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42 Cards in this Set

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Define low-risk prostate cancer
PSA <= 10ng/mL AND
Gleason score <= 6 and
T1 or T2 stage
Define intermediate-risk prostate cancer
PSA of 10-20 ng/mL OR
Gleason score 7 AND
T1 or T2 stage
Define high-risk prostate cancer
PSA > 20 ng/mL OR
Gleason score 8-10 AND
T1 or T2 stage
What is the typical prescription for prostate brachytherapy in the low-risk patient?
Permanent prostate implant with total dose 145 Gy with I125
Describe prostate cancer risk factors
Age
-Increases at age 50 for white men
-Increases at age 40 for black men
-Increase at age 40 for those with first-degree relative with prostate cancer
Age-no peak but increases with age
Family history
-Twofold risk if first-degree relative with prostate cancer
-Ninefold risk if two first-degree relatives with prostate cancer
What increases serum PSA?
Prostate cancer
Urinary retention
Prostatitis
BPH
Prostatic manipulation
Of those patients with a PSA > 4.0 ng/mL, what percent will have a diagnosis of cancer?
15-25%
Since there is little specificity in the 4-10ng/mL range, how can you increase testing specificity?
Use the percent-free PSA in this indeterminate zone
Biopsy men with percent-free PSA < 10%
No biopsy if > 25%
Define percent-free PSA
free PSA / total PSA
Where do adenocarcinomas of the prostate usually arise?
70% peripheral zone
20% transitional zone
10% central zone
Define Gleason score
Based on growth pattern and degree of differentiation
Equal to the sum of the two most prevalent differentiation patterns
Each is scored 1-5
What Gleason scores correspond to low-grade (well differentiated), moderately differentiated, and high-grade (poorly differentiated) cancers?
Low-grade=2,3, or 4
Mod=5,6, or 7
High grade=8,9, or 10
What are the most common sites of metastatic prostate cancer?
Direct extention to periprostatic fat
Via ejaculatory ducts into the seminal vesicles
Lymphatically to regional lymph nodes (hypogastric and obturator lymph nodes)
Hematogeneously to bone (lumbosacral spine)
Risk of prostate cancer on biopsy by PSA level
< 4:
4-10:
>10:
Risk of prostate cancer on biopsy by PSA level
< 4: 5-25%
4-10: 15-25%
>10: 50-67%
Rule of thumb: Risk of prostate cancer with Gleason score 7-10 is PSA x 2
__% of tumors involve prostate apex

__% of patients have multifocal disease
50-80% of tumors involve prostate apex

85% of patients have multifocal disease
What histology comprises 95% of prostate cancers?
Adenocarcinoma
Primary prostatic lymph node drainage pattern
Primary prostatic lymph node drainage pattern
1 Internal iliac obturator
2 External iliac
3 Presacral
But also
1 perirectal
2 Common iliac
3 Paraaortic
Most frequently used prognostic indicators
1
2
3
Most frequently used prognostic indicators
1 Gleason score
2 Clinical stage
3 Pretreatment PSA
Percentage of positive cores is related to risk of recurrence. What % of positive cores behaves more aggressively?
Percentage of positive cores is related to risk of recurrence. What % of positive cores behaves more aggressively? 50%
What PSA velocity in the year before RP or EBRT may be associated with increased risk of death from prostate cancer? Reference?
What PSA velocity in the year before RP or EBRT may be associated with increased risk of death from prostate cancer? <2 mg/ml

D'Amico NEJM 2004; JAMA 2005.
Workup for prostate cancer
H&P: AUA sx score, baseline erectile function, bony pain, DRE
Labs: PSA, testosterone, CBC, LFTs
Bone scan & pelvic CT if T3-4, GS >=8, or PSA >= 20
RTOG Meta-Analysis Risk Groups with 10yr DSS
I:
II:
III:
IV:
RTOG Meta-Analysis Risk Groups
I: T1-2 & GS < 7 (low: 86%)
II: T1-2 & GS 7 or T3 or N1 with GS < 7 (intermediate: 75%)
III: T1-2 & GS 8-10 or T3 or N1 with GS 7 (high: 62%)
IV: T3 or N1 with GS 8-10 (very high: 34%)
Roach formulae
ECE:
SV involvement
LN involvement:
Roach formulae
ECE: 3/2 PSA + 10 (GS-6)
SV involvement: PSA + 10 (GS-6)
LN involvement: 2/3 PSA + 10 (GS-6)
Kattan nomograms
Computerized models
Predict primarily PSA recurrence
May predict pCa mortality after tx
RTOG 94-13
- Patients
- Selection criteria
- Randomization
1323 pts with PSA < 100 with LN risk > 15% to compare WP RT to prostate only (PO) and neoadj/concurrent HT (NCHT) to adj HT (AHT)
RTOG 94-13
- Radiation
- Whole pelvis RT:
- Final prostate RT dose:
- Hormone therapy:
-- NCHT timing:
-- AHT timing:
-- Bias?
RTOG 94-13
- Radiation
- Whole pelvis RT: 50.4 Gy
- Final prostate RT dose: 70.2 Gy
- Hormone therapy
-- Goserelin or leuprolide + flutamide
-- NCHT timing: 2m before 2m during RT
-- AHT timing: 4 m after RT
-- 2m bias in favor of AHT since PFS defined from time of randomization
RTOG 94-13 Results
- WPRT vs PO RT:
- WPRT + NCHT vs other arms:
- OS:
RTOG 94-13 Results
- WPRT vs PO RT: 4yr PFS 40 --> 56%
- WPRT + NCHT vs other arms: PFS 61% --> 45-49%
- OS: No diff in 4yr OS
EORTC Bolla Lancet 2002
415 pts
T1-2N0 GS > 6 or T3-4N0 any grade
RT +/- gosereln for three years
RT WP to 50 Gy --> prostate boost to 70 Gy
HT improved
- 5 yr OS 62 --> 78%
- DFS 40 --> 74%
Prostate cancer: PIN

