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review course > 28 - prostate ca > Flashcards

28 - prostate ca Flashcards

1
Q

prostate cancer risk if 1 first degree relative has it

A

2x

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2
Q

prostate cancer risk if >1 first degree relative has it

A

10x

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3
Q

% with true hereditary prostate ca

A

10%

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4
Q

3 criteria for hereditary pca

A

> /= 3 affected relatives, OR >/= 2 relatives with early onset < 55yo, OR in 3 successive generations

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5
Q

difference with hereditary cap

A

earlier onset only, same biologic activity

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6
Q

REDUCE trial - what was it

A

8000 men randomized to dutasteride vs placebo - 25% reduction in prostate cancer risk

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7
Q

PCPT trial - what is it

A

19K randomized to finasteride vs placebo. 25% risk reduction for prostate cancer on finasteride, but equal number of prostate ca deaths. Higher incidence of G7-10 due to overdetection bias (effect of volume reduction on tumor detection)

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8
Q

PCPT and “normal” PSA values - 2

A

11% cap in PSA <1, 30% cap in PSA 3.1-4

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9
Q

overall survival for all stages at 5 and 10 yrs

A

99% and 91%

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10
Q

PLCO - what did it show

A

80K men 10 yr f/u, no difference in disease specific mortality

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11
Q

problems with PLCO

A

high contamination in control arm, low biopsy compliance in screening arm

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12
Q

ERSPC - what is it

A

16K men. NNS 1400, NNT 50

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13
Q

where are most tumors located and %

A

75% peripheral zone> transition zone (20%)

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14
Q

periurethral duct prostate ca AKA

A

urothelial ca

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15
Q

% cap detected by DRE alone

A

20%

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16
Q

what kind of molecule is PSA

A

kallikrein-like serine protease

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17
Q

what molecule is PSA bound to when referring to free psa

A

a1-antichemotrypsin

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18
Q

where is free:total psa useful

A

risk stratifying those with PSA 4-10

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19
Q

is F:T PSA affected by finasteride

A

no

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20
Q

F:T PSA AKA

A

% free PSA

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21
Q

x% with pca with F:T <10%

A

55%

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22
Q

when is PSA doubling time useful

A

recurrent prostate ca

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23
Q

what kind of marker is PCA3

A

prostate specific mRNA marker for DD3 gene

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24
Q

PCA3 use

A

not as primary screening but to dictate need for repeat biopsy in men with persistently elevated PSA

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25
Q

PCA3 compared to PSA

A

higher sensitivity/specificity

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26
Q

PCA3 and prostatitis/BPH

A

independent of inflammation/prostate size

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27
Q

how to collect PCA3

A

agressive DRE - voided urine

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28
Q

AUA best practice policy for post biopsy abx - 1st line

A

FQ or 2nd/3rd gen cephalosporin

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29
Q

is low dose aspirin an absolute contraindication to biospy

A

no

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30
Q

is complication rate associated with # biopsy cores

A

no

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31
Q

3 indications for repeat biopsy

A
  1. rising/persistent psa, 2. suspicious DRE, 3. ASAP
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32
Q

detection rate for pca for TURP

A

8%

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33
Q

why not biopsy transition zone

A

low detection rate

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34
Q

ideal method of examining prostate apex path

A

“cone method”

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35
Q

strongest predictor of pca outcome

A

gleason score

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36
Q

significance of PNI in pca

A

unknown

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37
Q

prostate cancer distribution by north vs southern europe

A

more common in northern vs southern europe

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38
Q

PSA levels vary with which 3 things

A

age, race, prostate volume

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39
Q

urinary retention rate in saturation vs nl prostate biopsy

A

higher in saturation (swelling)

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40
Q

significance of baseline PSA

A

baseline >1.5 (@ 50 yo) is powerful predictor of subsequent cap (6-10x rr)

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41
Q

BMI and PSA

A

higher BMI= PSA hemodilution and lower [psa]. more likely to have agressive disease at presentation and suffer relapse

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42
Q

ACS PSA screening

A

no screening, discussion w patient regarding pros and cons

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43
Q

NCCN PSA scrreening

A

no screening, discussion w patient regarding pros and cons. start at 40 for high risk men, and 50 for avg risk

