prostate radiotherapy

1. Management of Ca Prostate
By
Dr Parneet Singh
Moderator-Dr Anirudh U Punnakal

2. Different modalities of treatment
• Active surveillance
• Radical prostatectomy
• Radiation Therapy
• Hormonal Therapy
• Chemotherapy

3. Treatment Recommendations
Stage Recommended Treatment 5-Year
bPFS
5Year
CSS
Low Risk For life expectancy <10 years,
active surveillance or definitive
RT (3DCRT/IMRT with IGRT, or
brachytherapy).
For life expectancy >=10 years, RT,
RP ± pelvic LN dissection, or active
surveillance. Consider adjuvant RT
if +margin(s) after RP
75-90% >95%
NCCN 2015
SEER Data 2011

4. Stage Treatment recommendation 5Year
bPFS
5Year
CSS
Intermediate Risk For life expectancy <10 years,active
surveillance, RT ± short term androgen
deprivation therapy(ADT) , or RP
For life expectancy >10 years, RT + short-
term ADT (4–6 month)or RP ±pelvic LN
dissection
RT is 3DCRT/IMRT with IGRT
± brachytherapy boost.
Consider Adjuvant RT, especially
if multiple adverse features.
RT ± short-term ADT
indicated
for +margin(s) or pT3 or LN +ve
50-75% 85-90%
NCCN 2015
SEER Data 2011

5. Stage Treatment Recommendations 5 year
bPFS
5 year
CSS
High Risk RT (3DCRT/IMRT with IGRT
± brachytherapy boost) with
neoadjuvant,concurrent, and
adjuvant ADT (2–3 years)
Whole pelvic RT indicated.
If Post op Adjuvant RT +ADT
indicated
for +margin(s) or pT3 disease or LN+
60% if
N+
20%
80-85%
If N+
60%
NCCN 2015
SEER Data 2011

6. Active Surveillance
• DRE & PSA every 3-6 months with repeat biopsy in 1-2 years for GS
progression
• Low risk cases
– Life expectancy < 10 yrs
– Elderly patients
– Low volume disease (<2.5cc) with PSA <10 and GS 2-6
– Less than 3 cores positive and none over 50%
• Adv-Avoids side effects of T/t
• Disadvantages
• Chance of missed opportunity for cure.
• Risk of progression and/or metastases
• Subsequent treatment may be more intense with increased risk of side
effects.
• Increased anxiety.

7. Swedish trial
• 695 patients with T1b-T2 to Obs vs. RP
• With median follow-up 10.8 years
• RP reduced 12-year death from prostate cancer(20→14%) and DM
(26→19%)(p<.05), but no difference in OS (p > 0.09).
• Patients with ECE had 14× risk of prostate cancer death vs. those without
ECE.
• On subgroup analysis, men younger than 65 years at diagnosis had
significant improvements with RP, while there was no discernable
difference among those above 65 years.
Bill-Axelson et al. NEJM
2008

8. RADICAL PROSTATECTOMY
• Disease confined to prostate
• In low risk and intermediate risk cases
• Prostate ,seminal vesicals and pelvic LN are removed
 Approaches
• Retropubic-Bilateral pelvic lymph node dissection to precede prostatectomy
in patients with LN risk
• Transperineal-Better exposure of urethral stump and reduced risk of
involved apical margin, but increased risk of rectal damage.
• Laproscopic (robot assisted)
• A pelvic LN dissection frequently excluded in patients with<7% probability
of LN metastases by nomograms
• Recovery of erectile dysfunction related to preservation of cavernous nerves

9. • Advantages
– Removal of entire prostate and seminal vesicle
– Pelvic lymphadenectomy for staging
– Preservation of distal sphincter
– Preservation of cavernosal nerves-to prevent impotence
– Definitive pathologic information
• Disadvantages
– Sexual dysfunction (20-78%)
– Urinary Incontinence (4-70%)
– Bleeding
– Stricture (0-12%)
– Mortality (<1%)
Bianco et al Urology 2005
Catalona et al J urol 1999

