PROSTATE CANCER IN NUTSHELL

Dr. Kanhu Charan Patro
M.D,D.N.B[RT],P.D.C.R,C.E.P.C,FSIOP,FAROI
[EX – TATA MEMORIAL HOSPITAL]
Chief Consultant- Radiation Oncology
MAHATMA GANDHI CANCER HOSPITAL
VISAKHAPATNAM
Email-drkcpatro@gmail.com ,M-09160470564
RADIOTHRPEUTIC MANAGEMENT OF PROSTATE CANCER

Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
Histopathologist
Molecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

GOALS
 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
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Evolution of Treatment Techniques
CONVENTIONAL RT
Collimator shapes Beam
Rectangular Treatment Field
Shaped Treatment Field
1970s and earlier
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Anatomy
20gm ovoid shaped.
Between trigone and
perineal membrane.
Apex – ECE difficult to
define.
Dorsal venous plexus of
Santorini–anterolat.
Mobile structure.

Internal Anatomy
5 lobes – Ant, Post,
Median, Lat.
DRE - Post lobe.
Zones- Peripheral 70% -
95%
Central 25% - 4%
Transitional 5% -<1%.
BEP - Central

Natural History
Peripheral zone – Multifocal 77%.
Thus multiple biopsies.
Seminal vesicles/periprostatic tissue.
Apex least resistant area.
Later bladder neck, rectum.
Clinically organ confined – 8-53% has
microscopic ext beyond prostate.
Osterling et al – 53% localised, 35% ECE,
9% seminal vesicles. RP series.

Histopathology
• Adenocarcinoma- 95%, multifocal
,heterogeneous,papillary/cribriform/comedo/acinar
pattern.
• Periurethral duct ca.
• Transitional cell ca.
• Neuroendocrine tumor.
• Mucinous/sarcomatoid ca/endometroid.
• Sarcoma /lymphoma.

Screening in Ca prostate
DRE/PSA/TRUS.
DRE – Crude (only 25-50% of pt with
Abnormal DRE) but essential since 20%*
has N PSA.
American cancer society guidelines.
DRE/PSA / yr from 50yr who atleast as
life expectancy of 10 yrs or at 45 yr if high
risk.

INTRODUCTION
• Prostate cancer represents 4.9% of all cancer
incidences , and its average incidence all over
the world is about 3.4 /100000 population.
• It ranks 9th among all cancers all over the
world.
• The median age of patients with prostate
cancer is 72 years .

DIAGNOSIS
1.DRE
2.PSA
3.BIOPSY

DIAGNOSIS
• Pathology :
• Location : Majority (75%) in peripheral zone ,
• 15% in the central zone
• 10-15 % in the periurethral zone.

DIAGNOSIS
1. Grade : the most commonly adopted system is
the Gleason score (based on the fact that
prostate cancer is a multifocal disease with
heterogeneous glandular pattern )
2. 2-4 represent well differentiated cancers ,
3. 5-7 moderately differentiated ,
4. 8-10 poorly differentiated ( Gleason , 1992).

Diagnosis
• Radiology :
- TRUS : Is the earliest modality , and helps for
doing biopsy from suspicious lesions , for
screening purposes and target volume
determination for prostate brachytherapy .
Improvement in resolution power improved its
sensitivity a lot ( like the use of contrast
ultrasonography ( Sedelaar 1999) , and Gleason
et al (2003). .

DIAGNOSIS
• Bone scan is indicated if there is a high risk
factors (PSA > 10ng/ml ; Gleason score > 8 ),
or if the patient is symptomatic ( Scherr et al
2003).
• Pelvic CT scan and MRI are essential for local
staging and localization of prostate lesions and
targeting for conformal external beam
radiation therapy or brachytherapy ( Berthelet
et al 2003).

DIAGNOSIS
• MRI had a great addition to CT scan for initial
staging , and target localization for radiation
therapy ( Mah et al 2002).

