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Rad Onc Oral Boards > GU > Flashcards

GU Flashcards

1
Q

Prostate H/P

A

AUA, prior TURP, prior RT, IBD, ED, comorbidities, family history, DRE – gland size, nodules

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2
Q

PSA parameters concerning for cancer:

A

PSA parameters concerning for cancer:
Density (serum PSA/volume gland): >0.15 ng/mL/g
Free-to-total PSA: < 7%
Velocity (annual rate of change): > 2 ng/mL/yr

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3
Q

AUA components

A

AUA:
Scored 0-5 (NEW-FUSH)
•Nocturia
•Emptying
•Weak stream
•Frequency
•Urgency
•Straining
•Hesitancy

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4
Q

USPTF SCREENING guidelines:
NCCN screen:

A

USPTF SCREENING guidelines: age 55-69 make informed decision class C
NCCN screen: risk fx- fhx, family or personal hx of germiline mutations (BRAC2), hx of prostate disease or bx, African ancestry, medications.
-45-75 obtain PSA
-40-75 with risks.
-PSA<1 normal DRE: repeat 2/4 yrs
-PSA1-3 normal DRE: repeat 1 yr
->3 or abnormal DRE: bx

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5
Q

Very Low strat

A

T1c, G6, PSA<10, ≤2 cores, PSA density <0.15 ng/mL/g

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6
Q

Low Strat

A

Low (T1a-T2a, G6, PSA <10)

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7
Q

Prostate T Staging

A

T1a-c: clinically inapparent, detected by bx
T2a: ½ of 1 lobe or less
T2b: more than ½ of one of the lobes
T2c: both lobes
T3a: ECE and micro bladder neck
T3b: SV
T4: bladder, levator, pelvic wall
N1: regional nodes
M1a: non-regional nodes
M1b: bone
M1c: other sites

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8
Q

Prostate overall stage

A

I: T1-T2a, PSA <10, GG1 (LR)
IIA: GG 1 and either T2b-c or PSA 10-20
IIB: GG 2
IIC: GG 3-4, T1-2, PSA < 20
IIIA: PSA > 20
IIIB: T 3-4
IIIC: GG 5
IVA: N1
IVB : M1

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9
Q

Intermediate Risk factors and workup

A

Risk factors:
T2b-T2c
GG2-3
PSA 10-20

Favorable: (all)
1 Factor
<50% biopsy cores

if AS considered mpMRI w/biopsy or molecular analysis

Unfavorable:
2+ factors
GG3
>=50% cores

Bone and soft tissue imaging

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10
Q

High Risk Strat

A

one of:
T3a
GG4-5
PSA>20

Bone and soft tissue imaging

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11
Q

Very high risk

A

T3b-T4
Primary Gl 5
2 high risk factors
>4 cores GG 4-5

Bone and soft tissue imaging

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12
Q

Life expectancy
20
10
5

A

20y: 62
10y: 76
5y: 86

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13
Q

Very low risk treatment

A

>20 yr life expectancy: <62

  • Active surveillance
  • IMRT alone
  • Brachy alone
  • RP with PLND if prob LN mets > 2%

10-20 yr life expectancy: 62 - 76

  • Active surveillance
  • -PSA q 6 mo
  • -DRE q 12 mo
  • -Re-bx after 12 mo, then if PSA >50% in 1 yr (ProtecT) or PSA DT <3 yrs (Klotz)
  • can get prostate MRI
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14
Q

Low risk treatment

A

Low risk: 10y life expectancy: <76

1) AS
2) IMRT
3) Brachy alone (LDR)
- I-125 (t½ 60d), source activity 0.5, 145 Gy, 110 combined
- Pd-103 (t½17d) 125 Gy, 100 combined
4) RP with PLND if prob LN mets > 2%
- preferred for young age
- if + margins, SVI, ECE, or detectable PSA, early salvage RT
- if LN+ on PLND, RT+ADT

Triggers to end AS/start tx (30% will need tx by 3 yrs, 50% by 10 yrs) is

  • increase in # of cores
  • increase in Gleason
  • clinical progression
  • PSA>10
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15
Q

