Kidney Cancer

29
April
2014

Stereotactic Ablative Body Radiotherapy (SABR)

Stereotactic Ablative Body Radiotherapy (SABR)

Our First Guest Blog for May 2014 is by Dr Shankar Siva, a Radiation Oncologist from The Peter MacCallum Cancer Centre in Melbourne. He discusses the new technique of Sterotactic Ablative Body Radiotherapy for kidney cancer in patients who are not medically fit for surgery. This new approach is still in a study period, but may offer cancer control to patients who do not have other treatment options.


Shankar, can you explain what Stereotactic Ablative Body Radiotherapy (SABR) is, and what advantages it has over other forms of radiotherapy?


Stereotactic ablative body radiotherapy (SABR) is a high precision radiotherapy technique that involves between 1 and 5 treatments. This is very different from conventional radiotherapy that involves daily radiotherapy for up to 8 weeks. It is non-invasive, painless, delivered without any need for anaesthetic, and conveniently does not require in-patient hospitalisation. SABR requires high-tech radiotherapy equipment for safe delivery, such as motion management for the tumour, accurate image guidance, and robust immobilisation. When delivered correctly, SABR can achieve submillimetre accuracy. Because of its precision, the SABR technique allows for much higher biological doses than can be safely delivered using conventional radiotherapy techniques. As such, most studies in sites such as the brain, lung and spine report cancer control rates in the order of 90% or greater after SABR.


Sterotactic radiotherapy for some other types of tumour has been around for some time. Why has it only recently been looked at for kidney tumours?


Stereotactic radiotherapy was first devised for brain tumours by Swedish neurosurgeon Lars Leksell in 1951, who termed it “radiosurgery”, so yes, it has been around for a very long time! Cranial "radiosurgery" was performed by using a rigid frame around the skull which allowed for accurate delivery of the radiation dose. However, tumours in other organs such as the lung, liver, and kidney are all highly mobile due to normal breathing or from the pumping of the heart. Only recently have technological advances allowed us to account for and manage tumour motion during radiotherapy delivery. The kidney in particular is a challenging organ, as it is quite mobile and surrounded by many sensitive organs.


Which group of patients is likely to be suitable for this treatment for kidney tumours?


Surgery is still the standard of care for patients with kidney cancer. However, kidney cancer is typically a disease of the older population, with the average age of diagnosis being 65 years of age. Some patients have other medical conditions which make invasive procedures potentially risky, particularly those patients who may have significant pre-existing kidney dysfunction, are risky anaesthetic candidates, or have heart disease and are reliant on blood thinners. In light of this risk, other procedures such as SABR and radiofrequency or microwave ablation have emerged as treatment alternatives for inoperable patients. In contrast to SABR, the disadvantage of radiofrequency ablation and microwave ablation is that those techniques can typically treat only treat smaller tumours, require the insertion of electrodes through the skin into the kidney (invasive), and are not as effective when tumours are close to blood vessels. On the other hand, the disadvantage of SABR is that it is typically restricted to patients who have not previously received radiotherapy to the upper abdomen. Otherwise, we expect that most patients who are not suitable for surgery on medical grounds may be eligible for treatment using the SABR technique.


What are the potential side effects?


In the early period after treatment, we expect that most patients feel tired. There may be some nausea, or loose bowel actions. Some patients may experience some reflux or heartburn. We typically prescribe preventative medications to help with these side effects. There may be a mild skin reaction, similar to a very light sunburn, particularly around the back. These side effects usually resolve within the first 2-3 weeks, and we expect all of these side effects to be resolved by around 6 weeks post treatment. The longer term effects of SABR in the kidney are less well understood. There is a potential for decline in kidney function, rise in blood pressure, scarring or narrowing of the bowel, or very rarely ulceration of the bowel or stomach. To date, studies have shown that the risk of severe side effects to be less than 5%.


This treatment is currently part of a study at the Peter Mac. What do you think the future holds for this treatment for kidney tumours?


We have pioneered this technique in Australia through the FASTRACK clinical trial, one of the few clinical trials using SABR for localised kidney cancer in the world. This study is expected to be complete later in 2014, and to date the results have been very promising. We would like to make this treatment accessible to all patients in Australia. However, the problem is that technology is very complex and varies from centre to centre. The Peter Mac is one of the largest radiation oncology institutions in the southern hemisphere and an Australian leader in the SABR technique, so we are not certain whether our results can be immediately reproduced in other institutions across Australia.

The next phase in our research program is to lead a multicentre study of SABR for kidney cancer involving multiple cancer centres across Australia. All the treatment plans will be centrally reviewed by our team at the Peter Mac for quality assurance, in order for this new treatment to be safely introduced across Australia. If this study is successful, I imagine that stereotactic radiotherapy will become a readily available treatment alternative for inoperable patients with primary kidney cancer.


