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Bladder + Testicular Flashcards

1
Q

What is the S grouping for testicular cancers?

A

S classification is based on post-orchiectomy levels
- S0
– markers WNL
- S1
– LDH < 1.5x upper limit of normal
– AND AFP < 1000 ng/mL
– AND B-hCG < 5000 mlU/mL
- S2
– LDH 1.5 - 10x normal range
– OR AFP 1000-10,000 ng/mL
– OR B-hCG 5000-50,000 mlU/mL
- S3
– LDH > 10x normal range
– OR AFP > 10,000 ng/mL
– OR B-hCG >50,000 mlU/mL

The LABs of S grouping

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2
Q

What is the T staging for testicular cancers?

A
  • Tis: Germ cell neoplasia in situ
  • T1: Tumor limited to testis w/o LVSI
    – T1a - Tumor smaller than 3 cm in size
    – T1b - Tumor 3 cm or larger in size
  • T2:
    – Tumor limited to the testis (including rete testis invasion) w/ LVSI
    – OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea w/wo LVSI
  • T3 - Tumor invades spermatic cord soft tissue w/wo LVIS
  • T4 - Tumor invades scrotum w/wo LVSI
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3
Q

What is the clinical and pathologic N staging for testicular cancer?

A
  • Clinical
    – N1: 1 or more LNs ≤ 2 cm
    – N2: LN mass or multiple LNs 2 - 5 cm
    – N3: LN mass > 5 cm
  • Pathologic:
    – N1: LN mass ≤ 2 cm
    — ≤ 5 LN+, all ≤ 2 cm
    – N2:
    — LN mass 2 - 5 cm
    — > 5 LN+, all ≤ 5 cm
    — ENE
    – N3: LN mass > 5 cm
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4
Q

What is the NCCN stage grouping for testicular cancer?

A
  • IA: T1 N0 M0 S0
  • IB - T2-4 N0 M0 S0
  • IS: Any T N0 M0 S1-3
  • IIA: Any T N1 M0 S0-1
  • IIB: Any T N2 M0 S0-1
  • IIC: Any T N3 M0 S0-1
  • IIIA: Any T Any N M1a S0-1
  • IIIB: S2 and either N1-3 or M1a
  • IIIC: S3 and either N1-3 or M1a; any T/N/S and M1b
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5
Q

What is the clinical M staging for testicular cancer?

A
  • M1a - non-regional LNs or pulmonary mets
  • M1b - Distant mets
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6
Q

What is the NCCN recommendation for the adjuvant tx of Stage I gonadal SGCT post-orchiectomy?

A
  • Observation
    – Pt must be able to adhere to the obs schedule
    – Tox of CHT or RT outweighs benefits
    – 5-yr relapse rate is 10-20% but cause-specific-survival is 100%
  • If pt is unreliable
    – Carboplatin AU7
    – RT (20 Gy in 10 fx)
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7
Q

What is the relapse rate for stage I seminoma undergoing surveillance? Where do the majority of these relapses occur?

A
  • 10-20% (~13%)
  • PA nodes (aka RP nodes)
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8
Q

What is the combined relapse rate for stage I NSGCT (high and low risk) undergoing surveillance?

A

~ 19%

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9
Q

For NSGCT, what factors predict local recurrence?

A
  • Invasion of the spermatic cord (T3)
  • Invasion of scrotum (T4)
  • LVSI
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10
Q

For stage I NSGCT w/o risk factors undergoing surveillance post-surgery, what is the recommended schedule per NCCN?

A

Clinical Stage I NSGCT (Without Risk Factors*):
- Year 1
– Tumor markers q 2 mos
– CT AP q 4-6 mos
– CXR at 4 and 12 mos
- Year 2
– Tumor markers q 3 mos
– CT AP q 6 mos
– CXR annually
- Year 3
– Tumor markers q 4-6 mos
– CT AP annually
– CXR annually
- Year 4
– Tumor markers q 6 mos
– CXR annually
- Year 5
– Tumor markers q12 mos

*Risk factors for local recurrence:
- LVSI
- Invasion of the spermatic cord
- Invasion of scrotum

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11
Q

For stage I NSGCT w/ risk factors undergoing surveillance post-surgery, what is the recommended schedule per NCCN?

