Carcinoma Prostate

1. MANAGEMENT OF CARCINOMA
PROSTATE
Reference :
1) NCCN 2022
2) Perez and Brady’s principles and practice of
Radiation Oncology 7th edition

4. Risk Stratification

5. Very Low Risk
• Expected Patient survival:
More than 20 years :
• Active Surveillance ( Preferred)
• Radiation Therapy
• Radical Prostatectomy

6. Very Low Risk
• Expected Patient survival:
More than 10-20 years :
Active Surveillance
• Expected Patient survival:
Less than 10 years :
Observation

7. Low Risk
• Expected Patient survival:
More than 10 years :
• Active Surveillance ( Preferred)
• Radiation Therapy
• Radical Prostatectomy
Less than 10 years:
Observation

8. INTERMEDIATE RISK

9. IRF : Intermediate Risk factor

10. 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

11. 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

12. 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

14. UNFAVOURABLE INTERMEDIATE

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

16. HIGH & very RISK GROUP

17. 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

18. 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

19. 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

21. 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 .

22. 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.

23. • 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 .

24. 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.

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

26. DOSE ESCALATION

27. HYPOFRACTIONATION

28. ADJUVANT RADIATION THERAPY
• Treatment is individualized based on age/ co-morbidities /clinical and
pathological information , PSA level and PSADT.
• Molecular 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 .

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

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

31. HDR Brachytherapy –Absolute and radiobiological dose escalation –
high tumor 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%

34. CONTRAINDICATIONS

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

36. ANDROGEN DEPRIVATION THERAPY

37. • 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

38. • 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

40. 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

41. 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

42. 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

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