Prognosis of Incidental Brain Metastases in Patients With Advanced Renal Cell Carcinoma

Background: Metastatic renal cell carcinoma (mRCC) management guidelines recommend brain imaging if clinically indicated and the rate of occult central nervous system (CNS) metastasis is not well-defined. Early detection could have major therapeutic implications, because timely interventions may limit morbidity and mortality. Patients and Methods: A retrospective review was performed to characterize patients with mRCC incidentally diagnosed with asymptomatic brain metastases during screening for clinical trial participation at Gustave Roussy and Memorial Sloan Kettering Cancer Center. Descriptive statistics and time-to-event methods were used to evaluate the cohort. Results: Across 68 clinical trials conducted between 2001 and 2019 with a median 14.1-month follow-up, 72 of 1,689 patients (4.3%) with mRCC harbored occult brain metastases. The International Metastatic RCC Database Consortium (IMDC) risk status was favorable (26%), intermediate (61%), and poor (13%), and 86% of patients had ≥2 extracranial sites of disease, including lung metastases in 92% of patients. CNS involvement was multifocal in 38.5% of patients, and the largest brain metastasis was >1 cm in diameter in 40% of the cohort. Localized brain-directed therapy was pursued in 93% of patients, predominantly radiotherapy. Median overall survival was 10.3 months (range, 7.0–17.9 months), and the 1-year overall survival probability was 48% (95% CI, 37%–62%). IMDC risk and number or size of lesions did not correlate with survival (log-rank, P=.3, P=.25, and P=.067, respectively). Conclusions: This large multi-institutional mRCC cohort study identified occult brain metastasis in a notable proportion of patients (4.3%) and highlights that the risk of asymptomatic CNS involvement extends to those with favorable risk features per IMDC risk assessment. These data provide rationale for brain screening in patients with advanced RCC.

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Outcomes and prognostic factors in metastatic renal cell carcinoma patients with brain metastases.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.6_suppl.289 ◽

2021 ◽

Vol 39 (6_suppl) ◽

pp. 289-289

Author(s):

İzzet Dogan ◽

Ayca Iribas ◽

Nail Paksoy ◽

Meltem Ekenel ◽

Sezai Vatansever ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Prognostic Factors ◽

Brain Metastasis ◽

Brain Metastases ◽

Cell Carcinoma ◽

Renal Cell ◽

De Novo ◽

Brain Radiotherapy ◽

Metastatic Sites

289 Background: The study aimed to evaluate the outcomes and prognostic factors in patients with brain metastatic renal cell carcinoma (bmRCC). Methods: The data of 322 patients with renal cell carcinoma, between 2012 and 2020, were retrospectively reviewed. The clinicopathological features and treatments of the patients with bmRCC were recorded. Overall survival (OS) and prognostic factors were evaluated with Kaplan-Meier analysis and Cox-regression analysis. Results: Forty (12.4%) of the patients had bmRCC. The median follow-up period was 7.3 months (range, 0.2-55.5). The male/female ratio was 2.3, and the median age at diagnosis was 62 years (range, 25-84). Seventeen (42.5%) of the patients were de-novo metastatic, and nine (22.5%) of the patients had brain metastases at presentation. The most common extracranial metastatic sites of the disease were lung (72.5%), bone (47.5%), lymph node (27.5%), and liver (12.5%). Twenty-four (60%) patients previously had received various therapies (tyrosine kinase inhibitor, checkpoint inhibitors, or palliative radiotherapy). After brain metastases developed, 92% of the patients received brain radiotherapy (whole-brain radiotherapy or stereotactic radiosurgery), and twenty-five (62.5%) patients received different therapies. Nine patient received sunitinib, nine patient pazopanib, five patient nivolumab, and two patient axitinib. A total of 32 (80%) patients died during the study period. The median OS was 8.8 months (range, 2.9-14.6) for all patients with bmRCC. Six months- and one-years overall survival ratios were 60% and 40%, respectively. In univariate analysis, the number of brain metastasis (p = 0.352), the localization of brain metastasis (p = 0.790), the longest size of brain metastasis (p = 0.454), the number of extracranial metastatic sites (p = 0.812), de-novo metastatic disease (p = 0.177), primary tumor localization (left or right) (p = 0.903), and tumor grade (p = 0.093) were not statistically significant factors on OS. However, age (p = 0.02), a history of nephrectomy (p < 0.001), receiving brain radiotherapy (p = 0.005), and type of treatment (p = 0.044) was statistically significant. Only, the effect of brain radiotherapy on OS (p = 0.011) was confirmed in multivariate analysis. Conclusions: The prognostic data of patients with bmRCC is limited. In this study, we observed that the prognosis of patients with bmRCC was poor. Despite a small number of patients, we detected that the effect of tyrosine kinase inhibitors and nivolumab was comparable, and receiving brain radiotherapy was a prognostic factor for OS.

