GU Flashcards
Management of NMIBC
therapeutic TURBT, immediate intravesical gem, repeat TURBT to confirm no residual disease. Adj BCG only if high grade Tis or T1
Nodes make you what group stage in testicular
Stage II, IIA, IIB, IIC correspond to N1, N2, N3
S staging for AFP for Testicular
S1: AFP<1000, S2: AFP 1,000-10,000, S3: >10,000
Seminoma kidney constraint
V8<=50%, Single kidney V20<15%
Management of Stage I Seminoma
Observe, could do carbo platin or PA LN RT 20 in 10.
Lateral borders of PA LN RT
Lateral transverse process
Management for postop prostate with pN+
pelvic RT + 2y ADT
How do get tissue for testicular mass
Radical orchiectomy with high ligation of spermatic cord.
N staging bladder
N1: single LN, N2: multiple regional LN, N3: common iliac LN.
Bladder Dmax SBRT
38 Gy
Tumor markers for Seminoma
no AFP, Beta-HCG can be elevated, High LDH if bulky
Management of MIBC
Option 1: Neoadj gem/cis x 4 –> radical cystectomy + LND, (partial cystectomy if T2 in the dome, no Tis) Option 2: upfront radical cystectomy with adj CHT/adj RT 50.5/28, Option 3: bladder conservation
Urethra Dmax
39 Gy
Inferior border for dog leg
Top of acetabulum
I-125 half life
60d
Describe brachy procedure
Lithotomy with GA, betadine, foley, fill bladder, TRUS, place needles ant to post, intraop plain film, count seeds, irrigate bladder, discharge after urinating, 30d CT to assess post-implant dosimetry
How to treat recurrence after Bladder Conserving Therapy
if superficial, TURBT, if invasive, radical cystectomy
Chorio tumor markers
No AFP, Beta-HCG very high, LDH normal
What imaging is needed to workup testicular mass
Testicular US, CXR, CT A/P
what is PSA cutoff for adding pelvic RT and ADT to prostate RT
0.4
What tumor markers do you need to get for testicular cancer
AFP, Beta-HCT, LDH
T staging for bladder
Ta: non-invasive papillary, Tis: urotheilial carc in situ, T1: invasion of lamina propria, T2: muscularis propria, T3: perivesical, T4a: organs, T4b: pelvic or abdominal wall.
What nodes drain from bladder
perivesicular, common, internal, external, obturator
Postop Bladder constraints
V65<50%, V40<70%
70 in 28 rectum constraints
V74, V69, V64, V59 15, 25, 35, 50
What are GCT
Seminoma and NSGCT
N staging for testicular
cN1: Ln <=2 cm, cN2: LN>2cm but <=5cm, cN3: LN>5cm
Management of Stage IIA seminoma
BEP x3 or dog leg boost to 30Gy in 15 fx
Postop femoral heads constraint
V50<10%
How far down sacrum does CTV go for prsotate
S3/S4
Rectum Dmax during SBRT
38 Gy
Who are candidates for bladder conservation
Unifocal T2-T3, select T4a, cN0, Size < 5cm.
S staging for b-HCG for Testicular
S1: <5000, S2: 5000-50000, S3: >50,000
Two approaches for bladder conservation
if medically operable, do 44 in 22 fractions first then assess if less than CR, go to surgery. Otherwise finish with 20 Gy in 10 fx. Other option is to do CCRT 55/20
I-125 monotherapy and boost dose
145 Gy, 110 Gy
What is needed for bladder path
do a TURBT with muscle included in specimen.
What chemo for CCRT for bladder
cisplatin doublet, 5FU/MMC
Brachytherapy contraindications
AUA>15, Gland>60 cc or < 15 cc, pubic arch interference, median lobe hypertrophy, T3 disease, prior TURP with large defect
What isotopes can be used for prostate brachy
I-125 and Pd-103
S staging for LDH for testicular
S1: LDH<1.5NL, S2: 1.5-10 NL, S3: >10NL
70 in 28 bladder constraints
V79, V74, V64, V59 15, 25, 35, 50
S staging is based of preop or postop lab work
post op
Brachytherapy postplan constraints
D90>95%, D90<125%, V100>90%
What are intravesicular therapies
BCG, Gem, MMC
70 in 28 penile bulb constraints
Mean < 51
T1a, T1b for testicular
<3cm, >=3cm limited to testis without LVSI
Management of Stage IIB seminoma
BEP x 3 or RT dog leg boost to 36 in 18 only if LN<=3cm.
