Prostate cancer Flashcards
(119 cards)
1
Q
age prostate cancer
A
> 60y.o.
2
Q
race prostate cancer
A
more common in black and caribbean men lower in asian men
3
Q
diet factors that lead to a higher incidence of prostate cancer
A
Diet : Eating a diet that is high in dietary fats has a negative effect, while eating lots of dietary fiber has been known to have a protective effect
High red and processed meats
Low Lycopene (antioxidant), Phytoestrogens (estrogen-like compounds found in plants such as soy)
Low Vitamin E
Low selenium
4
Q
hormonal factors related to an increased risk for prostate cancer
A
High Plasma Androstenedione levels are linked to the development of prostatic cancer
High levels of testosterone +low levels of testosterone binding serum lead to higher rates of prostate cancer
5
Q
Screening for prostate cancer
A
PSA tests -for men >50
DRE - for men over 50 to be done annually
6
Q
what is PSA
A
prostate specific antigen
A protein found in seminal fluid and manufactured by the prostate. Its purpose is to keep the semen liquid. A small amount can get into the blood and be measured. As men age prostate size will increase and therefore a higher PSA is expected.
7
Q
Normal PSA levels in men on average
men 40-49
men 50-59
men 60-69
A
normal in general is 0-4ng/L
Age 40-49 - <2.5 ng/mL Favorable - <10
Age 50-59 - <3.5 ng/mL Intermediate – 10-20
Age 60-69 - <4.5 ng/mL Unfavorable - >20
8
Q
4 zones of prostate
A
Peripheral zone -palpated on DRE and most common place of origin of prostate cancer
Transitional zone -location of benign prostatic hypertrophy
Central zone -surrounds the ejacalatory ducts
Fibromuscular stroma zone -anterior fibrous band of muscle contiguous with bladder muscle and external sphincter
9
Q
hat is the function of the prostate
A
seminal fluid that protects and nourishes the sperm after ejaculation
10
Q
what provides the seminal fluid
A
The prostate provides 30% of the seminal fluid, the remaining 70%coming from the seminal vesicles, testicles and bulbourethral glands
11
Q
the prostate is \_\_\_\_ to the rectum and \_\_\_\_ to the bladder A. ant, post B.ant , inf C. sup, post d.sup, inf
A
b
12
Q
primary LN drainage to the prostate is the A. para-aortic LN B.Inguinal LN c.common iliac d.Orbutrator Ln
A
D
13
Q
what is not a primary diagnostic test for prostate cancer A. DRE B.PSA C.PET D.Transrectal Bx
A
c
14
Q
what is the most common histology of prostate cancer A. Transitional cell carcinoma B.clear cell carcinoma c. adenocarcinoma d. SCC
A
c
15
Q
distantly prostate spreads to the: A/liver B.bone C.lungs d.brain
A
B
16
Q
What is not an acceptable treatment for early stage prostate cancer? A. Hypofrartionated EBRT B.Prostatectomy C.brachytherapy D. hockey stick XRT
A
D
17
Q
When treating prostate cancer using conventional fractionation to the prostate the typical dose should be: A.78GY B.50.4GY] C.66GY D.72GY
A
A
18
Q
Which of the following are OAR when treating prostate cancer using IMRT: A. Femoral heads B.Small bowel C.Rectum D. bladder
A
ACD
19
Q
Which radioactive isotope may be used when treating prostate with bratty ? A.Pd103 B.Sm93 C.I121 D.Au43
A
a
20
Q
prostate patients with diarrhea are recommended to follow a \_\_\_\_\_ diet: A.high fiber B. low residue C.high fat D.gluten free
A
b
21
Q
where does prostate cancer originate vs prostatic hyperplasia
A
carcinomas usually originate LATERALLY AND PROSTATIC HYPERPLASIA usually originates centrally
22
Q
where do small vs larger tumours originate
A
small tumours originate anteriomedially and larger tumours originate posteriorly
23
Q
lymphatic spread prostate
A
Periprostatic and obturator nodes are involved first, followed by external iliac, hypogastric, common iliac and periaortic nodes.
24
Q
most common site of distant mets
A
bone (axial skeleton) spine and pelvis most often
25
local spread prostate
As the tumor grows, it can extend into or through the capsule of the gland, invade periprostatic tissues and seminal vesicles, and if left untreated, it can spread and involve the bladder neck or rectum. The tumor can also invade the perineural spaces, lymphatics, and blood vessels.
