Brain metastasis in hypernephroma

Radiotherapy and Renal Cell Carcinoma: A Continuing Saga

Renal cell carcinoma (RCC) is one of the most aggressive malignancies of the genito-urinary tract, having a poor prognosis especially in patients with metastasis. Surgical resection remains the gold standard for localized renal cancer disease, with radiotherapy (RT) receiving much skepticism during the last decades. However, many studies have evaluated the role of RT, and although renal cancer is traditionally considered radio-resistant, technological advances in the RT field with regards to modern linear accelerators, as well as advanced RT techniques have resulted in breakthrough therapeutic outcomes. Additionally, the combination of RT with immune checkpoint inhibitors and targeted agents may maximize the clinical benefit. This review article focuses on the role of RT in the therapeutic management of renal cell carcinoma.

Stereotactic Radiation Therapy for Renal Cell Carcinoma Brain Metastases in the Tyrosine Kinase Inhibitors Era: Outcomes of 120 Patients

BACKGROUND

The objective of the study was to evaluate the outcomes in terms of efficacy and safety of a large consecutive series of 362 patients with renal cell carcinoma (RCC) brain metastases treated using stereotactic radiosurgery (SRS) in the tyrosine kinase inhibitor (TKI) era.

PATIENTS AND METHODS

From 2005 to 2015, 362 consecutive patients with brain metastases from RCC were treated using SRS in 1 fraction: 226 metastases (61 patients) using Gamma-Knife at a median of 18 Gy (50% isodose line); 136 metastases (63 patients) using linear accelerator at a median of 16 Gy (70% isodose line). The median patient age was 58 years. At the first SRS, 37 patients (31%) received a systemic treatment. Among systemic therapies, TKIs were the most common (65%).

RESULTS

The local control rates were 94% and 92% at 12 and 36 months, respectively. In multivariate analysis, a minimal dose >17 Gy and concomitant TKI treatment were associated with higher rates of local control. The overall survival rates at 12 and 36 months were 52% and 29%, respectively. In multivariate analysis, factors associated with poor survival included age ≥65 years, lower score index for SRS, concomitant lung metastases, time between RCC diagnosis and first systemic metastasis ≤4 months, occurrence during treatment with a systemic therapy, no history of neurosurgery, and persistence or occurrence of neurological symptoms at 3 months after SRS. Seventeen patients had Grade III/IV adverse effects of whom 3 patients presented a symptomatic radionecrosis.

CONCLUSION

SRS is highly effective in patients with brain metastases from RCC. Its association with TKIs does not suggest higher risk of neurologic toxicity.

Improved Survival Outcomes for Kidney Cancer Patients With Brain Metastases

BACKGROUND

Brain metastases (BM) occur frequently in patients with metastatic kidney cancer and are a significant source of morbidity and mortality. Although historically associated with a poor prognosis, survival outcomes for patients in the modern era are incompletely characterized. In particular, outcomes after adjusting for systemic therapy administration and International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk factors are not well-known.

PATIENTS AND METHODS

A retrospective database of patients with metastatic renal cell carcinoma (RCC) treated at University of Texas Southwestern Medical Center between 2006 and 2015 was created. Data relevant to their diagnosis, treatment course, and outcomes were systematically collected. Survival was analyzed by the Kaplan-Meier method. Patients with BM were compared with patients without BM after adjusting for the timing of BM diagnosis, either prior to or during first-line systemic therapy. The impact of stratification according to IMDC risk group was assessed.

RESULTS

A total of 56 (28.4%) of 268 patients with metastatic RCC were diagnosed with BM prior to or during first-line systemic therapy. Median overall survival (OS) for systemic therapy-naive patients with BM compared with matched patients without BM was 19.5 versus 28.7 months (P = .0117). When analyzed according to IMDC risk group, the median OS for patients with BM was similar for favorable- and intermediate-risk patients (not reached vs. not reached; and 29.0 vs. 36.7 months; P = .5254), and inferior for poor-risk patients (3.5 vs. 9.4 months; P = .0462). For patients developing BM while on first-line systemic therapy, survival from the time of progression did not significantly differ by presence or absence of BM (11.8 vs. 17.8 months; P = .6658).

CONCLUSIONS

Survival rates for patients with BM are significantly better than historical reports. After adjusting for systemic therapy, the survival rates of patients with BM in favorable- and intermediate-risk groups were remarkably better than expected and not statistically different from patients without BM, though this represents a single institution experience, and numbers are modest.

Single Brain Metastases from Kidney Tumors. Clinico-Pathologic Considerations on a Series of 29 Cases

Twenty-nine cases of single cerebral metastases from renal carcinoma were the object of a retrospective and prospective study covering a period of 15 years (1975–1988). The best diagnostic means were NMR imaging with paramagnetic contrast medium and CAT scans after intravenous injection of a double dose of contrast medium. All patients underwent total surgical removal of the cerebral lesion. Radiotherapy was useful but had less influence on further reproduction than in metastases from tumors of other sites. The median survival was 28.1 months in patients who received radiotherapy and 23 months in the others. No significant difference in survival was found between the group of patients with unknown primary tumors and the other group with diagnosed primary neoplastic disease.

Stereotactic Radiosurgery for Renal Cancer Brain Metastasis: Prognostic Factors and the Role of Whole-Brain Radiation and Surgical Resection

Background. Renal cell carcinoma is a frequent source of brain metastasis. We present our consecutive series of patients treated with Stereotactic Radiosurgery (SRS) and analyse prognostic factors and the interplay of WBRT and surgical resection. Methods. This is a retrospective study of 66 patients with 207 lesions treated with the Cyberknife radiosurgery system in our institution. The patients were followed up with imaging and clinical examination 1 month and 2-3 months thereafter for the brain metastasis. Patient, treatment, and outcomes characteristics were analysed. Results. 51 male (77.3%) and 15 female (22.7%) patients, with a mean age of 58.9 years (range of 31–85 years) and a median Karnofsky Performance Status (KPS) of 90 (range of 60–100), were included in the study. The overall survival was 13.9 months, 21.9 months, and 5.9 months for the patients treated with SRS only, additional surgery, and WBRT, respectively. The actuarial 1-year Local Control rates were 84%, 94%, and 88% for SRS only, for surgery and SRS, and for WBRT and additional SRS, respectively. Conclusions. Stereotactic radiosurgery is a safe and effective treatment option in patients with brain metastases from RCC. In case of a limited number of brain metastases, surgery and SRS might be appropriate.

Are melanomas averse to cerebellum? Cerebellar metastases in a surgical series

OBJECTIVES

To study the propensity of different cancers to metastasize to the cerebrum and cerebellum, and to study overall survival (OS) and prognostic factors for patients after surgical resection for cerebellar metastases.

MATERIALS AND METHODS

From a prospectively collected tumor database, all patients that underwent a craniotomy for intracranial metastases between 2003 and 2011 at Oslo University Hospital were included.

RESULTS

One hundred and forty patients underwent resection for cerebellar metastases. Most common primary tumor sites were lung, colon/rectum, and breast in 45%, 19%, and 14%, respectively. None were prostate cancers. Melanoma metastases were significantly underrepresented, and colorectal cancer metastases significantly overrepresented in cerebellum, compared to the overall proportion of cerebellar/supratentorial metastases surgically resected (P < 0.05). Thirty-day post-operative mortality rate was 4.3%. Median OS was 7.7 months (95% CI 6.0-9.5 months) irrespective of post-operative adjuvant therapy. Median OS was 51.8, 8.4, and 3.4 months, respectively, for recursive partitioning analysis class 1(n = 11), 2 (n = 78) and 3 (n = 34). Significant negative prognostic factors were age ≥65 years, Karnofsky performance score (KPS) <70, extracranial metastases and uncontrolled systemic disease.

CONCLUSIONS

Melanoma metastases were significantly underrepresented in cerebellum, whereas colorectal cancer metastases were significantly overrepresented. Surgical mortality and OS after surgical treatment of cerebellar metastases were similar to the results of supratentorial metastases.

The impact of tyrosine kinase inhibitors on the multimodality treatment of brain metastases from renal cell carcinoma

OBJECTIVES

This study evaluated the effect of tyrosine kinase inhibitors (TKIs) on the brain metastasis (BM), local control (LC), and overall survival (OS) of patients with renal cell carcinoma (RCC) with BM.

METHODS

A retrospective review of patients with RCC BM was conducted. Eligible patients from 2 eras: pre-TKI, 2002 to 2003 and post-TKI, 2006 to 2007, were identified. Prognostic factors, use, and type of systemic therapy were noted. The timing, number, size, and treatment modality data for each BM were recorded. Use of TKI and BM treatment modality were correlated to LC and OS.

RESULTS

Eighty-one patients with 216 BMs were identified. Thirty-seven patients had BM at diagnosis and the remaining 44 were found to have BM at a later point. Forty-one patients never received a TKI and the remaining 40 received TKIs. Stereotactic radiosurgery, surgery, whole brain radiotherapy, or no local brain treatment was used for 89, 19, 24, and 75 lesions, respectively. The median OS from BM diagnosis was 5.4 months for the whole group: 4.4 versus 6.71 months in the never-TKI versus TKI groups, respectively. Patients who received TKIs post-BM development had a median OS of 23.6 months versus 2.08 and 4.41 months for the patients who received TKIs pre-BM or never-TKI, respectively (P=0.0001). LC was statistically superior in lesions managed with surgery or stereotactic radiosurgery versus the no local therapy.

CONCLUSIONS

In patients with RCC and BM, TKIs are associated with a trend of improved OS, but no significant improvement in LC of BM. They may provide a significant benefit to patients with BM with no prior TKI exposure.

Stereotactic radiosurgery with and without whole-brain radiotherapy for newly diagnosed brain metastases

Brain metastases develop in 20-40% of cancer patients and can cause significant morbidity. In selected patients with one to three lesions, stereotactic radiosurgery may be used to improve local control. However, it is unclear whether whole-brain radiotherapy is necessary for all patients who are candidates for stereotactic radiosurgery. While whole-brain radiotherapy may improve the locoregional control of brain metastases, it may cause long-term side effects and may not improve overall survival in some patients. Its benefits should be evaluated in the context of risks of neurocognitive deterioration, either from whole-brain radiotherapy or from uncontrolled brain metastases, and the possible need for salvage treatments with the omission of initial whole-brain radiotherapy. For certain radioresistant brain metastases, the benefit of whole-brain radiotherapy to patients who have stereotactic radiosurgery is uncertain.

Brain metastasis in renal cancer patients: metastatic pattern, tumour-associated macrophages and chemokine/chemoreceptor expression

Background:

The mechanisms of brain metastasis in renal cell cancer (RCC) patients are poorly understood. Chemokine and chemokine receptor expression may contribute to the predilection of RCC for brain metastasis by recruitment of monocytes/macrophages and by control or induction of vascular permeability of the blood–brain barrier.

