Incidental renal cell in Stage III NSCLC

[Ray D. Ayshun]

Have a patient with Stage III NSCLC with a PET avid (2 cm posterior) mass in the kidney, pending biopsy. Plan for typical chemorads for lung cancer, but wondering if I should SBRT this if it's RCC, and when. Given the typical issues with med onc getting everything perfect before seeing the patient, I figured I could just take care of this thing during the week before the lung/start of chemo. Otherwise, could wait until CRT is done and reassess/go down the typical RCC referral pathway and involve urology. Obv, could be a met, but solitary met in kidney parenchyma seems unlikely. Could also be nothing.

---

Members don't see this ad.

 

[Mandelin Rain]

I'd wait and let urology deal with it. Might as well give both cancers SOC treatment.

 

[Ray D. Ayshun]

I will add that I'm not suggesting I just flippantly throw SBRT around. It's more a matter of wondering if someone with stage III NSCLC is a little closer to inoperable inasmuch as it's reasonable to think that if you did a trial with 1000 of these patients and did SBRT to 500 and (even partial) nephrectomy to 500. I might prefer to be in the SBRT arm.

 

[OTN]

Nephrectomy

 

[Mandelin Rain]

I will add that I'm not suggesting I just flippantly throw SBRT around. It's more a matter of wondering if someone with stage III NSCLC is a little closer to inoperable inasmuch as it's reasonable to think that if you did a trial with 1000 of these patients and did SBRT to 500 and (even partial) nephrectomy to 500. I might prefer to be in the SBRT arm.

I definitely agree with your logic here, the Stage III lung cancer is obviously the greatest threat and likely to kill this patient long before some small RCC, even if it recurs post SBRT. Save them the invasive procedure. But... I'd hate to be the guy trying to explain in court why I didn't send the kidney cancer to a urologist if something goes south. While I don't think defensive medicine should guide all of our treatment decisions, you can't go wrong offering SOC treatment. A laprascopic partial nephrectomy won't be too morbid.

 

[evilbooyaa]

As much as we knock on Urologists in this forum, SOC in this clinical scenario is still a nephrectomy.

Treat stage III NSCLC first, but would get tuned in with Urology. Reasonable to discuss early SBRT data if they are agreeable, as may be a little tough to find a surgical window during consolidative durva (depending on how patient tolerates).

 

[RSAOaky]

Agree with what's been said. I think if the patient was not a surgical candidate or didn't want surgery it would be a reasonable approach and patient is far more likely to die of their lung cancer than even a suboptimally treated early stage RCC, but you'd hate to cure the lung and doom them because you got cute with the kidney.

 

[medgator]

Nephrectomy

Possibly Partial

 

[communitydoc13]

Surveillance may also be appropriate for this lesion, they will watch a fair number of lesions under 4 cm. Send to uro.

 

[ramsesthenice]

Possibly Partial

It sounds like this person would be a candidate for a partial nephrectomy. But honestly they probably won't even do that yet. My guess is that they will (appropriately) just observe it and see how quickly it is progressing. A lot of these things simply smolder and it is very reasonable to give his lung cancer the test of time before deciding what you want to do for the RCC. Are you planning on giving them adjuvant durvalumab for the lung cancer? Response rates in RCCs are pretty decent (especially if clear cell) so I would imagine you have time to make any decisions.

In practice, I SBRT several of these per year for inoperable patients and local control is probably in the range of 80-85% after a couple years. Those numbers are pretty good, but not quite as good as with a partial. I wouldn't pull the trigger just yet.

 

[Palex80]

This patient will receive numerous restaging scans in the future for his NSCLC. I would observe the kidney lesion now and decide what to do with it according to how the NSCLC responds to treatment and how the lesion behaves in the future scans. Surveillance is perfectly fine for small RCC-typical lesions. I wouldn't even ask for a biopsy now, to be honest.

The interesting question is what will happen to the lesion during Durvalumab-maintenance? Perhaps it will shrink?

 

[Ray D. Ayshun]

This patient will receive numerous restaging scans in the future for his NSCLC. I would observe the kidney lesion now and decide what to do with it according to how the NSCLC responds to treatment and how the lesion behaves in the future scans. Surveillance is perfectly fine for small RCC-typical lesions. I wouldn't even ask for a biopsy now, to be honest.

