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RO Clinical Boards > GU > Flashcards

GU Flashcards

1
Q

Lab findings of pure germinoma

A 
Normal AFP (<6-10 ng/mL)
Low b-hCG (<100 mIU/mL)
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2
Q

Lab findings of choriocarcinoma

A

High b-hCG (>100)

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3
Q

Lab findings of yolk sac tumor

A

Elevated AFP

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4
Q

Lab findings of embryonal germinoma

A

Elevated AFP and b-HCG

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5
Q

new cases of prostate ca per year

A

220000 (13% of new cancers)

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6
Q

PC is _____ leading cause of cancer death in men

A

2nd

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7
Q

How many cancers diagnosed in stag where 5 year OS is 100%

A

90%

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8
Q

What is most important factor associated with PC

A

age

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9
Q

What is relative risk reduction with finasteride

A

30% reduction in 7 year risk with finasteride

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10
Q

Initial concern with finasteride for prevention

A

increased risk of high grade disease

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11
Q

Risk of higher grade cancer is balanced by

A

No difference in OS between the two groups

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12
Q

70% of prostate cancer is located in which zone

A

peripheral

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13
Q

where are the neurovascular bundles located

A

posterolateral edges

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14
Q

What is blood supply to prostate

A

Int. Iliac artery

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15
Q

What is blood drainage from prostate

A

prostate plexus –> int. iliac vein

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16
Q

Gleason 3 path

A

crowded glands

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17
Q

Gleason 4 path

A

fusing glands

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18
Q

Gleason 5 path

A

sheets of cells

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19
Q

What is a barrier to rectal involvement of PC

A

Denonvilliers fascia

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20
Q

Half life of PSA

A

2-3 days

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21
Q

What PSA velocity is considered concerning for increased risk of PC death

A

0.35 ng/mL per year

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22
Q

What PSA DT is associated with 8.5x risk fo BCF

A

3 years or less

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23
Q

Free to total PSA ratio of X corresponds with low risk of cancer

A

25%

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24
Q

Free to total PSA ratio of X highly suspicious for cancer

A

7%

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25
Q

When should prostate MRI be obtained

A

4-6 weeks post bx

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26
Q

What is PSA threshold to order CT CAP

A

> 20

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27
Q

When to order bone scan

A

T3/T4

T2 with PSA > 10, GS 8+ or PSA >20

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28
Q

What MRI sequence good for intraprostatic lesions

A

T2

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29
Q

What is T1 sequence on MRI good for

A

invasion into fat

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30
Q

proPSMA study showed that upfront PSMA had X improvesd accuracy of detecting nodes or mets

A

27%

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31
Q

The number of positive cores can predict

A

lymph node involvement

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32
Q

T1 prostate

A

clinically inapparent on imaging or DRE

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33
Q

T1b prostate

A

histologic finding in >5% of resected tissue

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34
Q

T1c prostate

A

diagnosis via needle biopsy/elevated PSA

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35
Q

T2a prostate

A

1/2 of one lobe or less

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36
Q

T2b prostate

A

> 1/2 of one lobe

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37
Q

T2c prostate

A

both lobes affected

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38
Q

T3a prostate

A

ECE

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39
Q

T3b prostate

A

SVI

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40
Q

T4 prostate

A

invades nearby structures (bladder, levator muscles, pelvic wall)

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41
Q

N1 prostate

A

> 1 regional nodes

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42
Q

What stage is N1 patient

A

IVA

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43
Q

PSA above X constitutes high risk feature

A

20

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44
Q

Grade group 1

A

3+3=6

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45
Q

Grade Group 2

A

3+4=7

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46
Q

Grade Group 3

A

4+3=7

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47
Q

Grade Group 4

A

Gleason 8

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48
Q

Grade Group 5

A

9-10 (5+)

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49
Q

What stage is low risk

A

T1c-T2a

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50
Q

Intermediate risk

A

T2b
PSA 10-20
Gleason 7

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51
Q

Unfavorable intermediate risk

A

At least one risk factor
4+3 histology
>50% involved cores

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52
Q

High risk disease

A

T2c or higher
PSA >20
Gleason 8-10

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53
Q

REDUCE trial

A

RCT of dutasteride vs. placebo which found 23% reduction in prostate cancer

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54
Q

If very low risk prostate cancer what is preferred strategy

A

active surveillance for age 62-77

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55
Q

If low risk diagnosis prior to age 62, what is next step

A

MRI

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56
Q

Scandinavian Prostate Cancer Group 4 tril

A

compared RP to WW and RP associated with 13% reduction in death

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57
Q

Who had largest benefit for RP in Scandinavian trial

A

age <65

intermediate risk

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58
Q

PIVOT trial

A

RCT of RP vs. observation

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59
Q

Findings of PIVOT

A

HR death was 0.88 but p=0.06

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60
Q

Why might OS benefit not been significant?