Methods:

Frequency and patterns of brain metastasis were determined in 246 patients with metastatic RCC at autopsy. Expression of CXCR4, CCL7 (MCP-3), CCR2 and CD68⁺ tumour-associated macrophages (TAMs) were analysed in a separate series of 333 primary RCC and in 48 brain metastases using immunohistochemistry.

Results:

Fifteen percent of 246 patients with metastasising RCC had brain metastasis. High CXCR4 expression levels were found in primary RCC and brain metastases (85.7% and 91.7%, respectively). CCR2 (52.1%) and CCL7 expression (75%) in cancer cells of brain metastases was more frequent compared with primary tumours (15.5% and 16.7%, respectively; P<0.0001 each). The density of CD68⁺ TAMs was similar in primary RCC and brain metastases. However, TAMs were more frequently CCR2-positive in brain metastases than in primary RCC (P<0.001).

Conclusion:

Our data demonstrate that the monocyte-specific chemokine CCL7 and its receptor CCR2 are expressed in tumour cells of RCC. We conclude that monocyte recruitment by CCR2 contributes to brain metastasis of RCC.

Astrocytes directly influence tumor cell invasion and metastasis in vivo

Brain metastasis is a defining component of tumor pathophysiology, and the underlying mechanisms responsible for this phenomenon are not well understood. Current dogma is that tumor cells stimulate and activate astrocytes, and this mutual relationship is critical for tumor cell sustenance in the brain. Here, we provide evidence that primary rat neonatal and adult astrocytes secrete factors that proactively induced human lung and breast tumor cell invasion and metastasis capabilities. Among which, tumor invasion factors namely matrix metalloprotease-2 (MMP-2) and MMP-9 were partly responsible for the astrocyte media-induced tumor cell invasion. Inhibiting MMPs reduced the ability of tumor cell to migrate and invade in vitro. Further, injection of astrocyte media-conditioned breast cancer cells in mice showed increased invasive activity to the brain and other distant sites. More importantly, blocking the preconditioned tumor cells with broad spectrum MMP inhibitor decreased the invasion and metastasis of the tumor cells, in particular to the brain in vivo. Collectively, our data implicate astrocyte-derived MMP-2 and MMP-9 as critical players that facilitate tumor cell migration and invasion leading to brain metastasis.

A concise review of the efficacy of stereotactic radiosurgery in the management of melanoma and renal cell carcinoma brain metastases

Melanoma and renal cell carcinoma have a well-documented tendency to develop metastases to the brain. Treating these lesions has traditionally been problematic, because chemotherapy has difficulty crossing the blood brain barrier and whole brain radiation therapy (WBRT) is a relatively ineffective treatment against these radioresistant tumor histologies. In recent years, stereotactic radiosurgery (SRS) has emerged as an effective and minimally-invasive treatment modality for irradiating either single or multiple intracranial structures in one clinical treatment setting. For this reason, we conducted a review of modern literature analyzing the efficacy of SRS in the management of patients with melanoma and renal cell carcinoma brain metastases. In our analysis we found SRS to be a safe, effective and attractive treatment modality for managing radioresistant brain metastases and highlighted the need for randomized trials comparing WBRT alone vs. SRS alone vs. WBRT plus SRS in treating patients with radioresistant brain metastases.

Outcome predictors of gamma knife radiosurgery for renal cell carcinoma metastases

BACKGROUND

Although whole-brain radiation therapy (WBRT) has been a standard palliative management for brain metastases from renal cell carcinoma, its benefit has been elusive because of radiobiological resistance.

OBJECTIVE

To evaluate the role of stereotactic radiosurgery (SRS) in the management of brain metastases from renal cell carcinoma.

METHODS

We reviewed records from 158 consecutive patients (men = 111, women = 47) who underwent SRS for 531 brain metastases from renal cell carcinoma. The median patient age was 61 years (range, 38-83 years), and the median number of tumors per patient was 1 (range, 1-10). Seventy-nine patients (50%) had solitary brain metastasis. Fifty-seven patients (36%) underwent prior WBRT. The median total tumor volume for each patient was 3.0 cm3 (range, 0.09-47 cm).

RESULTS

The overall survival after SRS was 60%, 38%, and 19% at 6, 12, and 24 months, respectively, with a median survival of 8.2 months. Factors associated with longer survival included younger age, longer interval between primary diagnosis and brain metastases, lower recursive partitioning analysis class, higher Karnofsky performance status, smaller number of brain metastases, and no prior WBRT. Median survival for patients with < 2 brain metastases, higher Karnofsky performance status (> 90), and no prior WBRT was 12 months after SRS. Sustained local tumor control was achieved in 92% of patients. Symptomatic adverse radiation effects occurred in 7%. Overall, 70% of patients improved or remained neurologically stable.

CONCLUSION

Stereotactic radiosurgery is an especially valuable option for patients with higher Karnofsky performance status and smaller number of brain metastases from renal cell carcinoma.

Hepatocellular Carcinoma Metastasis to the Orbit in a Coinfected HIV+ HBV+ Patient Previously Treated with Orthotopic Liver Transplantation: A Case Report

Hepatocellular carcinoma rarely metastasizes to the orbit. We report a 45-year-old male, HBV+, HIV+, with a past history of a liver transplant for ELSD (end-stage liver disease) with hepatocellular carcinoma and recurrent HCC, who presented with proptosis and diplopia of the left eye. CT scans of the head revealed a large, irregular mass in the left orbit causing superior and lateral destruction of the orbital bone. Biopsy specimens of the orbital tumor showed features of metastatic foci of hepatocellular carcinoma. Only 16 other cases of HCC metastasis to the orbit have been described in literature, and this is the first case in a previously transplanted HIV+, HBV+ patient.

