Campbell Prostate Cancer

Question 1

Prostate cancer has been the most common _____ in US men since 1984, now accounting for 19% of all such cancers.

Prostate cancer incidence varies by race/ethnicity, with _____ experiencing a 73% higher incidence rate than whites

Answer 1

noncutaneous malignancy

African-Americans

Question 2

_______ have the highest incidence of prostate cancer in the world, although incidence rates have been decreasing at a similar rate to Caucasians, at least in part resulting from a recent decrease in PSA testing

Answer 2

African-Americans and Jamaicans of African descent

Question 3

Prostate cancer is the _____ most common cancer and the _____leading cause of cancer deaths worldwide, with an estimated 1.1 million new cases and 300,000 deaths in 2012

Answer 3

2nd most common

5th leading cause of cancer death

Question 4

In the Prostate Cancer Prevention Trial (PCPT), ____ of men in the placebo arm were diagnosed by annual PSA screening within ___ years of enrollment suggesting that lifetime risk for regular screening may approach ____

Answer 4

14% within 7 years of enrollment

Lifetime risk: 20%

Question 5

The rationale for finasteride (a selective type 2 5α-reductase inhibitor [5ARI]) as a chemopreventive agent was based on ______

Answer 5

the absence of prostate cancer in men with congenital deficiency of 5α-reductase (the enzyme that converts T to DHT) and the critical role of androgens in the development of prostate cancer.

Question 6

The main finding of PCPT was a ______ reduction in the period prevalence of prostate cancer in men taking finasteride (18.4%) compared with placebo (24.4%)

Answer 6

25% reduction in period prevalence

Question 7

However, a significant increase in the prevalence of _______ in men receiving finasteride (280 [37%]) compared with placebo (237 [22%]),

Answer 7

biopsy Gleason score 7 to 10 cancers was observed

particularly for biopsy Gleason score 8 to 10 cancers (90 [12%] in the finasteride arm vs. 53 [5%] in the placebo arm).

Question 8

Another observation:

Marked effect of finasteride on the prevalence of biopsy _____ , no effect on the prevalence of biopsy ______, and an increase in the prevalence of biopsy _______

Answer 8

Gleason score 2 to 6 tumors - marked effect

Gleason score 7 tumors - no effect

Gleason score 8 to 10 tumors - increase

Question 9

Secondary analyses of PCPT have demonstrated an overall _______ for the diagnosis of prostate cancer in the finasteride arm.

Finasteride-treated glands were also _______ on average compared with those in the placebo arm, and data suggest that having a smaller prostate ENHANCES the detection of cancer, and proportionately more diagnosed cancers are high-grade

Answer 9

improved sensitivity of DRE, and a higher accuracy of PSA

28% smaller

Question 10

Does finasteride cause development of high-grade PCa?

Answer 10

NO. There appeared to be no morphologic effect of finasteride on prostate cancer grading when specimens were reviewed by a panel of expert pathologists blinded to the treatment arm

** rate of upgrading from biopsy Gleason score 2 to 6 to pathologic Gleason score 7 to 10 among men treated by radical prostatectomy was higher in the placebo arm compared with the finasteride arm

Question 11

Dutasteride reduced the risk for ______ over 4 years by 23% (858 in the placebo arm vs. 659 in the dutasteride arm, P < 0.001) and showed similar reductions in years 1 to 2 and years 3 to 4

Answer 11

prostate cancer

Question 12

The PCPT and REDUCE trials confirm the consistency of effect of ____ at reducing the _____ with a similar magnitude of risk reduction across all subgroups.

Answer 12

5ARIs

risk for prostate cancer,

Question 13

Toremifene citrate: Does it reduce prostate Ca risk?

Answer 13

A randomized trial in 1467 men with HGPIN FAILED to show a reduction in prostate cancer incidence at 3 years among those receiving tore- mifene citrate 20 mg daily vs. placebo, even among select high-risk groups

Question 14

Organizations such as the AUA recommend shared decision making for men _____ considering PSA-based screening, a target age group for whom benefits may outweigh harms

Answer 14

55 to 69 years of age

Question 15

PRE-BIOPSY: After an FDA warning and label change in 2016 regarding fluoroquinolone toxicity (musculoskeletal concerns [tendinitis and tendon rupture], peripheral neuropathy, central nervous system side effects, or myasthenia gravis), the AUA recommended shortening the use of _____ prophylaxis to a ____

Answer 15

fluoroquinolone

maximum of 24 hours.

Question 16

Cleansing enema effect: _____

But its effect on ____ is debatable.

Answer 16

This practice decreases the amount of feces in the rectum, thereby producing a superior acoustic window for prostate imaging.

The enema’s effect on reducing infections is debatable.

Question 17

The technique of______ may prove superior to color Doppler imaging in identification of malignant areas in the prostate

conflicting data available at this time, at present should be considered an additional technology to complement but NOT replace _____

Answer 17

elastography

random biopsies

Question 18

From a center of excellence with a large cohesive multidisciplinary team for prostate MRI and MRI-targeted biopsy, the false-negative rate of mpMRI was ____ for detection of clinically significant cancer.