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Cytoreductive Nephrectomy and Overall Survival of Patients with Metastatic Renal Cell Carcinoma Treated with Targeted Therapy—Data from the National Renis Registry

Cancers ◽

10.3390/cancers12102911 ◽

2020 ◽

Vol 12 (10) ◽

pp. 2911

Author(s):

Alexandr Poprach ◽

Milos Holanek ◽

Renata Chloupkova ◽

Radek Lakomy ◽

Michal Stanik ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Cell Carcinoma ◽

Metastatic Renal Cell Carcinoma ◽

Renal Cell ◽

Locally Advanced ◽

Treatment Algorithm ◽

Progression Free Survival ◽

Cancer Center ◽

Cytoreductive Nephrectomy

The role of cytoreductive nephrectomy (CN) in treatment of locally advanced or metastatic renal cell carcinoma (mRCC) in the era of targeted therapies (TT) is still not clearly defined. The study population consisted of 730 patients with synchronous mRCC. The RenIS (Renal carcinoma Information System) registry was used as the data source. The CN/TT cohort included patients having CN within 3 months from the mRCC diagnosis and subsequently being treated with TT, while the TT cohort included patients receiving TT upfront. Median progression-free survival from the first intervention was 6.7 months in the TT arm and 9.3 months in the CN/TT patients (p < 0.001). Median overall survival was 14.2 and 27.2 months, respectively (p < 0.001). Liver metastasis, high-grade tumor, absence of CN, non-clear cell histology, and MSKCC (Memorial Sloan-Kettering Cancer Center) poor prognosis status were associated with adverse treatment outcomes. According to the results of this retrospective study, patients who underwent CN and subsequently were treated with TT had better outcomes compared to patients treated with upfront TT. The results of the study support the use of CN in the treatment algorithm for mRCC.

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Gamma Knife surgery in the management of radioresistant brain metastases in high-risk patients with melanoma, renal cell carcinoma, and sarcoma

Journal of Neurosurgery ◽

10.3171/jns/2008/109/12/s19 ◽

2008 ◽

Vol 109 (Supplement) ◽

pp. 122-128 ◽

Cited By ~ 35

Author(s):

John W. Powell ◽

Chung T. Chung ◽

Hemangini R. Shah ◽

Gregory W. Canute ◽

Charles J. Hodge ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Brain Metastases ◽

Cell Carcinoma ◽

Gamma Knife ◽

Treatment Option ◽

Renal Cell ◽

Gamma Knife Surgery ◽

Tumor Control ◽

Local Progression

Object The purpose of this study was to examine the results of using Gamma Knife surgery (GKS) for brain metastases from classically radioresistant malignancies. Methods The authors retrospectively reviewed the records of 76 patients with melanoma (50 patients), renal cell carcinoma (RCC; 23 patients), or sarcoma (3 patients) who underwent GKS between August 1998 and July 2007. Overall patient survival, intracranial progression, and local progression of individual lesions were analyzed. Results The median age of the patients was 57 years (range 18–85 years) and median Karnofsky Performance Scale (KPS) score was 80 (range 20–100). Sixty-two patients (81.6%) had uncontrolled extracranial disease. A total of 303 intracranial lesions (average 3.97 per patient, range 1–27 lesions) were treated using GKS. More than 3 lesions were treated in 30 patients (39.5%). Median GKS tumor margin dose was 18 Gy (range 8–30 Gy). Thirty-seven patients (48.7%) underwent whole brain radiation therapy. The actuarial 12-month rate for freedom from local progression for individual lesions was 77.7% and was significantly higher for RCC compared with melanoma (93.6 vs 63.0%; p = 0.001). The percentage of coverage of the prescribed dose to target volume was the only treatment–related variable associated with local control: 12-month actuarial rate of freedom from local progression was 71.4% for lesions receiving ≥ 90% coverage versus 0.0% for lesions receiving < 90% (p = 0.00048). Median overall survival was 5.1 months after GKS and 8.4 months after the discovery of brain metastases. Univariate analysis revealed that KPS score (p = 0.000004), recursive partitioning analysis class (p = 0.00043), and single metastases (p = 0.028), but not more than 3 metastases, to be prognostic factors of overall survival. The KPS score remained significant after multivariate analysis. Overall survival for patients with a KPS score ≥ 70 was 7.1 months compared with 1.3 months for a KPS score ≤ 60 (p = 0.013). Conclusions Gamma Knife surgery is an effective treatment option for patients with radioresistant brain metastases. In this setting, KPS score appeared to be a more important factor in predicting survival than having > 3 metastases. Higher rates of local tumor control were achieved for RCC in comparison with melanoma, and this may have an effect on survival in some patients. Although outcomes generally remained poor in this study population, these results suggest that GKS can be considered as a treatment option for many patients with radioresistant brain metastases, even if these patients have multiple lesions.