The brain microenvironment and cancer metastasis

The process of metastasis consists of a series of sequential, selective steps that few cells can complete. The outcome of cancer metastasis depends on multiple interactions between metastatic cells and homeostatic mechanisms that are unique to one or another organ microenvironment. The specific organ microenvironment determines the extent of cancer cell proliferation, angiogenesis, invasion and survival. Many lung cancer, breast cancer, and melanoma patients develop fatal brain metastases that do not respond to therapy. The blood-brain barrier is intact in and around brain metastases that are smaller than 0.25 mm in diameter. Although the blood-brain barrier is leaky in larger metastases, the lesions are resistant to many chemotherapeutic drugs. Activated astrocytes surround and infiltrate brain metastases. The physiological role of astrocytes is to protect against neurotoxicity. Our current data demonstrate that activated astrocytes also protect tumor cells against chemotherapeutic drugs.

Do patients receiving whole-brain radiotherapy for brain metastases from renal cell carcinoma benefit from escalation of the radiation dose?

PURPOSE

Whole-brain radiotherapy (WBRT) is the most common treatment for brain metastases from renal cell carcinoma (RCC). Most patients cannot receive more aggressive therapies including surgery or radiosurgery. The standard WBRT regimen, 30 Gy/10 fractions (10 × 3 Gy), has resulted in poor survival (OS). This study investigates whether escalation of the WBRT dose improves treatment outcomes.

METHODS AND MATERIALS

Data from 60 patients receiving WBRT for brain metastases from RCC were retrospectively analyzed. A dose of 10 × 3 Gy (n = 31) was compared with higher doses (40 Gy/20 fractions or 45 Gy/15 fractions; n = 29) for OS and local control (LC). Additional factors evaluated were patient age, sex, performance status, number of metastases, interval from diagnosis of RCC to WBRT, extracerebral metastases, recursive partitioning analysis (RPA) class, and year of WBRT.

RESULTS

The OS at 6 months was 29% after 10 × 3 Gy and 52% after higher doses (p = 0.003). The OS at 12 months was 13% and 47%, respectively. On multivariate analysis, higher WBRT doses (p = 0.022), Karnofsky performance status score ≥70 (p = 0.017), fewer than four brain metastases (p = 0.035), and RPA Class 1 (p = 0.003) resulted in better OS. The LC at 6 months was 21% after 10 × 3 Gy and 57% after higher doses (p = 0.013). The LC at 12 months was 7% and 35%, respectively. On multivariate analysis, fewer than four brain metastases (p < 0.001) were associated with LC. A trend was found for WBRT regimen (p = 0.06) and RPA class (p = 0.06).

CONCLUSIONS

The findings suggest that escalation of the WBRT dose beyond 10 × 3 Gy improves outcomes in patients with brain metastases from RCC. The results should be confirmed in a randomized trial stratifying for significant prognostic factors.

Current management of metastatic brain disease

Brain metastases are the most common intracranial tumor in adults. The incidence of metastases is thought to be rising due to better detection and treatment of systemic malignancy. More widespread use and improved quality of MRI may lead to early detection of brain metastases. Available evidence suggests that survival is longer and quality of life improved if brain metastases are treated aggressively. This article reviews current therapeutic management used for brain metastases. To select the appropriate therapy, the physician must consider the extent of the systemic disease, primary histology, and patient age and performance status, as well as the number, size, and location of the brain metastases. Available treatment options include whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), surgery, and chemotherapy. Multidisciplinary approaches such as the combination of WBRT with SRS or surgery have shown superior results in terms of survival time, neurocognitive function, and quality of life. The utility and optimal use of chemotherapy and radiosensitizing agents is less clear. It is hoped that further advances and multidisciplinary approaches currently under study will result in improved patient outcomes.

Orbital metastasis from hepatocellular carcinoma

We report a case of orbital metastasis from hepatocellular carcinoma and review the literature. A 45-year-old healthy male patient presented with proptosis due to an orbital mass. Histopathologic examination indicated that the tumor was a secondary from a hepatocellular carcinoma, and further investigations revealed the primary tumor in the liver. Hepatocellular carcinoma is a rare source of metastasis to the orbit, and to our knowledge, only 14 histopathologically proven cases have been reported previously. Proptosis was the most common presenting feature in the reviewed reports. A majority of patients had occult primary tumors at presentation and the diagnosis of the orbital mass was based on histopathologic features.

Solitary Brain Metastasis From Renal Cell Carcinoma 15 Years After Nephrectomy-Case Report-

A 77-year-old man presented with a metastatic brain tumor 15 years after nephrectomy for a renal cell carcinoma. Neurological examination showed recent memory disturbance and slight right hemiparesis. Magnetic resonance imaging revealed a round well-demarcated mass extending from the left thalamus to the left trigone of the lateral ventricle. Preoperative angiography showed tumor staining. Surgery was performed by opening the inferior temporal sulcus. Only biopsy could be performed because of extensive bleeding from the tumor. Histological examination identified metastatic renal cell carcinoma. Gamma knife surgery was performed which resulted in resolution of his hemiparesis. Metastatic renal cell carcinoma should be considered even if nephrectomy was performed 10 or more years before presentation.

