Böbrek Kanserinde Radyoterapi
Özet
Renal hücreli karsinom (RHK) tanısı, görüntüleme yöntemlerinin gelişmesiyle birlikte giderek artmaktadır. Primer RHK tedavisinde temel yaklaşım cerrahi olmakla birlikte, nefrektomi uygulamaları kronik böbrek hastalığı riskini artırmaktadır. Özellikle yaşlı ve komorbiditeleri olan hastalarda böbrek fonksiyonlarının korunması amacıyla radyofrekans ablasyon ve kriyoablasyon gibi alternatif lokal tedaviler geliştirilmiştir. Geleneksel çalışmalarda RHK hücrelerinin radyorezistan olduğu ve adjuvan veya neoadjuvan radyoterapinin (RT) sağkalım üzerinde olumlu bir etkisinin bulunmadığı saptanmıştır. Ancak stereotaktik radyocerrahi (SRS) ve stereotaktik vücut radyoterapisi (SBRT) gibi modern tekniklerin geliştirilmesi, böbrek tümörlerinde RT’ye olan ilgiyi yeniden artırmıştır. SBRT, ameliyat edilemeyen hastalarda glomerüler filtrasyon hızını koruyarak yüksek lokal kontrol ve sağkalım oranları sunmaktadır. Ayrıca RT, RHK hastalarında sıkça görülen akciğer, beyin ve kemik metastazlarının yönetiminde de kritik bir rol oynamaktadır. Beyin metastazlarında SRS bilişsel fonksiyonları korurken, kemik metastazlarında palyatif RT ve SBRT ağrı kontrolü sağlamakta ve iskeletle ilgili komplikasyonları azaltmaktadır. Sonuç olarak, Avrupa Üroloji Derneği (EAU) ve NCCN gibi kılavuzlar, RT'yi cerrahiye uygun olmayan lokalize olgularda bir seçenek ve metastatik hastalıklarda palyatif bir yaklaşım olarak önermektedir.
The diagnosis of renal cell carcinoma (RCC) is steadily increasing in parallel with the widespread use of advanced imaging modalities. Although surgical intervention remains the primary treatment for localized RCC, nephrectomy often leads to nephron loss and the development of chronic kidney disease. For elderly or comorbid patients, alternative minimally invasive options like radiofrequency ablation and cryoablation have emerged, though they carry risks of complications. Historically, RCC has been considered radioresistant, with traditional adjuvant or neoadjuvant radiotherapy (RT) showing no significant survival benefits. However, technological advancements such as stereotaktik body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) have renewed interest in radiation treatments. SBRT provides an effective, non-invasive alternative for inoperable primary tumors, preserving the glomerular filtration rate and yielding excellent local control. Furthermore, RT is highly utilized in managing advanced RCC metastases, which frequently occur in the lungs, brain, and bones. For brain lesions, SRS delivers superior survival outcomes while preserving cognitive function compared to whole-brain RT. In bone metastases, fractionated RT and SBRT effectively achieve pain control and reduce debilitating skeletal-related events. Consequently, major clinical guidelines like EAU and NCCN recommend RT as a viable option for inoperable localized tumors and as a cornerstone for palliative care.
Referanslar
Cancer stat facts: kidney and renal pelvis cancer [internet]. 2019. 2020. Available at: https://seer.cancer.gov/statfacts/html/kidrp.html
Alt AL, Boorjian SA, Lohse CM, et al. Survival after complete surgical resection of multiple metastases from renal cell carcinoma. Cancer. 2011;117:2873–82.
Zlotta AR. The changing natural history of renal cell carcinoma. J Urol. 2001;166:1611–23.
Kunkle DA, Haas NB, Uzzo RG. Adjuvant therapy for high-risk renal cell carcinoma patients. Curr Urol Rep 2007;8:19-30.
