Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

FRCR2 > Prostate > Flashcards

Prostate Flashcards

1
Q

What is the commonest prostate cancer histology
What are the others and how are they broadly managed

A

Adenocarcinoma
Small cell - manage as per small cell lung
TCC - typically of prostatic urethra - manage as bladder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Does renal function affect PSA

A

No

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the 2WW referral limits for PSA, by age

A

40–49yrs: 0 - 2.5
50–59yrs: 0 - 3.5
60–69yrs: 0 - 4.5
70–79yrs: 0 – 6.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

When is staging (CT & bone scan) done for prostate cancer

A

High risk cases - Gleason 8, PSA >20, T2c

CPG1-2 - no staging needed
CPG 3 - Bone scan +/- CTCAP
CPG 4-5 - bone scan, CTCAP +/- PSMA PET

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When is a PSMA PET scan indicated

A

HIgh risk pts ahead of radical tx - Gl 8, T2c, PSA >20

Suspected recurrence in patients with a rapidly rising PSA and negative or equivocal imaging where results would directly influence pt management

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the treatment options split by risk for localised prostate cancer

A

Low risk - active surveillance, radical prostatectomy, EBRT only, or LDR brachytherapy

Intermediate risk - radical prostatectomy, LDR brachytherapy, 6/12 ADT with EBRT, HDR brachytherapy followed by EBRT

High risk - 3yr ADT with EBRT, HDR brachytherapy followed by EBRT

Very high risk - up front docetaxel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the treatment options for relapsed prostate cancer after radical treatment

A

Relapse following RT - observation with delayed ADT, or local salvage - radical prostatectomy, HDR brachy

Relapse following surgery - prostate bed RT, consider 6-24mths ADT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What does active surveillance consist of

A

Yr1:
3-4mthly PSA
12mth dre
12-18mth MRI

Yr2:
6mthly PSA
12mth dre

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are advantages and disadvantages of a radical prostatectomy

A

Advantages
Immediate treatment
No androgen deprivation
Full histology
Easier to monitor PSA (should be undetectable)

Disadvantages
Higher rates of erectile dysfunction and incontinence
Erectile dysfunction (50%): can do nerve sparing operation
Urinary morbidity: 80% continent by 3 months
Likely to need adjuvant RT if T3 disease
25% risk of +ve margins: lack of tissue around prostate, esp at apex to allow wide margins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the side effects of ADT

A

Hot flushes
Erectile dysfunction and loss of libido
Osteoporosis
Mood change
Fatigue
Gynaecomastia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What can be given to treat hot flushes as a side effect

A

1st line: medroxyprogesterone 20mg OD for 10 weeks initially
2nd line: cyproterone acetate 50mg BD for 4 weeks then review

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What formula determines whether to treat the SV or not

And at what thresholds

A

= PSA + [(Gl -6) x10]

Low risk: <15% - base of SV only;
High risk: >15% or pathologically involved – whole SVs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What RT dose is given to the prostate, nodes (if treated), and SV

A

Prostate - 60Gy/20#
SV - 48Gy/20#
Pelvic nodes - 44Gy/20# (47Gy within pivotal boost)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the dose regime for HDR brachy followed by EBRT

A

Brachy boost - 15Gy/1# (brachy) followed by 37Gy/15# (EBRT) over 3 weeks (prostate only) or 46Gy/23# (prostate and nodes) IMRT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What RT volumes are included for a low or intermediate risk prostate cancer, and how are these defined

A

Low - int risk: ≤T2c, Gl 6-7, PSA ≤20

Volumes:
GTVp- prostate only
GTVpsv - prostate & SVs
<15% Roach -> prox 2cm of SV
15-30% Roach -> whole SVs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the hypofractionated dose for prostate SABR

A

36.25Gy/5#/2wks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the rate of erectile dysfunction after radical prostate RT
And bladder/bowel toxicity

A

40%
10-15% Urinary and bowel changes
Bowel and bladder - 95% minimal & 5% moderate-severe s/e

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the indications for adjuvant RT for prostate cancer

A

T3 disease, Gleason 8+, Positive margins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the three options for inclusion of brachytherapy & what dose

A

LDR only - approx 145Gy
HDR brachy (15Gy) followed by EBRT 37.5Gy/15#/3wks, (prostate only) or 46/23 (prostate + nodes) 2wks later
EBRT 46Gy/23# followed by LDR brachy boost (115Gy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

