In patients with good performance status, metastatic clear cell kidney cancer, and minimal metastatic disease, would you consider nephrectomy or partial nephrectomy if there are mets to brain?

Debulking nephrectomy has a clear role in the management of metastatic RCC, based on prospective trials showing an OS benefit. Patient selection, however, is critical for optimal benefit and minimizing risk. Brain metastases often portend a more aggressive systemic disease, and such patients often do not undergo cytoreductive nephrectomy. However, given the emergence of radiosurgery as a very effective, low morbidity option for local control of CNS metastases, I think cytoreductive surgery can be considered in select patients with limited CNS mets who undergo surgical resection or more likely radiosurgery, assuming good performance status, control of CNS disease and a resectable primary tumor.