Treatment of prostate cancer with radiotherapy: should the entire seminal vesicles be included in the clinical target volume?

Abstract

Purpose : When treating high-risk prostate cancer with radiation therapy, inclusion of the seminal vesicles (SVs) within the clinical target volume (CTV) can dramatically increase the volume of radiated normal tissues and hinder dose escalation. Because cancer may involve only the proximal portion of the frequently lengthy SVs, we performed a complete pathology review of prostatectomy specimens to determine the appropriate length of SV to include within the CTV when SV treatment is indicated. Methods and Materials : A detailed pathologic analysis was performed for 344 radical prostatectomy specimens (1987–2000). All slides from each case were reviewed by a single pathologist (N.S.G.). Factors recorded for each case included length of each SV (cm), length of cancer involvement in each SV (cm) measured from the prostate-SV junction, and percentage of SV length involved. Results : Fifty-one patients (15%) demonstrated SV involvement in 81 SVs (21 unilateral, 30 bilateral SV involvement). The median SV length was 3.5 cm (range: 0.7–8.5 cm). Factors associated with SV involvement included the pretreatment PSA level, biopsy Gleason score, and clinical T classification. The commonly used risk group stratification was very effective at predicting SV positivity. Only 1% of low-risk patients (PSA <10 ng/mL, Gleason ≤6, and clinical stage ≤T2a) demonstrated SV involvement vs. 27% of high-risk patients. Patients with only one high-risk feature still demonstrated a 15% risk of SV involvement, whereas 58% of patients with all three high-risk features had positive SVs. The median length of SV involvement was 1.0 cm (90th percentile: 2.0 cm, range: 0.2–3.8 cm). A median of 25% of each SV was involved with adenocarcinoma (90th percentile: 54%, range: 4%–75%). For the 81 positive SVs, no factor was associated with a greater length or percentage of SV involvement. In the entire population, 7% had SV involvement beyond 1.0 cm. There was an approximate 1% risk of SV involvement beyond 2.0 cm or 60% of the SV. In addition, this risk was less than 4% for all subgroups, including high-risk patients. Conclusions : A portion of the SV should be included in the CTV only for higher-risk patients (PSA ≥10 ng/mL, biopsy Gleason ≥7, or clinical T stage ≥T2b). When treating the SV for prostate cancer, only the proximal 2.0–2.5 cm (approximately 60%) of the SV should be included within the CTV.