Margins From Prostate

7/26/2019 Margins From Prostate

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PRIMARY PROSTATE

CONTOURING

Dr.Katta Reddy


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OBJECTIVES

. Pro!tate A"atomy

#. Ima$%"$ o& Pro!tate

'. TNM Sta$%"$ o& Pro!tate Ca"(er

). Pro!tate I"ter&ra(t%o" a"d I"tra&ra(t%o" Mo*eme"t

+. Te(h"%,ue! o& Mar$%" Redu(t%o"

-. Tar$et Voume de%"ea"at%o"

.


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PROSTATE ANATOMY/0OCATION. O*o%d /!ha1ed !tru(ture (om1o!ed o& 23rou!4 $a"duar4 a"

mu!(uar eeme"t!.

#. It %! o(ated %" the 1e*%!4 ad5a(e"t to the re(tum4 3adder4 a"d 1er%1ro!tat%( *e"ou! (om1e6e!4 1e*%( !%de7amu!(uature4 the 1e*%( 1e6u!4 a"d (a*er"ou! "er*e!.

'. the 1ro!tate a"d the re(tum (ur*e a7ay &rom ea(h other a(o"*e6 !ur&a(e!.

). Surrou"d! !e$me"t! o& the urethra 3e&ore %t 1a!!e! throu$$e"%tour%"ary d%a1hra$m 8GUD9.


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PROSTATE ANATOMY/BOUNDARIESThe 1ro!tate %! (o"ta%"ed 7%th%" a th%"4 23rou! adher(a1!ue that %! !tru(turay (o"t%"uou! 7%th the !tromthe $a"d.

The a1e6 o& the $a"d re!t! a3o*e the GUD. The GUD!urrou"d! the mem3ra"ou! !1h%"(ter a"d may *ary %e"$th a"d th%(:"e!!.

The atera mar$%"! o& the 1ro!tate are u!uay de%"ea$a%"!t the e*ator a"% mu!(e!4 &orm%"$ the atera1ro!tat%( !u(%.


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PROSTATE ANATOMY/BOUNDARIESThe 1u3o1ro!tat%( %$ame"t! e6te"d a"ter%ory &rom the !ur&athe $a"d to the 1u3%( !ym1hy!%!.

The 1ro!tate %! !e1arated &rom the re(tum 1o!ter%ory 3yDe"o"*%%er!; &a!(%a 8retro*e!%(a !e1tum94

It atta(he! a3o*e to the 1er%to"eum a"d 3eo7 to the GUD.

re!tr%(t! 1o!ter%or e6te"!%o" o& 1ro!tat%( (ar(%"oma %"to the re


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PROSTATE


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IMAGING/TEC>NI?UES

1. TRUS@Tra"!re(ta utra!o"o$ra1hy ha! 3ee" u!ed to $u%de"eede 3%o1!y a"d 3ra(hythera1y !eed %m1a"t.

2. T Scan@Com1uted tomo$ra1hy 8CT9 %! the moda%ty o& (h&or 7hoe/3ody !ta$%"$ a"d &oo7/u1 %" 1at%e"t! 7%th metad%!ea!e

!. "R#@Ma$"et%( re!o"a"(e 8MR9 %ma$%"$ %! 3e%"$ u!ed &or o!ta$%"$ 3e&ore treatme"t. MR !1e(tro!(o1%( %ma$%"$ 8MRSI1ro*%de! a" %"d%(at%o" o& tumor a$$re!!%*e"e!!.

$. P%T Scan: Ma%"y u!ed %" &oo7 u1


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TRANSRECTA0 U0TRASOUN8TRUS9. S%6ty to !e*e"ty 1er(e"t o& 1ro!tate (a"(er! are h&poecho

utra!ou"d 3ut # to ' are %!oe(ho%( 7%th "orma1are"(hyma a"d (a""ot 3e !ee" o" $ray!(ae utra!o"o$ra

#. Se"!%t%*%ty o& TRUS &or dete(t%"$ 1ro!tate (a"(er ra"$e! &r' to +

'. Coor Do11er4 rea/t%me ea!to$ra1hy4 a"d (o"tra!t e"ha"(utra!ou"d are 1rom%!%"$ te(h"%,ue! &or %m1ro*%"$ tumordete(t%o"


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CT SCAN

CT %! "ot the moda%ty o& (ho%(e&or e*auat%"$ primar& prostatecancer.

tumor (o"2"ed 7%th%" the (a1!uemay ma"%&e!t a! a "orma/!%=edor e"ar$ed 1ro!tate $a"d o" CT

Due to the %"a3%%ty o& CT todete(t (a"(er a"d to *%!ua%=e the1ro!tat%( (a1!ue4 a !mooth outer1ro!tat%( mar$%" doe! "ot e6(udethe 1re!e"(e o& (a"(er 7%th%" the$a"d.