10. After RP Only Results
• 432 patients, median f/u-122 months
• 40% -biochemical relapse
• 10 year PSA relapse free survival pT1-pT2-92%,pT3a-53%,pT3b-28%,pT4-
6%.
• Pts with GS<6- 10 year PSA control-90% vs 58% for GS(3+4),21% for
GS(4+3),11%GS(>8)
• 10 year PSA control 24vs 68% for pos vs neg margins
• Factors predictive of high chances relapse
– Larger volume , ECE
– Higher grade (GS 8-10)
– Positive sx margins
– High PSA
– pT3,pT4 disease Isbarn et al BJU Int 2010
University Hospital
,Germany

11. Radical Prostatectomy (RP)vs Observation
Prostate Cancer Intervention versus Observation Trial (PIVOT).
•From Nov 1994 -Jan 2002, 731 Pts with localized prostate cancer T1-T2 any
grade
•Mean age, 67 years; median PSA value, 7.8 ng/ml to RP or obs and f/u till Jan
2010.
•Patients also had an age of 75 years or less, negative results on a bone scan for
metastatic disease, and a life expectancy of at least 10 years from the time of
randomization.
Timonthy et al NEJM 2012

12. RADIOTHERAPY
• Radical
• Adjuvant
• Palliative
• EBRT- Conventional / Conformal
• Brachytherapy

13. Radical EBRT
• Indication:
– Stage T1b, T2, T3
– LN involvement detected by nodal sampling
– Low risk medically inoperable
– Risk of LN involvement ≥ 15%
– Gleason score ≥6
– PSA ≥ 10 ng/ml
• Treatment Volume- Prostate, SV, prostatic urethra and pelvic
LNs to be included if the lesion is T3
Europeon Urology 2014

14. Planning
• Positioning
• Patient immobilization in treatment position – supine
• Comfortably full bladder – 300ml 30 mins prior
• Empty rectum
• Localization
• Treatment planning
• Field selection: AP/PA,Four-field box technique

15. • Field Borders
– Superior border-L5-S1
– Inferior border- 1.5-2 cm distal to junction of prostatic and
membranous urethra (lower border of ischial tuberosity)
– Lateral border- 1.5-2 cm lateral to bony pelvis
• Common iliac LN treated by extending field 3 cm superiorly
CONVENTIONAL EBRT PORTALS

16. – Anterior margin-Anterior to pubic symphysis
– Posterior margin-S2-3 interspace to include the upper
presacral LNs
Lateral Borders University of stanford 1988

17. Boost field
• Prostate+ SV
– Superior border extends to the top of the acetabulum - 3-5 cm above
pubis
– Inferior border- ischial tuberosity
– Laterally to include 2/3 of the obturator foramen
– Anterior border-1.5 cm posterior to ant. margin of pubic symphysis
– Posterior border- 2 cm behind the rectal marker

18. 3DCRT
• Three dimensional imaging and treatment planning
• CT-based images used to localize the prostate and normal organs and to
generate 3D reconstructions of the patient
• Treatment fields are shaped to conform to the patient's CT-defined target
volume, thereby minimizing the volume of normal tissue irradiated
• Ability to increase total radiation dose
• Beam shaping done with MLCs
• DVH generated for the PTV, femoral heads, and rectum, bladder and bowel

19. 3DCRT FIELDS ARRANGEMENTS

20. IMRT
• Radiation beam intensity varies across the fields
• Delivery of an IMRT requires a computer-controlled beam-shaping
apparatus MLC which consists of many small individually moving leaves
• Defining dose Constraints for the target and normal tissues
• Many small ‘beamlets’ within each treatment field for dose distribution as
close as possible to the constraints
• Helps in better target coverage and decreased dose to normal structures

21. IMRT PHASE

22. 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

23. Target Volume Definitions
• CTV – includes whole prostate + any possible extracapsular
extensions +/- base or entire SV
• Roach’s formula – define the risk of SV involvement :
- LOW RISK OF SV INVOLVEMENT
PSA + [(GS – 6 ) X 10 ] < 15 %
CTV to include prostate + base of SV
- MOD/ HIGH RISK OF SV INVOLVEMENT
T3 or ( PSA + [ (GS – 6 ) X 10 ]) > 15 %

24. Target Volumes
• GTV = Prostate
• CTV= GTV+1 cm margin except post 6mm to rectum
• PTV= CTV+0.5 cm margin
• GTV= Prostate+SV in case of intermediate and high risk cases
• CTV= GTV+1cm cm margin except post 6mm to rectum
• PTV= CTV+0.5 cm margin
Zelefsky et al Radiother
Oncol 1999

25. For LN Treatment
• Risk of Pelvic LN Involvement = 2/3PSA + [(GS-6) X 10 ]
• LN treated if risk>15%
• In a study it was recommended that LN should be treated if
risk>6%
• As it leads to missing of around 1/3rd patients with LN mets in
intermediate and high risk
Abdollah et al IJROBP 2012

26. Summary of the guidelines for delineating nodal
regions
• Common iliac 7 mm margin around
• External iliac 7 mm margin around vessels- Extend anterior border by 10
mm anterolaterally along the iliopsoas muscle to include the lateral external
iliac nodes
• Internal iliac 7 mm margin around vessels
• Obturator- Join external and internal iliac regions with a 17 mm wide strip
along the pelvic side wall
• Pre-sacral : 10 mm strip over anterior sacrum
Taylor et al 2007 clin oncol

27. GTV+SV
GTV+ SV, PTV, CTV LNGTV P+SV, CTV P+SV
CTV P+SV

30. • Phase 1 – Pelvis and Prostate
- CTV T 46 = Prostate + SV
- CTV N 46 = LN AREAS upto ext illiac
- PTV TN 46 = CTV T 46 + 10 mm sup/ inf /right /left and 5 -10 mm post
- CTV N 46 + 5 -10 mm.
• Phase 2 - Prostate + SV
- CTV T 56 = Prostate + SV
- PTV 56 = CTV T 56 + 10 mm sup/ inf /right /left/ ant and 5 -10 mm post
• Phase 3 - Prostate
- CTV T 74 = Prostate only
- PTV 74 = CTV T 74 + 10 mm sup/ inf /right /left/ ant and 2 -5 mm post
Kupelian 2005 IJROBP

31. Single Phase
CTV 74 = Prostate + base of SV (or whole SV)
PTV 74 = CTV 74 + 10 mm sup/ inf /right /left and 5 -10 mm
post
Two Phase
Phase 1
CTV 56 = Prostate + base of SV (or whole SV)
PTV 56 = CTV 56 + 10 mm sup/ inf /right /left and 5 -10 mm
post
Phase 2
CTV 74 = Prostate only
PTV 74 = CTV 74 + 10 mm sup/ inf /right /left and 5 -10 mm
post

32. • Advantages of pelvic EBRT:
– Primary lesion along with periprostatic tissue and pelvic
LNs are homogenously irradiated
– Surgical complication avoided
– Good local control
– No anaesthetic with side effects
– No hospital admission
– Maintain usual activities

33. CONVENTIONAL RT CONFORMAL RT
• ADVANTAGES
– Time tested
– Easy to plan and execute
– Time saving in busy
setting
– Cost effective
• DISADVANTAGES
– Normal tissue more
irradiated
– Dose escalation not
possible
• ADVANTAGES
– Better sparing of normal
tissue
– Dose can be escalated
– 3D planning
• DISADVANTAGES
– Interphysician variability in
target delineation
– Chance of missing tumor
due to close margin
– Longer planning time

