This document summarizes the management of prostate carcinoma. It discusses clinical features, risk stratification, treatment options including active surveillance, radical prostatectomy, radiation techniques, adjuvant and salvage radiation therapy, brachytherapy, and androgen deprivation therapy. Treatment is tailored based on risk factors, tumor characteristics, and patient factors. Image-guided radiation therapy helps ensure accurate targeting of the prostate. Dose escalation and addition of hormones improves outcomes for intermediate- and high-risk disease.

1. MANAGEMENT OF
CARCINOMA PROSTATE
Reference :
1) NCCN
2) Perez and Brady’s principles and practice of
Radiation Oncology 7th edition

4. CLINICAL FEATURES
• Lower urinary tract symptoms - nocturia, urinary
frequency, urgency, decreased flow, incomplete
voiding, intermittent flow, or hesitancy and
occasionally erectile dysfunction .
• Bulky primary disease - urinary tract obstruction
or difficulty in passing stool or even bloody stool.
• With increasing PSA and Gleason score, the risk of
metastases increases.

5. • Metastatic spread is generally sequential,
proceeding from the prostate to the
periprostatic pelvic lymph nodes, but some
appear to spread directly to the common iliac
nodes and then to bone.
• Rarely, patients may present with renal failure,
lymphedema of the lower extremities, and
bone pain.

6. INTERMEDIATE RISK

8. FAVOURABLE
• Has all of the following :-
• 1 IRF
• Grade Group 1 / 2
• < 50 % Biopsy cores positive
UNFAVOURABLE
• Has 1 or more of the
following :-
• 2 or 3 IRF’s
• Grade group-3
• >= 50% Biopsy cores
positive.

9. FAVOURABLE INTERMEDIATE
Expected Survival >= 10 Years
• Active Surveillance
• EBRT / BT alone
• RP +/- PLND (If nodal
metastasis >=2 %)
Expected Survival <10 Years
• EBRT / BT Alone
• Observation

10. ACTIVE SURVEILLANCE
• Based on ProtecT trial
• Multiparametric MRI &/ or Prostate Biopsy &/or
Molecular tumour analysis.
• PSA – 6 monthly once
• DRE – Annually
• Repeat Biopsy –Annually
• Repeat MRI – Annually
(Unless clinically indicated not repeated )

11. OBSERVATION
• Involves monitoring the course of disease with
the intention to deliver palliative therapy for
symptoms or change in examination or PSA that
suggests that symptom is imminent.
• Selection of patients with indolent disease or
comorbidities that would impact the expected
survival is crucial

13. UNFAVOURABLE INTERMEDIATE

14. RADICAL PROSTATECTOMY
• Based on SPCG-4 & PIVOT Trial  RP is a
recommended treatment option if life
expectance is >=10 years.

17. HIGH & VERY RISK GROUP

18. Clinical and Pathological Features
(HIGH)
• Has no very high risk features and has atleast
one high risk feature:
T3a
Grade group-4 / 5
PSA >20 ng/ml

19. VERY HIGH RISK
• Has at least one of the following
T3b- T4
Primary Gleason pattern 5
2 – 3 high risk features
>4 cores with Grade 4 or 5

20. INITIAL THERAPY
Expected Survival >5 yrs / Symptomatic
• EBRT + ADT (1.5-3 yrs ) +/- Docetaxel (for very
high risk )
• EBRT + Brachytherapy + ADT (1-3 yrs)
• RP + PLND
Expected Survival <=5 yrs / Asymptomatic
• Observation
• ADT
• EBRT

22. • Undetectable PSA After RP / PSA Nadir after RT

25. RADIATION TECHNIQUES
• Highly conformal techniques should be used to
treat localized prostate cancer .
• Photon or Proton EBRT are highly effective.
• Accuracy of the treatment should be verified by
daily prostate localization with any of the
following :-
IGRT Using CT
USG
Implanted fiducials
Electromagnetic tracking / targeting .

26. IGRT
• Image-guided RT (IGRT) allows for the adjustment
of patient daily set up as well as the positional
correction of the radiation beams during radiation
delivery .
• A consequence of modern, high-conformality RT,
however, is the risk of a “geographic miss”.
• Geometric uncertainty include target delineation
error, patient setup uncertainty and target position
variation (both day-to-day interfraction motion and
intrafraction movement during the course of
treatment delivery

27. • Additionally, the use of IGRT allows for the
reduction of planning margins .
• Imaging methods :-
Non-radiation-based -ultrasound,
electromagnetic tracking, and MRI systems
integrated into the treatment room or
treatment machine.
 Radiation-based - static as well as real time
tracking, using either kV, MV, or hybrid
methods .

28. • intraprostatic radiopaque markers with daily in-
room imaging as this technique is low cost, is
easy to use, and provides limited interobserver
variability .
• Three radiopaque markers, such as gold seeds
or coils, are implanted into the periphery of the
prostate via a transrectal or transperineal
approach.
• The FMs remain stable within the prostate with
an average displacement of 1.01–2.8 mm

29. • The markers are a surrogate for the prostate
position and thus ensure that the prostate and
rectal interface is reproducibly identified even
with prostate rotation and deformation

31. DEFINITIVE RT
Favorable Intermediate
Risk
• Prophylactic lymph node RT ,
ADT is not performed
routinely unless there is
aggressive tumour behaviour.
Unfavorable
Intermediate
• Prophylactic Pelvic RT can
be given after assesment.
• ADT must be given unless
contraindicated.
• Duration of ADT can be
reduced if EBRT & BT is
administered.
• SBRT + ADT can be
administered.

32. HIGH and VERY HIGH RISK
• Prophylactic nodal radiation –considered.
• ADT is given unless contraindicated.
• Brachytherapy + ADT / SBRT +ADT can be
used .

33. DOSE ESCALATION

34. Conclusion
• This suggests that dose escalation alone
cannot replace hormones as a strategy to
improve cure, and that both may be necessary
in patients with intermediate- and high-risk
disease.

35. HYPOFRACTIONATION

36. ADJUVANT RT
SWOG-8794 randomly assigned 425 node-negative patients initially
treated with radical prostatectomy but found to have either PSM or
pT3 (ECE and/or SVI) disease to ART or observation.
Central pathology review was performed in 73% of patients, and
there was a 95% concordance with the community pathologist.
Ninety percent of patients had ECE or PSM.
Two-thirds of patients had a postoperative PSA <0.2 ng/mL.

37. RT consisted of 60 to 64 Gy.
Median PSA relapse-free survival was significantly longer with
ART (10.3 vs. 3.1 years; P <.001).
Updated results were recently published with a median follow-up of
12.6 years.
The 10-year distant metastasis-free survival (71% vs. 61%; HR
0.71; P = .016) and overall survival (74% vs. 66%; HR 0.72; P =
.023) were significantly improved with ART.
The median distant metastasis-free survival was prolonged from 12.9
to 14.7 years with ART, and overall survival from 13.3 to 15.2 years.

38. • As it stands, we have only retrospective data
that suggest that early salvage radiotherapy is
more effective than later salvage radiotherapy,
and this is likely due to reduced tumor
burden.
• Whether early salvage radiotherapy is as good
as adjuvant radiotherapy is unknown.

39. NODE POSITIVE
• In a subset analysis of RTOG-8531,
• 141 postoperative patients with histologically confirmed node-positive
disease were randomized to postoperative radiotherapy with
immediate or delayed hormonal therapy.
• In the immediate hormone arm, the hormones were commenced in the last
week of radiotherapy and continued indefinitely.
• This subgroup received 60 to 65 Gy (postprostatectomy) and 65 to 70 Gy
(radical treatment) with optional nodal irradiation.
• With a median follow-up of 6.5 years, updated results demonstrated that
immediate hormones improved 5-year biochemical progression-free
survival (54% vs. 10%; P <.0001).
• Multivariate analyses, immediate hormones was associated with improved
overall survival, biochemical PFS, distant metastasis-free survival.

40. • REGIONAL DISEASE
• Nodal irradiation must be given .
• Clinically Positive nodes must be dose escalated
as DVH parameters allow.
• ADT is required unless contraindicated .
• ABIRATERONE or fine particle Abiraterone can
be considered.

41. ADJUVANT RADIATION THERAPY
• Treatment is individualised based on age/ co-
morbidities /clinical and pathological information ,
PSA level and PSADT.
• Moloecular assay –if adverse features are present .
• Administered within 1 year of RP and after post-op
recovery is complete.
• Patients with positive margins may benefit the most
.

42. INDICATIONS
• Positive surgical margins
• Seminal vesicle invasion
• Extracapsular extension
• LN mets
• Poorly diffrentiated adenocarcinoma
• GS 8-10
• pT3 disease.

