Genitourinary Flashcards
(293 cards)
1
Q
Topics to cover in GU history
A
- Urinary frequency
- Urgency
- Hesitancy
- Hematuria
- Dysuria
- Diarrhea/constipation
- Blood in stool
- IBS symptoms
- ED
- Bone pain
- Abdominal or pelvic pain
2
Q
Other important topics to raise for prostate consult
A
AUA/IPSS score IIEF score Prior RT History of IBD Testosterone replacement Usage of BPH medications Comorbidities related to CV health Date of last colonscopy
3
Q
Topics to address in GU PE
A
Focused physical exam including –DRE feeling for nodules in the prostate or prostatic pain –ECE and loss of lateral sulci –Prostate firmness –Estimate size of the prostate
4
Q
IPSS score
A
Made up of 7 questions related to voiding symptoms scored 0-5. A score of 0 to 7 indicates mild symptoms, 8 to 19 indicates moderate symptoms and 20 to 35 indicates severe symptoms.
5
Q
IIEF score
A
IIEF-5 range from 5 to 25 ED was classified into five categories based on the scores: severe (5–7), moderate (8–11), mild to moderate (12–16), mild (17–21), and no ED (22–25)
6
Q
Standard prostate workup - labs
A
DRE Labs: PSA, CBC, CMP, LFTs, testosterone
7
Q
Standrad prostate workup - imaging
A
CT/MRI pelvis Bone scan (if indicated) by clinical staging Axumin PET or PSMA on protocol if high suspicion for mets Colonoscopy if GI symptoms or if never had one
8
Q
What kind of biopsy
A
TRUS guided Looking for Gleason primary and secondary grade, prostate size, presence of hypoechoic lesions
9
Q
How many cores needed on TRUS
A
At least 8, 12 is better
10
Q
What can be learned from biopsy
A
of cores involved % involvement of each core PNI Gleason grade primary and secondary
11
Q
What patients don’t need any further workup after dx of prostate cancer
A
Life expectancy <5 years & asymptomatic UNLESS high or very high risk disease
12
Q
What patients need a bone scan
A
T1 and PSA >20 T2 and PSA >10 Gleason score 8-10 T3 or T4 Symptomatic
13
Q
Pelvic CT or MRI needed if
A
T3, T4 T1 or T2 and nomogram indicates probability of LN involvement >10%
14
Q
What nomograms help to predict nodal involvement
A
Partin nomogram Roach formulas
15
Q
What does the Partin nomogram predict
A
Pathologic stage (organ confined, ECE, SV invasion or nodal invasion) based on cT, PSA, Gleason
16
Q
What is Roach formula for LN involvement
A
2/3*PSA + 10 (GS-6)
17
Q
If you are asked about clinical stage and patient had surgery when to consider stage
A
Prior to surgery or biopsy
18
Q
By AJCC 8th, what exam findings factor into cT stage
A
DRE only
19
Q
cT1a Prostate
A
Incidental histologic finding in <5% of tumor resected (TURP)
20
Q
cT1b Prostate
A
Incidental histologic finding in >5% of tumor resected (TURP)
21
Q
cT1c Prostate
A
Tumor identified by needly biopsy (due to elevated PSA)
22
Q
cT2a Prostate
A
Tumor in <1/2 of one lobe
23
Q
cT2b Prostate
A
Tumor in >1/2 of one lobe (but not both lobes)
24
Q
cT2c Prostate
A
Tumor involved both lobes of prostate
25
cT3a Prostate
ECE
26
cT3b Prostate
SVI
27
cT4 Prostate
Fixed tumor or invades through structures other than SV: bladder, levator and/or pelvic wall
28
N1 prostate
Any regional nodes - obturator, internal/external iliac, presacral
29
M1a prostate
Non-regional lymph nodes
30
M1b prostate
Bone mets
31
M1c prostate
Other visceral mets
32
Differences between clinical and path staging for prostate
No T1
33
What is pT2 prostate
organ confined
34
What is pT3a prostate
ECE or microscopic invasion of bladder neck, if +margin should say R1
35
What is pT3b prostate
SVI
36
What defines very low risk prostate cancer?
T1c Gleason 6 or lower PSA \<10 \<3 positive cores, \<50% in each core PSA density \<0.15
37
What defines low risk prostate cancer
T1 or T2a Gleason 6 or less PSA \< 10
38
What defines intermediate risk prostate cancer
T2b or T2c OR Gleason score 7 OR PSA 10-20
39
What defines high risk prostate cancer
T3a OR Gleason 8-10 OR PSA \>20
40
What defines very high risk prostate cancer
T3b or T4 Multiple high risk factors
41
What defines metastatic prostate cancer
Any N1 Any M1
42
What is 5-10 year bPFS for low risk PC
90%
43
What is 5-10 year bPFS for int risk PC
70-80%
44
What is 5-10 year bPFS for high risk PC
30-60% (50%)
45
What is 5-10 year CSS for low risk PC
95%
46
What is 5-10 year CSS for int risk PC
85%
47
What is 5-10 year CSS for high risk PC
75%
48
Management options for very low risk prostate cancer (good life expectancy)
If life expectancy \> 20 years 1. Active surveillance 2. RT or brachy mono 3. Radical prostatectomy +/- pelvic LN dissection if predicted probability of LN mets \>2%
49
Management options for very low risk prostate cancer (intermediate life expectancy)
If life expectancy 10-20 years 1. Active surveillance
50
Management options for very low risk prostate cancer (low life expectancy)
If life expectancy \<10 years Observation (no biopsies or PSA checks but manage symptoms as they arise)
51
What is included in active surveillance?
