Stereotactic body radiation therapy for kidney cancer. Where do we stand?

At present, surgery is still the gold standard for the local treatment of renal cancer. Nonetheless, in several clinical scenarios, stereotactic body radiation therapy (SBRT) also known as stereotactic ablative body radiotherapy (SABR) is emerging as a highly effective ablative technique in fragile patients and those with significant comorbidities, as well as in cases where percutaneous therapy (cryoablation or radiofrequency) is not viable. However, considering the intrinsic radioresistance of renal tumors, the optimal treatment schemes have not been established. In oligometastatic patients, it has been reported that the control of the oligometastases can be a potentially curable approach. Being a technique than can be administered exclusively or in combination with systemic therapy, treatment individualization based on patient characteristics is key. Another scenario under investigation is oligoprogression, where SBRT offers the possibility of delaying further lines of systemic therapy by eliminating subclones of resistant tumor with ablative doses, with the additional opportunity of stimulating the immune system (immunomodulatory role). In this review, we have conducted an analysis of recently published studies that test the role of this technique in different clinical scenarios of this disease. We have found promising results that make SBRT a potent therapeutic approach with low toxicity. We also comment on ongoing studies that will generate the necessary evidence needed for the implementation of this technique in our daily clinical practice.

Experiencia en el manejo de metástasis cerebrales tratadas con radiocirugía estereotáctica / Experience with the radiosurgical treatment of brain metastases

Objetivos: Analizar la supervivencia de una cohorte de pacientes con metástasis cerebrales tratados con radiocirugía y determinar qué factores pueden influir en los resultados. Pacientes y método: Estudio retrospectivo descriptivo sobre una cohorte de 126 pacientes diagnosticados de metástasis intracraneal tratados con radiocirugía. Se excluyeron aquellos casos en los que se realizó cirugía (antes o después de la radiocirugía). Se analizó la supervivencia en función de factores clínicos (edad, sexo, tumor primario), radiológicos (número, localización y volumen de las lesiones) y de radioterapia (dosis de tratamiento, radioterapia holocraneal). Se realizó análisis univariante y multivariante de regresión de Cox. Resultados: Entre febrero de 2008 y abril de 2015 se trataron 225 metástasis cerebrales en 126 pacientes con edad media de 59,8 ± 11,6 años. La mediana de supervivencia fue de 8,2 meses. La supervivencia global a los 6, 12 y 24 meses fue del 60,3, del 31,5 y del 12,8%, respectivamente. Los orígenes más frecuentes fueron pulmonar (59,5%) y mama (14,3%), y la localización principal, los hemisferios cerebrales (77%). El volumen medio fue de 10,35cc (0,2-43,5). Se encontraron como factores significativos de supervivencia, entre otros: edad menor de 60años (p = 0,046), sexo femenino (p < 0,001), cáncer de mama (p < 0,001); KPS > 80 (p = 0,001), puntuación en la escala SIR > 6,5 (p = 0,031), escala GPA ≥ 2,5 (p = 0,003). Conclusiones: La radiocirugía es una técnica adecuada para el tratamiento de las metástasis cerebrales, y entre los factores pronósticos encontrados destacan la edad menor de 60 años, el sexo femenino y las mejores puntuaciones en las escalas de Karfnosky, SIR y GPA

Objective: To analyse the survival rate of a cohort of patients with intracranial metastases treated with radiosurgery, and to determine the factors that influence the results. Patients and method: Retrospective analysis performed on a cohort of 126 patients undergoing radiosurgery for brain metastases. Patients treated with surgery before or after radiosurgery were excluded. Survival is analysed based on clinical (age, sex, primary tumour), radiological (number, location and volume of lesions), and radiotherapy factors (treatment dose, holocraneal radiation). Univariate and multivariate analyses were performed to determine significant prognostic factors. Results: A total of 225 brain metastases in 126 patients, with a mean age of 59.8 ± 11.6 years, were treated between February 2008 and April 2015. The mean survival was 8.2 months. The overall survival rates at 6 months, 1 year, and 2 years were 60.3%, 31.5%, and 12.8%, respectively. Lung (59.5%) and breast (14.3) were the most common primary tumours, and the most common site for metastases was the cerebral hemisphere (77%) and the average volume was 10.35 cc (0.2-43.5). Significant survival factors were: age under 60 (P = .046), female (P < .001), breast cancer (P < .001), KPS > 80 (P = .001), SIR6 > 5 (P = .031), and GPA ≥ 2.5 (P = .003). Conclusions: Radiosurgery is an appropriate technique for the treatment of brain metastases, and the main prognostic factors include being age under 65, female, breast cancer, and good scores on Karnofsky, SIR, and GPA scales

[Experience with the radiosurgical treatment of brain metastases]. / Experiencia en el manejo de metástasis cerebrales tratadas con radiocirugía estereotáctica.

