Radiotherapy For Renal Cell Carcinoma Research Articles

227: Respiratory Motion Management in Stereotactic Ablative Body Radiotherapy for Renal Cell Carcinoma

227: Respiratory Motion Management in Stereotactic Ablative Body Radiotherapy for Renal Cell Carcinoma

The role of stereotactic ablative body radiotherapy in renal cell carcinoma: focus on oligometastatic and oligoprogressive disease.

The role of stereotactic ablative body radiotherapy in renal cell carcinoma: focus on oligometastatic and oligoprogressive disease.

Stereotactic Body Radiotherapy for Renal Cell Carcinoma in Patients with Von Hippel-Lindau Disease-Results of a Prospective Trial.

Simple SummaryClear cell renal cell carcinoma (ccRCC) frequently occurs in patients with von Hippel–Lindau disease and is a leading cause of mortality in patients with this hereditary disorder. Partial nephrectomy, which is the standard treatment, is often complicated by multilocular tumor occurrence in both kidneys requiring repeated surgeries. Consequently, nephron-sparing resections become increasingly difficult ultimately leading to chronic kidney failure. In these patients or in patients who refuse surgery, alternative treatment approaches are needed. In this study, we investigated the outcome and toxicities especially for the kidney after stereotactic body radiotherapy (SBRT). We could demonstrate that SBRT in this highly vulnerable group of patients is feasible without any high-grade adverse events in the long-term and results in excellent local control at the site of treatment. Efficacy of SBRT is already proven for other anatomic sites and it could represent a valuable, non-invasive treatment option for ccRCC as well, especially for patients who are extremely vulnerable to any kidney injury. Further prospective trials evaluating SBRT for localized ccRCC are necessary to verify the promising findings and to examine its role as an alternative to surgery in inoperable patients.Von Hippel–Lindau disease (VHL) is a hereditary disorder associated with malignant tumors including clear cell renal cell carcinoma (ccRCC). Partial nephrectomy is complicated by multilocular tumor occurrence and a high recurrence rate. The aim of this study was to evaluate the potential of stereotactic body radiotherapy (SBRT) as an alternative treatment approach in VHL patients with multiple ccRCC. Patients with VHL and a diagnosis of ccRCC were enrolled. SBRT was conducted using five fractions of 10 Gy or eight fractions of 7.5 Gy. The primary endpoint was local control (LC). Secondary endpoints included alteration of renal function and adverse events. Seven patients with a total of eight treated lesions were enrolled. Median age was 44 years. Five patients exhibited multiple bilateral kidney cysts in addition to ccRCC. Three patients underwent at least one partial nephrectomy in the past. After a median follow-up of 43 months, 2-year LC was 100%, while 2-year CSS, 2-year PFS and 2-year OS was 100%, 85.7% and 85.7%, respectively. SBRT was very well tolerated with no acute or chronic toxicities grade ≥ 2. Mean estimated glomerular filtration rate (eGFR) at baseline was 83.7 ± 13.0 mL/min/1.73 m2, which decreased to 76.6 ± 8.0 mL/min/1.73 m2 after 1 year. Although the sample size was small, SBRT resulted in an excellent LC rate and was very well tolerated with preservation of kidney function in patients with multiple renal lesions and cysts.

Chronic expanding hematoma of the left erector spinae muscle after stereotactic body radiotherapy for renal cell carcinoma: a case report