Favorable intermediate age cutoffs

A

<5: Observation
5-10y: Observation preferred, EBRT or brachy
>10y: AS, EBRT or brachy, RP

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16
Q

Unfavorable intermediate age cutoffs

A

Unfavorable intermediate age cutoffs
>10: RP or EBRT+ADT +/- brachy
5-10: EBRT or obs

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17
Q

High risk age cutoffs

A

>5 or symptomatic: treat
<5 and asymptomatic: obs, or ADT or EBRT

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18
Q

Brachy contraindications

A

Brachy contra:
-AUA/IPSS >15
-Prostate size/anatomy
Pros >60 cc (<15 cc)
Pubic arch interfer
Median lobe hyper
-T3 disease
-Prior TURP w big defect

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19
Q

Prostate Sim

A
  • CT simulation
  • fiducials/spacer gel placed a week ahead of time
  • enema beforehand
  • bladder fill with 16-24 oz
  • bring to CT room 30 min after drinking
  • supine position, knee fix
  • acquire CT, set iso to prostate
CTV = prostate and proximal 1 cm SV 
PTV = CTV + 7 mm margin (5 mm posterior)
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20
Q

Brachy procedure

A

Brachy – IODINE 125 (half life 60 days) = 145 Gy
Pre-op
-1 week prior to implant bring pt in for volume study of prostate, determination of favorable anatomy (no pubic arch interference), and creation of preplan to order seeds
-gen med or cardiac clearance
-Flomax 1-2 weeks before
-bowel prep day before
-stop ASA, Plavix, 7 days before; NSAIDS 2-3 days

Day of:

  • bring pt to OR with GA
  • placed in lithotomy position in stir-ups
  • perineum is prepped with betadine
  • foley catheter is placed – 120 cc in bladder
  • 4 mg Decadron intra-op
  • TRUS is secured to table
  • insert TRUS: make sure prostate is centered on template (base = 0.0), with urethra in central sagittal plane
  • scan prostate
  • contour bladder, prostate, rectum, urethra
  • make plan based on this contour
  • contruct needles with seeds and spacers
  • place contructed needles based on plan
  • while inserting needles under ultrasound guidance, visualize in the desired plane (rotating bevel can help visualize). Verify position with sagittal and transverse US.
  • post-implant room survey
  • pt discharged after urinating
  • discharge with Flomax, NSAIDs, Pyridium, and Bactrim x 3 days
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21
Q

PSA Nadir

A

PSA nadir:
•4 wk after RP
•~3 yrs after EBRT or brachy

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22
Q

PSA bounce

A 
PSA bounce (transient rise in PSA usually \< 2 ng/ml): 
20-30% incidence median 1 year
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23
Q

Brachy planning goals and constraints

A

D90>95%
V100>95%
V200<20%

Urethra V125% < 1cc
Rectal V100% < 1cc

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24
Q

Prostate 70/28 constraints

A

Rectum/Bladder:
V45 < 45%
V65 < 15%

Bowel/Heads: max 52

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25
Q

Prostate conventional constraints

A

Rectum/Bladder:
V45 < 50%
V70 < 15%

Bowel/Heads max 52

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26
Q

Phoenix definition

A

nadir +2 regardless of HT or not

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27
Q

Prostate MRI

A

Prostate MRI

  • T2: lesion is hypointense
  • DWI: restricted diffusion
  • ADC: low #s

-normal: always T2 – peripheral zone is BRIGHT (this is part of the prostate!) – obturator internus – ALZ – know anatomy; if urine is bright it is T2.

