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20-30% of localized RCCs will relapse after primary therapy and the majority of relapses occur in the first 1-2 years. Therefore, with his history of papillary RCC that will be the first diagnostic consideration.
He needs full staging work up, including CT of Chest, Abdomen and Pelvis (CT CAP).
We would also get labs including LDH, serum calcium levels. Also liver function studies and urinalysis.
In the absence of symptoms a bone scan is probably not indicated, especially if alkaline phosphate comes back as normal.
Depending on the results of the CT CAP, he will need a biopsy for confirmation. If his cerebral metastasis is the only site, surgical resection would be recommended over a biopsy.
His work up is incomplete and it is premature to make any treatment decisions. But for sake of discussion, we know that papillary cancers constitute only 10-15% of all renal cancers and the data regarding management is limited. Ideally he should be enrolled in a trial. Otherwise the MSKCC prognostic factor model can be applied to see if he can get temsirolimus ( poor prognosis) or other therapy, such as everolimus (RAPTOR trial),the studies for these agents had small number of patients with papillary histology. Or sunitinib and sorafenib based on phase II data.
Temsirolimus has been associated with an increased risk of intracrebral hemorrhage in patients with CNS metastases, this may preclude the use of this agent for your patient, irrespective of risk stratification.