A

diluted by 40% low risk in the study

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61
Q

where is most common location for + margin for RP

A

apex

2nd: rectal/lateral surfaces

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62
Q

ProtecT trial design

A

RCT of 1 time PSA assessment men aged 50-69:

Then randomized to AS, RT or RP

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63
Q

Findings of ProtecT

A

No difference in OS, prostate cancer specific survival

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64
Q

What was different in ProtecT sudy

A

Higher rates of metastases in AS group

Bowel function/bother and urinary obstructive symptoms worse in RT

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65
Q

How much ADT for intermediate risk PC

A

If favorable –> none

If unfavorable –> 3-6 months

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66
Q

D’Amico study design

A

1872 patients treated with surgery vs. brachy vs. EBRT

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67
Q

Results of D’Amico study

A

5 year biochemical outcomes no worse for low risk

For intermediate/high risk, EBRT or surgery did better

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68
Q

Fox chase study results

A

Compared 76/38 Gy to 70.2/26 and found no difference

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69
Q

CHHiP research question

A

Hypofractionaction study

RCT, multicenter non-inferiority, primary endpoint of biochemical or clinical failure free rate

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70
Q

On CHHiP study how many received ADT?

A

Nearly all, 97%

3-6 months

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71
Q

What were the dose regimens utilized on CHHiP

A

60/30 vs. 74/37 (not inferior)

57/19 vs. 74/37 (inferior)

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72
Q

PROFIT trial design

A

Noninferiority of biochemical/clinical failure

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73
Q

Dose regimen used on PROFIT

A

60/30 vs. 78/39 (non inferior)

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74
Q

What are the requirements for SBRT?

A
  1. Prostate <100 cc
  2. No bleeding
  3. Able to lie still for 5 mins
  4. No IBD on DMARD
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75
Q

HYPO-RT-PC trial

A

SBRT vs. conventional fx question

42.7 Gy / 7 fx QOD vs. 78 / 39 fx

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76
Q

What patients were included in HYPO-RT-PC trial

A

intermediate and high risk

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77
Q

What were findings of HYPO-RT-PC

A

No difference in FFS at 5 years

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78
Q

Any toxicity differences?

A

SBRT associated with higher levels of acute urinary/bowel tox but these normalize and late rates similar

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79
Q

PACE B trial design

A

78/2 vs. 36.25 in 7.25 Gy fx –> similar toxicity

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80
Q

D’Amico study design

A

RCT of 206 patients to receive

  1. 70 Gy 3DCRT
  2. 70 Gy + 6 months ADT
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81
Q

D’Amico findings

A

6 months ADT prolongs survival in men without comorbidities but there was greater association with cardiac death in men with comorbidities

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82
Q

RTOG 9408 design

A

RCT of ~2000 low/intermediate risk men randomized to

  1. RT (66Gy)
  2. 4 months ADT with 66 Gy (2 months ADT –> RT)
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83
Q

RTOG 9408 results

A

Improvement in OS and DFS with 4 months ADT, mostly in intermediate risk men

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84
Q

ASCENDE-RT design

A

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
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85
Q

ASCENDE-RT results

A

Improved biochem FS with brachy boost: 83 vs. 62% at 5 years

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86
Q

Which risk groups benefitted from brachy boost on ASCENDE

A

intermediate and high risk

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87
Q

ASCENDE tox: GU

A

worse acute and late with brachy

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88
Q

ASCENDE tox: GI

A

no diff

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89
Q

ASCENDE tox: erectile function

A

no diff

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90
Q

22961 Bolla trial design

A

RCT of ADT duration

  1. RT + 6 months ADT
  2. RT + 30 months ADT
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91
Q

Dose used in Bolla trial

A

70Gy

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92
Q

How was Bolla Trial designed

A

non-inferiority

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93
Q

Results of 22961

A

6 months was not non-inferior to 30 monhts, long course associated with improved OS, CSS

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94
Q

For high risk, what is advantage of docetaxel?

A

4% improvement in 4 year OS

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95
Q

How much ADT is recommended for N+ disease

A

18-28 months

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96
Q

What are reasons to discuss adjuvant RT

A

+margin

T3+ disease

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97
Q

SWOG 8794

A

Adjuvant RT for patients with EPE, SVI or +margin

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98
Q

What did 8794 show?

A

Improved OS

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99
Q

Dose of RT on SWOG 8794

A

60-64 Gy

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100
Q

What is the criticism of SWOG study

A

Likely more of a salvage study since many already had PSA >0.2

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101
Q

EORTC 22911 research question

A

Adjuvant vs. salvage RT

Dose of 60 Gy

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102
Q

Results of 22911

A

Adjuvant improved bPFS and local control but is associated with more late effects

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103
Q

What is plt requirement for initial Xofigo

A

100

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104
Q

What is ANC requirement for initial Xofigo

A

1.5

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105
Q

What is platelet requirement for subsequent Xofigo

A

50

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106
Q

RADICALS trial design

A

Early salvage vs. adjuvant RT

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107
Q

Patient criteria for RADICALS

A 
IR or HR
Undetectable PSA post-op with at least 1 feature
pT3/T4
G7-10
pre-op PSA >10
\+surgical margins
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108
Q

Criteria to institute early salvage

A

2 consecutive PSA rise and PSA > 0.1 OR

3 consecutive PSA rises

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109
Q

RT dose in RADICALS

A

66/33

52.5/20

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110
Q

How many in RADICALS got ADT

A

30%

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111
Q

Result of RADICALS

A

No bPFS benefit and worse GI tox for adjuvant –> early salvage is preferred

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112
Q

RAVES

A

Similar design to RADICALS

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113
Q

Dose of RT on RAVES

A

64 Gy

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114
Q

Criteria to trigger salvage RT on RAVEs

A

PSA >0.2

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115
Q

Result of RAVES

A

Salvage RT didn’t meet noninferiority but still recommended it

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116
Q

RTOG 9601

A

Salvage RT +/- ADT

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117
Q

ADT used on 96-01

A

24 months bicalutamide

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118
Q

Rate of gynecomastia on 96-01

A

70% vs. 11% placebo

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119
Q

Results of 96-01

A

Addition of ADT improved OS, DMFS, PC death

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120
Q

Repeat look at 96-01 found that men with PSA < X might derive more harm than benefit from ADT

