GU Flashcards
(71 cards)
1
Q
Prostate H/P
A
AUA, prior TURP, prior RT, IBD, ED, comorbidities, family history, DRE – gland size, nodules
2
Q
PSA parameters concerning for cancer:
A
PSA parameters concerning for cancer:
Density (serum PSA/volume gland): >0.15 ng/mL/g
Free-to-total PSA: < 7%
Velocity (annual rate of change): > 2 ng/mL/yr
3
Q
AUA components
A
AUA:
Scored 0-5 (NEW-FUSH)
•Nocturia
•Emptying
•Weak stream
•Frequency
•Urgency
•Straining
•Hesitancy
4
Q
USPTF SCREENING guidelines:
NCCN screen:
A
USPTF SCREENING guidelines: age 55-69 make informed decision class C
NCCN screen: risk fx- fhx, family or personal hx of germiline mutations (BRAC2), hx of prostate disease or bx, African ancestry, medications.
-45-75 obtain PSA
-40-75 with risks.
-PSA<1 normal DRE: repeat 2/4 yrs
-PSA1-3 normal DRE: repeat 1 yr
->3 or abnormal DRE: bx
5
Q
Very Low strat
A
T1c, G6, PSA<10, ≤2 cores, PSA density <0.15 ng/mL/g
6
Q
Low Strat
A
Low (T1a-T2a, G6, PSA <10)
7
Q
Prostate T Staging
A
T1a-c: clinically inapparent, detected by bx
T2a: ½ of 1 lobe or less
T2b: more than ½ of one of the lobes
T2c: both lobes
T3a: ECE and micro bladder neck
T3b: SV
T4: bladder, levator, pelvic wall
N1: regional nodes
M1a: non-regional nodes
M1b: bone
M1c: other sites
8
Q
Prostate overall stage
A
I: T1-T2a, PSA <10, GG1 (LR)
IIA: GG 1 and either T2b-c or PSA 10-20
IIB: GG 2
IIC: GG 3-4, T1-2, PSA < 20
IIIA: PSA > 20
IIIB: T 3-4
IIIC: GG 5
IVA: N1
IVB : M1
9
Q
Intermediate Risk factors and workup
A
Risk factors:
T2b-T2c
GG2-3
PSA 10-20
Favorable: (all)
1 Factor
<50% biopsy cores
if AS considered mpMRI w/biopsy or molecular analysis
Unfavorable:
2+ factors
GG3
>=50% cores
Bone and soft tissue imaging
10
Q
High Risk Strat
A
one of:
T3a
GG4-5
PSA>20
Bone and soft tissue imaging
11
Q
Very high risk
A
T3b-T4
Primary Gl 5
2 high risk factors
>4 cores GG 4-5
Bone and soft tissue imaging
12
Q
Life expectancy
20
10
5
A
20y: 62
10y: 76
5y: 86
13
Q
Very low risk treatment
A
>20 yr life expectancy: <62
- Active surveillance
- IMRT alone
- Brachy alone
- RP with PLND if prob LN mets > 2%
10-20 yr life expectancy: 62 - 76
- Active surveillance
- -PSA q 6 mo
- -DRE q 12 mo
- -Re-bx after 12 mo, then if PSA >50% in 1 yr (ProtecT) or PSA DT <3 yrs (Klotz)
- can get prostate MRI
14
Q
Low risk treatment
A
Low risk: 10y life expectancy: <76
1) AS
2) IMRT
3) Brachy alone (LDR)
- I-125 (t½ 60d), source activity 0.5, 145 Gy, 110 combined
- Pd-103 (t½17d) 125 Gy, 100 combined
4) RP with PLND if prob LN mets > 2%
- preferred for young age
- if + margins, SVI, ECE, or detectable PSA, early salvage RT
- if LN+ on PLND, RT+ADT
Triggers to end AS/start tx (30% will need tx by 3 yrs, 50% by 10 yrs) is
- increase in # of cores
- increase in Gleason
- clinical progression
- PSA>10
15
Q
