I have a 52 year old male patient who presented with transient dysarthria and numbness at the right side of the face. The patient was transferred to the emergency room where an MRI of his head showed two lesions; one in the left parietal lobe, and the other is located in the right cerebellar hemisphere. The size of the lesions is around 1.5 cm in maximum diameter each. Both lesions were highly suggestive of metastasis. The neurological symptoms resolved completely within few hours of his presentation. A CT scan of chest and abdomen showed renal mass arising from the upper pole of the right kidney and invading the peri-nephric fat, with possible invasion of psoas muscle, and an enlarged subcarinal LN (around 3 cm in maximum dimension). CT guided biopsy from the kidney mass was performed at our center and confirmed the diagnosis of sarcomatoid renal cell carcinoma (not sarcoma arising in the kidney. It is the sarcomatoid subtype of RCC).
Bronchoscopy and EBUS biopsy from the subcarinal LN was carried out and showed negative LN. Additionally, an MRI for the abdominal wall was not suggestive of psoas muscle invasion by the tumor as it showed clear separation of the psoas muscle and the tumor, and as such, the kidney mass is resectable according to the opinion of the urologist at our center. The patient has history of coronary artery disease, had previous catheterization and coronary stent two years ago, he is also a known case of hypertension. His hypertension and coronary artery disease are well controlled with medications, his left ventricular ejection fraction is ok, and he is now asymptomatic and has a peformance status of 0.
What is the best therapeutic option for this patient ?
Surgery if you can. Next generation sequencing to look for a target if you have unresectable disease.
The primary kidney tumor is resectable. Unfortunately, the cerebellar metastatic lesion is unresectable. We treated the patient with stereotactic radiotherapy directed to the left parietal lobe and right cerebellar lesions, and we will proceed with radical nephrectomy in the next week. We may also consider whole brain radiotherapy after we already treated the patient with stereotactic radiotherapy to the brain lesions.
If this patient had systemic unresectable progression in the future following nephrectomy, and there was no progression in his brain metastasis, on what basis do you consider treatment with chemotherapy versus treatment with MTOR (Temsirolimus), or VEGF-TKI inhibitor (sunitinib or other agents), I would like to listen to your opinion and would appreciate any evidence that you provide favoring one option over the others. Through my limited experience in metastatic sarcomatoid RCC, I had never seen any responding patient, I tried sunitinib, and combination of doxorubicin and ifosfamide for other patients, and the outcomes are very poor regardless of what I used.
Surgery for the primary is advisable, plus in case of progression consider chemotherapy as a first line using gemcitibine
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