GU Flashcards
1
Q
Lab findings of pure germinoma
A
Normal AFP (<6-10 ng/mL) Low b-hCG (<100 mIU/mL)
2
Q
Lab findings of choriocarcinoma
A
High b-hCG (>100)
3
Q
Lab findings of yolk sac tumor
A
Elevated AFP
4
Q
Lab findings of embryonal germinoma
A
Elevated AFP and b-HCG
5
Q
new cases of prostate ca per year
A
220000 (13% of new cancers)
6
Q
PC is _____ leading cause of cancer death in men
A
2nd
7
Q
How many cancers diagnosed in stag where 5 year OS is 100%
A
90%
8
Q
What is most important factor associated with PC
A
age
9
Q
What is relative risk reduction with finasteride
A
30% reduction in 7 year risk with finasteride
10
Q
Initial concern with finasteride for prevention
A
increased risk of high grade disease
11
Q
Risk of higher grade cancer is balanced by
A
No difference in OS between the two groups
12
Q
70% of prostate cancer is located in which zone
A
peripheral
13
Q
where are the neurovascular bundles located
A
posterolateral edges
14
Q
What is blood supply to prostate
A
Int. Iliac artery
15
Q
What is blood drainage from prostate
A
prostate plexus –> int. iliac vein
16
Q
Gleason 3 path
A
crowded glands
17
Q
Gleason 4 path
A
fusing glands
18
Q
Gleason 5 path
A
sheets of cells
19
Q
What is a barrier to rectal involvement of PC
A
Denonvilliers fascia
20
Q
Half life of PSA
A
2-3 days
21
Q
What PSA velocity is considered concerning for increased risk of PC death
A
0.35 ng/mL per year
22
Q
What PSA DT is associated with 8.5x risk fo BCF
A
3 years or less
23
Q
Free to total PSA ratio of X corresponds with low risk of cancer
A
25%
24
Q
Free to total PSA ratio of X highly suspicious for cancer
A
7%
25
When should prostate MRI be obtained
4-6 weeks post bx
26
What is PSA threshold to order CT CAP
>20
27
When to order bone scan
T3/T4
| T2 with PSA > 10, GS 8+ or PSA >20
28
What MRI sequence good for intraprostatic lesions
T2
29
What is T1 sequence on MRI good for
invasion into fat
30
proPSMA study showed that upfront PSMA had X improvesd accuracy of detecting nodes or mets
27%
31
The number of positive cores can predict
lymph node involvement
32
T1 prostate
clinically inapparent on imaging or DRE
33
T1b prostate
histologic finding in >5% of resected tissue
34
T1c prostate
diagnosis via needle biopsy/elevated PSA
35
T2a prostate
1/2 of one lobe or less
36
T2b prostate
> 1/2 of one lobe
37
T2c prostate
both lobes affected
38
T3a prostate
ECE
39
T3b prostate
SVI
40
T4 prostate
invades nearby structures (bladder, levator muscles, pelvic wall)
41
N1 prostate
>1 regional nodes
42
What stage is N1 patient
IVA
43
PSA above X constitutes high risk feature
20
44
Grade group 1
3+3=6
45
Grade Group 2
3+4=7
46
Grade Group 3
4+3=7
47
Grade Group 4
Gleason 8
48
Grade Group 5
9-10 (5+)
49
What stage is low risk
T1c-T2a
50
Intermediate risk
T2b
PSA 10-20
Gleason 7
51
Unfavorable intermediate risk
At least one risk factor
4+3 histology
>50% involved cores
52
High risk disease
T2c or higher
PSA >20
Gleason 8-10
53
REDUCE trial
RCT of dutasteride vs. placebo which found 23% reduction in prostate cancer
54
If very low risk prostate cancer what is preferred strategy
active surveillance for age 62-77
55
If low risk diagnosis prior to age 62, what is next step
MRI
56
Scandinavian Prostate Cancer Group 4 tril
compared RP to WW and RP associated with 13% reduction in death
57
Who had largest benefit for RP in Scandinavian trial
age <65
| intermediate risk
58
PIVOT trial
RCT of RP vs. observation
59
Findings of PIVOT
HR death was 0.88 but p=0.06
60
Why might OS benefit not been significant?
diluted by 40% low risk in the study
61
where is most common location for + margin for RP
apex
| 2nd: rectal/lateral surfaces
62
ProtecT trial design
RCT of 1 time PSA assessment men aged 50-69:
| Then randomized to AS, RT or RP
63
Findings of ProtecT
No difference in OS, prostate cancer specific survival
64
What was different in ProtecT sudy
Higher rates of metastases in AS group
| Bowel function/bother and urinary obstructive symptoms worse in RT
65
How much ADT for intermediate risk PC
If favorable --> none
| If unfavorable --> 3-6 months
66
D'Amico study design
1872 patients treated with surgery vs. brachy vs. EBRT
67
Results of D'Amico study
5 year biochemical outcomes no worse for low risk
| For intermediate/high risk, EBRT or surgery did better
68
Fox chase study results
Compared 76/38 Gy to 70.2/26 and found no difference
69
CHHiP research question
Hypofractionaction study
| RCT, multicenter non-inferiority, primary endpoint of biochemical or clinical failure free rate
70
On CHHiP study how many received ADT?
