Prostate Flashcards
What is the commonest molecular abnormality in prostate cancer? What % cancers have it?
Translocations
Androgen responsive gene TMPRSS2 to ETS family transcription factors
60%
Are usual cancer mutations eg p53 BRAF and KRAS common in prostate cancer?
No- low rates
Which chromosome has SNPs conferring risk alleles for prostate cancer in multiple independent studies?
8q24
Is PTEN loss an early or late event in prostate cancer development?
Late event (not seen in PIN)
What are the early abnormalities seen in PIN?
Loss :-
NKX
GST pi
Prostate cancers mostly arise within which zone of the prostate?
Peripheral zone
Describe the Gleason system for grading prostate cancer
Graded on architecture not cytology
Score 1-5 (in reality only 3,4,5 used)
First number is most commonly seen pattern, second is the next most common
What is the maximum a Gleason score could be?
10 (5+5)
What is the risk of urosepsis after a prostate biopsy?
5%
What type of jewellery appearance on histology of prostate cancer denotes more aggressive?
Signet ring
A prostate cancer can’t be felt clinically, what T stage is it?
T1
What is the T stage of prostate cancer diagnosed on TURP?
T1 a or b (a if 5% of chips)
Describe T1a b and c prostate cancer?
T1a on TURP less than 5% of chips
T1b on TURP more than 5% of chips
T1c on needle biopsy
The seminal vesicles are involved, what is the T stage?
T3b
What is the cut off between T2 and T3 prostate cancer broadly?
T2 is confined to the prostate
T3 breaches the capsule
The capsule is breached but no SV involvement?
T3a
Describe T2a b and c in prostate cancer?
T2 is divided on how much of the gland is involved
T2a less than half a lobe
T2b more than half a lobe
T2c both lobes
Is there screening for prostate cancer in the UK?
No
If age >50 asks GP given info pack if still wants it then can have PSA
What are the two main prostate screening studies called and what did they show?
PLCO Study USA: no difference in prostate cancer mortality but flawed ++ (crossover, contamination)
ROTTERDAM showed 20% decrease in prostate mortality but NNT 37
According to the ESMO guidelines should a man above age 75 be given PSA screening?
Above 75 harms outweigh benefits
What is PSA actually made of?
It’s a glycoprotein
What’s the false negative rate of TRUS in prostate cancer?
20%
Which imaging in prostate tells you about seminal vesicle involvement?
MRI
Prostate cancer work up in a new patient who should get a bone scan? (4 indications)
PSA >10
T3 or 4
Gleason => 7
Suggestive signs or symptoms
Is PET scan of value in prostate cancer?
No- low sensitivity, low metabolism bladder in way
Which patients can be spared nodal evaluation with lap retroperitoneal LN biopsy?
T2 or less
PSA lower than 20
Gleason
Which is “nicer” 😇 PSA? Which is nasty PSA? 👹 free or bound?
Free PSA is nice 😇
What is the minimum % of free PSA considered normal?
Anything less than 10% is suspicious- free PSA is nice PSA
How long after ejaculation is the PSA falsely raised for?
48 hours
How long after DRE is the PSA falsely raised for?
7 days
Name the treatment options for T1/2 (localised prostate cancer)?
Surgery
Active surveillance
EBRT
Brachytherapy
Should adjuvant ADT be given after a radical prostatectomy?
No!
What are the advantages of laparoscopic or robotic prostatectomy over open?
Less blood loss
Shorter inpatient stay
What % of radical prostatectomy patients will have PSA free survival at 10 years?
60-75%
% impotence after radical prostatectomy?
50%
% incontinence after radical prostatectomy?
15%
Is there RCT evidence for open/lap/robotic prostatectomy?
No never compared head to head
Oncological outcomes seem same for all
Should patients with localised prostate cancer T1/2 have a lymph node resection?
No- the risk of LN mets is
Which trial is the evidence for radical prostatectomy? What were the two arms and what was the result
SPCG-4
Radical prostatectomy v observation
12% difference in OS -but flawed trial-
What were 3 criticisms of the SPCG4 study for radical prostatectomy v observation?
Pre PSA era
Not many “good” risk patients
The “observation” arm didn’t have active surveillance, if they progressed they were not treated
What were the two arms in the PIVOT trial and what were the findings? Was there a group that was an exception?
Radical prostatectomy v observation
No difference in prostate mortality
(Prostatectomy only helpful if PSA >10)
NICE criteria for active surveillance to be offered for prostate cancer? (Three things)
PSA
Name the two studies that have looked at active surveillance in prostate cancer?
KLOTZ Toronto
PRIAS - only has 18 months of follow up
Imagine driving a PRIAS in Toronto SURVEYING the scenery
In the KLOTZ study of active surveillance for prostate cancer what % of patients had switched to treatment within 5 years?
25%
In active surveillance according to the KLOTZ study what criteria should prompt moving to treatment? (3)
BIOPSY
DOUBLING time 3 yrs
NODULE
Unequivocal nodule palpable on DRE
Increase in Gleason on rebiopsy
PSA doubling time of less than 3 years
Does vitamin E help prevent prostate cancer?
No, actually increases risk
What did the prostate cancer prevention -finasteride- trial show?
Decrease in incidence prostate ca but more high risk prostate cancer
What PSA nadir after DXT for prostate cancer is considered high risk for relapse?
If it doesn’t fall below 1.0
What does dose escalation do in terms of outcomes of DXT for prostate cancer?
