra. (>50Gy)
 Urinary incontinence
 Cystitis
 Proctitis
51
Dept
of
Urology,
GRH
and
KMC,
Chennai.

52.  ERECTILE DYSFUNCTION (50%)
 Injury to the vasculature of the cavernous nerves and to the corpora
cavernosa of the penis
 begin about 1 year after the completion of treatment
 PDE5 inhibitors are useful in ameliorating the erectile dysfunction associated
with radiotherapy
52
Dept
of
Urology,
GRH
and
KMC,
Chennai.

53. CONTRAINDICATIONS
 Prior TURP - is a relative contraindication to brachytherapy / EBRT
- prostate does not hold the seeds well
- Associated with an increased risk of urethral stricture
 Inflammatory bowel disease
 Prior RT
53
Dept
of
Urology,
GRH
and
KMC,
Chennai.

54.  Cancer cells are not killed immediately after radiation.
 They sustain lethal DNA damage but do not die until they next
attempt to enter into cell division.
 The PSA level gradually decreases for up to 2 to 3 years after the
completion of radiotherapy.
 Accordingly, the PSA level is usually monitored at 6-month
intervals until it reaches a nadir.
ENDPOINTS FOR TREATMENT SUCCESS OR
FAILURE
54
Dept
of
Urology,
GRH
and
KMC,
Chennai.

55. PSA BOUNCE
 Due to post radiation prostatitis
 Seen in 20% of patients
 Usually during first 2 years
 More common with brachytherapy
 PSA bounce of >1.4ng/ml has been associated with
biochemical failure, metastasis & prostate cancer death
55
Dept
of
Urology,
GRH
and
KMC,
Chennai.

56.  10 year cure rate – 50% for localized prostate cancer
 5-year progression-free probability - 70% to 85%
TREATMENT RESULTS OF EXTERNAL BEAM
RADIOTHERAPY
56
Dept
of
Urology,
GRH
and
KMC,
Chennai.

57.  Radioactive sources (seeds or needles) are implanted directly
into the prostate gland
 Easy to perform
 Performed under general or regional anesthesia.
 Permanent implants (LDR)
 Iodine 125
 Palladium 103
 Cesium 137
 Temporary implants (HDR)
 Iridium 192
BRACHYTHERAPY
57
Dept
of
Urology,
GRH
and
KMC,
Chennai.

58. CONTRAINDICATIONS FOR BRACHYTHERAPY
 High volume
 High risk disease
 Prior TURP
58
Dept
of
Urology,
GRH
and
KMC,
Chennai.

59.  Urinary symptoms
 Urinary retention
 Urinary incontinence
 Erectile dysfunction
 Impotence
 Less common
Proctitis and rectal injury
SIDE EFFECTS OF BRACHYTHERAPY
59
Dept
of
Urology,
GRH
and
KMC,
Chennai.

60. ADJUVANT VS SALVAGE RT
 Extensive extracapsular
tumor extension
 Multiple or broad-based
positive surgical margins
 Seminal vesicle invasion
 Lymph node metastases.
 Focally positive margins or
minimal extracapsular tumor
extension
 Monitoring PSA every 4
months with early salvage
therapy being initiated when
the PSA reaches 0.2 ng/ mL
ADJUVANT RT SALVAGE RT
60
Dept
of
Urology,
GRH
and
KMC,
Chennai.

61. Adjuvant Radiotherapy
 Administered to the bed of the prostate gland
 Dose - 64 Gy to 72 Gy.
 Wait at least 3 to 4 months after surgery
 Radiation to the whole pelvis is usually discouraged because of the
higher risk for bowel complications
61
Dept
of
Urology,
GRH
and
KMC,
Chennai.

62.  If salvage radiotherapy is planned, it should be initiated before the
PSA level rises much above 0.5 ng/mL.
 Patients most likely to have favorable responses to salvage
radiotherapy are those with
 PSA recurrence long after surgery
 Slowly rising PSA level
 Low-grade tumor
 No seminal vesicle invasion or lymph node metastases.
SALVAGE RT
62
Dept
of
Urology,
GRH
and
KMC,
Chennai.

63.  Older men
 Significant medical comorbidities precluding the use of
curative therapy
 Those who do not wish to undergo curative therapy
PRIMARY HORMONE THERAPY
63
Dept
of
Urology,
GRH
and
KMC,
Chennai.

