Prostate

Question 1

survey or rad prostatectomy?

Answer 1

PIVOT trial: NEJM 2012 Wilt: 14% of target enrolled; no difference in disease-specific mortality; if: higher PSA, higher baseline risk, higher gleason–> trend of benefit for surgery

Question 2

active surveillance regimen for diagnosed cancer

Answer 2

repeat biopsy at baseline, then upon progression of PSA, if no progression every 3 years; q6mo PSA and DSE

Question 3

PSA rise–> when to think local

Answer 3

if extra capsular extension and late rise–>likely local;

Question 4

PSA doubling time (PSADT) cutoff for risk estimation

Answer 4

if <3mo after surgery/radiation (1/5 of population), likely to develop mets and die of cancer

Question 5

castration resistant

Answer 5

tumors not hormone-refractory, they just grow with lower levels

Question 6

intermittent androgen deprivation

Answer 6

reduced toxicity, does not delay castrate-resistance, improved quality of life: NEJM Hussain (if low PSA at 6 months, do intermittent: unable to conclude non-inferiority); other trials show equivalence–> NOW STANDARD to treat 6 months then d/c if PSA drops to <4

Question 7

if PSA goes down and bone scan worse

Answer 7

flare phenomenon–> repeat second scan, look for NEW lesions

Question 8

TROPIC trial

Answer 8

cabazitaxel in docetaxel-refractory–> OS benefit

Question 9

enzalutamide/xtandi

Answer 9

binds and inhibits AR, also inhibits transport to nucleus and binding to DNA (also taxanes inhibit transport to nucleus)

Question 10

prostate ca epi

Answer 10

1st in men 220k, 2nd most cause of death

Question 11

rising PSA with no mets

Answer 11

60,000 of patients, proportion develop clinical mets

Question 12

castrate resistant

Answer 12

means that castrate levels of testosterone but still progression

Question 13

paradigm for prostate ca treatment

Answer 13

intervene if Sx, or if risk of significant event might occur is high

Question 14

prostate cancer biospy

Answer 14

12-14 cores

Question 15

prostate cancer screening

Answer 15

T3a- extracapsular, T3b- seminal vescles

Question 16

nodal disease in prostate ca

Answer 16

pelvic nodes good prognosis, outside pelvis bad

Question 17

calculating risk of early stage prostate

Answer 17

need nomogram, which is still work in progress. T-stage alone insufficient

Question 18

localized prostate cancer risk assessment

Answer 18

if low risk, recommend 2nd biopsy. repeat biopsy with 24-30 cores to ensure sampling. alternative is MRI prostate to look for dominant lesion. low risk if no lesion. biopsies being guided using fused MRI/US imaging for adequate sampling

Question 19

active surveillance scheduling

Answer 19

every 6 months

Question 20

biochemical recurrence mgmt

Answer 20

use nomogram to predict liklihood of localized recurrence and benefit from RT

Question 21

first line therapy with PFS rise

Answer 21

use nomogram. if <3month PSA doubling, more likely to have mortality. treat with antigen depletion (castration)

Question 22

androgen depletion–> intermittent or continuous?

Answer 22

GnRH agonist + AR antagonist for 7 months for 7 months, . reduced toxicity and improved quality of life. does not delay development of resistance. non-inferiority. 13 trials–> no difference.

Question 23

bisphos or denosumab in prostate

Answer 23

shown to delay SRE

Question 24

causes of castrate resistance

Answer 24

up regulation of androgen receptor, or up regulation of androgen synthesis

Question 25

slow drift up of PSA with enzalutamide

Answer 25

do not stop...still effective. symptom-based may be way to go

Question 26

abiaraterone versus enzalutamide

Answer 26

prior response doesn't predict response, but responses are lower in patients who don't respond to one

Question 27

high volume (4+ bone lesions) newly diagnosed metastatic prostate cancer

Answer 27

unsure of addition of docetaxel at front-line, one trial showed survival benefit, another showed no difference

Question 28

DRE palpation

Answer 28

only peripheral zone, 70% of cancers. transition zone not evaluable

Question 29

familial prostate

Answer 29

10%; highest risk SNP is in HOXB13 TF

Question 30

adeno confirmation v. benign

Answer 30

expresion of alpha-methylacyl-coenzyme A racemase

Question 31

translocations in pr ca

Answer 31

TMPRSS2-ERG fusion.