BackgroundHematomas that slowly increase in size for more than 1 month after the initial hemorrhage are referred to as chronic expanding hematomas. Chronic expanding hematoma can also occur after radiosurgery; however, there have been no reports about chronic expanding hematoma in the trunk after stereotactic body radiotherapy. We report a case of chronic expanding hematoma of the left erector spinae muscle after stereotactic body radiotherapy for renal cell carcinoma.Case presentationA 74-year-old Japanese male complained of back pain 7 years after stereotactic body radiotherapy for renal cell carcinoma of the left kidney. There was no history of surgery or trauma to his back. After stereotactic body radiotherapy, there was no acute or late complication of more than grade 2. The renal cell carcinoma did not show shrinkage or progression, and he was diagnosed with stable disease on computed tomography. The patient remains in a stable disease condition 7 years after treatment without surgery or chemotherapy; however, he came to the hospital with gradually worsening back pain for several months. Computed tomography revealed the left erector spinae muscle to be swollen compared with the contralateral side at the third lumbar level. Ultrasonography showed a tumor of 30 mm in size without blood flow in the left paraspinal muscle. Positron emission tomography–computed tomography revealed uptake in the left paraspinal muscle. Pathological examination showed radiation-induced chronic expanding hematoma.ConclusionsWe present the first case report of chronic expanding hematoma of the left erector spinae muscle after stereotactic body radiotherapy for renal cell carcinoma. Usually, stereotactic body radiotherapy for renal cell carcinoma would be considered unlikely to cause chronic expanding hematoma, but the introduction of dialysis and antiplatelet drugs may have increased the risk.

75: Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncologic and Renal Function Outcomes

75: Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncologic and Renal Function Outcomes

Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncological and Renal Function Outcomes

AimsTo evaluate oncological and renal function outcomes of stereotactic body radiotherapy (SBRT) for medically inoperable patients with localised renal cell carcinoma. Materials and methodsConsecutive patients treated with curative intent SBRT (30–45 Gy in five fractions or 42 Gy in three fractions) were included. Data on local control (Response Evaluation Criteria in Solid Tumors [RECIST] v1.1), distant metastasis, impact on estimated glomerular filtration rate (eGFR) and proportional ipsilateral and contralateral renal functions (measured through renal scans) were collected. Univariate and multivariable analyses were conducted to determine association of variables with oncological and renal function outcomes. ResultsSeventy-four patients were analysed. The median follow-up was 27.8 months (interquartile range 17.6–41.7). Fifty-seven per cent had tumours ≥ T1b. One-, 2- and 4-year cumulative incidence of local failure was 5.85, 7.77 and 7.77%, respectively. The cumulative incidence of distant metastasis at 2 years was 4.24%. On multivariable analysis, a lower planning target volume (PTV) mean dose (P = 0.019) and a larger PTV (P = 0.005) were significantly associated with the risk of developing local failure. A lower PTV maximum dose (P = 0.039) was significantly associated with the risk of developing distant metastasis. The median change in global eGFR (ml/min) from pre-SBRT levels was –7.0 (interquartile range –14.5 to –1.0) at 1 year and –11.5 (interquartile range –19.5 to –4.0) at 2 years. The proportion of ipsilateral (differential) renal function decreased over time from 47% of overall renal function pre-SBRT to 36% at 2 years, whereas the proportion of contralateral renal function correspondingly improved. On multivariable analysis, a higher volume of uninvolved renal cortex (P < 0.0001) was significantly associated with a smaller decrease in eGFR over time. ConclusionIn this large institutional cohort, oncological outcomes of renal cell carcinoma treated with SBRT were favourable and a longitudinal decline in renal function in the ipsilateral kidney and compensatory increase in the contralateral kidney were observed. Clinical and dosimetric factors were significantly associated with oncological and renal function outcomes.

Hypofractionated radiotherapy for renal cell carcinoma with inferior vena cava tumour thrombus

Renal cell carcinoma (RCC) constitutes about 3% of all malignant neoplasms in adults. Clear cell carcinoma is the most frequent type, accounting for about 65% of cases. It tends to invade the veins and form tumour thrombi in inferior vena cava (IVC-TT), occasionally reaching the right atrium. Nephrectomy and thrombectomy are standard therapeutic procedures performed in RCC-IVC-TT. Despite proven effectiveness of surgery, this entity in IVC-TT is associated with poor outcome. The role of palliative radiotherapy in this entity is undetermined. We present a case of a 43-year-old female patient after right-sided nephrectomy due to advanced RCC which invaded the IVC, hepatic veins, and right atrium. The patient has been treated with postoperative, hypofractionated radiotherapy on the residual disease.

