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Genitourinary Flashcards

1
Q

Topics to cover in GU history

A
  • Urinary frequency
  • Urgency
  • Hesitancy
  • Hematuria
  • Dysuria
  • Diarrhea/constipation
  • Blood in stool
  • IBS symptoms
  • ED
  • Bone pain
  • Abdominal or pelvic pain
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2
Q

Other important topics to raise for prostate consult

A

AUA/IPSS score IIEF score Prior RT History of IBD Testosterone replacement Usage of BPH medications Comorbidities related to CV health Date of last colonscopy

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3
Q

Topics to address in GU PE

A

Focused physical exam including –DRE feeling for nodules in the prostate or prostatic pain –ECE and loss of lateral sulci –Prostate firmness –Estimate size of the prostate

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4
Q

IPSS score

A

Made up of 7 questions related to voiding symptoms scored 0-5. A score of 0 to 7 indicates mild symptoms, 8 to 19 indicates moderate symptoms and 20 to 35 indicates severe symptoms.

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5
Q

IIEF score

A

IIEF-5 range from 5 to 25 ED was classified into five categories based on the scores: severe (5–7), moderate (8–11), mild to moderate (12–16), mild (17–21), and no ED (22–25)

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6
Q

Standard prostate workup - labs

A

DRE Labs: PSA, CBC, CMP, LFTs, testosterone

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7
Q

Standrad prostate workup - imaging

A

CT/MRI pelvis Bone scan (if indicated) by clinical staging Axumin PET or PSMA on protocol if high suspicion for mets Colonoscopy if GI symptoms or if never had one

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8
Q

What kind of biopsy

A

TRUS guided Looking for Gleason primary and secondary grade, prostate size, presence of hypoechoic lesions

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9
Q

How many cores needed on TRUS

A

At least 8, 12 is better

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10
Q

What can be learned from biopsy

A

of cores involved % involvement of each core PNI Gleason grade primary and secondary

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11
Q

What patients don’t need any further workup after dx of prostate cancer

A

Life expectancy <5 years & asymptomatic UNLESS high or very high risk disease

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12
Q

What patients need a bone scan

A

T1 and PSA >20 T2 and PSA >10 Gleason score 8-10 T3 or T4 Symptomatic

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13
Q

Pelvic CT or MRI needed if

A

T3, T4 T1 or T2 and nomogram indicates probability of LN involvement >10%

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14
Q

What nomograms help to predict nodal involvement

A

Partin nomogram Roach formulas

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15
Q

What does the Partin nomogram predict

A

Pathologic stage (organ confined, ECE, SV invasion or nodal invasion) based on cT, PSA, Gleason

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16
Q

What is Roach formula for LN involvement

A

2/3*PSA + 10 (GS-6)

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17
Q

If you are asked about clinical stage and patient had surgery when to consider stage

A

Prior to surgery or biopsy

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18
Q

By AJCC 8th, what exam findings factor into cT stage

A

DRE only

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19
Q

cT1a Prostate

A

Incidental histologic finding in <5% of tumor resected (TURP)

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20
Q

cT1b Prostate

A

Incidental histologic finding in >5% of tumor resected (TURP)

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21
Q

cT1c Prostate

A

Tumor identified by needly biopsy (due to elevated PSA)

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22
Q

cT2a Prostate

A

Tumor in <1/2 of one lobe

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23
Q

cT2b Prostate

A

Tumor in >1/2 of one lobe (but not both lobes)

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24
Q

cT2c Prostate

A

Tumor involved both lobes of prostate

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25
Q

cT3a Prostate

A

ECE

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26
Q

cT3b Prostate

A

SVI

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27
Q

cT4 Prostate

A

Fixed tumor or invades through structures other than SV: bladder, levator and/or pelvic wall

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28
Q

N1 prostate

A

Any regional nodes - obturator, internal/external iliac, presacral

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29
Q

M1a prostate

A

Non-regional lymph nodes

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30
Q

M1b prostate

A

Bone mets

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31
Q

M1c prostate

A

Other visceral mets

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32
Q

Differences between clinical and path staging for prostate

A

No T1

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33
Q

What is pT2 prostate

A

organ confined

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34
Q

What is pT3a prostate

A

ECE or microscopic invasion of bladder neck, if +margin should say R1

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35
Q

What is pT3b prostate

A

SVI

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36
Q

What defines very low risk prostate cancer?

A

T1c Gleason 6 or lower PSA <10 <3 positive cores, <50% in each core PSA density <0.15

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37
Q

What defines low risk prostate cancer

A

T1 or T2a Gleason 6 or less PSA < 10

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38
Q

What defines intermediate risk prostate cancer

A

T2b or T2c OR Gleason score 7 OR PSA 10-20

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39
Q

What defines high risk prostate cancer

A

T3a OR Gleason 8-10 OR PSA >20

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40
Q

What defines very high risk prostate cancer

A

T3b or T4 Multiple high risk factors

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41
Q

What defines metastatic prostate cancer

A

Any N1 Any M1

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42
Q

What is 5-10 year bPFS for low risk PC

A

90%

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43
Q

What is 5-10 year bPFS for int risk PC

A

70-80%

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44
Q

What is 5-10 year bPFS for high risk PC

A

30-60% (50%)

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45
Q

What is 5-10 year CSS for low risk PC

A

95%

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46
Q

What is 5-10 year CSS for int risk PC

A

85%

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47
Q

What is 5-10 year CSS for high risk PC

A

75%

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48
Q

Management options for very low risk prostate cancer (good life expectancy)

A

If life expectancy > 20 years 1. Active surveillance 2. RT or brachy mono 3. Radical prostatectomy +/- pelvic LN dissection if predicted probability of LN mets >2%

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49
Q

Management options for very low risk prostate cancer (intermediate life expectancy)

A

If life expectancy 10-20 years 1. Active surveillance

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50
Q

Management options for very low risk prostate cancer (low life expectancy)

A

If life expectancy <10 years Observation (no biopsies or PSA checks but manage symptoms as they arise)

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51
Q

What is included in active surveillance?

