Genitourinary Flashcards
Low Risk Prostate (T, Gleason, PSA) Diagnostic Criteria and Treatment
Dx: ALL of the following
- cT1–T2a
- Grade Group 1 or Gleason score ≤6 AND
- PSA <10 ng ml
Treatment:
a. Repeat testing to confirm if appropriate for AS
b. RT
c. RP
Unfavorable Intermediate Risk Prostate Cancer Diagnostic Criteria
Has 2 or 3 IRF ONLY:
- cT2b–cT2c ( more than 1/2 or in both prostate lobes)
- Grade Group 3
- > 50% cores positive
- PSA 10- 20 ng/mL
Favorable Intermediate Risk (T, Gleason, PSA) Diagnostic Criteria
Has ALL of the following:
a. 1 IRF
b. Grade Group 1 or 2 (Gleason 6 or Gleason 3 +4)
c. <50% biopsy cores positive (eg, <6 of 12 cores)
Favorable Intermediate Risk (T, Gleason, PSA) Treatment
a. Active Surveillance
b. RT
c. RP +/- pelvic LN dissection
Unfavorable Intermediate Risk Prostate Cancer Treatment
a. RP + RPLD
- if LN positive or adverse features*, can treatment with adjuvant ADT +/- EBRT or once detectable PSA with salvage RT +/- ADT
b. RT + ADT 4-6 months
*Adverse laboratory/pathologic features include: positive margin(s); seminal vesicle invasion; extracapsular extension; or detectable PSA.
High Risk Prostate Cancer Treatment
a. RT + ADT 2-3 years
b. RP + PLND
High Risk Prostate Cancer Diagnostic Criteria
Has ONLY ONE high-risk feature:
- cT3a (EPE but NO SVI)
- Grade Group 4 or Grade Group 5
- PSA >20 ng/mL
VERY High Risk Prostate Cancer Diagnostic Criteria
Has at least ONE of the following:
* cT3b–cT4 (SVI or invasion or other structures)
* Primary Gleason pattern 5
* 2 or 3 high-risk features (GG4 or 5, PSA> 20, cT3a)
* >4 cores with Grade Group 4 or 5
VERY High Risk Prostate Cancer Treatment
a. RT + ADT (2-3 yrs) + Abiraterone 2 yrs
b. RP + PLND
- If adverse features ADT + EBRT
Pathogenic Mutations approved for use of Olaparib in CRPC (13) & in what setting is it used
A. Somatic or Germline Mutations:
BRCA1, BRCA2
ATM
BARD1
BRIP1
CDK12
CHEK2
FANCL
PALB2
RAD51B, RAD51C, RAD 51D or RAD54L.
B. Approval for use: HRR gene-mutated metastatic castration-resistant prostate cancer (mCRPC), who have progressed following prior treatment with enzalutamide or abiraterone and taxane based chemotherapy
Pathogenic mutations approved for use of talozoparib (12) & in combination with which anti-androgen
A . HRR mutations include a germline and/or somatic mutations:
- BRCA1, BRCA2
- ATM, ATR
- CDK12
- CHEK2
- FANCA
- MLH1
- MRE11A
- NBN
- PALB2
- RAD51C
B. Approval for use with Enzalutamide
Low Risk NMIBC Criteria (4)
A. Papillary urothelial neoplasm of low malignant potential
B. Low grade urothelial carcinoma + ALL of the following:
- Ta, 3 cm, + Solitary
NMIBC:
A. Diagnostic criteria for low grade
B. Diagnostic criteria for high grade
C. Diagnostic criteria for intermediate grade
A. Low grade urothelial carcinoma + ANY of the following:
- T1, 3 cm, Multifocal OR Recurrence within 1 year
B.. High grade urothelial carcinoma + ALL of the following:
- Ta + ≤3 cm + Solitary
C. Management: Intravesical chemotherapy (preferred) OR surveillance
High Risk NMIBC:
A. High risk diagnostic criteria
B. Very high risk diagnostic criteria
C. Clinical Management of high and very high risk NMIBC
A. High grade urothelial carcinoma: ANY of the following plus
- CIS or T1, 3 cm, OR Multifocal
B. Very high risk features: ANY of the following
- BCG unresponsive
- Variant histologies
- Lymphovascular invasion
- Prostatic urethral invasion
C. Management:
- High grade: BHCG (preferred)
- Very High Risk: Cystectomy (preferred)
Management of NMIBC by risk stratification
•Low-risk disease
– For patients with suspected low-risk disease or a European Organisation for Research and Treatment of Cancer (EORTC) recurrence score of <5, we suggest a postoperative single intravesical instillation of chemotherapy rather than no treatment or other regimens (Grade 2B), followed by surveillance. Among the available regimens, we suggest gemcitabine (Grade 2C), with mitomycin, epirubicin, and pirarubicin as acceptable alternatives.
•Intermediate-risk disease
– For patients with intermediate-risk disease, we suggest intravesical chemotherapy with gemcitabine, followed by one year of maintenance therapy to reduce the risk of disease recurrence, rather than other agents or treatment approaches (Grade 2C). - intravesical mitomycin is less preferred since it is significantly more toxic than gemcitabine.
-Although intravesical Bacille Calmette-Guérin (BCG) is an effective alternative, it is also less preferred since disease progression is infrequent in intermediate-risk disease, it is more toxic, and availability is limited due to an ongoing BCG shortage.
•High-risk disease
– For most patients with high-risk disease, we suggest treatment with intravesical BCG rather than intravesical chemotherapy (Grade 2C). BCG is administered as an induction course, followed by a three-year course of maintenance therapy. (See ‘High-risk disease’ above.)
•Very high-risk disease – For most patients with very high-risk disease, we suggest immediate radical cystectomy rather than intravesical therapy (Grade 2C).
- Intravesical therapy is an alternative for those with high-grade T1 tumors and concomitant focal carcinoma in situ (CIS), and trimodality therapy (TMT; maximal TURBT followed by chemoradiation) is an alternative for those with a well-functioning bladder who have T1 disease, lymphovascular invasion (LVI), and no CIS.
