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FRCR2 > Prostate > Flashcards

Prostate Flashcards

1
Q

What is the commonest prostate cancer histology
What are the others and how are they broadly managed

A

Adenocarcinoma
Small cell - manage as per small cell lung
TCC - typically of prostatic urethra - manage as bladder

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2
Q

Does renal function affect PSA

A

No

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3
Q

What are the 2WW referral limits for PSA, by age

A

40–49yrs: 0 - 2.5
50–59yrs: 0 - 3.5
60–69yrs: 0 - 4.5
70–79yrs: 0 – 6.5

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4
Q

When is staging (CT & bone scan) done for prostate cancer

A

High risk cases - Gleason 8, PSA >20, T2c

CPG1-2 - no staging needed
CPG 3 - Bone scan +/- CTCAP
CPG 4-5 - bone scan, CTCAP +/- PSMA PET

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5
Q

When is a PSMA PET scan indicated

A

HIgh risk pts ahead of radical tx - Gl 8, T2c, PSA >20

Suspected recurrence in patients with a rapidly rising PSA and negative or equivocal imaging where results would directly influence pt management

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6
Q

What are the treatment options split by risk for localised prostate cancer

A

Low risk - active surveillance, radical prostatectomy, EBRT only, or LDR brachytherapy

Intermediate risk - radical prostatectomy, LDR brachytherapy, 6/12 ADT with EBRT, HDR brachytherapy followed by EBRT

High risk - 3yr ADT with EBRT, HDR brachytherapy followed by EBRT

Very high risk - up front docetaxel

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7
Q

What are the categories of brachytherapy and what are the indications

A
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8
Q

What are the treatment options for relapsed prostate cancer after radical treatment

A

Relapse following RT - observation with delayed ADT, or local salvage - radical prostatectomy, HDR brachy

Relapse following surgery - prostate bed RT, consider 6-24mths ADT

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9
Q

What does active surveillance consist of

A

Yr1:
3-4mthly PSA
12mth dre
12-18mth MRI

Yr2:
6mthly PSA
12mth dre

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10
Q

What are advantages and disadvantages of a radical prostatectomy

A

Advantages
Immediate treatment
No androgen deprivation
Full histology
Easier to monitor PSA (should be undetectable)

Disadvantages
Higher rates of erectile dysfunction and incontinence
Erectile dysfunction (50%): can do nerve sparing operation
Urinary morbidity: 80% continent by 3 months
Likely to need adjuvant RT if T3 disease
25% risk of +ve margins: lack of tissue around prostate, esp at apex to allow wide margins

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11
Q

What are the side effects of ADT

A

Hot flushes
Erectile dysfunction and loss of libido
Osteoporosis
Mood change
Fatigue
Gynaecomastia

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12
Q

What can be given to treat hot flushes as a side effect

A

1st line: medroxyprogesterone 20mg OD for 10 weeks initially
2nd line: cyproterone acetate 50mg BD for 4 weeks then review

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13
Q

What formula determines whether to treat the SV or not

And at what thresholds

A

= PSA + [(Gl -6) x10]

Low risk: <15% - base of SV only;
High risk: >15% or pathologically involved – whole SVs

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14
Q

What RT dose is given to the prostate, nodes (if treated), and SV

A

Prostate - 60Gy/20#
SV - 48Gy/20#
Pelvic nodes - 44Gy/20# (47Gy within pivotal boost)

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15
Q

What is the dose regime for HDR brachy followed by EBRT

A

Brachy boost - 15Gy/1# (brachy) followed by 37Gy/15# (EBRT) over 3 weeks (prostate only) or 46Gy/23# (prostate and nodes) IMRT

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16
Q

What RT volumes are included for a low or intermediate risk prostate cancer, and how are these defined

A

Low - int risk: ≤T2c, Gl 6-7, PSA ≤20

Volumes:
GTVp- prostate only
GTVpsv - prostate & SVs
<15% Roach -> prox 2cm of SV
15-30% Roach -> whole SVs

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17
Q

What is the hypofractionated dose for prostate SABR

A

36.25Gy/5#/2wks

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18
Q

What is the rate of erectile dysfunction after radical prostate RT
And bladder/bowel toxicity

A

40%
10-15% Urinary and bowel changes
Bowel and bladder - 95% minimal & 5% moderate-severe s/e