A
  1. PSA no more often than every 6 months 2. DRE no more often than every 12 months 3. Repeat TRUS bx no more often than every 12 months
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52
Q

If a patient opts for RP, what are options after the surgery

A
  1. If adverse features –> consider RT or observation (probably obs given latest data) 2. If N+ –> ADT (category 1) +/- RT (category 2B) or observation
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53
Q

What are the treatment options for intermediate risk PC (good life expectancy)

A

If expectancy >10 years: 1. RP + PLND (if risk of N+ >2%) 2. RT +/- ADT +/- brachytherapy 3. Brachytherapy alone

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54
Q

What is the duration of ADT for IR PC?

A

4-6 months

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55
Q

What are the treatment options for intermediate risk PC (poorer life expectancy)

A

If expectancy <10 years: 1. RT +/- ADT (4-6 months) +/- brachytherapy 2. Brachy mono 3. Observation (if truly poor candidate)

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56
Q

If a patient is found to be N+ after RP what should be offered

A

ADT (Category 1) RT (Category 2B) Observation

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57
Q

What are the treatment options for high risk PC

A
  1. EBRT + ADT (2-3 years) ADT if N+ –>Likely obs if adverse features
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58
Q

What are the treatment options for very high risk PC

A
  1. EBRT + ADT (2-3 years)
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59
Q

What are the treatment options for N1 PC

A
  1. EBRT + ADT (2-3 years)
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60
Q

What are the treatment options for M1 PC

A
  1. Orchiectomy 2. LHRH agonist +/- anti-androgen >7d to prevent testosterone flare 3. LHRH agonist + anti-androgen 4. LHRH antagonist 5. Observation (if asymptomatic, poor life expectancy)
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61
Q

What is a commonly prescribed LHRH agonist

A

Lupron

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62
Q

Typical dose of Lupron

A

7.5mg SC monthly 22.5 mg q3months (depot)

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63
Q

What is the mechanism of bicalutamide

A

Anti-androgen (competes with binding of androgen receptor)

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64
Q

What is a commonly prescribed LHRH antagonist

A

Degarelix

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65
Q

Dose of degarelix

A

120 mg SC for 2 doses (ie, 2 separate injections totaling 240 mg), THEN after 28 days, begin maintenance dose of 80 mg SC q28d

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66
Q

If a patient returns with relapsed PSA what is best next step

A

Obtain imaging to clarify if sites of gross disease –> MRI pelvis –> CT CAP –> Axumin or PSMA on protocol –> bone scan

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67
Q

Treatment options for hormone refractory recurrent PC

A

If no evidence of mets –>Maintain castrate levels of testosterone –>clinical trial 1. Observation if PSADT >10 months 2. Secondary hormone therapy especially if PSADT <10 months

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68
Q

What are some secondary hormonal therapy options?

A

Antiandrogens - enzalutamide, abiraterone, apalutamide and darolutamide Ketoconazole Corticosteroids DES or other estrogen

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69
Q

Mechanism of enzalutamide

A

nonsteroidal antiandrogen medication

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70
Q

Dose of enzalutamide

A

160 mg (two 80 mg tablets or four 40 mg tablets or four 40 mg capsules) administered orally once daily

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71
Q

Mechanism of abiraterone

A

Androgen biosynthesis inhibitor, that inhibits 17 a-hydroxylase/C17,20-lyase (CYP17)

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72
Q

Dose of abiraterone

A

1000 milligrams (mg) (two 500 mg tablets or four 250 mg tablets) once a day, taken together with 5 mg oral prednisone 2 times a day.

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73
Q

Patient returns with biochemically relapsed disease and studies + for mets –> treatment options

A
  1. Maintain castrate levels of testosterone and offer denosumab or zolendronic acid if evidence of bone metastases 2. Remainder of options dictated by symptomatic or not
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74
Q

If patient has symptomatic M1 disease –> options

A
  1. Docetaxel (category 1) 2. Radium-223 for symptomatic BM 3. Mitoxantrone 4. Abi 5. Enzalutamide 6. Palliative RT or radionuclide for painful BM 7. Clinical trials 8. Best supportive care
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75
Q

Dose of docetaxel

A

Docetaxel 75mg/m2 IV Give with pred 5 BID Repeat q3wks for 6 cycles

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76
Q

Dose of bicalutamide

A

50 mg daily (if part of CAB)

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77
Q

If patient has asymptomatic M1 disease –> options

A
  1. Sipuleucel-T (category 1) 2. Secondary hormonal therapy 3. Docetaxel 4. Clinical trial
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78
Q

How to define biochemical failure after RP

A
  1. Failure of PSA to fall to undetectable levels (PSA persistence) 2. Undectable PSA with a subsequent detectability that increases on 2 or more determinations (PSA recurrence)
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79
Q

Treatment options for post-RP biochemical failure

A

Determine PSADT Imaging: CT/MRI pelvis +/- bone scan or Axumin/NaF PET/PSMA on protocol –>Prostate bed biopsy if imaging suggests local failure

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80
Q

Once workup is complete for post-RP biochemical failure what are treatment options?

