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Basma Medical Oncology > Prostate > Flashcards

Prostate Flashcards

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USMLE® Step 1 flashcards
1
Q

What is the commonest molecular abnormality in prostate cancer? What % cancers have it?

A

Translocations
Androgen responsive gene TMPRSS2 to ETS family transcription factors
60%

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2
Q

Are usual cancer mutations eg p53 BRAF and KRAS common in prostate cancer?

A

No- low rates

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3
Q

Which chromosome has SNPs conferring risk alleles for prostate cancer in multiple independent studies?

A

8q24

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4
Q

Is PTEN loss an early or late event in prostate cancer development?

A

Late event (not seen in PIN)

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5
Q

What are the early abnormalities seen in PIN?

A

Loss :-

NKX

GST pi

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6
Q

Prostate cancers mostly arise within which zone of the prostate?

A

Peripheral zone

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7
Q

Describe the Gleason system for grading prostate cancer

A

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

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8
Q

What is the maximum a Gleason score could be?

A

10 (5+5)

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9
Q

What is the risk of urosepsis after a prostate biopsy?

A

5%

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10
Q

What type of jewellery appearance on histology of prostate cancer denotes more aggressive?

A

Signet ring

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11
Q

A prostate cancer can’t be felt clinically, what T stage is it?

A

T1

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12
Q

What is the T stage of prostate cancer diagnosed on TURP?

A

T1 a or b (a if 5% of chips)

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13
Q

Describe T1a b and c prostate cancer?

A

T1a on TURP less than 5% of chips
T1b on TURP more than 5% of chips
T1c on needle biopsy

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14
Q

The seminal vesicles are involved, what is the T stage?

A

T3b

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15
Q

What is the cut off between T2 and T3 prostate cancer broadly?

A

T2 is confined to the prostate

T3 breaches the capsule

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16
Q

The capsule is breached but no SV involvement?

A

T3a

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17
Q

Describe T2a b and c in prostate cancer?

A

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

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18
Q

Is there screening for prostate cancer in the UK?

A

No

If age >50 asks GP given info pack if still wants it then can have PSA

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19
Q

What are the two main prostate screening studies called and what did they show?

A

PLCO Study USA: no difference in prostate cancer mortality but flawed ++ (crossover, contamination)
ROTTERDAM showed 20% decrease in prostate mortality but NNT 37

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20
Q

According to the ESMO guidelines should a man above age 75 be given PSA screening?

A

Above 75 harms outweigh benefits

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21
Q

What is PSA actually made of?

A

It’s a glycoprotein

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22
Q

What’s the false negative rate of TRUS in prostate cancer?

A

20%

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23
Q

Which imaging in prostate tells you about seminal vesicle involvement?

A

MRI

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24
Q

Prostate cancer work up in a new patient who should get a bone scan? (4 indications)

A

PSA >10
T3 or 4
Gleason => 7
Suggestive signs or symptoms

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25
Q

Is PET scan of value in prostate cancer?

A

No- low sensitivity, low metabolism bladder in way

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26
Q

Which patients can be spared nodal evaluation with lap retroperitoneal LN biopsy?

A

T2 or less
PSA lower than 20
Gleason

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27
Q

Which is “nicer” 😇 PSA? Which is nasty PSA? 👹 free or bound?

A

Free PSA is nice 😇

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28
Q

What is the minimum % of free PSA considered normal?

A

Anything less than 10% is suspicious- free PSA is nice PSA

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29
Q

How long after ejaculation is the PSA falsely raised for?

A

48 hours

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30
Q

How long after DRE is the PSA falsely raised for?

A

7 days

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31
Q

Name the treatment options for T1/2 (localised prostate cancer)?

A

Surgery
Active surveillance
EBRT
Brachytherapy

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32
Q

Should adjuvant ADT be given after a radical prostatectomy?

A

No!

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33
Q

What are the advantages of laparoscopic or robotic prostatectomy over open?

A

Less blood loss

Shorter inpatient stay

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34
Q

What % of radical prostatectomy patients will have PSA free survival at 10 years?

A

60-75%

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35
Q

% impotence after radical prostatectomy?

A

50%

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36
Q

% incontinence after radical prostatectomy?

A

15%

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37
Q

Is there RCT evidence for open/lap/robotic prostatectomy?