64.  Hormone therapy is never curative;
 Many patients experience long-term remissions.
 Bilateral orchiectomy and estrogen administration have largely
been replaced by luteinizing hormone–releasing hormone
analogs.
 Antiandrogens produce less sexual dysfunction and
osteoporosis
 But have a greater risk for adverse cardiovascular
complications
HORMONAL THERAPY
64
Dept
of
Urology,
GRH
and
KMC,
Chennai.

65. FOCAL THERAPIES
 Cryoablation
 High Intensity Focussed Ultrasound
 Radiofrequency ablation
65
Dept
of
Urology,
GRH
and
KMC,
Chennai.

66.  Cryoablation destroys prostate tissue through freezing.
 Cryoablation has been used as primary treatment for salvage after radical
prostatectomy or radiotherapy.
 The initial results were poor with incomplete eradication of the tumor and high
complication rates
 Urinary retention
 Incontinence
 Urinary-intestinal fistula
 Stricture
 Chronic rectal or perineal pain
 Erectile dysfunction
 With technical modifications, the complication rates have decreased, cancer
control has improved, and the procedure is better tolerated
CRYOABLATION
66
Dept
of
Urology,
GRH
and
KMC,
Chennai.

67.  It is minimally invasive
 It does not involve radiation exposure or surgical risk
 Repeated treatments are possible
 Preservation of potency is possible with cavernous nerve
warming.
ADVANTAGES OF CRYOABLATION
67
Dept
of
Urology,
GRH
and
KMC,
Chennai.

68.  Kill cancer cells selectively.
 Radiofrequency interstitial tumor ablation–induced
hyperthermia has been investigated as a treatment of the
primary tumor, in combination with radiotherapy, and for
salvage after radiotherapy failure
RADIOFREQUENCY INTERSTITIAL TUMOR
ABLATION
68
Dept
of
Urology,
GRH
and
KMC,
Chennai.

69.  office-based treatment
 can be repeated.
 Careful and constant monitoring is critical to limit the risk of
damage to normal tissue.
ADVANTAGES
69
Dept
of
Urology,
GRH
and
KMC,
Chennai.

70.  Acoustic energy can be used with ultrasound focusing to
generate heat within the prostate gland
 Transrectally applied highintensity focused ultrasound (HIFU)
can elevate the tissue temperature of the prostate up to 100°C .
 Within several seconds, a lesion develops with a sharp and
predictable volume, leaving the surrounding tissue intact.
 Tissue destruction by coagulative necrosis
HIGH-INTENSITY FOCUSED ULTRASOUND
70
Dept
of
Urology,
GRH
and
KMC,
Chennai.

71. MANAGEMENT ALGORITHMS
71
Dept
of
Urology,
GRH
and
KMC,
Chennai.

72. NCCN GUIDELINES
72
Dept
of
Urology,
GRH
and
KMC,
Chennai.

73. 73
Dept
of
Urology,
GRH
and
KMC,
Chennai.

74. 74
Dept
of
Urology,
GRH
and
KMC,
Chennai.

75. 75
Dept
of
Urology,
GRH
and
KMC,
Chennai.

76. 76
Dept
of
Urology,
GRH
and
KMC,
Chennai.

77. LOW
RISK
77
Dept
of
Urology,
GRH
and
KMC,
Chennai.

78. INTERMEDIATE
RISK
78
Dept
of
Urology,
GRH
and
KMC,
Chennai.

79. HIGH RISK DISEASE
79
Dept
of
Urology,
GRH
and
KMC,
Chennai.

80. MANAGEMENT OF LOCALLY
ADVANCED PROSTATE CANCER
80
Dept
of
Urology,
GRH
and
KMC,
Chennai.

81. DEFINITION
 Patients with regional or lymph node involvement
without distant metastasis
 T3-4 N+ M0
81
Dept
of
Urology,
GRH
and
KMC,
Chennai.

82. RISK STRATIFICATION - NCCN
82
Dept
of
Urology,
GRH
and
KMC,
Chennai.

83. ADDITIONAL INVESTIGATIONS
 Bone scan
 cT3-T4
 PSA >20 ng/ml
 Gleason score > 8
 Pelvic CT or MRI
 cT3-T4
 Calculated probability
of lymph node
involvement is greater
than 10%
83
Dept
of
Urology,
GRH
and
KMC,
Chennai.