Roach formula
LN risk: (GS-6)10 + PSA2/3
What is PTV55
GTV+1.5 cm, PTV 44 is bladder + 1.5 cm
top and bottom of PA LN RT
T10/T11, L5/S1
Bladder hypofrac small bowel constraint
V55<5cc
Do you biopsy testicular
no
How do you define biochemical failure post-RT
psa nadir + 2
Management of cT4b or N+ bladder
CCRT 64/32, or induction chemo with CCRT or radical cystectomy
How does lesion appear on MRI T2, DWI, and ADC
T2: Hypointense, DWI: Bright, ADC: Dark
low, int, and high risk targets for intact prostate
low: prostate only, int: prostate and 1 cm prox sv, high: prostate and seminal vesicles and pelvis
T2-T4 for testicular
T2: limited to testis with LVSI or invasion of epididymis or penetrating visceral mesothelial layer, T3: invasion of spermatic cord, T4: Invasion of scrotum
Postop Rectum constraints
V65<25%, V40<55%
What imaging is needed to workup bladder cancer
Cystoscopy, CT or MRI urography, CT Chest if MIBC, consider PET CT
Contraindications to Bladder preservation
Multifocal, extensive CIS, incomplete TUBT, hydro, common iliac LN, inflammatory bowel disease, prior rt
Bladder hypofrac small bowel constraint
V55<5cc, Max 58 Gy
Bladder hypofrac Rectum constraint
V55<3%, V30<50%
Bladder hypofrac fem head constraint
V40<50%
T staging kidney
T1a:<4, T1b:4-7, T2a: 7-10, T2b: >10 cm, T3a: renal vein or renal sinus, T3b: into vena cava below diaphragm, T3c: vena cava above diaphragm, T4: beyond gerota’s fascia
Usual management for localized RCC
Nephrectomy with adjuvant pembro for stage II and higher
Treatment for nonoperative RCC
Obs vs SBRT.
What size RCC can be treated with SBRT?
<7 cm
What dose for SBRT kidney?
26 in 1 for < 4 cm, 42 in 3 for >4 cm
Small bowel +3mm PRV constraint for 3 fraction kidney SBRT
V30<0.03 cc, V12.5 Gy < 30 cc, Max of 22.5 circumferentially
Stomach +3mm PRV constraint for 3 fraction kidney SBRT
Same as small bowel, V30, V12.5, Max 22.5 Gy circumferentially
Liver constraint for 3 fraction kidney SBRT
700 cc < 15 Gy
Contralateral kidney SBRT 3 fraction constraint
V10<33%
Prostate LDR coverage and OAR constraints
Urethra should be out of 150%, Rectum should be < 1 cc to 100%, V150 between 50-60%, D90%>100% of prescription dose.
Ir-192 Monotherapy dose
13.5 x 2
Ir-192 Boost dose
15 Gy x 1
Monotherapy and boost dose for Pd-103
125, 100 Gy
Coverage goals for LDR breachy prostate
D90>100% Rx(<125%), V150%<50%, V200<20%
Rectum V100 for prostate LDR
<1 cc
Urethra Dmax LDR prostate
<150%
Bladder D1cc LDR prostate
<100%
HDR urethra max
<115%
HDR brachy prostate goals
V100>95%
Rectum constraint for HDR prostate brachy
Dmax < 85%
Rectum constraint for SBRT prostate
V36<1cc
SB constraint for SBRT prostate
Max of 30 Gy
Bladder constraint for SBRT prostate
V37<5 cc
Urethra constraint for SBRT prostate
V42<50%
What biopsy is needed for penile lesion?
Excisional biopsy with circumcision
What biopsy is needed for inguinal LN in penile workup?
FNA
Treatment for early penile cancer
Mohs gland-sparing penile surgery vs partial penectomy
T1 staging penile
T1a: noninvasive without LVSI or PNI and not Grade 3, T1b: noninvasive but with LVSI and PNI or Grade 3 or sarcomatoid.
T2-T4 staging for penile
T2: corpus spongiosum, T3: invades corpora cavernosum, T4: adjacent structures, scrotum, prostate, pubic bone.
N staging penile
N1: single inguinal node, N2: multiple or bilat inguinal, N3: fixed inguinal or pelvic
Management of T1N0 penile
WLE, partial penectomy, or RT
Nodal management for T1a and cN0 penile
Do a SLNB, if 1 node +: complete inguinal LND, if 2+ complete inguinal and pelvic LND
Management of T2 Penile
PP, TP, RT, or CRT, IFLND f/b brachy vs EBRT with gross disease and ENI if not a surgical candidate.
Which penile cases get chemo?
Node +, NA TIP then surgery or concurrent cis if not a surgical candidate.
Dose of RT for penile
Shaft and inguinopelvic nodes to 50 Gy, Bst GD to 55-70 Gy with 2 cm margin
When should you cover pelvic in addition to Inguinals for penile?
> 4 cm or T3-4 or N+
Dose for EBRT alone for T1-2N0 <4 cm penile
66 Gy to primary lesion with 2 cm margin
What do you need before TURBT?
CT urogram
Neoadj chemo for bladder
ddMVAC
When can you do partial cystectomy for bladder?
Unifocal T2 without CIS or trigone involvement that can be removed w/2cm margin
How to decrease testicular dose?
Clam shell
