4.4 Radiation therapy

4.4 Radiation therapy^1,2,3

Radiation therapy uses ionising radiation, usually in the form of X-rays (photons), but electrons can also be used. The latter is used if radiotherapy is to be given in areas close to the body surface, e.g. skin/subcutaneous metastases.

The beams work by affecting the DNA of cancer cells so they either die or stop dividing.

Indications for radiotherapy

In kidney cancer, the indications for radiotherapy are:

Solitary metastasis/oligometastasis treatment
Stereotactic
Palliative

Solitary/oligometastasis treatment

Solitary/oligometastasis treatment in patients with kidney cancer may be considered if there is a single metastasis where there has been a long interval from primary surgery and the solitary recurrence (> 2 years). For example, a solitary bone metastasis in the spine, which cannot be removed surgically, or that tumour tissue has been left behind after surgery.

The decision must be made at a MDT conference and in consultation with a specialist in radiotherapy. In some cases, stereotactic radiotherapy may be considered, see below.

Stereotactic radiotherapy

Stereotactic radiotherapy can be offered for few metastases in the cerebrum or peripherally (see section on treatment options for metastatic renal cell carcinoma (mRCC)).

Stereotactic radiotherapy (stereotactic radiosurgery (SRS)) can be offered for few cerebral metastases or after resection of cerebral metastasis (to the surgical cavity). A decision on SRS is taken at a MDT conference in the presence of a neuroradiologist, neurosurgeon and oncologist. As a rule, SRS can be offered for up to 4 cerebral metastases, all of which are less than 3 cm. Fractionation depends on the size.
Stereotactic radiotherapy to a single/few peripheral metastases (stereotactic body radiation therapy (SBRT)). The decision on SBRT is to be made at an MDT conference and in consultation with a specialist in radiotherapy. SBRT can be offered if:
- Solitary recurrence of the patient’s kidney cancer is established (e.g. adjacent to the nephrectomy site, lymph nodes, lung, bone, etc.), which cannot be removed surgically
- There is oligoprogression of a single lesion during systemic oncology treatment

Palliative radiotherapy

Palliative radiotherapy may be offered if the patient has symptoms from one or more metastases. The objective is symptom relief. Depending on the organ, symptoms and general condition, different dosage and fractionation may be offered.
Bones

Painful bone metastasis without soft tissue component and non-fracture risk: 8 Gy x 1
Painful bone metastasis with soft tissue component or fracture risk: 5 Gy x 5
Medullary cross-section – possibly preceded by surgery (decompression): 3 Gy x 10. If poor AT consider 5 Gy x 5 or 8 Gy x 1

Brain:

Multiple symptomatic cerebral metastases – consider whole-brain radiation: 3 Gy x 10 or 4 Gy x 5 (if AT is poor). The decision must be made in consultation with a specialist

Skin:

Bothersome/bleeding skin metastasis/subcutaneous metastasis: 5 Gy x 5. Can most often be given as electrons

Lymph nodes/lung metastasis:

Lymph nodes in the neck or mediastinum and lung metastasis: 3 Gy x 10 or 5 Gy x 5

Bleeding metastasis/primary kidney tumour:

Bleeding metastasis/primary kidney tumour: 5 Gy x 3 may be offered

Pause of TKI in connection with radiotherapy

There are no data/recommendations for pausing TKI in connection with radiotherapy. However, to reduce the risk of side effects/radiation necrosis, pause should be considered in: