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EAMC Urology > NCCN Prostate 2.2020 > Flashcards

NCCN Prostate 2.2020 Flashcards

To become an NCCN master.

1
Q

A strong family history of prostate cancer consists of:

A

Brother or father or multiple family members diagnosed with prostate CA (NOT Grade Group I) at LESS THAN 60 YRS OLD OR who DIED from prostate CA

PROS-B

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2
Q

Family history criteria to prompt genetic testing:

A
  1. Strong family history
  2. Ashkenazi Jewish ancestry
  3. > = 3 cancers on same side of family, esp. diagnoses <= 50 yrs of age
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3
Q

Clinical/Pathologic Features:

Very low risk

A

ALL of the ff:

T1c AND
Grade Group 1 AND
PSA < 10ng/mL
< 3 prostate biopsy fragments/cores positive, <= 50% cancer in each fragment/core AND
PSA Density < 0.15 ng/mL/g

PROS-2

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4
Q

Clinical/Pathologic Features:

Low risk

A

ALL of the ff but does not qualify for low risk:

T1-T2a AND
Grade Group 1 AND
PSA < 10 ng/mL

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5
Q

Clinical/Pathologic Features:

Favorable intermediate

A

1 IRF and
Grade Group 1 or 2 and
< 50% biopsy cores positive

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6
Q

Clinical/Pathologic Features:

Unfavorable intermediate

A

2 or 3 IRFs and/or
Grade Group 3 and/or
>= 50% biopsy cores positive

PROS-2

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7
Q

Clinical/Pathologic Features:

High risk

A

T3a OR
Grade Group 4 or Grade Group 5 or PSA > 20ng/mL

PROS-2

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8
Q

Clinical/Pathologic Features:

Very high risk

A

T3b-T4 OR
Primary Gleason pattern 5 OR
>4 cores with Grade Group 4 or 5

PROS-2

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9
Q

Active surveillance definition

A

Actively monitoring the course of disease with the expectation to intervene with potentially curative therapy if the cancer progresses.

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10
Q

Active surveillance components

A

mpMRI and/or prostate biopsy to confirm candidacy for active surveillance

PSA every 6 mos
DRE every 12 mos
Repeat prostate biopsy every 12 mos
Repeat mpMRI every 12 mos

*No more often than, unless clinically indicated

PROS-3

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11
Q

Adverse features, post-RP, and treatment options if these are present:

A
  1. Positive margins
  2. Seminal vesicle invasion
  3. Extracapsular extension
  4. Detectable PSA

Treatment:
EBRT _+ ADT
OR
Observation

PROS-6

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12
Q

Observation definition

A

Monitoring the course of disease with expectation to deliver palliative therapy for the development of symptoms or change in PSA that suggests symptoms are imminent.

Palliative therapy = Palliative ADT

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13
Q

PSA nadir definition

A

NAY-dur

The lowest PSA value reached after RT.

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14
Q

PSA persistence and recurrence after RP

A
  1. Failure of PSA to fall to undetectable levels (persistence)
  2. Undetectable PSA after RP that increases on 2 or more determinations (PSA recurrence)
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15
Q

PSA persistence/recurrence after RT

A

PSA increase by 2 ng/mL or more above the nadir PSA

RTOG-ASTRO Phoenix

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16
Q

Genetic testing for germline variants should include:

A 
MLH1
MSH2
MSH6
PMS2 (Lynch syndrome)
BRCA1
BRCA2
ATM
PALB2
CHEK2
HOXB13
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17
Q

Treatment options for:

Very low risk, life expectancy >=20 y

A

Active surveillance
EBRT or brachytherapy
RP

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18
Q

Treatment options for:

Very low risk, life expectancy 10-20 y

A

Active surveillance

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19
Q

Treatment options for:

Very low risk, life expectancy <10y

A

Observation

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20
Q

Treatment options for:

Low risk, life expectancy >= 10 y

A

Active surveillance (PREFERRED)
EBRT or brachytherapy
RP

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21
Q

Treatment options for:

Low risk, life expectancy <10 y

A

Observation

22
Q

Treatment options for:

Favorable intermediate risk, life expectancy >=10 y

A

Active surveillance
EBRT or brachytherapy alone
RP _+ PLND if probability of LN mets >= 2%

23
Q

Treatment options for:

Favorable intermediate risk, life expectancy < 10y

A

EBRT or brachytherapy alone

Observation (preferred)

24
Q

Treatment options for:

Post-RP, positive LN mets, no adverse features

A

ADT (CATEGORY 1)
_+ EBRT (CATEGORY 2B)

OR

Observation

25
Q

Treatment options for:

Unfavorable intermediate risk, >= 10 y life expectancy

A

RP_+PLND if predicted probability of LN mets _>2%

EBRT + ADT (4-6 mos)
or
EBRT + brachytherapy _+ ADT (4-6 mos)

PROS-6

26
Q

Treatment options for:

Unfavorable intermediate, <10 y life expectancy

A

EBRT +ADT (4-6 mos)
or
EBRT + brachytherapy _+ ADT (4-6 mos)

Observation

PROS-6

27
Q

Treatment options for:

High or very high risk, >5 y life expectancy

A

EBRT + ADT (1.5 - 3 y; category 1 ADT) + docetaxel (cat 1, for very high risk)

EBRT + brachytherapy + ADT (1-3 y; category 1 for ADT)

RP + PLND

PROS-7

28
Q

Treatment options for:

High or very high risk, <= 5y and asymptomatic

A 
Observation
or
ADT
or
EBRT
29
Q

Initial management for:

PSA persistence/recurrence after RP

A

PSADT

Look for distant mets:

Bone imaging
Chest CT
Abdominal/pelvic CT or MRI
C-11 choline or F-18 fluciclovine PET/CT or PET/MRI
Prostate bed biopsy suggests local recurrence

If (-) distant mets/no imaging done: EBRT + ADT then wait for progression

If (+) mets: M1 na

PROS-11

30
Q

Treatment options for:

M0, castration-naïve

A

Observation (preferred)
or
ADT

PROS-13

31
Q

Define castration-naïve

A

Patients who are not on ADT at the time of progression
OR
have had neoadjuvant, concurrent, or adjuvant ADT as part of radiation therapy provided they have recoverede testicular function

32
Q

Differentiate: high-volume vs. low-volume disease

A

High-volume: visceral mets and/or 4 or more bone mets with at least one mets beyond the pelvis or vertebral column

33
Q

Treatment options for:

M1, castration-naïve

A 
ADT with one of the following:
Docetaxel 75 mg/m2 x 6 cycles (CAT 1)
Abiraterone (CAT 1)
Apalutamide (CAT 1)
Enzalutamide (CAT 1)

Other: fine-particle abiraterone (cat 2b)
EBRT to the primary tumor for low-volume M1

or

ADT

PROS-13

34
Q

Castrate levels of testosterone

A

< 50 ng/mL

35
Q

Treatment options for:

M0, CRPC, PSADT >10 mos

A

Observation
or
Secondary hormone therapy

36
Q

Treatment options for:

M0, CRPC, PSADT <=10 mos

A

Continue ADT to maintain serum levels of testosterone < 50 ng/dL

Apalutamide (Cat 1)
or 
Darolutamide (Cat 1)
or
Enzalutamide (Cat 1
or 
Other secondary hormone therapy

PROS-14

37
Q

Initial treatment options for:

M1CRPC

A

Metastatic biopsy of lesion: if it cannot be done - treat as adenocarcinoma;
MSI-H and dMMR testing;
Germline and tumor testing;

Continue ADT, maintain castrate levels of testosterone
\+
Bone antiresorptive therapy: denosumab (cat 1) or zoledronic acid IF bone mets present
OR
Sipuleucel-T (cat 1)
OR 
Palliative RT for painful bone mets
OR 
Best supportive care
38
Q