MP14-12 STEREOTACTIC ABLATIVE RADIATION THERAPY (SABR) FOR TREATMENT OF RENAL CELL CARCINOMA (RCC) WITH INFERIOR VENA CAVA TUMOR THROMBUS (IVC-TT)

INTRODUCTION AND OBJECTIVE:The mainstay of treatment for patients with RCC IVC-TT is surgical resection; however, surgery is associated with high morbidity rates. Furthermore, many of these patient...

Robotic stereotactic ablative radiotherapy for renal cell carcinoma in patients with impaired renal function

BackgroundRobotic stereotactic ablative radiotherapy (SABR) is currently under investigation as a noninvasive treatment option for patients with renal cell carcinoma (RCC). For radiation therapy of RCC, tumor motion and the need for high ablative doses while preserving the remaining renal parenchyma is a challenge. We aimed to analyze the safety and efficacy of robotic radiosurgery in RCC in a specific difficult subgroup of patients with impaired renal function.MethodsWe retrospectively identified all patients with RCC, treated with robotic SABR and motion compensation in our institution between 2012 and 2017. Either single fraction SABR of 24 or 25 Gy or 3 fractions of 12 Gy prescribed to the 70% isodose line was applied. Local control, overall survival, radiation side effects were evaluated together with renal function and tumor motion.ResultsWe analyzed data of 13 lesions treated in 10 patients with clear cell RCC and a mean age of 70.5 ± 13.6 years (range: 48–87). Prior to SABR, 8 patients underwent previous complete and/or partial nephrectomy, 7 patients presented with chronic kidney disease ≥ stage 3. The median of minimum, mean and maximum planning target volume doses were 23.2, 29.5 and 35.0 Gy for single fraction and 24.4, 42.5 and 51.4 Gy for the three fractions regime. Persistent local control by robotic SABR was achieved in 9 out of 10 patients (92.3% of all lesions) within a median follow-up period of 27 month (range: 15–54). One patient underwent nephrectomy due to progressive disease and sufficient renal function of the contralateral kidney. Renal function remained stable with a mean estimated glomerular filtration rate (eGFR) of 51.3 ± 19.7 ml/min at baseline and 51.6 ± 25.8 ml/min at follow-up. The largest respiratory-induced tumor motion was seen in superior-inferior direction, compensated by the CyberKnife with mean targeting errors of maximal 2.2 mm.ConclusionsRobotic SABR is technically feasible for the treatment of RCC in preexisting kidney disease with good local tumor control at about 2 years follow-up. Robotic SABR with motion tracking offers a valid treatment option for patients, who are at increased risk for progression to end-stage renal disease due to partial nephrectomy or ablative techniques.

Proton Stereotactic Body Radiotherapy as a Nephron-Sparing Approach for Patients with Localized Renal Cell Carcinoma: A Dosimetric Analysis