Answer 18

16%

Question 19

PSA testing improves the ______ of DRE for cancer.

Use of PSA increases the detection of prostate cancers that are more likely to be _____ when compared with detection without PSA

Answer 19

positive predictive value (PPV)

organ- confined

*** The PPV of DRE ranged from 4% to 11% in men with PSA levels of 0 to 2.9 ng/mL and from 33% to 83% in men with PSA levels of 3 to 9.9 ng/mL or greater

Question 20

Current NCCN guidelines recommend the use of _____ and _____ among high-risk and unfavorable intermediate-risk men deemed to be at high risk for occult metastasis on the basis of clinical parameters or nomograms

Answer 20

technetium-99m bone scan

cross- sectional imaging (CT or MRI)

**Bone scan has been the most widely used method for evaluating bone metastases of prostate cancer and remains the current standard imaging test for initial prostate cancer staging, recurrence, and metastatic disease.

**CT scan: it remains the guideline-endorsed imaging choice for staging in men at risk for lymph node involvement

Question 21

Surveillance should be recommended as the best care option for men with ____ and the preferable care option for most low-risk, localized prostate cancer.

Death in men on active surveillance occurs most commonly from _____ and rarely occurs from prostate cancer.

Answer 21

very low risk

Question 22

The deep dorsal vein leaves the penis under the Buck fascia between the corpora cavernosa and penetrates the urogenital diaphragm, dividing into three major branches: _____

Arterial blood supply of the prostate: ______
Two branches: _____ and _____

Answer 22

the superficial branch and the right and left lateral venous plexuses

Inferior vesical artery

• Urethral (posterolateral vesicoprostatic junction) - vesical neck and periurethral portion
• Capsular groups (pelvic sidewall): supplies outer portion

Question 23

Care is taken to preserve the soft tissue covering the ____ that contains the lymphatics draining the lower extremity. Interruption of these lymphatics may lead to ____

Answer 23

external iliac artery

lower extremity edema and lymphocele formation.

Question 24

If the striated sphincter is divided too close to the apex of the prostate, there is risk that the ____may be damaged. As it approaches the apex of the prostate, it is often_____

Answer 24

NVB

fixed medially beneath the striated sphincter by an apical vessel

Question 25

Control of the dorsal vein: In placing this running suture, the surgeon should _____.

To control back-bleeding from the anterior surface of the prostate, _____

Answer 25

face the head of the table, holding the needle driver against the pubis perpendicular to the patient.

the edges of the proximal dorsal vein complex on the anterior surface of the prostate are sewn together with the preplaced 2-0 suture

Question 26

To avoid bleeding from the capsular arteries and veins, some surgeons dissect beneath the______. This is called an ______ .

Because this plane is directly on the prostatic parenchyma, the risk for is high. This approach should never be used!

Rather, the most common site of positive margins is the ____ followed by _____ and then ______ sites.

Answer 26

prostatic fascia

intrafascial dissection

positive surgical margins

apex, followed by posterior and then posterolateral sites

Question 27

When should you decide to excise the NVB?

Answer 27

No final decision is made until the time of surgery.

If induration is palpable in the lateral pelvic fascia, the NVB on that side is widely excised.

If there is no induration BUT the NVB appears to be fixed to the prostate at the time it is being released, it is also excised.

However, the final decision about preservation or wide excision of the NVB does not need to be made until the prostate is removed.

If there appears to be inadequate tissue over the posterolateral surface after the prostate has been removed, the NVB can then be widely excised.

Question 28

The vascular branches to the NVBs are best controlled by small hemoclips placed parallel to the bundle. ______ should NEVER be used on the NVB or its branches

Answer 28

Thermal energy of any form (unipolar, bipolar, or Harmonic scissors) - NEVER

Question 29

Post-RP: Traditionally, men ambulate the evening of the procedure and are discharged on postoperative _____

Answer 29

Day 1 or 2

Question 30

the single best means to control bleeding from the dorsal vein complex.

Answer 30

the surgeon should completely divide the dorsal vein complex over the urethra and oversew the end.

Question 31

Post-RP causes of BNC: _____

Management of BNC: _____

Answer 31

They arise from inadequate coaptation of the mucosal surfaces. This may be a result of inadequate approximation at the time of surgery, urinary extravasation, or distraction of the bladder neck from a hematoma.

Diagnosis should be considered in any patient who complains of a poor urinary stream or in patients who have prolonged unexplained incontinence.

Simple cystoscopic dilation
Direct cold-knife incision of the bladder neck at 3-, 6-, and 9-o’clock followed by intermittent self-catheterization for a limited time usually corrects the problem.
Injection of triamcinolone acetonide (200 mg in 5 mL) at the bladder neck after cold-knife incision may be useful.