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28
Q

Prostate EBRT side effects

A

Acute GU:
•Grade 2: 20-30%
•Grade 3: <5%

Late GU:
•Grade 2 (chronic urethritis+meds): 10%
•Grade 3 (strictures): <1%

Acute GI:
G2: 30-40%
G3: < 5%

Late GI:
•Grade 2 rectal bleeding: <5%
•Grade 3 rectal bleeding (requiring transfusion or laser cauterization): <1%

ED: 30-50%
Depends on age and pre-tx fxn
>90% have reduction of ejaculate

Toxicity of Brachy:
Acute GU higher (40-50% G2); Acute GI lower; 3% risk urethral stricture

Frequency
-tx w Flomax 0.4 mg PO daily

Dysuria

  • tx w pyridium 200 mg PO 4 times daily (orange pee!) or ibuprofen or Flomax
  • ditropan 5-10 mg PO daily
  • FOLEY after brachy if needed (if peeing more than hourly)

ED:

  • sildenafil 60-70% improvement
  • inject PGY1
  • pump
  • prosthesis

Radiation proctitis

  • diet
  • proctofoam
  • argon laser coagulation

Radiation cystitis/urinating blood

  • continuous bladder irrigation
  • aluminum instillation
  • HBO
  • consult IR – thrombse internal vesical artery

SM – 1 in 300 10-15 years out

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29
Q

Prostate efficacy bPFS and CSS

A

bpfs - CSS
Low : 85% , >95%
Int: 80%, >90%
High: 60%, 85%

30
Q

Biochem Failure post RALP

A

PSA ½ life is 3 days. Post-op PSA should be 0 in 2 wks

  • PSA needs to be >0.1 to be failure
  • PSA >0.1 ng/ml on 2 occasions or single PSA >0.4 (after RT it is >2 than nadir)
  • check PSA 1 month after surgery, if 5 1 week after that is okay, wait 10 half lives
31
Q

Salvage Post prostatectomy

A

N+ or persistently positive PSA
Early salvage all others

32
Q

PSA level to add ADT and nodes in salvage setting

A

0.5

33
Q

Salvage CTV volumes

A

The CTV would be the prostate bed defined as:

  • Superior: SV or vas deferens; or 3 cm above pubis
  • Inferior: at the top of the penile bulb or 1 cm below the vesicourethral anastomosis, 1 cm below urine

Below pubic symphysis

  • Anterior: just posterior to pubic symphysis
  • Posterior: anterior border of rectal wall
  • Lateral: medial border of levator ani

Above pubic symphysis

  • Anterior: 1-2 cm of bladder
  • Posterior: mesorectal fascia
  • Lateral: sacrorectogenitopubic fascia

INCLUDE RETAINED SVs if involved

PTV= 1 cm (5 mm posteriorly) with daily CBCT

Dose: 66Gy / 46Gy

34
Q

Salvage Constraints

A

Bladder-CTV:
V65<50%;

Rectum:
V65<35%;

35
Q

PIRADS

A

PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present)
PI-RADS 2: low (clinically significant cancer is unlikely to be present)
PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal)
PI-RADS 4: high (clinically significant cancer is likely to be present)
PI-RADS 5: very high (clinically significant cancer is highly likely to be present)

36
Q

Half life bHCG and AFP

A

bHCG ~ 24 hours
AFP ~ 6 days

37
Q

Testicular 1st echelon nodes

A

1st echelon nodes:

  • PA (right), left renal hilum (left)
  • with scrotal invasion, inguinal nodes at risk
38
Q

Testicular ddx

A

testicular mass Ddx:
torsion,
infection (e.g. epididymitis),
hydrocele,
varicocele;
cancer (GCT, lymphoma, stromal tumors, sarcoma)

39
Q

Testicular H/P

A
  • ?h/o cryptorchidism (undescended testes), inguinal surgery, horseshoe kidney
  • B/L testicular exam, lungs, liver, nodes
40
Q

Testicular Workup

A

Labs:
B-HCG: < 50 (if VERY high, think choriocarcinoma)
AFP: <10 nl (never elevated in pure seminomas)
LDH: 100-330 nl
CBC, chemistries

Imaging:

  • B/L testicular U/S (tumors are hypoechoic)
  • CXR (pre-op)

Biopsy: no need, consider contralateral if suspicious

Other:
Consults: fertility assessment +/- sperm banking
- Pre-RT sperm counts low (40% w/ azospermia)

41
Q

Testicular initial treatment

A

Radical inguinal orchiectomy w/ high ligation of spermatic cord
PATH:
LVI
Size
Rete testis : carries sperm from seminiferous tubules to vas deferens