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PROSTATIC ANATOMY ONMRIThe


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PROSTATIC CAPSU0E

The 1ro!tate $a"d %! 1art%ay %"*e!ted 3y a (oa%t%o" o& 23rout%!!ueh%!tor%(ay4 (aed the (a1!ueFthat %! mo!t a11are1o!ter%ory a"d 1o!teroateray.

#mportant lan/mar0 &or a!!e!!%"$ e6tra1ro!tat%( tumore6te"!%o". The "euro*a!(uar 3u"de! (our!e 1o!teroatera to1ro!tate (a1!ue 3%ateray at the +/ a"d/o;(o(: 1o!%t%o"!.

At the a1e6 a"d the 3a!e4 the 3u"de! !e"d 1e"etrat%"$ 3ra"(throu$h the (a1!ue4 1ro*%d%"$ a route &or e6tra1ro!tat%( tumoe6te"!%o"

The a"atom%( or true (a1!ue !urrou"d%"$ the 1er%1hera =o"ea11ear! a! a th%" r%m o& o7 !%$"a %"te"!%ty o" T#/7e%$hted %


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PROSTATIC CANCER 8MRI9

T

A6%a T/7e%$hted

Tumor! are %m1o!!%3e to d%!(er".

1e*%( ade"o1athy4 o!!eou! 41o!t3%o1!y art%&a(t!.

T#

! orthoonal planes o the prostate.

Ho(a de(rea!ed !%$"a o" T#/7e%$hted %ma$%"$

Pro!tat%t%! 4 23rot%( (ha"$e!4 or 1o!t3%o1!y (ha"$e! mayde(rea!ed T# !%$"a

S%$"a %"te"!%ty rat%o! o" T#/7e%$hted MR %ma$e! (orreate !%$"%2(a"ty 7a$$re!!%*e"e!!4 7%th h%$her Gea!o" $rade! 3e%"$ a!!o(%ated 7%th o7er tmu!(e !%$"a %"te"!%ty rat%o!


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Po!t /3%o1!y (ha"$e! a"d 1ro!tate (a"(er may (o%"(%de at the !ame o(at%o" a%ma$%"$ (a""ot a7ay! d%ere"t%ate 3%o1!y (ha"$e! &rom tumor.

There&ore4 a deay o& !%6 to e%$ht 7ee:! 3et7ee" 3%o1!y a"d MR %ma$%"$ %! re


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MAGNETIC RESONANCESPECTOGRAP>Y IMAGING8MRSI9 %! a" e!ta3%!hedad*a"(ed %ma$%"$ te(h"%,ue &ormeta3o%( a"d &u"(t%o"ae*auat%o" o& the 1ro!tate$a"d.

>e"(e4 a" %"(rea!ed(ho%"e(%trate or 8(ho%"e (reat%"e9(%trate rat%od%!t%"$u%!he! 1ro!tate (a"(er&rom heathy t%!!ue

ormal prostate Prostatic

>%$h e*e! o&(%trate4 (reat%"%"ea"d (ho%"e

0o7 e*e o(ho%"e due%"(rea!edmeta3o%!m

>%$h e*e!(ho%"e due%"(rea!ed1ho!1ho%1mem3ra"e


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DIHHUSION LEIG>TED MR

D%u!%o"/7e%$hted %ma$%"$ 8DLI9 %! a"MR te(h"%,ue that mea!ure! theBro7"%a" mot%o" o& 7ater moe(ue! %"3%oo$%( t%!!ue!4 7h%(h %! %"*er!ey1ro1ort%o"a to (euar de"!%ty41re!uma3y 3e(au!e %"(rea!ed (euarde"!%ty %m%t! 7ater d%u!%o" %" the%"ter!t%t%a !1a(e.

The (om3%"at%o" o& T#/7e%$hted%ma$%"$ a"d DLI %! 3etter tha" T#/7e%$hted %ma$%"$ ao"e %" thedete(t%o" o& !%$"%2(a"t 1ro!tate (a"(er8%.e.4 (a"(er 7%th a Gea!o" !(ore o& atea!t !%6 a"d a d%ameter ) mm9 7%th%"the 1er%1hera =o"e.


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POSITRON EMISSIONTOMOGRAP>Y8PET9 SCANHDG PET ha! 3ee" &ou"d to ha*e o7 !e"!%t%*%ty &or dete(t%"$ 1r%mary1ro!tate (a"(er4 e6(e1t %" 1at%e"t! 7%th ad*a"(ed/!ta$e a"d morea$$re!!%*e tumor! .

