Palliative irradiation for focally symptomatic
metastatic renal cell carcinoma: support for dose escalation based on a biological model.
DiBiase SJ, J Urol. 1997 Sep;158(3 Pt 1):746-9.
Department of Radiation Oncology, Jefferson Medical College, Philadelphia, Pennsylvania,
USA.
Renal cell carcinoma has traditionally been regarded as a radioresistant cancer, yet
controversy continues as to whether escalation of the palliative radiation dose can
overcome the inherent resistance of such tumors when they metastasize. Between 1966 and
1995, 107 patients with renal cell metastases at 150 sites were irradiated with palliative
intent. Sites irradiated included bone (89), soft tissue (16), brain (20), spinal cord (9)
and pulmonary (16). To determine dose effectiveness the biologically effective dose was
calculated according to the formula, Gy10 = total dose (1 + fractional dose/alpha-beta),
using an alpha-beta of 10. RESULTS: For the entire group
86%
of patients derived a palliative response after treatment with irradiation, while 49%
derived a complete palliative response. The median duration of palliation was 6 months (range 1 to 150). With respect
to overall (that is, complete and partial) response rates, those presenting with high
Karnofsky performance status were most likely to respond (status 70 or greater versus less
than 70, 88% versus 78%, p < 0.04). With respect to the rate of complete palliative
response, performance status (status 70 or greater versus less than 70, 55% versus 31%, p
< 0.03) and the use of higher biologically effective doses of
irradiation (Gy10 50 or greater versus less than 50, 59% versus 39%, p = 0.001) were
associated with a statistically significant increased rate of response. The
independent prognostic value of performance status and higher biologically effective doses
of irradiation were maintained in multivariate analysis. CONCLUSIONS: Despite the prevailing concept that renal cell carcinoma is
generally resistant to radiotherapy, the overwhelming majority of patients seen at our
institution in whom metastatic renal cell carcinoma developed were palliated with
radiotherapy. A complete palliative response is more likely when
higher biologically effective doses of irradiation are delivered, especially to patients
with a relatively high performance status.
The role of radiation
therapy in the management of metastatic renal cell carcinoma.
Halperin EC, Harisiadis L. Cancer. 1983 Feb 15;51(4):614-7.
From 1965 to 1980, 35 patients were treated by radiation for palliation of symptoms
related to metastatic renal cell carcinoma. The male:female ratio was 1.9:1. Eighty-six
percent (30/35) of the patients were over 40 years of age at initial presentation.
Sixty-three percent (22/35) of the patients showed symptoms of metastatic disease within
three years of diagnosis of the primary malignancy. Sixty sites were irradiated in the 35
patients: 36 sites of metastatic bone pain, 14 obstructing and/or palpable masses, and ten
sites treated for symptoms due to central nervous system (CNS) metastases. Efficacy of
treatment was assessed at serial follow-up visits beginning one month after completion of
radiotherapy. Bone pain responded at 77% of the treated
sites. Mass effect responded in 64%. Disappointing results were obtained with CNS
metastases. There was only a 30% response of brain and spinal cord
lesions within the dose range that these patients were treated. No correlation between TDF
equivalent dose of radiation administered and frequency of palliative response was found.
In those sites where a response of bone pain to radiation was observed, 86% of the
responses lasted the remainder of the patient's life. No correlation was found between TDF
equivalent dose of radiation administered and duration of response. Radiation may be a
useful palliative tool for bone pain and mass effect from metastatic renal cell carcinoma.
Inordinately high doses need not be used to achieve the desired effect.
Treatment of osseous metastases secondary to renal cell carcinoma.
Smith EM, J Urol. 1992 Sep;148(3):784-7.
Division of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Osseous metastases occur in 25 to 50% of the patients with metastatic renal cell
carcinoma. We retrospectively reviewed our experience with 14 patients who underwent 20
palliative orthopedic procedures for treatment of bony metastases secondary to renal cell
carcinoma. Of the patients 6 presented after nephrectomy (group 1) and 8 presented
initially with osseous metastases (group 2). Only 1 of the group 2 patients underwent
adjunctive nephrectomy. Overall, 5 of 14 patients (36%) presented with fracture and 9 of
14 (64%) presented with impending fracture. Five patients required multiple procedures. A
total of 7 lesions had been previously treated with external radiation. Of the 20
orthopedic procedures 17 (85%) resulted in significant functional improvement and 18 (90%)
resulted in significant relief of pain. There were 4 major complications in the series,
including 2 culminating in amputation. Average survival after palliative orthopedic
procedures was 22 months (range 7 to 64 months) with a 1-year survival rate of 58%. Orthopedic palliation of osseous metastases from renal cell carcinoma is
effective, and our experience indicates that the majority of renal cancer patients
with bone metastases will survive long enough to benefit from palliative orthopedic
procedures.
External radiation of brain metastases from renal carcinoma: a
retrospective study of 119 patients from the M. D. Anderson Cancer Center.
Wronski M, Int J Radiat Oncol Biol Phys. 1997 Mar 1;37(4):753-9.
Department of Neuro-Oncology Research, Staten Island University Hospital, NY, USA.
Approximately 10% of patients with metastatic renal cell carcinoma are diagnosed with
brain metastases. Most of these patients receive palliative radiotherapy and die of
progressive brain metastatic disease. This retrospective study examines the M. D. Anderson
Cancer Center experience with such patients who received only whole brain radiation
therapy (WBRT). METHODS AND MATERIALS: Records of 200 patients with brain metastases from
renal carcinoma who were treated at M. D. Anderson Cancer Center between 1976 and 1993
were reviewed. Of these patients, 119 received WBRT only and constitute the basis of this
study. Different prognostic factors were analyzed. RESULTS: Overall median survival time
from diagnosis of the brain metastases was 4.4 months. Multiple brain tumors were treated
in 70 patients (58.8%) who had a survival of 3.0 months compared with 4.4 months for
patients having a single brain metastasis (p = 0.043). Among 117 patients the causes of
death were neurologic in 90 (76%), systemic cancer in 19 (16%), and unknown in 9 (8%).
Survival rates at 6 months, 1 year, and 2 years, were 33.6, 16.8, and 5.9%, respectively.
Patients in whom brain metastases were diagnosed synchronously with a renal primary (n =
24) had a median survival time of 3.4 months compared with 3.2 months for those 95 who
were diagnosed metachronously (p < 0.79, NS). In the Cox multivariate analysis of 13
possible prognostic factors, only a single brain metastasis (p = 0.0329), lack of distant
metastases at the time of diagnosis (p = 0.0056), and tumor diameter < or = 2 cm (p
< 0.0016) were statistically significant. CONCLUSION:
These
unsatisfactory results with WBRT suggest that more aggressive approaches, such as surgery
or radiosurgery should be applied whenever possible. |
