Prostate Cancer FRCR CO2A Flashcards
(127 cards)
1
Q
What are main types of prostate cancer
A
Adenocarcinoma > 95%
Transitional carcinoma
squamous cell carcinoma or
small cell carcinoma, Lymphoma, sarcoma, carcinosarcoma, carcinoid
2
Q
whats the peak age of Prostate cancer incidence
A
70 - 75 years
3
Q
where does most of the Prostate cancer arises
A
peripheral zone
4
Q
what are the RFs for prostate cancer
A
Family Hx, RR double with 1st degree relative diagnosed before 70 years of age and 4 times if two relatives and one under 65 years of age
BRCA2 mutation, 5 times
5
Q
How does Prostate cancer spread
A
Locally to involve seminal vesicle and base of bladder
Spread to rectum is inhibited by Denovillier’s fascia
Lymphatics to pelvic and PA Lns
Hematogenous spread to Bone, specially spine, femur, pelvis and ribs
Liver and lUng mets uncommon but can be in CRPC
6
Q
IS screening with PSA recommeded
A
No
to save 1 life, 781 men are screened and 27 cancers must be treated
7
Q
if at all, screening should be done for which people
A
Family History, BRCA 2 or Afro Caribbean descent, not done in UK
8
Q
what are symptoms and signs of Prostate cancer
A
Early: rarely produces symptoms
LUTS
Erectile dysfunction
Hematuria, Hematospermia
LN spread or metastatic disease: Bone mets: pain, nodal spread: lower body edema
9
Q
What investigations are suggested for Prostate cancer
A
TRUS guided sampling of the peripheral zone involving at least 10 cores covering all parts of gland
MRI : peripheral zone on T2 images, tumors visible as low signal region in an area of high signal (normal tissue)
Bone scan: not required in low risk pts
10
Q
How is MRI helpful in Prostate cancer
A
extracapsular involvment, seminal vesicle invasion and nodal disease can be identified as well as small bone mets that may not be seen on a bone scan can be identified
11
Q
what risk groups Prostate cancer pts be classified into
A
Low, Intermediate and High
12
Q
who falls in Low risk group for Prostate cancer
A
PSA < 10 ng/ml, GS </= 6 and T1-T2a
prognosis: excellant 90 % disease free at 10 years
13
Q
who falls in intermediate risk group for Prostate cancer
A
PSA 10 - 20 ng/ml, GS 7 and T2b
Prognosis: good, small chance of death at 10 years
14
Q
who falls in High risk group for Prostate cancer
A
PSA > 20 ng/ml, GS 8-10, >/= T2c
Prognosis: fair, significant chance of death within 10 years
15
Q
what are treatment options for localized Prostate cancer
A
Active Surveillance, radial prostatectomy, interstitial BT, EBRT (possibly with adjuvant Hormonal therapy)
16
Q
How is Low Risk Group Treated?
A
- Active Surveillance for younger pts
- watchful waiting for older patients
- RT including Brachy
- surgery
17
Q
How is Intermediate Risk Group Treated?
A
Monitoring is till reasonable in the elderly but not recommended for younger pts
Options of Prostatectomy or RT combined with HT
18
Q
How is high risk group treated?
A
- Standard Rx for T3 disease is primary RT with NA or adjuvant Hormone therapy for up to 3 years
- Nodal irradiation for those at increased risk of nodal involvment
- Radical Prostatectomy followed by post op RT
19
Q
when is prostatectomy preferred
A
T1/T2 disease and early T3 with post op RT
20
Q
what are advantages of Prostatectomy
A
good published outcomes, immediate treatmetn, rapid access to prognostic information and decrease in PSA following Sx
an undetectable PSA at around 6 weeks after Sx is a/w good long term results
21
Q
when is post op RT indicated post radical prostatectomy
A
- persistently raised PSA levels at 6 weeks (>0.1 ng/ml) and
- positive margins
22
Q
what are disadvantages of prostatectomy
A
- high rates of ED (50%)
- Urinary morbidity, persistent urinary incontinence
23
Q
what LDR source is used as permanent implants in prostate cancer and whats its T1/2
A
Iodine 125, 60 days
24
Q
What Dose is delivered with Iodine LDR sourrce in prostate cancer
A
140 - 145 Gy
25
What is included in RT field for Low risk disease
Prostate and proximal 2 cm of SV usually withou hormone therapy
26
What is included in RT field for Intermediate risk disease
Prostate and whole of SV and NA hormone therpay
27
What is included in RT field for High risk disease
Prophylactic nodal irradiation along with adjuvant hormone therapy for 2 - 3 years
28
What are relative C/I for RT in prostate cancer
IBD, Diverticulitis
29
How is simulation for RT in Prostate cancer done
1. supine position, 1 antr and 2 lateral tattoos, if nodal RT is considered, IV contrast, knee support, full bladder, enema b4 planning and b4 each treatment session
30
What RT dose is given in Prostate cancer
SIB 74 Gy/37#: prostate, 50 Gy/ 37# for nodal irradiation and 56 Gy/ 37# to prostate and SV with 1 cm margin
31
what has CHHiP study shown
prolonged fractionation in PC is not going to improve therapeutic ratio, slightly better control with 60 Gy/ 20# to 74 Gy/ 37# with comparable late toxicity at 5 years
32
How can Contouring Prostate be accurate ?
guidance from staging MRI scans and biopsy, IV contrast for nodal RT, prostatic apex should be carefully defined to minimise dose to rectum and penile bulb
33
What are OARs for Prostate cancer RT
Rectum, Bladder, Bowel, Femoral Heads and Penile Bulb
High dose region should be limited to < 25% of rectal volume
34
what nodal groups to be included in Prostate cancer RT fields?
Common iliac from the sacral promontary, the presacral nodes, External (upto femoral heads) and internal iliac, obturator nodes
35
How to ensure accuracy of RT treatment for prostate cancer
Daily online imaging with CBCT, alternatively 3 gold seed markers be placed, mandatory for SABR therapy
36
What is target volume for post op RT in prostate cancer
surgical anastomosis and prostate bed
Anter: pubic symphisis
Postr: includeds rectum
Lateral: NV bundles and adjacent ilio obturator muscles
supr: bladder neck and
Infr: to within 15 mm of penile bulb
37
what post op RT dose is given in Prostate cancer
60 - 64 Gy in 30-32# or 52.5 - 55 Gy in 20 #
38
for how long post RT patients should be followed up
life long for high risk pts
39
what tests on follow up is adviced for prostate cancer pts
PSA every 6 -12 months
40
How is Relapse defined with PSA
three successive incrases in PSA above a nadir value or nadir + 2 ng/mL
41
what indicates a cure post RT without Hormone therapy for prostate cancer pts
stable PSA 4 - 5 years post Rx
42
Is Salvage prostatectomy recommended in NICE post RT in prostate cancer?
No, complications are high
43
How is LHRH analogues different from LHRH inhibitors?
both gives castrate level of testosterone but antagonist give it without testosterone flare
Bicalutamide is prescribed for initial weeks for LHRH analgues
LHRH inhibitors useful in emergency
43
what are s/e of hormone therapy
impotence, sweats and flushes, deepression and decreased bone density
44
How is metastatic CSPC treated (NCCN)
ADT with docetaxel and one of
the following:
* Preferred regimens:
Abiraterone (category 1)
Darolutamide (category 1)
* Other recommended regimens
Apalutamide (category 2B)
Enzalutamide
45
how is M1 CRPC treated (NCCN)
Abiraterone,(category 1 if no visceral metastases)
Docetaxel(category 1)
Enzalutamide
Niraparib/abirateronefor BRCA mutation (category 1)
Olaparib/abirateronefor BRCA mutation (category 1)
Pembrolizumab for MSI-high (MSI-H)/dMMRddd (category 2B)
Radium-223 for symptomatic bone metastases (category 1)
Sipuleucel-T (category 1)
Talazoparib/enzalutamide for HRR mutation
46
how can gynecomastia be prevented or reduced with RT
8 Gy orthovoltage RT to breast buds
47
what RT dose is given for painful bony mets in Prostate cancer
SF 8 Gy usually give rapid pain relief
30 Gy / 10 #.
Strontium 89 therapy
48
How can toxicity of Docetaxel be reduced?
premedication with dexamethasone 8 mg BD starting 24 hours before Chemo
49
Which chemo has shown to be effective in 2nd L after docetaxel
Cabazitaxel
50
what are bisphosphonates used in Prostate cancer
Zoledronate ( Not recommended by NICE)
denosumab who are intolerant to bisphosphonates
51
What percentage of all cancers does prostate cancer account for?
12% of all cancers
## Footnote
This represents 23% of cancer cases in men.
52
How many new diagnoses of prostate cancer occur each year in the UK?
32,000 new diagnoses
## Footnote
Approximately 10,000 deaths occur each year due to prostate cancer.
53
In which age group does the majority of prostate cancer cases occur?
Over 70 age-group
## Footnote
Prostate cancer is rare in individuals under 50.
54
What has caused the large increase in incidence of prostate cancer over the past 10-15 years?
Increased detection through PSA screening and surgery for benign prostatic disease.
55
Does PSA screening reduce mortality rates from prostate cancer?
No evidence that it reduces mortality rates.
56
What does T1 N0 M0 indicate in tumor staging?
Tumour invades subepithelial connective tissue.
57
What is the significance of the Gleason grading system?
Describes the degree of differentiation of malignant cells.
58
How is the Gleason score determined?
Each tumour is graded twice, each out of five, for a total score out of 10.
59
What is the most common type of prostate tumour?
Adenocarcinomas.
60
Where do the majority of prostate tumours arise?
Peripheral zone of the prostate.
61
What are the common symptoms associated with prostate cancer?
Raised serum PSA level, asymptomatic in half of patients.
62
What is the Roach formula used for?
Predicting the risk of local extension and lymph node spread.
63
What initial investigations are performed for suspected prostate cancer?
PSA blood test and digital rectal examination (DRE).
64
What is the purpose of a transrectal biopsy in prostate cancer diagnosis?
To obtain histological diagnosis.
65
What PSA level is considered suspicious for prostate cancer?
fPSA levels of >4 ng/mL and <10 ng/mL
66
What does PSA density measure?
PSA/volume of gland.
67
What does a high Gleason score indicate?
Higher grade disease, extraprostatic extension, and distant metastases.
68
What are the common areas for metastases in prostate cancer?
* Bone
* Obturator lymph nodes
* Perivesical lymph nodes
* Para-aortic lymph nodes
* Rarely liver, lung, or brain.
69
What is the PSA doubling time used to assess?
The rate of tumor growth.
70
What is the significance of the PSA velocity?
Indicates the rate of tumor growth expressed as ng/ml/year.
71
What characterizes very poorly differentiated cancers in terms of PSA secretion?
They may not secrete PSA, making diagnosis and monitoring more difficult.
72
73
What are the treatment options for localized disease?
* Active surveillance
* Watchful waiting
* Radical treatment with surgery or radiotherapy or both
74
What does active surveillance entail?
Close monitoring with early curative treatment offered to patients showing signs of progression
75
What parameters are typically considered for active surveillance?
* T1–T2b disease
* Gleason grade ≤7
* PSA ≤15 (with favourable kinetics)
76
What is the difference between active surveillance and watchful waiting?
Active surveillance involves monitoring with the possibility of curative treatment, while watchful waiting involves palliative therapy for symptomatic progression
77
What are the criteria for considering radical treatment for patients on Active surveillance?