26
spread of transitional zone vs peripherall zone
Transitional zone -Lower frequency of extracapsular extension and more commonly have large volumes of disease with high PSAs but remain confined to the prostate, usually have good prognosis
Peripheral zone-Spread along capsular surface of the gland
27
most common presentation of prostate csncer
it is usually diagnosed early due to rising PSA levels, it is usually asymptomatic as it is diagnosed ear;y
28
most common method of diagnosing prostate cancer
```
elevated PSA (MOST COMMON)
Palpable mass on DRE (second most common)
```
29
what sympromts can be seen for bulky disease
difficulty starting the stream, urinary bleeding, urinary retention, and dribbling
30
local symptoms of prostate cancer
```
Bladder spasms
Increased urinary frequency *
Nocturia*
Hematuria*
Rectal spasm or pain
Rectal bleeding
Pelvic pain (sitting on a baseball)
Groin pain
Pain on ejaculation
* are most common
```
31
symptoms of LN involvement
Low back or pelvic pain
| Bilateral leg swelling
32
symptoms indicative of mets
```
Bone pain (common)
Hydronephrosis
Spinal cord compression
Shortness of Breath (very uncommon)
Jaundice
Anorexia
Weight loss
Malaise
```
33
most common pathology of prostate cancer
adenocsrcinoma
34
TNM staging of prostate cancer
TNM
T1: Non-palpable (picked up by PSA)
T2: Palpable nodule, contained within prostate gland
T3: Nodule with extra-capsular extension (ex: seminal vesicles)
T4: Invasion of neighbouring structure
N0: No regional lymph nodes
N1: Regional lymph nodes
M0: No mets
M1a: Non Regional Lymph nodes
M1b: Bone
M1c: Other sites
35
what is the gleason score and how is it determined
it is a score that determines how aggressive the prostate cancer is and it is determined by multiple core biopsies
36
gleason score
| what is considered low mid and high risk
2 – 6 Low
7 Intermediate
8 – 10 High Risk
37
gleason score vs grade
gleason grade is from 1-5
| gleason score is calculated by looking at the highest 2 grades of the tumour added together giving a score from 2-10
38
DRE can only detect cancers that are where?
is only detectable in the peripheral zone
39
where are most prostate cancers found in the transitional or peripheral zone
peripheral zone
40
when is TRUS used for diagnosis of prostate cancer
is the diagnostic method of choice
-os recommended when PSA is elevated or an abnormality is felt on DRE the base, midland and apex of the prostate will be sampled and seminal vesicles will be sampled for high risk disease
41
spread sup inf lats post
Sup to the bladder
inf to the seminal vesicles and urethra
lat to the bones
post to the rectum and anus
42
radical prostatectomy definition
Removal of the prostate from below the bladder, in front of the rectum, and immediately above the external sphincter. The PSA should become undetectable. Pelvic lymph node dissection may be performed at the same time for patients that are of high risk of spread.
43
indications of radical prostatectomy
Stage T1 or T2
Younger men
Good general medical condition
Life expectancy of at least 10 years
44
short term complications due to radical prostatectomy
pelvic pain and transient incontinenece are most common
45
most common long term complication of radical prostatectomy
impotence
46
surgery and PSA levels
PSA levels should drop after surgery however it may take a few months
47
indications for adjuvant XRT after radical prostatectomy
there are positive margins post-surgery
| a rise in the PSA level post-surgery (most common)
48
what is a biochemical recurrence?
following a radical prostatectomy if the PSA levels are at 0 after a while the PSA rises yet there is no detectable disease spread
49
Phases of 4 field box or 6 field conformal XRT
barely used today
Phase 1 was used to treat the prostate + seminal vesicles+pelvis to a dose of 46/23fx
Phase 2 is used to treat just the prostate to a dose of 20/10 -30/15
total dose is 66-78Gy
50
what treatment method is most often used today XRT
VMAT or IMRT
| 5-8 DIFFERENT BEAM ANGLES ARE USUALLY USED (FOR IMRT) with the MLC's opening and closing during treatment
51
why dose is used to treat prostate cancer post prostatectomy vs EBRT alone
IMRT and VMAT are used to treat prostate cancer now
78/39 or 76/38 alone
60/30 or 66/33 for post prostatectomy
52
what is the dose constraint for the rectum
limit rectum to <25% getting 70Gy
53
margins around the prosrate
typically 1cm all around except .7cm posteriorly to spare the rectum
54
when is systemic therapy usually administered
usually given adjuvantly
55
goal of androgen deprivation therapy
ADT is used to decrease the production of testosterone to reduce its ability to reach the prostate -which causes prostate cancer
56
what is required for total androgen supression
both ADT (androgen deprivation therapy) and LHRH antagonists
57
is androgen therapy used for patients with prostatectomy or no prostatectomy
can be used for either however it is mostly used for patients with an intact prostate