Nearly all, 97%
| 3-6 months
71
What were the dose regimens utilized on CHHiP
60/30 vs. 74/37 (not inferior)
| 57/19 vs. 74/37 (inferior)
72
PROFIT trial design
Noninferiority of biochemical/clinical failure
73
Dose regimen used on PROFIT
60/30 vs. 78/39 (non inferior)
74
What are the requirements for SBRT?
1. Prostate <100 cc
2. No bleeding
3. Able to lie still for 5 mins
4. No IBD on DMARD
75
HYPO-RT-PC trial
SBRT vs. conventional fx question
| 42.7 Gy / 7 fx QOD vs. 78 / 39 fx
76
What patients were included in HYPO-RT-PC trial
intermediate and high risk
77
What were findings of HYPO-RT-PC
No difference in FFS at 5 years
78
Any toxicity differences?
SBRT associated with higher levels of acute urinary/bowel tox but these normalize and late rates similar
79
PACE B trial design
78/2 vs. 36.25 in 7.25 Gy fx --> similar toxicity
80
D'Amico study design
RCT of 206 patients to receive
1. 70 Gy 3DCRT
2. 70 Gy + 6 months ADT
81
D'Amico findings
6 months ADT prolongs survival in men without comorbidities but there was greater association with cardiac death in men with comorbidities
82
RTOG 9408 design
RCT of ~2000 low/intermediate risk men randomized to
1. RT (66Gy)
2. 4 months ADT with 66 Gy (2 months ADT --> RT)
83
RTOG 9408 results
Improvement in OS and DFS with 4 months ADT, mostly in intermediate risk men
84
ASCENDE-RT design
RCT of 400 men
1. 12 months ADT + pelvic RT to 46 Gy + prostate EBRT boost to 78 Gy
2. 12 months ADT + pelvic RT to 46 Gy + LDR prostate boost
85
ASCENDE-RT results
Improved biochem FS with brachy boost: 83 vs. 62% at 5 years
86
Which risk groups benefitted from brachy boost on ASCENDE
intermediate and high risk
87
ASCENDE tox: GU
worse acute and late with brachy
88
ASCENDE tox: GI
no diff
89
ASCENDE tox: erectile function
no diff
90
22961 Bolla trial design
RCT of ADT duration
1. RT + 6 months ADT
2. RT + 30 months ADT
91
Dose used in Bolla trial
70Gy
92
How was Bolla Trial designed
non-inferiority
93
Results of 22961
6 months was not non-inferior to 30 monhts, long course associated with improved OS, CSS
94
For high risk, what is advantage of docetaxel?
4% improvement in 4 year OS
95
How much ADT is recommended for N+ disease
18-28 months
96
What are reasons to discuss adjuvant RT
+margin
| T3+ disease
97
SWOG 8794
Adjuvant RT for patients with EPE, SVI or +margin
98
What did 8794 show?
