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1
Q

Bladder cancer: indications for adjuvant radiaiton

A

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

45-50.4Gy

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2
Q

Prostate: EBRT target coverage

A

98/100

min 95%

max 107%

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3
Q

Gleason grade group 4

A

4+4=8

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4
Q

Testis stage IIC

A

N3, S0-1

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5
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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6
Q

Penile brachytherapy criteria

A

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

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7
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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8
Q

Testis pT2

A

limited to testis with LVSI

epididymis

tunica albuginea

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9
Q

Testis stage IIB

A

N2, S0-1

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10
Q

Prostate stage IVA/B

A

IVA: N1

IVB: M1

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11
Q

Prostate stage IIIB

A

T3-4N0

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12
Q

Bladder stage IIIA

A

T3a-T4a

N1

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13
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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14
Q

Penis T4

A

adjacent structures

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15
Q

Testis stage IIA

A

N1, S0-1

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16
Q

Bladder T1

A

lamina propria

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17
Q

Testis stage IIIC

A

S3 or M1b

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18
Q

Prostate LDR brachy: dosimetry

A

Modified peripheral loading. Plan to 180 Gy for I-125

Seattle:

D90>90% (goal is 130%)

V100>98%

V150<40%

V200<20%

urethral Dmax <110-120

rectal D1cc <100%

calculation grid < 2mm x 2mm x axial slice width

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19
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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20
Q