A

No never compared head to head

Oncological outcomes seem same for all

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38
Q

Should patients with localised prostate cancer T1/2 have a lymph node resection?

A

No- the risk of LN mets is

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39
Q

Which trial is the evidence for radical prostatectomy? What were the two arms and what was the result

A

SPCG-4
Radical prostatectomy v observation
12% difference in OS -but flawed trial-

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40
Q

What were 3 criticisms of the SPCG4 study for radical prostatectomy v observation?

A

Pre PSA era
Not many “good” risk patients
The “observation” arm didn’t have active surveillance, if they progressed they were not treated

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41
Q

What were the two arms in the PIVOT trial and what were the findings? Was there a group that was an exception?

A

Radical prostatectomy v observation
No difference in prostate mortality
(Prostatectomy only helpful if PSA >10)

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42
Q

NICE criteria for active surveillance to be offered for prostate cancer? (Three things)

A

PSA

43
Q

Name the two studies that have looked at active surveillance in prostate cancer?

A

KLOTZ Toronto
PRIAS - only has 18 months of follow up

Imagine driving a PRIAS in Toronto SURVEYING the scenery

44
Q

In the KLOTZ study of active surveillance for prostate cancer what % of patients had switched to treatment within 5 years?

A

25%

45
Q

In active surveillance according to the KLOTZ study what criteria should prompt moving to treatment? (3)

A

BIOPSY
DOUBLING time 3 yrs
NODULE

Unequivocal nodule palpable on DRE
Increase in Gleason on rebiopsy
PSA doubling time of less than 3 years

46
Q

Does vitamin E help prevent prostate cancer?

A

No, actually increases risk

47
Q

What did the prostate cancer prevention -finasteride- trial show?

A

Decrease in incidence prostate ca but more high risk prostate cancer

48
Q

What PSA nadir after DXT for prostate cancer is considered high risk for relapse?

A

If it doesn’t fall below 1.0

49
Q

What does dose escalation do in terms of outcomes of DXT for prostate cancer?

A

Higher doses inc biochem RFS but not OS

50
Q

What do the toxicity results from the CHHIP study in prostate cancer show so far?

A

Equivalent toxicity for hypofractionation arm

51
Q

When do acute DXT symptoms begin to appear in prostate cancer?

A

Week 3

52
Q

What % DXT prostate get ulcers or fistula? What procedures should be avoided

A

1%

Avoid biopsy leads to fistula

53
Q

% impotence after DXT for prostate ca?

A

30-60%

54
Q

In the uk do we irradiate pelvic nodes as part of prostate cancer EBRT?

A

No most UK oncologists don’t (wait RTOG 0924 study)

55
Q

What hormones should prostate cancer patients get with their DXT? For low, int and high risk

A

Low -none
Interm- neoadj and continue for 3 MONTHS
High- neoadj and continue for 3 YEARS

56
Q

What % DXT have bowel toxicity at 1 year?

A

10%

57
Q

Do you get incontinence with DXT for prostate ca?

A

No

58
Q

% irritable bladder at 1 yr after brachytherapy?

A

20%

59
Q

Impotence in RP/EBRT/brachytherapy?

A

44%, 22%, 13%

60
Q

What should the PSA be after RP?

A

Undetectable

61
Q

Definition of relapse after RP? The AUA/EUA criteria

A

Any PSA >= 0.2

Do a second reading to confirm

62
Q

What is salvage rx after RP with biochemical relapse? What is the evidence for it?

A

Salvage RT to prostate bed.
No prospective data
Retrospective data shows significant decrease in prostate cancer mortality

63
Q

A patient has biochemical relapse after RP. You offer him salvage DXT to prostate bed. What is the % chance of gaining biochemical control?

A

50%

64
Q

What is the Phoenix criteria in prostate cancer?

A

For the diagnosis of biochemical relapse after EBRT

A PSA 2mg/ml over nadir

65
Q

After biochemical relapse name three indications for starting ADT?

A

Proven mets
Symptomatic local disease
PSA doubling time for less than THREE months

66
Q

Should patients routinely get adjuvant DXT after RP?

A 
No 
ESMO Say: discuss with patient if 
\+ve surgical margin 
T3 disease (capsule breached) 
And the PSA is undetectable
67
Q

What is the impact of adjuvant DXT after RP on survival?

