Challenging RCC case

[Haybrant]

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60 something year old man who developed positional dyspnea 3 months ago progressively worsening to difficulty even sitting up. Diagnosed now with stage IV RCC with disease extending into the IVC growing down to the common iliac and growing superiorly into the right atrium through to the right ventricle. Surgery deferring, recommendation was to start with chemo/immuno and if she has a good response could then consider surgery. Was outpatient but bounced right back, PS isn’t great bc of sxs. Med onc asking if any reasonable RT options to temporize situation quicker. pt is anti coagulated. Appreciate any thoughts about this.

 

[OTN]

I think it's reasonable to offer palliative RT, given the seriousness of the situation. Good old 30 in 10 could even work. I've palliated disease in the IVC extending superiorly into the RA before with it.

 

[TheWallnerus]

I think it's reasonable to offer palliative RT, given the seriousness of the situation. Good old 30 in 10 could even work. I've palliated disease in the IVC extending superiorly into the RA before with it.

40/10 if the DVHs look ok. Very Spinal Tap-ish. Rob Reiner RIP.

 

[emt409]

Is this the primary growing all the way up the IVC or a discrete met?

Don’t be afraid of the heart, lumenal GI is your dose limiting structure here.

30-35/5fx is safe here if you’re equipped for real SBRT.

 

[Haybrant]

Is this the primary growing all the way up the IVC or a discrete met?

Don’t be afraid of the heart, lumenal GI is your dose limiting structure here.

30-35/5fx is safe here if you’re equipped for real SBRT.

thanks; yes growing all the way up the IVC, pretty crazy. the thoracic rads reads it as tumor thrombus the whole extent but that seems presumptive - thought MR might help distinguish tumor from bland thrombus and might make the case to just treat tumor thrombus - what do people think about that. Any theoretical risks of RT causing disease to "break off" and lead to PE.

 

[ultima]

There some literature for treating HCC tumor thrombus in IVC up to RA w SBRT like 30-40/5. I don’t see how this patient is ever going to get resectable if that is all tumor thrombus. Might as well get MRI to cover your bases. I’m not sure much will temporize the situation depending on what is meant by that but I doubt you’re likely to hurt either on the balance of things.

 

[emt409]

A PET scan is probably a little more useful than MRI here if you’re going to get another study, but you should be able to discriminate tumor from thrombus just by a contrasted CT. No harm in calling your radiology colleagues while your contouring.

This is not a curative situation. I wouldn’t try and give a hero dose, but give something you feel comfortable giving on your equipment. 30 in five is reasonable, so is 40 in 10.