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

4. The prostate lies along the back of the bladder

5. Side View of the Prostate, Cancers arise in the peripheral zone , close to the capsule The location of cancer in the prostate is critical for targeting the correct area

6. Prostate Zones: 80-85% cancers arise from the peripheral zone, 10-15% transitional and 5-10% from the central zone.

7. The peripheral zone is small at the top (base) of the gland but larger at the bottom (apex)

8. Cancer occurs along the outside edge of the prostate just under the capsule cancer

9. Cancer occurs along the outside edge of the prostate just under the capsule, so the radiation field may need to extend slightly outside the capsule cancer cancer

10. Risk of Extracapsular Spread for T1c, based on Gleason and PSA You can estimate the risk that the cancer has already grown into the capsule , this helps the doctor determine how large an area to treat

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

12. There are lymph nodes that may be involved, it is rare to have lymph node spread in low or intermediate risk patients

13. CT scans and MRI show the anatomy of the prostate quite well

14. Prostate Cross Section Anatomy Prostate rectum bladder

15. Cross section anatomy of the male pelvis

16. Cross section anatomy of the male pelvis

17. Bladder Prostate Rectum Prostate CT Anatomy

18. CT Scan = large prostate cancer

21. MRI showing Cancer Nodule

22. Prostate Stages

23. Most men with a low PSA (less than 10) and a low Gleason score (less than 7) have cancer cells in the gland too small to feel or see on CT scans

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

25. T2 lesion = big enough to feel

26. T3 if spread to the seminal vesicles

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

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

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

33. 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%

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

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

37. Declining PSA After External + Seeds

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

39. 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.

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

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

44. Treating prostate cancer Surgery? Radiation?

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

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

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

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

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

52. 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

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

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

55. bladder Radiation zone prostate rectum Goal = radiation zone precisely around the prostate cancer with small margin

56. 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

57. IMRT Identify organs and tumor target prostate rectum bladder

58. 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

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

60. 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)

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

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

64. 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)

66. 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

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

68. 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

69. 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

70. 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

71. If no adjustment was made Actual treatment on Tomotherapy

73. Using Tomotherapy to tightly target the prostate with very little radiation hitting the bladder or rectum

74. Tomotherapy is particularly useful in men with hip replacements

76. Tampa Bay Cyberknife Center

77. Cyberknife Radiosurgery

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

79. CyberKnife Multiple beamlets of radiation striking the prostate

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

81. Seed Implants

82. Prostate Seed Implants

83. Prostate Seed Implants

84. Rectal ultrasound used to image the prostate

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

86. The needles are distributed

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

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

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

90. 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

91. 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)

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

94. Long Term Side Effects of Radiation

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