A

0.6

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121
Q

What were the RCT arms for STAMPEDE metastatic trial

A
  1. ADT +/- docetaxel

2. ADT + EBRT (55/20 vs. 36/6)

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122
Q

How was high metastatic burden defined on STAMPEDE

A
  1. > /= 4 bone mets with at least 1 outside vertebral bodies or pelvis
  2. Visceral mets
  3. both
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123
Q

What was results

A

FFS significantly improved with RT to prostate

OS benefit only in low volume disease

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124
Q

How much SV should be covered for low/intermediate risk disease

A

1 cm per 0815

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125
Q

How much SV should be covered for intermediate risk

A

1.5 cm

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126
Q

How much SV should be covered for high risk

A

all

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127
Q

CTV to PTV margin

A

5-7 mm expansion, 3 mm posterior

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128
Q

Urethra SBRT constraint

A

D0.03 < 39

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129
Q

Rectum SBRT constraint

A

D0.03 cc < 38 Gy

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130
Q

Bladder SBRT constraint

A

D 0.03 <73, D35% < 70 Gy, D90% <35

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131
Q

Coverage goal for LDR brachytherapy

A

D90 > 90%

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132
Q

Phoenix criteria

A

nadir + 2

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133
Q

What proportion of bladder ca patients will be muscle invasive

A

33%

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134
Q

TCC of bladder is associated with which risk factors

A

smoking
aniline dyes
amines

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135
Q

SCC of bladder is associated with which risk factors

A

schistosomiasis

indwelling catheter

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136
Q

Adenocarcinoma of bladder is associated with

A

urachal remnant

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137
Q

Predictors of mets for bladder ca

A

bulk of tumor

depth of invasion

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138
Q

Bladder tumors commonly have mutations in which pathway

A

p16 (Rb pathway)

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139
Q

80% of patients with bladder ca present with

A

painless hematuria

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140
Q

But _____ patients with hematuria are diagnosed with bladder ca

A

10-20%

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141
Q

T1 bladder

A

subepithelial connective tissue

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142
Q

T2a bladder

A

invades into superficial muscularis propria

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143
Q

T2b bladder

A

invades into deep muscularis propria

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144
Q

T3 bladder

A

perivesicular tissue

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145
Q

T4a bladder

A

invades to prostate, uterus, vagina

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146
Q

T4b bladder

A

pelvic wall or abdominal wall invasion

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147
Q

N1 bladder

A

Single regional node in true pelvis

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148
Q

N2 bladder

A

Multiple regional nodes in true pelvis

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149
Q

N3 bladder

A

LN in common iliac

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150
Q

Paradigm for non-muscle invasive bladder cancer

A

TURBT

If high grade –> BCG

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151
Q

How many men experience recurrence after BCG

A

40-80%

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152
Q

How many patients s/p TURBT for T1 disease will get invasive disease

A

10-25%

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153
Q

Paradigm for muscle invasive bladder ca

A
  1. Cystectomy

2. maximal TURBT –> concurrent chemoRT (64 Gy)

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154
Q

What is pelvic control rate after radical cystectomy

A

90%

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155
Q

How many people get mets after radical cystectomy

A

50%

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156
Q

How to sim bladder cancer

A

bladder empty

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157
Q

Complete response rate after bladder sparing approaches

A

70%

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158
Q

Dose options for bladder

A

Small pelvis 40 Gy
Full bladder CD to 54 Gy
Bladder tumor CD to 64.8 Gy

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159
Q

Chemo options for concurrent

A

Cis 35 mg/m2
MMC + 5FU (500 mg/m2)
Gem twice weekly

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160
Q

BC2001 design

A

Two randomizations

  1. RT +/- chemotherapy
  2. whole bladder RT vs. reduced bladder RT
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161
Q

Chemo used on BC2001

A

MMC (12 mg/m2) on day 1

5FU (500 mg/m2) day 1-5 and 16-20

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162
Q

BC2001 main endpoint and result

A

2 year locoregional DFS

67% for chemoRT and 54% for RT

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163
Q

Any difference in OS for BC2001

A

no

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164
Q

Dose of RT used on BC2001

A

55/20 OR

64/32

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165
Q

PTV for BC2001 (standard arm)

A 
CTV = full bladder (empty)
PTV = 1.5 margin
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166
Q

PTV for BC2001 (experimental arm)

A 
CTV1 = full bladder
PTV1 = 1.5 cm margin
PTV2 = GTV + 1.5 cm
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167
Q

Dose requirements for different dose levels

A

100% of dose to PTV2

80% of dose to PTV1

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168
Q

Any differences between reduced volume and standard volume

A

none

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169
Q

VHL is associated with which type of kidney cancer

A

clear cell

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170
Q

Sickle cell is associated with which type of kidney cancer

A

medullary

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171
Q

Rough rate of salvage cystectomy after bladder preserving therapy

A

20%

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172
Q

T1 kidney

A

<7 cm

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173
Q

T2 kidney

A

> 7 cm confined to kidney

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174
Q

T3 kidney

A

tumor extends to major veins or perinephric tissue but not ipsilaeral adrenal gland and not beyond Gerota’s fascia

