Renal Cancer Management

Evaluation

Robson Staging System  

The Robson staging system is designed to correlate stage at presentation with prognosis and is as follows:

Stage I - Tumor is confined within the capsule of the kidney
Stage II - Tumor invades the perinephric fat but is still contained within the Gerota’s fascia
Stage III -Tumor invades the renal vein or inferior vena cava, regional lymph node involvement, or both
Stage IV -Tumor invades the adjacent viscera (excluding ipsilateral adrenal) or distant metastases  

TNM Classification  

The TNM classification is based on the 2017 American Joint Committee on Cancer (AJCC) TNM staging system for kidney cancer and is as follows:

Primary Tumor (T)

• TX Primary tumor cannot be assessed
• T0 No evidence of primary tumor
• T1 The tumor size is ≤7 cm and is limited to the kidney
  • T1a The tumor size is ≤4 cm and is limited to the kidney
  • T1b The tumor size is >4 cm but ≤7 cm and is limited to the kidney
• T2 The tumor size is >7 cm and is limited to the kidney
  • T2a The tumor size is >7 cm but ≤10 cm and is limited to the kidney
  • T2b The tumor size is >10 cm and is limited to the kidney
• T3 Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia
  • T3a Tumor extends into the renal vein or its segmental (muscle containing) branches, or the tumor invades the pelvicalyceal system, or invades perirenal and/or renal sinus fat (peri-pelvic) but not beyond the Gerota’s fascia
  • T3b Tumor extends into the vena cava below the diaphragm
  • T3c Tumor extends into the vena cava above the diaphragm or invades the wall of the vena cava
• T4 Tumor invades beyond the Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)

Regional Lymph Nodes (N)

• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Tumor has metastasized in the regional lymph node

Distant Metastasis (M)

• M0 Clinically no distant metastasis
• M1 Clinically distant metastasis

Clinical Staging  

The clinical staging is based on the 2017 AJCC anatomic stage and prognostic groups and is as follows:

Renal Cancer_Management

• Clear cell RCC (ccRCC) – the most common RCC (70%)
• Multilocular cystic renal neoplasm of low malignant potential

Papillary Renal Tumors

• Papillary RCC
• Papillary adenoma

Oncocytic and Chromophobe Renal Tumors

• Oncocytoma of the kidney
• Chromophobe RCC
• Other oncocytic tumors of the kidney

Collecting Duct Tumors

• Collecting duct carcinoma

Other Renal Tumors

• Acquired cystic disease-associated RCC
• Clear cell papillary renal cell tumor
• Eosinophilic solid and cystic (ESC) RCC
• Mucinous tubular and spindle cell carcinoma
• Tubulocystic RCC
• RCC not otherwise specified (NOS)

Molecularly Defined Renal Tumors

• ALK-rearranged RCCs
• ELOC-mutated RCC
• Fumarate hydratase-deficient RCC
• SMARCB1-deficient renal medullary carcinoma
• Succinate dehydrogenase-deficient RCC
• TFE-rearranged RCCs
• TFEB-altered RCC (TFEB-rearranged RCC and TFEB-amplified RCC)

Metanephric Tumors

• Metanephric adenoma
• Metanephric adenofibroma
• Metanephric stromal tumor

Mixed Epithelial and Stromal Tumor Family

• Mixed epithelial and stromal tumor
• Adult cystic nephroma

Adult Renal Mesenchymal Tumors

• Classic angiomyolipoma/PEComa of the kidney
• Epitheloid angiomyolipoma/epitheloid PEComa of the kidney
• Renal hemangioblastoma
• Juxtaglomerular cell tumor
• Renomedullary interstitial cell tumor

Pediatric Renal Mesenchymal Tumors

• Ossifying renal tumor of infancy
• Congenital mesoblastic nephroma
• Rhabdoid tumor of the kidney
• Clear cell sarcoma of kidney

Embryonal Neoplasms of the Kidney

• Nephroblastic tumors
  • Nephrogenic rests
  • Pediatric cystic nephroma
  • Cystic partially differentiated nephroblastoma
  • Nephroblastoma

Miscellaneous Tumors

• Germ cell tumors of the kidney

Principles of Therapy

The management of renal cancer depends upon the disease's TNM classification, histologic subtype, and prognosis.  

The goals of treatment are to reduce mortality and remission, and to prevent complications.