A

Clinical Stage I NSGCT (Without Risk Factors*):
- Year 1
– Tumor markers q 2 mos
– CT AP q 4 mos
– CXR q 4 mos
- Year 2
– Tumor markers q 3 mos
– CT AP q 4-6 mos
– CXR q 4-6 mos
- Year 3
– Tumor markers q 4-6 mos
– CT AP q 6 mos
– CXR q 6 mos
- Year 4
– Tumor markers q 6 mos
– CT AP manually
– CXR annually
- Year 5
– Tumor markers annually

*Risk factors for local recurrence:
- LVSI
- Invasion of the spermatic cord
- Invasion of scrotum

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12
Q

How are clinical stage I NSGCT risk stratified when considering observation post-orchiectomy?

A
  • High vs. low-risk:
    – pT3 or pT4
    – LVSI
    – The proportion of the embryonal carcinoma (EC) component in the primary tumor
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13
Q

What is the relapse rate for stage I low-risk NSGCT w/o LVSI or EC undergoing observation post-orchiectomy?

A

10-15%

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14
Q

What is the relapse rate for stage I high-risk NSGCT undergoing observation post-orchiectomy?

A

~50%

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15
Q

What is the role of RT in the primary management of gonadal NSGCT?

A
  • None, at present
  • Role of RT is limited to early stage seminomas
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16
Q

For pts undergoing PA RT for stage I testicular seminoma, what is the estimated scatter dose per fx to the remaining testicle w/ and w/o a scrotal shield?

A
  • w/o: ~0.7 cGy/fx
  • w: ~2 cGy/fx

Clamshell (scrotal) shielding reduces dose to 1/3

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17
Q

For pts undergoing dog-field RT for stage II testicular seminoma, what is the estimated scatter dose per fx to the remaining testicle w/ and w/o a scrotal shield?

A
  • w/o: 0-2 cGy/fx
  • w: 2-4 cGy/fx

Clamshell (scrotal) shielding reduces dose to 1/3

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18
Q

What is the fu schedule for stage I seminoma pt undergoing observation post-orchiectomy?

A
  • Year 1
    – H/P q 3-6 months
    – CT or MRI AP q 4-6 months
    – CXR as clinically indicated
  • Year 2:
    – H/P q 6 months
    – CT or MRI AP q 6 months
    – CXR as clinically indicated
  • Year 3:
    – H/P q 6-12 months
    – CT or MRI AP q 6-12 months
    – CXR as clinically indicated
  • Years 4-5:
    – H/P q 12 months
    – CT or MRI AP q 1-2 yrs
    – CXR as clinically indicated

Labs and Scrotal US are not a routine part of observation for seminomas

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19
Q

What features make a pt w/ metastatic NSGCT a good prognosis group?

A

Good prognosis metastatic NSGCT:
- Testicular or retroperitoneal primary tumor
- AND No non-pulmonary visceral metastasis
– Having lung mets is better than non-lung mets
- AND good markers (S0 or S1)
– AFP < 1,000 ng/mL
– B-hCG <5,000 mlU/mL
– LDH < 1.5x upper limit of normal

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20
Q

What features make a pt w/ metastatic NSGCT an intermediate prognosis group?

A

Intermediate prognosis metastatic NSGCT:
- Testicular or retroperitoneal primary tumor
- AND No non-pulmonary visceral metastasis
– Having lung mets is better than non-lung mets
- AND intermediate markers (S2)
– AFP 1,000-10,000 ng/mL
– B-hCG 5,000-50,000 mlU/mL
– LDH 1.5-10x upper limit of normal

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21
Q

What features make a pt w/ metastatic NSGCT a poor prognosis group?

A

Poor prognosis group
- Mediastinal primary tumor
- OR nonpulmonary visceral metastasis
– Having lung mets is better than non-lung mets
- OR poor markers (S3)
– AFP > 10,000 ng/mL
– OR B-hCG >50,000 mlU/mL
– OR LDH > 10x upper limit of normal

22
Q

What are the adjuvant tx options for Stage I seminoma?

A
  • Active surveillance: 15%–20% relapse
    – Preferred, especially for stage IA (< 3 cm)
  • Carboplatin (AUC 7 x1–2C): <5% relapse (TE19 trial)
  • RT (para-aortic strip, 20 Gy/10 fx)
    – <5% relapse (TE10/TE18 trials)
23
Q

What are the adjuvant tx options for Stage II seminoma?