OBJECTIVE: To analyse the survival rate of a cohort of patients with intracranial metastases treated with radiosurgery, and to determine the factors that influence the results. PATIENTS AND METHOD: Retrospective analysis performed on a cohort of 126 patients undergoing radiosurgery for brain metastases. Patients treated with surgery before or after radiosurgery were excluded. Survival is analysed based on clinical (age, sex, primary tumour), radiological (number, location and volume of lesions), and radiotherapy factors (treatment dose, holocraneal radiation). Univariate and multivariate analyses were performed to determine significant prognostic factors. RESULTS: A total of 225 brain metastases in 126 patients, with a mean age of 59.8±11.6years, were treated between February 2008 and April 2015. The mean survival was 8.2 months. The overall survival rates at 6months, 1year, and 2years were 60.3%, 31.5%, and 12.8%, respectively. Lung (59.5%) and breast (14.3) were the most common primary tumours, and the most common site for metastases was the cerebral hemisphere (77%) and the average volume was 10.35 cc (0.2-43.5). Significant survival factors were: age under 60 (P=.046), female (P<.001), breast cancer (P<.001), KPS >80 (P=.001), SIR6 >5 (P=.031), and GPA ≥2.5 (P=.003). CONCLUSIONS: Radiosurgery is an appropriate technique for the treatment of brain metastases, and the main prognostic factors include being age under 65, female, breast cancer, and good scores on Karnofsky, SIR, and GPA scales.

Cáncer de recto localmente avanzado. La necesidad de la superespecialización / Locally advanced rectal cancer. The need for further specialization

Presentamos un caso que por sus connotaciones diagnósticas y terapéuticas resulta especialmente didáctico e ilustrativo, pues aborda el cómo, el quién y dónde debe realizarse la cirugía de cáncer de recto localmente avanzado. Ilustra el manejo diagnóstico y la estadificación del cáncer de recto en el momento actual. Este caso se aborda en el comité de forma multidisciplinar, y reúne los distintos avances en la cirugía de cáncer de recto de los últimos años (escisión total mesorrectal, abordaje laparoscópico, radioterapia intraoperatoria, resección perineal extendida, reparación del suelo pélvico con material protésico). Todo ello aunado a la opinión de que deben ser instituciones y grupos muy especializados y dedicados al tratamiento de esta patología los que deberían centralizar su atención médica.

We present a case, which due to its diagnostic and therapeutic connotations makes it especially educational, as it addresses the how, the who and where should the surgery be performed for locally advanced rectal cancer. It illustrates the diagnostic management and staging of rectal cancer at the present time. The case is approached in a multidisciplinary committee manner, and binds the various advances in surgery of rectal cancer in recent years (total meso-rectal excision, laparoscopy, intraoperative radiotherapy, extended perineal resection, pelvic floor repair with prosthetic material). This serves to underline the view that there must be highly specialized institutions and groups dedicated to the treatment of this condition in order to centralize its health care.

Calidad de vida después recidiva bioquímica en los pacientes con cáncer de próstata. ¿Cómo y cuánto viven los pacientes después de recidiva bioquímica? / Quality of life after biochemical recurrence in patients with prostate cancer. How and how long do patients live after biochemical recurrence?

La monitorización rutinaria de PSA en pacientes con cáncer de próstata localizado tratados radicalmente permite identificar aquellos con recurrencia bioquímica exclusiva. Las opciones de tratamiento para el fallo bioquímico incluyen observación, cirugía, radioterapia externa sola o asociada a hormonoterapia, braquiterapia, crioterapia y hormonoterapia exclusiva. Estos tratamientos determinan un patrón específico de cambios (función urinaria, intestinal, sexual y hormonal) que puede impactar negativamente sobre la calidad de vida, de manera que su indicación debe realizarse de una manera juiciosa y siempre en consonancia con las expectativas y preferencias de los pacientes. Las decisiones sobre cómo y cuándo tratar un fallo bioquímico son complicadas y el impacto de las terapias de rescate sobre el resultado clínico final es desconocido. Las tasas de control del cáncer de próstata tras tratamiento de rescate con prostatectomía, crioterapia ó braquiterapia oscilan entre el 20-80% de los casos en función de las características de los pacientes seleccionados. Dado que los individuos con fallo bioquímico pueden estar clínicamente asintomáticos durante muchos años sin tratamiento es esencial que médicos y pacientes dispongan de un claro conocimiento del potencial impacto de las mismas sobre la calidad de vida(AU)

Routine monitoring of PSA in patients with localized prostate cancer radically treated permits to identify those with biochemical recurrence only. Treatment options for biochemical failure include observation, surgery, radiotherapy alone or combined with hormonal therapy, brachytherapy, cryotherapy and hormone therapy exclusively. These treatments determine a specific pattern of changes (urinary function, bowel, sexual and hormonal) that can negatively impact the quality of life, so that the indication must be made in a judicious way and always in consonance with patient’s expectations and preferences. Decisions on how and when to treat biochemical failure are complicated and the impact of salvage therapy on clinical outcome is unknown. Rates of prostate cancer control after salvage therapy with prostatectomy, brachytherapy or cryotherapy vary between 20-80% of cases according to selected patient characteristics. Because individuals with BF may be clinically asymptomatic for many years without treatment, it is essential that physicians and patients have a clear understanding of the potential impact of these on the quality of life(AU)