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175
Q

T4 kidney

A

tumor beyond Gerota’s

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176
Q

5 year OS for kidney confined disease

A

90%

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177
Q

What is function of leydig cell

A

testosterone

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178
Q

Radiation tolerance of leydig cell

A

40 Gy

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179
Q

What is function of sertoli cell

A

produces sperm

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180
Q

Radiation tolerance of sertoli cell

A

1-2 Gy

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181
Q

Breakdown of seminoma/NSGCT

A

60% seminoma

182
Q

Hallmark of pure seminoma

A

No AFP elevation

Mild-moderate B-HCG elevation

183
Q

Yolk sac tumors produce which hormone

A

AFP

184
Q

Right sided lymphatic drainage for testicular tumor

A

IVC (paracaval and aortocaval)

185
Q

Left sided lymphatic drainage for testicular tumor

A

renal vein –> IVC (left renal hilar area)

186
Q

Imaging needed if pure seminoma

A

CT AP only

187
Q

Imaging needed if NSGCT

A

CXR and CT AP

188
Q

Options after orchiectomy for seminoma

A
  1. surveillance
  2. RP radiotherapy
  3. 1 cycle carboplatin
189
Q

RT field

A

PA and ipsilateral common iliac

190
Q

Dose of RT for seminoma

A

20-25 Gy over 20 fx

191
Q

TE19 trial design

A

seminoma –> single dose carboplatin vs. RT (20-30 Gy)

192
Q

Dose of carboplatin

A

AUC 7

193
Q

Findings of TE19

A

Carbo non-inferior to RFR with reduction in contralateral GCT

194
Q

MRCUK

A

similar findings to TE19

more relapses in RP nodes with carbo but less contralateral GCT

195
Q

Recommendation for stage I seminoma

A

orchiectomy –> surveillance

196
Q

Definition of stage II seminoma

A

involvement of PA or pelvic LN

197
Q

Recommendation for stage II seminoma

A

IIB (2-5 cm) –> consider RP (dog leg) RT

IIC –> chemo (BEP x3 or EP x 4)

198
Q

Superior border of seminoma Field

A

bottom of T11

199
Q

Serotypes of HPV associated with penile cancer

A

16, 18

200
Q

Layers of penis deep to superficial

A

cavernosa –> spongiosa –> skin

201
Q

Where does penile prepuce and skin drain lymphatics

A

superficial inguinal

202
Q

Where does glans/deep penile structures drain

A

superficial or deep inguinal –> femoral or external iliac/common iliac

203
Q

Most common histology of penile ca

A

Squamous

204
Q

Most common location

A

glans then prepuce

205
Q

Gold standard imaging for penile cancer

A

MRI

206
Q

Which tumors have 50% risk of nodal involvement and should have surgical nodal staging

A

T2

Grade 3

207
Q

T1 penile

A

Subepithelial connective tissue

208
Q

T2 penile

A

invades spongiosum w/ or w/o urethra

209
Q

T3 penile

A

invades corpus cavernosum w/ or w/o urethra

210
Q

T4 penile

A

adjacent structures or scrotum

211
Q

N1 penile

A

unilateral inguinal

212
Q

N2 penile

A

multiple or bilateral inguinal

213
Q

N3 penile

A

fixed inguinal or pelvic

214
Q

Brachy control rate for penile

A

5 year local control of 77-87%

215
Q

Criteria for penile brachy

A

Tumors <4 cm
Less than 1 cm invasion
Circumcision prior to brachy

216
Q

If tumor is >4 cm and gets brachy, what is failure rate

A

50-60%

217
Q

EBRT dose for penile

A

At least 60 Gy

218
Q

What is EBRT control rate

A

41-70%

219
Q

Constraint for penile bulb

A

D90 < 50 Gy

220
Q

Evidence for dose escalation in salvage setting

A

Only retrospective

One prospective from China didn’t show diff between 66/72 (maybe G8+?)

221
Q

LDR mono dose I-125

A

145 Gy

222
Q

What was unique about ARO adjuvant study

A

Only one which required undetectable postop PSA

223
Q

Mechanism of bicalutamide

A

non-steroidal anti-androgen

224
Q

Share of stage I testicular relapses which occur in first 2-3 years

A

90%

225
Q

What makes NSGCT high risk

A

pT3/T4
LVI
Proportion of embroynal carcinoma

226
Q

Relapse rate of low risk NSGCT stage I

A

10-15%

227
Q

Relapse rate of high risk NSGCT stage I

A

50%

228
Q

Good “AFP” markers for testicular

A

<1000

229
Q

Good “BHCG” markers for testicular

A

<5000

230
Q

Good risk anatomic location for NSGCT

A

testicular or RP primary

No non-pulmonary mets

231
Q

Follow up of NSGCT year 1

A

tumor markers q2m
CT AP q4m
CXR q2m

232
Q

Risk factors in Spanish germ cell study

A

rete testis involvement

size > 4cm

233
Q

NCCN rec for stage I seminoma

A

active surveillance

234
Q

Anticipated relapse rate for stage I seminoma on surveillance

A

15-20%

235
Q

Follow-up of seminoma for first year

A

H&P q 3-6 months
CT AP 3, 6, 12 months
CXR as needed

236
Q

MRC testicular study design

A

stage I seminoma randomized to 30/15 to either

  • -PA
  • -PA + ipsi iliac
237
Q

MRC results

A

No difference in relapse free survival (97%)

