Therapeutic Advances and Key Case Studies in RCC - Episode 14

Role of TKIs in Oligometastatic RCC

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Oligometastatic disease involves an intermediate state of cancer spread between localized disease and widespread metastases. It may not always be prudent to start systemic therapy in the setting of oligometastatic renal cell carcinoma (RCC). Brian Rini, MD, discusses how his institution prefers the use of debulking nephrectomy in individuals with RCC positive for a primary tumor and solitary bone metastases. After this procedure, patients are restaged, and if there is still evidence of bone metastasis, Rini then considers focused radiation as an option.

Daniel Heng, MD, comments that no evidence of disease (NED) is the desired situation under these circumstances, as that implies the chance, albeit thin, for long-term control of disease. Before beginning any targeted therapy, Heng carefully observes patients who are NED by performing repeat CT scans to monitor for disease progression so that, for as long as possible, individuals are not subjected to toxicity from systemic therapy. Charles Henderson, MD, agrees that although he would also wait before beginning systemic therapy, he may consider treatment with a bisphosphonate.

Bone disease tends to be aggressive in kidney cancer, says Rini, so aggressive systemic treatment with a tyrosine kinase inhibitor (TKI) may be needed. When using TKIs, the overall goal is to maintain stable disease, although these therapies are not without toxicities. TKI agents, sunitinib and pazopanib, have the potential to cause liver and cardiac dysfunction.

Clinicians should be careful regarding the risk of cardiovascular abnormalities associated with TKI therapy. Both Henderson and Rini comment that they do not routinely perform cardiovascular scans, such as multigated acquisition (MUGA) and echocardiogram, but Henderson counsels his patients regarding potential toxicities and aggressively controls any hypertension.

Rini comments that he sometimes refers patients with uncontrolled hypertension to the cardiology department in the Cleveland Clinic to receive additional therapeutic oversight. Janice Dutcher, MD, adds that she is more concerned using TKIs in patients who present with metastatic disease and have an extensive cardiac history. In these patients, she considers a different approach.