Pharmacological therapy

Adjuvant Therapy  

A combination with Pembrolizumab should be considered in patients with stage II RCC with grade 4 or sarcomatoid features and clear cell histology, patients with stage III ccRCC after discussion with the patient of the potential benefits and risks or for treatment of stage IV ccRCC after metastasectomy with complete resection of disease within a year of nephrectomy.  

Sunitinib may be used for patients with stage III ccRCC with a high risk for relapse. Adjuvant Pembrolizumab may be considered in intermediate- to high-risk operable ccRCC patients, with treatment initiated within 12 weeks post-op and to continue for up to 1 year.  

Cancer Immunotherapy/Immunomodulating Agents  

Aldesleukin or Interleukin-2 (IL-2)  

Aldesleukin is a modified form of interleukin-2 produced by recombinant DNA technology. It promotes proliferation, differentiation and recruitment of T and B cells, natural killer (NK) cells and thrombocytes.  High-dose IL-2 is recommended as subsequent therapy under useful in certain circumstances for highly selected patients with relapsed or medically unresectable stage IV predominantly ccRCC with excellent performance status and normal organ function regardless of prior immuno-oncologic (IO) therapy status.  

Interferon-α (IFN-α)  

Interferon-α possesses antiviral, antiproliferative and immunomodulatory effects, and promotes cellular differentiation, regulation of cell surface major histocompatibility antigen expression and cytokine induction. Its use in ccRCC has been largely replaced with targeted therapeutic agents and checkpoint inhibitors.

Systemic Therapy  

Systemic therapy is recommended for patients with recurrence after cytoreductive nephrectomy for patients with multiple metastatic sites, or for patients with surgically unresectable tumors. This is recommended for patients with large-volume distant metastases or large sarcomatoid tumors.  

Axitinib  

Axitinib is a second-generation, potent tyrosine kinase inhibitor that selectively targets vascular endothelial growth factors (VEGF) 1, 2 and 3 and inhibits angiogenesis, metastasis and tumor growth. This is used as a first-line treatment option for patients with relapsed or medically unresectable predominantly clear cell and non-clear cell stage IV RCC for use under certain circumstances, as a subsequent therapy option after failure of prior IO therapy and useful in certain circumstances for IO therapy naive patients. It is used as a treatment option under useful in certain circumstances for patients with relapse or stage IV non-clear cell RCC.  

Axitinib + Avelumab  

Avelumab is a human IgG1 lambda monoclonal antibody that binds to the programmed death ligand-1 (PD-L1) found on T-cells and blocks the interaction of PD-L1 with PD-1 and B7.1 receptors on the tumor cell. This is an alternative option for first-line therapy of patients with relapsed or medically unresectable predominantly clear cell stage IV RCC. This is used as a subsequent treatment option under useful in certain circumstances for patients with relapsed or medically unresectable ccRCC regardless of prior IO therapy status.  

Axitinib + Pembrolizumab  

Pembrolizumab is a PD-1 blocking monoclonal antibody that works by preventing the interaction between PD-1 and the PD-L1 and PD-L2 ligands. This is a preferred option for first-line treatment of patients with relapsed or medically unresectable predominantly clear cell stage IV RCC. This is used as subsequent treatment option under useful in certain circumstances for patients with relapsed or medically unresectable ccRCC with prior IO therapy and under other recommended option for IO therapy naive patients.  

Belzutifan  

Belzutifan is a hypoxia-inducible factor 2α (HIF-2α) inhibitor that blocks the heterodimerization of HIF-2α with HIF-2β, thereby inducing tumor regression. This is a preferred therapy option for the treatment of VHL-associated RCC not requiring immediate surgery. It is used as subsequent therapy under other recommended option for patients with ccRCC and prior IO therapy and previously treated with PD-1 or PD-L1 inhibitor and a VEGF-TKI. It is also used as subsequent therapy under useful in certain circumstances for IO therapy naive patients.  

Bevacizumab  

Bevacizumab is a recombinant humanized monoclonal antibody that binds to VEGF that inhibits angiogenesis occurring during the growth of the tumor. It may be used as subsequent therapy under useful in certain circumstances for predominantly clear cell stage IV RCC regardless of prior IO therapy status. Approved biosimilars (eg Bevacizumab-awwb, Bevacizumab-bvzr) may be used in place of Bevacizumab.

