Radiation Oncology/Prostate/Prostate Overview

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Prostate: Main Page | Prostate Overview | Screening and Prevention | Workup | Natural History | External Beam RT | IMRT | Androgen Suppression Therapy | Brachytherapy | Protons | Prostatectomy | Adjuvant RT after Prostatectomy | Salvage RT | Chemotherapy | Localized prostate cancer | Node Positive | Advanced disease | Recurrence after RT | Cryotherapy | RTOG Prostate Trials | Randomized Evidence


Prostate Cancer Overview


Contents

[edit] Anatomy

[edit] PSA

  • Please see the PSA page


[edit] Workup

  • Use of bone scan and CT scan: Use of routine scans in early stage prostate cancer questioned. Bone scan + in <5% and CT scan + in <12% for those with PSA < 20, and <2% and 9% for those with PSA < 20 and Gleason 6 or less. For PSA > 50, positive in 10%; for Gleason 8-10 with PSA >20, positive in 20%. — (SEER data, Prostate Cancer Outcomes Study - Albertsen et al. PMID 10737483 J Urol. 2000 Apr;163(4):1138-43.)
  • PMID 15126770 reviews 48 articles and finds
    • Bone scan + in 2.3% if PSA < 10, in 5.3% with PSA 10-20 and 16.2% with PSA 20-50.
    • Bone scan + in 5.6% if Gleason 7 or less vs 29.9% if Gleason 8-10
    • Bone Scan + in 6.4% if stage T2 or less vs 49.5% if T3-4
    • CT + in 0% if PSA < 20 and 1.1% if PSA > 20
    • CT + in 1.2% Gleason 7 or less vs 12.5% Gleason 8-10
    • CT + in 0.7% T2 or less vs 25.8% of T3-4s


[edit] Pattern of spread to lymph nodes

Prostate lymphatic drainage is to hypogastric (primary), obturator (secondary), external iliac (tertiary), and presacral (quarternary). For radical prostatectomy, lymph node dissection includes only the obturator and external iliac LNs, and is recommended for PSA > 10 and Gleason > 6. Heidenreich et al (PMID 11912387) reported that with extended lymphadenectomy (including all four drainage regions), LN mets were detected in 26% vs 12%, and that 2/3 of patients had LN mets outside of the fields of standard lymphadectomy. Recommended extended lymphadenectomy of external and internal iliacs and obturator for pts with PSA > 10 and Gleason 7 or above (only 2% LN+). Do not recommend dissection of presacral region or common iliac.

[edit] Predictors of pathologic stage

[edit] Partin tables

  • Online tool: Partin tables (Johns Hopkins)
  • Original; 1993: PMID 7685418 — "The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer." Partin AW et al. J Urol. 1993 Jul;150(1):110-4.
  • Update; 1997: PMID 9145716 — "Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update." Partin AW et al. JAMA. 1997 May 14;277(18):1445-51.
  • Update; 2001: PMID 11744442 — "Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium." Partin AW et al. Urology. 2001 Dec;58(6):843-8.
  • 2007 (2000-2005) PMID 17572194 -- "Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy Gleason score (Partin tables) based on cases from 2000 to 2005." (Makarov DV, Urology. 2007 Jun;69(6):1095-101.)
    • Retrospective. 5730 men, prostatectomy, no neoadjuvant therapy. Variables used PSA (80% <10), clinical stage (77% T1c), biopsy Gleason (76% GS 5-6)
    • Outcome: Nomogram developed
    • Conclusion: Updated "Partin tables" reflect trends in presentation
  • Caution: The Partin tables assign the "worst-case" pathologic stage for each case; the categories are mutually exclusive. (E.g., those included as "capsular penetration" had to have no seminal vesicle involvement or lymph node involvement, and those included as "positive seminal vesicle" had to have no lymph node involvement. The categories sum to 100%.) This method gives an underestimation of the true rate of extracapsular extension and seminal vesicle involvement.

[edit] Roach equations

  • Seminal vesicle involvement - PSA +([Gleason -6] x 10) — PMID 7523343
    • Cutoff is 13%. If <13%, risk 7%; if >=13%, risk 37%.
  • Lymph node involvement - 2/3*PSA + ([Gleason-6] x 10) — PMID 7505775
    • Cutoff is 15%. If calculated risk is <15%, actual risk 6%; if >=15%, actual risk 40%.
  • Extracapsular extension - 1.5*PSA + ([Gleason-3) x 10) — PMID 10875450
    • Approximates actual risk.


  • Harvard; 2009 (2004) PMID 19286330 -- "Predicting the risk of pelvic node involvement among men with prostate cancer in the contemporary era." (Nguyen PL, Int J Radiat Oncol Biol Phys. 2009 May 1;74(1):104-9. Epub 2009 Mar 13.)
    • SEER analysis. 9,387 men with cT1c-T4 PCA, surgical LN evaluation, GS and PSA. 98% were cT1c/T2
    • Outcome: LN+ in 3.3%. Roach scores overestimated actual rates by 16x if score <10%, by 7x if score 10-20%, and by 2.5x if score >20%
    • Conclusion: Roach formula appears to overestimate contemporary patients with mainly T1c/T2 disease

[edit] Kattan nomogram

  • Preoperative nomogram - PMID 9605647, 1998 — "A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer." Kattan MW et al. J Natl Cancer Inst. 1998 May 20;90(10):766-71.