Favorable intermediate age cutoffs
A
<5: Observation
5-10y: Observation preferred, EBRT or brachy
>10y: AS, EBRT or brachy, RP
16
Q
Unfavorable intermediate age cutoffs
A
Unfavorable intermediate age cutoffs
>10: RP or EBRT+ADT +/- brachy
5-10: EBRT or obs
17
Q
High risk age cutoffs
A
>5 or symptomatic: treat
<5 and asymptomatic: obs, or ADT or EBRT
18
Q
Brachy contraindications
A
Brachy contra:
-AUA/IPSS >15
-Prostate size/anatomy
Pros >60 cc (<15 cc)
Pubic arch interfer
Median lobe hyper
-T3 disease
-Prior TURP w big defect
19
Q
Prostate Sim
A
- CT simulation
- fiducials/spacer gel placed a week ahead of time
- enema beforehand
- bladder fill with 16-24 oz
- bring to CT room 30 min after drinking
- supine position, knee fix
- acquire CT, set iso to prostate
CTV = prostate and proximal 1 cm SV PTV = CTV + 7 mm margin (5 mm posterior)
20
Q
Brachy procedure
A
Brachy – IODINE 125 (half life 60 days) = 145 Gy
Pre-op
-1 week prior to implant bring pt in for volume study of prostate, determination of favorable anatomy (no pubic arch interference), and creation of preplan to order seeds
-gen med or cardiac clearance
-Flomax 1-2 weeks before
-bowel prep day before
-stop ASA, Plavix, 7 days before; NSAIDS 2-3 days
Day of:
- bring pt to OR with GA
- placed in lithotomy position in stir-ups
- perineum is prepped with betadine
- foley catheter is placed – 120 cc in bladder
- 4 mg Decadron intra-op
- TRUS is secured to table
- insert TRUS: make sure prostate is centered on template (base = 0.0), with urethra in central sagittal plane
- scan prostate
- contour bladder, prostate, rectum, urethra
- make plan based on this contour
- contruct needles with seeds and spacers
- place contructed needles based on plan
- while inserting needles under ultrasound guidance, visualize in the desired plane (rotating bevel can help visualize). Verify position with sagittal and transverse US.
- post-implant room survey
- pt discharged after urinating
- discharge with Flomax, NSAIDs, Pyridium, and Bactrim x 3 days
21
Q
PSA Nadir
A
PSA nadir:
•4 wk after RP
•~3 yrs after EBRT or brachy
22
Q
PSA bounce
A
PSA bounce (transient rise in PSA usually \< 2 ng/ml): 20-30% incidence median 1 year
23
Q
Brachy planning goals and constraints
A
D90>95%
V100>95%
V200<20%
Urethra V125% < 1cc
Rectal V100% < 1cc
24
Q
Prostate 70/28 constraints
A
Rectum/Bladder:
V45 < 45%
V65 < 15%
Bowel/Heads: max 52
25
Prostate conventional constraints
Rectum/Bladder:
V45 \< 50%
V70 \< 15%
Bowel/Heads max 52
26
Phoenix definition
nadir +2 regardless of HT or not
27
Prostate MRI
Prostate MRI
- T2: lesion is hypointense
- DWI: restricted diffusion
- ADC: low #s
-normal: always T2 – peripheral zone is BRIGHT (this is part of the prostate!) – obturator internus – ALZ – know anatomy; if urine is bright it is T2.
28
Prostate EBRT side effects
Acute GU:
•Grade 2: 20-30%
•Grade 3: \<5%
Late GU:
•Grade 2 (chronic urethritis+meds): 10%
•Grade 3 (strictures): \<1%
Acute GI:
G2: 30-40%
G3: \< 5%
Late GI:
•Grade 2 rectal bleeding: \<5%
•Grade 3 rectal bleeding (requiring transfusion or laser cauterization): \<1%
ED: 30-50%
Depends on age and pre-tx fxn
\>90% have reduction of ejaculate
Toxicity of Brachy:
Acute GU higher (40-50% G2); Acute GI lower; 3% risk urethral stricture
Frequency
-tx w Flomax 0.4 mg PO daily
Dysuria
- tx w pyridium 200 mg PO 4 times daily (orange pee!) or ibuprofen or Flomax
- ditropan 5-10 mg PO daily
- FOLEY after brachy if needed (if peeing more than hourly)
ED:
- sildenafil 60-70% improvement
- inject PGY1
- pump
- prosthesis
Radiation proctitis
- diet
- proctofoam
- argon laser coagulation
Radiation cystitis/urinating blood
- continuous bladder irrigation
- aluminum instillation
- HBO
- consult IR – thrombse internal vesical artery
SM – 1 in 300 10-15 years out
29
Prostate efficacy bPFS and CSS
bpfs - CSS
Low : 85% , \>95%
Int: 80%, \>90%
High: 60%, 85%
30
Biochem Failure post RALP
PSA ½ life is 3 days. Post-op PSA should be 0 in 2 wks
- PSA needs to be \>0.1 to be failure
- PSA \>0.1 ng/ml on 2 occasions or single PSA \>0.4 (after RT it is \>2 than nadir)
- check PSA 1 month after surgery, if 5 1 week after that is okay, wait 10 half lives
31
Salvage Post prostatectomy
N+ or persistently positive PSA
Early salvage all others
32
PSA level to add ADT and nodes in salvage setting
0.5
33
Salvage CTV volumes
The CTV would be the prostate bed defined as:
- Superior: SV or vas deferens; or 3 cm above pubis
- Inferior: at the top of the penile bulb or 1 cm below the vesicourethral anastomosis, 1 cm below urine
Below pubic symphysis
- Anterior: just posterior to pubic symphysis
- Posterior: anterior border of rectal wall
- Lateral: medial border of levator ani
Above pubic symphysis
- Anterior: 1-2 cm of bladder
- Posterior: mesorectal fascia
- Lateral: sacrorectogenitopubic fascia
INCLUDE RETAINED SVs if involved
PTV= 1 cm (5 mm posteriorly) with daily CBCT
Dose: 66Gy / 46Gy
34
Salvage Constraints
Bladder-CTV:
V65\<50%;
Rectum:
V65\<35%;
35
PIRADS
PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present)
PI-RADS 2: low (clinically significant cancer is unlikely to be present)
PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal)
PI-RADS 4: high (clinically significant cancer is likely to be present)
PI-RADS 5: very high (clinically significant cancer is highly likely to be present)
36
Half life bHCG and AFP
bHCG ~ 24 hours
AFP ~ 6 days
37
Testicular 1st echelon nodes
1st echelon nodes:
- PA (right), left renal hilum (left)
- with scrotal invasion, inguinal nodes at risk
38
Testicular ddx
testicular mass Ddx:
torsion,
infection (e.g. epididymitis),
hydrocele,
varicocele;
cancer (GCT, lymphoma, stromal tumors, sarcoma)
39
Testicular H/P
- ?h/o cryptorchidism (undescended testes), inguinal surgery, horseshoe kidney
- B/L testicular exam, lungs, liver, nodes
40
Testicular Workup
Labs:
B-HCG: \< 50 (if VERY high, think choriocarcinoma)
AFP: \<10 nl (never elevated in pure seminomas)
LDH: 100-330 nl
CBC, chemistries
Imaging:
- B/L testicular U/S (tumors are hypoechoic)
- CXR (pre-op)
Biopsy: no need, consider contralateral if suspicious
Other:
Consults: fertility assessment +/- sperm banking
- Pre-RT sperm counts low (40% w/ azospermia)
41
Testicular initial treatment
