Prostate Cancer: Imaging for Radiotherapyeradiology.bidmc.harvard.edu/LearningLab/genito/Arvold.pdfGoluboff ET et al. Radical Prostatectomy for the Treatment of Prostate Cancer. In

July 2006Nils Arvold, HMS IVGillian Lieberman, MD

Imaging Prostate Cancer:Imaging Prostate Cancer:Diagnosis, Staging, and RadiotherapyDiagnosis, Staging, and Radiotherapy

Nils Nils ArvoldArvold, Harvard Medical School Year IV, Harvard Medical School Year IVGillian Lieberman, MDGillian Lieberman, MD

OverviewOverviewProstate Prostate –– Function and AnatomyFunction and AnatomyProstate Cancer Prostate Cancer –– Role of ImagingRole of Imaging–– Epidemiology and PresentationEpidemiology and Presentation–– Diagnosis: Diagnosis: TransrectalTransrectal U/S biopsyU/S biopsy–– Staging: Staging: EndorectalEndorectal coil MRI +/coil MRI +/-- bone scan, CTbone scan, CT

Radiotherapy Radiotherapy –– Reliance on ImagingReliance on Imaging–– Evolution: Conventional to 3D to 4DEvolution: Conventional to 3D to 4D–– External Beam RTExternal Beam RT

3D Conformal RT Imaging using CT3D Conformal RT Imaging using CTMR Spectroscopy and IntensityMR Spectroscopy and Intensity--Modulated RTModulated RT4D Image4D Image--guided RT with Electronic Portal Imagingguided RT with Electronic Portal Imaging

–– BrachytherapyBrachytherapyTRUS vs MR guidanceTRUS vs MR guidancePostPost--implantation CTimplantation CT

Nils Arvold, HMS IVGillian Lieberman, MD

ReviewReviewProstate is a 4 x 3 x 2cm exocrine gland Prostate is a 4 x 3 x 2cm exocrine gland encircling the urethra between the bladder encircling the urethra between the bladder and and urogenitalurogenital diaphragm diaphragm

Principal function = produce Principal function = produce proteins that proteins that form the bulk of seminal fluidform the bulk of seminal fluid

At ejaculation, prostate and seminal vesicle At ejaculation, prostate and seminal vesicle secretions turn into a gelsecretions turn into a gel--like structure like structure entrapping the spermatozoaentrapping the spermatozoa. The ejaculated . The ejaculated spermatozoa become progressively motile as spermatozoa become progressively motile as the the gel dissolvesgel dissolves..

SecretorySecretory functionfunction is mediated by is mediated by cholinergic cholinergic innervationinnervation (pelvic and (pelvic and hypogastrichypogastric nerves); nerves); contractilecontractile functionfunction is is mediated by alphamediated by alpha--adrenergic receptors of adrenergic receptors of the the fibromuscularfibromuscular stromastroma


http://www.malecare.com/services1.htm

http://www.mansgland.com


Netter FH. Atlas of Human Anatomy, 3rd ed. Saunders 2002.

Basic Anatomy

ProstateBase

Apex

The prostate is surroundedby a 2-3mm capsule

Zonal AnatomyZonal AnatomyNils Arvold, HMS IVGillian Lieberman, MD

Prostate territories are now described in terms of zones instead of lobes

Sagittal Coronal Axial

- Transition Zone = surrounds prostatic urethra- Central Zone = posterior to urethra, located superiorly- Peripheral Zone = mostly posterior to urethra, located inferiorly and laterally

“ Central Gland”

Goluboff ET et al. Radical Prostatectomy for the Treatment of Prostate Cancer. In Atlas ofGenitourinary Oncology; eds. Movsas, Hudes, Olsson. Saunders 2002; 17-44.

Novelline et al. Squire's Fundamentals of Radiology: Sixth Edition. Harvard University Press 2004.


Sagittal

Axial

AxialNetter FH. Atlas of Human Anatomy, 3rd ed. Saunders 2002.