A

If workup (-) for DM: pelvic RT +/- nodes +/- ADT +/- observation If workup (+) for DM: ADT +/- RT for sites of metastases if in weight-bearing bones or symptomatic or OBS

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81
Q

Defining recurrence after RT

A
  1. Positive DRE 2. nadir + 2 ng/mL (Phoenix criteria)
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82
Q

Workup if evidence of post-RT failure

A

Determine if patient is a candidate for subsequent local therapy: 1. Original clinical stage of cT1-T2, NX or N0 2. Life expectancy > 10 years 3. PSA <10 ng/mL If yes: –>PSADT –>TRUS biopsy –>Bone scan –>CT CAP and MRI pelvis

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83
Q

Treatment options if post RT recurrence demonstrates TRUS+ and DM-

A
  1. Observation 2. RP 3. Cryosurgery 4. Salvage brachytherapy
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84
Q

Treatment options if post RT recurrence demonstrated TRUS- and DM-

A
  1. Observation 2. ADT 3. Clinical trial 4. More aggressive workup for local recurrence (PSMA PET or Axumin etc.)
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85
Q

Simulation technique for IG-IMRT prostate

A

3 fiducials placed into the bladder Consider hydrogel spacer for lesions without any posterior ECE Supine immobilized an in alpha cradle arms on chest Full bladder and empty rectum (enema if needed) both for simulation and for daily treatment Fuse the patients sim CT with MRI for better delineation of the prostate

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86
Q

Location of prostate apex with respect to penile bulb

A

apex is 1.5 cm superior

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87
Q

Imaging guidance for prostate treatments

A

Daily KV imaging matched to fiducials Daily CBCT checking bladder and bowel filling, adjusting bowel regimen as needed

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88
Q

What is GTV, CTV for prostate

A

GTV=CTV = prostate gland and either entire or proximal 1-2 cm of SV

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89
Q

What is the PTV expansion for prostate (mod hypo)

A

8-10 mm radially, 3 mm posteriorly into rectum

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90
Q

What is the PTV expansion for prostate (SBRT)

A

5 mm anteriorly and radially

3 mm posteriorly into rectum

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91
Q

Dose options for prostate alone

A

Several options including –Dose escalated conventional RT (at least 78 Gy) –Moderate hypofractionation –SBRT

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92
Q

Moderate hypofractionation dose

A

70 Gy in 28 daily 2.5 Gy fractions

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93
Q

What is the expected benefit of dose escalation for PC

A

Improves bPFS by 10-20% for low, intermediate and high risk groups, no difference in OS

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94
Q

What are some of the risks of dose escalation

A

Increases G2+ acute GI toxicity Similar GU toxicity Acute tox peaks earlier

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95
Q

What patients can be offered SBRT?

A
  • Low Risk
  • Fav Int Risk – recommend on clinical trial
  • No evidence of ECE
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96
Q

What is the dose of SBRT for appropriate candidates?

A

36.25 in 5 fractions of 7.25 Gy

Deliver QOD for reduced toxicity

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97
Q

What is the dosing schedule for prostate SBRT

A

QOD

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98
Q

What is the rectal constraint for mod hypofrac?

A

D15% < 75

D25% < 70 Gy

D35% < 65 Gy

D50% < 60 Gy

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99
Q

What is the bladder constraint for moderate hypofrac?

A

D0.03 cc (MPD) < 73.5 (<105%)

D35% < 70 Gy

D50% < 65 Gy

D90% < 35%

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100
Q

What is the rectal constraint for SBRT

A

Remember dose is 36.25 in 5

  • D0.03cc < 38.06 (max <105%)
  • D3cc < 34.4 (<95%)
  • D10% < 32.63
  • D20% < 29 Gy
  • D50% <18.12 (<50%)
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101
Q

What is the bladder constraint for SBRT?

A
  • D0.03cc <38.06 (<105%)
  • D10% < 18.12 (<50%)
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102
Q

What is urethral constraint for SBRT?

A

D0.03 < 38.78 (<107%)

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103
Q

When does nadir occur after EBRT?

A

2-3 years after completion of RT

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104
Q

How many patients experience PSA bounce?

A

10% EBRT

20% brachy

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105
Q

What is the median time to PSA bounce?

A

9-12 months

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106
Q

What PSA level is bounce?

A

Usually <2 ng/mL, does not predict for subsequent PSA failure

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107
Q

Risk of urinary side effects from RP vs. RT

A

RP: 10%

EBRT: 10%

Brachy: 20%

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108
Q

Risk of GI side effects from RT vs. RP

A

RP: 2%

EBRT/brachy: 10%

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109
Q

Risk of sexual side effects RT vs. RP

A

RT: loss of sexual function 30-50%

RP: 50%

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110
Q

Absolute/relative contraindications to LDR brachy

A
  • SVI
  • Large T3 disease
  • Relative contraindications
    • Prostate size >60 cc (associated with increased tox and risk of obstruction)
    • Median lobe hypertrophy
    • Significant pre-treatment urinary symptoms (IPSS >15-18)
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111
Q

Options for LDR if the prostate is >50-60 cc

A

Consider 3 months of ADT for cytoreduction –> LDR

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112
Q

When is post procedure CT scan performed for LDR brachy?

