Prostate Cancer


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understanding and treating prostate cancer

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Prostate Cancer

  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. Prostate Anatomy…the nerves that can results in impotence are on the side of the gland
  5. 5. There are lymph nodes that may be involved
  6. 6. CT scans and MRI demonstrate the anatomy of the prostate well
  7. 7. Prostate CT Anatomy Prostate rectum bladder
  8. 8. Cross section anatomy of the male pelvis
  9. 9. Cross section anatomy of the male pelvis
  10. 10. Bladder Prostate Rectum Prostate CT Anatomy
  11. 11. CT Scan = large prostate cancer
  12. 14. MRI showing Cancer Nodule
  13. 15. Prostate Stages
  14. 16. T1c = too small to feel and biopsied because of an elevated PSA
  15. 17. T2 lesion = big enough to feel
  16. 18. T3 if spread to the seminal vesicles
  17. 19. Stage IV if spread to the lymph nodes or bone
  18. 20. Prostate Cancer Cure Rate After Radical Prostatectomy Based on Pathologic Stage
  19. 21. Prostate Cancer Cure Rate After Radical Prostatectomy Based on PSA Prior to Surgery
  20. 22. 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%
  21. 23. Note that the PSA levels slowly decline after completing radiation
  22. 24. Note that the PSA levels slowly decline after completing radiation
  23. 26. Prostate Cancer Cure Rate After Radical Prostatectomy Based on Pathologic Grade (i.e. how mutated the cancer cells appear)
  24. 27. 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.
  25. 28. The higher the Gleason Score, the lower the cure rates after surgery Gleason Score
  26. 29. The higher the Gleason Score, the lower the cure rates after radiation Gleason Score
  27. 30. 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>
  28. 31. 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>
  29. 32. Treating prostate cancer Surgery? Radiation?
  30. 33. American Urologic Association (AUA) came out with new treatment guidelines for prostate cancer in 2007
  31. 34. AUA: results the same for all three treatment modalities PSA Cure Rates Seeds External Surgery Low risk Intermediate High
  32. 37. RT = radiation therapy. IMRT = intensity modulated radiation therapy, IGRT = image guided RT e.g. Tomotherapy Brachytherapy = seeds
  33. 38. RT = radiation therapy. IMRT = intensity modulated radiation therapy Brachytherapy = seeds Androgen deprivation therapy = Lupron or Zoladex shots
  34. 39. 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
  35. 40. CT scan is obtained at this time CT images are then imported into the treatment planning computer
  36. 41. In the simulation process the CT and PET scan images are used to create a computer plan
  37. 42. 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
  38. 43. IMRT Identify organs and tumor target prostate rectum bladder
  39. 44. bladder Radiation zone prostate rectum Goal = radiation zone precisely around the prostate cancer
  40. 45. 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
  41. 46. IMRT Intensity modulated radiation therapy The computer then can generate different techniques of delivering the radiation
  42. 47. IMRT Computer will determine the optimal number of beams and beam angles
  43. 48. IMRT The cross sectional CT will show the dose clouds that surround the prostate and how close they are to other vital structures like the bladder or rectum
  44. 49. bladder prostate rectum IMRT The cross sectional image reconstruction of beams and targets
  45. 50. IMRT The radiation dose clouds that surround the target bladder prostate rectum
  46. 51. 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)
  47. 52. Even if the prostate has been removed radiation can be used to target the prostate bed (Tomo)
  48. 53. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment
  49. 55. 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)
  50. 57. 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
  51. 58. With daily image guided with a CT using Tomotherapy, radiation field can be very tight (‘close’) around prostate
  52. 59. 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
  53. 60. 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
  54. 61. 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
  55. 62. If no adjustment was made Actual treatment on Tomotherapy
  56. 64. Tomotherapy is particularly useful in men with hip replacements
  57. 66. Tampa Bay Cyberknife Center
  58. 67. Cyberknife Radiosurgery
  59. 68. With cyberknife you can use multiple beams from any direction
  60. 69. CyberKnife Multiple beamlets of radiation striking the prostate
  61. 70. bladder prostate rectum Radiation doses are conformed very closely or tightly to prostate avoiding the rectum and bladder
  62. 71. Seed Implants
  63. 72. Prostate Seed Implants
  64. 73. Prostate Seed Implants
  65. 74. Rectal ultrasound used to image the prostate
  66. 75. A grid or template with holes every 5mm are used to line up the needles
  67. 76. The needles are distributed
  68. 77. The Mick ‘Gun’ is used to push the radioactive seeds into the gland
  69. 78. The seeds are left behind, distributed through the gland and slowly radiate the cancer
  70. 79. CT scans of the prostate will show the seeds and the studies will be used to calculate the radiation dose
  71. 80. 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
  72. 81. 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)
  73. 82. Side Effects of Prostate Radiation The structures that will get radiation irritation: bladder, urethra and rectum Radiation zone
  74. 83. 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>
  75. 84. Long Term Side Effects of Radiation
  76. 85. 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>
  77. 86. 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>
  78. 87. Radiation prescription for # Diagnosis: # Hormones: # Seeds: # External radiation: #