42
Q

What to do after surgery for Testicular

A

Staging is based on POST-ORCHIECTOMY labs/etc.:

  • CT abd/pelvis
  • CT chest if positive CT a/p or abnl CXR
  • repeat b-HCG, AFP, LDH
43
Q

Testicular S stage

A

S0: normal
S1: LDH <1.5 ULN, hCG <5,000, AFP <1,000
S2: LDH 1.5-10 ULN, hCG 5,000-50,000, AFP 1,000-10,000
S3: LDH >10 ULN, hCG >50,000, AFP >10,000

44
Q

Testicular T/N/M staging

A

T1: testis, epididymis, tunica albuginea
T1a <3cm
T1b >3cm
T2: LVSI or tunica vaginalis or hilar invasion
T3: spermatic cord
T4: scrotum

N1: LN 0.1-2 cm, ≤5 LNs
N2: 2.1-5cm or >5 LNs (or pECE)
N3: > 5cm
(>= 10 mm short axis  37% sensitivity, 100% spec)

M1a: nonRP nodal or pulm mets
M1b: nonpulm visceral mets

45
Q

Testicular overall stage

A

IA: T1
IB: T2-4
IS: N0 S+
IIA: N1 S0-1
IIB: N2 S0-1
IIC: N3 S0-1
IIIA: M1a, S0-1
IIIB: [N+ or M1a] AND S2
IIIC: ([N+ or M1a] AND S3) OR any M1b

46
Q

IA/B: Seminoma (AFP neg) adj treatment

A

IA/B: Seminoma (AFP neg)

1) Surveillance (NCCN preferred for pT1-3):
- H&P and labs q 3 mo x yr 1, q 6 mo x yrs 2-3, then annual
- CT a/p @3, 6, 12mo, then annually through 5 yrs
- CXR as clinically indicated
- relapse rate 15-20% at 5 yrs-stop surveillance at 5 years

2) PA RT 20/2 Gy (midplane)
- used to be recommend for rete testis invasion or tumor > 4 cm, but is no longer (Chung JCO 2010)

3) Carboplatin AUC 7 x 1
- who to treat: in jail, in 60s

47
Q

IS testicular

A

Repeat workup, treat accordingly

48
Q

Seminoma IIA

A

IIA: N1 S0-1

  1. RT : DL 20/2 + 10/2 boost = 30 Gy
  2. Chemo alone: BEP x 3
    - bleomycin 30, etoposide 100, cisplatin 20 q 3 weeks
49
Q

Seminoma IIB

A

IIB: N2 S0-1

  1. RT: DL 20/2 + 16/2 boost = 36 Gy
  2. Chemo alone (NCCN preferred): BEP x 3
50
Q

NSGCT treatment

A

NSGCT (elevated AFP):
IA: orchiectomy + surveillance
IB/IIA: orchiectomy + open nerve-sparing RPLND  BEP X 2-3
IIB: BEP chemo x 3
IIC+: BEP chemo

RPLND for post-chemo residual mass > 1 cm (no PET needed)

51
Q

Seminoma simulation

A

SPERM BANKING AND SPERM ANALYSIS

ZOFRAN

Simulate supine, arms at side with custom immobilization
Clamshell shield on contralat testicle
Move penis out of field

Target: PA nodes +/- ipsi iliac (common, int, ext to top of acetabulum)
-only include inguinals if prior pelvic surgery

52
Q

Seminoma PA field

A

PA radiation:
CTV=(IVC+1 cm) + (aorta + 2 cm)
PTV=CTV+0.5 cm
Daily KV imaging
Goal is targeting para-aortic, paracaval, and preaortic nodes
*dogleg if prior pelvic surgery*

Fields
-T11/T12 – L5/S1
-lateral transverse process or 2 cm on nodes
* no longer need to cover renal hilar nodes

53
Q

seminoma DL field

A

Modified DL Radiation
CTV=(IVC+1 cm) + (aorta + 2 cm)+ (ipsilat common, external, and prox int iliac + 1 cm)
-nodes down to top of acetabulum
CTV_boost=GTV+1 cm
PTV=CTV+0.5 cm
(2 cm to block edge for boost)