* PSA progression (doubling time <2 years)
* Clinical progression
* Upgrading of the Gleason score on repeat biopsy
78
List the radical treatment options for prostate cancer.
* Radical prostatectomy
* External beam radiotherapy
* Brachytherapy (low-dose rate or high-dose rate)
79
What are the risks associated with radical prostatectomy?
5–15% risk of urinary dysfunction and approximately 50% impotence rates with nerve-sparing techniques
80
What is the significance of the Medical Research Council RT01 study?
a hazard ratio for biochemical progression-free survival of 0.67 in favour of escalated radiotherapy dosage
| standard dose of radiotherapy (64 Gray over 32 fractions over 6.5 weeks
## Footnote
an escalated dose of radiotherapy (74 Gray over 37 fractions over 7.5 weeks).
81
What are the acute side effects of radiotherapy?
* Dysuria
* Frequency
* Diarrhoea
* Lethargy
* Erythema
82
What are the late effects of radiotherapy?
* Proctitis
* Impotence
* Urinary incontinence
83
What is low-dose rate (LDR) brachytherapy?
Permanent radioactive seeds implanted directly into the prostate under ultrasound guidance
84
What are the eligibility criteria for LDR brachytherapy?
* Prostate volume <50 cc
* Gleason ≤6
* PSA ≤15
* T2 or less disease
85
What is high-dose rate (HDR) brachytherapy typically used for?
It is suitable for intermediate-high risk patients and can be used as a boost after external beam radiotherapy or as mono-therapy
86
Fill in the blank: Patients with _______ are treated with palliative endocrine therapy in watchful waiting.
symptomatic progression
87
What is the prescribed dose for LDR brachytherapy?
145 Gy
88
How is HDR brachytherapy administered?
Through catheters implanted into the prostate under general anaesthetic, typically in two or three fractions
89
What is the purpose of using conformal CT planning in radiotherapy?
To establish precise targeting for radiation treatment
90
True or False: There is long-term survival data confirming the efficacy of brachytherapy.
False
91
92
What is the purpose of neoadjuvant luteinizing hormone releasing hormone (LHRH) analogues in radical radiotherapy?
To enable a reduction in the volume of tissue irradiated due to shrinkage of the prostate gland.
93
What were the 5-year clinical disease-free survival rates in the EORTC study comparing radiotherapy alone versus radiotherapy with immediate androgen suppression?
40% versus 74% in favor of the adjuvant endocrine group.
50 Gy radiation was delivered to the pelvis and 20 Gy boost to prostate
| locally advanced prostate cancer
## Footnote
Goserelin (3.6 mg subcutaneously every 4 weeks) was started on the first day of irradiation and continued for 3 years; cyproterone acetate (150 mg orally) was given for 1 month starting 1 week before the first goserelin injection.
94
What is the overall survival rate comparison in the same EORTC study?
62% versus 78% in favor of the adjuvant endocrine group.
95
Who should be offered prolonged adjuvant treatment for 2–3 years in prostate cancer?
All patients with high-risk disease (Gleason 8–10, clinical T3/4 tumours or lymph node risk >30%).
96
What is the current treatment for low and intermediate risk patients undergoing radiotherapy?
3–6 months of LHRH analogues before and during radiotherapy.
97
What are some side effects of LHRH analogues?
* Hot flushes
* Weakness/loss of muscle bulk
* Weight gain
* Fatigue
* Osteoporosis/fracture risk
* Loss of libido and erectile function
* Mood changes
* Poor concentration/memory
98
Is there an established role for neoadjuvant or adjuvant hormonal manipulation in patients undergoing radical prostatectomy?
No.
99
What is the mainstay of treatment for patients with locally advanced prostate cancer?
LHRH analogues or anti-androgens.
100
What is the effect of prolonged treatment with LHRH analogues?
Significant toxicity due to reduction of testosterone levels.
101
What are androgens receptor inhibitors and give an example?
They reduce the delivery of testosterone to the prostate without reducing serum testosterone levels. Example: bicalutamide.