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44
Q

AUA PSA screening

A

baseline PSA at 40, if < 1 considered low risk and return at 45 yo

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45
Q

nccn very low risk cap criteria for AS

A

T1c, G6, PSA < 10, < 3 + cores w < 50% vol in each core, psa density < 0.15

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46
Q

AS and prostate ca specific mortality

A

5-10% esp if PSA doubling time < 3 yrs. nonprostate ca spcific mortality far outweighs prostte ca specific mortality

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47
Q

risk of progression requiring tx during AS

A

30%

48
Q

treatment modalities and prostate cancer survival

A

prostatectomy is the only treatment modality to confur survival advantage over no tx (35% reductin in death/mets vs no tx up to 10 yrs)

49
Q

recovery of erectile function post nerve sparing prostatectomy

A

50-90% recovery of some erection if potent beforehand, and upto 80% in pts < 60 yo

50
Q

penile rehab?

A

it works

51
Q

when is pelvic LN dissection considered not necessary

A

low risk cap

52
Q

2 indications for early adjvant radiation

A

pT3, positive surgical margins

53
Q

timing for giving early adjuvant radiation

A

once continence has returned

54
Q

is early radiation better than salvage radiation (waiting for biochemical recurrence)

A

unclear, but salvage avoids treating everyone with T3

55
Q

who benefits most from salvage radiation - 3

A

favorable biochemical recurrence characteristics (PSA <2, slow psa doubling time, long interval to failure after surgery)

56
Q

what to do before salvage radiation - 2

A

restage with imaging (CT, bone scan) and DRE

57
Q

PSA threshold post prostatectomy signifying recurrence

A

> 0.2 ng/dl

58
Q

how exactly does EBRT work

A

photons damage cellular DNA

59
Q

standard EBRT dose

A

70 gy over 7 weeks

60
Q

how does androgen depravation therapy help in EBRT - 2

A

volume reduction of prostate (reduce number of cells, diminish collateral damage to bladder/rectum by shrinking prostate)

61
Q

caveat to androgen ablation in EBRT

A

survival benefit wanes in > 65 yo with cardiac risk factors - consider cardiac eval

62
Q

how far does dose go from brachy seed

A

2-3mm

63
Q

radiation dose in brachytherapy - I-125 vs Pd-103

A

145 gy - I-125 vs 125 gy - Pd-103. same outcomes

64
Q

limitations to brachy - 3

A

cant do in prostate > 60 cc, higher risk of retention with IPSS > 15, higher risk of incontinence if hx TURP

65
Q

brachy + EBRT

A

done for intermediate - high risk disease

66
Q

Post EBRT PSA doubling time and clinical relapse

A

PSAdt < 12 months = high risk early clinical relapse if untreated

67
Q

significance of PSA rise post radiation

A

confirm with repeat psa to make sure rise is durable

68
Q

factors predicting success of salvage surgery - 3

A

PSA< 10 preop, </= T3a, hx brachy or IMRT

69
Q

radiation tx for locally advanced cap

A

ADT x 2-3 yrs + radiation = improved local and systemic control

70
Q

micromets to nodes and tx

A

can complete surg and give ADT postop or radiation + ADT = survival benefit

71
Q

risk factors for metastatic disease and survival in PSA recurrence - 3

A

time to psa recurrence (< / > 2 yrs), PSA doubling time < / > 9 mo, gleason score >/< PSA 8

72
Q

main difference between GNRH agonist vs antagonist

A

no flare with antagonist, vs agonist

73
Q

what class is degarelix

A

GNRH antagonist

74
Q

nilutamide, biclautamide, flutamide class

A

NONsteroidal antiandrogen

75
Q

nilutamide side effects - 2

A

interstitial lung disease, visual adaptation disturbances

76
Q

risk of gynecomastia with antiandrogen and potential mgmt

A

50%, pretreatment with breast radiation

77
Q

alternative to LHRH agonist - why better (2)/worse (1)

A

antiandrogen - fewer sexual side effects (loss of libido/ED), improved QOL with same survival but high risk of gynecomastia

