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Prostate Flashcards

1
Q

What were the findings of the MDACC dose-escalation trial (Pollack et al., JCO) for prostate cancer?

A
  • LR (20%), IR (46%), HR (34%) PCa
  • 70 Gy vs. πŸ† 78 Gy (no ADT era)

FFF, BC, and DM improved w/ 78 Gy
– 20-yr FFF 81% vs. 88%
– 20-yr BC 88% vs. 93%
– 20-yr DM 4% vs. 1%

Improved PCSM but not OS
– 20-yr PCSM 10% vs. 5%
– 20-yr other deaths 65% vs. 75% (p=0.061)
– 15-yr salvage therapy 39% vs. 22%
– 2nd malignancy 2% in the field in both arms

10-yr toxicity:
– GI Grade 3: 1% vs. 7%
– GI Grade 2: 13% vs. 26%
– GU Grade 3: 4% vs. 5% (NS)
– GU Grade 2: 8% vs. 13% (NS)

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2
Q

What are the findings of the NRG/RTOG 0126 dose escalation trial?

A
  • IR PCa β†’ 70.2 vs.πŸ† 79.2 Gy
    – 10-yr OS: ~67%
    – 15-yr DM: 11% vs. 6%
    – 15-yr Phoenix BC: 55% vs. 71%
    – 15-yr grade 2+ GI: 13% vs. 2%
    – 15-yr grade 2+ GU: 11% vs. 17%
    – No difference in late grade 3+
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3
Q

What are the 15-year findings of the UK PROTECT trial for prostate cancer?

A
  • AS vs. RP. vs RT
    – 15-yr PCM 2.2% vs. 1.5% vs. 2.1%
    – 15-yr DM 7.1% vs. 3.5% vs. 3.7% (SS)
    – 15-yr ADT salvage 9.4% vs. 5.3% vs. 5.6% (SS)
    – 15-yr clinical progression 21% vs. 8.0% vs. 8.4% (SS)
    – 15-yr all deaths 16% vs. 15% vs. 15%
  • QOL: AS vs. RP. vs RT
    – 7-yr erections 30% vs. 18% vs. 27%
    – 6-yr ED 53% vs. 85% vs. 74%
    β€” immediate ED 95% RP vs. 69% RT+ADT
    β€” ED converges at 12 years
    – 6-yr fecal incontinence 4% vs. NA. vs. 10%
    – 6-yr loose stools 13% AS vs. NA va. 16%
    – 6-yr bloody stool 6% (RT)
    – RP 6-yr GU incontinence 20% (none with RT)
    – Nocturia initially worse with RT, but similar to AS by year 6
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4
Q

What is the Phoenix criterion for PSA failure?

A

PSA rise β‰₯ 2 ng/mL above the nadir PSA

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5
Q

What side effects are worse w/ RT in the UK PROTECT trial?

A
  • 12-yr Fecal leakage
    – RT: 12%
    – RP or Obs: 6%
  • Other side effects were either the same or improved w/ RT
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6
Q

What GnRH agonists can be used for ADT for prostate cancer?

A
  • Leuprolide
  • Triptoerlin
  • Gosrelin
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7
Q

What GnRH antagonists can be used for ADT for prostate cancer?

A
  • Relugolix PO
  • Degarelix SQ
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8
Q

What non-steroidal anti-androgens can be used for ADT for prostate cancer?

A
  • Enzalutamide
  • Bicalutamide
  • Apalutamide
  • Darolutamide
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9
Q

What CYP17A inhibitors can be used for ADT for prostate cancer?

A
  • Abiraterone
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10
Q

What do the different zones of the prostate look like on CT scan?

A

T2-weighted MRI

  • Red: PZ
  • Yellow: periurethral zone
  • Green: transitional zone
  • Blue: fibromuscular stroma
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11
Q

What is the impact on RFS of each 0.1 ng/mL increase in PSA and each addition Gy beyond 60 Gy?

A
  • 0.1 ng/mL: -3% RFS
  • Each Gy: +2% RFS
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12
Q

What were the main findings of the TROG-TOAD trial?

A
  • Men w/ PSA relapse after prior RT of surgery?
  • Immediate ADT (w/i 8 weeks) vs. delayed ADT (2 yrs or sx development, whichever is earlier
    – 7-yr OS: 81% vs. 65%

TOAD β†’ Timing Of Androgen Depravation

Footnote

TOAD β†’ Timing Of Androgen Depravation

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13
Q

What is PSA bounce and how does it affect outcomes?

A
  • A brief rise in PSA following EBRT or brachytherapy 1-3 yrs post-RT
  • A/w a better prognosis
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14
Q

At which NCCN risk grouping do you initiate bone scan?

A

UFIR or higher

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15
Q

What are the findings of the RT01 trial for prostate cancer?

A
  • neoadj ADT 3-6mosβ†’64 Gy vs. 74 Gy
    – 10-yr OS: ~71%
    – ↑ 10-yr bPFS for all risk groups: 61% vs. 69% (SS)
    – ↑ 10-yr BPFS 43% vs. 55% (SS)
    – ↑ freedom from initiation of salvage ADT: 43% vs. 55%
    – Trend towards better clinical PFS, metastases-free survival, use of salvage HT (NS)
    – Grade 3 GI toxicity 10% vs. 6% (SS)
    – Grade 3 GU 4% vs. 2% (NS)
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16
Q

What surgical margin status is a/w a decreased risk of biochemical failure for prostate cancer undergoing salvage RT?

A

+marigns

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17
Q

What are the + prognostic markers for a pt with prostate cancer s/p definitive tx c/b biochem recurrence undergoing salvage RT?

A
  1. Positive surgical margins
  2. Low PSA level at recurrence
  3. Longer recurrence-free survival
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18
Q

What are the - prognostic markers for a pt with prostate cancer s/p definitive tx c/b biochem recurrence undergoing salvage RT?

A
  1. PSA doubling time < 6 months
  2. Gleason Score β‰₯ 8
  3. Lymph node-positive
  4. Positive seminal vesicle invasion
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19
Q

What were the results of the VISION trial for mCRPC?

A
  • Lu-177 (q6wks x 4-6C) + SOC vs. SOC alone
    – Median OS: 15.3 mos vs. 11.3 mos, SS
    – Imaging-based median PFS: 8.7 mos vs. 3.4 mos, SS
    – Median time to the first symptomatic skeletal event: 11.5 mos vs. 6.8 mos, SS
    – Grade β‰₯3 adverse events: 52.7% versus 38%
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20
Q

What are the CHAARTED/STAMPEDE trial criteria for metastatic prostate cancer disease burden?

A
  • Low:
    – ≀ 3 bone metastases
    β€” OR unlimited bone metastases confined to the pelvis/vertebral bodies
    – Unlimited pelvic LNs
    – No visceral metastases
  • High:
    – β‰₯ 4 bone metastases w/ at least one outside the pelvis/vertebral bodies
    – Any visceral metastases
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21
Q

What were the findings of the STAMPEDE Trial as they relate to RT vs no RT?

A
  • All patients: RT to prostate vs. no RT
    – ↑ 3-yr FFS: 33% vs. 23%
    – ↑ Median FFS: 17 mos vs. 13 mos
    – 3-yr OS: Not different
  • Low met burden: RT to prostate vs. no RT
    – ↑ 5-yr OS 65% vs. 53%
    – ↑ Median OS 85.5 vs. 63.6 mos
    – No change in severe toxicity
    – 5% grade 3-4 during RT, 4% grade 3-4 after RT
    – No difference in SBRT vs. hypofx
  • High Met burden: RT to prostate vs. no RT
    – 3-yr OS 52-53%, not different
    – 5-yr OS not different
    – 3-yr FFS 15-16% not different
  • Nonregional nodal mets: RT to prostate vs. no RT
    – 3-yr OS 80% vs. 73%
    – 3-yr FFS 51% vs. 29%
  • Mets to regional nodes: RT to prostate plus WPRT vs. no RT
    – 2-yr FFS 85% vs. 55%

  • HORRAD trial found NO OS, or PSA RFS benefit to adding RT, even when stratified by <5, 5-15, > 15 metastases
  • STAR-CAP MA (HORRAD + STAMPEDE) showed OS benefit in <3 bone metastases (77% w/ RT, 70% w/o RT), but no overall benefit for all pts.
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22
Q

What RT regimens were used in the STAMPEDE trial?

A
  • 55 Gy in 20 fx QD
  • 36 Gy in 6 fx weekly
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23
Q

What were the findings of POP-RT trial for prostate cancer?

A
  • HR PCA randomized to prostate-only RT (68/25) vs. πŸ† WPRT (50 Gy Pelvis + 68 Gy SIB to prostateΒ±SV):
    – 5-yr bPFS 81% vs. 95%
    – 5-yr DMFS 89% vs. 96%
    – 5-yr DFS 77% vs. 90%
    – 5-yr pelvic recurrence 52% vs. 13%
    – 5-yr OS: 91-92% (NS)
    – Late grade 2 GI toxicity 4.5% vs. 6.4%
    – Late grade 3 GI toxicity 0 vs. 1.8%

PO β†’ Prostate only
P-RT β†’ Pelvic RT

Footnote

PO β†’ Prostate only
P-RT β†’ Pelvic RT

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24
Q

What is the time to onset of action and recovery of testosterone for Relugolix?

A
  • Time-to-onset: 15 days
  • Recovery of testosterone: 90 days
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25
Q

What were the findings of the FLAME trial for prostate cancer?

A

IR or HR PCa β†’ 77 Gy/ 35 fx vs.β†’πŸ† Above + SIB focal boost up to 95 Gy to MRI nodules (95 Gy achieved in 20% 2/2 OAR constraints)
– ↑ 5-yr bDFS 85% vs. 92% (SS)
– DMFS and OS are not different
– Late grade β‰₯2 GU 23% vs. 28%, NS
– Late grade β‰₯3 GU 3.5% vs. 5.6%, NS
– Late grade β‰₯2 GI 12% vs. 13%, NS

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26
Q

What were the findings of the RADICALS-RT Trial as they relate to RT vs no RT?

A
  • adjuvant RT vs. πŸ† salvage RT at PSA failure (defined as two-consecutive PSA >0.1, or any PSA rising x3)
    – 10-yr DM 7% vs. 10%, NS
    – 10-yr PFS ~75%, NS
    – No change in OS
  • RT Choices: 66 Gy/33 fx vs. 52.5 Gy/20 fx (per treating physician choice)
27
Q

What are the standard LDR brachytherapy doses for the different isotopes when used as a monotherapy?

A
  • I-121: 145 Gy
  • Pd-103: 125 Gy
  • Cs-131: 115 Gy
28
Q

What are the standard LDR brachytherapy doses for the different isotopes when used as a boost?

A
  • I-121: 110 Gy
  • Pd-107: 100 Gy
29
Q

What are the standard HDR brachytherapy doses for the different isotopes when used as a monotherapy?

A
  • 13.5 Gy x 2 fx
  • 10.5 Gy x 3 fx
  • 9.4 Gy x 4 fx (BID)
30
Q

What were the main findings of the ARTISTIC MA (RADICALS, RAVES, and GETUG-AFU 17 trials) for early (adjuvant) vs. late (salvage) RT for men w/ IR, HR localized, or locally advanced PCa?

A
  • 5-yr EFS: 88% vs. 89%
    – Adjuvant RT does not improve EFS
  • ↑ GU tox
31
Q

What are the rates of biochem failure at 5 yrs and 8 yrs for pts who receive 79.2 vs. 70.2 CFRT for their PCa per RTOG 0126?

A
  • BCF for 79.2 Gy
    – 5 yr: 35%
    – 8 yr: 20%
  • BCF for 70.2 Gy
    – 5 yr: 47%
    – 8 yr: 35 %
  • OS not different
32
Q

What are the brachytherapy post-implant goals for prostate brachytherapy?

A
  • Prostate:
    – D90 > 100%
    – V100 > 90%
    – V150 < 50%
  • Rectum:
  • RV100 < 1 cc
  • UV5 < 150%
  • UV30 < 125%
  • UV150 = 0%
33
Q

What are the brachytherapy pre-implant goals for prostate brachytherapy?

A
  • V100% > 95%-98%
  • D90>100%
  • Homogeneity
    – V150% < 30-40%
    – V200% < 20%
  • Rectum
    – D2cc < reference prescription dose (145 Gy)
    – Dmax < 200 Gy
  • Prostatic urethra
    – D10 < 150% of Rx
    – D30 < 130% of Rx
34
Q

What are the brachytherapy post-implant goals for prostate brachytherapy?

A
  • D90% >140 Gy (for I-125)
  • D90% > 125 Gy (for Pd-103
  • V150% < 40%
  • V200% < 20%
  • Rectum
    – V100% < 1cc (can be as high 2.5cc)
  • Urethra mean
    – < 140% of prescription dose
35
Q

Per STAMPEDE, what effect does adding docetaxel to long-term HT have on OS for pts w/ HR, locally advanced, metastatic, or recurrent PCa?

A
  • ↑ OS
  • ↑ tox
36
Q

What is the usual vertebral body level for aortic bifurcation?

A

L4-L5

37
Q

What are the accepted dimensions of obturator LNs?

A
  • 1-2 cm
  • Extend posteriorly to the edge of the obturator internus muscle
  • Taper obturator nodes when SVs appear
  • End when SVs join prostate
38
Q

What were the findings of the RTOG 0815 trial for IR prostate cancer?

A
  • IR PCa β†’ 79.2 Gy vs. 79.2 Gy + 6 mos ADT
    – 45 Gy + brachy boost also allowed (12%)
    – 5-yr BCF 21% vs. 10%
    – 5-yr DM 4% vs. 1%
    – 5-yr PCM n=10 vs. 1
    – 5-yr OS 79-84%, NS
    – No benefit in Gleason ≀ 6
39
Q

What Decipher scores correspond to what risk levels?

A

Decipher

  • 0-0.45: low risk
  • 0.45-0.6: intermediate risk
  • 0.6-1.0 high risk
40
Q

In pts undergoing salvage RT Β± bicalutamide, which PSA levels correspond to increased OS benefit w/ bicalutamide x 24 mos?

A
  • PSA β‰₯ 0.7 (Feng et al., 2nday analysis of RTOG 9601)
    – Improves MFS, DSS, and OS
41
Q

In pts undergoing salvage RT, which PSA levels correspond to increased OS benefit w/ the addition of RT to the pelvis?

A

PSA > 0.34 (RTOG 0534)

42
Q

When considering adjuvant RT for PCa s/p RP, did the main trials deliver RT to the prostate and pelvis?

A

No pelvis only

43
Q

What were the rates of biochemical failure in the dose-escalated arm vs. CFRT arms of the proton dose-escalation trial for low-risk and intermediate-risk PCa (ZIetman et al. JAMA 2005, JCO 2010)?

A

Dose-escalated vs. CFRT in LR and IR PCa
- 17% vs. 32%

##

Compare w/ MDACC dose-escalation trial, which showed a biochem failure benefit in IR and HR PCa?

44
Q

What are the usual salvage RT doses for prostate cancer?

A
  • Doses: 64-72 Gy
  • If PSA > 0.48, Dose β‰₯ may ↓ biochemical failure
45
Q

For radio-recurrent prostate cancer, what is the 5-yr RFS w/ local interventions?

A

5-yr RFS: 50-60%

46
Q

Does IMRT, as compared to 3D-CRT, reduce late GU or GI or both tox?

A
  • ↓ GI tox
  • Similar GU tox
47
Q

What changes while on active surveillance for prostate cancer should prompt an initiation of tx?

