Lecture 2020 - Prostate Ca - Early stage Flashcards
62yoM s/p prostatectomy for gleason 3+3=6 prostate adenocarcinoma. Baseline PSA 4.5, undetectable after surgery. What are 4 reasons (from surgical path or biomarkers) to give adjuvant radiation?
- positive margins
- seminal vesicle invasion
- extracapsular extension
- detectable PSA
56yoM s/p prostatectomy for cT2b (gleason 3+4=7) prostate adenocarcinoma. PSA prior to surgery 8. At four weeks post-op his PSA is 0.25 and six months after that it is 0.41. NO metastatic disease on restaging. What should be next step in treatment for him?
Radiation therapy +/- ADT
He needs salvage RT. Indications for salvage RT are undetectable PSA that becomes detectable and increases on two measurements after prostatectomy. Or PSA that remains persistently detectable following prostatectomy
61yoM w/ screening PSA of 13.4, bx shows Gleason 3+4 prostate adeno in 7/12 cores (>50% positive cores). After abx, PSA drops to 10.4. Patient decides against prostatectomy after speaking with Urology. Life expectancy is well over 10 years.
What is his risk category?
What therapy do you offer?
- Unfavorable intermediate risk
- Offer radiation therapy with +/- 4 months of ADT
Tx options: radical prostatectomy or XRT w/ 4-6 months of ADT (adding ADT gives better OS than XRT alone)
63yoM w/ screening PSA of 13.4, bx shows Gleason 3+4 prostate adeno in 3/12 cores . After abx, PSA drops to 10.4. Patient decides against prostatectomy after speaking with Urology. Life expectancy is well over 10 years.
What is his risk category?
What therapy do you offer?
Favorable intermediate risk
Offer EBRT or brachytherapy alone
(no ADT)
Prostatectomy would also be an option for him, but he refused
Criteria for favorable intermediate risk: T2b-T2c, gleason 3+4, PSA 10-20, percentage of positive bx cores <50%
What is the criteria for unfavorable intermediate risk prostate cancer?
At least 1 Intermediate risk factor:
- T2b-T2c
- Gleason 3+4=7
- PSA 10-20
AND at least one of the following
- 2 or 3 of above intermediate risk factors
- 4+3=7
- > 50% core biopsies positive
What is the criteria for favorable intermediate risk prostate cancer?
Just 1 Intermediate risk factor: -T2b-T2c -Gleason 3+4=7 -PSA 10-20 AND must be grade group 1 or 2 (3+3 or 3+4) AND <50% biopsy cores positive
Criteria for high risk prostate adenocarcinoma
At least 1 of the high risk criteria:
- T3a
- > 20 PSA
- Grade group 4 or 5
Criteria for very high risk prostate adenocarcinoma
At least 1 of the following: -T3b-T4 -primary gleason pattern - >4 cores with grade group 4 or 5 -2 or 3 high risk features (T3a, >20 PSA, Grade group 4 or 5)
Explain difference between criteria for low risk vs very low risk prostate adenocarcinoma:
Very low risk has all the following:
T1c, grade group 1, PSA <10, fewer than 3 prostate bx cores are positive, <50% cancer in each core
Low risk T1-T2a, grade group 1, and PSA less than 10. They then must have one of the criteria that takes them out of the very low risk group. like # of positive cores, t stage, or % cancer in the cores.
61yo w/ unfavorable intermediate risk prostate adeno undergoes months of ADT along with EBRT. PSA monitored every 6 months. The PSA nadir is 0.5 ng/ml. What is the threshold level of PSA which would represent a biochemical failure in this patient?
2.5ng/mL
RTOG-ASTRO defines biochemical failure as a rise in PSA of 2ng/mL or more above the nadir PSA (after EBRT w/wo ADT)
66yoM presents with prostate cancer diagnosed with screening PSA of 15.6. Gleason is 4+5=9. Staging negative for mets. Clinically tumor is T3a. Expected survival >5 years.
What treatment should be offered?
-EBRT + ADT for 1.5-3 years
or
-EBRT + Brachytherapy + ADT 1-3 years
or
-Radical Prostatectomy w/ PLNDDescribe T stages in prostate cancer: T1 T2 T3 T4
T1 - clinically not apparent, not palpable
T2 - tumor palpable and confined to prostate
T3 - extraprostatic tumor that is not fixed and does no invade adjacent structures (can invade seminal vesicles)
T4 - tumor is fixed or invades into adjacent structures (other than seminal vesicles)
PROTECT trial in NEJM in 2016 compared active surveillance to radical prostatectomy to EBRT - in newly diagnosed localized prostate cancer (no LN involvement). How did survival compare among these groups?
10 year prostate-cancer-survival was 100%, no difference between groups.
It did show increased rates of disease progression and mets for the surveillance group
In which risk group should Docetaxel be considered in prostate cancer?
In very high risk patients only
In addition to the EBRT+ADT.
Improvement in overall survival without much added toxicity. Still controversial though, so should be a discussion.
What kind of adjuvant treatment should be given after radical prostatectomy if the patient has lymph nodes metastases?
ADT +/- EBRT