Radiotherapy for renal cell carcinoma (RCC) is limited by the radiosensitivity of both the kidney and nearby structures. Patients with compromised renal function are at further risk of kidney injury from the low-dose bath from VMAT-based SBRT. Our aim was to demonstrate the potential nephron-sparing dosimetry of pencil beam scanning (PBS) proton radiotherapy SBRT for early stage RCC. Three patients previously treated for pancreatic cancer were randomly selected. Spherical CTV contours were drawn to mimic renal tumors at 4 locations (superior and inferior poles, pelvis, and mid-posteriorly) in each kidney and 3 different sizes (1, 2, and 4 cm) per location. Dose prescription was 54 Gy in 3 fractions. Proton plans were robustly optimized to 3 mm. Photon plans had a 3 mm PTV expansion. 2-arc VMAT plans and orthogonal-pair proton plans were generated for every tumor. The subset of renal-pelvis and superior pole tumors additionally had oblique pair and single beam proton plans generated. DVHs for all plans were analyzed through custom software developed in-house. Ipsilateral kidney doses were calculated after subtracting the CTV. 216 treatment plans (72 photon and 144 proton) and corresponding DVHs were generated. The ipsilateral kidney V < 12 Gy was selected as our nephron-sparing metric. Single beam proton plans showed a mean 12.7% absolute improvement in V < 12 Gy, while orthogonal pair plans showed a 4.3% improvement (see table). Oblique-pair proton plans were in-between (data not shown). After accounting for location, the difference seen for orthogonal pair plans was only significant for mid-posterior tumors (mean 18.9% improvement in V < 12 Gy, p = 0.0002). However, mean improvement in V < 12 Gy was significant regardless of location for single-beam plans. Protons also yielded superior duodenum and small bowel dosimetry: Mean V20 Gy was 0.39 cc and 2.31 cc respectively for proton plans, vs. 1.54 cc and 5.54 cc respectively for photon plans. Proton beam angle and single vs. paired proton beams did not significantly alter dosimetry to OARs. Dosimetric parameters did not vary significantly based on laterality or size of the tumor. Other ROIs met dosimetric constraints regardless of treatment modality. PBS proton treatment planning demonstrates promise in the treatment of renal tumors and significantly improves nephron-sparing dosimetry. Notable improvements in dosimetric parameters for critical radiosensitive organs were seen compared to photons in this large treatment-plan analysis. Further analyses identifying optimal patient selection criteria will support future development of clinical protocols.Abstract 3663; Table 1Single Beam PBSOrthogonal Pair PBSCritical ROIsMean Ipsilateral Kidney V < 12 GyMean Ipsilateral Kidney V < 12 GyMean Duodenum V20 GyMean Small Bowel V20 GyProtons84.2 ± 15.4%75.8 ± 16.7%0.39 ± 1.59 cc2.31 ± 8.07 ccPhotons71.5 ± 19.7%71.5 ± 19.7%1.54 ± 5.51 cc5.54 ± 16.37 ccMean difference12.7%4.3%1.15 cc3.23 ccp0.00320.0480.0002910.000041 Open table in a new tab

Radiotherapy for renal cell carcinoma: renaissance of an overlooked approach.

Conventional radiotherapy previously had a limited role in the definitive treatment of renal cell carcinoma (RCC), owing to the disappointing outcomes of several trials and the perceived radioresistance of this type of cancer. In this context, radiotherapy has been relegated largely to the palliation of symptoms in patients with metastatic disease, with variable rates of response. Following the availability of newer technologies that enable safe delivery of high-dose radiotherapy, stereotactic ablative radiotherapy (SABR) has become increasingly used in patients with RCC. Preclinical evidence demonstrates that RCC cells are sensitive to ablative doses of radiotherapy (≥8-10 Gy). Trials in the setting of intracranial and extracranial oligometastases, as well as primary RCC, have demonstrated excellent tumour control using this approach. Additionally, an awareness of the capacity of high-dose radiation to stimulate antitumour immunity has resulted in novel combinations of SABR with immunotherapies. Here we describe the historical application of conventional radiotherapy, the current biological understanding of the effects of radiation, and the clinical evidence supporting the use of ablative radiotherapy in RCC. We also explore emerging opportunities to combine systemic targeted agents or immunotherapies with radiation. Radiotherapy, although once an overlooked approach, is moving towards the forefront of RCC treatment.

Renal atrophy after stereotactic body radiotherapy for renal cell carcinoma.

