Genitourinary Malignancies — Board Review Summary

PART I — PROSTATE: WORKUP, DEFINITIONS, AND MODERN RISK STRATIFICATION

Risk Groups and the 2026 Framing

Risk groupCore featuresPractical treatment implication
Low riskGenerally cT1-T2a, GG1, PSA <10Active surveillance preferred
Favorable intermediate riskSingle IR feature, GG1-2, limited core burdenRT alone is often enough
Unfavorable intermediate riskAt least 2 IR features, any GG3, or higher core burdenRT + short-course ADT
High riskcT3a, PSA >20, or GG4-5Definitive RT + long-course ADT
Very high riskDeck emphasizes STAMPEDE-style biology: at least 2 of cT3-4, GG4-5, PSA >40Consider systemic intensification, especially abiraterone
2026 slide-deck pearl: the old "very low risk" bucket has effectively been retired from the practical decision framework. Low-risk disease is treated as a strong active surveillance disease unless pathology or imaging reveals a hidden higher-risk feature.

Definitions to Memorize

Biochemical failure after definitive RT: nadir + 2 ng/mL (Phoenix definition).
After SBRT: the deck notes that true recurrence is more convincing if nadir + 2 occurs after 18 months, or if PSA at 18 months divided by PSA at 6 months is >~2.5.
Biochemical recurrence after RP: ≥0.2 ng/mL on 2 readings.
Surrogate endpoint pearl: MFS, not BCR or FFBF, is the validated surrogate for OS.

Imaging and Biomarkers

  • PSMA PET is now a major staging tool in unfavorable intermediate-risk and high-risk disease and has caused real stage migration.
  • ProPSMA showed superior accuracy versus CT + bone scan in higher-risk staging.
  • In the salvage setting, PSMA PET yield is limited at very low PSA, especially <0.2.
  • Decipher is the most relevant biomarker in the deck and is now built into multiple NRG strategies for de-intensification or intensification.
  • The deck explicitly notes that Oncotype and Prolaris are not emphasized because the evidence quality is weaker.

ProtecT and Cribriform Disease

ProtecT remains the core trial for counseling localized prostate cancer. At 15 years, prostate-cancer mortality was low and similar across active monitoring, RT, and surgery, but metastases were more frequent with monitoring. About 50% of active-monitoring patients underwent treatment by 10 years.
ProtecT cribriform update: about 15% of the cohort had cribriform morphology, including 21% of GG2 and 65% of GG3 disease. The lecture's bottom line is strong: cribriform / intraductal disease is not safe to monitor. In the slide interpretation, RT plus short-course ADT appeared more protective against metastasis than surgery in this subgroup.

PART II — INTACT PROSTATE: AS, RT, RP, FRACTIONATION, AND TECHNIQUE

AS vs RT vs RP

ProtecT showed no overall-survival difference among active monitoring, RT, and RP, but the functional tradeoffs remain highly testable. Surgery produced the most durable incontinence and worse erectile dysfunction. RT caused more bowel bother, although the RT arm used older 3D techniques without IMRT, IGRT, or spacers.
High-risk counseling pearl: the slide deck leans toward the view that metastasis risk is higher after RP than RT in high-risk disease, while low- and intermediate-risk disease are more equivalent. That is a counseling nuance, not a clean randomized conclusion.

Conventional vs Moderate Hypofractionation

TrialRegimensMain resultBoard takeaway
RTOG 041573.8/41 vs 70/28Similar FFBF; more grade 2 GI with hypofractionationNon-inferiority in low risk
PROFIT78/39 vs 60/20Same FFBF; late GI may be lower with 60/20Key regimen supporting moderate hypofractionation
CHHiP74/37 vs 60/20 vs 57/1960/20 non-inferior to 74/3760 Gy / 20 fx is the best memorized regimen
HYPRO78/39 vs 64.6/19Similar control, more grade 3 GU in hypofractionated armNot all hypofractionation is equal
MARCAP HYDRA is the modern synthesis: isodose moderate hypofractionation, exemplified by 60 Gy / 20, is the current standard. Dose-escalated moderate hypofractionation does not clearly improve efficacy and does increase GI toxicity.
Whole-gland dose principle: the lecture argues there is limited benefit to escalating the whole gland beyond about 80 Gy EQD2. The memorable equivalents given were about 80 Gy at 2 Gy/fx, 60 Gy at 3 Gy/fx, or 37.5 Gy in 5 fx.