1. PSA no more often than every 6 months 2. DRE no more often than every 12 months 3. Repeat TRUS bx no more often than every 12 months
52
If a patient opts for RP, what are options after the surgery
1. If adverse features --\> consider RT or observation (probably obs given latest data) 2. If N+ --\> ADT (category 1) +/- RT (category 2B) or observation
53
What are the treatment options for intermediate risk PC (good life expectancy)
If expectancy \>10 years: 1. RP + PLND (if risk of N+ \>2%) 2. RT +/- ADT +/- brachytherapy 3. Brachytherapy alone
54
What is the duration of ADT for IR PC?
4-6 months
55
What are the treatment options for intermediate risk PC (poorer life expectancy)
If expectancy \<10 years: 1. RT +/- ADT (4-6 months) +/- brachytherapy 2. Brachy mono 3. Observation (if truly poor candidate)
56
If a patient is found to be N+ after RP what should be offered
ADT (Category 1) RT (Category 2B) Observation
57
What are the treatment options for high risk PC
1. EBRT + ADT (2-3 years) ADT if N+ --\>Likely obs if adverse features
58
What are the treatment options for very high risk PC
1. EBRT + ADT (2-3 years)
59
What are the treatment options for N1 PC
1. EBRT + ADT (2-3 years)
60
What are the treatment options for M1 PC
1. Orchiectomy 2. LHRH agonist +/- anti-androgen \>7d to prevent testosterone flare 3. LHRH agonist + anti-androgen 4. LHRH antagonist 5. Observation (if asymptomatic, poor life expectancy)
61
What is a commonly prescribed LHRH agonist
Lupron
62
Typical dose of Lupron
7.5mg SC monthly 22.5 mg q3months (depot)
63
What is the mechanism of bicalutamide
Anti-androgen (competes with binding of androgen receptor)
64
What is a commonly prescribed LHRH antagonist
Degarelix
65
Dose of degarelix
120 mg SC for 2 doses (ie, 2 separate injections totaling 240 mg), THEN after 28 days, begin maintenance dose of 80 mg SC q28d
66
If a patient returns with relapsed PSA what is best next step
Obtain imaging to clarify if sites of gross disease --\> MRI pelvis --\> CT CAP --\> Axumin or PSMA on protocol --\> bone scan
67
Treatment options for hormone refractory recurrent PC
If no evidence of mets --\>Maintain castrate levels of testosterone --\>clinical trial 1. Observation if PSADT \>10 months 2. Secondary hormone therapy especially if PSADT \<10 months
68
What are some secondary hormonal therapy options?
Antiandrogens - enzalutamide, abiraterone, apalutamide and darolutamide Ketoconazole Corticosteroids DES or other estrogen
69
Mechanism of enzalutamide
nonsteroidal antiandrogen medication
70
Dose of enzalutamide
160 mg (two 80 mg tablets or four 40 mg tablets or four 40 mg capsules) administered orally once daily
71
Mechanism of abiraterone
Androgen biosynthesis inhibitor, that inhibits 17 a-hydroxylase/C17,20-lyase (CYP17)
72
Dose of abiraterone
1000 milligrams (mg) (two 500 mg tablets or four 250 mg tablets) once a day, taken together with 5 mg oral prednisone 2 times a day.
73
Patient returns with biochemically relapsed disease and studies + for mets --\> treatment options
1. Maintain castrate levels of testosterone and offer denosumab or zolendronic acid if evidence of bone metastases 2. Remainder of options dictated by symptomatic or not
74
If patient has symptomatic M1 disease --\> options
1. Docetaxel (category 1) 2. Radium-223 for symptomatic BM 3. Mitoxantrone 4. Abi 5. Enzalutamide 6. Palliative RT or radionuclide for painful BM 7. Clinical trials 8. Best supportive care
75
Dose of docetaxel
Docetaxel 75mg/m2 IV Give with pred 5 BID Repeat q3wks for 6 cycles
76
Dose of bicalutamide
50 mg daily (if part of CAB)
77
If patient has asymptomatic M1 disease --\> options
1. Sipuleucel-T (category 1) 2. Secondary hormonal therapy 3. Docetaxel 4. Clinical trial
78
How to define biochemical failure after RP
1. Failure of PSA to fall to undetectable levels (PSA persistence) 2. Undectable PSA with a subsequent detectability that increases on 2 or more determinations (PSA recurrence)
79
Treatment options for post-RP biochemical failure
Determine PSADT Imaging: CT/MRI pelvis +/- bone scan or Axumin/NaF PET/PSMA on protocol --\>Prostate bed biopsy if imaging suggests local failure
80
Once workup is complete for post-RP biochemical failure what are treatment options?
