Radiotherapy in

Renal Cell CarcinomaSimin Hemati . M.D

Assistant professor of Radiation OncologyIsfahan University of Medical Sciences

20 jan 2012

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

American Joint Committee on Cancer

Staging Classification for Kidney Tumors7th edition 2010

Primary Tumor Description

TX Primary tumor cannot be assessedT0 No evidence of primary tumorT1 Tumor 7 cm in greatest dimension, limited to the kidneyT1a Tumor 4 cm or less in greatest dimension, limited to the

kidneyT1b Tumor more than 4 cm but not more than 7 cm in greatest

dimension, limited to the kidneyT2 Tumor more than 7 cm in greatest dimension, limited to the

kidneyT2a Tumor more than 7 cm but less or equal to 10 cmT2b Tumor more than 10 cm limited to kidneyT3 Tumor extends into major veins or perinephric tissues but

not to epsilateral adrenal gland and not beyond Gerota's fascia

T3a Tumor grossly extends into the renal vein or its segmental (muscle-containing) branches, or tumor invades perirenal and or renal sinus fat but not beyond Gerota's fascia

T3b Tumor grossly extends in to the vena cava below the diaphragm

T3c Tumor grossly extends into the vena cava above the diaphragm or invades the wall of the vena cava

T4 Tumor invades beyond Gerota's fascia(including epsilateral adrenal gland)

American Joint Committee on Cancer Staging Classification for Kidney Tumors

Regional Lymph Nodes

Description

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis to regional lymph node

American Joint Committee on Cancer Staging Classification for Kidney Tumors

Distant Metastasis

Description

MX Presence of distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

Stage GroupingSTAGE Description

I T1 N0 M0

II T2 N0 M0

III T3T1,T2

N0N1

M0M0

IV T4Any T

Any NAny N

M0M1

Histopathologic GradeGRADE Description

GX Grade cannot be assessed

G1 Well differentiated

G2 Moderately well differentiated

G3,G4 Poorly differentiated or undifferentiated

Stage of Renal Cell Carcinoma Correlated with Survival After Radical NephrectomyAuthor No of

patientI II III IV

Robson et al. 88 66 64 42 11

Skinner et al. 309 65 47 51 8

Waters and Richie 130 51 59 12 0McNichols et al. 506 67 51 34 14

Selli et al. 115 93 63 80 13

Golimbu et al. 326 88 67 40 2

Dinney et al. 314 73 68 51 20

Guinan et al. 337 100 96 59 16

Javidan et al. 381 95 88 59 10

Kinouchi et al. 350 96 95 70 24

Tsui et al. 643 91 74 67 32

Initial treatment is most commonly a radical or partial nephrectomy

and remains the mainstay of curative treatment.

Adenocarcinoma of the kidney is a variably

radiosensitive neoplasm.

Huland and et all:

Radiotherapy before surgery decreased the

rate of tumor transplantation

some renal cell cancer are resistant to conventionally

fractionated RT

Other studies :

In vivo experiments

Clinical experiences

Palliative RT in advanced stage

very good subjective and objective

response

No improved the results

Adjuvant RT in early stage

Post operative radiotherapy

Palliative radiotherapy

Pre opreative radiotherapy

Rt in RCC

Pre operative RT

• Theoretical Benefits :

tumor shrinkage increased resectabilitydecreased tumor viability with

fewer distant metastases

Two European studies

Nephrectomy alone

Preoperative RT + nephrectomy

No improved in overall survivalNo improved in free metastatic survival

Increased resectability in T2 , T3 Tumors

Preoperative irradiation should be considered in patients with technically

unresectable nonmetastatic tumors to convert them to

resectable.

Post operative RT

A retrospective review from Memorial Sloan-Kettering Cancer Center of 172 patients treated by radical

nephrectomy alone

T1 or T2 tumors,N0

Local failure is 4%

Local failure is 21%

LN positive or positive margin

A retrospective series with 67 patient of T3 tumors

37 30

Nephrectomy + post operative

RT

Local failure is 10%

Local failure is 37%

Nephrectomy alone

Indications of post operative RT

• gross or microscopically positive margins

• LN positive

• Locally advanced tumors (T3,T4)

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.

At diagnosis, 30% of renal cell carcinomas have spread to the

ipsilateral renal vein

Complete ResectionNO RTX

Palliative radiotherapy :for relief from symptoms pain neorologic symptoms spinal cord compression nerve invasion

after surgery for metastatic lesion

Radiation therapy technique

Preoperative RTTotal dose : 45-50 GY

Target volume : kidney and regional LN

Technique : two POP technique multiple technique similar to post

operative setting

Post operative RT

Post operative RT

45 to 50 Gy 1.8 to 2Gy F

To kidney bed and regional lymph nodes

total dose 50 to 60 Gy

10-15 GY boost to small

volumes of microscopic or gross residual

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.

Radiation Oncologists must be attention to:

• Patient selection• Radiation therapy planning • Tolerance of the upper-abdominal

organs

• Tolerance dose of :

Liver : no more than 30% of the liver from

receiving doses >36 to 40 Gy

Spinal Cord : <45 Gy

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

•

• The use of 3D-CRT and IMRT:

Increased the tumor total doseDecreased the normal tissue dose

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.

LAT.

OBL.

POST

ANT

RT- LAT

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)

Palliative RT techniques• Stereotactic radiosurgery : has been successful at controlling

and palliating metastatic sites.

69 patients with brain metastases

33% stable

63% Responded

Initial treatment is most commonly

a Radical or Partial Nephrectomy And remains the mainstay of curative treatment

Complications of RT

nausea, vomiting, diarrhea, and abdominal cramping

radiation-induced liver damage duodenum and small-bowel

stenosis and bleedingSpinal damage

•

• Rate of complications related to:

• Total dose• Fraction size• Technique of irradiation