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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 8  |  Page : 260-262

Hypofractionated postoperative irradiation in localized renal cell cancer: A case report and pertinent literature review


1 School of Medical and Life Sciences, Shandong Academy of Medical Sciences, Jinan University; Department of Radiation Oncology II, Shandong Cancer Hospital and Institute, Jinan, China
2 Department of Oncology Medicine, People's Hospital of Xintai City, Affiliated to Taishan Medical University, Xintai, China
3 Department of Radiation Oncology II, Shandong Cancer Hospital and Institute, Jinan, China

Date of Web Publication26-Mar-2018

Correspondence Address:
Yong-Hua Yu
Department of Radiation Oncology II, Shandong Cancer Hospital and Institute, 440 Ji Yan Road, Jinan
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.172711

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 > Abstract 


For localized the incidence of renal cell carcinoma (RCC), nephrectomy is the standard treatment. As RCC is generally regarded as a radiation-resistant tumor, the value of postoperative adjuvant radiotherapy is controversial. However, with new advance in radiotherapy (i.e., three-dimensional conformal radiation therapy [3DCRT] and intensity-modulated radiation therapy [IMRT]), target volume delineation, intensity modulation in treatment planning, and treatment delivery are more accurate with fewer adverse effect. A right renal tumor was identified in a 50-year-old man during a routine examination. T1N0M0 RCC was clinically diagnosed as the tumor was 3 cm × 3.5 cm and well-enhanced with intravenously infused contrast material in the arterial phase on computed tomography (CT). No metastases to regional lymph nodes or distant sites were evident. 3DCRT after the operation was carried out. A total dose of 50 Gy in 20 fractions over 28 days was delivered using a 15-MV X-ray. No clinical acute or chronic side effects were recorded during or after treatment, which was well tolerated. After radiotherapy, the patient came back to the hospital for a check regularly, with no evidence of recurrence and metastasis more than 11 years, and the CT for abdominal showed partial function of the right renal remained. The present case showed a good response with recovery after CRT of 50 Gy in 20 fractions for postoperative RCC. Although further experiences and longer follow-up are mandatory to conclude the optimal treatment schedule and efficacy of CRT for RCC, postoperative radiotherapy definitely reduces locoregional recurrences and with acceptable gastrointestinal toxicity if modern techniques (CRT and IMRT) are utilized.

Keywords: Partial nephrectomy, postoperative, radiation therapy, renal-cell carcinoma


How to cite this article:
Zhao XR, Shan GL, Zhang Y, Yu YH. Hypofractionated postoperative irradiation in localized renal cell cancer: A case report and pertinent literature review. J Can Res Ther 2018;14, Suppl S1:260-2

How to cite this URL:
Zhao XR, Shan GL, Zhang Y, Yu YH. Hypofractionated postoperative irradiation in localized renal cell cancer: A case report and pertinent literature review. J Can Res Ther [serial online] 2018 [cited 2019 Aug 21];14:260-2. Available from: http://www.cancerjournal.net/text.asp?2018/14/8/260/172711




 > Introduction Top


Renal cell carcinoma (RCC) has progressively increased accounting for 3% of cancers [1] and has an estimated age-standardized mortality in Europe of 2.6% over the last 20 years.[2] It has the third highest mortality rate among genitourinary cancers after prostate cancer and bladder cancer. Long-term cigarette smoking, hypertension, and high body weight are associated with an increased risk of developing RCC. The standard therapy for nonmetastatic RCC is nephrectomy. However, local recurrence rates are high, especially in locally advanced disease even if the tumor has been removed totally. To reduce the recurrence rates, postoperative radiotherapy (PORT) may be considered. Then, we will report a case which a patient who was treated with partial nephrectomy and PORT was healed up without recurrence and metastasis in the past 11 years.


 > Case Report Top


In 2004, a right renal lesion was identified in a man who was 50 years old during a general health checkup, without hematuria and osphyalgia. On computed tomography (CT) for abdominal, the right renal lesion was low density which showed good enhancement with intravenously infused contrast material in the arterial phase on CT and was considered to be RCC clinically. No metastases to regional lymph nodes or distant sites were evident on whole-body CT. Therefore, T1N0M0 RCC was diagnosed. Then, enucleation was operated on the right renal lesion. What can be seen in operation was that the renal lesion was 3 cm × 3.5 cm and located in the posterolateral portion of the right kidney which was round, smooth with capsule. Clear cell RCC (right renal) with cystis degeneration was showed in the pathological examination after the operation. Immunohistochemically, the tumor cells were positive for CKAE1/CKAE3, CK8, vimentin. However, the operation led to positive surgical margins (PSMs). To reduce the risk of oncologic failure as far as possible, 3 × 106 units of interferon were administered for 3 months. Then, he received radiation therapy. Planning target volume (PTV) was determined as the gross tumor volume (GTV) of the right renal plus the personal internal margin with an additional margin of 5 mm to compensate for intrasession reproducibility and to provide a safety margin. Tumor position was adjusted to the planned position before every session using CT images taken in the vicinity of the tumor. Five different noncoplanar static beams were used for irradiation. The radiation port was made with sliding multileaves adjusted with 3 mm margins around the border of the PTV. A total dose to the center of 50 Gy in 20 fractions over 28 days was delivered using a 15-MV X-ray. Targets delineations and isovalue lines were written on CT. The right renal was circumvolutioed by GTV totally. The mean value of left renal was 58 cGy, and the maximum value of spinal-cord was 1231 cGy. PTV was within the 90% isodose line to the prescribed dose. No clinical acute or chronic side effects were recorded during or after treatment, which was well-tolerated. After radiotherapy, the patient came back to the hospital for a check regularly, with no evidence of recurrence and metastasis more than 11 years. Although the right renal is atrophied as a result of radiotherapy, CT for abdominal indicated partial function was remained which showed good enhancement on the edge of the right renal [Figure 1].
Figure 1: The patient reviewed again and had a computed tomography examination, on March 11, 2015. Good enhancement was still showed on the edge of the right renal lesion with intravenously infused contrast material in the arterial phase on computed tomography