<5% pelvic failure in PA group

238
Q

minimum margin for wide excision for penectomy

A

5-10 mm

239
Q

Recommended neoadjuvant chemo regimen for MIBC

A

gem-cis

240
Q

What is the OS benefit of cis based regimens for neoadjuvant MIBC

A

5%

241
Q

Can carbo be substituted for cis

A

no

242
Q

Stage IB of testicle

A

T2-4N0M0

243
Q

T2 ureter

A

muscularis

244
Q

T3 ureter

A

peripelvic or periureteric fat or renal parenchyma

245
Q

T4 ureter

A

adjacent organs or perinephric fat

246
Q

N1 ureter

A

single LN <2cm

247
Q

N2 ureter

A

single LN >2cm

Multiple LN

248
Q

Relapse rate at 5 years for stage I seminoma

A

13%

249
Q

Relapse rate at 5 years for stage I NSCGT

A

19%

250
Q

T1 testicle

A

only in testicle, includes rete testicle or tunica albuginea

no LVI

251
Q

T2 testicle

A

blood vessel or lymphatics (LVI)
epididimyis
tunica vaginalis

252
Q

T3 testicle

A

spermatic cord

253
Q

T4 testicle

A

scrotum invasion

254
Q

Dose for adjuvant bladder

A

45-50 Gy

255
Q

Contours for adjuvant bladder

A

neg margin - just pelvic nodes

pos margin - pelvis and cystectomy bed

256
Q

MRC TE18 design

A

20/10 vs. 30/10 for stage I seminoma

257
Q

MRC TE18 results

A

Overall very low relapses, 97% RFS in each arm

258
Q

Testicular IS disease

A

Any T
N0
M0
S1-3

259
Q

RTOG 0712 design

A
  1. Twice daily RT with cis/5FU
  2. Once daily RT with gem
    Both got adjuvant cis-gem
260
Q

RTOG 0712 dosing

A

Phase I to 40 Gy
Pause and TUR
If CR –> 64 Gy
If cystectomy

261
Q

Give adjuvant chemo for which stage of bladder disease

A

pT3-T4

N+

262
Q

Preferred chemo scenario for bladder cancer

A

neoadjuvant chemo for cT2 or greater

263
Q

% of kidney cancers which are renal cell

A

90%

264
Q

% of RCC which are clear cell

A

80%

265
Q

What field is used for N+ testicular cancer

A

dog leg

266
Q

What is stage IIA testicular

A

Nodes <2cm

267
Q

RT dose for stage IIA testicular

A

30 Gy (20 Gy to para-aortics + 10 Gy boost to gross disease)

268
Q

What is stage IIB testicular

A

Nodes 2-5 cm

269
Q

Dose for stage IIB testicular

A

36 Gy (20 Gy to para-aortics + 16 Gy boost for gross disease)

270
Q

Superior extent of dog leg field

A

bottom of T11

271
Q

Inferior extent of dog leg field

A

top of acetabulum

272
Q

Testicular chemo regimens for stage IIA or IIB

A

BEP x 3 [bleo, etop, cis]

EP x 4

273
Q

Top of PA field for testicular

A

T10-T11 (bottom of T11)

274
Q

Inferior aspect PA field for testicular

A

bottom of L5

275
Q

QUANTEC bilateral kidney constraint (mean)

A

mean < 18

276
Q

Dose guideline for contralateral kidney if one has dose mean > 18

A

V6 < 30%

277
Q

What is MRC trial for testicular

A

Stage I randomized to dogleg vs. PA (30 Gy in 15 fx)

278
Q

What was rate of normal sperm count at 3 years for dogleg arm?

A

92%

279
Q

Did PA have less sperm count reduction

A

Signifcantly faster recovery of counts

280
Q

What type of penile cancer associated with HPV

A

warty/basaloid

281
Q

precursors of keratinizing or verrucous penile cancer

A

lichen sclerosis, condylomata,

282
Q

Good prognosis seminoma

A

any site
no non lung mets
normal AFP, any HCG

283
Q

Intermediate prognosis seminoma

A

any site

non-lung mets

284
Q

Poor prognosis seminoma

A

none

285
Q

NSGCT good prognosis

A 
testis/RP primary
No non-lung mets
AFP <1000
HCG < 5000
LDH < 1.5 ULN
286
Q

NSGCT intermediate prognosis

A 
testis/RP primary
No non-lung mets
AFP: 1000-10000
HCG: 5000-50000
LDH: 1.5-10 ULN
287
Q

NSGCT poor prognosis

A 
mediastinal primary OR
non-pulm mets
AFP > 10000
HCG > 50000
LDH > 10 ULN
288
Q

Outcomes of 55/20 vs. 64/32

A

Meta analysis suggests 55/20 has lower invasive recurrences and similar rates of late toxicity