34. Dose Escalation
• Data from retrospective, sequential prospective and randomized studies
indicate that for patients with intermediate-to-high risk disease, doses above
70 Gy are associated with a significant reduction in biochemical failure.
• 3D-conformal radiotherapy to escalate radiation dose has resulted in
decrease in rectal and bladder toxicity.
• Intensity modulated radiotherapy allows for greater sparing of the
surrounding normal tissues so we can further escalate dose.
• The results of dose escalation, the ability of IMRT to reduce rectal and
bladder exposure to high radiation doses led to better targeting of prostate
Pollack 2003 World J Ural

35. Dose Escalation Trails
Study Patients Doses Med F/u Benefit
Kuban et al
2008
301,T1-3N0 no
ADT
70 vs 78 Gy 8 years 88vs
63%(p=.042)
Zietman et al
2005
393,T1-
T2,PSA<15
70,2 VS 79.2Gy 5.5 years 41 % reduction
in
bPFS(p<.001)
Zelesky et al
2011
2551,T1-T3 64.8 to 86.4
(5.4Gy
increments)
10 years bPFS for
doses>75.6 was
84% vs
70%(p=.04)
GETUP 1
(Beckendorf
2008)
304 ,T1-T2pN0 70 Gy vs 80Gy 59 months 31% to
24%,benefit
most if PSA>15
Peeters 2007 669,all stages 78Gy-78Gy 70 months bPFS 45%vs
56%(p=.03)

36. Rationale for Hypofarctionation
• Conventional fractionation have fraction sizes of 1.8-2.0 Gy are based on that
tumors are less responsive to fraction size than are late-responding normal
tissues
• The α/β ratio is estimated to be >10 Gy for early-responding tissues and 3–
5 Gy for late responding tissues
• Low α/β is consistent with a greater capacity for repair between fractions
• Prostate tumors have exceptionally low values of of 1.5-3 Gy same or less
than late-reacting normal tissues
• Rationale-Dose escalation to increase tumor control while maintaining the
same normal tissue complication probability
Ritter et al 2009 Cancer
Brenner et al 2002 IJROBP

37. Hypofractionation Trials
Study Patients Doses Med F/u Benefit
Pollack 2011 303,low-high
risk
76Gy/38# vs
70.2Gy/26#.wit
h ADT
68.4 months 21.4 vs 25.3%
bPFS(p=.745)
Yeoh 2006 217,T1-T2N0 64Gy/32# vs 55
Gy /2.75 Gy /#
5 years No diff in bPFS
and OS
ChiPP 2012 3216 ,low risk 74G/7.5 weeks
vs 60Gy/20#
2 years No increased
toxicities
Arcangelli 2010 168,high risk 80Gy/40# vs
62Gy/20#
35 months No difference in
late toxicities
FFBF 87 vs 79%
(p=.035)

38. Surgery vs RT in low risk Prostate
• 1054 treated with surgery and 628 with RT
• In surgery arm younger age ,low PSA,GS stage
• 8 year bPFS RP vs EBRT(72%vs 70% p=.01)
• In patients treated with doses>72Gy bPFS was similar to
RP(p=.08)
• Also Zelesky et al saw similar DM free survival in RP vs high
dose IMRT
Kupelian et al IJROBP 2004
Zelefsky et al JCO 2010

39. WPRT vs PORT
• RTOG94-13
• A 4-arm randomized trial attempted to see merits of pelvic nodal irradiation
versus prostate-only
• EBRT in patients with an estimated risk of lymph node involvement of 15%,
and timing (adjuvant versus neoadjuvant and concurrent) of hormonal
therapy
• The total duration of hormonal treatment was 4 months
• When neoadjuvant hormone therapy is used in conjunction with EBRT,
pelvic nodal irradiation yields an improved PFS versus prostate-only RT
• Neoadjuvant hormones plus pelvic nodal RT improved OS versus adjuvant
hormones plus pelvic nodal RT
• Late severe GU toxicities were similar in the 4 arms,though severe GI
toxicities were more frequent in the neoadjuvant hormone and whole-pelvis
arm
Lawten et al 2007 IJROBP

