Adjuvant RT after nephrectomy for renal cell carcinoma

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Kroll2013

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Dear colleagues, would you give adjuvant RT after nephrectomy for renal cell carcinoma but with residual disease in a LN that was not resected because of adherence to the vena cava ?

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There's no right answer in this situation. If that's the only site of gross disease, we'd probably SBRT it with fiducials and/or CBCT with 4D sim and attention to motion/motion management (though this may not move much or at all). Dose is 5 fractions to 30-60 Gy as limited by bowel tolerance. I'd only recommend doing that at a center that has expertise in GI SBRT.
 
There's no right answer in this situation. If that's the only site of gross disease, we'd probably SBRT it with fiducials and/or CBCT with 4D sim and attention to motion/motion management (though this may not move much or at all). Dose is 5 fractions to 30-60 Gy as limited by bowel tolerance. I'd only recommend doing that at a center that has expertise in GI SBRT.
Without SBRT, I think I'd ptobably treat the area to 54 in 6 weeks as tolerated by surrounding structures.
 
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I was referred a patient who had a prior nephrectomy on the left for RCC and now has a Right renal mass seen on contrast CT invading into the IVC (7 cm renal mass), non surgical candidate, no distant disease. Pt is on HD. Any role for RT you guys know of? Is cryo/RF/renal art ablation even an option in a stage III RCC. Should this be biopsied? Thanks, im pretty clueless about RCC as a rad onc.
 
Dear colleagues, would you give adjuvant RT after nephrectomy for renal cell carcinoma but with residual disease in a LN that was not resected because of adherence to the vena cava ?

Disclaimer that I'm a resident, not staff, but you did not mention systemic disease status (if positive then no RT in this situation). If this is the only site of disease otherwise I doubt our centre would treat (we honestly don't see these referrals because we don't treat, though they are occasionally seen in multidisciplinary GU clinic).

I could see the tempting rationale. On a cursory glance at the literature, there are some retrospective studies which may support lymph node dissection in high risk patients, and extending that rationale you could probably suggest treatment. That being said, I doubt you would find a surgeon who would put the patient under an additional procedure with separate side effects to retrieve that single lymph node. The patient would have to be aware he is likely undergoing extra side effects of SBRT without any evidence that treatment would improve survival or delay metastases (node positive RCC has a high risk of having metastatic disease). I'd be interested to hear what others think.
 
I was referred a patient who had a prior nephrectomy on the left for RCC and now has a Right renal mass seen on contrast CT invading into the IVC (7 cm renal mass), non surgical candidate, no distant disease. Pt is on HD. Any role for RT you guys know of? Is cryo/RF/renal art ablation even an option in a stage III RCC. Should this be biopsied? Thanks, im pretty clueless about RCC as a rad onc.

I have no good data behind this, but if the patient is already on HD, you could consider SBRT

https://www.ncbi.nlm.nih.gov/pubmed/28188682
 
Never done it, but think it makes absolute sense- I would treat to small bowel tolerance. Regarding stereotactic, unless you have a well defined lesion- which you usually dont in the postoperative setting- I wouldnt do it, especially 30GY/5. Really that is a low dose- in cervical cancer we are taught 30 GY/5 HDRs is equal to 40-45 Gy ? (I know that it what is used for pancreatic ca)
 
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I have no good data behind this, but if the patient is already on HD, you could consider SBRT

https://www.ncbi.nlm.nih.gov/pubmed/28188682

just looked at abstract but it seems this was T1/T2, no T3s. This lesion is too big anyway, 7 cm and invading into the IVC like 4 cm up from the renal art

Anyone think a renal artery emoblization is a better idea than RT? I mean with RT you could chase the thrombus up and include it in the field. I mean i dont know that going 2.5 to 40 (bowel tolerance) is going to do anything to a large T3 lesion?
 
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I was referred a patient who had a prior nephrectomy on the left for RCC and now has a Right renal mass seen on contrast CT invading into the IVC (7 cm renal mass), non surgical candidate, no distant disease. Pt is on HD. Any role for RT you guys know of? Is cryo/RF/renal art ablation even an option in a stage III RCC. Should this be biopsied? Thanks, im pretty clueless about RCC as a rad onc.

Why a nonsurgical candidate? How old?

No role for cryo/RF with T3 disease. Really only used for small masses away from the renal hilum. You can't freeze the renal vasculature.

No need for biopsy. Nothing else besides RCC will look like that on RCC. Path is usually concordant with his prior contralateral cancer.

In my opinion, no role for RT. If truly not a surgical candidate, I don't think RT is going to improve survival with large T3 lesion and IVC tumor thrombus. Prognosis very poor for a patient too unhealthy for surgery and on HD with this bad disease.

Renal artery embolization could be considered for palliative reasons if the patient develops intractable hematuria, but also unlikely to change survival.
 
Why a nonsurgical candidate? How old?

No role for cryo/RF with T3 disease. Really only used for small masses away from the renal hilum. You can't freeze the renal vasculature.

No need for biopsy. Nothing else besides RCC will look like that on RCC. Path is usually concordant with his prior contralateral cancer.

In my opinion, no role for RT. If truly not a surgical candidate, I don't think RT is going to improve survival with large T3 lesion and IVC tumor thrombus. Prognosis very poor for a patient too unhealthy for surgery and on HD with this bad disease.

Renal artery embolization could be considered for palliative reasons if the patient develops intractable hematuria, but also unlikely to change survival.