VARIOUS PS PARAMETER
• PSA density –
• Sr PSA / volume of prostate by TRUS.
More in Ca.
• PSA Velocity -
• Rate of rise of PSA.
• >0.75 ng/ml/yr Significant.
• Free PSA
Lower in Ca thus complexed / free PSA Ratio
more in Ca

Thus multiple biopsies
to be taken.
Score 1 to 5, WD to PD,
2-10.
Primary component
important than
secondary ie 4+3 = 3+4.

DIAGNOSIS
• Risk group stratification:
( eg T1/ T2 lesions with PSA > 20 ng/ml or with a
RISKGROUP PSA STAGE GLEASON
LOW RISK <10 <T2A <6
INTERMEDIATE RISK 10-20 T2b-T2c 7
HIGH RISK >20 >T2c >7
( Scherr et al 2003)

Treatment options
• Observation alone.
• Radical prostatectomy.
• Radiation therapy.
• Hormonal treatment.

OBSERVATION ALONE
• Rationale:
- Most cases will not die of their disease.
- A life expectancy.
- Patients are not left for just observation ; but a
close monitoring of disease progression is
done.
- Patient preference should be considered.

OBSERVATION –FOR WHOM
1. T1-T2 , and
2.Age 70 years or more ,
3. Gleason score <6, and ,
4.PSA < 10 ng/ml , and
5. PSA doubling time > 10years
Choo et al (2001)

OBSERVATION ALONE
• Follow up regimen :
- Scherr et al (2003) recommended to have a
6 monthly assessment of :
• PSA
• DRE
-Repeat prostate biopsy after the 1st year ( to
detect transformation to higher grades.

OBSERVATION ALONE
Signs of disease progression on observation
modality:
- Rise in PSA level.
- Clinical symptoms of disease progression.
-Increase in size as felt by DRE.
-Biologic transformation to higher grades.

OBSERVATION ALONE
• Survival figures :
• Aldolfssen et al (2000)
• 11, 500 cases of early prostate cancer treated with
watchful waiting between 1965 – 1993
• Found that only 5 % of these patients died ,
• This happened during the years 11-20 of follow up.

RADIACAL PROSTATECTOMY
• Indications:
• Organ confined prostate cancer ie T1 or T2 ,
pelvic lymph node dissection is indicated for any
one of these features :
-Either : PSA >20 ng/ml. + Gleason score 5-6.
Or- PSA 15 –20ng/ml + Gleason score >7.
(Bishoff et al 1995).

RADICAL PROSTATECTOMY PROS & CONS
• RP had the same overall and disease free survival
figures as the other local control modalities ( 3D-
CRT , IMRT , and brachytherapy ) however the
sequelae are more with surgery
• Higher incidence of
• urinary incontinence ,
• impotence

RADIATION
• Main problem: dose limitation usually radiation
dose does not exceed 70GY in CEBRT ( dose
limiting structures ;
• Rectum and urinary bladder) and for early T1 / T2
lesions , the results of CEBRT are much inferior
than 3D-CRT as shown by
Catton et al (2002) .

ROLE OF PORT-surv. benefit
• Patients with high PSA ,
• positive surgical margins ,
• Seminal v .inv
Do LV etal (2002).

(IMRT):
• A major advantage of IMRT in comparison to
three-dimensional conformal radiotherapy is the
higher capability in providing dose distributions
that conform very tightly to the target even for
very complex shapes so sparing a lot of adjacent
normal tissues
( Francescon et al 2003)

A) 3D reconstruction of the implant with dose distribution, (B) 3D reconstruction,
lateral view with dose distribution, and (C) 3D reconstruction, AP view with dose
distribution.
•

.
MODALITY 10 YEARS DFS 10 YEAR OS
SURGERY 82% Sciarra et al (2003)
72%(Han et al 2003)
88%(D'Amico et al 2002)
76%(Do LV et al 2002 ).
75%((Hanks 1988)
78%(Lu, Yao , 1997).
CEBRT 78%(D'Amico et al 2002)
78%(Nguyen et al 2002).
76%(Zimmermann 2001)
68% (Hahn et al 1996).
69%(Hank 1988).
65%(Lee et al 1994).
63%(Lu, Yao , 1997).
69%(Gray et al 2000).
BRACHYT
HERAPY
77% Ragde et al 2001
96%(Koutrouvelis et al
2003)
80%(5 years Nag S. 1985).
66%(Stamey et al 2000).