The interesting question is what will happen to the lesion during Durvalumab-maintenance? Perhaps it will shrink?

Don't biopsy?

 

[ramsesthenice]

Don't biopsy?

i would and I bet urology would as well (but run it by them). If it is a met (unlikely, but not impossible) they would probably not be interested in a metastatectomy.

 

[Ray D. Ayshun]

i would and I bet urology would as well (but run it by them). If it is a met (unlikely, but not impossible) they would probably not be interested in a metastatectomy.

Right, things are already in motion for biopsy, but wondering if there are ways of making an RCC dx based on imaging alone. I suppose I could've prevented this discussion by calling this oligomet NSCLC and SBRTing the met...

 

[Palex80]

Don't biopsy?

1. How probable is a synchronous, singular, isolated metastasis of a NSCLC in a kidney in patient with a stage IIIA NSCLC? Never seen that, you could probably write a case report.

2. Would it change your management if it was metastasis?
a) Would you call it stage IV, drop the RCT and go for systemic treatment only?
b) Would you SBRT or resect the lesion in parallel to the RCT? Bear in mind that you want to give this patient a platinum doublet and doing anything to the kidney now may jeopardize his renal function and ability to receive an adequate systemic treatment?
c) Would it be bad to take care of the lesion later? Do you think it will change the general outcome of the disease were you to resect/SBRT that metastasis in 3-6 months from now once you are done with the RCT of the lung? Is his outcome worse if that metastasis stays in for that period, while he is on systemic treatment anyway?
d) Is there a danger of overtreating the patient? Were you to SBRT/resect this prognosis-irrelevant metastasis now (he won't die from that kidney metastasis), but his primary tumor would not respond to the RCT, haven't you overtreated him then and performed a procedure that would not change his prognosis?

These are my arguments. Performing a biopsy now is not wrong, but I wouldn't do it.

 

[Ray D. Ayshun]

1. How probable is a synchronous, singular, isolated metastasis of a NSCLC in a kidney in patient with a stage IIIA NSCLC? Never seen that, you could probably write a case report.

2. Would it change your management if it was metastasis?
a) Would you call it stage IV, drop the RCT and go for systemic treatment only?
b) Would you SBRT or resect the lesion in parallel to the RCT? Bear in mind that you want to give this patient a platinum doublet and doing anything to the kidney now may jeopardize his renal function and ability to receive an adequate systemic treatment?
c) Would it be bad to take care of the lesion later? Do you think it will change the general outcome of the disease were you to resect/SBRT that metastasis in 3-6 months from now once you are done with the RCT of the lung? Is his outcome worse if that metastasis stays in for that period, while he is on systemic treatment anyway?
d) Is there a danger of overtreating the patient? Were you to SBRT/resect this prognosis-irrelevant metastasis now (he won't die from that kidney metastasis), but his primary tumor would not respond to the RCT, haven't you overtreated him then and performed a procedure that would not change his prognosis?

These are my arguments. Performing a biopsy now is not wrong, but I wouldn't do it.

I agree with everything you said, but...I feel like I can't not biopsy this.

 

[evilbooyaa]

Right, things are already in motion for biopsy, but wondering if there are ways of making an RCC dx based on imaging alone. I suppose I could've prevented this discussion by calling this oligomet NSCLC and SBRTing the met...

If it is truly within the renal parenchyma and not within an adrenal gland (we've all seen adrenal mets), I could see skipping a biopsy if a MDT agreed that it looked suspicious for RCC on imaging. However, the reason most RCCs don't get biopsy is because they get some form of nephrectomy anyways. I don't really see an issue with getting a biopsy to confirm everyone's thoughts.

In all honesty, I think the bolded thought process isn't a good look for a Radiation Oncologist, IMO.

Even my oligometastatic rectal cancer patients with a solitary lung met who are otherwise candidates for surgery (like the LAR they'll be getting) get a referral to thoracic surgery to discuss metastatectomy if they're coming to me from med onc/colorectal rather than just SBRTing it.

 

[ramsesthenice]

In all honesty, I think the bolded thought process isn't a good look for a Radiation Oncologist, IMO.

Its not a good look for anyone. How inclined are you to share patients with people who have a habit of going rouge? I will absolutely doctor shop to avoid these folks.

 

[Ray D. Ayshun]

Haha, was joking about SBRTing it without a biopsy. I only go rouge in Vegas, but have been known to go rogue at work on occasion.

