Prostate Flashcards
Roach formula
ECE: Risk (%) = 3/2 × PSA + 10 × (Gleason-3)
Seminal vesicle: Risk (%) = PSA + 10 × (Gleason-6)
Lymph nodes: Risk (%) = 2/3 × PSA + 10 × (Gleason-6)
Systemic therapy for m0 castration resistant prostate cancer. If psadt<10 months
Preferred regimens: • Apalutamide(category 1) • Darolutamide(category 1) assessment (PSA and imaging) • Enzalutamide (category 1) Other recommended regimens: • Other secondary hormone therapyt
Matastatic castration naive prostate cancer treatment
ADTt with one of the following: • Preferred regimens: Abiraterone (category 1)t,ff Apalutamide (category 1)t Docetaxel 75 mg/m2 for 6 cyclesxx (category 1)yy Enzalutamide (category 1)t
• EBRTo to the primary tumor for low-volume M1xx or ADTt,rr
ISUP consensus grouping of gleason score
<-6 =grade 1 3+4=7 grade 2 4+3=7 grade 3 8 grade 4 9-10 grade 5
PSA level increased in
prostatitis urinary retention DRE Ejaculation TRUS biopsy TURP BPH
prognostic factors
cinical staging by DRE, pretreatment PSA GS/Grade grouping on biopsy number of biopsy core involved with cancer cancer volume PNI on biopsy presence of disseminated cancer cells
indication of adjuvant RT
pT3a
+ve margin
seminal vesicle involvement
radiotherapy dosage of prostate
Hypofractionated:
- 60 gy in 20 fraction (+/- pelvic nodes) over four weeks ( Cheap protocol)
Conventional:
- 78 gy in 39 fractions (+/- pelvic nodes) over eight weeks
• Ultra-hypofractionated: 42.7 Gy in 7 fractions over two and a half weeks
• SBRT: 36.25 Gy in 5 fractions over five days
• Prostate bed: 66 Gy in 33 fractions given in six and a half weeks
prostate 2D border
upper: L5-S1 to lower border of ishial tuberosity
lat border: 1.5-2 cm lateral to bony pelvis
lateral view:
ant margin 0.5-1 cm posterior to projected cortex of symphysis pubis
posterior: S2-3 interspace to include presacral LN
Prostate 3D volume post op area
inferior border 5mm cranial to the superior border of penile bulbe
superior: base of seminal vesicle if risk below 15%
entire seminal vesicle if more risk
ant: post aspect of symphysis pubis
(<2cm above the vesicourethral anastomosis)
post 1/3rd of bladder wall (>2cm above anastomosis)
posterior: anterior rectal wall
lateral: medial border of obturator internus and levator ani muscle
Target volume in short: in localized
low risk: prostate + proximal sv
int risk: prostate +sv
high risk: prostate+sv+pelvic ln
Risk factors for prostate
Age:>50 Race: african american Nationality Family history: 1 1st degree 2 folds increase 2 1st degree 9 folds Hormonal influence Diet: red meat, high fat dairy product Obesity Smoking Enivrionmental factors STds Vasectomy
Prognostic factors for ca prostate
Stage
Positive surgical margin
Tumor grade
Involvement of seminal vesicle
Extension of tumor beyond seminal vesicle
High PSA value and short PSA doubling time
Molecular prognostic marker: loss of PTEN, P53 mutation, over expression of MYC
Prognostic nomograms: partin tables,
Side effects of hormonal therapy
Reduced or absent libido Impotency or erectile dysfuntion Shrinking of testicle Hot flashes Breast tenderrness Osteoporosis Weight gain Metabolic: increase TG, low HDL Anemia, fatigue Cognitive impairment Loss of muscle bulk GIT disturbance.
