Treatment Flashcards
Radical radiotherapy doses
76-78Gy, or hypofractionated 60Gy in 20 doses over 4 weeks or 70Gy in 28 doses over 6 weeks
ADT with RT in intermediate and high risk disease
short term ADT with intermediate risk 4-6 months, 2-3 years with high risk disease
Pound data on BCR after radical prostatectomy
JAMA 1999
1997 RP from 1982 to 1997
No adjuvant hormones prior to M+
304 patients 15% developed rising PSA >0.2
of which 103 patients developed M+ 34%
median time to M+ 8 years from PSA elevation
once M+ median time to death 5 years
further analysis high gleason score 8-10 vs 5-7, PSA recurrence under 2 years, PSADT less than 10 months all do worse on MFS
EAU low risk BCR and high risk BCR
PSADT >1 year and ISUP grade <4, high risk = PSA DT 1 year or less OR ISUP grade 4-5
Brachytherapy CI
7
TURP
Volume more than 50cc or large median lobe
LUTS IPSS more than 12, qmax less than 15
Previous RT
Coagulation discord we
Complications RP
Infection bleeding 5-10% Death 0%_1.5% 1/300 Stricture 10-15% Incontinece mild 50% improving over 12-18 months long term 5-10% requiring more than a pad a day Erectile 40-60% Recurrence 5-25% Rectal injury 5%
Complications EBRT
Cystitis 20% Haematuria 18% Proctor is 30% severe long term 3% Urethral stricture 4-8% Incontknence 1% severe long term Leg oedema 6% ED25-60% occurs over several years Second cancer 1/300, 1 in 70 in long term survivors
Risk of biochemical progression with T3
30-50% over 5 years
Bolla study on adjuvant radiotherapy
EORTC 22911
Immediate post RP ART in positive margins T3 disease
503 patients
Vs delayed RT in biochemical progression
In pT3N0M0 disease
Immediate RT improves BPFS but not overall survival
Side effects of LHRH agonists 10
Flushing 80% Erectile dysfunction Osteoporosis Hyperlipidaemia Gynaecomastia Cognitive decline Diabetes Anaemia Loss of muscle mass Reduced quality of life
Metastatic disease survival
5 year 15%
Median survival 42 months
Average 2-3 years with a symptomatic disease
12 months with symptomatic disease
12-18 months to castrate resistance then 14 months to death
Action bisphosphonatss
Inhibit osteoclast mediated bone reabsorption
Zolendeonic acid for 15 months reduced skeletal events pathological fracture
Can also reduce pain
Metastatic spinal cord compression pathway
Due to vertebral collapse secondary to tumour invasion of from extradural tumour growth
Brachytherapy low dose
Dose in Gy
125 iodine 150 Gy Seeds 60-120 Dose delivered weeks to months Acute side effects resolve over months Radiation protection issues for family
Brachytherapy high dose
Iridium 192
NICE brachytherapy indications
T2c or less
PSA 20 or less
Gleason 7 or less
Action cryotherapy
Protein denaturarion due to dehydration
Rupture of membranes by ice crystals
Vascular stasis micro thrombi resulting in is anemic apoptosis
Two freeze thaw cycles at minus 40
Castration level testosterone
50ng/dl in trials
20ng/dl
Intermittent hormone therapy
Non inferior
T takes 9 months to recover so must not cycle for less than 9 months
Restart if PSA above 10 in NICE guidelines
Aims to delay androgen resistance
If ADT stopped before cells become androgen independent then further growth may be androgen dependent cells
Castrate levels reached on LHRH
2-4 weeks
Vs 8 hours with orchidectomy
3 days with LHRH antagonist
Definition of castrate resistant prostate cancer EAU
T level less than 50 And Radiological progression Or 3 consecutive rises in PSA one week apart resulting in 2 x 50% increases over nadir and PSA above 2
Causes of androgen resistance
Androgen independent clones
Over expression of androgen receptor
Intra cellular synthesis of T by cancer cells- can be target of abiraterone
Docetaxel survival increase
9 months with HSPC but only 2 months survival advantage CRPC
Given every 3 weeks with pred for 8-10 cycles
CHIIP trial
60Gy in 20 fractions over 4 weeks non inferior to 74Gy in 37 fractions over 6 weeks in 3216 men
