Prostate Cancer FRCR CO2A Flashcards
What are main types of prostate cancer
Adenocarcinoma > 95%
Transitional carcinoma
squamous cell carcinoma or
small cell carcinoma, Lymphoma, sarcoma, carcinosarcoma, carcinoid
whats the peak age of Prostate cancer incidence
70 - 75 years
where does most of the Prostate cancer arises
peripheral zone
what are the RFs for prostate cancer
Family Hx, RR double with 1st degree relative diagnosed before 70 years of age and 4 times if two relatives and one under 65 years of age
BRCA2 mutation, 5 times
How does Prostate cancer spread
Locally to involve seminal vesicle and base of bladder
Spread to rectum is inhibited by Denovillier’s fascia
Lymphatics to pelvic and PA Lns
Hematogenous spread to Bone, specially spine, femur, pelvis and ribs
Liver and lUng mets uncommon but can be in CRPC
IS screening with PSA recommeded
No
to save 1 life, 781 men are screened and 27 cancers must be treated
if at all, screening should be done for which people
Family History, BRCA 2 or Afro Caribbean descent, not done in UK
what are symptoms and signs of Prostate cancer
Early: rarely produces symptoms
LUTS
Erectile dysfunction
Hematuria, Hematospermia
LN spread or metastatic disease: Bone mets: pain, nodal spread: lower body edema
What investigations are suggested for Prostate cancer
TRUS guided sampling of the peripheral zone involving at least 10 cores covering all parts of gland
MRI : peripheral zone on T2 images, tumors visible as low signal region in an area of high signal (normal tissue)
Bone scan: not required in low risk pts
How is MRI helpful in Prostate cancer
extracapsular involvment, seminal vesicle invasion and nodal disease can be identified as well as small bone mets that may not be seen on a bone scan can be identified
what risk groups Prostate cancer pts be classified into
Low, Intermediate and High
who falls in Low risk group for Prostate cancer
PSA < 10 ng/ml, GS </= 6 and T1-T2a
prognosis: excellant 90 % disease free at 10 years
who falls in intermediate risk group for Prostate cancer
PSA 10 - 20 ng/ml, GS 7 and T2b
Prognosis: good, small chance of death at 10 years
who falls in High risk group for Prostate cancer
PSA > 20 ng/ml, GS 8-10, >/= T2c
Prognosis: fair, significant chance of death within 10 years
what are treatment options for localized Prostate cancer
Active Surveillance, radial prostatectomy, interstitial BT, EBRT (possibly with adjuvant Hormonal therapy)
How is Low Risk Group Treated?
- Active Surveillance for younger pts
- watchful waiting for older patients
- RT including Brachy
- surgery
How is Intermediate Risk Group Treated?
Monitoring is till reasonable in the elderly but not recommended for younger pts
Options of Prostatectomy or RT combined with HT
How is high risk group treated?
- Standard Rx for T3 disease is primary RT with NA or adjuvant Hormone therapy for up to 3 years
- Nodal irradiation for those at increased risk of nodal involvment
- Radical Prostatectomy followed by post op RT
when is prostatectomy preferred
T1/T2 disease and early T3 with post op RT
what are advantages of Prostatectomy
good published outcomes, immediate treatmetn, rapid access to prognostic information and decrease in PSA following Sx
an undetectable PSA at around 6 weeks after Sx is a/w good long term results
when is post op RT indicated post radical prostatectomy
- persistently raised PSA levels at 6 weeks (>0.1 ng/ml) and
- positive margins
what are disadvantages of prostatectomy
- high rates of ED (50%)
- Urinary morbidity, persistent urinary incontinence
what LDR source is used as permanent implants in prostate cancer and whats its T1/2
Iodine 125, 60 days
What Dose is delivered with Iodine LDR sourrce in prostate cancer
140 - 145 Gy
What is included in RT field for Low risk disease
Prostate and proximal 2 cm of SV usually withou hormone therapy
What is included in RT field for Intermediate risk disease
Prostate and whole of SV and NA hormone therpay
What is included in RT field for High risk disease
Prophylactic nodal irradiation along with adjuvant hormone therapy for 2 - 3 years
What are relative C/I for RT in prostate cancer
IBD, Diverticulitis
How is simulation for RT in Prostate cancer done
- supine position, 1 antr and 2 lateral tattoos, if nodal RT is considered, IV contrast, knee support, full bladder, enema b4 planning and b4 each treatment session
What RT dose is give in Prostate cancer
SIB 74 Gy/37#: prostate, 50 Gy/ 37# for nodal irradiation and 56 Gy/ 37# to prostate and SV with 1 cm margin
what has CHHiP study shown
prolonged fractionation in PC is not going to improve therapeutic ratio, slightly better control with 60 Gy/ 20# to 74 Gy/ 37# with comparable late toxicity at 5 years
How is Contouring Prostate be accurate
guidance from staging MRI scans and biopsy, IV contrast for nodal RT, prostatic apex should be carefully defined to minimise dose to rectum and penile bulb
What are OARs for Prostate cancer RT
Rectum, Bladder, Bowel, Femoral Heads and Penile Bulb
High dose region should be limited to < 25% of rectal volume
what nodal groups to be included in Prostate cancer RT fields?
Common iliac from the sacral promontary, the presacral nodes, External (upto femoral heads) and internal iliac, obturator nodes
How to ensure accuracy of RT treatment for prostate cancer
Daily online imaging with CBCT, alternatively 3 gold seed markers be placed, mandatory for SABR therapy
What is target volume for post op RT in prostate cancer
surgical anastomosis and prostate bed
Anter: pubic symphisis
Postr: includeds rectum
Lateral: NV bundles and adjacent ilio obturator muscles
supr: bladder neck and
Infr: to within 15 mm of penile bulb
what post op RT dose is given in Prostate cancer
60 - 64 Gy in 30-32# or 52.5 - 55 Gy in 20 #
for how long post RT patients should be followed up
life long for high risk pts
what tests on follow up is adviced for prostate cancer pts
PSA every 6 -12 months
How is Relapse defined with PSA
three successive incrases in PSA above a nadir value or nadir + 2 ng/mL
what indicates a cure post RT without Hormone therapy for prostate cancer pts
stable PSA 4 - 5 years post Rx
Is Salvage prostatectomy recommended my NICE post RT in prostate cancer?
No, complications are high
How is LHRH analogues different from LHRH inhibitors?
both gives castrate level of testosterone but antagonist give it without testosterone flare
Bicalutamide is prescribed for initial weeks for LHRH analgues
LHRH inhibitors useful in emergency
what are s/e of hormone therapy
impotence, sweats and flushes, deepression and decreased bone density
How is CSPC treated (NCCN)
ADTz with docetaxel and one of
the following:
* Preferred regimens:
Abiraterone (category 1)
Darolutamide (category 1)
* Other recommended regimens
Apalutamide (category 2B)
Enzalutamide
how is M1 CRPC treated (NCCN)
Abirateronez,(category 1 if no visceral metastases)
Docetaxel(category 1)
Enzalutamide
Niraparib/abirateronefor BRCA mutation (category 1)
Olaparib/abirateronefor BRCA mutation (category 1)
Pembrolizumab for MSI-high (MSI-H)/dMMRddd (category 2B)
Radium-223s,nnn for symptomatic bone metastases (category 1)
Sipuleucel-Tddd,ooo (category 1)
Talazoparib/enzalutamide for HRR mutation
how can gynecomastia be prevented or reduced with RT
8 Gy orthovoltage RT to breast buds
what RT dose is given for painful bony mets in Prostate cancer
SF 8 Gy usually give rapid pain relief
30 Gy / 10 #.
Strontium 89 therapy
How can toxicity of Docetaxel be reduced?
premedication with dexamethasone 8 mg BD starting 24 hours before Chemo
Which chemo has shown to be effective in 2nd L after docetaxel
Cabazitaxel
what are bisphosphonates used in Prostate cancer
Zoledronate ( Not recommended by NICE)
denosumab who are intolerant to bisphosphonates
