RESUMO
Pioneering and implementing new technology successfully in a radiation oncology clinic requires hard work, team effort and management support. Over the last 15 years, we have pioneered the clinical implementation of intensitymodulated radiation therapy (IMRT) as well as combined radio-gene-therapy in the treatment of cancer. The entire department including physicists, dosimetrists, therapists, nurses, managers, data managers, radiation oncologists and residents in training, other medical specialists e.g. neurosurgeons, urologists, pathologists, radiologists, molecular biologists and many others have joined forces and contributed to the success. IMRT has transitioned from an initial experimental approach to a standard of care approach now in various disease sites. We are entering a new era of imageguided radiation therapy (IGRT) and molecular-targeted therapy and we continue to strive to implement these new technologies in the clinics. Frameless stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) have now become a clinical reality. Again, all these require a tremendous amount of efficient management and cooperation among all departmental staff. Five fundamental principles which can help the successful pioneering and implementation of innovative radiation oncology approaches will be discussed. These include identifying a project champion(s), pursuing a multi-disciplinary approach, showing clinical efficacy and return on investment (ROI), ability to articulate the project and celebrating the successful implementation.
RESUMO
Purpose: Brain metastases from renal cell carcinoma (RCC) have been successfully treated with stereotactic radiosurgery (SRS). Metastases to extra-cranial sites may be treated with similar success using stereotactic body radiation therapy (SBRT), where image-guidance allows for the delivery of precise high-dose radiation in a few fractions. This paper reports the authors’ initial experience with image-guided SBRT in treating primary and metastatic RCC. Materials and methods: The image-guided Brainlab Novalis stereotactic system was used. Fourteen patients with 23 extra-cranial metastatic RCC lesions (orbits, head and neck, lung, mediastinum, sternum, clavicle, scapula, humerus, rib, spine and abdominal wall) and two patients with biopsy-proven primary RCC (not surgical candidates) were treated with SBRT (24-40 Gy in 3-6 fractions over 1-2 weeks). All patients were immobilised in body cast or head and neck mask. Image-guidance was used for all fractions. PET/CT images were fused with simulation CT images to assist in target delineation and dose determination. SMART (simultaneous modulated accelerated radiation therapy) boost approach was adopted. 4D-CT was utilised to assess tumour/organ motion and assist in determining planning target volume margins. Results: Median follow-up was nine months. Thirteen patients (93%) who received SBRT to extra-cranial metastases achieved symptomatic relief. Two patients had local progression, yielding a local control rate of 87%. In the two patients with primary RCC, tumour size remained unchanged but their pain improved, and their renal function was unchanged post SBRT. There were no significant treatment-related side effects. Conclusion: Image-guided SBRT provides excellent symptom palliation and local control without any significant toxicity. SBRT may represent a novel, non-invasive, nephron-sparing option for the treatment of primary RCC as well as extra-cranial metastatic RCC.