Definition
Grades
Coincident with cancer
Prostate cancer: PIN

Definition: Prostatic intraepithelial neoplasia
Grades: Low and high
Coincident with cancer: 35% of patients with PIN had cancer on subsequent biopsy
Prostate cancer: Chemoprevention
1
2
3
Prostate cancer: Chemoprevention
1 LHRH anaalogues (goserelin, leuprolide)
- Side effects: anemia, atrophy of reproductive organs, decreased muscle mass, loss of libido, vasomotor instability
2 Nonsteroidal antiandrogens (flutamide, bicalutamide)
- SE: GI, gynecomastia, vasomotor sx
- Competitively bind to androgen receptors in target tissues
3 Competitive inhibitors of 5-alpha reductase (finasteride)
- Suppress intraprostatic dihydrotestosterone to castrate levels
- SE: No libido, potency, or muscle change
Prostate cancer: PSAV

Definition
Formula
Exponential increase in PSA begins ___ years before dx
Cutoff
Prostate cancer: PSAV

Definition: PSA Velocity
Formula: sPSA/time
Exponential increase in PSA begins 5 years before dx
Cutoff: Greater than or equal to 0.75 ng/mL/year=biopsy
Prostate cancer: PSAD

Definition
Formula
Cutoff
Prostate cancer: PSAD

Definition: PSA Density
Formula: sPSA/prostate vol (US-prolate elipsoid)
Cutoff: Greater than or equal to 0.15 ng/mL/cm3=biopsy
Prostate cancer: free PSA

Physiology
Cutoff
Prostate cancer: free PSA

Physiology: The proportion of PSA complexed to alpha one-antichymotrypsin > in patients with pCa, ratio freePSA/totalPSA (percent free PSA) is lower in men with cancer
Cutoff
- <15-20%=biopsy
- >25% cancer unlikely
Prostate Cancer: What are the arterial and venous vessels for the prostate?
Prostate Cancer: What are the arterial and venous vessels for the prostate?

Arterial: Internal iliac artery

Venous: Prostatic plexus to internal iliac vein
Prostate Cancer: What are the three main histologic types of prostatic epithelium?

Which produces PSA?
Prostate Cancer: What are the three main histologic types of prostatic epithelium?
1 Secretory
2 Basal
3 Neuroendocrine

Which produces PSA? Secretory even though it has the lowest proliferative activity of the three.
Prostate Cancer: What is the definition of a positive resection margin in pCa?
Prostate Cancer: What is the definition of a positive resection margin in pCa?

Tumor cells touching the inked surface of the prostate.
Prostate Cancer: What are the primary sites of bony metastasis?
1
2
3
4
5
Prostate Cancer: What are the primary sites of bony metastasis?
1 Vertebral column (74%)
2 Ribs (70%)
3 Pelvis (60%)
4 Femurs (44%)
5 Shoulder girdle (41%)
Prostate Cancer: When is a bones scan indicated in pretreatment evaluation?
Prostate Cancer: When is a bones can indicated in pretreatment evaluation?

Oesterling JAMA 1993;269:57:
Symptomatic patient
sPSA > 10 ng/mL
High-grade tumor
NCCN
T1/T2 with PSA > 20
Gleason >= 8
T3/T4
Symptomatic
Prostate Cancer: When is a ProstaScint scan indicated?
Prostate Cancer: When is a ProstaScint scan indicated?

In postprostatectomy patients with increased sPSA to differentiate between locoregional and distant disease but NOT in routine pretreatment evaluation
Prostate Cancer: What is the physiologic variation of PSA and what does it mean?
Prostate Cancer: What is the physiologic variation of PSA and what does it mean?

- Difference in PSA levels observed when a second sample is obtained from the same patient within a few weeks
- May be as high as 0.298; for a sPSA of 4, an increase to 5.2 (4 x 0.298) is in the range of physiologic variability
Prostate Cancer: What is the serum half-life of PSA and what does it mean?
Prostate Cancer: What is the serum half-life of PSA and what does it mean?

- 2.2-3.2 days
- May take several weeks for PSA to return to baseline after prostatic biopsy or to reach nadir after prostatectomy
Prostate Cancer: Which of the following causes increased sPSA: digital exam, prostatic massage, TRUS, ejaculation, cystoscopy, TURP, and prostate biopsy?
Prostate Cancer: Which of the following causes increased sPSA: digital exam, prostatic massage, TRUS, ejaculation, cystoscopy, and prostate biopsy?

TURP and biopsy