Guide Lines for Management

of Genitourinary Malignancy.
2. Prostate Cancer.

Mohamed S. Zaghloul
Hussein Khaled
Moneir Aboul Ella
 Diagnosis

 Prostatic symptoms + transrectal

ultrasound (TRUS) and biopsies from all
lobes of the prostate.
 Pathologic exam should include.
- Tumor grade (WHO).
- Gleason's score 1-5 + 1-5
 Work up
 Laboratory
 CBC
 S. Creatinine
 PSA (total &free)
 LFTS
 Imaging
 Chest x-ray
 CT abdomen and pelvis
 Bone scan (if PSA is more than 10,high S. alkaline
phosphatase , tender or painful bony symptoms )
 MRI pelvis (optional).

Staging: according toTNM classification system

 Treatment
Stage I&II : with intact prostatic capsule:
Either
 nerve sparing radical prostatectomy

or
 radical radiotherapy with, at least,

conformal radiotherapy (70-80 Gy).

 PORT
Indications of PORT after radical
prostatectomy:

i. Capsular infiltration.
ii. Seminal vesicle infiltration.
iii. Positive safety margin.
 Treatment
Stage III:
 Neoadjuvant hormonal manipulation by
LHRH agonist (with antiandrogen for the
first 2 weeks)(Goserelin “Zoladex” or
Leuproline “Leuporon” , for 2 months
before and 2 months during radiotherapy)
70 Gy radical radiotherapy whole pelvis for
50 Gy and 20 Gy boost to the prostate.
Maintenance LHRH agonist for 6-24
months (for high risk patients).
 Treatment
Stage IV (metastatic):
 Bilateral subcapsular orchiectomy ± flutamide
daily orally or androcure 250 mg/day.
 Second line hormonal therapy:
Bicalutamide (Casodex) 50-100 mg daily orally
 Palliative radiotherapy to bone metastasis
 Hormone refractory or resistant patients
- Mitoxantrone (Novantron) 12 mg/m2 every 3
wks + prednisone 10 mg daily.
- 2nd line: Docetaxil (Taxotere) 75 mg/m2 every
3 weeks.
 Treatment
 Management of biochemical failure after
radical treatment:
(Biochemical failure is defined as serum
prostate specific antigen levels of 0.4
ng/ml following surgery, 0.5 ng/ml
following radiotherapy and/or 2
consecutive rising prostate specific antigen
values 3 months apart).
Patients with biochemical failure need to
be investigated for local or systemic
recurrences.
 Follow-up

every 3 months for the first 3

years, every 6 months thereafter.
3.Renal Carcinoma & Renal
pelvis carcinoma

Mohamed S. Zaghloul
Hussein Khaled
Moneir Aboul Ella
 Work up
 * Laboratory
 CBC

 S.Creatinine
 LFTS

 * Radiologic
 Chest x-ray
 CT abdomen and pelvis (or IVU +
abdominopelvic US)
 Bone scan (optional)
 Treatment
1.Renal cell Ca.
 Resectable cases:

Radical nephrectomy: complete

removal of Gerota’s fascia and its
content including the adrenal gland,
kidney and perinephric fat. It may
include resection of hilar LN or even
regional LN.
 Post operative radiotherapy

may be added in the following :

 1. Invasion of the capsule

 2. Positive LN.
 3. Positive safety margin or
residual tumors.
 Metastatic Renal Cell Ca
 i. Metastatectomy in pulmonary or brain
metastases (maximum 3 separate metastases).
 ii.Palliative nephrectomy and/or removal of
metastatic foci
in the following conditions.
 No central nervous system, bone or liver
metastases.
 Adequate pulmonary and cardiac functions.
 Good performance status.
 Predominantoly clear cell histology.
 Severe renal symptoms eg repeated
hemorrhages, tumor pain or significant
paraneoplastic syndrome.
 Metastatic Renal Cell Ca

 iii. Cytoreductive maneuvers : embolization ,

chemoembolization, ….

 iv. Palliative radiotherapy or chemotherapy

and biologic therapy
- (Interferon 3 million units every other day
and Vinblatine 0.1 mg/kg body weight
every 3 weeks then reevaluation).
 Ca. of Renal pelvis
a. Resectable cases
 Radical nephrouretrectomy with removal
of a bladder cuff.

 Adjuvant PORT is added in:

1. Large tumors invading the renal
capsule or Gerota's fascia.
2. high grades.
 b. Inoperable cases : are palliated by
palliative radiotherapy or as metastatic cases

c. Metastatic renal pelvis Ca.

 Palliative radiotherapy or chemotherapy using

 Gemcitabine 1000 mg/m2 D1 & D8
 Cisplatin 70 mg/m2 D2
Every 3 weeks.
Testicular cancer

Mohamed S. Zaghloul
Hussein Khaled
Moneir Aboul Ella
 Diagnosis

Any solid testicular mass should be

diagnosed by scrotal US followed by
inguinal high orchiectomy (no direct
testicular or fine needle aspiration
biopsy).

CT-guided biopsy is recommended for

diagnosis of tumour on top of
abdominal undescended testis.
 Work up
 Laboratory
 CBC

 LFTS, S. Creatinine
 AFP, βHCG, LDH

 Radiologic
 Chest x-ray (CT in retroperitoneal
positive lymphadenopathy).
 Abdominopelvic CT (or IVU & bipedal

lymphangiography).
 Treatment
 Inguinal high orchiectomy and
biopsy of the other testis.

 Active treatment according to

the stage.
 Observation

is recommended only for

stage IA compliant patients.

 Pelviabdominal CT every 2 months

during the first year & every 4 months
thereafter.
 Treatment of relapsed cases
 a. relapsed stage I cases who did not receive
radiotherapy :
 i) Non bulky (< 5 cm) are treated with
radiotherapy 35- 40 Gy.
 ii) Bulky (≥ 5 cm) ,received radiotherapy or
having visceral or
pulmonary disease are treated with
chemotherapy as mentioned
above (as stages IIc and III).
 b. relapsed stage II & III are treated with
second line chemotherapy.
 Response Evaluation, further
management & follow up:
 CT scan has to be done 1-2 months post
treatment. If normal follow up to be performed
every 2 months during the first year and every 4
months thereafter. If abnormal and the mass is
≥ 3 cm either resect the mass or radiotherapy (if
no previous radiotherapy given). If the mass is
< 3 cm observe till the mass progress treat as
above.
 NB: If PET scan is available it will be of great
help in detecting residual disease.
 Non- Seminoma
 Nerve- sparing retroperitoneal lymph node
dissection (RPLND) :
1. If LN are negative : Observation.
2. If LN are positive either observe or
give chemotherapy in non-compliant
patients or if there are extensive
nodal involvement.
 Stage IB
 there are 2 options:
 i. RPLND.
 ii. Chemotherapy 2 courses of BEP.

 Stage IS :
Chemotherapy in the form of 4 cycles of EP or 3
cycles of BEP.
 Stage II (A or B):
i) If Tumor markers are not elevated patients are
treated by either RPLND + adjuvant 2 courses of
chemotherapy OR 4 courses of EP or 3 courses of BEP.
ii) If markers are elevated give chemotherapy.
 Stage IIC & III and extragonadal
primary sites (Mediastinum or
retroperitoneim

Primary Chemotherapy according to risk

status.
 i) Good risk : either 4 cycles of EP or 3
cycles of PEB.
 ii) Intermediate or poor risk : 4 cycles of
PEB.
Incompletely responded or relapsed
patients
treated with surgical salvage if presented
in a single site.
 Resistant cases are treated with third line
(high-dose) chemotherapy.
 Third line chemotherapy consisted of 2
cycles of high dose carboplatin and
etoposide ± cyclophosphamide (or
ifosphamide).
 Follow-up
 Every3 months in the first
years & every 6 months
thereafter.

 CXR and CT abdomen to be

performed every year