After Term Test 3 Flashcards
What are the risk factors of prostate cancer
Age
Family history
Race
Environmental
What race has the highest incidence of prostate cancer
African American
What diet related substances increase risk of prostate cancer
- fat
- sugar sweetened beverage
- lycopenes
- vitamin E
- selenium
What are the screening procedures of prostate cancer
- digital rectal examination
- prostate specific antigen (PSA)
Why are DREs not very recommended
- can cause false positives and negatives not very accurate
How do PSAs work
PSAs use biomarkers a protein found in seminal fluid and manufactured by the prostate. Gives insight into a biological process or predicts a biological endpoint.
Describe the accuracy of a PSA test
- 5 receive a false positive
- 2 cases are missed
- 3 are found
What are the positives and negatives of PSA screeening
Positive: lowers prostate cancer specific mortality
Negative
- overdiagnosis
- false positives
- harms of biopsy
- harms of treatment
What are the early signs and symptoms of prostate cancer
- LUTS (lower urinary track symptoms)
- hesitancy
- dribbling
- weak system
- sensation of bladder not fully empty
- urgency
- frequent urination
What are advanced stage symptoms of prostate cancer
- back / hip pain
- numbness of lower limb
- edema
- weight loss
- fatigue due to anemia
What are the signs of prostate cancer
- hardening of prostate
- elevated PSA
After a high PSA test, what would be the next step I suggested
- transrectal ultrasound (TRUS)
- biopsy
What are the 3 categories that can predict behaviour of prostate cancer
- biopsy
- T stage
- level of PSA in blood
What does the Gleason score grade ? And how does it work ?
- adenocarcinoma level of aggressiveness
- 2 growth patterns identified
- each graded from 1 - 5
- GS = sum of two grades
What is considered low, intermediate, and high in the Gleason score
- 2-6 low
- 7 intermediate
- 8-10
What is the T staging for prostate cancer
T1: the tumour of cancer cannot be felt by the doctor during examination
T1a: histological finding in <5% resected tissue
T1b: >5% of tissue resected
T2: the cancer can be felt but it has not spread outside the prostate
T2a: found <1/2% of one lobe
T2b: > 1/2 of one love or in both lobes
T3: the cancer has spread outside the prostate into nearby tissues
T3a: invasion of bladder neck
T3b: invasion of seminal vesicles
T4: the cancer has spread into nearby organs such as the bladder
What are the common routes of spread for prostate cancer
- to lymphnodes
- distant spread
Bone (90%)
Lung (46%)
Liver (25%)
What are the PSA levels are favourable, intermediate, or unfavourable
< 10
10-20
>20
What PSA level would usually have metastatic disease
> 100
What does a risk stratification system/group predict
- how quickly the cancer grows
- chance of cancer being outside the prostate
What are the treatment procedures for LOW risk prostate patients
Active surveillance
Prosectomy
Brachytherapy
External beam RT
What is the active surveillance procedure in prostate cancer
- PSA every 3-6 months
- DRE every year
- TRUS biopsy once every 12 months then once every 3-5 years
What can trigger treatment in the active surveillance stage
- progression of Gleason
- clinical local progression
- increased PSA
- patient’s preference
What are the types surgery in prostate cancer
- open
- laparoscopic
- robot assisted
What is the duration and recovery period of surgery in prostate cancers
2-4 hours
4-6 weeks
What are some side effects of prostate surgery
- incontinence
- erectile dysfunction
What are the doses for brachytherapy in low risk early stage prostate cancer LDR
145 Gy (80-100 seeds)
What are some contraindications for brachytherapy
- large prostate (bigger than 60cc)
- pubic arch interference
- poor urinary functions
In how many cases does seed migration occur
40-60%
What are the side effects of brachytherapy
Swelling and feeling of heaviness
Pain during urination
Burning sensation
Urgency
Dysuria
Urinary obstruction
What are the doses for EBRT for moderate hypofractionation and ultra hypofractionation prostate
240 - 349 cGy
> 500 cGy
What are the side effects of EBRT for prostate cancer