BackgroundRenal atrophy is observed in an irradiated kidney. The aim of this study was to determine dose-volume histogram parameters and other factors that predict renal atrophy after 10-fraction stereotactic body radiotherapy (SBRT) for primary renal cell carcinoma (RCC).MethodsA total of 14 patients (11 males, 3 females) who received SBRT for RCC at Tohoku University Hospital between April 2010 and February 2014 were analyzed. The median serum creatinine level was 1.1 mg/dl and two patients had a single kidney. Nine patients were implanted with fiducial markers. The median tumor diameter was 30 mm. SBRT was delivered at 70 Gy in 10 fractions for 7 tumors, at 60 Gy in 10 fractions for 2 tumors, and at 50 Gy in 10 fractions for 5 tumors with 6 and/or 15 MV X-ray using 5 to 8 multi-static beams. Renal atrophy was assessed using post-SBRT CT images after 12–24 months intervals. Correlations were examined by Spearman rank correlation analysis. Differences between two groups were evaluated by the Mann-Whitney test, and pairwise comparisons were made by the Wilcoxon signed-rank test.ResultsThe median tumor volume shrunk from 14.8 cc to 10.6 cc (p = 0.12), and the median irradiated kidney volume changed from 160.4 cc to 137.1 cc (p < .01). The median peak creatinine level was 1.6 mg/dl after treatment (p < .01). Percentage volumes of the irradiated kidney receiving at least 10 Gy (V10, p = 0.03), V20 (p < .01), V30(p < .01), V40 (p = 0.01), mean irradiated kidney dose (p < .01), and magnitude of overlap between PTV and kidney volume (p = 0.03) were significantly correlated with post-treatment irradiated kidney volume in percent, and V20-V30 had strong correlation (r < −0.70, p < .01). Patients with implanted fiducial markers showed a significantly lower ratio of renal atrophy (p = 0.02).ConclusionsSignificant renal atrophic change was observed. Dose distribution of SBRT at 20–30 Gy had a strong correlation with renal atrophy when irradiation was performed in 10 fractions.

Comparison of stereotactic body radiotherapy and conventional external beam radiotherapy in renal cell carcinoma.

434 Background: Renal cell carcinoma (RCC) is considered a radiation-resistant histology, often with poor response to conventionally fractionated external beam radiotherapy (EBRT). We compared outcomes for patients treated with EBRT versus stereotactic body radiotherapy (SBRT) for RCC. Methods: From 2004 and 2012, a total of 89 patients were treated with either EBRT or SBRT and retrospectively reviewed. Patients with locally recurrent RCC, bone or soft tissue RCC metastases, or primary RCC in a solitary kidney were included. 51 patients received EBRT, while 38 patients received SBRT. The median biologically effective dose (BED), assuming an α/β ratio of 10, was 32.6 Gy10 for the EBRT group and 48.0 Gy10 for the SBRT group. Local failure (LC) was defined pathologically or by imaging according to RECIST 1.1 and toxicity reported according to CTCAE v4.0 guidelines. Univariable and multivariable analyses using Cox’s regression model was performed to determine predictors of local control. Results: Median follow up from RT was 9.8 mo (range: &lt;1-73 mo) with EBRT and 19.7 mo (range: &lt;1-61 mo) with SBRT (p=0.26). EBRT patients were younger (p=0.02) and more were M1 (p=0.04), yet other baseline features did not differ significantly. Total RT dose, dose/fraction, and BED10 were significantly higher in the SBRT group (p≤0.002 for each), while number of fractions was significantly fewer (p&lt;0.001). The 1-year LC estimate was 88% (95% CI, 72-96%) with SBRT and 50% (95% CI, 32-65%) with EBRT (p=0.001), with no significant difference in rate of distant recurrences (p=0.37). The 1-year progression free survival (PFS) and overall survival (OS) between the EBRT and SBRT groups were 17% (95% CI, 8-29%) vs. 39% (95% CI, 24-54%) (p=0.06) and 39% (95% CI, 25-52%) vs. 82% (95% CI, 65-91%) (p=0.002), respectively. The use of SBRT was the most important independent factor significantly predictive of local control on multivariable analysis (p=0.001, LLR test; HR=0.29, 95% CI, 0.13-0.61), while neither age nor metastasis at diagnosis was predictive. No drade 3-4 toxicity was observed in either RT group. Conclusions: The data support that SBRT improves local control over standard fractionation schemes. Higher dose per fraction, with a BED in the range of 48 Gy10, is a safe and effective local treatment modality for RCC.

