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1
Q

Prostate: active surveillance criteria and management

A

Offer to very low and low risk patients. May offer to favorable intermediate risk if older (age >75).

PSA q6 mos

DRE q12 mos

Biopsy within 12 months with anterior directed cores, then serial biopsy every 2 years

If rising PSA and biopsy negative: Do MRI on suspicion of anteior lesion then biopsy

Progression=new Gleason score 7 or greater or significant increase in disease volume

at 10yrs, 65% remain on active surveillance

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2
Q

Prostate cancer: workup

A

H&P. PMH of cardiac disease, MI, diabetes, osteoporosis, TURP, AUA, sexual history inventory

Labs: PSA, CBC, CMP

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3
Q

Prostate: when to order staging scans

A

Bone scan: unfavorable intermediate risk if T2 and PSA > 10, all high risk patients

Pelvic/abdominal imaging: intermediate or high risk patients if nomogram predicts >10% probability of pelvic nodal involvement

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4
Q

Prostate: components of MSKCC nomogram

A

age, PSA, stage, GS, number of positive cores

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5
Q

Prostate: simulation

A

supine, vac loc, full bladder, empty rectum

fiducials prior to sim if not doing daily CBCT

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6
Q

Prostate: EBRT rectum V75 and V50

A

V75 < 15%

V50 < 50%

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7
Q

Prostate: EBRT bladder V75 and V65

A

V75 < 25%

V65 < 50%

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8
Q

Prostate: EBRT target coverage

A

98/100

min 95%

max 107%

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9
Q

Prostate: EBRT femoral head constraint

A

V50 < 5%

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10
Q

5yr bPFS for low risk prostate cancer (EBRT)

A

5yr bPFS 95%

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11
Q

Prostate: leuprolide dose and MOA

A

7.5mg per month (30mg for 4 months)

LHRH analog

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12
Q

Prostate: bicalutamide dose and MOA

A

50mg daily if given with leuprolide

150mg daily if given alone

nonsteroidal antiandrogen

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13
Q

Roach formulas

A

ECE= 3/2 PSA + 10 (GS - 3)

SVI = PSA + 10(GS -6)

LN = 2/3 PSA + 10(GS-6)

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14
Q

5yr bPFS for intermediate risk prostate cancer (EBRT)

A

5yr bPFS 85%

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15
Q

OS for intermediate risk prostate cancer w/wo ADT

A

88% with ADT

78% without ADT

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16
Q

Prostate: indications for salvage radiation

A

PSA rise to > 0.1 for 2 consecutive rises

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17
Q

Salvage prostate: constraints for bladder and rectum

A

bladder minus CTV: V65 < 35%, V40 < 70%

rectum: V65 < 35%, V40 < 55%

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18
Q

Prostate: indications for adjuvant radiation

A

T3a, T3b, positive margin

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19
Q

Prostate: contraindications to LDR brachytherapy

A

AUA > 12

size >60cc or <30 cc

prior TURP

median lobe hyperytrophy

inflammtory bowel disease

prior RT

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20
Q

Prostate LDR brachytherapy: dose, half-life, and energy for I-125 and Pd-103

A

I-125: 144 Gy, 60 days, 28keV

Pd-103: 125 Gy, 17 days, 21keV

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21
Q

Prostate LDR brachy: treatment narrative

A

I would first bring the patient to the clinic to perform a transrectal ultrasound guided volume study of the prostate. The patient would have done a bowel prep. the night before. I would place the patient in the dorsal lithotomy position and prep and drape. I would insert a foley with aerated jelly. Using a transrectal ultrasound with US gel, I would take images every 1 mm. I would assess for any pubic arch interference and record the angles of the probe and legs once finished. I would use these images to create a pre-plan using a peripheral loading technique with PTV of 3 mm laterally and 0 mm anteriorly and posteriorly. I would then take the patient to the OR and position the patient as in the pre-plan with general anesthesia. I would prep and drape the patient, place the templates, and load the seeds according to the plan. Once finished I would take AP and lateral orthogonal films in the OR to check the positioning of the seeds and do a rectal examination. The patient would then return one month later for post-implant CT and dosimetry.

