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42 Cards in this Set
- Front
- Back
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Define low-risk prostate cancer
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PSA <= 10ng/mL AND
Gleason score <= 6 and T1 or T2 stage |
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Define intermediate-risk prostate cancer
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PSA of 10-20 ng/mL OR
Gleason score 7 AND T1 or T2 stage |
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Define high-risk prostate cancer
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PSA > 20 ng/mL OR
Gleason score 8-10 AND T1 or T2 stage |
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What is the typical prescription for prostate brachytherapy in the low-risk patient?
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Permanent prostate implant with total dose 145 Gy with I125
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Describe prostate cancer risk factors
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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 |
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What increases serum PSA?
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Prostate cancer
Urinary retention Prostatitis BPH Prostatic manipulation |
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Of those patients with a PSA > 4.0 ng/mL, what percent will have a diagnosis of cancer?
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15-25%
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Since there is little specificity in the 4-10ng/mL range, how can you increase testing specificity?
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Use the percent-free PSA in this indeterminate zone
Biopsy men with percent-free PSA < 10% No biopsy if > 25% |
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Define percent-free PSA
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free PSA / total PSA
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Where do adenocarcinomas of the prostate usually arise?
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70% peripheral zone
20% transitional zone 10% central zone |
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Define Gleason score
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Based on growth pattern and degree of differentiation
Equal to the sum of the two most prevalent differentiation patterns Each is scored 1-5 |
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What Gleason scores correspond to low-grade (well differentiated), moderately differentiated, and high-grade (poorly differentiated) cancers?
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Low-grade=2,3, or 4
Mod=5,6, or 7 High grade=8,9, or 10 |
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What are the most common sites of metastatic prostate cancer?
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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) |
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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 |
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__% of tumors involve prostate apex
__% of patients have multifocal disease |
50-80% of tumors involve prostate apex
85% of patients have multifocal disease |
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What histology comprises 95% of prostate cancers?
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Adenocarcinoma
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Primary prostatic lymph node drainage pattern
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Primary prostatic lymph node drainage pattern
1 Internal iliac obturator 2 External iliac 3 Presacral But also 1 perirectal 2 Common iliac 3 Paraaortic |
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Most frequently used prognostic indicators
1 2 3 |
Most frequently used prognostic indicators
1 Gleason score 2 Clinical stage 3 Pretreatment PSA |
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Percentage of positive cores is related to risk of recurrence. What % of positive cores behaves more aggressively?
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Percentage of positive cores is related to risk of recurrence. What % of positive cores behaves more aggressively? 50%
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What PSA velocity in the year before RP or EBRT may be associated with increased risk of death from prostate cancer? Reference?
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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. |
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Workup for prostate cancer
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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 |
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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%) |
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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) |
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Kattan nomograms
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Computerized models
Predict primarily PSA recurrence May predict pCa mortality after tx |
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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)
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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 |
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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 |
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EORTC Bolla Lancet 2002
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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% |
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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 |
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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 |
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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 |
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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 |
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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 |
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Prostate Cancer: What are the arterial and venous vessels for the prostate?
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Prostate Cancer: What are the arterial and venous vessels for the prostate?
Arterial: Internal iliac artery Venous: Prostatic plexus to internal iliac vein |
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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. |
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Prostate Cancer: What is the definition of a positive resection margin in pCa?
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Prostate Cancer: What is the definition of a positive resection margin in pCa?
Tumor cells touching the inked surface of the prostate. |
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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%) |
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Prostate Cancer: When is a bones scan indicated in pretreatment evaluation?
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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 |
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Prostate Cancer: When is a ProstaScint scan indicated?
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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 |
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Prostate Cancer: What is the physiologic variation of PSA and what does it mean?
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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 |
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Prostate Cancer: What is the serum half-life of PSA and what does it mean?
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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 |
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Prostate Cancer: Which of the following causes increased sPSA: digital exam, prostatic massage, TRUS, ejaculation, cystoscopy, TURP, and prostate biopsy?
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Prostate Cancer: Which of the following causes increased sPSA: digital exam, prostatic massage, TRUS, ejaculation, cystoscopy, and prostate biopsy?
TURP and biopsy |