289
Q

RTOG 0926 patient population

A

T1 high risk failed BCG or non eligible planned for cystectomy

290
Q

RTOG 0926 design

A

phase II getting bladder conservation

291
Q

BC2001 question

A

2x2 factorial

  • -RT vs. chemoRT (5FU/MMC)
  • -Standard volume or reduced volume
292
Q

Dose on BC2001

A

55/20 or 64/32

293
Q

Results from BC2001

A

ChemoRT (5-FU/MMC) associated with improved

  • -met free survival
  • -local control
  • -not OS
294
Q

X% of penile cancers associated with HPV

A

> 40%

295
Q

What strains of HPV are associated

A

16, 18

296
Q

When will most NSGCT relapse if at risk

A

first 2-3 years

297
Q

relapse rate for stage I NSGCT

A

19%

298
Q

N3 for bladder ca

A

common iliac node

299
Q

N1 disease for bladder cancer is stage

A

IIIA

300
Q

N2-N3 disease for bladder cancer is stage

A

IIIB

301
Q

when are tumor markers checked for testicular

A

post orchiectomy

302
Q

N1 disease for penile is stage

A

IIIA

303
Q

N2 disease for penile is stage

A

IIIB

304
Q

Dose to contralateral testis with scrotal shield

A

1.5 cGy / fraction

305
Q

Dose to contralateral testis without scrotal shield

A

4 cGy/ fraction

306
Q

Rate of late GU G3+ tox from MGH meta analysis for bladder cancer

A

6%

no palliative cystectomies

307
Q

Rate of late GI G3+ tox from MGH meta analysis for bladder cancer

A

2%

308
Q

Primary treatment for early NSGCT

A

orchiectomy

309
Q

Options for stage IA NSGCT after orchiectomy

A
  1. Obs

2. RPLND

310
Q

Options for stage IA NSGCT after RPLND

A

pN1 –> obs
pN2 –> BEP x2
pN3 –> BEP x3-4

311
Q

N1 testicle

A

at least one node <2 cm

1-5 nodes

312
Q

N2 testicle

A

nodes 2-5 cm
or >5 nodes
or ENE

313
Q

N3 testicle

A

nodes >5 cm

314
Q

M1a testicle

A 
nonregional LN (pelvic, inguinal)
lung mets
315
Q

stage IIA testicle

A

N1

316
Q

stage IIB testicle

A

N2

317
Q

treatment for IS

A

primary chemo
BEP x 3
EP x 4
then surveillance

318
Q

stage IB testicle

A

p2-4 N0

319
Q

options for IB testicle NSGCT

A

orchiectomy

  1. RPLND
  2. BEP x 2
320
Q

options for stage IIA testicle NSGCT

A

if normalized markers –> RPLND or chemo

if non-normalized markers –> BEP x3 or EPx4

321
Q

PENILE: need for inguinal sampling

A

T1G3+
T2 any grade
LVI

322
Q

Findings of CARMENA trial for kidney ca

A

sunitinib alone non-inferior to sunitinib-cytoreductive nephrectomy for stage IV RCC [reduced OS with nephrectomy]

323
Q

Options for metastatic RCC

A
  1. cabozatinib

2. ipi/nivo

324
Q

neoadjuvant chemo results in x% OS benefit for bladder cancer

A

5%

325
Q

What is preferred neoadjuvant chemo for bladder

A

combination cis containing regimen

326
Q

When to consider adjuvant RT for bladder

A

T3/T4
Margin+
N1

327
Q

Adjuvant bladder dose

A

45-50.4

328
Q
  1. Options for concurrent CRT for bladder presevation
A

Cis-FU
Cis-paclitaxel
5FU-MMC
Cis alone

329
Q

Design for RTOG 0712

A

Twice daily RT with 5-FU/Cis vs. once daily with gemcitabine
Total dose of 64 Gy to bladder
Adjuvant chemo x4

330
Q

Rates of DMFS on 0712

A

Similar with two arms

~80% at 3 years

331
Q

Differences in tox between 0712 arms

A

G3/G4 not statistically different higher in FU/Cis arm

332
Q

Role for RT for pT1 G3 tumors after TURBT?

A

No- no diff in OS of PFS vs. BCG

333
Q

Long term control of RCC with SBRT

A

95%

334
Q

Proportion of men who get CKD after SBRT for RCC

A

roughly 1/3, two years later

335
Q

Toxicity benefits of PA field vs. dogleg for seminoma

A

decreased heme toxicity

decreased diarrhea

336
Q

Preplan LDR mono goal V100

A

> 95-98%

337
Q

Preplan LDR mono goal D90

A

> 100%

338
Q

Preplan LDR mono goal rectum

A

V100 < 1 cc

339
Q

Postpln LDR mono gol D90

A

> 140 Gy

340
Q

Postplan LDR mono V150

A

<40%

341
Q

Postplan LDR mono V200

A

<20%

342
Q

Postplan rectum V100

A

<1.3 cc

343
Q

Postplan urethra max

A

<140% Rx dose

344
Q

LDR mono dose with I-125

A

145 Gy

345
Q

LDR mono dose with pd-103

A

125 Gy

346
Q

LDR mono dose with Cs

A

115 Gy

347
Q

HRQOL on SWOG 8794 study

A

Adjuvant RT associated with early worse GU/GI tox but eventually improved and was then better than surgery alone in later time points

348
Q

Difference in ED on SWOG 8794 for adjuvant RT vs. surgery alone

A

No difference

349
Q

SPCG-7 trial of indefinite ADT vs. 70 Gy + ADT impact on 10 yr PCSS

A

Halved with RT

24% (ADT) vs. 12% (RT+ADT)