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Retrospective review of clear cell and non-clear cell renal carcinomas: Characteristics and course in the pre-TKI (tyrosine kinase inhibitor) and post-TKI era.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.e16052 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. e16052-e16052 ◽

Cited By ~ 1

Author(s):

Kanika Gupta ◽

Amanda Nizam ◽

Kristen Millado ◽

Jiaqi Liu ◽

Hiwot Guebre-Xabiher ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Cell Carcinoma ◽

Metastatic Disease ◽

Renal Cell ◽

Kinase Inhibitor ◽

Clear Cell ◽

Locally Advanced ◽

Local Treatment ◽

Cancer Center

e16052 Background: Renal cell carcinoma (RCC) confers a lifetime risk of 1.6% of developing cancers. Early, localized cancers have high cure rates after surgical treatment, but locally advanced/distant metastatic disease remains a devastating disease. The use of TKIs has been considered a mainstay of treatment for clear cell pathology, but other histologic subtypes such as papillary, chromophobe, and mixed subtypes, which is considered non-clear cell RCC, also make up a heterogeneous pattern and course of disease. This retrospective study characterizes renal cell carcinomas and their treatments. Methods: A retrospective chart review of the last 15 years was performed using data from a single-institution center at the George Washington University Cancer Center Tumor Registry Data. Statistical analysis was performed using the Fisher’s test, Chi-squared test, T-test, and Kaplan-Meier survival curves. Results: 1043 patients with RCC were identified. Preliminary data analysis was performed on 92 of these patients. 48 had pure clear cell renal cell carcinoma (CCRCC) and 44 had non-clear cell carcinoma (NCC). Mean age of diagnosis was similar for both groups (58.25 years for CCRCC vs 62.14 years for NCC, p = 0.0977). However, hemoglobin levels at diagnosis were statistically significantly lower for CCRCC (p = 0.0261), as were calcium levels (p = 0.0187). All patients underwent surgical or local treatment. Only 2 patients received chemotherapy and 5 patients received molecularly targeted therapy. While not statistically significant, patients with CCRCC had surgery sooner after diagnosis than NCC (71 days vs 92 days), had longer time to metastatic disease (1033 days vs 820 days), and improved overall survival (1955 days vs 1446 days). Conclusions: NCC was a less favorable pathology than CCRCC with apparent later institution of surgical intervention as well as shorter time to metastatic disease and worse overall survival. Identifying patients with more aggressive disease earlier allows for the potential role for more aggressive therapies that may result in improved outcomes.

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The impact of metastasis location on overall survival among patients with renal cell carcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.6_suppl.621 ◽

2020 ◽

Vol 38 (6_suppl) ◽

pp. 621-621

Author(s):

Devin Patel ◽

Fady Ghali ◽

Margaret Meagher ◽

Aaron Bradshaw ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Bone Metastases ◽

