metastic renal cell cancer favorable risk long term survivor · metastic renal cell cancer...
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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
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
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
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
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