Coakley FV et al. Radiologic Anatomy of the Prostate: A Clinical Approach.Radiologic Clinics of North America. 2000; 38(1): 15-30.

Depending on the level, an axial slicemay include bladder, prostate, and rectum,or just prostate and rectum.

Cross-Sectional Anatomy


Novelline et al. Squire's Fundamentals of Radiology: Sixth Edition. Harvard University Press 2004.

The urogenital diaphragmmarks the inferior borderto the prostate

Anatomy, cont’d.Sagittal


Netter FH. Atlas of Human Anatomy, 3rd ed. Saunders 2002.

The ‘pelvic nodes’

Anatomy, cont’d.

These are the route of spreadfor nodal metastases.

Prostate

Prostate AdenocarcinomaProstate AdenocarcinomaMost common cancer in American menMost common cancer in American men except nonexcept non--melanoma skin cancermelanoma skin cancerAmerican male American male lifetime risk of prostate CA = 1 in 6lifetime risk of prostate CA = 1 in 6 (lifetime risk of death from prostate CA = 3%)(lifetime risk of death from prostate CA = 3%)Second leading cause of cancer death in AmericaSecond leading cause of cancer death in America2006 estimate: ~ 235,000 men will be diagnosed, ~ 27,000 men wil2006 estimate: ~ 235,000 men will be diagnosed, ~ 27,000 men will diel dieRisk factors: age (>45), black race (RR = 1.5), brother/father wRisk factors: age (>45), black race (RR = 1.5), brother/father with prostate CA (RR = 2)ith prostate CA (RR = 2)

Most common presentation = Most common presentation = asymptomatic, with elevated serum PSAasymptomatic, with elevated serum PSAAlso presents early as asymmetry/Also presents early as asymmetry/indurationinduration on DREon DRELater presentation = urinary urgency, frequency, Later presentation = urinary urgency, frequency, nocturianocturia, hesitancy, ED, , hesitancy, ED, hematuriahematuria

Incidence of prostate CA has increased partly due to prevalent PIncidence of prostate CA has increased partly due to prevalent PSA screening, but incidence was SA screening, but incidence was increasing before introduction of PSA testing. Earlier CA detecincreasing before introduction of PSA testing. Earlier CA detection has unclear mortality benefit.tion has unclear mortality benefit.Usual criteria for an Usual criteria for an abnormal PSAabnormal PSA::

–– an an absolute level of 4.0 absolute level of 4.0 ngng/ml or greater/ml or greaterOROR

–– a a PSA velocityPSA velocity (PSA increase) (PSA increase) of 0.75 of 0.75 ngng/ml or greater over a 1 year period/ml or greater over a 1 year period


Jemal A et al. Cancer Statistics, 2006. CA Cancer J Clin 2006; 56:106.Coley CM et al. Early Detection of Prostate Cancer. Part I: PriorProbability and Effectiveness of Tests. Ann Intern Med. 1997; 126:394.

Initial WorkupInitial WorkupNils Arvold, HMS IVGillian Lieberman, MD

Prostate cancer is a tissue- based diagnosis.

Imaging is used for:- guiding the tissue biopsy- staging the cancer- planning treatment

Yu KK et al. Imaging Prostate Cancer. Radiologic Clinics of North America. 2000; 38(1): 59-85.

TransrectalTransrectal Ultrasound (TRUS)Ultrasound (TRUS)Nils Arvold, HMS IVGillian Lieberman, MD

TRUS imaging allows visualization of gland size, seminal vesicles, lesions, vasculatureProstate biopsy is the gold standard for cancer diagnosis and is done using TRUS

TRUS-based measurement of gland volume = length x width x height x 0.52Knowing gland volume allows calculation of the following 2 related values, which help predict risk of malignancy in some studies:

– PSA density = PSA TRUS gland volume

– Predicted PSA = TRUS gland volume x 0.12 ng/mL/mL

Sensitivity of TRUS-guided biopsy depends on number of cores:– Traditional sextant biopsy (6 cores): sensitivity ~80%– Routine sextant biopsy plus lateral biopsies at base and mid-gland (10 cores): sensitivity ~96%

Presti JC. Prostate Cancer: Assessment of Risk Using DRE, Tumor Grade, PSA, and Systematic Biopsy. Radiologic Clinics of North America. 2000; 38(1): 49-58.Siu W et al. Use of Extended Pattern Technique for Initial Prostate Biopsy. J Urol. 2005; 174:1256.

TRUS TechniqueTRUS Technique

1. DRE2. Gland volume (length x width x height x 0.52)3. Axial scanning (base to apex)4. Sagittal scanning (right to left)5. Vascular imaging6. Biopsy

Technique:

Biopsy: Usually no sedationor analgesia is given;local anasthesia is injectedor applied topicallywithin the rectum.


5-7 MHz transducer

Littrup PJ et al. Prostate Cancer: The Role of Transrectal Ultrasound and Its Impact onCancer Detection & Management.. Radiologic Clinics of North America; 38(1): 87-113.http://www.breast-ultrasound.com/images/practice/trus/full_p1.jpg

http://www.acuson.com/transducers/catalog/w_cat_r12_10-1-04/xdcr_son_acus%20_r12_10-1-04/son/adar/adara_spec/endo-pii_adara.htm

Cancer location by zone:- Peripheral Zone (PZ) = 70%- Transitional Zone (TZ) = 20%- Central Zone (CZ) = 10%

Sagittalview

TRUS probe location


Goluboff ET et al. Radical Prostatectomy for the Treatment of Prostate Cancer. In: Atlas of Genitourinary Oncology; eds. Movsas, Hudes, Olsson. Saunders 2002; 17-44.http://www.acuson.com/transducers/catalog/w_cat_r12_10-1-04/xdcr_son_acus%20_r12_10-1-04/son/adar/adara_spec/endo-pii_adara.htm

TRUS, cont’d. Biopsy needle


T1 = Microscopic tumor, cannot palpate or visualize on TRUST2 = Palpable, appears confined to glandT3 = Protrudes beyond capsule OR into the seminal vesicleT4 = Fixed tumor, and has extended well beyond prostate

TNM Clinical Staging

Kantoff PW et al. Overview of the Clinical Presentation, Diagnosis, and Staging of Prostate Cancer. UpToDate 2006.

Gleason GradeGleason GradeBased on degree of glandular differentiation and structural architectureProvides some index of prognosis and may guide therapy2 scores are reported: the 2 most prevalent patterns observedScores range 1-5. Most differentiated = 1, Least differentiated = 5.Gleason grades thus range from 2 (low-grade) to 10 (high grade)– e.g. “Gleason 3+5=8” means the most common histologic pattern observed had

a score of 3, and the second most common pattern had a score of 5. Overall Gleason grade of 8.


http://www.psc.edu/science/2000/wetzel/objective_view_of_cancer.html


Patient A

AxialSagittal

Peripheral zone

Enlarged central glandGland volume = 102ccPredicted PSA = 12

67M with slowly rising PSA over many years up to 7.9, asymptomatic. Imaged with TRUS, diagnosed with BPH, and underwent biopsy. No malignancy was identified.

Central gland

Peripheral zone

BIDMC PACS

R L

Central gland has heterogeneousechogenicity in BPH

Patient B56M with abnormal DRE. PSA rose from 3.5 to 5.2 over 3.5 years.

TRUS biopsy was performed, and pathology showed 5 of 6 cores had adenocarcinoma, Gleason 3+3=6, with perineural invasion.

Axial

Hypoechoic nodule

Peripheral zone

Gland volume = 26cc

Central gland


BIDMC PACS


Patient CPatient C 58M with PSA of 12.4,his first PSA test. Asymptomatic.

Gland volume = 90.5ccPredicted PSA = 10.8

TRUS revealed significantcentral gland enlargement. Also seen is a vague hypoechoic region in the left peripheral zone. Doppler revealed this region to be relatively avascular, less concerning for malignancy.