Kim SP, Thompson RH, Boorjian SA, et al. Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis. J Urol. 2012;188:51-57
Ristau BT, Kutikov A, Uzzo RG, et al. Active surveillance for small renal masses: When less is more. Eur Urol Focus 2016;2:660-8.
Kunkle DA, Uzzo RG. Cryoablation or radiofrequency ablation of the small renal mass : a meta-analysis. Cancer 2008;113:2671-80.
Deschavanne PJ, Fertil B. A review of human cell radiosensitivity in vitro. Int J Radiat Oncol Biol Phys 1996;34(1):251–66.
Juusela H, Malmio K, Alfthan O, et al. Preoperative irradiation in the treatment of renal adenocarcinoma. Scand J Urol Nephrol 1977;11(3):277–81.
Kjaer M, Iversen P, Hvidt V, et al. A randomized trial of postoperative radiotherapy versus observation in stage II and III renal adenocarcinoma. A study by the Copenhagen Renal Cancer Study Group. Scand J Urol Nephrol 1987; 21(4):285–9.
Van der Werf-Messing B. Proceedings: carcinoma of the kidney. Cancer 1973;32:1056–61.
Finney R. The value of radiotherapy in the treatment of hypernephroma–a clinical trial. Br J Urol 1973;45:258–69.
Kothari G, Louie AV, Pryor D, Vela I, Lo SS, Teh BS, et al. Stereotactic body radiotherapy for primary renal cell carcinoma and adrenal metastases. Chin Clin Oncol 2017; (Supl2):S17.
MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, Hilvano-Cabungcal AM, et al. Systematic review of oncological outcomes following surgical management of localised renal cancer. Eur Urol 2012;61:972–93.
Patel HD, Pierorazio PM, Johnson MH, Sharma R, Iyoha E, Allaf ME, et al. Renal functional outcomes after surgery, ablation, and active surveillance of localized renal tumors: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2017;12:1057–69.
Siva S, Pham D, Kron T, Bressel M, Lam J, Tan TH, et al. Stereotactic ablative body radiotherapy for inoperable primary kidney cancer: a prospective clinical trial. BJU Int 2017;120:623–30
Siva S, Louie AV, Warner A, Muacevic A, Gandhidasan S, Ponsky L, Ellis R, Kaplan I, et al. Pooled analysis of stereotactic ablative radiotherapy for primary renal cell carcinoma: A report from the International Radiosurgery Oncology Consortium for Kidney (IROCK). Cancer. 2018;124(5):934-42.
Meacci E, Nachira D, Congedo MT, Porziella V, Chiappetta M, Ferretti G, et al. Lung metastasectomy following kidney tumors: outcomes and prognostic factors from a single-center experience. J Thorac Dis 2017;9:S1267–72.
Hemal AK, Kumar A, Kumar R, Wadhwa P, Seth A, Gupta NP. Laparoscopic versus open radical nephrectomy for large renal tumors: a long-term prospective comparison. The Journal of urology. 2007;177:862-6.
Hofmann HS, Neef H, Krohe K, Andreev P, Silber RE. Prognostic factors and survival after pulmonary resection of metastatic renal cell carcinoma. Eur Urol 2005;48:77–81.
Hoerner-Rieber J, Duma M, Blanck O, Hildebrandt G, Wittig A, Lohaus F, et al. Stereotactic body radiotherapy (SBRT) for pulmonary metastases from renal cell carcinoma-a multicenter analysis of the German working group ‘‘Stereotactic Radiotherapy”. J Thorac Dis 2017;9:4512–22.
Wrónski M, Maor MH, Davis BJ, et al. External radiation of brain metastases from renal carcinoma: a retrospective study of 119 patients from the M. D. Anderson Cancer Center. Int J Radiat Oncol Biol Phys 1997;37:753-9.
Patchell RA. The management of brain metastases. Cancer Treat Rev 2003;29:533-40.
Sun M, De Velasco G, Brastianos PK, et al. The development of brain metastases in patients with renal cell carcinoma: epidemiologic trends, survival, and clinical risk factors using a population-based cohort. Eur Urol Focus 2019;5(3):474–81.