If workup (-) for DM: pelvic RT +/- nodes +/- ADT +/- observation If workup (+) for DM: ADT +/- RT for sites of metastases if in weight-bearing bones or symptomatic or OBS
81
Defining recurrence after RT
1. Positive DRE 2. nadir + 2 ng/mL (Phoenix criteria)
82
Workup if evidence of post-RT failure
Determine if patient is a candidate for subsequent local therapy: 1. Original clinical stage of cT1-T2, NX or N0 2. Life expectancy \> 10 years 3. PSA \<10 ng/mL If yes: --\>PSADT --\>TRUS biopsy --\>Bone scan --\>CT CAP and MRI pelvis
83
Treatment options if post RT recurrence demonstrates TRUS+ and DM-
1. Observation 2. RP 3. Cryosurgery 4. Salvage brachytherapy
84
Treatment options if post RT recurrence demonstrated TRUS- and DM-
1. Observation 2. ADT 3. Clinical trial 4. More aggressive workup for local recurrence (PSMA PET or Axumin etc.)
85
Simulation technique for IG-IMRT prostate
3 fiducials placed into the bladder Consider hydrogel spacer for lesions without any posterior ECE Supine immobilized an in alpha cradle arms on chest Full bladder and empty rectum (enema if needed) both for simulation and for daily treatment Fuse the patients sim CT with MRI for better delineation of the prostate
86
Location of prostate apex with respect to penile bulb
apex is 1.5 cm superior
87
Imaging guidance for prostate treatments
Daily KV imaging matched to fiducials Daily CBCT checking bladder and bowel filling, adjusting bowel regimen as needed
88
What is GTV, CTV for prostate
GTV=CTV = prostate gland and either entire or proximal 1-2 cm of SV
89
What is the PTV expansion for prostate (mod hypo)
8-10 mm radially, 3 mm posteriorly into rectum
90
What is the PTV expansion for prostate (SBRT)
5 mm anteriorly and radially
3 mm posteriorly into rectum
91
Dose options for prostate alone
Several options including --Dose escalated conventional RT (at least 78 Gy) --Moderate hypofractionation --SBRT
92
Moderate hypofractionation dose
70 Gy in 28 daily 2.5 Gy fractions
93
What is the expected benefit of dose escalation for PC
Improves bPFS by 10-20% for low, intermediate and high risk groups, no difference in OS
94
What are some of the risks of dose escalation
Increases G2+ acute GI toxicity Similar GU toxicity Acute tox peaks earlier
95
What patients can be offered SBRT?
* Low Risk
* Fav Int Risk – recommend on clinical trial
* No evidence of ECE
96
What is the dose of SBRT for appropriate candidates?
36.25 in 5 fractions of 7.25 Gy
Deliver QOD for reduced toxicity
97
What is the dosing schedule for prostate SBRT
QOD
98
What is the rectal constraint for mod hypofrac?
D15% \< 75
D25% \< 70 Gy
D35% \< 65 Gy
D50% \< 60 Gy
99
What is the bladder constraint for moderate hypofrac?
D0.03 cc (MPD) \< 73.5 (\<105%)
D35% \< 70 Gy
D50% \< 65 Gy
D90% \< 35%
100
What is the rectal constraint for SBRT
Remember dose is 36.25 in 5
* D0.03cc \< 38.06 (max \<105%)
* D3cc \< 34.4 (\<95%)
* D10% \< 32.63
* D20% \< 29 Gy
* D50% \<18.12 (\<50%)
101
What is the bladder constraint for SBRT?
* D0.03cc \<38.06 (\<105%)
* D10% \< 18.12 (\<50%)
102
What is urethral constraint for SBRT?
D0.03 \< 38.78 (\<107%)
103
When does nadir occur after EBRT?
2-3 years after completion of RT
104
How many patients experience PSA bounce?
10% EBRT
20% brachy
105
What is the median time to PSA bounce?
9-12 months
106
What PSA level is bounce?
Usually \<2 ng/mL, does not predict for subsequent PSA failure
107
Risk of urinary side effects from RP vs. RT
RP: 10%
EBRT: 10%
Brachy: 20%
108
Risk of GI side effects from RT vs. RP
RP: 2%
EBRT/brachy: 10%
109
Risk of sexual side effects RT vs. RP
RT: loss of sexual function 30-50%
RP: 50%
110
Absolute/relative contraindications to LDR brachy
* SVI
* Large T3 disease
* Relative contraindications
* Prostate size \>60 cc (associated with increased tox and risk of obstruction)
* Median lobe hypertrophy
* Significant pre-treatment urinary symptoms (IPSS \>15-18)
111
Options for LDR if the prostate is \>50-60 cc
Consider 3 months of ADT for cytoreduction --\> LDR
112
When is post procedure CT scan performed for LDR brachy?
