Abstract
Purpose
We report the outcomes of a multimodality treatment approach combining maximal surgical resection and intraoperative electron radiotherapy (IOERT) with or without external beam radiation therapy (EBRT) in patients with locoregionally (LR) recurrent renal cell carcinoma (RCC) after radical nephrectomy or LR advanced primary RCC.
Patients and methods
From 1983 to 2008, 25 patients with LR recurrent (n = 10) or LR advanced primary (n = 15) RCC were treated with this approach. Median patient age was 60 years (range, 16–79 years). Fifteen patients (60%) received perioperative EBRT (median dose, 44 Gy). Surgical resection was R0 (negative margins) in 6 patients (24%) and R1 (residual microscopic disease) in 19 patients (76%). The median dose of IOERT was 14 Gy (range, 9–15). Overall survival (OS) and relapse patterns were calculated using the Kaplan–Meier method.
Results
Median follow-up for surviving patients was 22.2 years (range, 3.6–26 years). OS and DFS at 5 and 10 years were 38% and 18% and 19% and 14%, respectively. LR control (tumor bed or regional lymph nodes) and distant metastases-free survival rates at 5 years were 80% and 22%, respectively. The death rate within 30 days of surgery and IOERT was 4% (n = 1). Six patients (24%) experienced acute or late toxicities of grade 3 or higher according to the National Cancer Institute Common Toxicity Criteria (NCI-CTCAE) v4.
Conclusion
In patients with LR recurrent or LR advanced primary RCC, a multimodality approach consisting of maximal surgical resection and IOERT with or without adjuvant EBRT yielded encouraging local control results, justifying further evaluation.
Zusammenfassung
Ziel
Vorgestellt werden Ergebnisse eines multimodalen Therapieansatzes, bei dem maximale chirurgische Resektion und intraoperative Elektronenstrahlentherapie (IOERT) ± externe Strahlentherapie (EBRT) bei Patienten mit lokoregional rezidivierendem Nierenzellkarzinom (RCC) nach radikaler Nephrektomie oder lokoregional fortgeschrittenem primärem RCC kombiniert wurden.
Material und Methoden
Von 1983 bis 2008 wurden 25 Patienten mit lokoregional rezidivierendem (n=10) oder lokoregional fortgeschrittenem primärem (n=15) RCC mit diesem Ansatz behandelt. Das durchschnittliche Patientenalter betrug 60 Jahre (Spanne: 16–79). Eine perioperative EBRT (mittlere Dosis: 44 Gy) erfolgte bei 15 Patienten (60%). Die chirurgische Resektion gelang bei 6 Patienten (24%) als R0-Resektion (mit negativen Rändern) und bei 19 (76%) als R1-Resektion (mikroskopische Residualerkrankung). Die mittlere IOERT-Dosis betrug 14 Gy (Spanne: 9–15). Gesamtüberleben (OS) und Rezidivmuster wurden mit der Kaplan-Meier-Methode ermittelt.
Ergebnisse
Im Durchschnitt erfolgte das Follow-up 22,2 Jahre lang (Spanne: 3,6–26 Jahre). OS und krankheitsfreies Überleben (DFS) betrugen nach 5 Jahren 38% bzw. 18% und nach 10 Jahren 19% bzw. 14%. Nach 5 Jahren lag eine lokoregionale Kontrolle (Tumorbett oder regionale Lymphknoten) in 80% und fernmetastasenfreies Überleben in 22% der Fälle vor. In 4% der Fälle (n=1) trat der Tod innerhalb von 30 Tagen nach Operation und IOERT ein. Bei 6 Patienten (24%) traten akute oder Spättoxizitäten ≥ Grad 3 nach den National Cancer Institute Common Toxicity Criteria (NCI-CTCAE), Version 4, auf.
Schlussfolgerungen
Bei Patienten mit lokoregional rezidivierendem oder lokoregional fortgeschrittenem primärem RCC führte der multimodale Ansatz aus maximaler chirurgischer Resektion und IOERT ± adjuvante EBRT zu vielversprechenden Ergebnissen bei der lokalen Kontrolle, was seine weitere Evaluation rechtfertigt.
References
Esrig D, Ahlering TE, Lieskovsky G, Skinner DG (1992) Experience with fossa recurrence of renal cell carcinoma. J Urol 147:1491–1494
Tanguay S, Pisters LL, Lawrence DD, Dinney C (1996) Therapy of locally recurrent renal cell carcinoma after nephrectomy. J Urol 155:26–29
Bruno JJ 2nd, Snyder ME, Motzer RJ, Russo P (2006) Renal cell carcinoma local recurrences: impact of surgical treatment and concomitant metastasis on survival. BJU Int 97:933–938
Itano NB, Blute ML, Spotts B, Zincke H (2000) Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. J Urol 164:322–325
Rabinovitch RA, Zelefsky MJ, Gaynor JJ, Fuks Z (1994) Patterns of failure following surgical resection of renal cell carcinoma: implications for adjuvant local and systemic therapy. J Clin Oncol 12:206–212
Frydenberg M, Gunderson L, Hahn G et al (1994) Preoperative external beam radiotherapy followed by cytoreductive surgery and intraoperative radiotherapy for locally advanced primary or recurrent renal malignancies. J Urol 152:15–21
Margulis V, McDonald M, Tamboli P et al (2009) Predictors of oncological outcome after resection of locally recurrent renal cell carcinoma. J Urol 181:2044–2051
Schrodter S, Hakenberg OW, Manseck A et al (2002) Outcome of surgical treatment of isolated local recurrence after radical nephrectomy for renal cell carcinoma. J Urol 167:1630–1633
Santos M, Ucar A, Ramos H et al (1989) Intraoperative radiotherapy in locally advanced carcinoma of the kidney: initial experience. Actas Urol Esp 13:36–40
National Cancer Institute (2011) Common toxicity criteria. Version 4.02, National Cancer Institute, Rockville
Kaplan E, Meier P (1958) Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457–481
Eble MJ, Stahler G, Wannenmacher M (1998) The intraoperative radiotherapy (IORT) for locally advanced and recurrent renal cell carcinomas. Strahlenther Onkol 174:30–36
Master VA, Gottschalk AR, Kane C, Carroll PR (2005) Management of isolated renal fossa recurrence following radical nephrectomy. J Urol 174:473–477 (discussion 477)
Hallemeier CL, Choo R, Davis BJ et al (2012) Long-term outcomes after maximal surgical resection and intraoperative electron radiotherapy for loco regionally recurrent or locorregionally advanced primary renal cell carcinoma. Int J Radiat Oncol Biol Phys 82:1938–1943
Brown PD, Brown CA, Pollock BE et al (2008) Stereotactic radiosurgery for patients with “radioresistant” brain metastases. Neurosurgery 62(Suppl 2):790–801
Goyal LK, Suh JH, Reddy CA, Barnett GH (2000) The role of whole brain radiotherapy and stereotactic radiosurgery on brain metastases from renal cell carcinoma. Int J Radiat Oncol Biol Phys 47:1007–1012
Mori Y, Kondziolka D, Flickinger JC et al (1998) Stereotactic radiosurgery for cerebral metastatic melanoma: factors affecting local disease control and survival. Int J Radiat Oncol Biol Phys 42:581–589
Mori Y, Kondziolka D, Flickinger JC et al (1998) Stereotactic radiosurgery for brain metastasis from renal cell carcinoma. Cancer 83:344–353
Motzer RJ, Hutson TE, Tomczak P et al (2007) Sunitinib versus interferonalfa in metastatic renal-cell carcinoma. N Engl J Med 356:115–124
Escudier B, Eisen T, Stadler WM et al (2007) Sorafenib in advanced clear-cell renal-cell carcinoma. N Engl J Med 356:125–134
Hudes G, Carducci M, Tomczak P et al (2007) Temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. N Engl J Med 356:2271–2281
Yang JC, Haworth L, Sherry RM et al (2003) A randomized trial of bevacizumab, an anti-vascular endothelial growth factor antibody, for metastatic renal cancer. N Engl J Med 349:427–434
Hellenthal NJ, Underwood W, Penetrante R et al (2010) Prospective clinical trial of preoperative sunitinib in patients with renal cell carcinoma. J Urol 184:859–864
Pascau J, Santos Miranda JA, Calvo FA et al (2012) An innovative tool for intraoperative electron beam radiotherapy simulation and planning: description and initial evaluation by radiation oncologists. Int J Radiat Oncol Biol Phys 83:287–295
Svedman C, Sandstrom P, Pisa P et al (2006) A prospective phase II trial of using extracranial stereotactic radiotherapy in primary and metastatic renal cell carcinoma. Acta Oncol 45:870–875
Zelefsky MJ, Greco C, Motzer R et al (2012) Tumour control outcomes after hypofractionated and single-dose stereotactic image-guided intensity-modulated radiotherapy for extracranial metastases from renal cell carcinoma. Int J Radiat Oncol Biol Phys 82:1744–1748
Hines-Peralta A, Goldberg SN (2004) Review of radiofrequency ablation for renal cell carcinoma. Clin Cancer Res 10:6328S–6334S
Ning S, Trisler K, Wessels BW, Knox SJ (1997) Radiobiologic studies of radioimmunotherapy and external beam radiotherapy in vitro and in vivo in human renal cell carcinoma xenografts. Cancer 80(12 Suppl):2519–2528
Acknowledgments
Supported in part by a grant from the Health Institute of Research Carlos III, Spanish Ministry of Science and Innovation (project code PI11–02908).
Conflict of interest
On behalf of all authors, the corresponding author states that there are no conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Calvo, F., Sole, C., Martinez-Monge, R. et al. Intraoperative EBRT and resection for renal cell carcinoma. Strahlenther Onkol 189, 129–136 (2013). https://doi.org/10.1007/s00066-012-0272-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00066-012-0272-3
Keywords
- Intraoperative radiation therapy
- Locally advanced or recurrent disease
- Renal cell carcinoma
- Surgical resection
- Outcomes