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Published in Renal Cell Carcinoma

Expert Opinion / Cases · October 23, 2014

Managing Brain Mets in a mRCC Patient—Next Steps?

Written by
Manjari Pandey MD


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  • Sylvia  Richey MD

    Oct 24, 2014

    Yes, since he had more than 4 brain mets and has recurrent disease in the brain this is definitely reasonable given that he has multiple brain metastases. Although it is considered a radiation-resistant disease, we know that addition of WBRT to stereotactic radio surgery (SRS) was associated with less intracranial relapses although there was no improvement in overall survival. For oligometastatic disease, that is 4 or less brain mets, an observation strategy may be used initially to avoid WBRT.

  • Manjari  Pandey MD

    Oct 24, 2014

    Thanks Dr. Richey! What systemic therapy options are available for this patient?

  • Sylvia  Richey MD

    Oct 28, 2014

    He has progressed on Sunitinib but still has a great performance status and favorable risk per the MSKCC prognostic score. In this setting it would be reasonable to consider second line treatment with Sorafenib, everolimus, or axitinib. There isn’t much data for the use of Pazopanib after a prior TKI. And the agents listed especially sorafenib would be a superior choice compared to Temsirolimus (INTORSECT trial). However with the history of intracranial hemorrhage (ICH) one should be cautious in the choice of agents as they have been associated with hemorrhage, including ICH , sorafenib> axitinib. However, this is not an issue with everolimus that had bleeding associated but mainly in the form of vaginal bleed, or intra-alveolar Hge. Again the experience with everolimus in this setting is very limited.

  • Moussa Sissoko

    Oct 30, 2014

    I would rather use mTOR inhibitors in this setting i.e. everolimus since he has progressed on Sunitinib.

  • maed osili

    Dec 10, 2014

    I would start by RT consultation , stereotactic radiotherapy could be done if he has less than 5 lesions, otherwise WBRT and then start a 2ed ligne TKI, axitinib could be a good choice"

  • Salah Elmesidy

    Dec 30, 2014

    Whole brain irradiation is highly recommended for this gentleman

  • Mark Stevens

    Dec 30, 2014

    I would definitely recommend WBRT with hippocampal sparing if the metastases met distance criteria from the hippos PRVs - in a patient with uncontrolled extracranial disease, but otherwise favourable GPA prognostic class, treatment goals should focus on both acute and potential late neurotoxicity.

  • Jul 04, 2022

    Pending Moderator approval.

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