Prostate Flashcards
PCa
Localized Workup
- H&P including DRE
- Labs including PSA and PSAD
- Review PBx
- Estimate Life Expectancy
- Obtain FH (Somatic and germline testing if needed)
- Assess QoL
PCa
Regional and Metastatic Workup
- H&P including DRE
- Labs including PSA and PSAD
- Imaging (CT/ Bone Scan, mpMRI, PSMA-PET)
- Estimate Life Expectancy
- Obtain FH (Somatic and germline testing if needed)
- Assess QoL
PCa
Low Risk Treatment
- Active Surveillance (p)
- RT (EBRT or Brachytherapy)
- RP
- Observation (< 10y Life expectancy)
PCa
PCa Epidemiology
- Incidence- 288,300 new cases (1 in 8)
- Deaths- 34,700 deaths (1 in 41)
PCa
Grade Groups for PCa
Grade group 1: 3+3
Grade group 2: 3+4
Grade group 3: 4+3
Grade group 4: Gleason 8 (3+5, 5+3, 4+4)
Grade group 5: Gleason 9 or 10 (4+5, 5+4, 5+5)
PCa
PCa T1 staging
T1a → <5% of tissue removed, incidental during unrelated sx
T1b → >5% of tissue removed, incidental during unrelated sx
T1c → cancer found on biopsy, usually related to elevated PSA
PCa
PCa T2 staging
T2a → in only < 50% of one lobe
T2b → in > 50% of one lobe
T2c → cancer in both lobes
PCa
PCa T3 staging
T3a → Extracapsular extension
T3b → SV invasion
PCa
PCa T4 staging
T4 → spread to nearby organs (rectum, bladder, levator muscles, pelvic wall)
PCa
N staging
N1 -> Regional LN metastasis
PCa
M staging
M1a -> non-regional LN metastasis
M1b -> boney metastasis
M1c -> Viseral metastasis
PCa
PCa Risk Stratification → Very Low Risk
Very Low Risk must have all:
PSA <10
GG1 (Gl 6)
T1-T2a
<34% total biopsy cores positive
no core >50% involved
PSA density <0.15
PCa
PCa Risk Stratification → Low Risk
Low Risk must have all:
PSA < 10
Grade Group 1
T1-T2a
PCa
PCa Risk Stratification → Intermediate Risk
Intermediate Risk:
PSA 10-20 OR
GG 2-3 OR
T2b-c
Favorable GG1: (with PSA 10 - <20) or GG2, <50% positive cores
Unfavorable: >50% positive cores or T2b-c or GG3 (PSA < 20)
PCa
PCa Risk Stratification → High Risk
High Risk:
PSA >20 OR
GG 4-5 OR
_>_T3
PCa
PCa Epidemiology
- Incidence- 288,300 new cases (1 in 8)
- Deaths- 34,700 deaths (1 in 41)
PCa
PCa African Ancestry Disparties
- Incidence 60-70% higher
- Mortality 2-4 times higher
- 1.2-5.1 years earlier diagnosis
- More aggressive
- Increased risk of metastatic progression
- More advanced at presentation
PCa
PCa Biomarker Tests (10)
- PSA (blood)
- fPSA (blood)
- PCA3 (urine)
- PHI (blood)
- 4k score (blood)
- ExoDx (urine)
- Select MDx (urine)
- Confirm MDx (tissue)
- IsoPSA (blood)
- MyProstateScore (blood and urine)
PCa
ASAP and PIN risk
- ASAP- 40% cancer risk
- PIN- 20-30% cancer risk
PCa
Favorable Int Risk Treatment
- AS
- EBRT or Brachytherapy
- RP +/- LND
PCa
Unfavorable Int Risk Treatment
_>_10y LE
* RP + LND
* RT + 4-6m ADT (EBRT, EBRT with Brachytherapy boost, Brachytherapy)
<10y LE
* RT +4-6m ADT (EBRT)
* Watchful waiting
PCa
High Risk Treatment
> 5y or symptoms
* RP + LND
* RT + 1.5-3y ADT (EBRT, EBRT with Brachytherapy boost)
* RT + 3y ADT + Abiraterone (very high risk)
_<_5y and no symptoms
* Watchful waiting
* ADT
* EBRT
PCa
N1 Treatment
> 5y or symptoms
* EBRT + 3y ADT + Abiraterone (p)
* EBRT + 1.5-3y ADT
* ADT + Abiraterone
* RP + LND (select pts)
_<_5y and no symptoms
* Watchful waiting
* ADT
PCa
List of Post-RP adverse features
- Positive margin
- Extracapsular extension
- SV invasion
- Detectable PSA
PCa
Adjuvant therapay post RP with adverse features
Adverse features
* Monitoring (p)
* EBRT +/- ADT
N1
* Monitoring
* ADT +/- EBRT
PCa
Post RP PSA persistence/recurrence
Imaging negative
* EBRT +/- ADT 3y (p)
* Monitoring
Fossa recurrence
* EBRT +/- ADT 3y (p)
* Monitoring
Pelvic LN mets on imaging
* EBRT + ADT 3y +/- Abiraterone
PCa
Post RT PSA Recurrence
Imaging negative
* Consider prostate/SV biopsy and monitoring
* ADT based on PSADT
* Local secondary treatment
Pelvic LN mets on imaging
* Consider prostate/ SV biopsy and monitoring
* ADT +/- Abiraterone
