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.
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Challenging RCC case
Started by Haybrant
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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.
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.
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.
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.
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.
Does this patient have distant Mets? If not, Consider pushing to get the patient to a tertiary center.
RCC with a stage IV thrombus looks awful on imaging but is still a form of localized, curable disease. A good oncology program will do this as a joint case with urology, vascular, and cardiac surgery, get the patient on bypass, and get-the kidney and all thrombus out 5 year PFS rates 30-50%. .
RCC with a stage IV thrombus looks awful on imaging but is still a form of localized, curable disease. A good oncology program will do this as a joint case with urology, vascular, and cardiac surgery, get the patient on bypass, and get-the kidney and all thrombus out 5 year PFS rates 30-50%. .
Above statement very reasonable.
In a vacucum, SBRT it. 40/5 as feasible, respect Luminal GI OARs. Consider escalating what you can to 50Gy safely. The vasculature will handle it just fine (limit point dose to say < 50-52.5Gy in 5Fx). Heart might have some pericarditis but nothing life threatening.
In a vacucum, SBRT it. 40/5 as feasible, respect Luminal GI OARs. Consider escalating what you can to 50Gy safely. The vasculature will handle it just fine (limit point dose to say < 50-52.5Gy in 5Fx). Heart might have some pericarditis but nothing life threatening.