350
Q

SPCG-7 trial of indefinite ADT vs. 70 Gy + ADT impact on 10 yr OS

A

40% with ADT

30% with RT+ADT

351
Q

Malone study for intermediate risk prostate cancer (short term androgen deprivation) design

A

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
Q

Dose of RT used on Malone trial

A

76 Gy

353
Q

ADT used on Malone trial

A

goserelin + bicalutamide

354
Q

Malone trial outcomes (overall)

A

No differences in any outcomes or late toxicity in either arm

355
Q

Malone trial 10 year bRFS

A

81% vs. 87% (concurrent)

356
Q

Which zone of prostate BPH

A

transitional zone

357
Q

Median time from prostate biochem progression to form mets

A

5-10 years

358
Q

STAMPEDE trial patients

A

High risk, locally advanced, metastatic or recurrent prostate cancer

359
Q

STAMPEDE arms

A

Randomized 2:1:1:1 to

  • -ADT (at least 2 years)
  • -ADT + docetaxel
  • -ADT + zolendronic acid
  • -ADT + docetaxel + zolendronic acid
360
Q

STAMPEDE % of metastatic pts

A

61%

361
Q

STAMPEDE % of N1M0

A

15%

362
Q

STAMPEDE % N0M0

A

24%

363
Q

STAMPEDE results

A
  1. docetaxel improves OS and bPFS

2. zolendronic acid does not improve outcomes

364
Q

Duration of OS improvement from docetaxel

A

10 months (81 months vs. 71)

365
Q

Duration of bPFS improvement from docetaxel

A

17 months (37 mos vs. 20)

366
Q

Rate of G3-5 adverse events with docetaxel vs. ADT

A

52% (doc+ADT)

32% ADT

367
Q

Dose of docetaxel used on STAMPEDE

A

75 mg/m2 q3w x 6 cycles

368
Q

Studies for docetaxel + ADT in hormone sensitive PC

A
  1. STAMPEDE

2. CHAARTED

369
Q

RADICALS dose

A

66/33

52.5/20

370
Q

ADT used on RADICALS

A

not mandated

371
Q

ARTISTIC meta analysis of adjuvant vs. early salvage result

A

No evidence that adjuvant RT improves EFS compared to early salvage

372
Q

ASCO/ASTRO/AUA guidelines on mod hypofrac utilization

A

acceptable to treat prostate/SV for any risk group

373
Q

ASCO/ASTRO/AUA guidelines on ultrahypofract utilization

A
  1. Not recommended above dose of 3625
  2. Not recommended daily fractions
    due to risks of late tox
374
Q

ASCO/ASTRO/AUA guidelines on image guidance

A

do not give mod or ultra hypo without image guidance

375
Q

Design of MD Anderson dose escalation study

A 
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
Q

Patients included on MDA study

A

T1b to T3
20% low risk
46% int risk
34% high risk

377
Q

MDA study freedom from BCR

A

73% (DE) vs. 50% (std)
at 10 years
Only in patients with initial PSA >10

378
Q

MDA study ADT

A

no hormones

379
Q

MDA study patient group with greatest beneift

A

PSA > 10

380
Q

Did dose escalation help with PC specific mortality

A

yes

381
Q

Did DE help with distant mets

A

yes

382
Q

Did DE help with OS

A

no diff

383
Q

Did DE cause greater toxicity

A

yes, sig higher G2 and G3 GI tox

384
Q

MGH/Loma Linda dose escalation study design

A

PROTON trial of
1. 70.2
2. 79.2
First 50,4 Gy given using 3DConformal photons then subsequent dose given with protons

385
Q

Which patients in MGH proton study

A 
Low risk (58%)
Intermediate risk (37%)
High risk (4%)
386
Q

MGH study: OS advantage

A

NSS

~80% at 9 years

387
Q

MGH study: freedom from biochem failure

A

17% (79 Gy)

32% (70 Gy)

388
Q

Which group was BCR advantage demonstrated

A

low risk

trend for intermediate risk

389
Q

MGH study: toxicity difference

A

Greater G2 GU tox for dose escalation but not G3

390
Q

What labwork should be obtained for patients starting ADT

A

CBC

Liver enzymes

391
Q

How often should labwork be checked on ADT

A

monthly

392
Q

Major adjuvant RT trials for prostate

A
  1. SWOG 8794
  2. RTOG 22911 [Bolla]
  3. ARO 9602 [Wiegel]
393
Q

For the adjuvant trials where was RT delivered anatomically

A

prostate bed only [NO PELVIS]

394
Q

What dose did these studies recommend adjuvantly

A

60Gy

395
Q

RTOG 0534 (SPPORT trial) design

A

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
Q

Dose to prostate bed on SPPORT trial

A

64.8-70.2

397
Q

Dose to nodes on SPPORT trial

A

45

398
Q

What was short term ADT on SPPORT trial

A

4-6 months, starting 2 months pre RT

399
Q

FFP difference for SPPORT trial

A

prostate + pelvis + ADT best - 89%
prostate + ADT - 83%
prostate alone - 71%

400
Q

Distant mets from SPPORT trial

A

Suggests improved 5 year FFDM with prostate + pelvis

401
Q

OS difference SPPORT trial

A

no sig difference

402
Q

Toxicity differences with prostate + pelvis RT

A

Increase G2+ GI tox (39%)
Increase G2+ heme (29%)
Increase G3+ heme (15%)

403
Q

Positive or negative margin lower risk of biochemical failure after salvage prostate RT

