Radiotherapy for Kidney cancer Dr Kate Fife Consultant Clinical Oncologist Addenbrooke’s Hospital, Cambridge

Radiotherapy for Kidney cancer What is Radiotherapy? Some history Advances in radiotherapy When is it used in cancer treatment? When is it used in kidney cancer? Some examples Questions and Answers

What is Radiotherapy? High energy XRays XRays interact with atoms Direct DNA damage Ionisation of water molecules Cause DNA damage such as ‘Double strand breaks’ Cell ‘suicide’

Why does it work? DNA damage has to be repaired for cell to continue dividing Normal cells are good at repairing themselves Cancer cells are not Cancer cells preferentially killed Some damage to normal tissues

How is radiotherapy given? Linear Accelerator produces XRays Shaped to the area to be treated ‘field’

Treatments Treatment planning: CT Quick and painless! Single treatment Multiple treatments Dose and number of treatments depends on Purpose Sensitivity of tumour Sensitivity of normal tissues

History I XRays discovered 1895 (Roentgen) XRays used for head and neck and skin cancers and benign conditions eg ringworm Did not penetrate deeply and high dose on the skin 1922: fractionation produced fewer side effects

History II Radium discovered 1898 (Curie): natural radioactive emitter Radium used as implants for cancers of womb and other sites

History III Post 1945: artificially produced radioisotopes became available eg radioiodine, cobalt-60 (atomic weapon technology) 1952: First linear accelerator (LINAC) introduced Magnetron (high power electron source) developed during war for Radar

History III Linacs have high energy XRays which penetrate deep into body with much lower dose on skin (limiting factor with early XRay treatments) Computerisation has revolutionised treatment planning to improve accuracy, spare normal tissues and increase dose to tumour

Present and Future Improved planning: CT planning now routine Intensity modulated radiotherapy: planning technique producing shaped beams of varying intensity Tomotherapy: ‘Image guided’ radiotherapy

Tomotherapy Combines CT and Linac RT delivered in multiple spiral fields Allows very accurate dose delivery Daily real time CT imaging: high accuracy

Standard treatments Conventional planning and Linac treatment highly accurate Sufficient for most treatments

Use of Radiotherapy in Cancer treatment Surgery Local treatment Early stage Radiotherapy Early and late stage Systemic therapy: early and late stage Chemotherapy Hormone therapy Targeted therapy

What about RT for kidney cancer Treatment of primary tumour Usually surgery Treatment of advanced disease Usually TKIs/immunotherapy Treatment of symptoms from tumour deposits in advanced disease Radiotherapy

Does RT work in kidney cancer? Many websites and medical texts say kidney cancer is resistant to radiotherapy Kidney cancers have a range of sensitivity to RT Some respond well, others not so well

Sites for radiotherapy Anywhere! Bone Spine Soft tissue Lymph nodes Brain Lung Combined with surgery in some cases

Soft tissue chest wall

After RT and TKIs (4 years later….)

Severe pain from secondary tumour 4 months after RT

MRI Femur

Bone scan and XRay

Cambridge Study Over 100 radiotherapy treatments given to patients with bone or ‘soft tissue’ secondary cancers Response rate (improvement in symptoms or scans) in those reassessed after treatment was 85%

Could we treat the kidney tumour itself? Previously very toxic because of normal tissue damage (bowel, liver) Probably, with new techniques… Small kidney tumours in people who can’t have surgery Tumour bed if some tumour left after surgery