78
Q

why is DES not used for medical castration

A

high CV risk of mortality

79
Q

only setting where adjuvant ADT assd w survival benefit

A

post prostatectomy LN positive disease

80
Q

actual survival benefit of provenge

A

4.1 mo

81
Q

exclusion criteria for provenge - 3

A

pain requiring narcotics, visceral mets, life expectancy < 6 mo

82
Q

how to monitor response to provenge

A

no measurable way to detect response

83
Q

party line on intermittent ADT

A

considerd safe with suggestion of improved QOL without negative effects on time to disease progression/survival

84
Q

2 tx options for pts presenting with spinal cord compression

A

ketoconazole, degarelix

85
Q

what does it mean when tumor is castrate resistant - 3

A
  1. tumor may produce its own androgen (autocrine), 2. amplify low levels of testerone ligand signaling through androgen receptor mutations or duplications, 3. or activation of AR through other ligands
86
Q

2 caveats to labeling tumor as hormone refractory

A
  1. tumor may become hypersensitive to androgens –> dangerous to stop antiandrogen immediately, 2. may be sensitive to other hormonal manipulations
87
Q

mgmt of RISING psa while recieving ANTIandrogen

A

1/3 patients will have PSA decline when antiandrogen is stopped.

88
Q

docetaxel va mitoxantrone

A

3 month survival benefit with docetaxel

89
Q

how is docetaxel administered

A

with prednisone

90
Q

docetaxel side effects - 2 main

A

myelosupression and peripheral neuropathy

91
Q

additional docetaxel side effects - 4

A

constipation, tearing due to deposition in tear ducts, onycholysis, fluid retention (peripheral/pulmonary edema)

92
Q

significance of normalized psa while on docetaxel

A

33 mo survival vs 16 mo

93
Q

best prognostic marker for survival while on docetaxel

A

> 30% reduction in PSA in first 3 months

94
Q

circulating tumor cells and docetaxel

A

can be used to monitor treatment response and correlates with overall survival.

95
Q

use of mitoxantrone + prednisone

A

palliation of pain + QOL once failed docetaxel, and carbazetaxel

96
Q

main mitoxantrone toxicity

A

cumulative cardiotoxicity

97
Q

type of bone remodeling seen with prostate cancer

A

osteoblastic - bone mets assd w increased bone formation aroud tumor deposits, however causes osteolysis

98
Q

role of bisphosophonates in bone mets

A

stops osteolysis

99
Q

what exactly does zolendronic acid do in prostate cancer - 3

A

delay in need for radiation, pathologic fx onset, bone pain

100
Q

who gets zolendronic acid

A

castrate resistant (only). no role in hormone sensitive

101
Q

2 side effects for zolendronic acid

A

renal failure, osteonecrosis of jaw

102
Q

what is denosumab

A

inhibitor AB to block RANKL (mediates osteoclast-mediated bone resorbtion). prevents SRE

103
Q

who gets denosumab

A

castrate resistant (only). no role in hormone sensitive

104
Q

second line after failing docetaxel

A

carbazetaxel + prednisone

105
Q

survival benefit of carbazitaxel

A

2 months

106
Q

major side effect of carbazitaxel and mgmt

A

neutropenia (upto 8%) and prophylactically given GMCSF

107
Q

indication for abiraterone

A

mcrpc who have recieved prior docetaxel

108
Q

abiraterone MOA

A

blocks CYP450 c17 (lyase and hydroxylase) steps in testosterone synthesis in periphery and in tumor

109
Q

electrolyte abnormalities while taking abiraterone - 2

A

hypokalemia and hypophosphatemia

110
Q

infection/ stress while taking abiraterone or if steroid is stopped

A

get adrenal insufficiency

111
Q

3 reasons for treatment discontinuation in abiraterone

A

AST/ALT elevation, urosepsis, cardiac failure

112
Q

T1a,b,c

A

a/b - incidental histologic finding </> 5%, c - dx by needle biopsy due to elevated PSA

113
Q

T2a,b,c

A

a - 1/2 one lobe but not both sides, c - both lobes

114
Q

T3a/b

A

a - ECE, b - invades SV

115
Q

T4

A

invades bladder, or adjacent structures

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