Impact of resection and systemic therapy on the survival of patients with brain metastasis of metastatic renal cell carcinoma

Fatal tumoral hemorrhage from brain metastases of renal cell carcinoma after stereotactic radiotherapy and immune checkpoint inhibitor and vascular endothelial growth factor-targeted therapy combinations

Introduction

Brain metastasis in renal cell carcinoma, which is reported in 10% of cases, leads to significant morbidity and mortality. Establishment of appropriate and safe treatment for brain metastasis renal cell carcinoma remains a pressing need.

Case presentation

A 56-year-old female patient, presenting with anorexia, headache, and occipital swelling, was subsequently diagnosed with clear cell renal cell carcinoma with multiple metastases, including intracranial and epicranial tumors. The patient initially underwent stereotactic radiotherapy for metastatic brain tumors and then received combination therapy with pembrolizumab and lenvatinib. However, after 30 days of treatment, the patient experienced a sudden loss of consciousness due to massive multifocal intracranial hemorrhage, leading to her death the following day.

Conclusion

Although fatal tumoral hemorrhage during combined stereotactic radiotherapy and immune checkpoint inhibitor/VEGF-targeted therapy for patients with brain metastasis renal cell carcinoma is an extremely rare complication, it should always be considered a possibility.

Evaluating the impact of early identification of asymptomatic brain metastases in metastatic renal cell carcinoma

BACKGROUND

Brain metastases (BM) in metastatic renal cell carcinoma (mRCC) have been reported to be present in up to 25% of patients diagnosed with mRCC. There is limited published literature evaluating the role of routine intra-cranial imaging for the screening of asymptomatic BM in mRCC.

AIMS

To evaluate the potential utility of routine intra-cranial imaging, a retrospective cohort study was conducted to characterize the outcomes of mRCC patients who presented with asymptomatic BM, as compared to symptomatic BM.

METHODS AND RESULTS

The Canadian Kidney Cancer Information System (CKCis) database was used to identify mRCC patients diagnosed with BM. This cohort was divided into two groups based on the presence or absence of BM symptoms. Details regarding patient demographics, disease characteristics, systemic treatments, BM characteristics and survival outcomes were extracted. Statistical analysis was through chi-square tests, analysis of variance, and Kaplan-Meier method to characterize survival outcomes. A p-value of <0.05 was considered statistically significant for all analyses. A total of 267 mRCC patients with BM were identified of which 106 (40%) presented with asymptomatic disease. The majority of patients presented with multiple (i.e., >1) BM (75%) with no significant differences noted in number of BM or BM-directed therapy received in symptomatic, as compared to asymptomatic BM patients. Median [95% confidence interval (CI)] overall survival (OS) from mRCC diagnosis was 42 months (95% CI: 32-62) for patients with asymptomatic BM, and 39 months (95% CI: 29-48) with symptomatic BM (p = 0.10). OS from time of BM diagnosis was 28 months (95% CI: 18-42) for the asymptomatic BM group, as compared to 13 months (95% CI: 10-21) in the symptomatic BM group (p = 0.04).

CONCLUSIONS

Given a substantial proportion of patients may present with asymptomatic BM, limiting intra-cranial imaging to patients with symptomatic BM, may be associated with a missed opportunity for timely diagnosis and treatment. The utility of routine intra-cranial imaging in patients with renal cell carcinoma, warrants further prospective evaluation.

The Emerging Role of Radiation Therapy in Renal Cell Carcinoma

Simple Summary

Stereotactic ablative radiation therapy (SAbR) is a safe and effective local therapy for renal cell cancer (RCC) with emerging and evolving indications. In this review we provide an overview of the evidence to support SAbR for RCC in a variety of clinical settings.

Abstract

Advancements in radiation delivery technology have made it feasible to treat tumors with ablative radiation doses via stereotactic ablative radiation therapy (SAbR) at locations that were previously not possible. Renal cell cancer (RCC) was initially thought to be radioresistant, even considered toxic, in the era of conventional protracted course radiation. However, SAbR has been demonstrated to be safe and effective in providing local control to both primary and metastatic RCC by using ablative radiation doses. SAbR can be integrated with other local and systemic therapies to provide optimal management of RCC patients. We will discuss the rationale and available evidence for the integration and sequencing of SAbR with local and systemic therapies for RCC.

