The value of postoperative radiotherapy in advanced renal cell cancer.

Makarewicz R, Zarzycka M, Kulinska G, Windorbska W

Department of Radiation Oncology, Bydgoszcz Regional Cancer Center, Poland.

The study reviews experience with the treatment of advanced renal cell cancer at Bydgoszcz Regional Cancer Center within a 10-year period from 1985 to 1996. The aim of this paper was to evaluate the value of postoperative radiotherapy. The medical records of 186 patients with locally advanced renal cell cancer were reviewed retrospectively. Postoperative radiation therapy with a median dose of 50.0 Gy/t was given in 114 patients. The overall and disease-free survival, the pattern of recurrences, time interval to recurrence were assessed. For all patients, the 5-year overall and disease-free survival rates were 36.2% and 30.5%, respectively. Non significant difference was observed in terms of 5-year overall and disease-free survival between the group of patients with postoperative radiotherapy and without, 37.9%/29.5% vs. 35.5%/31.3%, respectively. A total of 29 patients (15.6%) developed local recurrences. Local failure by stage was as follows: T3N0 without postoperative radiation therapy--15.8%, with irradiation--8.8%; T3N(+) without radiation therapy--33.3%, with irradiation--33.3%; T4N0 without radiation therapy--33.3%, with irradiation--33.3%, T4N(+) without radiation therapy--33.3%, with irradiation--25.0%. 73 patients (39.3%) had distant metastases as a first symptom of renal cell cancer relapse. The median time to relapse for local recurrence or distant metastases were approximately two times longer in patients with adjuvant radiotherapy compared to those without, 27.0/21.0 months vs. 16.0/12.5 months, respectively. In our opinion postoperative radiotherapy reduces the probability of local recurrences in selected patients, mainly with pathologic stage T3N0, but its impact on survival is minimal.

Radiother Oncol 1992 May;24(1):41-4

The value of postoperative irradiation in renal cell cancer.

Stein M, Kuten A, Halpern J, Coachman NM, Cohen Y, Robinson E

Northern Israel Oncology Center, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel.

This is a retrospective analysis of 147 evaluable patients, with histologically proven renal cell carcinoma, who were referred to our center between 1977 through 1988. All patients with disease limited to the kidney underwent nephrectomy. Post-operative megavoltage irradiation, with a median dose of 46 Gy, was given to 56 patients, using parallel opposing portals, or multiple field technique. Five and 10 year actuarial survivals in irradiated patients (Rt+) were 50 and 44%, respectively, and in non-irradiated patients (Rt-) 40 and 32%, respectively. The disease recurred locally in a total of 19 patients; 16 had tumor bed recurrence and three had scar recurrence. Local recurrence by stage was as follows: T2 N0M0: RT+ 0/17, RT- 2/28; T3 N0M0: RT+ 4/37 (10%), RT- 11/30 (37%) (p less than 0.05); T4 N0M0: RT+ 1/2, RT- 1/5. Two of the local recurrences in irradiated patients developed in a surgical scar which was not included in the treatment volume. Significant toxicity developed in three patients (5%). It is concluded that post-operative irradiation can reduce local recurrence rate in T3 N0M0 renal cell carcinoma. It is recommended that the surgical scar should always be included in the treatment volume and irradiated to a full dose.

Radiology 1994 Dec;193(3):725-30

Locally advanced renal cell carcinoma: low complication rate and efficacy of postnephrectomy radiation therapy planned with CT.

Kao GD, Malkowicz SB, Whittington R, D'Amico AV, Wein AJ

Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia 19104.

The authors retrospectively analyzed the treatment records and follow-up status of 12 consecutive patients who underwent radical nephrectomy and postoperative radiation therapy for locally advanced renal cell carcinoma. Records' of 12 consecutive patients who underwent only radical nephrectomy were also analyzed. RESULTS: None of the patients who received radiation therapy after nephrectomy had local-regional recurrence, despite disease at the surgical margins in six patients; the actuarial disease-free survival at 5 years was 75%. In contrast, the 5-year actuarial local failure rate in the surgery-only group was 30% (significant difference at P < .01) and the disease-free survival rate was 62% (mean and median follow-up was 4.6 and 5.1 years, respectively). CONCLUSION: With CT, radiation can be delivered to the renal bed safely and without undue morbidity. Given the lack of chronic complications associated with the side effects of radiation therapy and uniform local control of cancer in these patients, the role of radiation therapy in patients at high risk for local failure may be reconsidered.

Ann Clin Res 1977 Aug;9(4):252-6

Postoperative radiotherapy of renal adenocarcinoma.

Mantyla M, Nordman E, Minkkinen J

125 patients with renal adenocarcinoma treated at two departments of radiotherapy in Finland are presented. 82 (66%) of the patients had localized disease and 43 (34%) had distant metastases. The five year survival for all stages was 38% and for cases with local disease 56%. There were no essential differences among Stage I, II and III patients treated with surgery alone or treated with combined operation and postoperative radiotherapy. For tumours with infiltration to adjacent organs or metastases in the lymph nodes the survival was slightly higher after combined surgery and radiotherapy than after surgery alone. For patients with P4 tumours or regional lymph node dissemination postoperative radiotherapy is recommended.