 

[DoctwoB]

If it is truly within the renal parenchyma and not within an adrenal gland (we've all seen adrenal mets), I could see skipping a biopsy if a MDT agreed that it looked suspicious for RCC on imaging. However, the reason most RCCs don't get biopsy is because they get some form of nephrectomy anyways. I don't really see an issue with getting a biopsy to confirm everyone's thoughts.

In all honesty, I think the bolded thought process isn't a good look for a Radiation Oncologist, IMO.

Even my oligometastatic rectal cancer patients with a solitary lung met who are otherwise candidates for surgery (like the LAR they'll be getting) get a referral to thoracic surgery to discuss metastatectomy if they're coming to me from med onc/colorectal rather than just SBRTing it.

You are correct that we usually skip the bx in renal masses since based on size we can usually give a high enough probability of cancer (90-95%) and even most of the rest (oncytoma) can harbor malignancy. However one exception to that is when met is in the differential, so I would get a biopsy in this case.

I would involve urology, but my plan would be to do nothing for the time being. Manage the NSCLC, i'll follow the mass with serial imaging, and depending on growth/prognosis from his lung cancer, anatomy of the mass, and other health factors will either recommend active surveillance, partial nephrectomy, or percutaneous cryoablation

 

[Ray D. Ayshun]

You are correct that we usually skip the bx in renal masses since based on size we can usually give a high enough probability of cancer (90-95%) and even most of the rest (oncytoma) can harbor malignancy. However one exception to that is when met is in the differential, so I would get a biopsy in this case.

I would involve urology, but my plan would be to do nothing for the time being. Manage the NSCLC, i'll follow the mass with serial imaging, and depending on growth/prognosis from his lung cancer, anatomy of the mass, and other health factors will either recommend active surveillance, partial nephrectomy, or percutaneous cryoablation

Thanks, welcome back. Thought we had run you off.

 

[FrostyHammer]

Agree on doing partial neph but only during the durva phase, it shouldn't delay chemo rads at all. For this reason I wouldn't get biopsy now either. In the very low chance that it's a met and you do surgery eventually, that's (with some modifications) basically doing Gomez-type LAT, so you're good either way.

 

[thesauce]

I definitely agree with your logic here, the Stage III lung cancer is obviously the greatest threat and likely to kill this patient long before some small RCC, even if it recurs post SBRT. Save them the invasive procedure. But... I'd hate to be the guy trying to explain in court why I didn't send the kidney cancer to a urologist if something goes south. While I don't think defensive medicine should guide all of our treatment decisions, you can't go wrong offering SOC treatment. A laprascopic partial nephrectomy won't be too morbid.

It is sad that we have to be thinking about this constantly. Yes there is a 0.1% chance that they survive the LA-NSCLC AND the SBRT is not effective for the RCC AND then it goes on to become metastatic. Of course the surgical risk of even a lap is higher than all 3 of these things happening, but that will probably be where this ends up honestly.

 

[GI_RadOnc]

Its not a good look for anyone. How inclined are you to share patients with people who have a habit of going rouge? I will absolutely doctor shop to avoid these folks.

There's no shame in going rouge. Or some shade of blue. Or heavy eyeliner. I don't judge my peer physicians based on their makeup

 

[Ray D. Ayshun]

It is sad that we have to be thinking about this constantly. Yes there is a 0.1% chance that they survive the LA-NSCLC AND the SBRT is not effective for the RCC AND then it goes on to become metastatic. Of course the surgical risk of even a lap is higher than all 3 of these things happening, but that will probably be where this ends up honestly.

This sounds like one vote for SBRT.

 

[thesauce]

This sounds like one vote for SBRT.

I do think ultimately it's probably the best option for this patient but I wouldn't jump on it until after CRT for lung, restaging scans, and urology input.

 

[thecarbonionangle]

I would have no issue with SBRT. Protons would be even better in some cases depending on location. 4DCT with compression. I have had some kidney lesions move a ton with breathing.

 

[Palex80]

I do think ultimately it's probably the best option for this patient but I wouldn't jump on it until after CRT for lung, restaging scans, and urology input.

I do not agree.

The best option for this patient is to complete the CRT for his stage IIIA NSCLC, put him on maintenance Durvalumab and observe.