Higher doses inc biochem RFS but not OS
What do the toxicity results from the CHHIP study in prostate cancer show so far?
Equivalent toxicity for hypofractionation arm
When do acute DXT symptoms begin to appear in prostate cancer?
Week 3
What % DXT prostate get ulcers or fistula? What procedures should be avoided
1%
Avoid biopsy leads to fistula
% impotence after DXT for prostate ca?
30-60%
In the uk do we irradiate pelvic nodes as part of prostate cancer EBRT?
No most UK oncologists don’t (wait RTOG 0924 study)
What hormones should prostate cancer patients get with their DXT? For low, int and high risk
Low -none
Interm- neoadj and continue for 3 MONTHS
High- neoadj and continue for 3 YEARS
What % DXT have bowel toxicity at 1 year?
10%
Do you get incontinence with DXT for prostate ca?
No
% irritable bladder at 1 yr after brachytherapy?
20%
Impotence in RP/EBRT/brachytherapy?
44%, 22%, 13%
What should the PSA be after RP?
Undetectable
Definition of relapse after RP? The AUA/EUA criteria
Any PSA >= 0.2
Do a second reading to confirm
What is salvage rx after RP with biochemical relapse? What is the evidence for it?
Salvage RT to prostate bed.
No prospective data
Retrospective data shows significant decrease in prostate cancer mortality
A patient has biochemical relapse after RP. You offer him salvage DXT to prostate bed. What is the % chance of gaining biochemical control?
50%
What is the Phoenix criteria in prostate cancer?
For the diagnosis of biochemical relapse after EBRT
A PSA 2mg/ml over nadir
After biochemical relapse name three indications for starting ADT?
Proven mets
Symptomatic local disease
PSA doubling time for less than THREE months
Should patients routinely get adjuvant DXT after RP?
No ESMO Say: discuss with patient if \+ve surgical margin T3 disease (capsule breached) And the PSA is undetectable
What is the impact of adjuvant DXT after RP on survival?
NO impact on OS or metastasis free survival
A patient has a positive margin after RP what are the options?
Repeat surgery NOT recommended
Can discuss adjuvant DXT as this is a possible indication but NO evidence it increases survival
When is the only situation in prostate cancer which intermittent ADT is ok?
Biochemical relapse only
What % of patients with bone mets will respond to primary hormone treatment in mPC?
70%
What is median duration of control in mPC?
12-18 months
What is the evidence for stilboestrol in secondary hormone manipulation in prostate cancer?
VACURG II study
What is the dose of docetaxel in metastatic prostate cancer?
75mg/m2
Which group in the CHAARTED study benefited most from docetaxel? What was the OS benefit
> = 4 bone mets
Or
Lung/liver mets
17 months
Did patients with a low burden of disease benefit from docetaxel in the CHAARTED study?
Yes
What was the OS in the CHAARTED study for ADT v ADT plus docetaxel?
57 v 44 months (IE OS Advantage 13 months)
What is the mode of action of abiraterone?
CYP17 inhibitor
Which prostate cancer treatment has to have pred 5mg co-prescribed with it?
Abiraterone
Name three toxicities of Abiraterone?
Peripheral oedema
Low K
high BP
A patient is on Abiraterone and his PSA is rising shall we stop it?
No, in the trials only stop Abiraterone if imaging or clinical progression- biochem progression doesn’t count
What kind of drug is enzalutamide?
It is an ARSI (androgen receptor signalling inhibitor)
Blocks AR binding, nuclear translocation and DNA binding
Side effects of enzalutamide
Fatigue
Mild BP increase
Seizures
Which drug causes more bone pain? Enzalutamide or Abiraterone?
Enzalutamide
Does enzalutamide have proven efficacy in patients who have had docetaxel?
Yes there have been RCTS in the pre and post docetaxel settings
What is sipleucel T?
Immunotherapy activated autologous dendritic cells
Is sipleucel T available in the uk?
No. Too expensive
Is sipleucel T better for rapidly progressive large volume disease or smaller volume stable disease?
Small and stable
What is Radium-223?
Bone targeted alpha emitter
What is the benefit of Radium 223 in metastatic prostate cancer?
Improved OS!
Longer time to first skeletal event
Criteria for a patient to get Radium 223?
Bone predominant symptoms
Castrate resistant prostate cancer
No visceral mets
What is the name of the trial of Radium 223?
ALSYMPCA
Two side effects of Radium 223?
Myelosupression
Diarrhoea
What is the benefit of cabazitaxel?
Survival benefit post docetaxel but not available in the uk
How should bone pain be treated in prostate cancer?
Steroids
Bisphosphonates for bone pain or if high fracture risk
What is denosumab?
A rank ligand inhibitor
What imaging should a patient with vertebral mets get?
MRI to look for cord compression
Father has prostate cancer, what is RR?
X2
Brother has prostate cancer, RR?
3x
Which BRCA is associated with prostate cancer?
Both 1 and 2
BRCA 1 RR x2
BRCA 2 RR X 4-9
What are the treatment options for high risk prostate cancer?
EBRT with ADT
Radical prostatectomy
Dose of prostate EBRT?
74 Gy in 33 #
Do patients with intermediate risk prostate cancer need adt with EBRT?
Yes (3 months) neoadj and concurrent
What is definition of relapse after RP?
Psa >=0.2
Osteoblastic or osteolytic mets in prostate cancer?
OsteoBLASTIC