[edit] SV invasion

Seminal vesicle invasion:

  • Mayo (1988-93) - PMID 8948342, 1996 — "Correlation of pretherapy prostate cancer characteristics with seminal vesicle invasion in radical prostatectomy specimens." Pisansky TM et al. Int J Radiat Oncol Biol Phys. 1996 Oct 1;36(3):585-91.
    • T-stage (T2a or less vs. T2b-c vs. T3a-b), primary Gleason grade (1-2, vs. 3, vs 4+), and PSA predict for SVI on multivariate analysis.

[edit] Definitions of Risk Groups

  • NCCN (v2.2009)
    • Low risk: T1-T2a and GS 2-6 and PSA <10
    • Intermediate risk: T2b-T2c or GS 7 or PSA 10-20
    • High risk: T3a or GS 8-10 or PSA >20
    • Locally advanced: T3b-T4
    • Metastatic: N1
    • Metastatic: M1
  • RTOG risk group classification - PMID 10837943 (Roach) - does not include PSA information. Used in RTOG Meta-Analysis
    • Group 1 / low risk (T1-2,G<=6)
    • Group 2 / int (T1-2,G7; T3 or N1, G<=6)
    • Group 3 / high (T1-2,G>=8; T3 or N1, G7)
    • Group 4 / very high (T3 or N1, G>=8)
  • D'Amico, 1998 (1989-97) - PMID 9749478 — "Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer." D'Amico AV et al. AMA. 1998 Sep 16;280(11):969-74.
    • 1872 pts treated by RP, implant, or EBRT. Defined risk groups:
      • Low risk: T1c-T2a, PSA 10 or less, and Gleason 6 or less - PSA failure risk <25% at 5 years.
      • Intermediate risk: T2b, or PSA >10 and <= 20, or Gleason 7 - 25-50% risk.
      • High risk: T2c or PSA > 20 or Gleason 8 or more - > 50% risk.
    • See also update of trial under Comparison of Primary Treatments section (D'Amico, Cancer 2002)
  • Pisansky (Mayo), 1997 (1987-93) - PMID 9179062 — "An enhanced prognostic system for clinically localized carcinoma of the prostate." Pisansky TM et al. Cancer. 1997 Jun 1;79(11):2154-61.
    • 500 pts, T1-4N0M0 treated with RT alone (median dose 64-66 Gy). Elective nodal RT in 30%.
    • Median f/u 43 mos.
      • Risk groups (and 5-yr relapse-free survival): Low - 92, Intermediate - 67, High - 24.

[edit] Other prognostic factors

  • Percent positive prostate cores: D'Amico 2004 (1988-2002) - retrospective
    • PMID 15365069 — "Impact of the percentage of positive prostate cores on prostate cancer-specific mortality for patients with low or favorable intermediate-risk disease." D'Amico AV et al. J Clin Oncol. 2004 Sep 15;22(18):3726-32.
    • 421 pts, low or "favorable intermediate risk", treated with RT alone.
    • Median f/u 4.5 yrs. Percetage of positive prostate cores (>=50 vs <50%) was the only significant predictor of disease-specific mortality, with a RR between 6 and 12.

[edit] Utilization


  • Center for Disease Control (CDC), Atlanta; 2007 PMID 17469027 -- "Use of additional treatment for prostate cancer after radical prostatectomy, radiation therapy, androgen deprivation, or watchful waiting." (Berge V, Scand J Urol Nephrol. 2007;41(3):198-203.)
    • SEER + Medicare claims data. 12,711 patients. Initial RP 31%, initial RT 31%, initial ADT 9%, initial WW 28%
    • Outcome: Initial RP: 8% additional RT, 12% additional ADT. Initial RT: 23% additional ADT. Initial WW: 22% additional ADT
    • Conclusion: If initially treated with RT or observation, more likely to receive ADT as follow-up treatment than if initially treated with RP
  • American College of Radiology; 2002 (1992-1993) PMID 12065564 -- "Comparing the costs of radiation therapy and radical prostatectomy for the initial treatment of early-stage prostate cancer." (Burkhardt JH, J Clin Oncol. 2002 Jun 15;20(12):2869-75.)
    • Linked SEER-Medicare analysis.
    • Outcome: Costs RT $14,048 vs. RP $17,226 (SS)
    • Conclusion: For early-stage PCA, average costs were at least 23% greater for RP
  • UCLA; 2000 (1993-1996) PMID 11042575 -- "A nationwide charge comparison of the principal treatments for early stage prostate carcinoma." (Brandeis J, Cancer. 2000 Oct 15;89(8):1792-9.)
    • HCFA claims data for inpatient, outpatient and Part B claims. 10,107 men with initial diagnosis of prostate cancer, treatment, +6 months of follow-up. RT 58%, brachy 7%, RP 35%. During the 4 years, RT decreased by 20%, brachy increased by 21%
    • Cost: RP + adjuvant RT $31,329 vs. RT + brachy boost $24,407 vs. RP $19,019 vs RT $15,937 vs brachy $15,301 (SS). Utilization varied with age, race, and geographic region
    • Outcome: Without clear survival advantage, costs, QoL and patient preference take on paramount importance
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