for patients who had a prostatectomy ADT can be used to suppress the testosterone being produced by the adrenal glands
58
indications for ADT alone
used for patients with comorbidities or elderly patients who can not tolerate chemo and radiation
59
which patients may not be given ADT
Patients who have comorbidities, heart disease or are on medications may not be able to tolerate ADT some men may not want ADT as it gives menopause like side effects
60
shirt term vs long term ADT (duration) for what risk of patients
short term is for 3-6 months of use and is given before and during XRT and is used for mid risk patients
long term is 2-3 years and is given for high risk patient
61
hormone therapy drugs
LHRHa) monthly injection & Casodex (Androgen receptor antagonist) daily oral medication
62
leutinizing hormone releasing hormone
mimics leutinizing hormone and fills the receptors of the pituitary gland. For a period of 7-14 days, the pituitary gland perceives the agonist as normal LHRH and causes the testicles to produce large amounts of testosterone. This rise can cause painful and possibly dangerous to patients with metastasis of the bone. After 7-10 days, the agonist still occupies the pituitary gland’s receptors. Therefore, the pituitary stops telling the testicles to make testosterone. The level of hormone then drops by 90-95% which is called the castration level
63
what is castration resistant prostate cancer
cancer cells can come back and grow while the patient is being treated with hormone therapy prostate cancer can develop a resistance to hormone therapy
64
survival of castration resistant prostate cancer
18 months, worse prognosis than a typical prostate cancer
65
treatment for castration resistant prostate cancer
docatexel + prednisone is given every 21 days
66
what happens when gynecomastica occurs in patients who receive hormone therapy
they are treated with 15Gy/3fx to an 8cm electron field, we only provide this treatment when gynecomastic is accompanied by pain
67
contraindications to brachy therapy of the prostate
patient is on blood thinners
| patient had a narrow pubic angle
68
technique used for low risk brachy of the prostate
perineal implants
69
low risk bratty sources and doses associated
PD103- 115Gy or permanent I-125 = 144gy
70
for an average prostate gland how many needles are used in bratty and how many seeds low risk
25 needles, 100 seeds
71
dose for bratty boost in low risk setting after EBRT
EBRT dose is typically 45Gy and is followed by 90-110 Gy brachy boost
72
typical candidates for brachytherapy in prostate cancer
Low risk patients because they have a smaller lesion, a prostate less than 50cc and its confined to the prostate
73
low risk brachy procedure
TRUS for planning > Seed insertion > Post-implant CT one month afterwards to ensure V100>90% and D9>140Gy
74
mid-high risk bratty procedure
Use of a perineal template to introduce needles via a catheter. The catheters are left in place and the patient is hospitalized
75
mid-high risk brachy dose
Doses have ranged from 50Gy in each of three fractions to 90Gy for two fractions – Usually delivered over 2 days
HDR Iridium-192 BOOST to a dose of (10Gy x 2) 20Gy + EBRT 45Gy/25 to the prostate and seminal vesicles
76
combined treatment modality for low risk prostate cancer
active surveillance
prostatectomy
seeded brachy ---144Gy
EBRT 70-80Gy
77
combined treatment for mid risk prostate cancer
prostatectomy
| EBRT ( 45/25)+HDR brachy (20/2)
78
combined treatment for high risk prostate cancer
in old patients
in young patients
in general
in old patients ADT
in younger patients ADT+EBRT +Brachy
in general
Prostatectomy + EBRT + ADT ➔ 70-80 Gy & 46 Gy to LN
79
combined treatment for patients with mets
ADT alone +/- palliative XRT
80
Indications for active surveillance
for patients between 60-75
for early stage T1c-T2a
when patient has >10 year life expectancy
81
when should a patient come off of active surveillance?
when the patients PSA doubles within <2 years
when on repeat biopsy the stage increases
upon patient request
local tumour progression
82
VMAT in prostate cancer
increases dose to the target decreases dose to normal tissue, uses inverse planning to determine the start and stop angles
83
CT scanning limits
Sup L2-L3
| Inf 5cm inf of ischial tuberosities
84
small field borders for XRT
```
Sup: Level of acetabulum
Inf: Bottom of ischial tuberosities
Lat: Mid obturator foramen
Ant: ½ of symphysis pubis
Post: ant ½ of rectum
```
85
large field borders for XRT
```
Sup: L5-S1
Inf: Bottom of obturator foramen
Lat: 2cm wide of pelvic brim
Ant: ant portion of symphysis pubis
Post: S2/S3
```
86
Small field includes, dose and treatment techniqie
```
includes prostate +/- seminal vesicles
dose is typically 66/33 (prostate bed) or 76/38 (prostate intact)
treatment technique (was 4 field box) now mostly IMRT
```
87
Large fields include, dose and treatment technique
large fields typically include internal external iliac and arbitrator LN
treatment technique was typically 4 field box but is now more often IMRT
