A clinical scenario of renal cell carcinoma treated with surgery and adjuvant pembrolizumab is reviewed by a panel of experts.
Maria I. Carlo, MD: This is a 74-year-old man who presented with an incidentally found left renal mass on an abdominal ultrasound. He proceeded with a CT scan of the abdomen and that showed a 5.7-cm solid enhancing, partially exophytic mass in the left kidney. There was no evidence of metastatic disease. The patient otherwise feels very well. He has a past medical history of skin psoriasis, for which he uses occasional topical medications but no systemic medications. He’s a retired accountant with a family history of melanoma. The chest x-ray is normal, his laboratory test results were grossly normal, including CBC [complete blood count] and comprehensive metabolic panel. He proceeded with a left radical nephrectomy based on the location of the tumor, uncomplicated hospital course. The pathology comes out as a clear cell renal cell carcinoma [RCC], grade 3. There are no sarcomatoid or rhabdoid features, but based on tumor invading the branches of the renal vein, it is a stage IIIA. At 10 weeks from surgery, he has a CT of the chest, abdomen, and pelvis that shows no evidence of recurrent or metastatic disease. He begins adjuvant pembrolizumab, 200 mg every 3 weeks. At the 6-week mark, he has grade 1 arthralgias, but he continues treatment.
Robert J. Motzer, MD:That’s a new paradigm that’s been established, with the adjuvant pembrolizumab. Can you let us know in terms of how you assess the risk for recurrence for patients with RCC, and what’s the basis for offering this patient adjuvant pembrolizumab?
Maria I. Carlo, MD: I used to use various nomograms, but in the contemporary era, honestly I use the data from the adjuvant pembrolizumab trial. I discuss, essentially the natural history would be the placebo arm, and then the incremental benefit in disease-free survival with pembrolizumab. This gentleman would have been eligible for the trial based on a stage III, grade 3 tumor. We have recent data presented at the GU [Genitourinary Cancers] Symposium showing further stratified by risk group, those with metastatic disease, M1, who were resected, those with grade IV vs him, who would be in the high intermediate-risk group. But in general, I tend to discuss with them that at the 2-year mark, roughly speaking, 70% of people in the placebo arm, if we just observed, would be disease-free vs about 80% in the pembrolizumab arm for somebody similar to him. Then I also discuss that there is no overall survival advantage, but we review the data, and then I have that discussion with patients. With somebody like this with stage III, grade 3 disease, I do tend to recommend pembrolizumab, adjuvant pembrolizumab, but it’s a discussion with the patient. Again, without the overall survival advantage, I have an honest discussion with the patient. In this case too, skin psoriasis is something to think about and that he may be at higher risk of autoimmune adverse effects. But given that he had never had systemic therapy, I was comfortable initiating therapy and observing.
Transcript edited for clarity.