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It would be unusual for prostate cancer to metastasize to the brain. We have biopsy proven metastatic ccRCC to axillary LN. Given his extensive smoking history, I would push for bronchoscopy with biopsy again for tissue diagnosis vs CT guided biopsy of lung mass. Brain lesion would need XRT one way or the other. Would use pathology from the lung (lung primary vs RCC met) to dictate which systemic therapy to use as lung cancer, if present, could be more immediately life threatening than his RCC.
Very interesting and challenging case, obviously it is unlikely to be prostate cancer, Biopsy of the axillary and brain mass showed clear cell feature of unknown origin, CK7-, CK20-,CD10+ which is likely renal cell of unknown primary which has been reported and addressed before. RCC IHC is negative and adding PAX-8 and Vimentin staining should be considered for further confirmation of the diagnosis and if it RCC TKI would be an option. John D. Hainsworth and his colleagues reported as an ASCO abstract in 2013 that Renal cell carcinoma (RCC) can be presented as cancer of unknown primary (CUP), diagnosed by molecular tumor profiling (MTP) using (RT-PCR 92-gene assay, CancerTYPE ID, bioTheranostics, Inc.). Molecular changed for RCC has been reported like nicotinamide N-methyltransferase (NNMT), L-plastin (LCP1) and nonmetastatic cells 1 protein (NM23A). RCC is a subset of CUP which can be diagnosed by MTP. RCC is usually not suspected in the absence of clear cell features, and occult RCC appears to commonly be the papillary subtype. RCC IHC may be diagnostic in some CUP tumors, but may be omitted in the initial pathologic evaluation. CUP-RCC pts are important to identify as they may benefit from standard RCC targeted therapies, and respond poorly to empiric chemotherapy.
Thank you for your input on this case. Something like a CancerTYPE ID would be helpful here. For this patient, given that he has two cancers that have both been studied using Nivolumab as treatment, we proceeded with starting him on this mainly because we know that Squamous Cell Carcinoma will respond to Nivolumab from the Checkmate 017 trial vs docetaxel, but also RCC has shown promise in phase II trials with good response at 2 and 3 years. In this case, the pathology showed that both tumors (Lung and Axilla) were positive for PD-1.
Pending Moderator approval.
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