PRIMARY PROSTATE

CONTOURING

Dr.Katta Charu Goutham

Reddy

OBJECTIVES
1. Prostate Anatomy
2. Imaging of Prostate
3. TNM Staging of Prostate Cancer
4. Prostate Interfraction and Intrafraction Movement
5. Techniques of Margin Reduction
6. Target Volume delineanation
.

PROSTATE ANATOMYLOCATION
1. Ovoid -shaped structure composed of fibrous, glandular, and
muscular elements.
2. It is located in the pelvis, adjacent to the rectum, bladder, dorsal,
and periprostatic venous complexes, pelvic sidewall
musculature, the pelvic plexus, and cavernous nerves.
3. the prostate and the rectum curve away from each other as two
convex surfaces.
4. Surrounds segments of the urethra before it passes through the
genitourinary diaphragm (GUD).

PROSTATE ANATOMYBOUNDARIES
The prostate is contained within a thin, fibrous adherent
capsule that is structurally continuous with the stroma of
the gland.
The apex of the gland rests above the GUD. The GUD
surrounds the membranous sphincter and may vary in
length and thickness.
The lateral margins of the prostate are usually delineated
against the levator ani muscles, forming the lateral
prostatic sulci.

PROSTATE ANATOMYBOUNDARIES
The puboprostatic ligaments extend anteriorly from the surface of
the gland to the pubic symphysis.
The prostate is separated from the rectum posteriorly by
Denonvilliers fascia (retrovesical septum),
It attaches above to the peritoneum and below to the GUD. It
restricts posterior extension of prostatic carcinoma into the rectum.

PROSTATE ZONAL ANATOMY

There are four zones of the prostate
the peripheral zone (PZ), PZ, extending across the entire posterior
surface of the gland that is palpated on rectal examination and is the
location of most prostate cancers, prominent in young people
transition zone (TZ): location of benign prostatic hypertrophy,
prominent in older men
central zone: The central zone that surrounds the ejaculatory ducts
anterior fibromuscular stroma zone. The anterior fibromuscular
zone consists of an anterior band of fibromuscular tissue contiguous
with bladder muscle and external sphincter

IMAGING-TECHNIQUES
1. TRUS:Transrectal ultrasonography has been used to guide
needle biopsy and brachytherapy seed implant.
2. CT Scan:Computed tomography (CT) is the modality of choice
for whole-body staging and follow-up in patients with metastatic
disease
3. MRI:Magnetic resonance (MR) imaging is being used for local
staging before treatment. MR spectroscopic imaging (MRSI)
provides an indication of tumor aggressiveness.
4. PET Scan: Mainly used in follow up

TRANSRECTAL ULTRASOUND
(TRUS)
1. Sixty to seventy percent of prostate cancers are hypoechoic on
ultrasound but 12% to 30% are isoechoic with normal
parenchyma and cannot be seen on grayscale ultrasonography
2. Sensitivity of TRUS for detecting prostate cancer ranges from
30% to 85%
3. Color Doppler, real-time elastography, and contrast enhanced
ultrasound are promising techniques for improving tumor
detection

CT SCAN
CT is not the modality of choice
for evaluating primary prostate
cancer.
tumor confined within the capsule
may manifest as a normal-sized
or enlarged prostate gland on CT
Due to the inability of CT to
detect cancer and to visualize the
prostatic capsule, a smooth outer
prostatic margin does not exclude
the presence of cancer within the
gland.

PROSTATIC ANATOMY ON
MRI
The Zonal anatomy of the prostate cannot be distinguished on T1weighted images because the prostate appears to be of uniform
intermediate signal intensity.
the prostatic zones are well shown on T2-weighted images
ANTERIOR FIBROMUSCULAR STROMA :low T1 and T2 signal intensity.
PERIPHERAL ZONE : high T2 signal intensity similar to or greater than
the signal of adjacent periprostatic fat. There is also an age-related
increase in the T2 signal intensity of the peripheral zone
CENTRAL AND TRANSITION ZONES are both of lower T2 signal
intensity than the peripheral zone, possibly because of more compact
smooth muscle and sparser glandular elements.

