Prostate cancer treatment, prostate cancer brachytherapy

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	Three-dimensional computed tomography (CT) image showing critical structures in the pelvic region. The prostate is in blue, seminal vesicles in light blue, urethra in pink, penile bulb in purple, bladder in yellow, rectum in brown.

So the diagnosis has been made. Now what do you do? You start by finding a team of professionals who can help you fully understand your options. At the Dattoli Cancer Center, our team of experienced medical experts uses the most state-of-the-art technology to offer more options to patients than ever thought possible. Because each individual case is different, each should be treated as such. Unlike many of the larger institutional cancer centers, the Dattoli Team creates a customized course of treatment for each patient ensuring that they also achieve the highest level of physical, mental and emotional well being. It is our objective to discuss all treatment options at length with our patients, so that they can make informed decisions that are in their best interest and the best interests of their loved ones. And we work in partnership with our patients on their chosen course of treatment to ensure maximum recovery.

Today most prostate cancers can be cured. The extent to which your cancer can be cured will depend upon how early it was diagnosed, and how accurate and appropriate the treatment plan is for your cancer. Perhaps the greater challenge is to eliminate the cancer without impacting the quality of life after prostate cancer. As these cancers are being found at younger ages, many newly diagnosed men have decades of life ahead of them, beyond this experience. We want to do everything we can to ensure that those years will not only be cancer free but also free of those negative post-surgical side effects - impotency and incontinence.

Before we can begin to combat your cancer, we must first learn everything we can about it. Your initial evaluation will include a customized panel of blood tests, performed in our own laboratory, and several in-depth imaging exams.

Depending on the specifics of the case, a number of tests may be indicated and are commonly used at the Dattoli Cancer Center. Some of these tests, or markers, may be used to identify mutant tumor populations, or aggressive tumors in patients without elevated PSAs. Markers of this type include NSE (Neuron Specific Enolase), CGA (Chromagranin A), and CEA (Carcinoembryonic Antigen). A number of other lab tests help to determine whether or not some form of hormonal therapy may be indicated either in the short tern or at a later date. These tests include those that measure levels of Testosterone (total and bio-available), DHT (dihydrotestosterone), DHEA-S (dehydroepiandrosterone sulphate), Estradiol, Prolactin, LH (Luteinizing Hormone) and Androstenedione.

Other evaluative procedures such as Urine Pyrilinks-D (Dpd), N-telopeptide (serum or urine), and Bone Specific Alkaline Phosphatase, are often used in addition to a Bone Mineral Density (BMD) test to establish a baseline for bone integrity. This is especially important for patients undergoing hormonal therapy, which can cause bone loss or resorption. At our Center, a quantitative computerized tomography (QCT) scan is preferred over the Dual Energy X-ray Absorptiometry (DEXA) scan, as the QCT provides more accurate results. Additional tests such as a urine cytology study and NMP-22 bladder cancer marker may be used to evaluate for other malignancies. Tests such as IGF-1 and 2L-6 may be included in a systemic evaluation.

There are other areas within the pathology itself which we may want to examine. Whether or not a cancer has attached itself to a nerve (perineural invasion or PNI) is important because we know that a nerve typically tracts throughout the gland and outside of the gland, and that it can act as something of a conduit for the cancer. In addition, genetic markers like bcl2, p27, p53, and MIB-1 may help to determine the aggressiveness of tumors.

For more detailed information about these laboratory tests:
Blood Tests - What are they for? (81 KB)

Dattoli Cancer Center uses the Hitachi EUB-5500 color-flow Doppler Ultrasound Scanner with a custom "true" 3-D application. Technically referred to as transrectal ultrasonography (TRUS), this is a technique that projects sound waves off the prostate and surrounding organs to create an image. The sound waves are generated by a probe placed inside the rectum. Transrectal ultrasound imaging can in many cases accurately identify the local spread of cancer through the prostate capsule. The technique is also used for real time guidance in conjunction with seed implants, external radiation therapy, and other treatments.

Comparison of Color-Flow Doppler image (left) with conventional gray-scale ultrasound image (right) of the same patient. Note: the bright red areas in the Color-Flow Doppler image reveal the location of suspected cancer sites, which are not visible using gray-scale ultrasound imaging.

At our institution, color-flow Doppler ultrasound is used because it provides enhanced visualization and greater definition compared to the conventional gray-scale technique. While there is an art to interpreting color-flow Doppler images, tumors tend to show increased blood flow or hypervascularity as findings consistent with malignancy. Tumors are growing faster than normal prostate cells and require more blood to nurture their growth. Tumors therefore tend to create blood vessels around them as they grow, and these can be identified by color-flow Doppler ultrasound.

A conventional TRUS typically shows what are called hypoechogenic areas, which are darker shades of gray. A color-flow Doppler ultrasound may show the same image, but provides additional insight into how much perfusion of blood is going into the region, and can reveal whether just one prostate nodule is involved or if there is more cancer dispersed throughout the gland. A unique 3-D application gives us the ability to rotate these images in the computer, displaying the most accurate and complete picture of your gland and surrounding organs. Our Center was the first in the world to adapt this 3-D program to color-flow Doppler ultrasound equipment for the diagnosis and treatment of prostate cancer.

	Computed tomography (CT) of the pelvis, showing radiation beam placement and color wash isodose plan.

CT scans can identify prostate enlargement and show the size and shape of the gland, but it is not as effective for assessing the extent of cancer or visualizing cancer within the gland itself. While CT scans provide less defined images of the outer prostatic contour and internal architecture, CT images do accurately delineate the spatial relationship between the prostate, rectum and public bones. More contemporary spiral or helical CT scans provide greater resolution while taking less time to acquire the information.

The Center's GE High Speed Helical CT Scanner captures high resolution images of the prostate, seminal vesicles, bladder, urethra and rectum, which are required to accurately design your individual treatment plan. This scanner is also equipped to perform QCT Bone Density evaluations for patients undergoing hormone therapy as part of their treatment.

More advanced imaging techniques such as magnetic resonance imaging (MRI), bone scan, or ProstaScint scan may also be beneficial in more complex situations.

Although each individual is unique, most patients being treated at Dattoli Cancer Center receive a treatment protocol of combination therapy utilizing 4D IG-IMRT (4-Dimensional Image-Guided Intensity Modulated Radiation Therapy) and seed implant (brachytherapy). Patients may also receive a short course of hormonal therapy. In most cases, patients return approximately 3 months post seeding to receive additional IG-IMRT to the surrounding periprostatic tissue.

		The delivery of external beam radiation to the prostatic gland and surrounding area to kill cancerous cells. It may be done using either conventional, 3-D conformal or IMRT techniques. The latter is used at the Dattoli Cancer Center and dramatically minimizes the risk of incontinence and erectile disfunction when compared to surgery or other therapies, such as cryosurgery.

		An outpatient procedure which implants radioactive seeds within the prostate to generate an internal "cloud" of radiation to the affected prostate gland. Despite the high dose to intra-prostatic tissue (and especially to select cancerous regions), surrounding organs are exposed to minimal radiation dosages.

		A treatment regimen which involves blocking or antagonizing the action of testosterone, this may be used for advanced stages of the disease, or in combination with definitive local treatments.