On biopsy 4 months later,1 of 13 cores showedadenocarcinoma in 10% of the core, Gleason 3+3=6.

Adding Doppler to TRUS can increase specificity and PPV for carcinoma, but generally does not improve sensitivity.

AxialBIDMC PACS

Shigeno K et al. The Role of Colour Doppler Ultrasonography in Detecting Prostate Cancer. BJU Int. 2000 Aug;86(3):229-33.

Risk Stratification and ImagingRisk Stratification and ImagingRisk of Risk of ‘‘biochemical failurebiochemical failure’’ (rising PSA) after treatment:(rising PSA) after treatment:-- Low risk: Low risk: T1c/T2aT1c/T2a PSA PSA ≤≤1010 Gleason Gleason ≤≤

66-- Intermediate Risk:Intermediate Risk: T2bT2b PSA >10, PSA >10, ≤≤2020 Gleason 7Gleason 7-- High Risk:High Risk: T2cT2c PSA >20PSA >20 Gleason Gleason ≥≥88

and and

or

or or

or

PSAClinical StageTRUS-guided biopsyGleason grade

Low risk

Intermediate risk

High risk

?

erMRI

erMRIRadionuclide bone scanCT Abd/Pelvis


Shipley et al. Radiation Therapy for Clinically Localized Prostate Cancer. JAMA. 1999; 281:1598-604.

EndorectalEndorectal Coil MRI (Coil MRI (erMRIerMRI))erMRIerMRI utilizes an utilizes an endorectalendorectal coil in addition to a pelvic phasedcoil in addition to a pelvic phased--array coil array coil for highest image resolutionfor highest image resolutionBest imaging modality to visualize the anatomy of the prostateBest imaging modality to visualize the anatomy of the prostateUsed to stageUsed to stage prostate cancer, primarily by examining for prostate cancer, primarily by examining for extracapsularextracapsular spreadspread of the mass and seminal vesicle involvementof the mass and seminal vesicle involvementStaging accuracy for high field strength (1.5T) MR imaging is ~ Staging accuracy for high field strength (1.5T) MR imaging is ~ 85%85%


http://www.reliantmedicalsystems.com/rmscoils.htm

Endorectal coilPelvic coil

http://www.medrad.com/photos/products/mr/arrays-and-coils/prodbody_mrc_mrinnervu.jpg

Sagittal

Yu KK et al. Imaging Prostate Cancer. RadiologicClinics of North America. 2000; 38(1): 59-85.

Endorectal coil in rectum


Peripheral zone

Axial

Endorectal coil

Seminal vesicles

Corpus spongiosum

Corpus cavernosum

Neurovascularbundle

CoronalCentral gland

Obturator

Pubic symphysis

Central gland

Peripheral zone

Normal Anatomy – T2-weighted erMRI

Coakley FV et al. Radiologic Anatomy of the Prostate: A Clinical Approach. Radiologic Clinics of North America. 2000; 38(1): 15-30.

http://www.medscape.com/content/2001/00/40/90/409049/art-cc0803.01.sand.fig4c.jpg


Tc-99m diphosphonate bone scan

CT Abdomen/Pelvis

Metastatic Imagingfor High Risk Patients

72M with prostate CA and leftretroperitoneal adenopathy

Nudell DM et al. Imaging for Recurrent Prostate Cancer. Radiologic Clinics of North America. 2000; 38(1): 213-29.


Patient D – Index Case

60 year old patient who presented with gross hematuria. Workup included MR urogram (no endorectal coil), which revealed an enlarged and grossly abnormal prostate gland.

Bladder

Left peripheral zoneCentral gland

Coronal

Gland volume = 110ccDimensions = 5.8 x 5.8 x 6.3cm BIDMC PACS


Peripheral zone

Endorectal coilBladder

Sagittal Coronal

Seminal vesicles

Concern for posterior bladder wall involvement

Central glandLeft peripheral zoneenlarged, asymmetric

Patient D, cont’d.

BIDMC PACS



Axial(Superior)

Axial(Inferior)

Concern for extracapsular extension (ECE)from left peripheral zone

Probable bladder wall involvement

BIDMC PACS


Bladder

Prostate massalong bladderwall

Endorectal coil

??Sagittal


BIDMC PACS

Patient D, cont’d.Previous slide: ?? = tampon60 y.o. male60 y.o. male--toto--femalefemale transsexualtranssexual

–– Began Began PremarinPremarin (estrogen) at age 19(estrogen) at age 19–– Gender reGender re--assignment surgery at age 34assignment surgery at age 34–– Stopped Stopped PremarinPremarin between ages 36 and 57 due to disclosure issuesbetween ages 36 and 57 due to disclosure issues–– Married at age 41Married at age 41

Asian ethnic background, no family history of prostate CAAsian ethnic background, no family history of prostate CANo prior PSA screeningNo prior PSA screening

Presented with intermittent gross Presented with intermittent gross hematuriahematuria and and UTIsUTIs over past 2 yrsover past 2 yrsWorkup: Workup: PSA = 252, prostate volume 110cc, Gleason 4+4=8 on b/l coresPSA = 252, prostate volume 110cc, Gleason 4+4=8 on b/l cores, bone scan , bone scan and CT chest/and CT chest/abdabd/pelvis negative for mets/pelvis negative for metsStaging MRI revealed Staging MRI revealed likely likely extracapsularextracapsular extensionextension in region of left peripheral zone, in region of left peripheral zone, and apparent posterior bladder wall invasionand apparent posterior bladder wall invasion

Began Began AvodartAvodart (5(5--alpha alpha reductasereductase inhibitor) and inhibitor) and CasodexCasodex (androgen receptor blocker) (androgen receptor blocker) prior to External Beam Radiation Therapyprior to External Beam Radiation Therapy


We will return later to Patient D…

Treatment OptionsTreatment Options for Localized Prostate Cancerfor Localized Prostate Cancer

Radical ProstatectomyRadical ProstatectomyRadiotherapy (RT)Radiotherapy (RT)–– External Beam RTExternal Beam RT–– BrachytherapyBrachytherapy

+ / – Androgen Deprivation TherapyObservationObservation


Choice of therapy depends on patient’s medical condition/comorbidities, age, Gleason score, PSA, clinical stage, treatment-related side effects, and patient preference.

Radiation TherapyRadiation Therapy


Goal: Maximize dose of ionizing radiation to the tumorGoal: Maximize dose of ionizing radiation to the tumorand minimize dose received by surrounding normal tissueand minimize dose received by surrounding normal tissue

For prostate cancer, aim is to minimize dose received by the blaFor prostate cancer, aim is to minimize dose received by the bladder,dder,rectum, urinary sphincters, and neurovascular bundlesrectum, urinary sphincters, and neurovascular bundles

Accurate dosing is Accurate dosing is highly dependenthighly dependenton imagingon imaging

http://www.ucsf.edu/jpouliot/Course/Lesson12.htm


External Beam Radiation Therapy (EBRT)Conventional EBRT relied on plain filmswith contrast enhancement to visualizethe bladder and rectum, with limitedability to define anatomy.

Surrounding structures receivedrelatively high amounts of radiation,since imaging technology did not existto allow more precise targeting. Retrograde urethrogram (RUG)

45 rads

30 rads

30 rads

30 rads

Prostate and surrounding structuresall receive 90 rads.

Adding 1 more view/field:Prostate receives 90 rads, butsurrounding structures receivecloser to 60 rads.

2 Field 3 Field

L5-S1

Ischial tuberosities

Improved imaging allowsimproved precision

Speight JL et al. Imaging and Radiotherapy of the Prostate. Radiologic Clinics of North America. 2000; 38(1): 159-177.http://lagrange.math.trinity.edu/tumath/research/reports/report86.pdf

Example:

45 rads


Then beams from multiple anglesplus lead ‘blocks’ or collimators allow radiation doses that conform to the edges of the prostate.

http://www.ecu.edu/ecuphysicians/radiation_oncology/IMRT.htm http://www.prostatehttp://www.prostate--cancercancer--radiotherapy.org.uk/standard_ebrt.htmradiotherapy.org.uk/standard_ebrt.htm

3D CRT utilizes CT reconstruction to depictaccurate organ/tissue volumes.