If that mass progresses while he is on maintenance, have it resected. You are going to be doing chest imaging every 6 months during maintenance therapy anyway, no reason not to include the kidneys on that imaging.

If the lesion does not progress, complete maintenance therapy, rescan and then talk to the patient about resecting the lesion or ablating it or even continuing observation.

From the NCCN-guidelines:

This is a T1a lesion and I would certainly call a stage IIIA NSCLC a "significant competing risk of death".


Data for SBRT are not bad, but SBRT is certainly not s.o.c. yet for patients with operable lesions and in good general condition.

 

[thecarbonionangle]

I do not agree.

The best option for this patient is to complete the CRT for his stage IIIA NSCLC, put him on maintenance Durvalumab and observe.

If that mass progresses while he is on maintenance, have it resected. You are going to be doing chest imaging every 6 months during maintenance therapy anyway, no reason not to include the kidneys on that imaging.

If the lesion does not progress, complete maintenance therapy, rescan and then talk to the patient about resecting the lesion or ablating it or even continuing observation.

From the NCCN-guidelines:
View attachment 337305
This is a T1a lesion and I would certainly call a stage IIIA NSCLC a "significant competing risk of death".


Data for SBRT are not bad, but SBRT is certainly not s.o.c. yet for patients with operable lesions and in good general condition.

I agree with you that is the textbook answer but i hope this eventually changes. The idea of organ preservation makes sense to people. Taking out organs and irradiating brains “prophylactically” does not make sense to the common folk who are often our patients.

 

[thesauce]

I do not agree.

The best option for this patient is to complete the CRT for his stage IIIA NSCLC, put him on maintenance Durvalumab and observe.

If that mass progresses while he is on maintenance, have it resected. You are going to be doing chest imaging every 6 months during maintenance therapy anyway, no reason not to include the kidneys on that imaging.

If the lesion does not progress, complete maintenance therapy, rescan and then talk to the patient about resecting the lesion or ablating it or even continuing observation.

From the NCCN-guidelines:
View attachment 337305
This is a T1a lesion and I would certainly call a stage IIIA NSCLC a "significant competing risk of death".


Data for SBRT are not bad, but SBRT is certainly not s.o.c. yet for patients with operable lesions and in good general condition.

Sounds like you're suggesting CRT for lung, restaging scans, and urology input. Not exactly sure how we disagree.

 

[Palex80]

Sounds like you're suggesting CRT for lung, restaging scans, and urology input. Not exactly sure how we disagree.

I agree with you that is the textbook answer but i hope this eventually changes. The idea of organ preservation makes sense to people. Taking out organs and irradiating brains “prophylactically” does not make sense to the common folk who are often our patients.

I think SBRT is not the s.o.c. treatment for this patient.
Observation and resection if/when this lesion grows is s.o.c.
Partial nephrectomy is a wonderful organ sparing procedure.

 

[thesauce]

I think SBRT is not the s.o.c. treatment for this patient.
Observation and resection if/when this lesion grows is s.o.c.
Partial nephrectomy is a wonderful organ sparing procedure.

Not sure where this derailed but sounds like a strawman. No one said SBRT was standard of care unless I missed it - which is possible. Opinion and statement of fact are of course 2 different things.

I do personally think SBRT is the best treatment in a patient such as this as it’s non-invasive and has a very high control rate based a large and growing number of studies. Doesn’t mean I’d jump to it (since it isn’t S.O.C.).

Again, I would wait to address after lung cancer treatment, restaging, and urology input. Exactly what you said. Of course I wouldn’t suggest getting urology input unless I actually plan to take their input into account. If they recommend surgery, they’ll do it and SBRT is off the table. If they want to observe, then that’s more than likely what we’d do.

Just fyi that we had someone in our area get a partial and had significant complications which led to the doctor getting sued. It isn’t always such a wonderful procedure.

 

[thecarbonionangle]

The idea that surgery has minimal side effects is always funny to me. I have seen people die from “minimally invasive” procedures. a partial nephrectomy is a big surgery cutting through an extremely vascular organ. We often talk of it like it is nothing. Same goes for a VATS.

 

[Palex80]

Not sure where this derailed but sounds like a strawman.

I am sorry if I sounded like that. Let me help you out:

Plan for typical chemorads for lung cancer, but wondering if I should SBRT this if it's RCC, and when.

