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GU Flashcards

1
Q

Bladder cancer: indications for adjuvant radiaiton

A

pT3-4, positive nodes, positive margins, high grade

45-50.4Gy

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2
Q

Prostate: EBRT target coverage

A

98/100

min 95%

max 107%

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3
Q

Gleason grade group 4

A

4+4=8

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4
Q

Testis stage IIC

A

N3, S0-1

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5
Q

Bladder cancer: dose and fields

A

39.6Gy/22fxs to pelvis, 54Gy/30fxs to bladder, 64.8Gy/36fxs to tumor

Superior border: mid-SI, L4/5 if T4 or N+

inf: bottom of obturator foramen
lateral: 2 cm on pelvic brim
ant: 2.5 cm ant to bladder boundary
post: 2.5 cm beyond bladder/mass

block femoral heads, bowel, rectum

Bladder boost: 2.5 cm PTV around bladder

Tumor boost: use pre-CT, cysto mapping to delineate

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6
Q

Penile brachytherapy criteria

A

T1-2N0, size < 4cm, any grade

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7
Q

Stage II seminoma treatment paradigm(s)

A

orchiectomy with high inguinal ligation then:

Stage IIA: RT preferred

Stage IIB: EPx4 cycles (per NCCN), RT also an option

Stage IIC: BEP chemo, no RT

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8
Q

Testis pT2

A

limited to testis with LVSI

epididymis

tunica albuginea

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9
Q

Testis stage IIB

A

N2, S0-1

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10
Q

Prostate stage IVA/B

A

IVA: N1

IVB: M1

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11
Q

Prostate stage IIIB

A

T3-4N0

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12
Q

Bladder stage IIIA

A

T3a-T4a

N1

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13
Q

Urethral ca: workup

A

cystoscopy (with EUA and TUR), image pelvis and upper urinary tract, biopsy any suspicious nodes (could be infection)

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14
Q

Penis T4

A

adjacent structures

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15
Q

Testis stage IIA

A

N1, S0-1

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16
Q

Bladder T1

A

lamina propria

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17
Q

Testis stage IIIC

A

S3 or M1b

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18
Q

Prostate LDR brachy: dosimetry

A

Modified peripheral loading. Plan to 180 Gy for I-125

Seattle:

D90>90% (goal is 130%)

V100>98%

V150<40%

V200<20%

urethral Dmax <110-120

rectal D1cc <100%

calculation grid < 2mm x 2mm x axial slice width

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19
Q

Prostate: active surveillance criteria and management

A

Offer to very low and low risk patients. May offer to favorable intermediate risk if older (age >75).

PSA q6 mos

DRE q12 mos

Biopsy within 12 months with anterior directed cores, then serial biopsy every 2 years

If rising PSA and biopsy negative: Do MRI on suspicion of anteior lesion then biopsy

Progression=new Gleason score 7 or greater or significant increase in disease volume

at 10yrs, 65% remain on active surveillance

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20
Q

Testis pN1

A

5 fewer nodes, all <2cm

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21
Q

Testis stage IIIA

A

M1a, S0-1

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22
Q

Gleason grade group 2

A

3+4=7

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23
Q

Bladder N1

A

single node in true pelvis

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24
Q

Prostate stage I

A

low risk group

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25
Q

Penis clinical N1

A

unilateral inguinal node

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26
Q

Testis pN2

A

node 2-5cm in size, 6+ nodes, or ECE

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27
Q

Prostate: simulation

A

supine, vac loc, full bladder, empty rectum

fiducials prior to sim if not doing daily CBCT

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28
Q

Penis clinical N3

A

fixed inguinal node

pelvic nodal involvement

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29
Q

Urethra stage II

A

T2N0

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30
Q

Blader T4a

A

prostate, uterus, vagina

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31
Q

Prostate: leuprolide dose and MOA

A

7.5mg per month (30mg for 4 months)

LHRH analog

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32
Q

Urethra N1

A

single node (inguinal, pre-sacral, or true pelvis)

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33
Q

Seminoma: dose and fields for stage II

A

20 Gy in 10 fractions + 10 Gy boost to IIA nodes or 16 Gy to IIB nodes

Modified dog leg field:

T11/T12 down to top of acetabulum, 2 cm boost on gross nodal disease. At L5/S1, curve dogleg. New medial border should be medial obturator foramen, new lateral is acetabulum. Maintain 10-12 cm width if not contouring.