Radical inguinal orchiectomy w/ high ligation of spermatic cord
PATH:
LVI
Size
Rete testis : carries sperm from seminiferous tubules to vas deferens
42
What to do after surgery for Testicular
Staging is based on POST-ORCHIECTOMY labs/etc.:
- CT abd/pelvis
- CT chest if positive CT a/p or abnl CXR
- repeat b-HCG, AFP, LDH
43
Testicular S stage
S0: normal
S1: LDH \<1.5 ULN, hCG \<5,000, AFP \<1,000
S2: LDH 1.5-10 ULN, hCG 5,000-50,000, AFP 1,000-10,000
S3: LDH \>10 ULN, hCG \>50,000, AFP \>10,000
44
Testicular T/N/M staging
T1: testis, epididymis, tunica albuginea
T1a \<3cm
T1b \>3cm
T2: LVSI or tunica vaginalis or hilar invasion
T3: spermatic cord
T4: scrotum
N1: LN 0.1-2 cm, ≤5 LNs
N2: 2.1-5cm or \>5 LNs (or pECE)
N3: \> 5cm
(\>= 10 mm short axis 37% sensitivity, 100% spec)
M1a: nonRP nodal or pulm mets
M1b: nonpulm visceral mets
45
Testicular overall stage
IA: T1
IB: T2-4
IS: N0 S+
IIA: N1 S0-1
IIB: N2 S0-1
IIC: N3 S0-1
IIIA: M1a, S0-1
IIIB: [N+ or M1a] AND S2
IIIC: ([N+ or M1a] AND S3) OR any M1b
46
IA/B: Seminoma (AFP neg) adj treatment
IA/B: Seminoma (AFP neg)
1) Surveillance (NCCN preferred for pT1-3):
- H&P and labs q 3 mo x yr 1, q 6 mo x yrs 2-3, then annual
- CT a/p @3, 6, 12mo, then annually through 5 yrs
- CXR as clinically indicated
- relapse rate 15-20% at 5 yrs-stop surveillance at 5 years
2) PA RT 20/2 Gy (midplane)
- used to be recommend for rete testis invasion or tumor \> 4 cm, but is no longer (Chung JCO 2010)
3) Carboplatin AUC 7 x 1
- who to treat: in jail, in 60s
47
IS testicular
Repeat workup, treat accordingly
48
Seminoma IIA
IIA: N1 S0-1
1. RT : DL 20/2 + 10/2 boost = 30 Gy
2. Chemo alone: BEP x 3
- bleomycin 30, etoposide 100, cisplatin 20 q 3 weeks
49
Seminoma IIB
IIB: N2 S0-1
1. RT: DL 20/2 + 16/2 boost = 36 Gy
2. Chemo alone (NCCN preferred): BEP x 3
50
NSGCT treatment
NSGCT (elevated AFP):
IA: orchiectomy + surveillance
IB/IIA: orchiectomy + open nerve-sparing RPLND BEP X 2-3
IIB: BEP chemo x 3
IIC+: BEP chemo
RPLND for post-chemo residual mass \> 1 cm (no PET needed)
51
Seminoma simulation
SPERM BANKING AND SPERM ANALYSIS
ZOFRAN
Simulate supine, arms at side with custom immobilization
Clamshell shield on contralat testicle
Move penis out of field
Target: PA nodes +/- ipsi iliac (common, int, ext to top of acetabulum)
-only include inguinals if prior pelvic surgery
52
Seminoma PA field
PA radiation:
CTV=(IVC+1 cm) + (aorta + 2 cm)
PTV=CTV+0.5 cm
Daily KV imaging
Goal is targeting para-aortic, paracaval, and preaortic nodes
\*dogleg if prior pelvic surgery\*
Fields
-T11/T12 – L5/S1
-lateral transverse process or 2 cm on nodes
\* no longer need to cover renal hilar nodes
53
seminoma DL field
Modified DL Radiation
CTV=(IVC+1 cm) + (aorta + 2 cm)+ (ipsilat common, external, and prox int iliac + 1 cm)
-nodes down to top of acetabulum
CTV\_boost=GTV+1 cm
PTV=CTV+0.5 cm
(2 cm to block edge for boost)
Fields:
T11/12 to L5-S1 then diagonal down to top of acetabulum or top of obturator foramen
Full DL Radiation:
Modified DL + inguinals
Use CLAMSHELL: reduces dose by ~2-3x
PA w/ clamshell = 0.6 cGy
Dogleg w/clamshell = 1.5 cGy
54
Seminoma constraint
Kidney: D50% \< 8 Gy (no more than 50% of each kidney can receive 8 Gy or higher). If only one kidney, D15% \< 20 Gy
V20\<70%
Stomach
Bowel
55
seminoma RFS 10 y OS, side effects
5y RFS 97%; 10 yr OS \> 90%
Acute: n/v, enteritis, fatigue, bone marrow suppression
-give antiemetic prophylaxis!
