A report published by Kotecha et al in JNCCN–Journal of the National Comprehensive Cancer Network suggests that baseline brain imaging should be considered in most patients with metastatic renal cell carcinoma (RCC). Researchers found incidental brain metastases occur in a clinically significant percentage of patients with newly diagnosed advanced disease.
A research team studied 1,689 patients with metastatic RCC who had been considered for clinical trial participation at two institutions between 2001 and 2019 and had undergone brain imaging in this context without clinical suspicion for brain involvement. The researchers discovered 4% of patients had asymptomatic brain metastases in this setting. This group was found to have a low median 1-year overall survival rate (48%), and median overall survival (10.3 months).
“With 4% overall incidence in this cohort, one might conclude that baseline brain imaging should be considered in all patients with metastatic kidney cancer, particularly those with multiorgan involvement and/or pulmonary metastases” said lead researcher Ritesh R. Kotecha, MD, of Memorial Sloan Kettering Cancer Center, who also worked with investigators from Gustave Roussy.
“Brain imaging is routinely obtained for patients with kidney cancer and symptoms that suggest central nervous system (CNS) metastases, but none of the patients with brain metastases included here were symptomatic,” added senior researcher Martin H. Voss, MD, also of Memorial Sloan Kettering Cancer Center. “In current practice, the chest, abdomen, and pelvis are routinely imaged from the time that metastatic disease is first detected, yet many oncologists do not image the brain.”
The researchers found 86% of the patients with asymptomatic brain metastases harbored metastatic disease in two or more additional organ systems—most commonly, the lung, followed by liver and bone.
Commentary
The findings in this study are important for two reasons. First, they show that the overall prognosis of patients with brain metastases is consistently worse than the broader population of patients with metastatic RCC...Second, they underscore the utility for magnetic resonance imaging of all patients with metastatic RCC both at initial diagnosis and at regular intervals to detect occult brain metastases, since specific treatment strategies are required for this patient population.— Eric Jonasch, MD
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“The retrospective study by Kotecha et al demonstrates that incidental brain metastases occur in a clinically significant percentage of patients with newly diagnosed metastatic RCC,” commented Eric Jonasch, MD, Professor of Genitourinary Medical Oncology at The University of Texas MD Anderson Cancer Center, who was not involved in this research.
Dr. Jonasch, who is Vice Chair of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Kidney Cancer, continued, “The findings in this study are important for two reasons. First, they show that the overall prognosis of patients with brain metastases is consistently worse than the broader population of patients with metastatic RCC. We need to develop a deeper scientific understanding of why this patient population has a worse outcome, and we need to include them in future clinical trials. Second, they underscore the utility for magnetic resonance imaging of all patients with metastatic RCC both at initial diagnosis and at regular intervals to detect occult brain metastases, since specific treatment strategies are required for this patient population.”
The researchers acknowledged that their data cannot provide input as to how frequently brain surveillance should be repeated and called for additional study.
Disclosure: For full disclosures of the study authors, visit jnccn.org.