Question 32

chemoprevention

Answer 32

analysis shows that you can avoid 4 low-grade tumors for 1 high grade- not recommended for healthy men. No OS benefit

Question 33

AUA PSA recommendations

Answer 33

shared decision for age 55-69; otherwise no

Question 34

PSA predictors

Answer 34

PSA 4: 23% PPV; PSA velocity >0.75/yr and PSA 4-10--> suspicious

Question 35

number cores needed for TRUS Bx

Answer 35

12

Question 36

free psa

Answer 36

% less than 25% is associated with +cancer. not recommended clinically to make decision

Question 37

pelvic MRI recommendation

Answer 37

if T3/T4 (thru capsule or fixed/invasion) or nomogram LN risk >20%.

Question 38

bone mets prostate

Answer 38

more often blastic.

Question 39

bone scan recommended if

Answer 39

PSA >20, gleason 8, T3/T4 (capsule invasion), or Sx

Question 40

PSA elevation after prostatectomy

Answer 40

median 8 years to Sx; higher risk - time to progression short, high glassine, high doubling time

Question 41

Tx of PSA elevation after prostatectomy

Answer 41

no gold standard of whether to start ADT. can do intermittent with similar disease-specific survival

Question 42

RT v. prostatectomy v. observe

Answer 42

can use nomograms.

Question 43

biochem relapse after RT

Answer 43

nadir + 2.0 points

Question 44

RT dose for prostate

Answer 44

78-79Gy.

Question 45

ADT after prostate RT

Answer 45

needed for intermediate disease (6 months, if PSA velocity >2.0/yr). if node-posalsitive, need 2 years adjuvant ADT.

Question 46

RT following prostatectomy

Answer 46

pT3 (capsule penetration), positive margins, detectable PSA after surgery.

Question 47

salvage RT following prostatectomy

Answer 47

consider if PSA relapse and low risk features (i.e. >1 yr from surgery, glee 7, no LN or seminal vesicle invasion at surgery)

Question 48

denosumab to prevent fracture on ADT

Answer 48

need 60mg SQ every 6 months. effective

Question 49

bone flare on ADT

Answer 49

3-6 months after initiation of therapy

Question 50

PSA to assess initial ADT response

Answer 50

7 month PSA: 4 high risk

Question 51

ADT combined blockade versus just GnRH

Answer 51

modest improvement in survival. anti-androgen alone is inferior.

Question 52

anti-androgens

Answer 52

flutamide, bicalutamide, nilutamide.

Question 53

ADT after prostectomy

Answer 53

no

Question 54

intermittent v continuous ADT for metastastic

Answer 54

data not conclusive. intermittent not non-inferior. however meta-analysis shows same OS and improved QOL

Question 55

docetaxel + ADT for newly metastatic

Answer 55

survival benefit for visceral disease, or 4+ boney sites. only 1 study

Question 56

medical castration

Answer 56

defined as testosterone

Question 57

newly castrate resistant disease

Answer 57

trial of anti-androgen withdrawl, and consider second ant9-androgen or ketoconazole or hydrocortisone (non-cross-resistant sometimes)

Question 58

abiatarone

Answer 58

oral CYP17 inhibitor + prednisone, blocks androgen synth. 1g daily plus prednisone 5mg BID

Question 59

enzalutamide

Answer 59

another potent anti-androgen,

Question 60

sipuleucel-T

Answer 60

autologous vaccine of prostatic acid phosphatase and G-CSF, q2wks x 3

Question 61

docetaxel for prostate

Answer 61

75mg/m2 q3wk + prednisone

Question 62

cabazitaxel for prostate

Answer 62

25mg/m2 + 10mg day predinsone. improved survival. consider G-CSF given high rates of neutropenia

Question 63

alpharadin

Answer 63

approved for symptomatic bone mets (cannot have visceral disease), improved survival.

Question 64

regimens for adrenocortical caricinoma

Answer 64

surgery. poor prognosis if >5cm. mitotane. adding EDT (etoposide, doxorubicin, cisplatin) improves PFS but not OS.