Thanks thats all very helpful; so basically he should go to surgery, its his only chance. He's 80 years old, COPD/CHF but not terrible. I mean hes not an amazing candidate but hes between a rock and a hard place. Im still not sure why you cant just ablate the renal artery, thats what I would opt for. I mean Kidney isnt working anyway, just cut off its blood supply entirely, see what happens. Its prob a better palliative procedure than RT.
 
Thanks thats all very helpful; so basically he should go to surgery, its his only chance. He's 80 years old, COPD/CHF but not terrible. I mean hes not an amazing candidate but hes between a rock and a hard place. Im still not sure why you cant just ablate the renal artery, thats what I would opt for. I mean Kidney isnt working anyway, just cut off its blood supply entirely, see what happens. Its prob a better palliative procedure than RT.

Surgery is definitely his only chance at cure. His prognosis isn't awesome either way. Just being on HD alone at his age with comorbidities has a pretty poor prognosis. There are risk stratification nomograms you can plug his info into to better assess competing risks of mortality. Check out Fox Chase CC website. They have some good ones with references. That said, this is the type of kidney cancer that will kill him in a couple of years without treatment, so the risks of surgery might be worth it.

If by ablate you mean embolize, that is a palliative option if the patient is having intractable hematuria or local symptoms. However, having a dead necrotic kidney in there can be painful, get infected, cause a large inflammatory response. I would not advise it unless he is having a lot of hematuria (requiring frequent transfusion). RCC is highly angiogenic (VEGF mediated) and it will already have many collaterals and form more. Embolization doesn't treat the cancer or improve prognosis. May help with symptoms if the patient is a hospice, comfort care type of patient.
 
wrote out the case then realized i asked the same thing above. So this guy really isnt going to surgery. Med onc asked again if there is a role for palliative RT here, his IVC is just getting more filled with his RCC? If so, would you treat the entire primary and the IVC component? Can you just treat the IVC component? What would this even do? Could it make things worse, ie cause thrombus?
 
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Firstly there are very few patients who should not be surgical candidates for T3b RCC. It will kill him in reasonably short order, and likely become very symptomatic with LE edema if it hasn't already. All the competing risk analysis data (i.e. the fox chase normograms) is assuming treatment of the primary tumor, and in any case just accounts for tumor size, not T3 disease. Because of this, there is going to be almost no data for expectant or non-operative management of T3b disease. My thought in that setting would be to 1. reassess what it means to "not be a surgical candidate" in this setting, and 2. place the patient on a TKI if tolerated, with XRT/embolization treatments resolved only for symptomatic management.
 
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What is he on now @Haybrant ? He should be on some systemic therapy if he's been deemed surgically unresectable.

As urologists, @cpants and @DoctwoB , you're doing a IVC reconstruction with enbloc resection of the tumor thrombus involved IVC for this patient, co-morbidities willing? Even with obvious hematogenous seeding of tumor?
 
What is he on now @Haybrant ? He should be on some systemic therapy if he's been deemed surgically unresectable.

As urologists, @cpants and @DoctwoB , you're doing a IVC reconstruction with enbloc resection of the tumor thrombus involved IVC for this patient, co-morbidities willing? Even with obvious hematogenous seeding of tumor?

It is not an IVC resection, generally involves opening the IVC, thrombectomy, then closing the IVC. Often done in conjunction with vascular surgery, HPB for retrohepatic IVC, or cardiac surgery if bypass or required for atrial thrombus. RCC with IVC or even atrial thrombus without evidence of nodal or metastatic involvement is still a form localized disease with a reasonably good chance for cure with surgical resection, which is why I would advocate for being aggressive in patient selection. 5 year CSS for T3b RCC (thrombus extending into IVC below the diaphragm) is about 50%. While there is the theoretical risk of tumor seeding, the larger concern is of tumor embolus causing a pulmonary embolus type phenomenon and even sudden cardiac death. From a logical standpoint, I would think that having tumor thrombus growing into your IVC is the real seeding risk, not the additional manipulation from removing it.
 
We this guy having one kidney at age 80, expectant management is the only reasonable choice. Sorry, tell him to put his affairs in order.
 
I am not sure what the downside is for hypofractionated xrt- I would expect it to have a better local response rate and less toxicity than a tki, Opdivo in second line also has minimal toxicity and can hit the ball out of the park in 20% of cases and who knows, maybe will synergize with the xrt.
 
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I guess what you are guys are saying, go ahead and sacrifice the remaining kidney by slapping fields on it, since the pt is already on HD?
 
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Why would you sacrifice the remaining kidney- unless I am missing something.
 
Why would you sacrifice the remaining kidney- unless I am missing something.

Per Haybrant's initial post (NOT the OP, but post #4), patient previously had a L nephrectomy, now presents with R Kidney disease invading IVC. Currently on HD. I believe that's what seper is referencing to, "sacrificing" the kidney as he's already on HD.
 
We this guy having one kidney at age 80, expectant management is the only reasonable choice. Sorry, tell him to put his affairs in order.

Why? He is already on HD. Whack the other one out.
 
Why? He is already on HD. Whack the other one out.

Agree. As I said above that is the only chance to cure this disease. Also likely the only way to avoid some seriously unpleasant morbidity. Locally advanced kidney cancer is a nasty animal.

I haven't heard yet why he's not a surgical candidate.

If he truly isn't a surgical candidate -- eg. Child's class C cirrhotic, on an LVAD, something like that -- then I think you start him on TKI's and do watchful waiting. I wouldn't radiate him or embolize just to make yourself feel better about not treating the cancer. There is no benefit.
 
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