Dose 46/23 To the whole pelvis + 20-30/10-15 to the prostate giving a total dose of 76-86Gy/ 33-38
88
which side effect usually starts first
proctitis occurs within the first 1-2 weeks and then dysuria after 2-3 weeks
89
how long does it take for dysuria to be resolved and what are some interventions used
dysuria occurs after 2-3 weeks and is resolved 3 months after treatment
avoid smoking, coffee, alcohol, spicy foods
increase fluid intake
90
constipation and prostate cancer
is usually NOT a result of radiation usually as a result of pain medication
interventions : increase fluid and increase finer in diet
91
proctitis length of time to resolve after XRT and interventions
begins 1-2 weeks after the start of radiation and takes about 1-2 weeks after radiation to be resolved
interventions: sitz bath, + fluid intake -avoid gassy foods, milk , caffeine, eat low finer avoid spicy foods
92
OTC medications to be given to prostate cancer patients
Immodium (loperamide HCI) – Antidiarrheal Kaopectate (attapulgite) - Antidiarrheal Colace (docusate sodium) – Stool Softner
Senokot (sennosides) – Relief of constipation
93
prescription mediations used to combat XRT side effects
Pyridium (phenaxopyridine HCI) – Urinary analgesic
Urispas (Flavoxate HCI) – Urinary tract antispasmodic
Ditropan (Oxybutynin Chloride) – Anticholinergic - Antispasmodic
Lomotil (diphenoxylate HCI – atropine sulfate) - Antidiarrheal
94
what do you need to warn patients of when giving pyrudium
pyrudium will turn the patients urine orange
95
medications used to treat cystitis
Urodine – anaesthetic to relieve pain
| Flomax, Hytrin, Cardura – alpha-blockers to relax smooth muscle and relieve obstruction to make urination easier
96
why do we set a TH and not an SSD for prostate cancer
We use TH because it is more stable, and we don’t verify the ODI (SSD) because we cone-beam
97
when would we use EBRT after brachytherapy?
If the PSA is detectable or if after the post-CT scan there are cold spots, they can either place a seed in that cold spot or they use EBRT to ensure uniform dose.
98
the prostate is attached anteriorly to the pubic symphysis with _____? its sepa4rated from the rectum posteriorly by the _____?
puboprostatic ligament
| Denonvilliers' fascia
99
most important prognostic indicators
primary tumour stage, pretreatment PSA levels andGleason score are most important
100
Beam energy
IMRT -6MV
| Non IMRT -10MV OR MORE
101
Indications for brachytherapy as a sole modality
patients with T1-T2 tumours , Gleason score <6, pretreatment spa of 10ng/ml or less
102
permanent vs temporary implant sources
PD103 and I125 are permanent
| Ir192 is temporary
103
I125 half life and energy dose alone or with EBRT
half life is 60 days
energy is 28Kev
Dose alone is 144Gy
Dose with EBRT- 45Gy EBRT + 110Gy brachy
104
Pd103 half life and energy dose alone or with EBRT
Pd103 has a half life of 17 days
energy is 21 Kev
125Gy when its brachy alone
45Gy EBRT +100 Gy brachy
105
when are permanent prostate implants NOT recomended
for patients with a prostate volume >60ml or an American Urological Association Urine Symptom score of >15
106
is diet related in what % of cancers
25%
107
what % pros cancer is associated with family history of prostate cancer? Are these patients diagnosed young or old
10% cases are hereditary
| they are generally diagnosed art you're ages <50 y.o
108
what zone of the postage can be palpated on DRE
the peripheral zone
109
what is the size in cc of a normal prostate gland
20-30 cc
110
how many cores are taken to determine gleason score
8-12 cores are taken
111
what is PSA nadir
PSA nadir is when after xrt the ps IS remeasured after 3 years and is expected to be close to 0 THIS LEVL can determine expected survivel
112
metastatic PSAlevel
>100ng/ml
113
When is a bone scan done
when PSA >25
114
When is CT/MRI done ?
when there is >10% risk LN involvement
115
active surveillance vs watchful waiting
watchful waiting is when pt is either old or has comorbidities and life expectancy <10y.o. no further action is taken until pt experiences side effects
Active surveillance occurs in 60-75 y.o. patients with low grade cancer and >10 year life expectancy. these patients still get frequent DRE,PSA and biopsies to check for gleason score progression, PSA doubling time <2 years etc
116
CT scan limits
S: L2-L3
I: 5 cm below ischial tuberosities
117
hormones for mid and high risk patients
mid risk patients get short course of hormones 3-6 months and is given before and during the course of XRT
high risk patients get a long course of hormones (2-3 years) given during XRT and continues after XRT
118
what hormones need to be given (2 different types) what does each do ?
ADT- androgen deprivation therapy is given with GHRH (GONADOTROPINRLEASING HORMONE HORMONE )
ADT-BLOCKS testosterone from reaching the prostate
GHRH- blocks the testes from creating more testosterone
119
how are different hormones administered
LHRH/ GHRH- is an injection given monthly or once every 3 months ex: leuporide or zalodex
ADT- is given daily in a pill form
(ex: casodex)