Bevacizumab + Erlotinib  

Bevacizumab + Erlotinib is a treatment option for select patients with advanced papillary RCC, including HLRCC-associated RCC.  

Bevacizumab + Everolimus  

Bevacizumab + Everolimus is a treatment option under useful in certain circumstances for select patients with relapse or stage IV non-clear cell RCC.  

Bevacizumab + IFN-α  

Based on the AVOREN (phase III) double-blind trial, the addition of Bevacizumab to IFN-α significantly increases progression-free survival (PFS).  

Cabozantinib  

Cabozatinib is a small-molecule inhibitor of tyrosine kinases such as VEGFRs, MET and AXL. It is a preferred option for first-line treatment of poor- and intermediate-risk patients with relapsed or medically unresectable predominantly clear cell stage IV RCC, as subsequent therapy under other recommended regimens for patients with clear cell RCC regardless of prior IO therapy status and preferred treatment option for relapsed or stage IV non-clear cell RCC. This is an alternative option for first-line treatment of patients with relapsed or medically unresectable predominantly clear cell stage IV RCC with favorable-risk features. According to the results of an interim analysis of the Phase III METEOR trial, it has significantly delayed the progression of the disease as compared with Everolimus in patients with advanced ccRCC with prior VEGR-TKI treatment. The trial results showed that Cabozantinib was able to shrink the tumors and slow down the tumor growth.  

Cabozantinib + Nivolumab  

Cabozantinib + Nivolumab is a preferred option for first-line treatment of patients with relapsed or medically unresectable predominantly clear cell stage IV RCC. This is used as subsequent treatment under other recommended options for patients with relapsed or medically unresectable ccRCC who are IO therapy naive and useful in certain circumstances for patients with prior IO therapy. This is a preferred treatment option for patients with relapsed or medically unresectable non-clear cell stage IV RCC. CheckMate 9ER study results showed superior progression-free survival and response rates with significant overall survival advantages for Cabozantinib and Nivolumab combination therapy irrespective of IMDC prognostic subgroups and PD-L1 biomarker status. This may be used for patients with HLRCC-associated RCC.  

Everolimus  

Everolimus is a macrolide immunosuppressant and analog of Sirolimus that inhibits mammalian target of Rapamycin (mTOR), a serine-threonine kinase, downstream of the PI3K/AKT pathway. It is used for subsequent treatment under useful in certain circumstances for predominantly advanced ccRCC after treatment failure regardless of prior IO therapy status. The RECORD-1 trial results revealed that Everolimus can be safely given to patients with previous intolerance to vascular endothelial growth factor receptors-tyrosine kinase inhibitor (VEGFr-TKI) therapy. This may be considered as a treatment option useful under certain circumstances for relapse or stage IV non-clear cell RCC patients. It is preferred for patients with TSC-associated RCC.  

Everolimus + Lenvatinib  

Lenvatinib is a multi-targeted tyrosine kinase inhibitor of vascular endothelial growth factor (VEGF) receptors 1, 2 and 3 and other kinases involved in pathogenic angiogenesis, tumor growth and cancer progression. This is used as a subsequent treatment option for patients with relapsed or medically unresectable stage IV ccRCC after treatment failure, regardless of prior IO therapy status. It is used as other recommended treatment option for patients with relapsed or medically unresectable non-clear cell stage IV RCC.  

Ipilimumab + Nivolumab  

Ipilimumab is a monoclonal antibody that binds to cytotoxic T-lymphocyte antigen 4 (CTLA-4) thereby blocking CTLA-4 interactions with its ligands. Preferred combination treatment for first-line therapy for favorable and intermediate- or poor-risk patients with previously untreated, relapsed or medically unresectable, predominantly clear cell stage IV renal cancer. It is also used as one of the subsequent treatment regimens under other recommended option for patients with predominantly advanced ccRCC who are IO therapy naive and useful in certain circumstances for patients with prior IO therapy. This may be used as a treatment option useful in certain circumstances for patients with relapse or stage IV non-clear cell RCC.  

Lenvatinib + Pembrolizumab  

Lenvatinib + Pembrolizumab is a preferred option for first-line treatment of patients with relapsed or medically unresectable stage IV ccRCC. This is used as subsequent treatment under other recommended option for patients with relapsed or medically unresectable ccRCC who are IO therapy naive and useful in certain circumstances for patients with prior IO therapy. This is the preferred treatment option for patients with relapsed or medically unresectable non-clear cell stage IV RCC.  