Prognostic factors following resection of intracranial metastases

Background:

The aim of this study was to identify prognostic factors associated with resection of intracranial metastases.

Methods:

A retrospective case series including patients who underwent resection of cranial metastases from March 2014 to April 2021 at a single center. This identified 112 patients who underwent 124 resections. The median age was 65 years old (24–84) and the most frequent primary cancers were nonsmall cell lung cancer (56%), breast adenocarcinoma (13%), melanoma (6%), and colorectal adenocarcinoma (6%). Postoperative MRI with contrast was performed within 48 hours in 56% of patients and radiation treatment was administered in 41%. GraphPad Prism 9.2.0 was used for the survival analysis.

Results:

At the time of data collection, 23% were still alive with a median follow-up of 1070 days (68–2484). The 30- and 90-day, and 1- and 5-year overall survival rates were 93%, 83%, 35%, and 17%, respectively. The most common causes of death within 90 days were as follows: unknown (32%), systemic or intracranial disease progression (26%), and pneumonia (21%). Age and extent of neurosurgical resection were associated with overall survival (P < 0.05). Patients aged >70 had a median survival of 5.4 months compared with 9.7, 11.4, and 11.4 for patients <50, 50–59, and 60–69, respectively. Gross-total resection achieved an overall survival of 11.8 months whereas sub-total, debulking, and unclear extent of resection led to a median survival of 5.7, 7.0, and 9.0 months, respectively.

Conclusion:

Age and extent of resection are potential predictors of long-term survival.

Survival benefit with resection of brain metastases from renal cell carcinoma in the setting of molecular targeted therapy and/or immune therapy

Patient survival with renal cell carcinoma (RCC) has improved with the use of molecular targeted agents and immunotherapy. Given the potential activity of these agents in treating brain metastases, the role of aggressive local management with surgery and/or radiation may diminish. The aim of this study was to evaluate the role of aggressive local therapy for RCC brain metastasis in the setting of molecular targeted agents and/or checkpoint inhibitor therapy. A retrospective single-center review between 2011-2018 identified patients that developed brain metastasis from RCC. Data analyzed included demographic information, systemic treatments, intracranial interventions, progression free survival and overall survival (OS). Of 1194 patients, 108(9.0%) were diagnosed with brain metastasis from RCC. OS from diagnosis of brain metastasis (OS_BM) was 12.3 months. OS_BM was analyzed based on three treatment groups: systemic therapy (ST) only (2.0 months, n = 23), systemic and radiotherapy (RT + ST) (12.3 months, n = 52), and systemic and radiotherapy plus resection (Surg + RT + ST) (21.7 months, n = 33). Survival benefit was seen with Surg + RT + ST compared to ST (P = 0.001), but not RT + ST (P = 0.081). Progression free survival was significantly prolonged with Surg + RT + ST compared to RT + ST (10.9 vs 5.9 months, respectively, P = 0.04). Variables such as performance status and number of brain metastases at the time of brain metastasis diagnosis did not differ significantly. In the setting of molecular targeted agents and immunotherapy, resection may benefit the appropriate surgical candidate. Prospective clinical trials are necessary to better understand the role of aggressive RCC brain metastasis treatment. Micro Abstract • Renal cell brain metastasis is often excluded from studies and brain metastases effect a large portion of RCC patients. • Retrospective study of 1194 RCC patients, 108 patients had brain metastasis, determination of the role of surgical resection in the setting of recent advances in checkpoint inhibitors. • A benefit was seen in overall survival in patients that had surgical while undergoing radiation therapy and systemic therapies. • In the setting of molecular targeted agents and immunotherapy, resection may benefit the appropriate surgical candidate(s).