40. Post op RT
• Indications:
– Immediate- after RP with positive Sx margins, SVI,ECE,
poorly diff. ca (GS 8-10),T3-T4, LN mets
– Delayed- ↑PSA level with no e/o distant mets, clinically
local recurrence and LN mets
Dose- 45-50 Gy/20-25#/4-5weeks f/b 18 Gy with boost to
the prostate bed

41. SWOG -8794
• Randomized 425 patients with T3N0M0 prostate cancer to 60 –64 Gy
in 30 –32 fractions versus observation
• The primary study endpoint was metastasis-free survival(MFS)
• Updated results with median follow-up exceeding 12 years
demonstrated a significant improvement in MFS(10-year estimate 71
versus 61%, HR: 0.71)(p<.05)
• OS was improved with adjuvant RT (59 versus 48%, HR:0.72),
particularly important was that a third of the patients in the
observation group received salvage RT(p<.05)
• Subset analysis was unable to identify a subset of patients that should
not receive RT
Thompson et al 2009 J urol

42. Indications for Brachytherapy
• Monotherapy
• Clinical stage T1–T2a,
• Gleason sum 2–6, and
• PSA <10 ng/ml
• EBRT boost
• Clinical stage T2b–T2c,
• Gleason sum 8–10, or
• PSA >20 ng/ml
• EBRT boost (other)
• Perineural Invasion
• MRI evidence of capsular
penetration
• Other
• Prior pelvic radiation therapy
• Prominent median lobe
• Medical inoperability
• History of multiple pelvic
surgeries
Subir Nag et al ABS
IJROBP 1999

43. RADIOISOTOPES
IODINE125 PALLADIUM103 IRIDIUM192
T1/2 (days) 59.4 16.97 73.83
Energy(keV) 27.4 21 340
Form Seeds Seeds Seeds
Implant type Permanent Permanent Temporary
Dose rate 8 20 Variable
Mean activity/seed 0.42 1.3
Monotherapy dose 145 125
+EBRT dose 110 100 20-25
TVL(mm) Pb 0.01 0.03 HVL-4.5 mm

44. LDR Permanent seed brachytherapy

45. • Seattle technique
- GA  lithotomy position  TRUS probe inserted into the
rectum attached to a stepping unit  template , the coordinates
are transposed on the USG images  5 mm slices
- 2-3 mm margin added in all directions except posteriorly = PTV
- No. and position of seeds calculated
- Replicate under 2nd anesthetic to insert the seeds

47. Precautions
• Travel and contact with adults can be done
• For the first two months following seed implantation, small children
and pregnant women should not be in direct contact with the patient
for prolonged periods – e.g. children should not sit on the patient’s
knee for any length of time
• Sexual intercourse can start again within a few weeks.
• Very occasionally a seed can be expelled in the semen on ejaculation;
if this does happen, it will usually occur in the first few ejaculations,
so condom usage for the 1st 2-3 times after LDR.

48. HDR AFTER LOADING Brachytherapy
• Hollow needles are placed through the perineum into the prostate.
• Soft nylon tubes (catheters) are placed in these needles  needles are
then removed but the catheters stay in place.
• Radioactive Iridium-192 or Cesium-137 is then placed in the
catheters, usually for 5 to 15 minutes.
• The treatments are usually given over 2 days.
• After the last treatment the catheters are removed.