Nivolumab  

Nivolumab is a human PD-1 blocking antibody used in patients who already received angiogenesis inhibitor therapy. This is used as subsequent treatment under other recommended option for patients with predominantly clear cell stage IV RCC who are IO therapy naive and other recommended treatment option for select patients with advanced non-clear cell RCC.  

Pazopanib  

Pazopanib is an oral angiogenesis inhibitor that targets the VEGFR-1, -2, and -3, platelet-derived growth factor receptors (PDGFR-α and -β) and stem cell factor receptor (c-KIT). It is an alternative option for first-line treatment of patients with relapsed or medically unresectable predominantly clear cell stage IV RCC with favorable and poor- to intermediate-risk features. This may be considered as subsequent therapy in patients with relapsed or medically unresectable stage IV ccRCC under certain circumstances regardless of prior IO therapy status. It is also used as an alternative subsequent therapy option for patients unresponsive to first-line therapy regimens. This may be considered for patients with VHL-associated RCC. It is important to monitor the liver function tests (LFTs) before and during treatment with Pazopanib.

Pembrolizumab  

Pembrolizumab is another recommended treatment option for stage IV or relapsed non-clear cell RCC patients.  

Sirolimus  

Sirolimus is another recommended therapy for patients with TSC-associated RCC.  

Sorafenib  

Sorafenib is a small molecule that inhibits multiple isoforms of the intracellular serine/threonine kinase, RAF and also other receptor tyrosine kinases, including VEGFR-1, -2, and -3, PDGFR-β, FMS-like tyrosine kinase (FLT-3), c-KIT and neurotrophic factor receptor (RET).  

Sunitinib  

Sunitinib is a multikinase inhibitor targeting several tyrosine kinase inhibitors that is implicated in PDGFR-α and -β, VEGFR-1, -2, and -3, c-KIT, FLT-3, colony-stimulating factor (CSF-1R) and RET. This is a treatment option for first-line therapy of patients with relapsed or medically unresectable predominantly clear cell stage IV RCC with favorable or poor- to intermediate-risk features, and as an alternative subsequent therapy option under useful in certain circumstances for patients unresponsive to first-line therapy regardless of prior IO therapy status. It is also used as an adjuvant therapy option for patients with clear cell localized RCC at high-risk for disease recurrence. It is also used as other recommended treatment option for stage IV or relapsed non-clear cell RCC patients.  

Temsirolimus  

Temsirolimus is an inhibitor of the mTOR protein that regulates micronutrients, cell growth, apoptosis and angiogenesis by its downstream effects on a variety of proteins.     

Tivozanib  

Tivosanib is a selective VEGF tyrosine kinase inhibitor of VEGFR1, VEGFR2 and VEGFR3 approved in European countries as an alternative first-line treatment for patients with ccRCC with favorable risk factors. This is used as subsequent treatment under other recommended option for patients with relapsed or medically unresectable ccRCC after treatment failure with ≥2 prior systemic therapies and have received prior IO therapy, and useful in certain circumstances for patients who are IO therapy naïve.

Recommended Chemotherapeutic Agents for Metastatic RCC  

Treatment with Gemcitabine + Doxorubicin or Sunitinib may be considered in patients with sarcomatoid RCC. Gemcitabine with Carboplatin or Cisplatin and Paclitaxel with Carboplatin may be used for patients with other non-clear cell subtypes.  

Supportive Therapy  

Bone-modifying agents (eg bisphosphonates, RANK-L inhibitor Denosumab) and supplementation with vitamin D and calcium are recommended for RCC patients with bone metastases and creatinine clearance ≥30 mL/min.  Bisphosphonate therapy with Zoledronic acid has been shown to reduce skeletal-related events in patients with bone metastases.

