GU Flashcards
Prostate H/P
AUA, prior TURP, prior RT, IBD, ED, comorbidities, family history, DRE – gland size, nodules
PSA parameters concerning for cancer:
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
AUA components
AUA:
Scored 0-5 (NEW-FUSH)
•Nocturia
•Emptying
•Weak stream
•Frequency
•Urgency
•Straining
•Hesitancy
USPTF SCREENING guidelines:
NCCN screen:
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
Very Low strat
T1c, G6, PSA<10, ≤2 cores, PSA density <0.15 ng/mL/g
Low Strat
Low (T1a-T2a, G6, PSA <10)
Prostate T Staging
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
Prostate overall stage
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
Intermediate Risk factors and workup
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
High Risk Strat
one of:
T3a
GG4-5
PSA>20
Bone and soft tissue imaging
Very high risk
T3b-T4
Primary Gl 5
2 high risk factors
>4 cores GG 4-5
Bone and soft tissue imaging
Life expectancy
20
10
5
20y: 62
10y: 76
5y: 86
Very low risk treatment
>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
Low risk treatment
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
Favorable intermediate age cutoffs
<5: Observation
5-10y: Observation preferred, EBRT or brachy
>10y: AS, EBRT or brachy, RP
Unfavorable intermediate age cutoffs
Unfavorable intermediate age cutoffs
>10: RP or EBRT+ADT +/- brachy
5-10: EBRT or obs
High risk age cutoffs
>5 or symptomatic: treat
<5 and asymptomatic: obs, or ADT or EBRT
Brachy contraindications
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
Prostate Sim
- 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)
Brachy procedure
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
PSA Nadir
PSA nadir:
•4 wk after RP
•~3 yrs after EBRT or brachy
PSA bounce
PSA bounce (transient rise in PSA usually \< 2 ng/ml): 20-30% incidence median 1 year
Brachy planning goals and constraints
D90>95%
V100>95%
V200<20%
Urethra V125% < 1cc
Rectal V100% < 1cc
Prostate 70/28 constraints
Rectum/Bladder:
V45 < 45%
V65 < 15%
Bowel/Heads: max 52
Prostate conventional constraints
Rectum/Bladder:
V45 < 50%
V70 < 15%
Bowel/Heads max 52
Phoenix definition
nadir +2 regardless of HT or not
Prostate MRI
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.
Prostate EBRT side effects
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
Prostate efficacy bPFS and CSS
bpfs - CSS
Low : 85% , >95%
Int: 80%, >90%
High: 60%, 85%
Biochem Failure post RALP
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
Salvage Post prostatectomy
N+ or persistently positive PSA
Early salvage all others
PSA level to add ADT and nodes in salvage setting
0.5
Salvage CTV volumes
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
Salvage Constraints
Bladder-CTV:
V65<50%;
Rectum:
V65<35%;
PIRADS
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)
Half life bHCG and AFP
bHCG ~ 24 hours
AFP ~ 6 days
Testicular 1st echelon nodes
1st echelon nodes:
- PA (right), left renal hilum (left)
- with scrotal invasion, inguinal nodes at risk
Testicular ddx
testicular mass Ddx:
torsion,
infection (e.g. epididymitis),
hydrocele,
varicocele;
cancer (GCT, lymphoma, stromal tumors, sarcoma)
Testicular H/P
- ?h/o cryptorchidism (undescended testes), inguinal surgery, horseshoe kidney
- B/L testicular exam, lungs, liver, nodes
Testicular Workup
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)
Testicular initial treatment
Radical inguinal orchiectomy w/ high ligation of spermatic cord
PATH:
LVI
Size
Rete testis : carries sperm from seminiferous tubules to vas deferens
What to do after surgery for Testicular
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
Testicular S stage
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
Testicular T/N/M staging
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
Testicular overall stage
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
IA/B: Seminoma (AFP neg) adj treatment
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
IS testicular
Repeat workup, treat accordingly
Seminoma IIA
IIA: N1 S0-1
- RT : DL 20/2 + 10/2 boost = 30 Gy
- Chemo alone: BEP x 3
- bleomycin 30, etoposide 100, cisplatin 20 q 3 weeks
Seminoma IIB
IIB: N2 S0-1
- RT: DL 20/2 + 16/2 boost = 36 Gy
- Chemo alone (NCCN preferred): BEP x 3
NSGCT treatment
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)
Seminoma simulation
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
Seminoma PA field
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
seminoma DL field
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
Seminoma constraint
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
seminoma RFS 10 y OS, side effects
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
Radical Cystectomy
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
Bladder LN drainage
LN drainage:
- perivesicular
- external iliac
- internal iliac
- common iliac
(not pre-sacral)
Bladder H/P
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
Bladder workup
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
Bladder surgical eval
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
Bladder Staging
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
BCT contraindications:
BCT contraindications:
- hydronephrosis
- poor renal function
- poor bladder function
- ca in situ (Cis)
- diffuse bladder involvement
- common iliac nodes
Bladder Non muscle invasive TX
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
Muscle invasive (cT2-T4aN0) treatment
Muscle invasive (cT2-T4aN0):
- 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+ - 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
Bladder T4b, N+, or Medically inoperable:
T4b, N+, or Medically inoperable:
1. Definitive chemoRT
55/20 w/ cisplatin
2. Cis/Gem x3-> if response, cystectomy or chemoRT
3. Chemo alone
Bladder Sim, Volumes
-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
Bladder small pelvis fields
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)
Bladder Constraints
Rectum
- V50 <10%
Bowel: exclude from PTV
-max 53 Gy
Bladder 5 y OS
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
Bladder FU
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
Penile staging
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
