Radiotherapy in Renal Cell Carcinoma

1. Radiotherapy in Renal Cell Carcinoma Simin Hemati . M.D Assistant professor of Radiation Oncology Isfahan University of Medical Sciences 20 jan 2012

2. RCC is the most common type( 80% ) of kidney cancer in adults , It is also known to be the most lethal of all the genitourinary tumors

3. American Joint Committee on Cancer Staging Classification for Kidney Tumors7th edition 2010

5. American Joint Committee on Cancer Staging Classification for Kidney Tumors

6. American Joint Committee on Cancer Staging Classification for Kidney Tumors

7. Stage Grouping

8. Histopathologic Grade

9. Stage of Renal Cell Carcinoma Correlated with Survival After Radical Nephrectomy

10. Initial treatment is most commonly a radical or partial nephrectomyand remains the mainstay of curative treatment.

11. Adenocarcinoma of the kidney is a variably radiosensitive neoplasm.

12. In vivo experiments Huland and et all: Other studies : some renal cell cancer are resistant to conventionally fractionated RT Radiotherapy before surgery decreased the rate of tumor transplantation

13. Clinical experiences Palliative RT in advanced stage Adjuvant RT in early stage very good subjective and objective response No improved the results

14. Post operative radiotherapy Pre opreative radiotherapy Palliative radiotherapy Rt in RCC

15. Pre operative RT • Theoretical Benefits : • tumor shrinkage • increased resectability • decreased tumor viability with fewer distant metastases

16. Two European studies Preoperative RT + nephrectomy Nephrectomy alone No improved in overall survival No improved in free metastatic survival Increased resectability in T2 , T3 Tumors

17. Preoperative irradiation should be considered in patients with technically unresectable nonmetastatic tumors to convert them to resectable.

18. Post operative RT

19. A retrospective review from Memorial Sloan-Kettering Cancer Center of 172 patients treated by radical nephrectomy alone T1 or T2 tumors,N0 LN positive or positive margin Local failure is 4% Local failure is 21%

20. A retrospective series with 67 patient of T3 tumors 30 37 Nephrectomy + post operative RT Nephrectomy alone Local failure is 10% Local failure is 37%

21. Indications of post operative RT • gross or microscopically positive margins • LN positive • Locally advanced tumors (T3,T4)

22. Patients with renal cell carcinoma confined to the kidney and/or renal vein have a low recurrence rate and a high survival rate after radical nephrectomy alone and should not be considered for adjuvant radiation therapy.

23. At diagnosis, 30% of renal cell carcinomas have spread to the ipsilateral renal veinComplete ResectionNO RTX

24. Palliative radiotherapy :for relief from symptomspain neorologic symptoms spinal cord compression nerve invasionafter surgery for metastatic lesion

25. Radiation therapy technique

26. Preoperative RT Total dose : 45-50 GY Target volume : kidney and regional LN Technique : two POP technique multiple technique similar to post operative setting

27. Post operative RT

28. Post operative RT 45 to 50 Gy 1.8 to 2Gy F To kidney bed and regional lymph nodes 10-15 GY boost to small volumes of microscopic or gross residual total dose 50 to 60 Gy If the scar cannot be covered without increasing the amount of normal tissue irradiated, an additional electron beam field to treat the scar may be considered.

29. Radiation Oncologists must be attention to: • Patient selection • Radiation therapy planning • Tolerance of the upper-abdominal organs

30. Tolerance dose of : Liver : no more than 30% of the liver from receiving doses >36 to 40 Gy Spinal Cord : <45 Gy

31. Techniques: • Anterior-Posterior technique: • particularly on the right side , irradiated of large volumes of bowel and liver beyond tolerance. • Multiple-beam technique: • including anterior, posterior, oblique, and lateral projections with beam's eye-view shaping and differential weighting of dose from each field, can optimize the radiation dose distribution to maximize target volume coverage while minimizing the dose to normal bowel or liver

32. The use of 3D-CRT and IMRT: Increased the tumor total dose Decreased the normal tissue dose

33. ANT RT- LAT LAT. OBL. POST A CT–based treatment plan using a combination of four fields (anterior, posterior, right lateral, and right posterior oblique) to cover the tumor bed (dark oval) with 54 Gy (isodose line displayed). This combination of fields and beam's-eye-view shaping allows sparing of the liver, bowel, and spinal cord.

34. Palliative RT techniques • EBRT : • Treatment fields: metastatic foci with 2- 3cm margins. • Dose: 35 - 40 Gy (symptomatic relief in 65% to 85% of patients). • Some series have reported higher symptomatic response rates with higher irradiation dose( 45 to 50 Gy in 3 to 4.5 weeks)

35. Palliative RT techniques • Stereotactic radiosurgery : has been successful at controlling and palliating metastatic sites. 63% Responded 69 patients with brain metastases 33% stable

37. Initialtreatment is most commonly a Radical or Partial Nephrectomy And remains the mainstay of curative treatment

38. Complications of RT • nausea, vomiting, diarrhea, and abdominal cramping • radiation-induced liver damage • duodenum and small-bowel stenosis and bleeding • Spinal damage

39. Rate of complications related to: • Total dose • Fraction size • Technique of irradiation