Int J Radiat Oncol Biol Phys 1987 May;13(5):665-72

Postoperative radiotherapy in stage II and III renal adenocarcinoma. A randomized trial by the Copenhagen Renal Cancer Study Group.

Kjaer M, Frederiksen PL, Engelholm SA

Since 1979, 11 urological and surgical departments and 2 oncological departments in the greater Copenhagen area have been investigating the role of postoperative radiotherapy (XRT) in patients with renal adenocarcinoma Stage II and III staging modified from Holland. After nephrectomy, patients were randomized to receive XRT (50 Gy in 20 F to the kidney bed, regional ipsi- and contralateral lymph nodes) or no further treatment. Patients in both arms were followed until relapse, death, or 5 years after operation. Seventy-two were randomized by January 1984. An update of the treatment results showed the following: 7/72 were excluded from further analysis because of major protocol violations, 34/65 were in Stage II and 31/65 in Stage III. There were 43 men and 22 women, median age 61 years, range 34-75; 33/65 were randomized in observation, 32/65 to XRT. Relapse was found in 28/65 or 43% during the follow-up period without any difference between the two groups. According to protocol criteria 27/32 randomized to XRT accomplished treatment. Significant complications from stomach, duodenum, or liver occurred in 12/27 or 44%, median 5 mo. range 1-44 mo. after XRT. In 5/27 or 19% the postirradiatory complications contributed to the death of the patients. The median survival in the XRT-group was 26 mo. The survival at 26 mo., in the observation group, was 62%. This difference is not statistically significant. We conclude that postoperative XRT, as given in the present study in patients nephrectomized for Stages II and III renal adenocarcinoma, is without any beneficial effect on relapse rate and survival. Moreover, XRT is associated with an unacceptable complication rate and the protocol has been closed for further patient accrual since January 1984.

Radiother Oncol 1997 May;43(2):155-7

Is post-operative radiation for renal cell carcinoma justified?

Aref I, Bociek RG, Salhani D

Ottawa Regional Cancer Centre, Ontario Cancer Treatment and Research Foundation, Canada.

The records of 116 patients with unilateral, non-hematogenous metastatic RCC who were treated with definitive surgery and referred to the Ottawa Regional Cancer Centre between 1977 and 1988 were reviewed. Distribution by stage included T1 (3 patients), T2 (42 patients) and T3 (71 patients). The median follow-up was 44 months, with a range of 4-267 months. RESULTS: Local regional failure (LRF) developed in 8 patients. Nine patients developed local or regional recurrence, plus distant failure. Fifty-eight patients had distant metastases (DM) only. The 7-year actuarial rate for LRF and DM were 12%, and 67%, respectively. The overall 7-year actuarial survival rate was 35%, and cause-specific survival was 42%. CONCLUSIONS: LRF alone is rare following nephrectomy. DM is the main pattern of failure. This data does not support the role of adjuvant radiation therapy in this disease.

Int J Radiat Oncol Biol Phys 1992;24(4):743-5

Adjuvant radiotherapy in high stage transitional cell carcinoma of the renal pelvis and ureter.

Cozad SC, Smalley SR, Austenfeld M, Noble M, Jennings S, Reymond R

Department of Radiation Oncology, University of Kansas Medical Center, Kansas City.

This review was undertaken to assess the influence of adjuvant radiation therapy on failure patterns and survival in high stage transitional cell carcinoma of the renal pelvis or ureter. Ninety-four patients with transitional cell carcinoma of the renal pelvis or ureter were retrospectively reviewed. Twenty-six had American Joint Commission stage T3 or T4 N0/+, M0 disease and underwent curative resections (median follow-up 13.5 months, range 3-311). Local failure was defined as recurrence in the tumor bed, regional nodes, or ureteral stump. Time to recurrence and survival were calculated from the time of pathologic diagnosis. Variables associated with local failure, distant metastasis, and survival were analyzed using univariate and multivariate analysis. Seventeen received surgery only, nine received adjuvant radiation therapy (median dose 50 Gy). Local failure occurred in 9 of 17 without and 1 of 9 with adjuvant radiation therapy (p = 0.07). Actuarial 5-year local control was 34% without and 88% with adjuvant radiation therapy. Cox step-wise regression confirmed adjuvant radiation therapy (p = 0.006) and grade (p = 0.006) as significantly associated with local failure. No patients with low grade lesions suffered local failure either with or without adjuvant radiation therapy. High grade lesions had an local failure rate of 15% with and 71% without adjuvant radiation therapy. Metastatic disease occurred in 4 of 9 and 8 of 17 with and without radiation therapy. No significant factors influencing distant failure were identified. Five-year actuarial survival was 44% with and 24% without adjuvant radiation therapy. The survival differences were not statistically significant on univariate or multivariate analysis. High staged transitional cell carcinoma of the renal pelvis or ureter has a substantial local failure risk after surgery alone. Adjuvant radiation therapy markedly reduces this risk but has no impact on distant disease which occurs in approximately 50%. Effective adjuvant therapy will require effective systemic therapy in addition to adjuvant radiation therapy.