Patient Scenario 2: Second-Line Treatment Options in Clear-Cell RCC
Reviewing the case of a case of a 73-year-old man with metastatic clear cell kidney cancer, experts discuss second-line treatment options informed by prior treatment response, patient goals, and adverse event profiles.
Summary:
In the second case presented, a 73-year-old man, DM, was diagnosed with clear cell kidney cancer after presenting with hematuria, loss of appetite, and left upper quadrant discomfort. Following a left total nephrectomy in January 2021 for a 6-cm left kidney mass (stage 3A, grade 3), the patient experienced liver metastases 8 months later. The initiation of ipilimumab and nivolumab, an immunotherapy combination suitable for intermediate or poor-risk renal cell carcinoma (RCC), eventually led to disease progression, necessitating second-line treatment.
In considering second-line treatments for metastatic kidney cancer, the focus shifts to VEGF receptor tyrosine kinase inhibitors (TKIs) and immunotherapies. The recently presented CheckMate 9ER trial revealed cabozantinib’s notable response rate (41%) in the second line after progression on first-line treatment. Other effective second-line options include tivozanib, lenvatinib plus everolimus, axitinib, and nivolumab, with considerations based on patient-specific factors, treatment history, and adverse effect profiles. Factors influencing the choice of second-line treatment involve evaluating the patient’s response to prior therapies, understanding their goals of care, and considering past medical history. Cardiovascular issues, hypertension, chronic kidney disease, or preexisting conditions like pneumonitis impact the selection of appropriate medications. The diverse adverse effect profiles of different treatments are crucial in aligning therapy with patient tolerance and avoiding exacerbation of existing conditions.
Monitoring patients undergoing advanced kidney cancer treatment involves regular clinic visits (every 4 to 6 weeks on average) for blood work assessing kidney and liver function, urine protein levels, and physical assessments to detect and manage potential TKI adverse effects. The frequency of visits may vary based on individual patient response and adverse effect concerns. Imaging, typically through CT scans, occurs every 10 to 12 weeks, with variations based on treatment response. Recognizing signs of disease progression is vital, involving vigilant monitoring for symptoms such as new or increasing pain, systemic symptoms (fevers, weight loss, fatigue), and difficulties in various bodily functions. These indicators prompt timely intervention, potentially necessitating scans ahead of the regular schedule to assess treatment efficacy. The patient-centered approach integrates clinical, physical, and imaging assessments to tailor ongoing treatment strategies and ensure optimal outcomes.
Summary is AI-generated and reviewed by Cancer Network editorial staff.
Hereditary Renal Tumor Syndromes and the Use of mTOR Inhibitors
A 47-year-old woman with a history of drug-resistant epilepsy during childhood presented to the emergency department with sudden dyspnea and chest pain. Upon admission, her oxygen saturation was 88%.