Cell Carcinoma ◽

Metastatic Disease ◽

Renal Cell ◽

Lung Metastases ◽

Univariate Analysis ◽

The Impact ◽

Disease Location

621 Background: Current staging guidelines define all patients with metastatic renal cell carcinoma (RCC) as a singular group. We sought to compare the impact of metastatic disease location on overall survival (OS) in patients with RCC. Methods: We queried our institutional database of consecutive patients with metastatic RCC. A confirmatory analysis was performed using the National Cancer Database (NCDB) for cases between 2010 to 2015. Only cases from which all metastatic disease location was known were used. Patients were grouped into having brain or bone metastases, liver or lung metastases or other metastases. From our institutional database, we performed a univariate analysis to determine the impact of metastasis location on OS. From the NCDB, univariable and multivariable Cox proportional hazards and Kaplan-Meier survival analysis with log-rank testing was performed. Multivariable models were adjusted for age, comorbidity, race, gender, and treatment with either palliative care, chemotherapy or immunotherapy. Results: A total of 95 patients were analyzed from our institutional database, with 30 (31.9%) having brain/bone metastases, 20 (21.3%) having lung/liver metastases, and 44 (46.8%) having other site metastases. On univariate analysis, patients with brain/bone metastases had significantly worse OS (HR 1.87; 95% CI 1.01-3.47). However, no significant difference was seen in patients with liver/lung metastases (HR 1.44; 95% CI 0.64-3.27). A total of 25,528 patients met inclusion for our NCDB analysis, of which 12,119 (47.5%) had brain/bone metastases, 10,004 (39.2%) had liver/lung metastases, and 3,405 (13.3%) had other site metastases. On univariate analysis, patients with lung/liver (HR 1.46; 95% CI 1.38-1.53) and patients with bone/brain (HR 1.69; 95% CI 1.60-1.77) had progressively worse OS with non-overlapping confidence intervals. Multivariable analysis again showed that patients with lung/liver disease (HR 1.51; 95% CI 1.43-1.59) and brain/bone disease (HR 1.66; 95% CI 1.60-1.75) had progressively worse OS. Conclusions: Our results highlight the heterogeneity of patients with metastatic renal cell carcinoma. Location of metastatic disease may drive differences in survival.

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The effect of targeted agents on outcomes in patients with brain metastases from renal cell carcinoma treated with Gamma Knife surgery

Journal of Neurosurgery ◽

10.3171/2012.2.jns111353 ◽

2012 ◽

Vol 116 (5) ◽

pp. 978-983 ◽

Cited By ~ 53

Author(s):

D. Clay Cochran ◽

Michael D. Chan ◽

Mebea Aklilu ◽

James F. Lovato ◽

Natalie K. Alphonse ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Brain Metastases ◽

Cell Carcinoma ◽

Gamma Knife ◽

Local Control ◽

Renal Cell ◽

Local Failure ◽

Targeted Agents ◽

Distant Failure

Object Gamma Knife surgery (GKS) has been reported as an effective modality for treating brain metastases from renal cell carcinoma (RCC). The authors aimed to determine if targeted agents such as tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, and bevacizumab affect the patterns of failure of RCC after GKS. Methods Between 1999 and 2010, 61 patients with brain metastases from RCC were treated with GKS. A median dose of 20 Gy (range 13–24 Gy) was prescribed to the margin of each metastasis. Kaplan-Meier analysis was used to determine local control, distant failure, and overall survival rates. Cox proportional hazard regression was performed to determine the association between disease-related factors and survival. Results Overall survival at 1, 2, and 3 years was 38%, 17%, and 9%, respectively. Freedom from local failure at 1, 2, and 3 years was 74%, 61%, and 40%, respectively. The distant failure rate at 1, 2, and 3 years was 51%, 79%, and 89%, respectively. Twenty-seven percent of patients died of neurological disease. The median survival for patients receiving targeted agents (n = 24) was 16.6 months compared with 7.2 months (n = 37) for those not receiving targeted therapy (p = 0.04). Freedom from local failure at 1 year was 93% versus 60% for patients receiving and those not receiving targeted agents, respectively (p = 0.01). Multivariate analysis showed that the use of targeted agents (hazard ratio 3.02, p = 0.003) was the only factor that predicted for improved survival. Two patients experienced post-GKS hemorrhage within the treated volume. Conclusions Targeted agents appear to improve local control and overall survival in patients treated with GKS for metastastic RCC.

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Impact of precise quantitative assessment of visceral obesity on outcomes of patients with metastatic renal cell carcinoma treated with systemic therapy.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.2_suppl.597 ◽

2016 ◽

Vol 34 (2_suppl) ◽

pp. 597-597

Author(s):

Ryuichi Mizuno ◽

Akira Miyajima ◽

Nozomi Hayakawa ◽

Eiji Kikuchi ◽

Shuji Mikami ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Cell Carcinoma ◽