Fritz C, Borsky K, Stark LS, et al. Repeated courses of radiosurgery for new brain metastases to defer whole brain radiotherapy: feasibility and outcome with validation of the new prognostic metric brain metastasis velocity. Front Oncol 2018;8:551.
Brown PD, Jaeckle K, Ballman KV, et al. Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases a randomized clinical trial. JAMA. 2016;316:401–9.
Haque W, Verma V, Butler EB, et al. Utilization of stereotactic radiosurgery for renal cell carcinoma brain metastases. Clin Genitourin Cancer 2018;16(4): e935–43.
Shaw E, Scott C, Souhami L, et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys. 2000; 47:291–8.
Sahgal A, Soffietti R, Peereboom DM, et al. Hypofractionated radiation therapy for large brain metastases. Front Oncol. 2018;8:379.
Swanson DA, Orovan WL, Johnson DE, et al. Osseous metastases secondary to renal cell carcinoma. Urology 1981;18(6):556–61.
Zekri J, Ahmed N, Coleman RE, Hancock BW. The skeletal metastatic complications of renal cell carcinoma. Int J Oncol 2001;19:379-382
Antczak C, Trinh VQ, Sood A. et al. The health care burden of skeletal related events in patients with renal cell carcinoma and bone metastasis. J Urol. 2014;191(6): 1678–84.
Kassamali RH, Ganeshan A, Hoey ETD, et al. Pain management in spinal metastases: the role of percutaneous vertebral augmentation. Ann Oncol 2010; 22(4):782–6.
Lipton A, Colombo-Berra A, Bukowski RM. et al. Skeletal complications in patients with bone metastases from renal cell carcinoma and therapeutic benefts of zoledronic acid. Clin Cancer Res. 2004;10(18):6397-403.
Amini A, Altoos B, Bourlon MT, et al. Local control rates of metastatic renal cell carcinoma (RCC) to the bone using stereotactic body radiation therapy: Is RCC truly radioresistant? Pract Radiat Oncol. 2015; 5(6):e589–e596.
Wilson D, Hiller L, Gray L, Grainger M, Stirling A, and James N. The efect of biological efective dose on time to symptom progression in metastatic renal cell carcinoma. Clin Oncol. 2003;15(7):400–7.
Ganju RG, TenNapel M, Mahan N, et al. The Efficacy of Conventionally Fractionated Radiation in the Management of Osseous Metastases from Metastatic Renal Cell Carcinoma. J Oncol 2018;2018:6384253.
Hunter, G.K., et al. The efficacy of external beam radiotherapy and stereotactic body radiotherapy for painful spinal metastases from renal cell carcinoma. Pract Radiat Oncol, 2012. 2: e95.
Zelefsky, M.J., et al. Tumor control outcomes after hypofractionated and single-dose stereotactic image-guided intensity-modulated radiotherapy for extracranial metastases from renal cell carcinoma. Int J Radiat Oncol Biol Phys, 2012. 82: 1744.
Gunderson LL, Ashman JG, Haddock MG, et al. Integration of radiation oncology with surgery as combined-modality treatment. Surg Oncol Clin N Am. 2013;22:405-32.
Hallemeier CL, Choo R, Davıs BJ, Pısansky TM, Gunderson LL, et al. Long-Term Outcomes After Maxımal Surgıcal Resectıon And Intraoperatıve Electron Radıotherapy For Locoregıonally Recurrent Or Locoregıonally Advanced Prımary Renal Cell Carcınoma. Int J Radiat Oncol Biol Phys. 2012;82(5):1938-43.
Fokas, E., et al. Radiotherapy for brain metastases from renal cell cancer: should whole-brain radiotherapy be added to stereotactic radiosurgery?: analysis of 88 patients. Strahlenther Onkol, 2010. 186: 210.
