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ABSTRACT & COMMENTARY
Synopsis: Metastatic renal cell carcinoma can have a variable clinical course with some patients living for long periods of time despite the presence of metastatic disease. It is not uncommon for patients with indolent disease to develop one or more metastatic brain lesions. Surgical removal, especially of single lesions, has been reported to prolong survival in patients with renal cell carcinoma. The experience with management of multiple brain metastases is less well described. In this study, Amendola and colleagues report the results of gamma knife radiosurgery in 22 renal cell carcinoma patients with an average of six metastatic brain tumors. Almost all patients achieved control of the metastatic brain lesions and died of systemic disease. Gamma knife radio surgery or stereotactic radiation should be considered in patients with indolent renal cell carcinoma, even in the presence of multiple CNS metastases.
Source: Amendola BE, et al. Cancer J 2000;6:372-376.
Amendola and colleagues report their experience giving 38 radiosurgery treatments in patients with metastatic renal cell carcinoma to the brain from November 1993 to March 1999. Patients ranged from 38-80 years of age with a median age of 60 years. Previous whole brain radiation had been used in 11 of 22 patients. Four patients had single metastasis and 18 had multiple lesions. The number of lesions that were treated ranged from 1-21 sites with an average of six sites per patient. An average of 3.5 sites were treated per treatment. All patients with newly diagnosed or recurrent brain metastasis from renal cell carcinoma were included in the study regardless of the status of the primary tumor or extra-cranial disease. All but two patients had Karnofsky performance statuses of 70% or more. Only two patients did not have evidence of extra-cranial metastasis. Survival was reported from the date of radio surgery to the date of death. The overall survival for the entire group was 56% at six months and 19% at 24 months. Local control was achieved in 20 of 22 patients with one patient developing radiation necrosis; thus three of the 22 patients (14%) experienced a CNS-related death. The remainder of the patients died from non-neurologic causes. One patient remains alive 63 months after the first radio surgical procedure. One patient with 20 metastatic sites in the brain lived 22 months and died of non-neurologic causes.
COMMENT BY MICHAEL J. HAWKINS, MD
Management of patients with isolated CNS metastasis from renal cell carcinoma is generally straightforward, especially if the patient has indolent systemic disease and is an excellent candidate for surgery or stereotactic radiation.1,2 Management of patients with multiple CNS metastases is less straightforward. Even though renal cell carcinoma is generally considered a radio-resistant tumor, responses to stereotactic or gamma knife radiosurgery clearly occur and effective palliation can be achieved. This study confirms the reports of others, demonstrating the use of radio surgery in selected patients with renal cell carcinoma. The mean tumor volume in the patients treated in this study was 3.9 cc but ranged from 0.1-75.5 cc.
The management of this complication in patients with renal cell carcinoma is even more complex because of the need for corticosteroids to manage the vasogenic edema that typically surrounds these lesions. Corticosteroids have been shown to abrogate the anti-tumor activity of Interluken-2 in animal models and are generally contraindicated in patients with renal cell carcinoma who are receiving Interluken-2. For patients with a good performance status and an isolated brain metastasis that is easily resected, surgery can often control their disease with minimal use of corticosteroids. Radiosurgery frequently may require prolonged steroid usage due to edema that is generated following the treatment. Thus, the relative risks of surgery vs. delaying systemic therapy due to a continuing need for steroids need to be balanced when determining the best overall approach to these patients. However, stereotactic radiosurgery should strongly be considered for patients with multiple CNS metastases and relatively indolent systemic disease.
1. Wronski M, et al. Urology 1996;47:187-193.
2. Payne PR, et al. J Neurosurg 2000;92:760-765.