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 > Discussion Top


RCC is considered to be a radioresistant tumor. The standard therapy for nonmetastatic RCC is nephrectomy. However, one of the unique characteristics of RCC is tumor recurrence after 5 or more years without apparent evidence of disease.[3] In one study, the observation of 113 T1 patients for a mean period of 39 months detected recurrence in 8.[4] Yet, another study showed a substantial number of recurrences (18 of 123 patients with T1 disease).[5] What's more a recent survey found an increased risk of local recurrence in patients with PSMs; furthermore, in these patients, there was a shorter time to disease recurrence than in patients with negative surgical margins (21.3 vs. 27.7 months, respectively; P = 0.004).[6] To minimize the risks of locoregional failure (LRF), PORT to renal bed and draining lymph node may be accepted. However, even if the recurrence rate of RCC is so high, the value of postoperative adjuvant radiotherapy is controversial. A number of retrospective studies have suggested that the addition of radiotherapy to nephrectomy may prolong survival. The LRF was significantly low in patients with PORT (P = 0.0001). The pooled odds ratio was 0.47 (99% confidence interval 0.33–0.68). The meta-analysis by Tunio et al. showed PORT definitely reduces locoregional recurrences and with acceptable gastrointestinal toxicity if modern techniques three-dimensional conformal radiation therapy and intensity-modulated radiation therapy (3DCRT and IMRT) are utilized for high-risk patients (T3, capsule infiltration, renal vein).[7] In the study by Ulutin et al., further analysis showed that the benefit of PORT was seen. In this study, distant metastases were seen at 50% and 79% in PORT and nephrectomy-alone arms, respectively, favoring to PORT.[8] They reported the 5-year disease-free survival rates were 66% in the PORT group and 16% in the no adjuvant treatment group, with a significant difference in both univariate and multivariate analyses (P = 0.045 and P = 0.0007, respectively). However, two randomized trials have not confirmed the survival benefit of PORT. The two trials by the Copenhagen RCC Study Group [9] and Finney [10] showed higher gastrointestinal and hepatic sequelae and mortality in the PORT arm. Interestingly, these trials used higher daily radiation doses (>2 Gy) and larger treatment fields. However, with new advance in radiotherapy (3DCRT and IMRT), target volume delineation, intensity modulation in treatment planning, and treatment delivery are more accurate with fewer adverse effect. In the presented case, although the patient was treated with high daily radiation dose (2.5 Gy), no clinical acute or chronic side effects were recorded during or after treatment, as CRT is used. What's more, no recurrence and metastasis were found more than 11 years in the reexamination so far. What's more, although the right renal is atrophied as a result of radiotherapy, CT for abdominal indicated partial function was remained which showed good enhancement on the edge of the right renal. Contribute to the good compensatory function of the left kidney, the patient have not appeared symptoms of kidney atrophy, such as hypertension, anemia, and edema. Despite PORT has remained controversial in the literature so far, the present case showed encouraging consequence.


 > Conclusion Top


The present case showed a good response with recovery after CRT of 50 Gy in 20 fractions for postoperative RCC. Although further experiences and longer follow-up are mandatory to conclude the optimal treatment schedule and efficacy of CRT for RCC, PORT definitely reduces locoregional recurrences, and with acceptable gastrointestinal toxicity if modern techniques (CRT and IMRT) are utilized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58:71-96.  Back to cited text no. 1
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Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917.  Back to cited text no. 2
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Ljungberg B, Alamdari FI, Rasmuson T, Roos G. Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy. BJU Int 1999;84:405-11.  Back to cited text no. 3
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Levy DA, Slaton JW, Swanson DA, Dinney CP. Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 1998;159:1163-7.  Back to cited text no. 4
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Chae EJ, Kim JK, Kim SH, Bae SJ, Cho KS. Renal cell carcinoma: Analysis of postoperative recurrence patterns. Radiology 2005;234:189-96.  Back to cited text no. 5
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6.
Bensalah K, Pantuck AJ, Rioux-Leclercq N, Thuret R, Montorsi F, Karakiewicz PI, et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol 2010;57:466-71.  Back to cited text no. 6
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7.
Tunio MA, Hashmi A, Rafi M. Need for a new trial to evaluate postoperative radiotherapy in renal cell carcinoma: A meta-analysis of randomized controlled trials. Ann Oncol 2010;21:1839-45.  Back to cited text no. 7
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8.
Ulutin HC, Aksu G, Fayda M, Kuzhan O, Tahmaz L, Beyzadeoglu M. The value of postoperative radiotherapy in renal cell carcinoma: A single-institution experience. Tumori 2006;92:202-6.  Back to cited text no. 8
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Kjaer M, Iversen P, Hvidt V, Bruun E, Skaarup P, Bech Hansen J, et al. A randomized trial of postoperative radiotherapy versus observation in stage II and III renal adenocarcinoma. A study by the Copenhagen Renal Cancer Study Group. Scand J Urol Nephrol 1987;21:285-9.  Back to cited text no. 9
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10.
Finney R. The value of radiotherapy in the treatment of hypernephroma – A clinical trial. Br J Urol 1973;45:258-69.  Back to cited text no. 10
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