1 month post procedure
113
LDR brachy V100
As close to 100% as possible, at least 90%
114
LDR brachy D90
Dose going to 90% of the prostate
| (\>90%)
115
LDR brachy: urethral point dose
No more than 150% of Rx dose
116
LDR brachy: rectal constraint
\<1cc of rectum should receive \>100% of Rx dose
117
What is D90?
Minimum dose going to 90% of prostate (\>90%, ideally 100%)
118
What is V100?
Volume of prostate receiving 100% of Rx dose
(goal \>95%, ideally 100%)
119
I-125 Rx dose
145 Gy if mono
110 Gy if boost
120
Pd-103 dose
125 Gy if mono
90 Gy if boost
121
Ir-192 HDR dose
13.5 x 2 fractions
Boost dose = 15 Gy x 1
122
t1/2 of I-125
60d
123
t1/2 of Pd-103
17d
124
t1/2 of Ir-192
74 days
125
Risk of urinary obstruction after brachy
~10%
126
Risk of impotence post brachy
~1/3 (maybe less than EBRT)
127
Risk of urethral stricture post brachy
3%
128
Risk of incontinence post brachy
129
2% normally
5% if prior TURP
130
Risk of rectal bleeding from brachy
\<10%
131
Risk of rectal fistula from brachy
\<1%
132
Risk of ED after RP
50% even with nerve sparing techniques
133
Risk of urinary incontinence after RP
* 50% occasional leakage
* 10% frequent leakage
* 3% no urinary control
134
Definition of PSA failure after RP
Use AUA standard: \>0.2 on 2 separate measurements
135
Typical follow-up for patient after definitive RT
NCCN says PSA q6-12m x 5 years with annual DRE
136
What are the pros/cons of brachy boost for intermediate to high risk PC
* Pros
* Improves bPFS
* No change in OS, DMFS
* Cons
* Increased acute GU toxicity (mostly retention)
* Increased delayed GU toxicity (5--\>18%)
* Mostly urethral strictures
* Trend towards delayed GI toxicity
137
If you want to do combo therapy what dose
* 45 Gy EBRT + 15 Gy x 1 HDR
* 45 Gy EBRT + 100 Gy LDR (Pd-103)
* 45 Gy EBRT + 110 Gy LDR (I-125)
138
For which N0 patients would you consider prophylactic nodal irradiation
* High risk (all)
* Unfavorable intermediate (especially if young, healthy, many risk factors -- SVI, G5 disease, high amounts of G4 disease)
139
If treating full pelvis, what is treated
* Obturator (stop at top of pubic symphysis)
* External iliac (stop at top of femoral head)
* Internal iliac
* Common iliac (up to L4-L5)
* Presacral
140
For high risk prostate cancer, how much ADT is required
18-36 months
18 endorsed by NCCN
141
What is the benefit of ADT for high risk disease
10% OS and bPFS benefit
142
Patients who are likely to benefit from salvage RT
* Low pre-tx PSA (\<0.2)
* Positive margin
* Low PSADT
* Gleason \<8
* Negative LN
* Long interval to PSA failure after RP or elevated PSA immediately after RP
143
Dose for salvage RT
pelvis to 45 Gy in 25 fractions
prostate boost to 64.8 Gy in 1.8 Gy fractions
144
Rectal constraint for salvage prostate RT
V65 \< 35%
V40
145
Bladder constraint for salvage prostate RT
(minus CTV)
V65 \< 50%
V40 \< 70%
146
Femoral head constraint for salvage prostate RT
V50 \< 10%
147
CTV delineation for salvage prostate RT
Inferior edge is top of penile bulb
Lateral is medial edge of obturator internus muscles
Anterior is full bladder neck until pubic symphysis then gradually extend backwards off anterior bladder
Posterior is anterior edge of rectum
148
How high superiorly should salvage RT extend for prostate
Cut end of vas deferens OR
Max of 3-4 cm above the pubic symphysis
149
What is the CTV to PTV expansion for salvage prostate?
8 mm
150
Which salvage patients should we consider WPRT?
High risk - N+, PSA \> 0.3
151
Which patients might you opt for adjuvant RT?
N+
| (maybe best for T3/T4, 3-4 nodes)
152
If doing salvage RT, when to start?
About 3 months post op, maximal urinary recovery
153
If doing salvage RT, dose?