PROSTATIC CAPSULE
The prostate gland is partially invested by a coalition of fibrous
tissuehistorically, called the capsulethat is most apparent
posteriorly and posterolaterally.
Important landmark for assessing extraprostatic tumor
extension. The neurovascular bundles course posterolateral to the
prostate capsule bilaterally at the 5- and7-oclock positions.
At the apex and the base, the bundles send penetrating branches
through the capsule, providing a route for extraprostatic tumor
extension
The anatomic or true capsule surrounding the peripheral zone
appears as a thin rim of low signal intensity on T2-weighted images

PROSTATIC CANCER (MRI)

T1

Axial T1-weighted
Tumors are impossible to discern.
pelvic adenopathy, osseous ,postbiopsy artifacts.

T2

3 orthogonal planes of the prostate.

Focal decreased signal on T2-weighted imaging
Prostatitis , fibrotic changes, or postbiopsy changes may lead to
decreased T2 signal

Signal intensity ratios on T2-weighted MR images correlate significantly with tumor

aggressiveness, with higher Gleason grades being associated with lower tumor-tomuscle signal intensity ratios

Post -biopsy changes and prostate cancer may coincide at the same location and thus MR
imaging cannot always differentiate biopsy changes from tumor.
Therefore, a delay of six to eight weeks between biopsy and MR imaging is recommended

MAGNETIC RESONANCE
SPECTOGRAPHY IMAGING
(MRSI) is an established
advanced imaging technique for
metabolic and functional
evaluation of the prostate
gland.
Hence, an increased
choline/citrate or (choline +
creatine)/citrate ratio
distinguishes prostate cancer
from healthy tissue

Normal prostate

Prostatic Cancer

High levels of
citrate, creatinine
and choline
Low level of
choline due to
increased
metabolism
High levels of
choline due to
increased
phospholipid cell
membrane

DIFFUSION WEIGHTED MRI

Diffusion-weighted imaging (DWI) is an
MR technique that measures the
Brownian motion of water molecules in
biologic tissues, which is inversely
proportional to cellular density,
presumably because increased cellular
density limits water diffusion in the
interstitial space.
The combination of T2-weighted
imaging and DWI is better than T2weighted imaging alone in the
detection of significant prostate cancer
(i.e., cancer with a Gleason score of at
least six and a diameter >4 mm) within
the peripheral zone.

POSITRON EMISSION
TOMOGRAPHY(PET) SCAN
FDG PET has been found to have low sensitivity for detecting primary
prostate cancer, except in patients with advanced-stage and more
aggressive tumors .
1. glucose utilization in well-differentiated prostate cancer is often lower
than in other tumor types-overlap in the degree of uptake between
prostate cancer, benign prostatic hyperplasia, and inflammation.
2. normal urinary excretion of radioisotope can mask pathological uptake
.C-choline, the uptake of which is increased in malignant tissue due to
increased synthesis of membranal phosphatidylcholine in tumor cells
.C-choline has the advantage of reduced urinary excretion, and thus may
provide more accurate information for the localization of dominant primary
prostate cancer lesions.

PRIMARY TUMOR STAGING

OF PROSTATE CANCER

T2A
PERIPHERAL ZONE TUMOR THAT INVOLVES < 1/2 OF 1 LOBE

T2B
TUMOR INVOLVES MORE THAN HALF OF LOBE BUT NOT BOTH

T2C
TUMOR INVOLVES BOTH LOBES

T3A
EXTRACAPSULAR EXTENSION

T3B
TUMOR INVOLVING SEMINAL
VESICLES

T4
TUMOR INVADES ADJACENT
STRUCTURES

PROSTATE MOTION
SIGNIFICANCE
1. the prostate represents a moving targetas changes in
bladder and bowel filling can displace the prostate
significantly between, or even during, radiotherapy fractions
2. prostate is not attached directly to bony anatomy, prostate
motion differs substantially from pelvic bony anatomic
position.
3. Adding larger margins to the prostate increases dose to
bladder and rectum, improving target coverage but also
increasing the probability of toxicity: this is a less than
optimal solution to ensure tumor coverage.

PROSTATE MOTION-TWO
QUESTIONS
1. How much does the prostate move on a daily
basis (i.e., interfractional) and during each
treatment (i.e., intrafractional)?
2. Is the positional relationship between the
prostate and bony anatomy static (i.e., can bony
anatomy be used as a surrogate of the prostate
location)?