A
  • IIA:
    – Modified dogleg RT, 20 Gy/10 fx with a boost to 30 Gy
  • IIB:
    – CHT preferred (NCCN): EP x 4C or ВЕР Х 3С
    – RT for select non-bulky disease (nodes ≤3 cm).
    – Modified dogleg RT, 20 Gy/10 fx with a boost to 36 Gy
  • Stage IIC:
    – EP × 4C or BEP × 3C
    – RT/surgery for salvage
24
Q

What are the adjuvant tx options for Stage III seminoma?

A
  • EP × 4C or BEP × 3C
  • RT/surgery for salvage
25
Q

What CHT regimens are used in adj. tx of Stage I/II/III seminomas?

A
  • Stage I:
    – Single-agent carboplatin (AUC 7) × 1–2 cycles
  • Stage II/III:
    – EP (etoposide, cisplatin) × 4 cycles
    – BEP (bleomycin, etoposide, cisplatin) × 3 cycles
26
Q

What are the borders of the modified dogleg RT field used for Stage IIA/B seminomas and for the cone-down boost?

A
  • Mod. dog leg:
    – Sup: bottom of T11 vertebral body
    – Inf: top of acetabulum.
    – Lat: the tip of the ipsilateral transverse process of L5 to the superolateral border of the ipsilateral acetabulum.
    – Medial: the tip of the contralateral transverse process of L5 toward the medial border of the ipsilateral obturator foramen
  • Cone-down:
    – Contour GTV
    – A uniform, 2-cm margin from the GTV
27
Q

What are the borders of the AP/PA RT field used for Stage I seminomas?

A

PA fields:
- Sup: bottom of T10 or T11 vertebral body
– *Note: Historically, the superior border was top of T11
- Inf: bottom of L5
- Lat: tips of the transverse processes bilaterally
– Careful attention should be paid to renal doses because wide lateral borders will result in increased doses to the kidney
– Include the left renal hilum for left-sided cancers. Left renal hilar nodes are usually included when the left lateral border is placed at the tips of the transverse processes

28
Q

What are the usual renal constraints for pts w/ one or two functioning kidneys?

A
  • Two fx kidneys
    – D50% ≤ 8 Gy (ie, no more than 50% of each kidney can receive ≥ 8 Gy)
  • One fx. kidney
    – D15% should be ≤ 20 Gy (ie, no more than 15% of the volume of the kidney can receive ≥20 Gy)
29
Q

What tox are increased w/ mod dogleg fields as opposed to PA fields?

A
  • GI
  • Hematologic
30
Q

What are the contraindications to RT for seminomas?

A
  • Horseshoe kidney
  • IBD
  • Previous RT
31
Q

Per TE19, how many pts who received carboplatin AU7 vs. RT to 20 Gy in 10 fx developed contralateral GCTs?

A

5-yr risk of contralateral GCT development
- Carboplatin AU7: 2 (0.2)%
- RT: 15 (1.2%)
- p=0.03

32
Q

Per TE19, what is the RFS of pts who received carboplatin AU7 vs. RT to 20 Gy in 10 fx?

A

5-yr RFS
- Carboplatin AU7: 95%
- RT: 96%
- p =0.03

33
Q

What is the median time to first normal sperm count post-tx w/ PA versus DL fields?

A
  • Sperm count prior to RT: WNL
    – PA: 13 mos
    – DL: 20 mos
  • Sperm count prior to RT: low
    – PA: 24 mos
    – DL: 37 mos
  • At 3 yrs
    – DL: 92% had normal sperm counts
34
Q

What is the complete response rate to bladder-preserving CRT for pts w/ MIBC?

A

69%

35
Q

What % of bladder cancers are muscle-invasive at dx?

A

~20%

36
Q

What was the pt population, randomization, and primary EP of BC2001 for bladder cancer?

A
  • Pts: T2-T4a
  • Randomization: 2 x 2
    1. RT Randomization (Choice of 55 Gy/20 fx or 64 Gy/32 fx)
    – Standard whole bladder RT
    – reduced high-dose volume RT (RHDVRT; Full dose to GTV, 80% to the uninvolved bladder)
    2. CHT Randomization:
    – concurrent 5FU/MMC
    – no chemo
  • RT primary endpoint: Noninferiority of 2-yr LRC between standard and RHDVRT
37
Q

What were the results and the conclusions of BC2001 for bladder cancer?

A
  • RT randomization: Noninferiority of LRC of standard RT vs. RHDVRT could not be confirmed
    – 2-yr LRC 62% vs. 67% (not noninferior)
    – 5-yr LRC ~55%, 10-yr ~48%
    – inv LRC 2-yr ~81%, 5-yr 76%, 10-yr 69%
    – 2-yr bladder preservation ~89%
    – Grade 3-4 toxicity 13% in both RT arms
  • Chemo randomization: CHT concurrent w/ RT improves LRC
    – 5-yr LRC 63% vs. 49%
    – 5-yr inv LRC 79% vs. 64%
    – 5-yr bladder preservation 86% vs. 78%
  • At long term f/u at 9.9 yrs, there were some trends to improvements in DFS, MFS, OS, and CSS with chemo, but no differences
  • Conclusions:
    – CHT concurrent w/ RT improves LC and bladder preservation rates.
    – There is a trend to improved OS, CSS, DFS, and MFS when adding 5FU and MMC to radiation; however this is not significant long-term.
38
Q

What were the findings of the BCON/BC2001 combined meta-analysis for MIBC?

A
  • Comparison:
    – 55 Gy/20 fx vs. 64 Gy/32 fx in BC2001 and BCON
    – Combined analysis of LC, OS, and toxicity in these trials to assess noninferiority
  • Findings: Median FU 10 yrs
    – 55 Gy had ↓ invasive LRR than 64 Gy (HR 0.71 after adjustment
    – No difference in OS
    – Similar toxicity
39
Q

Is RT recommended for pT1 cancers post-TURBT?

A

No

40
Q

Is hydronephrosis a prognostic factor for selective bladder preservation (SBP)?

A

It’s a very poor prognostic factor

41
Q

What are some poor prognostic factors for selective bladder preservation (SBP)?

A
  1. Hydronephrosis
  2. Tumor near a ureteral orifice
  3. Nodes near the bifurcation
  4. Small bladder capacity
  5. > 5cm tumor
  6. Residual disease post-TURBT
42
Q

When should adjuvant CHT be offered to pts who underwent RC?

A
  • No neoadj CHT
  • pT3-T4
  • N+
43
Q

What is the rate of ≥ Gr 3 GU tox pts receiving selective bladder preservation w/ CRT?

A

~5%

44
Q

When is a urethral bx indicated in a newly dx pt w/ bladder cancer?

A
  1. Bladder neck involvement
  2. Carcinoma in situ
  3. Vaginal extension
  4. Positive cytology without evidence of bladder tumor
  5. Visible lesions or abnormalities of the prostatic urethra
  6. Trigone involvement
45
Q

What is the difference in CTV contouring for a pt receiving adj. RT after RC w/ + vs. -margins?

A
  • +margins
    – CTV includes pelvic LNs + cystectomy bed
  • -margins
    – CTV includes pelvic LNs only
46
Q

How often should image guidance be used for Bladder ca pts undergone selective bladder preservation?

A

Daily

47
Q

What RT technique/planning method is standard for the tx of bladder cancer?

A
  • 3D-CRT
  • IMRT is not well-studied
48
Q

What % of pts are upstaged vs. downstaged following RC for bladder cancer?

A
  • Upstaged: 40%
  • Downstages: 5%
49
Q

Which lab findings are suggestive of a UTI vs. noninfective cystitis in a BC pt undergoing CRT?

A
  • Nitrites + Leukocyte Esterase
  • Nitrites + WBCs
50
Q

Prior to initiating RT for BCa, what should be requested from the urologist?

A
  • Bladder map:
    – bx from different areas of the bladder
51
Q

For NMIBC, what should be done within 34 hrs of TURBT?

A
  • Single instillation of gemcitabine or mitomycin C
    – Reduced LR by 1/3 (47% → 35%)
52
Q

How long after TURBT should adjuvant BCG be started for NMIBC?

A

6 weeks

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