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Sumanta Kumar Pal, MD, presents a case study focused on the treatment of a 65 year-old female with a 6.7 cm right-sided renal mass. Following imaging, both CNS and bone lesions were not detected; however, multiple pulmonary lesions were present. The patient was nephrectomized and pathology revealed a T3b tumor, no regional lymph node involvement, and clear cell histology with 30% sarcomatoid elements, Pal notes. Following 6 months of treatment with sunitinib, the patient progressed. After this point, doxorubicin and gemcitabine were administered.
The utilization of CNS imaging before the administration of systemic therapy is essential, Brian I. Rini, MD, believes. The risk of bleeding into an untreated metastasis is high for patients receiving VEGF-targeted therapies. As a result, CNS lesions should be treated prior to the initiation of therapy, Rini notes. Despite the clear need to detect CNS metastases prior to treatment, many insurance providers will not cover the required imaging, Nizar M. Tannir, MD, suggests. Additionally, before initiating systemic therapy, Tannir suggests inferior vena cava thrombectomy, when possible.
The 30% sarcomatoid elements suggest a much higher-grade histology, Daniel J. George, MD, states. The sarcomatoid histology is representative of an epithelial to mesenchymal transition that may predict a short response to VEGF-targeted therapy. Additionally, elevated HGF and IL-6 levels in the plasma are predictors of a poor response and survival to VEGF-targeted therapy, George notes. For patients with these markers, the upfront treatment should be adjusted.