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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
Stage I seminoma treatment paradigm
orchiectomy with high inguinal ligation observation carboplatin AUC 7 x 1 cycle xrt 20Gy/10fxs
26
Seminoma: simulation
supine, clamshell, position penis out of field
27
Seminoma: dose and fields for stage I
20Gy/10fxs T11/T12 down to L5/S1 (i.e T12-L5), laterally out to transverse processes
28
stage I seminoma: follow up
H&P and CT q3mo for first year then q12 months. Per NCCN serum markers are optional and only recommended for bulky disease.
29
stage I seminoma: recurrence rate with observation
15%
30
Stage II seminoma treatment paradigm(s)
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
31
Seminoma: dose and fields for stage II
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.
32
Seminoma: kidney constraints
kidney D50% \< 8Gy Mean dose to both kidneys \<9 Gy For solitary kidney D15%\<20 Gy
33
Seminoma: 10yr RFS for stage IIA, IIB, IIC
10yr RFS: IIA 90% IIB 80% IIC 70%
34
Bladder cancer: criteria for bladder preservation
T2-T4a (per NCCN), no hydronephrosis, no extensive CIS, must have "maximal" TURBT
35
Bladder cancer: workup
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
36
Bladder cancer: simulation
supine, vac loc, scan with empty and full bladder
37
Bladder cancer: dose and fields
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
38
Bladder cancer: 5yr OS and 5yr intact bladder
5yr OS 55% 5yr intact bladder 80%
39
Bladder cancer: indications for adjuvant radiaiton
pT3-4, positive nodes, positive margins, high grade 45-50.4Gy
40
Urethral ca: workup
cystoscopy (with EUA and TUR), image pelvis and upper urinary tract, biopsy any suspicious nodes (could be infection)
41
Penile brachytherapy criteria
T1-2N0, size \< 4cm, any grade
42
Penile cancer: brachy and EBRT procedures
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
Penis T1a
superficial, grade 1-2, no LVSI
44
Penis T1b
superficial, grade 3 and/or LVSI
45
Penis T2
spongiosum with or without urethral invasion
46
Penis T3
cavernosum with or without urethral invasion
47
Penis T4
adjacent structures
48
Penis clinical N1
unilateral inguinal node
49
Penis clinical N2
multiple unilateral inguinal nodes or bilateral inguinal nodes
50
Penis clinical N3
fixed inguinal node pelvic nodal involvement
51
Penis stage IIB
T3N0 T1b-2N0 is IIA
52
Penis stage IIIA
N1
53
Penis stage IIIB
N2
54
Penis stage IV
any T4, N3, or M1
55
Gleason grade group 1
3+3=6
56
Gleason grade group 2
3+4=7
57
Gleason grade group 3
4+3=7
58
Gleason grade group 4
4+4=8
59
Gleason grade group 5
gleason 9/10
60
Prostate stage I
low risk group
61
Prostate stage IIA
intermediate risk, grade group 1
62
Prostate stage IIB
intermediate risk, grade group 2
63
Prostate stage IIC
intermediate risk, grade group 3 also grade group 4 with T1-2 and PSA \< 20
64
Prostate stage IIIA
PSA \> 20
65
Prostate stage IIIB
T3-4N0
66
Prostate stage IIIC
grade group 5
67
Prostate stage IVA/B
IVA: N1 IVB: M1
68
Testis pT1
limited to testis, no LVSI
69
Testis pT2
limited to testis with LVSI epididymis tunica albuginea
70
Testis pT3
spermatic cord
71
Testis pT4
scrotum
72
Testis pN1
5 fewer nodes, all \<2cm
73
Testis pN2
node 2-5cm in size, 6+ nodes, or ECE
74
Testis pN3
node \>5cm
75
Testis S2 criteria
LDH 1-10x upper limit of normal hCG 5k-50k AFP 1k-10k
76
Testis stage IIA
N1, S0-1
77
Testis stage IIB
N2, S0-1
78
Testis stage IIC
N3, S0-1
79
Testis stage IIIA
M1a, S0-1
80
Testis stage IIIB
S2
81
Testis stage IIIC
S3 or M1b
82
Bladder T1
lamina propria
83
Bladdder T2
muscularis propria
84
Bladder T3
perivesical soft tissue
85
Blader T4a
prostate, uterus, vagina
86
Bladder T4b
pelvic wall, abdominal wall
87
Bladder N1
single node in true pelvis
88
Bladder N2
multiple nodes in true pelvis
89
Bladder N3
common iliac nodes
90
Bladder stage II
T2N0
91
Bladder stage IIIA
T3a-T4a N1
92
Bladder stage IIIB
N2-3
93
Bladder stage IVA
T4b or M1a
94
Non-prostatic urethra T2
spongiosum or periurethral tissue
95
Non-prostatic urethra T3
cavernosum or anterior vagina
96
Prostatic urethra T2
prostatic stroma
97
Prostatic urethra T3
periprostatic fat
98
Urethra stage II
T2N0
99
Urethra stage III
T3 or N1
100
Urethra N1
single node (inguinal, pre-sacral, or true pelvis)

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