A
  • PSA doubling time < 3 years
  • Histologic upgrade on repeat bx
  • Unequivocal clinical progression (palpable nodule during surveillance confirmed histologically)
48
Q

What is the reduction in prostate size w/ 4-5 mos of 5Ξ±-reductase inhibitors?

A

↓ by 20% w/ 5 mos of ARIs

49
Q

What is the reduction in prostate size w/ 4-5 mos of LHRH agonists of anti-androgen therapy?

A

↓ by ~30%

50
Q

What were the findings of EORTC 22863 trial (Bolla et al.) for prostate cancer?

A
  • HR and LN+ β†’ RT 70 Gy (50 WPRT + 20 Gy boost) concurrent & adj ADT x 36 mos
    vs. RT alone
    – 10-yr OS 58% vs. 40% (SS)
    – 10-yr DFS 48% vs. 23% (SS)
    – 10-yr CSS 90% vs. 70% (SS)
    – 10-yr LRF: 6% vs. 24% (SS)
    – 10-yr DMFS: 51% vs. 30% (SS)
51
Q

What were the findings of D’Amico at al trial (JAMA, 2008, 2015) for prostate cancer?

A
  • IR (70%) + others (LR/HR) PCa β†’70 Gy to prostate vs. 70 Gy + ADT for 6 months (2 months neoadj):
    – 8-yr OS 74% vs. 61% (SS)
52
Q

What labs must be checked prior to initiating bicalutamide?

A
  • LFTs
  • It can occasionally cause fulminant hepatic failure
53
Q

Per the UK ProtecT trial, how do GU and GI sx compare b/w the three arms?

A
  • GU:
    – w/ RT, lower urinary sx get worse at 6 mos, but become comparable to AS and RP at 1 yr
    – urinary incontinence gets hit the worst w/ RP, and never recovers to the levels of RT or AS
  • GI:
    – w/ RT, bowel fx is consistently worse after RT when compared to AS or RP
54
Q

Per the UK ProtecT trial, how does sexual fx compare b/w the three arms?

A
  • RP has worse sexual fx at all time points, and it never recovers to the RT or AS levels
55
Q

Per the UK ProtecT trial, how does health-related QOL compare b/w the three arms?

A

No difference in the three arms

56
Q

How often should you PSA screen men?

A
  • ERSPC trial: q4 yrs
  • Sweden: q2 yrs
  • NCCN:
    – PSA < 1 β†’ q2-4 yrs
    – PSA 1-3 β†’ q1-2 yrs
57
Q

What were the findings of the RADICALS-RT trial for prostate cancer?

A
  • IR + HR localized PCa β†’ adj. RT vs. salvage RT (RT options for both: 66 Gy in 33 fx or 52.5 Gy in 20 fx)
  • bPFS: 85% vs. 88% (NS)
  • urinary incontinence: worse w/ adj. RT
58
Q

What was the indication to initiate salvage RT in RADICALS-RT for prostate cancer?

A
  • 2 consecutive PSA rises and PSA > 0.1 ng/mL
  • 3 consecutive PSA rises regardless of whether the final reading was greater than 0.1 ng/mL
59
Q

What doses of Ca and Vit D should be used for pts receiving ADT?

A
  1. Calcium 1200 mg daily
  2. Vitamin D3 800-1000 IU daily
60
Q

How often was PSA checked in the UK ProtecT trial?

A
  • q3mos x 1 yr
  • q6mos afterwards
61
Q

At 15 yrs, how many pts in the AS arm had converted to tx on the UK ProtecT trial?

A

~60%

62
Q

When is a tertiary Gleason score provided on a path report?

A
  • Provided only on RP specimen WHEN
  • Tertiary component of the Gleason score is higher than the primary and secondary AND
  • Occupies <5% of the whole tumor
63
Q

What are the blood work requirements for initiation Ra-223 tx and continuing txs?

A
  • Before first administration:
    – ANC β‰₯ 1500
    – PIt β‰₯ 100k
    – Hgb β‰₯ 10
  • Subsequent administration:
    – ANC β‰₯ 1000
    – Pit β‰₯ 50k

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