Improved OS
99
Dose of RT on SWOG 8794
60-64 Gy
100
What is the criticism of SWOG study
Likely more of a salvage study since many already had PSA >0.2
101
EORTC 22911 research question
Adjuvant vs. salvage RT
| Dose of 60 Gy
102
Results of 22911
Adjuvant improved bPFS and local control but is associated with more late effects
103
What is plt requirement for initial Xofigo
100
104
What is ANC requirement for initial Xofigo
1.5
105
What is platelet requirement for subsequent Xofigo
50
106
RADICALS trial design
Early salvage vs. adjuvant RT
107
Patient criteria for RADICALS
```
IR or HR
Undetectable PSA post-op with at least 1 feature
pT3/T4
G7-10
pre-op PSA >10
+surgical margins
```
108
Criteria to institute early salvage
2 consecutive PSA rise and PSA > 0.1 OR
| 3 consecutive PSA rises
109
RT dose in RADICALS
66/33
| 52.5/20
110
How many in RADICALS got ADT
30%
111
Result of RADICALS
No bPFS benefit and worse GI tox for adjuvant --> early salvage is preferred
112
RAVES
Similar design to RADICALS
113
Dose of RT on RAVES
64 Gy
114
Criteria to trigger salvage RT on RAVEs
PSA >0.2
115
Result of RAVES
Salvage RT didn't meet noninferiority but still recommended it
116
RTOG 9601
Salvage RT +/- ADT
117
ADT used on 96-01
24 months bicalutamide
118
Rate of gynecomastia on 96-01
70% vs. 11% placebo
119
Results of 96-01
Addition of ADT improved OS, DMFS, PC death
120
Repeat look at 96-01 found that men with PSA < X might derive more harm than benefit from ADT
0.6
121
What were the RCT arms for STAMPEDE metastatic trial
1. ADT +/- docetaxel
| 2. ADT + EBRT (55/20 vs. 36/6)
122
How was high metastatic burden defined on STAMPEDE
1. >/= 4 bone mets with at least 1 outside vertebral bodies or pelvis
2. Visceral mets
3. both
123
What was results
FFS significantly improved with RT to prostate
| OS benefit only in low volume disease
124
How much SV should be covered for low/intermediate risk disease
1 cm per 0815
125
How much SV should be covered for intermediate risk
1.5 cm
126
How much SV should be covered for high risk
all
127
CTV to PTV margin
5-7 mm expansion, 3 mm posterior
128
Urethra SBRT constraint
D0.03 < 39
129
Rectum SBRT constraint
D0.03 cc < 38 Gy
130
Bladder SBRT constraint
D 0.03 <73, D35% < 70 Gy, D90% <35
131
Coverage goal for LDR brachytherapy
D90 > 90%
132
Phoenix criteria
nadir + 2
133
What proportion of bladder ca patients will be muscle invasive
33%
134
TCC of bladder is associated with which risk factors
smoking
aniline dyes
amines
135
SCC of bladder is associated with which risk factors
schistosomiasis
| indwelling catheter
136
Adenocarcinoma of bladder is associated with
urachal remnant
137
Predictors of mets for bladder ca
bulk of tumor
| depth of invasion
138
Bladder tumors commonly have mutations in which pathway
p16 (Rb pathway)
139
80% of patients with bladder ca present with
painless hematuria
140
But _____ patients with hematuria are diagnosed with bladder ca
10-20%
141
T1 bladder
subepithelial connective tissue
142
T2a bladder
invades into superficial muscularis propria
143
T2b bladder
invades into deep muscularis propria
144
T3 bladder
perivesicular tissue
145
T4a bladder
invades to prostate, uterus, vagina
146
T4b bladder
pelvic wall or abdominal wall invasion
147
N1 bladder
Single regional node in true pelvis
148
N2 bladder
Multiple regional nodes in true pelvis
149
N3 bladder
LN in common iliac
150
Paradigm for non-muscle invasive bladder cancer
TURBT
| If high grade --> BCG
151
How many men experience recurrence after BCG
40-80%
152
How many patients s/p TURBT for T1 disease will get invasive disease
10-25%
153
Paradigm for muscle invasive bladder ca
1. Cystectomy
| 2. maximal TURBT --> concurrent chemoRT (64 Gy)
154
What is pelvic control rate after radical cystectomy
90%
155
How many people get mets after radical cystectomy
50%
156
How to sim bladder cancer
bladder empty
157
Complete response rate after bladder sparing approaches
70%
158
Dose options for bladder
Small pelvis 40 Gy
Full bladder CD to 54 Gy
Bladder tumor CD to 64.8 Gy
159
Chemo options for concurrent
Cis 35 mg/m2
MMC + 5FU (500 mg/m2)
Gem twice weekly
160
BC2001 design
Two randomizations
1. RT +/- chemotherapy
2. whole bladder RT vs. reduced bladder RT
161
Chemo used on BC2001
MMC (12 mg/m2) on day 1
| 5FU (500 mg/m2) day 1-5 and 16-20
162
BC2001 main endpoint and result
2 year locoregional DFS
| 67% for chemoRT and 54% for RT
163
Any difference in OS for BC2001
no
164
Dose of RT used on BC2001
55/20 OR
| 64/32
165
PTV for BC2001 (standard arm)
```
CTV = full bladder (empty)
PTV = 1.5 margin
```
166
PTV for BC2001 (experimental arm)
```
CTV1 = full bladder
PTV1 = 1.5 cm margin
PTV2 = GTV + 1.5 cm
```
167
Dose requirements for different dose levels
100% of dose to PTV2
| 80% of dose to PTV1
168
Any differences between reduced volume and standard volume
none
169
VHL is associated with which type of kidney cancer
clear cell
170
Sickle cell is associated with which type of kidney cancer
medullary
171
Rough rate of salvage cystectomy after bladder preserving therapy
20%
172
T1 kidney
<7 cm
173
T2 kidney
>7 cm confined to kidney
174
T3 kidney
tumor extends to major veins or perinephric tissue but not ipsilaeral adrenal gland and not beyond Gerota's fascia
175
T4 kidney
tumor beyond Gerota's
176
5 year OS for kidney confined disease
90%
177
What is function of leydig cell
testosterone
178
Radiation tolerance of leydig cell
40 Gy
179
What is function of sertoli cell
produces sperm
180
Radiation tolerance of sertoli cell
1-2 Gy
181
Breakdown of seminoma/NSGCT
60% seminoma
182
Hallmark of pure seminoma
No AFP elevation
| Mild-moderate B-HCG elevation
183
Yolk sac tumors produce which hormone
AFP
184
Right sided lymphatic drainage for testicular tumor
IVC (paracaval and aortocaval)
185
Left sided lymphatic drainage for testicular tumor
renal vein --> IVC (left renal hilar area)
186
Imaging needed if pure seminoma
CT AP only
187
Imaging needed if NSGCT
CXR and CT AP
188
Options after orchiectomy for seminoma
1. surveillance
2. RP radiotherapy
3. 1 cycle carboplatin
189
RT field
PA and ipsilateral common iliac
190
Dose of RT for seminoma
20-25 Gy over 20 fx
191
TE19 trial design
seminoma --> single dose carboplatin vs. RT (20-30 Gy)
192
Dose of carboplatin
AUC 7
193
Findings of TE19
Carbo non-inferior to RFR with reduction in contralateral GCT
194
MRCUK
similar findings to TE19
| more relapses in RP nodes with carbo but less contralateral GCT
195
Recommendation for stage I seminoma
orchiectomy --> surveillance
196
Definition of stage II seminoma
involvement of PA or pelvic LN
197
Recommendation for stage II seminoma
IIB (2-5 cm) --> consider RP (dog leg) RT
| IIC --> chemo (BEP x3 or EP x 4)
198
Superior border of seminoma Field
bottom of T11
199
Serotypes of HPV associated with penile cancer
16, 18
200
Layers of penis deep to superficial
cavernosa --> spongiosa --> skin
201
Where does penile prepuce and skin drain lymphatics
superficial inguinal
202
Where does glans/deep penile structures drain
superficial or deep inguinal --> femoral or external iliac/common iliac
203
Most common histology of penile ca
Squamous
204
Most common location
glans then prepuce
205
Gold standard imaging for penile cancer
MRI
206
Which tumors have 50% risk of nodal involvement and should have surgical nodal staging
T2
| Grade 3
207
T1 penile
Subepithelial connective tissue
208
T2 penile
invades spongiosum w/ or w/o urethra
209
T3 penile
invades corpus cavernosum w/ or w/o urethra
210
T4 penile
adjacent structures or scrotum
211
N1 penile
unilateral inguinal
212
N2 penile
multiple or bilateral inguinal
213
N3 penile
fixed inguinal or pelvic
214
Brachy control rate for penile
5 year local control of 77-87%
215
Criteria for penile brachy
Tumors <4 cm
Less than 1 cm invasion
Circumcision prior to brachy
216
If tumor is >4 cm and gets brachy, what is failure rate
50-60%
217
EBRT dose for penile
At least 60 Gy
218
What is EBRT control rate
41-70%
219
Constraint for penile bulb
D90 < 50 Gy
220
Evidence for dose escalation in salvage setting
Only retrospective
| One prospective from China didn't show diff between 66/72 (maybe G8+?)
221
LDR mono dose I-125
145 Gy
222
What was unique about ARO adjuvant study
Only one which required undetectable postop PSA
223
Mechanism of bicalutamide
non-steroidal anti-androgen
224
Share of stage I testicular relapses which occur in first 2-3 years
90%
225
What makes NSGCT high risk
pT3/T4
LVI
Proportion of embroynal carcinoma
226