Proctitis, cystitis, prostatitis
Impotence
Late rectal bleeding
What is the treatment procedure for intermediate risk groups
Prosectomy
Brachytherapy
External beam RT
Brachy + EBRT
What are the treatment options for high risk groups for prostate
EBRT + ADT
Prostectomy + EBRT + ADT
EBRT + brachytherapy + ADT
ADT
What is HDR brachytherapy
- US or MR guided
- iridium 192
Remote after loading through catheter
what are the doses of HDR brachytherapy prostate
15 Gy / 1
EBRT 37.5 / 15
Where are androgens produced
90% released by luteinizing hormone releasing hormone
10% produced in adrenal glands
What are the two mechanisms in ADT
- suppressing testosterone production
(Orichiectomy, LHRH agonist) - suppressing testosterone action
(Anti androgen)
What are forms of LHRH agonist
Zoladex lupron
What are forms of anti androgens
Casodex
What is the difference between short and long term androgen deprivation therapy
Short term (3-6 months)
- before (neoadjuvant)
Shrinks prostate, improves local control
- during (adjuvant)
Improves local control, reduces distant metastasis, improves survival
Long term (2-3 years)
- improves survival for men with higher risk cancer
What are the side effects of ADT
Hot flashes
Impotence
Weight gain, loss of muscle mass
Loss of body hair
Fatigue, anemia, cholesterol, bone
What is CRPC
Castrate resistant prostate cancer
- biochemical progression following total androgen blockage
- androgen independent growth
What is the role of EBRT in metastatic disease for prostate cancer
Palliative
Improve survival for low metastatic burden
What are the risk factors of kidney cancer
Age / gender
Smoking
Overweight / obesity
Hypertension
Alcohol (not rlly)
Exposure to TCE
Family history
Genetic disorder < 5%
(Von hippel lindau disease)
(HRPC)
Why are some presenstations of kidney cancer
Abdominal and back pain
Painless haematuria
Reoccurring fever
Fatigue
Weight loss
High blood pressure
Swelling in ankles
Mass in abdomen
Anemia or erythrocytosis
Symptoms of metastatic disease
What are the common pathologies of kidney cancer
Renal cell carcinoma (90%)
Clear cell (80%)
Non clear cell
Papillary
Chromophobe
Collecting duct
Renal pelvis transitional cell (10%)
What are the forms of surgery for kidney cancer
Radical nephrectomy
Partial nephrectomy
Tumour ablation: RFA and cryoblation
When is systemic therapy used for kidney cancer
Metastatic disease
In what situations is SABR a good alternative kidney cancer
- does not want general anaesthetic
- peri hilar tumours
- large tumours
- non invasive
What are the doses for SABR / SBRT for kidney disease for tumours < 5 cm and tumours >5cm
- 26 Gy / 1
- 40 Gy / 3-5 fractions
Tutorial: 27.5-40 / 5 on alternate days
What is the 5 year survival for each kidney stage
T1a, T1b- T2, T3, T4 or node positive , distant Mets
T1a: 90-95%
T1b - T3: 80-85%
T3: 60%
T4 or node positive: 8%
Distant Mets: <5%
What is the peak age for testicular cancer
15-44
What are tumour markers for testicular cancer
HCG (beta human chorionic gonadotrophin)
Alpha fetoprotien (AFP)
Lactate dehydrogenase (LDH)
What is the histology of testicular cancer
Germ cell tumours >95%
- seminoma
- non seminoma
Define the staging of testituclar cancer T stage
T: tumour limited to testis and epididymis no vascular/ lymphatic invasion
T2: limited to testis and epididymis with vascular lymphatic invasion
T3: tumour invades spermatic cord
T4: tumour invades scrotum
Define the staging of testituclar cancer N stage
N0 : no regional node metastatsis
N1: metastasis in single or multiple nodes 2 cm or less in greatest dimension
N2: metastasis in single or multiple nodes in 2-5cm greatest dimension
N3: metastasis in lymphnodes > 5cm in max diameter
Define the staging of testituclar cancer M stage
M0 - no
M1a - non regional lymph node or pulmonary metastasis
M1 b - non pulmonary visceral metastasis
Define the staging of testituclar cancer S stage
S0 - within normal limits
S1 - LDH < 1.5 x N and HCG < 5000 and AFP < 1000
S2 - LDH 1.5 - 10 x N or HCG 5000 - 500000 or afp 1000 - 10000
S3 - LDH > 10 x N or HCG > 50,0000 or AFP > 10,000
What would be the treatment for stage I testicular cancer seminoma