Prostate very low risk group
Has all of the following
CT1c
Grade group 1
PSA<10ng/ml
Fewer than 3 prostate biopsy fragments/cores positive, </50% cancer in each fragments
PSA densitiy <0.15ng/mL/g
Low risk group of prostate cancer
Has all of the following but does not quality for very low risk
CT1-cT2a
Grade group 1
PSA<10ng/mL
Intermediate risk group of prostate cancer
Has all of the followings:
No high risk group features
No very high risk group features
Has one or more intermediate risk factors
- cT2b-cT2c
Grade group 2 or 3
PSA 10-20ng/ml
Favorable intermediate group
Has all of the following:
1 IRF
Grade group 1 or 2
<50% biopsy cores positive
Unfavorable intermediate
Has one or more of the following
2 or 3 IRF
Grade group 3
>/50% biopsy cores positive
High risk group of prostate cancer
Has no very high risk features and has exactly one high risk features
CT3a or
Grade group 4 or grade group 5 or
Psa>20ng/mL
Very high risk group of prostate cancer
Has at least one of the following
CT3b-cT4
Primary gleason pattern 5
2 or 3 high risk features
>4 cores with grade group 4 or 5
Very low risk group management
> 20years: AS/EBRT/RP
10-20yr: AS
<10yr: observation
Yr in survival
Low risk group management of prostate cancer
> /10yr: AS/EBRT/Brachytherapy/RP
After RP if adverse features:EBRT+-ADT
No adverse features monitoring
<10yr: observation
Management of favorable intermediate prostate cancer
> 10yr: AS/EBRT,BT/RP
If adverse features and lo LNM: EBRT+-ADT
If LNM: ADT
No adverse features: monitor
5-10yr: EBRT or brachytherapy or observation(preferred)
Unfavorable intermediate risk group management of prostate cancer:
> 10 yr: RP+PLND
If adverse features and no LNM: EBRT+-ADT
If LNM: ADT+- EBRT
Or
EBRT+- ADT (4-6mo)
Or EBRT+BT+- ADT
If 5-10 yr: observation
Or EBRT+-ADT
Or EBRT+BT+-ADT
High or very high risk group of prostate cancer management
> 5 yr or symptomatic:
EBRT+ADT (1.5-3yr) or EBRT+BT+ADT
Or EBRT+ADT(2yr)+abiraterone
Or or
RP+PLND: according to adverse feature:
If adverse feature and LNM absent:
EBRT+-ADT o rmonitoring with consideration of early RT
If LNM: ADT+-EBRT
If no adverse features than monitor
<-5 yr and asymptomatic:
Observation or ADT or EBRT than best supportive care
What are the germline mutation you look for in prostate cancer if criteria met
germline multigene testing that includes at least BRCA1, BRCA2, ATM, PALB2, CHEK2, HOXB13,
MLH1, MSH2, MSH6, and PMS2 is recommende
Prostate pathology
Adenocarcinoma (90-95%): arise in acinar and proximal ductal epithelium. PNI is common.
Periurethral duct carcinoma.
Transitional cell carcinoma
. Ductal adenocarcinoma
5. Neuroendocrine tumors
6. Mucinous carcinoma
7. Sarcomatoid carcinoma
8. Endometrioid tumors
9. Adenoid cystic carcinoma
10. Carcinoid or small cell carcinoma
11. Sarcomas (leiomyosarcoma, rhabdomyosarcoma, or fibrosarcoma)
12. Carcinosarcoma
13. Primary lymphoma
What is castrate resistant prostate cancer?
CRPC is prostate cancer that progresses clinically, radiographically, or biochemically despite castrate levels of serum testosterone (<50 ng/dL). Scher HI, et al. J Clin Oncol 2008;26:1148-1159.
Prostate complication of radiotherapy
Acute:
Urgency, frequency, nocturia, dysuria, urinary retention, diarrhea
Rectal irritation, pain, bleeding, fatigue
Late:
Urinary stricture
Rectal bleeding
Decreased volume of ejaculation
Absolute excess risk of secondary bladder or rectal cancer
Complication of brachytherapy:
Peri operative: pain, dysuria, urinary retention, hematuria, urinary frequency
Obstructive symptoms
Histopathology of prostate cancer
Adenocarcinoma (90-95%)
Periurethral duct carcinoma.
Transitional cell carcinoma
Ductal adenocarcinoma
5. Neuroendocrine tumors
6. Mucinous carcinoma
7. Sarcomatoid carcinoma
8. Endometrioid tumors
9. Adenoid cystic carcinoma
10. Carcinoid or small cell carcinoma
11. Sarcomas (leiomyosarcoma, rhabdomyosarcoma, or fibrosarcoma)
12. Carcinosarcoma
13. Primary lymphoma