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22
Q

Prostate LDR brachy: dosimetry

A

Modified peripheral loading. Plan to 180 Gy

Seattle:

V100>98%

D90>90% (minimum, goal is 130%)

V150<40%

V200<20%

urethral Dmax <110-120

rectal D2cc <100%

calculation grid < 2mm x 2mm x axial slice width (also report V90, V80, V150), U200

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23
Q

Prostate hypofrac: dosimetry

A

60Gy/30fxs as per PROFIT and CHHIP

rectal wall: D30<46 Gy, D50<37 Gy

bladder wall: same as rectum

femoral heads: D5<43 Gy

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24
Q

Seminoma: workup

A

H&P: painless testicular mass. History of undescended testicle, trauma, genetic syndromes, birth defects, sexual history

Ask about history of prior ipsilatearl surgery, horseshoe kidney, inflammatory bowel disease.

Imaging: U/S of bilateral testicles shows homogenous hypoechoic mass (pathognomonic)

Fertility sparing: sperm count/sperm banking

Labs: beta-HCG, AFP, LDH before and after surgery (TNM staging is based on post-surgery labs)

Surgery: radical inguinal orchiectomy with high ligation of spermatic cord

Post-op labs, imaging: recheck serum markers in 1-2 months (half life of AFP 3-5 days, beta-HCG 24-36 hr), CT A/P. CT chest if CT A/P or CXR positive. Staging is based on post surgery markers. Consider brain MRI or bone scan.

(If persistent elevation in markers after surgery, this is Stage IS and is treated with chemo alone)

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25
Q

Stage I seminoma treatment paradigm

A

orchiectomy with high inguinal ligation

observation

carboplatin AUC 7 x 1 cycle

xrt 20Gy/10fxs

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26
Q

Seminoma: simulation

A

supine, clamshell, position penis out of field

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27
Q

Seminoma: dose and fields for stage I

A

20Gy/10fxs

T11/T12 down to L5/S1 (i.e T12-L5), laterally out to transverse processes

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28
Q

stage I seminoma: follow up

A

H&P and CT q3mo for first year then q12 months. Per NCCN serum markers are optional and only recommended for bulky disease.

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29
Q

stage I seminoma: recurrence rate with observation

A

15%

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30
Q

Stage II seminoma treatment paradigm(s)

A

orchiectomy with high inguinal ligation then:

Stage IIA: RT preferred

Stage IIB: EPx4 cycles (per NCCN), RT also an option

Stage IIC: BEP chemo, no RT

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31
Q

Seminoma: dose and fields for stage II

A

20 Gy in 10 fractions + 10 Gy boost to IIA nodes or 16 Gy to IIB nodes

Modified dog leg field:

T11/T12 down to top of acetabulum, 2 cm boost on gross nodal disease. At L5/S1, curve dogleg. New medial border should be medial obturator foramen, new lateral is acetabulum. Maintain 10-12 cm width if not contouring.

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32
Q

Seminoma: kidney constraints

A

kidney D50% < 8Gy

Mean dose to both kidneys <9 Gy

For solitary kidney D15%<20 Gy

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33
Q

Seminoma: 10yr RFS for stage IIA, IIB, IIC

A

10yr RFS:

IIA 90%

IIB 80%

IIC 70%

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34
Q

Bladder cancer: criteria for bladder preservation

A

T2-T4a (per NCCN), no hydronephrosis, no extensive CIS, must have “maximal” TURBT

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35
Q

Bladder cancer: workup

A

H&P. Assess for hematuria, urinary irritation, fever, back pain, travel history (Egypt), dye or toxin exposure, obstructive symptoms, smoking history, past chemo (cytoxan)

Labs: UA, urine cytology, CBC, alk phos

Cystoscopy with maximal TURBT, tumor mapping

Imaging of upper tract: CT urogram, MR urogram, renal ultrasound

Imaging: CT A/P, MRI

Staging: bone scan if alk phos elevated or bone pain, CXR or chest CT

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36
Q

Bladder cancer: simulation

A

supine, vac loc, scan with empty and full bladder

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37
Q

Bladder cancer: dose and fields

A

39.6Gy/22fxs to pelvis, 54Gy/30fxs to bladder, 64.8Gy/36fxs to tumor

Superior border: mid-SI, L4/5 if T4 or N+

inf: bottom of obturator foramen
lateral: 2 cm on pelvic brim
ant: 2.5 cm ant to bladder boundary
post: 2.5 cm beyond bladder/mass

block femoral heads, bowel, rectum

Bladder boost: 2.5 cm PTV around bladder

Tumor boost: use pre-CT, cysto mapping to delineate

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38
Q

Bladder cancer: 5yr OS and 5yr intact bladder

A

5yr OS 55%

5yr intact bladder 80%

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39
Q

Bladder cancer: indications for adjuvant radiaiton

A

pT3-4, positive nodes, positive margins, high grade

45-50.4Gy

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40
Q

Urethral ca: workup

A

cystoscopy (with EUA and TUR), image pelvis and upper urinary tract, biopsy any suspicious nodes (could be infection)

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41
Q

Penile brachytherapy criteria

A

T1-2N0, size < 4cm, any grade

42
Q

Penile cancer: brachy and EBRT procedures

A

I would sterilze and drape the patient and place a foley catheter. I would insert 6 insterstitial needles and treat in two planes

60-65 Gy Ir-192 interstitial (limit urethra to 60 Gy) vs EBRT 40 Gy to shaft in box bolus plus 20 Gy boost with 2 cm margin. NCCN: 65-70 Gy with chemo

43
Q

Penis T1a

A

superficial, grade 1-2, no LVSI

44
Q

Penis T1b

A

superficial, grade 3 and/or LVSI

45
Q

Penis T2

A

spongiosum with or without urethral invasion

46
Q

Penis T3

A

cavernosum with or without urethral invasion

47
Q

Penis T4

A

adjacent structures

48
Q

Penis clinical N1

A

unilateral inguinal node

49
Q

Penis clinical N2

A

multiple unilateral inguinal nodes or bilateral inguinal nodes

50
Q

Penis clinical N3

A

fixed inguinal node

pelvic nodal involvement

51
Q

Penis stage IIB

A

T3N0

T1b-2N0 is IIA

52
Q

Penis stage IIIA

53
Q

Penis stage IIIB

54
Q

Penis stage IV

A

any T4, N3, or M1

55
Q

Gleason grade group 1

56
Q

Gleason grade group 2

57
Q

Gleason grade group 3

58
Q

Gleason grade group 4

59
Q

Gleason grade group 5

A

gleason 9/10

60
Q

Prostate stage I

A

low risk group

61
Q

Prostate stage IIA

A

intermediate risk, grade group 1

62
Q

Prostate stage IIB

A

intermediate risk, grade group 2

63
Q

Prostate stage IIC

A

intermediate risk, grade group 3

also grade group 4 with T1-2 and PSA < 20

64
Q

Prostate stage IIIA

65
Q

Prostate stage IIIB

66
Q

Prostate stage IIIC

A

grade group 5

67
Q

Prostate stage IVA/B

A

IVA: N1

IVB: M1

68
Q

Testis pT1

A

limited to testis, no LVSI

69
Q

Testis pT2

A

limited to testis with LVSI

epididymis

tunica albuginea

70
Q

Testis pT3

A

spermatic cord

71
Q

Testis pT4

72
Q

Testis pN1

A

5 fewer nodes, all <2cm

73
Q

Testis pN2

A

node 2-5cm in size, 6+ nodes, or ECE

74
Q

Testis pN3

75
Q

Testis S2 criteria

A

LDH 1-10x upper limit of normal

hCG 5k-50k

AFP 1k-10k

76
Q

Testis stage IIA

77
Q

Testis stage IIB

78
Q

Testis stage IIC

79
Q

Testis stage IIIA

80
Q

Testis stage IIIB

81
Q

Testis stage IIIC

82
Q

Bladder T1

A

lamina propria

83
Q

Bladdder T2

A

muscularis propria

84
Q

Bladder T3

A

perivesical soft tissue

85
Q

Blader T4a

A

prostate, uterus, vagina

86
Q

Bladder T4b

A

pelvic wall, abdominal wall

87
Q

Bladder N1

A

single node in true pelvis

88
Q

Bladder N2

A

multiple nodes in true pelvis

89
Q

Bladder N3

A

common iliac nodes

90
Q

Bladder stage II

91
Q

Bladder stage IIIA

A

T3a-T4a

N1

92
Q

Bladder stage IIIB

93
Q

Bladder stage IVA

A

T4b or M1a

94
Q

Non-prostatic urethra T2

A

spongiosum or periurethral tissue

95
Q

Non-prostatic urethra T3

A

cavernosum or anterior vagina

96
Q

Prostatic urethra T2

A

prostatic stroma

97
Q

Prostatic urethra T3

A

periprostatic fat

98
Q

Urethra stage II

99
Q

Urethra stage III

100
Q

Urethra N1

A

single node (inguinal, pre-sacral, or true pelvis)

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