A

1 month post procedure

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113
Q

LDR brachy V100

A

As close to 100% as possible, at least 90%

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114
Q

LDR brachy D90

A

Dose going to 90% of the prostate

(>90%)

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115
Q

LDR brachy: urethral point dose

A

No more than 150% of Rx dose

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116
Q

LDR brachy: rectal constraint

A

<1cc of rectum should receive >100% of Rx dose

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117
Q

What is D90?

A

Minimum dose going to 90% of prostate (>90%, ideally 100%)

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118
Q

What is V100?

A

Volume of prostate receiving 100% of Rx dose

(goal >95%, ideally 100%)

119
Q

I-125 Rx dose

A

145 Gy if mono

110 Gy if boost

120
Q

Pd-103 dose

A

125 Gy if mono

90 Gy if boost

121
Q

Ir-192 HDR dose

A

13.5 x 2 fractions

Boost dose = 15 Gy x 1

122
Q

t1/2 of I-125

123
Q

t1/2 of Pd-103

124
Q

t1/2 of Ir-192

125
Q

Risk of urinary obstruction after brachy

126
Q

Risk of impotence post brachy

A

~1/3 (maybe less than EBRT)

127
Q

Risk of urethral stricture post brachy

128
Q

Risk of incontinence post brachy

129
Q

2% normally

5% if prior TURP

130
Q

Risk of rectal bleeding from brachy

131
Q

Risk of rectal fistula from brachy

132
Q

Risk of ED after RP

A

50% even with nerve sparing techniques

133
Q

Risk of urinary incontinence after RP

A
  • 50% occasional leakage
  • 10% frequent leakage
  • 3% no urinary control
134
Q

Definition of PSA failure after RP

A

Use AUA standard: >0.2 on 2 separate measurements

135
Q

Typical follow-up for patient after definitive RT

A

NCCN says PSA q6-12m x 5 years with annual DRE

136
Q

What are the pros/cons of brachy boost for intermediate to high risk PC

A
  • Pros
    • Improves bPFS
    • No change in OS, DMFS
  • Cons
    • Increased acute GU toxicity (mostly retention)
    • Increased delayed GU toxicity (5–>18%)
      • Mostly urethral strictures
    • Trend towards delayed GI toxicity
137
Q

If you want to do combo therapy what dose

A
  • 45 Gy EBRT + 15 Gy x 1 HDR
  • 45 Gy EBRT + 100 Gy LDR (Pd-103)
  • 45 Gy EBRT + 110 Gy LDR (I-125)
138
Q

For which N0 patients would you consider prophylactic nodal irradiation

A
  • High risk (all)
  • Unfavorable intermediate (especially if young, healthy, many risk factors – SVI, G5 disease, high amounts of G4 disease)
139
Q

If treating full pelvis, what is treated

A
  • Obturator (stop at top of pubic symphysis)
  • External iliac (stop at top of femoral head)
  • Internal iliac
  • Common iliac (up to L4-L5)
  • Presacral
140
Q

For high risk prostate cancer, how much ADT is required

A

18-36 months

18 endorsed by NCCN

141
Q

What is the benefit of ADT for high risk disease

A

10% OS and bPFS benefit

142
Q

Patients who are likely to benefit from salvage RT

A
  • Low pre-tx PSA (<0.2)
  • Positive margin
  • Low PSADT
  • Gleason <8
  • Negative LN
  • Long interval to PSA failure after RP or elevated PSA immediately after RP
143
Q

Dose for salvage RT

A

pelvis to 45 Gy in 25 fractions

prostate boost to 64.8 Gy in 1.8 Gy fractions

144
Q

Rectal constraint for salvage prostate RT

A

V65 < 35%

V40

145
Q

Bladder constraint for salvage prostate RT

A

(minus CTV)

V65 < 50%

V40 < 70%

146
Q

Femoral head constraint for salvage prostate RT

147
Q

CTV delineation for salvage prostate RT

A

Inferior edge is top of penile bulb

Lateral is medial edge of obturator internus muscles

Anterior is full bladder neck until pubic symphysis then gradually extend backwards off anterior bladder

Posterior is anterior edge of rectum

148
Q

How high superiorly should salvage RT extend for prostate

A

Cut end of vas deferens OR

Max of 3-4 cm above the pubic symphysis

149
Q

What is the CTV to PTV expansion for salvage prostate?

150
Q

Which salvage patients should we consider WPRT?

A

High risk - N+, PSA > 0.3

151
Q

Which patients might you opt for adjuvant RT?

A

N+

(maybe best for T3/T4, 3-4 nodes)

152
Q

If doing salvage RT, when to start?

A

About 3 months post op, maximal urinary recovery

153
Q

If doing salvage RT, dose?