SBRT and Modern Platform Trials

TrialComparisonMain message
PACE-ASBRT vs RPRP produced permanently worse incontinence and sexual function; SBRT caused more temporary bowel bother
PACE-B36.25 Gy / 5 vs conventional / moderate-hypo RTNon-inferior efficacy; very low grade 3 toxicity; somewhat more cumulative grade 2+ GU with SBRT
PACE-C36.25 Gy / 5 vs 60 Gy / 20 with 6 months ADTSimilar early efficacy and overall toxicity; GI signal slightly favored moderate hypofractionation
MIRAGEMR-guided vs CT-guided SBRTTighter MR margins reduced toxicity
PartiQOLProton vs photonNo meaningful QOL or disease-control advantage for protons
Spacer pearl: spacers reduce rectal dose and may reduce some acute grade 2 GI toxicity, but the lecture is intentionally balanced. Patient-reported QOL advantages are less convincing, and placement complications do occur.

Focal Therapy and Brachytherapy

  • Focal therapy is acknowledged in 2026 NCCN, but the deck is blunt: no randomized evidence against RT or RP, recurrence is common, and it should not be used outside a clinical trial.
  • Brachytherapy remains a technically strong option in selected men, but utilization is falling sharply because noninvasive 5-20 fraction EBRT is now so good.
  • After prior definitive RT, the deck views SBRT and brachytherapy as the strongest salvage local modalities from the retrospective MASTER meta-analysis.

LUTS / IPSS Practical Pearl

IPSS ≥15-25 is a relative contraindication to prostate RT, and the threshold is lower for SBRT. High LUTS is especially problematic for brachytherapy.
First-line management is typically alpha-blockers, with escalation based on whether symptoms are irritative or obstructive. The deck also emphasizes not blaming RT until you have excluded UTI, medication effects, and systemic causes.

PART III — INTACT PROSTATE INTENSIFICATION: ADT, DOSE ESCALATION, PELVIC RT, AND cN1

Who Needs ADT?

Risk groupTypical ADT approachBoard-style summary
Low riskNoneActive surveillance preferred
Favorable intermediate riskOften noneADT benefit is not compelling in FIR
Unfavorable intermediate risk4-6 monthsBest-supported short-course ADT group
High risk12-36 months on boards; often practically closer to 18 monthsADT improves MFS and OS
Very high risk / cN1Long-course ADT + abirateroneMain modern intensification strategy
RTOG 9408, EORTC 22991, and RTOG 0815 together teach that short-course ADT in intermediate-risk disease improves biochemical, metastatic, and prostate-cancer-specific endpoints, but the benefit is strongest in unfavorable intermediate-risk disease, not favorable intermediate-risk disease.
MARCAP / SANDSTORM: concurrent + adjuvant ADT is better than prolonged neoadjuvant + concurrent ADT. This is a high-yield sequencing pearl.
Duration nuance: the deck's biologic interpretation is that the sweet spot for many high-risk men may be closer to 9-12 months, but the practical exam answer in 2026 remains 12-36 months for high-risk disease.

High-Risk Dose Escalation

TrialSchemaMain resultTakeaway
ASCENDE-RTEBRT boost vs LDR brachy boost after pelvic RT + ADTLarge bPFS gain, no OS gain, major increase in grade 3 GUBrachy boost improves control but is toxic
FLAME77 Gy / 25 vs same + DIL SIB to 95 GyImproved bDFS without significant late GU/GI penaltyBest modern dose-escalation strategy
GETUG-1870 Gy vs 80 Gy with 36 months ADTOS signal favored 80 Gy, but toxicity and interpretation caveats remainImportant positive trial, but not enough to overturn broader whole-gland dose principles