49. TRUS GUIDED HDR INTERSTITIAL BRACHYTHERAPY

50. Dose fractionation
• Monotherapy
- LDR – 145 Gy (I-125) , 125 Gy (Pa-103)
- HDR – 34-36 Gy/4#
• Combination therapy
- EBRT –45 Gy /25# /5 weeks @ 1.8 Gy/#
- LDR - 110 Gy (I-125) , 90 Gy (Pa-103)
- HDR – 17 Gy/2# (Ir- 192)in 24 hrs
Subir Nag et al ABS
IJROBP 1999

51. Max Protocol
• For low risk-60Gy/20#
• Intermediate risk-68Gy/25# with neoadjuvant , concurrent and
Adjuvant ADT for 6 months
• High risk-68Gy/25# with neoad , concurrent and Adjuvant
ADT for 2years
Arcangeli et al 2010 IJROBP

52. Normal tissue dose limits-Conventional
• Bladder –V75<25%,V70<35%,V40<50%
• Rectum- V75<15%,V50<50%,V45<35-40%
• Femurs to V50<5%
• Small bowel ≤ 50 Gy (66%)
• Penile Bulb-Mean dose -52.5 Gy
Chung et al IJROBP 2009

53. OAR-Hypofractionation
60Gy/20#
• Bladder wall-70%<=40Gy
only bladder in PTV >57Gy
• Rectal Wall-70% <40Gy
only bladder in PTV >57Gy
• Femoral head-Max 40 Gy
68Gy/25#
• Rectum -30%<=60Gy
• Bladder-30%<=65Gy
• Small Bowel -Max Dose
<=54Gy
• Femur-Max Dose<=52Gy
Pervez et al 2010 IJROBP

54. RT Sequelae
Acute
1. Urinary frequency ,
incontinence
2. Slight burning with urination
3. Diarrhea or more frequent,
softer bowel movements.
4. Rectal discomfort,tenesmus
5. Mild skin irritation is now
rarely seen
6. Fatigue is common
Sub-Acute(6 months)
1. Chronic diarrhoea ,
proctitis, rectal-anal
stricture
2. Bleeding PR- 3.3%,
bowel obst./
perforation- 0.6%
3. Erectile dysfunction
(10–85%)

55. RT Sequelae (Chronic)
1. Chronic diarrhoea
2. Proctitis, rectal-anal stricture
3. Bleeding
4. Bowel obst./ perforation
5. Erectile dysfunction
• Radiation sequelae have decreased in this era of IMRT/IGRT

56. 2D vs 3DCRT vs IMRT for Toxicity profile
• MSKCC compared 3 modalities
• Mean bowel dose reduced by 20 % in 3DCRT ,IMRT (p=.001)
• Bladder V45 (87,56.8,25.6%;p<.001)
• No acute grade 3-4 toxicities with 3DCRT,IMRT
• 1 patient in 2D arm required t/t for proctitis
Ashman et al 2005 IJROBP

57. Better Cure Rates with Image Guided IMRT
compared to IMRT for Prostate
Intermediate Risk High Risk

58. MECHANISMS OF ANDROGEN AXIS BLOCKADE
(HORMONAL THERAPY)
• Male sex hormones (testosterone, androgens) are critical to growth of
prostate cancer
• Tumor masses decrease by half or more in 30-50%
• Improvement in symptoms (bone pain, urinary obstruction)- 60%
• There are four general forms of ADT:
Ablation of
androgen source
Inhibition of
LHRH or LH
Inhibition of
androgen synthesis
Antiandrogens
Orchiectomy DES
Leuprolide
Aminogluthemide Cyprotene acetate
Goserelin Ketoconazole Flutamide
Triptorelin Biclutamide
Histrelin Nilutamide
Cetrorelix
Abarelix

59. Strategies for Androgen Deprivation

61. D’Amico et al(intermediate risk)
• Phase III clinical trial to compare RT with or without 6 months of ADT
• 80% of 206 randomized patients had intermediate-risk prostate cancer
• Conformal radiation comprised 70.35 Gy in 36 fractions
• Initial results at a median follow-up of 4.5 years revealed statistical
improvements in prostate cancer-specific survival and OS rates
• Updated results after a median follow-up of 7.6 years showed that all-cause
mortality was significantly greater in the RT alone arm (HR 1.8, p = 0.01)
Amico et al JAMA 2008