* Local secondary treatment +/- ADT
PCa
M0 CSPC s/p maximal pelvic therapy
- Monitoring (p)
- ADT
- Enzalutamide + ADT (select pts)
PCa
M0 CRPC s/p maximal pelvic therapy
PSADT > 10m
* ADT + Monitoring (p)
* ADT + Secondary hormone therapy
PSADT< 10m
* ADT + Apalutamide or Darolutimide or Enzalutimide
PCa
High volume PCa definition
- Visceral metastasis
- > /= 4 bone lesions with at least 1 beyond the vertebral body/ pelvis
Based on CHAARTED criteria
PCa
High volume M1 CSPC (synchronous or metachronous)
- ADT + Docetaxel + Abiraterone or Darolutimide
- ADT + Abiraterone or Apalutamide or Enzalutimide
PCa
Low volume M1 CSPC (synchronous)
- ADT + Docetaxel + Abiraterone or Darolutimide
- ADT + Abiraterone or Apalutamide or Enzalutimide
- ADT + EBRT to primary +/- Abiraterone or Docetaxel
PCa
Low volume M1 CSPC (metachronous)
- ADT + Abiraterone or Apalutamide or Enzalutimide
PCa
Denovo M1 CSPC Workup
- H&P including DRE
- Labs including PSA and PSAD
- Imaging (CT/ Bone Scan, mpMRI, PSMA-PET)
- Estimate Life Expectancy
- Obtain FH
- Somatic and germline genetic testing
- Assess QoL
PCa
LHRH Agonist vs Antagonist
Agonist
* Leuprolide (Lupron)
* Goserelin (Zoladex)
* Triptorelin (Trelstar)
Antagonist
* Degarelix (Firmagon)
* Relugolix (Orgovyx)
PCa
SHIM score
- Sexual Health Inventory for Men
- 5 questions, score 1-5
- confidence in getting and keeping an erection? hard enough for penetration? maintain erection after penetration? maintain erection to completion? satisfaction?
- 1-7: severe
- 8-11: moderate
- 12-16: mild-moderate
- 17-21: mild
- 22-25: no ED
PCa
IPSS score
- International prostate symptom score
- 7+1 questions
- Incomplete emptying? frequency less than 2 hours? intermittent stream? urgency? weak stream? strain? nocturia? bother?
- 0-7: mild
- 8-19: moderate
- 20-35: severe
PCa
M1 CRPC pre-treatment workup
- Metastatic lesion biopsy
- Somatic testing for homologous recombination repair (HRR), microsatellite instability (MSI)/ mismatch repair deficiency (dMMR) and tumor mutational burden (TMB)
- Continue ADT
- Denosumab (p) or Zoledronic acid +/- palliative RT
PCa
Small cell/ neuroendocrine prostate cancer
- Cisplatin/ etoposide
- Carboplatin/ etoposide
- Docetaxel/ carboplatin
- Cabazitaxel/ carboplatin
PCa
M1 CRPC treatment (no prior docetaxel/ no prior novel hormone therapy)
- Abiraterone (p)
- Docetaxel (p)
- Enzalutimide (p)
- Niraparib/ abiraterone (BRCA)
- Olaparib/ abiraterone (BRCA)
- Pembrolizumab (MSI-high/ dMMR)
- Radium-223 (symptomatic bone mets)
- Sipuleucel-T (minimal symptoms)
- Talazoparibe/ enzalutimide (HRR)
PCa
M1 CRPC treatment (failed prior docetaxel/ no prior novel hormone therapy)
- Abiraterone (p)
- Cabazitaxel (p)
- Enzalutimide (p)
- Cabazitaxel/ carboplatin
- Mitoxantrone (palliative)
- Niraparib/ abiraterone (BRCA)
- Olaparib/ abiraterone (BRCA)
- Pembrolizumab (MSI-high/ dMMR)
- Radium-223 (symptomatic bone mets)
- Sipuleucel-T (minimal symptoms)
- Talazoparibe/ enzalutimide (HRR)
PCa
M1 CRPC treatment (no prior docetaxel/ failed prior novel hormone therapy)
- Docetaxel (p)
- Olaparib (BRCA) (p)
- Rucaparib (BRCA) (p)
- Cabazitaxel/ carboplatin
- Niraparib/ abiraterone (BRCA)
- Olaparib (HRR)
- Pembrolizumab (MSI-high/ dMMR)
- Radium-223 (symptomatic bone mets)
- Sipuleucel-T (minimal symptoms)
- Talazoparibe/ enzalutimide (HRR)
PCa
M1 CRPC treatment (failed prior docetaxel/ failed prior novel hormone therapy)
- Cabazitaxel (p)
- Docetaxel rechallenge (p)
- Cabazitaxel/ carboplatin
- Lutetium Lu 177 vipivotide tetraxetan (PSMA + lesions)
- Mitoxantrone (palliative)
- Olaparib (HRR)
- Pembrolizumab (MSI-high/ dMMR/ TMB >10)
- Radium-223 (symptomatic bone mets)
- Rucaparib (BRCA)
PCa
Germline testing
- BRCA 1/2
- ATM
- PALB2
- CHEK2
- HOXB13
- MLH1
- MSH2
- MSH6
- PMS2
PCa
Somatic Tumor Testing
- HRR (BRCA 1/2, ATM, PALB2, FANCA, RAD51D, CHEK2, CDK12)
- MSI-H
- dMMR
- TMB
- ctDNA