Systemic Intensification Beyond ADT

TrialIntensificationMain resultBoard takeaway
RTOG 0521Docetaxel added to RT + ADTEarly OS signal faded with longer follow-upDo not routinely add docetaxel to all high-risk M0 men
STAMPEDE G/JAbiraterone/prednisone +/- enzalutamide added to RT + ADTClear MFS and OS benefit with abi; no added efficacy from enza, only more toxicityUse abiraterone, not abi+enza, in very high-risk / N1
cN1 M0 answer: the deck explicitly says to treat pelvic node-positive disease at diagnosis with curative intent using EBRT + ADT + abiraterone.

Whole-Pelvis RT

TrialMain resultInterpretation
RTOG 9413Complicated 2 x 2 design; not cleanly definitive for modern pelvic RTHistoric but hard to apply literally
POP-RTImproved bFFS and DMFS with WPRT; no OS differenceBest positive modern nodal-RT trial, but still debated
RTOG 0924No DM or OS benefit for WPRTWhole-pelvis RT is selective, not automatic
HOPEPelvic 25 Gy / 5 after HDR boost had similar QOL to conventional pelvic RTInteresting modern hypofractionated pelvic strategy
cN1 modern 20-fraction schema from the deck: prostate 60 Gy / 20, elective pelvic nodes 44 Gy / 20, and involved pelvic nodes up to 55 Gy / 20.

PART IV — POST-PROSTATECTOMY, SALVAGE, AND RADIORECURRENT DISEASE

Adjuvant vs Early Salvage

ARTISTIC plus RAVES, RADICALS-RT, and GETUG-17 established that early salvage RT is favored over routine adjuvant RT for most men with adverse pathology after RP. Adjuvant RT improves biochemical control but increases overtreatment and toxicity, without a clear OS gain for the average patient.
Definitions:
Adjuvant RT: post-RP RT with undetectable PSA for adverse pathology.
Salvage RT: post-RP RT for rising PSA.
Early salvage: generally PSA 0.5.
Very early salvage: the deck highlights PSA 0.01-0.2.

Post-Op Dose and Fractionation

The deck is cautious here:
  • No clear routine role for escalating the prostate bed beyond about 66 Gy
  • NRG GU-003 supports moderate hypofractionated salvage RT from a 2-year QOL standpoint
  • But a long-term retrospective hypofractionated series showed notable late severe toxicity, so durable follow-up still matters

Post-Op Volume Pearls

PSMA PET failures versus standard RTOG CTV show that failures are often posterior, inferior, and lateral to the classic postop bed volume. The deck uses this to argue that our historic postop volumes may be missing a meaningful fraction of disease.

Who Benefits from ADT in Salvage RT?

TrialMain resultBoard takeaway
RTOG 9601Bicalutamide improved OS overall, but benefit was concentrated in higher pre-salvage PSA, especially >1.5At very low PSA, ADT benefit is small and may be offset by harm
GETUG-166 months LHRH improved BCR endpointsMostly an early-salvage / biochemical-benefit trial
SPPORT / RTOG 0534Most of the benefit came from adding ADT; no evidence supporting pelvic RT aloneIf you intensify, do not forget the systemic part
POSEIDONNo meaningful OS benefit to adding HT when pre-PORT PSA was ≤0.5Very low PSA is the key "do less" group
RADICALS-HDNo OS benefit to longer ADT; only marginal MFS gainNo compelling reason for routine prolonged HT postop
Post-op synthesis: in early salvage disease with PSA roughly 0.1-0.5, ADT usually does not improve MFS or OS meaningfully. In later salvage, especially at higher PSA, the case for ADT is stronger. The slide set repeatedly emphasizes that pre-salvage PSA is both prognostic and predictive.

High-Risk BCR and EMBARK

EMBARK defined high-risk biochemical recurrence as PSA >2 after RT or >1 after RP, with PSA doubling time <9 months and testosterone >150. Enzalutamide + leuprolide outperformed leuprolide alone for MFS. This is a major systemic-therapy update for aggressive M0 recurrence.

