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CARCINOMA PROSTATE- Dr Manoj Kumar B, PGI

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PGIMER, AIIMS
PGIMER, AIIMS
Salud y medicina
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CARCINOMA PROSTATE AND IT’S MANAGEMENT ,[object Object],[object Object]
ANATOMY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Lobes Zones
EPIDEMIOLOGY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ETIOLOGY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
NATURAL HISTORY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CLINICAL MANIFESTATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PHYSICAL EXAMINATION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
DIAGNOSTIC WORK-UP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
LABORATORY INVESTIGATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TEMPORAL VARIATION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
IMAGING ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TRANRECTAL ULTRASONOGRAPHY(TRUS) ,[object Object],[object Object],[object Object],The mature average prostate is between 20 and 25 g and remains relatively constant until about age 50, when the gland enlarges in many men ( Griffiths, 1996 ) The paired seminal vesicles are positioned posteriorly at the base of the prostate. They have a smooth, saccular appearance and should be symmetrical. Normal SV measures 4.5 to 5.5 cm(l) and 2 cm (w)
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CT SCAN ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
MRI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MRSI ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
99 TC BONE SCAN ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PATHOLOGY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
GLEASON SYSTEM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
GLEASON GRADING It is important to recognize Gleason pattern 4 tumor because tumors with this pattern have a significantly worse prognosis than those with pure Gleason pattern 3 ( McNeal et al, 1990 ). Tumors with Gleason score 4 + 3 = 7 have a worse prognosis than those with Gleason score 3 + 4 = 7 ( Chan et al, 2000 ) GS Gleason’s Pattern Histo. Grade Differentiation 10 yr Progression (%) 2, 3, 4 1, 2 I Well <25 5, 6, 7 3 II Mod. 50 8, 9, 10 4, 5 III Poorly 75
TNM STAGING SYSTEM
TNM STAGING SYSTEM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TREATMENT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WATCHFUL WAITING ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RADICAL PROSTATECTOMY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RADIOTHERAPY ,[object Object],[object Object],[object Object],[object Object],[object Object]
RADICAL EBRT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],CONVENTIONAL EBRT PORTALS
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[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CONFORMAL RT - 3DCRT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
GTV+SV GTV+ SV, PTV, CTV LN GTV P+SV, CTV P+SV CTV P+SV
3DCRT FIELDS ARRANGEMENTS
[object Object],[object Object]
IMRT ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
IMRT PHASE
CONVENTIONAL RT CONFORMAL RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SEQUELAE OF XRT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
BRACHYTHERAPY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RADIOISOTOPES IODINE 125 PALLADIUM 103 IRIDIUM 192 T 1/2 (days) 59.4 16.97 73.83 Energy(keV) 27.4 21 340 Form Seeds Seeds Seeds Implant type Permanent Permanent Temporary Dose rate 8 20 Variable Mean activity/seed 0.42 1.3 Monotherapy dose 145 125 Variable (~600) +EBRT dose 110 100 20-25 TVL(mm) Pb 0.01 0.03 HVL-4.5 mm
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PREPLANNED TRANSPERINEAL TECHNIQUE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TRUS GUIDED HDR INTERSTITIAL BRACHYTHERAPY
 
ADJUVANT RADIOTHERAPY ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
METASTATIC CA PROSTATE: PALLIATIVE RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MECHANISMS OF ANDROGEN AXIS BLOCKADE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ablation of androgen source Inhibition of LHRH or LH Inhibition of androgen synthesis Antiandrogens Orchiectomy DES Leuprolide Aminogluthemide Cyprotene acetate Goserelin Ketoconazole Flutamide Triptorelin Biclutamide Histrelin Nilutamide Cetrorelix Abarelix
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Strategies for Androgen Deprivation
COMBINED ANDROGEN BLOCKADE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SIDE-EFFECTS OF HORMONAL THERAPY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CHEMOTHERAPY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TAX 327 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],William Berry and Mario Eisenberger -The Oncologist 2005;10(suppl 3):30–39 Charles J. Ryan and Mario Eisenberger - J Clin Oncol 23:8242-8246
ADJUNCTIVE T/T ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TARGETED CRYOABLATION OF PROSTATE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PROGNOSTIC FACTORS ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
SCREENING GUIDELINES FOR THE EARLY DETECTION OF PROSTATE CANCER (AMERICAN CANCER SOCIETY) ,[object Object],[object Object],[object Object],[object Object]
Very high : T3b-T4 <10yr >10yr Expectant m/m or RT or RP±PLND RP±PLND or RT Androgen ablation or RT+Androgen ablation Any T, N1 Any T, Any N, M1 Androgen ablation Androgen ablation or RT+Androgen ablation Relapse risk Expected survival Initial T/t LOW : T1, T2a GS 2-6 PSA< 10 <10yr Intermediate : T2b, T2c GS 7 PSA-10-20 Expectant m/m or RT or RP±PLND High : T3a GS 8-10 PSA>20 >10yr Expectant m/m or RT Androgen ablation +RT or RT or RP±PLND
THANK YOU
 
 
 
 
 
 
 
 
 
 
 
 
 
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Targeted Cryoablation of the Prostate (TCAP) Before Probes Placed Prostate frozen
 
 
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IMRT PLAN SUM
 
 

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CARCINOMA PROSTATE- Dr Manoj Kumar B, PGI

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  • 37. GLEASON GRADING It is important to recognize Gleason pattern 4 tumor because tumors with this pattern have a significantly worse prognosis than those with pure Gleason pattern 3 ( McNeal et al, 1990 ). Tumors with Gleason score 4 + 3 = 7 have a worse prognosis than those with Gleason score 3 + 4 = 7 ( Chan et al, 2000 ) GS Gleason’s Pattern Histo. Grade Differentiation 10 yr Progression (%) 2, 3, 4 1, 2 I Well <25 5, 6, 7 3 II Mod. 50 8, 9, 10 4, 5 III Poorly 75
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  • 55. GTV+SV GTV+ SV, PTV, CTV LN GTV P+SV, CTV P+SV CTV P+SV
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  • 66. RADIOISOTOPES IODINE 125 PALLADIUM 103 IRIDIUM 192 T 1/2 (days) 59.4 16.97 73.83 Energy(keV) 27.4 21 340 Form Seeds Seeds Seeds Implant type Permanent Permanent Temporary Dose rate 8 20 Variable Mean activity/seed 0.42 1.3 Monotherapy dose 145 125 Variable (~600) +EBRT dose 110 100 20-25 TVL(mm) Pb 0.01 0.03 HVL-4.5 mm
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  • 72. TRUS GUIDED HDR INTERSTITIAL BRACHYTHERAPY
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  • 79. Strategies for Androgen Deprivation
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  • 90. Very high : T3b-T4 <10yr >10yr Expectant m/m or RT or RP±PLND RP±PLND or RT Androgen ablation or RT+Androgen ablation Any T, N1 Any T, Any N, M1 Androgen ablation Androgen ablation or RT+Androgen ablation Relapse risk Expected survival Initial T/t LOW : T1, T2a GS 2-6 PSA< 10 <10yr Intermediate : T2b, T2c GS 7 PSA-10-20 Expectant m/m or RT or RP±PLND High : T3a GS 8-10 PSA>20 >10yr Expectant m/m or RT Androgen ablation +RT or RT or RP±PLND
  • 91. THANK YOU
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  • 107. Targeted Cryoablation of the Prostate (TCAP) Before Probes Placed Prostate frozen
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Notas del editor

  1. Unenhanced CT scan in 78-year-old man with prostate cancer, Gleason score of 34 at biopsy, PSA level of 21 ng/mL, and palpable tumor shows enlarged prostate with evidence of gross tumor ECE (arrow) along left posterolateral margin of the gland.