I suppose I could've prevented this discussion by calling this oligomet NSCLC and SBRTing the met...

I would have no issue with SBRT. Protons would be even better in some cases depending on location.

Too many voices calling for SBRT, in my opinion. Some even calling for one now. Too premature in my opinion. It sounds a bit like...
"Hey, that patient is on my LINAC couch for her stage IIIA NSCLC and she may have a small RCC too. Let's zap that RCC, SBRT is so cool."

I do personally think SBRT is the best treatment in a patient such as this as it’s non-invasive and has a very high control rate based a large and growing number of studies. Doesn’t mean I’d jump to it (since it isn’t S.O.C.).

But, why? Why do you think that? Do we have studies looking at SBRT for operable patients? Do we have data on long term kidney function post SBRT?
What makes SBRT "the best treatment in a patient such as this"? What are the criteria? The fact that he has a stage IIIA NSCLC? Or simply the fact that he walked through the door of a radiation oncology department?
It's a long way until SBRT becomes a valid option for operable RCC-patients, we need have a lot of homework to do

Again, I would wait to address after lung cancer treatment, restaging, and urology input. Exactly what you said. Of course I wouldn’t suggest getting urology input unless I actually plan to take their input into account. If they recommend surgery, they’ll do it and SBRT is off the table. If they want to observe, then that’s more than likely what we’d do.

It is imperative to get urology input on this and not getting urology input is bad medicine IMHO. But that's just my opinion.

 

[IRattending2021]

Surprised to read through the whole thread without cryoablation mentioned once.

In my opinion this lesion is best managed by referral to urology or discussion in the urology case conference. I imagine they would either go with active survilence or partial nephrectomy if patient is a surgical candidate. If patient is not a surgical candidate then what they usually do in my practice is refer them to IR and do cryoablation.

Sounds like this lesion needs a biopsy no matter what. A biopsy of this lesion is literally almost the same amount of “invasiveness” to a renal ablation. A tiny 2cm lesion, if favorably located, could be a lot easier to treat by IR versus SBRT given the motion aspect.

I may be biased, but if it’s my parents, I would send them to Radonc for SBRT for lung mass but would insist on cryoablation for RCC knowing how well they work. For smaller lesions they are comparable to surgery.

https://pubs.rsna.org/doi/abs/10.1148/radiol.2020192325?journalCode=radiology

 

[Ray D. Ayshun]

Too many voices calling for SBRT, in my opinion. Some even calling for one now. Too premature in my opinion. It sounds a bit like...
"Hey, that patient is on my LINAC couch for her stage IIIA NSCLC and she may have a small RCC too. Let's zap that RCC, SBRT is so cool."

My original thinking is along the lines of thesauces math re the best outcome for the patient: odds of curing the lung cancer X odds this RCC recurs with SBRT X odds it recurs and mets X odds I cause him toxicity. Wondering, despite what history says is SOC, what people think has the highest expected value for the patient, not my med mal insurance. Maybe it's: odds of curing the lung cancer x odds RCC progresses and mets with observation. That's the point of asking a question/discussing. We just had the cookbook discussion in a separate thread. Maybe the urologist will opt for obs, but if they opt for anything surgical I'll think a more harmful route has been chosen. IR ablation seems reasonable. In any case, given location, I can offer a treatment with 80-100% LC and very limited likelihood of toxicity. My comment regarding calling it oligomet disease was facetious, but isn't far off from using the original COMET study for decision-making, which we seem to base a lot of overly aggressive treatment approaches upon, and which kind of reeks of "let's zap that __________, SBRT is so cool."

 

[Palex80]

We just had the cookbook discussion in a separate thread. Maybe the urologist will opt for obs, but if they opt for anything surgical I'll think a more harmful route has been chosen. IR ablation seems reasonable. In any case, given location, I can offer a treatment with 80-100% LC and very limited likelihood of toxicity.

Can you show me some good data pointing out that kidney function is less impaired following SBRT than following partial nephrectomy? I am not aware of any.