Radiorecurrent Local Failure After Prior RT

MASTER suggests that among salvage local options after prior RT, SBRT and brachytherapy have the best combination of control and toxicity. This is retrospective evidence, but it is highly board-relevant.

PART V — METASTATIC PROSTATE: PRIMARY RT, MDT, mHSPC, AND mCRPC

Low-Volume vs High-Volume Matters

CHAARTED / STAMPEDE high-volume means 4 or more bone metastases with at least one outside the axial pelvis/spine region, or visceral metastases. This distinction remains central to decisions about RT to the primary.

RT to the Primary in De Novo mHSPC

TrialMain resultTakeaway
STAMPEDE Arm HOS benefit in low-volume metastatic diseasePrimary RT is standard in de novo low-volume mHSPC
HORRADNo OS benefit overallOlder negative study, especially in higher-volume disease
STOPCAPApproximate 7% 3-year OS gain for men with <5 bone metsMemorize this number
PEACE-1RT to prostate improved rPFS and delayed serious GU events, but not OS in the abiraterone eraRT still matters, but its main value is no longer purely survival

Metastasis-Directed RT

STOMP, ORIOLE, and related studies established MDT as a real progression-delaying strategy in oligometastatic prostate cancer. The lecture's pooled meta-analysis, WOLVERINE, showed hazard ratios of roughly 0.5-0.6 across the main progression endpoints.
Emerging 2026 concept: adding 177Lu-PNT2002 before SBRT in oligorecurrent hormone-sensitive disease improved PFS from 7.4 to 17.6 months and prolonged hormone-therapy-free survival. This is not yet routine standard, but it is a major future-direction trial.

Systemic Therapy Landscape the Rad Onc Should Know

  • mHSPC: ARPI intensification is now standard.
  • mCRPC: radiopharmaceuticals are central, especially Ra-223 for bone-predominant disease and Lu-PSMA in PSMA-positive disease.
  • ARTO and PCS-9 provide supportive phase II data for MDT in selected oligometastatic / oligoprogressive mCRPC settings.

PART VI — BLADDER CANCER

Where RT Matters

CIS: no RT.
T1: essentially no routine curative RT role.
T2-T4a, select N0-1: bladder preservation with chemoRT is a core standard option.

Why Bladder Preservation Matters

The deck's logic is straightforward: survival with bladder preservation is similar to cystectomy in well-selected patients, cystectomy is morbid, long-term QOL after cystectomy is worse, and many patients are elderly, frail, or poor surgical candidates. The lecture explicitly frames bladder preservation as a major win for function-preserving oncology.

Ideal Trimodality Candidate

  • Unifocal cT2-4 disease
  • Maximal TURBT
  • No extensive CIS
  • No significant hydronephrosis, or corrected if possible
  • Reasonable baseline bladder function

Continuous-Course CRT vs Split-Course CRT

ParadigmField designTakeaway
Continuous courseBladder only, not elective pelvic nodesPreferred modern approach
Split course / Shipley styleBladder + pelvic nodes with planned interim cystoscopic reassessmentHistorically important but less favored now

Key Trials and Regimens

Trial / regimenRTChemoMain message
BC200164 Gy / 32 or 55 Gy / 20MMC + 5-FUCRT improved locoregional control vs RT alone
BC2001 reduced high-dose volume55 Gy / 20 SIB with 44 Gy / 20 to uninvolved bladderMMC + 5-FUModern partial-bladder dose painting concept
Michigan / RTOG 0712 eraDaily RTGemcitabine-based or cis/5FU-basedGemcitabine is a real radiosensitizer option
BC2001 + BCON pooled analysis: 55 Gy / 20 had better local control than 64 Gy / 32. This is one of the clearest GU hypofractionation wins.

Post-Cystectomy RT

BART suggests that adjuvant IMRT 50.4 Gy to the cystectomy bed and pelvic nodes improves LRFS in high-risk MIBC with acceptable toxicity. This is important but not yet a blanket recommendation for every patient after cystectomy.