45 Gy to pelvis
70.2 to prostate bed if gross disease
Otherwise 68 Gy to prostatic fossa
154
Typical ADT side effects
* hot flashes
* bone loss
* impotence
* decreased libido
* increased body fat
* hair loss
* anemia
* metabolic syndrome risk
155
Bone risk if starting ADT
If short course ADT planned: FRAX score --\> DEXA
If long course ADT: get DEXA --\> referral to endo if osteoporosis/osteopenia
156
If contouring N+, how to contour
* Start contouring distal common iliac vessels at L5/S1
* 7 mm expansion on vessels, carve out bone/bowel/bladder
* Include presacral nodes S1-S3
* Stop external iliac contours at top of femoral heads
* Stop obturator LNs at top of symphysis
157
What is the CTV for low risk prostate cancer
prostate alone
158
What is the CTV for intermediate risk prostate cancer
Prostate and proximal 1 cm of SV
159
What is the CTV for high risk prostate cancer
* First phase: entire prostate, entire SV plus pelvic LN (obturator, internal/external iliac, presacral)
* Second phase: cone down on prostate + SV
160
LDR brachytherapy script
* Ensure patient has adequate bowel prep
* Take to OR --\> induce general anesthesia
* Give IV antibiotics (cefazolin or gent)
* Place patient in dorsal lithotomy position
* Insert foley catheter and irrigate rectum copiously
* Tape scrotum out of the way
* Insert rectal ultrasound probe and secure to stepper unit
* Connect template to the rectal ultrasound stepper unit to divide the prostate into coordinates
* Needles are then placed into the prostate under US guidance -- typically 16 needles with 12 placed peripherally about 1 cm spaced and 4 centrally to minimize dose to urethra
* We then capture several coronal slices of the prostate which is fed to laptop with brachy planning software
* The prostate, urethra and rectum are then contoured using the slices
* A real time plan is created to maximize prescription and constraints
* Seeds are then placed into the prostate using a Mick applicator through the template and spacing recommended by the brachy planning software
* We then perform a fluoroscopy CT scan to confirm seed location
* Physicist performs radiation survey to ensure no loose seeds
* Patient is awoken and able to discharge when able to void
* Post implant CT 1 month later
161
Guidelines for needle placement for LDR
* 16 needles total
* 12 in periphery spaced 1 cm apart
* 4 in the center to minimize urethral dose
* Spacing of 5 mm from the posterior wall to reduce rectal dose
162
Appropriate time to do post implant CT for LDR and why?
1 month
Prior to then there is prostatic edema
163
HDR brachy script
* Patient is given good GI bowel prep
* Take to OR and induce general anesthesia
* Give IV antibiotics (2-3g of cefazolin)
* Insert Foley --\> insert 300 cc of fluid and clamp
* Irrigate rectum and then do betadine wash of the perineum
* Secure scrotum and penis out of the way
* Insert the ultrasound into rectum and lock with slight upward pressure to get good view of prostate
* Switch to sagital view to make sure that the urethra and catheter appear in the same plane (i.e., everything is straight)
* Template then connected to the ultrasound probe and the stepper unit is slid forward to press against the perineum -- maps the prostate into coordinates
* Needles are inserted through the perineum using template
* Typically 13 needles are inserted - 11 peripheral and 2 needles centrally to cover the urethral dose but to minimize rectal/urethral dose
* Start with top two needles to assess for pubic arch interference
* Once the needles are placed, switch to sagittal view to check for depth and ensure not in bladder
* We then obtain serial axial images of the prostate which are connected to laptop with realtime planning software
* The prostate, urethra, rectum and needles are contoured on the US axial images
* While planning occuring I hook up afterloaders to needles
* I then evaluate plan and deliver therapy
* Once done, unclamp foley, remove needles, remove probe, apply pressure to perineum
* Patient can be discharged when able to void
164
Needle placement for HDR
* Generally 13 needles
* 11 peripheral
* 2 central posterior to the urethra
* space 1 cm from each other (or so)
* 5 mm spacing from posterior wall to reduce rectal dose
* top row of 4, middle row of 4, bottom row of 4-6
165
Acceptable prostate dose for low volume M1 disease
55 Gy in 20 fractions (2.75 Gy per fraction)
Per STAMPEDE
166
Mechanism of Lupron or Zoladex
* LHRH agonists
* Bind to receptors in pituitary --\> increase in FSH/LH --\> increase in testosterone
* Receptor downregulation and decreased release of LH/FSH via negative feedback
167
Side effects of Casodex
Gynecomastia
Hepatotoxicity (remember to check LFTs)
168
Possible treatment option for gynecomastic
Prophylactic breast RT (4 Gy x 3)
169
Treatment strategy for high risk prostate cancer getting definitive RT
* Overall plan is EBRT + long term ADT (18 months)
* Neoadjuvant until PSA \<1
* CAB through end of RT
* Total of 18 mos
* IG-IMRT to 45 Gy to prostate/pelvis (1.8 x 25 = 45 Gy)
* IG-IMRT to 81 Gy to prostate/SV (1.8 x 20)
170
Dose for grossly involved nodes
56.25 (2.25 Gy x 25 fx)