SEQUELAE OF DIFFERENT TREATMENT MODALITIES
MODALITY RECTAL TOXICITY INCONTINENCE IMPOTENCE
SURGERY 1%(Catalona et al 1999).
1.1% (Guillonneau 1999)
80%(.post surgery)
6%(.late ; 1 year later)
Schaefffer et al 1998).
53%(Schwartz et al 2002)
25%((Guillonneau 1999) (6
months).
66%(neve spring)
75%%(standard RP)
Robinson et al (2002).
CEBRT 29.6%(Scwartz et al 2002).
14%(Storey et al 2000).
15% (Dearnaley et al 1999).
19.2%(Scharwz et al 2002).
20%(Storey et al 2000).
10%(Lawton et al 1991).
45%(Robinson et al 2002).
50%((Bagshawet al 1988).
35%(Schroder et l 2000).
3D-CRT 21%(Storey et al 2000).
5%( (Dearnaley et al 1999).
9%(Strorey et al 2000). 40%(Robinson et al 2002)
BRACHYTH
ERAPY
1%(Koutrouvelis et al 2003).
1%(Kang et al 2002).
2% (Syed et al 2001
3%( Schroder et al 2000).
1% (Koutrouvelis et al
2003).
2%(Syed et al 2001)
3%(Sharkey et al(1998).
3%(Schroder et al 2000).
24%(Robinson etal).
7%(Nag S. 1985).
10% (Sharkey et al(1998).
IMRT 17%((Teh et al 2002).
4.5%(Zelefsky et al 2002)
9%(Zelefsky et al 2002) 10%(Zelefsky et al 2002)

NEOADJUVANT HORMONAL
TREATMENT
• Wachter et al(2002) in a study on 164 patients
with early prostate carcinoma were randomized
to either a total dose of 66 Gy (n = 109) alone or in
combination with a short-term hormonal
treatment (n = 55) . The 4-year rates of no
biochemical evidence of disease for all patients
was 58%.

NEOADJUVANT HORMONAL
TREATMENT
• For the high-risk group the 4-year
rates could be improved with
borderline significance from 35% to
66% (p = 0.057) by additional
neoadjuvant hormonal treatment.
• In contrast for the low-risk group
no significant improvement was
observed: 73% and 82%, respectively
(p = 0.5).

CONCLUSION
• while if these patients are at a high
risk category , it is better to give
them a neoadjuvant hormonal
treatment for 2-3 months before
the local treatment ( surgery or
radiation) as this will improve their
disease free survival.

PLANNING RADIATION
NEO-ADJUVANT HORMONAL THERAPY
WAIT FOR 3-6MONTH
PLAN FOR RADIATION
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CONVENTIONAL RT
10/20/12 01:12 PM

ENZULTAMIDE CAPSULE
10/20/12 01:12 PM

PROSTATE CANCER VACCINE
10/20/12 01:12 PM

FAMOUS PERSONALITIES WITH
CANCER
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METASTASIS
-please do not watch crying
82

METASTASIS- give a smiling
death
84

Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

Superscan-extensive bone mets
92

CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the
body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

Change in bowel habits
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Change in bladder habits
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A sore that does not heal
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Unusual bleeding or discharge
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Thickening or lump in the
breast or any part of the body
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Indigestion or difficulty
swallowing
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Obvious change in a wart or
mole
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Nagging cough or hoarseness
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Liver cancer-
hepatitis B vaccine

Cervix cancer vaccine
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Promise-Stop drinking alcohol
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Meditation
10/20/12 01:12 PM 114

115
Dietary protective factors

LOTS OF BLOOD REQUIRE
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TABLET FORMS
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All specialities under one roof
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Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
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10/20/12 01:12 PM 134
Whenever not
possible,
make friends

PROSTATE CANCER IN NUTSHELL

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