Metastatic Renal Cell Carcinoma ◽

Systemic Therapy ◽

Visceral Fat ◽

Renal Cell ◽

Visceral Obesity ◽

Cancer Center ◽

Visceral Fat Area

597 Background: With its excellent resolution of adipose tissue, CT presents precise quantitative assessment of visceral obesity. We assessed the impact of visceral obesity on progression free and overall survival in patients treated with systemic therapy for metastatic renal cell carcinoma. Methods: This retrospective cohort study included 114 patients treated with systemic therapy for metastatic renal cell carcinoma between 2007 and 2015 at Keio university hospital in Japan. The visceral fat area was measured at the level of umbilicus using CT. A visceral fat area ≥100cm2 was used as the definition of visceral obesity. Progression free and overall survival was compared according to visceral obesity. Results: In the whole cohort, the median progression free survival in first line treatment was 12.0 month. The median overall survival was 42.5 month. According to Memorial Sloan-Kettering Cancer Center classification, 31 patients were favorable risk, 61 were intermediate risk, and 22 were poor risk; median overall survival for these groups were 76.9, 40.8, and 23.7 months, respectively (P<0.0001). Visceral obesity correlated with improved progression free (P=0.0095) and overall survival (P=0.0002). On multivariate analysis, visceral obesity (HR 0.64, P=0.0393) and Memorial Sloan-Kettering Cancer Center classification (P=0.0037) were independent indices to predict progression free survival in first line treatment. In addition, visceral obesity (HR 0.42, P=0.0016) and Memorial Sloan-Kettering Cancer Center classification (P=0.0006) independently predicted overall survival. Conclusions: The precision of CT imaging for measuring visceral fat tissue provides useful clinical venue to predict prognosis for metastatic renal cell carcinoma. Visceral obesity may be a useful and independent indicator for a better prognosis in patients treated with systemic therapy for metastatic renal cell carcinoma.

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Overall survival with or without brain metastases from diagnosis of metastatic renal cell carcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e16112 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e16112-e16112

Author(s):

I. Alex Bowman ◽

Alana Christie ◽

Tri Cao Le ◽

Alisha Bent ◽

James Brugarolas

Keyword(s):

Risk Factors ◽

Renal Cell Carcinoma ◽

Overall Survival ◽

Brain Metastases ◽

Cell Carcinoma ◽

Surgical Resection ◽

Systemic Therapy ◽

Renal Cell ◽

Local Therapy ◽

Metastatic Rcc

e16112 Background: Brain metastases (BM) in metastatic renal cell carcinoma (mRCC) have historically been associated with a poor prognosis. We have previously reported improved outcomes for RCC patients diagnosed with brain metastases prior to or during 1st line systemic therapy among patients treated with modern systemic and local therapies. Here we report outcomes in all mRCC patients regardless of the timing of BM diagnosis. Methods: A retrospective database of mRCC patients treated at our institution between 2006 and 2015 was compiled and patients with BM identified. Overall survival (OS) was analyzed by the Kaplan-Meier method from the diagnosis of metastatic RCC, according to BM status and by IMDC risk group. Results: 271 patients with mRCC were identified, including 79 (29.2 %) diagnosed with BM. Clear-cell histology was more common among BM (94.2 v 81.0%, p = 0.01), otherwise patient characteristics were similar. BM were diagnosed prior to systemic therapy (44.3%), or after one or more lines of therapy (one 26.6%, two 13.9%, three 5.1%, four 6.3%, five 3.8%). Among BM patients, 54 (68.4%) received local therapy with stereotactic radiosurgery (SRS) and/or surgical resection, 14 (17.7%) received WBRT alone, and 11 (13.9%) had no CNS-directed treatment. Local therapy consisted of SRS in 43 (54.4%) and surgical resection in 18 (22.8%), with some patients receiving both. Medial OS from metastatic diagnosis for those with BM was not significantly different from those without BM (26.4 v 28.7 mo, p = 0.305). This remained true when analyzed according to IMDC risk factors (see table). Conclusions: OS from the diagnosis of metastatic RCC did not significantly differ with or without BM in a cohort treated with modern systemic and CNS-directed therapies regardless of the timing of BM diagnosis or presence of IMDC risk factors. [Table: see text]

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The impact of the metastasis region on patients with metastatic renal cell cancer in the intermediate-risk group.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e17091 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e17091-e17091

Author(s):

