Role of Radiation in Renal Cell Carcinoma

Summary:

To do or not to do!

Role of Radiation in Renal Cell Carcinoma

radtuxabhishek 22 Sep 2010 07:22

RCC is relatively rare; but indications for post operative XRT vary from "positive margins", to capsular invasion and nodal metastasis. While I was reading about it, I was struck that much of the "evidence" comes in from retrospective studies and few poorly designed prospective studies where loco-regional recurrence rates was not the end point of the study design. In addition to that, there have been few number of patients and literature quotes that this is "radio-resistant" tumor (http://www.ncbi.nlm.nih.gov/pubmed/12118559?dopt=Abstract).

I am linking to meta-analysis published in recent issue of Annals of Oncology here: http://www.scribd.com/doc/37912346/Need-for-a-New-Trial-to-Evaluate-Postoperative-Radiotherapy-in-Renal-Cell-Carcinoma-a-Meta-Analysis-of-Randomized-Controlled-Trials. Please feel free to download it. (PMID: 20139152).

At the same time, it led me to think that since this is "radio-resistant" tumor, can hypofractionation (with conformal techniques) be really helpful?

A Pubmed search lead me to following articles:
http://www.scribd.com/doc/37912667/Do-Patients-Receiving-Whole-Brain-Radiotherapy-for-Brain-Metastases-From-Renal-Cell-Carcinoma-Benefit-From-Escalation-of-the-Radiation-Dose

What is the opinion of the forum to push for Radiation in Renal Cell Carcinoma? It's time that overt reliance on targeted therapy be discarded in favor or perhaps stereotactic/ conformal hypofractionated regimens and/or under the ambit of a well designed prospective clinical trial.

@Santam: Am on Linux Mint (9) now and realized that Ubuntu's installer is best in Linux world at present. Maybe perhaps in near future (when I have better bandwidth), I'd shift to a rolling release distro; most likely debian only.

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Reality is merely a persistent illusion

Re: Role of Radiation in Renal Cell Carcinoma

Rohit Malde 28 Sep 2010 20:14

The meta-analysis concluded , PORT significantly reduces locoregional failure (p=0.0001), but has no impact on OS and DFS.

The authors state new trials are needed and conformal and IMRT treatments may do the trick.
I could not find in the paper the rates / patterns of spread of distant disease.

You thik, abhishek hypofractionated RT may work.
But it makes me wonder, why would you want to reduce this risk of local failure even further and get this p value to 0.0000001, when the problem is that these patients relapse systemically and RT has no chance of controlling that.
If a pT3a cancer has spread to the renal vein, ot pT3b has gone into IVC, where do you think these patients relapse ?

The last decade has given us new targeted drugs which have proved to be a new revolution in mgt of mets renal cell cancer.
We will soon have results of adjuvant therapy for these patients, which hopefully may improve overall survival.

I personally believe RT will never improve OS in the adjuvant setting. However, once adjuvant therapy becomes std practce in future, and if the patterns of relapse change (which means more local relapse, compared to systemic relapse…. then may be RT may have some chance in 2050 ? god knows).

But in our life times, RT has no role in the adjuvant setting. Moreso, there are no currently open trials on NCRI website.

Re: Role of Radiation in Renal Cell Carcinoma

radtuxabhishek 29 Sep 2010 02:57

I do agree with you. At this point of time, I have no clear cut answer that better "local rate" actually improves OS (the much wanted end point). At the same time, Surgery for "local control" has been advocated to a large extent.

My only grouse. Trials with XRT were carried out in orthovoltage era and in the times when Emami's data was scarce. Most of the proper phase III trials have been done perhaps up to 1990's. Given this, backdrop, I still hold that even if the patients fail systemically (most of the other cancers also- namely Breast), why not "secure" the local spread first?

I would still hold that local control is the most important aspect. It has also been seen that once the primary is taken care of, the metastasis also tends to regress.

Why not push for increased role of Radiation?

As for the open trials on NCI, to be honest, the initiative has to come from within the community to start of something on those lines.

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Reality is merely a persistent illusion