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19
Q

What are the indications for adjuvant RT for prostate cancer

A

T3 disease, Gleason 8+, Positive margins

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20
Q

What are the three options for inclusion of brachytherapy & what dose

A

LDR only - approx 145Gy
HDR brachy (15Gy) followed by EBRT 37.5Gy/15#/3wks, 2wks later
EBRT 46Gy/23# followed by LDR brachy boost (115Gy)

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21
Q

When is brachytherapy contraindicated

A

Previous TURP - high risk of urinary incontinence
IPSS >15 ie urinary outflow restriction - more likely to have complications
Gland >50ml & likelihood of pubic arch interference
Inability to undergo anaesthesia

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22
Q

What isotope does LDR brachy use

A

I-125 - 50-70 seeds, T1/2 60days

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23
Q

When is LDR brachy indicated
What is the advantage
What are the disadvantages

A

Low and intermediate risk pts - up to T2b/c (TBC)
(<T2a, Gleason ≤7, PSA ≤10)
IPSS score low, <10 ideally
Prostate volume <50ml

Advantage - lower risk of impotence and incontinence

Disadvantage - higher rate of acute urinary retention & dysuria
Radiation protection issues for 6mths post implant

24
Q

What are the side effects of LDR brachy

A

Urinary:
Urethritis - 50% have moderate urinary sx at 6mths
10% risk of acute urinary retention in first 2wks (higher risk for high IPSS and large prostate)
Urethral stenosis

Rectal - 5% proctitis, intermittent bleeding and discomfort. 0.1-0.2% risk of fistula

Erectile function - 30-40% risk of erectile dysfunction

25
Q

What is the indication for EBRT followed by an LDR brachy boost
What is the advantage demonstrated by what trial
Is ADT given or not

A

Int-high risk pts
Improved 7yr PFS benefit according to Ascende RT trial
Trial also gave 12mths ADT

26
Q

What is the indication for HDR brachy +EBRT
What is the dose used

A

Intermediate and high risk pts
46Gy/23# EBRT followed by 15Gy HDR boost as 2x 8.5Gy (although can be other way round)

27
Q

What is the GTV-CTV and CTV-PTV margin for prostate EBRT

A

GTVp/psv - Prostate & SVs
CTVp - GTVp + 5mm
PTVp - CTVp + 10mm

28
Q

What is the GTV-CTV and CTV-PTV margin for involved nodal EBRT

A

GTVn-CTVn - 1cm margin
CTVn-PTVn - 0.7cm

29
Q

What is the indication for breast bud irradiation
And what dose and modality is used

A

Prophylaxis of gynaecomastia on bicalutamide (if planned for >6mths), or treatment of established symptoms

Dose:
8Gy/1# by electrons or orthovoltage
15Gy/3#/1wk alternate days with photons

30
Q

What histological marker is seen in prostate small cell carcinoma

A

TMP RSS2:ERG gene fusion seen by FISH

31
Q

What is the definition of biochemical relapse after RT

A

Phoenix definition: rise of PSA nadir +2

32
Q

What workup is considered for a relapsed prostate cancer

A

CTCAP, bone scan, and PET / PSMA PET, to determine extent of recurrence

33
Q

What are the treatment options for a biochemical relapse of prostate cancer after RT

A

Consider restarting ADT (indications - symptomatic disease, proven mets, PSA doubling time <3mths)
Prostatectomy
HDR brachytherapy
HIFU

34
Q

What are the indications to restart ADT following biochemical relapse of prostate cancer

A

Symptomatic disease
Proven mets
PSA doubling time <3mths

35
Q

What is the rate of biochemical relapse following prostatectomy, and how is it defined

A

20-40%
3 consecutive rises in PSA, or persistently rising PSA >0.2

36
Q

What is the dose for salvage RT to the prostate bed, for biochemical relapse following prostatectomy

What is the rate of biochemical control

A

55Gy/20#

5yr biochemical control with salvage RT 88% as per the Radicals-RT trial

37
Q

When should ADT be considered post surgery at biochemical relapse

A

Men with risk factors prior to salvage RT - PSA >0.7, Gl8-10, positive margins at surgery

Spport trial randomised to prorate bed RT only, prostate bed RT & 6mths ADT, and prostate bed and pelvic nodes RT & 6mths ADT.
There was an increasing rate of freedom from progression, and distant metastasis rates were significantly lower for the triple treatment approach

