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Barbour AB, Upadhyay R, Anderson AC, Kutuk T, Kumar R, Wang SJ, Psutka SP, Fekrmandi F, Skalina KA, Bruynzeel AME, Correa RJM, Dal Pra A, Biancia CD, Hannan R, Louie A, Singh AK, Swaminath A, Tang C, Teh BS, Zaorsky NG, Lo SS, Siva S. Stereotactic Body Radiation Therapy for Primary Renal Cell Carcinoma: A Case-Based Radiosurgery Society Practice Guide. Pract Radiat Oncol 2024:S1879-8500(24)00156-5. [PMID: 39019209 DOI: 10.1016/j.prro.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/24/2024] [Accepted: 06/06/2024] [Indexed: 07/19/2024]
Abstract
Traditionally, renal cell carcinoma (RCC) was considered a radioresistant tumor, thereby limiting definitive radiation therapy management options. However, several recent studies have demonstrated that stereotactic body radiation therapy (SBRT) can achieve high rates of local control for the treatment of primary RCC. In the setting of expanding use of SBRT for primary RCC, it is crucial to provide guidance on practical considerations such as patient selection, fractionation, target delineation, and response assessment. This is particularly important in challenging scenarios where a paucity of evidence exists, such as in patients with a solitary kidney, bulky tumors, or tumor thrombus. The Radiosurgery Society endorses this case-based guide to provide a practical framework for delivering SBRT to primary RCC, exemplified by 3 cases. This article explores topics of tumor size and dose fractionation, impact on renal function and treatment in the setting of a solitary kidney, and radiation's role in the management of inferior vena cava tumor thrombus. Additionally, we review existing evidence and expert opinion on target delineation, advanced techniques such as magnetic resonance imaging guided SBRT, and SBRT response assessment.
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Affiliation(s)
- Andrew B Barbour
- Department of Radiation Oncology, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - August C Anderson
- Department of Radiation Oncology, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Ritesh Kumar
- Department of Radiation Oncology, Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Shang-Jui Wang
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sarah P Psutka
- Department of Urology, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington
| | - Fatemeh Fekrmandi
- Department of Radiation Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Karin A Skalina
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York
| | - Anna M E Bruynzeel
- Department of Radiation Oncology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rohann J M Correa
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Cesar Della Biancia
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alexander Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Anurag K Singh
- Department of Radiation Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Anand Swaminath
- Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Chad Tang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Bin S Teh
- Department of Radiation Oncology, Cancer Center and Research Institute, Houston Methodist Hospital, Houston, Texas
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve, Cleveland, Ohio
| | - Simon S Lo
- Department of Radiation Oncology, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington.
| | - Shankar Siva
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Center, University of Melbourne, Melbourne, Victoria, Australia
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Kotzki L, Udrescu C, Lapierre A, Badet L, Rouviere O, Paparel P, Chapet O. Stereotactic body radiotherapy for inoperable patients with renal carcinoma. THE FRENCH JOURNAL OF UROLOGY 2024; 34:102575. [PMID: 38364353 DOI: 10.1016/j.fjurol.2024.102575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/29/2023] [Accepted: 12/10/2023] [Indexed: 02/18/2024]
Abstract
INTRODUCTION The objective of this study was to analyze the dose-dependent safety profiles of stereotactic body radiation therapy (SBRT) in patients with inoperable small renal cell carcinoma (RCC). MATERIAL This is a retrospective study from a single institution including patients with RCC treated between 2011 and 2020 with SBRT on the primary tumor or on a local recurrence after surgery. All patients had been declared inoperable or refused surgery. The patients were divided into two dose level groups: group 1 (BED10<60Gy) and group 2 (BED10≥60Gy). Acute and late toxicities, renal function and local control (LC) were compared between the two groups. RESULTS A total of 24 patients were analyzed with an average follow-up of 25.1 months. Nine patients (37%) and three patients (14%) reported grade 1-2 acute and late toxicities, respectively. No grade≥3 acute and late toxicities were observed. There was no significant difference in acute and late toxicities between the two groups (P=0.21 and P=0.27, respectively). There was no significant difference in estimated glomerular filtration rate in the 15 patients, eligible for renal toxicity analysis between the pre-radiation and the 12-month follow-up (P=0.1) and the last follow-up (P=0.06). LC at the last follow-up was noted in 19 out of 23 patients (83%) and was based on imaging acquisition. LC was 77.8% for group 1 and 85.7% for group 2 (P=1.95). CONCLUSION Dose escalation was not associated with an increase in acute and late grade≥2 toxicities. There appears to be a trend towards increased LC at higher doses.
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Affiliation(s)
- Léa Kotzki
- Department of Radiotherapy-Oncology, Lyon Sud Hospital, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - Corina Udrescu
- Department of Radiotherapy-Oncology, Lyon Sud Hospital, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - Ariane Lapierre
- Department of Radiotherapy-Oncology, Lyon Sud Hospital, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - Lionel Badet
- Department of Urology, Édouard-Herriot Hospital, 5, place d'Arsonval, 69003 Lyon, France
| | - Olivier Rouviere
- Department of Radiology, Édouard-Herriot Hospital, 5, place d'Arsonval, 69003 Lyon, France
| | - Philippe Paparel
- Department of Urology, Lyon Sud Hospital, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - Olivier Chapet
- Department of Radiotherapy-Oncology, Lyon Sud Hospital, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
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Sargos P, Le Guevelou J, Khalifa J, Albiges L, Azria D, de Crevoisier R, Supiot S, Créhange G, Roubaud G, Chapet O, Pasquier D, Blanchard P, Latorzeff I. The role of radiation therapy for de novo metastatic bladder and renal cancers. Cancer Radiother 2024; 28:56-65. [PMID: 37286452 DOI: 10.1016/j.canrad.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/21/2023] [Indexed: 06/09/2023]
Abstract
Metastatic bladder and renal cancers account respectively for 2.1% and 1.8% of cancer deaths worldwide. The advent of immune checkpoint inhibitors has revolutionized the management of metastatic disease, by demonstrating considerable improvements in overall survival. However, despite initial sensitivity to immune checkpoint inhibitors for most patients, both bladder and renal cancer are associated with short progression-free survival and overall survival, raising the need for further strategies to improve their efficacy. Combining systemic therapies with local approaches is a longstanding concept in urological oncology, in clinical settings including both oligometastatic and polymetastatic disease. Radiation therapy has been increasingly studied with either cytoreductive, consolidative, ablative or immune boosting purposes, but the long-term impact of this strategy remains unclear. This review intends to address the impact of radiation therapy with either curative or palliative intent, for synchronous de novo metastatic bladder and renal cancers.