 

[IRattending2021]

My original thinking is along the lines of thesauces math re the best outcome for the patient: odds of curing the lung cancer X odds this RCC recurs with SBRT X odds it recurs and mets X odds I cause him toxicity. Wondering, despite what history says is SOC, what people think has the highest expected value for the patient, not my med mal insurance. Maybe it's: odds of curing the lung cancer x odds RCC progresses and mets with observation. That's the point of asking a question/discussing. We just had the cookbook discussion in a separate thread. Maybe the urologist will opt for obs, but if they opt for anything surgical I'll think a more harmful route has been chosen. IR ablation seems reasonable. In any case, given location, I can offer a treatment with 80-100% LC and very limited likelihood of toxicity. My comment regarding calling it oligomet disease was facetious, but isn't far off from using the original COMET study for decision-making, which we seem to base a lot of overly aggressive treatment approaches upon, and which kind of reeks of "let's zap that __________, SBRT is so cool."

There are many ways to skin a cat. Personally when there are many different ways to do it, I would always review the literature myself and then consider the ease of the procedure / biology / current regional pattern of practice.

Basically, I always asked myself, if something have gone horribly wrong and there is a litigation, can I defend myself. And also, if there is a higher power that I’ll meet at the end of my life, can I justify what I did to them.

Things like bypassing tumor board or biopsy and go straight to SBRT by pretending this thing is RCC just to justify treatment is both shady from a medicolegal standpoint and (personally) from a spiritual standpoint because it seems to me that it’s not something I would want for my own family (I would want a tumor board discussion and urology referral first). It’s a little shady from medicolegal standpoint because I can bet someone can find an expert witness asking you why you haven’t biopsied it or left it alone if there was somehow a significant complication to SBRT.

 

[Ray D. Ayshun]

Can you show me some good data pointing out that kidney function is less impaired following SBRT than following partial nephrectomy? I am not aware of any.

Good data, I don't know, but a quick search of some retrospective stuff with both approaches showed a modest decline in GFR for either. I'm not so worried about kidney function in his case given the size of the lesion, or location, nor bowel toxicity. My reason for wanting to avoid surgery goes to the colloquialism, "a minor surgery is a surgery on someone else." If he gets a partial nephrectomy, things would probably be fine, but, again, if this were me I would put surgery way down the list of preferences. If I didn't have stage III lung cancer, I'd feel differently.

 

[Ray D. Ayshun]

There are many ways to skin a cat. Personally when there are many different ways to do it, I would always review the literature myself and then consider the ease of the procedure / biology / current regional pattern of practice.

Basically, I always asked myself, if something have gone horribly wrong and there is a litigation, can I defend myself. And also, if there is a higher power that I’ll meet at the end of my life, can I justify what I did to them.

Things like bypassing tumor board or biopsy and go straight to SBRT by pretending this thing is RCC just to justify treatment is both shady from a medicolegal standpoint and (personally) from a spiritual standpoint because it seems to me that it’s not something I would want for my own family (I would want a tumor board discussion and urology referral first). It’s a little shady from medicolegal standpoint because I can bet someone can find an expert witness asking you why you haven’t biopsied it or left it alone if there was somehow a significant complication to SBRT.

Like I said, the biopsy is happening. that was a separate discussion as some here wouldn't, though they also wouldn't treat without one presumably. My reason for asking this question boils down to what you're suggesting, if this is an RCC, using all the knowledge we have, and not concerning ourselves with what has been established as SOC because of history (which in most every case will be surgery), what would you want done if you were this patient? My main reason for asking is that discussing this is more fun than talking about Paul Wallner's house or how ****ty the job market is. I'm not waking up at night over the untreated RCC in my stage III lung cancer patient.

 

[IRattending2021]

Like I said, the biopsy is happening. that was a separate discussion as some here wouldn't, though they also wouldn't treat without one presumably. My reason for asking this question boils down to what you're suggesting, if this is an RCC, using all the knowledge we have, and not concerning ourselves with what has been established as SOC because of history (which in most every case will be surgery), what would you want done if you were this patient? My main reason for asking is that discussing this is more fun than talking about Paul Wallner's house or how ****ty the job market is. I'm not waking up at night over the untreated RCC in my stage III lung cancer patient.

I send many of our pts to radonc for HCC in a location difficult for us to address. Those people always come back with a huge part of their liver fibrosed and shrunk post radiation which is expected.

It would be interesting to see what’s the outcome for GFR over time in the case of renal SBRT.

 

[Ray D. Ayshun]

I send many of our pts to radonc for HCC in a location difficult for us to address. Those people always come back with a huge part of their liver fibrosed and shrunk post radiation which is expected.

