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 Post Chemotherapy and Brain RT with Local-Regional Recurrence with Bilateral Low Limbs Edema: the Role and Treatment Consideration of Further 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 metastases post chemotherapy and brain RT with local-regional recurrence with bilateral lower limbs edema; to discuss the role and treatment consideration of further 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 huge intra-abdomen mass with bilateral lower limbs edema. S: 1. In 2008/08, he was histologically diagnosed to have RCC of the left kidney with multiple lung mets and a single brain metastasis. On 2008/08/11, left nephroureterectomy was done. Chemotherapy was also given. 2. In 2008/12, 3DCRT to the single brain mets was given (5940 cgy in 33 fractions). 3. On 2009/06/23, you visited this patient in the ward. Histories: NDKA; no major medical disease history Review of systems: ataxia, bilateral lower limbs edema (especially the left lower limbs) for days; severe left frank region soreness and pain also for days O: 1. ECOG: 4, lying on bed, speech: OK 2. PEs: (1). HEENT & SCF: no neck LNs; (2). CHE: neg.; (3). ABD: a large surgical scar with drainage tube in place; (4). Back & Spine: mild knocking pain over the left frank region; (5). Extremities: free movement but decreasing in the muscle power; bilateral lower limbs edema, Gr. 2-3, the left lower limb severer than the right 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 lung. (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 and a single brain metastasis. (4). Bone scan in 2008/08: neg. (5). CT in 2009/06: pending result.

2 Key Image(s): Fig. 1. Fig. 2. Fig. 3.

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); rct4n1m1, rc-stage IV (2009/06, 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), with Gerota's facia invasion, pt4n0m1(multiple lung and single brain mets), stage IV (2008/08, AJCC 2006), post chemotherapy and brain 3DCRT (2009/12, 5940 cgy in 33 fractions), with disease progression, rct4n1m1, rc-stage IV (2009/06, AJCC 2006), with bilateral lower limbs edema and severe left frank soreness Q5: What is your Oncology Plan for this case? A5: Suggest: (1). Keep your current palliative care; (4). add palliative RT to the left abdomen huge local recurrence 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: metastatic RCC with huge symptomatic local recurrence (2). Goal: palliative; symptoms alleviation (3). Target & Volume: left abdomen mass with adequate margin (4). Technique: 3DCRT (5). Dose & Fractionation: cgy in fractions. Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/07/11

5 Key Image(s): (with marked) Fig. 1. Fig. 1. The huge left retroperitoneal mass with size more than 10 cm over the left renal fossa, c/w local recurrence of left RCC (as the white arrows). Fig. 2. Fig. 2. The huge left intra-abdomen mass with size more than 10 cm with central necrosis was noted, c/w local recurrence (as the short white arrows); small LN was also noted in the pre-vascular space, c/w nodal disease (as the long white arrow); the lateral abdomen wall showed increase soft tissue density, c/w edema pattern (as the black arrow). Fig. 3. Fig. 3. Multiple lung metastases over bilateral lungs were noted (as the short white arrows); bilateral mild pleural effusion were noted (as the long white arrows).

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