Challenges and advances for the treatment of renal cancer patients with brain metastases: From immunological background to upcoming clinical evidence on immune-checkpoint inhibitors

The introduction of checkpoint inhibitors (ICIs) in renal cell carcinoma (RCC) treatment landscape, resulted in improvements in overall survival (OS) in metastatic patients. Brain metastases (BMs) are a specific metastatic site of interest representing a predictive factor of poor prognosis. Patients with BMs were usually excluded from prospective clinical trials in the past. Despite recent evidence suggest the efficacy and safety of ICIs, the BMs treatment remains a challenge; the immunotherapy responsiveness seems to be multifactorial and dependent on several factors, such as the genetic intratumor heterogeneity and the immunosuppressive role of the brain tumor microenvironment. This review, starting from the immunological background in RCC BMs, provide an overview of the upcoming evidence from clinical trials, address the issues related to the neuroradiological immunotherapy response evaluation and, with a look to the future, describes how the epigenetic modulation of immune evasion could represent a background for new therapeutic strategies.

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.

Brain Metastases in Elderly Patients-The Role of Surgery in the Context of Systemic Treatment

In patients with brain metastases (BM), advanced age is considered a negative prognostic factor. To address the potential reasons for that, we assessed 807 patients who had undergone BM resection; 315 patients aged at least 65 years (group A) were compared with 492 younger patients (group B). We analyzed the impact of the pre- and postoperative Karnofsky performance status (KPS), postoperative treatment structure and post-treatment survival. BM resection significantly improved KPS scores in both groups (p = 0.0001). Median survival after BM resection differed significantly between the groups (A: 5.81 vs. B: 8.12 months; p = 0.0015). In both groups, patients who received postoperative systemic treatment showed significantly longer overall survival (p = 0.00001). However, elderly patients less frequently received systemic treatment (p = 0.0001) and the subgroup of elderly patients receiving such therapies had a significantly higher postsurgical KPS score (p = 0.0007). In all patients receiving systemic treatment, age was no longer a negative prognostic factor. Resection of BM improves the functional status of elderly patients, thus enhancing the likeliness to receive systemic treatment, which, in turn, leads to longer overall survival. In the context of such a treatment structure, age alone is no longer a prognostic factor for survival.

Impact of Systemic Therapy in Metastatic Renal-Cell Carcinoma Patients With Synchronous and Metachronous Brain Metastases

BACKGROUND

Modern radiation techniques have led to significant improvements in intracranial disease control and overall survival (OS) for metastatic renal-cell carcinoma (mRCC) patients diagnosed with brain metastases (BM). The impact of systemic therapy in patients developing mRCC BM remains undercharacterized.

PATIENTS AND METHODS

We performed a retrospective cohort study of mRCC patients diagnosed with BM. Patients were grouped as having either metachronous BM (ie, ≥ 3 months from mRCC diagnosis) or synchronous BM (ie, < 3 months from mRCC diagnosis). Details of patient demographics, BM, systemic therapy, and outcomes were extracted. Statistical analysis comprised chi-square tests, analysis of variance, and Kaplan-Meier method to characterize survival outcomes.

RESULTS

Seventy-four patients were identified (40 at ≥ 3 months from mRCC diagnosis and 34 at < 3 months from mRCC diagnosis) of which 72 (97%) received local therapy for their BM. Median (interquartile range [IQR]) duration while first line treatment was longer at 7.8 (3.6-17.0) versus 5.1 (3.3-12.6) in patients with metachronous BM versus patients with synchronous BM (P = 0.6), respectively. After BM diagnosis, the metachronous BM cohort continued to receive the same systemic therapy for a median (IQR) duration of 1.9 (0.4-5.5) months, with eventual change most commonly the result of extracranial disease progression. Median (IQR) OS from mRCC diagnosis favored metachronous BM patients versus synchronous BM patients, at 64.2 (31.4-not yet reached) versus 22.4 (9.7-34.1) months (P = .003), respectively. However, this was not significantly different from the time of BM diagnosis, with median (IQR) survival of 20.6 (9.2-31.2) versus 15.7 (11.6-not yet reached) months (P = .95), respectively.

CONCLUSION

Prolonged OS was found for mRCC patients with BM that presented either metachronously or synchronously. For patients diagnosed with metachronous BM, the development of BM may be an early sign of systemic therapy failure.

Is there a role for stereotactic radiotherapy in the treatment of renal cell carcinoma?

