Prostate cancer is common in men in western countries. Screening methods include digital rectal exam, PSA testing, and transrectal ultrasound with biopsy. PSA levels can help determine cancer risk and likelihood of spread, but PSA is not cancer-specific. Treatment depends on cancer risk and stage, and may include radical prostatectomy, radiation therapy, hormone therapy, or active surveillance. Outcomes are difficult to predict and depend on factors like PSA doubling time, Gleason score, and stage. Radiation therapy techniques aim to maximize dose to the prostate while minimizing dose to surrounding organs. Hormone therapy is an important addition for higher risk patients.

2. Common in western world
 One in six American men will be diagnosed with
prostate cancer during his lifetime
 Europe, the annual incidence rates were 214 per
1000 men


4. DRE
 PSA
 TRUS
 Biopsy and histopathology


5. •
•
•
•
•
simple, cost effective method
Positive predictive value from 21% to 53%
Good staging method
sensitivity of 52% and specificity of 80%
MAY UNDER/OVER ESTIMATE
J URO 1999;161:835-9

6. The normal PSA are <4 ng/ml
 threshold PSA level for detection of cancer is 4.0
ng/ml
 BUT 25% will have a normal or low PSA
 PSA <10 ng/ml - low risk of peri-prostatic spread
and metastases


7. PSA >20 ng/ml-An increased risk of periprostatic spread, seminal vesicle involvement and
distant metastases
 GENERAL RULES
 PSA >10 ng/ml indicates capsularpenetration in
more than 50% patients
 PSA >50 ng/ml – metastatic disease.


8. prostate specific
 Not cancer specific
 BPH, prostatitis, tuberculosis etc
 borderline zone of 4-10ng/ml


9. Extended biopsy is more preferable
 cancer detection rate- 40%,
 sextant biopsy -20% to 25%

REV UROLOGY 2007 SUMMER,9(3):93-98

10. NATURAL HISTORY OF PROSTATE CANCER
IS DIFFICULT TO PREDICT
 Men with similar stage ,glisson score,psa can
have markedly different outcome


11. 
Localized prostate cancer (T1 – T3a N0)

Locally advanced disease (T3b-T4 N0)

Metastatic disease: Any T, N+ or Any T,
Any N &distant metastasis (M+)

12. 
Low risk (cT1-T2a and Gleason score 2-6 and
PSA< 10)

Intermediate risk (cT2b-T2c or Gleason score =
7or PSA 10-20)

High Risk (cT3a or Gleason score 8-10 or PSA >
20)

15. PSA doubling time
 re-biopsy score
 , tumor volume
 stage progression
 patient preference.


16. 
RP -removal of the entire prostate gland between
the urethra and the bladder, with resection of both
seminal vesicles

is recommended for the organ confined prostate
cancer with life expectancy of >10 years

17. 
Importance-to determine adjuvant therapy

Only ePLND

removal of obturator, external iliac, and
hypogastric lymph nodes
int j radtn oncol biol phys 2012 jun;83(2) 624-9

18. •
No direct RCT between surgery vs RT
Retrospective analysis not much of difference
between both modalities
•
radical&palliative
•
EBRT
EBRT+BT
BT
•
•
•

19. •
Patient supine
•
Hands over chest
•
Immobilization –
•
Four field BOX
•
Shrinking field technique

20. •
Superior border-L4-L5-to include the common iliac
nodes
•
Inferior border-1.5 -2cm below the junction of
prostatic and membranous urethra –just below the
ischial tuberosities
•
Lateral margin-1-2 cm from the lateral boney
pelvis

21. 
Anterior -pubic symphysis

Posterior margin-S2-S3 junction to include the
pelvic and presacral nodes+sparing posterior
rectal wall

24. Cystogram –
 supine ,catheter insitu-20 ml of contrast+10ml of
air introduced into bladder
 20 ml of contrast into catheter balloon which is
pulled down to bladder base
 AP film in simulator-2cm margin is given with
bladder base as center


25. Depends on risk
 Low risk-a minimum dose of 70 - 74 Gy is
(external with / without brachytherapy)
 Ideal-75-79 GY for low risk
 Intermediate &high risk-can extent to 81GY.


26. Permanent
 Temporary


Permanent-Ideal-are those with favorable risk
prognostic features who have a high likelihood of
organ-confined disease

27. •
PSA levels 10ng/mL or less,
•
Gleason scores less than 6-7,
•
Clinical stages T1b- T2a
•
prostate volume of < 50 cm3 and
•
good International Prostatic Symptom Score (IPSS)

28. 
International Prostate Symptom Score
(IPSS) is an 8 question (7 symptom questions +
1 quality of life question)

29. IPSS result of 7 symptoms questions
Score
Correlation[1]
0-7
Mildly symptomatic
8-19
Moderately symptomatic
20-35
Severely symptomatic

30. •
•
•
•
.
more easily optimize the delivery of RT to the
prostate
reducing the potential for under-dosage ,
reduces radiation exposure
radiobiologically more efficacious in terms of
tumor cell kill for patients with increased tumor
bulk or adverse prognostic features.

31. 
Indication-positive surgical margins, seminal
vesicle invasion and/or extracapsular extension

recommended doses are 60-64Gy
radiother oncol.2008 jul88(1)

32. Clinically localized disease
 Neo adjuvant/concomitant/adjuvant-prolongs
survival in radiation managed patients
 When ever used cab should use
 Indicated in all high risk + locally advanced +
metastatic disease(2-3 yrs)
 Short term androgen deprivation in intermediate
risk (4-6 months)


33. Hot flushes
 vasomotor instability
 Osteoporosis
 Obesity insulin resistance
 Greater risk of DM, cardiac diseses


34. mainstay of treatment -of long term hormonal
therapy
 local therapy- with radiation therapy preferred


35. EBRT-for painful or unstable skeletal metastases
 DOSE -800 CGY –SINGLE fraction(Level of
evidence: 1b)
 Fractionated RT for bone metastases may be
considered-spinal cord compression


36. Strontium89
 Samarium153
 improve bone pains in upto 70% patients


37. reduce bone pains
• skeletal-related events including fractures
• inhibit
osteoclast-mediated bone resorption and
osteoclast precursors
effective-HRPC
response rate of 70-80%
•

38. •
Androgen deprivation- suppressing the secretion
of testicular androgens –
surgical
medical castration
•
Anti-androgens -inhibiting the action of the
circulating androgens at the level of their receptor
in prostate cells

39. Simple&quickest way to achieve a castration level
 Usually- obtained in less than 12 hours
 main drawback- negative psychological effect


40. Currently the predominant forms of ADT
 Synthetic analogues of LHRH
 interfere with the hypothalamic-pituitary-gonadal
axis
 initially stimulate pituitary LHRH receptors


inducing a transient rise in LH and FSH release

41. compete with testosterone and DHT for binding
sites on their receptors in the prostate cell nucleus
 promoting apoptosis and inhibiting Prostate
Cancer growth
 Steroidal& non steroidal
 Both competes with androgen at receptor but


42. long-term CAB- which stimulates prostate cell
apoptosis
 fails to eliminate the entire malignant cell
population
 after a variable period-tumor invariably relapseaveraging 24 months
 Androgenindependent state of growth


43. •
Role of Radiotherapy in Ca Prostate is timetested.
•
All stages and risk groups are benefitted with RT.
•
In future , Radiobiology research , Molecular
Pathways and Technological innovations are the
keys to enhance the treatment.