It would be interesting to see what’s the outcome for GFR over time in the case of renal SBRT.

Best I can find is decrease of 5.5 to 9 mL/min at a year/last follow-up. Partial nephrectomy for tumors <4cm seems to be about the same, though stable over time with longer follow-up.

 

[IRattending2021]

Best I can find is decrease of 5.5 to 9 mL/min at a year/last follow-up. Partial nephrectomy for tumors <4cm seems to be about the same, though stable over time with longer follow-up.

I am not as familiar with renal SBRT. Is it something that’s less constrained by size? For us anything over 3cm is iffy.

 

[thecarbonionangle]

@IRattending2021
IROCK guidelines have been published:

DEFINE_ME

The ASCO Post

DEFINE_ME

The Emerging Role of Stereotactic Ablative Radiotherapy for Primary Renal Cell Carcinoma: A Systematic Review and Meta-Analysis - PubMed

Stereotactic ablative radiotherapy is a high-precision, noninvasive radiation treatment requiring few outpatient visits, and represents a safe and effective management option for primary renal cell carcinoma.

pubmed.ncbi.nlm.nih.gov

Stereotactic Radiotherapy as a Treatment Option for Renal Tumors in the Solitary Kidney: A Multicenter Analysis from the IROCK - PubMed

In this analysis of the IROCK database stereotactic ablative radiotherapy in patients with a solitary kidney had an acceptable impact on renal function and achieved excellent oncologic outcomes, similar to those in patients with bilateral kidneys. Thus, stereotactic ablative radiotherapy...

pubmed.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

I am not as familiar with renal SBRT. Is it something that’s less constrained by size? For us anything over 3cm is iffy.

I suppose the correct answer is yes and no. Constrained by size inasmuch as normal tissue constraints are more challenging to meet as things get bigger, and you slowly go from SBRT to what's more honestly, aggressive palliative RT. IOW, ablative therapy to not so much. If the present case were a much bigger tumor or in a more "eloquent" spot, I'd be less inclined to wonder about SBRT, but it's small and posterior. Perfect spot for IR ablation as well.

Slice fwiw as I like images

I pointed to it as the other kidney things are cysts/not avid on PET.

 

[radtothebone]

I suppose the correct answer is yes and no. Constrained by size inasmuch as normal tissue constraints are more challenging to meet as things get bigger, and you slowly go from SBRT to what's more honestly, aggressive palliative RT. IOW, ablative therapy to not so much. If the present case were a much bigger tumor or in a more "eloquent" spot, I'd be less inclined to wonder about SBRT, but it's small and posterior. Perfect spot for IR ablation as well.

Slice fwiw as I like images
View attachment 337381
I pointed to it as the other kidney things are cysts/not avid on PET.

 

[radtothebone]

If you start doing any RCC SBRT, just be sure to be aware that lesions often simply stop growing and don’t decrease much in size. Most also continue to enhance on CT, which will freak everyone out and lead to concerns of residual tumor. It’s not as comforting as the radiographic responses seen with ablation. That being said it’s a great option for certain patients (those on anticoagulants who are at high with holding those/bridging). That being said it’s tough to get many referrals if you have an active IR group (ablation is also a great technique). The others I tend to get from tumor board are those over 3 cm or abutting the renal vessels.

 

[IRattending2021]

I suppose the correct answer is yes and no. Constrained by size inasmuch as normal tissue constraints are more challenging to meet as things get bigger, and you slowly go from SBRT to what's more honestly, aggressive palliative RT. IOW, ablative therapy to not so much. If the present case were a much bigger tumor or in a more "eloquent" spot, I'd be less inclined to wonder about SBRT, but it's small and posterior. Perfect spot for IR ablation as well.

Slice fwiw as I like images
View attachment 337381
I pointed to it as the other kidney things are cysts/not avid on PET.

case would be chip shot for most IRs if labs and clinical data otherwise check out.

 

[Ray D. Ayshun]

case would be chip shot for most IRs if labs and clinical data otherwise check out.

Technically speaking, ir referral would be a standard of care in this case, right?

 

[IRattending2021]

Technically speaking, ir referral would be a standard of care in this case, right?

not quite. Urology referral is the right play. In my practice Uro would talk to pt and figure out if surgical candidate or not. Evidently posterior location is difficult for them to operate on so often we get those referrals but it’s their call as surgery is more standard of care.