56 gy in 28 fx
171
What nodal regions are covered for prostate
* Distal common iliacs (L5-S1)
* Presacral (S1-S3)
* Internal and external iliac (to top of femoral head)
* Obturators (down to pubic symphysis)
172
Approach for nodal contouring
* Contour vessels starting from L5-S1 interspace
* 7 mm expansion to CTV, carve off bone, bowel, bladder
* Contour presacral space S1-S3 from anterior sacrum to 1 cm anterior and carve off bowel, bladder, bone
* Stop external iliac and top of femoral heads
* Stop obturator at top of pubic symphysis
CTV to PTV expansion of 7 mm
173
When to stop CAB for high risk disease
End of RT typically
174
Criteria for PSA failure after RT
Phoenix criteria
nadir + 2
175
Nadir periods after RP, RT, brachy
RP: 3 weeks
RT: 2-3 years
Brachy: 3-4 years
176
What is a reasonable PSA DT to consider hormones after definitive therapy
\<6 months
177
Mechanism of bicalutamide
Oral non-steroidal anti-androgen - binds to AR receptor and prevents the binding of testosterone and it's downstream effects
178
For initial metastatic disease, what is rough duraion of disease control on ADT
~3 years
179
If patient is metastatic, PSA is rising, what is next step
Check testosterone --\> ensure castrate, if not, add a different agent
180
Mechanism of abiraterone
17-alpha hydroxylase inhibitor which is an enzyme expressed in testicular, adrenal and prostate tissue
The enzyme catalyzes the formation of DHEA and androstendione which are androegns and precursors of testosterone
Inhibition of the enzyme reduces testosterone levels
181
What needs to be given with abi
5 mg prednisone BID
182
What is mechanism of enzalutamide
AR antagonist with stronger affinity than casodex
183
What would be the indication for Ra-223
Symptomatic bone mets
184
Mechanism of action of Ra-223
Alpha particles, high LET
185
Half life of Ra-223
11.4 days
186
History questions to ask for bladder cancer
* Hematuria
* Irritative voiding symptoms
* Pelvic pain
* Obstructive uropathy
* Hydronephrosis
* Risk factors such as smoking, dyes, cytoxan exposure, prior prostate ca, chronic irritation from stones or indwelling foley, travel/schistosomia
187
Lab workup for bladder cancer
U/A
Urine cytology
PSA
Office cystoscopy
188
What is detection capability of cytology?
50-80% of poorly diff
20% of well diff
189
Bladder T1
Invades subepithelial connective tissue
190
Bladder T2a
Invades superficial muscularis propria
191
Bladder T2b
Invades deep muscularis propria
192
Bladder T3a
Invades perivesicular tissue microscopically
193
Bladder T3b
Invades perivesicular tissue macroscopically
194
Bladder T4a
Invades prostate, SV, uterus, vagina
195
Bladder T4b
Invades abdominal or pelvic wall
196
Bladder N1
single regional LN in true pelvis (perivesical, obturator, internal/external iliac, sacral)
197
Bladder N2
Multiple pelvic LN
198
Bladder N3
common iliac LN
199
Stage of N+ bladder ca
IIIA (N1)
IIIB (N2-3)
200
Management of non-invasive bladder cancer
* CT urogram before TURBT
* EUA (bimanual)
* TURBT w random biopsies
* If trigone involved, biopsy prostatic urethra
201
Management of cTa (non-invasive papillary tumor)
* Depends on grade
* If low grade
* Observation
* Or single dose intravesicular chemo
* If high grade
* If incomplete resection --\> repeat TURBT
* If no muscle in specimen --\> repeat TURBT
* Intravesical therapy
* BCG weekly x 6
* MMC
* If high grade with very high risk features (LVI, prostatic urethral involvement, T1 with extensive CIS) --\> cystectomy
202
Management of cT1 bladder cancer
Repeat TURBT or cystectomy for high grade
If residual disease --\> BCG
If no residual disease --\> BCG or MMC
203
Follow-up for NMIBC
* Cytology and cystoscopy q3m x 2 years
* q6m x 3 years
* Then annually
204
Definition of MIBC
cT2 or greater
205
Workup for MIBC
* CBC/CMP
* Chest imaging
* Abdomen/pelvis CT or MRI
* Bone scan if elevated AP or symptoms
* EUA/cytoscopy
* TURBT
206
Treatment for MIBC
* Determine if cystectomy candidate
* If yes:
* Neoadjuvant chemo
* Radical cystectomy
* Consider adjuvant chemo based on path risk factors (T3-T4 or N+) if no neoadjuvant chemo given
* If no
* Concurrent chemoRT
207
Chemo used for MIBC
Gemcitabine
Cisplatin
for 4 cycles
208
What is removed in radical cystectomy
* Start with nodal sampling bilaterally --\> if + do cystectomy only for palliation of symptoms
* If negative
* En bloc removal of bladder, perivesical tissue
* For men: prostate/SV, vas deferens
* For women: urethra, TAH/BSO, anterior vaginal wall
209
Reconstruction options for bladder ca
* Incontinent: ureters attached to ileal loop conduit to skin surface and required urostomy
* Continent
* Cutaneous diversion: ureters drain to bowel segment reconstructed into a pouch that is connected to skin via stoma -\> need to self-catheterize periodically
* Used when urethra or bladder neck is involved
* Orthotopic neobladder: intestinal detubularized segment anastomosed to intact urethra which allows for volitional voiding
210
Follow up for MIBC
Cystectomy and urine cytology with labs/electrolytes 3-6 months and then as clinically indicated
Imaging of chest, upper tracts, A/P q 3-6 month for 2 years