Renal cell carcinoma (RCC) has traditionally been regarded as radioresistant tumor based on preclinical data and negative clinical trials using conventional fractionated radiotherapy. However, there is emerging evidence that radiotherapy delivered in few fractions with high single-fraction and total doses may overcome RCC s radioresistance. Stereotactic radiotherapy (SRT) has been successfully used in the treatment of intra- and extracranial RCC metastases showing high local control rates accompanied by low toxicity. Although surgery is standard of care for non-metastasized RCC, a significant number of patients is medically inoperable or refuse surgery. Alternative local approaches such as radiofrequency ablation or cryoablation are invasive and often restricted to small RCC, so that there is a need for alternative local therapies such as stereotactic body radiotherapy (SBRT). Recently, both retrospective and prospective trials demonstrated that SBRT is an attractive treatment alternative for localized RCC. Here, we present a comprehensive review of the published data regarding SBRT for primary RCC. The radiobiological rationale to use higher radiation doses in few fractions is discussed, and technical aspects enabling the safe delivery of SBRT despite intra- and inter-fraction motion and the proximity to organs at risk are outlined.

Brain Metastasis From Renal-Cell Carcinoma: An Institutional Study

BACKGROUND

Brain metastases (BM) are frequently observed in advanced renal-cell carcinoma (RCC). Historically these individuals have been excluded from clinical trials, but recently, with better local control, many can receive aggressive therapy after treatment. We evaluate our single-institution experience over various treatment eras.

PATIENTS AND METHODS

Patients undergoing evaluation for RCC BM from 2001 to 2018 were identified from our institutional database. Clinical notes, demographics, comorbidities, histology, central nervous system (CNS) treatments, systemic therapy, and outcomes were reviewed. Overall survival (OS) and CNS recurrence-free survival (RFS) were evaluated by the Kaplan-Meier method. Cumulative incidence was evaluated using a competing risk model.

RESULTS

We identified 158 patients with RCC BM, of whom 94.4% had clear-cell RCC, and 90.6% had extracranial metastases at diagnosis. Of these patients, 94 (60%) developed RCC BM over time, while 46 (29.1%) had RCC BM at initial presentation. Clinical symptoms were noted in 81.9% of patients. The median OS after diagnosis of RCC BM was 8.4 months, with a 3-year OS of 28.2%. The median CNS RFS was 8.5 months overall; however, those with one and more than one lesion had median CNS RFS of 12.4 and 6 months, respectively (P < .001).

CONCLUSION

The majority of RCC patients with BM are symptomatic and had prior metastatic disease that progressed to the brain. Those with a solitary RCC BM are less likely to develop CNS recurrence after local therapy and are ideal candidates for enrollment onto clinical trials.

Prognostic factors and survival in Japanese patients with brain metastasis from renal cell cancer

BACKGROUND

Patients with brain metastasis from renal cell carcinoma have poor outcomes despite recent advances in diagnosis and treatment. Moreover, factors affecting such poor outcomes are unclear. This study aimed to evaluate the prognostic factors associated with overall survival in renal cell carcinoma patients with brain metastasis.

METHODS

We retrospectively reviewed the data of 50 consecutive patients with brain metastasis from renal cell carcinoma at our institution between 1988 and 2017. The evaluated prognostic factors for overall survival included clinicopathological factors at diagnosis, treatment for brain metastasis, and the Graded Prognostic Assessment score of renal cell carcinoma. The associations between preoperative clinicopathological factors and overall survival were assessed using the log-rank test and Cox proportional hazards models for univariate and multivariate analyses, respectively.

RESULTS

Forty-five patients were included, among whom 39 died during follow-up. The median follow-up was 8.2 months. The median survival time was 8.2 months (95% confidence interval 5.5-13.7). A Graded Prognostic Assessment score ≤ 2 (hazard ratio 1.967; 95% confidence interval 1.024-3.892; P = 0.042), the presence of sarcomatoid components (hazard ratio 3.299; 95% confidence interval 1.424-7.193; P = 0.007), and no treatment for brain metastasis (hazard ratio 2.594; 95% confidence interval 1.033-5.858; P = 0.043) were independently associated with poor prognosis in the multivariate analysis.

