Retrospective Study of Metastatic Melanoma and Renal Cell Carcinoma to the Brain with Multivariate Analysis of Prognostic Pre-Treatment Clinical Factors

A Retrospective Study of Metastatic Renal Cell Carcinoma Patients With Brain Metastases

Metastatic renal cell carcinoma (mRCC) involving the central nervous system is currently an excluded subgroup of patients in the systemic treatment; for this reason, there is no solid data to support the efficacy of therapies in this subgroup. That is why it is important to describe real-life experiences in order to know if there is a special change in clinical behavior or treatment response in these kinds of patients. Patients and methods A retrospective review was performed to characterize mRCC patients diagnosed with brain metastases (BrM) during treatment at the National Institute of Cancerology of Bogota, Colombia. Descriptive statistics and time-to-event methods are used to evaluate the cohort. For the descriptive measures of quantitative variables, the mean with standard deviation was taken, and the minimum and maximum values were reported. In the case of qualitative variables, absolute and relative frequencies were used. The software used was R - Project v4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Results A total of 16 patients were included with mRCC between January 2017 to August 2022 with a median 35.1-month follow-up, 4/16 (25%) were diagnosed with BrM at the time of screening and 12/16 (75%) during treatment. The International Metastatic RCC Database Consortium risk (IMDC) was favorable for 12.5%, intermediate for 43.7%, and poor for 25%, and not classified for 18.8%, BrM involvement was multifocal in 50% of the population and localized, brain-directed therapy was done in 43.7% of patients, predominantly palliative radiotherapy. Median overall survival (OS) for all the patients regardless of the time of metastatic presentation of the disease in the central nervous system was 53.5 months (0-70.3), and OS for cases with central nervous system involvement was 10.9 months. IMDC risk did not correlate with survival (log-rank, p=0.67). The OS for the subgroup of patients who debut with metastatic disease in the central nervous system is different from the group that developed metastasis in the progression of their disease (OS of 42 vs 3.6 months, respectively). Conclusions This is the largest descriptive study in Latin America and the second in the world from one institution that admits patients with metastasic renal cell carcinoma and central nervous system metastasis. In these kinds of patients with metastatic disease or progression to the central nervous system, there is a hypothesis that shows more aggressive clinical behavior. There is limited data on locoregional intervention to metastatic disease in the nervous system drastically, but trends show this could impact overall survival outcomes.

Systematic literature review and meta-analysis of clinical outcomes and prognostic factors for melanoma brain metastases

Background

More than 60% of all stage IV melanoma patients develop brain metastases, while melanoma brain metastases (MBM) is historically difficult to treat with poor prognosis.

Objectives

To summarize clinical outcomes and prognostic factors in MBM patients.

Methods

A systematic review with meta-analysis was conducted, and a literature search for relevant studies was performed on November 1, 2020. Weighted average of median overall survival (OS) was calculated by treatments. The random-effects model in conducting meta-analyses was applied.

Results

A total of 41 observational studies and 12 clinical trials with our clinical outcomes of interest, and 31 observational studies addressing prognostic factors were selected. The most common treatments for MBM were immunotherapy (IO), MAP kinase inhibitor (MAPKi), stereotactic radiosurgery (SRS), SRS+MAPKi, and SRS+IO, with median OS from treatment start of 7.2, 8.6, 7.3, 7.3, and 14.1 months, respectively. Improved OS was observed for IO and SRS with the addition of IO and/or MAPKi, compared to no IO and SRS alone, respectively. Several prognostic factors were found to be significantly associated with OS in MBM.

Conclusion

This study summarizes pertinent information regarding clinical outcomes and the association between patient characteristics and MBM prognosis.

Cerebral metastases

Brain metastases are common and deadly. Over the last 25 years GKNS has been established as an invaluable treatment. It may be used as a primary treatment or after either surgery or WBRT. Patients are assessed using one of a number of available scales. GKNS may be repeated for new metastases and for unresponsive tumors. Prescription doses are usually between 18 and 20Gy. The use of advanced MR techniques to highlight sensitive structures like the hippocampi have extended the efficacy of the treatment. More recently GKNS has been used with different target therapies with improved results. More recently frameless treatments have become more popular in this group of very sick patients. GKNS controls tumors in between 80% and over 95% of cases and may even be used for brainstem tumors.