Testis pN1

A

5 fewer nodes, all <2cm

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21
Q

Testis stage IIIA

A

M1a, S0-1

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22
Q

Gleason grade group 2

A

3+4=7

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23
Q

Bladder N1

A

single node in true pelvis

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24
Q

Prostate stage I

A

low risk group

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25
Penis clinical N1
unilateral inguinal node
26
Testis pN2
node 2-5cm in size, 6+ nodes, or ECE
27
Prostate: simulation
supine, vac loc, full bladder, empty rectum fiducials prior to sim if not doing daily CBCT
28
Penis clinical N3
fixed inguinal node pelvic nodal involvement
29
Urethra stage II
T2N0
30
Blader T4a
prostate, uterus, vagina
31
Prostate: leuprolide dose and MOA
7.5mg per month (30mg for 4 months) LHRH analog
32
Urethra N1
single node (inguinal, pre-sacral, or true pelvis)
33
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.
34
Salvage prostate: constraints for bladder and rectum
bladder minus CTV: V65 \< 35% rectum: V65 \< 35%
35
Prostate: components of MSKCC nomogram
age, PSA, stage, GS, number of positive cores
36
Penis T1a
superficial, grade 1-2, no LVSI
37
Prostate stage IIB
intermediate risk, grade group 2
38
Seminoma: workup
H&P, undescended testicle, trauma, genetic syndromes, birth defects, sexual history, ipsilatearl surgery, horseshoe kidney, IBD Imaging: U/S (homogenous hypoechoic mass, pathognomonic) Fertility sparing: sperm banking Labs: beta-HCG, AFP, LDH before and after surgery (post-surgery labs for TNM) Surgery: radical inguinal orchiectomy with high ligation of spermatic cord Post-op: serum markers at 6 wks, CT C/A/P (If persistent elevation in markers after surgery, this is Stage IS and is treated with chemo alone)
39
Penis T2
spongiosum with or without urethral invasion
40
Bladder stage IVA
T4b or M1a
41
Prostate: contraindications to LDR brachytherapy
Absolute: ## Footnote * limited life expectancy * large TURP defect * absence of rectum * distant mets * high operative risk * ataxia telangiectasia Relative: * IPSS score \> 20 * previous pelvic radiation * prior TURP (small) * large median lobe * gland size \>60cc * IBD
42
Testis pT3
spermatic cord
43
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.
44
Non-prostatic urethra T3
cavernosum or anterior vagina
45
Non-prostatic urethra T2
spongiosum or periurethral tissue
46
Bladder T4b
pelvic wall, abdominal wall
47
Penis stage IIB
T3N0 T1b-2N0 is IIA
48
Penis stage IIIB
N2
49
Prostate: indications for salvage radiation
PSA rise to \> 0.1 for 2 consecutive rises
50
Prostate: bicalutamide dose and MOA
50mg daily if given with leuprolide 150mg daily if given alone nonsteroidal antiandrogen
51
Prostate stage IIA
intermediate risk, grade group 1
52
Bladder cancer: 5yr OS and 5yr intact bladder
5yr OS 55% 5yr intact bladder 80%
53
Prostate cancer: workup
H&P. PMH of cardiac disease, MI, diabetes, osteoporosis, TURP, AUA, sexual history inventory Labs: PSA, CBC, CMP
54
Roach formulas
ECE= 3/2 PSA + 10 (GS - 3) SVI = PSA + 10(GS -6) LN = 2/3 PSA + 10(GS-6)
55
Seminoma: 10yr RFS for stage IIA, IIB, IIC
10yr RFS: IIA 90% IIB 80% IIC 70%
56
Testis pT4
scrotum
57
Prostate: EBRT rectum V75 and V50
V75 \< 15% V50 \< 50%
58
Prostatic urethra T3
periprostatic fat
59
Bladder cancer: criteria for bladder preservation
T2-T4a (per NCCN), no hydronephrosis, no extensive CIS, must have "maximal" TURBT
60
Gleason grade group 5
gleason 9/10
61
5yr bPFS for intermediate risk prostate cancer (EBRT)
5yr bPFS 85%
62
stage I seminoma: recurrence rate with observation
15%
63
Penis stage IV
any T4, N3, or M1
64
Bladder T3
perivesical soft tissue
65
Bladdder T2
muscularis propria
66
5yr bPFS for low risk prostate cancer (EBRT)
5yr bPFS 95%
67
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
68
Bladder stage IIIB
N2-3
69
Prostate: when to order staging scans
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
70
Penis T3
cavernosum with or without urethral invasion
71
Prostate stage IIIC
grade group 5
72
Penis T1b
superficial, grade 3 and/or LVSI
73
Prostate LDR brachytherapy: dose, half-life, seed strength, and energy for I-125 and Pd-103
I-125: 145Gy, 110Gy with EBRT, 60 days, ~0.5mCi, 28keV Pd-103: 120Gy, 100Gy with EBRT, 17 days, ~1.5mCi, 21keV
74
Testis pN3
node \>5cm
75
Prostate: EBRT femoral head constraint
V50 \< 5%
76
Prostate hypofrac: dosimetry
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
77
Urethra stage III
T3 or N1
78
Prostate stage IIC
intermediate risk, grade group 3 also grade group 4 with T1-2 and PSA \< 20
79
Seminoma: dose and fields for stage I
20Gy/10fxs T11/T12 down to L5/S1 (i.e T12-L5), laterally out to transverse processes
80
Prostate: indications for adjuvant radiation
T3a, T3b, positive margin
81
Seminoma: kidney constraints
kidney D50% \< 8Gy Mean dose to both kidneys \<9 Gy For solitary kidney D15%\<20 Gy
82
Bladder stage II
T2N0
83
OS for intermediate risk prostate cancer w/wo ADT
88% with ADT 78% without ADT
84
Gleason grade group 1
3+3=6
85
Bladder cancer: simulation
supine, vac loc, scan with empty and full bladder
86
Gleason grade group 3
4+3=7
87
Testis pT1
limited to testis, no LVSI
88
Testis S2 criteria
LDH 1-10x upper limit of normal hCG 5k-50k AFP 1k-10k
89
Bladder N3
common iliac nodes
90
Penis clinical N2
multiple unilateral inguinal nodes or bilateral inguinal nodes
91
Seminoma: simulation
supine, clamshell, position penis out of field
92
Bladder N2
multiple nodes in true pelvis
93
Prostate LDR brachy: treatment narrative
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.
94
Bladder cancer: workup
H&P, hematuria, dysuria, urinary obstruction, fever, travel history, smoking history, dye/toxin exposure Labs: CBC, CMP, alk phos, UA w/ cytology Cystoscopy with maximal TURBT, tumor mapping Imaging: PET/CT, image upper tract with CT/MR urogram
95
Prostatic urethra T2
prostatic stroma
96
Stage I seminoma treatment paradigm
orchiectomy with high inguinal ligation observation carboplatin AUC 7 x 1 cycle xrt 20Gy/10fxs
97
Testis stage IIIB
S2
98
Penis stage IIIA
N1
99
Prostate: EBRT bladder V75 and V65
V75 \< 25% V65 \< 50%
100
Prostate stage IIIA
PSA \> 20

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