Localized Prostate CA Flashcards
Give me the TNM scoring for prostate cancer.
T1 - not palpable
a - <5% on TURP tissue
b - >5% on TURP tissue
c - by needle biopsy
T2 - palpable
a - < 50% on one side of DRE
b- >50% on one side of DRE
c- both sides
T3 -
a- outside prostate (not in SV0
b- in SV
T4 - adjacent tissues (rectum, bladder, etc)
Give examples of when and when not to use genomic biomarkers.
high volume Gleason 6, or intermediate favorable - deciding on AS
not to be used in intermediate favorable planning for treatment, or low volume Gl 6
What are examples of genomic biomarkers?
Decipher - mets and survival (mrna analysis)
OncotypeDX (GG3 or EPE) - mRNA
Polaris - 10 year survival (mRNA)
What are indications for germline testing?
strong family hx of prostate CA, strong family hx of related CA, known family germline hx, ashkenazi descent, HR disease (or intraductal or cribriform in intermediate)
What is metastatic imaging of choice for high risk disease?
bone scan + CT Pelvis OR mpMRI Pelvis
If negative, get PSMA-PET
ALSO GET IMAGING IF PATIENT IS SYMPTOMATIC, REGARDLESS OF RISK
What do you need to counsel a patient on in preparation for any treatment of prostate CA?
Effect on sexual fx, urinary fx, and bowel fx - MUST GET BASELINE - use EPIC 26 questionnaire
Guidance on effect o QoL, mixed with life expectancy
SDM!
What is best data for active surveillance?
ProtecT study
(For Intermediate Risk) Of note does show increased compared to treatment of progression and chance of metastasis, but no difference in overall mortality
Give a proposed protocol for AS
serial PSA q6 months + DRE 1-2 years + serial Bx q1-4 yrs
If MRI done in MRI-naive patient, and they have PRADS 4-5, do repeat biopsy earlier within six months. All others confirm at 12 months
What is watchful waiting?
When patient has <= 5 years to live - no follow up - mainly just palliative care. Use nomogram to identify if within this criteria. No ADT no treatments
What happens if patient wants whole gland ablation or focal therapy?
Need to information there is lack of quality of evidence when comparing to prostatectomy, radiation therapy, and AS
Should be clinical trial prioritization (esp in high risk)
What is tx for high risk, with clinical + nodes w/ T3 or T4, PSA >/= 40, or Gl >=8 (need two of these), what is tx?
RT + ADT + abiraterone + prednisone
When is primary ADT used?
mainly only for palliative management in limited life patients
transient cytoreduction of prostate for urination
What are factors for when nerve sparing is to be performed?
tell patient there is data that supports it improves erectile fx + continence
Also state it did not compromise rates of positive surgical margin or biochemical recurrence
Important to establish baseline erectile and urinary fx
consider PSA, DRE, biopsy results, MRI findings
AND PATIENT PRIORITIES
What is counseling on PLND?
That it does not offer improvement on biochemical recurrence or overall survival, metastasis free, etc
But it does help in stratification for future txs
Should USE NOMOGRAMS to select patients that would benefit
What is the template for a PLND?
extended > limited
Boundaries are the genitofemoral, inferior mesenteric artery, circumflex iliac vein
results in higher chance for lymphocele, but also chance for greater positive lymph node yield
What happens if positive nodes?
SDM on adjuvant radiation or ADT vs surveillance with early salvage
What is consensus on adjuvant radiation?
Should not be routinely recommended - as no demonstrable oncologic outcomes - but still SDM - need to consider each patient’s disease
What must you use for EBRT?
dose escalation (IMRT)
What about proton vs radiation?
No superior evidence of proton to radiation - but theoretically lower doses to NORMAL tissue
so far similar toxicity rates
What are EBRT or brachytherapy treatment options for low and intermediate risk patients?
- moderate hypo fractionated EBRT, but MAY offer ultra hypo fractionated
Only for low and favorable intermediate risk
- permanent LDR seeds
- temporary HDR seeds
some studies have shown equal toxicity and SE
others have shown a slight increase in SE
Do you irradiate pelvic lymph nodes in low and intermediate risk patients?
NO
Only in high risk patients (w/ IMRT)
When should ADT be used?
Unfavorable intermediate and high risk prostate CA
unfavorable intermediate - 4-6 months
high risk - 18-36 months
What are ADT side effects to counsel?
decreased libido, ED, hot flashes, depression, mood disturbance, fatigue, weight gain, change in metabolic function, reduced bone density
What is EBRT treatment for unfavorable intermediate or high risk?
- moderate hypofractionated (dose escalated)
- combined EBRT + brachytherapy (LDR or HDR) - more GI toxicity
