GU Flashcards
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
Life expectancy
20
10
5
20y: 62
10y: 76
5y: 86
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 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
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
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%;
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 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
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
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 Constraints
Rectum
- V50 <10%
Bowel: exclude from PTV
-max 53 Gy
