Case-Based Overview: Newly Diagnosed Renal Cell Carcinoma

This is a case of a 70-year-old male who actually went to the emergency department with complaints of abdominal pain. In the work-up he underwent a CT computed tomography scan for this, and the CT scan was notable for a right renal mass with associated lymphadenopathy. There was a concern for a lytic lesion in his spine. He subsequently underwent a CT of the chest, which showed enumerable sub-centimeter pulmonary nodules with associated hilar lymphadenopathy. He was referred to urology where they elected to undergo a biopsy of the abdominal lymphadenopathy, which revealed clear cell renal cell carcinoma without any features. His past medical history was notable for ulcerative colitis as well as hypertension. And laboratory tests were notable for essentially normal chemistry with a CBC [complete blood count] showing a mild anemia at 12.5 g/dL with no thrombocytosis or neutrophilia.

This is obviously a common situation. Patient presents with new diagnosis of renal cell carcinoma. And we always have to ask what’s the best way to treat these patients. And I think with the advent of the data regarding targeted therapy combination with immunotherapy in the modern era, really looking at risk stratification is going to be important. And so the one I often use is the IMDC [International Metastatic Renal Cell Carcinoma Database Consortium] risk stratification, which takes into account clinical factors of the patient that were developed in the era of TKIs [tyrosine kinase inhibitors] but really are showing to have an important role in the era of immunotherapy. This is going to involve looking at the patient, the performance status, as well as lab values, and looking at the CBC, looking for neutrophilia, thrombocytosis, anemia, looking for elevated calcium, and really trying to get a sense for that patient and obviously whether they need therapy or not.

So in this patient who’s presenting with metastatic disease, if you’re going to pursue therapy, I would say he has intermediate-risk disease by the IMDC criteria.

Transcript edited for clarity.

Case: A 70-Year-Old Man with Intermediate-Risk RCC

A 70-year-old Caucasian man presented to ER complaining of blood in his urine and abdominal pain.

H & P

• History of ulcerative colitis, controlled hypertension, and controlled hypercholesterolemia
• Lower back tender to touch

Labs

• CBC: Hgb 12.5 g/dL, HCT, PLT, WBC all WNL
• BP: WNL
• Lipid panel: WNL

Imaging

• Bone CT scan of the chest, abdomen, and pelvis showed a bilateral renal mass, a small lytic lesion in the lumbar vertebrae, several pulmonary nodules, and mediastinal and right hilar lymphadenopathy.
• Diagnosis: stage IV clear-cell renal cell carcinoma; intermediate-risk

Treatment

• Received cytoreductive nephrectomy
• He was started on cabozantinib 60 mg daily

Follow-up

• At 3 weeks of therapy patient tolerated treatment well, with mild fatigue and diarrhea, HTN remains controlled; blood in urine and lower back pain resolved; ECOG 0
• At 6 weeks of therapy the patient shows PR and reduction in size of the renal masses and lymphadenopathy.