Robert Alter, MD, presents the patient profile of a 56-year-old man with metastatic clear cell renal cell carcinoma presenting with chromaturia.
Robert Alter, MD: Hello, and welcome to this OncLive® My Treatment Approach program titled “Improving Outcomes in Advanced RCC: Translating Evidence to Clinical Practice.” I’m Robert Alter, the co-division chief of the division of the genitourinary oncology at the John Theurer Cancer Center, HMH [Hackensack Meridian Health], at Hackensack University Medical Center in Hackensack, New Jersey. I’m joined by my colleague and friend Dr Elan Diamond. I’m going to ask Elan to introduce himself.
Elan Diamond, MD: My name is Elan Diamond. I’m the medical director of urologic oncology for New Jersey Urology, a Summit Health affiliate.
Robert Alter, MD: Elan, welcome, and thank you for joining me. We’re going to discuss recent advances in the treatment of advanced RCC [renal cell carcinoma] and their impact on clinical practice. We’ll present 3 real-world patient cases and discuss our treatment approaches to illustrate how we incorporate recent data in our practice. Let’s get started on our first topic.
The first case I’m going to present is of a patient we actively see. This is a 56-year-old gentleman. Borderline hypertension is his only past medical history. Diverticulitis in the past required 1 hospitalization, but he never had a recurrence. He had anal fistula repair, which was incidental. He takes Rapaflo at home. He has a good social history, with 3 children. He’s married and is a high school principal not far from our center. He drinks alcohol socially and denies cigarette use. We see a remote family history: his mother had a smoking history and lung cancer.
In September 2017, he had an episode of painless gross hematuria, initially pinkish, and wasn’t quite sure what it was. It turned red the following day, and he presented himself to his primary care physician. He immediately underwent a CT scan of the abdomen and pelvis, which revealed a right lower pole renal mass extending into the central sinus fat and involving the right renal pelvis, extended exophytically to the right perinephric space, and infiltration of the right perinephric fat measuring 9 by 8.6 by 6.8 cm. He was met by the urologist and underwent a robot-assisted right radical nephrectomy 9 days later, with pathology revealing an 8.5-cm clear cell renal cell carcinoma, Fuhrman nuclear grade 3—this goes back to the Fuhrman grades—with tumor involving the right renal sinus fat, right renal pelvis, and no evidence of lymphovascular invasion or a perinephric fat invasion, all negative margins. By size and extension, this is a T3 disease.
He was seen by me the following month. Based on his age and the aggressiveness of the disease, we discussed the S-TRAC data of adjuvant Sutent, which is FDA approved. The patient was hesitant after having a lengthy conversation about toxicities, and my hesitation was the efficacy, long-term data, and overall survival, so we both chose not to do it. My approach is always to educate patients about opportunities that exist. We both agreed that this wasn’t the right therapy for them. The following month, we did a formal staging, and he had pulmonary micronodules with the right hilar lymph node measuring 1.5 by 0.9 cm in size. The patient was totally asymptomatic. We continued scans. Those nodules and the lymph node were unchanged in size over the course of the next year and a half. Then because of COVID-19 and his limitations of accessibility, he was lost to follow-up.
Three and a half years later, he presented to his primary care physician complaining of left flank pain, a 15-lb weight loss, mild anorexia, and mild dyspnea on exertion. Outpatient CT scan revealed a 1.7-by-1.1-cm right hilar lymph node and a 2.5-cm exophytically enhancing lesion in the left interpolar kidney, which is now the contralateral side. The MRI confirmed a 2.7-by-2.5-cm solid lesion, partially exophytic, from the posterior medial interpolar kidney. However, this region extends to involve the renal pelvis with a vascular invasion extending into the IVC [inferior vena cava].
The patient was subsequently seen by his urologist with the hopes of having the patient go for partial nephrectomy and thrombectomy. No guarantees were offered, with the potential complication of more extensive resection leading to a radical nephrectomy or a decrease in kidney function with the possibility of needing to go for hemodialysis. The patient re-presented to myself, and options of therapy were discussed. I recommended that if we were going to initiate therapy, [our best option was] the recent FDA approval of the pembrolizumab-lenvatinib data. We discussed and applied the patient to receive lenvatinib at 20 mg/m2 as well as pembrolizumab 200 mg IV [intravenously] every 3 weeks as based on the CLEAR clinical trial.
Scans performed 2 months after initiation of therapy showed the left renal mass decreasing in size. It went from 2.7 cm to 1.8 cm. Vascular invasion was unchanged. The right hilar adenopathy resolved. He had toxicities of grade 2 to 3 diarrhea, which was controlled by Lomotil. He had mild fatigue. Because of the toxicity, lenvatinib was held for 1 week and then reduced to 14 mg daily, and the patient had much better tolerance and continued system therapy.
We’re going to go through the scans of the next few studies. In November 2021, the 2.7-cm lesion that went to 1.8 cm was down to 0.6 cm. Vascular extension has resolved, and scans performed 3 weeks ago revealed no evidence of disease. The renal mass has resolved as well. Not listed is that we scanned the chest again and the hilar adenopathy has resolved, so the patient has achieved a complete remission. As of last week, he received his 13th dose of pembrolizumab. He maintains himself on lenvatinib at 14 mg. Grade 1 fatigue is still being monitored. The patient is fully functional at work and still wearing a mask.
Transcript edited for clarity.