Late:
Secondary malignancy: 2nd neoplasms (RR=2-3); 5-10% increased as compared to baseline population
Risk of 2nd cancer was 16% at 25 yrs and 23% at 30 yrs compared to expected 9% and 14% for general population (Travis, JNCI)
Infertility:
1/5 azospermia
-1/3 oligospermia
with clam shell 1-2% of primary dose reaches testis
-25-50cGy if Stage I
-35-70cGy if Stage II
-This ignores internal scatter
- 1Gy causes total azoospermia
- 50cGy cases transient azoospermia, 50% recover at 1 year
\*\* try not to have kids for 1 year following tx
\*\* 30% able to have children after RT
56
Radical Cystectomy
Radical cystectomy:
•Male= bladder/prostate/sv/vas deferens/proximal urethra
•Female=bladder/urethra/TAH-BSO and anterior vaginal wall
•Incontinent diversion – ureters to ileal loop to skin to urostomy bag
-includes bilateral pelvic LND; common, int, ext iliac and obturator nodes
•Continent (80% continence rate if attempted):
-ureters to ileal loop to skin to stoma which is catheterized
-neobladder: detubularized intestine to urethra, allows volitional voiding
57
Bladder LN drainage
LN drainage:
- perivesicular
- external iliac
- internal iliac
- common iliac
(not pre-sacral)
58
Bladder H/P
History: hematuria, dysuria, pelvic/back pain
-risk factors: smoking, chemical exposure (dyes, rubber, plastics, leathers)
Physical: abdominal exam, pelvic for women, CVA tenderness, LNs, rectal exam, penile/testicular for men
59
Bladder workup
Labs: CBC, CMP, alk phos, UA with urine cytology (not very sensitive)
Imaging: office cystoscopy
Once dx of muscle invasive made:
-CT c/a/p w/ CT urography
-Or otherwise image upper tract – IVP, MRI urogram, renal US with retrograde pyelogram (5% synchronous lesions)
-Bone scan – if clinical suspicion or symptoms
60
Bladder surgical eval
Primary eval/surgical tx:
- EUA with bimanual exam
- Cystoscopy with bladder mapping, biopsy of any masses, bx prostatic urethra if lesion in trigone
- TURBT with random bx to exclude CIS
- Should include bladder wall muscle (detrusor)
On path:
- is muscle present and/or involved?
- is there LVSI?