LINAC radiosurgery for brain metastasis of renal cell carcinoma

The purpose of the study was to evaluate the efficacy and toxicity of stereotactic radiotherapy in the treatment of the brain metastasis of renal cell carcinoma. From 1994 to 2001, 28 patients presenting with 65 metastases of renal cell cancer were treated by radiosurgery. Median age was 55 years (35-75), and median Karnofski performance status ranges between 50 and 100. Seven patients had received whole brain radiotherapy (WBRT) before radiosurgery. Twelve patients were treated by radiosurgery for 1 metastasis, 5 patients for two metastases and 6 for three, and 5 for more than three metastases. One procedure was performed in 22 patients and, 2 or 3 procedures for 6 patients. Median metastasis diameter was 19 mm (5-55 mm). Median metastasis volume was 1.28 cc (0.02-28 cc). Irradiation was delivered by linear accelerator. Median minimal dose (on the 70% isodose) was 14.7 Gy (10.8 Gy, 19.5 Gy), median maximal dose (at the isocenter) 20.5 Gy (14.3 Gy, 39.6 Gy). Median follow-up was 14 months (1-33). Two metastases progressed (3%), 2 and 12 months after radiosurgery. Overall, crude local control rate was 97% and 3-, 6- and 12-month local control rates were 98% +/- 2%, 98% +/- 2%, and 93% +/- 5%, respectively. In univariate analysis, no prognostic factor of local control was retrieved. Median brain disease-free survival was 25 months after RS. the 3-, 6- and 12-month distant brain control rates were 91% +/- 4%, 91% +/- 4%, and 70% +/- 12%, respectively. Median survival duration was 11 months. The 3-, 6-, 12- and 24-month overall survival rates were 82% +/- 7%, 67% +/- 9%, 48% +/- 10%, and 33% +/- 10%, respectively. According to univariate analysis, only site of metastasis was overall survival prognostic factor. Radiosurgery for brain metastasis of renal cell carcinoma is an effective and accurate treatment. The use of radiosurgery alone is an appropriate management strategy for many patients with brain metastasis of renal cell carcinoma. Radiosurgery is efficient even after development of new metastasis appearing after WBRT.

Neurologic complications of solid tumors

This article reviews the neurologic complications of the most common solid tumors, including lung, breast, gastrointestinal, genitourinary, gynecologic, head and neck cancers, melanoma and sarcomas. As systemic therapy improves for many of these tumors, patients are surviving longer and the incidence of neurologic complications is increasing.

Radiosurgery in patients with renal cell carcinoma metastasis to the brain: long-term outcomes and prognostic factors influencing survival and local tumor control

OBJECT

Renal cell carcinoma is a leading cause of death from cancer and its incidence is increasing. In many patients with renal cell cancer, metastasis to the brain develops at some time during the course of the disease. Corticosteroid therapy, radiotherapy, and resection have been the mainstays of treatment. Nonetheless, the median survival in patients with renal cell carcinoma metastasis is approximately 3 to 6 months. In this study the authors examined the efficacy of gamma knife surgery in treating renal cell carcinoma metastases to the brain and evaluated factors affecting long-term survival.

METHODS

The authors conducted a retrospective review of 69 patients undergoing stereotactic radiosurgery for a total of 146 renal cell cancer metastases. Clinical and radiographic data encompassing a 14-year treatment interval were collected. Multivariate analyses were used to determine significant prognostic factors influencing survival. The overall median length of survival was 15 months (range 1-65 months) from the diagnosis of brain metastasis. After radiosurgery, the median survival was 13 months in patients without and 5 months in those with active extracranial disease. In a multivariate analysis, factors significantly affecting the rate of survival included the following: 1) younger patient age (p = 0.0076); 2) preoperative Karnofsky Performance Scale score (p = 0.0012); 3) time from initial cancer diagnosis to brain metastasis diagnosis (p = 0.0017); 4) treatment dose to the tumor margin (p = 0.0252); 5) maximal treatment dose (p = 0.0127); and 6) treatment isodose (p = 0.0354). Prior tumor resection, chemotherapy, immunotherapy, or whole-brain radiation therapy did not correlate with extended survival. Postradiosurgical imaging of the brain demonstrated that 63% of the metastases had decreased, 33% remained stable, and 4% eventually increased in size. Two patients (2.9%) later underwent a craniotomy and resection for a tumor refractory to radiosurgery or a new symptomatic metastasis. Eighty-three percent of patients died of progression of extracranial disease.

CONCLUSIONS

Stereotactic radiosurgery for treatment of renal cell carcinoma metastases to the brain provides effective local tumor control in approximately 96% of patients and a median length of survival of 15 months. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including radiosurgery can offer patients an extended survival.

Repeated gamma knife surgery for multiple brain metastases from renal cell carcinoma

OBJECT

The aim of this study was to evaluate the therapeutic profile of repeated gamma knife surgery (GKS) for renal cell carcinoma that has metastasized to the brain on multiple occasions.

METHODS

Data from this study were culled from a single institution and cover a 6-year period of outpatient radiosurgery. A standard protocol for indication, dose planning, and follow up was established. In cases of distant or local recurrences, radiosurgery was undertaken repeatedly (up to six times in one individual). Seventy-five patients harboring 350 cerebral metastases were treated. Relief from pretreatment neurological symptoms occurred in 72% of patients within a few days or a few weeks after the procedure. The actuarial local tumor control rate after the initial GKS was 95%. In patients free from relapse of intracranial metastases after repeated radiosurgery, long-term survival was 91% after 4 years; median survival was 11.1+/-3.2 months after radiosurgery and 4.5+/-1.1 years after diagnosis of the primary kidney cancer. Survival following radiosurgery was independent of patient age and sex, side of the renal cell carcinoma, pretreatment of the cerebrum by using radiotherapy or surgery, number of brain metastases and their synchronization with the primary renal cell carcinoma, and the frequency of radiosurgical procedures. In contrast, survival was dependent on the patient's clinical performance score and the extracranial tumor status. Tumor bleeding was observed in seven patients (9%) and late radiation toxicity (LRT) in 15 patients (20%). Treatment-related morbidity was moderate and mostly transient. Late radiation toxicity was encountered predominantly in long-term survivors.

CONCLUSIONS

Outpatient repeated radiosurgery is an effective and only minimally invasive treatment for multiple brain metastases from renal cell cancer and is recommended as being the method of choice to control intracranial disease, especially in selected patients with limited extracranial disease. Physicians dealing with such patients should be aware of the characteristic aspects of LRT.

Stereotactic Radiosurgery for Patients with “Radioresistant” Brain Metastases

OBJECTIVE

Our aim was to evaluate the efficacy of stereotactic radiosurgery (SRS) for the treatment of patients with brain metastases that have been determined to be “radioresistant” on the basis of histological examination.

METHODS

We reviewed the medical records of 41 consecutive patients who presented with 83 brain metastases from radioresistant primaries and subsequently underwent SRS. All patients were followed until death or for a median of 31 months after SRS. Tumor histologies included renal cell carcinoma (16 patients), melanoma (23 patients), and sarcoma (2 patients). Eighteen patients (44%) had a solitary metastasis, and 23 patients (56%) had multiple metastases.

RESULTS

The median overall survival time was 14.2 months after SRS. On the basis of univariate analysis, systemic disease status (P = 0.006) and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (P = 0.005) were associated with survival. The median survival time was 23.5 months for patients in RPA Class I status and 10.5 months for patients in RPA Class II or III status. There was a trend (P = 0.12) toward improved median survival for patients with renal cell carcinoma (17.8 mo) as compared with patients with melanoma (9.7 mo). Multivariate analysis showed RPA class (P = 0.038) and histological diagnosis of primary tumor (P &lt; 0.001) to be independent predictors for overall survival. In the 35 patients who underwent follow-up imaging, 9 (12%) of 73 tumors recurred locally. In 54% of the patients, distant brain failure (DBF) developed. Whole brain radiotherapy (WBRT) improved local control and decreased DBF, according to the univariate and multivariate analyses. Patients who received adjuvant WBRT in addition to SRS had 6-month actuarial local control of 100% as compared with 85% among those who did not receive WBRT (P = 0.018). Patients who received adjuvant WBRT with SRS had a 6-month actuarial DBF rate of 17%, as compared with a rate of 64% among patients who had SRS alone (P = 0.0027).

CONCLUSION

Well-selected patients with brain metastases from radioresistant primary tumors who undergo SRS survive longer than historical controls. RPA Class I status and primary renal cell carcinoma predict longer survival. Adjuvant WBRT improves local control and decreases DBF but does not affect overall survival. Further studies are needed to determine which patients should receive WBRT.

Metastasis to and from the central nervous system--the 'relatively protected site'

The brain has long been recognised as a site with a very low rate of metastases, despite the potential for cancers to be extremely locally aggressive. This feature contrasts with most of the rest of the body, where metastatic spread is much more common. The pathological behaviour of any tumour is governed by both its inherent composition and the composition of the matrix in which it is sited. Much work has been done in recent years to elucidate the factors within the central nervous system (CNS) that give the brain its unique properties. Tumour interactions with the blood-brain barrier, microglia, and various matrix proteins, cytokines, and growth factors have a central role. This review concentrates mainly on the process of tumour spread from the CNS and explores how the brain is a protected site. CNS metastases from extraneural sites are also briefly covered.

Incidence of brain metastases in a cohort of patients with carcinoma of the breast, colon, kidney, and lung and melanoma

BACKGROUND

The objective of this study was to report on the incidence of and factors related to the occurrence of central nervous system metastases in a cohort of patients who were diagnosed with colorectal, lung, breast, or kidney carcinoma or melanoma.

METHODS

Using the population-based Maastricht Cancer Registry (MCR), a cohort was created of patients with colorectal carcinoma (n = 720 patients), lung carcinoma (n = 938 patients), breast carcinoma (n = 802 patients), renal carcinoma (n = 114 patients), and melanoma (n = 150 patients). The patients had to live in the catchment area of the University Hospital Maastricht (UHM) and had to have been diagnosed at the UHM during the period 1986-1995. Patients with brain metastases were searched for by linking the MCR to the Neuro-Oncology Registry of the UHM. Radiology files were checked as well. Follow-up lasted until December 31, 1998.

RESULTS

Brain metastases were diagnosed in 232 patients (8.5%) in the cohort (n = 2724 patients). Of these patients, 84 patients were diagnosed with brain metastases within 1 month after their primary diagnosis, 82 patients were diagnosed with brain metastases within 1 year of their primary diagnosis, and 66 patients were diagnosed with brain metastases more than 1 year after their primary diagnosis. The cumulative incidence after 5 years was estimated at 16.3% in patients with lung carcinoma, 9.8% in patients with renal carcinoma, 7.4% in patients with melanoma, 5.0% in patients with breast carcinoma, and 1.2% in patients with colorectal carcinoma. The incidence was lower in patients age > or = 70 years compared with younger patients (breast and lung carcinoma), lower in patients who were diagnosed before 1991 compared with patients who were diagnosed after 1991 (breast and lung carcinoma), and lower in patients who had nonsmall cell lung carcinoma compared with patients who had small cell lung carcinoma.