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34
Q

Salvage prostate: constraints for bladder and rectum

A

bladder minus CTV: V65 < 35%

rectum: V65 < 35%

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35
Q

Prostate: components of MSKCC nomogram

A

age, PSA, stage, GS, number of positive cores

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36
Q

Penis T1a

A

superficial, grade 1-2, no LVSI

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37
Q

Prostate stage IIB

A

intermediate risk, grade group 2

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38
Q

Seminoma: workup

A

H&P, undescended testicle, trauma, genetic syndromes, birth defects, sexual history, ipsilatearl surgery, horseshoe kidney, IBD

Imaging: U/S (homogenous hypoechoic mass, pathognomonic)

Fertility sparing: sperm banking

Labs: beta-HCG, AFP, LDH before and after surgery (post-surgery labs for TNM)

Surgery: radical inguinal orchiectomy with high ligation of spermatic cord

Post-op: serum markers at 6 wks, CT C/A/P

(If persistent elevation in markers after surgery, this is Stage IS and is treated with chemo alone)

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39
Q

Penis T2

A

spongiosum with or without urethral invasion

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40
Q

Bladder stage IVA

A

T4b or M1a

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41
Q

Prostate: contraindications to LDR brachytherapy

A

Absolute:

  • limited life expectancy
  • large TURP defect
  • absence of rectum
  • distant mets
  • high operative risk
  • ataxia telangiectasia

Relative:

  • IPSS score > 20
  • previous pelvic radiation
  • prior TURP (small)
  • large median lobe
  • gland size >60cc
  • IBD
42
Q

Testis pT3

A

spermatic cord

43
Q

stage I seminoma: follow up

A

H&P and CT q3mo for first year then q12 months. Per NCCN serum markers are optional and only recommended for bulky disease.

44
Q

Non-prostatic urethra T3

A

cavernosum or anterior vagina

45
Q

Non-prostatic urethra T2

A

spongiosum or periurethral tissue

46
Q

Bladder T4b

A

pelvic wall, abdominal wall

47
Q

Penis stage IIB

A

T3N0

T1b-2N0 is IIA

48
Q

Penis stage IIIB

A

N2

49
Q

Prostate: indications for salvage radiation

A

PSA rise to > 0.1 for 2 consecutive rises

50
Q

Prostate: bicalutamide dose and MOA

A

50mg daily if given with leuprolide

150mg daily if given alone

nonsteroidal antiandrogen

51
Q

Prostate stage IIA

A

intermediate risk, grade group 1

52
Q

Bladder cancer: 5yr OS and 5yr intact bladder

A

5yr OS 55%

5yr intact bladder 80%

53
Q

Prostate cancer: workup

A

H&P. PMH of cardiac disease, MI, diabetes, osteoporosis, TURP, AUA, sexual history inventory

Labs: PSA, CBC, CMP

54
Q

Roach formulas

A

ECE= 3/2 PSA + 10 (GS - 3)

SVI = PSA + 10(GS -6)

LN = 2/3 PSA + 10(GS-6)

55
Q

Seminoma: 10yr RFS for stage IIA, IIB, IIC

A

10yr RFS:

IIA 90%

IIB 80%

IIC 70%

56
Q

Testis pT4

A

scrotum

57
Q

Prostate: EBRT rectum V75 and V50

A

V75 < 15%

V50 < 50%

58
Q

Prostatic urethra T3

A

periprostatic fat

59
Q

Bladder cancer: criteria for bladder preservation

A

T2-T4a (per NCCN), no hydronephrosis, no extensive CIS, must have “maximal” TURBT

60
Q

Gleason grade group 5

A

gleason 9/10

61
Q

5yr bPFS for intermediate risk prostate cancer (EBRT)

A

5yr bPFS 85%

62
Q

stage I seminoma: recurrence rate with observation

A

15%

63
Q

Penis stage IV

A

any T4, N3, or M1

64
Q

Bladder T3

A

perivesical soft tissue

65
Q

Bladdder T2

A

muscularis propria

66
Q

5yr bPFS for low risk prostate cancer (EBRT)

A

5yr bPFS 95%

67
Q

Penile cancer: brachy and EBRT procedures

A

I would sterilze and drape the patient and place a foley catheter. I would insert 6 insterstitial needles and treat in two planes

60-65 Gy Ir-192 interstitial (limit urethra to 60 Gy) vs EBRT 40 Gy to shaft in box bolus plus 20 Gy boost with 2 cm margin. NCCN: 65-70 Gy with chemo

