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Renal Cell Carcinoma
Center of Excellence
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George Yaghmour
Jul 27, 2015
Did the patient have any further staging studies to look for other location of her recurrent cancer? And if so it is diffuse or solitary? Any recurrence in the right kidney?
Assuming the CT staging is negative and patient has only one brain mets, her cancer recurred in one year in her brain, which might demonstrate higher risk and more aggressive microenviroment and molecular pathology, and would be interesting to run molecular assay on the recurrent cancer tissue, which will also help directing further therapy.
Taking in consideration that RCC is relatively radio-resistant. Here, would consider higher dose of SRS at 20 Gy for local treatment of brain metastasis prior to systemic treatment. D Radeset al, Impact of Stereotactic Radiosurgery Dose on Control of Cerebral Metastases From Renal Cell Carcinoma.
For adjuvant further treatment, DA Bastos et al, in his retrospective study demonstrated more favorable survival in clear cell histology, favorable risk status according to the Memorial Sloan Kettering stratification, and solitary brain metastasis. The treatment of brain metastasis with local and targeted therapy may help optimize survival.
There is limited date for adjutant therapy after SRS. It was addressed in retrospective studies, with no randomized, prospective data. However, in specific situation with good prognostic features, a survival improvement has been reported.
For this patient given the age and co-morbidities would consider close monitoring, and discuss with her the adjuvant target therapy and risk of toxicity, but are still an option if progressed.
Effective therapy that crosses the blood brain barrier is required VEGFR, Everolimus which has been shown to have the ability to cross the BBB (O’Reilly T et al Cancer Chemother Pharmacol. 2010;65:625-639; Fox JH et al. Mol Neurodegener. 2010;5:26; Zhao H et al. Breast Ca Res Treat. 2012;131:425-436; Kwon CH et al. Proc Natl Acad Sci U S A. 2003;100:12923-12928). An alternative strategy is immunotherapy.
Andrew Fintel
Jul 28, 2015
Bone Scan and CT of the Chest. Abdomen, and Pelvis were found to be negative for other metastases
George Yaghmour
Jul 29, 2015
CT staging is negative and patient has only one brain mets, with other co-morbidities and her age.I would suggest SRS, taking in consideration that RCC is relatively radio-resistant. Here, would consider higher dose of SRS at 20 Gy for local treatment of brain metastasis prior to systemic treatment. D Radeset al, Impact of Stereotactic Radiosurgery Dose on Control of Cerebral Metastases From Renal Cell Carcinoma.
For adjuvant further treatment, DA Bastos et al, in his retrospective study demonstrated more favorable survival in clear cell histology, favorable risk status according to the Memorial Sloan Kettering stratification, and solitary brain metastasis. The treatment of brain metastasis with local and targeted therapy may help optimize survival. However, here would consider observation after SRS as there is limited data for adjutant therapy after SRS.
Andrew Fintel
Sep 14, 2015
I appreciate the input on this interesting case. We did look into treating with GammaKnife, but there was concern about ventricular involvment and risk of CSF contamination/seeding. For this reason we went ahead and started Palliative Whole Brain radiotherapy, 30Gy in 10 fractions. She has only showed up for her radiation thus far and has not followed with the medical oncologist, but likely we will start systemic therapy given that her disease has not been definitively treated.
George Yaghmour
Sep 14, 2015
Thanks for the update. Sounds a reasonable plan to consider systemic therapy. Which one are you considering starting ?
Apr 20, 2024
Pending Moderator approval.
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Andrew
Fintel
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George Yaghmour
Jul 27, 2015
Andrew Fintel
Jul 28, 2015
George Yaghmour
Jul 29, 2015
Andrew Fintel
Sep 14, 2015
George Yaghmour
Sep 14, 2015
Apr 20, 2024
Pending Moderator approval.