ESMO Preceptorship Programme

METASTATIC RENAL CELL CARCINOMA

(Case Study)

ENG JIE YI

ONCOLOGY TRAINEE UNIVERSITY MALAYA MEDICAL CENTER

MALAYSIA (MD)

Metastatic Bladder and Kidney Cancer 2018– Singapore– 19 till 20 September 2018

ESMO PRECEPTORSHIP PROGRAMME

Disclosures

� No disclosures

History of Madam PA

� 57 years old lady

� Complaining of non specific symptoms (loss of appetite and

loss of weight) for few months in 2012

� CT Abdomen Pelvis September 2012 showed large right

upper lobe renal mass with lung nodules (largest

1.4x1.5cm)

� Background

- Works as lecturer

- No co-morbidity

� Right nephrectomy was done in Oct 2012

� HPE: renal cell carcinoma with tumor size of 10x8x6cm. It

was infiltrating the capsule but not involving perinephric

fat and Gerota fascia (pT2N0Mx)

� Repeated CT restaging on 31/12/2012 showed multiple

lung nodules and L2 vertebra metastasis.

� Bone scan: L2 vertebra metastasis

� Referred to oncologist for further management

� Fit, ECOG 0, asymptomatic

� Blood parameters: Hypercalcemia with corrected calcium

2.8 mmol/L

Treatment History

� Surgery

� Oncology

Heng’s criteria: Intermediate risk

Treatment History

o Sunitinib 50mg OD 4/2 on 16/1/2013 with monthly

Zoledronic acid

o G1 HFS, tiredness, gastritis, mucositis and grade 2

diarrhea

o CT restaging 3 months after Sunitinib: PR

o Switch to denosumab in Nov 2013 as patient preferred for

subcutaneous instead of intravenous injection

o 1 year later, CT assessment on 15/1/2014 showed new

mediastinal LN, 3cm with new lytic lesion at T1 and T10

vertebra.

� 1st line

Sunitinib

~ 1 year

o Everolimus 10mg OD started on 29/1/2014 and

continue with monthly denosumab

o CT reassessment 3 months after everolimus:

mediastinal LN did reduce in size but overall still SD

o The disease was progressing after 6 months of

everolimus with local recurrence and enlarging right

hilar and paraoartic lymph node

o CT scan on 29/9/2014: disease progression with bigger

renal bed lesion and larger mediastinal LN and lung

nodule.

�2nd line

Everolimus

~ 8 months

Treatment History

Treatment History

� 3rd line

Axitinib

~ 4 months

o Axitinib 5mg BD started on 9/10/2014. Disease was

progressed 2 months later, axitinib dose increased to

7mg BD but patient only took 7mg OM, 5mg ON due to

asthenia

o Unfortunately in June 2015, disease progressed again in

lung, hilar LN and bone metastasis at T10,11 with

extradural extension at T10-11 level

o She had back pain at that area as well

o She was re-challenged with Sunitinib on 17/6/2015,

started with 25mg OD 2/1 then increased the dose to

37.5mg OD 2/1

o Palliative RT 40Gy/15# was given to T9 to T12 for

bone metastasis in August 2015

Treatment History

� 4th line

Sunitinib

(re-challenged on

17/6/2015 till

1/2017)

~ 1 and a ½ years

� Patient complaint of intermittent

toothache then noted to have

osteonecrosis of jaw in January 2016

� Denosumab was stopped since then

(was on denosumab for 2 years)

Treatment History

� Patient had more side effects from

Sunitinib this time

- More lethargy

- Grade 2 mucositis

- Hypertension (Amlodipine 10mg OD)

- Hypothyroidism (L-thyrosine 100mcg

OD)

Osteonecrosis of jaw

� The disease was progressed in Feb 2016 with enlarging

right renal bed lesion and worsening lung metastasis

� Patient stopped the sunitinib in Jan 2017 as suffered from

G3 lethargy and no appetite. ECOG was 3 at that time

� CT reassessment in March 2017 showed disease

progressed

� In early of May 2017, she was admitted to ward for

symptomatic hypercalcemia and anemia. Her condition

deteriorating and succumbed to death

Treatment History

� 4th line

Sunitinib

(re-challenged

on 17/6/2015

till 1/2017)

~ 1 and a ½

years

ESMO PRECEPTORSHIP PROGRAMME

Summary (Oct 2012-May 2017)

mRCC in Oct 2012

-post cytoreductive

nephrectomy

1 year

Everolimus 10mg OD

1/2014

- Grade 1 mucositis

and lethargy

8 months

Axitinib 5mg BD

-2 months later disease

progressed and increase

dose to 7mg BD

-Very bad asthenia

4 months

Sunitinib 25mg OD 2/1

Then 37.5mg OD 2/1

- Developed HFS, mucositis,

hypertension, hypothyroidism

- Palliative RT to T9-T11

Developed ONJ

- Stop denosumab

1 & ½ years

Death

Sunitinib 50mg OD 4/2

1/2013 + zometa

-Grade 2 diarrhea with

grade 1 HFS, lethargy,

mucositis

-Switched to Denosumab

ESMO Preceptorship Programme

Thank you