102
What can be done prophylactically to reduce gynaecomastia in patients treated with LHRH analogues?
* Prophylactic radiotherapy to the breast buds
* Prophylactic tamoxifen 10–20 mg/day.
103
What is the typical duration of response to first-line endocrine therapy with LHRH analogues in metastatic prostate cancer?
18–24 months.
104
What is the typical schedule for intermittent LHRH analogue therapy?
Treat until PSA falls below 4 ng/ml and restart when PSA rises above 10 ng/ml.
105
What is the usual treatment for elderly patients with significant comorbidities?
Symptomatic treatment with or without hormones.
106
When is recommended for postoperative radiotherapy in cases with a positive margin at radical prostatectomy?
Some authorities advocate postoperative radiotherapy, while others wait for PSA to rise.
107
What is the most effective timing for salvage radiotherapy?
Before the PSA reaches a value of 2 ng/ml.
108
What type of cancer is chemotherapy typically reserved for?
Advanced metastatic prostate cancer that has become refractory to endocrine treatment.
109
What is the first-line chemotherapy agent for hormone refractory prostate cancer?
Docetaxel.
110
What is the dosing schedule for docetaxel in prostate cancer treatment?
75 mg/m2 administered on a 3-weekly basis for up to 10 cycles.
111
What is the significance of cabazitaxel in prostate cancer treatment?
It has demonstrated a 2.5 month survival benefit in the second-line setting.
112
What is the typical side effect associated with chemotherapy for prostate cancer?
Low-grade neutropenia.
113
What is the risk of febrile neutropenic sepsis with docetaxel without colony-stimulating factor support?
Less than 3%.
114
What are some new invasive techniques showing success after radiotherapy failures?
* Cryotherapy
* High frequency ultrasound (HiFU).
115
116
What is the daily dosage range of low-dose steroids effective in some patients?
0.5–2 mg of dexamethasone daily
## Footnote
Low-dose steroids can improve quality of life and PSA control in certain cancers.
117
What is the purpose of administering zoledronic acid intravenously once a month?
To reduce the incidence of skeletal events in men with bone metastases
## Footnote
This includes fractures or the need for radiotherapy and helps control refractory metastatic bone pain.
118
What is the effectiveness of external beam radiotherapy for palliation ?
Very effective in controlling metastatic bone pain and symptoms of primary tumour invasion
## Footnote
Symptoms include haematuria and pain.
119
What has been shown regarding prolonged fractionation regimes in radiotherapy for palliation ?
They have not been shown to be more beneficial than a single fraction of 8 Gy
## Footnote
This indicates that simpler treatment regimens can be equally effective.
120
What is the role of radiotherapy in cases of spinal cord or nerve root compression?
Commonly used for vertebral metastases
## Footnote
It helps alleviate compression-related symptoms.
121
Which radioisotopes are effective at controlling pain in patients with widespread bone metastases?
Strontium-89 and Samarium-153
## Footnote
These treatments can help in cases of diffuse bone pain not easily targeted by external beam radiotherapy.
122
What should be considered if chemotherapy is planned after radioisotope treatment?
A suppressive effect on the bone marrow
## Footnote
This requires careful planning to avoid complications.
123
What factors influence survival figures from prostate cancer?
Histology, stage, PSA level, and therapeutic intervention
## Footnote
These factors can lead to widely varying survival outcomes.
124
What are the 5-year biochemical control rates for patients with localized disease treated with radiotherapy or radical surgery?
75–85%
## Footnote
This indicates a high success rate for localized treatments.
125
What are the 10-year overall survival rates for patients with localized prostate cancer?
60–70%
## Footnote
These figures demonstrate the long-term effectiveness of treatment in localized cases.
126
Can patients with metastatic prostate cancer survive for many years?
Yes, particularly if the tumours are hormone-responsive and if the metastatic spread is confined to the bones
## Footnote
This highlights the importance of tumor characteristics in prognosis.