CONCLUSIONS

The frequency of brain metastases in this cohort was highest in patients with lung carcinoma, followed by patients with renal carcinoma. There was no evidence of an increasing incidence of brain metastasis in patients with carcinoma of the breast or lung.

The role of whole brain radiotherapy and stereotactic radiosurgery on brain metastases from renal cell carcinoma

PURPOSE

We reviewed our experience with patients who have undergone stereotactic radiosurgery (SRS) for brain metastases secondary to renal cell carcinoma (RCC). Analysis was performed to determine the survival, local control, distant brain failure (DBF), and then to define which tumors may not require upfront whole-brain radiotherapy (WBRT).

METHODS AND MATERIALS

Twenty-nine patients with 66 tumors underwent SRS from 1991 to 1998. Median follow-up from time of brain metastases diagnoses relative to each tumor was 12.5 months and 6.8 months from the time of SRS. Median SRS dose was 1,800 cGy to the 60% isodose line. Three patients had undergone SRS for previously treated tumors.

RESULTS

Median survival time from diagnosis was 10.0 months. Overall survival was not affected by age, addition of WBRT, number of lesions, tumor volume, or the presence of systemic disease. Of the 23 patients with follow-up neuroimaging, 4 of 47 (9%) tumors recurred. The addition of WBRT did not improve local control. Of the 13 patients who presented with a single lesion, 3 went on to develop DBF (23%), while 6 of the 10 patients who presented with multiple metastases developed DBF (60%).

CONCLUSION

Patients with brain metastases secondary to RCC treated by SRS alone have excellent local control. The decision of whether or not to add WBRT to SRS should depend on whether the patient has a high likelihood of developing DBF. Our study suggests that patients who present with multiple brain lesions may be more likely to benefit from the addition of WBRT because they appear to be more than twice as likely to develop DBF as compared to patients with a single lesion.

Stereotactic radiosurgery for brain metastasis from renal cell carcinoma

BACKGROUND

The authors evaluated results after stereotactic radiosurgery (SR) for brain metastases from renal cell carcinoma (RCC) and identified factors associated with improved survival and tumor control.

METHODS

The authors reviewed the management results from a total of 52 RCC brain metastases in 35 consecutive patients who underwent stereotactic radiosurgery (SR) during a 9-year interval. Twenty-eight patients also underwent whole brain radiation therapy (WBRT). The mean tumor volume was 2.4 mL (range, 0.1-14.1 mL). The mean dose delivered to the tumor margin was 17 gray (Gy) (range, 13-20 Gy). Univariate and multivariate testing was performed to determine significant prognostic factors.

RESULTS

The median survival was 11 months after SR and 14 months after brain tumor diagnosis. Only 2 patients (8%) died of progression of the irradiated tumor. Age < 55 years, lack of active systemic disease, and use of chemotherapy and/or immunotherapy after SR were significant favorable prognostic factors in multivariate testing. Post-SR imaging was evaluated in 26 patients (39 tumors). The local control rate from the 39 treated tumors imaged was 90% (tumor disappearance, 21%; tumor regression, 44%; and stable disease, 26%). Local recurrence developed in 3 patients (4 lesions) and remote brain disease in 12 patients. No patient developed a new focal neurologic deficit due to SR. Patients were classified into two groups: SR with and SR without WBRT. The addition of WBRT to SR did not improve survival. Distant failure occurred similarly in both groups (46% vs. 50%). WBRT combined with SR may contribute to local control, but did not prevent the development of new remote tumors.

CONCLUSIONS

SR for brain metastasis from RCC results in brain disease control in the majority of patients and was associated with few complications. Early detection of brain metastases and treatment with SR provides extended quality survival.

Renal cell carcinoma: diagnosis based on metastatic manifestations

Renal cell carcinomas are notorious for their tendency to metastasize early, often before the primary tumor has become apparent. Frequently, the initial complaint is referable to a distant metastatic lesion. Metastatic lesions have been found in almost every organ or tissue of the body. When a patient with a clinically asymptomatic renal cell carcinoma has signs and symptoms referable to a localized lesion, the final diagnosis depends on histologic and cytologic evaluation of a biopsy specimen. In this article, we describe a patient who had a pulsating transcalvarial occipital-suboccipital mass as the initial manifestation of an occult renal cell carcinoma. Initial manifestations by site of metastasis described in the literature are reviewed, and the differential diagnosis of primary clear cell tumor versus metastatic lesions from a renal cell carcinoma, according to their pathologic features, is discussed.

Surgical resection of brain metastases from renal cell carcinoma in 50 patients

OBJECTIVES

Metastases are frequently diagnosed among patients with renal cell carcinoma (RCC). Of 709 patients with brain metastases (BMET) who were operated on at our institution between 1974 and 1993, 50 (7%) were of renal origin.

METHODS

Medical records were reviewed retrospectively. Survival time was calculated by the Kaplan-Meier method and Cox proportional hazards model.

RESULTS

There were 38 men and 12 women. The median age was 60 years. The primary RCC was resected in 47 patients. Forty patients had a metachronous diagnosis of RCC and BMET. Median interval between the diagnosis of RCC and BMET was 17 months. In all 50 patients overall median survival (MS) from diagnosis of primary RCC was 31.4 months and from craniotomy was 12.6 months. Postoperative mortality was 10% (5 patients). In patients with primary RCC in the left kidney (n=25) versus right kidney (n=25) median survival from craniotomy was longer; 21.3 versus 7.4 months (P<0.014). Twenty-three patients (46%) had intratumoral hemorrhage. Eight patients had cerebellar metastasis (MS, 3.0 months) and 9 had multiple metastases resected (MS, 7.6 months). Thirty-eight patients had both brain and pulmonary metastases, and 16 of them had pulmonary resection (MS, 18.6 versus 8.0 months; P<0.03). Twenty-two patients received whole-brain radiation therapy (WBRT) after craniotomy and 18 did not receive WBRT (MS, 13.3 versus 14.5 months; P<0.62). The 1-year, 2-year, 3-year, and 5-year survival was 51%, 24%, 22%, and 8.5% respectively.