Systemic therapy options for M1CRPC, adenocarcinoma, FIRST LINE:

A 
Category 1:
Abiraterone
Docetaxel
Enzalutamide
Sipuleucel-T 
Radium-223 for symptomatic bone mets

Not Cat 1:
Mitoxantrone for palliation
Fine-particle abiraterone
Other secondary hormone therapy

PROS-16

39
Q

Systemic therapy options for M1CRPC, adenocarcinoma, who had prior therapy abiraterone/enzalutamide SECOND LINE:

A

Preferred:
Docetaxel (cat 1)
Sipuleucel-T (cat 1)
Radium-223 for symptomatic bone metastasis (cat 1)

Others:
Olaparib for HRRm
Pembrolizumab for MSI-H and dMMR (cat 2B)
Rucaparib for BRCAm

[if AR-V7 (+): use taxanes for increase OS]

PROS-16

40
Q

Systemic therapy options for M1CRPC, adenocarcinoma, prior therapy docetaxel, SECOND LINE:

A

Abiraterone (cat 1)
Cabazitaxel (cat 1)
Enzalutamide (cat 1)

Olaparib for HRRm
Pembrolizumab for MSI-H and dMMR (cat 2B)
Rucaparib for BRCAm
Radium-223 for symptomatic bone mets

PROS-16

41
Q

Category 1 FIRST LINE Systemic therapy options for:

M1CRPC, adenocarcinoma

A 
Abiraterone
Docetaxel
Enzalutamide
Sipuleucel-T
Radium-223 for symptomatic bone mets

PROS-16

42
Q

Category 1 SECOND LINE Systemic therapy options for:

M1CRPC, previous therapy with enzalutamide, abiraterone

A

Preferred:
Docetaxel (cat 1)
Sipuleucel-T

Radium-223 for symptomatic bone mets
Olaparib for HRRm

43
Q

Category 1 SECOND LINE Systemic therapy options for:

M1CRPC, previous therapy with docetaxel

A

Abiraterone
Enzalutamide
Cabazitaxel

Radium-223 for symptomatic bone mets

PROS-16

44
Q

What is the Will Rogers effect?

A

When the worst prognosis patients from one risk group move to the higher risk group, the average outcome of both risk groups will improve even if treatment has no impact on disease.

45
Q

During active surveillance, cancer progression may have occurred if:

A
  1. Gleason Grade 4 or 5 on repeat biopsy
  2. Prostate CA found in a greater number of prostate biopsies or occupies a greater extent of prostate of prostate biopsy

PROS-D

46
Q

Advantages of active surveillance (4):

A
  1. 2/3 of men eligible for active surveillance will avoid treatment
  2. Avoidance of possible side effects of definitive therapy that may be unnecessary
  3. Quality of life/normal activities potentially less affected
  4. Risk of unnecessary treatment of small, indolent cancers reduced
47
Q

Disadvantages of active surveillance (3):

A
  1. Chance of missed opportunity for cure (but very low)
  2. 1/3 of men will require treatment
  3. Periodic follow-up mpMRI and prostate biopsies may be necessary
48
Q

Advantages of observation:

A

Avoidance of possible side effects of unnecessary definitive therapy and early initiation and/or continuous ADT

49
Q

Disadvantages of observation:

A

Risk of urinary retention or pathologic fracture without prior symptoms or concerning PSA levels

50
Q

Boundaries of extended PLND:

A 
Anterior: external iliac VEIN
Posterior: pelvic floor
Medial: bladder wall
Lateral: pelvic sidewall
Proximal: internal iliac ARTERY
Distal: Cooper's ligament
51
Q

Differentiate favorable and unfavorable intermediate in terms of IMAGING choices

A

Favorable: Bone imaging NOT recommended

Unfavorable: Bone imaging recommended if T2 and PSA > 10 ng/mL

EAMC Urology (7 decks)

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