Nonpharmacological

Active Surveillance  

Active surveillance is a management option for patients with stage T1 kidney tumors. This is done in patients with tumors <2 cm, T1a masses ≤4 cm with a predominantly cystic component, or clinical stage T1 masses at risk for death or morbidity if managed aggressively. It may also be considered in select asymptomatic patients with favorable-risk ccRCC. The initial monitoring of tumor size by serial abdominal imaging (ultrasound, CT scan or MRI scan) with timely intervention is reserved for tumors showing clinical progression during follow-up. This is an alternative strategy for elderly patients, patients with short life expectancy, and significant comorbidities. It may utilize renal biopsy for surveillance and should include periodic metastatic survey including hematologic exams and chest imaging if with tumor growth.  

Surgery

Surgery is the preferred treatment for localized RCC. The choice of surgical procedure depends on the extent of the disease, as well as patient-specific factors such as age and comorbidity. This may be carried out through a conventional approach or by a minimally-invasive approach.  

Partial Nephrectomy or Nephron-Sparing Surgery (NSS)  

Partial nephrectomy is indicated for patients with a solitary kidney, one kidney with contralateral renal function, and bilateral synchronous RCC. This is recommended for patients with unilateral stage I to III tumors if technically feasible or with renal insufficiency, bilateral masses, familial renal cell cancer, in a uninephric state or at relative risk for progressive chronic kidney disease development due to young age or medical risk factors (eg diabetes, hypertension, nephrolithiasis). Partial nephrectomy is a preferred surgical management for patients with stage I (pT1a, pT1b). The diseased or injured portion of the kidney is removed. The goal is to obtain optimal locoregional tumor control while minimizing ischemia time to <30 minutes. This is preferred in patients with ≤10 cm tumor size and if partial nephrectomy is technically feasible, to preserve renal function. This is contraindicated in patients with locally advanced tumor growth, a tumor in an unfavorable location, or confirmed nodal metastases.  

Radical Nephrectomy  

Radical nephrectomy is the most widely used approach and the preferred procedure if there is evidence of invasion into the adrenal gland, renal vein, inferior vena cava, or perinephric fat. It involves the perifascial resection of the kidney, ipsilateral adrenal gland, perirenal fat, and regional lymph nodes using open, laparoscopic, or robotic techniques. Radical nephrectomy is the preferred surgical management for patients with stage II to III. This is an alternative for patients with stage I (T1a) RCC if partial nephrectomy is not technically feasible and an option for patients with stage I (T1b) RCC. Radical nephrectomy has an increased risk for chronic kidney disease and cardiovascular morbidity and mortality compared to nephron-sparing surgery.  

Candidates for radical nephrectomy include patients with:

• >10 cm tumor size
• Tumors involving a more central position of the kidney
• Tumors with increased oncologic potential as evidenced by suspected lymph node involvement, tumors with associated renal vein or inferior vena cava thrombus and direct extension into the ipsilateral adrenal gland

Ablative Techniques  

Ablative techniques have a higher local recurrence rate compared to conventional surgery and may need multiple therapies to achieve similar oncologic results. This is a therapy option for patients with clinical stage T1 renal tumors.  

Cryoablation  

Cryoablation is indicated for frail patients at high surgical risk with ≤3 cm solitary renal tumor located away from the collecting system.  

Microwave Ablation  

Microwave ablation is indicated for frail patients at high surgical risk with ≤3 cm solitary renal tumor, renal impairment, hereditary RCC or multiple bilateral tumors.

Radiofrequency Ablation  

Radiofrequency ablation is an alternative treatment in patients with contraindications to nephrectomy, VHL disease and unfit elderly patients. It creates molecular friction, denaturation of cellular proteins and cell membrane disintegration causing heat-based tissue destruction with a high-frequency electrical current (400 to 500 kHz).

Other Procedures  

Adrenalectomy  

Adrenalectomy is considered in patients with large upper pole tumors or abnormal-appearing adrenal glands on CT scan and should be assessed on a case-to-case basis.  

Cytoreductive or Debulking Nephrectomy  

Cryoreductive or debulking nephrectomy mostly involves the removal of the primary tumor from the kidney. Recommended in patients with good performance (Eastern Cooperative Oncology Group [ECOG] performance status <2) preceding systemic therapy and with no brain metastasis. This may be considered in patients with stage IV or relapsed disease if the primary tumor is surgically resectable.  

Metastasectomy  

The lungs, bones, brain and liver are the most common sites of metastasis. Patients with stage IV disease may be considered for metastasectomy if the primary RCC and oligometastatic sites (includes lung, bone, brain) present upon initial diagnosis and if the patient develops oligometastases after a prolonged disease-free interval after nephrectomy.  

Regional Lymph Node Dissection  

Regional lymph node dissection may be considered in patients with resectable enlarged or palpable lymph nodes that are seen in preoperative imaging tests or visible or palpable lymph nodes during surgery.  

Risks and Side Effects of Surgery  

Short-term risks include reactions to anesthesia, excess bleeding that may require blood transfusions, blood clots and infections. Damage to internal organs and blood vessels such as the spleen, pancreas, aorta, vena cava, large or small bowel, may be seen during surgery. There may also be leakage of urine into the abdomen after partial nephrectomy and kidney failure if the remaining kidney fails to function well.  

Palliative Surgery  

Palliative surgery may be done for the management of spinal cord compression or possible/confirmed fractures in weight-bearing bones in select patients.

Radiation Therapy

Stereotactic Body Radiation Therapy (SBRT)  

Stereotactic body radiation therapy is recommended in patients with poor prognosis or those with unsuitable clinical conditions. This should be considered as the primary radiation modality in all cases unless inhibited by anatomic site, proximity to organs at risk or past therapies. This may also be considered for patients with medically inoperable stage I to III primary disease. SBRT can be considered in patients with T1 tumors (<7 cm in diameter).  

Conventional and stereotactic RT are frequently useful to treat a single or limited number of metastases. These should be considered in patients with oligometastasis unless metastasectomy is planned or SBRT cannot be delivered due to anatomic site, proximity to organs at risk or past therapies. This is an effective therapy for the palliation of local and symptomatic metastatic disease. It prevents the progression of metastatic disease in critical sites, the bones and brain.  

Recommended doses for primary disease:

• 26 Gy in 1 fraction
• 42-48 Gy in 3-4 fractions
• 40-50 Gy in 5 fractions

Recommended doses for spine metastases:

• 16-24 Gy in 1 fraction
• 20-24 Gy in 2 fractions
• 24-27 Gy in 3 fractions
• 25-40 Gy in 5 fractions

Recommended doses for metastases in other body sites:

• 16-24 Gy in 1 fraction
• 48-60 Gy in 3 fractions
• 35-60 Gy in 4-5 fractions

Recommended doses for palliative treatment of symptomatic extracranial metastases:

• 20-24 Gy in 2 fractions for spine metastases
• 24-27 Gy in 3 fractions
• 32-48 Gy in 4 fractions
• 30-50 Gy in 5 fractions
• 36 Gy in 6 fractions

Other potential doses for palliative treatment of symptomatic extracranial metastases:

• 8 Gy in 1 fraction
• 20 Gy in 5 fractions
• 30 Gy in 10 fractions

Stereotactic Radiosurgery (SRS) and Fractionated Stereotactic RT (SRT)  

Stereotactic radiosurgery (SRS) and fractionated stereotactic RT (SRT) deliver a high dose of radiation to a specific target while delivering a minimal dose to surrounding tissues, specifically in the brain and spine in 1-5 sessions. Image-guided RT (IGRT) is used to improve the accuracy of RT delivery.  

Recommended doses for primary treatment:

• Smaller tumors: Maximal dose of 15-24 Gy in 1 fraction
  • Tumors with maximal diameter of ≤20 mm: Up to 24 Gy
  • Tumors with maximal diameter of 21-30 mm: Up to 18 Gy
  • Tumors with maximal diameter of 31-40 mm: Up to 15 Gy
• Larger tumors: 24-27 Gy in 3 fractions or 25-35 Gy in 5 fractions

Recommended doses when used as adjuvant therapy:

• Smaller cavities: 12-20 Gy in 1 fraction
• Larger cavities: 24-27 Gy in 3 fractions or 25-35 Gy in 5 fractions

Whole Brain RT (WBRT)  

Whole brain RT is used for palliative purposes when SRS or SRT is not possible in patients with disease which has progressed and with good performance status. Palliative WBRT can be considered if clinical, pathological or radiographic signs of leptomeningeal carcinomatosis are present.  

Common regimens for palliative WBRT include:

• Standard doses: 30 Gy in 10 fractions or 20 Gy in 5 fractions
• Standard doses: 30 Gy in 10 fractions or 20 Gy in 5 fractions
• For patients with poor predicted prognosis and with symptomatic brain metastases: 20 Gy in 5 fractions