CONCLUSIONS

Patients with renal cell carcinoma who develop brain metastasis have poor overall survival. The Graded Prognostic Assessment score, sarcomatoid components, and treatment for brain metastasis from renal cell carcinoma were independent factors associated with prognosis.

Cabozantinib in Renal Cell Carcinoma With Brain Metastases: Safety and Efficacy in a Real-World Population

BACKGROUND

Cabozantinib showed efficacy and manageable toxicity in patients with metastatic renal cell carcinoma (mRCC). In this study we aimed to describe the safety and to collect evidence on the potential efficacy of cabozantinib in mRCC patients with brain metastases (BM) in a real-world experience.

MATERIALS AND METHODS

We retrospectively collected data of patients treated with cabozantinib within the Italian Managed Access Program. Patients were selected for the presence of BM before the start of treatment and for at least 1 previous tyrosine kinase inhibitor (TKI) treatment regimen for metastatic disease. Safety data were reported, and overall response rate (ORR), brain-specific response, progression-free survival (PFS), and median overall survival (OS) were analyzed.

RESULTS

Overall, 12 patients treated with cabozantinib were evaluated. Any grade adverse events (AEs) accounted for 92%, Grade 3/4 AEs rated at 36% with no major neurological side effects. The most common AEs included hypertension (33%), fatigue (24%), aminotransferase elevation (25%), hypothyroidism (16%), and gastrointestinal toxicity (16%). The ORR was 50% with a disease control rate of 75%. All 5 patients treated with a combined systemic and brain-directed approach obtained intracranial disease control, without increased toxicity. Median PFS and median OS were 5.8 and 8.8 months, respectively. Comparable safety and tolerability results for other TKI regimens were reported from the literature.

CONCLUSION

Cabozantinib showed safety, acceptable tolerability, and promising antitumor activity in a population of mRCC patients with BM from a real-world experience. A combined modality approach for renal cell carcinoma with BM, whenever feasible, could be recommended to improve oncological outcomes.

Precision Medical Approaches to the Diagnoses and Management of Brain Metastases

OPINION STATEMENT

Brain metastases represent a common and devastating complication of cancer with survival on the order of a few months in most patients. Melanoma, breast cancer, and lung cancer remain the primary disease histologies with the highest rates of metastatic spread to the brain. The incidence of brain metastases has continued to rise, likely explained by multiple factors. Improvement in progression-free survival in systemic cancer is likely attributable to advances in medical therapy, earlier supportive and symptomatic care, and improved precision around diagnosis and detection. In this context, longer survival and improved extracranial control disease has likely contributed to the increased development of metastatic spread intracranially. The foundation of management remains systemic therapy, as well as a combination of surgery and radiation therapy. In the era of targeted therapies, specific agents have demonstrated improved CNS penetration, however with varying degrees of durable responses. Most patients develop resistance to targeted agents, limiting their duration of use for patients. In this era of personalized medicine, the role of genomic characterization in cancer has been critical in the field of brain metastases, as alterations unique to both the brain metastases and its systemic predecessor have been identified, potentially offering new avenues for therapy.

Timing of brain metastases development in metastatic renal cell cancer patients treated with targeted therapies and survival outcomes: An Australian multicenter study

AIM

Targeted therapy (TT) has improved survival for metastatic renal cell carcinoma (mRCC). However, survival is usually limited if brain metastases (BMs) develop. We aimed to evaluate survival outcomes in mRCC patients based on timing of BM diagnosis.

METHODS

We conducted a multicenter, retrospective study of mRCC patients with BM who received TT at any point between 2005 and 2014. We determined overall survival (OS) from stage IV diagnosis, TT initiation and BM diagnosis, and prognostic factors. Patients were grouped into three categories: synchronous-BM, metachronous-BM diagnosed while conservatively managed (metachronous-BM before TT) and metachronous-BM diagnosed during TT. Survival was calculated by Kaplan-Meier method and predictors were calculated using Cox hazards regression.

