Managing Brain Mets in a mRCC Patient—Next Steps?

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.

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

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.