Prognosis of Incidental Brain Metastases in Patients With Advanced Renal Cell Carcinoma

BACKGROUND

Metastatic renal cell carcinoma (mRCC) management guidelines recommend brain imaging if clinically indicated and the rate of occult central nervous system (CNS) metastasis is not well-defined. Early detection could have major therapeutic implications, because timely interventions may limit morbidity and mortality.

PATIENTS AND METHODS

A retrospective review was performed to characterize patients with mRCC incidentally diagnosed with asymptomatic brain metastases during screening for clinical trial participation at Gustave Roussy and Memorial Sloan Kettering Cancer Center. Descriptive statistics and time-to-event methods were used to evaluate the cohort.

RESULTS

Across 68 clinical trials conducted between 2001 and 2019 with a median 14.1-month follow-up, 72 of 1,689 patients (4.3%) with mRCC harbored occult brain metastases. The International Metastatic RCC Database Consortium (IMDC) risk status was favorable (26%), intermediate (61%), and poor (13%), and 86% of patients had ≥2 extracranial sites of disease, including lung metastases in 92% of patients. CNS involvement was multifocal in 38.5% of patients, and the largest brain metastasis was >1 cm in diameter in 40% of the cohort. Localized brain-directed therapy was pursued in 93% of patients, predominantly radiotherapy. Median overall survival was 10.3 months (range, 7.0-17.9 months), and the 1-year overall survival probability was 48% (95% CI, 37%-62%). IMDC risk and number or size of lesions did not correlate with survival (log-rank, P=.3, P=.25, and P=.067, respectively).

CONCLUSIONS

This large multi-institutional mRCC cohort study identified occult brain metastasis in a notable proportion of patients (4.3%) and highlights that the risk of asymptomatic CNS involvement extends to those with favorable risk features per IMDC risk assessment. These data provide rationale for brain screening in patients with advanced RCC.

Operative and peri-operative considerations in the management of brain metastasis

The number of patients who develop metastatic brain lesions is increasing as the diagnosis and treatment of systemic cancers continues to improve, resulting in longer patient survival. The role of surgery in the management of brain metastasis (BM), particularly multiple and recurrent metastases, remains controversial and continues to evolve. However, with appropriate patient selection, outcomes after surgery are typically favorable. In addition, surgery is the only means to obtain a tissue diagnosis and is the only effective treatment modality to quickly relieve neurological complications or life-threatening symptoms related to significant mass effect, CSF obstruction, and peritumoral edema. As such, a thorough understanding of the role of surgery in patients with metastatic brain lesions, as well as the factors associated with surgical outcomes, is essential for the effective management of this unique and growing patient population.

Metastatic spread of cutaneous melanoma to the sigmoid colon: a rare but important consideration

BACKGROUND

Cutaneous melanoma is known for its aggressive tendency for metastasis, most commonly to lymph nodes, lung, liver, and brain.

CASE REPORT

We present the case of an 80-year-old male, with a history of cutaneous melanoma, found to have biopsy-proven metastatic melanoma deposits in the sigmoid colon. This rare case was initially thought to be a walled-off perforation secondary to diverticulitis. Although, computed tomography, showed features more strongly suggestive of malignancy. We propose early consideration of bowel metastasis in patients with a history of cutaneous melanoma presenting with lower gastrointestinal symptoms.

CONCLUSION

Once malignancy is included in the differential for any inflammatory type bowel lesion, arranging endoscopy and biopsy is essential to confirm the diagnosis and guide management. Multidisciplinary team discussion is recommended to determine the most appropriate treatment strategy - radical versus palliative, which must always consider the patient's performance status alongside cancer staging. HIPPOKRATIA 2017, 21(4): 194-196.