- surgery
- surveillance
- adjuvant radiotherapy
- adjuvant chemotherapy
What would be the treatment for stage I testicular cancer non seminoma
- surgery
- surveillance
- adjuvant chemotherapy - nerve sparing retroperitoneal LN dissection (RPLND)
How does the surveillance period work for testicular cancer
- examination of CT abdomen and pelvis
- every 4 months for 2 years
- every 6 months for 3-5 years
- annually for 5-10 years
What is the fractionation for stage I testicular cancer
25/20 or 20/10
What is the fractionation for stage II testicular cancer
25/20 + 10 Gy dose
What is the fractionation for stage II testicular non seminoma
No role
What is the chemo therapy for stage I testicular cancer
- adj chemo in seminoma: Carboplatin
- adj chemo in non seminoma: BEP , belomycin, eptoposide and cisplatin
What is the chemo therapy for stage II testicular cancer
- adj chemo in seminoma: IIB
- adj chemo in non seminoma: BEP x3 cycles (IIa/b)
What is the chemo therapy for stage IIc-III testicular cancer
- adj chemo in seminoma: BEP x3 cycles
- adj chemo in non seminoma: BEP 3-4 cycles
What are the symptoms of bladder cancer
- hematuria
- urinary frequency, dysuria, recurrent infections
- symptoms of metastatic disease
What are the diagnostic tools for bladder cancer
- urine cytology
- cytoscopy and biopsy
- TURBT (transurethral resection of bladder tumour)
- CT abdomen and pelvis
- MRI pelvis
- Chest x ray
- bone scan if symptoms
What is the pathology of bladder cancer
- Urothelial 90%
- squamous cell 5%
- adeno <2%
- others
Define the T staging of bladder cancer
Ta: non invasive papillar
Tis: flat carcinoma in situ
T1: invades into laminate propria
T2: invades muscle
PTA: inner half
PTB: outer half
T3: invades perivesical tissue
T3a: microscopic
T3b: macroscopic
T4: invades surrounding organs
What percentage of bladder cancers are non muscle invasive vs muscle invasive
70% non muscle invasive
- 70% Ta (low risk)
- 10% Tis (intermediate risk)
- 20% T1 (high risk)
30% muscle invasive (T2-T4)
What are the characteristics of NMIBC: Ta
> 50% of all bladder tumours
90% are low grade
Usually cured by resection
What are the characteristics of NMIBC: T1
- usually high grade
- 80% recurrence following TUR alone
- understating 30-60% are really T2+
How is non muscle invasive bladder treated for stage 1 (Tis)
Primary - surgery
Adjuvant BCG: intravesical therapy
How is muscle invasive bladder treated for stages 2-3
Stage 2-3
Primary treatment
- surgery option 1
- XRT option 2
Option 1
- Neo chemo (cisplatin + gem_
- maybe adjuvant chemo if positive LNs
Option 2
- concurrent CRT (cisplatin, 5FU or mitomycin)
- dose 46/23 + 20/10 or 55/20 How is muscle invasive bladder treated
How is muscle invasive bladder treated for stage 4
- primary : XRT or Surgery
- adjuvant chemo (gemcitabine and cisplatin)
- or MVAC
- XRT for symptomatic TRT
What are the side effects of surgery bladder
- infection
- ureteric obstuction
- stromal complications
- urinary leaks
- pouch rupture
- bowel complication
What are the roles of chemotherapy in bladder cancer
- Neo
- adj
- metastatic
- bladder preservation with radiation
What is the goal of neoadjuvant chemo therapy in bladder cancer
- treat micro metastatic disease early and make cancer more operable - down staging
- cisplatin / gemcitabine is mostly used
Benefit is best for T3 cancers
Improves survival by 5%
What chemos are used in bladder cancer for metastasis
- GC (gemcitabine/cisplatium) or MVAC (methotrexate, visblastine, adriamycin, cysplatin)
- 46-49%
Gemcitabine if poor tolerance of platinum agents - 25%
Why would a patient with muscle invasive bladder cancer go for the treatment without radical cystectomy and choose radiotherapy and chemo therapy
- patient who are not surgical candidates
- want to preserve bladder
- early cancers T2 grossly resected who should be considered for preservation
What are the histologies of endometrial cancer
- epithelial
Adenometrioid carcinoma (75-80)
Adenosquamous
Papillary
Clear cell - non epithelial
Sarcomas
Carcinoma
Leiomyo
Endo stromal
Lymphomas
Metastatic
What is the treatment for cervix cancer for early stage (<4cm, 1A-1B1)
