Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

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1 Renal Cell Carcinoma of the Left Kidney Post Radical Surgery with pt4 Classification with Multiple Lung and Single Brain Metastases: the Role and Treatment Consideration of Radiotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with renal cell carcinoma of the left kidney post radical surgery with pt4 classification with multiple lung and single brain metastasis; to discuss the role and treatment consideration of radiotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 58 year-old male patient, 曾 OO, was referred to us for radiotherapy assessment of left kidney tumor, pt4nxmx s/p left nephroureterectomy, with multiple lung and brain mets. S: 1. In 2008/08, he was diagnosed to have left kidney tumor with multiple lung and brain metastatic lesions. 2. On 2008/08/11, left radical nephroureterectomy was done. Pathology reported renal cell carcinoma. 3. On 2008/09/24, you visited this patient in the ward. Histories: NDKA; no major medical disease history Review of systems: partial impairment of the left eye visual activity for months; still mild weakness due to post-abdominal surgery status. O: 1. General Condition: ECOG: 1-2, lying on bed, speech: OK, the drainage tube in the abdominal region in place. 2. Physical Examinations: (1). HEENT & SCF: no neck LNs; (2). CHE: neg.; (3). ABD: a large surgical scar with drainage tube in place; (4). Back & Spine: no knocking pain; (5). Extremities: free movement; no numbness; (6). Others: partial impairment of the left eye visual activity 3. ***Pathology in 2008/08, radical nephroureterectomy: renal cell carcinoma, grade III, of kidney, a renal mass, measuring 11x10x7.5 cm, at the upper pole of kidney with ruptured to the Gerota's facia with hemorrhagic cystic formation; pt4nxmx (AJCC 2006) 4. Images: (1). CXR in 2008/08: multiple lung nodular lesions over the both lungs. (2). ABD CT in 2008/08: a left kidney mass with size 8*6 cm with active bleeding sign; no intra-abdominal Lns; lung mets nodular lesion was found on the RLL of the lung. (3). Chest CT in 2008/08: multiple lung mets on the both lungs and a single brain metastases. (4). Bone scan in 2008/08: neg. 5. Others: neg.

2 Key Image(s): Fig. 1. Fig. 2.

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: ct4n0m1(multiple lung and single brain mets), stage IV (2008/08, AJCC 2006) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: pt4(gerota's facia invasion)-cn0-cm1(multiple lung and single brain mets), stage IV (2008/08, AJCC 2006) Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Oncology Diagnosis: Renal cell carcinoma, Gr. 3, of the left kidney, ct4n0m1(multiple lung and single brain mets), stage IV (2008/08, AJCC 2006), post left radical nephroureterectomy (2008/08/11), pt4(gerota's facia invasion)-cn0-cm1(multiple lung and single brain mets), stage IV (2008/08, AJCC 2006) Q5: What is your Oncology Plan for this case? A5: Suggest: (1). Brain MRI with contrast to further interpret single or multiple brain metastases. (2). Consult OPH section for his eye survey, especially the left eye. (3). keep current chemotherapy, immune therapy, and supportive care (4). add palliative RT to brain metastasis Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: RCC with multiple lung and single brain mets on CT (2). Goal: palliative; intention of function preservation for the left eye visual ability. (3). Target & Volume: isolated gross brain metastatic tumor with adequate margin (with an intention of deferring whole brain irradiation) (4). Technique: 3DCRT (5). Dose & Fractionation: 5040 cgy to 5940 cgy in fractions to the single brain metastatic lesion. Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/05/01

5 Key Image(s): (with marked) Fig. 1. Fig. 1. A single brain metastasis over the left occipital lobe of the brain with no noted peri-focal edema (as the white arrow). Fig. 2. Fig. 2. Multiple lung metastases over bilateral lungs (as the white arrows).

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