When is brachytherapy contraindicated

A

Previous TURP - high risk of urinary incontinence
IPSS >15 ie urinary outflow restriction - more likely to have complications
Gland >50ml & likelihood of pubic arch interference
Inability to undergo anaesthesia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What isotope does LDR brachy use

A

I-125 - 50-70 seeds, T1/2 60days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

When is LDR brachy indicated
What is the advantage
What are the disadvantages

A

Low and intermediate risk pts - up to T2b/c
(<T2a, Gleason ≤7, PSA ≤10)
IPSS score low, <10 ideally
Prostate volume <50ml

Advantage - lower risk of impotence and incontinence

Disadvantage - higher rate of acute urinary retention & dysuria
Radiation protection issues for 6mths post implant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are the side effects of LDR brachy

A

Urinary:
Urethritis - 50% have moderate urinary sx at 6mths
10% risk of acute urinary retention in first 2wks (higher risk for high IPSS and large prostate)
Urethral stenosis

Rectal - 5% proctitis, intermittent bleeding and discomfort. 0.1-0.2% risk of fistula

Erectile function - 30-40% risk of erectile dysfunction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the indication for EBRT followed by an LDR brachy boost
What is the advantage demonstrated by what trial if ADT given or not

A

Int-high risk pts
Improved 7yr PFS benefit according to Ascende RT trial
Trial also gave 12mths ADT

25
Q

What is the indication for HDR brachy +EBRT
What is the dose used

A

Intermediate and high risk pts
46Gy/23# EBRT followed by 15Gy HDR boost as 2x 8.5Gy (although can be other way round)

26
Q

What is the GTV-CTV and CTV-PTV margin for prostate EBRT

A

GTVp/psv - Prostate & SVs
CTVp - GTVp + 5mm
PTVp - CTVp + 10mm

27
Q

What is the GTV-CTV and CTV-PTV margin for involved nodal EBRT

A

GTVn-CTVn - 1cm margin
CTVn-PTVn - 0.7cm

28
Q

What is the indication for breast bud irradiation
And what dose and modality is used

A

Prophylaxis of gynaecomastia on bicalutamide (if planned for >6mths), or treatment of established symptoms

Dose:
8Gy/1# by electrons or orthovoltage
15Gy/3#/1wk alternate days with photons

29
Q

What histological marker is seen in prostate small cell carcinoma

A

TMP RSS2:ERG gene fusion seen by FISH

30
Q

What is the definition of biochemical relapse after RT

A

Phoenix definition: rise of PSA nadir +2

31
Q

What workup is considered for a relapsed prostate cancer

A

CTCAP, bone scan, and PET / PSMA PET, to determine extent of recurrence

32
Q

What are the treatment options for a biochemical relapse of prostate cancer after RT

A

Consider restarting ADT (indications - symptomatic disease, proven mets, PSA doubling time <3mths)
Prostatectomy
HDR brachytherapy
HIFU

33
Q

What are the indications to restart ADT following biochemical relapse of prostate cancer

A

Symptomatic disease
Proven mets
PSA doubling time <3mths

34
Q

What is the rate of biochemical relapse following prostatectomy, and how is it defined

A

20-40%
3 consecutive rises in PSA, or persistently rising PSA >0.2

35
Q

What is the dose for salvage RT to the prostate bed, for biochemical relapse following prostatectomy

What is the rate of biochemical control

A

55Gy/20#

5yr biochemical control with salvage RT 88% as per the Radicals-RT trial

36
Q

When should ADT be considered after biochemical relapse following prostatectomy

A

Men with risk factors prior to salvage RT - PSA >0.7, Gl8-10, positive margins at surgery

Spport trial randomised to prostate bed RT only, prostate bed RT & 6mths ADT, and prostate bed and pelvic nodes RT & 6mths ADT.
There was an increasing rate of freedom from progression, and distant metastasis rates were significantly lower for the triple treatment approach

37
Q

How is very high risk non-metastatic castrate-sensitive prostate cancer defined

How are these patients treated

A

Node positive disease
OR
at least 2 of T3/4, PSA >40, Gleason 8-10

Tx:
consider upfront docetaxel
ADT (3yrs)
Abiraterone and pred

38
Q

How is non-metastatic castrate resistant prostate cancer defined

And how is high risk NM-CRPC defined

What treatment is indicated

And based on what trials

A

No mets on conventional imaging (excluding PSMA PET)
Rising PSA
Suppressed testosterone <50 (castrate)

