Common in western world One in six American men will be diagnosed with

prostate cancer during his lifetime Europe, the annual incidence rates were 214 per

1000 men

DRE PSA TRUS Biopsy and histopathology

• simple, cost effective method• Positive predictive value from 21% to 53%• Good staging method• sensitivity of 52% and specificity of 80%• MAY UNDER/OVER ESTIMATE

J URO 1999;161:835-9

The normal PSA are <4 ng/ml threshold PSA level for detection of cancer is 4.0

ng/ml BUT 25% will have a normal or low PSA PSA <10 ng/ml - low risk of peri-prostatic spread

and metastases

PSA >20 ng/ml-An increased risk of peri-prostatic spread, seminal vesicle involvement and distant metastases

GENERAL RULES PSA >10 ng/ml indicates capsularpenetration in

more than 50% patients PSA >50 ng/ml – metastatic disease.

prostate specific Not cancer specific BPH, prostatitis, tuberculosis etc borderline zone of 4-10ng/ml

Extended biopsy is more preferable cancer detection rate- 40%, sextant biopsy -20% to 25%

REV UROLOGY 2007 SUMMER,9(3):93-98

NATURAL HISTORY OF PROSTATE CANCER IS DIFFICULT TO PREDICT

Men with similar stage ,glisson score,psa can have markedly different outcome

Localized prostate cancer (T1 – T3a N0)

Locally advanced disease (T3b-T4 N0)

Metastatic disease: Any T, N+ or Any T, Any N &distant metastasis (M+)

Low risk (cT1-T2a and Gleason score 2-6 and PSA< 10)

Intermediate risk (cT2b-T2c or Gleason score = 7or PSA 10-20)

High Risk (cT3a or Gleason score 8-10 or PSA > 20)

PSA doubling time re-biopsy score , tumor volume stage progression patient preference.

RP -removal of the entire prostate gland between the urethra and the bladder, with resection of both seminal vesicles

is recommended for the organ confined prostate cancer with life expectancy of >10 years

Importance-to determine adjuvant therapy

Only ePLND

 removal of obturator, external iliac, and hypogastric lymph nodes

int j radtn oncol biol phys 2012 jun;83(2) 624-9

• No direct RCT between surgery vs RT• Retrospective analysis not much of difference

between both modalities

• radical&palliative

• EBRT• EBRT+BT• BT

• Patient supine

• Hands over chest

• Immobilization –

• Four field BOX

• Shrinking field technique

• Superior border-L4-L5-to include the common iliac nodes

• Inferior border-1.5 -2cm below the junction of prostatic and membranous urethra –just below the ischial tuberosities

• Lateral margin-1-2 cm from the lateral boney pelvis

Anterior -pubic symphysis

Posterior margin-S2-S3 junction to include the pelvic and presacral nodes+sparing posterior rectal wall

Cystogram – supine ,catheter insitu-20 ml of contrast+10ml of

air introduced into bladder 20 ml of contrast into catheter balloon which is

pulled down to bladder base AP film in simulator-2cm margin is given with

bladder base as center

Depends on risk Low risk-a minimum dose of 70 - 74 Gy is

(external with / without brachytherapy) Ideal-75-79 GY for low risk Intermediate &high risk-can extent to 81GY.

Permanent Temporary

Permanent-Ideal-are those with favorable risk prognostic features who have a high likelihood of organ-confined disease

• PSA levels 10ng/mL or less,

• Gleason scores less than 6-7,

• Clinical stages T1b- T2a

• prostate volume of < 50 cm3 and

• good International Prostatic Symptom Score (IPSS)

 International Prostate Symptom Score (IPSS) is an 8 question (7 symptom questions + 1 quality of life question) 

IPSS result of 7 symptoms questions

Score Correlation[1]

0-7 Mildly symptomatic

8-19 Moderately symptomatic

20-35 Severely symptomatic

• more easily optimize the delivery of RT to the prostate

• reducing the potential for under-dosage ,• reduces radiation exposure • radiobiologically more efficacious in terms of

tumor cell kill for patients with increased tumor bulk or adverse prognostic features.

.

Indication-positive surgical margins, seminal vesicle invasion and/or extracapsular extension

recommended doses are 60-64Gy

radiother oncol.2008 jul88(1)

Clinically localized disease Neo adjuvant/concomitant/adjuvant-prolongs

survival in radiation managed patients When ever used cab should use Indicated in all high risk + locally advanced +

metastatic disease(2-3 yrs) Short term androgen deprivation in intermediate

risk (4-6 months)

Hot flushes vasomotor instability Osteoporosis Obesity insulin resistance Greater risk of DM, cardiac diseses

mainstay of treatment -of long term hormonal therapy

local therapy- with radiation therapy preferred

EBRT-for painful or unstable skeletal metastases DOSE -800 CGY –SINGLE fraction(Level of

evidence: 1b) Fractionated RT for bone metastases may be

considered-spinal cord compression

Strontium89 Samarium153 improve bone pains in upto 70% patients

• reduce bone pains • skeletal-related events including fractures• inhibit osteoclast-mediated bone resorption and

osteoclast precursors effective-HRPCresponse rate of 70-80%

• Androgen deprivation- suppressing the secretion of testicular androgens –

surgical medical castration

• Anti-androgens -inhibiting the action of the circulating androgens at the level of their receptor in prostate cells

Simple&quickest way to achieve a castration level Usually- obtained in less than 12 hours main drawback- negative psychological effect

Currently the predominant forms of ADT Synthetic analogues of LHRH interfere with the hypothalamic-pituitary-gonadal

axis initially stimulate pituitary LHRH receptors

inducing a transient rise in LH and FSH release

compete with testosterone and DHT for binding sites on their receptors in the prostate cell nucleus

promoting apoptosis and inhibiting Prostate Cancer growth

Steroidal& non steroidal Both competes with androgen at receptor but

long-term CAB- which stimulates prostate cell apoptosis

fails to eliminate the entire malignant cell population

after a variable period-tumor invariably relapse- averaging 24 months

Androgenindependent state of growth

• Role of Radiotherapy in Ca Prostate is time-tested.

• All stages and risk groups are benefitted with RT.

• In future , Radiobiology research , Molecular Pathways and Technological innovations are the keys to enhance the treatment.