3D Conformal RT


http://www.imagingequipment.co.uk/pdf/RO5p9.pdf

Body molds/castsfor reproducible body positioningduring imaging, simulation, and therapy

Example of a linear accelerator (linac)

http://www.cerebromente.org.br/n02/tecnologia/linac3.jpg

Positioning for Imaging and Treatment


Rectum-sparing with conformal RT

Dose-Volume Histogram (DVH)

Isobars

Freedman GM et al. Radiotherapy for Prostate Cancer. In: Atlas ofGenitourinary Oncology; eds. Movsas, Hudes, Olsson. Saunders 2002; 45-73.

http://www.prostate-cancer-radiotherapy.org.uk/standard_ebrt.htm Speight JL et al. Imaging and Radiotherapy of the Prostate.Radiologic Clinics of North America. 2000; 38(1): 159-177.

3D CRT, cont’d.

Rectum

IntensityIntensity--Modulated Radiation Therapy (IMRT)Modulated Radiation Therapy (IMRT)

Instead of beams of a single intensity, IMRT uses collimators thInstead of beams of a single intensity, IMRT uses collimators that are at are dynamically adjusted during the exposure time, in effect creatindynamically adjusted during the exposure time, in effect creating beams of g beams of varying varying ‘‘intensitiesintensities’’Surrounding structures are thus spared even further from ionizinSurrounding structures are thus spared even further from ionizing radiation, g radiation, and regions of interest within the prostate can be more preciseland regions of interest within the prostate can be more precisely targetedy targeted


http://www.prostatehttp://www.prostate--cancercancer--radiotherapy.org.uk/standard_ebrt.htmradiotherapy.org.uk/standard_ebrt.htm

Magnetic Resonance Spectroscopy Imaging Magnetic Resonance Spectroscopy Imaging (MRSI)(MRSI)


MRSI can identify characteristicpeaks that correspond to variousprostate metabolites.

Normal prostate secretions have highcitrate concentrations, while malignantcells do not produce citrate.

Regions containing carcinoma willtypically have reduced citrate andelevated choline.

MRSI with IMRT in theory can allowa region of malignancy within the prostateto be specifically targeted.

Carcinoma Normal

Kurhanewicz J et al. The Prostate: MR Imaging and Spectroscopy. Radiologic Clinics of North America. 2000; 38(1): 115-138.

Electronic Portal Imaging Devices (EPID)


Portal imaging is done with the patient in positionfor therapy, to assess the exact position of the prostatewithin 2mm and display images of the treatment fields.

Organ movement from day to day can be considerable,and organ size/location may change in response to therapy,weight changes, etc. Displacement of the prostate’s center ofas little as 3-8mm can result in dose reductions to the prostateof up to 10%, and dose increases to the rectum of up to 12%.

Thus EPID now allows for‘4D’ radiation therapy,accounting for the variableof time (daily organmovement). Also referredto as image-guided radiationtherapy (IGRT).

Megavoltage cone-beam CT (MV CBCT)for imaging during therapy sessions

http://www.ucsf.edu/jpouliot/Course/Lesson16.htmChen J et al. Dose Reconstruction Using an Amorphous-SiliconDetector and Low-Exposure MV Cone-Beam CT. ASTRO 2004

Pickett B et al. The Impact of Pickett B et al. The Impact of IsocenterIsocenter Placement Errors Associated with DosePlacement Errors Associated with DoseDistributions Used in Irradiating Prostate Cancer. Med Distributions Used in Irradiating Prostate Cancer. Med DosimDosim. 1996;21:61. 1996;21:61--72.72.