High risk:
Also Baseline PSA >2
Rising PSA with doubling time <10mths, taken from 3 readings at least one week apart

Tx:
ADT (3yrs), likely with EBRT
ARTA - apalutamide, darolutamide, enzalutamide

Based on Spartan / Prosper / Aramis trials
Increase in time to progression

39
Q

When is enzalutamide contraindicated
What needs to be seen before prescribing it

A

Epilepsy - can lower seizure threshold

Need to see that cancer is hormone responsive, ie falling PSA in response to ADT (castrate sensitive) before giving enzalutamide

40
Q

When is apalutamide indicated

A

High risk non-metastatic castrate resistant PC, with ADT
Metastatic hormone sensitive prostate cancer in combination with ADT

41
Q

What are the indications for enzalutamide

A

Non-metastatic castrate-resistant prostate cancer
Metastatic hormone sensitive prostate cancer
Metastatic castrate resistant prostate cancer (before or after docetaxel)

42
Q

What are the indications for darolutamide

A

Non-metastatic castration-resistant prostate cancer (nmCRPC) who are at high risk of developing metastatic disease

In combination with docetaxel & ADT for newly diagnosed metastatic hormone-sensitive prostate cancer

43
Q

What is the purpose of oligometastatic directed treatment in the hormone sensitive setting

A

To delay the start of ADT

44
Q

What are the treatment options for a new presentation of metastatic hormone sensitive prostate cancer

A

If low vol disease - ADT + enza/apa + prostate only RT
If high volume disease
Fit - ADT + docetaxel +/- darolutamide
Unfit for docetaxel - ADT + apa/enza

45
Q

What is the prognostic benefit of docetaxel in the metastatic setting, based on what trial

A

17mths, vs ADT alone, for high volume disease
Based on Chaarted trial
10mths as per Stampede trial

46
Q

When is prostate RT beneficial in metastatic disease, and based on what trial
And at what dose

A

Stampede trial
Low volume disease only
Prostate only RT - 36Gy/6#/6wks

47
Q

What is the median time to progression on ADT alone in the metastatic hormone sensitive setting

A

18mths
mOS 42mths

48
Q

What is the benefit to enzalutamide in the castrate resistant metastatic setting

A

Pre-docetaxel: approx 10mth PFS benefit (prevail trial)
Post-docetaxel: approx 5mth PFS benefit (Affirm trial)

49
Q

What is the indication for Radium 223
What are the side effects?
What is the survival benefit?

A

mCRPC with symptomatic bone mets & no visceral or nodal >30mm disease
+/- docetaxel
PS 0-1

SE: Diarrhoea, myelosuppression, thrombocytopaenia

Survival benefit based on Alsympca trial: 2.8mth OS survival benefit and delayed time to skeletal events

50
Q

What are the contraindications to radium treatment

A

cord compression
PS 2 or worse
LNs >3cm or visceral mets

51
Q

When in 177-Lu indicated
What is the benefit
What are the side effects

A

Advanced metastatic prostate cancer, following chemotherapy, and if PSMA positive disease

Based on Vision trial: prolonged PFS (median, 8.7 vs. 3.4 months) and OS (median, 15.3 vs. 11.3 months)

SE: N/V, fatigue

52
Q

What is the indication for use of a PARP inhibitor in metastatic CRPC

What is the benefit
Based on what trial

A

Monotherapy for pts who have progressed (prior therapy must include an ARTA) for mCRPC bearing germline and/or somatic BRCA 1/2 mutations and PS 0-2

Profound trial - longer PFS by approx 3mths

Survival benefit

53
Q

When is bone directed treatment indicated in metastatic prostate cancer

A

Osteoporosis
Bone mets and bone pain

54
Q

when is adjuvant RT needed post prostatectomy

A

PSA >0.2 at 6wks

55
Q

what is the threshold to stage prostate cancer

A

CPG 3
Gl 3+4 with PSA 10-20 & T1-2
or Gl 4+3 and T1-2 stage

56
Q

for radiotherapy to the prostate in metastatic disease, how is high volume disease defined

A

4 or more mets within the axial skeleton with one or more outside the vertebral bodies or pelvis, or visceral mets, or both.

Patients with low metastatic burden disease, according to the CHAARTED definition, may have an unlimited number of metastases provided they are confined to lymph nodes and the axial skeleton.

otherwise classified as low volume disease and Stampede demonstrates a benefit to prostate RT - 36/6

57
Q
A
58
Q
A

FRCR2 (38 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions