28 - prostate ca Flashcards
(115 cards)
1
Q
prostate cancer risk if 1 first degree relative has it
A
2x
2
Q
prostate cancer risk if >1 first degree relative has it
A
10x
3
Q
% with true hereditary prostate ca
A
10%
4
Q
3 criteria for hereditary pca
A
> /= 3 affected relatives, OR >/= 2 relatives with early onset < 55yo, OR in 3 successive generations
5
Q
difference with hereditary cap
A
earlier onset only, same biologic activity
6
Q
REDUCE trial - what was it
A
8000 men randomized to dutasteride vs placebo - 25% reduction in prostate cancer risk
7
Q
PCPT trial - what is it
A
19K randomized to finasteride vs placebo. 25% risk reduction for prostate cancer on finasteride, but equal number of prostate ca deaths. Higher incidence of G7-10 due to overdetection bias (effect of volume reduction on tumor detection)
8
Q
PCPT and “normal” PSA values - 2
A
11% cap in PSA <1, 30% cap in PSA 3.1-4
9
Q
overall survival for all stages at 5 and 10 yrs
A
99% and 91%
10
Q
PLCO - what did it show
A
80K men 10 yr f/u, no difference in disease specific mortality
11
Q
problems with PLCO
A
high contamination in control arm, low biopsy compliance in screening arm
12
Q
ERSPC - what is it
A
16K men. NNS 1400, NNT 50
13
Q
where are most tumors located and %
A
75% peripheral zone> transition zone (20%)
14
Q
periurethral duct prostate ca AKA
A
urothelial ca
15
Q
% cap detected by DRE alone
A
20%
16
Q
what kind of molecule is PSA
A
kallikrein-like serine protease
17
Q
what molecule is PSA bound to when referring to free psa
A
a1-antichemotrypsin
18
Q
where is free:total psa useful
A
risk stratifying those with PSA 4-10
19
Q
is F:T PSA affected by finasteride
A
no
20
Q
F:T PSA AKA
A
% free PSA
21
Q
x% with pca with F:T <10%
A
55%
22
Q
when is PSA doubling time useful
A
recurrent prostate ca
23
Q
what kind of marker is PCA3
A
prostate specific mRNA marker for DD3 gene
24
Q
PCA3 use
A
not as primary screening but to dictate need for repeat biopsy in men with persistently elevated PSA
25
PCA3 compared to PSA
higher sensitivity/specificity
26
PCA3 and prostatitis/BPH
independent of inflammation/prostate size
27
how to collect PCA3
agressive DRE - voided urine
28
AUA best practice policy for post biopsy abx - 1st line
FQ or 2nd/3rd gen cephalosporin
29
is low dose aspirin an absolute contraindication to biospy
no
30
is complication rate associated with # biopsy cores
no
31
3 indications for repeat biopsy
1. rising/persistent psa, 2. suspicious DRE, 3. ASAP
32
detection rate for pca for TURP
8%
33
why not biopsy transition zone
low detection rate
34
ideal method of examining prostate apex path
"cone method"
35
strongest predictor of pca outcome
gleason score
36
significance of PNI in pca
unknown
37
prostate cancer distribution by north vs southern europe
more common in northern vs southern europe
38
PSA levels vary with which 3 things
age, race, prostate volume
39
urinary retention rate in saturation vs nl prostate biopsy
higher in saturation (swelling)
40
significance of baseline PSA
baseline >1.5 (@ 50 yo) is powerful predictor of subsequent cap (6-10x rr)
41
BMI and PSA
higher BMI= PSA hemodilution and lower [psa]. more likely to have agressive disease at presentation and suffer relapse
42
ACS PSA screening
no screening, discussion w patient regarding pros and cons
43
NCCN PSA scrreening
no screening, discussion w patient regarding pros and cons. start at 40 for high risk men, and 50 for avg risk
44
AUA PSA screening
baseline PSA at 40, if < 1 considered low risk and return at 45 yo
45
nccn very low risk cap criteria for AS
T1c, G6, PSA < 10, < 3 + cores w < 50% vol in each core, psa density < 0.15
46
AS and prostate ca specific mortality
5-10% esp if PSA doubling time < 3 yrs. nonprostate ca spcific mortality far outweighs prostte ca specific mortality
47
risk of progression requiring tx during AS
30%
48
treatment modalities and prostate cancer survival
prostatectomy is the only treatment modality to confur survival advantage over no tx (35% reductin in death/mets vs no tx up to 10 yrs)
49
recovery of erectile function post nerve sparing prostatectomy
50-90% recovery of some erection if potent beforehand, and upto 80% in pts < 60 yo
50
penile rehab?