CONCLUSIONS

Only the resection of lung metastasis, supratentorial location of BMET, left-sided localization of primary RCC, and lack of neurologic deficit before craniotomy were statistically significant prognostic factors in Cox regression analysis. In the absence of effective systemic treatment, we suggest that patients with BMET from RCC be considered for operative resection for treatment and palliation.

High incidence of asymptomatic brain lesions in metastatic renal cell carcinoma

The metastatic pattern of renal cell carcinoma has been well established. Studies have revealed a relatively high incidence of spread to lung, liver, bone and brain. A retrospective review of the records of ninety patients with metastatic renal cell carcinoma showed seven to have evidence of brain metastases. Six of the seven were asymptomatic at time of diagnosis. This study shows a significant incidence of asymptomatic brain metastases in patients with metastatic renal cell carcinoma. Subsequent to our chart review, an additional two patients have presented to our institution with asymptomatic brain lesions from metastatic renal cell carcinoma.

Hepatocellular carcinoma metastasizing to the brain and orbit: report of three cases

Hepatocellular carcinoma rarely metastasizes to the brain or orbit. We report 3 clinically manifest examples, one of which occurred in a 13-yr-old boy. In 2 cases the intracranial metastasis was the initial presenting lesion. The 2 cases of brain metastasis both presented with intracerebral hemorrhage. Light microscopic examination of these tumors revealed a trabecular hepatocellular carcinoma of Edmondson grade II with focal hemorrhage and necrosis. Their immunohistochemical profile was identical to that described for primary hepatocellular carcinoma. The differential diagnosis from other intracranial metastatic tumors is discussed.

Ten years survival after recurrent intracranial metastases from a renal cell carcinoma

The clinical behaviour of renal cell carcinoma is often unpredictable. We report a patient who underwent three palliative resections over 10 years for recurrent intracerebral metastases from a renal cell carcinoma.

Metastatic renal cell carcinoma presenting as impotence

We describe a patient who initially presented with impotence followed by progressive lethargy and visual disturbances. Endocrine and radiological evaluation was suggestive of pituitary adenoma but pathological evaluation after transsphenoidal hypophysectomy revealed renal cell carcinoma metastatic to the pituitary. The etiology of this unusual presentation and prior reports of renal cell carcinoma spread to the pituitary are reviewed.

Late solitary cerebral metastases from renal cell carcinoma: report of two cases

We report two cases of solitary cerebral metastases from renal cell carcinoma 15 and 18 years after nephrectomy. In a review of the literature, only two cases of solitary brain metastasis from renal cell carcinoma with latency periods greater than 10 years have been documented. Our two cases represent the longest latency periods reported between nephrectomy and detection of a solitary cerebral metastasis. Histologic examination and immunohistochemical profile of the primary renal tumors and metastatic cranial tumors showed identical morphology and immunophenotype.

Solitary brain metastasis 13 years after removal of renal adenocarcinoma

We report a case of a patient who developed a single brain metastasis to the cerebellum 13 years after removal of a renal adenocarcinoma. The cerebellar metastasis was removed twice due to local recurrence one year after the first operation. The patient is alive and doing well 18 months after the second neurosurgical procedure. The metastasis was not associated with any other evidence of disease. Brain metastasis may present many years after removal of kidney adenocarcinoma and when not associated with other evidence of disease their operative treatment may carry a good prognosis.

Low incidence of asymptomatic brain metastases in patients with renal cell carcinoma

Brain metastases from renal cell carcinoma are uncommon. The present study was undertaken to determine the value of routine computerized tomographic (CT) scanning of the brain in patients with renal cell carcinoma. A review of 106 patients with renal cell carcinoma who had undergone CT scan of the brain revealed brain metastases in only 13.2 percent. Brain metastases were accompanied by central nervous system (CNS) symptoms in 78.6 percent of patients, with headaches constituting the most common presenting symptom (64.3%). Brain metastases were detected in only 3.3 percent of patients who had no CNS symptoms at the time of evaluation. It is concluded that CT scanning of the brain should be performed routinely only for those patients who report CNS symptoms at the time of evaluation.

Unique patterns of brain metastasis produced by different human carcinomas in athymic nude mice

The purpose of this study was to develop an in vivo model to study the growth pattern and biological behavior of brain metastases produced by different human carcinomas. To do so, human tumor cells from 8 different carcinomas of the colon, breast, kidney and lung were injected into athymic nude mice either by a direct intracerebral route or into the internal carotid artery. All carcinoma cells invaded through the blood-brain barrier and produced progressively growing lesions in the brain parenchyma. Unique patterns of growth were discernible among the carcinomas. Human colon carcinomas produced multiple lesions that spread by extension. Lung carcinoma cells produced widespread lesions throughout the brain. A very high degree of vascularization was associated with lesions produced by renal-cell carcinoma. The influence of estrogen on the growth of estrogen-receptor-positive human breast carcinoma cells was well demonstrated in this model. We conclude that the athymic nude mouse can be a useful model for studies of the biology and perhaps therapy of brain metastases produced by human carcinoma cells.