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Affiliation(s)
- P Sargos
- Department of Radiation Oncology, institut Bergonié, Bordeaux, France.
| | - J Le Guevelou
- Faculty of Medicine, Geneva, Switzerland; Department of Radiation Oncology, centre Eugène-Marquis, Rennes, France
| | - J Khalifa
- Department of Radiation Oncology, institut Claudius-Regaud, Institut universitaire du cancer de Toulouse - Oncopole, Toulouse, France
| | - L Albiges
- Department of Cancer Medicine, institut Gustave-Roussy, Villejuif, France
| | - D Azria
- Department of Radiation Oncology, Institut du cancer de Montpellier (ICM), IRCM U1194 Inserm, université de Montpellier, Montpellier, France
| | - R de Crevoisier
- Department of Radiation Oncology, centre Eugène-Marquis, Rennes, France
| | - S Supiot
- Department of Radiation Oncology, Institut de cancérologie de l'Ouest, Saint-Herblain, France; CRCINA CNRS, Nantes, France; Inserm, Nantes, France; Université de Nantes et d'Angers, Nantes, France
| | - G Créhange
- Department of Radiation Oncology, institut Curie, Saint-Cloud, France
| | - G Roubaud
- Department of Medical Oncology, institut Bergonié, Bordeaux, France
| | - O Chapet
- Department of Oncology Department, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - D Pasquier
- Department of Radiation Oncology, centre Oscar-Lambret, Lille, France; Cristal UMR 9189, université de Lille, Lille, France
| | - P Blanchard
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, université Paris-Saclay, Oncostat U1018 Inserm, Villejuif, France
| | - I Latorzeff
- Department of Radiation Oncology, clinique Pasteur, Toulouse, France
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Siva S, Louie AV, Kotecha R, Barber MN, Ali M, Zhang Z, Guckenberger M, Kim MS, Scorsetti M, Tree AC, Slotman BJ, Sahgal A, Lo SS. Stereotactic body radiotherapy for primary renal cell carcinoma: a systematic review and practice guideline from the International Society of Stereotactic Radiosurgery (ISRS). Lancet Oncol 2024; 25:e18-e28. [PMID: 38181809 DOI: 10.1016/s1470-2045(23)00513-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 01/07/2024]
Abstract
Surgery is the standard of care for patients with primary renal cell carcinoma. Stereotactic body radiotherapy (SBRT) is a novel alternative for patients who are medically inoperable, technically high risk, or who decline surgery. Evidence for using SBRT in the primary renal cell carcinoma setting is growing, including several rigorously conducted prospective clinical trials. This systematic review was performed to assess the safety and efficacy of SBRT for primary renal cell carcinoma. Review results then formed the basis for the practice guidelines described, on behalf of the International Stereotactic Radiosurgery Society. 3972 publications were screened and 36 studies (822 patients) were included in the analysis. Median local control rate was 94·1% (range 70·0-100), 5-year progression-free survival was 80·5% (95% CI 72-92), and 5-year overall survival was 77·2% (95% CI 65-89). These practice guidelines addressed four key clinical questions. First, the optimal dose fractionation was 25-26 Gy in one fraction, or 42-48 Gy in three fractions for larger tumours. Second, routine post-treatment biopsy is not recommended as it is not predictive of patient outcome. Third, SBRT for primary renal cell carcinoma in a solitary kidney is safe and effective. Finally, guidelines for post-treatment follow-up are described, which include cross-axial imaging of the abdomen including both kidneys, adrenals, and surveillance of the chest initially every 6 months. This systematic review and practice guideline support the practice of SBRT for primary renal cell carcinoma as a safe and effective standard treatment option. Randomised trials with surgery and invasive ablative therapies are needed to further define best practice.
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Affiliation(s)
- Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Melissa N Barber
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Muhammad Ali
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mi-Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, IRCCS-Humanitas Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
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Leeman JE. Role of Radiation in Treatment of Renal Cell Carcinoma. Hematol Oncol Clin North Am 2023; 37:921-924. [PMID: 37246085 DOI: 10.1016/j.hoc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Initial studies of radiotherapy in renal cell carcinoma (RCC) failed to demonstrate significant clinical impact. With the advent of stereotactic body radiotherapy (SBRT) that allows for delivery of more effective radiation doses in a precise fashion, radiotherapy has become an essential component in the multidisciplinary management of patients with RCC both in the setting of localized and metastatic disease beyond the traditional role of palliative treatment. Recent evidence has demonstrated high rates of long-term local control (∼95%) when SBRT is delivered to kidney tumors with limited toxicity risks and only minor impact on renal function.
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Affiliation(s)
- Jonathan E Leeman
- Department of Radiation Oncology, Dana Farber Cancer Institute/ Brigham and Women's Hospital, Boston, MA 02115, USA.
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6
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Barbour AB, Kirste S, Grosu AL, Siva S, Louie AV, Onishi H, Swaminath A, Teh BS, Psutka SP, Weg ES, Chen JJ, Zeng J, Gore JL, Hall E, Liao JJ, Correa RJM, Lo SS. The Judicious Use of Stereotactic Ablative Radiotherapy in the Primary Management of Localized Renal Cell Carcinoma. Cancers (Basel) 2023; 15:3672. [PMID: 37509333 PMCID: PMC10377531 DOI: 10.3390/cancers15143672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Localized renal cell carcinoma is primarily managed surgically, but this disease commonly presents in highly comorbid patients who are poor operative candidates. Less invasive techniques, such as cryoablation and radiofrequency ablation, are effective, but require percutaneous or laparoscopic access, while generally being limited to cT1a tumors without proximity to the renal pelvis or ureter. Active surveillance is another management option for small renal masses, but many patients desire treatment or are poor candidates for active surveillance. For poor surgical candidates, a growing body of evidence supports stereotactic ablative radiotherapy (SABR) as a safe and effective non-invasive treatment modality. For example, a recent multi-institution individual patient data meta-analysis of 190 patients managed with SABR estimated a 5.5% five-year cumulative incidence of local failure with one patient experiencing grade 4 toxicity, and no other grade ≥3 toxic events. Here, we discuss the recent developments in SABR for the management of localized renal cell carcinoma, highlighting key concepts of appropriate patient selection, treatment design, treatment delivery, and response assessment.
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Affiliation(s)
- Andrew B Barbour
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Simon Kirste
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, 79085 Freiburg, Germany
| | - Anca-Liga Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, 79085 Freiburg, Germany
| | - Shankar Siva
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Center, University of Melbourne, Parkville, VIC 3052, Australia
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Hiroshi Onishi
- Department of Radiology, School of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Anand Swaminath
- Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Bin S Teh
- Department of Radiation Oncology, Cancer Center and Research Institute, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Emily S Weg
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Jonathan J Chen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - John L Gore
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Evan Hall
- Department of Medical Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
| | - Rohann J M Correa
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA 98195, USA
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Yim K, Leeman JE. Radiation Therapy in the Treatment of Localized and Advanced Renal Cancer. Urol Clin North Am 2023; 50:325-334. [PMID: 36948675 DOI: 10.1016/j.ucl.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Renal cell carcinoma (RCC) has historically been considered resistant to radiotherapy. However, advances in the field of radiation oncology have led to safe delivery of higher radiation doses through the use of stereotactic body radiotherapy (SBRT) that have shown significant activity against RCC. SBRT has now been shown to be a highly effective modality for management of localized RCC for nonsurgical candidates. Increasing evidence also points to a role for SBRT in the management of oligometastatic RCC as a means for not only providing palliation but prolonging time to progression and potentially improving survival.
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Affiliation(s)
- Kendrick Yim
- Division of Urology, Brigham and Women's Hospital, 45 Francis Street, Boston, MA 02215, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana Farber Cancer Institute/ Brigham and Women's Hospital, Boston, MA, USA.
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8
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Stereotactic Body Radiotherapy for Kidney Cancer: Ready for Prime Time? Clin Oncol (R Coll Radiol) 2023; 35:163-176. [PMID: 36443137 DOI: 10.1016/j.clon.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
The standard treatment for renal cell carcinoma (RCC) is surgery. However, a number of patients will not be candidates for surgical treatment or will reject this therapeutic approach. Therefore, alternative approaches are required. Historically, radiotherapy has been considered an ineffective treatment for RCC due to the radioresistance of renal tumour cells to conventional fractionation and the increased rate of toxicity. Stereotactic body radiotherapy (SBRT) is a radiotherapy technique that provides a non-invasive ablative treatment with remarkable rates of local control in both primary tumours and metastases in several locations, with a low associated morbidity due to the highly conformal dose and the use of image-guided techniques. Current evidence shows that a higher dose per fraction, achieving a higher biological effective dose, can overcome the radioresistance of RCC cells. Therefore, SBRT, as well as the combination of SBRT and new emerging immune therapies, has a potential role in the local treatment of primary RCC and oligometastatic RCC patients.
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Hao C, Liu J, Ladbury C, Dorff T, Sampath S, Pal S, Dandapani S. Stereotactic body radiation therapy to the kidney for metastatic renal cell carcinoma: A narrative review of an emerging concept. Cancer Treat Res Commun 2023; 35:100692. [PMID: 36842365 DOI: 10.1016/j.ctarc.2023.100692] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
This narrative review provides a historical overview of cytoreductive nephrectomy for metastatic renal cell carcinoma (mRCC) and examines the safety and therapeutic potential of cytoreductive stereotactic body radiation therapy (SBRT) for mRCC in the modern immunotherapy era. In the last five years, the introduction of immune checkpoint inhibitors for the treatment of mRCC has improved outcomes for patients. This has brought forth new exploration of the role of CN in combination with immunotherapy. Early retrospective evidence suggests that there may be a benefit of deferred CN after immunotherapy (IOT) for de novo mRCC patients. However, there has also been concern regarding the feasibility of surgery after IOT due to inflammation. SBRT may be an appropriate alternative in these circumstances. Since 1999, cytoreductive SBRT has been used for inoperable primary RCC. Several prospective and retrospective studies treating the kidney tumor for localized RCC have shown that this technique is safe and produces favorable and durable local control. SBRT has also exhibited similar effectiveness to CN, while providing additional benefits including noninvasiveness and the ability to treat tumors that can't be treated with nephrectomy or ablation due to size or location. Furthermore, SBRT confers immunostimulatory effects, which are hypothesized to work synergistically with immunotherapy. Clinicians should consider SBRT a safe and reliable alternative to CN for RCC patients. Ongoing studies are exploring the utility of SBRT for treatment of the primary tumor in mRCC patients receiving standard of care immunotherapy.
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Affiliation(s)
- Claire Hao
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Tanya Dorff
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Sagus Sampath
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Sumanta Pal
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA.
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Buller DM, Antony M, Ristau BT. Adjuvant Therapy for High-Risk Localized Renal Cell Carcinoma: Current Landscape and Future Direction. Onco Targets Ther 2023; 16:49-64. [PMID: 36718243 PMCID: PMC9884052 DOI: 10.2147/ott.s393296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/15/2023] [Indexed: 01/25/2023] Open
Abstract
Locally and regionally advanced renal cell carcinoma (RCC) can recur at high rates even after visually complete resection of primary disease. Both targeted therapies and immunotherapies represent potential agents that might help reduce recurrence of RCC in these patients. This paper reviews the current body of evidence defining their potential impact and examines the large Phase III randomized clinical trials that have been performed to assess the safety and efficacy of these systemic therapies in the adjuvant setting. Given that the findings from these trials have been predominantly negative, this paper also explores the role of other potential adjuvant agents, including single and combination agent targeted therapies and immunotherapies, whose use is currently limited to metastatic RCC. Finally, the use of radiation therapy and the use of advanced imaging modalities in RCC are also considered.
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Affiliation(s)
| | - Maria Antony
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Benjamin T Ristau
- Division of Urology, UConn Health, Farmington, CT, USA,Correspondence: Benjamin T Ristau, Division of Urology, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, Tel +1 860 679 3438, Fax +1 860 679 6109, Email
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11
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Le Guevelou J, Sargos P, Siva S, Ploussard G, Ost P, Gillessen S, Zilli T. The Emerging Role of Extracranial Stereotactic Ablative Radiotherapy for Metastatic Renal Cell Carcinoma: A Systematic Review. Eur Urol Focus 2023; 9:114-124. [PMID: 36151031 DOI: 10.1016/j.euf.2022.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/12/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022]
Abstract
CONTEXT Although the management of metastatic renal cell carcinoma (mRCC) has been revolutionized by the advent of new systemic agents, still few patients experience a long-term durable response. Stereotactic ablative radiotherapy (SABR) is nowadays commonly used as metastasis-directed therapy (MDT), but limited data exist on how best to implement this strategy as part of a multimodal approach. OBJECTIVE To evaluate the potential role of extracranial SABR in mRCC and to identify future therapeutic developments of SABR in different disease settings. EVIDENCE ACQUISITION A systematic review was conducted in May 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement on the PubMed database. Thirty-four studies were selected for inclusion in this systematic review. EVIDENCE SYNTHESIS SABR has been used with four main goals: (1) eradication of the whole metastatic burden in synchronous and metachronous oligometastatic patients, resulting in a long-term local control (LC) rate of >90% and median progression-free survival (PFS) ranging between 8 and 15 mo; (2) eradication of oligoprogressive lesions, enabling an extension of the duration of the systemic therapy by approximately 9 mo; (3) improvement of the response to systemic therapy in polymetastatic patients, resulting in an overall response rate ranging from 17% to 56%; and (4) cytoreduction in polymetastatic mRCC patients, with LC rates ranging between 71% and 100%, and preservation of the renal function, but unclear PFS and overall survival impact. Overall, the combination of SABR and systemic agents has been associated with overall good tolerance, with grade ≥3 toxicity ranging from 0% to 13%. CONCLUSIONS Current data highlight the role of SABR as an emerging MDT treatment option in both oligometastatic and oligoprogressive extracranial mRCC, able to ensure long-term disease control and delay the use of next-line systemic therapies. The use of SABR for cytoreduction in the de novo metastatic disease and as an immunological booster in the polymetastatic setting remains investigational and warrants further investigations. PATIENT SUMMARY Radiotherapy delivered with ablative doses (>6 Gy per fraction) is a promising treatment strategy for patients diagnosed with metastatic renal cell carcinoma. Excellent outcome results have been observed in patients with a limited number of metastases, improving metastasis-free survival by several months. For patients with a few metastases progressing under systemic therapy, radiotherapy allows an extension of the duration of the ongoing therapy by several months.
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Affiliation(s)
- Jennifer Le Guevelou
- Department of Radiation Oncology, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France; Institut Universitaire du Cancer Oncopole, Toulouse, France
| | - Piet Ost
- Iridium Network, Radiation Oncology, Antwerp, Belgium; Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland; Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland.
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Rich BJ, Noy MA, Dal Pra A. Stereotactic Body Radiotherapy for Localized Kidney Cancer. Curr Urol Rep 2022; 23:371-381. [PMID: 36383304 DOI: 10.1007/s11934-022-01125-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Stereotactic body radiation therapy (SBRT) is increasingly utilized in the management of localized kidney cancers, particularly for patients who are not surgical candidates. Herein, we provide a narrative review of SBRT in the management of localized kidney cancers. RECENT FINDINGS Recent prospective studies and multi-institutional retrospective studies highlight the safety and efficacy of SBRT in the management of renal tumors, a disease previously thought to be radioresistant. Studies have shown that local control is greater than 90% with rare grade 3 or 4 toxicity and no grade 5 toxicity. SBRT can be utilized successfully in the treatment of large kidney tumors (> 5 cm). New techniques such as MRI-guided radiation therapy may further improve the therapeutic ratio. However, randomized clinical trials are necessary to confirm the optimal dosing schedule and compare outcomes with nephrectomy, which remains the standard of care in suitable patients. Advances in SBRT have made this modality a safe and effective treatment option in the management of localized kidney cancers.
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Affiliation(s)
- Benjamin J Rich
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Alan Dal Pra
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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13
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Spyropoulou D, Tsiganos P, Dimitrakopoulos FI, Tolia M, Koutras A, Velissaris D, Lagadinou M, Papathanasiou N, Gkantaifi A, Kalofonos H, Kardamakis D. Radiotherapy and Renal Cell Carcinoma: A Continuing Saga. In Vivo 2021; 35:1365-1377. [PMID: 33910814 PMCID: PMC8193295 DOI: 10.21873/invivo.12389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 11/10/2022]
Abstract
Renal cell carcinoma (RCC) is one of the most aggressive malignancies of the genito-urinary tract, having a poor prognosis especially in patients with metastasis. Surgical resection remains the gold standard for localized renal cancer disease, with radiotherapy (RT) receiving much skepticism during the last decades. However, many studies have evaluated the role of RT, and although renal cancer is traditionally considered radio-resistant, technological advances in the RT field with regards to modern linear accelerators, as well as advanced RT techniques have resulted in breakthrough therapeutic outcomes. Additionally, the combination of RT with immune checkpoint inhibitors and targeted agents may maximize the clinical benefit. This review article focuses on the role of RT in the therapeutic management of renal cell carcinoma.
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Affiliation(s)
- Despoina Spyropoulou
- Department of Radiation Oncology, University of Patras Medical School, Patras, Greece;
| | - Panagiotis Tsiganos
- Clinical Radiology Laboratory, Department of Medicine, University of Patras, Patras, Greece
| | - Foteinos-Ioannis Dimitrakopoulos
- Division of Oncology, Department of Medicine, University Hospital of Patras, Patras, Greece
- Clinical and Molecular Oncology Laboratory, Medical School, University of Patras, Patras, Greece
| | - Maria Tolia
- Radiotherapy Department, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Angelos Koutras
- Division of Oncology, Department of Medicine, University Hospital of Patras, Patras, Greece
| | - Dimitris Velissaris
- Emergency Department and Internal Medicine Department, University Hospital of Patras, Patras, Greece
| | - Maria Lagadinou
- Emergency Department University Hospital of Patras, Patras, Greece
| | | | - Areti Gkantaifi
- Radiotherapy Department, Interbalkan Medical Center, Thessaloniki, Greece
| | - Haralabos Kalofonos
- Division of Oncology, Department of Medicine, University Hospital of Patras, Patras, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, University of Patras Medical School, Patras, Greece
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14
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Blitzer GC, Wojcieszynski A, Abel EJ, Best S, Lee FT, Hinshaw JL, Wells S, Ziemlewicz TJ, Lubner MG, Alexander M, Yadav P, Bayouth JE, Floberg J, Cooley G, Harari PM, Bassetti MF. Combining Stereotactic Body Radiotherapy and Microwave Ablation Appears Safe and Feasible for Renal Cell Carcinoma in an Early Series. Clin Genitourin Cancer 2021; 19:e313-e318. [PMID: 34024743 DOI: 10.1016/j.clgc.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 01/20/2023]
Abstract
Microwave (MW) ablation and stereotactic body radiation therapy (SBRT) are both used in treating inoperable renal cell carcinoma (RCC). MW ablation and SBRT have potentially complementary advantages and limitations. Combining SBRT and MW ablation may optimize tumor control and toxicity for patients with larger (> 5 cm) RCCs or those with vascular involvement. Seven patients with RCC were treated at our institution with combination of SBRT and MW ablation, median tumor size of 6.4 cm. Local control was 100% with a median follow-up of 15 months. Four patients experienced grade 2 nausea during SBRT. Three patients experienced toxicities after MW ablation, 2 with grade 1 hematuria and 1 with grade 3 retroperitoneal bleed/collecting system injury. Median eGFR (estimated glomerular filtration rate) preceding and following SBRT and MW ablation was 69 mL/min/1.73 m2 and 68 mL/min/1.73 m2 (P = .19), respectively. In patients who are not surgical candidates, larger RCCs or those with vascular invasion are challenging to treat. Combination treatment with SBRT and MW ablation may balance the risks and benefits of both therapies and demonstrates high local control in our series. MW ablation and SBRT have potentially complementary advantages and limitations.
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Affiliation(s)
- Grace C Blitzer
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI.
| | | | - E Jason Abel
- Department of Urology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Sara Best
- Department of Urology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Fred T Lee
- Department of Radiology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - J Louis Hinshaw
- Department of Radiology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Shane Wells
- Department of Radiology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Timothy J Ziemlewicz
- Department of Radiology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Marci Alexander
- Department of Radiology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Poonam Yadav
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - John E Bayouth
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - John Floberg
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Greg Cooley
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Paul M Harari
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI
| | - Michael F Bassetti
- Department of Human Oncology, University of Wisconsin Hospitals & Clinics, Madison, WI
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15
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Grozman V, Onjukka E, Wersäll P, Lax I, Tsakonas G, Nyren S, Lewensohn R, Lindberg K. Extending hypofractionated stereotactic body radiotherapy to tumours larger than 70cc - effects and side effects. Acta Oncol 2021; 60:305-311. [PMID: 33448899 DOI: 10.1080/0284186x.2020.1866776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Stereotactic body radiotherapy (SBRT) for tumours ≥5 cm is poorly studied and its utility and feasibility is uncertain. We here report the Karolinska experience of SBRT in this setting. MATERIAL AND METHODS All patients had a gross tumour volume (GTV) ≥70 cc, a prescribed physical dose of at least 40 Gy and received treatment between 1995-2012. RESULTS We included 164 patients with 175 tumours located in the thorax (n = 86), the liver (n = 27) and the abdomen (n = 62) and treated with a median prescribed dose (BEDα/β 10Gy) of 80 Gy (71.4-113). One- and 2- year local control rates were 82% and 61%. In multivariate analyses, minimum dose to the GTV and histological subtype were associated with local control. Renal cell carcinoma (RCC) histology showed the most favourable local control - 94% at 2 years for all histologies. Thirty-seven patients experienced grade 3-5 toxicity most likely related to SBRT. Seven of the ten patients with grade 5 toxicity, had a centrally located tumour in the thorax. CONCLUSION SBRT of tumours >5 cm in diameter may be an option for peripherally located lung and abdominal tumours. Histological origin and tumour location should be considered before treatment.
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Affiliation(s)
- Vitali Grozman
- Section of Thoracic Radiology, Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Eva Onjukka
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wersäll
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Ingmar Lax
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsakonas
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumours, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Nyren
- Section of Thoracic Radiology, Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Rolf Lewensohn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumours, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumours, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
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16
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Safety and Efficacy of Robotic Radiosurgery for Visceral and Lymph Node Metastases of Renal Cell Carcinoma: A Retrospective, Single Center Analysis. Cancers (Basel) 2021; 13:cancers13040680. [PMID: 33567564 PMCID: PMC7915686 DOI: 10.3390/cancers13040680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary In metastatic renal cell carcinoma (mRCC), systemic treatment with checkpoint inhibitors or tyrosine kinase inhibitors is recommended in guidelines. However, the treatment of patients with oligometastatic disease or mixed responses remains challenging. We aimed to investigate the safety and efficacy of robotic radiosurgery in patients with mRCC. Sixty patients with visceral and lymph node metastases were selected for robotic radiosurgery. The median progression free survival of all patients was 17.4 months, local tumor control was achieved in 96.7% of patients, and only 8.3% of patients experienced adverse events. Robotic radiosurgery might be a powerful tool in addition to systemic treatment for patients with mRCC, but additive effects of both treatments require further investigation. Abstract Despite rapid advances of systemic therapy options in renal cell carcinoma (RCC), local tumor or metastases treatment remains important in selected patients. Here, we assess the safety and efficacy of robotic radiosurgery (RRS) as an ablative therapy for visceral and lymph node metastases of RCC. Patients with histologically confirmed RCC and radiologically confirmed progression of visceral or lymph node metastases underwent RRS and were retrospectively analyzed. Overall survival and progression free survival were calculated by the Kaplan–Meier method and log-rank test. Sixty patients underwent RRS and were included in the analysis. Patients presented for RRS treatment with a median age at RRS treatment of 64 years (range 42–83), clear cell histology (88.3%) and favorable international metastatic renal cell carcinoma database (IMDC) risk score (58.3%). Treatment parameters differed for the number of fractions (median visceral metastases: 1, range 1–5; median lymph node metastases: 1, range 0–5; p = 0.003) and prescription dose (median visceral metastases 24 Gy, range 8–26; median lymph node metastases 18 Gy, range 7–26, p < 0.001). The median overall survival was 65.7 months (range: 2.9–108.6), the median progression free survival was 17.4 months (range: 2.7–70.0) and local tumor control was achieved in 96.7% of patients. Adverse events were limited to 8.3% of patients, with one grade 4 toxicity within 6 weeks after RRS therapy. RRS is a safe and effective treatment option in selected patients with metastatic RCC in a multimodal approach. Further research is warranted to confirm our findings prospectively.
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17
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Peng J, Lalani AK, Swaminath A. Cytoreductive stereotactic body radiotherapy (SBRT) and combination SBRT with immune checkpoint inhibitors in metastatic renal cell carcinoma. Can Urol Assoc J 2021; 15:281-286. [PMID: 33410742 DOI: 10.5489/cuaj.6963] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Preclinical evidence demonstrates the immunogenic potential of stereotactic body radiotherapy (SBRT). There is growing interest in investigating this interplay with the immune system in metastatic renal cell carcinoma (mRCC). Cytoreduction with SBRT and combination therapy with SBRT and checkpoint inhibitor immuno-oncology agents (IO) are two potential therapeutic strategies in mRCC. In this review, we summarize the current clinical evidence for the use of cytoreductive SBRT to primary kidney and combination SBRT with IO. METHODS A literature review for articles and abstracts published between January 2000 and March 2020 was conducted through the PubMed, the American Society of Clinical Oncology (ASCO), and the American Society of Radiation Oncology (ASTRO) databases. Evaluation of studies followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) criteria. RESULTS A total of three articles for cytoreductive SBRT and one article and three abstracts for combination SBRT and IO in mRCC met inclusion criteria for this review. Evidence for SBRT to primary kidney is limited by small series and pilot studies. Outcomes vary widely due to small patient numbers and study heterogeneity. Local control ranges from 85-100% and one- and two-year overall survival ranges from 38-71% and 19-53%, respectively. Combination SBRT and IO are tolerable for patients with early data, suggesting grade 3-4 adverse event rates of 0-24%. Long-term survival data is not yet available. CONCLUSIONS Cytoreductive SBRT and combination SBRT with IO therapy represent promising treatment strategies in mRCC. The evidence for clinical benefit is currently limited and requires further study with well-designed, randomized controlled trials.
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Affiliation(s)
- Jonathan Peng
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Aly-Khan Lalani
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Anand Swaminath
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
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Siva S, Correa RJM, Warner A, Staehler M, Ellis RJ, Ponsky L, Kaplan ID, Mahadevan A, Chu W, Gandhidasan S, Swaminath A, Onishi H, Teh BS, Lo SS, Muacevic A, Louie AV. Stereotactic Ablative Radiotherapy for ≥T1b Primary Renal Cell Carcinoma: A Report From the International Radiosurgery Oncology Consortium for Kidney (IROCK). Int J Radiat Oncol Biol Phys 2020; 108:941-949. [PMID: 32562838 DOI: 10.1016/j.ijrobp.2020.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with larger (T1b, >4 cm) renal cell carcinoma (RCC) not suitable for surgery have few treatment options because thermal ablation is less effective in this setting. We hypothesize that SABR represents an effective, safe, and nephron-sparing alternative for large RCC. METHODS AND MATERIALS Individual patient data from 9 institutions in Germany, Australia, USA, Canada, and Japan were pooled. Patients with T1a tumors, M1 disease, and/or upper tract urothelial carcinoma were excluded. Demographics, treatment, oncologic, and renal function outcomes were assessed using descriptive statistics. Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards regression were generated for oncologic outcomes. RESULTS Ninety-five patients were included. Median follow-up was 2.7 years. Median age was 76 years, median tumor diameter was 4.9 cm, and 81.1% had Eastern Cooperative Oncology Group performance status of 0 to 1 (or Karnofsky performance status ≥70%). In patients for whom operability details were reported, 77.6% were defined as inoperable as determined by the referring urologist. Mean baseline estimated glomerular filtration rate (eGFR) was 57.2 mL/min (mild-to-moderate dysfunction), with 30% of the cohort having moderate-to-severe dysfunction (eGFR <45mL/min). After SABR, eGFR decreased by 7.9 mL/min. Three patients (3.2%) required dialysis. Thirty-eight patients (40%) had a grade 1 to 2 toxicity. No grade 3 to 5 toxicities were reported. Cancer-specific survival, overall survival, and progression-free survival were 96.1%, 83.7%, and 81.0% at 2 years and 91.4%, 69.2%, 64.9% at 4 years, respectively. Local, distant, and any failure at 4 years were 2.9%, 11.1%, and 12.1% (cumulative incidence function with death as competing event). On multivariable analysis, increasing tumor size was associated with inferior cancer-specific survival (hazard ratio per 1 cm increase: 1.30; P < .001). CONCLUSIONS SABR for larger RCC in this older, largely medically inoperable cohort, demonstrated efficacy and tolerability and had modest impact on renal function. SABR appears to be a viable treatment option in this patient population.
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Affiliation(s)
- Shankar Siva
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Rohann J M Correa
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | | | - Rodney J Ellis
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Lee Ponsky
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - William Chu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Senthilkumar Gandhidasan
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Anand Swaminath
- Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, Texas
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | | | - Alexander V Louie
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Berghen C, Joniau S, Vulsteke C, Albersen M, Devos G, Rans K, Haustermans K, De Meerleer G. Metastasis-directed therapy for oligometastatic urological tumours: still no second-hand news. Ecancermedicalscience 2020; 14:1036. [PMID: 32565889 PMCID: PMC7289610 DOI: 10.3332/ecancer.2020.1036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 12/31/2022] Open
Abstract
For patients presenting with limited metastatic disease burden, known as the oligometastatic state of disease, a more aggressive treatment approach targeting the new or progressive metastatic lesions might improve patient outcome, with no or only limited toxicity to be expected from the treatment. This review provides an overview of the existing evidence and on-going trials on oligometastatic disease and metastasis-directed therapy in the field of renal, bladder and prostate cancer.
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Affiliation(s)
- Charlien Berghen
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Christof Vulsteke
- Department of Oncology, Ghent Maria Middelares Hospital, Ghent, Belgium
- Department of Molecular Imaging, Pathology, Radiotherapy and Oncology (MIPRO), Center for Oncological Research (CORE), University of Antwerp, Antwerp, Belgium
| | - Maarten Albersen
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Gaëtan Devos
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Kato Rans
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
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20
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Uhlig A, Uhlig J, Trojan L, Kim HS. Stereotactic Body Radiotherapy for Stage I Renal Cell Carcinoma: National Treatment Trends and Outcomes Compared to Partial Nephrectomy and Thermal Ablation. J Vasc Interv Radiol 2020; 31:564-571. [PMID: 32127324 DOI: 10.1016/j.jvir.2019.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/27/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To assess use of stereotactic body radiotherapy (SBRT) for stage I renal cell carcinoma (RCC) and compare outcomes with thermal ablation and partial nephrectomy (PN). MATERIALS AND METHODS The 2004-2015 National Cancer Database was investigated for histopathologically proven stage I RCC treated with PN, cryoablation, radiofrequency (RF) or microwave (MW) ablation, or SBRT. Patients were propensity score-matched to account for potential confounders, including patient age, sex, race, comorbidities, tumor size, histology, grade, tumor sequence, administration of systemic therapy, treatment in academic vs nonacademic centers, treatment location, and year of diagnosis. Overall survival (OS) was evaluated with Kaplan-Meier plots, log-rank tests, and Cox proportional hazards models. RESULTS A total of 91,965 patients were identified (SBRT, n = 174; PN, n = 82,913; cryoablation, n = 5,446; RF/MW ablation, n = 3,432). Stage I patients who received SBRT tended to be older women with few comorbidities treated at nonacademic centers in New England states. After propensity score matching, a cohort of 636 patients was obtained with well-balanced confounders between treatment groups. In the matched cohort, OS after SBRT was inferior to OS after PN and thermal ablation (PN vs SBRT, hazard ratio [HR] = 0.29, 95% confidence interval [CI] 0.19-0.46, P < .001; cryoablation vs SBRT, HR = 0.40, 95% CI 0.26-0.60, P < .001; RF/MW ablation vs SBRT, HR = 0.46, 95% CI 0.31-0.67, P < .001). Compared with PN, neither cryoablation nor RF/MW ablation showed significant difference in OS (cryoablation vs PN, HR = 1.35, 95% CI 0.80-2.28, P = .258; RF/MW ablation vs PN, HR = 0.64, 95% CI 0.95-2.55, P = .079). CONCLUSIONS Current SBRT protocols show lower OS compared with thermal ablation and PN, whereas thermal ablation and PN demonstrate comparable outcomes.
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Affiliation(s)
- Annemarie Uhlig
- Departments of Urology, University Medical Center Goettingen, Goettingen, Germany
| | - Johannes Uhlig
- Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany; Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Lutz Trojan
- Departments of Urology, University Medical Center Goettingen, Goettingen, Germany
| | - Hyun S Kim
- Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510; Section of Medical Oncology, Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510; Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510.
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21
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The Emerging Role of Stereotactic Ablative Radiotherapy for Primary Renal Cell Carcinoma: A Systematic Review and Meta-Analysis. Eur Urol Focus 2019; 5:958-969. [DOI: 10.1016/j.euf.2019.06.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/17/2019] [Accepted: 06/05/2019] [Indexed: 11/22/2022]
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22
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Rühle A, Andratschke N, Siva S, Guckenberger M. Is there a role for stereotactic radiotherapy in the treatment of renal cell carcinoma? Clin Transl Radiat Oncol 2019; 18:104-112. [PMID: 31341985 PMCID: PMC6630187 DOI: 10.1016/j.ctro.2019.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 12/23/2022] Open
Abstract
Renal cell carcinoma (RCC) has traditionally been regarded as radioresistant tumor based on preclinical data and negative clinical trials using conventional fractionated radiotherapy. However, there is emerging evidence that radiotherapy delivered in few fractions with high single-fraction and total doses may overcome RCC s radioresistance. Stereotactic radiotherapy (SRT) has been successfully used in the treatment of intra- and extracranial RCC metastases showing high local control rates accompanied by low toxicity. Although surgery is standard of care for non-metastasized RCC, a significant number of patients is medically inoperable or refuse surgery. Alternative local approaches such as radiofrequency ablation or cryoablation are invasive and often restricted to small RCC, so that there is a need for alternative local therapies such as stereotactic body radiotherapy (SBRT). Recently, both retrospective and prospective trials demonstrated that SBRT is an attractive treatment alternative for localized RCC. Here, we present a comprehensive review of the published data regarding SBRT for primary RCC. The radiobiological rationale to use higher radiation doses in few fractions is discussed, and technical aspects enabling the safe delivery of SBRT despite intra- and inter-fraction motion and the proximity to organs at risk are outlined.