A

45 Gy to pelvis

70.2 to prostate bed if gross disease

Otherwise 68 Gy to prostatic fossa

154
Q

Typical ADT side effects

A
  • hot flashes
  • bone loss
  • impotence
  • decreased libido
  • increased body fat
  • hair loss
  • anemia
  • metabolic syndrome risk
155
Q

Bone risk if starting ADT

A

If short course ADT planned: FRAX score –> DEXA

If long course ADT: get DEXA –> referral to endo if osteoporosis/osteopenia

156
Q

If contouring N+, how to contour

A
  • Start contouring distal common iliac vessels at L5/S1
  • 7 mm expansion on vessels, carve out bone/bowel/bladder
  • Include presacral nodes S1-S3
  • Stop external iliac contours at top of femoral heads
  • Stop obturator LNs at top of symphysis
157
Q

What is the CTV for low risk prostate cancer

A

prostate alone

158
Q

What is the CTV for intermediate risk prostate cancer

A

Prostate and proximal 1 cm of SV

159
Q

What is the CTV for high risk prostate cancer

A
  • First phase: entire prostate, entire SV plus pelvic LN (obturator, internal/external iliac, presacral)
  • Second phase: cone down on prostate + SV
160
Q

LDR brachytherapy script

A
  • Ensure patient has adequate bowel prep
  • Take to OR –> induce general anesthesia
  • Give IV antibiotics (cefazolin or gent)
  • Place patient in dorsal lithotomy position
  • Insert foley catheter and irrigate rectum copiously
  • Tape scrotum out of the way
  • Insert rectal ultrasound probe and secure to stepper unit
  • Connect template to the rectal ultrasound stepper unit to divide the prostate into coordinates
  • Needles are then placed into the prostate under US guidance – typically 16 needles with 12 placed peripherally about 1 cm spaced and 4 centrally to minimize dose to urethra
  • We then capture several coronal slices of the prostate which is fed to laptop with brachy planning software
  • The prostate, urethra and rectum are then contoured using the slices
  • A real time plan is created to maximize prescription and constraints
  • Seeds are then placed into the prostate using a Mick applicator through the template and spacing recommended by the brachy planning software
  • We then perform a fluoroscopy CT scan to confirm seed location
  • Physicist performs radiation survey to ensure no loose seeds
  • Patient is awoken and able to discharge when able to void
  • Post implant CT 1 month later
161
Q

Guidelines for needle placement for LDR

A
  • 16 needles total
  • 12 in periphery spaced 1 cm apart
  • 4 in the center to minimize urethral dose
  • Spacing of 5 mm from the posterior wall to reduce rectal dose
162
Q

Appropriate time to do post implant CT for LDR and why?

A

1 month

Prior to then there is prostatic edema

163
Q

HDR brachy script

A
  • Patient is given good GI bowel prep
  • Take to OR and induce general anesthesia
  • Give IV antibiotics (2-3g of cefazolin)
  • Insert Foley –> insert 300 cc of fluid and clamp
  • Irrigate rectum and then do betadine wash of the perineum
  • Secure scrotum and penis out of the way
  • Insert the ultrasound into rectum and lock with slight upward pressure to get good view of prostate
  • Switch to sagital view to make sure that the urethra and catheter appear in the same plane (i.e., everything is straight)
  • Template then connected to the ultrasound probe and the stepper unit is slid forward to press against the perineum – maps the prostate into coordinates
  • Needles are inserted through the perineum using template
  • Typically 13 needles are inserted - 11 peripheral and 2 needles centrally to cover the urethral dose but to minimize rectal/urethral dose
  • Start with top two needles to assess for pubic arch interference
  • Once the needles are placed, switch to sagittal view to check for depth and ensure not in bladder
  • We then obtain serial axial images of the prostate which are connected to laptop with realtime planning software
  • The prostate, urethra, rectum and needles are contoured on the US axial images
  • While planning occuring I hook up afterloaders to needles
  • I then evaluate plan and deliver therapy
  • Once done, unclamp foley, remove needles, remove probe, apply pressure to perineum
  • Patient can be discharged when able to void
164
Q

Needle placement for HDR

A
  • Generally 13 needles
  • 11 peripheral
  • 2 central posterior to the urethra
  • space 1 cm from each other (or so)
  • 5 mm spacing from posterior wall to reduce rectal dose
  • top row of 4, middle row of 4, bottom row of 4-6
165
Q

Acceptable prostate dose for low volume M1 disease

A

55 Gy in 20 fractions (2.75 Gy per fraction)

Per STAMPEDE

166
Q

Mechanism of Lupron or Zoladex

A
  • LHRH agonists
  • Bind to receptors in pituitary –> increase in FSH/LH –> increase in testosterone
  • Receptor downregulation and decreased release of LH/FSH via negative feedback
167
Q

Side effects of Casodex

A

Gynecomastia

Hepatotoxicity (remember to check LFTs)

168
Q

Possible treatment option for gynecomastic

A

Prophylactic breast RT (4 Gy x 3)

169
Q

Treatment strategy for high risk prostate cancer getting definitive RT

A
  • Overall plan is EBRT + long term ADT (18 months)
    • Neoadjuvant until PSA <1
    • CAB through end of RT
    • Total of 18 mos
  • IG-IMRT to 45 Gy to prostate/pelvis (1.8 x 25 = 45 Gy)
  • IG-IMRT to 81 Gy to prostate/SV (1.8 x 20)
170
Q

Dose for grossly involved nodes

A

56.25 (2.25 Gy x 25 fx)

56 gy in 28 fx

171
Q

What nodal regions are covered for prostate

A
  • Distal common iliacs (L5-S1)
  • Presacral (S1-S3)
  • Internal and external iliac (to top of femoral head)
  • Obturators (down to pubic symphysis)
172
Q

Approach for nodal contouring

A
  • Contour vessels starting from L5-S1 interspace
  • 7 mm expansion to CTV, carve off bone, bowel, bladder
  • Contour presacral space S1-S3 from anterior sacrum to 1 cm anterior and carve off bowel, bladder, bone
  • Stop external iliac and top of femoral heads
  • Stop obturator at top of pubic symphysis

CTV to PTV expansion of 7 mm

173
Q

When to stop CAB for high risk disease

A

End of RT typically

174
Q

Criteria for PSA failure after RT

A

Phoenix criteria

nadir + 2

175
Q

Nadir periods after RP, RT, brachy

A

RP: 3 weeks

RT: 2-3 years

Brachy: 3-4 years

176
Q

What is a reasonable PSA DT to consider hormones after definitive therapy

177
Q

Mechanism of bicalutamide

A

Oral non-steroidal anti-androgen - binds to AR receptor and prevents the binding of testosterone and it’s downstream effects

178
Q

For initial metastatic disease, what is rough duraion of disease control on ADT

179
Q

If patient is metastatic, PSA is rising, what is next step

A

Check testosterone –> ensure castrate, if not, add a different agent

180
Q

Mechanism of abiraterone

A

17-alpha hydroxylase inhibitor which is an enzyme expressed in testicular, adrenal and prostate tissue

The enzyme catalyzes the formation of DHEA and androstendione which are androegns and precursors of testosterone

Inhibition of the enzyme reduces testosterone levels

181
Q

What needs to be given with abi

A

5 mg prednisone BID

182
Q

What is mechanism of enzalutamide

A

AR antagonist with stronger affinity than casodex

183
Q

What would be the indication for Ra-223

A

Symptomatic bone mets

184
Q

Mechanism of action of Ra-223

A

Alpha particles, high LET

185
Q

Half life of Ra-223

186
Q

History questions to ask for bladder cancer

A
  • Hematuria
  • Irritative voiding symptoms
  • Pelvic pain
  • Obstructive uropathy
  • Hydronephrosis
  • Risk factors such as smoking, dyes, cytoxan exposure, prior prostate ca, chronic irritation from stones or indwelling foley, travel/schistosomia
187
Q

Lab workup for bladder cancer

A

U/A

Urine cytology

PSA

Office cystoscopy

188
Q

What is detection capability of cytology?

A

50-80% of poorly diff

20% of well diff

189
Q

Bladder T1

A

Invades subepithelial connective tissue

190
Q

Bladder T2a

A

Invades superficial muscularis propria

191
Q

Bladder T2b

A

Invades deep muscularis propria

192
Q

Bladder T3a

A

Invades perivesicular tissue microscopically

193
Q

Bladder T3b

A

Invades perivesicular tissue macroscopically

194
Q

Bladder T4a

A

Invades prostate, SV, uterus, vagina

195
Q

Bladder T4b

A

Invades abdominal or pelvic wall

196
Q

Bladder N1

A

single regional LN in true pelvis (perivesical, obturator, internal/external iliac, sacral)

197
Q

Bladder N2

A

Multiple pelvic LN

198
Q

Bladder N3

A

common iliac LN

199
Q

Stage of N+ bladder ca

A

IIIA (N1)

IIIB (N2-3)

200
Q

Management of non-invasive bladder cancer

A
  • CT urogram before TURBT
  • EUA (bimanual)
  • TURBT w random biopsies
  • If trigone involved, biopsy prostatic urethra
201
Q

Management of cTa (non-invasive papillary tumor)

A
  • Depends on grade
  • If low grade
    • Observation
    • Or single dose intravesicular chemo
  • If high grade
    • If incomplete resection –> repeat TURBT
    • If no muscle in specimen –> repeat TURBT
    • Intravesical therapy
      • BCG weekly x 6
      • MMC
      • If high grade with very high risk features (LVI, prostatic urethral involvement, T1 with extensive CIS) –> cystectomy
202
Q

Management of cT1 bladder cancer

A

Repeat TURBT or cystectomy for high grade

If residual disease –> BCG

If no residual disease –> BCG or MMC

203
Q

Follow-up for NMIBC

A
  • Cytology and cystoscopy q3m x 2 years
  • q6m x 3 years
  • Then annually
204
Q

Definition of MIBC

A

cT2 or greater

205
Q

Workup for MIBC

A
  • CBC/CMP
  • Chest imaging
  • Abdomen/pelvis CT or MRI
  • Bone scan if elevated AP or symptoms
  • EUA/cytoscopy
  • TURBT
206
Q

Treatment for MIBC

A
  • Determine if cystectomy candidate
  • If yes:
    • Neoadjuvant chemo
    • Radical cystectomy
    • Consider adjuvant chemo based on path risk factors (T3-T4 or N+) if no neoadjuvant chemo given
  • If no
    • Concurrent chemoRT
207
Q

Chemo used for MIBC

A

Gemcitabine
Cisplatin

for 4 cycles

208
Q

What is removed in radical cystectomy

A
  • Start with nodal sampling bilaterally –> if + do cystectomy only for palliation of symptoms
  • If negative
    • En bloc removal of bladder, perivesical tissue
    • For men: prostate/SV, vas deferens
    • For women: urethra, TAH/BSO, anterior vaginal wall
209
Q

Reconstruction options for bladder ca

A
  • Incontinent: ureters attached to ileal loop conduit to skin surface and required urostomy
  • Continent
    • Cutaneous diversion: ureters drain to bowel segment reconstructed into a pouch that is connected to skin via stoma -> need to self-catheterize periodically
      • Used when urethra or bladder neck is involved
    • Orthotopic neobladder: intestinal detubularized segment anastomosed to intact urethra which allows for volitional voiding
210
Q

Follow up for MIBC

A

Cystectomy and urine cytology with labs/electrolytes 3-6 months and then as clinically indicated

Imaging of chest, upper tracts, A/P q 3-6 month for 2 years

Urethral wash cytology q6-12 mos

211
Q

Candidates for bladder preservation

A
  • Unifocal T2-T4a
  • <5 cm
  • No hydronephrosis or hydroureter
  • Good bladder function
  • Good renal function
  • Visibly complete TURBT with random biopsies
  • No CIS
  • LN negative
212
Q

Treatment of MIBC bladder sparing

A
  • Maximal TURBT
  • Phase I - CRT to 45 Gy to the full pelvis
  • Second look cystoscopy 4 weeks later with multiple biopsies and urine cytology
    • If residual disease >T1 –> salvage cystectomy
    • If no residual disease –> boost primary plus 2 cm to 64.8 Gy
213
Q

Preferred chemo regimen for CRT for bladder cancer

A

cisplatin 100 mg/m2 3 cycles

214
Q

Follow up for MIBC

A

Cytology and cystoscopy q3-6 months for 2 years

Labwork for kidney function

CT chest, upper tracts, AP for q3-6 months for 2 years then as clinically indicated

215
Q

Simulation for bladder cancer

A
  • Supine in alpha cradle
  • Perform 2 CT scans –
    • First is empty bladder for the first phase of the plan
    • Second is full bladder for the conedown
216
Q

RT technique for the bladder cancer

A
  • 3DCRT using 4 field boxes
  • GTV- macroscopic tumor
  • CTV_pelvis: GTV+ whole bladder + LN + proximal urethra, prostate and prostatic urethra in men
  • CTV_bladder: GTV+whole bladder + 2 cm to field edge
  • CTV_boost: GTV + 2cm to field edge
217
Q

Dose levels for bladder cancer

A

CTV pelvis: 45 Gy in 25 fractions (1.8 Gy per day)

CTV bladder: 54 Gy in 30 fractions (1.8 Gy per day)

CTV boost: 64.8 in 36 fractions (1.8 Gy per day)

218
Q

Bladder dose constraint for bladder ca

219
Q

Rectum constraint for bladder cancer

220
Q

Outcomes after CRT for bladder cancer

A

50% OS at 5 years

50-70% of survivors have functioning bladder

Approx 1/3 of patients ultimately require cystectomy

221
Q

Management of LR failure after cystectomy

A

Cisplatin + RT (45-50 Gy to pelvis and boost to 60-64 Gy to gross disease)

**Remeber neobladder is made of bowel so need to respect that tolerance of 45 gy

222
Q

Management of dysuria

A

Make sure no UTI –> abx

Try oxybutinin for bladder spasm

Try ibuprofen or pyridium for dysuria

223
Q

Alternative dosing regimen for bladder cancer

A

55/20 with 5-FU and MMC

224
Q

History for testicular mass

A

Duration of testicular mass

Prior trauma or torsion

History of undescended testicle

Prior inguinal or scrotal surgery

Prior RT or IBD

225
Q

Labs should be ordered for testicular mass

A
  • CBC
  • CMP
  • B-HCG
  • AFP
  • LDH
226
Q

Other workup for testicular mass

A

Bilateral testicular ultrasounds

CXR

Discuss sperm banking

227
Q

Managment of presumed testicular cancer

A

Radical inguinal orchiectomy with high ligation of spermatic cord

228
Q

Path factors to consider post orchiectomy

A

Pathology (tumor type)

LVSI

229
Q

pT1 testicular

A

invasion of tunica albuginea

230
Q

pT2 testicle

A

invasion of tunica vaginalis/epidydmis

or +LVSI

231
Q

pT3 testicle

A

invasion of spermatic cord

232
Q

pT4 testicle

A

scrotal invasion

233
Q

Serum markers for pure seminoma

A

Histology is pure seminoma

No AFP elevation

b-HCG is mildly elevated

234
Q

Workup for seminoma

A
  • Start with CT AP
  • If CXR or CT AP is positive –> CT chest
  • Repeat serum markers after orchiectomy
  • Brain MRI or bone scan if indicated
235
Q

Staging is based on serum marker measurements when

A

after orchiectomy

236
Q

What is stage IA testicle

237
Q

What is stage IB testicle

238
Q

N1 testicle

A

No more than 5 LN, all smaller than 2 cm

239
Q

N2 testicle

A

Mets 2-5 cm

>5 nodes, none >5 cm

ENE

240
Q

N3 testicle

A

Nodal mass >5 cm

241
Q

Stage IIA testicle

242
Q

Stage IIB testicle

243
Q

Stage IIC testicle

244
Q

What is recommended management for a stage IA or IB tumor

A

surveillance

245
Q

Other treatment options for stage I tumors

A
  • Single agent carboplatin (AUC =7 for 1-2 cycles)
  • RT (20 Gy in 10 fx)
246
Q

Follow-up for stage I testciular

A

Serum markers q3 mons years 1-2, q6 months years 3-4 and annual

CT AP q6m 1-2 years, q6-12 months year 3 then annually

CXR as indicated

247
Q

Treatment options for stage IIA seminoma

A
  • RT to include para-aortics and ipsi iliac LN to dose of 30-36 Gy (preferred)
  • EP x 4 (etoposide/cisplatin)
  • BEP x 3 (bleo, etoposide, cisplatin)
248
Q

Preferred treatment for stage IIB testicular

A
  • EP x 4 (preferred)
  • BEP x 3
  • Dog leg RT to 36 Gy
249
Q

Preferred treatment for IIC or III testicular

A

Chemo: EP x4, BEP x 3-4

250
Q

Simulation for testicular

A
  • supine
  • immobilized in alpha cradle with arms at the sides
  • CT based planning to contour the at risk nodal regions, block kidneys and rule out horseshoe kidney
  • Clamshell on unaffected testicle
  • Tape penis out of field
  • Add 5 HVL block below treatment field
251
Q

How much does testicular clamshell reduce dose

252
Q

Treatment technique for stage I testicle

A
  • Treat para-aortics only
  • AP/PA
  • Superior T10/T11
  • Inferior L5-S1
  • Lateral: Tips of transverse processed for lumbar vertebrae with 2 cm margin on all nodes
  • If LEFT sided, 1 cm margin on L renal hilar nodes
253
Q

Treatment technique for stage II testicle

A
  • Dogleg strategy
  • AP/PA
  • Contour the nodal regions using CT planning with 2 cm margin
  • Superior (top of T11)
  • Inferior (top of acetabulum)
  • Lateral: edges of the transverse processed, width of 9-11 cm
  • Block kidney!
    • Deliver 20 Gy to full dog leg then boost to 30-36 Gy with 2 cm expansion of GTV
254
Q

After testicular treatment, rate of fertility

255
Q

If patients have low energy and libido after testicle cancer RT, options

A

Check testosterone, supplement

256
Q

Testicular dose from PA field

257
Q

What RT dose causes transient azospermia

258
Q

RT dose for total azospermia

A

80-100 cGy, recovery in 1-2 years for some patients

259
Q

RT dose causing total sterilization

260
Q

RT level causing reduction in testosterone level

261
Q

Kidney constrain for testicular cancer

A

At least 2/3 of 1 kidney < 20 Gy

Combined mean dose <18 Gy

262
Q

Differences in management of non-seminoma

A

Do nerve sparing RPLND instead of RT

RT really only for brain mets

263
Q

Medications prescribed to patient after LDR brachy

A
  • Flomax
  • Cipro x 3d
  • NSAIDs or pyridium PRN
264
Q

What is D90

A

Dose going to 90% of the prostate

D90 >100%

265
Q

What is V100

A

Volume receiving 100% of dose (100% IDL)

>90-95%

266
Q

What is V150 prostate goal

267
Q

What is V200 of the prostate goal

268
Q

Which patients next germline testing?

A
  • FHx of high risk germline mutations (BRCA 1/2, Lynch)
  • FHx is suspicious
  • Presecen fo intraductal or cribriform histology in intermediate-risk PC
  • High risk
  • Very high risk
269
Q

Criteria for very low risk prostate cancer

A

Must have all of the following:

  • T1c
  • Grade group 1
  • PSA < 10
  • Fewer than 3 prostate fragments or cores positive
  • <50% disease in each fragment/core
  • PSA density < 0.15 ng/mL/g
270
Q

Criteria for low risk PC

A

Has all the following but doesn’t meet criteria for very low risk

  • T1c or T2a
  • Grade group 1
  • PSA < 10 ng/mL
271
Q

Criteria for intermediate risk prostate cancer

A

Has all of the following:

  • No high risk group features
  • No very high risk group features
  • Has one more more intermediate risk factors which are:
    • T2b-T2c
    • PSA 10-20
    • Gleason group 2 or 3
272
Q

Criteria for favorable intermediate risk

A
  • Just 1 intermediate risk factor
    • T2b-T2c
    • Group 2 or 3
    • PSA 10-20
  • Gleason group 1 or 2
  • <50% biopsy cores positive
273
Q

Criteria for unfavorable intermediate risk

A
  • 2 or 3 intermediate risk factors
  • Gleason Group 3
  • >/= 50% cores positive
274
Q

Criteria for high risk prostate cancer

A
  • No very high risk features
  • Just one high risk feature
    • T3a
    • Gleason grade group 4 or 5
    • PSA > 20
275
Q

Definition of very high risk prostate cancer

A
  • Has at least one of the following:
    • T3b or T4
    • Primary gleason pattern 5
    • 2 or 3 high risk features
      • T3a
      • PSA > 20
      • Gleason group 4 or 5
    • >4 cores with GG 4 or 5
276
Q

Grade Group 1

277
Q

Grade group 2

278
Q

Grade group 3

279
Q

Grade group 4

280
Q

Grade Group 5

281
Q

Imaging for very low dose and low dose prostate cancer

A

Consider mpMRI to establish candidacy for AS

282
Q

Imaging for favorable intermediate risk PC

A
  • mpMRI
  • CT AP recommended if nomogram predicts >10% risk of pelvic nodes
  • No bone imaging
283
Q

Imaging for unfavorable risk PC

A

Bone imaging recommended if T2 and PSA >10

CT AP if nomogram suggests >10% risk of pelvic nodes

284
Q

Imaging of high risk and very high risk

A

Bone imaging

CT AP

285
Q

What is threshold to do LN dissection for surgery

A

>2% on nomogram

286
Q

Why do we dose escalate?

A
  • Improves PFS (biochemical or clinical) by 10 – 20%
287
Q

How does dose escalated RT change tox

A

Increases G2+ late GI toxicities 13 -> 26%,

similar GU toxicity ~ 10%

288
Q

What is the dose for conventional fx

A

1.8 x 44 = 79.2

289
Q

What is dose for moderate hypo

A

2.5 x 28 = 70

290
Q

What is dose for SBRT

A

7.25 x 5 = 36.25

291
Q

Acceptable doses for M1 disease to prostate

A

55/20 (2.75)

36/6 (6)

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