Case Study

Prostrate Cancer
David Lloyd

June 1944 Invasion of Normandy D-Day

Patient5

MRN: 907062216
70 Y/O
Caucasian
Male
Currently treated on the STX
Consult was September 2014
CT Sim September 18th
Treatment October 1st

Presenting Symptoms 5
Pt is
asymptomatic

Pt was Dx in
December
2001

Pts consult states that he

denies any symptoms
related to his current
mass.

Gleason 5+5

Stage pT3b
Prostate
Adenocarcinom No Path Report available
a
for review

Epidemiology3
According to American Cancer Society:
In 2014 About 233,000 men
in the US will be Dx with Prostate CA.
About 29,480 men in the US will
died from Prostate CA.
About 1 man in 36 will die from
Prostate CA

About 1 man in 7 will be Dx with Prostate Ca

When including all stages of Prostrate Ca

The relative 5-year survival rate is almost 100%.

Epidemiology3
Top 3 Cancers Males in United States All Races

1 Prostrate (other than Skin

CA)
2 Lung and Bronchus
3 Colon and Rectum

in the
h
t
a
e
of d
e
s
u
a
ing c
d
a
e
l
is the
t
a
h
W
Heart Disease

e s?
t
a
t
S
United

Etiology4
Genetics IGF-1,
BRCA1 and
BRCA2

Age 6/10 cases

of prostate Ca
are in men over
age 65

*Smoked 1 pack a
day for 3 years,
quit smoking in
1964 (50 years
ago).

*Drinks 14
glasses of wine
per week

Family Hx
having a father
or brother nearly
doubles a mans
risk

Race most
often in AfricanAmerican men

*Former
smokeless
tobacco user

Diet high in fat

increases the
risk

Typical Presentation of Prostate

CA1
Pts with Prostate Carcinoma may complain of:
Decrease
d urinary
stream

Hematuri
a

Dysuriapainful
urination

Frequent
urination

Difficulty
in
starting
urination

These symptoms can also be caused by conditions

other than CA Benign Prostatic Hyperplasia (BPH)

Basic Prostate Anatomy 1

Lymphes nodes of the pelvis

d
o
n e
h
p t lin r
ym rs fo r?
l
t e f ge ce
a
n
h h
a
W e t ain ca
ar dr ate
of ost
pr
Obturator

Nodes

Inguinal nodes

Screening for Prostate Ca 1

American Cancer Society suggests:

PSA test annually

Beginning at age 50
Normal PSA Levels are 0-4
ng/mL.
DRE - Digital Rectal Exam
High risk African Americans with
family Hx should start age 40 - 45.

Detection and Diagnosis for

Prostate Ca1
Labs

PSA
CBC
LFT
Testosterone

Pelvic CT or
MRI

Bone Scan

TRUS

To look for Mets

Trans-Rectal Ultra Sound

guided Biopsy

Histology of Prostate Cancer 1

95%
Adenocarcinoma
This Pts Diagnosis

AJCC Staging of Prostate Ca 6

AJCC Staging of Prostate Ca 6

Grading of Prostate Ca 1
Staging system is AJCC TNM (tumor - node metastasis)
Gleason Scoring System
Looks at how differentiated cells are in two areas where
cancer cells present in the biopsy
Assigns each one a score 1-5, then adds together for a
total Gleason score
What is the biggest
prognostic indicator
for Prostate CA?

Score 6
or lower
Well
Differentiat
ed

Gleason Score

Score 7
Moderately
Differentiat
ed

Score 8
or higher
Poorly
Differentiat
ed

5-year relative survival by stage

at the time of diagnosis 8
Stage

5-year relative survival rate

local

nearly 100%

regional

nearly 100%

distant

28%

Possible Treatments 1

Observation

older with slow growing tumor

Prostatectomy
good for T1 and T2

Hormonal
Therapy to
reduce androgenic
stimulation of cells

Chemothera
py Adriamycin
and
Cyclophosphamide

Radiation
Therapy
72-80 Gy at1.8-2.0
Gy/day

Brachythera
py I-125 145 Gy
Pd-103 115 Gy

Patient Hx (since Dx of Prostate CA

2001)5
12/01 Dx 5+5
Prostate
Adenocarcinoma
2002 Radical prostatectomy
RMH OH
2002-05 Hormonal Casodex
2005 Traveled to
Charlottesville, VA

2011 Provenge
John Hopkins
Bal. MD
2012 booster Provenge
Vanderbilt University

2013 Started Firmagon

L1-L2 lesion Orl, FL
4/14 XRT R Hip
6/14 XRT Lumbar Spine

2005 PSA increasing

IMRT prostate bed Sara. FL
2005-10 Multiple
Hormones Cin, OH
2011 Radiation Left
Sacrum. Orl, FL

2003 Melanoma R foot

9/14 XRT c&t spine

@OSU
10/14 XRT R Middle
Cranial Fossa

From 12/01 thru current Tx

Pt had 49 Tx Chemo,
Hormones, Experimental Yervoy,
Radiation Therapy and Surgeries

Metastasis of Prostate CA

Batson's plexus, a network of veins draining the

deep pelvic veins and connect the internal
vertebral venous plexi.

90% of prostatic
metastases involve
the spine.

Patient Most Recent

Diagnosis5
Pt found to have a lesion involving the anterior
margin of the middle cranial fossa on the right
side.
There is a epidural component
Extension into temporal lobe

Middle Cranial Fossa Anatomy 1

Patient Positioning 5
Q2+C
ustom
Head
Rest
Supin
e
Head
First
Confo
rmal
Board

1mm
shim
x2
Aquap
last
Mask

Knee
Spong
e

Hands
on
abdo
men
holdin
g ring

Pts current treatment plan

(SRT)5

3400

257 cGy

2200

6
X
12

3350

243 cGy
330

2290

2776.4 cGy

2500 cGy

Planning Isodose lines 5

500 cGy

2758.9 cGy

Sagittal view

Axial view

Dose Volume Histogram 5

Side Effects5

Acute Side
Effects skin
irritation,
brain
swelling,
nausea,
vomiting

Late Side
Effects
hearing
loss,
cognitive
dysfunction
, additional
cancer
formation

References
1. Reviews CT. e-Study Guide for: Principles and Practice of Radiation Therapy by
Charles Washington, ISBN 9780323053624. Cram101; 2012.
2. Vann AM, Dasher B, Wiggers N. Portal Design in Radiation Therapy, 3rd Edition.
2013.
3. Available at: http://www.cancer.org/cancer/prostatecancer/ . Accessed October 1,
2014.
4. Available at: http://www.cancer.org/cancer/prostatecancer/detailedguide/prostatecancer-risk-factors. Accessed October 1, 2014.
5. IHIS
6. Available at: http://www.ncbi.nlm.nih.gov/books/NBK49532/. Accessed October 1,
2014.
7. Available at: http://http://www.aafp.org/afp/2002/0501/p1834.html . Accessed
October 1, 2014.
8. Available at: http
://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-survival-rate
s
. Accessed October 1, 2014.