Relapse rate of low risk NSGCT stage I
10-15%
227
Relapse rate of high risk NSGCT stage I
50%
228
Good "AFP" markers for testicular
<1000
229
Good "BHCG" markers for testicular
<5000
230
Good risk anatomic location for NSGCT
testicular or RP primary
| No non-pulmonary mets
231
Follow up of NSGCT year 1
tumor markers q2m
CT AP q4m
CXR q2m
232
Risk factors in Spanish germ cell study
rete testis involvement
| size > 4cm
233
NCCN rec for stage I seminoma
active surveillance
234
Anticipated relapse rate for stage I seminoma on surveillance
15-20%
235
Follow-up of seminoma for first year
H&P q 3-6 months
CT AP 3, 6, 12 months
CXR as needed
236
MRC testicular study design
stage I seminoma randomized to 30/15 to either
- -PA
- -PA + ipsi iliac
237
MRC results
No difference in relapse free survival (97%)
| <5% pelvic failure in PA group
238
minimum margin for wide excision for penectomy
5-10 mm
239
Recommended neoadjuvant chemo regimen for MIBC
gem-cis
240
What is the OS benefit of cis based regimens for neoadjuvant MIBC
5%
241
Can carbo be substituted for cis
no
242
Stage IB of testicle
T2-4N0M0
243
T2 ureter
muscularis
244
T3 ureter
peripelvic or periureteric fat or renal parenchyma
245
T4 ureter
adjacent organs or perinephric fat
246
N1 ureter
single LN <2cm
247
N2 ureter
single LN >2cm
| Multiple LN
248
Relapse rate at 5 years for stage I seminoma
13%
249
Relapse rate at 5 years for stage I NSCGT
19%
250
T1 testicle
only in testicle, includes rete testicle or tunica albuginea
| no LVI
251
T2 testicle
blood vessel or lymphatics (LVI)
epididimyis
tunica vaginalis
252
T3 testicle
spermatic cord
253
T4 testicle
scrotum invasion
254
Dose for adjuvant bladder
45-50 Gy
255
Contours for adjuvant bladder
neg margin - just pelvic nodes
| pos margin - pelvis and cystectomy bed
256
MRC TE18 design
20/10 vs. 30/10 for stage I seminoma
257
MRC TE18 results
Overall very low relapses, 97% RFS in each arm
258
Testicular IS disease
Any T
N0
M0
S1-3
259
RTOG 0712 design
1. Twice daily RT with cis/5FU
2. Once daily RT with gem
Both got adjuvant cis-gem
260
RTOG 0712 dosing
Phase I to 40 Gy
Pause and TUR
If CR --> 64 Gy
If cystectomy
261
Give adjuvant chemo for which stage of bladder disease
pT3-T4
| N+
262
Preferred chemo scenario for bladder cancer
neoadjuvant chemo for cT2 or greater
263
% of kidney cancers which are renal cell
90%
264
% of RCC which are clear cell
80%
265
What field is used for N+ testicular cancer
dog leg
266
What is stage IIA testicular
Nodes <2cm
267
RT dose for stage IIA testicular
30 Gy (20 Gy to para-aortics + 10 Gy boost to gross disease)
268
What is stage IIB testicular
Nodes 2-5 cm
269
Dose for stage IIB testicular
36 Gy (20 Gy to para-aortics + 16 Gy boost for gross disease)
270
Superior extent of dog leg field
bottom of T11
271
Inferior extent of dog leg field
top of acetabulum
272
Testicular chemo regimens for stage IIA or IIB
BEP x 3 [bleo, etop, cis]
| EP x 4
273
Top of PA field for testicular
T10-T11 (bottom of T11)
274
Inferior aspect PA field for testicular
bottom of L5
275
QUANTEC bilateral kidney constraint (mean)
mean < 18
276
Dose guideline for contralateral kidney if one has dose mean > 18
V6 < 30%
277
What is MRC trial for testicular
Stage I randomized to dogleg vs. PA (30 Gy in 15 fx)
278
What was rate of normal sperm count at 3 years for dogleg arm?
92%
279
Did PA have less sperm count reduction
Signifcantly faster recovery of counts
280
What type of penile cancer associated with HPV
warty/basaloid
281
precursors of keratinizing or verrucous penile cancer
lichen sclerosis, condylomata,
282
Good prognosis seminoma
any site
no non lung mets
normal AFP, any HCG
283
Intermediate prognosis seminoma
any site
| non-lung mets
284
Poor prognosis seminoma
none
285
NSGCT good prognosis
```
testis/RP primary
No non-lung mets
AFP <1000
HCG < 5000
LDH < 1.5 ULN
```
286
NSGCT intermediate prognosis
```
testis/RP primary
No non-lung mets
AFP: 1000-10000
HCG: 5000-50000
LDH: 1.5-10 ULN
```
287
NSGCT poor prognosis
```
mediastinal primary OR
non-pulm mets
AFP > 10000
HCG > 50000
LDH > 10 ULN
```
288
Outcomes of 55/20 vs. 64/32
Meta analysis suggests 55/20 has lower invasive recurrences and similar rates of late toxicity
289
RTOG 0926 patient population