A

POSITIVE margin

404
Q

POP-RT study design

A

RCT for men with intermediate/high risk disease randomized to

  1. prostate RT alone
  2. prostate RT + pelvic RT
405
Q

What ADT did men get on POP-RT trial

A

2 years ADT

406
Q

What share of men on POP-RT trial got PSMA imaging

A

80%

407
Q

Dose to prostate and pelvis on POP-RT trial

A

68/25 prostate

50/25 pelvis

408
Q

Findings of POP-RT

A

Nodal RT improvement in biochemical free survival (82–95%)

DFS improvement with nodal RT

409
Q

Findings of OS in POP-RT

A

No difference with pelvic

410
Q

GETUG AFU 17

A

Adjuvant RT vs. early salvage

411
Q

What is consistent finding of RADICALS, RAVES, GETUG 17

A

No improvement in PFS with adjuvant RT and increased late GU tox relative to salvage

412
Q

What dose of adjuvant/salvage RT used in RADICALS, RAVES, GETUG 17

A

RADICALS: 66/33 or 52.5/20
GETUG: 66/33
RAVES: 64/32

413
Q

ARTISTIC meta analysis adjuvant RT effect on 5 year EFS

A

89% vs. 88%

414
Q

What percentage of patients from ARTISTIC assigned to early salvage went on to RT

A

39%

415
Q

Criticisms of STAMPEDE prostate RT trial for metastatic disease

A

18% got docetaxel

none received abi

416
Q

Impact of dose escalation on late GU toxicity

A

Significantly greater G2+ tox (21% v. 15% at 5 years)

417
Q

Impact of dose escalation on late GI toxicity

A

Significantly greater G2+ tox (12% v. 7% at 5 years)

418
Q

What is the PSA cutoff recommended for benefit for 2 years ADT with salvage RT from RTOG 9601

A

0.7

419
Q

Secondary analysis of 9601 suggests higher DECIPHER scores associated with better OS/DMFS/PCM at which PSA levels

A

All, even <0.7

420
Q

Median time to PSA bounce

A

15 months (vs. 37 months for BCR)

421
Q

PSA bounce is associated with better/worse prognosis

A

better

422
Q

TROG study of immediate vs. delayed ADT concluded benefit for

A

immediate ADT had improved OS

423
Q

Per RTOG 0534 (SPPORT) rectal dose constraint V65 is

A

V65 < 35%

424
Q

Per RTOG 0534 (SPPORT) rectal dose constraint V40 is

A

<55%

425
Q

Per RTOG 0534 (SPPORT) bladder dose constraint V65 is

A

<50% [bladder - CTV]

426
Q

HORRAD trial design

A

RCT of ADT +/- prostate RT for men with newly diagnosed metastatic PC with bone involvement

427
Q

How were bone mets stratified on HORRAD

A
  1. <5
  2. 5-15
  3. > 15
428
Q

What were findings of HORRAD

A

No significant differences in OS or biochemical RFS

429
Q

How did metastatic burden influence OS benefit on HORRAD

A

No significant differences, even <5 mets

430
Q

Findings of STOPCAP meta analysis

A

Overall, no OS difference

However, sig improvement in OS for group with <5 mets

431
Q

Per RTOG 0534 (SPPORT) bladder dose constraint V40 is

A

<70% (bladder minus CTV)

432
Q

In STAMPEDE primary prostate trial, for which patients did prostate RT improve FFS

A

all patients

not just low burden

433
Q

STAMPEDE definition of low volume

A

<4 bone mets OR all mets in pelvis/spine

No visceral mets

434
Q

Patients included in POP-RT study

A

High risk node negative (at least 20% risk using Roach formula)

435
Q

DART trial randomization

A

intermediate/high risk patients randomized to 4 vs. 28 months of ADT with DE EBRT

436
Q

DART RT dose

A

78 Gy

437
Q

DART finding

A

Improved BRFS, Met Free survival and OS with 28 months ADT

438
Q

DART findings concluded 28 months were appropriate for

A

Men with high risk disease, benefit did not translate to intermediate risk

439
Q

Superior edge of postop prostate field

A

level of cut vas deferens OR

3-4 cm above pubic symphysis

440
Q

Inferior edge of postop prostate field

A

8-12 mm below VUA

441
Q

Anterior edge of postop prostate field

A

posterior 1-2 cm of bladder wall

442
Q

Posterior edge of postop prostate field

A

mesorectal fascia

443
Q

When do you start to pull back to posterior 1-2 cm of bladder wall

A

above symphysis

444
Q

Percentage of freedom from biochemical failure lost for each 0.1 ng/mL increase in post prostatectomy PSA before initiation of salvage

A

3%

445
Q

What is Roach formula threshold for covering lymph nodes

A

10-30%

446
Q

Very high risk features

A

T3b-T4
Primary G5
2-3 high risk features
>4 cores Group 4-5

447
Q

High risk features

A

T3a
Grade group 4 or 5
PSA >20

448
Q

Intermediate risk factors

A

T2b-T2c
Group 2-3
PSA 10-20

449
Q

Unfavorable intermediate

A

2-3 intermediate risk factors
Group 3
>50% cores positive

450
Q

Which intermediate risk pts should get bone scan

A

T2 and PSA>10

451
Q

For salvage prostate RT doses > X associated with reduced incidence of biochemical failure following treatment?

A

66 Gy

RO Clinical Boards (13 decks)

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