Urethral wash cytology q6-12 mos
211
Candidates for bladder preservation
* Unifocal T2-T4a
* \<5 cm
* No hydronephrosis or hydroureter
* Good bladder function
* Good renal function
* Visibly complete TURBT with random biopsies
* No CIS
* LN negative
212
Treatment of MIBC bladder sparing
* Maximal TURBT
* Phase I - CRT to 45 Gy to the full pelvis
* Second look cystoscopy 4 weeks later with multiple biopsies and urine cytology
* If residual disease \>T1 --\> salvage cystectomy
* If no residual disease --\> boost primary plus 2 cm to 64.8 Gy
213
Preferred chemo regimen for CRT for bladder cancer
cisplatin 100 mg/m2 3 cycles
214
Follow up for MIBC
Cytology and cystoscopy q3-6 months for 2 years
Labwork for kidney function
CT chest, upper tracts, AP for q3-6 months for 2 years then as clinically indicated
215
Simulation for bladder cancer
* Supine in alpha cradle
* Perform 2 CT scans --
* First is **_empty bladder_** for the first phase of the plan
* Second is **_full bladder_** for the conedown
216
RT technique for the bladder cancer
* 3DCRT using 4 field boxes
* GTV- macroscopic tumor
* CTV\_pelvis: GTV+ whole bladder + LN + proximal urethra, prostate and prostatic urethra in men
* CTV\_bladder: GTV+whole bladder + 2 cm to field edge
* CTV\_boost: GTV + 2cm to field edge
217
Dose levels for bladder cancer
CTV pelvis: 45 Gy in 25 fractions (1.8 Gy per day)
CTV bladder: 54 Gy in 30 fractions (1.8 Gy per day)
CTV boost: 64.8 in 36 fractions (1.8 Gy per day)
218
Bladder dose constraint for bladder ca
V70 \< 30%
219
Rectum constraint for bladder cancer
V70 \< 20%
220
Outcomes after CRT for bladder cancer
50% OS at 5 years
50-70% of survivors have functioning bladder
Approx 1/3 of patients ultimately require cystectomy
221
Management of LR failure after cystectomy
Cisplatin + RT (45-50 Gy to pelvis and boost to 60-64 Gy to gross disease)
\*\*Remeber neobladder is made of bowel so need to respect that tolerance of 45 gy
222
Management of dysuria
Make sure no UTI --\> abx
Try oxybutinin for bladder spasm
Try ibuprofen or pyridium for dysuria
223
Alternative dosing regimen for bladder cancer
55/20 with 5-FU and MMC
224
History for testicular mass
Duration of testicular mass
Prior trauma or torsion
History of undescended testicle
Prior inguinal or scrotal surgery
Prior RT or IBD
225
Labs should be ordered for testicular mass
* CBC
* CMP
* B-HCG
* AFP
* LDH
226
Other workup for testicular mass
Bilateral testicular ultrasounds
CXR
Discuss sperm banking
227
Managment of presumed testicular cancer
Radical inguinal orchiectomy with high ligation of spermatic cord
228
Path factors to consider post orchiectomy
Pathology (tumor type)
LVSI
229
pT1 testicular
invasion of tunica albuginea
230
pT2 testicle
invasion of tunica vaginalis/epidydmis
or +LVSI
231
pT3 testicle
invasion of spermatic cord
232
pT4 testicle
scrotal invasion
233
Serum markers for pure seminoma
Histology is pure seminoma
No AFP elevation
b-HCG is mildly elevated
234
Workup for seminoma
* Start with CT AP
* If CXR or CT AP is positive --\> CT chest
* Repeat serum markers after orchiectomy
* Brain MRI or bone scan if indicated
235
Staging is based on serum marker measurements when
after orchiectomy
236
What is stage IA testicle
pT1 N0
237
What is stage IB testicle
T2-T4 N0
238
N1 testicle
No more than 5 LN, all smaller than 2 cm
239
N2 testicle
Mets 2-5 cm
\>5 nodes, none \>5 cm
ENE
240
N3 testicle
Nodal mass \>5 cm
241
Stage IIA testicle
Any T, N1
242
Stage IIB testicle
Any T, N2
243
Stage IIC testicle
Any T, N3
244
What is recommended management for a stage IA or IB tumor
surveillance
245
Other treatment options for stage I tumors
* Single agent carboplatin (AUC =7 for 1-2 cycles)
* RT (20 Gy in 10 fx)
246
Follow-up for stage I testciular
Serum markers q3 mons years 1-2, q6 months years 3-4 and annual
CT AP q6m 1-2 years, q6-12 months year 3 then annually
CXR as indicated
247
Treatment options for stage IIA seminoma
* RT to include para-aortics and ipsi iliac LN to dose of 30-36 Gy (preferred)
* EP x 4 (etoposide/cisplatin)
* BEP x 3 (bleo, etoposide, cisplatin)
248
Preferred treatment for stage IIB testicular
* EP x 4 (preferred)
* BEP x 3
* Dog leg RT to 36 Gy
249
Preferred treatment for IIC or III testicular
Chemo: EP x4, BEP x 3-4
250
Simulation for testicular
* supine
* immobilized in alpha cradle with arms at the sides
* CT based planning to contour the at risk nodal regions, block kidneys and rule out horseshoe kidney
* Clamshell on unaffected testicle
* Tape penis out of field
* Add 5 HVL block below treatment field
251
How much does testicular clamshell reduce dose
2-3x
252
Treatment technique for stage I testicle
* Treat para-aortics only
* AP/PA
* Superior T10/T11
* Inferior L5-S1
* Lateral: Tips of transverse processed for lumbar vertebrae with 2 cm margin on all nodes
* If LEFT sided, 1 cm margin on L renal hilar nodes
253
Treatment technique for stage II testicle
* Dogleg strategy
* AP/PA
* Contour the nodal regions using CT planning with 2 cm margin
* Superior (top of T11)
* Inferior (top of acetabulum)
* Lateral: edges of the transverse processed, width of 9-11 cm
* Block kidney!