Reconstruction of a chronic late post-nephrectomy wound with an extended free latissimus dorsi flap

This report describes the case of a 74-year-old man who spontaneously developed a chronic loin and posterior thoracic wound 28 years after a nephrectomy and adjuvant radiotherapy for renal cell carcinoma. His wound was successfully managed surgically, with an ipsilateral free latissimus dorsi myocutaneous flap, the vascular pedicle of which was extended using 15cm saphenous vein grafts.

Need for a new trial to evaluate postoperative radiotherapy in renal cell carcinoma: a meta-analysis of randomized controlled trials

BackgroundA meta-analysis was conducted to assess the impact of postoperative radiotherapy (PORT) in renal cell carcinoma (RCC) on overall survival (OS), disease-free survival (DFS) and locoregional failure (LRF). Materials and methodsThe Medline, CANCERLIT, Cochrane library database and search engines were searched to identify randomized controlled studies comparing radical nephrectomy alone with radical nephrectomy followed by PORT for localized RCC. Further, radiotherapy techniques and associated side-effects were evaluated. ResultsSeven controlled trials with a total patient population of 735 were identified. Pooled results from these trials showed a significant reduction of LRF in patients treated with PORT (P ≤ 0.0001). However, there was no difference in OS (P = 0.29) and DFS (P = 0.14). The majority of patients was treated with larger field sizes with parallel-opposed anteroposterior fields. PORT was generally well tolerated; in total, six PORT-related deaths were seen. The resultant funnel plot was broader (Egger test P = 0.14) due to low number of patients. ConclusionsPORT significantly reduces LRF but has no effect on OS and DFS. However, due to poor patient accrual and older radiotherapy techniques in previous studies, there is a need for a new trial to evaluate PORT using conformal and intensity-modulated radiotherapy techniques.

Radiation-induced stricture of the common bile duct

This 62-year-old female patient presented to surgical outpatients with features of obstructive jaundice ten years following radiotherapy for renal cell carcinoma. Investigations demonstrated an apparently benign mid common bile duct (CBD) stenosis. The lesion was stented giving temporary relief but subsequent blockage necessitated a hepaticojejunostomy with Roux-en-Y. Pathological examination of the excised CBD showed the presence of widespread chronic inflammation and fibrosis most likely secondary to radiation. No malignancy was found. Reports of these fibrotic stenoses remain rare in the literature; we discuss the investigation and management of these difficult diagnostic challenges.

Probability of late recurrence and distant metastases after nephrectomy and radiotherapy in renal cell carcinoma

Probability of late recurrence and distant metastases after nephrectomy and radiotherapy in renal cell carcinoma

Long-term overall survival and disease-free survival after nephrectomy and radiotherapy in renal cell carcinoma

Long-term overall survival and disease-free survival after nephrectomy and radiotherapy in renal cell carcinoma

The Role of Radiotherapy for Adult Renal Cell Carcinoma

In this paper the most important articles about the role of radiotherapy for renal cell carcinoma (CPR) are reviewed. Both pre- and post-operative radiotherapy do not seem to improve the survival rates, nor perhaps the local control in comparison with surgery. But trials have been limited and with evident bias: patients were staged without stratification for prognostic factors (grading and lymphonode metastases in particular) and radiotherapy techniques were often incorrect because of too frequent early and late damage. The role of radiotherapy for treating the metastatic disease is undisputed Particularly for patients with a single metastasis, because of the possibility of long survival if adequately controlled.

587 - Potentials and Limitations of Monoclonal Antibody (MAB) – Targeted Radiotherapy for Renal Cell Carcinoma (RCC)

587 - Potentials and Limitations of Monoclonal Antibody (MAB) – Targeted Radiotherapy for Renal Cell Carcinoma (RCC)