Case Presentation: A 69-Year-Old Woman with Advanced RCC

Chung-Han Lee, MD: The case I’m presenting today is a 69-year-old woman with advanced renal cell carcinoma. She originally presented with about a 2-month history of fatigue, lower back pain, and some unintentional weight loss. Her only relevant past medical history was diabetes, which was medically controlled. On physical examination, she had flank pain and some lower back discomfort on palpation. Clinical work-up with a CT of the chest, abdomen, and pelvis demonstrated a right-sided 7.9-cm renal mass and some slightly enlarged paraaortic lymph nodes. Percutaneous biopsy was done, which confirmed clear-cell renal cell carcinoma.

Given her stage of disease, she underwent a right total nephrectomy. Overall, the surgery was well tolerated and was followed with serial imaging at 3, 9, 12, and 24 months, which was all unremarkable. However, she subsequently developed stage IV disease with multifocal disease in her lungs. At that time, her laboratory [test results] were all within normal limits. She remained ECOG [performance status score] 0 and was felt to be good risk by IMDC [International Metastatic RCC Database Consortium] and MSKCC [Memorial Sloan Kettering Cancer Center] risk scores.

She was then started on pazopanib, which was well tolerated, and she achieved a partial response. However, 2 years after she was on the pazopanib, she suffered progression of disease with some increasing lung nodules, the largest being 30 mm, after which the combination of lenvatinib 18 mg by mouth every day and everolimus 5 mg by mouth every day was started. The first set of imaging at 8 weeks showed a 33% reduction in the baseline from the largest lung lesion, about 20 mm. At week 24 of treatment, there was a total 40% reduction in the baseline largest lung lesion, down to about 18 mm. The other lung nodules there also decreased in size. At 6 months she continued to have stable disease. At about 12 months, unfortunately, a CT showed 2 new liver nodules.

Going over some initial impressions I have of the case, this is a fairly typical time course for a patient who developed metastatic renal cell carcinoma. The initial management is often of localized disease, which the primary therapy at that time would be surgical resection or some sort of local therapy. Most patients who undergo this type of therapy don’t typically undergo any adjuvant therapy and are followed with serial imaging. Unfortunately, a good portion of these patients, especially those who have lymph node metastases or stage III disease, ultimately do develop metastatic disease, with the most common site being the lungs, which is where this patient ended up presenting.

When we saw this patient initially, she continued to be good risk, given her long duration of being disease free with normal labs and also good performance status. From a timing standpoint, if you think about historically where they were treated, pazopanib would be a very reasonable first-line agent, which she had a good response to single-agent TKI [tyrosine kinase inhibitor], and subsequently developed increasing metastatic lesions, in which she was started on second-line therapy.

Transcript edited for clarity.

Case Overview:

Initial presentation

• A 69-year-old woman presents with a 2-month history of fatigue, lower back pain and unintentional weight loss
• PMH: DM medically controlled
• PE: flank and lower back discomfort on palpation

Clinical workup

• Chest/abdominal/pelvic CT showed a right-sided 7.9 cm renal mass; paraaortic lymph node involvement
• Percutaneous biopsy confirmed clear cell renal cell carcinoma

Treatment and follow-up

• The patient underwent right total nephrectomy; surgery was well-tolerated
  • Follow-up at 3, 9, 12 months were unremarkable
• At 24 months the patient developed disease with multifocal disease in her lungs; Stage IV
• Labs within normal limits
• ECOG 0; good risk disease by IMDC and MSKCC risk
• She started treatment on pazopanib; well-tolerated, achieved PR
• 2 year later the patient suffered progression of disease; with increasing lung nodules, largest (30 mm)
• Lenvatinib 18 mg PO QD + everolimus 5 mg PO QD was initiated
  • Imaging at week 8 showed a 33% reduction from baseline of the largest lung lesion (20 mm);
  • At week 24 of treatment showed 40% reduction from baseline of largest lung lesion (18 mm); decrease in size of other pulmonary lesions noted
  • At 6 months she continued to have stable disease
  • At 12 months of treatment CT showed 2 new liver nodules