RESULTS

Incidence of BM was 17% in mRCC patients treated with TT (two centers). Fifty-four mRCC-BM patients were identified from five tertiary centers. Twenty-eight percentage (15/54) had synchronous-BM, 28% (15/54) had metachranous-BM before TT and 44% (24/54) had metachronous-BM during TT. Most had central nervous system (CNS) symptoms at BM diagnosis (78%; 42/54). Median OS from stage IV diagnosis, TT commencement and BM diagnosis was 28 months (95% confidence interval [CI] 16-43), 19 months (95% CI 9-26) and 9 months (95% CI 5-16), respectively. Synchronous-BM group trended toward poorer survival from TT commencement (P = 0.06). Metachronous-BM during TT group had lower survival from BM diagnosis than synchronous-BM and metachronous-BM before TT group (P < 0.001). Eight of 50 deaths (16%) were from neurological complications. The presence of CNS symptoms did not predict worse survival from stage IV diagnosis (P = 0.73).

CONCLUSION

In patients with mRCC, the development of BM while on TT portends shorter prognosis compared with synchronous diagnosis of BM at stage IV disease or metachronous BM developed prior to commencing TT. The presence of CNS symptoms does not predict worse survival.

Renal cell carcinoma and brain metastasis: Questioning the dogma of role for cytoreductive nephrectomy

INTRODUCTION

Renal cell carcinoma (RCC) brain metastasis is generally viewed as poor prognostic features and often excludes patients from cytoreductive nephrectomy or participation in clinical trials. We aim to evaluate patients presenting with brain metastasis and their outcomes.

METHODS

Surveillance Epidemiology and End Results-18 registries database was queried for all patients with metastatic RCC from 2010 to 2014. Patients with renal cancer as their only malignancy were included. Information was available for metastatic disease to bone, liver, lung, and brain. Patients were then further stratified into those with isolated brain metastases and those with additional metastasis to other sites as well. Overall survival was compared between groups using logrank analysis.

RESULTS

A total of 6,667 patients were identified with metastatic RCC. Among them, 775 (12.1%) had brain metastasis at time of diagnosis. Of these patients with brain metastasis, 152 (20.4%) had isolated brain metastasis. Only 23.8% of all patients with brain metastasis underwent cytoreductive nephrectomy, compared to 40.8% of patients with isolated brain metastasis. Patients with brain and other metastasis and brain metastasis only treated by cytoreductive nephrectomy exhibited a median survival of 11 and 33 months, respectively. Those patients who did not undergo cytoreductive nephrectomy experienced a median survival of 4 and 5 months, respectively.

CONCLUSION

It appears that selected patients with brain metastasis may experience durable long-term survival. This information may be beneficial for patient counseling, surgical planning, and consideration for inclusion in clinical trials.

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.

Stereotactic Radiosurgery for Multiple Brain Metastases From Renal-Cell Carcinoma

BACKGROUND

Brain metastases (BM) pose a significant problem in patients with metastatic renal-cell carcinoma (mRCC). Local and systemic therapies including stereotactic radiosurgery (SRS) are rapidly evolving, necessitating reassessments of outcomes for modern patient management.

PATIENTS AND METHODS

The mRCC patients with BM treated with SRS were reviewed. Patient demographics, clinical history, and SRS treatment parameters were identified.

RESULTS

Among 268 patients with mRCC treated between 2006 and 2015, 38 patients were identified with BM. A total of 243 BM were treated with SRS with 1 to 26 BMs treated per SRS session (median, 2 BMs). The median (range) BM size was 0.6 (0.2-3.1) cm and median (range) SRS treatment dose was 18 (12-24) Gy. Treated BM local control rates at 1 and 2 years were 91.8% (95% confidence interval, 85.7-95.4) and 86.1% (95% confidence interval, 77.1-91.7), respectively. BM control declined for larger tumors. Survival after 1-year was 57.5% (95% CI 40.2-71.4) for all patients. Survival was not statistically different between patients with < 5 BM versus ≥ 5 BM. Survival was prognostic based on International Metastatic Renal Cell Carcinoma Database (IMDC) risk groups in patients with < 5 BM. Two patients experienced grade 3 radiation necrosis requiring surgical intervention.

CONCLUSION

SRS is effective in controlling BM in patients with mRCC. Over half of treated patients survive past a year, and no differences in survival were noted in patients with > 5 metastases. Prognostic risk categories based on systemic disease (IMDC) are predictive of survival in this BM population, with limited rates of symptomatic radiation necrosis.

