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Case Reports
. 2015;16(5):657-61.
doi: 10.1080/15384047.2015.1026506.

Stereotactic radiation therapy of renal cancer inferior vena cava tumor thrombus

Raquibul Hannan  1 , Vitaly Margulis, Stephen G Chun, Nathan Cannon, D W Nathan Kim, Ramzi E Abdulrahman, Arthur Sagalowsky, Ivan Pedrosa, Hak Choy, James Brugarolas, Robert D Timmerman
Affiliations
Case Reports

Stereotactic radiation therapy of renal cancer inferior vena cava tumor thrombus

Raquibul Hannan et al. Cancer Biol Ther. 2015.

Abstract

Renal Cell Carcinoma (RCC) is a common malignancy world-wide that is rising in incidence. Up to 10% of RCC patients present with inferior vena cava (IVC) tumor thrombus (IVC-TT). Although surgery is the only treatment with proven efficacy for IVC-TT, the surgical management of advanced (level III and IV) IVC-TT is difficult with high morbidity and mortality, and offers a poor survival outcome. Currently, there are no treatment options in the setting of recurrent or unresectable RCC IVC-TT. Even though RCC may be resistant to conventionally fractionated radiation therapy, hypofractionated radiation has shown excellent control rates for both primary and metastatic RCC. We report our experience treating 2 RCC patients with Level IV IVC-TT -one recurrent and the other unresectable-with stereotactic ablative radiation therapy (SABR). The first patient is a 75-year-old gentleman with a level IV RCC IVC-TT who presented 9 months after his radical nephrectomy and thrombectomy with a growing level IV IVC-TT that became refractory to 4 targeted agents. He received SABR of 50Gy in 5 fractions and at 2-year follow-up is doing well with a significant decrease in the enhancement and size of the IVC-TT. The second patient is an 83-year-old gentleman who presented with metastatic RCC and level IV IVC-TT but was not a surgical candidate. After progression on temsirolimus, he received SABR of 36Gy in 4 fractions to his IVC-TT and survived 18 months post-SABR. Both patients improved symptomatically and did not experience any acute or late treatment-related toxicity. Their survival of 24 months and 18 months are comparable to the reported median survival of 20 months in patients with level IV IVC-TT that underwent surgical resection. Therefore, SABR can be a potentially safe treatment option in the unresectable setting for RCC patients with IVC-TT and should be further evaluated in prospective trials.

Keywords: radiosurgery; renal cell carcinoma; stereotactic body radiotherapy.

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Figures

Figure 1.
Figure 1.
MRI of IVC Tumor Thrombus in clear cell RCC before and after SABR. Coronal (top) and axial (bottom) contrast enhanced MR images at different time points during the course of treatment. After nephrectomy and thrombectomy, the patient had an intraluminal recurrence of tumor thrombus, which was adherent to the IVC wall (arrowheads, A). The superior extent of the thrombus is inferior to the diaphragm (Level III; arrow, A). Note the size of the thrombus at the level of the right hepatic vein (arrow, B). After systemic targeted therapy (C) there was obvious disease progression with thrombus extending superior to the diaphragm (level IV, arrow) and increased enhancement (arrowhead, C). Note marked increased in transverse diameter (arrow, D). Two years after SABR therapy there is persistent thrombus extending above the diaphragm (arrow, E) although exhibiting clear decrease in enhancement (arrowhead, E) and marked reduction in transverse diameter (arrow, F).
Figure 2.
Figure 2.
SABR Treatment of Recurrent IVC-TT. (A-C) Representative axial, sagittal, and coronal images of the SABR treatment plan with isodose lines showing dose distribution and coverage of the IVC-TT. Patient was immobilized with a vacuum bag in an Elekta body frame. Abdominal compression and 4D-CT with contrast was used for respiratory motion management and assessment respectively. Treatment planning MRI was fused for target delineation. The dose was prescribed to the 84% isodose line via 11 non-coplanar photon beams of 10 MV and 3D optimization ensuring >95% PTV coverage with a 0.5 cm margin on the TT. (D) Radiation dose volume histogram from SABR plan of 50 Gy in 5 fractions showing optimized doses to critical organs as well as target volume (PTV). (E) Radiation dose constraints used for treatment planning.
Figure 3.
Figure 3.
SABR Treatment of Unresectable IVC-TT. (A) Coronal contrast-enhanced MRI during the venous phase demonstrates low level enhancement in a large renal mass (asterisk), which infiltrates the entire right kidney parenchyma and extends superiorly with a expansile tumor thrombus in the inferior vena cava (arrowheads). Note the superior extent of the tumor thrombus (black arrow) above the diaphragm (i.e. level IV thrombus). (B) Radiation dose volume histogram from SABR plan of 45 Gy in 5 fractions showing optimized doses to critical organs and target volumes. The patient set-up and target delineation was similar to the first case. The plan required 13 non-coplanar photon beams of 10 MV and IMRT optimization to ensure >95% PTV coverage with a 0.5 cm margin on the TT. C-E) Representative axial, sagittal, and coronal images of the SABR treatment plan with isodose lines showing dose distribution and coverage of the IVC-TT.
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