SBRT for lung metastases: Case report

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1 SBRT for lung metastases: Case report Guillermo de Velasco MD, PhD University Hospital 12

2 Case report 71 years old man Smoker DM 2005 Right radical nephrectomy Histology: clear cell, Fuhrman grade 3

3 Case report March 2014 Chest pain CT scan Pulmonary nodules

4 Renal cell carcinoma and lung metastases Lungs are the most common sites of metastases in RCC patients ~ 15% Only lung metastases

5 Management only-lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT The length of active surveillance was associated with 1) Site of metastases (1 vs 2 vs more than two; p=0 0239), 2) Location Systemic of therapy metastases (lung only vs other organs only vs both; p=0 0280), Rini et al. Lancet Oncol 2016

6 Management only-lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy Choueiri & Motzer, NEJM 2017

7 Management only-lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy Overall Alt et al. Cancer 2011

8 Management only-lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy Only lung metastases Alt et al. Cancer 2011

9 Management only-lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT The resection of oligometastases is Systemic therapy supported by Level C evidence Zhao et al. International Journal of Surgery, 2017

10 Management only-lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy

11 SBRT Renal-cell carcinoma is considered to be a radioresistant tumor However high fraction dose, stereotactic body radiotherapy seems to be relevant

12

13 Management lung metastases from RCC Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy

14 Renal cell carcinoma and lung metastases Lungs are the most common sites of metastases in RCC patients 15% Only lung metastases 45% lung metastases +

15 Management lung metastases from RCC Only lung metastases Lung metastases and other mets Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy + + Active Surveillance Local treatment Surgery RFA/SBRT Systemic therapy

16 Case Report March Pazopanib

17 Case Report March 2014 January 2015

18 Case Report March 2014 January 2015

19 Case Report March 2014 January 2015

20 Case report May 2015 Stop treatment due to toxicity

21 Case report June 2015

22 Case report Re-start treatment Second line therapy Local treatment

23 Case report Re-start treatment Second line therapy Local treatment

24 Concept Oligometastatic disease

25 SBRT SBRT is generally safe and feasible Many single-center retrospective case series of highly selected patients

26 Studies of oligometastasis from renal-cell carcinoma with high-dose and high-dose-per-fraction radiotherapy Gert De Meerleer et al. Lancet Oncology 2014

27 Concept Oligometastatic disease Oligoprogression disease?

28 Case report June 2015

29 Oct 2015 TKI was restarted

30 Patient continues on his 1 st line Feb 2017

31 Evidence Clinical trials

32 Stereotactic Body Radiation Therapy in Treating Patients With Metastatic or Recurrent Kidney Cancer PRIMARY OBJECTIVES: To establish that patients can be treated with 5-fraction stereotactic body radiation therapy (SBRT) to all sites of metastatic disease with a low (< 16%) rate of severe (grade 4) toxicity. NCT

33 Evidence Clinical trials Guidelines

34 No general guidelines can be given

35 Guidelines Recommendations Metastasectomy and other local treatment strategies including Whole brain radiotherapy (WBRT) Conventional radiotherapy Stereotactic radiosurgery (SRS) Stereotactic body radiotherapy (SBRT) Cyberknife radiotherapy Hypofractionated radiotherapy can be considered and carried out for selected patients after multidisciplinary review.

36 Conclusions Patient has been on 1L nearly 3 years SBRT is a feasible and may help to control oligometastatic progression withing the lungs Prostective randomized trials are needed (or not)

37 Acknowledgements Hopsital 12 de Octubre JM. Sepúlveda D. Castellano MD Anderson Cancer Center Madrid P. López Criado Dana-Farber Cancer Insitute Toni K. Choueiri

38 Thank you

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