A

NO impact on OS or metastasis free survival

68
Q

A patient has a positive margin after RP what are the options?

A

Repeat surgery NOT recommended

Can discuss adjuvant DXT as this is a possible indication but NO evidence it increases survival

69
Q

When is the only situation in prostate cancer which intermittent ADT is ok?

A

Biochemical relapse only

70
Q

What % of patients with bone mets will respond to primary hormone treatment in mPC?

A

70%

71
Q

What is median duration of control in mPC?

A

12-18 months

72
Q

What is the evidence for stilboestrol in secondary hormone manipulation in prostate cancer?

A

VACURG II study

73
Q

What is the dose of docetaxel in metastatic prostate cancer?

A

75mg/m2

74
Q

Which group in the CHAARTED study benefited most from docetaxel? What was the OS benefit

A

> = 4 bone mets
Or
Lung/liver mets

17 months

75
Q

Did patients with a low burden of disease benefit from docetaxel in the CHAARTED study?

A

Yes

76
Q

What was the OS in the CHAARTED study for ADT v ADT plus docetaxel?

A

57 v 44 months (IE OS Advantage 13 months)

77
Q

What is the mode of action of abiraterone?

A

CYP17 inhibitor

78
Q

Which prostate cancer treatment has to have pred 5mg co-prescribed with it?

A

Abiraterone

79
Q

Name three toxicities of Abiraterone?

A

Peripheral oedema
Low K
high BP

80
Q

A patient is on Abiraterone and his PSA is rising shall we stop it?

A

No, in the trials only stop Abiraterone if imaging or clinical progression- biochem progression doesn’t count

81
Q

What kind of drug is enzalutamide?

A

It is an ARSI (androgen receptor signalling inhibitor)

Blocks AR binding, nuclear translocation and DNA binding

82
Q

Side effects of enzalutamide

A

Fatigue
Mild BP increase
Seizures

83
Q

Which drug causes more bone pain? Enzalutamide or Abiraterone?

A

Enzalutamide

84
Q

Does enzalutamide have proven efficacy in patients who have had docetaxel?

A

Yes there have been RCTS in the pre and post docetaxel settings

85
Q

What is sipleucel T?

A

Immunotherapy activated autologous dendritic cells

86
Q

Is sipleucel T available in the uk?

A

No. Too expensive

87
Q

Is sipleucel T better for rapidly progressive large volume disease or smaller volume stable disease?

A

Small and stable

88
Q

What is Radium-223?

A

Bone targeted alpha emitter

89
Q

What is the benefit of Radium 223 in metastatic prostate cancer?

A

Improved OS!

Longer time to first skeletal event

90
Q

Criteria for a patient to get Radium 223?

A

Bone predominant symptoms
Castrate resistant prostate cancer
No visceral mets

91
Q

What is the name of the trial of Radium 223?

A

ALSYMPCA

92
Q

Two side effects of Radium 223?

A

Myelosupression

Diarrhoea

93
Q

What is the benefit of cabazitaxel?

A

Survival benefit post docetaxel but not available in the uk

94
Q

How should bone pain be treated in prostate cancer?

A

Steroids

Bisphosphonates for bone pain or if high fracture risk

95
Q

What is denosumab?

A

A rank ligand inhibitor

96
Q

What imaging should a patient with vertebral mets get?

A

MRI to look for cord compression

97
Q

Father has prostate cancer, what is RR?

A

X2

98
Q

Brother has prostate cancer, RR?

A

3x

99
Q

Which BRCA is associated with prostate cancer?

A

Both 1 and 2
BRCA 1 RR x2
BRCA 2 RR X 4-9

100
Q

What are the treatment options for high risk prostate cancer?

A

EBRT with ADT

Radical prostatectomy

101
Q

Dose of prostate EBRT?

A

74 Gy in 33 #

102
Q

Do patients with intermediate risk prostate cancer need adt with EBRT?

A

Yes (3 months) neoadj and concurrent

103
Q

What is definition of relapse after RP?

A

Psa >=0.2

104
Q

Osteoblastic or osteolytic mets in prostate cancer?

A

OsteoBLASTIC

Basma Medical Oncology (26 decks)

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