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Cancer > Prostate > Flashcards

Prostate Flashcards

1
Q

PSA Screening (age and frequency)

A

< 40: none
40-54: High risk (AA, family history)
55-70 (AUA)/55-75 (NCCN): shared decision
Every 1-2 years

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2
Q

What do you do with HGPIN

A

Nothing; no longer requires repeat biopsy

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3
Q

What can impact free PSA

A

Hemodialysis

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4
Q

What do you do with ASAP

A

Repeat biopsy in 6-12 mo or look at slides w/ deeper sections

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5
Q

What are the clinical T stages of prostate cancer

A

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

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6
Q

What are different risk categories of prostate cancer

A

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

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7
Q

What are the different grades of Prostate Cancer

A 
Grade 1 : 3+3
Grade 2 : 3+4
Grade 3: 4+3
Grade 4: 4+4
Grade 5: Gleason 9 or 10
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8
Q

how does prostate cancer appear on MRI

A

low signal on T1 and T2

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9
Q

when is CT warranted on prostate cancer work up

A
  • intermediate if LND probability > 10%
  • high
  • very high
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10
Q

when is bone scan warranted on prostate cancer work up

A
  • unfavorable intermediate (4+3 or >50% cores on bx 3+4 ) if T2 and PSA > 10
  • high
  • very high
  • PSA > 20
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11
Q

when do you obtain germline testing in prostate cancer

A
  • 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
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12
Q

What genes are associated with Lynch syndrome in prostate cancer

A

MLH1, MSH2, MSH6, PMS2

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13
Q

when would you consider testing for MSI or dMMR?

A

N1 or M1 positive disease

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14
Q

If positive for MSI or dMMR what do you do?

A

Test for Lynch

May be eligible for pemborlizumab fo CRPC

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15
Q

Treatment options for low risk Prostate cancer

A 
Active surveillance
Brachy alone
EBRT alone
Radical prostatectomy
watchful waiting if life expectancy < 10 years
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16
Q

Treatment options for intermediate risk prostate cancer

A

Active surveillance (favorable only)
Brachy alone (favorable only)
Brachy + EBRT +/- ADT 4 months (Unfavorable)
Radical prostatectomy +LND > 2% metastasis

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17
Q

Treatment options for high risk local prostate cancer

A

EBRT + ADT (1.5- 3years)
Brachy + EBRT + ADT (1-3 years)
Radical prostatectomy + LND

18
Q

What are your options for Regional risk (extended Nodal disease present prior to treatment)

A

Germline testing
MSI and dMMR testing
ADT + EBRT +/- abiraterone and prednisone

19
Q

What is the definition of recurrence after radiation

A

ASTRO: 3 consecutive rises
Phoenix: nadir + 2

20
Q

Management for high risk features after prostatectomy (positive margin, T3)

A

EBRT +/- ADT

21
Q

what were the outcomes of the PLCO trial? what were it’s flaws

A

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

22
Q

What were the outcomes of the ESRPC trial?

A

20% reduction in CA mortality at 11 years between those screened w/ PSA and those not,

23
Q

What were the outcomes of the PROMIS trial?

A

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

24
Q

How is risk of lymph node involvement determined

A

Nomogram: MSK, Briganti, Partin

25
Q

How do you manage lymph node involvement

A

clinical: ADT + EBRT +/- abiraterone and prednisone

pathological (post prostatectomy): ADT

26
Q

Options for Castrate Sensitive M1 disease

A

ADT + Docetaxel (high volume disease), Apalutamide, enzalutimde, or abiraterone and prednisone

27
Q

Options for non metastatic M0 Castrate Resistant disease (index 1)

A
  1. ADT + enzalutamide or apalutamide (standard)
  2. NCCN includes Darolutamide if PSADT < 10mo
  3. ADT alone if refuse treatment or PSADT > 10mo
  4. ADT + abiraterone and prednisone
28
Q

Options for asymptomatic metastatic Castrate Resistant disease, good performance, no prior docetaxel (index 2)

A

A. ADT + abiraterone and prednisone or enzalutamide
B. ADT + Provenge or docetaxel
C. ADT + Ketoconazole and prednisone

29
Q

Options for symptomatic metastatic Castrate Resistant disease, good performance, no prior docetaxel (index 3)

A

A. ADT + abiraterone and prednisone or enzalutamide
B. ADT + docetaxel or mitoxantrone OR radium 223 if bony mets
C. ADT + Ketoconazole and prednisone

30
Q

Options for symptomatic metastatic Castrate Resistant disease, poor performance, no prior docetaxel (index 4)

A

A. ADT + abiraterone and prednisone or enzalutamide
C. ADT + Ketoconazole and prednisone
Expert Opinion. ADT + docetaxel or mitoxantrone

31
Q

Options for symptomatic metastatic Castrate Resistant disease, good performance, prior docetaxel (index 5)

A

A. ADT + abiraterone and prednisone or enzalutamide
B. ADT + cabazitaxel or Radium 223 if bony mets
C. ADT + Ketoconazole and prednisone or docetaxel

32
Q

Options for symptomatic metastatic Castrate Resistant disease, poor performance, prior docetaxel (index 6)

A

palliative care

33
Q

Abiraterone

A

MOA: CYP 17 inhibitor; inhibits androgen production throughout body
SE: HTN, hypokalemia, fluid retention, hepatoxicity
indications
Indications: CRPC, Metastatic CSPC, cN1 involvement

34
Q

Enzalutamide

A

MOA: Anti androgen; blocks receptor binding
SE: lowers seizure threshold, neurologic deficit
Indications: CRPC, Metastatic CSPC,

35
Q

Docetaxel

A

MOA: Taxane; microtubule disarray
SE: myelosuppresion, neurotoxicity, liver dysfunction
Indications: CSPC, metastatic CRPC

36
Q

What affect does pre-prostatectomy ADT have?

A

Can artificially elevate Gleason score, i.e. difficult to interpret

37
Q

where is the primary landing zone for nodal mets?

A

internal iliac

38
Q

What is the best way to manage castrate sensitive symptomatic metastatic disease?

A

LHRH antagonist

39
Q

how does one define high volume metastasis?

A

4 bone mets w/ one outside the spine/eplvis or visceral mets

40
Q

how is biochemical recurrence managed after exhaustion of local therapy and no evidence of metastasis?

A

Intermittent ADT or observation

41
Q

what is an option for select metastatic hormorone sensitive low volume disease who are not on androgen pathway directed therapy?

A

continuous ADT plus primary radiotherapy to prostate

Cancer (6 decks)

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