PART VII — RCC, SEMINOMA, AND PENILE CANCER

Renal Cell Carcinoma

Old conventional RCC RT failed badly. Modern RCC RT is fundamentally different: high dose per fraction, tighter volumes, and a nephron-sparing treatment goal in a disease where CKD drives non-cancer mortality.
StudyMain resultTakeaway
iROCKExcellent outcomes in T1b-T2 RCC; single-fraction SBRT commonly 25-26 Gy x 1SBRT is not just for tiny tumors
Correa meta-analysisLocal control 97%, grade 3+ toxicity 1%, small impact on kidney functionAnchor SBRT numbers for primary RCC
Common RCC SBRT regimens: 26 Gy x 1, 14 Gy x 3, and 8 Gy x 5. Planning relies on motion assessment, 4DCT when available, MRI fusion when helpful, and tight ITV-based margins.

Seminoma

All seminoma patients: radical transinguinal orchiectomy with high ligation of the cord. Never scrotal biopsy.
Stage I: observation is preferred; alternate options are carboplatin or 20 Gy para-aortic RT.
Stage IIA: 20 Gy / 10 dogleg + boost to 30 Gy or cis/etop x4.
Stage IIB: chemo is often preferred, but RT remains an option with boost to 36 Gy.
Stage IIC+: chemotherapy.
Seminoma RT technique: AP/PA only, no IMRT. The deck also emphasizes kidney D50 <8 Gy to each kidney if both kidneys are present, and no RT for horseshoe kidney. Use contralateral testicular shielding / clamshell when appropriate.

Penile Cancer

Penile cancer is treated conceptually more like vulvar or head-and-neck disease than typical GU adenocarcinoma.
Surgery remains primary treatment, but RT matters for R1, LN+, and T3-4 cases and for organ preservation in selected patients.
Prepubic fat is part of the high-risk CTV in modern contouring.
SettingDose guidance
Gross penile disease65-70 Gy
Nodal basin with ECEAbout 60 Gy
Adjuvant elective volume45-60 Gy
Palliation30 Gy / 10

CROSS-CUTTING HIGH-YIELD POINTS

  • MFS, not BCR or FFBF, is the validated surrogate for OS in prostate RT trials.
  • Cribriform / intraductal prostate cancer should not be managed with surveillance.
  • Prostate moderate hypofractionation standard: 60 Gy / 20.
  • Whole-gland dose escalation beyond about 80 Gy EQD2 has limited value.
  • FLAME is the cleanest positive dose-escalation study because it boosts the DIL rather than the whole gland.
  • ASCENDE-RT improves biochemical control but causes major GU toxicity and no OS gain.
  • UIR prostate is the clearest intermediate-risk group that benefits from short-course ADT.
  • Concurrent + adjuvant ADT is superior to prolonged neoadjuvant + concurrent sequencing.
  • Very high-risk / cN1 prostate: RT + ADT + abiraterone is the major 2026 intensification answer.
  • WPRT improves progression endpoints more consistently than OS and remains controversial.
  • Post-prostatectomy: early salvage beats routine adjuvant RT for most men.
  • Post-op ADT benefit depends on PSA; it is strongest when salvage is later and PSA is higher.
  • Low-volume de novo mHSPC: RT to the primary improves OS.
  • Oligometastatic prostate cancer: MDT is now a genuine standard in selected patients.
  • Bladder preservation is a mainstream standard for selected MIBC and is best delivered as continuous-course CRT.
  • Bladder hypofractionation winner: 55 Gy / 20.
  • Primary RCC: SBRT is a real nephron-sparing treatment, not just palliative RT.
  • Stage I seminoma: observation preferred; if irradiating, memorize 20 Gy para-aortic.
  • Penile cancer: remember the high-risk CTV includes prepubic fat.

CONSOLIDATED DOSE TABLE

SettingDose / regimenComment
Localized prostate moderate hypofractionation60 Gy / 20 fxModern default standard
Localized prostate SBRT36.25 Gy / 5 fxPACE-style regimen
DIL boost (FLAME)77 Gy / 25 with SIB to 95 GyImproved bDFS without major late-toxicity penalty
cN1 prostate60 Gy / 20Prostate dose in modern 20-fx schema
cN1 elective pelvic nodes44 Gy / 20Elective nodal dose
cN1 involved nodesUp to 55 Gy / 20Boosted nodal disease
Oligopelvis nodal recurrence54 Gy / 30 with SIB to 66.6 GyOLIGOPELVIS
Bladder conventional64 Gy / 32Classic BC2001 schedule
Bladder hypofractionation55 Gy / 20Preferred modern regimen
Bladder reduced high-dose-volume RT55 Gy / 20 SIB + 44 Gy / 20Partial bladder dose painting
Adjuvant post-cystectomy RT50.4 GyBART
Primary RCC SBRT26 Gy x 1Common single-fraction regimen
Primary RCC SBRT14 Gy x 3Common multifraction regimen
Primary RCC SBRT8 Gy x 5Common multifraction regimen
Stage I seminoma20 GyPara-aortic RT
Stage IIA seminoma20 Gy / 10 + boost to 30 GyDogleg + GTV boost
Stage IIB seminoma20 Gy + boost to 36 GySelected patients only; chemo often preferred
Gross penile disease65-70 GyDefinitive gross disease dose
Penile nodal basin with ECE~60 GyBoosted nodal basin
Penile elective adjuvant RT45-60 GyAdjuvant range
Penile palliation30 Gy / 10Palliative course

KEY LANDMARK TRIALS (memorize)

TrialDiseaseOne-line takeaway
ProtecTLocalized prostateNo OS difference among monitoring, RT, and RP; monitoring has more metastases
ProtecT cribriform analysesLocalized prostate pathologyCribriform / intraductal disease is not safe to monitor
CHHiP / PROFITLocalized prostateModerate hypofractionation is non-inferior to conventional RT
HYDRA-MARCAPLocalized prostate fractionationIsodose moderate hypofractionation such as 60/20 is modern SOC
PACE-B / CLocalized prostate SBRTSBRT is an accepted standard option with low severe-toxicity rates
RTOG 9408Intermediate-risk prostateShort-course ADT improves outcomes, especially in UIR
FLAMEHigh-risk prostate dose escalationDIL boost improves biochemical control without major late-toxicity penalty
ASCENDE-RTHigh-risk prostate boostBrachy boost improves biochemical control but at major GU-toxicity cost
STAMPEDE G/JVery high-risk / cN1 prostateAbiraterone added to RT + ADT improves MFS and OS
POP-RTWhole-pelvis RT in intact prostateImproves progression endpoints, not OS
RTOG 0924Whole-pelvis RT in intact prostateNo DM or OS benefit for WPRT
ARTISTICPost-prostatectomy timingEarly salvage RT is favored over routine adjuvant RT
RTOG 9601Salvage RT +/- ADTADT benefit is concentrated in later salvage / higher PSA
GETUG-16Early salvage RT +/- ADTImproves biochemical control, not clearly OS
SPPORT / RTOG 0534Salvage RT intensificationMain postoperative benefit comes from ADT, not pelvic RT alone
EMBARKHigh-risk BCREnzalutamide + leuprolide beats leuprolide alone
STAMPEDE Arm HDe novo low-volume mHSPCRT to the primary improves OS
STOPCAPPrimary RT in metastatic prostateMemorize the roughly 7% 3-year OS gain for men with <5 bone mets
PEACE-1mHSPC primary RT + abi eraImproves rPFS and delays GU progression, not OS
WOLVERINEOligometastatic prostate MDTPooled modern trials support SBRT as a real progression-delaying strategy
BC2001MIBC bladder preservationChemoRT improves locoregional control versus RT alone
BCON / Choudhury pooled analysisBladder fractionation55 Gy / 20 outperforms 64 Gy / 32 for local control
BARTPost-cystectomy high-risk MIBCAdjuvant IMRT improves LRFS with acceptable toxicity
iROCKPrimary RCC SBRTStrong data for localized RCC, including larger tumors
Correa meta-analysisPrimary RCC SBRTLocal control about 97% with grade 3+ toxicity about 1%