. $u(o!e ut%%=at%o" %" 7e/d%ere"t%ated 1ro!tate (a"(er %! o&te" otha" %" other tumor ty1e!/o*era1 %" the de$ree o& u1ta:e 3et7ee1ro!tate (a"(er4 3e"%$" 1ro!tat%( hy1er1a!%a4 a"d %"ammat%o".

#. "orma ur%"ary e6(ret%o" o& rad%o%!oto1e (a" ma!: 1athoo$%(a u1

.C/(ho%"e4 the u1ta:e o& 7h%(h %! %"(rea!ed %" ma%$"a"t t%!!ue due t%"(rea!ed !y"the!%! o& mem3ra"a 1ho!1hat%dy(ho%"e %" tumor (e!

.C/(ho%"e ha! the ad*a"ta$e o& redu(ed ur%"ary e6(ret%o"4 a"d thu! 1ro*%de more a((urate %"&ormat%o" &or the o(a%=at%o" o& dom%"a"t 11ro!tate (a"(er e!%o"!.


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PRIMARY TUMOR STAGINGOH PROSTATE CANCER


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T#APERIP>ERA0 AT INVO0VES # OH


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T#BTUMOR INVO0VES MORE T>AN >A0H OH 0OBE BUT NOT


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T#CTUMOR INVO0VES BOT> 0OB


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T'A


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T'AETRACAPSU0AR ETENSIO


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T'B


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T'BTUMOR INVO0VING SEMINA

VESIC0ES


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T)


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T)TUMOR INVADES ADJACEN

STRUCTURES


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PROSTATE MOTIONSIGNIHICANCE. the 1ro!tate re1re!e"t! a Qmo*%"$ tar$et;a! (ha"$e! %"

3adder a"d 3o7e 2%"$ (a" d%!1a(e the 1ro!tate!%$"%2(a"ty 3et7ee"4 or e*e" dur%"$4 rad%othera1y &ra(

#. 1ro!tate %! "ot atta(hed d%re(ty to 3o"y a"atomy4 1ro!mot%o" d%er! !u3!ta"t%ay &rom 1e*%( 3o"y a"atom%(

1o!%t%o".'. Add%"$ ar$er mar$%"! to the 1ro!tate %"(rea!e! do!e to

3adder a"d re(tum4 %m1ro*%"$ tar$et (o*era$e 3ut a!o%"(rea!%"$ the 1ro3a3%%ty o& to6%(%ty@ th%! %! a e!! tha"o1t%ma !out%o" to e"!ure tumor (o*era$e.


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PROSTATE MOTION/TLO?UESTIONS

. >o7 mu(h doe! the 1ro!tate mo*e o" a da%y3a!%! 8%.e.4 %"ter&ra(t%o"a9 a"d dur%"$ ea(htreatme"t 8%.e.4 %"tra&ra(t%o"a9

#. I! the 1o!%t%o"a reat%o"!h%1 3et7ee" the1ro!tate a"d 3o"y a"atomy !tat%( 8%.e.4 (a" 3o"a"atomy 3e u!ed a! a !urro$ate o& the 1ro!tateo(at%o"9


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PROSTATE MOTION

COMPRE>ENSIVE STUDY

HROM T>E MAYO C0INICThe u!e o& 2du(%a$od !eed mar:er!a"d da%y ee(tro"%(1orta %ma$%"$ 8EPI9

&or determ%"%"$1ro!tate mot%o" a"d3o"y 1e*%( a"atomy

PROSTATE MOTION


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PROSTATE MOTION INTERHRACTION MOVEMENirection Rane "ean

Su1er%or/I"&er%or

.mm #.+mm

A"ter%or

Po!ter%or

+.#mm '.mm

R%$ht /0e&t +.#mm .mm


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INTERHRACTION MOTIONLIT> BONY ANATOMY

Prostate +on&'natom&

Preo(a%!at%o"

+.-mm ).)mm

Po!to(a%!at%o"

#.mm ).)mm


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PROSATE INTRAHRACTIONMOTIONirection o

"otion

Prostate(mm) +on&

'natom&

A"ter%or/Po!ter%or

. /.+

Su1er%or/I"&er%or

.) .)

R%$ht/0e&t . .'"ar0er miration 3as oun/ to be minimal, 3ith 456 3ithin 1 mm

3ithin 1.8 mm.

TYPES OH INTRAHRACTION MOTION


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TYPES OH INTRAHRACTION MOTIONE0ECTROMAGNETIC TRANSPONDERS/0ANG

STUDY

T7o ty1e! o& I"tra&ra(t%o" mot%o" %! 1o!!%3e

. So7 4 !ma dr%&t4 u!uay 1o!ter%ory a"d %"&er%ory4 that %!thou$ht to 3e a!!o(%ated 7%th 1e*%( mu!(e rea6at%o" or t$radua mo*eme"t o& re(ta (o"te"t! a7ay &rom the 1ro!ta

#. Sudde" a"d tra"!%e"t mot%o"4 u!uay a"ter%ory a"d !u1er

that (a" 3e !%$"%2(a"t %" e6te"t a"d %! thou$ht to 3e due to1er%!ta!%!.

the a*era$e 1ro1ort%o" o& the tota treatme"t t%me that the 1ro7a! d%!1a(ed 3y ' mm a"d + mm 7a! '.- a"d '.'4re!1e(t%*ey.

C G S


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CTV/PTV MARGINSTo Co*er + O& The CTV L%th The Pre!(r%3ed Do!e

A + Pro3a3%%ty

9ithout*i/ucialocalisation

9ith *i/ocalisa

Su1er%or

I"&er%or

+. mm #. mm

A"ter%or/1o!ter%or

.' mm #. mm

R%$ht 0e&t A6%! +. mm #. mm


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TEC>NI?UES

*i/ucial ol/ see/ mar0ers a"d da%y ee(tro1orta %ma$%"$ 8EPI9 7%th o"%"e (orre(t%o"

%lectromanetic transpon/ers that (a" 3e%m1a"ted %"to the 1ro!tate

one beam compute/ tomoraph& (+T)o"%"e (orre(t%o" %! $a%"%"$ 1o1uar%ty a! %t ao7!o&t t%!!ue mat(h%"$4 a"d doe! "ot re,u%re a"%"*a!%*e 1ro(edure to %m1a"t 2du(%a mar:er!

G O


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TARGET VO0UMEDE0INEATIONCTV de2"%t%o" o& the 1ro!tate$a"d 1u! a" add%t%o"a(%r(um&ere"t%a mar$%" o& + mm7oud thu! (o*er more tha" o& tumor e6te"!%o"! out!%dethe 1ro!tate.

At the 1ro!tatere(tum%"ter&a(e4 the a"ter%or re(ta7a re1re!e"t! a !o%d 3ou"dary&or tumor (e! !o that the CTV(a" 3e redu(ed 1o!ter%ory.


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r%!: o& tra"!(a1!uar e6te"!%o" %! *ery !ma %" the a"ter%or or a"teroatera 1$a"d4 %t %! h%$he!t %" the 1o!ter%or a"d 1o!teroatera 1art!. Thu! the 1er%1ro!at the 1ro!tate re(tum %"ter&a(e %! at the h%$he!t r%!: o& tumor re(urre"(e 7u"derdo!ed 3y rad%othera1y


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HINDINGS BY KESTIN ET A0

CT de2"%t%o"! a"d 1athoo$%(a mea!ureme"t! are %" $ooda$reeme"t

H%"ay o"y o& o7/r%!: 1at%e"t! had a" SVI 7h%(h (o"2rmto %"(ude SV! %"to CTV %" th%! 1at%e"t $rou1.

I"(ud%"$ the 1ro6%ma # (m o& the SV %"to the CTV 7oud %"( o& 1athoo$%(ay %"*o*ed !em%"a *e!%(e!.

L%th ea(h 1ro$"o!t%( h%$h r%!: &a(tor4 the rate o& SVI r%!e! &rom 7%th o"e h%$h/r%!: &a(tor4 # 7%th t7o4 to + 7%th threer%!: &a(tor!4 re!1e(t%*ey.

CT SCAN IN DE0INEATING


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CT SCAN IN DE0INEATINGPROSTATE#naccuracies o T Scan in Prostate elineation

CT !(a"! o*ere!t%mate the trueF 1ro!tate *oume 3y #- (om1ared 7%th MRI !(a"!. D%ere"(e! are ma%"y !ee" at

. A1e6 O& The Pro!tate

#. Sem%"a Ve!%(e!


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CTV/PTV MARGIN

. PTV %! a" automat%(ay$e"erated mar$%". The PTVmu!t "ot 3e $e"erated 3yha"d a! %t %! "ot 1o!!%3e todra7 a three/d%me"!%o"amar$%" e"(om1a!!%"$ the

CTV.#. em1ty re(tum dur%"$

1a""%"$ CT 1ro*%de!%m1ro*ed 3%o(hem%(a (o"tro%" 1at%e"t! u"der$o%"$de2"%t%*e rad%othera1y &or

1ro!tate (a"(er


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GRAHH ET A0 STUDY


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Documents

Margins From Prostate