Cengiz Karacin ◽

Fatma Bugdaycı Basal ◽

Irem Bilgetekin ◽

Omur Berna Oksuzoglu

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Lymph Node ◽

Brain Metastasis ◽

Cell Carcinoma ◽

Metastatic Renal Cell Carcinoma ◽

Renal Cell ◽

Risk Group ◽

Intermediate Risk ◽

The Impact

e17091 Background: The majority of patients with metastatic renal cell carcinoma (mRCC) are in the intermediate-risk group, according to International Metastatic Renal Cell Carcinoma Database Consortium (IMDC). Some patients in the intermediate-risk group have similar overall survival (OS) with those in the good-risk group, while others with those in the poor-risk group. In our study, we aimed to evaluate the prognostic significance of the region of the metastasis and to classify the intermediate-risk group into two as favorable or unfavorable according to the metastasis region. Methods: We retrospectively analyzed the clinical data of patients with mRCC those in the intermediate-risk group seen at our Oncology Training and Research Hospital from 2010 to 2018. Patients who received at least one line of tyrosine kinase inhibitor (TKI) were included in the study. Overall survival was calculated. The log-rank test was used to check the statistical significance for OS. Results: Of 113 patients, median age 58 (range 34-78) years, 99 (88%) had more than one site of metastasis: 61 (54%) lung, 41 (36%) bone, 21 (18%) lymph node, and 19 (17%) brain metastasis. Nine patients received one, 86 patients received two, and 18 patients received three lines of systemic therapy. Median follow up was 14 (range 4 – 54) months. Median OS for patients with bone and/or brain metastasis was 10 (95% CI = 6.1 – 13.9) months compared to 16 (95% CI = 10.1 – 22.2) months for patients with lung and/or lymph node metastasis (HR = 1.675, p-value = 0.012). Conclusions: Our data suggest that the bone and/or brain metastasis in the intermediate-risk group mRCC patients treated with TKI are unfavorable prognostic factors.

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Stereotactic Radiosurgery for Patients with “Radioresistant” Brain Metastases

Neurosurgery ◽

10.1227/00006123-200209000-00009 ◽

2002 ◽

Vol 51 (3) ◽

pp. 656-667 ◽

Cited By ~ 5

Author(s):

Paul D. Brown ◽

Cerise A. Brown ◽

Bruce E. Pollock ◽

Deborah A. Gorman ◽

Robert L. Foote

Keyword(s):

Renal Cell Carcinoma ◽

Overall Survival ◽

Brain Metastases ◽

Cell Carcinoma ◽

Survival Time ◽

Stereotactic Radiosurgery ◽

Median Survival ◽

Local Control ◽

Renal Cell ◽

Class I

Abstract OBJECTIVE Our aim was to evaluate the efficacy of stereotactic radiosurgery (SRS) for the treatment of patients with brain metastases that have been determined to be “radioresistant” on the basis of histological examination. METHODS We reviewed the medical records of 41 consecutive patients who presented with 83 brain metastases from radioresistant primaries and subsequently underwent SRS. All patients were followed until death or for a median of 31 months after SRS. Tumor histologies included renal cell carcinoma (16 patients), melanoma (23 patients), and sarcoma (2 patients). Eighteen patients (44%) had a solitary metastasis, and 23 patients (56%) had multiple metastases. RESULTS The median overall survival time was 14.2 months after SRS. On the basis of univariate analysis, systemic disease status (P = 0.006) and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (P = 0.005) were associated with survival. The median survival time was 23.5 months for patients in RPA Class I status and 10.5 months for patients in RPA Class II or III status. There was a trend (P = 0.12) toward improved median survival for patients with renal cell carcinoma (17.8 mo) as compared with patients with melanoma (9.7 mo). Multivariate analysis showed RPA class (P = 0.038) and histological diagnosis of primary tumor (P < 0.001) to be independent predictors for overall survival. In the 35 patients who underwent follow-up imaging, 9 (12%) of 73 tumors recurred locally. In 54% of the patients, distant brain failure (DBF) developed. Whole brain radiotherapy (WBRT) improved local control and decreased DBF, according to the univariate and multivariate analyses. Patients who received adjuvant WBRT in addition to SRS had 6-month actuarial local control of 100% as compared with 85% among those who did not receive WBRT (P = 0.018). Patients who received adjuvant WBRT with SRS had a 6-month actuarial DBF rate of 17%, as compared with a rate of 64% among patients who had SRS alone (P = 0.0027). CONCLUSION Well-selected patients with brain metastases from radioresistant primary tumors who undergo SRS survive longer than historical controls. RPA Class I status and primary renal cell carcinoma predict longer survival. Adjuvant WBRT improves local control and decreases DBF but does not affect overall survival. Further studies are needed to determine which patients should receive WBRT.

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