84. TREATMENT OPTIONS
 Reserved for low
volume tumors that can
be completely excised
 With higher risk of
biochemical failure
RP + PLND ADT + RT
Men with high risk prostate cancer including those with locally
advanced disease – significant risk of disease progression and
cancer specific death if left untreated 84
Dept
of
Urology,
GRH
and
KMC,
Chennai.

85. SURGERY
 Select patients with T3 disease – low volume
disease may benefit
 Local control
 Complete cancer excision
 Adjuvant and combined therapy – required
 Without secondary treatment, 5 yr biochemical relapse
is higher than 60%
85
Dept
of
Urology,
GRH
and
KMC,
Chennai.

86. PATHOLOGIC PARAMETERS PREDICTION
PROGRESSION
 Extraprostatic extension
 Seminal vesicle involvement
 Lymph node involvement
 Positive surgical margin – greatest risk
86
Dept
of
Urology,
GRH
and
KMC,
Chennai.

87. ROLE OF NEOADJUVANT ADT
 Affects tumor behaviour and biology
 Reduction in positive surgical margin in cT1-2
disease
 cT3 – current data – do not support benefit of NAD
 Clinical downstaging may occur
 No difference in pathological downstaging
 Similar rates of positive margins
 With PSA >20 ng/ml  greater PSA free survival
87
Dept
of
Urology,
GRH
and
KMC,
Chennai.

88. NEOADJUVANT CHEMO/CHEMO-HORMONAL RX
 Decreased overall positive surgical margins
 Pathological downstaging
 Decreased biochemical relapse
 Decreased local recurrence
88
Dept
of
Urology,
GRH
and
KMC,
Chennai.

89. NEOADJUVANT CHEMO/CHEMO-HORMONAL RX
 Two 6-weekly cycles of ketoconazole + doxorubicin
alternating with vinblastine & Estramustine (Pettaway et
al)
 4-6 months of ADT + paclitaxel, Estramustine &
carboplatin (Konety et al)
 3 cycles of oral Estramustine & Etoposide (Clark et al
Cleveland clinic)
 Single agent Docetaxel (Oh et al, Dreicer et al) 89
Dept
of
Urology,
GRH
and
KMC,
Chennai.

90. ADJUVANT RT
 Improved biochemical control
 Significant reduction in local recurrence
 Low risk of metastatic disease
 Improved overall survival
 Freedom from subsequent ADT
 Early adjuvant RT – administered within 3-6 months
of surgery with undetectable PSA
 Biochemical free survival: 50-80% at 5 years 90
Dept
of
Urology,
GRH
and
KMC,
Chennai.

91. ADJUVANT RT
 Traditionally low dose : 45-60 Gy
 Higher dose: >64 Gy – improved 30 month
freedom from failure
91
Dept
of
Urology,
GRH
and
KMC,
Chennai.

92.  Treatment benefit primarily seen in – positive surgical
margins
 Seminal vesicle invasion – significant risk for distant
metastasis
 May not benefit from local or regional RT
 SV invasion who achieve a low PSA level (<0.3 ng/ml) after
RP – favourable group, Adj RT may be considered.
 EPE without SV invasion – predictor of better outcome
with RT 92
Dept
of
Urology,
GRH
and
KMC,
Chennai.

93. ADJUVANT ADT
 Improved overall, cancer specific and progression
free survival
 Adj. ADT + RT – improved survival when compared
with adj ADT alone
93
Dept
of
Urology,
GRH
and
KMC,
Chennai.

94. EAU RECOMMENDATIONS
94
Dept
of
Urology,
GRH
and
KMC,
Chennai.

95. EAU RECOMMENDATIONS
95
Dept
of
Urology,
GRH
and
KMC,
Chennai.

96. 96
Dept
of
Urology,
GRH
and
KMC,
Chennai.

97. GENERAL GUIDELINES
97
Dept
of
Urology,
GRH
and
KMC,
Chennai.

98. 98
Dept
of
Urology,
GRH
and
KMC,
Chennai.

99. 99
Dept
of
Urology,
GRH
and
KMC,
Chennai.

100. 100
Dept
of
Urology,
GRH
and
KMC,
Chennai.

101. RECOMMENDATIONS FOR FOLLOW UP
101
Dept
of
Urology,
GRH
and
KMC,
Chennai.

102. THANK YOU
102
Dept
of
Urology,
GRH
and
KMC,
Chennai.