Workup/Staging Flashcards
Name 4 important aspects of a focused Hx to include in a pt with newly diagnosed prostate cancer.
GI/GU Sx: may inform the most appropriate type of therapy
Comorbid illnesses: especially Hx of inflammatory bowel Dz or previous bowel Sgs (e.g., candidacy for RT, Sg, hormone suppression)
Meds: especially use of α-blockers or androgen suppression
New-onset bone pain: should result in a thorough evaluation for bone mets
What are the 3 most important clinical and pathologic factors for risk stratifying men with locally confined prostate cancer?
- Pre-Tx PSA
- DRE-defined cT
- Gleason group
Describe the recommended procedure for Bx of the prostate.
Prostate Bx should be performed using a transrectal approach with a US transducer in the rectum. A sextant Bx directed at the peripheral zone should result in 12 cores of prostate tissue.
Describe the appearance of prostate cancer on TRUS.
Prostate cancer on TRUS is usually hypoechoic.
Define the current NCCN (2018) prostate cancer risk groups.
Very low: T1c, GS ≤6, PSA <10 ng/mL, <3 Bx cores +, ≤50% cancer per core, PSA density <0.15 ng/mL/g
Low: T1–T2a, GS ≤6, PSA <10 ng/mL
Favorable Intermediate: T2b–T2c or GS 3 + 4 = 7 or PSA 10–20 ng/mL and <50% postive cores
Unfavorable intermediate: T2b–T2c or GS 3 + 4 = 7 or PSA 10–20 ng/mL
High: T3a or GS 8–10 or PSA >20 ng/mL
Very high: T3b–T4 or primary Gleason pattern 5 or >4 cores with GS 8–10
What men should undergo a bone scan per NCCN guidelines (2018)?
T2 and PSA >10 ng/mL; high or very high risk groups
What men should undergo pelvic imaging (CT or MRI)?
Per NCCN guidelines (2018) pelvic imaging is indicated for intermediate, high and very high risk groups if nomogram indicated probability of LN involvement >10%. However, developing literature suggests a broader role for MRI. The PROMIS study was a multicenter randomized trial from 2012 to 2015 in 576 Bx-naïve pts who underwent 1.5T MRI plus Bx and found that for clinically significant cancer (GS ≥4 + 3 or a max cancer core length 6 mm or longer), MRI was more sensitive (93% vs. 48%; p < 0.0001) but less specific (41% vs. 96%; p < 0.0001) than TRUS-Bx. MRI may also be sup in the identification of Gleason ≥3 + 4. (Rais-Bahrami et al., J Urol 2013) T3 MRI has been shown to be advantageous in predicting ECE at Sg with a sensitivity and specificity of 58.2% and 89.1%, respectively. (Somford et al., J Urol 2013)
What is the role of tissue-based molecular assays in decision making for prostate cancer?
A number of tissue-based molecular assays have been developed for treated and untreated men with localized prostate cancer (e.g., Decipher, Oncoptype DX, Prolaris) and shown in retrospective analyses to provide prognostic information beyond NCCN risk groups regarding outcomes such as risk of biochemical failure, metastatic Dz and mortality. Their exact role remains incompletely defined pending prospective evaluation but current Molecular Diagnostic Services Program recommendations support their post-RP with adverse features (Decipher), and post-Bx in low-risk Dz (Oncotype DX; Prolaris; ProMark).
Describe the AJCC 8th edition (2018) clinical TNM staging of prostate cancer.
Note: Per the AJCC, clinical T staging may use imaging.
cT1: Clinically inapparent tumor not palpable
cTla: Incidental histologic finding in ≤5% of tumor resected
cT1b: Incidental histologic finding in >5% of tissue resected
cT1c: Tumor identified by needle Bx but not palpable
cT2: Palpable organ-confined Dz
cT2a: Tumor involves one-half of 1 side or less
cT2b: Tumor involves more than one-half of 1 side but not both sides
cT2c: Tumor involves both sides
cT3: Extraprostatic tumor that is not fixed or does not invade adjacent structures
cT3a: ECE
cT3b: Seminal vesicle invasion
cT4: Adjacent organ involvement (bladder, external sphincter, rectum, pelvic wall, or levator muscles)
N1: regional LN mets
M1: DMs
M1a: Nonregional LNs
M1b: Bone(s)
M1c: Other sites
Describe the AJCC 8th edition (2018) pathologic TNM staging of prostate cancer.
pT2: Organ-confined Dz
pT3: ECE
pT3a: ECE or microscopic invasion of bladder neck
pT3b: Seminal vesicle involvement
pT4: Adjacent organ involvement (bladder, external sphincter, rectum, pelvic wall, or levator muscles)
Note: Per the AJCC, pathologic assessment is based on evaluation of a prostatectomy specimen, unless a Bx shows involvement of the rectum, seminal vesicles, or extraprostatic tissues.
N1: regional LN mets
M1: DMs
M1a: Nonregional LNs
M1b: Bone(s)
M1c: Other sites