Click this link to display a news item and video on the SABR technique.


Dr Siva is a Radiation Oncologist, Research Staff Specialist and NHMRC Scholar at the Peter MacCallum Cancer Centre in Melbourne. His major research interests are in high-tech radiation delivery and radiation biology. He is the lead clinician of the stereotactic body radiotherapy program at the Peter MacCallum Cancer Centre, and coordinates the first dedicated Stereotactic Ablative Body Radiotherapy (SABR) clinic in Australia. He published the first original research using the SABR technique in Australia. He serves on the Radiation Oncology Research Committee (RORC) of the Royal Australian and New Zealand College of Radiologists, on the renal subcommittee of the Australian and New Zealand Urogenital and Prostate (ANZUP) trials group, and as the radiation oncologist on the Management Advisory Committee (MAC) of the Australasian Lung Cancer Trials Group (ALTG). He is the principal investigator of multiple radiotherapy clinical trials of SABR in the context of lung, kidney and prostate malignancies.

Follow this link for more information on Dr. Shankar Siva


Categories: Video, Updates, Kidney Cancer

07
July
2013

Urology cancers in women

Urology cancers in women

The early symptoms of bladder and kidney cancer may be harder to detect in women than in men, a recent study suggests.

The study from the journal BMJ Open revealed that women in the UK diagnosed with kidney or bladder cancer were twice as likely as men to have visited their GP three or more times before they were referred to a specialist.

This is probably because the symptoms associated with benign conditions such as urinary tract infection (cystitis) can be similar, and UTI/cystitis is much more common in women than men. Men rarely get UTIs, so it is easier to establish that blood in the urine is related to something other than a UTI.

The principal trigger for referral is blood in the urine, detected on a urine test. The difficulty is that blood is often present when the patient has a UTI, and in this setting, blood does not necessarily indicate anything sinister. If blood persists after an infection is treated, further investigation may be needed.

If a UTI is present along with blood in the urine (on a lab test), the UTI should be treated, and the urine re-tested after treatment. If blood is still present, a urological referral is usually made.

If you actually see blood in your urine at any time, you must let your GP know straight away.

Link to article
BMJ Open

Categories: Updates, Kidney Cancer, Bladder Cancer

03
June
2013

Kidney cancer – a new class of drugs to watch for the future

Kidney cancer – a new class of drugs to watch for the future

The American Society of Clinical Oncology Annual meeting is in Chicago this week, and promising data on a new class of cancer drugs for will be presented.

Drugs known as Anti-PD-1 are a type of immune-therapy. PD-1 is a receptor on the surface of T cells, the immune system's disease fighters.


A cancer cloaking device

Some cancer cells have something called a PD-1 cloaking device; the cancer cells produce a molecule that binds to PD-1 to prevent the body’s cells from recognising and killing cancer.

Anti-PD-1 drugs disable that shield so that the body’s own immune cells can recognise and attack the cancer.

In one study, one third of patients with advanced kidney cancer demonstrated tumour shrinkage. Whilst this is encouraging, it is important to recognise that:

  1. These results are preliminary
  2. There are side effects of the drugs
  3. Two thirds of patients did not respond
  4. The drugs do not offer a cure
  5. Not all investigational drugs become treatment drugs, and if they do it can take a long time for them to pass safety tests.
  6. However, these developments do hold out hope for the future treatment of advanced kidney cancer

Categories: Kidney Cancer

21
May
2013

Survival advantage for partial nephrectomy questioned by new study

Small renal tumours can be treated by either complete (radical) or partial nephrectomy. Over the past few years, there has been a trend to use partial nephrectomy where possible, despite the higher complication rate from this surgery. This trend has been driven by evidence that overall survival is better in patients treated by partial nephrectomy, perhaps because kidney function is preserved, which in turn may have beneficial effects on overall health. A study published in May from Yale School of Medicine and the National Cancer Institute questions this belief, with evidence that the survival benefit seen with partial nephrectomy may actually be due to 'selection bias'. This means that the survival benefit may be due to the fact that healthier patients were chosen for partial nephrectomy, and they would have survived longer regardless of treatment option.

In summary, our current understanding is that both treatment options are reasonable for patients with small kidney tumours. Partial nephrectomy, where possible, is favourable for those patients who have reduced renal function, or have a disease that may make them prone to kidney problems later in life, such as diabetes and high blood pressure.

The following link takes you to a summary of the study

Link
Overall survival advantage with partial nephrectomy: A bias of observational data?

Categories: Kidney Cancer

25
April
2013

Kidney Cancer-Mayo Clinic

Categories: Video, Kidney Cancer

25
April
2013

Kidney Cancer Diagnosis

Categories: Video, Kidney Cancer

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