Real-time 3D imaging of3 implanted markers


BrachytherapyUsed in capsule-confined prostate cancer, increasing in useTransperineal approach under general anesthesia Low dose rate (LDR) = Permanent I-125 or Pd-103 seeds High dose rate (HDR) = Temporary Ir-192 sources

TRUS-guided needles are introduced, dosimetry iscalculated, seeds are placedPost-implant CT imaging to re-calculate/refine dosimetry

‘Brachy’ = ‘short’

Freedman GM et al. Radiotherapy for Prostate Cancer. In: Atlas ofGenitourinary Oncology; eds. Movsas, Hudes, Olsson. Saunders 2002; 45-73.

http://www.prostatecancercentre.co.uk/treatments/brachy.html


Plain films

MRI

CT

Dosimetry to spare a TURP defect

75-125 seeds are typicallyplaced in LDR brachytherapy

http://www.brachytherapy.co.nz/brachytherapy.php

http://www.cetmc.com/prostate.htmlhttp://egems.gehealthcare.com/geCommunity/europe/clinical_cases/mr/clinical_cases/cotw33_files/cotw33.jsp

Speight JL et al. Imaging and Radiotherapy of the Prostate.Radiologic Clinics of North America. 2000; 38(1): 159-177.

Post-Implantation Imaging


Interventional MRI: Brachytherapy

Brachytherapy seeds are now being placed using erMR-guidance rather than TRUSAdvantages include real-time imaging for more accurate seed position anddosimetry

Endorectal coil

Needle template

Susil RC et al. System for Prostate Brachytherapy and Biopsy in aStandard 1.5T MRI Scanner. Magnetic Resonance in Medicine. 2004; 52:683-7.http://egems.gehealthcare.com/geCommunity/europe/clinical_cases/mr/clinical_cases/cotw33_files/cotw33.jsp


Before treatment s/p 8 weeks of External Beam RT + 8 months ADT

Gland volume = 110ccPSA = 252

Gland volume = 36ccPSA = < 1

Patient D: FollowupObliterated zonalanatomy

Periprostaticfibrosis

BIDMC PACS

AcknowledgmentsAcknowledgments

Jeff Velez, MDJeff Velez, MDMara Barth, MDMara Barth, MDNeil Neil RofskyRofsky, MD, MDGillian Lieberman, MDGillian Lieberman, MDDaphne HaasDaphne Haas--KoganKogan, MD, MDPamela LepkowskiPamela LepkowskiLarry BarbarasLarry Barbaras


