Case Analyses in Renal Cell Carcinoma - Episode 1

Case 1: Metastatic Renal Cell Carcinoma, Intermediate Risk

Tom Hutson, DO, PharmD, reviews the case of a 59-year-old woman with metastatic renal cell carcinoma, with intermediate risk and the role of risk assessment in patient management.

Robert Motzer, MD: Thank you for joining us for this Targeted Oncology Virtual Tumor Board®, which is focused on practice updates in renal cell carcinoma [RCC]. In today’s presentation, my colleagues and I will review 3 clinical cases. We’ll discuss individualized approaches to RCC management and will share our perspectives on key clinical trial data that may impact our decisions. I’m Dr Robert Motzer from Memorial Sloan Kettering Cancer Center [in New York, New York]. I’m joined by Dr Eric Jonasch from The University of Texas MD Anderson Cancer Center [in Houston, Texas], Dr Bradley McGregor from the Dana-Farber Cancer Institute [in Boston, Massachusetts], and Dr Tom Hutson from the Texas Oncology-Baylor Charles A. Sammons Cancer Center [in Dallas, Texas]. Thank you for joining us.

Let’s get started with our first case. Case No. 1 involves metastatic renal cell carcinoma, intermediate risk, and will be presented by Dr Tom Hutson.

Tom Hutson, DO, PharmD: Thank you, Bob. I’m certainly happy to be here for our case discussions. The first case is of a 59-year-old African American woman who was diagnosed with clear cell RCC. The personal medical history was blood pressure hypertension, with blood pressure 167/99 and no prior history of hypertension. Otherwise, she was healthy. She underwent a left total nephrectomy. The blood pressure postnephrectomy was 125/90. Nine months later, she developed metastatic disease to bilateral lung, mediastinum, with a 3.5-by-3.8-cm mass, as well as retroperitoneal lymph nodes. The diagnosis was made as a stage IV RCC with clear cell histology, and metastases to the lung and retroperitoneum. The performance status of this woman was 90%. Laboratory studies, particularly hemoglobin, neutrophil count, and platelets, were all within normal limits. The patient was, however, noted to have an elevated corrected calcium above the institution’s upper limit of normal. Blood pressure on examination is 120/85.

Robert Motzer, MD: That’s a very interesting case, Tom. In terms of your management strategy, there have been various risk groupings identified for RCC and first-line management, so how would you assess this person’s risk? These risk systems, are they something you use in your own management?

Tom Hutson, DO, PharmD: Yes, we tend to, at least in my practice, utilize the risk groupings. They have prognostic significance, and at least at some level, we believe these clinical factors may relate to underlying biology differences among the cancer. The historical ones, as you know, Bob, you’ve been involved with them, and they’ve been developed in the cytokine era. They’ve been subsequently updated through the IMDC [International Metastatic RCC Database Consortium], in the TKI [tyrosine kinase inhibitor], in what we call the modern era, and they tend to focus on the same clinical factors readily assessable. The presence of hypercalcemia, which we recognize as a paraneoplastic effect, would be 1 risk factor, and it would make this patient an intermediate risk based on the modern criteria.

Your question was if this is something that we do all the time now. In the past few years, yes, but it’s becoming, in my mind, less needed as several of our new therapies in the frontline setting were evaluated in all the risk groups: the favorable, intermediate, and poor risk. And I’m referring to several of the I/O [immuno-oncology]–TKI [tyrosine kinase inhibitor] combinations. You’re allowed 1 to choose them and not have to worry about which risk classification the patient is in. That may be useful moving forward for some of the community oncologists who aren’t as familiar with the classification. One more point is that many of our electronic medical records have checkboxes. To get in pathways in US Oncology, where I’m affiliated, we need to check boxes for the patient’s prognostic classification.

Robert Motzer, MD: Bradley, your center was pivotal in developing the international criteria. Would you apply that criteria to this patient, and do you commonly do that in your practice?

Bradley McGregor, MD: Yes, I do. This is something we do up front, and then we do a risk stratification on all our patients. We generally use the IMDC criteria. To Tom’s point, it’s unclear how much it’s going to make a big difference in the treatment options. That being said, nivolumab-ipilimumab is a great regimen that’s approved in intermediate- and poor-risk disease. There are trials that have opened recently such as COSMIC-313, which looks at nivolumab-ipilimumab vs the addition of cabozantinib, and the ongoing PDIGREE trial, which looks at this adaptive approach. Those are all required for intermediate- and poor-risk disease. Thus, we’re certainly looking at IMDC risk stratification up front to give us an idea how the patient is going to do overall in framing that treatment discussion.

Transcript edited for clarity.