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Clinical Oncology > Prostate Cancer > Flashcards

Prostate Cancer Flashcards

1
Q

Epidemiology

A
  • second greatest cause of male cancer mortality
  • highest rates are in Scandinavia, lowest in Asia
  • higher incidence in African American men
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2
Q

Etiology

A
  • increasing age
  • diets high in fat
  • race
  • family history
  • geographic location
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3
Q

Natural history of prostate ca

A
  • found in peripheral zone of gland
  • multifocal disease
  • tend to extend into and through capsule of the gland, invade bladder neck, peri prostatic tissues and seminal vesicles
  • have late local spread to the rectum and bladder
  • slow growing
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4
Q

Screening process

A
  • age 50-70 years annually (asymptomatic)
  • DRE + PSA blood test
  • only 25-50% with abnormal DRE have prostate ca on biopsy
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5
Q

Why is PSA screening currently debated?

A

does not reduce mortality from disease which is the whole rationale for screening programs!

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6
Q

Clinical presentation

A

-typically asymptomatic at presentation

Local disease: urinary hesitancy, nocturne, decreased stream, increased frequency, urinary obstruction, renal failure

Metastatic disease: bone pain, bone marrow failure, lymphedema

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7
Q

What are normal PSA levels by age

A

40-49: 0-2.5
50-59: 0-3.5
60-69: 0-4.5
70+: 0-6.5

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8
Q

Diagnosis

A
  1. Patient hx and physical exam
  2. DRE (can only detect posterior tutors through rectal wall)
  3. PSA test (>4/ng/mL requires referral to urology)
  4. TRUS (transracial ultrasound)
  5. Confirm malignancy via biopsy
  6. CBC, urinalysis, renal function test, calcium
  7. CT/MR pelvis (LN involvement)
  8. Bone scan is metastatic disease suspected
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9
Q

What percentage of lesions on the prostate are benign?

A

50%

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10
Q

What is a six quadrant TRUS guided bx?

A

Biopsy that takes samples from four zones of the prostate: base, apex, two sides and mid-gland

Has the highest diagnostic accuracy

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11
Q

What is done in the place of pelvic LN biopsies?

A

-LN dissection during radical prostatectomy is nodal involvement suspected (not routine for low risk pts)

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12
Q

Pathology of prostate ca?

A

-95% are adenocarcinomas and are located peripherally

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13
Q

What is BPH?

A
  • Benign prostate hyperplasia
  • enlargement of prostate due to overgrowth of cells
  • not cancerous
  • found in transition zone, surrounding urethra
  • does NOT increase risk of having prostate ca
  • typically asymptomatic
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14
Q

BPH tx

A

Alpha blockers to relax muscles near the prostate and lifestyle changes (examples: dec night time fluid intake, inc pelvic floor exercise)

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15
Q

Routes of spread of prostate ca?

A
  • bone (90%)
  • lung (46%)
  • liver (25%)
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16
Q

Gleason system

A

-higher score=worse prognosis

G1: low grade, well differentiated (2-6)
G2: intermediate, moderately differentiated (7)
G3: high, poorly differentiated (8-10)

17
Q

Grade groups

A
  • group Gleason scores
  • group 1 is most likely to spread slowly
  • group 5 is most likely to grow and spread quickly
18
Q

Staging

A

Localized=disease confined to prostate (Stages 1 and 2)

Locally advanced=spread through prostate capsule to surrounding tissue (Stages 3 and 4)

Metastatic disease=spread to other parts of the body

19
Q

Risk levels

A
  • Guide tx options and prognosis

- higher risk pts will be offered more aggressive tx than lower risk pts

20
Q

Tx options-low risk patients

A
  • active surveillance
  • surgery (radical prostatectomy; T1 or T2)
  • EBRT or brachy
21
Q

RT doses for low risk patients

A

Proton: 76-82 Gy

EBRT: >10 MV, 4 field, IMRT, VMAT, fields include seminal vesicles and prostate gland (regional LN if advanced); 60Gy/ 20 fr or 78Gy/ 39

Brachy: Iridium 192, 45.5 Gy/7 fr/ 3.5 days

22
Q

Organs at risk and their TD 5/5s

A
  • bladder (65 Gy)
  • rectum (60 Gy)
  • small bowel (40 Gy)
  • femoral heads (52 Gy)
23
Q

Acute RT side effects

A
  • erythema
  • fatigue
  • bladder irritation
  • radiation proctitis-diarrhea, bleeding, rectal urgency
  • erectile dysfunction
24
Q

Chronic RT side effects

A
  • impotency
  • cystitis, hematuria, incontinence
  • proctitis
  • rectal ulcers/fistulas
  • lymphedema
25
Q

Eligibility for brachy?

A
  • early stage
  • life expectancy > 10 years
  • TRUS imaging to assess prostate volume (less than 60 cc)
  • good surgical candidate
  • no prior surgery
  • no prior pelvic RT
  • no urinary obstructive symptoms
26
Q

Brachy side effects

A
  • urinary symptoms for 6-12 mo after tx (e.g. urgency, nocturia, hematuria)
  • rectal symptoms possibly up to 2 years (e.g. cramping, rectal bleeding, tenesmus)
  • erectile dysfunction
27
Q

Tx options for high risk patients

A

-Systemic therapies, endocrine therapy and EBRT

28
Q

EBRT dose for high risk pts

A

Phase I-whole pelvis including LNs at risk; 45-50 Gy/25 fr

Phase II-prostate and seminal vesicles; 70-80 Gy/39 fr

29
Q

EBRT borders for phase I (high risk pts)

A

Superior: L5
Inferior: bottom of ischial tuberosities
Lateral: 1.5-2 cm clearance beyond pelvic rim
Anterior: anterior of symphysis pubis
Posterior: S2/S3 junction (include rectum)

30
Q

Tx options for metastatic patients

A
  • ADT: surgical or medical castration

- Chemo: docetxel, cabazitaxel, mitoxantrone

31
Q

Medical castration

A
  • LH-RH agonist injection
  • get an initial flare reaction (i.e., increase in testosterone levels)
  • anti-androgens (e.g. Flutamide) given to prevent flare reaction and can be added to a tx if orchiectomy/LHRH agonist no longer working
32
Q

Side effects of endocrine therapy

A
  • hot flashes
  • mood swings
  • fatigue
  • osteoporosis
  • loss of muscle mass, increase in obesity
  • change in lipid profiles/blood sugar
  • impotence
  • dec in sexual desire
  • breast and nipple tenderness
  • flare reaction in the first 1-2 wks of tx
33
Q

Are surgery and radical EBRT/brachy approximately equivalent in outcomes?

A

Yes

34
Q

Best prognostic pt group?

A

T1/T2, PSA<10, Gleason<6

35
Q

What if PSA rises after tx?

A

Suspect nodal or metastatic spread

Clinical Oncology (5 decks)

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