http://mednews.stanford.edu/stanmed/2003fall/prostate.html

ReferencesReferencesBucci MK et al. Advances in Radiation Therapy: Conventional to 3D, to IMRT, to 4D, and Beyond. CA Cancer J Clin. 2005; 55:117-34.Chen J et al. Dose Reconstruction Using an Amorphous-Silicon Detector and Low-Exposure MV Cone-Beam CT. ASTRO 2004.Coakley FV et al. Radiologic Anatomy of the Prostate: A Clinical Approach. Radiologic Clinics of North America. 2000; 38(1): 15-30.Coley CM et al. Early Detection of Prostate Cancer. Part I: Prior Probability and Effectiveness of Tests. Ann Intern Med. 1997; 126:394.Freedman GM et al. Radiotherapy for Prostate Cancer. In: Atlas of Genitourinary Oncology; eds. Movsas, Hudes, Olsson. Saunders 2002; 45-73.Goluboff ET et al. Radical Prostatectomy for the Treatment of Prostate Cancer. In: Atlas of Genitourinary Oncology; eds. Movsas, Hudes, Olsson. Saunders 2002; 17-44.Jemal A et al. Cancer Statistics, 2006. CA Cancer J Clin 2006; 56:106.Kantoff PW et al. Overview of the Clinical Presentation, Diagnosis, and Staging of Prostate Cancer. UpToDate 2006.Kurhanewicz J et al. The Prostate: MR Imaging and Spectroscopy. Radiologic Clinics of North America. 2000; 38(1): 115-138.Littrup PJ et al. Prostate Cancer: The Role of Transrectal Ultrasound and Its Impact on Cancer Detection & Management. Radiologic Clinics of North America; 38(1): 87-113.Netter FH. Atlas of Human Anatomy, 3rd ed. Saunders 2002.Novelline et al. Squire's Fundamentals of Radiology: Sixth Edition. Harvard University Press 2004.Nudell DM et al. Imaging for Recurrent Prostate Cancer. Radiologic Clinics of North America. 2000; 38(1): 213-29.Pickett B et al. Pickett B et al. The Impact of The Impact of IsocenterIsocenter Placement Errors Associated with Dose Distributions Used in IrrPlacement Errors Associated with Dose Distributions Used in Irradiating Prostate Canceradiating Prostate Cancer. Med . Med DosimDosim. 1996;21:61. 1996;21:61--72.72.Presti JC. Prostate Cancer: Assessment of Risk Using DRE, Tumor Grade, PSA, and Systematic Biopsy. Radiologic Clinics of North America. 2000; 38(1): 49-58.Roach M III et al. Pretreatment Staging Prostate Cancer. American College of Radiology. 2005 online pub; 11p.Shigeno K et al. The Role of Colour Doppler Ultrasonography in Detecting Prostate Cancer. BJU Int. 2000; 86:229-33.Shipley et al. Radiation Therapy for Clinically Localized Prostate Cancer. JAMA. 1999; 281:1598-604.Siu W et al. Use of Extended Pattern Technique for Initial Prostate Biopsy. J Urol. 2005; 174:1256.Speight JL et al. Imaging and Radiotherapy of the Prostate. Radiologic Clinics of North America. 2000; 38(1): 159-177.Susil RC et al. System for Prostate Brachytherapy and Biopsy in a Standard 1.5T MRI Scanner. Magnetic Resonance in Medicine. 2004; 52:683-7.Yu KK et al. Imaging Prostate Cancer. Radiologic Clinics of North America. 2000; 38(1): 59-85.


References, contReferences, cont’’d.d.http://www.acuson.com/transducers/catalog/w_cat_r12_10-1-04/xdcr_son_acus%20_r12_10-1-04/son/adar/adara_spec/endo-pii_adara.htmhttp://www.brachytherapy.co.nz/brachytherapy.phphttp://www.breast-ultrasound.com/images/practice/trus/full_p1.jpghttp://www.cerebromente.org.br/n02/tecnologia/linac3.jpghttp://www.cetmc.com/prostate.htmlhttp://www.ecu.edu/ecuphysicians/radiation_oncology/IMRT.htmhttp://egems.gehealthcare.com/geCommunity/europe/clinical_cases/mr/clinical_cases/cotw33_files/cotw33.jsphttp://www.imagingequipment.co.uk/pdf/RO5p9.pdfhttp://lagrange.math.trinity.edu/tumath/research/reports/report86.pdfhttp://www.malecare.com/services1.htmhttp://http://www.mansgland.comwww.mansgland.comhttp://mednews.stanford.edu/stanmed/2003fall/prostate.htmlhttp://mednews.stanford.edu/stanmed/2003fall/prostate.htmlhttp://www.medrad.com/photos/products/mr/arrays-and-coils/prodbody_mrc_mrinnervu.jpghttp://www.medscape.com/content/2001/00/40/90/409049/art-cc0803.01.sand.fig4c.jpghttp://www.prostatehttp://www.prostate--cancercancer--radiotherapy.org.uk/standard_ebrt.htmradiotherapy.org.uk/standard_ebrt.htmhttp://www.psc.edu/science/2000/wetzel/objective_view_of_cancer.htmlhttp://www.reliantmedicalsystems.com/rmscoils.htmhttp://www.ucsf.edu/jpouliot/Course


Documents

Prostate Cancer: Imaging for Radiotherapyeradiology.bidmc.harvard.edu/LearningLab/genito/Arvold.pdfGoluboff ET et al. Radical Prostatectomy for the Treatment of Prostate Cancer. In