* Deliver 20 Gy to full dog leg then boost to 30-36 Gy with 2 cm expansion of GTV
254
After testicular treatment, rate of fertility
~30%
255
If patients have low energy and libido after testicle cancer RT, options
Check testosterone, supplement
256
Testicular dose from PA field
25-40 cGy
257
What RT dose causes transient azospermia
50 cGy
258
RT dose for total azospermia
80-100 cGy, recovery in 1-2 years for some patients
259
RT dose causing total sterilization
200 cGy
260
RT level causing reduction in testosterone level
14 Gy
261
Kidney constrain for testicular cancer
At least 2/3 of 1 kidney \< 20 Gy
Combined mean dose \<18 Gy
262
Differences in management of non-seminoma
Do nerve sparing RPLND instead of RT
RT really only for brain mets
263
Medications prescribed to patient after LDR brachy
* Flomax
* Cipro x 3d
* NSAIDs or pyridium PRN
264
What is D90
Dose going to 90% of the prostate
D90 \>100%
265
What is V100
Volume receiving 100% of dose (100% IDL)
\>90-95%
266
What is V150 prostate goal
\<40%
267
What is V200 of the prostate goal
\<20%
268
Which patients next germline testing?
* FHx of high risk germline mutations (BRCA 1/2, Lynch)
* FHx is suspicious
* Presecen fo intraductal or cribriform histology in intermediate-risk PC
* High risk
* Very high risk
269
Criteria for very low risk prostate cancer
Must have all of the following:
* T1c
* Grade group 1
* PSA \< 10
* Fewer than 3 prostate fragments or cores positive
* \<50% disease in each fragment/core
* PSA density \< 0.15 ng/mL/g
270
Criteria for low risk PC
Has all the following but doesn't meet criteria for very low risk
* T1c or T2a
* Grade group 1
* PSA \< 10 ng/mL
271
Criteria for intermediate risk prostate cancer
Has all of the following:
* No high risk group features
* No very high risk group features
* Has one more more intermediate risk factors which are:
* T2b-T2c
* PSA 10-20
* Gleason group 2 or 3
272
Criteria for favorable intermediate risk
* Just 1 intermediate risk factor
* T2b-T2c
* Group 2 or 3
* PSA 10-20
* Gleason group 1 or 2
* \<50% biopsy cores positive
273
Criteria for unfavorable intermediate risk
* 2 or 3 intermediate risk factors
* Gleason Group 3
* \>/= 50% cores positive
274
Criteria for high risk prostate cancer
* No very high risk features
* Just one high risk feature
* T3a
* Gleason grade group 4 or 5
* PSA \> 20
275
Definition of very high risk prostate cancer
* Has at least one of the following:
* T3b or T4
* Primary gleason pattern 5
* 2 or 3 high risk features
* T3a
* PSA \> 20
* Gleason group 4 or 5
* \>4 cores with GG 4 or 5
276
Grade Group 1
= 6
277
Grade group 2
3+4=7
278
Grade group 3
4+3=7
279
Grade group 4
Gleason 8
280
Grade Group 5
9-10
281
Imaging for very low dose and low dose prostate cancer
Consider mpMRI to establish candidacy for AS
282
Imaging for favorable intermediate risk PC
* mpMRI
* CT AP recommended if nomogram predicts \>10% risk of pelvic nodes
* No bone imaging
283
Imaging for unfavorable risk PC
Bone imaging recommended if T2 and PSA \>10
CT AP if nomogram suggests \>10% risk of pelvic nodes
284
Imaging of high risk and very high risk
Bone imaging
CT AP
285
What is threshold to do LN dissection for surgery
\>2% on nomogram
286
Why do we dose escalate?
* Improves PFS (biochemical or clinical) by 10 – 20%
287
How does dose escalated RT change tox
Increases G2+ late GI toxicities 13 -\> 26%,
similar GU toxicity ~ 10%
288
What is the dose for conventional fx
1.8 x 44 = 79.2
289
What is dose for moderate hypo
2.5 x 28 = 70
290
What is dose for SBRT
7.25 x 5 = 36.25
291
Acceptable doses for M1 disease to prostate
55/20 (2.75)
36/6 (6)
292
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