Q: what is castrate resistance and what do you do about it?
Castrate resistance:
* PSA goes up while testosterone castrate
o Add bicalutamide first for total androgen blockage
* Others: docetaxel, Radium 223
Others: Lu-177, abiraterone, enzalutamide, cabazitaxel
Brachytherapy procedure
- If a patient undergoing LDR then complete volume study 3 weeks prior, contour the prostate on the volume study and order needles with pre-spaced seeds.
- Consult anesthesia, ECG, bloodwork
- Bowel prep patient the day before
- General anesthetic with intraoperative antibiotics (Ancef 1g)
- Place in dorsal lithotomy position
- Place foley, irrigate rectum
- Drain the bladder and load it with contrast
- Prep the perineum with antiseptic, tape the scrotum forward
- Insert TRUS and secure the probe
- Place needles/catheters confirming placement on US (12-16 needles for HDR, >100
seeds for LDR, primarily peripherally loaded) - Capture an U/S image of the prostate with bubble enhanced saline through the urethra
- Contour on planning software
- Insert seeds as per plan or connect afterloader for LDR and HDR respectively
- Withdraw needles/catheters, applying pressure to perineum
- Remove Foley and TOV
- Discharge patient with 3 month prescription for Flomax
- For LDR brachytherapy followup CT in 1 month
Name two ARATs and their contraindications
2) abiraterone MOA, what must give with, S/E
Contra-indications: Siezures -> enzalutamide
CHF -> abiraterone
ARAT stands for: androgen receptor axis-targeted (ARAT) agents
2) CYP17 inhibitor
- S/E: HTN, Heart failure, elevated LFTs
- Must give prednisone with abiraterone to minimize mineralcorticoid effects: this is why you cannot give with CHF
Bladder: when do we do RT and what do we give?
The only indication is if a patient declines cystectomy.
- We give 60Gy/30# to whole bladder with concurrent cisplatin 40mg weekly
Stage II bladder: define and management
Stage II is muscle invasive node negative and anything higher than that.
Note: n1 is only one positive lymph node
N2 is multiple lymph nodes
Treatment is neoadjuvant chemotherapy with cisplatin/gemcitabine followed by radical cystectomy and pelvic LND
What is removed in a radical cystectomy
Males: prostate, SVs, distal vas deferens, proximal 1-2cm of urethra, visceral peritoneum, distal ureter, bladder.
Females: hysterectomy + BSO, anterior vaginal wall, anterior pelvic peritoneum, urethra, bladder, distal ureter
Management Ta, Tis, T1
1st: MAXIMAL TURBT
Then:
Ta= noninvasive papillary carcinoma. If low grade: observe.
Tis: insitu, T1= lamina propria. These plus Ta grade 2/3: BCG weekly x 6 weeks.
If recurrence, repeat above. If persistent recurrence: cystectomy. Recurrence rate 50%; half of recurrences are muscle invasive.
Who can be considered for partial cystectomy
- Should be solitary tumor <5cm in suitable location (lateral walls or dome)
- Absence of CIS or previous multifocal disease (think: bc bladder cancer has like field defects).
Who is the ideal candidate for bladder preservation
- T2-3a (only microscopically invades through muscularis propria into perivesicular fat
- unifocal
- <5cm
- no hydronephrosis or hydroureter (LOL DUH): RT will make worse
- good renal function (Bc rt to kidneys <3)
- node negative (just becase: remember we also do not treat the nodes so this is easy to recall)
- Good initial bladder function: bc rt will make this worse - like what is the benefit or preserving an organ that does not work well in the first place
Treatment for:
1) High risk prostate
2) n1 prostate
3) low burden metastatic:
4) High metastatic burden with bone only and then with visceral mets
1) EBRT + ADT x 2 years
2) N1: RT to prostate + WPRT plus ADT
3) RT to prostate + ADT + abiraterone
4) ADT + abiraterone, if visceral mets ADT + docetaxel
1) What is first eschelon drainage for testicular cancer?
2) What are two variants of lymphatic drainage of the left testes:
1) Right testes: first echelon drainage along IVC to paracaval and aortocacal lymph nodes
- Left testicle: first echelon along L renal vein (this is why we include the left peri-hilar nodes for left sided tumors) to the para-aortic LN
2) left renal hilum, directly to PA nodes
Bladder preservation pcr, 5yr OS:
PCR 70%, OS 50%
What are the 2 important dosimetric constraints and what are the coverage goals for
1) LDR?
2) HDR
1) - Urethra Dmax<150%
- Rectum D1 cc<100% of prescription dose
Coverage: CTV V100 > 95%
CTV V150< 60%
CTV V200 < 20%
2) urethra Dmax <130%,
- Rectum Dmax <80%
THINK: HDR is 20% less for both
Coverage: CTV V100 > 95%
CTV V150< 35%
CTV V200 < 11%
Prostate: 4 different ways of daily on treatment verification
Fiducial markers and KV imaging
Cone beam CT
Portal images
Transabdominal Ultrasound with IGRT
Bladder case, presumably for CRT. What is important on EUA and cystoscopy report (4 things?)
Location of tumor
Completeness of TURBT
fixation to pelvic side wall
multifocality
papillary or flat
outlet obstruction
were random biopsies done for CIS?
Was the UVJ biopsied? Was the prostatic urethra biopsied for tumours near the trigone?
Volume for post op prostate surgery
Note: it includes nodes and 2 years of ADT
8 bad prognostic features for locally invasive bladder cancer
- High grade
- Multifocality
- Incompleted TURBT
- Coexisting extensive CIS
- Hydronephrosis
- Lymph node involvement
- LVI +
- Mixed histology
- Tumour T category: more adverse with greater wall invasion
Others - Residual disease after chemoRT
- Tumor size >3cm
- Ureteral obstruction
- age
- KPS
- poor bladder function,
