Prostate Low Risk

Treatment Modalities

Radiation

  • May be offered to all except M1

Radical prostatectomy

  • Low risk: Radical prostatectomy ±PLND
  • Intermediate risk: Radical prostatectomy + PLND (unless risk of PLN < 3%)
  • High risk: select patients with no fixation of prostate and low volume

Advantages of Perineal approach

  • better apical margin
  • urethral anastomosis is better exposed

Retropubic approaches (standard)

  • familiar to urologis
  • less rectal damage
  • pelvic lymphadenectomy is easier
  • more consistent preservation of neurovascular bundle
  • low rate of positive margin

Expectant management

  • Maybe offered in patients with < 10 yr. Life expectancy.

Androgen ablation

  • T3, T4, N1, or M1 (needed regardless of any other modality contiplated)
  • With radiation for high-risk patients.

Expectant Management

Technique

  • DRE Q6 mo.; bx in 18 mo. (6 mo. If < 10 cores initially).
  • Repeat bx for any concerning PSA or DRE or Symptoms

Advantages

  • No side-effects of definitive therapy and thus improved quality of life

Disadvantage

  • Risk of progression, subsequent treatment may have more side-effects and may not be as effective
  • Frequent examinations

Radiation Therapy Planning and Techniques

GTV
Visible Tumor including pathologic nodes (ex: prostate)
Include seminal vesicles in intermediate and high-risk groups but no low-risk groups

CTV
Tumor suspected but not visible (ex: seminal vesicles and pelvic nodes)
Pelvic nodes may be included in for patiets with “high” risk of pelvic metastasis.

PTV
Setup and motion uncertainty (5-10 mm depending on direction)
Comparison of Immobilization Techniques [1]

Dimension No Balloon (1 S.D.) Yes Balloon
A-P 4.1 mm < 1 mm
Sup-Inf 3.6 mm 1.78 mm
Lateral 0.9 mm minimal

Prognostic factors

Patient related

  • Black men (?)

Disease related

  • PSA, Gleason, tumor stage
  • Others include: % cores positive

Treatment related

  • Radiation Dose and the use of Hormones

PSA as a surrogate endpoint

  • PSA is a harbinger of eventual clinical relapse in 2-5 years
  • Intensive biopsy yields evidence of local persistence in 30-50% of cases

Patterns of Failure (localized disease, if)

  • > 2 years from treatment
  • Doubling time of > 1 year as calculated
  • log(x) = log(PSAi /PSAf)/ (time between PSA) {this is a form of slope}
  • time = log(2)/ log(x) {this uses the slope to calculate the doubling time}
  • Pre-treatment Gleason < 8
Bibliography
1. McGary, Teh, Butler,Grant. J Appl Clin Med Phys. 2002 Winter;3(1):6-11
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