Eighth European International

Kidney Cancer Symposium Budapest – 03-04 May 2013

Metastic renal cell cancer favorable risk long term survivor

Prof. Cezary Szczylik, MD PhD Department of Oncology

Military Institute of Medicine Warsaw

Case history

• 48 yrs old male,

• Jan.2002 CT scan – left kidney lower pole mass (10,3 x 10,2 x 10,0)

• 22 Jan.2002 -Left nephrectomy

• ccRCC G2

• MSKCC score – 0, favorable

Case history • Nephrectomy – left

kidney

2002

• Right adrenal gland 2003

• Right lung, left femur 2006

• Right femur 2009

• Right kidney - (NSS) 2010

• Skin (sculp) 2011

• IL-2/IFN/Vbl

2003

• IFN, RTx 2007

• Sunitinib (XVc) • Pamidronic acid

2007-2009

• Everolimus (XIIIc)

• Zoledronic acid 2009-2011

• Sorafenib (VIIc) 2011-2012

• … 2012

• Nefrektomia lewostronna

2002

• Nadnercze prawe 2003

• Płuco prawe, kość udowa lewa

2006

• Kość udowa prawa 2009

• Nerka prawa 2010

• Skóra głowy 2011

2012

surgery • Nephrectomy

• Metastasectomy + IFN/IL-2/5-Fu

• -

• Bilobectomy

• Total hip replacement

• 5.01.2002 – left kidney lower pole 10,2x10,3x10cm

• 09.02.2003 – right adrenal gland 61x56x49mm

• 2004-2006 – disease free

• 27.07.2006 –right lung mets. seg. 9-10

• 8.11.2006 - right femur and hip multiple mets

Robert Hinckley , The First Operation with Ether 1846

Nephrectomy 2002 NSS

2010

Cytokines -IFN • 04.2007 - 11.2007 IFN 9 mln

U/3 x weekly

• Typical IFN side effects – high fever, muscle and bone pain

Jacek Yerka, Fever, 2008

TKI and mTORI treatment

• 11.2007 Sunitinib (XV - cycles) – Bleeding (nose)

– Skin oedema

– HT

– Stenocardial chest pain

– Hypothyroidism

• 02.2010 – Everolimus (XIII cycles)

• Tolerated well

• 07.2011 – Sorafenib (X cycles)

– Neuropathies

Vincent van Gogh, Ward of Arles Hospital, 1889

Radiotherapy

01.08.2012

14.11.12

Daniel Graves, Marie Curie.

1995.

06.03.2012 routine CT scan revealed 25 mm intramyocardial tumor

(06.03.2012) Robert A. Thom , Laënnec and the Stethoscope. c. 1960.

MRI proved multilple metastates and 5th line therapy

with votrient was started (04.04.2012)

1.3x0.7

1.0

0.7 1.3 1.4

4.4x3.1

1.3

1.3

1.8

Cardiology testing on diagnosis

Blood test 16.04.2012

CKMB (N = 0-16)

39 U/l

Troponin I (N < 0,035, MI > 0,12)

0.07 ng/ml

NT-proBNP 799.4 pg/ml

MRI 16.04.2012

EDV 170 ml

ESV 85.9 ml

SV 74.3 ml

LV mass 173 g

LV 57 x 52 mm

RV 36 mm

EF 49%

Holter monitor

1. atrial extrasystoles 2. single episode of atrial fibrillation 3. premature ventricular complexes

Control MRI, after 3 months proved SD

1.3x0.7

1.1

1.0 1.4 1.4

4.4x3.2

1.4

1.3

1.5

(03.07.2012)

Control MRI after 3 months proved SD

1.3x0.7

1.1

1.0 1.4 1.4

4.4x3.2

1.4

1.3

1.5

(03.07.2012)

MRI Norm 16.04.2012 03.07.2012 16.10.2012

EDV 120 ml 170 ml 137 ml 131 ml

ESV 50 ml 85.9 ml 75.5 ml 66.7 ml

SV 70 ml 74.3 ml 61.5 ml 59.2 ml

LV mass 43-95 g 173 g 177 g 181g

LV 42x59 mm 57 x 52 mm 52 x 44 mm 52x40 mm

RV 35 mm 36 mm 34 mm 33 mm

EF 58% 49% 45% 38%

16.04.2012 03.07.2012 16.10.2012

16.04.2012 03.07.2012 16.10.2012

Cardiology testing on treatment

Blood test 16.04. 2012

01.08. 2012

02.08. 2012

08.01. 2013

30.01. 2013

15.02. 2013

CK (N=55-170) [U/l]

47 49 58 20 16 16

CKMB (N = 0-16) [U/l]

39 11 13 13 11 23

Troponin I (N < 0,035, MI > 0,12) [ng/ml]

0.070 0.055 0.066 0.097 0.076 0.076

NT-proBNP N<125 [pg/ml]

799.4 - - - 1875.0 1879.3

LDH (135-232) [U/l]

243 - 178 - 134 196

Votrient IFN IFN Inlyta BSC BSC

ECG + Holter ECG 100% Normal

Renal function on treatment

14.11.2012

07.04.2010

26.08.2010 – NSS dex

Multiple line treatment

Case summary • Died 08.03.2013 due to fatal cardiocirculatory insufficiency • All possible metastases have been surgically systematically removed (hip

replacement) • Systemic therapy with cytokines (IL-2, IFN), TKI and mTORI was used • Radiotherapy - to unoperable bone mets • Since first metastases in 09.02.2003 he survived 10 years with good quality of life • Myocardial metastases detected in 2012 can be treated with TKI with carefull MRI

observation • Development of necrosis inside myocardial lesion can be dangerous • He survived 1 yrs with myocardial metastases

Take home message

Evaluation of treatment options for patients with advanced renal cell carcinoma: assessment of appropriateness, using the validated semi-quantitative RAND corporation/University of California, Los Angeles methodology. Gore ME, Bellmunt J, Eisen T, Escudier B, Mickisch G, Patard J, Porta C, Ravaud A, Schmidinger M, Schöffski P, Sternberg CN, Szczylik C, De Nigris E, Wheeler C, Kirpekar S. Eur J Cancer. 2012 May;48(7):1038-47.

Eighth European International

Kidney Cancer Symposium Budapest – 03-04 May 2013

Acknowledgements

Oncology team (2003-2013): Justyna Barzał, MD Anna M. Czarnecka, MD PhD Jan Korniluk, MD PhD Przemysław Langiewicz, MD Paweł Nurzyński, MD PhD Jakub Żołnierek, MD PhD

Radiology team: Dorota Piotrowska, MD Paweł Skrobowski, MD

Eighth European International

Kidney Cancer Symposium Budapest – 03-04 May 2013

Thank you for your attention