Update on the biology and management of renal cell carcinoma

Renal cell cancer (RCC) (epithelial carcinoma of the kidney) represents 2%-4% of newly diagnosed adult tumors. Over the past 2 decades, RCC has been better characterized clinically and molecularly. It is a heterogeneous disease, with multiple subtypes, each with characteristic histology, genetics, molecular profiles, and biologic behavior. Tremendous heterogeneity has been identified with many distinct subtypes characterized. There are clinical questions to be addressed at every stage of this disease, and new targets being identified for therapeutic development. The unique characteristics of the clinical presentations of RCC have led to both questions and opportunities for improvement in management. Advances in targeted drug development and understanding of immunologic control of RCC are leading to a number of new clinical trials and regimens for advanced disease, with the goal of achieving long-term disease-free survival, as has been achieved in a proportion of such patients historically. RCC management is a promising area of ongoing clinical investigation.

Prognostic Factors for Survival of Patients With Synchronous or Metachronous Brain Metastasis of Renal Cell Carcinoma

INTRODUCTION

We evaluated the oncological outcomes of synchronous or metachronous brain metastasis (BM) of metastatic renal cell carcinoma (RCC) according to clinicopathologic factors.

PATIENTS AND METHODS

Patients with metastatic RCC (n = 93) with synchronous and metachronous BM were retrospectively identified. We analyzed patients and tumor characteristics, treatment methods, prognostic factors, BM progression, and overall survival (OS).

RESULTS

Seventy-six patients (81.7%) received local therapy (stereotactic radiosurgery [60.2%], radiation therapy [22.6%], and neurosurgery [10.8%]), and 54 patients (58.1%) were treated with systemic medical therapy. In multivariable analysis, poor Memorial Sloan-Kettering Cancer Center (MSKCC) risk (hazard ratio [HR] 3.672; 95% confidence interval [CI], 1.441-9.36; P = .0064), sarcomatoid component (HR 4.264; 95% CI, 2.062-8.820; P = .0001), and multiple BMs (HR 2.838; 95% CI, 1.690-4.767; P = .0001) were prognostic indicators of a poorer OS outcome. Local (HR 0.436; 95% CI, 0.237-0.802; P = .0076) and systemic treatment (HR 0.322; 95% CI, 0.190-0.548; P < .0001) were independent factors for a better OS. Although OS from initial RCC diagnosis in patients with metachronous BM was better than that for patients with synchronous BM, there were no differences found between synchronous and metachronous patients in terms of BM progression and OS after the diagnosis of BM.

CONCLUSIONS

Poor MSKCC risk, sarcomatoid component of histology, and multiple BMs are prognostic indicators for poor OS in patients with BM from metastatic RCC. Systemic and/or local treatment improves the OS. Because the type of BM, synchronous or metachronous, does not influence BM progression or the OS outcome, routine evaluation for BM is not recommended.

[Is surgical treatment ever indicated in metastatic renal cell carcinoma and if so, based on which scientific rationale?]

BACKGROUND

Metastasis is a common event in renal cell carcinoma. Surgical resection of metastases may be feasible in two scenarios: aiming at palliation, which may be feasible due to reduced radiosensitivity of renal cell cancer, and aiming at prolonging survival, which may be feasible given the rather good prognosis of some patterns of metastasis.

OBJECTIVE

This review intends to reflect on current evidence for surgical resection of metastases in both scenarios. The literature was searched in PubMed and respective guidelines were reviewed.

RESULTS AND CONCLUSIONS

Palliative resection is mainly feasible to control symptoms like spinal compression; adjuvant radiation is advisable. Resection is markedly feasible, however, for improvement of cancer-specific survival in probably all resectable patterns of metastasis-solitary, multiple, syn- and metachronous, and in all organs-provided complete resection can be achieved. A fairly good prognosis is seen in solitary pulmonary metastasis without concomitant hilar or mediastinal lymph node metastasis and a metachronous appearance following long recurrence-free survival after tumor nephrectomy; complete resection may be considered curative in certain cases. Neo- or adjuvant medical therapy or radiation is not established. In cases lacking complete resectability, stereotactic radiation may be considered as an alternative.