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Affiliation(s)
- Alexander Rühle
- Department of Radiation Oncology, University Hospital of Zurich, University Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University Zurich, Zurich, Switzerland
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, University Zurich, Zurich, Switzerland
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23
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Siva S, Chesson B, Bressel M, Pryor D, Higgs B, Reynolds HM, Hardcastle N, Montgomery R, Vanneste B, Khoo V, Ruben J, Lau E, Hofman MS, De Abreu Lourenco R, Sridharan S, Brook NR, Martin J, Lawrentschuk N, Kron T, Foroudi F. TROG 15.03 phase II clinical trial of Focal Ablative STereotactic Radiosurgery for Cancers of the Kidney - FASTRACK II. BMC Cancer 2018; 18:1030. [PMID: 30352550 PMCID: PMC6199711 DOI: 10.1186/s12885-018-4916-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 10/08/2018] [Indexed: 12/21/2022] Open
Abstract
Background Stereotactic ablative body radiotherapy (SABR) is a non-invasive alternative to surgery to control primary renal cell cancer (RCC) in patients that are medically inoperable or at high-risk of post-surgical dialysis. The objective of the FASTRACK II clinical trial is to investigate the efficacy of SABR for primary RCC. Methods FASTRACK II is a single arm, multi-institutional phase II study. Seventy patients will be recruited over 3 years and followed for a total of 5 years. Eligible patients must have a biopsy confirmed diagnosis of primary RCC with a single lesion within a kidney, have ECOG performance ≤2 and be medically inoperable, high risk or decline surgery. Radiotherapy treatment planning is undertaken using four dimensional CT scanning to incorporate the impact of respiratory motion. Treatment must be delivered using a conformal or intensity modulated technique including IMRT, VMAT, Cyberknife or Tomotherapy. The trial includes two alternate fractionation schedules based on tumour size: for tumours ≤4 cm in maximum diameter a single fraction of 26Gy is delivered; and for tumours > 4 cm in maximum diameter 42Gy in three fractions is delivered. The primary outcome of the study is to estimate the efficacy of SABR for primary RCC. Secondary objectives include estimating tolerability, characterising overall survival and cancer specific survival, estimating the distant failure rate, describing toxicity and renal function changes after SABR, and assessment of cost-effectiveness of SABR compared with current therapies. Discussion The present study design allows for multicentre prospective validation of the efficacy of SABR for primary RCC that has been observed from prior single institutional and retrospective series. The study also allows assessment of treatment related toxicity, overall survival, cancer specific survival, freedom from distant failure and renal function post therapy. Trial registration Clinicaltrials.govNCT02613819, registered Nov 25th 2015.
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Affiliation(s)
- Shankar Siva
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia. .,University of Melbourne, Royal Parade, Parkville, 8006, Australia.
| | - Brent Chesson
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia
| | - Mathias Bressel
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Braden Higgs
- University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hayley M Reynolds
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia
| | - Nicholas Hardcastle
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia
| | | | | | | | - Jeremy Ruben
- Alfred Health and Monash University, 55 Commercial Rd, Melbourne, 3004, Australia
| | - Eddie Lau
- Austin Health, Heidelberg, 3084, Australia
| | - Michael S Hofman
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | | | - Nicholas R Brook
- Trans Tasman Radiation Oncology Group (TROG), Waratah, Australia
| | - Jarad Martin
- Calvary Mater Newcastle, Newcastle, NSW, Australia
| | - Nathan Lawrentschuk
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia.,University of Melbourne, Royal Parade, Parkville, 8006, Australia
| | - Tomas Kron
- Peter MacCallum Cancer Centre, 305 Grattan Street Melbourne, Melbourne, 3000, Australia
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24
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Correa RJM, Ahmad B, Warner A, Johnson C, MacKenzie MJ, Pautler SE, Bauman GS, Rodrigues GB, Louie AV. A prospective phase I dose-escalation trial of stereotactic ablative radiotherapy (SABR) as an alternative to cytoreductive nephrectomy for inoperable patients with metastatic renal cell carcinoma. Radiat Oncol 2018; 13:47. [PMID: 29558966 PMCID: PMC5859400 DOI: 10.1186/s13014-018-0992-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 03/06/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Cytoreductive nephrectomy is thought to improve survival in metastatic renal cell carcinoma (mRCC). As many patients are ineligible for major surgery, we hypothesized that SABR could be a safe alternative. METHODS In this dose-escalation trial, inoperable mRCC patients underwent SABR targeting the entire affected kidney. Toxicity (CTCAE v3.0), quality of life (QoL), renal function, and tumour response (RECIST v1.0) were assessed. RESULTS Twelve patients of mostly intermediate (67%) or poor (25%) International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic class, median KPS of 70%, and median tumour size of 8.7 cm (range: 4.8-13.8) were enrolled in successive dose cohorts of 25 (n = 3), 30 (n = 6), and 35 Gy (n = 3) in 5 fractions. SABR was well tolerated with 3 grade 3 events: fatigue (2) and bone pain (1). QoL decreased for physical well-being (p = 0.016), but remained unchanged in other domains. SABR achieved a median tumour size reduction of - 17.3% (range: + 5.3 to - 54.4) at 5.3 months. All patients progressed systemically and median OS was 6.7 months. Crude median follow-up was 5.8 months. CONCLUSIONS In non-operable mRCC patients, renal-ablative SABR to 35 Gy in 5 fractions yielded acceptable toxicity, renal function preservation, and stable QoL. SABR merits further prospective investigation as an alternative to cytoreductive nephrectomy. TRIAL REGISTRATION ClinicalTrials.gov NCT02264548. Registered July 22 2014 - Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT02264548.
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Affiliation(s)
- Rohann J M Correa
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Belal Ahmad
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Craig Johnson
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - Mary J MacKenzie
- Department of Medical Oncology, London Regional Cancer Program, London, Canada
| | - Stephen E Pautler
- Division of Urology, Western University, London, Canada.,Division of Surgical Oncology, Western University, London, Canada
| | - Glenn S Bauman
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada
| | - George B Rodrigues
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, London Regional Cancer Program, London, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, Canada.
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25
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Haque W, Verma V, Lewis GD, Lo SS, Butler EB, Teh BS. Utilization of radiotherapy and stereotactic body radiation therapy for renal cell cancer in the USA. Future Oncol 2018. [PMID: 29527938 DOI: 10.2217/fon-2017-0536] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
AIM This study evaluated national practice patterns of cT1N0M0 renal cell cancer, with a focus on stereotactic body radiation therapy (SBRT) utilization. METHODS The National Cancer Database was queried (2004-2013) for patients with newly-diagnosed cT1a/bN0M0 renal cell cancer that received definitive treatment. Temporal trends in utilization were tabulated. RESULTS Altogether, 138,495 patients met inclusion criteria; 13,725 (9.9%) patients received ablative therapy, 57,924 (41.8%) partial nephrectomy, 67,168 (48.5%) radical nephrectomy and 308 (0.2%) external beam radiation therapy (EBRT). The proportion of EBRT that was SBRT increased substantially from 25% in 2004 to 95.4% in 2013, with a sharp inflection point from 2005 to 2006. CONCLUSION SBRT utilization has sharply risen over time; in most recent years, the vast majority of EBRT is delivered in the form of SBRT.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA 15212, USA
| | - Gary D Lewis
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Edward Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX 77030, USA
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