- primary: SX
- adjuvant RT if high risk
- concurrent CRT if contraindications to SX
- EBRT
What is the dose regime for early stage and late cervical cancer
45/25
What is the chemo used for cervix cancer
Cisplatin
What is the primary treatment for locally advanced cervix cancer (greater than =4cm, 1B2 - IVA)
- primary: RT
- concurrent CRT (EBRT) + brachy (HDR)
What is the dose regime for cervix cancer brachy
28/4
What are the surgeries done for endometrial cancer
- total abdominal hysterectomy
- bilateral salpino - oophorerctomy
- pelvic and par aortic lymphnode dissection
- omentectomy
What are the options of adjuvant radiation therapy in endometrial cancer
- EBRT
- VBT
What is the principle for adjuvant radiation therapy in cervix cancer
- use prognostic factors to tailor therapy
- when what how
What are major negative prognostic factors for early stage endometrial cancers
- age is > 65
- grade 3
- LVSI present
- depth outer half myometrial invasion
What is the FIGO staging for endometrial cancer
- based on size and invasion (confined to uterus, invading into vagina, bladder, rectum)
- based on history and clinical examination
- does not include LN assessment
What is the TNM staging for endometrial cancer
- comparable to FIGO
- used for determining tx but not for staging
What is the treatment for stage I endometrial cancer
- primary surgery
- EBRT or VBT if 2 or more negative prognostic factors present
What is the treatment for stage II endometrial cancer
primary surgery
EBRT + VBT
What is the treatment for stage III endometrial cancer
- primary surgery
EBRT + VBT and Cx
What are the doses for endometrial cancer for EBRT and VBT
- 45/25
- 21/3
What is encompassed in the vaginal CTV for endometrial cancer
- vagina + paravaginal soft tissue
How are patients scanned for endometrial cancer to create the ITV
With full and empty bladder to take motion into account
What is encompassed in the nodal CTV for endometrial cancer
- external iliac , internal iliac, Obturator, presacral nodes (L5-S1)
What are the acute side effects of cervix RT
- fatigue
- bladder irritation
- rectal irritation
- 2 weeks after RT resolve 2-4 weeks post RT
What are the late side effects of cervix RT
- cystitis (rare)
Change in bowel habits
More common in 4 field box than IMRT
20 percent then 10 percent
What are the prognostic factors for cervical cancer patient related
Age
Obesity
Co morbidities
What are the prognostic factors for cervical cancer treatment related
Surgery vs RT
What are the prognostic factors for cervical cancer tumour related
Stage
Grade
Depth of myoinvasion
LVSI
Histology
What are the 5 year survivals for each stage of cervical cancer
1- 90
2 - 50-80
3 - 30-40
4 <10
What is the treatment for ovarian cancer
- primary surgery
- neoadjuvant chemo to treat microscopic disease (Carboplatin and taxol)
- adjuvant RT for non serous subtypes
- palliation for symptom management (RT or chemo)
What is the treatment for vaginal cancer
- surgery mainly in early lesions of upper vagina
- otherwise concurrent CRT
What is the dose for vaginal cancer
85 Gy to disease
What is the treatment for early vulva cancer
Primary - surgery
- adjuvant chemo if risk features
RT if inoperable
What are risk features for vulva cancers
- positive or close margins
> 8 mm
+ve LVI
DOI > 5 mm
What is the treatment for locally advanced vulva cancer
- primary surgery
- neoadjuvant concurrent CRT or definitive CRT
- treatment volume includes groin LNs
What are the does for vulva cancer
If uninvolved LNs, XRT = 45-50 (microscopic disease)
Definitive XRT, positive lymphnodes : 60-70 GY
Adjuvant XRT, positive lymphnodes: at least 50 Gy
What is the histology for ovarian cancers
- epithelial cells (cover the ovary)
- germ cells (inside the ovary)
- stromal cells (structural tissue holding ovary together)
What are the imaging work ups for ovarian cancer
- Transvaginal ultrasound
- CT / MR
What are the lab workups for ovarian cancer
CBC, LFTs, BUN/Cr
- tumour marker : CA - 125
What is the staging for ovarian cancer
1: only in ovaries
2: tumour has spread beyond the ovaries to the uterus, fallopian tubes, and or other pelvic tissues