Safety-net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow-up care and outcomes

BACKGROUND

Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but it requires adherence to frequently scheduled follow-up neuroimaging because of the risk of distant brain metastasis. The effect of disparities in access to follow-up care on outcomes after SRS alone is unknown.

METHODS

This retrospective study included 153 brain metastasis patients treated consecutively with SRS alone from 2010 through 2016 at an academic medical center and a safety-net hospital (SNH) located in Los Angeles, California. Outcomes included neurologic symptoms, hospitalization, steroid use and dependency, salvage SRS, salvage whole-brain radiotherapy, salvage neurosurgery, and overall survival.

RESULTS

Ninety-three of the 153 patients were private hospital (PH) patients, and 60 were SNH patients. The median follow-up time was 7.7 months. SNH patients received fewer follow-up neuroimaging studies (1.5 vs 3; P = .008). In a multivariate analysis, the SNH setting was a significant risk factor for salvage neurosurgery (hazard ratio [HR], 13.65; P < .001), neurologic symptoms (HR, 3.74; P = .002), and hospitalization due to brain metastases (HR, 6.25; P < .001). More clinical visits were protective against hospitalizations due to brain metastases (HR, 0.75; P = .002), whereas more neuroimaging studies were protective against death (HR, 0.65; P < .001).

CONCLUSIONS

SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with PH patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases. Cancer 2018;124:167-75. © 2017 American Cancer Society.

Tumor cerebri: Metastatic renal cell carcinoma with dural venous sinus compression leading to intracranial hypertension; a case report

BACKGROUND

Pseudotumor cerebri (PTC), also known as idiopathic intracranial hypertension (IIH), is a condition associated with increased intracranial pressure (ICP) in the absence of radiographic findings such as mass lesions or cerebral edema.

CASE DESCRIPTION

We describe a case of progressive headache and visual disturbances attributed to PTC that resulted from subacute superior sagittal sinus (SSS) stenosis by a metastatic tumor.

CONCLUSIONS

Venous outflow obstruction often presents with an acute symptomatology including infarcts, hemorrhages, and seizures, but only rarely does it cause the progressive development of raised ICP. The sinister presentation of our patient's pathology stemmed from local mass effect caused by a tumor that has hitherto not been reported to cause intracranial hypertension (IH) and was best elucidated using magnetic resonance venography (MRV).

Improving the Prognostic Value of Disease-Specific Graded Prognostic Assessment Model for Renal Cell Carcinoma by Incorporation of Cumulative Intracranial Tumor Volume

BACKGROUND

We tested the prognostic value of cumulative intracranial tumor volume (CITV) in the context of a disease-specific Graded Prognostic Assessment (ds-GPA) model for renal cell carcinoma (RCC) patients with brain metastasis (BM) treated with stereotactic radiosurgery (SRS).

METHODS

Patient and tumor characteristics were collected from RCC cohorts with new BM who underwent SRS. Univariable and multivariable logistic regression model was used to test the prognostic value of CITV, Karnofsky Performance Score (KPS), and the number of BM. Net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to assess whether CITV improved the prognostic utility of RCC ds-GPA.

RESULTS

In univariable logistic regression models, CITV, KPS, and the number of BM were independently associated with RCC patient survival. In a multivariable Cox proportional hazard model, the association between CITV and survival remained robust after controlling for KPS and the number of BM (P = 0.042). The incorporation of the CITV into the RCC ds-GPA model (consisting of KPS and number of BM) improved prognostic accuracy with NRI >0 of 0.3156 (95% confidence interval [CI], 0.0883-0.5428; P = 0.0065) and IDI of 0.0151 (95% CI, 0.0036-0.0277; P = 0.0183). These findings were validated in an independent cohort of 107 SRS-treated RCC BM patients.

CONCLUSION

CITV is an important prognostic variable in SRS-treated RCC patients with BM. The prognostic value of the ds-GPA scale for RCC brain metastasis was enhanced by the incorporation of CITV.