68
Q

Bladder stage IIIB

A

N2-3

69
Q

Prostate: when to order staging scans

A

Bone scan: unfavorable intermediate risk if T2 and PSA > 10, all high risk patients

Pelvic/abdominal imaging: intermediate or high risk patients if nomogram predicts >10% probability of pelvic nodal involvement

70
Q

Penis T3

A

cavernosum with or without urethral invasion

71
Q

Prostate stage IIIC

A

grade group 5

72
Q

Penis T1b

A

superficial, grade 3 and/or LVSI

73
Q

Prostate LDR brachytherapy: dose, half-life, seed strength, and energy for I-125 and Pd-103

A

I-125: 145Gy, 110Gy with EBRT, 60 days, ~0.5mCi, 28keV

Pd-103: 120Gy, 100Gy with EBRT, 17 days, ~1.5mCi, 21keV

74
Q

Testis pN3

A

node >5cm

75
Q

Prostate: EBRT femoral head constraint

A

V50 < 5%

76
Q

Prostate hypofrac: dosimetry

A

60Gy/30fxs as per PROFIT and CHHIP

rectal wall: D30<46 Gy, D50<37 Gy

bladder wall: same as rectum

femoral heads: D5<43 Gy

77
Q

Urethra stage III

A

T3 or N1

78
Q

Prostate stage IIC

A

intermediate risk, grade group 3

also grade group 4 with T1-2 and PSA < 20

79
Q

Seminoma: dose and fields for stage I

A

20Gy/10fxs

T11/T12 down to L5/S1 (i.e T12-L5), laterally out to transverse processes

80
Q

Prostate: indications for adjuvant radiation

A

T3a, T3b, positive margin

81
Q

Seminoma: kidney constraints

A

kidney D50% < 8Gy

Mean dose to both kidneys <9 Gy

For solitary kidney D15%<20 Gy

82
Q

Bladder stage II

A

T2N0

83
Q

OS for intermediate risk prostate cancer w/wo ADT

A

88% with ADT

78% without ADT

84
Q

Gleason grade group 1

A

3+3=6

85
Q

Bladder cancer: simulation

A

supine, vac loc, scan with empty and full bladder

86
Q

Gleason grade group 3

A

4+3=7

87
Q

Testis pT1

A

limited to testis, no LVSI

88
Q

Testis S2 criteria

A

LDH 1-10x upper limit of normal

hCG 5k-50k

AFP 1k-10k

89
Q

Bladder N3

A

common iliac nodes

90
Q

Penis clinical N2

A

multiple unilateral inguinal nodes or bilateral inguinal nodes

91
Q

Seminoma: simulation

A

supine, clamshell, position penis out of field

92
Q

Bladder N2

A

multiple nodes in true pelvis

93
Q

Prostate LDR brachy: treatment narrative

A

I would first bring the patient to the clinic to perform a transrectal ultrasound guided volume study of the prostate. The patient would have done a bowel prep. the night before. I would place the patient in the dorsal lithotomy position and prep and drape. I would insert a foley with aerated jelly. Using a transrectal ultrasound with US gel, I would take images every 1 mm. I would assess for any pubic arch interference and record the angles of the probe and legs once finished. I would use these images to create a pre-plan using a peripheral loading technique with PTV of 3 mm laterally and 0 mm anteriorly and posteriorly. I would then take the patient to the OR and position the patient as in the pre-plan with general anesthesia. I would prep and drape the patient, place the templates, and load the seeds according to the plan. Once finished I would take AP and lateral orthogonal films in the OR to check the positioning of the seeds and do a rectal examination. The patient would then return one month later for post-implant CT and dosimetry.

94
Q

Bladder cancer: workup

A

H&P, hematuria, dysuria, urinary obstruction, fever, travel history, smoking history, dye/toxin exposure

Labs: CBC, CMP, alk phos, UA w/ cytology

Cystoscopy with maximal TURBT, tumor mapping

Imaging: PET/CT, image upper tract with CT/MR urogram

95
Q

Prostatic urethra T2

A

prostatic stroma

96
Q

Stage I seminoma treatment paradigm

A

orchiectomy with high inguinal ligation

observation

carboplatin AUC 7 x 1 cycle

xrt 20Gy/10fxs

97
Q

Testis stage IIIB

A

S2

98
Q

Penis stage IIIA

A

N1

99
Q

Prostate: EBRT bladder V75 and V65

A

V75 < 25%

V65 < 50%

100
Q

Prostate stage IIIA

A

PSA > 20

OB2 (10 decks)

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