T1 high risk failed BCG or non eligible planned for cystectomy
290
RTOG 0926 design
phase II getting bladder conservation
291
BC2001 question
2x2 factorial
- -RT vs. chemoRT (5FU/MMC)
- -Standard volume or reduced volume
292
Dose on BC2001
55/20 or 64/32
293
Results from BC2001
ChemoRT (5-FU/MMC) associated with improved
- -met free survival
- -local control
- -not OS
294
X% of penile cancers associated with HPV
>40%
295
What strains of HPV are associated
16, 18
296
When will most NSGCT relapse if at risk
first 2-3 years
297
relapse rate for stage I NSGCT
19%
298
N3 for bladder ca
common iliac node
299
N1 disease for bladder cancer is stage
IIIA
300
N2-N3 disease for bladder cancer is stage
IIIB
301
when are tumor markers checked for testicular
post orchiectomy
302
N1 disease for penile is stage
IIIA
303
N2 disease for penile is stage
IIIB
304
Dose to contralateral testis with scrotal shield
1.5 cGy / fraction
305
Dose to contralateral testis without scrotal shield
4 cGy/ fraction
306
Rate of late GU G3+ tox from MGH meta analysis for bladder cancer
6%
| no palliative cystectomies
307
Rate of late GI G3+ tox from MGH meta analysis for bladder cancer
2%
308
Primary treatment for early NSGCT
orchiectomy
309
Options for stage IA NSGCT after orchiectomy
1. Obs
| 2. RPLND
310
Options for stage IA NSGCT after RPLND
pN1 --> obs
pN2 --> BEP x2
pN3 --> BEP x3-4
311
N1 testicle
at least one node <2 cm
| 1-5 nodes
312
N2 testicle
nodes 2-5 cm
or >5 nodes
or ENE
313
N3 testicle
nodes >5 cm
314
M1a testicle
```
nonregional LN (pelvic, inguinal)
lung mets
```
315
stage IIA testicle
N1
316
stage IIB testicle
N2
317
treatment for IS
primary chemo
BEP x 3
EP x 4
then surveillance
318
stage IB testicle
p2-4 N0
319
options for IB testicle NSGCT
orchiectomy
1. RPLND
2. BEP x 2
320
options for stage IIA testicle NSGCT
if normalized markers --> RPLND or chemo
| if non-normalized markers --> BEP x3 or EPx4
321
PENILE: need for inguinal sampling
T1G3+
T2 any grade
LVI
322
Findings of CARMENA trial for kidney ca
sunitinib alone non-inferior to sunitinib-cytoreductive nephrectomy for stage IV RCC [reduced OS with nephrectomy]
323
Options for metastatic RCC
1. cabozatinib
| 2. ipi/nivo
324
neoadjuvant chemo results in x% OS benefit for bladder cancer
5%
325
What is preferred neoadjuvant chemo for bladder
combination cis containing regimen
326
When to consider adjuvant RT for bladder
T3/T4
Margin+
N1
327
Adjuvant bladder dose
45-50.4
328
1. Options for concurrent CRT for bladder presevation
Cis-FU
Cis-paclitaxel
5FU-MMC
Cis alone
329
Design for RTOG 0712
Twice daily RT with 5-FU/Cis vs. once daily with gemcitabine
Total dose of 64 Gy to bladder
Adjuvant chemo x4
330
Rates of DMFS on 0712
Similar with two arms
| ~80% at 3 years
331
Differences in tox between 0712 arms
G3/G4 not statistically different higher in FU/Cis arm
332
Role for RT for pT1 G3 tumors after TURBT?
No- no diff in OS of PFS vs. BCG
333
Long term control of RCC with SBRT
95%
334
Proportion of men who get CKD after SBRT for RCC
roughly 1/3, two years later
335
Toxicity benefits of PA field vs. dogleg for seminoma
decreased heme toxicity
| decreased diarrhea
336
Preplan LDR mono goal V100
>95-98%
337
Preplan LDR mono goal D90
>100%
338
Preplan LDR mono goal rectum
V100 < 1 cc
339
Postpln LDR mono gol D90
>140 Gy
340
Postplan LDR mono V150
<40%
341
Postplan LDR mono V200
<20%
342
Postplan rectum V100
<1.3 cc
343
Postplan urethra max
<140% Rx dose
344
LDR mono dose with I-125
145 Gy
345
LDR mono dose with pd-103
125 Gy
346
LDR mono dose with Cs
115 Gy
347
HRQOL on SWOG 8794 study
Adjuvant RT associated with early worse GU/GI tox but eventually improved and was then better than surgery alone in later time points
348
Difference in ED on SWOG 8794 for adjuvant RT vs. surgery alone
No difference
349
SPCG-7 trial of indefinite ADT vs. 70 Gy + ADT impact on 10 yr PCSS
Halved with RT
| 24% (ADT) vs. 12% (RT+ADT)
350
SPCG-7 trial of indefinite ADT vs. 70 Gy + ADT impact on 10 yr OS
40% with ADT
| 30% with RT+ADT
351
Malone study for intermediate risk prostate cancer (short term androgen deprivation) design
Intermediate risk randomized to 6 months ADT + dose esclated RT. Question is timing of ADT. Randomized to
1. concurrent RT/ADT
2. neoadjuvant ADT (4 months) --> RT