38
Q

How is high risk non-metastatic castrate-sensitive prostate cancer defined

How are these patients treated

A

Node positive disease
OR
at least 2 of T3/4, PSA >40, Gleason 8-10

Tx:
consider upfront docetaxel
ADT (3yrs)
Abiraterone and pred

39
Q

How is non-metastatic castrate resistant prostate cancer defined

And how is high risk NM-CRPC defined

What treatment is indicated

And based on what trials

A

No mets on conventional imaging (excluding PSMA PET)
Rising PSA
Suppressed testosterone <50 (castrate)

High risk:
Also Baseline PSA >2
Rising PSA with doubling time <10mths, taken from 3 readings at least one week apart

Tx:
ADT (3yrs), likely with EBRT
ARTA - apalutamide, darolutamide, enzalutamide

Based on Spartan / Prosper / Aramis trials
Increase in time to progression

40
Q

When is enzalutamide contraindicated
What needs to be seen before prescribing it

A

Epilepsy - can lower seizure threshold

Need to see that cancer is hormone responsive, ie falling PSA in response to ADT (castrate sensitive) before giving enzalutamide

41
Q

When is apalutamide indicated

A

High risk non-metastatic castrate resistant PC, with ADT
Metastatic hormone sensitive prostate cancer in combination with ADT

42
Q

What are the indications for enzalutamide

A

Non-metastatic castrate-resistant prostate cancer
Metastatic hormone sensitive prostate cancer
Metastatic castrate resistant prostate cancer (before or after docetaxel)

43
Q

What are the indications for darolutamide

A

Non-metastatic castration-resistant prostate cancer (nmCRPC) who are at high risk of developing metastatic disease

In combination with docetaxel & ADT for newly diagnosed metastatic hormone-sensitive prostate cancer

44
Q

What is the purpose of oligometastatic directed treatment in the hormone sensitive setting

A

To delay the start of ADT

45
Q

What are the treatment options for a new presentation of metastatic hormone sensitive prostate cancer

A

If low vol disease - ADT + enza/apa + prostate only RT
If high volume disease
Fit - ADT + docetaxel +/- darolutamide
Unfit for docetaxel - ADT + apa/enza

46
Q

What is the prognostic benefit of docetaxel in the metastatic setting, based on what trial

A

17mths, vs ADT alone, for high volume disease
Based on Chaarted trial
10mths as per Stampede trial

47
Q

When is prostate RT beneficial in metastatic disease, and based on what trial
And at what dose

A

Stampede trial
Low volume disease only
Prostate only RT - 36Gy/6#/6wks

48
Q

What is the median time to progression on ADT alone in the metastatic hormone sensitive setting

A

18mths
mOS 42mths

49
Q

What is the benefit to enzalutamide in the castrate resistant metastatic setting

A

Pre-docetaxel: approx 10mth PFS benefit (prevail trial)
Post-docetaxel: approx 5mth PFS benefit (Affirm trial)

50
Q

What is the indication for Radium 223
What are the side effects?
What is the survival benefit?

A

mCRPC with symptomatic bone mets & no visceral or nodal >30mm disease
+/- docetaxel
PS 0-1

SE: Diarrhoea, myelosuppression, thrombocytopaenia

Survival benefit based on Alsympca trial: 2.8mth OS survival benefit and delayed time to skeletal events

51
Q

When in 177-Lu indicated
What is the benefit
What are the side effects

A

Advanced metastatic prostate cancer, following chemotherapy, and if PSMA positive disease

Based on Vision trial: prolonged PFS (median, 8.7 vs. 3.4 months) and OS (median, 15.3 vs. 11.3 months)

SE: N/V, fatigue

52
Q

What is the indication for use of a PARP inhibitor in metastatic CRPC

What is the benefit
Based on what trial

A

Monotherapy for pts who have progressed (prior therapy must include an ARTA) for mCRPC bearing germline and/or somatic BRCA 1/2 mutations and PS 0-2

Profound trial - longer PFS by approx 3mths

Survival benefit

53
Q

When is bone directed treatment indicated in metastatic prostate cancer

A

Osteoporosis
Bone mets and bone pain

54
Q
A
55
Q
A

FRCR2 (28 decks)

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