Prostate Flashcards
PSA Screening (age and frequency)
< 40: none
40-54: High risk (AA, family history)
55-70 (AUA)/55-75 (NCCN): shared decision
Every 1-2 years
What do you do with HGPIN
Nothing; no longer requires repeat biopsy
What can impact free PSA
Hemodialysis
What do you do with ASAP
Repeat biopsy in 6-12 mo or look at slides w/ deeper sections
What are the clinical T stages of prostate cancer
T1c - non palpable nodule/no lesion on TRUS/MRI
T2a - palpable nodule or lesion < 1/2 lobe
T2b - palpable nodule or lesion > 1/2 lobe
T2c - palpable nodule or lesion both lobes
T3a - Extraprostatic extension
T3b - Seminal vesicle invasion
T4 invading nearby structures
What are different risk categories of prostate cancer
very low (NCCN): Grad 1, PSA < 10, T1c, < 3 cores, < 50% involvement per core, PSAD < 0.15
low: Grade 1, PSA< 10, cT1c or 2a
intermediate: Grade 2 or 3, PSA 10-20, cT2b or T2c (NCCN)
favorable int (NCCN): Grade 1 or 2 and < 50% of cores positive and PSA 10-20 OR T2b/c OR Grade 2
unfavorable int (NCCN): Grade 3 or > 50% positve or 2-3 risk factors (2b or 2c, Grade 2 or 3, PSA 10-20)
high: Grade 4-5, PSA > 20, >/=cT2c (AUA) or cT3a (NCCN)
very high (NCCN): cT3b or cT4
What are the different grades of Prostate Cancer
Grade 1 : 3+3 Grade 2 : 3+4 Grade 3: 4+3 Grade 4: 4+4 Grade 5: Gleason 9 or 10
how does prostate cancer appear on MRI
low signal on T1 and T2
when is CT warranted on prostate cancer work up
- intermediate if LND probability > 10%
- high
- very high
when is bone scan warranted on prostate cancer work up
- unfavorable intermediate (4+3 or >50% cores on bx 3+4 ) if T2 and PSA > 10
- high
- very high
- PSA > 20
when do you obtain germline testing in prostate cancer
- Family history of high risk germ line mutation
- suspicious family history
- strong family hx < 60 and > Grade Group 1
- Ashkenazi Jew
- > 3 breast, pancreatic, ovarian, prostate, urothelial, small bowel, colorectal, melanoma
- presence of intraductal carcinoma
What genes are associated with Lynch syndrome in prostate cancer
MLH1, MSH2, MSH6, PMS2
when would you consider testing for MSI or dMMR?
N1 or M1 positive disease
If positive for MSI or dMMR what do you do?
Test for Lynch
May be eligible for pemborlizumab fo CRPC
Treatment options for low risk Prostate cancer
Active surveillance Brachy alone EBRT alone Radical prostatectomy watchful waiting if life expectancy < 10 years
Treatment options for intermediate risk prostate cancer
Active surveillance (favorable only)
Brachy alone (favorable only)
Brachy + EBRT +/- ADT 4 months (Unfavorable)
Radical prostatectomy +LND > 2% metastasis
Treatment options for high risk local prostate cancer
EBRT + ADT (1.5- 3years)
Brachy + EBRT + ADT (1-3 years)
Radical prostatectomy + LND
What are your options for Regional risk (extended Nodal disease present prior to treatment)
Germline testing
MSI and dMMR testing
ADT + EBRT +/- abiraterone and prednisone
What is the definition of recurrence after radiation
ASTRO: 3 consecutive rises
Phoenix: nadir + 2
Management for high risk features after prostatectomy (positive margin, T3)
EBRT +/- ADT
what were the outcomes of the PLCO trial? what were it’s flaws
No reduction in prostate cancer-specific mortality associated with screening after a median follow-up of 10 years. Flaws: pre-testing PSA in 40% of the study subjects and contamination (by PSA testing) in 70% of the “unscreened” control cohort.3
What were the outcomes of the ESRPC trial?
20% reduction in CA mortality at 11 years between those screened w/ PSA and those not,
What were the outcomes of the PROMIS trial?
MRI was more sensitive for detecting high risk cancer but less specific, detected up to 18% more clinically significant cancers w/ fusion biopsy then standard alone
How is risk of lymph node involvement determined
Nomogram: MSK, Briganti, Partin
How do you manage lymph node involvement
clinical: ADT + EBRT +/- abiraterone and prednisone
pathological (post prostatectomy): ADT
Options for Castrate Sensitive M1 disease
ADT + Docetaxel (high volume disease), Apalutamide, enzalutimde, or abiraterone and prednisone
Options for non metastatic M0 Castrate Resistant disease (index 1)
- ADT + enzalutamide or apalutamide (standard)
- NCCN includes Darolutamide if PSADT < 10mo
- ADT alone if refuse treatment or PSADT > 10mo
- ADT + abiraterone and prednisone
Options for asymptomatic metastatic Castrate Resistant disease, good performance, no prior docetaxel (index 2)
A. ADT + abiraterone and prednisone or enzalutamide
B. ADT + Provenge or docetaxel
C. ADT + Ketoconazole and prednisone
Options for symptomatic metastatic Castrate Resistant disease, good performance, no prior docetaxel (index 3)
A. ADT + abiraterone and prednisone or enzalutamide
B. ADT + docetaxel or mitoxantrone OR radium 223 if bony mets
C. ADT + Ketoconazole and prednisone
Options for symptomatic metastatic Castrate Resistant disease, poor performance, no prior docetaxel (index 4)
A. ADT + abiraterone and prednisone or enzalutamide
C. ADT + Ketoconazole and prednisone
Expert Opinion. ADT + docetaxel or mitoxantrone
Options for symptomatic metastatic Castrate Resistant disease, good performance, prior docetaxel (index 5)
A. ADT + abiraterone and prednisone or enzalutamide
B. ADT + cabazitaxel or Radium 223 if bony mets
C. ADT + Ketoconazole and prednisone or docetaxel
Options for symptomatic metastatic Castrate Resistant disease, poor performance, prior docetaxel (index 6)
palliative care
Abiraterone
MOA: CYP 17 inhibitor; inhibits androgen production throughout body
SE: HTN, hypokalemia, fluid retention, hepatoxicity
indications
Indications: CRPC, Metastatic CSPC, cN1 involvement
Enzalutamide
MOA: Anti androgen; blocks receptor binding
SE: lowers seizure threshold, neurologic deficit
Indications: CRPC, Metastatic CSPC,
Docetaxel
MOA: Taxane; microtubule disarray
SE: myelosuppresion, neurotoxicity, liver dysfunction
Indications: CSPC, metastatic CRPC
What affect does pre-prostatectomy ADT have?
Can artificially elevate Gleason score, i.e. difficult to interpret
where is the primary landing zone for nodal mets?
internal iliac
What is the best way to manage castrate sensitive symptomatic metastatic disease?
LHRH antagonist
how does one define high volume metastasis?
4 bone mets w/ one outside the spine/eplvis or visceral mets
how is biochemical recurrence managed after exhaustion of local therapy and no evidence of metastasis?
Intermittent ADT or observation
what is an option for select metastatic hormorone sensitive low volume disease who are not on androgen pathway directed therapy?
continuous ADT plus primary radiotherapy to prostate