Fields:
T11/12 to L5-S1 then diagonal down to top of acetabulum or top of obturator foramen

Full DL Radiation:
Modified DL + inguinals

Use CLAMSHELL: reduces dose by ~2-3x
PA w/ clamshell = 0.6 cGy
Dogleg w/clamshell = 1.5 cGy

54
Q

Seminoma constraint

A

Kidney: D50% < 8 Gy (no more than 50% of each kidney can receive 8 Gy or higher). If only one kidney, D15% < 20 Gy

V20<70%
Stomach
Bowel

55
Q

seminoma RFS 10 y OS, side effects

A

5y RFS 97%; 10 yr OS > 90%

Acute: n/v, enteritis, fatigue, bone marrow suppression
-give antiemetic prophylaxis!

Late:
Secondary malignancy: 2nd neoplasms (RR=2-3); 5-10% increased as compared to baseline population
Risk of 2nd cancer was 16% at 25 yrs and 23% at 30 yrs compared to expected 9% and 14% for general population (Travis, JNCI)

Infertility:
1/5 azospermia
-1/3 oligospermia
with clam shell 1-2% of primary dose reaches testis
-25-50cGy if Stage I
-35-70cGy if Stage II
-This ignores internal scatter

  • 1Gy causes total azoospermia
  • 50cGy cases transient azoospermia, 50% recover at 1 year

** try not to have kids for 1 year following tx

** 30% able to have children after RT

56
Q

Radical Cystectomy

A

Radical cystectomy:
•Male= bladder/prostate/sv/vas deferens/proximal urethra
•Female=bladder/urethra/TAH-BSO and anterior vaginal wall
•Incontinent diversion – ureters to ileal loop to skin to urostomy bag
-includes bilateral pelvic LND; common, int, ext iliac and obturator nodes
•Continent (80% continence rate if attempted):
-ureters to ileal loop to skin to stoma which is catheterized
-neobladder: detubularized intestine to urethra, allows volitional voiding

57
Q

Bladder LN drainage

A

LN drainage:
- perivesicular
- external iliac
- internal iliac
- common iliac
(not pre-sacral)

58
Q

Bladder H/P

A

History: hematuria, dysuria, pelvic/back pain
-risk factors: smoking, chemical exposure (dyes, rubber, plastics, leathers)

Physical: abdominal exam, pelvic for women, CVA tenderness, LNs, rectal exam, penile/testicular for men

59
Q

Bladder workup

A

Labs: CBC, CMP, alk phos, UA with urine cytology (not very sensitive)

Imaging: office cystoscopy
Once dx of muscle invasive made:
-CT c/a/p w/ CT urography
-Or otherwise image upper tract – IVP, MRI urogram, renal US with retrograde pyelogram (5% synchronous lesions)
-Bone scan – if clinical suspicion or symptoms

60
Q

Bladder surgical eval

A

Primary eval/surgical tx:

  • EUA with bimanual exam
  • Cystoscopy with bladder mapping, biopsy of any masses, bx prostatic urethra if lesion in trigone
  • TURBT with random bx to exclude CIS
  • Should include bladder wall muscle (detrusor)

On path:

  • is muscle present and/or involved?
  • is there LVSI?
  • Cis is risk factor for more multiple lesions/aggressive histology
61
Q

Bladder Staging

A

Ta: non-invasive papillary
Tis: CIS (flat)

T1: lamina propria

T2: invades muscularis propria
T2a: inner 1/2
T2b: outer 1/2

T3: invades perivesicular tissue
T3a: microscopic
T3b: macro, ie-extravesicular mass)

T4: adjacent organs
a-prostate, uterus, vagina
b-pelvic or abdominal sidewall

N1: single pelvic below common iliac
N2: multiple pelvic below common iliac
N3: common iliac

M1a: LN beyond com. iliac
M1b: non-LN distant met

I – T1
II – T2
IIIA – T3-T4a and/or N1
IIIB – N2-3
IVA – T4b and/or M1a
IVB – M1b

62
Q

BCT contraindications:

A

BCT contraindications:

  • hydronephrosis
  • poor renal function
  • poor bladder function
  • ca in situ (Cis)
  • diffuse bladder involvement
  • common iliac nodes
63
Q

Bladder Non muscle invasive TX

A

Non-invasive:
Ta:
Low gr: TURBT
High gr: TURBT -> BCG
T1:
Low gr: TURBT -> BCG
High gr: TURBT -> BCG
Tis: TURBT -> BCG 50 mg q wk x 6
-other adj intravesicular agents include MMC

64
Q

Muscle invasive (cT2-T4aN0) treatment

A

Muscle invasive (cT2-T4aN0):

  1. Neoadj gem/cis x 4 -> radical cystectomy w LND
    - Neoadj gem/cis x 4 -> partial cystectomy if unifocal T2 without CIS or trigone involvement that can be removed w/ 2 cm margin
    - if neo-adj chemo not given, give adj chemo for pT3-4 or N+
  2. Bladder preservation for the best players**
    - max TURBT (+/- fiducials)
    - Cisplatin + RT 55/20
    - re-cysto at 3 months. If PR, salvage cystectomy or BCG if small. If CR, surveillance
65
Q

Bladder T4b, N+, or Medically inoperable:

A

T4b, N+, or Medically inoperable:
1. Definitive chemoRT
55/20 w/ cisplatin
2. Cis/Gem x3-> if response, cystectomy or chemoRT
3. Chemo alone

66
Q

Bladder Sim, Volumes

A

-Ensure maximal TURBT performed, and bladder mapping

*****only treat nodes if N+****

CT simulation
-supine, immobilized, empty bladder, CT w/ contrast

GTV=gross tumor on CT/MRI/TUBRT map

(CTV_44=GTV+ whole bladder + prostate + LN (ext iliac, int iliac, obturator – not common)
PTV_44=CTV + 1.5 ant, 1 cm post/lat, 0.5 inf, 2 cm sup)

CTV_55=GTV+ whole bladder + 1 cm
PTV_55=CTV + 0.5 cm
Exclude bowel from PTV

67
Q

Bladder small pelvis fields

A

Small pelvis fields: AP-PA and laterals

    • sup – mid SI (S2/3)
    • inf – bottom of obturator foramen or 2 cm below tumor (treating prostate in men)
    • lat – 2 cm on pelvic brim (block fem heads)

Laterals – same sup-inf,
2 cm ant/post margin on bladder w blocks for rectum, small bowel (corner block under symphysis, corner block ant/sup, anterior to ext. iliacs)

68
Q

Bladder Constraints

A

Rectum
- V50 <10%

Bowel: exclude from PTV
-max 53 Gy

69
Q

Bladder 5 y OS

A

5 yr OS (cystectomy/bladder preservation) – LF
Ta: 95%
T1: 70%
T2: 60/60% – 5%/
T3-T4: 40/40% – 10-50%/

75% CR rate (only ~35% if hydronephrosis)
50-70% with functioning bladder
1/3 require cystectomy (only <5% due to RT complications)

N+: 5 yr OS 30%
M+: MS 6-12 months

70
Q

Bladder FU

A

Follow-up:

  • Cystoscopy with cytology q 3 mo x 1 yr, then q 6-12 months
  • Image upper tract q 1-2 yrs
  • For muscle invasive disease, add: CT c/a/p q 6 months x 2 yrs, then as clinically indicated
  • For bladder preservation, add: selected mapping biopsy q 6 mo x yr 1-2

Dysuriia: pyridium, Ditropan because it’s a muscle relaxant– not flomax

71
Q

Penile staging

A

T1: subepithelial connective tissue
- T1a is no LVI, PNI, G3-4
- T1b is LVI, PNI, or G3-4
T2: corpus spongiosum (w/ or w/out urethral invasion)
T3: corpus cavernosus (w/ or w/out urethral invasion)
T4: other adj structures

Clinical
N1: single inguinal node
N2: multiple or bilat inguinal
N3: fixed inguinal or pelvic

Path
N1: 1-2 U/L ingnl, no ECE
N2: >=3 U/L or B/L
N3: ECE or pelvic

Rad Onc Oral Boards (11 decks)

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