Early identification of asymptomatic brain metastases from renal cell carcinoma

Abstract

Current guidelines for metastatic renal cell carcinoma (mRCC) do not recommend routine brain imaging as part of the surveillance protocol unless central nervous system (CNS) symptoms or abnormal laboratory values suggest brain involvement. We hypothesized that strict adherence to these guidelines will delay diagnosis and management of RCC brain metastases. Retrospective review of our IRB-approved kidney cancer database examined a consecutive series of subjects from 1995 to 2012. We identified all mRCC patients with radiographic evidence of renal cell brain metastasis (RCCBM). RCCBM patients were divided into two cohorts: CNS symptoms present at RCCBM diagnosis and those without symptoms present at diagnosis. Fifty-two patients within our database met criteria; CNS symptoms were present at RCCBM diagnosis in 73 % (36) of patients. Median size of RCCBM on presentation was smaller in the asymptomatic verses the symptomatic cohort (0.83 vs. 1.7 cm, p = 0.003). Multivariate analysis demonstrated presence of CNS symptoms and female gender as a survival advantage (p < 0.05) while poor performance status, history of tobacco abuse and coexistence of lung metastasis were poor indicators for survival (p < 0.05). Patients with pulmonary metastases and a history of tobacco abuse are more likely to harbor RCCBM and perhaps in the absence of CNS symptoms these subjects should have routine brain surveillance incorporated into the RCC follow up. Overall, the current urologic guidelines may be missing a subset of metastatic RCC patients who could potentially benefit from early radiation or neurosurgical intervention. This may result in improved overall survival.

Clinical utility of head computed tomography scan during systemic therapy for metastatic renal cell carcinoma

“…Hence, they advocated that early asymptomatic BM diagnosis and early radiation or neurosurgical intervention might improve OS. 13 On the contrary, Choi et al did not recommend routine evaluation for BM, because their study did not show OS difference between synchronous and metachronous BM. 10 In the present study, earlier detection of BM did not improve the survival or rate of unrecovered neurological symptoms.…”

Brain metastases assessment by FDG-PET/CT: can it eliminate the necessity for dedicated brain imaging?

“…It was reported that 50% of advanced melanoma patients developed BM and 10% of metastatic lesions presented as an intraparenchymal hemorrhage [26]. With respect to renal cell carcinoma, it was estimated that BM occurred in 2-16% of patients and that when BM emerged late in illness, renal cell carcinoma was refractory to other therapies [27]. BM is an unusual event for patients with aggressive lymphoma [28,29].…”

Arteriovenous malformation and thyroid metastasis from underlying renal cell carcinoma, an unusual presentation of malignancy: A case report

“…Current guidelines pertaining to metastatic RCC do not recommend routine brain imaging for surveillance purposes unless there are concurrent CNS symptoms or other abnormalities indicating brain involvement (19). Patients with a history of tobacco abuse and pulmonary metastases are more likely to have metastasis to the brain; therefore, this may serve as an indication for surveillance imaging of the brain (19).…”

“…Patients with a history of tobacco abuse and pulmonary metastases are more likely to have metastasis to the brain; therefore, this may serve as an indication for surveillance imaging of the brain (19). With increasing understanding of the role of angiogenic dysregulation in the pathogenesis of RCC, novel therapeutic strategies are utilizing targeted anti-angiogenic agents with varying degrees of success (20).…”