352
Dose of RT used on Malone trial
76 Gy
353
ADT used on Malone trial
goserelin + bicalutamide
354
Malone trial outcomes (overall)
No differences in any outcomes or late toxicity in either arm
355
Malone trial 10 year bRFS
81% vs. 87% (concurrent)
356
Which zone of prostate BPH
transitional zone
357
Median time from prostate biochem progression to form mets
5-10 years
358
STAMPEDE trial patients
High risk, locally advanced, metastatic or recurrent prostate cancer
359
STAMPEDE arms
Randomized 2:1:1:1 to
- -ADT (at least 2 years)
- -ADT + docetaxel
- -ADT + zolendronic acid
- -ADT + docetaxel + zolendronic acid
360
STAMPEDE % of metastatic pts
61%
361
STAMPEDE % of N1M0
15%
362
STAMPEDE % N0M0
24%
363
STAMPEDE results
1. docetaxel improves OS and bPFS
| 2. zolendronic acid does not improve outcomes
364
Duration of OS improvement from docetaxel
10 months (81 months vs. 71)
365
Duration of bPFS improvement from docetaxel
17 months (37 mos vs. 20)
366
Rate of G3-5 adverse events with docetaxel vs. ADT
52% (doc+ADT)
| 32% ADT
367
Dose of docetaxel used on STAMPEDE
75 mg/m2 q3w x 6 cycles
368
Studies for docetaxel + ADT in hormone sensitive PC
1. STAMPEDE
| 2. CHAARTED
369
RADICALS dose
66/33
| 52.5/20
370
ADT used on RADICALS
not mandated
371
ARTISTIC meta analysis of adjuvant vs. early salvage result
No evidence that adjuvant RT improves EFS compared to early salvage
372
ASCO/ASTRO/AUA guidelines on mod hypofrac utilization
acceptable to treat prostate/SV for any risk group
373
ASCO/ASTRO/AUA guidelines on ultrahypofract utilization
1. Not recommended above dose of 3625
2. Not recommended daily fractions
due to risks of late tox
374
ASCO/ASTRO/AUA guidelines on image guidance
do not give mod or ultra hypo without image guidance
375
Design of MD Anderson dose escalation study
```
RCT of two dose levels
1. 70/35
2. 78/39
Conventional 4 field box to 46 Gy
Std arm got 4 field box to smaller field to 70
DE arm then got 3D boost to 78
```
376
Patients included on MDA study
T1b to T3
20% low risk
46% int risk
34% high risk
377
MDA study freedom from BCR
73% (DE) vs. 50% (std)
at 10 years
Only in patients with initial PSA >10
378
MDA study ADT
no hormones
379
MDA study patient group with greatest beneift
PSA > 10
380
Did dose escalation help with PC specific mortality
yes
381
Did DE help with distant mets
yes
382
Did DE help with OS
no diff
383
Did DE cause greater toxicity
yes, sig higher G2 and G3 GI tox
384
MGH/Loma Linda dose escalation study design
PROTON trial of
1. 70.2
2. 79.2
First 50,4 Gy given using 3DConformal photons then subsequent dose given with protons
385
Which patients in MGH proton study
```
Low risk (58%)
Intermediate risk (37%)
High risk (4%)
```
386
MGH study: OS advantage
NSS
| ~80% at 9 years
387
MGH study: freedom from biochem failure
17% (79 Gy)
| 32% (70 Gy)
388
Which group was BCR advantage demonstrated
low risk
| trend for intermediate risk
389
MGH study: toxicity difference
Greater G2 GU tox for dose escalation but not G3
390
What labwork should be obtained for patients starting ADT
CBC
| Liver enzymes
391
How often should labwork be checked on ADT
monthly
392
Major adjuvant RT trials for prostate
1. SWOG 8794
2. RTOG 22911 [Bolla]
3. ARO 9602 [Wiegel]
393
For the adjuvant trials where was RT delivered anatomically
prostate bed only [NO PELVIS]
394
What dose did these studies recommend adjuvantly
60Gy
395
RTOG 0534 (SPPORT trial) design
Short term ADT plus two field designs for SALVAGE RT
1. prostate bed alone
2. prostate bed + short term ADT
3. prostate bed + nodes + short term ADT
396
Dose to prostate bed on SPPORT trial
64.8-70.2
397
Dose to nodes on SPPORT trial
45
398
What was short term ADT on SPPORT trial
4-6 months, starting 2 months pre RT
399
FFP difference for SPPORT trial
prostate + pelvis + ADT best - 89%
prostate + ADT - 83%
prostate alone - 71%
400
Distant mets from SPPORT trial
Suggests improved 5 year FFDM with prostate + pelvis
401
OS difference SPPORT trial
no sig difference
402
Toxicity differences with prostate + pelvis RT
Increase G2+ GI tox (39%)
Increase G2+ heme (29%)
Increase G3+ heme (15%)
403
Positive or negative margin lower risk of biochemical failure after salvage prostate RT
POSITIVE margin
404
POP-RT study design
RCT for men with intermediate/high risk disease randomized to
1. prostate RT alone
2. prostate RT + pelvic RT
405
What ADT did men get on POP-RT trial
2 years ADT
406
What share of men on POP-RT trial got PSMA imaging
80%
407
Dose to prostate and pelvis on POP-RT trial
68/25 prostate
| 50/25 pelvis
408
Findings of POP-RT
Nodal RT improvement in biochemical free survival (82--95%)
| DFS improvement with nodal RT
409
Findings of OS in POP-RT
No difference with pelvic
410
GETUG AFU 17
Adjuvant RT vs. early salvage
411
What is consistent finding of RADICALS, RAVES, GETUG 17
No improvement in PFS with adjuvant RT and increased late GU tox relative to salvage
412
What dose of adjuvant/salvage RT used in RADICALS, RAVES, GETUG 17
RADICALS: 66/33 or 52.5/20
GETUG: 66/33
RAVES: 64/32
413
ARTISTIC meta analysis adjuvant RT effect on 5 year EFS
89% vs. 88%
414
What percentage of patients from ARTISTIC assigned to early salvage went on to RT
39%
415
Criticisms of STAMPEDE prostate RT trial for metastatic disease
18% got docetaxel
| none received abi
416
Impact of dose escalation on late GU toxicity
Significantly greater G2+ tox (21% v. 15% at 5 years)
417
Impact of dose escalation on late GI toxicity
Significantly greater G2+ tox (12% v. 7% at 5 years)
418
What is the PSA cutoff recommended for benefit for 2 years ADT with salvage RT from RTOG 9601
0.7
419
Secondary analysis of 9601 suggests higher DECIPHER scores associated with better OS/DMFS/PCM at which PSA levels
All, even <0.7
420
Median time to PSA bounce
15 months (vs. 37 months for BCR)
421
PSA bounce is associated with better/worse prognosis
better
422
TROG study of immediate vs. delayed ADT concluded benefit for
immediate ADT had improved OS
423
Per RTOG 0534 (SPPORT) rectal dose constraint V65 is
V65 < 35%
424
Per RTOG 0534 (SPPORT) rectal dose constraint V40 is
<55%
425
Per RTOG 0534 (SPPORT) bladder dose constraint V65 is
<50% [bladder - CTV]
426
HORRAD trial design
RCT of ADT +/- prostate RT for men with newly diagnosed metastatic PC with bone involvement
427
How were bone mets stratified on HORRAD
1. <5
2. 5-15
3. >15
428
What were findings of HORRAD
No significant differences in OS or biochemical RFS
429
How did metastatic burden influence OS benefit on HORRAD
No significant differences, even <5 mets
430
Findings of STOPCAP meta analysis
Overall, no OS difference
| However, sig improvement in OS for group with <5 mets
431
Per RTOG 0534 (SPPORT) bladder dose constraint V40 is
<70% (bladder minus CTV)
432
In STAMPEDE primary prostate trial, for which patients did prostate RT improve FFS
all patients
| not just low burden
433
STAMPEDE definition of low volume
<4 bone mets OR all mets in pelvis/spine
| No visceral mets
434
Patients included in POP-RT study
High risk node negative (at least 20% risk using Roach formula)
435
DART trial randomization
intermediate/high risk patients randomized to 4 vs. 28 months of ADT with DE EBRT
436
DART RT dose
78 Gy
437
DART finding
Improved BRFS, Met Free survival and OS with 28 months ADT
438
DART findings concluded 28 months were appropriate for
Men with high risk disease, benefit did not translate to intermediate risk
439
Superior edge of postop prostate field
level of cut vas deferens OR
| 3-4 cm above pubic symphysis
440
Inferior edge of postop prostate field
8-12 mm below VUA
441
Anterior edge of postop prostate field
posterior 1-2 cm of bladder wall
442
Posterior edge of postop prostate field
mesorectal fascia
443
When do you start to pull back to posterior 1-2 cm of bladder wall
above symphysis
444
Percentage of freedom from biochemical failure lost for each 0.1 ng/mL increase in post prostatectomy PSA before initiation of salvage
3%
445
What is Roach formula threshold for covering lymph nodes
10-30%
446
Very high risk features
T3b-T4
Primary G5
2-3 high risk features
>4 cores Group 4-5
447
High risk features
T3a
Grade group 4 or 5
PSA >20
448
Intermediate risk factors
T2b-T2c
Group 2-3
PSA 10-20
449
Unfavorable intermediate
2-3 intermediate risk factors
Group 3
>50% cores positive
450
Which intermediate risk pts should get bone scan
T2 and PSA>10
451
For salvage prostate RT doses > X associated with reduced incidence of biochemical failure following treatment?
66 Gy