- Cis is risk factor for more multiple lesions/aggressive histology
61
Bladder Staging
Ta: non-invasive papillary
Tis: CIS (flat)
T1: lamina propria
T2: invades muscularis propria
T2a: inner 1/2
T2b: outer 1/2
T3: invades perivesicular tissue
T3a: microscopic
T3b: macro, ie-extravesicular mass)
T4: adjacent organs
a-prostate, uterus, vagina
b-pelvic or abdominal sidewall
N1: single pelvic below common iliac
N2: multiple pelvic below common iliac
N3: common iliac
M1a: LN beyond com. iliac
M1b: non-LN distant met
I – T1
II – T2
IIIA – T3-T4a and/or N1
IIIB – N2-3
IVA – T4b and/or M1a
IVB – M1b
62
BCT contraindications:
BCT contraindications:
- hydronephrosis
- poor renal function
- poor bladder function
- ca in situ (Cis)
- diffuse bladder involvement
- common iliac nodes
63
Bladder Non muscle invasive TX
Non-invasive:
Ta:
Low gr: TURBT
High gr: TURBT -\> BCG
T1:
Low gr: TURBT -\> BCG
High gr: TURBT -\> BCG
Tis: TURBT -\> BCG 50 mg q wk x 6
-other adj intravesicular agents include MMC
64
Muscle invasive (cT2-T4aN0) treatment
Muscle invasive (cT2-T4aN0):
1. Neoadj gem/cis x 4 -\> radical cystectomy w LND
- Neoadj gem/cis x 4 -\> partial cystectomy if unifocal T2 without CIS or trigone involvement that can be removed w/ 2 cm margin
- if neo-adj chemo not given, give adj chemo for pT3-4 or N+
2. Bladder preservation for the best players\*\*
- max TURBT (+/- fiducials)
- Cisplatin + RT 55/20
- re-cysto at 3 months. If PR, salvage cystectomy or BCG if small. If CR, surveillance
65
Bladder T4b, N+, or Medically inoperable:
T4b, N+, or Medically inoperable:
1. Definitive chemoRT
55/20 w/ cisplatin
2. Cis/Gem x3-\> if response, cystectomy or chemoRT
3. Chemo alone
66
Bladder Sim, Volumes
-Ensure maximal TURBT performed, and bladder mapping
\*\*\*\*\*only treat nodes if N+\*\*\*\*
CT simulation
-supine, immobilized, empty bladder, CT w/ contrast
GTV=gross tumor on CT/MRI/TUBRT map
(CTV\_44=GTV+ whole bladder + prostate + LN (ext iliac, int iliac, obturator – not common)
PTV\_44=CTV + 1.5 ant, 1 cm post/lat, 0.5 inf, 2 cm sup)
CTV\_55=GTV+ whole bladder + 1 cm
PTV\_55=CTV + 0.5 cm
Exclude bowel from PTV
67
Bladder small pelvis fields
Small pelvis fields: AP-PA and laterals
- - sup – mid SI (S2/3)
- - inf – bottom of obturator foramen or 2 cm below tumor (treating prostate in men)
- - lat – 2 cm on pelvic brim (block fem heads)
Laterals – same sup-inf,
2 cm ant/post margin on bladder w blocks for rectum, small bowel (corner block under symphysis, corner block ant/sup, anterior to ext. iliacs)
68
Bladder Constraints
Rectum
- V50 \<10%
Bowel: exclude from PTV
-max 53 Gy
69
Bladder 5 y OS
5 yr OS (cystectomy/bladder preservation) – LF
Ta: 95%
T1: 70%
T2: 60/60% – 5%/
T3-T4: 40/40% – 10-50%/
75% CR rate (only ~35% if hydronephrosis)
50-70% with functioning bladder
1/3 require cystectomy (only \<5% due to RT complications)
N+: 5 yr OS 30%
M+: MS 6-12 months
70
Bladder FU
Follow-up:
- Cystoscopy with cytology q 3 mo x 1 yr, then q 6-12 months
- Image upper tract q 1-2 yrs
- For muscle invasive disease, add: CT c/a/p q 6 months x 2 yrs, then as clinically indicated
- For bladder preservation, add: selected mapping biopsy q 6 mo x yr 1-2
Dysuriia: pyridium, Ditropan because it’s a muscle relaxant– not flomax
71
Penile staging
T1: subepithelial connective tissue
- T1a is no LVI, PNI, G3-4
- T1b is LVI, PNI, or G3-4
T2: corpus spongiosum (w/ or w/out urethral invasion)
T3: corpus cavernosus (w/ or w/out urethral invasion)
T4: other adj structures
Clinical
N1: single inguinal node
N2: multiple or bilat inguinal
N3: fixed inguinal or pelvic
Path
N1: 1-2 U/L ingnl, no ECE
N2: \>=3 U/L or B/L
N3: ECE or pelvic
