The document discusses prostate cancer including anatomy, staging, Gleason scoring, treatment options, and side effects. It covers imaging like CT and MRI scans to visualize the prostate and surrounding structures. Radiation treatments like IMRT, Tomotherapy, Cyberknife and seed implants are described in detail, noting their ability to precisely target the prostate gland and avoid nearby organs to minimize side effects. Typical radiation protocols are provided for low and higher risk prostate cancer cases.

3. The prostate gland has a capsule around it, and cancers arise close to the capsule

4. Prostate Anatomy…the nerves that can results in impotence are on the side of the gland

5. There are lymph nodes that may be involved

6. CT scans and MRI demonstrate the anatomy of the prostate well

7. Prostate CT Anatomy Prostate rectum bladder

8. Cross section anatomy of the male pelvis

9. Cross section anatomy of the male pelvis

10. Bladder Prostate Rectum Prostate CT Anatomy

11. CT Scan = large prostate cancer

14. MRI showing Cancer Nodule

15. Prostate Stages

16. T1c = too small to feel and biopsied because of an elevated PSA

17. T2 lesion = big enough to feel

18. T3 if spread to the seminal vesicles

19. Stage IV if spread to the lymph nodes or bone

20. Prostate Cancer Cure Rate After Radical Prostatectomy Based on Pathologic Stage

21. Prostate Cancer Cure Rate After Radical Prostatectomy Based on PSA Prior to Surgery

22. PSA (prostate specific antigen) and radiation results PSA Level Relapsed after Radiation 0.1 to 4 4% 4 to 10 7% 10 to 20 22% 20 - 50 48% over 50 67%

23. Note that the PSA levels slowly decline after completing radiation

24. Note that the PSA levels slowly decline after completing radiation

26. Prostate Cancer Cure Rate After Radical Prostatectomy Based on Pathologic Grade (i.e. how mutated the cancer cells appear)

27. Gleason Scoring System From the biopsy, the pathologist grades the appearance of the cells. From least serious (slow growing or Grade 1) to the fastest growing and most dangerous or grade 5). The Gleason score doubles the score So the slowest is a 2 and the fastest is a 10.

28. The higher the Gleason Score, the lower the cure rates after surgery Gleason Score

29. The higher the Gleason Score, the lower the cure rates after radiation Gleason Score

32. Treating prostate cancer Surgery? Radiation?

33. American Urologic Association (AUA) came out with new treatment guidelines for prostate cancer in 2007

34. AUA: results the same for all three treatment modalities PSA Cure Rates Seeds External Surgery Low risk Intermediate High

37. RT = radiation therapy. IMRT = intensity modulated radiation therapy, IGRT = image guided RT e.g. Tomotherapy Brachytherapy = seeds

38. RT = radiation therapy. IMRT = intensity modulated radiation therapy Brachytherapy = seeds Androgen deprivation therapy = Lupron or Zoladex shots

39. Cure Rates with Radiation versus Surgery for Early Stage Prostate Cancer are the same from the Cleveland Clinic. Kupelian. JCO Aug 15 2002: 3376-3385

40. CT scan is obtained at this time CT images are then imported into the treatment planning computer

41. In the simulation process the CT and PET scan images are used to create a computer plan

42. The CT scan images are then converted into a 3 dimensional view inside the patient You can actually see inside the man’s body and locate the key organs

43. IMRT Identify organs and tumor target prostate rectum bladder

44. bladder Radiation zone prostate rectum Goal = radiation zone precisely around the prostate cancer

45. IMRT using 7 different beams to target the prostate The computer can determine the optimal number of beams to deliver the radiation dose to hit the target and avoid other structures

46. IMRT Intensity modulated radiation therapy The computer then can generate different techniques of delivering the radiation

47. IMRT Computer will determine the optimal number of beams and beam angles

48. IMRT The cross sectional CT will show the dose clouds that surround the prostate and how close they are to other vital structures like the bladder or rectum

49. bladder prostate rectum IMRT The cross sectional image reconstruction of beams and targets

50. IMRT The radiation dose clouds that surround the target bladder prostate rectum

51. The computer identifies targets and using IMRT techniques applies low doses to some structures (like lymph nodes) and high doses to the main target (prostate)

52. Even if the prostate has been removed radiation can be used to target the prostate bed (Tomo)

53. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment

55. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

57. With Tomotherapy the beam can hit the target (nodes) in the upper abdomen and avoid the bladder and small intestine and lower in the pelvis hit the prostate, nodes and seminal vesicles and still avoid the bladder and rectum

58. With daily image guided with a CT using Tomotherapy, radiation field can be very tight (‘close’) around prostate

59. Significant movement of the prostate gland based on daily gas in rectum Planned target Rectal gas No Rectal gas Planned target, missed badly if rectal gas pushes the prostate forward

60. 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

61. Importance of daily CT targeting on Tomotherapy and adjusting the treatment daily Very little bowel gas on initial study and the dose (red) targets the prostate gland closely large bowel gas on later treatment day and the dose (red) will cover half the rectum if an adjustment is Not made

62. If no adjustment was made Actual treatment on Tomotherapy

64. Tomotherapy is particularly useful in men with hip replacements

66. Tampa Bay Cyberknife Center

67. Cyberknife Radiosurgery

68. With cyberknife you can use multiple beams from any direction

69. CyberKnife Multiple beamlets of radiation striking the prostate

70. bladder prostate rectum Radiation doses are conformed very closely or tightly to prostate avoiding the rectum and bladder

71. Seed Implants

72. Prostate Seed Implants

73. Prostate Seed Implants

74. Rectal ultrasound used to image the prostate

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

76. The needles are distributed

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

78. The seeds are left behind, distributed through the gland and slowly radiate the cancer

79. CT scans of the prostate will show the seeds and the studies will be used to calculate the radiation dose

80. Side Effects of Prostate Radiation Is related to the size and area of normal structures that are over lapped by the radiation zone…the goal is to keep the radiation zone as small as possible

81. Side Effects of Prostate Radiation With IMRT and image guided techniques the goal is to shape the radiation zone very precisely , based on the type of cancer (high Gleason might require a larger margin around the gland)

82. Side Effects of Prostate Radiation The structures that will get radiation irritation: bladder, urethra and rectum Radiation zone

84. Long Term Side Effects of Radiation

87. Radiation prescription for # Diagnosis: # Hormones: # Seeds: # External radiation: #