3 and 4: malignant cells have grown and spread
In ovarian cancer what are the symptoms of Carboplatin and taxol
- Carboplatin : bone marrow suppression
- taxol: hair loss, bone marrow suppression, pins and needles in hands and feet (neurotoxicity)
What are the follow-ups for ovarian cancer
History and physical exam every 3 months for 2 years then every 6 months until year 5 then annually
CA - 125 each visit only image if elevated
What are the 5 year overall survivals for epithelial ovarian cancers
1 - 90
2 - 70
3 - 40
4 - 20
75% of women present with 3-4
What are the vulvar cancer specific symptoms
Pain
Spotting / bleeding
Discharge
Pruritus
Lump
What are the vulvar cancer regional symptoms
- difficulty urinating
Difficulty defecating
Dyspareunia
Lower extremity edema
What is the work up for vulvar cancer
H and P
Blood work
EUA
Colposcopy
Biopsy
Imaging: MRI pelvis, CT TAP
What is the histology for vulvar cancer s
squamous cell carcinoma: 80-90
Melanoma: 10%
Adenocarcinoma: tumours of vestibular glands (bartholins glands)
What premalignant conditions may vulvar tumours arise from
Lichen sclerosis
Pagets disease
Bowels disease
What are the common LOCAL routes of spread for vulvar cancer
- distal to proximal / caudal to cranial
- direct invasion: lower urethra, vagina, anus
- more extensive : upper urethra/vagina, bladder, rectum, bony pelvis
What are the common NODAL routes of spread for vulvar cancer and what does the risk depend on
- Inguinal femoral nodes (sup and deep)
- pelvic nodes
- risk depends on
Tumour size, depth of stromal invasion, LVI
What is the FIGO staging for vaginal cancer
1: limited to the vaginal wall
2: involved the subvaginal tissue
3: extended to the pelvic wall
4: beyond the true pelvis or involves bladder or rectum or distant Mets
What is the survival for each stage of vaginal cancer
I/II median survival 6 years
III/IV medial survival 2.5 years a
What is the general workup for vagina cancer
Physical exam
MRI pelvis
CT pelvis
Biopsy
CXR
CBC LFTs
What is the histology of vagina cancer
Squamous cell carcinoma
What lymphatics are included in vaginal cancer
Upper: internal iliac
Lowe: Inguinal and iliac
When can vulvar cancer cannot be resected
Extensive vulvar regions without large tissue defect and compromises anal sphincter (definitive RT)
What are indications for adjuvant RT for vulvar cancer (risk factors for locally recurrence)
Margins < 8 mm
LVSI
DOI > 5 mm
What is the CTV (ITV) primary for vulvar cancer
Adjuvant : entire vulva and post op bed
Definitive: GTV + 1cm + entire vulva
What is the nodal CTV for vulvar cancer
Pelvis and inguinofemoral (internal and external Obturator lymphnodes)
What is the PTV for vulvar cancer
CTV/ITV + 7-10 mm
For vulvar cancers
Groin node involvement is prevalent = _______ prognosis
Groin failures are rarely _______
Management of groin nodes is clearly indicated for any patients with tumour invasion greater than ______
Poor
Salvageable
1 mm depth
What makes a vulva operable
margin status
Adequate margin and Local control (heaps)
Planned surgical margin of 1 cm will take into account 20% shrinkage as a result of formalin fixation
Margins <8mm associated with 50% of LR
What is the figo staging of vulva cancer
1: confined to vulva
1A: less than equal to 2 cm confined to premium, stromal invasion < equal to 1 mm, negative nodes
1B: > 2cm in size or stromal invasion > 1mm, confined to vulva/perinium
2: tumour of any size with extension to adjacent perineal structures, negative nodes
3 tumour of any size with or without extension to adjacent perineal structures, POSITIVE Inguinofemoral lymphnodes
3A: with one lymph node Mets > = 5 mm or one OR two lymphnode Mets less than 5 mm
3B: with two or more lymphnode Mets > = 5mm OR 3 or more lymphnode metastasis > 5 mm
What is the general approach to manage the vulva (primary) for resectable and inoperable tumours
if resectable
Wide local excision +/- adj RT
If inoperable
CRT +/- resect residual
What is the management of the Inguinal femoral LNs
clinically node negative
- SLNB or IFL +/- adj RT
Palpable mobile LN
- bilateral IFL +/- adj RT
Fixed / ulcerating LN
- CRT + boost / resect residual