MEASUREMENT OF
PROSTATE MOTION
COMPREHENSIVE STUDY
THE MAYO CLINIC
TheFROM
use of fiducial

gold seed markers

and daily electronic
portal imaging (EPI)
for determining
prostate motion and
bony pelvic anatomy

PROSTATE MOTION
INTERFRACTION MOVEMENT
Direction

Range

Mean

SuperiorInferior
Anterior
Posterior

9.1mm

2.5mm

15.2mm

3.7mm

Right -Left

15.2mm

1.9mm

INTERFRACTION MOTION
WITH BONY ANATOMY
Prostate
Prelocalisatio 5.6mm
n
Postlocalisati 2.8mm
on

Bony
Anatomy
4.4mm
4.4mm

PROSATE INTRAFRACTION
MOTION
Direction of
Prostate(mm)
Bony
Motion

AnteriorPosterior
SuperiorInferior
Right-Left

Anatomy(mm)

0.1

-0.5

0.4

0.4

0.1

0.3

Marker migration was found to be minimal, with 79% within 1 mm and 96%
within 1.5 mm.

TYPES OF INTRAFRACTION MOTION

ELECTROMAGNETIC TRANSPONDERS-LANGEN
STUDY
Two types of Intrafraction motion is possible
1. Slow , small drift, usually posteriorly and inferiorly, that is
thought to be associated with pelvic muscle relaxation or the
gradual movement of rectal contents away from the prostate
2. Sudden and transient motion, usually anteriorly and superiorly,
that can be significant in extent and is thought to be due to
peristalsis.
the average proportion of the total treatment time that the prostate
was displaced by >3 mm and >5 mm was 13.6% and 3.3%,
respectively.

CTV-PTV MARGINS
To Cover 95% Of The CTV With The Prescribed Dose With
A 95% Probability

Superior
Inferior
Anteriorposterior
Right Left Axis

Without
Fiducial
Localisation
5.1 mm

With Fiducial
Localisation

7.3 mm

2.9 mm

5.0 mm

2.8 mm

2.7 mm

TECHNIQUES
Fiducial gold seed markers and daily electronic
portal imaging (EPI) with online correction
Electromagnetic transponders that can be
implanted into the prostate
Cone -beam computed tomography (CBCT) for
online correction is gaining popularity as it allows for
soft tissue matching, and does not require an
invasive procedure to implant fiducial markers

TARGET VOLUME
DELINEATION
CTV definition of the prostate
gland plus an additional
circumferential margin of 5 mm
would thus cover more than 90
% of tumor extensions outside
the prostate.
At the prostaterectum
interface, the anterior rectal
wall represents a solid boundary
for tumor cells so that the CTV
can be reduced posteriorly.

risk of transcapsular extension is very small in the anterior or anterolateral parts of the
gland, it is highest in the posterior and posterolateral parts. Thus the periprostatic region
at the prostate rectum interface is at the highest risk of tumor recurrence when
underdosed by radiotherapy

FINDINGS BY KESTIN ET AL
CT definitions and pathological measurements are in good
agreement
Finally only 1 % of low-risk patients had an SVI which confirms not
to include SVs into CTV in this patient group.
Including the proximal 2 cm of the SV into the CTV would include 90
% of pathologically involved seminal vesicles.
With each prognostic high risk factor, the rate of SVI rises from 15
% with one high-risk factor, 28 % with two, to 58 % with three highrisk factors, respectively.

CT SCAN IN DELINEATING
PROSTATE
Inaccuracies of CT Scan in Prostate Delineation
CT scans overestimate the true prostate volume by 2060 % when
compared with MRI scans. Differences are mainly seen at
1. Apex Of The Prostate
2. Seminal Vesicles

CTV-PTV MARGIN
1. PTV is an automatically
generated margin. The PTV
must not be generated by
hand as it is not possible to
draw a three-dimensional
margin encompassing the
CTV.
2. empty rectum during
planning CT provides
improved biochemical control
in patients undergoing
definitive radiotherapy for
prostate cancer.

GRAFF ET AL STUDY