43. ADVANTAGES
• Increased local control
• Eradicating microscopic periprostatic disease
• Decreased distant mets
• Improved survival

44. SALVAGE RADIATION THERAPY
• Indications :- Undetectable PSA that becomes
subsequently detectable and increases on 2
measurements or a PSA that is persistantly
detectable after RP .
• Treatment is more effective when pre-treatment
PSA Is low and PSAdt is long .

45. RAVES TRIAL
SRT spares approximately half of men
from pelvic radiotherapy, and is
associated with significantly lower levels
of GU toxicity.

48. BRACHYTHERAPY
• As per NCCN –
• Recommended only in low-risk or favourable
intermediate risk( MONOTHERAPY)
• Unfavourable intermediate risk – EBRT + BT +/-
Androgen Deprivation therapy – Based on
ASCENDE-RT trial
• High risk – Dose Escalation – Highly beneficial.

50. • HDR Brachytherapy –Absolute and radiobiological
dose escalation – high tumour control and low
toxicity .
• Dose rate - >=12 Gy /h.
• Boost schedules vary from 9-15 Gy in a single
fraction to 26 Gy in 4 fractions .
• 5 year Biochemical disease control –
Low risk – 85-100 %
Intermediate – 83-98%
High risk – 51- 96%

51. • Patient Evaluation
• Sexual function assessment.
• Gastrointestinal / Rectal function assessment.
• Urinary function assessment .
• Serum PSA
• Biopsy and HPE report
• MRI / CT – With Endorectal coil is preferred for
extracapsular extension.
• Bone Scan

52. • PRIOR PROSTATE RADIATION
• HDR Monotherapy - Salvage treatment for local
failure after EBRT / Permanent Seed
Brachytherapy –Promising results in patients
who don’t fit the criteria for salvage
prostatectomy .

55. CONTRAINDICATIONS

56. SEEDS AND IMPLANTATION
 PERMANENT
• Iodine 125
• Palladium 103
• Cesium 131
 TEMPORARY
• Iridium 192
• Cesium 137

57. • APPROACHES :
Perineal approach-
• Needles are introduced above the anus and are
guided into the prostate with the index finger in
the rectum
 Suprapubic Cystotomy Approach-
• The needles are placed directly in the prostate
through the open bladder with a finger in rectum
guiding the placement
 Retropubic approach-
• This approach is used most extensively, though it’s
a more difficult procedure.

58. ANDROGEN DEPRIVATION THERAPY

59. • ADT acts by reducing the level of androgen
hormones, to prevent the prostate cancer cells from
growing
 INDICATIONS
• Intermediate unfavorable prostate cancer
• High risk and Very High Risk Prostate Cancer
• Metastatic Prostate Cancer
• In recurrence after RT or Surgery
• Most patients with T3 are, at the present time,
treated with NAHT followed by RT

60. • Prolongs survival in selected patients.
LHRH Agonist alone
Goserelin , Histrelin , Leuprolide or Triptorelin .
LHRH Agonist + First generation Antiandrogen
Nilutamide, Flutamide or Bicalutamide
LHRH Antagonist
Degarelix

62. TIMING OF ADT
• Intermediate Risk:
• NACT : 3 to 6 months + Concurrent +/- Adjuvant : 6
months
• High and Very High Risk :
NACT : 3 to 6 months + Concurrent +/- Adjuvant : 24
to 36 months
• Metastatic : Gold Standard for metastasis at time of
presentation

63. CASTRATION RESISTANT PROSTATE
CANCER
Defined by disease progression despite
androgen depletion therapy (ADT) and may
present as :
o Continuous rise in serum prostate-specific antigen
(PSA) levels
o Progression of pre-existing disease
o Appearance of new metastases

64. Second Line Hormonal Therapy
ABIRATERONE ACETATE:
• 1000MG DAILY(250 Mg 4 tabs daily)
• Taken with Prednisone 5mg BD
• FDA approved 1st line therapy in asymptomatic
CRPC
• 2nd line therapy after failure of docetaxel
ENZALUTAMIDE:
• Inhibits signaling of androgen receptor
• Poor PS
• Given with GNRH Agonists

66. FOLLOW UP SCHEDULE
• First follow-up : 3 months
• Years 0–1 : Every 3 –4 months
• Years 2–5 : Every 6 months
• Years 5+ : Annually