it works
51
when is pelvic LN dissection considered not necessary
low risk cap
52
2 indications for early adjvant radiation
pT3, positive surgical margins
53
timing for giving early adjuvant radiation
once continence has returned
54
is early radiation better than salvage radiation (waiting for biochemical recurrence)
unclear, but salvage avoids treating everyone with T3
55
who benefits most from salvage radiation - 3
favorable biochemical recurrence characteristics (PSA <2, slow psa doubling time, long interval to failure after surgery)
56
what to do before salvage radiation - 2
restage with imaging (CT, bone scan) and DRE
57
PSA threshold post prostatectomy signifying recurrence
> 0.2 ng/dl
58
how exactly does EBRT work
photons damage cellular DNA
59
standard EBRT dose
70 gy over 7 weeks
60
how does androgen depravation therapy help in EBRT - 2
volume reduction of prostate (reduce number of cells, diminish collateral damage to bladder/rectum by shrinking prostate)
61
caveat to androgen ablation in EBRT
survival benefit wanes in > 65 yo with cardiac risk factors - consider cardiac eval
62
how far does dose go from brachy seed
2-3mm
63
radiation dose in brachytherapy - I-125 vs Pd-103
145 gy - I-125 vs 125 gy - Pd-103. same outcomes
64
limitations to brachy - 3
cant do in prostate > 60 cc, higher risk of retention with IPSS > 15, higher risk of incontinence if hx TURP
65
brachy + EBRT
done for intermediate - high risk disease
66
Post EBRT PSA doubling time and clinical relapse
PSAdt < 12 months = high risk early clinical relapse if untreated
67
significance of PSA rise post radiation
confirm with repeat psa to make sure rise is durable
68
factors predicting success of salvage surgery - 3
PSA< 10 preop,
69
radiation tx for locally advanced cap
ADT x 2-3 yrs + radiation = improved local and systemic control
70
micromets to nodes and tx
can complete surg and give ADT postop or radiation + ADT = survival benefit
71
risk factors for metastatic disease and survival in PSA recurrence - 3
time to psa recurrence (< / > 2 yrs), PSA doubling time < / > 9 mo, gleason score >/< PSA 8
72
main difference between GNRH agonist vs antagonist
no flare with antagonist, vs agonist
73
what class is degarelix
GNRH antagonist
74
nilutamide, biclautamide, flutamide class
NONsteroidal antiandrogen
75
nilutamide side effects - 2
interstitial lung disease, visual adaptation disturbances
76
risk of gynecomastia with antiandrogen and potential mgmt
50%, pretreatment with breast radiation
77
alternative to LHRH agonist - why better (2)/worse (1)
antiandrogen - fewer sexual side effects (loss of libido/ED), improved QOL with same survival but high risk of gynecomastia
78
why is DES not used for medical castration
high CV risk of mortality
79
only setting where adjuvant ADT assd w survival benefit
post prostatectomy LN positive disease
80
actual survival benefit of provenge
4.1 mo
81
exclusion criteria for provenge - 3
pain requiring narcotics, visceral mets, life expectancy < 6 mo
82
how to monitor response to provenge
no measurable way to detect response
83
party line on intermittent ADT
considerd safe with suggestion of improved QOL without negative effects on time to disease progression/survival
84
2 tx options for pts presenting with spinal cord compression
ketoconazole, degarelix
85
what does it mean when tumor is castrate resistant - 3
1. tumor may produce its own androgen (autocrine), 2. amplify low levels of testerone ligand signaling through androgen receptor mutations or duplications, 3. or activation of AR through other ligands
86
2 caveats to labeling tumor as hormone refractory
1. tumor may become hypersensitive to androgens --> dangerous to stop antiandrogen immediately, 2. may be sensitive to other hormonal manipulations
87
mgmt of RISING psa while recieving ANTIandrogen
1/3 patients will have PSA decline when antiandrogen is stopped.
88
docetaxel va mitoxantrone
3 month survival benefit with docetaxel
89
how is docetaxel administered
with prednisone
90
docetaxel side effects - 2 main
myelosupression and peripheral neuropathy
91
additional docetaxel side effects - 4
constipation, tearing due to deposition in tear ducts, onycholysis, fluid retention (peripheral/pulmonary edema)
92
significance of normalized psa while on docetaxel
33 mo survival vs 16 mo
93
best prognostic marker for survival while on docetaxel
>30% reduction in PSA in first 3 months
94
circulating tumor cells and docetaxel
can be used to monitor treatment response and correlates with overall survival.
95
use of mitoxantrone + prednisone
palliation of pain + QOL once failed docetaxel, and carbazetaxel
96
main mitoxantrone toxicity
cumulative cardiotoxicity
97
type of bone remodeling seen with prostate cancer
osteoblastic - bone mets assd w increased bone formation aroud tumor deposits, however causes osteolysis
98
role of bisphosophonates in bone mets
stops osteolysis
99
what exactly does zolendronic acid do in prostate cancer - 3
delay in need for radiation, pathologic fx onset, bone pain
100
who gets zolendronic acid
castrate resistant (only). no role in hormone sensitive
101
2 side effects for zolendronic acid
renal failure, osteonecrosis of jaw
102
what is denosumab
inhibitor AB to block RANKL (mediates osteoclast-mediated bone resorbtion). prevents SRE
103
who gets denosumab
castrate resistant (only). no role in hormone sensitive
104
second line after failing docetaxel
carbazetaxel + prednisone
105
survival benefit of carbazitaxel
2 months
106
major side effect of carbazitaxel and mgmt
neutropenia (upto 8%) and prophylactically given GMCSF
107
indication for abiraterone
mcrpc who have recieved prior docetaxel
108
abiraterone MOA
blocks CYP450 c17 (lyase and hydroxylase) steps in testosterone synthesis in periphery and in tumor
109
electrolyte abnormalities while taking abiraterone - 2
hypokalemia and hypophosphatemia
110
infection/ stress while taking abiraterone or if steroid is stopped
get adrenal insufficiency
111
3 reasons for treatment discontinuation in abiraterone
AST/ALT elevation, urosepsis, cardiac failure
112
T1a,b,c
a/b - incidental histologic finding 5%, c - dx by needle biopsy due to elevated PSA
113
T2a,b,c
a - 1/2 one lobe but not both sides, c - both lobes
114
T3a/b
a - ECE, b - invades SV
115
T4
invades bladder, or adjacent structures
