02 TNM and Risk-Stratification PCa

Question 1

T1

Answer 1

Clinically inapparent tumour that is not palpable

Question 2

T1a

Answer 2

incidental histological finding in < 5% of tissue resected

Question 3

T1b

Answer 3

incidental histological finding in > 5% of tissue resected

Question 4

T1c

Answer 4

Tumour identified by needle biopsy

Question 5

T2

Answer 5

Tumour is palpable and confined within prostate

Question 6

T2a

Answer 6

Tumour involves one half of one lobe or less

Question 7

T2b

Answer 7

Tumour involves more than half of one lobe, but not both lobes

Question 8

T2c

Answer 8

Tumour involves both lobes

Question 9

T3a

Answer 9

Extracapsular extension

Question 10

T3b

Answer 10

Tumour invades seminal vesicle

Question 11

T4

Answer 11

Tumour invades external sphincter, rectum, levator muscles, and/or pelvic wall

Question 12

N1

Answer 12

Regional lymph node metastasis

Question 13

M1a

Answer 13

Non-regional lymph node

Question 14

M1b / c

Answer 14

b: bones
c: other sites (no LN)

Question 15

ISUP Grade and Gleason score

Answer 15

GS 2-6 : Grade 1
GS 7 (3+4) : Grade 2
GS 7 (4+3) : Grade 3
GS 8 : Grade 4
GS 9 : Grade 5

Question 16

Low-risk PCa

Answer 16

PSA < 10
and GS < 7
and T1-2a

Question 17

Intermediate Risk PCa

Answer 17

PSA 10-20
or GS 7
or T2b

Question 18

High Risk PCa

Answer 18

PSA > 20
or GS 8-10
or as from T2c

Question 19

Tissue-based prognostic biomarker testing in PCa

Answer 19

5 commercially available tests (Oncotype Dx®, Prolaris®, Decipher®, Decipher PORTOS and ProMark®).
These tests should not be offered routinely but only in subsets of pts where the test result provides clinically actionable information, such as for instance in men with favourable intermediate-risk PCa who might opt for AS or men with unfavourable intermediate-risk PCa scheduled for radiotherapy (RT) to decide on treatment intensification with hormonal therapy (HT).

Question 20

Value of PSMA-PET in N-Staging in PCa

Answer 20

PSMA PET/CT has a good sensitivity and specificity for LN involvement, however, small LN metastases, under the spatial resolution of PET (~5 mm), may still be missed.

Question 21

PSMA-PET in PCa

Answer 21

PSMA PET/CT is more accurate for staging than CT and bone scan for high-risk disease but to date no outcome data exist to inform subsequent management.
In absence of prospective studies demonstrating survival benefit, caution must be used when taking therapeutic decisions

Question 22

Staging in intermediate risk PCa

Answer 22

include at least cross-sectional abdominopelvic imaging and a bone-scan for metastatic screening (Weak)

Question 23

Staging in high risk PCa

Answer 23

Perform metastatic screening including at least cross-sectional abdominopelvic imaging and a bone-scan (Strong)
When using PSMA-PET or whole body MRI to increase sensitivity, be aware of the lack of outcome data of subsequent treatment changes (Strong)

Question 24

Who gets treated for PCa

Answer 24

Active treatment mostly benefits patients with intermediate- or high-risk PCa. In localised disease, over 10 years life expectancy is considered mandatory for any benefit from local treatment. Health status, frailty, and co-morbidity should also be considered.

Question 25

Co-morbidity in PCa

Answer 25

Co-morbidity is a major predictor of non-cancer-specific death in localised PCa. Ten years after not receiving active treatment for PCa, most men with a high co-morbidity score had died from competing causes.
Use Cumulative Illness Score Rating-Geriatrics (CISR-G) and Charlson Co-morbidity Index (CCI)

Question 26

G8 screening tool

Answer 26

Question 27

Decision tree for health status screening (men > 70 years)**

Answer 27