62. RTOG 85-31
• Randomized trial of 977 patients to adjuvant goserelin vs observation
• Eligible patients had advanced tumor characteristics (cT3,N+, or pathologic
penetration through the capsule or SV involvement)
• Goserelin was administered indefinitely or until disease progression
• RT portals included treatment of the regional lymphatics to an initial 44 –46
Gy followed by a prostate boost to 65 –70 Gy
• 10-year updated results demonstrated significant improvements in: local
failure (23 versus 38%), disease-specific mortality (16 versus 22%), DM (24
versus 39%)
• NED survival (37 versus 23%), and OS (49 versus 29%), favoring the use of
adjuvant goserelin
Pilepich et al 2005 IJROBP

63. RTOG 92-02
• EBRT was directed to the prostate and pelvic nodes (44 –50 Gy), followed by
a prostate boost to 65 –70 Gy
• All patients received 4 months of goserelin and flutamide,2 months before
and after RT
• Patients were randomization to no further treatment versus 24 months of
goserelin
• 10-year updated results demonstrated significant improvements for long-
versus short-term androgen suppression for multiple endpoints
• DFS (13 versus 23%), DSS (84 versus 89%), local progression(22 versus 12%),
DM (23versus 15%), and biochemical failure (68 versus 52%) favored long-
term androgen suppression
• OS was not improved, except for the subgroup of patients with Gleason 8 –
10 tumors
Hanks et al 2008 JCO

64. Side-effects of Androgen Blockage
• Loss of libido
• Erectile dysfunction
• Hot flashes (55–80% during ADT)
• Gynaecomastia and breast pain
• Increase in body fat
• Cardiovascular toxic effects (AMI, CHF, CVA, DVT, pulmonary
embolism)
• Decrease in bone mineral density, Osteoporosis
• Muscle wasting
• Cognitive decline
• Androgen deprivation is very effective therapy against prostate cancer;
unfortunately, with time, almost all prostate cancers will become
androgen refractory

65. Chemotherapy
• Docetaxel + estramustine
• Docetaxel + Steroids
• Mitoxantrone + corticosteroids
• Estramustine phosphate + vinblastine
• Paclitaxel + Estramustine

67. Follow up
• DRE and PSA every 6 month for 5 years and then annually. In the first 1–3
years after definitive RT, PSA may be ordered more frequently (e.g., every
3–6 month).
• New AUA standard is PSA >0.2 ng/mL on two measurements (J Urol 2007).
• The 1996 ASTRO definition of PSA failure following EBRT is 3 consecutive
PSA rises, with the time of failure backdated to the midpoint between the
PSA nadir and the first rising PSA,or any rise great enough to provoke
initiation of salvage therapy
• The “Phoenix Definition” (current ASTRO/RTOG definition) of PSA failure
after EBRT, with or without short-term HT, is defined as a rise by >2 ng/mL
above the nadir

68. • Patients who undergo salvage therapy (e.g., with HT, RP, brachytherapy , or
cryosurgery) are declared failures at the time of + biopsy or salvage therapy
administration
• The PSA nadir after RP is ~3 weeks, after EBRT ~2–3 years (but can be up to
4–5 years), and after brachytherapy ~3–4 years.
• PSA “bounce” consists of transient PSA rises (usually <2 ng/mL)after RT
with a subsequent fall in the value. After brachytherapy,~20% of patients
have a bounce , and ~90% occur within 3 years with median duration 14
month.
• The median time to bounce after EBRT is ~9–12 month and ~10–20% of
patients have a bounce.
• PSA bounce after brachytherapy or EBRT does not predict PSA failure.
• MRI Pelvis with contrast once a year

69. Thanks

71. A grid or template with holes every 5mm are used to
line up the needles

72. The needles are distributed

73. The Mick ‘Gun’ is used to push the radioactive seeds
into the gland

74. The seeds are left behind, distributed through
the gland