Kidney

Question 1

What is the study for SABR in primary renal cell carcinoma?

Answer 1

IROCK Consortium 190
25Gy single fraction
Multi-fraction to 42Gy
Median tumour 4 cm
5 yr local failure rate 5.5%

FASTTRACK II Trial
<4cm 26Gy/1#
>4cm 42Gy/3#
ITV to PTV = 5mm iso expansion
99% of the PTV to be covered by 100% of the dose
Dmax between 125-143%
100% local control rate, 92% FFDF at 5 years
15 mls/min reduction in eGFR

Question 2

What is FASTRACK II Trial show?

Answer 2

<4cm 26Gy/1#
>4cm 42Gy/3#
ITV to PTV = 5mm iso expansion
99% of the PTV to be covered by 100% of the dose
Dmax between 125-143%
100% local control rate, 92% FFDF at 5 years
15 mls/min reduction in eGFR

Question 3

What treatment guideline avaialble for kidney SABR?

Answer 3

IROCK Consensus Treatment Guideline

Question 4

What type of chemotherapy for TMT for MIBC?

Answer 4

Cisplatin-based chemo
Low-dose gemcitabine (poor renal function)

Question 5

What dose fractionation available for chemoRT for MIBC?

Answer 5

Moderate hypofractionation (bladder alone)
55Gy/20#

Standard fractionation + elective nodal
64Gy/32# + 52Gy elective nodes

Ultrahypofractionation (no chemo, RT alone)
36Gy/6#
HYBRID trial

Question 6

What is the retrospective meta-analysis for bladder preservation vs RC for MIBC?

Answer 6

Mount Sinai Hospital/Uni of Toronto
Multi institution, retrospective
<7 cm solitary tumour
Only unilateral hydronephrosis
TMT - 13% salvage cystetomy, 21% NMIBC recurrence
90% cT2
Improved 5 yr-OS

Question 7

What are the key steps for MIBC management with chemoRT?

Answer 7

Maximal TURBT of bladder tumour
EBRT with concurrent chemo
Cystocopy surevillance w prompt cystectomy for persistent or recurrent tumour (2-3 months later)

Question 8

What is the management approach for Stage I Seminoma?

Answer 8

Orchiectomy followed by observation is preferred (85% cured)

If to treat
- Single agent carbo
- Radiation = limited field, limited dose, para-aortic strip, 20Gy/10#

MRC TE 19 trial - caboplatin non inferior to RT
MRC TE18 trial - 20Gy non inferior to 30Gy
MRC TE10 trial - PA field similar to dogleg (periaortic + inguinal field)

Question 9

What is the management approach for Stage II Seminoma?

Answer 9

Chemo and RPLND (IIA)
Radiation treatment option for IIA and non-bulky IIB (<3cm)

Initial dog-leg (retroperitoneal and proximal ipsilateral iliac LN)
20Gy/10#
Boost involved node plus 2cm
-IIA 30Gy
-IIB 36Gy

IIA preferred RT
IIB preferred Chemotherapy (Etopside/Cisplatin 4 cycles)

Stage IIA/IIB
Seminoma
- < 3cm = RT, Chemor, Nerve-sparing RPLND
- > 3cm = chemotherapy

Question 10

Describe treatment planning field for Stage I Seminoma

Answer 10

PA field
Contour IVC and aorta separately from 2 cm below top of kidney down to bifurcation
1.2 cm expansion around IVC, and 1.9cm expansion around aorta
PTV = CTV +0.5cm

Dogleg field
In addition to PA field
contour ipslateral common, external and proximal internal iliac veins and artery down to upper border of acetabulum
1.2 cm expansion

Question 11

What are the patterns of failure for seminoma?

Answer 11

Paly Radiotherapy and Oncology 2013

Most nodes within 2.5cm lateral and 2.1cm anterior expansion of the aorta inferior to T12/L1

Question 12

Describe the difference between non-seminoma vs seminoma

Answer 12

Non-seminoma - increased AFP
- less radiosensitive, more chemosensitive, BEP preferred for adjuvant

Seminoma
- normal AFP, maybe b-HCG
- more radiosensitive, RT preference depends on risk for adjuvant

Chemotherapy first line for Stage II
THEN RT for seminoma as additional
or Chemo for non-seminoma as additional

Teratoma must be surgically removed

RT generally not favoured due to increased secondary malignancy and cardiovascular risk

PET scan for monitoring seminoma